The Amino Acid Valine Helps Maintain Hematopoietic Stem Cell Niches


Hematopoietic stem cells (HSCs) populate our bone marrow and divide throughout our lifetimes to provide the red and white blood cells we need to live. However, during normal, healthy times, only particular HSCs are hard at work dividing and making new blood cells. The remaining HSCs are maintained in a protective dormant state. However, in response to blood loss or physiological stress of some sort, dormant HSCs must wake from their “slumbers” and begin dividing to make the needed blood cells. Such conditions, it turns out, can cause HSCs to experience a good deal of damage to their genomes. A paper that was published in Nature last year by Walter Dagmar and colleagues (Vol 520: pp. 549) showed that repeatedly subjecting mice to conditions that required the activation of dormant HSCs (in this case they injected the mice with polyinosinic:polycytidylic acid or pI:pC to mimic a viral infection and induce a type I interferon response) resulted in the eventual collapse of the bone marrow’s ability to produce new blood cells. The awakened HSCs accumulated such large quantities of DNA damage, that they were no longer able to divide and produce viable progeny. How then can HSCs maintain the integrity of their genomes while still dividing and making new blood cells?

The answer to this question is not completely clear, but a new paper in the December 2 edition of Science magazine provides new insights into HSC physiology and function. This paper by Yuki Taya and others, working in the laboratories of Hiromitsu Nakauchi at the Institute for Stem Cell Biology and Regenerative Medicine at Stanford University School of Medicine, and Satoshi Yamazaki from the University of Tokyo, has shown that amino acid metabolism plays a vital role in HSC maintenance. As it turns out, the amino acid concentrations in bone marrow are approximately 100-fold higher than the concentrations of these same amino acids in circulating blood. Taya and others reasoned that such high amino acid concentrations must exist for reasons other than protein synthesis. Therefore, they designed dietary regimens that depleted mice for specific amino acids. Sure enough, when mice were fed valine-depleted diets, the HSCs of those mice lost their ability to repopulate the bone marrow.

Valine
Valine

After only two weeks of valine depletion, several nooks and crannies of the bone marrow – so-called stem cell “niches” – were devoid of HSCs. The bone marrow of such mice was easily reconstituted with HSCs from donor mice without the need for radiation or chemical ablation treatments.

Taya and others found that vascular endothelial stromal cells in the bone marrow secrete valine and that this secreted valine (which, by the way, is a branched-chain amino acid) is integral for maintaining HSC niches.

The excitement surrounding this finding is plain, since using harsh chemicals or radiation to destroy the bone marrow (a procedure known as “myeloablation”) causes premature ageing, infertility, lousy overall health, and other rather unpleasant side effects. Therefore, finding a “kinder, gentler” way to reconstitute the bone marrow would certainly be welcomed by patients and their physicians. However, valine depletion, even though it does not affect sterility, did cause 50% of the mice to die once valine was restored to the diet. This is due to a phenomenon known as the “refeeding effect” which has also been observed in human patients. Such side effects could probably be prevented by gradually returning valine to the diet. Taya and others also showed that cultured human HSCs required valine and another branched-chain amino acid, leucine. Since both leucine and valine are metabolized to alpha-ketoglutatate, which is used as a substrate for DNA-modifying enzymes, these amino acids might exert their effects through epigenetic modifications to the genome.

Alpha-ketoglutarate
Alpha-ketoglutarate

More work is needed in this area, but the Taya paper is a welcomed finding to a vitally important field.

Advertisements

Inhibition of AKT Kinase Increases Umbilical Cord Blood Growth in Culture and Engraftment in Mice


Dr. Yan Liu from the Department of Pediatrics and the Herman B Wells Center for Pediatric Research at the Indiana University School of Medicine in Indianapolis, Indiana and his colleagues have increased the engraftment efficiency of umbilical cord hematopoietic (blood cell-making) stem cells in immunodeficient mice. The technique developed by Lui and his colleagues is simple and increases the proliferation of umbilical cord blood hematopoietic stem cells (UCB-HSCs) in culture, which potentially solves several long-standing problems with umbilical cord blood transplantation.

