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，也是开发新药的障碍。在英国，大约有1 / 16的住院患者是由于某种形式的药物不良反应。其中一个最著名但最不为人所知的药物副作用是t淋巴细胞介导的过敏反应。就药物的化学性质和病人的生物学特性而言，这种反应是不可预测的。CFTR调节疗法现在广泛用于双重或三重治疗，这些疗法已将囊性纤维化（CF）转变为一种较轻的疾病。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。本研究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CFTR调节剂治疗患者的临床结果联系起来。我们的方法将为更有效地评估对这类重要药物过敏的患者提供一个框架。通过在重新引入CFTR调节剂治疗期间收集血液样本，我们将定义药物特异性t细胞反应在治疗期间如何发展以及调节效应t细胞反应的途径。t细胞参与决定药物暴露是否会导致过敏反应的决策过程。因此，利用来自皮肤和肝脏反应患者的PBMC和药物反应性克隆t细胞，我们将定义超敏表型并确定药物特异性t细胞激活途径。这些数据将确定与不良事件相关的药物，并提供有关疾病发病机制的宝贵信息。结果将与de-novo启动实验进行比较，并用于不良事件患者的分层。对患者细胞的分析虽然很重要，但却不能提供有关原代t细胞反应的信息。因此，我们将利用我们的健康供体HLA基因型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调节剂药物特异性刺激naïve/记忆t细胞的特性，评估前光标t细胞频率和药物特异性t细胞的表型和功能。从CF患者（有或没有CFTR调节剂治疗过敏症）获得PBMC库将使我们能够进行基于HLA序列的基因分型。任何关联都将使我们能够确定特定HLA分子在CFTR调节剂药物向t细胞呈递中的作用，并可能为药物使用前的基因检测铺平道路。我们最近利用质谱法来表征药物、药物代谢物和药物蛋白加合物，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量化人血浆中CFTR调节剂药物和代谢物水平，并将暴露与患者结果（健康益处或不良事件）联系起来。类似的方法将用于评估CFTR调节剂药物在免疫细胞共培养系统中表达HepG2细胞的CYP3A4代谢，以将代谢物的形成与人类t细胞的激活联系起来。一些免疫证实不良事件的患者将被提供替代疗法或减少剂量的相同疗法，或通过药物激发或药物脱敏。将在治疗之前、期间和之后进行血液采样，以探索：(i)药物特异性效应t细胞反应如何发展；（ii）效应和调节性细胞因子的表达，（iii）通过Tregs和共抑制分子的功能进行抑制。一旦我们开发出一种强有力的评估方法，将对CFTR调节剂治疗不良事件的个体患者进行风险分层，它就可以应用于其他患者群体，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.