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Etretinate Augments Interferon Beta-1b Effects on Suppressor Cells in Multiple Sclerosis
Zhi Xiang Qu, PhD;
Neil Pliskin, PhD;
Mark W. Jensen, PhD;
David White, PhD;
Barry G. W. Arnason, MD
Arch Neurol. 2001;58:87-90.
ABSTRACT
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Background Interferon beta treatment is only partially effective in multiple sclerosis
(MS) suggesting a potential role for adjunctive therapies. Retinoids can augment
the clinical efficacy of type 1 interferons in patients with cancer. We reasoned
that the same might hold in MS. Interferon beta-1b added to peripheral blood
mononuclear cells in vitro partially reverses the CD8 suppressor cell defect
of patients with MS. All-trans retinoic acid added to peripheral
blood mononuclear cells from untreated patients with MS or from controls potentiates
this ability of interferon beta-1b to augment CD8 suppressor cell function
in vitro.
Objective To determine whether retinoid administration to patients with MS who
are being treated with interferon beta-1b augments their CD8 suppressor cell
function.
Setting A university hospital MS clinic.
Participants Patients with MS who were being treated with interferon beta-1b, 14
patients with secondary progressive MS and 3 patients with relapsing remitting
MS.
Results Seventeen patients with MS received etretinate treatment for up to 6
months. Planned dosing was 10 mg 3 times daily for the first month, 25 mg
twice daily for the second and third months, and 10 mg twice daily thereafter.
The 25-mg twice daily dose was not well tolerated and of the 14 patients who
remained in the phase 1 clinical trial through month 3 dose reduction to 10
mg thrice daily was required in 1 patient and to 10 mg twice daily in 4 patients.
Eleven patients completed the trial. Etretinate treatment significantly augmented
suppressor function over baseline values at 1, 3, and 6 months. No meaningful
change was noted in disability or quality of life over the course of the phase
1 clinical trial. Neuropsychological testing of completers suggested improvement
on selected aspects of verbal memory at 6 months compared with baseline values.
Conclusions Etretinate treatment at a dose of 10 mg twice or three times daily augments
suppressor cell function in patients with MS receiving interferon beta-1b.
Higher dose etretinate treatment (25 mg twice daily) is poorly tolerated by
patients with MS. Even at 10 mg twice daily adverse experiences involving
the mucous membranes and the skin become troublesome for some, but not all,
patients. Whether pulse therapy or administration of retinoid restricted to
the day of interferon beta dosing will also augment suppressor function, while
being better tolerated, remains to be determined.
INTRODUCTION
INTERFERON BETA preparations are widely employed to treat multiple sclerosis
(MS) but they are only partially effective. Retinoids have been found to potentiate
the clinical efficacy of interferon alfa and interferon beta preparations
(ie, type 1 interferons [INFs]) in patients with cancer.1, 2, 3
When type 1 IFNs bind to their cell membrane–bound receptor, 2 receptor-associated
kinases known as JAK1 and Tyk2 are phosphorylated. These then phosphorylate
cytoplasmic proteins known as STAT1 and STAT2 that, once phosphorylated, dimerize,
and bind a protein known as p48. The complex translocates to the nucleus and
initiates transcription of interferon  (IFN-) and ß (IFN-ß)
responsive genes. Retinoid treatment increases the levels of STAT1 and STAT2
severalfold.4 Levels of 2 additional IFN-induced
transcription factors called "interferon regulatory factor 1" and "interferon
regulatory factor 2" are also increased by retinoids.5
For these reasons the response to a given dose of interferon is sometimes
increased by retinoid treatment.
Nonspecific CD8 suppressor cell function is subnormal during MS relapses,
returning to normal with remission.6 The CD8
suppressor cell function is persistently subnormal in secondary progressive
MS.7 Interferon beta-1b treatment augments
CD8 suppressor function in patients with MS.8
This restorative effect may contribute to the beneficial effect of the agent
in MS. We showed that interferon beta-1b, when added to peripheral blood mononuclear
cells from patients with MS or controls in vitro, augments suppressor function
and that when all-trans retinoic acid is added as
well suppressor function is further augmented.9, 10
This finding prompted us to determine whether the same would hold in vivo
in patients with MS who are receiving interferon beta-1b treatment. The results
of a phase 1 clinical trial to test this hypothesis are presented.
