WO2018118857A1 - Systèmes et procédés d'atténuation d'un trouble immunitaire - Google Patents

Systèmes et procédés d'atténuation d'un trouble immunitaire Download PDF

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Publication number
WO2018118857A1
WO2018118857A1 PCT/US2017/067213 US2017067213W WO2018118857A1 WO 2018118857 A1 WO2018118857 A1 WO 2018118857A1 US 2017067213 W US2017067213 W US 2017067213W WO 2018118857 A1 WO2018118857 A1 WO 2018118857A1
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Prior art keywords
immune
disorder
subject
syndrome
target site
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PCT/US2017/067213
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English (en)
Inventor
Jan Schwab
Phillip POPOVICH
Ali R. Rezai
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Ohio State Innovation Foundation
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Priority claimed from US15/382,911 external-priority patent/US20170100605A1/en
Application filed by Ohio State Innovation Foundation filed Critical Ohio State Innovation Foundation
Publication of WO2018118857A1 publication Critical patent/WO2018118857A1/fr

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/02—Details
    • A61N1/04—Electrodes
    • A61N1/0404—Electrodes for external use
    • A61N1/0408—Use-related aspects
    • A61N1/0456—Specially adapted for transcutaneous electrical nerve stimulation [TENS]

Definitions

  • the present disclosure generally relates to improving a patient's immune response by neuromodulation and other forms of therapy.
  • the central nervous system controls the immune system by several pathways, including being hardwired to the autonomic nervous system (ANS). Sensors within the central and peripheral autonomic system (PNS) relay information about the status of the immune system. Disruption of coordinated CNS-immune system interaction after injury or disease can result in an abrupt and drastic increase or decrease in immune function.
  • a method of improving an immune disorder in a subject suffering therefrom is provided.
  • the immune disorder is an autoimmune disorder, a hypersensitivity syndrome, an immune deficiency disorder, or combinations thereof.
  • the method involves positioning a therapy delivery device in communication with a neural target site that contributes and modulates the to immune activity of the subject and activating the therapy delivery device to deliver a therapy signal to the neural target site to improving the subject's immune disorder.
  • a method for improving an immune disorder includes determining the level of a physiological parameter that is indicative of immune activity of a subject and predicting dysfunction of the subject's immune system by comparing the determined level of the physiological parameter with a control value.
  • the method further includes placing a therapy delivery device into electrical communication with a neural target site that contributes to immune activity if the subject suffers from immune system dysfunction.
  • the method further includes activating the therapy delivery device to deliver a therapy signal to the neural target site to improve the subject's immune disorder.
  • FIG. 1 is a process flow diagram illustrating a method for modulating immune function in a patient according to an embodiment of the present disclosure
  • FIG. 1 A is a process flow diagram illustrating a method for improving an immune disorder in a subject according to an embodiment of the present disclosure
  • FIG. 2 is a schematic illustration of the levels of integration of the sympathetic
  • FIG. 3 is a process flow diagram illustrating a method for modulating immune function in a subject according to another embodiment of the present disclosure
  • FIG. 4 is a schematic illustration of the neurogenic pathophysiology and targets of maladaptive sympathetic signaling perpetuating functional spinal cord injury induced immune depression syndrome after spinal cord injury;
  • FIG. 5 is a process flow diagram illustrating a method for improving an immune disorder in a subject according to an embodiment of the present disclosure.
  • the present disclosure is generally directed to improving a patient's immune function. Improving a patient's immune function includes normalizing, modulating, optimizing, tuning restoring, regulating, increasing immune activity and function, or decreasing immune activity and function so that the patient's immune system is modulated to improve or prevent
  • hyperactive, hypoactive, or otherwise abnormal immune systems to improve symptoms of the subject that are caused by the abnormal immune system.
  • the terms “a,” “an,” and “the” include at least one or more of the described element unless otherwise indicated. Further, the term “or” and “and” refer to “and/or” unless otherwise indicated. It will be understood that when an element is referred to as being “over,” “on,” “attached” to, “connected” to, “coupled” with, “contacting,” “in communication with,” etc., another element, it can be directly over, directly on, attached to, connected to, coupled with, contacting, or in communication with the other element or intervening elements may also be present.
  • an element when an element is referred to as being “directly over,” “directly on,” “directly attached” to, “directly connected” to, “directly coupled” with, “directly contacting,” or in “direct communication” with another element, there are no intervening elements present.
  • An element that is disposed “adjacent” another element may have portions that overlap or underlie the adjacent element.
  • immune disorders that are improved by methods and systems of the present disclosure can have characteristics of one or more of an "autoimmune disorder," "a
  • hypersensitivity syndrome or an "immune deficiency disorder.”
  • a disorder may be classified as both an autoimmune disorder and a hypersensitivity syndrome.
  • combination of such target sites are also included as part of the disclosed target site.
  • the term "subject” can be used interchangeably with the term “patient” and refers to any warm-blooded organism including human beings and domesticated animals.
  • domesticated animals include livestock such as, for example, pigs, goats, sheep, chicken, horses, and cattle; and domesticated pets such as dogs and cats.
