Thalidomide Treatment Reduces
`Tumor Necrosis Factor a Production
`and Enhances Weight Gain in Patients
`with Pulmonary Tuberculosis
`
`Jane M. Tramontana,* Utaiwan Utaipat,*t Anthony Molloy,*
`Pasakorn Akarasewi,* Margaret Burroughs,*
`Sanit Makonkawkeyoon,t Barbara Johnson,*
`Jeffrey D. Klausner,§ William Rom,§ and Gilla Kaplan*
`*Laboratory of Cellular Physiology and Immunology, The Rockefeller
`University, 1230 York Avenue, New York, New York, U.S.A.
`tDepartment Microbiology and Faculty Medicine, Chiang Mai
`University, Chiang Mai, Thailand
`tChiang Mai Anti-TB Association, Chiang Mai, Thailand
`§Department Medicine and Pulmonary and Critical Care Medicine,
`New York University Medical Center, 550 First Avenue, New York,
`New York, U.S.A.
`
`ABSTRACT
`
`Background: The monocyte-derived cytokine, tumor
`necrosis factor a (TNFa), is essential for host immunity,
`but overproduction of this cytokine may have serious
`pathologic consequences. Excess TNFa produced in pul-
`monary tuberculosis may cause fevers, weakness, night
`sweats, necrosis, and progressive weight loss. Thalido-
`mide (a-N-phthalimidoglutarimide) has recently been
`shown to suppress TNFa production by human mono-
`cytes in vitro and to reduce serum TNFa in leprosy
`patients. We have therefore conducted a two-part place-
`bo-controlled pilot study of thalidomide in patients with
`active tuberculosis to determine its effects on clinical
`response, immune reactivity, TNFa levels, and weight.
`Materials and Methods: 30 male patients with active
`tuberculosis, either human immunodeficiency virus type
`1 positive (HIV- 1+) or HIV- 1 -, received thalidomide or
`
`placebo for single or multiple 14 day cycles. Toxicity of
`the study drug, delayed type hypersensitivity (DTH), cy-
`tokine production, and weight gain were evaluated.
`Results: Thalidomide treatment was well tolerated,
`without serious adverse events. The drug did not ad-
`versely affect the DTH response to purified protein de-
`rivative (PPD), total leukocyte, or differential cell counts.
`TNFa production was significantly reduced during tha-
`lidomide treatment while interferon--y (IFNy) produc-
`tion was enhanced. Daily administration of thalidomide
`resulted in a significant enhancement of weight gain.
`Conclusions: The results indicate that thalidomide is
`well tolerated by patients receiving anti-tuberculosis
`therapy. Thalidomide treatment reduces TNFa produc-
`tion both in vivo and in vitro and is associated with an
`accelerated weight gain during the study period.
`
`INTRODUCTION
`Tumor necrosis factor a (TNFa) is one of the
`important immunologic mediators generated by
`cells of the monocyte/macrophage lineage and
`
`Address correspondence and reprint requests to: Gilla
`Kaplan, The Rockefeller University, 1230 York Avenue,
`New York, NY 10021, U.S.A.
`
`has been shown to have significant effects on
`host immunity in bacterial and parasitic infec-
`tions (1). Tuberculosis is a chronic mycobacterial
`infection (of macrophages and monocytes) in
`which TNFa is characteristically produced. TNFa
`is present in the pleural effusions of patients
`tuberculosis, and
`infected with Mycobacterium
`monocytes isolated from patients with active dis-
`
`384
`
`Copyright © 1995, Molecular Medicine, 1076-1551/95/$10.50/0
`Molecular Medicine, Volume 1, Number 4, May 1995
`384-397
`
`ALVOGEN, Exh. 1005, p. 0001
`
`