Umbilical cord blood has been used in the clinic for more than 40 years in hematopoietic stem cell transplantation therapies to treat patients with bone marrow diseases or to reconstitute the bone of those cancer patients who had to have theirs wiped out to cure their leukemia or lymphoma.

One of the problems with umbilical cord blood transplantations, however, is the small amount of material in a typical cord blood collection and, therefore, the small number of hematopoietic stem cells (HSCs) available for transplantation. To ameliorate these shortcomings, hematologists will transplant more than one lot of cord blood (a so-called “double umbilical cord blood transplantation”), which, unfortunately, also increases the risk of immunological rejection (so-called Graft Versus Host response).

A second strategy to get around the low numbers of UCB-HSCs is to expand them in culture, which has proven difficult. However, some experiments have given us more than enough hope to suspect this this is a feasible option (see Flores-Guzmán P, et al., Stem Cells Transl Med. 2013 Nov;2(11):830-8; Bari S., et al., Biol Blood Marrow Transplant. 2015 Jun;21(6):1008-1; Pineault N, Abu-Khader A. Exp Hematol. 2015 Jul;43(7):498-513).

Dr. Lui and his coworkers wanted to examine the role of the signaling protein AKT (also known and protein kinase B) in UCB-HSC expansion in culture. To this end, they used silencing RNAs to knock-down AKT gene expression in cultured UCB-HSCs. AKT knock-down enhanced UCB-HSC quiescence and growth in culture. In a separate experiment, Lui and others treated human UCB-HSCs (so-called CD34+ cells) with a chemical that specifically inhibits AKT activity. Then they subjected these cells to a battery of tests in culture and in laboratory mice.

The results were astounding.  Treatment of human UCB-HSCs did not affect the identity of the HSCs and enhanced their ability to form isolated colonies in cell culture growth tests known as “replating assays.”  Additionally, the short-term inhibition of AKT with drugs also enhanced the ability of UBC-HSCs to repopulate the bone marrow of immunodeficient mice.

ubc-hsc-engraftment-improved-with-akt-inhibition

In summary, inhibition of AKT increases human UCB-HSC quiescence, growth potential, and engraftment in laboratory mice.

These interesting pre-clinical results suggest that AKT inhibitor can increase the expansion of UCB-HSCs in culture and potential increase their tendency of these cells to engraft in patients.

Gamida Cell Announces First Patient with Sickle Cell Disease Transplanted in Phase 1/2 Study of CordIn™ as the Sole Graft Source


An Israeli regenerative therapy company called Gamida Cell specializes in cellular and immune therapies to treat cancer and rare (“orphan”) genetic diseases. Gamida Cell’s main product is called NiCord, which provides patients who need new blood-making stem cells in their bone marrow an alternative to a bone marrow transplant. NiCord is umbilical cord blood that has been expanded in culture. In clinical trials to date, NiCord has rapidly engrafted into patients and the clinical outcomes of NiCord transplantation seem to be comparable to transplantation of peripheral blood.

Gamida Cell’s two products, NiCord and CordIn, as well as some other products under development utilize the company’s proprietary NAM platform technology to expand umbilical cord cells. The NAM platform technology has the remarkable capacity to preserve and enhance the functionality of hematopoietic stem cells from umbilical cord blood. CordIn is an experimental therapy for those rare non-malignant diseases in which bone marrow transplantation is the only currently available cure.

Gamida Cell has recently announced that the first patient with sickle cell disease (SCD) has been transplanted with their CordIn product.  Mark Walters, MD, Director of the Blood and Marrow Transplantation (BMT) Program is the Principal Investigator of this clinical trial. The patient received their transplant at UCSF Benioff Children’s Hospital Oakland.