  • electrical communication refers to the ability of an electric field generated by an electrode to be transferred to neural tissue.
  • abnormal immune activity is decreased, increased, imbalanced, or impaired immune activity as compared to the immune activity of a healthy subject.
  • a healthy subject is a subject who has not previously been diagnosed as having any signs or symptoms indicating the presence of immune system dysfunction, a history of an immune system dysfunction, or evidence of immune system dysfunction.
  • a healthy subject is also a subject who, if examined by a medical professional, would be characterized as free of immune system dysfunction.
  • neural target site refers to a target site of the body that receives input from or delivers input to nervous system tissue.
  • a method 100 of improving an immune response in a patient suffering from a condition resulting or caused by an abnormal or deficient immune system comprises positioning a therapy delivery device in communication with a neural target site of a maladaptive sympathetic reflex or disturbance of the patient 102.
  • the therapy delivery device is activated to deliver a therapy signal to the neural target site 104 to improve the patient's immune response 106.
  • the neural target site can be a PNS or a CNS structure anatomically relevant to maladaptive sympathetic reflexes or disturbances.
  • the neural target site innervates an endocrinological or lymphatic tissue or organ involved in the immune response of the patient.
  • the neural target site is a neural target site of the ANS.
  • the neural target site can be a celiac ganglion, a superior mesenteric ganglion, an aorticorenal ganglion, a renal plexus, a inferior mesenteric ganglion, a superior hypogastric ganglion, a lumbar plexus, a celiac plexus, a splenic nerve, a sympathetic trunk, a splanchnic nerve, an intrinsic nervous system of an organ, and their input and output nervous system structures.
  • the neural target site can be the spinal cord (including the thoracic, cervical, and lumbar segments), a dorsal root ganglion, a pre-ganglionic fiber, a post-ganglionic fiber, or an adrenal nerve.
  • the neural target site can be other central regions such as within the forebrain, including the hypothalamus; the insular cortex; the nucleus coeruleus; or the prefrontal cortex and brainstem including the midbrain-pons-medulla circuitry that controls output from the spinal cord to immune organs.
  • Such central structures or neural regions directly "map" to spinal cord interneurons or sympathetic preganglionic neurons and subsequently to peripheral neural target sites such as ganglia controlling immune organs.
  • the neural target site is part of the enteric nervous system, such as a nerve, ganglion or plexus of the enteric nervous system.
  • the neural target site is pre-ganglionic fibers in the spinal cord efferent fibers and the intermediolateral column; epidural spinal cord; ventral (VRG) and dorsal roots (DRG); DRG afferent fibers, the doral horn; white rami; gray rami; sympathetic ganglia and the sympathetic chain, thoracic splanchnic nerves; para-aortic ganglia, such as the celiac ganglion; sympathetic plexus; or post ganglionic fibers.
  • VRG ventral
  • DRG dorsal roots
  • a method 400 includes improving an immune disorder in a subject suffering therefrom by positioning a therapy delivery device in communication with a neural target site that contributes to immune activity of a subject 402. The method further includes activating the therapy delivery device to deliver a therapy signal to the neural target site 404 and improving the subject's immune disorder 406. By improving the subject's immune disorder, the symptoms caused by the immune disorder are alleviated.
  • Symptoms vary based on the type and location of the abnormal immune response.
  • An immune disorder includes autoimmune disorders, hypersensitivity syndromes, immune deficiency disorders, and combinations thereof. Such immune disorders can be caused by cell-mediated immunity (T lymphocytes), humoral immunity (B lymphocytes) and immune tolerance. Immune disorders may result in destruction of body tissue, abnormal growth of an organ, and/or changes in organ function. An immune disorder may affect one or more organ or tissue types.
  • An autoimmune disorder is a type of immune disorder resulting from an abnormal or exaggerated adaptive immune response that targets healthy cells or tissues that should not normally cause an immune reaction in the body.
  • Autoimmune disorders include disorders in line with Witebsky's Postulates. Areas often affected by autoimmune disorders include, for example, the blood and blood vessels; connective tissue; endocrine glands or hormone producing organs such as the thyroid, pancreas, or adrenal glands; joints; muscles such as the heart; red blood cells; eyes; the skin; the gastrointestinal (GI) or digestive system; the brain, spinal cord, central nerves and peripheral nerves; bone; reproductive tissues such as the ovaries and testes; and breast tissue.
  • GI gastrointestinal
  • the autoimmune disorder is multiple sclerosis, ankylosing spondylitis, rheumatoid arthritis, celiac disease, myositis, myasthenia gravis, Addison's disease, lupus, hemolytic anemia, vitiligo, scleroderma, psoriasis, Hashimoto's disease, Addison's disease, Grave's disease, reactive arthritis, Sjogren's syndrome, nephritis, chronic Lyme disease, vasculitis, endocarditis, alopecia areata, urticaria, vasculitis, uveitis, pemphigus, Fibromyalgia, thrombophelebitis, erythema nodusum, dermatitis, eczema, Type 1 Diabetes, temporal arteritis, Crohn's Disease, Behcet's disease, or psoriatic arthritis.
