Final Report Summary - DIABIL-2 (Ultra-low dose of IL-2 for the treatment of recently diagnosed type 1 diabetes)
Executive Summary:
Type 1 Diabetes (T1D) disease is caused by the immune-mediated destruction of the pancreatic islet ß-cells, leading eventually to insulin deficiency. The development of autoimmunity precedes the clinical diagnosis of T1D and is due in large part to the inability of regulatory T cells (Treg) to block the destruction of pancreatic ß-cells. Treg stimulation has the potential to stop the process, preserve ß-cells’ insulin secretion, and likewise prevent or delay disease progression and improve clinical outcome for patients.
Low-dose interleukin-2 (ld-IL2) was recently shown to directly and specifically stimulate Tregs. In diabetic mouse model (NOD mice), ld-IL2 can prevent and cure T1D. In humans, we reported that (i) ld-IL2 is safe, induces Tregs and is associated with clinical improvement in patients with autoimmune vasculitis; and (ii) a dose-finding study in T1D defined an ultra-low dose IL-2 (uld-IL2) that is well tolerated and induces Tregs’ numbers and functionality.
In this context, DIABIL-2 aims at testing the efficacy of low dose Interleukin 2 for preventing or delaying T1D progression in newly diagnosed patients. Indeed, at the time of T1D clinical diagnosis, there are still remaining ß-cells capable of producing insulin, and halting the immune destruction at this stage should have significant therapeutic benefit.
DIABIL-2 is a double-blind, randomised, placebo-controlled, stratified on age from 6 to 35 years, parallel-group, multicentre European phase-IIb clinical trial. The efficacy and safety of ld-IL2 is evaluated in 138 recently-diagnosed T1D patients. The methodology used strictly followed the Immunology of Diabetes Society consensus recommendations and European regulatory guidelines.
The clinical trial was successfully implemented and all regulatory authorizations obtained in Belgium, Switzerland, Germany, Sweden, France and The Netherlands and 30 recruitments sites have been set up. The IL2 drug substance was produced and validated for EU release. The compliance of Good Clinical Practice and Good Clinical Laboratory Practice was enforced. The recruitment of children was defined within a Paediatric Investigational Plan (PIP) procedure that was defined with the Paediatric Committee of the European Medicinal Agency to define how children and adolescents should be recruited and assessed within the overall clinical development.
During the trial, samples were collected and sent to two centralized laboratories: one central laboratory (EUROFINS, Breda the Netherlands) evaluates plasma C-peptide, HbA1c and plasma glucose that are key parameters of clinical efficacy; a second central laboratory (Centre d’Investigation Clinique de Biothérapie (CICBT), Paris, France) performs immunological investigations including cytometry, dosage of inflammatory cytokines, Tregs functionality in vitro and dosage of anti-ILT-101 antibodies. A standardized procedure to perform staining of Tregs by flow cytometry on fresh whole blood on-site have been successfully implemented across Europe in 15 immunology labs involved in the trial.
The initiation of the trial has been delayed by the need to re-formulate IL2 at the suitable dosage such as to avoid that patients had to come to the hospital for each injection. Then, additional delay came from the waiting time for approval from the regulatory authorities for the treatment of children between 6 to 11 years. This was totally unexpected as an authorization for such patients had previously been obtained from the French regulatory authorities. Finally, despite our best efforts, patient recruitment has been much slower than anticipated. This is in large part due to poor acceptance for participating to a placebo controlled trial, with many visits, by patients (or their parents) at the time they just learned that they have a chronic disease. Altogether, and despite a first extension of the project duration, it appeared that we would not be able to complete the trial in the planned time. Given that all the pitfalls and drawbacks had now been successfully overcome - with the trial now being well on track with 129/141 patients already randomized and a steady recruitment of approximately 3 patients/month. As a second time extension of the project was not granted, DIABIL-2 results could not be delivered at the end of the program.
We are now seeking additional external support by charities and institutional partners. We are optimistic that the trial will be completed. This is of utmost importance for the patients who gave their consent and their commitment to a placebo-controlled trial, and for the scientific community that much awaits these results concerning a molecule which mode of action is at the center of T1D pathophysiology. This is also of utmost importance as ultimately ld-IL2 as a strong potential for the prevention of T1D that would only be tested after positive clinical and safety results from DIABIL-2.
Project Context and Objectives:
Type 1 Diabetes is one of the most common severe chronic autoimmune diseases (AIDs) worldwide. In Europe its incidence is rapidly rising in children, with a predicted 70% increase in cases over the next 15 years. It affected more than 3 million individuals in Europe, the majority of them diagnosed in childhood or adolescence with a predicted doubling of cases in children under the age of 5 years in the same period.
The discovery of Tregs has revolutionized our understanding of autoimmune diseases. As T1D is caused by the failure of Tregs to block autoimmune destruction of pancreatic ß-cells, Treg stimulation has the potential to stop the process, preserve ß-cells’ insulin secretion, and likewise prevent or delay disease progression and improve clinical outcome for patients.
The main aim of DIABIL-2 project is to undertake a major clinical trial in T1D patients with a focus on children and adolescents with newly diagnosed disease in order to improve glycaemic control and management of the disease.
This is a double-blind randomised placebo-controlled, age-stratified (6-35 year), multicentre European trial assessing efficacy and safety of uld-IL2 (0.5M IU/m2/day with a maximum of 1 M IU/m2/day for adult patients) in 138 recently-diagnosed T1D patients. The primary end-point is to preserve remaining endogenous insulin secretion at 1 year as measured by the C-peptide AUC during a mixed meal tolerance test (MMTT). The trial is precisely and conservatively powered to detect an effect size of d=0.5.
The ancillary objectives of the project were:
• to further investigate response to ultra-low dose IL-2 by molecular phenotyping using genetics, genomics, transcriptomics and cutting-edge immunological methods for future stratification of individualized patient care
• to validate urinary C-peptide assay as a non-invasive endpoint in T1D trials
• to strengthen basic-clinical European Scientific Excellence by the dissemination of landmark results and the foundation of a European network of excellence operating in the T1D field
• to contribute to the competitiveness of the European Industry by valorising IL-2 development, generating novel intellectual property and exploiting it.