`

`J. M. Tramontana et al.: Thalidomide Reduces TNFa in TB Patients
`
`385
`
`ease and systemic symptoms release elevated
`amounts of TNFa into the culture supernatant in
`response to stimuli (2-4). In vitro, mycobacterial
`preparations have been shown to induce TNFa
`production by human monocytes (5). TNFa is
`essential for granuloma formation (6,7), which is
`intimately associated with resistance against my-
`cobacteria (8).
`While production of TNFa is essential for
`host immunity, overproduction of this cytokine
`may have serious pathologic consequences. In
`experimental animals, high levels of TNFa in-
`duce fever by direct action on the hypothalamus
`(1), and long-term administration of this cyto-
`kine causes marked losses of fat and muscle cells
`or cachexia (9). Elevated levels of TNFa produced
`in pulmonary tuberculosis may be responsible for
`many of the pathologic symptoms of the disease,
`including fevers, weakness, fatigue, night sweats,
`lung necrosis, and progressive weight loss (10).
`The control of these pathologic effects of ex-
`cess TNFa production has received increasing at-
`tention. In animal models of gram-negative sep-
`sis, administration of either antibodies directed
`against TNFa or pharmaceutical agents that sup-
`press TNFa production, leads to reduced fevers,
`less wasting, and significantly decreased mortal-
`ity (11). One drug, thalidomide (a-N-phthalimi-
`doglutarimide), has recently been shown to sup-
`press TNFa production by human monocytes in
`vitro (12,13) and to normalize elevated levels of
`serum TNFa in vivo (12,14). The inhibitory ac-
`tivity of thalidomide is due to a selective desta-
`bilization of the TNFa mRNA (15); thalidomide
`selectively suppresses TNFa production in vitro
`without directly affecting the levels of other cy-
`tokines such as interleukin-1 (IL-1), IL-6, and
`granulocyte/macrophage-colony stimulating fac-
`tor (GM-CSF) (13).
`Since thalidomide inhibits but does not abol-
`ish TNFa production, thalidomide therapy might
`reduce the toxicities linked with overproduction
`of the cytokine, without interfering with its im-
`portant role(s) in host immunity. Recent studies
`have shown that thalidomide has prompt and
`dramatic effects when given to leprosy patients
`with erythema nodosum leprosum (ENL), in-
`cluding the elimination of the lesions, a decrease
`in inflammation, and general enhancement of
`patient well-being. These studies suggest that
`thalidomide may play a therapeutic role in tu-
`berculosis patients, where much of the pathology
`may be TNFa mediated, but where a normal
`immune response and granuloma formation is
`important in the control of the infection.
`
`In order to determine the effect of thalido-
`mide on TNFa levels and whether thalidomide
`treatment is associated with any untoward side
`effects, including drug toxicity or suppression of
`immune reactivity, we have conducted a two-
`part placebo-controlled pilot study of thalido-
`mide in patients with active tuberculosis. The
`results of our study indicate that thalidomide
`reduces TNFa production by peripheral blood
`mononuclear cells (PBMCs) in patients receiving
`anti-tuberculosis therapy without any adverse
`all
`patients
`effects.
`Furthermore,
`although
`showed the normal expected response to anti-
`tuberculosis therapy, only patients treated with
`thalidomide demonstrated significant increased
`weight gain during the study period.
`
`MATERIALS AND METHODS
`Study Drug
`Thalidomide (CG-217) was provided in 100-mg
`(Lot 204 and 206) by Grunenthal
`tablets
`GMBH (Aachen, Germany). Placebo tablets were
`also provided by Grunenthal GMBH (Aachen,
`Germany).
`
`Study Design
`A total of 30 male patients with active tubercu-
`losis, either HIV-1+ or HIV-1-, were studied.
`Twenty of the patients were studied in Chiang
`Mai, Thailand (Group I), and 10 were studied in
`New York City, U.S.A. (Group II). In Thailand,
`patients were evaluated at the Tuberculosis Cen-
`ter in Chiang Mai and admitted to the Tubercu-
`losis Sanitorium. In New York, patients were
`transferred from Bellevue Hospital to the Clinical
`Research Center (CRC) at the Rockefeller Uni-
`versity Hospital.
`All patients received 300 mg of thalidomide
`or placebo in tablet form (3 tablets) daily at bed-
`time. The Thailand patients received only a sin-
`gle 14-day cycle of thalidomide or placebo. In
`New York, after the first treatment cycle with
`thalidomide or placebo, Patients 25-30 were al-
`lowed a 7-day washout period and then treated
`with a second, third, and in some a fourth cycle
`of thalidomide or placebo. Of the 10 New York
`patients, one completed only 7 days of thalido-
`cycle
`of treatment
`mide during the initial
`(Patient 21); the remaining nine completed the
`full initial cycle of 14 days of thalidomide or
`placebo.
`
`ALVOGEN, Exh. 1005, p. 0002
`
`