CordIn, as previously mentioned, is an experimental therapy for rare non-malignant diseases, including hemoglobinopathies such as Sickel Cell Disease and thalassemia, bone marrow failure syndromes such as aplastic anemia, genetic metabolic diseases and refractory autoimmune diseases. CordIn potentially addresses a presently unmet medical need.

“The successful enrollment and transplantation of our first SCD patient with CordIn as a single graft marks an important milestone in our clinical development program. We are eager to demonstrate the potential of CordIn as a transplantation solution to cure SCD and to broaden accessibility to patients with rare genetic diseases in need of bone marrow transplantation,” said Gamida Cell CEO Dr. Yael Margolin. “In the first Phase 1/2 study with SCD, the expanded graft was transplanted along with a non-manipulated umbilical cord blood unit in a double graft configuration. In the second phase 1/2 study we updated the protocol from our first Phase 1/2 study so that patients would be transplanted with CordIn as a standalone graft, which is expanded from one full umbilical cord blood unit and enriched with stem cells using the company’s proprietary NAM technology.”

Somewhere in the vicinity of 100,000 patients in the U.S suffer from SCD; and around 200,000 patients suffer from thalassemia, globally. The financial burden of treating these patients over their lifetime is estimated at $8-9M. Bone marrow transplantation is the only clinically established cure for SCD, but only a few hundred SCD patients have actually received a bone marrow transplant in the last ten years, since most patients were not successful in finding a suitable match. Unrelated cord blood could be available for most of the patients eligible for transplantation, but, unfortunately, the rate of successful engraftment of un-expanded cord blood in these patients is low. Therefore, cord blood is usually not considered for SCD patients. Without a transplant, these patients suffer from very high morbidity and low quality of life.

Eight patients with SCD were transplanted in the first Phase 1/2 study performed in a double graft configuration. This study is still ongoing. Preliminary data from the first study will be summarized and published later this year. A Phase 1/2 of CordIn for the treatment of patients with aplastic anemia will commence later this year.

Genetic Switch to Making More Blood-Making Stem Cells Found


A coalition of stem cell scientists, co-led in Canada by Dr. John Dick, Senior Scientist, Princess Margaret Cancer Centre, University Health Network (UHN) and Professor, Department of Molecular Genetics, University of Toronto, and in the Netherlands by Dr. Gerald de Haan, Scientific Co-Director, European Institute for the Biology of Ageing, University Medical Centre Groningen, the Netherlands, have uncovered a genetic switch that can potentially increase the supply of stem cells for cancer patients who need transplantation therapy to fight their disease.

Their findings were published in the journal Cell Stem Cell and constitute proof-of-concept experiments that may provide a viable new approach to making more stem cells from umbilical cord blood.

“Stem cells are rare in cord blood and often there are not enough present in a typical collection to be useful for human transplantation. The goal is to find ways to make more of them and enable more patients to make use of blood stem cell therapy,” says Dr. Dick. “Our discovery shows a method that could be harnessed over the long-term into a clinical therapy and we could take advantage of cord blood being collected in various public banks that are now growing across the country.”

Currently, all patients who require stem cell transplants must be matched to an adult donor. The donor and the recipient must share a common set of cell surface proteins called “human leukocyte antigens” HLAs. HLAs are found on the surfaces of all nucleated cells in our bodies and these proteins are encoded by a cluster of genes called the “Major Histocompatibility Complex,” (MHC) which is found on chromosome six.

Map of MHC

There are two main types of MHC genes: Class I and Class II.

