Remission induction in Behçet’s disease following lymphocyte depletion by the anti-CD52 antibody CAMPATH 1-H

C. M. Lockwood, G. Hale1, H. Waldman2 and D. R. W. Jayne

Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, 1Therapeutic Antibody Centre and 2Dunn School of Pathology, University of Oxford, Oxford, UK.

Correspondence to: D. R. W. Jayne, Box 157 Department of Medicine, School of Clinical Medicine, Hills Road, Cambridge CB2 2SP, UK. E-mail: dj106{at}cam.ac.uk


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objective. Behçet’s disease (BD) is a multisystem vasculopathy of unknown cause with variable clinical presentation and the outcome of current treatments is often unsatisfactory. There is evidence for T-cell autoreactivity in BD and this study explores the therapeutic response to lymphocyte depletion with a humanized anti-CD52 antibody, CAMPATH-1H.

Methods. Eighteen patients with active BD received a single course of 134 mg of CAMPATH-1H. Immunosuppressives were withdrawn and prednisolone reduced according to clinical status. Treatment response was assessed by remission of clinical features of disease activity, erythrocyte sedimentation rate, C-reactive protein, prednisolone dose, the need for subsequent immunosuppressives and disease relapse.

Results. By 6 months, 13/18 (72%) had entered remission and average, daily prednisolone dose was reduced from 17.7 to 6.7 mg/day (P < 0.005). At patient follow-up after 37 (6–60) months, seven had relapsed after an average of 25 months, five had required the introduction of an immunosuppressive drug and two had been retreated with CAMPATH-1H; 10 were in stable remission and six were receiving no therapy. Moderate infusion-related adverse effects occurred in five and two developed hypothyroidism. Circulating CD4+ T cells fell to low levels after CAMPATH-1H and remained depressed for at least 1 yr; no opportunistic infections were seen.

Conclusions. The therapeutic response to CAMPATH-1H suggests a central role for autoreactive lymphocytes in BD. The potential of CAMPATH-1H to induce sustained treatment-free remission in BD poorly controlled by conventional therapy requires further evaluation.

KEY WORDS: Behçet’s disease, Lymphocyte depletion, T cell, Monoclonal antibody, CAMPATH-1H, CD52, Therapy.


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Behçet’s disease (BD) is a multisystem vasculopathy with a worldwide distribution [1]. There is currently no available laboratory test or characteristic histology by which a patient with the disorder may be identified. A presumptive diagnosis rests on the presence of a constellation of pathological features and their associated clinical symptomatology. Pathologically, there are three important vascular abnormalities: perivascular lymphocyte cuffing, transmural polymorphonuclear infiltration and spontaneous intravascular thrombosis. Hippocrates in the 5th century described the salient features of the clinical aspects of the disease and, in particular, painful ulceration of the mucosa lining the mouth and genitalia [2]. Behçet in 1937 highlighted the link between this and inflammation of the eye; more recently sets of diagnostic criteria incorporating these as well as other associated symptoms and signs have evolved to facilitate recognition of the disorder [3]. However, because of the broad nature of the vascular pathology and multisystem involvement, and geographical differences in the clinical presentation of BD, these criteria are wide ranging and uncertainty exists as to how broadly based the individual patient’s clinical syndrome has to be to rank with the condition [4].

Consensus would have that BD is a genetically determined autoimmune condition owing to the strong association with HLA-B51 [1]. However, there are uncertainties as to the contribution made by genetic factors, because of the variation in the prevalence of HLA-B51 in different populations. Equally, there are aspects which present difficulty in accepting an autoimmune aetiology, since there is a lack of evidence for a humoral component in the autoimmune response, circulating autoantibodies being identifiable only in a minority of patients.

Without defined pathogenetic mechanisms, the treatment of Behçet’s disease has evolved empirically; relatively few controlled studies exist and morbidity as well as mortality due to the disorder remain substantial. Current therapies aim to suppress immune responses with corticosteroids and azathioprine, to modulate cytokine dysregulation with interferon-{alpha} and thalidomide or control inflammation and hypothetical infection [510]. Several lines of evidence point to the contribution of T-cell autoreactivity to the pathogenesis of BD. In addition to the MHC association, oligoclonal expansion of a restricted repertoire of T-cell Va and Vb genes correlates with active disease, T cells specific for the autoantigen, heat shock protein 60, have been identified from BD patients, and BD responds to therapy with calcineurin antagonists [1113].

