Invest in ME/Prof Jonathan Edwards statement on UK Rituximab trial, 30 July

[Jonathan Edwards]

But wouldn't one need to know the trout for that?

Yes. In theory you could stock 5000 ponds each with a pure species of fish without knowing their names and do some fishing and then when you find you have 120 hooks in your bag that catch fish 3986 you can look up in the book and see they are trout. But in reality, to find out how many antibodies you have to a particular antigen you have to work with antibody forming cells (they have antibodies on their surface so will bind to antigen like the individual hooks do). You have to see how many different cells stick to the antigen and then clone their antibody genes from their messenger RNA, and see how many different sequences you have. To do that you need more than just a microarray, you need a big panning plate coated with antigen or something similar.

Knowing how many types of antibody you have to a particular antigen is not that helpful in practice. The main reason for studying it is to try to get a better understanding of how antibodies change or 'affinity mature' over time and how that relates to regulatory pathways.

The real problem, as I think you are suggesting, is how you find any antibodies unless you know what they are going to bind to. This has always been a problem and it is not clear that newer techniques are that much better than the old way of pouring serum on to slices of tissue and looking for binding down a microscope using fluorescent tag dyes. Newer array systems should be helpful but you have to be sure you know how to interpret them.

 

[lansbergen]

The real problem, as I think you are suggesting, is how you find any antibodies unless you know what they are going to bind to.

You are right.

This has always been a problem and it is not clear that newer techniques are that much better than the old way of pouring serum on to slices of tissue and looking for binding down a microscope using fluorescent tag dyes. Newer array systems should be helpful but you have to be sure you know how to interpret them

Still not much progress then.

I guess there are not many experienced researchers who can interpret the array results.

 

[Marco]

The real problem, as I think you are suggesting, is how you find any antibodies unless you know what they are going to bind to. This has always been a problem and it is not clear that newer techniques are that much better than the old way of pouring serum on to slices of tissue and looking for binding down a microscope using fluorescent tag dyes. Newer array systems should be helpful but you have to be sure you know how to interpret them.

I'd be interested to know if you have any thoughts as to how to narrow down the search given that most ME/CFS symptoms are non-specific and multi-system and the one symptom that may be relatively unique (PEM) isn't as yet explained in terms of any specific physiology?

Secondly (and this may be a daft question) - do you need to identify what antibodies are binding to, to confirm that you are dealing with an autoimmune disease? Presumably repeated successful trials of Rituximab (if that were the case) might point this way but not conclusively?

 

[Jonathan Edwards]

I'd be interested to know if you have any thoughts as to how to narrow down the search given that most ME/CFS symptoms are non-specific and multi-system and the one symptom that may be relatively unique (PEM) isn't as yet explained in terms of any specific physiology?

Secondly (and this may be a daft question) - do you need to identify what antibodies are binding to, to confirm that you are dealing with an autoimmune disease? Presumably repeated successful trials of Rituximab (if that were the case) might point this way but not conclusively?

Difficult to say, I think, but receptors on nerve or muscle or more generally for cytokines might be things to go for first I guess.

If an autoimmune disease is by definition one with adaptive immune reactivity to self, which so far has meant autoantibodies, then it would seem you need to find the antibodies to call it that. You may find the antibodies in a form in which you do not know what they are binding to though. In MS it is still not sure that the antibodies are even against self, although some of them would seem to have to be. For a long time all that was known about autoantibodies was the tissue they bound to, not the antigen. Moreover, we are increasingly finding that autoimmune diseases can have more than one autoantibody and it is not clear which one does what. In RA there are rheumatoid factors and anti-citrullinated protein antibodies and it is not clear how the interrelate.

Having said all that, if we find a shift in B cell behaviour (maybe a bit like in MS) and a response to rituximab that follows the same sort of kinetics as for autoimmune diseases then I think we have pretty good evidence for an autoimmune mechanism. And knowing what the antibodies are to may not be of any great importance to finding better treatments as time goes by. That is why in some ways I think it may be more useful to find some shift in B cell behaviour rather than a specific antibody, because it might relate more closely to how one might develop therapies.

 

[Marco]

Having said all that, if we find a shift in B cell behaviour (maybe a bit like in MS) and a response to rituximab that follows the same sort of kinetics as for autoimmune diseases then I think we have pretty good evidence for an autoimmune mechanism. And knowing what the antibodies are to may not be of any great importance to finding better treatments as time goes by. That is why in some ways I think it may be more useful to find some shift in B cell behaviour rather than a specific antibody, because it might relate more closely to how one might develop therapies.

