Augmenting the Persistence and Efficacy of Engineered Regulatory T Cells to Suppress Anti-Drug Antibody Formation

Background Adoptive cell therapy (ACT) using engineered antigen specific regulatory T cells (Tregs) is a powerful tool for delivering immune tolerance in autoimmune disease, transplantation and in suppressing undesirable anti-drug antibody (ADA) responses against therapeutic proteins. An important example of the latter is hemophilia A (HA), a genetic disorder characterized by deficiency of the blood clotting protein, factor VIII (FVIII). Replacement therapy with recombinant FVIII can be neutralized by ADA development in up to 30% of severe HA patients. We previously showed that ACT with Tregs expressing a chimeric CD3ε based T cell receptor fusion construct (TRuC), encoding extracellular antibody fragments with specificity to human FVIII, suppressed ADA formation to FVIII in a preclinical HA model [Mol Ther. 2021 29(9):2660-2676].

Ensuring adequate in vivo persistence and a suppressive phenotype without risk of plasticity are major concerns that impede translation of ACT with engineered Tregs. Here we evaluate a synthetic single chain antibody fusion IL2 cytokine product (IL2-IC) to selectively expand adoptively transferred FVIII-TRuC Tregs in vivo. We then combine IL2-IC delivery with FVIII-TRuC Tregs expressing the co-inhibitory receptor PD-L1 to test improved suppression to ADA formation.

Methods IL2-IC was generated by fusing IL-2 cytokine to the anti-IL-2 monoclonal antibody F5111 via a flexible linker. This complex specifically delivers IL2 to cells that express high levels of IL2 receptor α (IL2Rα) (i.e., Tregs) while avoiding interaction with cells that express low levels (i.e., Tconv, NK and CD8+ T cells). To assess whether IL2-IC could expand TRuC Tregs in vivo, 2x10⁶ FVIII TRuC Tregs were injected intravenously (IV) into HAmice followed 5 hrs later with low dose IL2-IC or IL2 fused to an irrelevant Ab (FITC-IC) as control. 24 hrs later, mice received 2 international units (IU) of FVIII, and spleens were assayed on days 3 and 6.

Murine PD-L1 was co-expressed in FVIII TRuC Tregs and in vitro assessed by stimulating TRuC PDL1 Tregs with 2IU FVIII alone or in combination with 2 ug/ml of PD1-Fc to understand the impact of PDL1 signaling on the Treg phenotype. In vivo, 0.5x10⁶ FVIII TRuC PD-L1 Tregs were IV injected in HAmice followed 5 hrs later by mock, IL2-IC or FITC-IC IV injections. 24 hrs later, mice received weekly IV injections of 1IU FVIII.

Results IL2-IC treated FVIII TRuC Tregs were preferentially expanded over endogenous Tregs (fold expansion 7.47 vs 4.56 respectively) in spleens on day 3 post ACT. Whereas both IL2-IC and FITC-IC treated FVIII TRuC Tregs had higher division indices over mock treatment (4.047 ± 0.03 and 5.070 ± 0.07 over 2.00 ± 0.00), only IL2-IC treated FVIII TRuC Tregs showed increased frequencies (1.72% ± 0.376% of CD4+ T cells) as compared to FITC-IC (0.28% ± 0.005% of CD4+ T cells) or mock treatment (0.23% ± 0.023% of CD4+ T cells). FITC-IC treatment nonspecifically expanded CD8+ Tconv cells as well as NK cells, whereas IL2-IC selectively expanded Tregs.

PD1-Fc triggered PD-L1 signals in FVIII stimulated TRuC Tregs resulted in significant upregulation of Treg associated activation markers FoxP3, CD69, LAP, CTLA4, PD1, ICOS and BCL2 in vitro. In vivo, IL2-IC administration combined with FVIII TRuC PD-L1 ACT led to complete suppression of ADA formation in HA mice. At 4 weeks, mice that only received FVIII infusions developed high functional ADA titers (29.53 ± 19.58 BU/mL), while IL2-IC, TRuC PDL1 Treg and TRuC PDL1 Treg + IL2-IC groups had significantly lower titers of 1.117 ± 0.952 BU/mL, 1.805 ± 0.702 BU/mL and 0.423 ± 0.243 BU/mL, respectively. FITC-IC combined with PDL1 TRuC Tregs resulted in high ADAs of average 109 ± 21.31 BU/mL, confirming the requirement for the IL2Rα targeting antibody to selectively expand Tregs.

Conclusion We show that the PD-L1/PD1 axis is an important pathway that can be exploited to improve the suppressive capacity of engineered Tregs. We also demonstrate that exogenous administration of the novel IL2-IC can robustly expand FVIII TRuC Tregs. These 2 strategies can be readily combined to selectively expand and enhance the suppressive capacity of engineered Tregs. The concepts defined here can be extended for improving the persistence and suppressive potential of engineered Tregs for various autoimmune disorders and to prevent transplant rejection. We are currently evaluating long term suppression of ADA responses using this approach.

Rana:Bayer Pharmaceutic company: Research Funding. VanDyke:John Hopkins University: Other: filed intellectual property concerning the technology. Spangler:John Hopkins University: Other: filed intellectual property .