T1DM Immunotherapy Using CD4+CD127lo/-CD25+ Polyclonal Tregs - Full Text View

Purpose

The investigational therapy under study in this trial, regulatory T cells (Tregs), offers the hope of stabilizing further destruction of insulin producing beta cells in type 1 diabetes. Tregs are a specialized subset of T cells that function to control the immune response. Pre-clinical studies in non-obese diabetic mice have demonstrated that adoptive transfer of Tregs can slow diabetes progression and, in some cases, reverse new onset diabetes. The primary purpose of this Phase 1 study is to assess the safety and feasibility of intravenous infusion of ex vivo selected and expanded autologous polyclonal Tregs in patients with type 1 diabetes (T1DM) to support dose selection for a future efficacy trial. The study also aims to assess the effect of Tregs on beta cell function as well as on other measures of diabetes severity and the autoimmune response underlying T1DM.

Condition	Intervention	Phase
Type 1 Diabetes Mellitus	Biological: Ex vivo Expanded Human Autologous CD4+CD127lo/-CD25+ Polyclonal Regulatory T Cells	Phase 1

Study Type:	Interventional
Study Design:	Endpoint Classification: Safety/Efficacy Study Intervention Model: Single Group Assignment Masking: Open Label Primary Purpose: Treatment
Official Title:	A Phase I Safety Trial of CD4+CD127lo/-CD25+ Polyclonal Treg Adoptive Immunotherapy for the Treatment of Type 1 Diabetes

Resource links provided by NLM:

Genetics Home Reference related topics: type 1 diabetes

MedlinePlus related topics: Diabetes Diabetes Medicines Diabetes Type 1

U.S. FDA Resources

Further study details as provided by University of California, San Francisco:

Primary Outcome Measures:

Number of Participants with Adverse events as a Measure of Safety and Tolerability. [ Time Frame: Up to 5 years ] [ Designated as safety issue: Yes ]
Primary outcome measures will be the number of participants with adverse events, laboratory abnormalities and other signs of toxicity. Particular focus will be on the number and severity of infusion reactions, complications related to infection, and any potential negative impact on the course of diabetes.

Secondary Outcome Measures:

C-peptide response [ Time Frame: Up to 5 years ] [ Designated as safety issue: No ]
Secondary diabetes-related outcome measure will include C-peptide response during mixed meal tolerance tests at 26 and 52 weeks
Insulin Use [ Time Frame: Up to 5 years ] [ Designated as safety issue: No ]
Secondary diabetes-related outcome measure will include insulin use
Hemoglobin A1c [ Time Frame: Up to 5 years ] [ Designated as safety issue: No ]
Secondary diabetes-related outcome measure will include hemoglobin A1c
Immunologic Markers [ Time Frame: Up to 5 years ] [ Designated as safety issue: No ]
Secondary surrogate immunologic markers will include those related to general immune function and those related to the diabetes autoimmune response.

Estimated Enrollment:	14
Study Start Date:	November 2010
Estimated Study Completion Date:	December 2016
Estimated Primary Completion Date:	May 2016 (Final data collection date for primary outcome measure)

Intervention Details:

Patients with Type 1 Diabetes Mellitus will have their regulatory T cells (Tregs) isolated by researchers. The researchers will multiply/expand the Tregs in the laboratory using anti-CD3/anti-CD28 coated beads plus IL-2. Then, the Tregs will be infused back into the patient in a single infusion. The first cohort will receive 0.05 x10^8 cells. The second cohort will receive 0.4 x10^8 cells. The third cohort will receive 3.2 x10^8 cells. The fourth cohort will receive 26 x10^8 cells.

Detailed Description:

Currently, there is no approved medical treatment for preservation of the body's ability to produce insulin in patients with Type 1 Diabetes Mellitus (T1DM), and the progression of the disease can have devastating consequences. Inadequate blood glucose control results in many long term complications including kidney disease, blindness, amputation and nerve damage. In spite of the advances in insulin therapy and subsequent glucose control, patients are required to infuse insulin subcutaneously daily throughout their lives, monitor their diet and blood sugar levels, and deal with life-long uncertainties. The investigational therapy under study in this trial, regulatory T cells (Tregs), offers the hope of stabilizing diabetes. Tregs are a specialized subset of T cells that function to control the immune response. Pre-clinical studies in non-obese diabetic mice have demonstrated that adoptive transfer of Tregs can slow diabetes progression and, in some cases, reverse new onset diabetes. The primary objective of this study is to assess the safety of a single intravenous infusion of Tregs in patients with T1DM. The study will also assess the effect of Tregs on insulin-producing beta cell function as well as other outcomes related to diabetes management. Researchers will isolate Tregs from the patient's own blood using specific T cell surface markers (CD4, CD25, and CD127). This subset of cells is then expanded in the laboratory by co-stimulating with anti-CD3 and anti-CD28 immobilized on magnetic beads, and with the use of growth medium containing human serum and IL-2. Following the 14-day expansion, anti-CD3/anti-CD28 beads will be removed and the Tregs will be concentrated and consolidated. The cells will then be resuspended in sterile infusion solution at the required concentration and infused back into the patient through a standard peripheral intravenous line. Subjects will be observed overnight in the clinical research center for any possible side effects following the infusion. A total of 14 subjects will be enrolled. The study will involve 4 dosing cohorts with 3 or 4 adults in each cohort. Each cohort will receive increasing amounts of Tregs. Subjects will be followed over five years to assess safety of the Treg therapy.

Eligibility

Ages Eligible for Study:	18 Years to 45 Years
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

Diagnosis of T1DM within >3 and <24 months of screening according to the American Diabetes Association criteria
Between 18 and 45 years of age
Positive test for Epstein-Barr antibody
Positive test for at least one of the following antibodies:
- ICA512-antibody
- ICA
- GAD65-antibody
- Insulin (if assessed within 10 days of the onset of insulin therapy)
- ZnT8
Peak C-peptide >0.1 pmol/ml (>0.3 ng/ml) during MMTT challenge
Adequate venous access to support draw of 400 ml whole blood and infusion of investigational therapy

Exclusion Criteria:

Hemoglobin <10.0 g/dL; leukocytes <3,000/µL; neutrophils <1,500/µL; lymphocytes <800/µL; platelets <100,000/µL
Regulatory T cells present in peripheral blood at <10 per µl as determined by flow cytometry
Serologic evidence of HIV-1 or HIV-2 infection
Evidence of current hepatitis B as demonstrated by HBsAg or circulating hepatitis B genomes
Serologic evidence of hepatitis C infection
Detectable circulating EBV or CMV genomes or active infection
Positive PPD skin test defined as greater than or equal to 10 mm induration
Chronic use of systemic glucocorticoids or other immunosuppressive agents, or biologic immunomodulators within 6 months prior to study entry. Specifically, subjects who have received over 7 days of treatment with 7.5mg of prednisone (or the equivalent) within 6 months prior to study entry will be excluded.
History of malignancy ( including squamous cell carcinoma of the skin or cervix) except adequately treated basal cell carcinoma
Any chronic illness or prior treatment which in the opinion of the investigator should preclude participation in the trial
Pregnant or breastfeeding women, any female who is unwilling to use a reliable and effective form of contraception for 2 years afer Treg dosing and any male who is unwilling to use a reliable and effective form of contraception for 3 months after Treg dosing.

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT01210664

Contacts

Contact: Kathleen Fraser	415-353-9084	kfraser@diabetes.ucsf.edu
Contact: Christine Torok		TorokC@peds.ucsf.edu

Locations

United States, California
University of California, San Francisco Medical Center	Recruiting
San Francisco, California, United States, 94143
Principal Investigator: Stephen E Gitelman, MD
United States, Connecticut
Yale University	Recruiting
New Haven, Connecticut, United States, 06519
Contact: Linda Rink linda.rink@yale.edu
Principal Investigator: Kevan Herold, MD

Sponsors and Collaborators

University of California, San Francisco

Juvenile Diabetes Research Foundation

National Institute of Allergy and Infectious Diseases (NIAID)

Investigators

Study Chair:	Stephen E Gitelman, MD	University of California, San Francisco
Study Director:	Jeffrey Bluestone, PhD	University of California, San Francisco
Principal Investigator:	Kevan Herold, MD	Yale University

More Information

Publications:

Chatenoud L, Bluestone JA. CD3-specific antibodies: a portal to the treatment of autoimmunity. Nat Rev Immunol. 2007 Aug;7(8):622-32. Epub 2007 Jul 20. Review.

