MEMum presents the second article in a series of three about the recent 12th Invest In ME International Conference (IIMEC12) in London.
The 12th Invest in ME International ME Conference (IIMEC12) was held at One Great George Street on Friday June 2nd, 2017.
The highly recommended DVD of the conference, which includes David Tuller’s pre-conference evening dinner presentation as well as all of the presentations at the public conference, is now available for pre-order.
This article covers some of the more “technically challenging” talks. I am no expert, but have been to four previous conferences, and have a relevant degree from the last century.
My article is mainly from notes taken on the day. I did not have access to pictures of the slides and am likely to have made errors. So apologies to the speakers and members in advance. I have tried to convey the aspects of talks which stood out the most. Abstracts, where available, are now on the IiMER website.
Professor Donald Staines: ‘Dysregulation of Transient Receptor Potential (TRP) ion channels and calcium in natural killer cells in CFS/ME patients’
Professor Don Staines from the National Centre for Neuroimmunology and Emerging Diseases (Gold Coast, Australia) ran through their work on TRPM3 receptors in Natural Killer (NK) cells. These cells are present in a range of cells throughout the body.
I did not spot anything new, though they are now looking at these receptors in a severely affected group, doing home visits. (No results yet.)
These receptors are involved in letting calcium ions (Ca2+) in to the cells. Their expression and function in NK cells are reduced in people with ME (PwME). Calcium is one of the most important intracellular signals, managing a variety of cellular functions, and these receptors are also present intracellularly, for example on the mitochondrial membranes, and those of the endoplasmic reticulum. The levels of Ca2+ ions are 100s-1000s times greater outside the cells than inside.
These receptors are also known as “Threat Receptors” and respond to a wide range of stimuli. As well as temperature, pH, stretch and osmotic pressure, they respond to vibrations (such as travelling), infection and irritants.
In a paper published earlier this year, they measured NK cytotoxicity under various stimulants. On Friday he commented that in healthy cells, Pregnenolone S (PregS) activates TRPM3 channels, to increase Ca2+ levels inside the cells. CD56dim CD16+ cells from people with ME do not give a good response to PregS alone. They show a better response to Thapsigargin (TG). TG inhibits the replenishment of the Ca2+ into intracellular stores, such as the Endoplasmic Reticulum (ER). However with TG then PregS, there is a disproportionate increase in intracellular Ca2+ and cytotoxic activity.
PregS has an important role in the CNS, including memory and cognitive function. A paper earlier this year by Papanikolaou showed that TRPM3 are among the main calcium channel receptors in glial cells.
There was also mention that the different classes of TRP receptors respond at varying temperatures. TRPM3 are in the mid range, namely 20-35 degrees.
My favourite quote of Don Staines is from a few years ago. His final slide showed data of the abnormalities in a range of cytokines and other similar signalling chemicals and said: “If anyone thinks that lot can be cured with a bit of exercise they should be delisted,” (the Australian Version of Struck Off).
Dr. Jo Cambridge and Fane Mensah (UCL PhD student): ‘Immunoregulation in patients with ME’
Fane Mensah listed previous researchers who have demonstrated the following:
- Viral infections lead to decreased numbers and function of Natural Killer (NK) cells.
- Improved understanding of the molecular basis of the NK cells, altered DPP4/CD26 expression. (DPP4 is an enzyme that plays a potential role in immune cell modulation)
- Understanding of genetic polymorphisms of NK cell receptors.
- Instances of EBV infection in ME.
- An altered cytokine profile for differing disease durations (<3 or>3 yrs)
He tweets @Fane Mensah
Dr. Jo Cambridge then took over. Rituximab was first used in rheumatoid arthritis (RA) in the late ’90s. It removes the harmful immune complexes.
It is also very successful in treating ;upus patients with (very rare) renal problems.
Rituximab works by depleting the peripheral CD20 B cells, leaving plasma and stem cells. When the B cells start returning, they are “naïve”, i.e., not producing the same antibodies (Ab) that were previously causing problems.
PwME who do not respond to Rituximab seem to have higher sCD23 levels (A surrogate marker of B cell maturity). This suggests that “bad” B cells had not been removed, but were still maturing in the tissues.
