The Use of Senolytic and Anti-Fibrotic Agents to Improve the Beneficial Effect of Bone Marrow Stem Cells for Osteoarthritis

摘要：骨性关节炎是一种进行性关节疾病，可导致软骨损伤、疼痛和关节功能丧失。 功能。虽然许多治疗骨性关节炎的干细胞疗法正在调查中，但目前没有一种是FDA批准的 改变疾病的病程。在许多可能适用于骨性关节炎的成体干细胞类型中，骨髓 来自骨髓抽吸物浓缩物(BMC)的干细胞(BMSCs)是临床上最可翻译的(并且是 已经在临床使用)，因为可以使用微创技术获取它们，并且不需要 体外扩增。然而，骨髓间充质干细胞治疗骨性关节炎的疗效仍有很大的潜力。这个 BMC中衰老细胞的数量随着年龄和骨性关节炎的增加而增加，这些细胞释放促炎因子 细胞因子/趋化因子、蛋白酶和其他与衰老相关的分泌表型(SASP) 损害干细胞功能，并可能促进骨性关节炎的发展/进展。柯克兰博士的实验室(联合- 研究人员)已经确定了专门杀死衰老细胞的化合物，消除了系统性SASP因子。 我们已经证明，在临床前模型中，这些感觉神经降解剂可以延迟骨性关节炎。我们还表明， 氯沙坦(一种转化生长因子-β1阻断剂)阻断纤维化可以通过促进软骨再生来促进软骨修复 透明软骨的同时减少纤维软骨的数量。因此，我们假设政府 抗衰老和/或抗纤维化药物将增强骨髓间充质干细胞治疗骨性关节炎的有利作用。我们建议 在Steadman诊所(TSC)和Steadman Philippon研究所进行的随机临床试验 (SPRI)。这项I/II期试验将评估非瑟丁(一种抗衰老的膳食补充剂)的安全性和有效性。 氯沙坦(一种抗纤维化药物)，单独使用或联合使用，以提高临床疗效 骨髓间充质干细胞在膝骨性关节炎治疗中的应用感觉剂(非赛汀1000毫克/天，前FDA Ind 批准的)方案将是在BMSC之前和之后3个月给药的2天/28天的周期 治疗。抗肝纤维化药物(氯沙坦，25毫克/天，以前免服IND)将持续30天 在骨髓间充质干细胞治疗后立即开始。OA膝关节在基线和18个月后进行MRI检查。 治疗以评估软骨形态和结构随时间的变化。患者报告的结果 疼痛和功能将在基线和3、6、12和18个月时收集。关节和软骨功能会 在基线和18个月时使用视频运动分析进行评估。与软骨相关的骨性关节炎生物标志物 将在基线和18个月时对变性、炎症和疼痛进行评估。血液和滑液会 在基线、治疗后4天和18个月进行评估，以评估细胞衰老和 OA生物标记物。这项试验将建立在目前正在进行的治疗骨性关节炎的生物学临床试验的基础上，网址为 SPRI(利用相同的患者群体和结果评估)，展示我们团队的能力 为了执行所提议的研究并且还利用组合试验来有效地提供6臂， 全面评估改善骨性关节炎治疗的生物疗法。

Abstract: Osteoarthritis (OA) is a progressive joint disease leading to cartilage damage, pain and loss of function. While many stem cell therapies for OA are under investigation, none are currently FDA-approved for modifying the course of the disease. Of the many adult stem cell types potentially applicable to OA, bone marrow stem cells (BMSCs) from bone marrow aspirate concentrate (BMC) are the most clinically translatable (and are already in clinical use) since they can be harvested using minimally invasive technology and do not require in vitro expansion. There is, however, significant potential for improving efficacy of BMSC treatment for OA. The number of senescent cells in BMC increases with age and OA, and these cells release pro-inflammatory cytokines/chemokines, proteases, and other senescence-associated secretory phenotypes (SASP) that can impair stem cell function and likely contribute to OA development/progression. Dr. Kirkland’s laboratory (co- investigator) has identified compounds that specifically kill senescent cells, abrogating systemic SASP factors. We have shown that these senolytic agents can delay OA in a preclinical model. We have also shown that blocking fibrosis with Losartan (a TGF-β1blocker) can improve cartilage repair by promoting regeneration of hyaline cartilage while reducing the amount of fibrocartilage. Thus, we hypothesize that administration of senolytic and/or anti-fibrotic agents will enhance the beneficial effect of BMSCs for treating OA. We propose to perform, a randomized clinical trial at The Steadman Clinic (TSC) and Steadman Philippon Research Institute (SPRI). This phase I/II trial will evaluate the safety and efficacy of Fisetin (a senolytic dietary supplement) and Losartan (an anti-fibrotic drug), used either individually or in combination, for improving the clinical efficacy of BMSCs in the treatment of knee osteoarthritis. The senolytic (Fisetin 1000mg/day, previously FDA IND approved) regimen will be cycles of 2 days on/28 days off, administered before and 3 months after BMSC treatment. The anti-fibrotic (Losartan, 25mg/day, previously IND-exempted) will be administered for 30 days starting immediately after BMSC treatment. OA knee joints will undergo MRI at baseline and 18 months post- treatment to assess changes in cartilage morphology and structure over time. Patient-reported outcomes for pain and function will be collected at baseline and 3, 6, 12 & 18 months. Joint and cartilage function will be assessed using video-motion analysis at baseline and 18 months. OA biomarkers related to cartilage degeneration, inflammation and pain will be assessed at baseline and 18 months. Blood and synovial fluid will be evaluated at baseline, 4 days and 18 months after treatment to assess changes in cellular senescence and OA biomarkers. This trial will build upon a currently active clinical trial on orthobiologics for OA treatment at SPRI (utilizing the same patient population and outcomes assessments), demonstrating the ability of our teams to perform the proposed study and also leveraging the combined trials to effectively provide a 6-arm, comprehensive assessment of biological therapies for improving treatment of OA.