Current and Future Immunomodulation Strategies to Restore Tolerance in Autoimmune Diseases

Autoimmune diseases reflect a breakdown in self-tolerance that results from defects in thymic deletion of potentially autoreactive T cells (central tolerance) and in T-cell intrinsic and extrinsic mechanisms that normally control potentially autoreactive T cells in the periphery (peripheral tolerance). The mechanisms leading to autoimmune diseases are multifactorial and depend on a complex combination of genetic, epigenetic, molecular, and cellular elements that result in pathogenic inflammatory responses in peripheral tissues driven by self-antigen-specific T cells. In this article, we describe the different checkpoints of tolerance that are defective in autoimmune diseases as well as specific events in the autoimmune response which represent therapeutic opportunities to restore long-term tolerance in autoimmune diseases. We present evidence for the role of different pathways in animal models and the therapeutic strategies targeting these pathways in clinical trials in autoimmune diseases.Autoimmune diseases are debilitating conditions that affect a large and growing portion of the population (∼3%–5% in the United States) (Jacobson et al. 1997). Autoimmune diseases take a devastating toll on affected families and have a considerable economic impact. Thus, improving the understanding of autoimmune diseases and developing novel therapies have been significant goals in public health. The development of autoimmune diseases reflects a loss of tolerance of the immune system for self-antigens. With the exception of a few rare monogenic diseases such as immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX), and autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome, the development of autoimmunity is a complex and multifactorial process. This process usually involves genetic predispositions and poorly defined environmental factors that result in slight alterations in many different checkpoints, which in turn tilts the balance toward autoreactivity and away from immunoregulation. Although clearly there are key roles for B cells, antigen-presenting cells (APCs), and the innate immune response in the development and progression of autoimmune diseases, this article will focus on autoreactive T cells and potential targets of tolerogenic treatments (Fig. 1). In addition, we will discuss selected strategies currently available or being developed in the clinic as well as future opportunities to prevent and treat these diseases. Finally, current clinical strategies available as the standard of care for autoimmune diseases rely on immunosuppressive and anti-inflammatory treatments that curtail the pathological events, alleviate symptoms, and provide short-term relief in some patients. Thus, we will focus for the most part on immunotherapies aimed at reestablishing long-term tolerance.Open in a separate windowFigure 1.Development of the pathogenic autoimmune response and targets for immunotherapy. Autoreactive T cells that escape thymic negative selection are usually controlled by intrinsic (inhibitory receptors) and extrinsic (regulatory cell populations) mechanisms of tolerance in the periphery. In individuals genetically prone to autoimmunity, one or several of these checkpoints are defective, resulting in expansion of autoreactive T cells that cannot be controlled by Tregs (red, autoreactive effector T cells; green, Tregs; gray, polyclonal conventional T cells). Autoreactive T cells migrate to their targeted tissue where cytotoxic mechanisms and uncontrolled inflammation mediated by soluble mediators released by T cells and innate cells result in tissue damage. Various immunotherapeutic strategies target different steps in this process. (A) The ultimate goal of immunotherapy is to alter the balance of pathogenic versus regulatory T cells to restore tolerance, as detailed in Figure 2. (B) Anti-CD3 mAbs, antigen-specific therapies, and costimulation blockade alter the interactions between autoreactive T cells and antigen-presenting cells (APCs) and/or the signaling pathways resulting from productive T-cell receptor (TCR) ligation after presentation of cognate self-peptide/MHC (major histocompatibility complexes) in the presence of costimulatory signals, leading to deletion, anergy, immune deviation, or induction of Tregs. (C) Many strategies aim at boosting Tregs, either by concomitantly deleting Teff and promoting Tregs, and thus resetting the immune system to various degrees, such as antithymocyte globulin (ATG), rapamycin plus IL-2, and autologous hematopoietic stem cell transplantation (HSCT), or directly providing Tregs through cellular therapy. (D,E) Some therapies target populations of APCs, such as depletion of B cells by rituximab or the promotion of self-antigen presentation specifically by tolerogenic dendritic cells (DCs). (F) The migration of autoreactive T cells to their target tissue is being altered by inhibitors of leukocyte trafficking such as natalizumab and fingolimod. These drugs may further promote tolerance by keeping autoreactive T cells in the lymph nodes (LN) during immunosuppression, a prerequisite for efficient immunomodulation in some cases. (G) Anti-inflammatory therapies such as tumor necrosis factor (TNF) antagonists reduce tissue damage but also create an immunological environment more favorable to the induction of Tregs and restoration of tolerance.