`

`386
`
`Molecular Medicine, Volume 1, Number 4, May 1995
`
`Table 1 summarizes the pa-
`INCLUSION CRITERIA.
`tient characteristics. Patients were included in
`the study if they had acid fast organisms on
`sputum examination with eventual growth of M.
`tuberculosis in culture and met one or more of the
`following
`fever greater than 38°C;
`criteria:
`weight loss greater than 5 kg; night sweats; and
`evidence of pulmonary disease on chest X-ray
`consistent with tuberculosis. Patients were ex-
`cluded from the study if there was growth of
`mycobacteria other than tuberculosis or if pa-
`tients refused human immunodeficiency virus type
`1 (HIV- 1) testing. Also patients with pre-existing
`peripheral neuropathy were excluded, since this is
`a well-described side effect of thalidomide.
`
`All patients received
`CONCOMITANT THERAPIES.
`multidrug anti-tuberculosis regimens (MDT) as
`shown in Table 1. Anti-retroviral therapy was
`administered to the New York patients who were
`HIV- 1+ (Table 1) but was not available for the
`Thailand patients. The protocol was approved by
`the Institutional Review Board of the Rockefeller
`University Hospital and by the Ministry of Health
`in Thailand. Written consent was obtained for all
`patients.
`
`Evaluation of Patients
`All patients were evaluated by history and phys-
`ical exam at baseline, at multiple time points
`during the study, and after cessation of the drug.
`Vital signs, including weight, were obtained
`twice daily. In Thailand, complete blood counts
`with differentials and biochemistry profiles were
`obtained before, on Day 7 of treatment and 5
`days after the end of drug treatment. In New
`York, in addition to complete blood counts and
`biochemistry profile, laboratory evaluation in-
`cluded phenotyping of blood mononuclear leu-
`kocytes. Chest radiographs were obtained at
`baseline and after cessation of treatment with
`thalidomide or placebo. Delayed type hypersen-
`sitivity (DTH) was assessed by the response to
`intradermal injection of 0.1 ml of the tuberculin
`PPD (Mantoux, Connaught Laboratories, Inc.,
`Swiftwater, PA, U.S.A.) and quantitated after
`48 hr. DTH testing was performed at baseline, on
`Day 7 of treatment with drug or placebo, and 5
`days after discontinuation of thalidomide or pla-
`cebo. The size of the response is expressed as the
`mean of the two greatest diameters (in mm).
`Anergy testing was performed using the Multi-
`test skin test reaction (Connaught). Patients 20,
`23, 25, and 26 were not available for repeated
`
`skin testing. Complete caloric intake was re-
`corded for patients in New York (Group II) only.
`
`PBMC PHENOTYPING. PBMCs were isolated as pre-
`viously described (15). For indirect immunoflu-
`orescent staining, PBMCs were stained with a
`saturating amount of the following monoclonal
`antibodies: anti-CD3 (Leu-4), anti-CD4 (Leu-
`3a), anti-CD8 (Leu-2a), anti-CD19 (Leu-12)
`(Becton Dickinson, Mountain View, CA, U.S.A.),
`anti-CD56 (NKHI) (Coulter, Hialeah, FL, U.S.A.),
`and anti-CD14 (Ortho Diagnostics, Westwood,
`MA, U.S.A.). Cells were then analyzed with the
`Becton Dickinson FACScan flow cytometer.
`
`Tissue Culture
`PBMCs were isolated from blood obtained from all
`patients in the study and resuspended at a density
`of 2 x 106/ml in 2X culture medium (CM). CM
`consisted of RPMI 1640 (Gibco, Grand Island, NY,
`U.S.A.) supplemented with 10% pooled human
`AB+ serum (Biocell, Carson, CA, U.S.A.), 100 U
`penicillin/ml, 100 jig streptomycin/ml, and 2 mM
`L-glutamine (Gibco). Incomplete tissue culture re-
`sults were obtained for Patients 21-23 because of
`tissue culture contamination; not all assays were
`available for Patients 20 and 30.
`
`Cytokine Measurements
`
`IN VITRO.
`Bacterial preparations: The Pasteur
`Bacillus
`of Mycobacterium
`bovis
`1011
`strain
`Calmette-Guerin (BCG) (Ataufo de Paiva Foun-
`dation, Rio de Janeiro, Brazil), the purified pro-
`tein derivative (PPD) of M. tuberculosis for use in
`vitro (Statenseruminstitut, Copenhagen, Den-
`mark), synthetic muramyl dipeptide (MDP) (Sig-
`ma, St. Louis, MO, U.S.A.), and gram-negative
`lipopolysaccharide isolated from Salmonella typhi-
`murium (LPS) (List Biological Laboratories, Camp-
`bell, CA, U.S.A.) were obtained commercially.
`For induction of cytokines, 0.1 -ml aliquots of
`cell suspensions were added to each well of 96-
`well flat bottom tissue culture plates (Costar,
`Cambridge, MA, U.S.A.) containing 0.1-ml ali-
`quots of RPMI 1640 alone, or bacterial prepara-
`tions suspended in RPMI 1640, to give final con-
`centrations of 10 jig PPD, 10 ,ug BCG, 0.5 ,ug
`MDP, or 10 ng LPS per ml.
`Plates were incubated for 16 hr at 37°C, in
`5% CO2. Then enzyme-linked immunosorbent
`assays (ELISA) (Endogen, Boston, MA, U.S.A.),
`were performed according to the manufacturer's
`
`ALVOGEN, Exh. 1005, p. 0003
`
`