Rituximab works best where there are aberrant or autoimmune Abs.
Currently, they are immunophenotyping B cells, using markers IgD/CD38, and IgD/CD24.
Marginal Zone B cells (MZB) show high CD38 and are associated with IgM response, especially to EBV. ME patients have significantly more of these MZB cells.
- There is a T cell independent rapid activation of innate B cells (9G4+) in the sub-epithelium of the tonsils. After the stimulus they migrate to the MZ of the spleen. They produce IgM in a germline configuration.
- These innate B cells (9G4+) are only present transiently and are hugely increased in EBV.
- The IgM requires carbohydrate, (N-acetyl lactosamine) on virus affected B cells to “paint” these cells. This structure then attaches to complement and lyses.
- These B cells are also present in lupus and RA, and are potent drivers of autoimmunity.
They are also looking at CD24, which is expressed on naïve B cells and is significantly increased in people with ME v Healthy Controls (HC). CD24 is retained on old senescent B cells that have resisted T1 stimulation.
CD21 B cells seem to correlate with disease duration.
There is a reduction in size, mass and function of mitochondria in B cells in People with ME (PwME)
There are Abs to neurotransmitters, a skewing of the natural Ab pool and aberrant anti microbial Abs. These are interfering with normal metabolic processes.
Professor Simon Carding: Panel discussion with PhD students from Quadram Institute Biosciences
Daniel Vipond is close to writing up his PhD. (Or at least Professor Carding hopes he is). He has been:
- Looking at gut inflammation
- Taking quantitative measurements of IgA coated bacteria.
- Hoping to separate and sequence the coated bacteria.
There is an increase in IgA production in PwME.
Along with other researchers, such as Maureen Hanson, he has found a reduced bacterial diversity which is similar in people with IBS.
Fiona Newbury and Ernie Hsieh are studying the Intestinal Virome in ME.
Viruses can also reduce bacterial diversity . They plan to:
- Define the gut, viral and bacterial populations, and see if this changes with disease progression.
- Determine if viruses isolated from PwME can influence and kill their bacterial hosts in the gut.
- Try and develop an animal model in which they can study influences on intestinal and systemic inflammation.
There are technical problems with analysing viral genomes. There is a lack of a good database on viruses. In addition, there are large areas of the genome which are similar in many viruses.
Associate Professor Mady Hornig: ‘Gut-metabolome-immune disturbances in ME/CFS subsets’
Mady Hornig from Columbia University spoke at great speed, about:
- Epigenetics (switching genes on and off). There are important interactions between genes and the environment. There are particular stages of early development that are key in this process.
- Brain, gut and ME. There are many molecules that are active in the gut and the brain. These include: GABA, noradrenaline, dopamine, serotonin, short chain fatty acids and acetylcholine. There is also a direct link to the brain via the vagus nerve.
- CfII (Centre for Infection and Immunity) have collected longitudinal samples which have not yet been analysed. When funds permit they will be analysing these, looking at microbiome, mycobiome and virome (DNA and RNA species). They aim to match these samples for geographical residence, time of day (to remove circadian effect) and season (time of year), as well as the usual age, sex, etc. Subjects were asked to complete a questionnaire prior to sampling, to stimulate a mild stress response.
- Using Multiplex assays, it has been shown that presence of parvovirus is associated with autoantibodies. Also, with EBV, 10-15 % of people with mononucleosis will go on to develop ME.
- Viral activation can result in a signal in the CNS as well as the peripheral nervous system.
- Fever production: this involves IL-6 production in the median preoptic nucleus of the hypothalamus, where there are thermoregulatory neurons. Il-6 also influences production of PGE2 (prostaglandin E2), a major pyrogenic mediator of fever.
- Long-term “immune exhaustion”. This refers to their study demonstrating different immune profiles between patients with disease durations of less or more than three years.
- Looking at CSF (Cerebospinal fluid). Generally cytokine levels are reduced in PwME. IL-6 is very significantly down. It has memory signalling effects.
- Atypical ME (as defined in a more recent paper of theirs). These PwME show a strange encephalitis, which is also seen in people with Gulf War Syndrome or cancer. They also have much lower levels of pro-inflammatory IL-17A and the chemokine CXCL9 in the CSF.