Lymphocyte depletion with antithymocyte globulin has led to remission in BD, but this approach is limited by the development of an antiglobulin response [14, 15]. Humanized monoclonal antibodies avoid antiglobulin responses of clinical significance, allowing repeated dosing, which is of importance in relapsing autoimmune disease. The CD52 antigen is present on lymphocytes and macrophages, but the predominant effect of anti-CD52 antibody therapy (CAMPATH 1-H) is T-cell depletion where recovery of the CD4+ subset is usually delayed and incomplete [16]. CAMPATH 1-H is capable of inducing sustained treatment-free remission in other immune vasculopathies, including polyarteritis and Wegener’s granulomatosis, as well as in rheumatoid arthritis, multiple sclerosis and inflammatory eye disease [1620]. We have investigated the use of CAMPATH-1H in 18 patients referred to us with stigmas which qualified them for a presumptive diagnosis of Behçet’s disease.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Patients
Eighteen patients were recruited from the vasculitis clinic at Addenbrooke’s hospital and received CAMPATH-1H after giving informed consent. Thirteen were female; the mean age was 37 yr (range: 18–61) (Table 1). They were all Caucasian, 16 were born in the UK, one in the USA and one in Canada. The average prior disease duration was 78 months (range: 1–354). All patients had had episodes of recurrent oral and genital ulceration and met international criteria for BD [3]. In addition, there was evidence from non-invasive imaging of active inflammation in at least one other system commonly involved in BD in 15/18 (83%), and supportive histology from an affected organ in 15/18 (83%). The pathergy phenomenon was observed in 9/18 (50%). Autoimmune serology was negative for antinuclear antibodies, rheumatoid factor, antineutrophil cytoplasmic antibody (ANCA) ELISAs for proteinase 3-ANCA and myeloperoxidase-ANCA, cryoglobulins and anticardiolipin antibodies [21,22]. No patient had evidence of hepatitis B, hepatitis C or human immunodeficiency virus infection. Thirteen had failed steroid, immunosuppressive and other therapies, while five had received previous steroids but had not had immunosuppressive therapy (Table 1).


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TABLE 1. Patient demography

 
Treatment with anti-CD52
CAMPATH 1-H (Millenium Pharmaceuticals) was supplied by the Therapeutic Antibody Centre (Oxford, UK). It was produced from the culture supernatant of Chinese hamster ovary cells grown in a hollow-fibre fermentor, and purified by affinity chromatography on Protein A, ion exchange chromatography on S-sepharose and size-exclusion chromatography of Superdex 200 (Amersham Biosciences, Little Chalfont, UK). Patients were advised about the previous clinical experience with humanized monoclonal antibodies used for systemic vasculitis. Other immunosuppressives were discontinued prior to treatment apart from prednisolone. An escalating regimen of CAMPATH 1-H of 4, 10, 40, 40 and 40 mg intravenously daily, total 134 mg, was administered. There was routine prophylaxis against infusion reactions with 100 mg of hydrocortisone and 10 mg of chlorpheniramine and against subsequent infections with oral acyclovir for 1 month and nystatin mouthwashes for 2 months [23]. Prednisolone dose was tapered according to the patients’ clinical status with the aim of withdrawal within 1 yr of CAMPATH-1H treatment.

Organ involvement
The pattern of organ involvement before entry and at the time of CAMPATH-1H is listed (Tables 1 and 2). Twelve (67%) had had uveitis, and in four there was active ocular inflammation at the time of entry (patients 1, 6, 13 and 15). Neuropsychiatric involvement had been present in 12 (67%), joint involvement in 13 (70%), skin involvement in 12 (67%) and involvement of the gastrointestinal tract in seven (39%). Less common features were cardiac and pulmonary involvement in three each (16%), and renovascular involvement in two (11%).


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TABLE 2. Organ involvement at the time of treatment with anti-CD52 and outcome

 
Twelve patients were entered with frequently relapsing disease with the aim of reducing their cumulative steroid or immunosuppressive therapy. Six presented acutely, two with life-threatening multiple organ infarcts (patients 5 and 12), two with gastrointestinal vasculitis and haemorrhage (patients 1 and 2), and two with disturbed cerebral function (patients 9 and 11).

Investigations
Sequential evaluation of haematological and biochemical indices included C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and CD4+ T-cell levels. They were performed prior to and at 3, 6, 9 and 12 months after CAMPATH-1H.