`

`J. M. Tramontana et al.: Thalidomide Reduces TNFxi in TB Patients
`
`387
`
`TABLE 1. Patient characteristics, clinical status, and therapies
`
`Study
`Druga
`
`HIV-1
`Status
`
`Age
`(years)
`
`Baseline
`Weight
`(kg)
`
`No. Lung Fields
`Involved"
`
`Medicationc
`
`+ +
`
`+ + + +
`
`t t t t t t t t t t t t p p t pt pt p
`
`Patient
`Number
`
`Thailand
`
`1 2 3 4 5 6 7 8 9 1
`
`0
`11
`12
`13
`14
`15
`16
`17
`18
`19
`20
`
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`RPE
`RIP
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`Rifater, E
`
`RIPE + Anti retroviral
`RIPE + Anti retroviral
`RIPE + Anti retroviral
`RIPE + Anti retroviral
`RIPE
`RIPE + Anti retroviral
`RIPE + Anti retroviral
`RIPE + CIP¶ + ETH¶
`RIPE + Anti retroviral
`RIPE
`
`6 4 4 4 4 4 1 2 3 1 3 2 2 4 S 5 1 1 3 N
`
`A
`
`1 2 1 3 3 2 3 3 1 2
`
`43
`51
`32
`65
`46
`60
`31
`38
`25
`25
`49
`38
`25
`53
`55
`64
`22
`46
`63
`42
`
`44
`37
`33
`45
`32
`35
`30
`38
`42
`46
`
`48.0
`49.0
`43.0
`40.5
`43.3
`41.3
`52.8
`48.3
`56.5
`49.5
`44.5
`50.5
`40.0
`50.0
`52.0
`49.0
`42.0
`63.3
`71.0
`58.0
`
`63.3
`71.0
`77.7
`76.5
`53.7
`66.5
`63.3
`74.5
`83.8
`89.6
`
`t t p p t
`
`;t;p;t
`t;t
`t;t
`t;t;p;t
`p;t;t
`t;p;t;p
`
`New York
`21
`22
`23
`24
`25
`26
`27
`28
`29
`30
`
`NA, not available; R, Rifampin; I, Isoniazid; P, Pyrazinamide; E, Ethambutol; CIP¶, Cipro for 16 days; ETH¶, Ethionamide for 16
`days.
`aPatients received either thalidomide (t), placebo (p), or multiple cycles of t or p in the sequence shown.
`bInfiltration, granulomas, or cavities present on chest X-ray: a total of six lung fields were evaluated and results given for each
`patient.
`'Rifater, Rifampin isoniazid pyrazinamide.
`
`ALVOGEN, Exh. 1005, p. 0004
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`

`388
`
`Molecular Medicine, Volume 1, Number 4, May 1995
`
`instructions on 0.1 -ml aliquots of culture super-
`natants, or of 10-fold dilutions of the same su-
`pernatants, to determine TNFa, IL-1, and inter-
`feron-y (IFNy) levels.
`All data points were
`derived from triplicate cultures.
`
`Sam-
`DIRECT ASSAY OF CYTOKINES IN PATIENT SERA.
`ples of serum obtained from the patients at the
`same time points as PBMCs were assayed directly
`for TNFa, IL- 1, and IFNy by ELISA (Endogen). All
`assays were performed in triplicate. Serum samples
`were also assayed for total TNFa (receptor bound
`as well as free bioactive TNFa) by a commercial
`EIA (Medgenix, Fleurus, Belgium) (16).
`
`Lymphocyte Transformation Tests
`Culture conditions for lymphocyte transforma-
`tion tests (LTTs) were identical to those described
`above except that U-bottom plates were used.
`After 5 days of incubation, 1 ,ACi of tritiated
`thymidine ([3H]) -TdR) (New England Nuclear,
`Boston, MA, U.S.A.) was added to U-bottom mi-
`crowells. Following a 16-hr incubation, wells
`were harvested onto paper mats which were
`thoroughly washed, dried, and immersed in scin-
`tillation fluid for counting ,B emission. Data is
`also presented as stimulation index (SI) calcu-
`lated as: (the cpm in the presence of stimulus)/
`(cpm in the CM alone).
`
`Quantitative Reverse Transcriptase-
`Polymerase Chain Reaction Analysis of
`Cytokine mRNA Levels
`Freshly isolated PBMCs obtained from all group
`II patients (New York) were used. RNA isolated
`from PBMCs obtained from Group I patients
`(Thailand) was partially degraded and not used
`for analyses. Reverse transcriptase-polymerase
`chain reaction (RT-PCR) for cytokine mRNA was
`carried out as described in detail elsewhere (17).
`Briefly, RNA was extracted from 4-6 X 106
`PBMC immediately after isolation using RNAzol
`B (Cinna/Biotecx, Houston, TX, U.S.A.) accord-
`ing to the manufacturer's instructions. Absorp-
`tion spectroscopy was used to measure purity
`and concentration of RNA with a A260/280 ratio of
`2.0 indicating highly purified RNA. RNA was
`reverse transcribed into cDNA which was then
`amplified using the Gene-Amp RNA-PCR kit
`(Perkin Elmer Cetus, Norwalk, CT, U.S.A.) with
`30 cycles of 950C for 1 min (denaturation) and
`60°C for 1 min (primer annealing and exten-
`sion). To normalize for the amount of input
`
`RNA, RT-PCR was performed on the constitu-
`tively expressed gene encoding glyceraldehyde
`phosphate dehydrogenase (GA3PD). PCR prod-
`ucts were electrophoresed and transferred to ny-
`lon membranes (Zetabind, Cuno, Inc., Meriden,
`CT, U.S.A.). After prehybridization, membranes
`were hybridized with 5 X 105 cpm/ml of 32p-
`labeled oligonucleotide probes for 8-12 hr at
`40°C. After washing, membranes were exposed
`to X-ray film (Hyperfilm-MP, Amersham Corp.,
`Arlington Heights, IL) at room temperature with
`an intensifier screen. Quantitative analysis by
`comparison with known standards, and primer
`and probe sequences have been detailed (17).
`
`Statistical Analysis
`Data obtained were evaluated by the Wilcoxon
`signed rank test (two-sided test), or by the Stu-
`dent's paired sample t test. p values of 0.05 or less
`were considered significant.
`
`RESULTS
`Drug Tolerance and Adverse Effects
`At the inception of the study, 10 male patients
`(Table 1) were enrolled in Group I (Thailand).
`The patients had been recently diagnosed with
`active tuberculosis and all began anti-tuberculo-
`sis treatment with MDT simultaneously or
`within a few days of treatment with thalidomide.
`All patients received one 14-day cycle of thalid-
`omide, as described in Materials and Methods.
`The thalidomide treatment was well tolerated.
`No peripheral neuropathy, excessive sedation, or
`other adverse events were observed. The only
`side effects noted were morning drowsiness, dry
`mouth, and constipation. In addition, all patients
`responded well to concomitant anti-tuberculosis
`therapy and showed clinical improvement.
`Since there were no adverse effects, approval
`was granted for enrollment of an additional 10
`patients in the study (in Thailand). These 10
`additional male patients (Table 1) were random-
`ized to receive either thalidomide or placebo. All
`patients completed the 14-day cycle of thalido-
`mide or placebo treatment. Administration of
`either thalidomide or placebo did not result in
`any clinical or radiographic deterioration in any
`of the patients. Again, clinical improvement was
`noted after beginning anti-tuberculosis therapy.
`One patient (Patient 6, Table 1) developed a
`macular rash which resolved with discontinua-
`
`ALVOGEN, Exh. 1005, p. 0005
`
`

