1. Nanoparticle-Based Immune Tolerance Therapies for Treatment of Multiple Sclerosis Miller Lab Rosenblum MS Foundation Presentation Chicago, IL June 4, 2014 Stephen D. Miller, Ph.D. Department of Microbiology-Immunology and The Interdepartmental Immunobiology Center Northwestern University Medical School Chicago, IL

2. Multiple Sclerosis MS is a heterogeneous disease which affects 400,000 in the United States and 2.5 million people around the world. Cause of MS is unknown - but it is associated with an infectious etiology Multiple sclerosis (MS) is a demyelinating disease characterized by inflammatory, autoimmune-mediated attacks resulting in variable relapsing or progressive central nervous system deficits. HEALTHY NERVE DAMAGED NERVE myelin sheath nerve axon scarred myelin nerve cell

3. Protocol for Induction of Relapsing Experimental Autoimmune Encephalomyelitis (R-EAE) in SJL Mice 11-21 Days Clinical Signs: 1 limp tail 2 limp tail & hindlimb weakness 3 partial hindlimb paralysis 4 complete hindlimb paralysis 5 moribund Day 0: 20-100  g Myelin Protein or Peptide/CFA s.c.

4. IL-4, IL-10 CD4 + CD25 + T regs T cell apoptosis DAYS POST-INDUCTION CLINICAL SEVERITY ACUTE PHASE 1 o RELAPSE2 o 102050406070 PLP139-151 PRIMED  PLP139-151  PLP178-191  MBP84-104 ?  MAG/  MOG ?  PLP 3 o epitope 30 DAYS POST-INDUCTION CLINICAL SEVERITY ACUTE PHASE 1 o RELAPSE 2 o 10203050406070 PRIMED  PLP139-151  MBP84-104  PLP178-191 ?  MAG/  MOG ?  PLP 3 o epitope T cells specific for spread epitopes can be isolated from the periphery and the CNS of mice with ongoing disease following recovery from acute disease IFN-  IL-17 TNF-  LT Intra- and Intermolecular Epitope Spreading in R-EAE in SJL Mice: A Model of Relapsing-Remitting Multiple Sclerosis Endogenous Ags

5. Activated T Cells, Microglia and Macrophages Accumulate in EAE Lesions - CARS Microscopy Red: myelin sheath Green: IB 4 -FITC (microglia and macrophage). Control tissueEAE tissue (score 2) 20 µ m Ji-Xen Chen Purdue Univ.

6. Question - can ‘induced’ peripheral immune tolerance be used to treat Th1/17-mediated autoimmune disease, Th2-mediated allergic responses or prevent graft rejection in the absence of the application of immune subset depleting agents or prolonged use of immunosuppressive drugs/Abs/biologics Immunologic Tolerance - antigen-specific inhibition of selective immune responses is the‘holy grail’ and the ‘future’ for the treatment of autoimmune diseases, allergy and tissue transplantation Tolerance Strategies for Treatment of Immune- Mediated Diseases Current Lab People Daniel Getts Joe Podojil Suchitra Prasad Charles Smarr Derrick McCarthy Chris Harp Zoe Hunter Rachael Terry Former Lab People Carol Vanderlugt Todd Eagar Cassandra Smith Emma Feeney Danielle Turley Aaron Martin Adam Kohm FSM Collaborators Xunrong Luo – Islet Transplant Taba Kheramand Sushen Wang Paul Bryce – Allergy Chia-Lin Hsu Lonnie Shea – Nanoparticles Woon Teck Yap Kelan Hlavaty GOAL – ‘cure’ disease by specifically targeting ‘only’ the immunopathologic T cells rather than continuously ‘suppressing’ the effector molecules and trafficking of autoreactive T cells with mAbs/biologics/small molecules

7. Composition of the Immune Repertoire in a Healthy Individual vs. a MS Patient... 10-100x10 6 12345Clone Anti- Influenza Virus Anti- Salmonella Anti- Hepatitis Virus Anti- Lung Cancer Protein Anti- Myelin... 10-100x10 6 12345Clone Anti- Influenza Virus Anti- Salmonella Anti- Hepatitis Virus Anti- Lung Cancer Protein Anti- Myelin Healthy Individual MS Patient MS