  • the autoimmune disorder is multiple sclerosis, rheumatoid arthritis, lupus, celiac disease, Sjogren's syndrome, ankylosing spondylitis, Type 1 Diabetes, myositis, myasthenia gravis, alopecia areata, vasculitis, temporal arteritis, or eczema.
  • Hypersensitivity syndromes include immediate (Type I) hypersensitivity, antibody- mediated (Type II) hypersensitivity, immune complex -medicated (Type III) hypersensitivity, and cell-mediated (Type IV) hypersensitivity.
  • Type I hypersensitivity the immune response releases vasoactive and spasmogenic substances that act on vessels and smooth muscle and releases pro-inflammatory cytokines that recruit inflammatory cells.
  • Type II hypersensitivity secreted antibodies participate directly in injury to tissues by inducing inflammation. Antibodies may also interfere with cellular functions and cause disease without tissue injury.
  • Type III hypersensitivity antibodies bind antigens and then induce inflammation directly or by activating complement.
  • the leukocytes that are recruited produce tissue damage by the release of lysosomal enzymes and the generation of toxic free radicals.
  • sensitized T lymphocytes are the cause of the cellular and tissue damage.
  • Non-limiting examples of Type I hypersensitivity disorders are chronic or acute allergies, atopic forms of bronchial asthma, and anaphylaxis.
  • Non-limiting examples of Type II hypersensitivity syndromes are autoimmune hemolytic anemia, autoimmune thrombocytopenic purpura, pemphigus vulgaris, vasculitis caused by antineutrophil cytoplasmic antibodies, Goodpasture syndrome, acute rheumatic fever, myasthenia gravis, Graves disease, insulin- resistant diabetes, and pernicious anemia.
  • Type II hypersensitivity syndromes may be caused by the production of antibodies that bind to non-self antibodies, such as after an allogenic transplantation resulting in organ rejection; blood-group incomparability resulting in hemolysis; antibodies that bind to tumor-associated antigens resulting in paraneoplastic syndromes, neuropathies, and channelopathies, for example.
  • Type II hypersensitivity may also be caused by antibodies directed against cell-membrane bound medications resulting in medication-induced cell death, such as heparin-induced thrombocytopenia, for example.
  • Type III hypersensitivity disorders are systemic lupus erythematosus, poststreptococcal glomerulonephritis, acute glomerulonephritis, serum sickness, Arthus reaction, reactive arthritis, and polyarteritis nodosa.
  • Type IV hypersensitivity syndromes are contact dermatitis, multiple sclerosis, type 1 diabetes, transplant rejection, rheumatoid arthritis, tuberculosis, and peripheral neuropathy.
  • Immune deficiency disorders include primary immunodeficiency disorders and secondary immunodeficiency disorders. Most primary immunodeficiency disorders are genetically determined and affect specific immunity (i.e. the humoral and cellar arms of adaptive immunity) or non-specific host defense mechanisms mediated by complement proteins and cells such as phagocytes or NK cells (innate immunity). Primary immunodeficiency disorders can be mediated by T-cell defects, B-cell defects or both T-cell and B-cell defects.
  • Non-limiting examples of primary immunodeficiency disorders are X-linked agammaglobulinemia, common variable immunodeficiency, isolated IgA deficiency, hyper-IgM syndrome, DiGeorge syndrome, severe combined immunodeficiency disease (SCID), Wiskott-Aldrich syndrome, and genetic deficiencies of the complement system.
  • Secondary immunodeficiency disorders are acquired and may arise as complications of infections; malnutrition; aging; or side effects of
  • AIDS Immunodeficiency Syndrome
  • HAV human immunodeficiency virus
  • CUDS combined immune deficiency syndrome
  • SCI-IDS spinal cord injury-induced immune depression syndrome
  • a method of improving an immune disorder such as an autoimmune disorder, a hypersensitivity syndrome or an immune deficiency disorder, includes improving tolerability of long-lasting immune modulatory therapy.
  • Such a method can be used when orthodox immune modulatory treatment (e.g. steroids) cannot be provided because of limiting side effects of such treatment.
  • side effects include, for example, osteoporosis and psychosis.
  • an exemplary method involves a corticosteroid sparing approach, which allows for better treatment tolerability. This can be advantageous in chronically ill patients when long lasting therapy regimens are required.
  • the patient population is patients that cannot tolerate corticosteroids or other pharmaceutical (e.g. drug) or biological agents to improve their immune disorder.
  • a method of improving an immune disorder comprises positioning a therapy delivery device in communication with a neural target site that contributes to immune activity of a subject. The method further includes activating the therapy delivery device to deliver a therapy signal to the neural target site and improving the subject's immune disorder. The subject's immune disorder is improved without the administration of corticosteroids or other pharmaceutical agents that are indicated for treating or otherwise improving immune disorders.
  • a method of improving an immune disorder includes positioning a therapy delivery device in communication with a neural target site that contributes to immune activity.
  • a neural target site can be part of the brain, spinal cord, PNS or enteric nervous system.
  • the neural target site can be the hypothalamus, insular cortex, nucleus coeruleus, or the pre-frontal cortex.