The consortium comprised 5 partners, including 3 academic partners (Assistance Publique-Hôpitaux de Paris (APHP), France; Leiden University Medical Center (LUMC), The Netherlands; University Hospital of Basel (UHB), Switzerland), one SME (ILTOO-biotech, France) and a project management partner (Inserm Transfert, France).
The programme was divided into six work packages (WPs) with the specific objectives detailed below.
WP1: Management and coordination of the consortium
WP1 was dedicated to the management activities and dealt with all usual and contractual administrative tasks (financial, reporting, organisation of consortium and ExCom meetings). These included the following activities:
• Coordinating the project’s administrative and financial issues as defined by the European Commission (by acting as a permanent helpdesk for all partners to answer their questions)
• Informing each partner, including the EC, about the project status, emerging issues, the work planning (adjustments) and all other aspects which are important and relevant for obtaining maximum transparency and achieve synergy of the cooperation
• Assisting the interface between the coordinator and the European Commission
• Organizing and facilitating the consortium and ExCom meetings during the course of the project (agenda, date, place, logistic, minutes)
• Developing and updating effective communication channels within and outside the consortium (address book, public and private websites)
• Ensuring correctly and timely scientific and administrative reporting to the European Commission and reporting to all partners
• Ensuring that the periodic reports are prepared in the most efficient and practical way according to European Commission guidelines by quality-checking all the partners’ contributions
WP2: Clinical trial implementation
The WP2 was dedicated to design, get approval and organize the clinical trial. General objectives were:
• To develop all ICH Essential Documents, get approval from regulatory bodies and Institutional Review Boards (IRBs)
• To organize Clinical Trial Treatment Units (CTTUs) production and preparation, clinical data collection, sample collection, banking and assay in a Good Clinical Practice (GCP) and Good Clinical Laboratory Practice (GCLP) compliant phase-II Randomized Clinical Trial (RCT)
The specific objectives were:
• Defining trial responsibilities and drafting all subsequent contracting
• Developing and submitting all regulatory and IRBs files
• Producing and preparing treatment units, sample kits and sample transport logistics
• Developing all trial instruments (SOPs, Specific study documents, eCRF)
• Selecting clinical sites to ensure timely recruitment and GCPs compliance
• Initiating trial sites
WP3: Clinical trial conduct
The objective of WP3 was to carry out the clinical trial in compliance with GCPs/ GCLPs rules, in order to demonstrate in patients with recently diagnosed Type-1 Diabetes (T1D) the efficacy and safety of ultra-low-dose IL-2.
The specific objectives were:
• To manage and feed information to the Steering Committee (SC), Data Safety Monitoring Board (DSMB), IRBs, and Regulatory Authorities
• To recruit, include and follow up to 138 T1D patients according to protocol
• To monitor recruitment, clinical and laboratory follow-up, and treatment of patients according to GCPs
• To perform and monitor laboratory assays according to GCLPs
• To manage data and database, perform statistical analysis and draft the final report of the trial
WP4: Deep phenotyping
The general objective of WP4 was to gain insights into the molecular and cellular impact of ultra low-dose IL-2 treatment (versus a placebo control) in newly diagnosed T1D patients. The specific objectives were:
• to determine how ultra low-dose IL-2 treatment alters number and activation status of immune cell populations
• to determine correlation between changes in C-peptide levels and antigen-specific responses to islet antigens, and other expression phenotypes
• to determine transcriptome and TCR repertoire dynamics in the course of ultra-low dose IL-2 treatment,
• to perform a multiscale analysis of biological and clinical results to define biomarkers
WP5: Dissemination and exploitation plans
The general objective of WP5 was to organize a well-targeted dissemination effort and early liaison with key stakeholders, including patients’ organizations and the pharmaceutical industry.
The specific objectives were:
• to adopt a corporate dissemination strategy to reach out the general public as well as specialised audiences, with consortium rules for dissemination aiming at protecting the IP potential of the generated foreground
• to disseminate the project and more specifically the clinical trial, and establishing as early as possible a network with future end-users, regulatory bodies and the community for 1) optimizing our dissemination effort, 2) preventing bottlenecks, and 3) collecting useful feedback from the external community
• to develop in an early phase of the project an exploitation strategy that will satisfy all parties involved in the DIABIL-2 project, avoiding any conflict between the partners
Project Results:
A major breakthrough in immunology was the discovery of regulatory T cells (Tregs) and their role in preventing autoimmune diseases (ADs) (Sakaguchi, 1995). It took a few years before Tregs became one of the hottest topics in immunology, in part by the recognition of their major therapeutic potential.
In this context, we were the first to show that low dose IL-2 (ld-IL2) was a safe stimulator of Tregs in patients with ADs and that this stimulation improved patients’ condition. Our proof-of-concept trial of 10 patients was published in The New England Journal of Medicine (NEJM), indicating that it was perceived as a potential major breakthrough (Saadoun, 2011).
IL-2 has therapeutic potential for numerous ADs, as notably shown by its therapeutic efficacy in over 30 autoimmune disease models in mice. Clinical trials in more than 20 ADs have shown some indication of efficacy. We recently published the results of TRANSREG, which study ld-IL2 across 11 different autoimmune diseases. These results show an excellent safety profile, a universal specific effect of ld-IL2 on Tregs and a global indication of efficacy across all diseases (Rosenzwajg, 2018). These results clearly call for phase-IIb trials to confirm efficacy that are now on their way in T1D, systemic lupus erythematosus, rheumatoid arthritis and ulcerative colitis, for those we know of.
The investigation of ld-IL2 in ADs has become a very hot topic. This is notably highlighted by recent deals made in the pharma industry. For example, Delinia, a recently created biotech that was developing an IL2 derivative tested only in mice and macaques was bought for more than 850M$ by Celgene.
