Posted online on September 3, 2012. Link to original blog: http://www.sciclips.com/sciclips/blogArticle.do?

id=1020&blog=Potential%20Use%20of%20Drug% 20Response-Efficacy%20Biomarkers%20for%20Predicting%20LifeThreatening%20Disease%20Causing%20Side%20Effects%20of%20Therapeutic%20Drugs

Potential Use of Drug Response-Efficacy Biomarkers for Predicting LifeThreatening Disease Causing Side Effects of Therapeutic Drugs
Drug response-efficacy biomarkers, excluding drug targets, can be used 1) for predicting the clinical outcome in patients, 2) for identifying responders and non-responders to specific drug therapy, 3) for selecting patients for alternative treatment methods, 4) for optimizing personalized drug treatment regimen (drug dose, drug treatment schedule etc.,) and 5) for predicting potential side effects, which are generally identified using specific biomarkers, for nephotoxicity, cardiotoxicity, or hepatoxicity, expressed in response to a specific drug treatment. Changes in the level of expression of these toxicity biomarkers are currently used for predicting potential side effects of therapeutic drugs. Drug response-efficacy biomarkers may also include surrogate biomarkers, surrogate endpoint biomarkers and certain pharmacodynamic biomarkers, which can also be used for predicting potential side effects of drugs, including disease causing side effects, in addition to its use in identifying pharmacological activity of drugs. Though drug response-efficacy biomarkers are powerful tool in differentiating responders from non-responders to a specific treatment and can be used for developing diagnostic tools for personalized therapy, the question remains that can these biomarkers give clues to future onset of drug therapy induced life-threatening diseases in patients? This question came from two major observations 1) for the same drug therapy distinct drug response-efficacy biomarkers have been identified in different patients and 2) there are conflicting reports on side effects of a specific drug therapy from different patient studies. If drug response-efficacy biomarkers can be used for predicting disease causing side effects of drug treatment, we might be able to develop smart biomarkers, which can reduce morbidity and mortality in patients, and can revolutionize the personalized medicine approaches. Intelligent data mining and comprehensive data analysis might provide valuable information that can be translated into meaningful predictive models. In this exploratory analysis, we took anti-TNF therapy response markers of rheumatoid arthritis (RA) as an example to demonstrate that drug response-efficacy biomarkers can be potentially used for predicting potential disease causing side effects of a specific drug treatment. Analysis using anti-TNF therapy response biomarkers in rheumatoid arthritis (RA) patients Integrin alpha-X (CD11c or ITGAX) expression in monocytes is a potential candidate biomarker for identifying the efficacy of anti-TNF therapy, as reported in adalimumab montherpay, in rheumatoid arthritis (RA) patients (1,2). Increased expression of CD11c was identified as a potential biomarker for selecting adalimumab therapy responders, CD11c biomarker was not associated with methotrexate (MTX) therapy alone or in combination with adalimumab (1). CD11c is largely expressed in monocytes and granulocytes where it is important in monocyte adhesion and chemotaxis, and is involved in cell-tocell interaction during inflammatory responses. Monocytes can differentiate into monocyte-derived dendritic cells (DCs) or inflammatory DCs (iDCs) upon upregulated expression of the CD11c together

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with MHC and co-stimulatory molecules under certain inflammatory conditions. (3). Based on our preliminary data extraction and data mining, we found several CD11c linked functional roles that are associated with diseases other than RA (Table 1). Analysis of these data indicates that CD11c may be associated with metabolic disorders, infectious diseases and the risk in developing cardiovascular diseases such as atherosclerosis, which has been shown to be associated with RA (3).

