Kocot Joanna, Kosa Peter, Ashida Shinji, Pirjanian Nicolette, Goldbach-Mansky Raphaela, Peterson Karin, Fossati Valentina, Holland Steven M, Bielekova Bibiana
Neuroimmunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health; Bethesda, MD 20892, USA.
The New York Stem Cell Foundation Research Institute; New York, NY 10019, USA.
medRxiv. 2024 Apr 10:2024.04.09.24305506. doi: 10.1101/2024.04.09.24305506.
Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system (CNS). Clemastine fumarate, the over-the-counter antihistamine and muscarinic receptor blocker, has remyelinating potential in MS. A clemastine arm was added to an ongoing platform clinical trial TRAP-MS (NCT03109288) to identify a cerebrospinal fluid (CSF) remyelination signature and to collect safety data on clemastine in patients progressing independently of relapse activity (PIRA). The clemastine arm was stopped per protocol-defined criteria when 3/9 patients triggered individual safety stopping criteria (χ p=0.00015 compared to remaining TRAP-MS treatments). Clemastine treated patients had significantly higher treatment-induced disability progression slopes compared to remaining TRAP-MS participants (p=0.0075). Quantification of ~7000 proteins in CSF samples collected before and after clemastine treatment showed significant increase in purinergic/ATP signaling and pyroptosis cell death. Mechanistic studies showed that clemastine with sub-lytic doses of extracellular ATP activates inflammasome and induces pyroptotic cell death in macrophages. Clemastine with ATP also caused pyroptosis of induced pluripotent stem cell-derived human oligodendrocytes. Antagonist of the purinergic channel P2RX7 that is strongly expressed in oligodendrocytes and myeloid cells, blocked these toxic effects of clemastine. Finally, re-analyses of published snRNAseq studies revealed increased P2RX7 expression and pyroptosis transcriptional signature in microglia and oligodendrocytes in MS brain, especially in chronic active lesions. CSF proteomic pyroptosis score was increased in untreated MS patients, was higher in patients with progressive than relapsing-remitting disease and correlated significantly with rates of MS progression. Thus, pyroptosis is likely first well-characterized mechanism of CNS injury underlying PIRA even outside of clemastine toxicity.
多发性硬化症（MS）是一种由免疫介导的中枢神经系统（CNS）脱髓鞘疾病。富马酸氯马斯汀是一种非处方抗组胺药和毒蕈碱受体阻滞剂，在MS中具有促进髓鞘再生的潜力。在一项正在进行的平台临床试验TRAP-MS（NCT03109288）中增加了一个氯马斯汀治疗组，以确定脑脊液（CSF）髓鞘再生特征，并收集氯马斯汀在独立于复发活动进展的患者（PIRA）中的安全性数据。当9名患者中有3名触发个体安全停止标准时，根据方案定义的标准停止了氯马斯汀治疗组（与其余TRAP-MS治疗相比，χ p=0.00015）。与其余TRAP-MS参与者相比，接受氯马斯汀治疗的患者治疗引起的残疾进展斜率显著更高（p=0.0075）。对氯马斯汀治疗前后收集的脑脊液样本中的约7000种蛋白质进行定量分析，结果显示嘌呤能/ATP信号传导和细胞焦亡性细胞死亡显著增加。机制研究表明，氯马斯汀与亚裂解剂量的细胞外ATP一起可激活炎性小体，并在巨噬细胞中诱导细胞焦亡性细胞死亡。氯马斯汀与ATP一起还导致诱导多能干细胞来源的人少突胶质细胞发生细胞焦亡。在少突胶质细胞和髓样细胞中强烈表达的嘌呤能通道P2RX7拮抗剂可阻断氯马斯汀的这些毒性作用。最后，对已发表snRNAseq研究的重新分析显示，MS脑内小胶质细胞和少突胶质细胞中P2RX7表达增加和细胞焦亡转录特征增加，尤其是在慢性活动性病变中。未经治疗的MS患者脑脊液蛋白质组细胞焦亡评分增加，进展型患者高于复发缓解型患者，且与MS进展率显著相关。因此，即使在氯马斯汀毒性之外，细胞焦亡可能是PIRA潜在的首个得到充分表征的中枢神经系统损伤机制。