Many thanks.

On the face of it then, that sounds more of a manageable task than looking for the needle in a haystack of possibilities?

 

[lansbergen]

That is why in some ways I think it may be more useful to find some shift in B cell behaviour rather than a specific antibody, because it might relate more closely to how one might develop therapies.

Will that be tested in the trial?

 

[Jonathan Edwards]

Will that be tested in the trial?

I hope so.

 

[lansbergen]

I hope so.

Then I asume you will advice it. I guess it was not calculated in the cost estimate and more money will be needed.

Maybe the advocates on here can help raising the money.

It would be stupid to do a B cell depletion trial and not look for differences between the old B cell actions and the new ones if the tests are availeble.

 

[Gemini]

That is why in some ways I think it may be more useful to find some shift in B cell behaviour rather than a specific antibody, because it might relate more closely to how one might develop therapies.

Professor, could you please give a mini-tutorial on what you mean by "shift in B-cell behavior"? I'm wondering if you mean the study of B-cell sub-populations such as that done by Dr. Bansal in ME/CFS or something entirely else?

 

[ukxmrv]

Thanks Professor Edwards for all your valuable contributions here.

I'm wondering if genetic factors will be found to have any value in determining who will respond to Rituximab? Just looking at a paper here which analysed a interleukin-6 gene polymorphism.

http://www.ncbi.nlm.nih.gov/pubmed/22734797

<snip> These results suggest that -174 IL-6 (rs1800795) gene polymorphism plays a role in the response to rituximab in systemic autoimmune diseases. Validation of these findings in independent cohorts is warranted <end>

I looked up that gene and it is included in the 23andme report I downloaded.

The paper from 2012 does have the usual disclaimer that "Validation of these findings in independent cohorts is warranted" so this may not pan out of course given further study.

 

[Marco]

Thanks Professor Edwards for all your valuable contributions here.

I'm wondering if genetic factors will be found to have any value in determining who will respond to Rituximab? Just looking at a paper here which analysed a interleukin-6 gene polymorphism.

http://www.ncbi.nlm.nih.gov/pubmed/22734797

<snip> These results suggest that -174 IL-6 (rs1800795) gene polymorphism plays a role in the response to rituximab in systemic autoimmune diseases. Validation of these findings in independent cohorts is warranted <end>

I looked up that gene and it is included in the 23andme report I downloaded.

The paper from 2012 does have the usual disclaimer that "Validation of these findings in independent cohorts is warranted" so this may not pan out of course given further study.

Funny you should mention IL6.

I came across this abstract yesterday (the full paper is pay to view unfortunately) :

Role of interleukin-6 in stress, sleep, and fatigue

http://onlinelibrary.wiley.com/doi/...ionid=0A05D9E6672C79C5D5287482A21B960B.d04t04

 

[Marco]

Thanks Professor Edwards for all your valuable contributions here.

I'm wondering if genetic factors will be found to have any value in determining who will respond to Rituximab? Just looking at a paper here which analysed a interleukin-6 gene polymorphism.

http://www.ncbi.nlm.nih.gov/pubmed/22734797

<snip> These results suggest that -174 IL-6 (rs1800795) gene polymorphism plays a role in the response to rituximab in systemic autoimmune diseases. Validation of these findings in independent cohorts is warranted <end>

I looked up that gene and it is included in the 23andme report I downloaded.

The paper from 2012 does have the usual disclaimer that "Validation of these findings in independent cohorts is warranted" so this may not pan out of course given further study.

Funny you should mention IL6.

I came across this abstract yesterday (the full paper is pay to view unfortunately) :

Role of interleukin-6 in stress, sleep, and fatigue

http://onlinelibrary.wiley.com/doi/...ionid=0A05D9E6672C79C5D5287482A21B960B.d04t04

 

[Jonathan Edwards]

I'm wondering if genetic factors will be found to have any value in determining who will respond to Rituximab? Just looking at a paper here which analysed a interleukin-6 gene polymorphism.

http://www.ncbi.nlm.nih.gov/pubmed/22734797
.

The IL-6 polymorphism link is certainly interesting. I think it would be helpful to repeat the study on homogeneous disease groups like RA or lupus. The effect might turn out to be different for each disease mechanism. Finding such variation in responses in ME is I think a fine detail in comparison to just getting the data confirmed and trying to get an idea who might have B cell related disease and who might not. Interesting though.