  • the neural target site can also be the brainstem including the pons (which includes pontine noradrenergic cell groups and the pontine reticular formation) or the medulla.
  • the neural target site can be a cervical, thoracic lumbar or sacral segment, such as a C1-S5 segment.
  • the neural target site is a thoracic spinal segment, which is the origin of pre-ganglionic sympathetic neurons.
  • the neural target site can be a site of the ANS, which includes the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS).
  • SNS sympathetic nervous system
  • PSNS parasympathetic nervous system
  • Such sites include autonomic nerves (including pre- and post-ganglionic fibers of the ANS), autonomic ganglia, and autonomic plexus.
  • the neural target site is a part of the SNS, such as a sympathetic ganglion, a sympathetic nerve or a sympathetic plexus.
  • the neural target site can be a prevertebral ganglion or a paravertebral ganglion (sympathetic nerve chain ganglion).
  • paravertebral ganglia include a cervical ganglion, a thoracic ganglion, a lumbar ganglion, and a sacral ganglion.
  • Cervical ganglia include a superior cervical ganglion, a middle cervical ganglion, and an inferior cervical ganglion (or a stellate ganglion).
  • prevertebral ganglia include a celiac ganglion, an aorticorenal ganglion, a superior mesenteric ganglion, and an inferior mesenteric ganglion.
  • the neural target site can be a splanchnic nerve, including a greater, lesser, and least splanchnic nerve.
  • the neural target site can be a superior hypogastric plexus or a pulmonary plexus.
  • the neural target site can be a spinal nerve, a spinal ganglion, a spinal plexus or a localized intrinsic nervous system of an organ.
  • the neural target site can be a dorsal root ganglion, a lumbar plexus, or a hypogastric nerve.
  • the neural target site is a dorsal root ganglion, a ventral root ganglion, a lumbar plexus, or a hypogastric nerve, or white rami, gray rami.
  • the neural target site is pre-ganglionic fibers in the spinal cord efferent fibers and the intermediolateral column; epidural spinal cord; ventral (VRG) and dorsal roots (DRG); DRG afferent fibers, the doral horn; white rami; gray rami; sympathetic ganglia and the sympathetic chain, thoracic splanchnic nerves; para-aortic ganglia, such as the celiac ganglion; sympathetic plexus; or post-ganglionic fibers.
  • the neural target site can also be an excitatory or inhibitory interneuron.
  • Chemogenetic silencing of excitatory interneurons can be sufficient to reverse aberrant sympathetic nervous system hyperexcitability and subsequent immune suppression.
  • the therapy delivery device can be programmmed to inhibit or activate Vglut2+ interneurons or VGAT+ inhibitory interneurons.
  • the neural target site for improving an immune disorder can also be a dermatome specific to the lumbar or thoracic levels of the spinal cord and organ specific head zones.
  • the neural target site can also be nerves that innervate or receive input from the endocrine, lymphatic or pulmonary systems, including the spleen, bone marrow, gut/bowels, immune cells, adrenal gland and lungs.
  • the neural target site can be a cutaneous nerve.
  • a neural target site for improving an immune disorder is the thoracic or lumbar spinal cord and all accessible nerve roots including efferent and afferent nerve roots.
  • the neural target site is a T-1 to L-5 spinal cord segment or a T-1 to L-5 nerve root.
  • the target site is at the level of T5-T9 spinal segments, for example, when modulating systemic immune function.
  • the neural target site is a greater, lesser and least splanchnic nerve; an afferent nerve receiving input from tissues and organs of the endocrine, lymphatic or pulmonary system; an efferent nerve innervating tissues and organs of the endocrine, lymphatic or pulmonary systems; a dorsal root ganglion; a pre- or post-ganglionic autonomic nerve; a celiac ganglion; a pulmonary plexus; a superior mesenteric ganglion; an aorticorenal ganglion; an inferior mesenteric ganglion; a superior hypogastric ganglion; or a lumbar plexus.
  • pharmacotherapy can be used as adjuvant therapy together with neuromodulation.
  • Pharmacotherapy can include, for example, medications such as antibiotics, anti-fungal agents, and biologies (such as genetically-engineered proteins derived from human genes). Medications can also include those that reduce viral load (virus-static treatment) and subsequent inflammation (steroids and NSAIDs) and agents that shift the patient's autonomic tone such as, for example, beta blockers, angiotensin converting enzyme (ACE) blockers, clonidine, anti-spasticity, and anti-convulsive drugs. Pharmacotherapies can also include medications or combinations of medications that can mimic or replace the effects of neuromodulation on the immune system. Such drugs can be used alone or in combination with neuromodulation.
  • medications such as antibiotics, anti-fungal agents, and biologies (such as genetically-engineered proteins derived from human genes). Medications can also include those that reduce viral load (virus-static treatment) and subsequent inflammation (steroids and NSAIDs) and agents that shift the patient's autonomic tone such as, for example, beta blockers,
  • Such drugs include, for example, select adrenergic receptor blockers that target alpha or beta (e.g., Bl, B2 and B3) adrenergic receptors found on immune cells or glucocorticoid receptor antagonists.
  • Other agents include ganglion blockers such as mecamylamine and alcohol instillations.