`

`J. M. Tramontana et al.: Thalidomide Reduces TNFa in TB Patients
`
`389
`
`TABLE 2. Delayed type hypersensitivity
`response to PPD during first cycle of studya
`
`Skin Test Response to PPD
`(mm)b
`
`Mid
`
`Post
`
`24.0
`18.5
`20.5
`24.5
`16.5
`NDC
`21.5
`13.0
`17.0
`26.0
`31.0
`10.0
`23.0
`17.0
`16.0
`ND
`12.0
`17.0
`ND
`ND
`ND
`18.0
`17.5
`10.0
`
`0 0 0
`
`11.5
`
`0 N
`
`D
`
`20.5
`25.0
`16.0
`18.0
`12.0
`65.0
`14.5
`18.0
`26.0
`21.0
`22.0
`18.0
`22.5
`20.5
`18.0
`ND
`15.5
`19.0
`ND
`ND
`ND
`14.5
`12.5
`14.0
`
`9.5
`19.5
`12.5
`9.0
`
`0
`19.0
`
`Pre
`
`26.5
`14.0
`19.0
`16.5
`14.0
`23.5
`18.5
`14.5
`19.5
`15.0
`26.5
`16.0
`26.0
`20.0
`15.5
`ND
`11.0
`22.0
`ND
`ND
`19.0
`13.0
`13.0
`18.0
`
`0 0 0 0 0 0
`
`Patient
`Number
`
`PPD+
`
`1 3 4 6 7 9
`
`11
`12
`1 3d
`14d
`15
`16d
`18d
`19
`20d
`21
`22
`23d
`25
`26
`27
`28
`29d
`
`PPD-
`
`2 8
`
`10
`17
`24d
`30
`
`aPatients in Thailand and New York were skin tested 3X
`during the first cycle of study.
`bMean diameter of the indurated area at 48 hr after 5 u
`PPD administration. Diameter >10 mm is termed PPD+.
`CND, not done.
`dPatients received placebo during the first cycle of study.
`
`tion of isoniazid and hence was not associated
`with thalidomide treatment.
`This phase of the study established that a
`single 14-day cycle of thalidomide treatment was
`well tolerated and did not induce untoward side
`effects. We then received (FDA and IRB) ap-
`proval to extend the studies for multiple cycles of
`thalidomide treatment. Therefore, an additional
`10 male patients, ages 30 to 46, (Group II) were
`enrolled in the study in New York (Table 1). All
`had been diagnosed with active tuberculosis, and
`had received anti-tuberculosis therapy for 1-4
`weeks prior to their entry into the study. During
`the study, 4 patients (Patients 21-24, Table 1)
`received a single cycle of thalidomide or placebo;
`the remaining 6 patients (Patients 25-30, Table
`1) received multiple cycles of thalidomide and/or
`placebo (Table 1). All patients in Group II (New
`York) responded well to thalidomide treatment;
`there were no adverse responses in either the
`thalidomide- or placebo-treated patients, except
`for sedation, dry mouth, and constipation, as
`previously noted.
`
`Effect of Thalidomide Treatment on
`Delayed Type Hypersensitivity
`Delayed type hypersensitivity (DTH) was as-
`sessed in each patient by the skin test response to
`soluble antigen. The response to PPD was quan-
`titated before, during, and after therapy to deter-
`mine the effect of thalidomide on cell mediated
`immunity. At Day 0 (baseline) before the first
`cycle of thalidomide or placebo treatment, 21
`patients were PPD+ while 6 patients were PPD
`(nonresponsive) (Table 2). Treatment with tha-
`lidomide did not alter the DTH response to PPD
`in patients who were already PPD+ (Table 2).
`However, in the five patients who were nonre-
`sponsive to PPD at the beginning of the treat-
`ment cycle, thalidomide administration was as-
`sociated with a significantly enhanced DTH
`reaction. This responsiveness returned to base-
`line after discontinuation of thalidomide in three
`of the patients. Both HIV- 1 - and HIV- 1 + showed
`similar DTH patterns in response to thalidomide
`treatment.
`Reactivity to the Connaught panel of anti-
`gens was also tested. Responses to Old Tubercu-
`lin were similar to those observed with PPD (not
`shown). No patient became anergic to this or any
`other antigen during the course of the study.
`
`ALVOGEN, Exh. 1005, p. 0006
`
`