Table. 1: Potential association of CD11c expression with human diseases

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Though the risk in developing cancers, especially lymphoma, hepatosplenic T-Cell Lymphoma (HSTCL), nonmelanocytic skin cancers and melanoma, from anti-TNF therapy in RA patients has been well documented (20,21,22,23), the reports on the effect of anti-TNF therapy in developing cardiovascular diseases are conflicting. There are few reports showing the negative association of anti-TNF antagonists with congestive heart failure, heart failure and atheroscleorsis in patients with RA (24, 25). On the contrary, majority of the reports have shown improvement in atherosclerosis and other cardio vascular diseases in RA patients following anti-TNF therapy (26,27,28,29, 30, 31, 32, 33, 34, 35, 36, 37). It is important to point out that these independent study results were based on small number of patients for a limited period of time (6 18 months), which may not be ideal for studying the development of cardiovascular diseases (CVDs) like atherosclerosis. It is evident from the above mentioned studies that some RA patients who were treated with anti-TNF therapy may develop cardiovascular diseases (CVDs) and other patients may show signs of improvement in CVDs associated with RA. In this scenario, identification of biomarker(s) that can differentiate high risk patients from low risk patients may have significant impact on anti-arthritis drug therapy. Patients response to a drug treatment might depend on several known and unknown cellular, genetic, epigenetic or physiological factors, which are not detectable during pre-clinical studies using cell based or animal model screening studies. However, the drug response biomarkers, along with physical and anatomical markers, that are identified during clinical trials and follow-up studies may provide valuable information that can be used for predicting potential side effects of therapeutic drugs. In order to test this argument, we took the anti-TNF drug response biomarker CD11c and analyzed, by intelligent data mining and functional mapping, the potential of this biomarker for predicting the risk of developing atherosclerosis in RA patients. The functional role of CD11c in developing atherosclerosis has been well studied in case of postprandial lipemia (high fat-diet). The pathway of CD11c in atherosclerosis development is shown in Fig. 1. This pathway analysis shows that high-fat diet can induce CD11c overexpressing monocytes that can bind to VCAM-1 causing VCAM-1 arrest and accumulation in atherosclerotic lesions (38). During hypertriglyceridemia, monocytes internalize lipids, upregulate CD11c, and increase adhesion to VCAM-1 (39). The question is whether CD11c overexpressing moncytes generated from anti-TNF therapy can also have similar effect in patients? Detailed analysis of the data generated from patient studies may be required to confirm this. However, the role of CD11c monocytes resulting from high-fat may provide some indications on the use of anti-TNF therapy along with high-fat diet or in patients with obesity, diabetes, hypochloertermia and other similar conditions associated with cardiovascular diseases. Moreover, studies need to be conducted to test whether the expression of CD11c during or after anti-TNF therapy is associated with an increased risk in developing cardiovascular complications in RA patients with obesity, diabetes, hypochloertermia etc. Significant increase in total cholesterol, HDL cholesterol and triglycerides levels was reported to be associated with anti-TNF-alpha treatment in RA patients (40). Moreover, CD11c expression has been reported as a drug response-efficacy biomarker for drug treatments other than anti-TNF agents. Decreased expression of CD11c was reported as a drug efficacy biomarker in psoriasis patients treated with phosphodiesterase 4 (PDE4) inhibitors (41), whereas, increased expression of CD11c in circulating leukocytes was reported during Raptiva (anti-CD11a, Efalizumab) therapy in psoriasis patients (42). Additionally, CD11c was shown to be associated with inflammatory papules developed during Raptiva therapy (42) and increase in CD11c+ myeloid DCs was associated with psoriasis

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relapse in patients who were treated with Raptiva (43). Additionally, serious infections have also been reported in patients who were treated with Raptiva (44). In pulmonary tuberculosis (PTB) patients treated with anti-TB agents, decreased expression of CD11c was associated with favorable therapy response (45). The association of CD11c expression and tuberculosis is noteworthy since it has been reported that RA patients who were treated with adalimumab (anti-TNF antibody) were at risk of developing tuberculosis (46). Thus, CD11c expression may also be associated with infectious diseases in patients treated with various therapeutic drugs such as anti-TNF agents and Raptiva. Based on our preliminary analyses, we can speculate that CD11c expression may be associated with CVDs in RA patients treated with anti-TNF agents, however, conflicting reports on the development of CVDs in anti-TNF treated patients can be contradictory to our speculation. The conflicting reports can be explained partially, if not completely by analyzing other anti-TNF therapy response-efficacy biomarkers reported in RA patients. Possibly, CD11c expressing monocytes may be associated with patients who were susceptible to CVDs and patients who do not develop CVDs may have different anti-TNF response biomarker/s. This

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might be possible since several anti-TNF response biomarkers have been reported in RA patients. Some of the biomarkers include, elevated expression of an anti-atherogenic protein CD36 (47), decreased levels of cartilage oligomeric matrix protein (COMP)-C3b complexes ((48), decreased salivary IL-1beta (49), calprotectin expression (50), IgM antibodies against phosphorylcholine (anti-PC) (51) . Further, biomarkers associated with combination therapy with anti-TNF agents and methotrexate (MTX), have also been reported. Some of these biomarkers include decreased IL-17 expression (52), increased plasma type I IFN levels (53), and increased expression of TH2 receptors, chemokine receptor CCR4 and IL-4R (54). Interestingly, some of the above-mentioned biomarkers, such as CD36 or anti-PC, are anti-atherosclerosis related proteins and others, like calprotectin, are associated with atherosclerosis , cardiovascular disease , acute myocardial infarction, multiple sclerosis, cancer and infectious diseases (55, 56,57) (Fig. 2). Thus, multiple biomarkers associated with anti-TNF therapy can have varying functional roles in the development of CVDs and other diseases (Fig. 2). Increased expression of type 1 IFNs in response to combination therapy with MTX and anti-TNF agents may be an indication that these patients are susceptible to atherosclerosis. MTX therapy was shown to reduce cardiovascular risk by upregulating reverse cholesterol transport (RCT) proteins, ATP-binding cassette transporter A1 (ABCA1) and 27-hydroxylase, which are downregulated by COX-2 inhibitors, a known inducer of atherosclerosis (58, 59, 60, 61). IFN-gamma was shown to inhibit RCT by decreasing the expression of 27-hydroxylase and ABCA1 (62), and probably, increased expression of IFN-gamma in RA patients treated with the combination of MTX and anti-TNF may have increased risk in developing CVDs. Detailed analysis of the various biomarkers in patients combined with intelligent data mining will open up possibilities for analyzing and predicting disease causing side effects of various drugs that may ultimately pave paths for developing most efficient personalized medicine strategies. In order to achieve this goal, we might need to consider adopting new concepts in biomarker