  • the medications can be incorporated with polymers to slowly release analgesic, anti-inflammatory, or immune modulators, for example.
  • the medications can also take the form of slow release injectable pellets or chips that modulate the sympathetic nervous system for 3-6 months or another duration of time. Such pellets or chips can be delivered via percutaneous injection and can be used instead of a long-term mechanical neurostimulator.
  • Biologies that can be used include, for example, Abatacept Adalimumab, Anakinra, Certolizumab pegoi, Etanercept, Etanercept-szzs, Golimumab, Infliximab, Rituximab, Tocilizumab or Tofacitinib.
  • a method of improving an immune disorder such as
  • autoimmune disorders, hypersensitivity syndromes, and immune deficiency disorders in a subject involves positioning a therapy delivery device on a neural target site of a maladaptive sympathetic reflex or disturbance of the subject.
  • a maladaptive sympathetic reflex or disturbance is imbalanced sympathetic nerve activity that enters the lymphatic organs (e.g., spleen, bone marrow); endocrine organs such as the liver or adrenal gland; or immune system organ or immune systems cells as illustrated in FIG. 2.
  • a maladaptive sympathetic reflex or disturbance causes abnormal immune activity such as decreased, increased, imbalanced, or impaired immune activity as compared to the immune activity of a healthy subject.
  • a healthy subject is a subject who has not previously been diagnosed as having any signs or symptoms indicating the presence of an immune system dysfunction, a history of immune system dysfunction, or evidence of an immune system dysfunction (such as an autoimmune disorder, hypersensitivity syndrome, or immune deficiency disorders).
  • a healthy subject is also a subject who, if examined by a medical professional, would be characterized as free of immune system dysfunction.
  • a maladaptive sympathetic reflex or disturbance can be disinhibited sympathetic nerve activity that enters the lymphatic organs or immune system organs.
  • a maladaptive reflex or disturbance includes a sympathetic anti-inflammatory reflex, Sympathico-Babinski, disinhibited spinally generated sympathetic activity, and paroxysmal sympathetic activity. These conditions generally act on the ANS causing a systemic immune-suppression or immune-activation.
  • a maladaptive sympathetic reflex or disturbance can be present in a subject with a hyperactive or hypoactive immune system.
  • a maladaptive sympathetic reflex or disturbance can be present after CNS injury including injury to the brain, such as stroke, TBI, and subarachnoid hemorrhage (SAH); SCI; and other CNS or spinal cord or nervous system damage/injury, such as damage to nerves.
  • Injury can be due to acute or chronic degenerative conditions.
  • Chronic degeneration conditions include injury to the brain or spinal cord by compressive tumor growth but also degenerative myelopathy and neurodegenerative disease.
  • FIG. 4 schematically illustrates the neurogenic pathophysiology and targets of maladaptive sympathetic signaling perpetuating functional SCI- IDS after SCI. Under physiological conditions, excitatory sympathetic signals are controlled by supraspinal inhibition.
  • SNA spinally generated SNA.
  • SNA originates below SCI injury and leads to maladaptive efferent sympathetic activity signaling to the spleen, via the splenic or splanchnic nerve and directly to the adrenal gland. Such activity can culminate in large excitatory spinal sympathetic reflexes.
  • Spinal sympathetic reflexes occur in analogy to pathological Babinski motor reflexes, which are caused by a loss of supraspinal (bulbospinal) tonic inhibition ("Sympathetic-Babinski").
  • disinhibited spinal generated SNA after high thoracic (Th3) SCI can lead to ad hoc induction of excitatory SNA burst entering the splenic nerve and adrenal gland associated with increased levels of norepinephrine (NE) in the circulation and the spleen, which in turn causes apoptosis of immune cells in the spleen and other lymphoid organs. This results in a decrease of spleen size, partial loss of immune cells and an elevated susceptibility to infection.
  • Blocking SNA signaling ("shielding") by preceding peripheral denervation of the splenic nerve ameliorates functional SCI-IDS and bacterial load after Th3-SCI.
  • peripheral splenic nerve can be a target for immunomodulation after SCI in order to restore impaired host defense after SCI (SCI-IDS) by blocking SNA to the spleen.
  • SCI-IDS impaired host defense after SCI
  • spleen and adrenal gland shielding can be an interventional strategy to ameliorate functional SCI-IDS to prevent infections in patients at risk.
  • enhancing the maladaptive sympathetic reflex or disturbance may also artificially immune-suppress a patient and may attenuate immune diseases, including immune disorders affecting all systems of the body.
  • Those systems include, but are not limited to, the nervous system (peripheral and central), bone, cartilage, bronchial system/lung, pancreas, liver, and hematological systems. Blocking sympathetic activation reactive to stress responses may harness a patient's immune defense system against cancer. Other conditions causing immune suppression and elevated risk for infections are listed in Table I below. TABLE 1 Term
  • the therapy signal blocks neural conduction in the neural target site.
  • Such blocking of neural conduction can reduce or balance the patient's sympathetic tone to improve the patient's immune response.