`

`390
`
`Molecular Medicine, Volume 1, Number 4, May 1995
`
`TABLE 3. White blood cell counts and differentials
`
`Thalidomide
`HIV+
`
`HIV
`
`Placebo
`HIV+/1
`
`Cell Count per mm3 of Blood (mean ± SD)
`
`Total WBCs
`
`Lymphocyte
`
`Monocyte
`
`Eosinophil
`
`pre
`mid
`post
`
`pre
`mid
`post
`
`pre
`mid
`post
`
`6765 ± 2286
`6403 ± 2489
`6331 ± 1564
`
`8435 ± 3519
`7560 ± 2402
`6941 ± 1735
`
`7573 ± 3289
`6806 ± 3035
`6588 + 4012
`
`1700 ± 927
`1438 ± 669
`1784 ± 1165
`
`1762 ± 876
`2402 ± 1294
`2310 ± 801
`
`1699 ± 440
`2140 ± 1019
`2024 ± 806
`
`359 ± 276
`320 ± 237
`427 ± 273
`
`579 ± 367
`393 ± 301
`454 ± 393
`
`616 ± 392
`336 ± 198
`282 ± 170
`
`318 ± 247
`463 ± 562
`703 ± 562
`
`513 ± 492
`524 ± 613
`445 ± 451
`
`195 ± 151
`317 ± 321
`178 ± 167
`
`Results are means ± one standard deviation (SD) evaluated before (pre), during (mid), and 5 days after (post) 14-day treatment
`cycles with 300 mg/day of thalidomide or placebo (see Table 1). No significant changes were observed. WBC, white blood cells.
`
`Effect of Thalidomide Treatment on Blood
`Parameters
`Complete blood counts and differential analyses
`were performed on all patients receiving thalid-
`omide or placebo. Thalidomide treatment did not
`cause any significant changes in total leukocyte
`count or differential cell count (Table 3). Fluo-
`rescence-activated cell analysis (FACS) of leuko-
`cyte subsets was also carried out during the study
`in New York (Group II patients). No significant
`effect on subset distribution was observed either
`in thalidomide- or placebo-treated patients, re-
`gardless of whether patients were HIV-1- or
`HIV-1+ (not shown). The percent of leukocyte
`or HIV- 1+
`subsets was similar in both HIV-1
`patients receiving either placebo or thalidomide
`treatment. There was, however, a slight increase
`in CD8+ T cells in HIV- 1+ patients compared
`with HIV- 1
`patients.
`
`Lymphocyte Function in Vitro
`PBMCs were isolated from all patients prior to,
`on Day 7, and after thalidomide or placebo ad-
`ministration, and the proliferation in vitro in
`response to PPD and BCG was determined. Tha-
`lidomide did not significantly affect the ability of
`the cells to incorporate [3H] -TdR in response to
`
`the antigens tested (Table 4) although some fluc-
`tuations in the stimulation index were observed.
`HIV- 1+ patients were still responsive to PPD in
`vitro. This responsiveness was not significantly
`altered by treatment with thalidomide (Table 4).
`
`Effect of Thalidomide Treatment on
`Cytokine Production
`
`To determine whether thalid-
`IFNy PRODUCTION.
`omide treatment reduced the ability of the host
`to produce protective cytokines in response to
`infection, IFNy production was evaluated both in
`vivo in the blood of thalidomide and placebo
`treated individuals and in vitro, in PBMCs.
`
`Patients treated with thalidomide had
`In vivo.
`significantly enhanced serum IFNy levels after 7
`days of the first cycle of thalidomide treatment
`(Fig. 1). The serum IFNy levels returned to base-
`line upon discontinuation of drug. In contrast,
`there was no increase in serum IFNy levels in
`patients treated with placebo (Fig. 1).
`
`In
`vitro. When PBMCs isolated from patients
`were stimulated with PPD, IFNy was released
`into the culture medium (Fig. 1). Similar results
`
`ALVOGEN, Exh. 1005, p. 0007
`
`

