A personalised approach to manage adverse reactions to CFTR modulator therapy in patients with cystic fibrosis

药物不良反应是一个主要的健康问题，也是新药开发的一个障碍。在英国，大约每16例住院患者中就有1例是由于某种形式的药物不良反应。最广为人知但最不为人所知的药物副作用之一是T淋巴细胞介导的超敏反应。就药物的化学成分和患者的生物学而言，这种反应是不可预测的。CFTR调节剂疗法现在广泛用于二联或三联疗法，这些疗法已经将囊性纤维化(CF)转变为一种温和得多的疾病。然而，CFTR调节剂治疗的不良反应，如皮肤药物过敏和肝损伤，可导致停药和有害的临床结果。这项建议的目的是将药物暴露、HLA等位基因表达和药物特异性免疫反应与接受CFTR调节剂治疗的患者的临床结果联系起来。我们的方法将提供一个框架，以更有效地评估对这一重要类别药物过敏的患者。通过在重新引入CFTR调节器疗法期间采集血液样本，我们将确定药物特异性T细胞反应在治疗过程中是如何发展的，以及调节效应器T细胞反应的途径。T细胞参与了决定接触药物是否会导致过敏反应的决策过程。因此，利用皮肤和肝脏反应患者的PBMC和药物反应克隆的T细胞，我们将定义超敏表型，并确定药物特异性T细胞激活的途径。这些数据将确定与不良事件相关的药物(S)，并提供有关疾病发病机制的有价值的信息。结果将与从头启动实验进行比较，并用于对有不良事件的患者进行分层。对患者细胞的分析虽然很重要，但不能提供有关主要T细胞反应的信息。因此，我们将利用我们的健康供者的人类白细胞抗原基因分型PBMC库来研究药物特异性T细胞的来源。我们的评估将包括CFTR调节剂对幼稚/记忆T细胞的药物特异性刺激的特征，以及对先驱T细胞频率和药物特异性T细胞的表型和功能的评估。访问CF患者的PBMC库(有或没有CFTR调节剂治疗超敏反应)将使我们能够进行基于人类白细胞抗原序列的基因分型。任何关联都将使我们能够确定特定的HLA分子在CFTR调节剂药物呈递给T细胞中的作用，并可能为药物使用前的基因测试铺平道路。我们最近利用质谱学来表征药物、药物代谢物和药物蛋白质加合物，并将暴露与药物特异性T细胞反应的激活联系起来。我们现在将使用这些方法来量化人类血浆中CFTR调节剂、药物和代谢物的水平，并将暴露与患者结局(健康益处或不良事件)联系起来。类似的方法将被用来评估在免疫细胞共培养系统中表达CYP3A4的HepG2细胞的CFTR调节剂药物代谢，以将代谢物的形成与人类T细胞的激活联系起来。几名免疫确诊的不良事件患者将被提供替代疗法或相同的疗法，但剂量较小，或通过药物激发或药物脱敏。在治疗前、治疗中和治疗后将进行血液采样，以探索：(I)药物特异性效应器T细胞反应是如何发展的；(Ii)效应器和调节性细胞因子的表达；以及(Iii)通过Treg和共抑制分子的功能抑制。一旦我们制定了一项可靠的评估，将对患有CFTR调节剂治疗不良事件的个体患者进行风险分层，它可以应用于其他患者组，包括那些接受新药治疗的患者。

Adverse drug reactions are a major health concern and an impediment to the development of new medicines. Approximately 1 in 16 hospital admissions in the UK are due to some form of adverse drug reaction. One of the best known, but least understood drug side-effects is T-lymphocyte-mediated hypersensitivity. Such reactions are unpredictable with respect to the chemistry of the drug and the biology of the patient. CFTR modulator therapies are now widely available as dual or triple therapy and these have transformed cystic fibrosis (CF) into a much milder disease. However, adverse reactions to CFTR modulator therapy such as cutaneous drug hypersensitivity and liver injury can result in drug discontinuation and deleterious clinical outcome. The objective of this proposal is to relate drug exposure, HLA allele expression and drug-specific immune responses to clinical outcome in patients exposed to CFTR modulator therapies. Our approach will provide a framework to more effectively assess patients hypersensitive to this important class of drug. By collecting blood samples during reintroduction of CFTR modulator therapies, we will then define how the drug-specific T-cell response develops during treatment and the pathways that regulate effector T-cell responses. T-cells are involved in the decision process that determines whether drug exposure will lead to a hypersensitivity reaction. Thus, using PBMC and drug-responsive cloned T-cells from patients with skin and liver reactions, we will define a hypersensitivity phenotype and identify pathways of drug-specific T-cell activation. These data will identify the drug(s) associated with adverse events and provide valuable information on the disease pathogenesis. Resulted will be compared with de-novo priming experiments and used to stratify patients with adverse events. Analysis of patient cells, although important, provides no information about the primary T-cell response. Thus, we will utilize our healthy donor HLA genotyped PBMC bank to study the origin of drug-specific T-cells. Our assessment will involve characterization of CFTR modulator drug-specific stimulation of naïve/memory T-cells with assessment of the pre-curser T-cell frequency and the phenotype and function of drug-specific T-cells. Access to a repository of PBMC from patients with CF (with and without CFTR modulator therapy hypersensitivity) will allow us to conduct HLA sequence-based genotyping. Any associations will allow us to define of the role of specific HLA molecules in CFTR modulator drug presentation to T-cells and may pave the way to genetic testing prior to drug use.We have recently utilized mass spectrometry to characterize drugs, drug metabolites and drug protein adducts and relate exposure to the activation of a drug-specific T-cell response. We will now use these methods to quantify CFTR modulator drug and metabolite levels in human plasma and relate exposure to patient outcome (health benefit or adverse event). Similar methods will be used to assess CFTR modulator drug metabolism by CYP3A4 expressing HepG2 cells in an immune cell co-culture system to relate metabolite formation to the activation of human T-cells. Several patients with immunologically confirmed adverse events will be offered alternative therapies or the same therapy at reduced dose or through drug provocation or drug desensitisation. Blood sampling will be undertaken prior to, during and after treatment to explore: (i) how the drug-specific effector T-cell response develops; (ii) expression of effector and regulatory cytokines, and (iii) suppression through the function of Tregs and co-inhibitory molecules. Once we have developed a robust assessment that will risk stratify individual patients with CFTR modulator therapy adverse events it could be applied to other patient groups, including those receiving novel medicines.