The use of ld-IL2 in type 1 diabetes (T1D) has a very strong rationale. First, their genetic background makes T1D patients produce less IL-2 than healthy individuals. Second, we showed in mice that a short IL-2 treatment can cure them from overt T1D (Grinberg 2010). Third, we showed that ld-IL2 does stimulate Tregs in a dose dependent manner and is safe in patients with established T1D, also providing the dose of ld-IL2 to be used in further trials (Hartemann, 2013).
This was the context that justified DIABIL-2 awarding in the frame of a very competitive call on T1D immunotherapy, and then allowed us to enrol prominent European Key Opinion Leaders in this project.
We are the only group conducting a phase-II trial in T1D as this indication is not of prime interest for the industry. We are treating patients with newly diagnosed T1D (less than3months) as stopping the autoimmune process at this stage should translate in clinical improvement, as shown 20 years ago with immunosuppressive drugs that had too many side effects to be used.
Importantly, researchers and clinicians of the T1D field are eagerly awaiting our results to evaluate the potential of this treatment and engage in more studies, notably in exploring the potential of IL-2 for the prevention of T1D, which is our holy grail. In fact, the National Institutes of Health has specifically put on hold projects for clinical trials similar to DIABIL-2 in the United States, based on the fact that this was ongoing in Europe.
At this stage, the trial has not been completed but has made the following main achievements:
• The re-formulation of IL2 at the suitable dosage for DIABIL-2 trial. Initially, it was foreseen that patients would receive their IL-2 treatment in a hospital setting. However, in a study preceding the DIABIL-2 trial (DF-IL2-child, NCT01862120), this proved to be unfeasible due to very poor acceptability by patients (children and adolescents) and their parents to attend repeated visits to the hospital for drug administration (every visit to the hospital requires that the parent takes a day off). As an alternative, specialized research nurses, as we had to do for DF-IL2-child, would have for each treatment administration to obtain the treatment units prepared at the hospital pharmacy and then visit the patients at home for treatment administration, all this under strict procedures and monitoring (including temperature for the prepared treatment). This has a very high cost and would not have been feasible considering the DIABIL-2 budget. Consequently, we had to revise our organisation for administering IL2. The only option appeared to be the production of the drug at the proper dosage requiring a simple reconstitution before injection, allowing storage of product at patients’ location and the administration by local nurses. We solved all these issues and developed a novel drug formulation, which could be considered as a tour de force in such short time.
• A Paediatric Investigational Plan (PIP) procedure was initiated and achieved with the Paediatric Committee of the European Medicinal Agency to define how children and adolescents should be recruited and assessed within the overall clinical development. Methodology for recruitment of children within DIABIL-2 was defined as well as for further clinical studies up to market approval.
• All regulatory authorizations, including the approval for children aged 6 to 11 years old have been obtained in all the 6 countries involved in the project, despite the considerable hurdles that come from the fact that the EU does not have a shared regulatory path. The research has been authorized by all the regulatory authorities in all the countries involved in the study (France, Belgium, Switzerland, Germany, the Netherlands, and Sweden;
o Submission of substantial amendments have been performed to all the regulatory authorities in all countries involved in the study (13 substantial amendments)
o 30 centres have been activated
o 129 patients have been randomized to date
o more than 100 monitoring visits have been performed
o 7 DSMB meetings have been held
o 67 steering committee meetings have been held
o 4 audits have been conducted
• A manuscript reporting the DF-IL2-chil study, that is related to DIABIL-2, has recently been submitted: Salet R, Rosenzwajg M, Lorenzon R, Roux A, Carel JC, Storey C, Polak M, Beltrand J, Amouyal C, Hartemann A, Corbeau P, Bernard C, Vicaut E, Bibal C, Bougnères P, Tran TA, Klatzmann D. Low-dose interleukin 2 in children with recently diagnosed type 1 diabetes: a phase 1/2 randomised, double-blind, placebo-controlled dose finding study (Submitted)
• Several other publications related to DIABIL-2 have been published:
o Churlaud G, Rosenzwajg M, Cacoub P, Saadoun D, Valteau-Couanet D, Chaput N, Pugliese A, Klatzmann D. IL-2 antibodies in type 1 diabetes and during IL-2 therapy. Diabetologia. 2018 Sep;61(9):2066-2068. doi: 10.1007/s00125-018-4649-4. Epub 2018 Jun 2. PubMed PMID: 29860627.
o Ruggiero E, Nicolay JP, Fronza R, Arens A, Paruzynski A, Nowrouzi A, Ürenden G, Lulay C, Schneider S, Goerdt S, Glimm H, Krammer PH, Schmidt M, von Kalle C. High-resolution analysis of the human T-cell receptor repertoire. Nat Commun. 2015 Sep 1;6:8081. doi: 10.1038/ncomms9081. PubMed PMID: 26324409; PubMed Central PMCID: PMC4569693
o Klatzmann D, Abbas AK. The promise of low-dose interleukin-2 therapy for autoimmune and inflammatory diseases. Nat Rev Immunol. 2015 May;15(5):283-94. doi: 10.1038/nri3823. Epub 2015 Apr 17. Review. PubMed PMID: 25882245.
o Churlaud G, Pitoiset F, Jebbawi F, Lorenzon R, Bellier B, Rosenzwajg M, Klatzmann D. Human and Mouse CD8(+)CD25(+)FOXP3(+) Regulatory T Cells at Steady State and during Interleukin-2 Therapy. Front Immunol. 2015;6:171. doi: 10.3389/fimmu.2015.00171. eCollection 2015. PubMed PMID: 25926835; PubMed Central PMCID: PMC4397865.
o Rosenzwajg M, Churlaud G, Mallone R, Six A, Dérian N, Chaara W, Lorenzon R, Long SA, Buckner JH, Afonso G, Pham HP, Hartemann A, Yu A, Pugliese A, Malek TR, Klatzmann D. Low-dose interleukin-2 fosters a dose-dependent regulatory T cell tuned milieu in T1D patients. J Autoimmun. 2015 Apr;58:48-58. doi: 10.1016/j.jaut.2015.01.001. Epub 2015 Jan 26. PubMed PMID: 25634360.