- Human Microbiome studies. Microbial products can affect gut motility and alter transit time. Gases, such as hydrogen sulphide and methane can slow the gut, whereas tryptamine and serotonin will increase motility. Butyrate producing bacteria are more prevalent in healthy controls than in ME, type 1 diabetes and other autoimmune diseases. There are often altered GI function comorbidities with brain disorders, such as IBS with ME.
- Autoimmune disturbances may result from failed uptake of dietary precursors of antioxidants.
- Systems involving Tryptophan to Kyneurine and conversion of 5HT to Melatonin. The balance of these systems is important for memory and immune function.
Professor Olav Mella: ‘Update on the clinical trials RituxME and CycloME’
Professor Olav Mella summarised how he and Dr. Oystein Fluge had become involved in ME research. They are consultant oncologists. A couple of patients who had undergone treatment for lymphoma returned to the Clinics saying that their lymphoma treatment had also “cured” their ME.
He was keen to emphasise that the selection of Rituximab (Rx) as a potential treatment of ME was not some random process, but an intellectual understanding of the four chemotherapy drugs used in lymphoma treatment and a process of evaluation, leading to the decision to try Rx.
Their pilot trial showed 10/15 responding to the Rx, and 2/15 from the placebo group also showing a positive response. Their initial endpoint for this pilot was three months after the first two infusions. However, they later realised that their two initial patients had demonstrated an unusually quick response to Rx, and that in 18 responders the mean response time was 29 weeks (range 8-66).
Their Phase 2 trial involved giving top-up infusions to responders. Three years after interventions 11/18 were still responding, but there were then some gradual recurrences. Professor Mella commented that you give someone their life back and then are not permitted to give them more Rx outside a trial setting. The patients who had received saline were offered Rx treatment after the pilot.
They had also tried to treat a severe/very severe ME patient group. Unfortunately, there were significant problems as these people had great difficulty getting to the hospital. Rx has to be administered via IV in a hospital setting with specially trained medical staff. They were only able to treat a handful of patients. Due to logistical difficulties and a low level of response they abandoned this study.
Note: Cyclophosphamide (Cyclo) can be administered in the setting of a small community hospital, so is far easier to access.
The secondary endpoints (from SF-36) showed that responders had improved on: physical function, vitality, bodily pain and social function. Mental health had remained the same. (Not surprising as this is not a mental health disorder!)
Their conclusions were that autoantibodies were involved in ME, so they started their Phase 3 trial of Rx (RituxME) in 2014.
The protocol is IV treatment with Rx (500mg), or saline (with 0.4 mg albumen). The albumen is added, so that the nurses cannot detect which is being given. The initial treatment is two infusions, two weeks apart, and they have then chosen to give further infusions at three, six, nine and 12 months.
This study is “proof of concept” — it may be that different timings of “top-up” infusions are required. (I believe this is the case for Rx treatment of rheumatoid arthritis.) The patients are then assessed 24 months after the initial treatment. None of the data will be unblinded until two years after the final patient had begun their treatment. This is not until September, 2017. He did say that there are a number of patients in remission.
The data will not be unblinded until October, 2017, and no results will be shared until their results are published! This is an agonising wait, but essential if the results are to be taken seriously.
One of the problems with placebo trials is that there can be “regression to the mean”. This means that reported improvements may be smaller than actual improvements, because patients may be worried about reporting a good response and then finding out they have received the placebo.
- Self-report of fatigue. This is done by the patients, at baseline and then every fortnight through the trial period. People can have problems in the second year, remembering how bad they were initially.
- SF-36 Quality of life and level of function
- Sensewear armbands at baseline and after 17-21 months. (Worn for a week.)
They have found overall that patient recall has correlated well with objective measures.
- 2 day CPET
- GI examination including ultrasound and gastroscopy
- Endothelial function both FMD (Flow Mediated Dilatation) and PORH (Post-Occlusive Reactive Hyperaemia)
The data from patients at the start of the trial, before Rx treatment, has been analysed.
As a group they do have endothelial dysfunction, in both large and small vessels. Their ability to respond to NO2 is intact, using nitroglycerin.