  • the patient is suffering from sepsis, a central nervous system injury, antibiotic resistance, compensatory anti-inflammatory response syndrome (CARS), chronic inflammatory response syndrome (CIRS), CNS injury-induced immune deficiency syndrome (CIDS), including stroke-induced immune deficiency syndrome (SIDS), SCI-IDS, traumatic brain injury-induced immune depression syndrome (TBI-IDS), or other immune deficiencies.
  • CARS compensatory anti-inflammatory response syndrome
  • CIRS chronic inflammatory response syndrome
  • CIDS CNS injury-induced immune deficiency syndrome
  • SIDS stroke-induced immune deficiency syndrome
  • TBI-IDS traumatic brain injury-induced immune depression syndrome
  • the therapy signal stimulates neural conduction in the neural target site.
  • Such stimulation can enhance the patient's sympathetic tone to immune-suppress the patient, suppress the patient's baseline sympathetic tone to suppress disease-associated increases in immune function, or increase activity of the patient's intact sympathetic circuitry to suppress the patient's immune function.
  • Such stimulation can be used in circumstances where the patient has undergone organ transplantation (including bone marrow transplantation); suffers from an autoimmune disorder, including multiple sclerosis, rheumatoid arthritis, myasthenia gravis or myositis; suffers from corticosteroid side effects including osteoporosis or cortisone-induced psychosis; or suffers from other adverse effects from immune suppressive therapies.
  • Other conditions include hyper-immune disorders including multiple sclerosis, rheumatoid arthritis, and allergic conditions. Conditions also include hypo-active immune system disorders such as cancers or infections.
  • the present disclosure provides a method of improving an immune response in a patient suffering from a condition resulting or caused by an abnormal or deficient immune system 200.
  • the method includes positioning a therapy delivery device on an autonomic neural target site that innervates an endocrinological or lymphatic tissue involved in an immune response in the patient 202.
  • the method further includes blocking neural conduction in the autonomic neural target site 204 and improving the patient's immune response 206.
  • the autonomic neural target site can be a celiac ganglion, a superior mesenteric ganglion, an aorticorenal ganglion, a renal plexus, a inferior mesenteric ganglion, a superior hypogastric ganglion or a lumbar plexus.
  • the condition can be, for example, sepsis, a central nervous system injury, antibiotic resistance, CARS, CIRS, SCI-IDS, TBI-IDS, or CIDS.
  • the present disclosure includes various therapy delivery devices (not shown) and related systems configured to modulate a patient's immune response to improve an immune disorder, such as an autoimmune disorder, a hypersensitivity syndrome or an immune deficiency disorder.
  • therapy delivery devices may be positioned directly on a target nerve, neuron or nerve structure.
  • the therapy delivery device may be directly implanted in the submucosal (Meissner's) or myenteric (Auerbach's) plexus of the GI mucosa or muscularis propria, respectively.
  • therapy delivery devices may be positioned below the skin of a mammal but not directly on a target nerve, neuron or nerve structure.
  • therapy delivery devices may comprise an external device, e.g., positioned in a lumen adjacent a target nerve, neuron or nerve structure.
  • therapy delivery devices can include an external device, e.g., positioned on the skin of a mammal adjacent a target nerve, neuron or nerve structure. Therapy delivery devices can be temporarily or permanently implanted within, on, or otherwise associated with a subject in need of immune function modulation.
  • Therapy delivery devices can be configured or programmed to deliver various types of therapy signals to a target nerve, neuron or nerve structure.
  • therapy delivery devices can be configured or programmed to deliver only electrical energy, only a
  • therapy delivery devices can comprise at least one electrode and an integral or remote electrical energy generator (not shown), which is in electrical communication with the one or more electrodes and configured to produce one or more electrical signals (or pulses).
  • therapy delivery devices can include a pharmacological or biological agent reservoir, a pump, and a fluid dispensing mechanism, or a long-lasting polymer that encapsulates the drug in the form of a pellet, sheet or other form, for example, to allow slow infusion or delivery of medications and other agents that can modulate nervous system activity.
  • pharmacological and biological agents include chemical compounds, drugs, nucleic acids, polypeptides, stem cells.
  • the therapy delivery device can also be configured or programmed to deliver various other energy forms within the energy spectrum and/or biological forms of therapy, such as, for example, sound waves, ultrasound, radiofrequency (continuous or pulsed), optical, infrared, microwave, magnetic waves, cryotherapy, heat, or optogenetic therapy.
  • various other energy forms within the energy spectrum and/or biological forms of therapy such as, for example, sound waves, ultrasound, radiofrequency (continuous or pulsed), optical, infrared, microwave, magnetic waves, cryotherapy, heat, or optogenetic therapy.
  • therapy delivery devices can be configured or programmed to deliver magnetic nerve stimulation with desired field focality and depth of penetration.
  • therapy delivery devices can include a stimulator (or inhibitor), such as an electrode or electrical lead, a controller or programmer, and one or more connectors for connecting the stimulating (or inhibiting) device to the controller.
  • a stimulator or inhibitor
  • controller or programmer for controlling the stimulation (or inhibiting) device to the controller.
  • connectors for connecting the stimulating (or inhibiting) device to the controller.