o Yu A, Snowhite I, Vendrame F, Rosenzwajg M, Klatzmann D, Pugliese A, Malek TR. Selective IL-2 responsiveness of regulatory T cells through multiple intrinsic mechanisms supports the use of low-dose IL-2 therapy in type 1 diabetes. Diabetes. 2015 Jun;64(6):2172-83. doi: 10.2337/db14-1322. Epub 2015 Jan 9. PubMed PMID: 25576057.
o Rosenzwajg M, Churlaud G, Hartemann A, Klatzmann D. Interleukin 2 in the pathogenesis and therapy of type 1 diabetes. Curr Diab Rep. 2014 Dec;14(12):553.
doi: 10.1007/s11892-014-0553-6. Review. PubMed PMID: 25344788.
o Hartemann A, Bensimon G, Payan CA, Jacqueminet S, Bourron O, Nicolas N, Fonfrede M, Rosenzwajg M, Bernard C, Klatzmann D. Low-dose interleukin 2 in patients with type 1 diabetes: a phase 1/2 randomised, double-blind, placebo-controlled trial. Lancet Diabetes Endocrinol. 2013 Dec;1(4):295-305. doi: 10.1016/S2213-8587(13)70113-X. Epub 2013 Oct 8. PubMed PMID: 24622415.
o Pitoiset F et al. A standardized flow cytometry procedure for the monitoring of regulatory T cells in clinical trials. Cytometry B Clin Cytom. 2018 Sep;94(5):621-62
o Pitoiset F et al. Deep phenotyping of immune cell populations by optimized and standardized flow cytometry analyses. Cytometry A. 2018 Aug;93(8):793-802*
• The CICBT implemented the organization of samples collection, logistics and standardized procedures to perform staining of Tregs by flow cytometry on fresh whole blood locally in each clinical site involved in the trial. The CICBT has coordinated the immuno-monitoring procedure which is now fully implemented in 15 immunology labs involved in the trial (10 in France, 2 in Germany, 1 in Sweden, Netherlands and Belgium). In addition, a thorough work has been carried out to establish standardized experimental procedures for samples processing required to produce quality-controlled data for deep phenotyping (immunophenotyping, TCR repertoire, transcriptome, genetics and cytokine profiling) which will be performed at the CICBT in Paris. Two articles have been published on the implementation of deep immunophenotyping (see above). In addition, bioinformatic workflows for single- and multi-scale omics data analysis have been established.
Altogether, and despite a first extension of the project duration, it appeared that we would not be able to complete the trial in the planned time. Given that all the pitfalls and drawbacks had now been successfully overcome - with the trial now being well on track with 129/141 patients already randomized and a steady recruitment of approximately 3 patients/months - we asked for a second time extension that was not granted. Therefore, DIABIL-2 results could not be delivered at the end of the program.
We are now seeking additional external support by charities and institutional partners. We are optimistic that the trial will be completed. This is of utmost importance for the patients who gave their consent and their commitment to a placebo-controlled trial, and for the scientific community that much awaits these results concerning a molecule which mode of action is at the center of T1D pathophysiology.
Potential Impact:
DIABIL-2 clinical trial has been designed to demonstrate efficacy of low dose IL-2 as a treatment aimed at stopping autoimmune pancreatic beta cell destruction in patients with recently diagnosed T1D (http//ClinicalTrial.gov: NCT0135383).
Ultimately, the results of our trial will deliver measurable improvements to clinical management by restoring and maintaining immunoregulation via restoration of Treg functions and anti-inflammatory therapeutic effects in T effector cell activities.
In addition, the in depth analysis of the effects of IL-2 administration on the immune system, should help to discover biomarkers that could be correlated with clinical outcomes to provide a safe, specific and personalized treatment for type 1 diabetes. Beyond, it should also provide some insights on the immune imbalance of T1D patients.
If successful, this trial will have profound impacts for the management of patients with recently-diagnosed T1D, their families and EU economy:
Impact on T1D management:
Ultra-low dose as a safe treatment aimed at halting autoimmune β-cell destruction could enable patients to achieve optimal glycaemic control without recurrent hypoglycaemia. Insulin intake in adult and children T1D patients will be drastically reduced and even stopped leading ultimately to decreased risk of long-term complications generally associated with incorrect metabolic control. Moreover, the efficacy of IL-2 at halting autoimmune β-cell destruction in newly diagnosed T1D could lead to further studies investigating its potential in prevention of T1D.
Impact on Global health issues:
More than 20 million people in Europe suffer from T1D. The costs of treating and managing this disease and its complications are approximately 2 billion € annually. Progress in autoimmune and inflammatory diseases management: Noteworthy, any clinical success ultra-low dose in T1D could lead to its clinical development in other autoimmune diseases, including Multiple Sclerosis or Rheumatoid Arthritis, that have a significant public health burden. A confirmation of the global anti-inflammatory effect of IL-2 already observed in HCV-related vasculitis patients will pave the way for studying IL-2 in other inflammatory diseases.
Impact on Child Health:
This disease has a major impact on children and adolescents since it interferes with all aspects of life and is often disrupting for the whole family and social structure around the child. By using IL-2 treatment, quality of life of children (and their parents), for whom the disease is often more sudden and aggressive, will be alleviated.
Economic impact:
The use of IL-2 in T1D and other autoimmune diseases has been patented by the DIABIL-2 coordinating public institution AP-HP, and the patent is currently licensed to ILTOO-biotech, a small company also a partner in this project. Demonstration of efficacy in this T1D trial should be a milestone in developing novel indications for IL-2. Europe will have a chance to become a leader in this field, which targets a very large market, and likewise this project should contribute to increasing employment in the pharmaceutical sector in the EU.
All these potential impacts could be obtained only when (if) the trial is completed.
