Neutrophil Vesicles as a novel autologous regenerative therapeutic for joint disease.

There is an unmet need for the treatment of rheumatoid arthritis since a significant proportion of patients do not respond to current therapies (~30%): this is evident from clinical trials and is even more acute in the community, where patients are 'not chosen' and comorbidities like obesity and diabetes increment the extent of therapeutic failures. As such, new approaches to improve prognosis and impact on patient quality of life are necessary. At the same time, as RA is diffuse in the adult population (1 in 20) better disease control can reduce the current health economic burden to our society (between 1 and 2.5% of GDP), determined by medicine and care costs as well as by loss of working hours.

To address this clinical need, we propose herein a research project to establish the biology to underpin the future development of an innovative autologous therapy for rheumatoid arthritis patients. This therapeutic opportunity comes from the use of vesicles (bubbles) that can be generated from white blood cells that circulate in the blood together with red blood cells and can also reach the inflamed joint. In fact, we have quantified an enrichment of specific bubbles in the joint of rheumatoid arthritis patients and, to our surprise, reported that they protected the joint from inflammation and the cartilage from degradation.

With this grant application we propose to study in experimental settings how these bubbles work; definition of the mechanisms activated by these bubbles to protect the joint can open avenues for developing an innovative autologous therapy: that is, we envisage a future scenario where rheumatoid arthritis patients will come to an out-patient clinic to donate their own white blood cells for the generation of bubbles which will then be injected into their own inflamed joint to exert anti-arthritic and analgesic effects. However, to accomplish this futuristic vision we must -

1) Understand the processes activated/modulated by the bubbles in the arthritic joint;
2) Define how many bubbles are required, an how often must be administered, to produce the beneficial effects on the joint;
3) Establish efficacy of the bubbles not only in experimental animals but also on human cartilage.

Completion of this project with a successful outcome will pave the way to the development phase for this innovative therapy, a path we will take with the guidance and advice of important players in the field, like the Cell and Gene Therapy Catapult and the MHRA, both of which have already been engaged.

We are seeking support to define the molecular and cellular pathways activated in vivo by neutrophil-derived extracellular vesicles (PMN EVs) to enable cartilage repair during joint inflammatory arthritis. This is the main thrust of this application. Supported by our recent publication, and a series of unpublished data, we propose a 2-year integrated research programme to define -

1. Efficacy, and mechanisms behind it, following intra-articular injection of PMN EVs in inflammatory arthritis.
2. Minimally required criteria in specific assays to establish inter-preparation variability/quality controls for efficacy and begin to pave the way to further development for this therapeutic approach.
3. The biomolecular mechanisms triggered by PMN EVs prepared by patient suffering from rheumatoid arthritis.

As such we will use one model of joint disease (for mechanistic purpose, to identify new markers of efficacy, complementing assessment of cartilage status with monitoring of inflammation and structural damage), one model of ectopic cartilage implantation (to assess translational potential for PMN EVs in human tissues) and a series of in vitro assays to establish the required degree of in vitro efficacy to predict efficacy in vivo. These in vitro assays will be applied also to define the bio-actions of PMN EVs produced from rheumatoid arthritis patients.

This project will deliver the biological information and quality controls required for further development of PMN EVs as a novel autologous regenerative therapy.

This proposal aims to test the feasibility of a novel treatment for Rheumatoid Arthritis (RA) based on a regenerative medicine approach. We anticipate that this work could impact on a number of beneficiaries, firstly patients affected by RA and possibly other joint diseases, but also the NHS, the economy and the commercial private sector.

PATIENTS: A large proportion of patients with RA develop cartilage loss, particularly if control of inflammation is incomplete or when it is achieved late. At that point, even if inflammation is under control, joint destruction inexorably progresses and leads to chronic disability. The ultimate clinical impact of this work will be the prevention of cartilage breakdown in RA, whether it is in conjunction to traditional DMARDs or in addition with biologics. With its potential to lead to regeneration of cartilage, it could possibly mean reducing the frequency of treatments and drug intake, with consequent improvement in quality of life. Our proposed approach could be delivered to patients between 5 and 10 years. While this proposal is focused on RA (a choice based on the underpinning experimental work), this approach also has the potential to be applied to other joint diseases (e.g. osteoarthritis), further amplifying the potential impact of this work.

NHS AND HEALTH PROVIDERS. A report from 2010 from the National Rheumatoid Arthritis Society estimated that in excess of 690,000 people in the UK as a whole live with RA, with a cost to the NHS of ~£700M per annum. Our treatment has the potential not only to halt the progression of the disease, but also to lead to cartilage regeneration, therefore it could help to significantly reduce the burden to the NHS.

ECONOMY. The same report detailing a ~£700M cost to the NHS for RA treatment, also found that the overall cost to the UK economy of productivity losses due to RA is almost £8 billion per year. Our treatment has the potential to significantly improve the quality of life of RA patients (e.g. staying in work) and consequently it could help to significantly reduce the cost to the economy.

INDUSTRY. The proposed research could be of interest to manufacturing and biopharma companies in various ways, depending on what developmental route will be pursued. For example, manufacturing companies could be interested in developing a bioreactor to optimise EVs production, as an innovative technical development for the autologous approach. Biotech companies working on EVs could be interested in collaborating to develop cell lines for EVs production, if instead an allogeneic approach is undertaken (although this approach won't be the subject of study of the current proposal). The early engagement with the Cell and Gene Therapy Catapult and their support will ensure that the best therapeutic approach can be developed into a sound and commercially viable product.

CHARITIES AND GOVERNMENT AGENCIES. The research outputs will be of interest to charities and government agencies seeking to support healthy ageing and improved treatments for chronic diseases. Representatives from charities and funding bodies regularly attend events at Barts and The London Medical School. As example, every year we hold the William Harvey Day a celebrative day of the School of Medicine that is attended by representatives from the Wellcome Trust, The British Heart Foundation and The Wolfson Foundation. In addition, this work fits within the 'therapeutic innovation' remit of a newly established inter-faculty Centre for inflammation and Therapeutic Innovation at QMUL (MP, acting Director; CP Deputy Director, FDA, Faculty of the Centre; see http://www.qmul.ac.uk/citi/) which has close links with Arthritis Research UK.