MHC Functions

Class I MHC contains three genes (HLA-A, B, and C). The three proteins encoded by these genes, HLA-A, -B, & -C, are found on the surfaces of almost all cells in our bodies. The exceptions are red blood cells and platelets, which do not have nuclei. Class II MHC genes consist of HLA-DR, DQ, and DP, and the proteins encoded by these genes are exclusive found on the surfaces of immune cells called “antigen-presenting cells” (includes macrophages, dendritic cells and B cells). Antigen-presenting cells recognize foreign substances in our bodies, grab them and, if you will, hold them up for everyone to see. The cells that usually respond to antigen presentation are immune cells called “T-cells.” T-cells are equipped with an antigen receptor that only binds antigens when those antigens are complexed with HLA proteins.

If you are given cells from another person who is genetically distinct from you, the HLA proteins on the surfaces of those cells are recognized by antigen-presenting cells as foreign substances. The antigen-presenting cells will them present pieces of the foreign HLA proteins on their surfaces, and T-cells will be sensitized to those proteins. These T-cells will them attack and destroy any cells in your body that have those foreign HLA proteins. This is the basis of transplant rejection and is the main reason transplant patients must continue to take drugs that prevent their T-cells from recognizing foreign HLA proteins as foreign.

When it comes to bone marrow transplantations, patients can almost never find a donor whose HLA surface proteins match perfectly. However, if the HLA proteins of the donor are too different from those of the recipient, then the cells from the bone marrow transplant attack the recipient’s cells and destroy them. This is called “Graft versus Host Disease” (GVHD). The inability of leukemia and lymphoma and other patients to receive bone marrow transplants is the unavailability of matching bone marrow. Globally, many thousands of patients are unable to get stem cell transplants needed to combat blood cancers such as leukemia because there is no donor match.

“About 40,000 people receive stem cell transplants each year, but that represents only about one-third of the patients who require this therapy,” says Dr. Dick. “That’s why there is a big push in research to explore cord blood as a source because it is readily available and increases the opportunity to find tissue matches. The key is to expand stem cells from cord blood to make many more samples available to meet this need. And we’re making progress.”

Umbilical cord blood, however, is different from adult bone marrow. The cells in umbilical cord blood are more immature and not nearly as likely to generate GVHD. Therefore, less perfect HLA matches can be used to treat patients in need of a bone marrow transplant. Unfortunately, umbilical cord blood has the drawback of have far fewer stem cells than adult bone marrow. If the number of blood-making (hematopoietic) stem cells in umbilical cord blood can be increased, then umbilical cord blood would become even more useful from a clinical perspective.

There has been a good deal of research into expanding the number of stem cells present in cord blood, the Dick/de Haan teams took a different approach. When a stem cell divides it produces a large number of “progenitor cells” that retain key properties of being able to develop into every one of the 10 mature blood cell types. These progenitor cells, however, have lost the critical ability to self-renew.

Dick and his colleagues analyzed mouse and human models of blood development, and they discovered that a microRNA called miR-125a is a genetic switch that is on in stem cells and controls self-renewal, but gets turned off in the progenitor cells.

“Our work shows that if we artificially throw the switch on in those downstream cells, we can endow them with stemness and they basically become stem cells and can be maintained over the long-term,” says Dr. Dick.

In their paper, Dick and de Haan showed that forced expression of miR-125 increases the number of hematopoietic stem cells in a living animal. Also, miR-125 induces stem cell potential in murine and human progenitor cells, and represses, among others, targets of the MAP kinase signaling pathway, which is important in differentiation of cells away from the stem cell fate. Furthermore, since miR-125 function and targets are conserved in human and mouse, what works in mice might very well work in human patients.

graphical abstract CSC_v9

This is proof-of-concept paper – no human trials have been conducted to date, but these data may be the beginnings of making more stem cells from banked cord blood to cure a variety of blood-based conditions.

Here’s to hoping.

Autologous Stem Cell Transplantation With Complete Ablation of Bone Marrow Delays Progression of Multiple Sclerosis in Small Phase 2 Trial


Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system. Around 2 million people, worldwide, suffer from MS. MS results from the patient’s immune system attacking the myelin sheath that surrounds nerve axons. These constant and relentless attacks upon the myelin sheath causes “demyelination,” resulting in loss of the sensory and motor function.

