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Advanced Course in Basic & Clinical Immunology

February 21, 2018

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Immunotherapy

Mark S. Anderson UCSF

FOCiS

Disclosures

• Own stock in Medtronic

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February 21, 2018

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Lecture outline

• Biotherapeutics

• Challenges

• Where the field is going


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Biopharmaceutical Market Sector• Biopharmaceuticals are recombinant proteins,

Mabs, or nucleic acid based products• The annual global market for

biopharmaceuticals is >$100 billion USD• 2003 >140 biopharmaceuticals were approved

>500 were in clinical evaluation• 2010 ~50% of drugs in development are

biopharmaceuticals

Genentech Confidential - do not copy, distribute or use without prior written consent.

Evolution of Top Ten Selling Pharmaceuticals

2005

Product Company TA

Lipitor Pfizer CV

Advair GSK IMM-RESP

Norvasc Pfizer CV

Nexium AZ GI

Zocor Merck CV

Zyprexa Eli Lilly NEURO-PSYCH

Plavix BMS CV

Diovan Novartis CV

Effexor Wyeth NEURO-PSYCH

Rituxan Roche ONC

2015

Product Company TA

Humira AbbVie IMM

Harvoni Gilead ID

Rituxan Roche ONC-IMM

Lantus Sanofi MET

Avastin Roche ONC

Herceptin Roche ONC

Prevnar Pfizer ID

Revlimid Celgene ONC

Remicade JNJ IMM

Advair GSK IMM-RESP

Worldwide sales: source Evaluate Pharma

Small molecule

Large molecule

Vaccine


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Why Antibodies as Therapeutics?


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- High affinity and specificity

- Low immunogenicity, predictable pharmacokinetics

- Can harness host immune effector functions

- Developed production and regulatory systems

Advantages of Recombinant MAbTherapeutics

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Strategies to Generate Therapeutic Abs

• Mouse hybridoma technology

• Humanized mouse hybridoma technology

• Mouse B cell cloning technologies

• Phage display technologies

• Human B cell cloning technologies


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Mouse Ab

Splenic Cells Myeloma Fusion partner

Mouse Ab

Mouse Hybridoma Technology

1984

.. ‘ Cesar MilsteinGeorges Kohler

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Humanized Rodent Technologies

VL JL C

VH DH JH C

VL JL C

VH DH JH C

Human IgH

Human IgL

Mouse IgH

Mouse IgL

VL JL C

VH DH JH C

Human IgH

Human IgL

HIg


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Naïve B cells

Amplified natural

repertoires

Immune

VL2 JL2

VH1 DH3 JH2

T

T

T

T

T

T

T

T

T

G

G

T

G

T

T

T

T

T

CG

G

G

T

T

G

C

C

G

Trp

Cys

Phe

Leu

T

SyntheticCDR

diversity

DNA Synthesis

Synthetic

VL1 JL4

VH8 DH6 JH4

E. Coli expressing Fabs

Phage Display Technologies

Phage Library

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3

4

5

Phage Binds to TargetWash Away

Unbound PhageElute Bound

Phage

12

3

4

5

3

3

Phage diversity library ~1010

Propagate Phage in E. Coli

SequenceDNA

IgH

IgL

Clone 3

VL JL

VH DH JH

Human antibody(Clone 3)

Phage Display Technologies

Natural Ab repertoire >1012


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Therapeutic Abs Directly from Humans

Vaccinated, infected, or recovered human

Monoclonal Ab(e.g., pavilizumab)

Polyclonal antiserum(e.g., IVIG, CMV immune globulin)

Single B cell cloning VL1 JL1

VL2 JL2

VL3 JL3

B CA

Ig cloning

Ig expression

Screening for activity

A B C

Act

ivity

Human antibody(Clone A)

Antibody-Drug Conjugates

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emtansine

Toxin

Non-cleavableLinker

-N-H

Ag Ag

MCC

CancerTargeting Ab

(Bouchard et al, Bioorg & Med Chem Lett, 24:5357, 2014)

Endocytosis

Lysosome degradation(drug release)

Endosomeformation

Lysosome trafficking

Lysosome

Drug binding to target

Antigen binding

mAb-Linker-Drug(ADC)


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Laptatinib-Capecitabine 25.1 182T-DM1 30.9 149

(Stratified HR 0.68 (95% CI, 0.55-0.85, P < 0.001)

Median survival (mo) No. of events

Verma et al (EMILIA), NEJM 367:1783, 2012

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Kadcyla for Her2+ MBC

emtansine

Toxin

Non-cleavableLinker

-N-H

Her2 Her2

MCC

CancerTargeting Ab

Transtuzumab

Antibody-Drug Conjugates for Her2+ Breast CA

Activation of T and/or B cells results in increased

immune response

Trafficking of leukocytes, which are capable of cytokine production

Secretion of cytokines and other products from

activated immune cells tissue injury

Failure to downregulate

If you were to design a therapy for immune-mediated diseases, which pathway(s) should you

target?

