Dupilumab suppresses type 2 inflammatory biomarkers across multiple atopic, allergic diseases

Abstract Background Type 2 inflammation is common in numerous atopic/allergic diseases and can be identified by elevated biomarker levels. Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin‐4 and interleukin‐13, key and central drivers of type 2 inflammation. Objective Assessment of dupilumab effect on type 2 inflammatory biomarkers in atopic dermatitis (AD), asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) and eosinophilic esophagitis (EoE). Methods Data were extracted from three randomized placebo‐controlled trials of dupilumab in AD (NCT02277743, N = 671; NCT02277769, N = 708; NCT02260986, N = 740); and one each in asthma (NCT02414854, N = 1902); CRSwNP (NCT02898454, N = 448); and EoE (NCT02379052, N = 47). Biomarkers assessed were serum thymus and activation‐regulated chemokine (TARC), plasma eotaxin‐3, serum total immunoglobulin E (IgE), serum periostin and blood eosinophil count. Results Dupilumab versus placebo significantly suppressed most type 2 inflammatory biomarker levels across all studies/indications where data were assessed. Reductions in serum TARC, plasma eotaxin‐3 and serum periostin occurred rapidly, whereas reductions in serum total IgE were more gradual. Across diseases, at the end of treatment, median percentage change from baseline in TARC levels ranged from −24.8% to −88.6% (placebo +2.6% to −53.6%); −38.2% to −51.5% (placebo +8.3% to −0.16%) in eotaxin‐3; −24.8% to −76.7% (placebo +8.3% to −4.4%) in total IgE; and −13.6% to −41.1% (placebo +10.1% to −6.94%) in periostin levels. Blood eosinophil responses to dupilumab varied by disease, with minimal changes in AD in the SOLO studies (median percentage change from baseline to end of treatment: 0% [95% CI: −15.8, 0]); transient increases followed by decreases to below‐baseline levels in asthma (−14.6% [−20.0, −7.7]) and CRSwNP (−29.4% [−40.0, −16.3]); and significant decreases in EoE (−50.0% [−50.0, −33.3]). Conclusion and clinical relevance Dupilumab reduced levels of type 2 biomarkers across clinical studies in patients with AD, asthma, CRSwNP and EoE.


| INTRODUC TI ON
are known to be regulated by IL-4 and/or IL-13 and are associated with various pathological features of type 2 inflammatory diseases.
TARC and eotaxin-3 are key chemokines for attracting inflammatory cells into the target tissue, including Th2 lymphocytes and eosinophils. [5][6][7] Periostin is an extracellular matrix protein associated with activated fibroblasts, thought to play a role in the tissue remodelling and fibrosis observed in atopic diseases. 8  with either IL-2Ryc or IL13Ra1 in heterodimeric receptors. Binding of the complex to type yc chain forms type I receptors, common in lymphocytes, whereas both IL-4 and IL-13 bind the shared type II receptor complex, containing IL13Ra1. 9 Activation of Janus kinases results in generation of phosphorylated STAT6 which in turn up-regulates genes that govern production of mediators of inflammation. Since the distribution of type I and II receptor expression varies among cells types, IL-4/IL-13 have differential effects in tissues. IL-4 is also required for immunoglobulin isotype switching to IgE, a key downstream mediator in the type 2 adaptive immune response. 10 Nitric oxide, a ubiquitous messenger molecule, is also a key inflammatory mediator in the respiratory tract whose production is partly regulated by IL-13. Nitric oxide is produced by several cell types, including epithelial cells, mast cells, macrophages, neutrophils and vascular endothelial cells. 11 Eosinophils are pro-inflammatory leukocytes recruited from the bloodstream to inflammation sites by IL-5 and the eotaxin family of chemokines. 5 Eosinophilia and IgE production are hallmarks of type 2 inflammation in asthma, AD and CRSwNP, 1,10 and type 2 activation results in eosinophilia and other features of EoE. 12 Dupilumab, a fully human monoclonal antibody, 13

| Statistical analysis
Consistent with previous analyses, biomarker levels were analysed using the observed values with censoring after rescue treatment use for CHRONOS, SOLO-1, SOLO-2 and PoC safety populations; observed treatment values without censoring in the SINUS-52-

| Patients
Appendix S1 summarizes baseline demographics and comorbid type 2 inflammatory diseases in all studies. Individual study treatment groups had similar baseline demographics and disease characteristics.  .0552 .0174 .0552 .0282 Note: Grey cells indicate that data were not collected or available for these patients.

| Serum TARC
Treatment with dupilumab was associated with sustained reductions in median serum levels of TARC (Table 1 and Figure 2) in all four diseases. In AD patients, rapid, significant reductions versus placebo were evident from week 2, with maximum effects observed at week 8, and maintained until the last assessment at week 52 or 16.