List of Websites:
http://www.diabil-2.eu/en/(opens in new window)
Contact Details:
Pr David Klatzmann
Head of Biotherapy service and Director of CICBT
83 boulevard de l’Hôpital
75651 Paris Cedex 13
Tel : +33142177461
E-mail: david.klatzmann@upmc.fr
Type 1 Diabetes (T1D) disease is caused by the immune-mediated destruction of the pancreatic islet ß-cells, leading eventually to insulin deficiency. The development of autoimmunity precedes the clinical diagnosis of T1D and is due in large part to the inability of regulatory T cells (Treg) to block the destruction of pancreatic ß-cells. Treg stimulation has the potential to stop the process, preserve ß-cells’ insulin secretion, and likewise prevent or delay disease progression and improve clinical outcome for patients.
Low-dose interleukin-2 (ld-IL2) was recently shown to directly and specifically stimulate Tregs. In diabetic mouse model (NOD mice), ld-IL2 can prevent and cure T1D. In humans, we reported that (i) ld-IL2 is safe, induces Tregs and is associated with clinical improvement in patients with autoimmune vasculitis; and (ii) a dose-finding study in T1D defined an ultra-low dose IL-2 (uld-IL2) that is well tolerated and induces Tregs’ numbers and functionality.
In this context, DIABIL-2 aims at testing the efficacy of low dose Interleukin 2 for preventing or delaying T1D progression in newly diagnosed patients. Indeed, at the time of T1D clinical diagnosis, there are still remaining ß-cells capable of producing insulin, and halting the immune destruction at this stage should have significant therapeutic benefit.
DIABIL-2 is a double-blind, randomised, placebo-controlled, stratified on age from 6 to 35 years, parallel-group, multicentre European phase-IIb clinical trial. The efficacy and safety of ld-IL2 is evaluated in 138 recently-diagnosed T1D patients. The methodology used strictly followed the Immunology of Diabetes Society consensus recommendations and European regulatory guidelines.
The clinical trial was successfully implemented and all regulatory authorizations obtained in Belgium, Switzerland, Germany, Sweden, France and The Netherlands and 30 recruitments sites have been set up. The IL2 drug substance was produced and validated for EU release. The compliance of Good Clinical Practice and Good Clinical Laboratory Practice was enforced. The recruitment of children was defined within a Paediatric Investigational Plan (PIP) procedure that was defined with the Paediatric Committee of the European Medicinal Agency to define how children and adolescents should be recruited and assessed within the overall clinical development.
During the trial, samples were collected and sent to two centralized laboratories: one central laboratory (EUROFINS, Breda the Netherlands) evaluates plasma C-peptide, HbA1c and plasma glucose that are key parameters of clinical efficacy; a second central laboratory (Centre d’Investigation Clinique de Biothérapie (CICBT), Paris, France) performs immunological investigations including cytometry, dosage of inflammatory cytokines, Tregs functionality in vitro and dosage of anti-ILT-101 antibodies. A standardized procedure to perform staining of Tregs by flow cytometry on fresh whole blood on-site have been successfully implemented across Europe in 15 immunology labs involved in the trial.
The initiation of the trial has been delayed by the need to re-formulate IL2 at the suitable dosage such as to avoid that patients had to come to the hospital for each injection. Then, additional delay came from the waiting time for approval from the regulatory authorities for the treatment of children between 6 to 11 years. This was totally unexpected as an authorization for such patients had previously been obtained from the French regulatory authorities. Finally, despite our best efforts, patient recruitment has been much slower than anticipated. This is in large part due to poor acceptance for participating to a placebo controlled trial, with many visits, by patients (or their parents) at the time they just learned that they have a chronic disease. Altogether, and despite a first extension of the project duration, it appeared that we would not be able to complete the trial in the planned time. Given that all the pitfalls and drawbacks had now been successfully overcome - with the trial now being well on track with 129/141 patients already randomized and a steady recruitment of approximately 3 patients/month. As a second time extension of the project was not granted, DIABIL-2 results could not be delivered at the end of the program.
We are now seeking additional external support by charities and institutional partners. We are optimistic that the trial will be completed. This is of utmost importance for the patients who gave their consent and their commitment to a placebo-controlled trial, and for the scientific community that much awaits these results concerning a molecule which mode of action is at the center of T1D pathophysiology. This is also of utmost importance as ultimately ld-IL2 as a strong potential for the prevention of T1D that would only be tested after positive clinical and safety results from DIABIL-2.
Project Context and Objectives:
Type 1 Diabetes is one of the most common severe chronic autoimmune diseases (AIDs) worldwide. In Europe its incidence is rapidly rising in children, with a predicted 70% increase in cases over the next 15 years. It affected more than 3 million individuals in Europe, the majority of them diagnosed in childhood or adolescence with a predicted doubling of cases in children under the age of 5 years in the same period.
The discovery of Tregs has revolutionized our understanding of autoimmune diseases. As T1D is caused by the failure of Tregs to block autoimmune destruction of pancreatic ß-cells, Treg stimulation has the potential to stop the process, preserve ß-cells’ insulin secretion, and likewise prevent or delay disease progression and improve clinical outcome for patients.
The main aim of DIABIL-2 project is to undertake a major clinical trial in T1D patients with a focus on children and adolescents with newly diagnosed disease in order to improve glycaemic control and management of the disease.
This is a double-blind randomised placebo-controlled, age-stratified (6-35 year), multicentre European trial assessing efficacy and safety of uld-IL2 (0.5M IU/m2/day with a maximum of 1 M IU/m2/day for adult patients) in 138 recently-diagnosed T1D patients. The primary end-point is to preserve remaining endogenous insulin secretion at 1 year as measured by the C-peptide AUC during a mixed meal tolerance test (MMTT). The trial is precisely and conservatively powered to detect an effect size of d=0.5.
The ancillary objectives of the project were:
• to further investigate response to ultra-low dose IL-2 by molecular phenotyping using genetics, genomics, transcriptomics and cutting-edge immunological methods for future stratification of individualized patient care
• to validate urinary C-peptide assay as a non-invasive endpoint in T1D trials
• to strengthen basic-clinical European Scientific Excellence by the dissemination of landmark results and the foundation of a European network of excellence operating in the T1D field
• to contribute to the competitiveness of the European Industry by valorising IL-2 development, generating novel intellectual property and exploiting it.