Chronic Inflammation


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RORtCD4+

TCR

AntigenPresenting Cell

MHCII

Ag

StimulusTLR

p40p35

IL‐12

IL‐23

p40p19

IL‐17(Th17)

IL‐23R IL‐12R1

Interleukin-23 is a Th17 survival factor by sustaining RORgt and IL-17

expression

Comparison of ustekinumab (anti-p40) and etanercept for moderate-

to-severe psoriasis

Griffiths et al. N Engl J Med; 362:118-28.


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Rich P, et al. Britich Journal of Dermatology. 2012; DOI: 10.1111/bjd.12070

Secukinumab (anti-IL17a) for induction and maintenance therapy in moderate to severe

plaque psoriasis

Hueber W, et al. Gut. 2012; 61:1693-1700.

Crohn’s disease: Primary endpoint at week 6 shows no treatment benefit of

secukinumab


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Why do some fail and some succeed?

• No better data then that directly in humans

• Need to learn better from negative results

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Target Validation

Drug Discovery

IND FilingPhase 1 Phase 2 Phase 3

Regulatory Review Phase 4Discovery

Phase 4

Efficacy

Safety

Drug development 101‐ A quick overview

Phase 1

Safety and Tolerability

Pharmacodynamic markers

Pharmacokinetics

Phase 2

Proof of Clinical Activity

Dose finding

Safety

Phase 3

Demonstration of Benefit

Safety


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• INCREASING COSTS

• DECREASING SUCCESS RATES

1987 2001 2003 2005 2016

Fully burdened costs

$318M $802M $897M $1,200M > $2,600M

Tufts CSDD study of biopharmaceutical development details R&D costs, 2006Adams and Brantner, Health Economics, 19:130-141, 2010

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1996-1998

1999-2001 2002-2004

2005-2007

2008-2010

Phase 1 to launch 17.6% 12.9% 8.8% 10.5% 7.0%

Drug development costs and success rates worsening

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Reasons for high failure rates of clinical studies (a partial list)

Pre-clinical models are poor models of human disease

Lack of understanding of human disease

Lack of understanding of mechanisms of therapeutic candidates

Little learned from negative clinical trials

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Dunn, Mertsching, Peach, Kehry (Biogen-IDEC)

Martin, Gong, Lee (GNE)

Mouse collagen-induced arthritis (intervention)

Challenge 1: Selection of pre-clinical modelsImmunization(100ug CII/CFA)

Immunization(100ug CII/IFA)

Day 021

70

Terminate study

0

2

4

6

8

10

12

20 30 40 50 60 70Study days

Mea

n ar

thri

tis

scor

e

Control

Anti-CD20

TNFRII-Fc+ methotrexate

Treatment beginsDay 24

18

51

51

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12

0

10

20

30

40

50

60

ACR20 ACR50 ACR70%

Pa

tien

ts

Placebo (N=201)

Rituximab (N=298)

p < 0.0001

p < 0.0001

p < 0.0001

Anti-TNF failures

REFLEX Study

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Joint transcriptome of mouse collagen induced arthritis is different than human RA

-3 +3

CD90

CD14

CD8

CD8

CD19

CD22

IL-1

IL-6

LT-

LT-

TNF-

BAFF

(Flavius Martin and colleagues)

Mouse CIA jointHuman RA synovium

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Which pre-clinical model?Model Spontaneous

(S) or Inducible (I)

H-2 haplotype

Unique characteristics Autoantibodies

Collagen-induced arthritis

I q or r Anti-collagen II AbsAnti-CCP Abs

Autoantibody-induced arthritis

I all

Pristane-induced arthritis

I d or q Rheumatoid nodules Rheumatoid factorAnti-collagen II AbsAnti-HSP Abs

Proteoglycan-induced arthritis

I d or k Ankylosing spondylitis Anti-PG Abs

Chronic antigen-induced arthritis

I b Lymphoid aggregates

D1CC (rCII promoter/enhancer-hCIITA)

I (hCII) q Rheumatoid nodulesInterstitial pneumonitis

Anti-cII Abs Anti-CCP Abs

K/B X N S I

I-Ag7 all

Anti-GPI Abs

SKG S and I d or b/d Skin inflammationInterstitial pneumonitis

Rheumatoid factor 31

Challenge : Co-medications and active comparators

How do we control in pre-clinical models the potpourri effects of co-administration of SOC medications?