Treatment usually required the use of drugs that suppress the immune response. Some of these drugs work better than others, while other patients have forms of MS that do not respond to common MS treatment.

A new report published in the Lancet, has shown that chemotherapy followed by autologous hematopoietic stem cell transplantation (aHSCT) can completely halt clinical relapses of MS and prevent the development of new brain lesions in 23 of 24 MS patients. Patients who participated in this study experienced a prolonged period without the need for ongoing medication. Eight of the 23 patients had a sustained improvement in their disability 7.5 years after treatment. This is the first treatment to produce this level of disease control or neurological recovery from MS, but, unfortunately, treatment related risks limit its widespread use.

There are a few specialist centers that offer MS patients aHSCT. This treatment involves harvesting bone marrow stem cells from the patient, and then employing chemotherapy to suppress the patient’s immune system and essentially partially wipe it out. The isolated bone marrow is then reintroduced into the blood stream to “reset” the immune system and stop it attacking the body. However, a respectable percentage of MS patients relapse after these treatments. Therefore, these treatments must be refined and tweaked to improve their efficacy.

Drs Harold L Atkins and Mark S Freedman from The Ottawa Hospital and the University of Ottawa, Ottawa, Canada, respectively, and their colleagues, tested if complete destruction, rather than suppression, of the immune system during aHSCT could reduce the relapse rate in patients and increase the long-term rates of disease remission. They enrolled 24 patients aged 18-50 from three Canadian hospitals. All of these subjects had previously undergone standard immunosuppressive therapy, but these treatments had failed to control their MS. These patients all had poor prognosis and their disability ranged from moderate to requiring a walking aid to walk 100 meters (according to their Expanded Disability Status Scale or EDSS score).

Adkins and Freeman and their coworkers used a chemotherapy regimen of busulfan, cyclophosphamide and rabbit anti-thymocyte globulin to wipe out the patient’s bone marrow. Atkins explained that this treatment is “similar to that used in other trials, except our protocol uses stronger chemotherapy and removes immune cells from the stem cell graft product. The chemotherapy we use is very effective at crossing the blood-brain barrier and this could help eliminate the damaging immune cells from the central nervous system.” After being treated with chemotherapy regimen, the patients’ bone marrow was reconstituted with their previously isolated bone marrow.

This study’s primary outcome was activity-free survival at 3 years, using EDSS scores as the means of measuring MS progression, in addition to scanning for brain lesions, and assessing MS symptoms.

Of the 24 patients enrolled, one (4%) died from liver failure and sepsis caused by the chemotherapy. In the 23 surviving patients, prior to treatment, patients experienced 1.2 relapses per year on average, but after aHSCT, no relapses occurred during the follow-up period (between 4 and 13 years). These clinical outcomes were nicely complemented by an absence of newly detected brain lesions (as assessed by MRI images taken after the treatment). Initially, 24 MRI scans of the brains of all 24 subjects revealed 93 brain lesions, and after the treatment only one of the 327 scans showed a new lesion.

Despite the exciting success of this clinical trial, Freedman emphasized the need to interpret these results with caution: “The sample size of 24 patients is very small, and no control group was used for comparison with the treatment group. Larger clinical trials will be important to confirm these results. Since this is an aggressive treatment, the potential benefits should be weighed against the risks of serious complications associated with aHSCT, and this treatment should only be offered in specialist centers experienced both in multiple sclerosis treatment and stem cell therapy, or as part of a clinical trial. Future research will be directed at reducing the risks of this treatment as well as understanding which patients would best benefit from the treatment.”

Dr Jan Dörr, from the NeuroCure Clinical Research Center, Charité-Universitätsmedizin, Berlin, Germany, made this comment about this clinical trial: “These results are impressive and seem to outbalance any other available treatment for multiple sclerosis. This trial is the first to show complete suppression of any inflammatory disease activity in every patient for a long period…However, aHSCT has a poor safety profile, especially with regards to treatment-related mortality.”