The consortium comprised 5 partners, including 3 academic partners (Assistance Publique-Hôpitaux de Paris (APHP), France; Leiden University Medical Center (LUMC), The Netherlands; University Hospital of Basel (UHB), Switzerland), one SME (ILTOO-biotech, France) and a project management partner (Inserm Transfert, France).
The programme was divided into six work packages (WPs) with the specific objectives detailed below.
WP1: Management and coordination of the consortium
WP1 was dedicated to the management activities and dealt with all usual and contractual administrative tasks (financial, reporting, organisation of consortium and ExCom meetings). These included the following activities:
• Coordinating the project’s administrative and financial issues as defined by the European Commission (by acting as a permanent helpdesk for all partners to answer their questions)
• Informing each partner, including the EC, about the project status, emerging issues, the work planning (adjustments) and all other aspects which are important and relevant for obtaining maximum transparency and achieve synergy of the cooperation
• Assisting the interface between the coordinator and the European Commission
• Organizing and facilitating the consortium and ExCom meetings during the course of the project (agenda, date, place, logistic, minutes)
• Developing and updating effective communication channels within and outside the consortium (address book, public and private websites)
• Ensuring correctly and timely scientific and administrative reporting to the European Commission and reporting to all partners
• Ensuring that the periodic reports are prepared in the most efficient and practical way according to European Commission guidelines by quality-checking all the partners’ contributions
WP2: Clinical trial implementation
The WP2 was dedicated to design, get approval and organize the clinical trial. General objectives were:
• To develop all ICH Essential Documents, get approval from regulatory bodies and Institutional Review Boards (IRBs)
• To organize Clinical Trial Treatment Units (CTTUs) production and preparation, clinical data collection, sample collection, banking and assay in a Good Clinical Practice (GCP) and Good Clinical Laboratory Practice (GCLP) compliant phase-II Randomized Clinical Trial (RCT)
The specific objectives were:
• Defining trial responsibilities and drafting all subsequent contracting
• Developing and submitting all regulatory and IRBs files
• Producing and preparing treatment units, sample kits and sample transport logistics
• Developing all trial instruments (SOPs, Specific study documents, eCRF)
• Selecting clinical sites to ensure timely recruitment and GCPs compliance
• Initiating trial sites
WP3: Clinical trial conduct
The objective of WP3 was to carry out the clinical trial in compliance with GCPs/ GCLPs rules, in order to demonstrate in patients with recently diagnosed Type-1 Diabetes (T1D) the efficacy and safety of ultra-low-dose IL-2.
The specific objectives were:
• To manage and feed information to the Steering Committee (SC), Data Safety Monitoring Board (DSMB), IRBs, and Regulatory Authorities
• To recruit, include and follow up to 138 T1D patients according to protocol
• To monitor recruitment, clinical and laboratory follow-up, and treatment of patients according to GCPs
• To perform and monitor laboratory assays according to GCLPs
• To manage data and database, perform statistical analysis and draft the final report of the trial
WP4: Deep phenotyping
The general objective of WP4 was to gain insights into the molecular and cellular impact of ultra low-dose IL-2 treatment (versus a placebo control) in newly diagnosed T1D patients. The specific objectives were:
• to determine how ultra low-dose IL-2 treatment alters number and activation status of immune cell populations
• to determine correlation between changes in C-peptide levels and antigen-specific responses to islet antigens, and other expression phenotypes
• to determine transcriptome and TCR repertoire dynamics in the course of ultra-low dose IL-2 treatment,
• to perform a multiscale analysis of biological and clinical results to define biomarkers
WP5: Dissemination and exploitation plans
The general objective of WP5 was to organize a well-targeted dissemination effort and early liaison with key stakeholders, including patients’ organizations and the pharmaceutical industry.
The specific objectives were:
• to adopt a corporate dissemination strategy to reach out the general public as well as specialised audiences, with consortium rules for dissemination aiming at protecting the IP potential of the generated foreground
• to disseminate the project and more specifically the clinical trial, and establishing as early as possible a network with future end-users, regulatory bodies and the community for 1) optimizing our dissemination effort, 2) preventing bottlenecks, and 3) collecting useful feedback from the external community
• to develop in an early phase of the project an exploitation strategy that will satisfy all parties involved in the DIABIL-2 project, avoiding any conflict between the partners
Project Results:
A major breakthrough in immunology was the discovery of regulatory T cells (Tregs) and their role in preventing autoimmune diseases (ADs) (Sakaguchi, 1995). It took a few years before Tregs became one of the hottest topics in immunology, in part by the recognition of their major therapeutic potential.
In this context, we were the first to show that low dose IL-2 (ld-IL2) was a safe stimulator of Tregs in patients with ADs and that this stimulation improved patients’ condition. Our proof-of-concept trial of 10 patients was published in The New England Journal of Medicine (NEJM), indicating that it was perceived as a potential major breakthrough (Saadoun, 2011).
IL-2 has therapeutic potential for numerous ADs, as notably shown by its therapeutic efficacy in over 30 autoimmune disease models in mice. Clinical trials in more than 20 ADs have shown some indication of efficacy. We recently published the results of TRANSREG, which study ld-IL2 across 11 different autoimmune diseases. These results show an excellent safety profile, a universal specific effect of ld-IL2 on Tregs and a global indication of efficacy across all diseases (Rosenzwajg, 2018). These results clearly call for phase-IIb trials to confirm efficacy that are now on their way in T1D, systemic lupus erythematosus, rheumatoid arthritis and ulcerative colitis, for those we know of.
The investigation of ld-IL2 in ADs has become a very hot topic. This is notably highlighted by recent deals made in the pharma industry. For example, Delinia, a recently created biotech that was developing an IL2 derivative tested only in mice and macaques was bought for more than 850M$ by Celgene.