PATIENTS AND METHODS
Seventeen patients (9 men and 8 women) from the MS clinic at the University
of Chicago, Chicago, Ill, were enrolled in a 6-month phase 1 (safety) clinical
trial of etretinate treatment (Tegison; Hoffman-LaRoche Inc, Nutley, NJ).
All patients had been receiving interferon beta-1b treatment for at least
6 months and most for several years. The protocol was approved by the University
of Chicago Institutional Review Board. All patients gave written informed
consent after the nature of the clinical trial had been fully explained.
Fourteen patients had secondary progressive MS and 3 patients had relapsing-remitting
MS. Mean (±SEM) age was 45.0 ± 2.8 (age range, 29-58 years).
There were 5 premenopausal women, all of who were made aware both verbally
and in writing of the need to exercise adequate birth control indefinitely.
The planned etretinate dose was 10 mg 3 times daily for the first month, 25
mg twice daily for the second and third months, and 10 mg 3 times daily for
the fourth through sixth months. Etretinate treatment was taken with meals.
Venous blood was drawn at baseline and at 1, 3, and 6 months for evaluation
of suppressor cell function. An electrocardiogram was obtained at baseline
and complete blood cell counts, liver profiles, and lipid profiles were obtained
at baseline and at 1, 3, and 6 months. Neurologic examinations were conducted
at these times and Expanded Disability Status Score,11
Scripps Rating Scale,12 and Quality of Life
instrument score recorded.13 A limited neuropsychological
battery was administered at baseline and at 6 months.
CONCANAVALIN A (ConA) SUPPRESSOR ASSAY
The 6 x 106 peripheral blood mononuclear cells in 6
mL of RPMI medium were cultured with or without ConA (5 µg/mL) in 25-cm
tissue culture flasks. After 48 hours, cells were harvested, treated with
100 µg/mL mitomycin C (Sigma Chemical Co, St Louis, Mo) for 45 to 60
minutes, washed 3 times in Hanks balanced salt solution, and resuspended at
106 cells per milliliter in RPMI medium. One hundred microliters
of ConA-activated mitomycin C–treated suppressor cells (S cells) or
nonactivated mitomycin C–treated control cells (C cells) was added to
U-bottom microwells (Costar Corp, Cambridge, Mass) followed by 100 µL
of responder peripheral blood mononuclear cells (106/mL) freshly
isolated from a healthy donor (R cells) plus ConA to a final concentration
of 5 µg/mL. Quadruplicate cultures were incubated for 72 hours. Wells
were pulsed with 37 MBq of tritiated thymidine for the last 5 hours of incubation.
Percentage of suppression was calculated as follows:
STATISTICAL ANALYSES
Unpaired t test and paired 2-tailed t test were used for analysis of suppressor function. P<.05 was considered statistically significant.
RESULTS
DOSE TOLERANCE
All 17 patients completed the first month of the phase 1 clinical trial
at an etretinate dose of 10 mg 3 times daily. Dose escalation to 25 mg twice
daily was less well tolerated and of the 14 patients who remained in the clinical
trial through month 4 dose reduction to 10 mg 2 or 3 times daily was required
in 5 patients.
DROPOUTS
One patient with progressive MS withdrew at the end of the second month
because of hallucinations. Psychosis is described, albeit rarely, in patients
receiving retinoids but this patient had experienced intermittent hallucinations
prior to the initiation of etretinate treatment. Nevertheless, an exacerbation
of a tendency to hallucinations ascribable to the drug seems possible.
One patient aged 57 years with progressive MS suffered a myocardial
infarction after 6 weeks of etretinate treatment and the drug was immediately
withdrawn. His father had died at age 50 years of myocardial infarction. An
electrocardiogram at study enrollment showed nonspecific ST-segment abnormalities
unchanged from 3 prior electrocardiograms obtained over the preceding 3 years
because of the family history of coronary disease. Triglyceride levels at
enrollment were 1.99 mmol/L (177 mg/dL) (upper limit of normal, 1.80 mmol/L
[160 mg/dL]) and when seen 1 month after myocardial infarction and drug withdrawal
4.76 mmol/L (381 mg/dL). Retinoids raise triglyceride levels (see "Blood Chemistry"
section below) and hypertriglyceridemia may increase cardiovascular risk status.
Accordingly, a relation between treatment and myocardial infarction in this
patient is distinctly possible. This patient's walking had improved from 100
m using a cane to 200 m using a cane after 1 month of etretinate treatment.
Two months after stopping etretinate treatment, walking had deteriorated to
30 m using a cane.