• RA: NSAIDs, Plaquenil, Sulfasalazine, Methotrexate• SLE: Steroids, Imuran, Methotrexate, Cellcept

Active comparator to demonstrate superiority

• Importance of specific biological pathways can be under-and over-estimated in specific pre-clinical models (e.g., IL1 pathway and LFA-1 biology in collagen-induced arthritis) 32


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Clinical Symptom C

Clinical Symptom D

Clinical Symptom E

Clinical Symptom A

Clinical Symptom B

Molecular PathwayDysregulation

Therapy A

Adenosine deaminase deficiencyFabry’s disease (-galactosidase)Factor VIII & IX deficiencyPompe disease (-glucosidase)

Monogenic diseases with a single disease pathogenic mechanism have high drug discovery success rates

Therapy A

Therapy B

Therapy C

Developing “targeted” therapies AND ability to identify the “right” patient for a drug will increase success and provide greater patient benefit

Molecular Pathway 1

Molecular Pathway 2

Molecular Pathway 3

CDx

CDx

CDx

34Identifying patient subsets driven by dominant molecular pathways to increase drug discovery/development success


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Predictive Diagnostics to find the right therapy for the right patient

67% responders

3% responders missed

= Responder

= Non-responder

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20.3 mo

25.4 mo (25% )

RR = 0.76p = .025


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The right therapy for the right patient

3% responders missed

67% responders= Responder

= Non-responder

5 months

(22.7%)

Actual Benefit(All Patients)

5 mos (22.7%)

Expected Benefit Target PrevalenceRequired Sample Size

and Study Duration

1250 52 mo100%

1.25 mos (5.7%) 11000 349 mo25%37 v

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A Phase III in which 25% of patients show a treatment effect.

Without patient selection, a potentially beneficial therapy would have been missed


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Disease Molecular Pathway Incidence Targeted Therapy Approval(with Dx)

Breast Estrogen receptor 70% tamoxifen (Nolvadex)faslodex (Fulvestrant)anastrozole (Arimidex)

197720022005

Breast Her2/Neu/Erb2 overexpression

25% trastuzumab (Herceptin)pertuzumab (Perjeta)

19982013

CML Bcr-Abl fusion 90% imatinib (Gleevac)nilotinib (Tasigna)dasatinib (Sprycel)bosutinib (Bosulif)ponatinib (Iclusig)

20012010201320132016

Colorectal cancer

K-ras mutations (codons 12 and 13)

40% Contraindicated:cetuximab (Erbitux)

pantimumab (Vectibix)

2009

NSCLC Nucleophosmin-anaplastic lymphoma

kinase (NPM/ALK)

3% crizotinib (Xalkori)alectinib (Alecensa)

20112016

Melanoma Raf (V600E) mutation 50% vemurafenib (Zelboraf)dabrafenib (Tafinlar)

20112016

Transforming clinical into molecular oncology39

Anti-PDL1 mAb: Releasing a T cell checkpoint

SS

Dendritic Cell/tumor

Stimulation

CD28TCR

B7‐1

HLA

T cell SS

Dendritic cell/tumor

Stimulation

CD28PD‐1

Inhibition

TCR

PD‐L1B7‐1

HLA PD‐L2

T cell

Exhaustion

Anti-PD1/L1 mAb

RejuvenationImmune Activation

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PD-L1 Is Broadly Expressed in Human Cancer

Tumor Type Estimated PD‐L1 Prevalence (≈ %)*

NSCLC (SCC) 50

NSCLC (adeno) 45

Colon 45

Melanoma 40

Renal 20

* Staining of archival tumor tissue (GNE); Brown chromogen: PDL1; Blue: hematoxylin counterstain

PD-L1

Garon, AACR 2015

PDL1 staining: < 1% 1 - 49% > 50%

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Obj

ecti

ve R

espo

nse

Rat

e (%

)

KEYNOTE 001 KEYNOTE 010

PD-L1 Score

8.1%

12.9%

19.4%

29.6%

45.4%

10.0%

30.0%

(Grigg and Rizvi, J Immunother CA 4:48, 2016)