 

[Jonathan Edwards]

Professor, could you please give a mini-tutorial on what you mean by "shift in B-cell behavior"? I'm wondering if you mean the study of B-cell sub-populations such as that done by Dr. Bansal in ME/CFS or something entirely else?

Dr Bansal's data would certainly qualify but we might see all sorts of shifts in B cell dynamics. Levels of the B cell growth factor BAFF and its receptors might be interesting as it might tell us the system is in 'overdrive'. There are other markers that might suggest a shift towards tending to make autoantibodies - like the usage of certain heavy chain genes for making antibodies - but it all gets a bit technical from there on (even for me).

 

[Sasha]

The interview that Prof. Edwards kindly agreed to is up on the homepage now:

http://phoenixrising.me/archives/18701

but I suggest that we bring any discussion back to this thread so it's all in one place.

 

[Gemini]

Dr Bansal's data would certainly qualify but we might see all sorts of shifts in B cell dynamics. Levels of the B cell growth factor BAFF and its receptors might be interesting as it might tell us the system is in 'overdrive'. There are other markers that might suggest a shift towards tending to make autoantibodies - like the usage of certain heavy chain genes for making antibodies - but it all gets a bit technical from there on (even for me).

Professor Edwards, thank you so very much for educating us and keeping us focused. A while back I found this figure in "B cells in HIV infection and disease" by Moir & Fauci showing B cell interactions (drag image down to reposition).The paper concludes with a very short section on autoimmune diseases mentioning rituximab.

http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click on image to zoom&p=PMC3&id=2779527_nihms156340f2.jpg

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779527/

 

[Sushi]

Thank you so much Jonathan Edwards for joining this forum and entering into discussion with us on these complex topics that are so vital to us.

Forgive me for jumping in and asking a question without having read the whole thread, but here goes!

Recently Professor Kenny De Meirleir et al published:
Plasmacytoid Dendritic Cells in the Duodenum of Individuals Diagnosed with Myalgic Encephalomyelitis Are Uniquely Immunoreactive to Antibodies to Human Endogenous Retroviral Proteins


http://iv.iiarjournals.org/content/27/2/177.full

And one of the interesting findings was: (from the Abstract)

In eight out of 12 individuals with ME, immunoreactivity to HERV proteins was observed in duodenal biopsies. In contrast, no immunoreactivity was detected in any of the eight controls. Immunoreactivity to HERV Gag and Env proteins was uniquely co-localized in hematopoietic cells expressing the C-type lectin receptor CLEC4C (CD303/BDCA2), the co-stimulatory marker CD86 and the class II major histocompatibility complex HLA-DR, consistent with plasmacytoid dendritic cells (pDCs).

These findings are in ongoing investigation but I believe that the autoimmunity that was found cannot be tested by the usual markers. I wonder if this research would be of interest in your current investigation plan?
Thanks,
Sushi

 

[wastwater]

I visit and find the Encephalitis society and the St Barts MS blog interesting,not that I understand much,maybe clues can be found in these areas too.

 

[Jonathan Edwards]

Thank you so much Jonathan Edwards for joining this forum and entering into discussion with us on these complex topics that are so vital to us.

Forgive me for jumping in and asking a question without having read the whole thread, but here goes!

Recently Professor Kenny De Meirleir et al published:
Plasmacytoid Dendritic Cells in the Duodenum of Individuals Diagnosed with Myalgic Encephalomyelitis Are Uniquely Immunoreactive to Antibodies to Human Endogenous Retroviral Proteins


http://iv.iiarjournals.org/content/27/2/177.full

And one of the interesting findings was: (from the Abstract)


These findings are in ongoing investigation but I believe that the autoimmunity that was found cannot be tested by the usual markers. I wonder if this research would be of interest in your current investigation plan?
Thanks,
Sushi

Thanks, that would not be autoimmunity. I think they found that antibodies to viruses (from somewhere else) also bound to duodenal cells from patients. To be honest the abstract does not quite make sense so I am not sure what to think.

 

[lansbergen]

Thanks, that would not be autoimmunity. I think they found that antibodies to viruses (from somewhere else) also bound to duodenal cells from patients. To be honest the abstract does not quite make sense so I am not sure what to think.

With from somewere else you mean the retrovirus antibodies they used?

It falls outside this trial but the question is why do patients pDC's in the duodenum make EVR proteins.