He added: “So, will this study change our approach to treatment of multiple sclerosis? Probably not in the short-term, mainly because the mortality rate will still be considered unacceptably high. Over the longer term (and) in view of the increasing popularity of using early aggressive treatment, there may be support for considering aHSCT less as a rescue therapy and more as a general treatment option, provided the different protocols are harmonized and optimized, the tolerability and safety profile can be further improved, and prognostic markers become available to identify patients at risk of poor prognosis in whom a potentially more hazardous treatment might be justified.”

Mesoblast Limited Scales Down Phase 3 Trial


Mesoblast Limited announced that the number of subjects treated in their ongoing Phase 3 clinical trial in chronic heart failure (CHF) that is testing their proprietary cell-based medicine MPC-150-IM will be substantially reduced.

CHF is characterized by an enlarged heart, coupled with insufficient blood supply to the organs and extremities of the body. Unfortunately, this is a progressing condition that tends to get worse with time. CHF is caused by many different factors such as chronic high blood pressure, faulty heart valves, infections, or congenital heart problems.

Mesoblast centers their company around the isolation and expansion of so-called mesenchymal precursor cells (MPCs) from bone marrow.  Mesenchymal stem cells are found in many different tissues and organs throughout our bodies.  They play vital roles in maintaining tissue health.  However, relatively speaking, mesenchymal stem cells are rare cells.  They are found around blood vessels and respond to signals associated with tissue damage.  They secrete mediators and growth factors that promote tissue repair and control the immune response to prevent it from going out of control.

Mesoblast uses an array of monoclonal antibodies to isolate primitive mesenchymal stem cells that are actually precursors to mesenchymal stem cells or mesenchymal precursor cells (MPCs).  These cells are then expanded in culture without being differentiated into any other cell type.

Mesoblasts, MPC-150-IM product consists of 150 million MPCs that are injected straight into the heart muscle (hence the moniker, “IM” for intramuscular).  Once in the heart muscle, the MPCs induce the formation of new blood vessels to feed the heart muscle, stimulate resident stem cell populations in the heart to repair the heart muscle, and quell inflammation that can cause scarring and decrease heart function (see Yanping Cheng, et al., Cell Transplantation 22(12): 2299-2309; Jaco H. Houtgraaf, Circulation Research. 2013; 113: 153-166). 

Initially, Mesoblast planned to test their product on 1,165 subjects, but have scaled that number back to approximately 600 patients.

Mesoblast’s development and commercial partner, Teva Pharmacueticals has communicated this reduction in the number of subjects to the US Food and Drug Administration (USFDA). “The reduction in the size of the Phase 3 trial may significantly shorten the time to trial completion,” said Mesoblast CEO Silviu Itescu.

The reduction in the number of patients was due to a proposed change in the primary endpoint of the trial. The revised primary endpoint is now a comparison of recurrent heart failure-related major adverse cardiovascular events (HF-MACE) between patients treated with Mesoblast’s MPC-150-IM cells and the control patients who were not treated with these cells.

Why the change in the primary endpoint? The reason lies in the success that MPC-150-IM cells had their Phase 2 clinical trial. In this trial, a single injection of MPC-150-IM cells successfully prevented HF-MACE over three years. This second, confirmatory study will be conducted in parallel with a patient population that has an identical clinical profile; approximately 600 of them using the same primary endpoint.

In the completed Phase 2 trial, patients treated with MPC-150-IM had no HF-MACE over 36 months of follow-up, compared with 11 HF-MACE in the control group. From this same clinical trial, of those patients who suffered from advanced heart failure (defined by baseline Left Ventricular Systolic Volume being greater than 100 milliliters), 71 percent of the controls (who received no cells) had at least on HF-MACE versus none of those who received a single injection of MPC-150-IM cells. As it turns out, this Phase 2 patient population closely resemble the patients being recruited in the Phase 3 trial.