  • An electrode can be controllable to provide output signals that may be varied in voltage, frequency, pulse-width, current and intensity.
  • the electrode can also provide both positive and negative current flow from the electrode and/or is capable of stopping current flow from the electrode and/or changing the direction of current flow from the electrode.
  • therapy delivery devices can include an electrode that is controllable, i.e., in regards to producing positive and negative current flow from the electrode, stopping current flow from the electrode, changing direction of current flow from the electrode, and the like.
  • the electrode has the capacity for variable output, linear output and short pulse-width.
  • the electrode can comprise a coil configured to deliver magnetic stimulation.
  • the electrical energy generator can comprise a battery or generator, such as a pulse generator that is operatively connected to the electrode.
  • the electrical energy generator can include a battery that is rechargeable by inductive coupling.
  • the electrical energy generator may be positioned in any suitable location, such as adjacent the electrode ⁇ e.g., implanted adjacent the electrode), or a remote site in or on the mammal's body or away from the mammal's body in a remote location.
  • An electrode may be connected to the remotely positioned electrical energy generator using wires, e.g., which may be implanted at a site remote from the electrode or positioned outside the mammal's body.
  • implantable electrical energy generators analogous to a cardiac pacemaker may be used.
  • the electrical energy generator can control the pulse waveform, the signal pulse width, the signal pulse frequency, the signal pulse phase, the signal pulse polarity, the signal pulse amplitude, the signal pulse intensity, the signal pulse duration, and combinations thereof of an electrical signal.
  • the electrical energy generator may be programmed to convey a variety of currents and voltages to one or more electrodes and thereby modulate the activity of a nerve, neuron, or nerve structure.
  • the electrical energy generator may be programmed to control numerous electrodes independently or in various combinations as needed to provide stimulation.
  • an electrode may be employed that includes its own power source, e.g., which is capable of obtaining sufficient power for operation from surrounding tissues in the mammal's body, or which may be powered by bringing a power source external to the mammal's body into contact with the mammal's skin, or which may include an integral power source.
  • Internal power sources can obtain sufficient energy, for example, from muscle movements, aortic pulsations, peristalsis, and other source of body energy generation that can be harnessed via a capacitor or a balloon device that harnesses the energy, for example, so that an internal battery, IPG, or external power source is not needed.
  • An electrical signal may be constant, intermittent, varying and/or modulated with respect to the current, voltage, pulse-width, waveform, cycle, frequency, amplitude, and so forth.
  • a current may range from about 0.001 to about 1000 milliampere (mA) and, more specifically, from about 0.1 to about 100 mA.
  • the voltage may range from about 0.1 millivolt to about 25 volts.
  • the frequency may range from about 0.5 to about 20,000 Hz.
  • the pulse-width may range from about 10 to about 10,000 microseconds.
  • the waveform can be a sine wave, a square wave, or the like.
  • the type of stimulation may vary and involve different waveforms.
  • the stimulation may be based on the H waveform found in nerve signals ⁇ i.e., Hoffman Reflex). In another example, different forms of interferential stimulation may be used.
  • voltage or intensity may range from about 0.1 millivolt to about 1 volt or more, e.g., 0.1 volt to about 50 volts ⁇ e.g., from about 0.2 volt to about 20 volts), and the frequency may range from about 1 Hz to about 100 Hz ⁇ e.g., from about 2 Hz to about 100 Hz).
  • pure DC voltages may be employed and in other instance AC may be employed.
  • the pulse-width may range from about 1 microsecond to about 2000 microseconds or more, e.g., from about 10 microseconds to about 1000 microseconds ⁇ e.g., from about 10 microseconds to about 1000 microseconds).
  • the electrical signal may be applied for at least about 1 millisecond or more, e.g., about 1 second ⁇ e.g., about several seconds). In some instances, stimulation may be applied for as long as about 1 minute or more, e.g., about several minutes or more (e.g., about 30 minutes or more).
  • voltage or intensity may range from about 1 millivolt to about 1 volt or more, e.g., 0.1 volt to about 50 volts (e.g., from about 0.2 volt to about 20 volts), and the frequency may range from about 1 Hz to 100 Hz or from 100Hz to ultrahigh frequency of 10,000 or 20,000 Hz. In some instances, pure DC voltages may be employed.
  • the pulse-width may range from about 1 microseconds to about 2000 microseconds or more, e.g., from about 10 microseconds to about 2000 microseconds (e.g., from about 15 microseconds to about 1000 microseconds).
  • the electrical signal may be applied for at least about 1 millisecond or more, e.g., about 1 second (e.g., about several seconds). In some instances, the electrical energy may be applied for as long as about 1 minute or more, e.g., about several minutes or more (e.g., about 30 minutes or more may be used).
  • the stimulation may be continuous or of intermittent durations of as little a 1 minute to as long as 24 hours.
  • the electrode may be mono-polar, bipolar or multi-polar of any configuration and geometry to fit the desired target of interest. Further, the electrode (and any wires and optional housing materials) can be made of inert materials, such as silicon, metal, plastic and the like. In one example, a therapy delivery device can include a multi-polar electrode having about four exposed contacts (e.g., cylindrical contacts).