8. Comparison of Immunosuppressive vs. Tolerance Therapies for Treatment of MS Tolerance Therapy Immunosuppressive Therapy... 10-100x10 6 12345Clone Anti- Influenza Virus Anti- Salmonella Anti- Hepatitis Virus Anti- Lung Cancer Protein Anti- Myelin MS XXXXX... 10-100x10 6 12345Clone Anti- Influenza Virus Anti- Salmonella Anti- Hepatitis Virus Anti- Lung Cancer Protein Anti- Myelin MS X

9. ECDI RBCs lysed Peptide Antigen-coupled Splenocytes (Ag-SP) Spleens removed from naïve syngeneic mice Protocol for Inducing T Cell-Mediated Immunity and Antigen- Specific Tolerance Using ECDI-Fixed Splenocytes (Ag-SP) Single Cell Suspension 1 hour, 4 o C s.c. i.v. Tolerance DTH Miller, et. al. J. Exp. Med. 149:758-773, 1979 Covalent attachment of peptide Apoptosis

10. PLP178-SP Tolerance IL-4, IL-10 CD4 + CD25 + T regs T cell apoptosis DAYS POST-INDUCTION ACUTE PHASE 1 o RELAPSE2 o 102050406070 PLP139-151 PRIMED  PLP139-151  PLP178-191  MBP84-104 ?  MAG/  MOG ?  PLP 3 o epitope 30 DAYS POST-INDUCTION CLINICAL SEVERITY ACUTE PHASE 1 o RELAPSE 2 o 10203050406070 PRIMED  PLP139-151  MBP84-104  PLP178-191 ?  MAG/  MOG ?  PLP 3 o epitope IFN-  IL-17 TNF-  LT PLP139-SP Tolerance PLP139 Tolerance Ag-SP Tolerance Therapy in Regulation Induction and Progression of Relapsing EAE in SJL Mice PLP178-191 CLINICAL SEVERITY Autoimmune diseases are moving targets due to epitope spreading – also true for pathogenesis of spontaneous T1D in NOD mice PLP139-SP Tolerance Caveat - Inhibition of relapses by peptide-specific tolerance administered during disease remission is only induced by the spread epitope Tolerance-based immunotherapy can be used to treat ongoing autoimmune disease

11. Potential Clinical Applications of Antigen- Coupled APC Tolerance CD4 Th1/Th17-mediated autoimmune diseases: MS - myelin protein/peptide coupled PBLs NMO – aquaporin 4 (AQP4)-coupled PBLs Type 1 Diabetes - insulin-coupled PBLs Atherosclerosis - Ox-LDL/Hsp60-coupled PBLs Celiac Disease - gluten-coupled PBLs Tolerance induction to recombinant enzymes, proteins or humanized antibody therapeutics - preceding initiation of enzyme replacement or virus- delivered gene therapy in genetic enzyme deficiency disorders [e.g. Pompe disease (  glucosidase); Fabry disease (  galactosidase); hemophilia (Factor VIII or IX); AAV-delivered dystrophin, e.g. in MD]; antibody therapy [e.g. Remicaid, etc.]; or cytokine therapy [e.g. IFN-β] Tolerance to alloantigens or xenoantigens - to promote long-term acceptance of organ and tissue grafts and bone marrow transplants without the need for immunosuppressive therapy CD4 Th2-mediated diseases - allergic asthma, topical allergies and food allergies

12. Establish Tolerance In MS (ETIMS) - MRI-Controlled Phase I*/IIA Trial for Treatment of Relapsing MS Using Peptide-Coupled PBL Tolerance Stephen Miller, Ph.D. – Northwestern Univ. Medical School Roland Martin, M.D. & Andreas Lutterotti, M.D. – Univ. of Hamburg/Zürich Leukocyta- phaeresis PBLs i.v. re-infusion of autologous Ag-PBLs (3x10 9 ) Antigen-coupled PBLs (Ag-PBL) ECDI MBP 13-32 MBP 83-99 MBP 111-129 MBP 146-170 MOG 1-20 MOG 35-55 PLP 139-154 Cocktail of Immunodominant Myelin Peptides Funding: German Government Cumming Foundation Myelin Repair Foundation Early R-R MS Patient (Pre-existing T cell response To 1-2 myelin epitopes) *Phase I successfully completed 11/2011, Phase IIa will start 9/2012

13. ETIMS Phase I Design and Overall Results Administration of antigen-coupled PBMCs had a favorable safety profile and was well tolerated in MS patients. Compared to the pre-treatment observation period there was no increase in clinical and MRI parameters of disease activity and in most patients no new MRI lesions were observed in the 6 month follow-up. Patients receiving the higher doses (>10 9 ) of peptide-coupled PBMCs had a decrease in antigen-specific T cell responses following cell therapy. Lutterotti, et al. 2013. Sci. Transl. Med. In press.