Saudek F, Havrdova T, Boucek P, Karasova L, Novota P, Skibova J. Polyclonal anti-T-cell therapy for type 1 diabetes mellitus of recent onset. Rev Diabet Stud. 2004 Summer;1(2):80-8. Epub 2004 Aug 10.

Couri CE, Oliveira MC, Stracieri AB, Moraes DA, Pieroni F, Barros GM, Madeira MI, Malmegrim KC, Foss-Freitas MC, Simões BP, Martinez EZ, Foss MC, Burt RK, Voltarelli JC. C-peptide levels and insulin independence following autologous nonmyeloablative hematopoietic stem cell transplantation in newly diagnosed type 1 diabetes mellitus. JAMA. 2009 Apr 15;301(15):1573-9.

Tang Q, Bluestone JA. Regulatory T-cell physiology and application to treat autoimmunity. Immunol Rev. 2006 Aug;212:217-37. Review.

Tang Q, Henriksen KJ, Bi M, Finger EB, Szot G, Ye J, Masteller EL, McDevitt H, Bonyhadi M, Bluestone JA. In vitro-expanded antigen-specific regulatory T cells suppress autoimmune diabetes. J Exp Med. 2004 Jun 7;199(11):1455-65.

Liu W, Putnam AL, Xu-Yu Z, Szot GL, Lee MR, Zhu S, Gottlieb PA, Kapranov P, Gingeras TR, Fazekas de St Groth B, Clayberger C, Soper DM, Ziegler SF, Bluestone JA. CD127 expression inversely correlates with FoxP3 and suppressive function of human CD4+ T reg cells. J Exp Med. 2006 Jul 10;203(7):1701-11. Epub 2006 Jul 3.

Putnam AL, Brusko TM, Lee MR, Liu W, Szot GL, Ghosh T, Atkinson MA, Bluestone JA. Expansion of human regulatory T-cells from patients with type 1 diabetes. Diabetes. 2009 Mar;58(3):652-62. Epub 2008 Dec 15.

Levine BL. T lymphocyte engineering ex vivo for cancer and infectious disease. Expert Opin Biol Ther. 2008 Apr;8(4):475-89. Review.

Rapoport AP, Stadtmauer EA, Aqui N, Vogl D, Chew A, Fang HB, Janofsky S, Yager K, Veloso E, Zheng Z, Milliron T, Westphal S, Cotte J, Huynh H, Cannon A, Yanovich S, Akpek G, Tan M, Virts K, Ruehle K, Harris C, Philip S, Vonderheide RH, Levine BL, June CH. Rapid immune recovery and graft-versus-host disease-like engraftment syndrome following adoptive transfer of Costimulated autologous T cells. Clin Cancer Res. 2009 Jul 1;15(13):4499-507. Epub 2009 Jun 9.

Levine BL, Bernstein WB, Aronson NE, Schlienger K, Cotte J, Perfetto S, Humphries MJ, Ratto-Kim S, Birx DL, Steffens C, Landay A, Carroll RG, June CH. Adoptive transfer of costimulated CD4+ T cells induces expansion of peripheral T cells and decreased CCR5 expression in HIV infection. Nat Med. 2002 Jan;8(1):47-53.

Miao D, Yu L, Eisenbarth GS. Role of autoantibodies in type 1 diabetes. Front Biosci. 2007 Jan 1;12:1889-98. Review.

Wenzlau JM, Juhl K, Yu L, Moua O, Sarkar SA, Gottlieb P, Rewers M, Eisenbarth GS, Jensen J, Davidson HW, Hutton JC. The cation efflux transporter ZnT8 (Slc30A8) is a major autoantigen in human type 1 diabetes. Proc Natl Acad Sci U S A. 2007 Oct 23;104(43):17040-5. Epub 2007 Oct 17.

Responsible Party:	University of California, San Francisco
ClinicalTrials.gov Identifier:	NCT01210664 History of Changes
Other Study ID Numbers:	UCSFDC411AI, JDRF4-2005-1168
Study First Received:	September 23, 2010
Last Updated:	November 16, 2012
Health Authority:	United States: Food and Drug Administration United States: Institutional Review Board

Keywords provided by University of California, San Francisco:

Diabetes
Treg

Additional relevant MeSH terms:

Diabetes Mellitus
Diabetes Mellitus, Type 1
Glucose Metabolism Disorders
Metabolic Diseases

Endocrine System Diseases
Autoimmune Diseases
Immune System Diseases

ClinicalTrials.gov processed this record on May 16, 2013