“Patients with advanced heart failure continue to represent among the largest unmet medical needs, where existing therapies are inadequate and the economic burden is the greatest. The current Phase 3 trial targets this patient population, continues to recruit well across North America, and is now expanding to Europe,” said Itescu.

ASTIC Clinical Trial Fails to Show Clear Advantage to Hematopoietic Stem Cell Transplantation as a Treatment for Crohn’s Disease


Patients with Crohn’s disease (CD) sometimes suffer from daily bouts of stomach pain and diarrhea. These constant gastrointestinal episodes can prevent them from absorbing enough nutrition to meet their needs, and, consequently, they can suffer from weakness, fatigue, and a general failure to flourish.

To treat Crohn’s disease, physicians use several different types of drugs. First there are the anti-inflammatory drugs, which include oral 5-aminosalicylates such as sulfasalazine (Azulfidine), which contains sulfur, and mesalamine (Asacol, Delzicol, Pentasa, Lialda, Apriso). These drugs, have several side effects, but on the whole are rather well tolerated. If these don’t work, then corticosteroids such as prednisone are used. These have a large number of side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and increased chance of infection.

If these don’t work, then the stronger immune system suppressors are brought out. These drugs have some very serious side effects. Azathioprine (Imuran) and mercaptopurine (Purinethol) are two of the most widely used of this group. If used long-term, these drugs can make the patient more susceptible to certain infections and cancers including lymphoma and skin cancer. They may also cause nausea and vomiting. Infliximab (Remicade), adalimumab (Humira) and certolizumab pegol (Cimzia) are the next line of immune system suppressors. These drugs are TNF inhibitors that neutralize an immune system protein known as tumor necrosis factor (TNF). These drugs are also associated with certain cancers, including lymphoma and skin cancers. The next line of drugs include Methotrexate (Rheumatrex), which is usually used to treat cancer, psoriasis and rheumatoid arthritis, but methotrexate also quells the symptoms of Crohn’s disease in patients who don’t respond well to other medications. Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause potentially life-threatening pneumonia. Long-term use can lead to bone marrow suppression, scarring of the liver and sometimes to cancer. You will need to be followed closely for side effects.

Then there are specialty medicines for patients who do not respond to other medicines or who suffer from openings in their lower large intestines to the outside world (fistulae). These include cyclosporine (Gengraf, Neoral, Sandimmune) and tacrolimus (Astagraf XL, Hecoria). These have the potential for serious side effects, such as kidney and liver damage, seizures, and fatal infections. These medications are definitely cannot be used for long period of time as their side effects are too dangerous.

If the patient still does not experience any relief, then two humanized mouse monoclonal antibodies natalizumab (Tysabri) and vedolizumab (Entyvio). Both of these drugs bind to and inhibit particular cell adhesion molecules called integrins, and in doing so prevent particular immune cells from binding to the cells in the intestinal lining. Natalizumab is associated with a rare but serious risk of a brain disease that usually leads to death or severe disability called progressive multifocal leukoencephalopathy. In fact, so serious are the side effects of this medicine that patients who take this drug must be enrolled in a special restricted distribution program. The other drug, vedolizumab, works in the same way as natalizumab but does not seem to cause this brain disease. Finally, a drug called Ustekinumab (Stelara) is usually used to treat psoriasis. Studies have shown it’s useful in treating Crohn’s disease and might useful when other medical treatments fail. Ustekinumab can increase the risk of contracting tuberculosis and an increased risk of certain types of cancer. Also there is a risk of posterior reversible encephalopathy syndrome. More common side effects include upper respiratory infection, headache, and tiredness.