Imaging. After the risk of infection had been excluded, standard techniques were employed to image sites of possible inflammation, including autologous leucocyte scintiscanning, MRI with enhancement, bone scan with tomography, angiography and cranial single photon emission computed tomography (SPECT).

Statistics
Laboratory variables are expressed as mean ± standard deviation and other continuous variables are described as median and range. For comparison of results before and after treatment with CAMPATH-1H, such as CRP and ESR, data series were assessed by two-tailed t-test after logarithmic conversion.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Disease activity
Remission. Three months after treatment with one course of CAMPATH-1H, eight patients had lost all features of disease activity and seven had a partial remission. Two developed worsening features of BD controlled by an increase in prednisolone and reintroduction of an immunosuppressive. Patient 14 was discovered to have herpes simplex encephalitis during CAMPATH-1H infusion and received only 17 mg of antibody. She made a complete recovery after appropriate therapy. By 6 months after entry 13/18 (72%) were in remission (Table 2).

Follow-up. The duration of follow-up averaged 37 months (range: 6–60). Relapses were seen in seven of the 13 (54%) entering remission with CAMPATH-1H, after an average of 25 months (range 12–39) (Figure 1). In two, retreatment with CAMPATH-1H led to further remission, other relapses were treated by an increase in prednisolone with reintroduction of immunosuppressives in two. Patient 1 died at 60 months of a cardiovascular event while in stable remission. Of the five in partial remission at 6 months, three had inactive disease on continued treatment while two had persistent, grumbling disease.



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FIG. 1. Survival to first disease relapse after successful remission induction with CAMPATH-1H.

 
Immunosuppressive drugs
Prednisolone doses were reduced from an average of 17.7 (range: 0–60) mg/day before treatment to 6.8 (0–20) mg/day at 3 (P < 0.005), 4.7 (0–20) mg/day at 6 (P < 0.005), and 2.8 (0–10) mg/day by 12 months (P < 0.005) (Figure 2). Cyclosporin was reintroduced in four patients to control persisting or relapsing disease. Patient 17 had a partial remission after CAMPATH-1H and full remission followed mycophenolate mofetil. Concomitant treatment with plasma exchange (patient 14), and anti-CD18 monoclonal antibodies and prostacyclin (patients 5 and 12) was used in order to achieve rapid control of fulminant disease [24]. There were no adverse effects associated with these additional interventions and disease activity was controlled without further agents.



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FIG. 2. Prednisolone dose (mg/day) after treatment with CAMPATH-1H (mean, interquartile and range).

 
Laboratory markers
There were non-significant falls in CRP at 3 and 6 months; the ESR at 6 months was lower than at the time of treatment (P = 0.007) (Table 3). Platelet counts were lower after treatment but remained in the normal range. The most dramatic changes were in lymphocyte and CD4+ T-cell counts after CAMPATH-1H, which remained markedly depressed (Table 3 and Fig. 3).


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TABLE 3. Laboratory data at entry and 3 and 6 months after CAMPATH-1H

 


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FIG. 3. Sequential CD4+ T cells (x106) after treatment with CAMPATH-1H (mean, interquartile and range).

 
Adverse effects
Infusion reactions. A cytokine release syndrome occurs following CAMPATH-1H consisting of fevers, chills, backache, wheezing and malaise [23]. Despite prophylactic measures, 5/18 (28%) experienced a moderate reaction, which abated at the end of the infusion course (Table 4).


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TABLE 4. Adverse effects after treatment with CAMPATH-1H

 
Other adverse effects. Infections were unusual; neither reported infection was directly attributable to CAMPATH-1H or to lymphocyte depletion (Table 4). Hypothyroidism developed in two following CAMPATH-1H and has required continued thyroxine replacement. Thyroid autoantibodies were not detectable in either patient.


    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Behçet’s disease is a multisystem vasculopathy for which there is neither a diagnostic test or characteristic biopsy histopathology. As a consequence uncertainty exists as to identification of the condition, hampering progress towards logical treatment of the disorder. This has led to the proposal of various sets of criteria by which diagnosis by consensus can be established. The most recently formulated are those put forward by the International Study Group for Behçet’s Disease and require recurrent oral ulceration, as the major criterion and two minor criteria from amongst four, those being recurrent genital ulceration, evidence of ocular vasculitis, skin lesions or a positive pathergy test [3]. All 18 patients met these critera. Additionally, imaging studies were consistent with the presence of sites of active inflammation in 15/18 and biopsies revealed active inflammation in the absence of infection or other non-autoimmune cause in 15/18. Moreover, features consistent with the diagnosis of other common small vessel vasculopathies, such as Wegener’s granulomatosis or microscopic polyangiitis, were sought and were absent. The demography of patients in this series differs from those of large cohort studies where severe disease was more common in men and cardiac and major arterial disease were more frequent [25]. Part of this difference may be explained by a selective referral policy and by differences in the geographical expression of BD; and it is possible that therapeutic responses to CAMPATH-1H will vary in other BD cohorts.