14. Ag-bearing biodegradable PLG nanoparticles serve as surrogates for apoptotic membranes for efficient induction of tolerance Antigen-coupled apoptotic cells 1979 Antigen-coupled carboxylated PLG Nanoparticle 2008 Next Generation Tolerogenic Immune Modifying Particle (TIMP) 2012 Next Generation Miller Lab – Northwestern University Daniel Getts, Ph.D. Aaron Martin, Ph.D. Chris Harp, Ph.D. Derrick McCarthy, B.S. Zoe Hunter, Ph.D. Rachael Terry Lonnie Shea – Northwestern Universi ty Woon Teck Yap Kelan Hlavaty -- - - - - - - - - - - - - - - - - - - - - - - - - -

16. Antigen-Coupled Biodegradable PLG Nanoparticles Effectively Prevent, but more Importantly, Therapeutically Treat Established Autoimmune Disease in the EAE Model of MS d+10 Rx d-7 Rx Preventative Tolerance: Therapeutic Tolerance:

17. Results of Double-Blind, Two-Arm Validation of Ag-PLG Nanoparticles Tolerance Performed by CBI Ability of PLP 139-151 -coupled PLG Nanoparticles to prevent and treat Active EAE is validated

18. Control of Autoreactive T cells Antigen Presenting Cells (APC) take up & process TIMP Naïve T Cell Naïve T Cell iTreg Naïve T Cell TIMP Apoptosis Apoptosis of TIMP- monocytes in the spleen/liver TIMP and apoptotic debris picked up by antigen presenting cells (APCs) in spleen/liver Immune Tolerance T cell deletion or anergy from: negative co-stimulation lack of positive stimulation IL-10 and TGF-β induce Tregs maintain tolerance TIMPs bind to monocytes – divert to spleen Naïve T Cell iTreg Proprietary surface modification: ζ = < 50 mV Disease specific autoreactive antigen Naïve T Cell Antigen Presentation Autoreactive antigen is: processed by APCs presented to T cells T cells get: negative co-stimulation – PD-L1 anti-inflammatory milieu (IL-10 / TGF-β) Deletion Anergy MHCTCR Peripheral T cell regulation SPLEEN/LIVER Naïve T Cell iTreg Monocyte APC SPLEEN Auto- reactive T cell BLOOD Naïve T Cell iTreg Naïve T Cell iTreg BLOOD PD-L1 PD1 LIVER TFG-  IL-10 MARCO Proposed Mechanisms of Ag-Nanoparticle Tolerance (Recapitulates how tolerance is maintained in the hematopoietic compartment) - - -- 1 1 2 2 3 3 500 nm Naïve T cell CD28

19. Advantages of Ag-PLG NPs for Treatment of (Auto)Immune Diseases No need to isolate and expand immature DCs (or Tregs) ex vivo No need to be concerned with immature DCs being activated upon ex vivo manipulation and becoming ‘stimulatory’ rather than tolerogenic; or Tregs converting to Th1/17 after transfer Directs Ag to ‘tolerogenic’ DCs in splenic MZ and liver via the MARCO scavenger receptor - ‘host’ tolerogenic APCs process and represent the antigen in a tolerogenic manner, i.e. host APCs can select the relevant immunodominant self epitopes from PLG NPs encapsulating intact auto-Ags or tissue extracts (e.g. OVA encapsulated PLG NPs prevent OVA/Alum-induced AAD) The protocol appears to be exquisitely Ag-specific (no apparent bystander suppression), non-toxic, safe, highly efficient and can induce unresponsiveness in both effector T cells (Th1, Th2, Th17 and CD8) and naïve T cells involved with epitope spreading Rapidity and simplicity of tolerogen preparation and induction using a GMP manufacturable off-the-shelf ‘universal’ tolerogenic carrier - theoretically useful for any immune-mediated disease by simply switching the Ag PLG Nanoparticles carry inherent anti-inflammatory properties - enhances their ability to induce tolerance