Cyclophosphamide Trial (CycloME)
Once again they had patients who were treated with a chemotherapy drug, this time Cyclophosphamide (Cyclo), for breast cancer, and two out of three showed significant clinical improvements.
Their pilot study, which ends in July, 2017, has been carried out in two centres: Bergen and Oslo. The patients include 15 from previous studies and 25 who have had no previous treatment. Cyclo can attenuate ME. Patients who have responded to Rx and Cyclo report that the effects are equivalent. At high doses, Cyclo is immune-suppressant. They may well try using lower doses.
Patients with ME seem to suffer more from the side effects of nausea and vomiting, but are still keen to continue the treatment. I believe that they are receiving treatment every four weeks, six times in total. Another worrying side effect is early onset menopause, so it cannot be used in younger women.
It is a more broad acting drug than Rx. It may well be that other potent immune modulating drugs could help in ME.
Professor Mella’s comment was that it would be surprising if the first or second drug they tried proved to be the most effective in ME. No, we weren’t told what would be next …
ME is in THE BLOOD, NOT BETWEEN THE EARS!
Professor Mella is very clear on the above, not only because of the striking results they have seen with Rx and Cyclo, but also because of the changes they see when healthy cells are bathed in serum from ME patients. The healthy cells then function as if they are from someone with ME, and vice versa.
His view is that ME is an immune disease which has an effect on mitochondrial function. Lack of adequate ATP affects all cell types. There are widespread symptoms, which may be, in part, due to compensation mechanisms within the body.
He stresses that when patients start improving, ALL Symptoms START improving, though not necessarily at the same rate.
Once they have finished the trial they will want to give all the patients who had placebo the chance to have Rx.
Whatever the results, they will continue with trials on CycloME.
They are VERY OPTIMISTIC for the future. There was some mention about PARTYING in the NEW YEAR, though probably not as soon as 1 January, 2018.
Dr. Oystein Fluge: ‘Metabolic Profiling in ME/CFS’
Dr. Ingrid Rekeland spoke for Dr. Olav Mella, who had fallen off a ladder 10 days ago, while mending his roof!
She began by summarising the reasons why autoimmunity (AI) is likely to be important in ME, such as the lag time in response to Rx, and overlapping autoimmune syndromes, such as POTS (postural orthostatic tachycardia syndrome) and CRPS (complex regional pain syndrome).
In addition, they have found in their patients that over 40% of them have a first degree relative with an AI disease. It affects more women. There is a genetic predisposition and there is a sudden start to ME in about 70% of cases.
Dr. Rekeland summarised the amino acid patterns found in 200 PwME v 102 Healthy Controls (HC), as per their paper. Also PR thread “Metabolic Profiling indicates impaired Pyruvate Dehydrogenase Function in ME/CFS“. I will not repeat the detail here.
Healthy myoblasts grown in the presence of serum from patients with severe ME show metabolic adaptations, including increased mitochondrial respiration and excessive lactate secretion. Anaerobic metabolism appears to be activated at rest or minimal levels of exertion. This is the equivalent of running for a Healthy Control.
The pattern of amino acid changes in ME could not explained by: symptom severity, disease duration, age, body mass index or physical activity level among patients (steps). It is definitely NOT due to deconditioning.
From Q & A:
- The functional inhibition of the mitochondria is due to an immune response. It is not associated with classical inflammation.
- There may well be benefits in looking at individuals in remission and relapse, although the differences they have shown are demonstrated at a group rather than an individual level.
- They have no recommendations for specific diets.
- If the Rx results are good it will need to be replicated in another country, such as the United States. “Everything needs to be done in the U.S.” I think he said this meaning, to get FDA approval in the United States a trial will need to be done there.
- Re: biosimilars, they hope that some industrial partners may become involved to do trials of their biosimilar v Rx or against another company’s biosimilar.
- Are there any biomarkers? Not yet, though there may be information soon within the results from Canada and Arizona … possibly a pattern predicting response.
This completely destroys the Psychological Theories of ME and provides explanation at a cellular level why GET is not effective or relevant.
COMING UP SOON: In the final article in this series, OverTheHills reflects on her experience as a patient attending the conference.