One patient with progressive MS withdrew after 3 months because of skin
changes (see "Skin and Mucous Membrane Changes" section below). Two patients
with progressive MS stopped treatment after 4 months, one because of skin
changes and the second because another neurologist switched the treatment
to glatiramer acetate. An additional patient with relapsing-remitting MS stopped
treatment after 5 months during an attack of MS from which the patient ultimately
recovered completely.
SKIN AND MUCOUS MEMBRANE CHANGES
Retinoids inhibit keratinization and major dermatologic side effects
were encountered. Fourteen patients reported 1 or more of the following: (1)
dryness of skin, eyes, mouth, or nose; (2) rash and/or scaling, itching, and
redness or peeling especially of hands and feet; (3) cracking of toenails
and fingernails; (4) hair loss including scalp, eyelashes, and eyebrows; and
(5) cheilosis (chapped lips). These skin changes were tolerable to most patients
at an etretinate dose of 10 mg 3 times daily but intolerable at a dose of
25 mg twice daily. Two patients dropped out because of skin changes.
OTHER UNTOWARD EVENTS
One progressive patient developed depression 3 months into the clinical
trial. The emotional well-being score embedded in the Quality of Life instrument
(see "Quality of Life" subsection of "Clinical Results" section below) did
pick up the depression. This patient had a history of a prior major depression
2 years earlier. The patient responded promptly to antidepressant medication
and completed the clinical trial.
BLOOD CHEMISTRY
In published series 25% of the patients treated with etretinate have
shown an elevation in the levels of plasma triglycerides, 15% changes in high-density
lipoproteins, 7% an elevation in cholesterol, and 15% an elevation in liver
enzymes. In this study 10 patients had normal triglyceride values ( 1.80
mmol/L [160 mg/dL]) at baseline, 6 had mild elevations (<2.82 mmol/L
[<250 mg/dL]), and 1 was highly elevated ( 2.82 mmol/L [250 mg/dL]).
Values over the course of the clinical trial remained normal in 4 patients,
were mildly elevated on at least 1 occasion in 10 patients, and became highly
elevated in 3 patients. There was no change in cholesterol values over the
course of the clinical trial. High-density lipoprotein cholesterol values
were normal at baseline in 15 patients and low (ie, abnormal) in 1. Four patients
with normal baseline values showed low values on 1 or more occasions over
the course of the clinical trial and the patient with a low value at baseline
remained low. No meaningful changes were noted in the liver profile over the
course of the clinical trial. White blood cell, red blood cell, and platelet
counts were also unchanged.
CLINICAL RESULTS
Expanded Disability Status Score
No meaningful changes in mean score were noted over the course of this
intention-to-treat clinical trial (Table
1). Of the 16 patients evaluable at 6 months the Expanded Disability
Status Score was improved in 1, unchanged in 12, and worse in 3 including
1 relapsing-remitting patient who was in the midst of an attack, as the clinical
trial ended. The patient subsequently recovered to the clinical trial enrollment
baseline value.
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Table 1. Neurologic Rating Scores in Patients With Multiple Sclerosis
Receiving Etretinate Treatment
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Scripps Rating Scale
No meaningful change was noted over the course of the clinical trial
(Table 1).
Quality of Life
A Quality of Life instrument13 was administered
at baseline and at 3 and 6 months. The Quality of Life instrument evaluates
mobility, symptoms, emotional well-being, general contentment, thinking, fatigue,
and family and social well-being. There was no meaningful change in any of
these measures over the course of the clinical trial or in the composite score
(Table 1). Emotional well-being,
general contentment, and family and social well-being scales were lower at
baseline in dropouts than in completers and the difference for the 3 scores
combined was statistically significantly different for completers than for
dropouts (61.18 ± 4.3 vs 44.33 ± 5.19, P<.03)
suggesting a potential role for quality of life screening in patient selection
for clinical trials.
Neuropsychological Testing
The group as a whole had an average of 15 years of education and was
of average (±SEM) estimated intelligence (National Adult Reading Test
Full Scale IQ [NART FSIQ] = 104.2 ± 9.0). All subjects were right-handed.