The use of ld-IL2 in type 1 diabetes (T1D) has a very strong rationale. First, their genetic background makes T1D patients produce less IL-2 than healthy individuals. Second, we showed in mice that a short IL-2 treatment can cure them from overt T1D (Grinberg 2010). Third, we showed that ld-IL2 does stimulate Tregs in a dose dependent manner and is safe in patients with established T1D, also providing the dose of ld-IL2 to be used in further trials (Hartemann, 2013).
This was the context that justified DIABIL-2 awarding in the frame of a very competitive call on T1D immunotherapy, and then allowed us to enrol prominent European Key Opinion Leaders in this project.
We are the only group conducting a phase-II trial in T1D as this indication is not of prime interest for the industry. We are treating patients with newly diagnosed T1D (less than3months) as stopping the autoimmune process at this stage should translate in clinical improvement, as shown 20 years ago with immunosuppressive drugs that had too many side effects to be used.
Importantly, researchers and clinicians of the T1D field are eagerly awaiting our results to evaluate the potential of this treatment and engage in more studies, notably in exploring the potential of IL-2 for the prevention of T1D, which is our holy grail. In fact, the National Institutes of Health has specifically put on hold projects for clinical trials similar to DIABIL-2 in the United States, based on the fact that this was ongoing in Europe.
At this stage, the trial has not been completed but has made the following main achievements:
• The re-formulation of IL2 at the suitable dosage for DIABIL-2 trial. Initially, it was foreseen that patients would receive their IL-2 treatment in a hospital setting. However, in a study preceding the DIABIL-2 trial (DF-IL2-child, NCT01862120), this proved to be unfeasible due to very poor acceptability by patients (children and adolescents) and their parents to attend repeated visits to the hospital for drug administration (every visit to the hospital requires that the parent takes a day off). As an alternative, specialized research nurses, as we had to do for DF-IL2-child, would have for each treatment administration to obtain the treatment units prepared at the hospital pharmacy and then visit the patients at home for treatment administration, all this under strict procedures and monitoring (including temperature for the prepared treatment). This has a very high cost and would not have been feasible considering the DIABIL-2 budget. Consequently, we had to revise our organisation for administering IL2. The only option appeared to be the production of the drug at the proper dosage requiring a simple reconstitution before injection, allowing storage of product at patients’ location and the administration by local nurses. We solved all these issues and developed a novel drug formulation, which could be considered as a tour de force in such short time.
• A Paediatric Investigational Plan (PIP) procedure was initiated and achieved with the Paediatric Committee of the European Medicinal Agency to define how children and adolescents should be recruited and assessed within the overall clinical development. Methodology for recruitment of children within DIABIL-2 was defined as well as for further clinical studies up to market approval.
• All regulatory authorizations, including the approval for children aged 6 to 11 years old have been obtained in all the 6 countries involved in the project, despite the considerable hurdles that come from the fact that the EU does not have a shared regulatory path. The research has been authorized by all the regulatory authorities in all the countries involved in the study (France, Belgium, Switzerland, Germany, the Netherlands, and Sweden;
o Submission of substantial amendments have been performed to all the regulatory authorities in all countries involved in the study (13 substantial amendments)
o 30 centres have been activated
o 129 patients have been randomized to date
o more than 100 monitoring visits have been performed
o 7 DSMB meetings have been held
o 67 steering committee meetings have been held
o 4 audits have been conducted
• A manuscript reporting the DF-IL2-chil study, that is related to DIABIL-2, has recently been submitted: Salet R, Rosenzwajg M, Lorenzon R, Roux A, Carel JC, Storey C, Polak M, Beltrand J, Amouyal C, Hartemann A, Corbeau P, Bernard C, Vicaut E, Bibal C, Bougnères P, Tran TA, Klatzmann D. Low-dose interleukin 2 in children with recently diagnosed type 1 diabetes: a phase 1/2 randomised, double-blind, placebo-controlled dose finding study (Submitted)
• Several other publications related to DIABIL-2 have been published:
o Churlaud G, Rosenzwajg M, Cacoub P, Saadoun D, Valteau-Couanet D, Chaput N, Pugliese A, Klatzmann D. IL-2 antibodies in type 1 diabetes and during IL-2 therapy. Diabetologia. 2018 Sep;61(9):2066-2068. doi: 10.1007/s00125-018-4649-4. Epub 2018 Jun 2. PubMed PMID: 29860627.
o Ruggiero E, Nicolay JP, Fronza R, Arens A, Paruzynski A, Nowrouzi A, Ürenden G, Lulay C, Schneider S, Goerdt S, Glimm H, Krammer PH, Schmidt M, von Kalle C. High-resolution analysis of the human T-cell receptor repertoire. Nat Commun. 2015 Sep 1;6:8081. doi: 10.1038/ncomms9081. PubMed PMID: 26324409; PubMed Central PMCID: PMC4569693
o Klatzmann D, Abbas AK. The promise of low-dose interleukin-2 therapy for autoimmune and inflammatory diseases. Nat Rev Immunol. 2015 May;15(5):283-94. doi: 10.1038/nri3823. Epub 2015 Apr 17. Review. PubMed PMID: 25882245.
o Churlaud G, Pitoiset F, Jebbawi F, Lorenzon R, Bellier B, Rosenzwajg M, Klatzmann D. Human and Mouse CD8(+)CD25(+)FOXP3(+) Regulatory T Cells at Steady State and during Interleukin-2 Therapy. Front Immunol. 2015;6:171. doi: 10.3389/fimmu.2015.00171. eCollection 2015. PubMed PMID: 25926835; PubMed Central PMCID: PMC4397865.
o Rosenzwajg M, Churlaud G, Mallone R, Six A, Dérian N, Chaara W, Lorenzon R, Long SA, Buckner JH, Afonso G, Pham HP, Hartemann A, Yu A, Pugliese A, Malek TR, Klatzmann D. Low-dose interleukin-2 fosters a dose-dependent regulatory T cell tuned milieu in T1D patients. J Autoimmun. 2015 Apr;58:48-58. doi: 10.1016/j.jaut.2015.01.001. Epub 2015 Jan 26. PubMed PMID: 25634360.
