Pegtarazimod limits acute graft-versus-host disease mortality and severity in mice and is tolerated in patients
Verena Holzmüller, Jana Gawron, Ann-Cathrin Burk, Anna-Verena Stell, Anna-Sophia Baur, Alexander Zähringer, Viktor Fetsch, Annika Mäder, Alina Hartmann, Nana Talvard-Balland, Neel Krishna, Kenji Cunnion, Ulrich Thienel, Paolo Martini, Lindsey Glenn, James L.M. Ferrara, Monzr M. Al Malki, Hannah Choe, José Antonio Pérez-Simón, Annette Schmitt-Graeff, Joerg Buescher, Natalie Köhler, Zohreh Mansoori Moghadam, Philipp Henneke, Geoffroy Andrieux, Melanie Boerries, Robert Zeiser
Verena Holzmüller, Jana Gawron, Ann-Cathrin Burk, Anna-Verena Stell, Anna-Sophia Baur, Alexander Zähringer, Viktor Fetsch, Annika Mäder, Alina Hartmann, Nana Talvard-Balland, Neel Krishna, Kenji Cunnion, Ulrich Thienel, Paolo Martini, Lindsey Glenn, James L.M. Ferrara, Monzr M. Al Malki, Hannah Choe, José Antonio Pérez-Simón, Annette Schmitt-Graeff, Joerg Buescher, Natalie Köhler, Zohreh Mansoori Moghadam, Philipp Henneke, Geoffroy Andrieux, Melanie Boerries, Robert Zeiser
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Research Article Hematology Immunology

Pegtarazimod limits acute graft-versus-host disease mortality and severity in mice and is tolerated in patients

Abstract

The success of allogeneic hematopoietic cell transplantation (allo-HCT) is limited by acute graft-versus-host disease (aGVHD). We have previously reported that neutrophils can exacerbate tissue damage caused by conditioning regimens. Pegtarazimod is a synthetic peptide, derived from the capsid protein of human astrovirus serotype 1, that was shown to reduce neutrophil effector functions. Therefore, we evaluated the therapeutic activity of pegtarazimod against aGVHD. Pegtarazimod significantly reduced aGVHD-related mortality, histological aGVHD severity, and proinflammatory cytokines in multiple in vivo mouse models while maintaining the antileukemia effect. Mechanistically, pegtarazimod reduced inflammation by decreasing ROS production, as investigated using allo-HCT recipient mice with genetic inactivation of NADPH oxidase in the BM. In addition to the antiinflammatory effect, pegtarazimod protected intestinal organoids against TNF-induced toxicity and oxidative DNA damage. In the phase II clinical trial AURORA, pegtarazimod treatment was well tolerated in patients with corticosteroid-refractory aGVHD (ClinicalTrials.gov NCT06343792), with an overall response rate of 4/7 patients at day 28. In summary, pegtarazimod reduced aGVHD in mice by suppressing proinflammatory neutrophil effector functions and preserving enterocyte integrity. The clinical trial data support tolerability of pegtarazimod in aGVHD patients, and further studies are needed to determine efficacy.

Authors

Verena Holzmüller, Jana Gawron, Ann-Cathrin Burk, Anna-Verena Stell, Anna-Sophia Baur, Alexander Zähringer, Viktor Fetsch, Annika Mäder, Alina Hartmann, Nana Talvard-Balland, Neel Krishna, Kenji Cunnion, Ulrich Thienel, Paolo Martini, Lindsey Glenn, James L.M. Ferrara, Monzr M. Al Malki, Hannah Choe, José Antonio Pérez-Simón, Annette Schmitt-Graeff, Joerg Buescher, Natalie Köhler, Zohreh Mansoori Moghadam, Philipp Henneke, Geoffroy Andrieux, Melanie Boerries, Robert Zeiser

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Figure 3

Pegtarazimod binds to neutrophils and decreases ROS production and NETosis in aGVHD.

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Pegtarazimod binds to neutrophils and decreases ROS production and NETos...
(A) Representative images showing IF staining for DAPI (blue), α-tubulin (pink), and pegtarazimod (green) of primary mouse neutrophils, treated with vehicle (upper panel) or pegtarazimod (lower panel) for 1 h. Scale bars: 10 μm. (B) Inhibition of MPO activity by pegtarazimod, assessed by absorbance measurement of TMB oxidation. Results are derived from 2 independent experiments. P values were calculated using the Kruskal-Wallis test with Dunn’s multiple-comparison test. (C) Inhibition of ROS production by pegtarazimod in neutrophils activated with PMA, measured by ROS-dependent conversion of DHR123 to fluorescent R123 using flow cytometry. Results are derived from 3 independent experiments. P values were calculated using an ordinary 1-way ANOVA with Holm-Šidák multiple-comparison test. (D–F) Analysis of MPO levels (D), MPO activity (E), and NE levels (F) in the serum of BALB/c allo-HCT mice on day 7, treated with pegtarazimod or vehicle from days 0 to 7. (D) MPO levels measured by ELISA (n = 13–15). P values were calculated using the Mann-Whitney test. (E) MPO activity measured using an MPO peroxidation activity assay kit (n = 12–14). P values were calculated using the Mann-Whitney test. (F) NE levels measured by ELISA (n = 9). P values were calculated using the Mann-Whitney test. (G and H) IF staining of NETosis. SI of BALB/c allo-HCT mice on day 7, treated with pegtarazimod or vehicle from days 0 to 7. (G) Representative image. IF staining for DAPI (blue), citrullinated histone H3 (red), and MPO (green). Scale bar: 5 μm. (H) Quantification of NETosis was performed using automated detection of cells with high signal for citrullinated histone H3 and granular MPO signal, divided by the number of single cells detected in the sample (n = 19). P values were calculated using an unpaired 2-tailed Student’s t test.