`

`J. M. Tramontana et al.: Thalidomide Reduces TNFa in TB Patients
`
`391
`
`TABLE 4.
`
`Proliferative response of PBMC to PPD and BCG
`
`Lymphocyte Proliferation-counts per minute (stimulation index)
`
`Thalidomide
`
`HIV+ CPM
`(SI)
`
`704 ± 337
`2264 ± 4694
`1487 ± 1694
`
`38253 ± 38987
`(60 ± 64)
`49341 ± 46031
`(52 ± 56)
`44077 ± 43822
`(56 ± 61)
`
`32879 ± 36725
`(42 ± 37)
`44767 ± 54076
`(42 ± 58)
`40172 ± 42663
`(43 ± 50)
`
`HIV- CPM
`(SI)
`
`1239 ± 1028
`2620 ± 2949
`1140 ± 664
`
`57926 ± 41427
`(64 ± 46)
`44717 ± 23963
`(34 ± 31)
`53078 ± 31411
`(59 ± 44)
`
`22096 ± 28567
`(28 ± 36)
`23788 ± 17519
`(23 ± 32)
`23259 ± 17060
`(26 ± 19)
`
`Placebo
`
`HIV+/ CPM
`(SI)
`
`1037 ± 524
`1158 ± 664
`1632 ± 1376
`
`51878 ± 33764
`(63 ± 50)
`60007 ± 28475
`(80 ± 75)
`52682 ± 43678
`(63 ± 52)
`
`26777 ± 18977
`(32 ± 26)
`34200 ± 29931
`(42 ± 53)
`27891 ± 32902
`(33 ± 36)
`
`Controls:
`pre
`mid
`post
`
`PPD:
`pre
`
`mid
`
`post
`
`BCG:
`pre
`
`mid
`
`post
`
`Results are means ± one standard deviation (SD) of counts per minute (stimulation indexes) of proliferative responses to antigen
`stimulation of PBMC tested before (pre), during (mid), and 5 days after (post) treatment with thalidomide or placebo (see
`Table 1). No significant changes were observed.
`
`were observed when PBMCs from patients were
`stimulated with BCG (Table 5), but not with LPS
`or MDP (not shown). Thalidomide treatment in
`vivo enhanced the release in vitro of IFNy by
`PBMCs in response to mycobacterial antigens
`regardless of the patient's HIV status. The height-
`ened response to both BCG and PPD was tran-
`sient, and IFNy levels returned to baseline levels
`after discontinuation of thalidomide treatment
`(Fig. 1 and Table 5). Thalidomide treatment did
`not appreciably alter levels of IFN'y mRNA ex-
`pressed in freshly isolated PBMC (not shown).
`Placebo treatment had little effect on PPD- and
`BCG-stimulated release of IFNy by PBMCs (Fig. 1
`and Table 5).
`
`TNFa PRODUCTION.
`
`To determine whether treat-
`
`ment with thalidomide caused changes in pro-
`duction of inflammatory cytokines, PBMCs were
`stimulated with a variety of agonists in vitro. In
`one series of experiments, PBMCs isolated from
`all patient bloods during the first treatment cycle
`were treated with LPS in vitro, and TNFa re-
`leased into the culture supernatant was quanti-
`tated. At the midpoint of thalidomide treatment
`(7 days), there was a reduction in TNFa levels
`released by LPS stimulated PBMCs when com-
`pared with the prestudy levels (Fig. 2). The in-
`hibitory effect of thalidomide treatment on TNFa
`production was observed in HIV- 1+ as well as
`patients. Thalidomide treatment also re-
`HIV- 1
`duced the amount of TNFa produced in vitro in
`response to BCG (Table 5) and PPD (not shown).
`The thalidomide-induced reduction of TNFa re-
`
`ALVOGEN, Exh. 1005, p. 0008
`
`