o Yu A, Snowhite I, Vendrame F, Rosenzwajg M, Klatzmann D, Pugliese A, Malek TR. Selective IL-2 responsiveness of regulatory T cells through multiple intrinsic mechanisms supports the use of low-dose IL-2 therapy in type 1 diabetes. Diabetes. 2015 Jun;64(6):2172-83. doi: 10.2337/db14-1322. Epub 2015 Jan 9. PubMed PMID: 25576057.
o Rosenzwajg M, Churlaud G, Hartemann A, Klatzmann D. Interleukin 2 in the pathogenesis and therapy of type 1 diabetes. Curr Diab Rep. 2014 Dec;14(12):553.
doi: 10.1007/s11892-014-0553-6. Review. PubMed PMID: 25344788.
o Hartemann A, Bensimon G, Payan CA, Jacqueminet S, Bourron O, Nicolas N, Fonfrede M, Rosenzwajg M, Bernard C, Klatzmann D. Low-dose interleukin 2 in patients with type 1 diabetes: a phase 1/2 randomised, double-blind, placebo-controlled trial. Lancet Diabetes Endocrinol. 2013 Dec;1(4):295-305. doi: 10.1016/S2213-8587(13)70113-X. Epub 2013 Oct 8. PubMed PMID: 24622415.
o Pitoiset F et al. A standardized flow cytometry procedure for the monitoring of regulatory T cells in clinical trials. Cytometry B Clin Cytom. 2018 Sep;94(5):621-62
o Pitoiset F et al. Deep phenotyping of immune cell populations by optimized and standardized flow cytometry analyses. Cytometry A. 2018 Aug;93(8):793-802*
• The CICBT implemented the organization of samples collection, logistics and standardized procedures to perform staining of Tregs by flow cytometry on fresh whole blood locally in each clinical site involved in the trial. The CICBT has coordinated the immuno-monitoring procedure which is now fully implemented in 15 immunology labs involved in the trial (10 in France, 2 in Germany, 1 in Sweden, Netherlands and Belgium). In addition, a thorough work has been carried out to establish standardized experimental procedures for samples processing required to produce quality-controlled data for deep phenotyping (immunophenotyping, TCR repertoire, transcriptome, genetics and cytokine profiling) which will be performed at the CICBT in Paris. Two articles have been published on the implementation of deep immunophenotyping (see above). In addition, bioinformatic workflows for single- and multi-scale omics data analysis have been established.
Altogether, and despite a first extension of the project duration, it appeared that we would not be able to complete the trial in the planned time. Given that all the pitfalls and drawbacks had now been successfully overcome - with the trial now being well on track with 129/141 patients already randomized and a steady recruitment of approximately 3 patients/months - we asked for a second time extension that was not granted. Therefore, DIABIL-2 results could not be delivered at the end of the program.
We are now seeking additional external support by charities and institutional partners. We are optimistic that the trial will be completed. This is of utmost importance for the patients who gave their consent and their commitment to a placebo-controlled trial, and for the scientific community that much awaits these results concerning a molecule which mode of action is at the center of T1D pathophysiology.
Potential Impact:
DIABIL-2 clinical trial has been designed to demonstrate efficacy of low dose IL-2 as a treatment aimed at stopping autoimmune pancreatic beta cell destruction in patients with recently diagnosed T1D (http//ClinicalTrial.gov: NCT0135383).
Ultimately, the results of our trial will deliver measurable improvements to clinical management by restoring and maintaining immunoregulation via restoration of Treg functions and anti-inflammatory therapeutic effects in T effector cell activities.
In addition, the in depth analysis of the effects of IL-2 administration on the immune system, should help to discover biomarkers that could be correlated with clinical outcomes to provide a safe, specific and personalized treatment for type 1 diabetes. Beyond, it should also provide some insights on the immune imbalance of T1D patients.
If successful, this trial will have profound impacts for the management of patients with recently-diagnosed T1D, their families and EU economy:
Impact on T1D management:
Ultra-low dose as a safe treatment aimed at halting autoimmune β-cell destruction could enable patients to achieve optimal glycaemic control without recurrent hypoglycaemia. Insulin intake in adult and children T1D patients will be drastically reduced and even stopped leading ultimately to decreased risk of long-term complications generally associated with incorrect metabolic control. Moreover, the efficacy of IL-2 at halting autoimmune β-cell destruction in newly diagnosed T1D could lead to further studies investigating its potential in prevention of T1D.
Impact on Global health issues:
More than 20 million people in Europe suffer from T1D. The costs of treating and managing this disease and its complications are approximately 2 billion € annually. Progress in autoimmune and inflammatory diseases management: Noteworthy, any clinical success ultra-low dose in T1D could lead to its clinical development in other autoimmune diseases, including Multiple Sclerosis or Rheumatoid Arthritis, that have a significant public health burden. A confirmation of the global anti-inflammatory effect of IL-2 already observed in HCV-related vasculitis patients will pave the way for studying IL-2 in other inflammatory diseases.
Impact on Child Health:
This disease has a major impact on children and adolescents since it interferes with all aspects of life and is often disrupting for the whole family and social structure around the child. By using IL-2 treatment, quality of life of children (and their parents), for whom the disease is often more sudden and aggressive, will be alleviated.
Economic impact:
The use of IL-2 in T1D and other autoimmune diseases has been patented by the DIABIL-2 coordinating public institution AP-HP, and the patent is currently licensed to ILTOO-biotech, a small company also a partner in this project. Demonstration of efficacy in this T1D trial should be a milestone in developing novel indications for IL-2. Europe will have a chance to become a leader in this field, which targets a very large market, and likewise this project should contribute to increasing employment in the pharmaceutical sector in the EU.
All these potential impacts could be obtained only when (if) the trial is completed.
List of Websites:
http://www.diabil-2.eu/en/(opens in new window)
Contact Details:
Pr David Klatzmann
Head of Biotherapy service and Director of CICBT
83 boulevard de l’Hôpital
75651 Paris Cedex 13
Tel : +33142177461
E-mail: david.klatzmann@upmc.fr