The ready response to therapeutic intervention with CAMPATH-1H was surprising. Long-term treatment-free remission was achieved in the majority of patients, which is more striking than in other groups of patients treated with CAMPATH-1H, such as those with rheumatoid arthritis and Wegener’s granulomatosis [16, 18]. The therapeutic responses in BD approached those seen in multiple sclerosis patients given first-time treatment (no new lesions but progression of previously established lesions) [19]. The control of disease after CAMPATH-1H also supports a central role of CD4+ T cells in the pathogenesis of BD, which merits further investigation.

In our patients, some with severe life-threatening disease, the treatment was generally well tolerated, with all patients completing the course of CAMPATH-1H apart from one in whom treatment was suspended owing to concurrent infection. Infusion reactions did not persist beyond the infusion period and were controlled with symptomatic treatments. Of more concern has been the prolonged lymphopenia observed after CAMPATH-1H, again noted here (Figure 3). Opportunistic infections were not seen although herpes simplex and fungal prophylaxis was routine. The low incidence of infections may relate to the reduction in steroid doses after CAMPATH-1H and avoiding immunosuppressives unless the clinical status deteriorated. Hypothyroidism has also occurred following the treatment of multiple sclerosis with CAMPATH-1H, but the mechanism for this promotion of thyroid autoimmunity is not understood [26].

Our studies indicate that Behçet’s disease may be particularly amenable to treatment with CAMPATH-1H. These observations provide clues to the pathogenesis and more specific immunotherapy for the constellation of pathologies and their related symptomatology classified eponymously as constituting Behçet’s disease.