<1% 1-24% 25-49% 50-74% 75-100% 1-49% >50%

Prevalence (%) 39.2 31.0 6.7 8.6 14.6 37.9 28.4

50

40

30

20

10

0

PD-L1+ in advanced NSCLC enriches for benefit with pembrolizumab (anti-PD1 mAb)


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Breast CA Colon CA Melanoma Lung CA

Estrogen R

Her 2

EGFR Raf K-ras

PDL1PI3K/PTEN loss

Unknown

Redefining clinical phenotypes into molecular mechanisms 43

Identifying patient subsets driven by dominant molecular pathways may increase drug discovery/development success

Therapy A

Therapy B

Therapy C

Developing “targeted” therapies AND ability to identify the “right” patient for a drug will increase probability of success and provide greater patient benefit

CancersAsthma

Rheumatoid ArthritisSystemic Lupus ErythematosusInflammatory Bowel Disease

….

Molecular Pathway 1

Molecular Pathway 2

Molecular Pathway 3

Polygenic diseases have multiple pathogenic molecular/cellular pathways that contribute to disease

Biomarker

Biomarker

Biomarker

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Rheumatoid Arthritis: synovial heterogeneity

Synovium

FACS profile

Histology

Transcriptome Sorted Cells

Histology scores

Total Synovial Transcriptome

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“Lymphoid”(33%)

“Myeloid”(33%)

“Fibroid”(33%)

Synovial Gene Expression Clusters have Differential Representation of Biological Pathways

Dennis et al, Arthritis Research and Therapy 2014, 16:R90.

• Training cohort of active RA patients (n=69) on standard of care therapies

• >3 years of disease

• Majority Rheumatoid Factor positive

• Synovial tissue from involved joints (small and large) undergoing orthopedic surgery to correct deformity or for joint replacement


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“Lymphoid”(33%)

“Myeloid”(33%)

“Fibroid”(33%)

Synovial Gene Expression Clusters have Differential Representation of Biological Pathways and Histologies

Dennis et al, Arthritis Research and Therapy 2014, 16:R90.

Lymphoid gene score

Monocyte/M1 macrophage gene score

Lower serum C reactive protein

CD3 CD20

Minimal inflammation

CD3 CD20

~25% have GC-like structures

CD3 CD20

>80% have GC-like structures

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Baseline Synovial Myeloid Gene Score Predicts EULAR ‘GOOD’ Infliximab (anti-TNF) Response

Myeloid

Interrogation of pre-treatment synovial tissue GEO data set

p=N.S. p=N.S.

Lymphoid Fibroid

p<0.05

*

Data shown as median/IQR(p values derived from t-statistic of EULAR Good vs. Moderate vs Poor clinical response at 16 weeks)

(Dennis et al, Arthritis Research and Therapy 2014, 16:R90; Lindberg et al, PloS One 5:e11310) 2010)

ICAM1hi CXCL13lo ICAMllo CXCL13hi ICAM1lo CXCL13loSerum:


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Serum ICAM1 and CXCL13 levels can differentially enrich anti-TNF vs. anti-IL6R responders

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(Dennis et al, Arthritis Research and Therapy 2014, 16:R90)

Working Model for RA Heterogeneity and Drug Response Groups

Chondrocytes

Jointcellularity(Early & Late

Disease)Lymphocytes

Fibroblasts

Macrophages

‘Lymphoid’Axis ‘Myeloid’Axis ‘Fibroid’ Axis

Patients

CXCL13SystemicBiomarkers

sICAM CRP, ESR, Antibodies

Anti-TNF

Poor anti-inflammatory drug response (methotrexate,

Rituxan)

Anti-IL-6RDrug

ResponseAnti-CD20

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ER/PR Her 2 PI3K Ras Raf?? PDL1

Molecular Medicine- 2017 and beyondBreast CA Lung CAMelanomaColon CA

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Lupus Geographic atrophy

Ulcerative colitis

Asthma

IFN BAFF IL13 7 TNF fD

Biomarker development to decrease disease heterogeneity!

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February 21, 2018

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Immunotherapy

• Many pathways/targets now developed

• Cancer Immunotherapy: very exciting developments

• How does it work???

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Acknowledgements

• Scott Plevy

• Andy Chan

disclosures...lipitor pfizer cv advair gsk imm-resp norvasc pfizer cv nexium az gi zocor merck cv...

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