| Serum total IgE
Dupilumab versus placebo significantly reduced concentrations of serum total IgE in AD, asthma, CRSwNP and EoE during treatment; however, across all type 2 diseases, the effect was more gradual than with the other type 2 biomarkers (Table 1 and Figure 4). In

| Serum periostin
In patients with asthma, CRSwNP and EoE, dupilumab treatment was associated with rapid, sustained reductions in serum levels of periostin versus placebo. Significant reductions versus placebo were evident from the earliest assessment (week 2 or 4), with the maximum effect observed at week 52 (

| Blood eosinophils
In dupilumab-treated patients with asthma and CRSwNP, transient elevations in blood eosinophils were observed in a subset of patients (median percentage change from baseline), followed by a decrease to near-baseline levels by the end of treatment (Table 1 and All of the patient populations included in these studies had moderate-to-severe disease. As previously reported, 26 AD is

F I G U R E 4
The effect of dupilumab on concentrations of serum total IgE (IU/mL). *p < .05; **p < .01, ***p < .001 vs matched placebo. P-values represent differences between dupilumab and placebo in change from baseline (A and C) or percentage change from baseline (B and D) and were analysed using a rank ANCOVA model. CHRONOS, SOLO-1 and SOLO-2 included the corresponding baseline values as covariates and the treatment, geographic region, baseline IGA strata and study identifier as fixed factors. EoE PoC included the corresponding baseline values as covariates and the treatment, baseline SDI strata and study identifier as fixed factors. QUEST included the corresponding baseline value, age, sex, geographic region (pooled country), baseline eosinophil strata and baseline inhaled corticosteroid dose level as covariates. SINUS-52 included the corresponding baseline value, age, geographic region (pooled country), asthma/NSAID-ERD status and prior surgery history as covariates. AD, atopic dermatitis; CI, confidence interval; CRSwNP, chronic rhinosinusitis with nasal polyps; EoE, eosinophilic esophagitis; NSAID-ERD, nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease; PoC, proof of concept; qw, weekly; q2w, every 2 weeks; SDI, Straumann Dysphagia Instrument

AD patients from CHRONOS
Placebo qw Dupilumab 300 mg q2w

EoE patients from EoE PoC
Placebo qw Dupilumab 300 qw

EoE patients from EoE PoC
Placebo qw Dupilumab 300 qw

CRSwNP patients from SINUS-52
Placebo q2w Dupilumab 300 mg q2w allergens, and present the processed allergens to T cells, resulting in local T cell activation. 38  Week There is increasing evidence that nitric oxide plays a key role in modulating type 2 inflammation and in regulating type 2 immune responses, as an endogenous modulator of airway function and as a proinflammatory and immunomodulatory mediator. 11,45 In the context of asthma, the inflammatory response results in increased symptoms and airway obstruction. 11,46 Increased levels of exhaled nitric oxide in asthma are often associated with airway eosinophilic inflammation and may also be associated with exacerbations and disease severity. 11 As previously published, dupilumab was associated with greater reductions in FeNO levels over the course of the treatment period in QUEST, compared with placebo. 22 Further, we have also previously reported a significant correlation between suppression of FeNO and improvement in FEV 1 in dupilumab asthma trials. 47 The data on type 2 inflammation suppression and efficacy of dupilumab observed in the indications tested to date demonstrate that the common underlying pathological mechanism in these diseases is mediated by IL-4 and IL-13, and that suppression of inflammatory mediators by dual blockade of these cytokines and their downstream pathways consequently reduces disease activity.
Significant improvements have been observed in lung function and exacerbation rates in asthma; 22,42 signs and symptoms of AD; [19][20][21] sinonasal outcomes in CRSwNP; 23  Control of type 2 inflammation, as evidenced by reduced biomarkers observed in this study together with the observed clinical efficacy of dupilumab across the diseases studied and additional transcriptome analysis, 25,57 indicates that dupilumab is acting on the underlying disease pathogeneses and by reducing inflammation. The reduction in the type 2 mediators measured and described in this study also contribute to the improvement of barrier mucosal and epithelial function to a healthier phenotype, including direct effects suppressing epithelial or epidermal hyperproliferation seen in these diseases. 30,32 For example, reducing IgE in patients with asthma may restore the antiviral functions of plasmacytoid dendritic cells, thus reducing the risk of exacerbations. 3 By disrupting the inflammatory cycle, barrier function can be restored, reducing the exposure to causative agents and thus further reducing inflammation and release of pro-inflammatory cytokines. 58 The consistent modulation of type 2 biomarkers with dupilumab treatment seen in these studies highlights the shared aetiology of type 2 inflammation in these diseases driven by IL-4 and IL-13.

| CON CLUS IONS
Dupilumab consistently and significantly reduced most type 2 inflammatory biomarkers in patients with AD, asthma, CRSwNP and EoE. The data support the hypothesis that IL-4 and IL-13 are key and central drivers of type 2 inflammation across numerous type 2 inflammatory diseases. Added to other clinical and preclinical evidence, the findings demonstrate dupilumab inhibits a common pathophysiological mechanism fundamental to type 2 inflammatory diseases.

ACK N OWLED G EM ENTS
We thank the participating investigators of the phase 3 LIBERTY

E TH I C A L S TATEM ENT
All studies were conducted in accordance with the Declaration of Helsinki and the International Conference on Harmonization's good clinical practice guideline. All study documents and procedures were approved by institutional review board/ethics committees at each study site. All patients provided written informed consent before participating in the study.

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