At 6 months, 14 subjects returned for retesting. 10 were still taking etretinate
and 4 were no longer taking etretinate. All subjects were administered a short
battery of neuropsychological measures assessing memory (Selective Reminding
Test, Visual Reproduction), concentration/mental speed (Paced Auditory Serial
Addition Test, Trailmaking Test), upper extremity motor speed/dexterity (Grooved
Pegboard), speeded word generation (Verbal Fluency), and depression screening
(Beck Depression Inventory). Using repeated measures analysis of variance,
significant differences suggesting improved performance after 6 months were
noted on selected aspects of verbal memory (Selective Reminding Test). Specific
indexes included the following: Consistent Long-term Retrieval [CLTR Trial
1] F1,25 = 11.5, P = .002; and CLTR2,
F1,25 = 8.2, P = .008; CLTR3, F1,25 = 4.5, P = .04; Long-term Storage Trial 1,
F1,25 = 11.8, P = .002; and Long-term
Storage Trial 2, F1,25 = 4.7, P = .04.
All other measures of memory, concentration, upper extremity motor speed/dexterity,
speeded word generation, and depression screening did not differ across the
2 assessments.
SUPPRESSOR CELL FUNCTION
Suppressor cell function was improved above baseline values during etretinate
treatment (Table 2). Data are
presented both for all patients evaluated at baseline, 1, 3, and 6 months
and as paired data comparing baseline 1-, 3-, and 6-month values for individual
patients. Etretinate is eliminated slowly so that at least some residual drug
effect is likely for weeks to months after stopping treatment. In this intention-to-treat
study, dropouts were included in the suppressor cell function evaluations
at all time points, whenever possible. All values are statistically significant.
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Table 2. Nonspecific Suppressor Function in Patients With Multiple
Sclerosis Receiving Etretinate Treatment
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COMMENT
Etretinate treatment of patients with MS receiving interferon beta-1b
augments suppressor cell function indicating that retinoid therapy can potentiate
at least 1 of the immunomodulating effects of interferon beta-1b in vivo,
as it had earlier been shown to do in vitro.10
Retinoids also inhibit interferon  production,10, 14
and interferon gamma administration to patients with MS has been reported
to provoke MS attacks.15 Retinoid therapy lessens
the severity of experimental autoimmune encephalomyetitis, a widely studied
model disease for MS.16, 17, 18
Together these findings suggest a possible adjunctive role for retinoids in
the treatment of MS. However, adjunctive therapy with etretinate is far from
hazard free. Only 11 of 17 patients completed the 6 months of the clinical
trial and 14 patients reported troublesome cutaneous and mucous membrane side
effects, sufficient in 2 patients to cause them to drop out of the clinical
trial. Hallucinations, probably not drug related, occurred in one dropout
and a myocardial infarction, possibly drug related, in a second. One of 3
relapsing-remitting patients experienced a relapse during the clinical trial.
No meaningful changes in Expanded Disability Status Score or Scripps
Rating Scale scores were observed over the course of the clinical trial. Neuropsychological
testing at 6 months suggested improved performance in selected aspects of
verbal memory as compared with baseline. This finding should be viewed circumspectly
given the small sample size and bearing in mind that interferon beta treatment
alone can improve cognitive performance.19
There was no meaningful change in the quality of life overall, but dropouts
scored lower (ie, worse) at enrollment on measures of emotional well-being,
contentment, and family and social well-being than completers. Whether such
measures can serve as predictors of propensity to drop out will need to be
tested in a larger clinical trial.
Following completion of this trial etretinate was withdrawn and replaced
with acitretin (Soriatane; Hoffman-LaRoche Inc), the active metabolite of
etretinate. Acitretin has a much shorter elimination half-life than etretinate
(49 hours vs 120 days).
AUTHOR INFORMATION
Accepted for publication April 19, 2000.
This research was supported by grants from the National Multiple Sclerosis
Society, New York, NY (Dr Arnason); Berlex Laboratories Inc, Richmond, Calif
(Dr Arnason); and a gift from the Butz Foundation, Chicago, Ill (Dr Arnason).
Dr Jensen is a fellow of the National Multiple Sclerosis Society.
We thank Stacey Dutkiewicz for typing the manuscript. We thank our patients
for their kind cooperation.
From the Departments of Neurology (Drs Qu, Pliskin, Jensen, White,
and Arnason) and Psychiatry (Dr Pliskin) and the Brain Research Institute
(Drs Pliskin and Arnason), University of Chicago, Chicago Ill. The authors
have no commercial, proprietary, or financial interest in the products and
companies described in this article.
Reprints: Barry G. W. Arnason, MD, University of Chicago, Department
of Neurology, 5841 S Maryland Ave, MC 2030, Chicago, IL 60637.
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