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discovery and translational utilization of these biomarkers for personalized treatments. This means, current methods of biomarker selection and validation need to be revised. A model for identification, validation and clinical utilization of drug response-efficacy biomarkers Biomarkers are identified, selected and validated based on the specificity and sensitivity of any given biomarker in detecting a disease in question. This means, a valid diagnostic biomarker should be statistically significant in detecting that disease and an ideal biomarker should have high specificity, sensitivity and prevalence (positive predictive value (PPV) or precision rate). The question is whether we should adopt similar approaches for the identification and validations of drug response-efficacy biomarkers, which can vary significantly, in terms of expression as well as the types of biomarkers, from patient to patient depend on known or unknown genetic or physiological make up of a patient. It may not be surprising if drug response-efficacy biomarkers were found to be associated with gender, race, geographical location and other gene-social environment factors. Therefore, it may be difficult to find a single or common biomarker as a drug response-efficacy biomarker, which can identify responders from non-responders. In contrast, variations in drug response-efficacy biomarkers may indicate the use of these biomarkers for predicting the severity or complexity of diseases and potential drug induced future side effects, which can be analyzed with the help of intelligent data mining and data analysis. Based on these observations, we propose a model for the identification, validation and clinical utilization of drug response-efficacy biomarkers (Fig. 3). According to this model, each and every drug response-efficacy biomarkers identified in clinical trials, excluding biomarkers identified using cell or animal model studies, should be carefully selected and validated based on pre- and post-therapy expression analysis along with patients clinical, phenotypic, physiologic, anatomical, environmental and genetic characteristics. A simple pathway analysis may not be sufficient to predict the impact of these biomarkers in disease causing side effects, rather global data mining and comprehensive data analysis should be performed to understand functional roles of drug response-efficacy biomarkers. Accordingly, every drug efficacy biomarkers that are significantly associated with the drug treatment, whether it is positive in one or few patients, should be considered as a valid or valuable biomarker, which should be then evaluated beyond clinical trials, this means, the analysis of drug response-efficacy biomarkers should be a continuous process where patient samples are continuously monitored and evaluated during the prescription based treatment process. The data generated from such continuous large-scale analysis will help in identifying and validating reliable drug response-efficacy biomarkers, which can be used for developing robust diagnostic/treatment methods and for predicting potential life-threatening side effects of therapeutic drugs. This will ultimately help in developing an efficient and reliable personalized medicine strategy. The importance of each and every biomarker is evident from the two similar definitions of a biomarker - A biological marker or biomarker is defined as a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or biological responses to a therapeutic intervention. A biomarker can be a physiologic, pathologic, or anatomic characteristic or measurement that is thought to relate to some aspect of normal or abnormal biologic function or process. (Source: US FDA (63), and, A biomarker is a biological characteristic that can be objectively measured and that serves as an indicator of normal biological processes, pathogenic processes, or responses to therapeutic interventions. Biomarkers can be broadly characterized into 3 groups: those that measure physical or genetic traits (anthropometric indexes, metabolic gene polymorphisms), those that measure chemical or biochemical agents in the biological system (plasma retinol, iron, zinc), and those that assess a measureable physiologic function (test of night vision, cognitive assessment) or future clinical risk (64).

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Finally, the choice of biomarker identification method is very critical in the discovery of drug responseefficacy biomarkers considering the limited availability of patient derived samples. Cell or animal model based systems for drug response-efficacy biomarkers discovery may not be a suitable method mainly due to the fact that these model systems will not mimic the real-world patient response to a drug therapy. Exploratory methods such as proteomic approaches may not be a viable option for the identification of biomarkers since this technology has severe limitations such as complex sample preparation steps, sample loss, lack of reproducibility, laborious, expertise-dependency, mass spectrometry detection limitations etc.

Immunological or molecular assays, including next generation sequencing methods, that are robust and involve minimal sample preparation steps and sample loss need to be considered for identifying drug response-efficacy biomarkers using patient samples. Note: This scientific blog is a contribution from Sciclips Consultancy (http://www.sciclips.com/sciclips/consultancy.do) team.

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References References are hyperlinked to respective abstracts or full articles. Please click the reference numbers to the citation details.

Link to original blog: http://www.sciclips.com/sciclips/blogArticle.do?id=1020&blog=Potential%20Use%20of%20Drug% 20Response-Efficacy%20Biomarkers%20for%20Predicting%20LifeThreatening%20Disease%20Causing%20Side%20Effects%20of%20Therapeutic%20Drugs

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