If this litany of side effects sounds undesirable, then maybe a cell-based treatment can help Crohn’s patients. To that end, a clinical trial called the Autologous Stem Cell Transplantation International Crohn’s Disease or ASTIC trial was conducted and its results were published in the December 15th, 2015 edition of the Journal of the American Medical Association.

The ASTIC trial enrolled 45 Crohn’s disease patients, all of whom underwent stem cell mobilization with cyclophosphamide and filgrastim, and were then randomly assigned to immediate stem cell transplantation (at 1 month) or delayed transplantation (at 13 months; control group).  Blood samples were drawn and mobilized stem cells were isolated from the blood.  In twenty-three of these patients, their bone marrow was partially wiped out and reconstituted by means of transplantations with their own bone marrow stem cells. The other 22 patients were given standard Crohn disease treatment (corticosteroids and so on) as needed.

The bad news is that hematopoietic stem cell transplantations (HSCT) were not significantly better than conventional therapy at inducing sustained disease remission, if we define remission as the patient not needing any medical therapies (i.e. drugs) for at least 3 months and no clear evidence of active disease on endoscopy and GI imaging at one year after the start of the trial. All patients in this study had moderately to severely active Crohn’s disease that was resistant to treatment, had failed at least 3 immunosuppressive drugs, and whose disease that was not amenable to surgery.  All participants in this study had impaired function and quality of life.  Also, the stem cell transplantation procedure, because it involved partially wiping out the bone marrow, cause considerable toxicities.

Two patients who underwent HSCT (8.7%) experienced sustained disease remission compared to one control patient (4.5%). Fourteen patients undergoing HSCT (61%) compared to five control patients (23%) had discontinued immunosuppressive or biologic agents or corticosteroids for at least 3 months. Eight patients (34.8%) who had HSCTs compared to two (9.1%) patients treated with standard care regimens were free of the signs of active disease on endoscopy and radiology at final assessment.

However, there were 76 serious adverse events in patients undergoing HSCT compared to 38 in controls, and one patient undergoing HSCT died.

So increased toxicities and not really a clear benefit to it; those are the downsides of the ASCTIC study.  An earlier report of the ASTIC trial in 2013, while data was still being collected and analyzed was much more sanguine.  Christopher Hawkey, MD, from the University of Nottingham in the United Kingdom said this: “Some of the case reports are so dramatic that it’s reasonable to talk about this being a cure in those patients.”  These words came from a presentation given by Dr. Hawkey at Digestive Disease Week 2013.  Further analysis, however, apparently, failed to show a clear benefit to HSCT for the patients in this study.  It is entirely possible that some patients in this study did experience significant healing, but statistically, there was no clear difference between HSCT and conventional treatment for the patients in this study.

The silver lining in this study, however, is that compared to the control group, significantly more HSCT patients were able to stop taking all their immunosuppressive therapies for the three months prior to the primary endpoint. That is a potential upside to this study, but it is unlikely for most patients that this upside is worth the heightened risk of severe side effects. An additional potential upside to this trial is that patients who underwent HSCT showed greater absolute reduction of clinical and endoscopic disease activity. Again, it is doubtful if these potential benefits are worth the higher risks for most patients although it might be worth it for some patients.

Therefore, when HSCT was compared with conventional therapy, there was no statistically significant improvement in sustained disease remission at 1 year. Furthermore, HSCT was associated with significant toxicity. Overall, despite some potential upside to HSCT observed in this study, the authors, I think rightly, conclude that their data do not support the widespread use of HSCT for patients with refractory Crohn’s disease.

Could HSCT help some Crohn’s patients more than others? That is a very good question that will need far more work with defined patient populations to answer.  Perhaps further work will ferret out the benefits HSCT has for some Crohn’s disease patients relative to others.

The ASTIC trial was a collaborative project between the European Society for Blood and Marrow Transplantation (EBMT) and the European Crohn’s and Colitis Organization (ECCO) and was funded by the Broad Medical Foundation and the Nottingham Digestive Diseases Centers.