`

`392
`
`Molecular Medicine, Volume 1, Number 4, May 1995
`
`LL
`
`z '
`
`a 0
`
`-aC
`CO
`0.
`-J
`
`Pre
`
`Mid
`
`Post
`
`Pre
`
`Mid
`
`Post
`
`Thalidomide Treatment
`
`Placebo Treatment
`
`FIG. 2. The effect of thalidomide treatment on
`TNFa production in vitro
`TNFa levels were evaluated by ELISA in the super-
`natants of PBMCs obtained from 12 HIV-1- and 10
`HIV-1 + patients treated with MDT and 300 mg/day
`of thalidomide (left) and eight patients (5 HIV- 1-)
`treated with MDT and placebo (right). PBMCs ob-
`tained before (Pre) on Day 7 of treatment (Mid) and
`5 days after (Post) the first cycle of treatment were
`stimulated with LPS and culture supernatants were
`collected for assay. Results are means ± one SEM
`for samples obtained from all patients tested. TNFa
`levels were significantly lower during treatment with
`thalidomide relative to levels before (p = 0.001) or
`after (p = 0.002) thalidomide.
`
`and waned when thalidomide treatment ended,
`a group of patients from Group II was treated
`with a second 14-day cycle of thalidomide after a
`7-day washout period. When PBMCs were ob-
`tained from patients during the second cycle of
`thalidomide treatment and stimulated with LPS,
`the effect on TNFa levels was reproduced (Fig. 3).
`To test whether the thalidomide-induced
`capacity
`of
`TNFa-producing
`reduction
`in
`PBMC was correlated with lower circulating
`patients, serum TNFa
`the
`TNFa levels
`in
`levels were measured during two consecutive
`14-day cycles of thalidomide treatment (with
`washout periods between treatment cycles).
`When serum from patients was assayed for
`TNFa during repeated cycles of thalidomide
`a decrease in serum TNFa was
`treatment,
`observed at the midpoint of each thalidomide
`3). In addition, mRNA was
`treatment (Fig.
`isolated from unstimulated PBMCs of patients
`thalido-
`cycles
`sequential
`of
`receiving
`the
`mide treatment. Analysis of levels from unstimu-
`lated PBMC during thalidomide
`treatment,
`showed decreases in the number of copies of
`TNFa mRNA, mirroring the decrease in serum
`TNFa levels (Fig. 3).
`
`0
`
`E
`
`o
`
`*
`
`I7'
`
`50-
`
`40-
`
`30-
`
`20-
`
`I-J
`.nIV
`-I
`
`1400-
`
`1200-
`
`1000-
`
`800-
`
`600-
`
`400-
`
`E U
`
`-
`
`IL
`
`0)
`n)
`
`U-
`-o
`~0
`0
`0_
`0~
`
`C-
`
`Pre
`
`Mid
`
`Post
`
`Thalidomide/Placebo Treatment
`
`FIG. 1. The effect of thalidomide treatment on
`IFNy production
`IFN,y levels were evaluated by ELISA in the serum of
`patients (top) and in the supernatants of PBMCs ob-
`tained from patients and stimulated in vitro with
`PPD (bottom). (Top) 14 patients were treated for 14
`days with 300 mg/day of thalidomide (U). Serum
`levels were significantly higher after 7 days on the
`drug (Mid) relative to the pretreatment time point
`(p = 0.05) and significantly lower after discontinua-
`tion of treatment (Post) (p = 0.005). Ten patients
`were treated with MDT and placebo (O). (Bottom)
`release of IFNy into the culture supernatants by pa-
`tient PBMCs stimulated in vitro with PPD before,
`during, and after thalidomide (0) or placebo treat-
`ment (0). Results are means ± one SEM.
`
`lease was transient, and, for most patients, levels
`of cytokine released by the cells returned to base-
`line or higher after thalidomide treatment was
`discontinued (Fig. 2 and Table 5). It is notewor-
`thy that cells from patients receiving placebo
`failed to show any reduction in TNFa release at
`the midstudy time point, regardless of their
`HIV-1 status (Fig. 2 and Table 5).
`Since the effect of thalidomide treatment on
`TNFa release by the cells in response to LPS was
`most pronounced at the midpoint of treatment
`
`ALVOGEN, Exh. 1005, p. 0009
`
`

`

`J. M. Tramontana et al.: Thalidomide Reduces TNFai in TB Patients
`
`393
`
`TABLE 5. BCG induced cytokine production by PBMC
`
`Thalidomide treatment (n = 18)"
`
`Placebo treatment (n = 8)a
`
`Cytokine
`
`Pre
`
`Mid
`
`Post
`
`Pre
`
`Mid
`
`Post
`
`TNFa
`IFNy
`
`1871 ± 601
`218 ± 122
`
`1274 ± 565
`549 ± 330
`
`2504 ± 793
`218 ± 58
`
`1875 ± 797
`197 ± 69
`
`2283 ± 775
`236 ± 79
`
`1815 ± 790
`231 ± 55
`
`TNFa and IFNy levels were assayed by ELISA (as described in Materials and Methods) in the supernatants of PBMCs obtained
`from patients treated with either thalidomide or placebo. Results are expressed as pg/ml.
`'The means for the number of patients shown in the parentheses ± SEM are given.
`
`IL-1 PRODUCTION. TNFa and IL- I are usually pro-
`duced by PBMC in response to the same stimuli
`in vitro (e.g., LPS). Since thalidomide treatment
`of tuberculosis patients reduces the capacity of
`
`PBMC to release TNFa, it was important to de-
`termine whether the production of other inflam-
`matory cytokines, such as IL-1, was similarly
`affected. We therefore examined the plasma and
`PBMC for production and release of IL-1. IL-1
`was not detected in either plasma or serum from
`patients receiving