    Acknowledgments
 
Dr M. Lockwood, who designed and conducted this study, sadly died in 1999 before its completion. The authors are grateful to the staff of the therapeutic antibody centre for production of CAMPATH 1-H, to Prof. D. Scott for permission to study his patients, to Dr P. Meyer, medical ophthalmologist, for his opinions, to Sister J. Elliott and Sister C. Drummond for patient care and data collection, and to S. Nowottny for preparation of the manuscript.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. Sakane T, Takeno M, Suzuki N, Inaba G. Behçet’s disease. N Engl J Med 1999;341:1284–91.[Free Full Text]
  2. Kaklamani VG, Vaiopoulos G, Kaklamanis PG. Behçet’s disease. Semin Arthritis Rheum 1998;27:197–217.[ISI][Medline]
  3. Criteria for diagnosis of Behçet’s disease. International Study Group for Behçet’s Disease. Lancet 1990;335:1078–80.[ISI][Medline]
  4. Ehrlich GE. Behçet disease and the emergence of thalidomide. Ann Intern Med 1998;128:494–5.[Free Full Text]
  5. Demiroglu H, Ozcebe OI, Barista I, Dundar S, Eldem B. Interferon {alpha}-2b, colchicine, and benzathine penicillin versus colchicine and benzathine penicillin in Behçet’s disease: a randomised trial. Lancet 2000;355:605–9.[CrossRef][ISI][Medline]
  6. Kosar A, Haznedaroglu S, Karaaslan Y et al. Effects of interferon-{alpha}2a treatment on serum levels of tumor necrosis factor-{alpha}, tumor necrosis factor-{alpha}2 receptor, interleukin-2, interleukin-2 receptor, and E-selectin in Behçet’s disease. Rheumatol Int 1999;19:11–4.[CrossRef][ISI][Medline]
  7. Hirohata S, Suda H, Hashimoto T. Low-dose weekly methotrexate for progressive neuropsychiatric manifestations in Behçet’s disease. J Neurol Sci 1998;159:181–5.[CrossRef][ISI][Medline]
  8. Hamuryudan V, Mat C, Saip S et al. Thalidomide in the treatment of the mucocutaneous lesions of the Behçet syndrome. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1998;128:443–50.[Abstract/Free Full Text]
  9. Hamuryudan V, Ozyazgan Y, Hizli N et al. Azathioprine in Behçet syndrome: effects on long-term prognosis. Arthritis Rheum 1997;40:769–74.[ISI][Medline]
  10. Calguneri M, Kiraz S, Ertenli I, Benekli M, Karaarslan Y, Celik I. The effect of prophylactic penicillin treatment on the course of arthritis episodes in patients with Behçet’s disease. A randomized clinical trial. Arthritis Rheum 1996;39:2062–5.[ISI][Medline]
  11. Direskeneli H, Eksioglu-Demiralp E, Kibaroglu A, Yavuz S, Ergun T, Akoglu T. Oligoclonal T cell expansions in patients with Behçet’s disease. Clin Exp Immunol 1999;117:166–70.[CrossRef][ISI][Medline]
  12. Esin S, Gul A, Hodara V et al. Peripheral blood T cell expansions in patients with Behçet’s disease. Clin Exp Immunol 1997;107:520–7.[ISI][Medline]
  13. Masuda K, Nakajima A, Urayama A, Nakae K, Kogure M, Inaba G. Double-masked trial of cyclosporin versus colchicine and long-term open study of cyclosporin in Behçet’s disease. Lancet 1989;i:1093–6.
  14. Bonnet M. Immunosuppressive therapy of Behçet’s syndrome. Long term follow-up evaluation. J Fr Ophtalmol 1981;4:455–64.[ISI][Medline]
  15. Silingardi V, Montemurno C, Venezia L et al. Clinico-immunological study of 6 cases of Behçet’s disease. Minerva Med 1979;70:3269–84.[ISI][Medline]
  16. Isaacs JD, Manna VK, Rapson N et al. CAMPATH-1H in rheumatoid arthritis—an intravenous dose-ranging study. Br J Rheumatol 1996;35:231–40.[ISI][Medline]
  17. Lockwood CM, Thiru S, Isaacs JD, Hale G, Waldmann H. Long-term remission of intractable systemic vasculitis with monoclonal antibody therapy. Lancet 1993;341:1620–2.[CrossRef][ISI][Medline]
  18. Lockwood CM. Refractory Wegener’s granulomatosis: a model for shorter immunotherapy of autoimmune diseases. J R Coll Physicians Lond 1998;32:473–8.[ISI][Medline]
  19. Paolillo A, Coles AJ, Molyneux PD et al. Quantitative MRI in patients with secondary progressive MS treated with monoclonal antibody Campath 1H. Neurology 1999;53:751–7.[Abstract/Free Full Text]
  20. Dick AD, Meyer P, James T et al. Campath-1H therapy in refractory ocular inflammatory disease. Br J Ophthalmol 2000;84:107–9.[Abstract/Free Full Text]
  21. Hagen EC, Daha MR, Hermans J et al. Diagnostic value of standardized assays for anti-neutrophil cytoplasmic antibodies in idiopathic systemic vasculitis. EC/BCR Project for ANCA Assay Standardization. Kidney Int 1998;53:743–53.[CrossRef][ISI][Medline]
  22. Zhao MH, Jayne DR, Ardiles LG, Culley F, Hodson ME, Lockwood CM. Autoantibodies against bactericidal/permeability-increasing protein in patients with cystic fibrosis. Q J Med 1996;89:259–65.
  23. Wing MG, Moreau T, Greenwood J et al. Mechanism of first-dose cytokine-release syndrome by CAMPATH 1-H: involvement of CD16 (Fc{gamma}RIII) and CD11a/CD18 (LFA-1) on NK cells. J Clin Invest 1996;98:2819–26.[Abstract/Free Full Text]
  24. Lockwood CM, Elliott JD, Brettman L et al. Anti-adhesion molecule therapy as an interventional strategy for autoimmune inflammation. Clin Immunol 1999;93:93–106.[CrossRef][ISI][Medline]
  25. Kural-Seyahi E, Fresko I, Seyahi N et al. The long-term mortality and morbidity of Behçet syndrome: a 2-decade outcome survey of 387 patients followed at a dedicated center. Medicine (Baltimore) 2003;106:60–76.[CrossRef]
  26. Coles AJ, Wing M, Smith S et al. Pulsed monoclonal antibody treatment and autoimmune thyroid disease in multiple sclerosis. Lancet 1999;354:1691–5.[CrossRef][ISI][Medline]
Submitted 19 December 2002; Accepted 28 April 2003





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