  • a controller or programmer may also be associated with a therapy delivery device.
  • a programmer for example, can include one or more microprocessors under the control of a suitable software program.
  • the programmer can include other components such as an analog-to- digital converter, etc.
  • Therapy delivery devices can be pre-programmed with desired stimulation parameters.
  • Stimulation parameters can be controllable so that an electrical signal may be remotely modulated to desired settings without removal of the electrode from its target position.
  • Remote control may be performed, e.g., using conventional telemetry with an implanted electric signal generator and battery, an implanted radiofrequency receiver coupled to an external transmitter, and the like.
  • some or all parameters of the electrode may be controllable by the subject, e.g., without supervision by a physician.
  • some or all parameters of the electrode may be automatically controllable by a programmer or controller comprising the therapy delivery device.
  • the therapy delivery device can be configured for different forms of placement, insertion or implantation. This includes, for example, direct stimulation, epidural stimulation, and indirect stimulation, external or internal stimulation, or transluminal stimulation.
  • Neural target sites can be approached via direct open surgical procedures; or indirect procedures such as percutaneous, subcutaneous, transcutaneous, transvascular (including transvenous), transesophageal, transabdominal, or other forms of indirectly modulating the neural target site.
  • the neural target site can also be accessed via an endoscopic procedure.
  • the therapy delivery device can be configured for percutaneous placement or implantation.
  • the therapy delivery device can comprise one or more implantable electrodes shaped or configured, for example, as a wire, a rod, a filament, a ribbon, a cord, a tube, a formed wire, a flat strip, a pellet, or a combination thereof.
  • one or more of the electrodes can comprise a laminotomy electrode array.
  • Laminotomy electrodes for example, generally have a flat paddle configuration and typically possess a plurality of electrodes (e.g., 2, 3, 4 or more) arranged on the paddle.
  • the arrangement of electrodes on the paddle may be in rows and columns, staggered, spaced, circular, or any other arrangement that will position the electrodes for optimal delivery of electrical energy.
  • the one or more implantable electrodes may be controlled individually, in series, in parallel, or any other manner desired. Once implanted, the implantable electrode(s) may be held in position using various fixation devices, such as stitches, epoxy, tape, glue, sutures, or a combination thereof.
  • the device can be configured for transvascular placement or implantation.
  • the therapy delivery device can be placed across the azygous vein, vena cava or another venous and arterial system adjacent to the structure innervating or influencing the patient's immune function.
  • the therapy delivery device can be configured for intravascular or intraluminal placement or implantation using passive leads that anchor to the wall of the vessel for example.
  • a therapy delivery device configured for intravascular or intraluminal placement or implantation can be configured in an identical or similar manner as the expandable electrode disclosed in U.S. Patent Application Serial No. 11/641,331 to Greenberg et al. (hereinafter, "the '331 application"), which is incorporated by reference herein.
  • the therapy delivery device is a passive lead with wire anchors that attach to the vessel wall via a zigzag pattern that is separate from an electrically active stent.
  • the therapy delivery device can be configured for transcutaneous neuromodulation.
  • transcutaneous neuromodulation can include positioning an electrode on a skin surface so that a therapy signal can be delivered to a target nerve, neuron, or nerve structure.
  • transcutaneous neuromodulation can include positioning an electrode, without penetrating the skin of the subject and without necessarily contacting the electrode with the skin surface, so that a therapy signal can be delivered to a target nerve, neuron, or nerve structure.
  • Transcutaneous neuromodulation can additionally include partially transcutaneous methods ⁇ e.g., using a fine, needle-like electrode to pierce the epidermis).
  • a surface electrode can be placed into electrical contact with a nerve, neuron, or nerve structure ⁇ e.g., of the ANS) associated with immune function.
  • an electrical signal used for transcutaneous neuromodulation may be constant, varying and/or modulated with respect to the current, voltage, pulse-width, cycle, frequency, amplitude, and so forth (e.g., the current may be between about 0.1 to 100 milliamps), about 1-30 V (average), about 1 to about 10,000 Hz, with a pulse-width of about 10 to about 5000 microseconds.
  • a transcutaneous therapy delivery device may be configured as a belt or strap having at least one electrode operably attached thereto.
  • a therapy delivery device can be incorporated into clothing (such as, for example, a neck collar, brace, sweater, shirt, pants, socks, glove, stocking, skirt, shoes, underwear, vest, necklace, scarf, wrist band, waist band, ring, other jewelry, sportswear, ear pieces, adhesive patches, stickers, skin tattoos, skin paint, or a neuro- paint of other inductive and coupling material).
  • a therapy delivery device can be embedded in a pillow, a bed, a head rest of a chair, a car seat, a car neck rest, a computer console, and other types of furniture. These devices can provide either electrodes for delivering a therapy signal, sensors, or a combination of both.
  • Therapy delivery devices can be part of an open- or closed-loop system.
  • a physician or subject may, at any time, manually or by the use of pumps, motorized elements, etc., adjust treatment parameters, such as pulse amplitude, pulse-width, pulse frequency, duty cycle, dosage amount, type of pharmacological or biological agent, etc.
  • treatment parameters e.g., electrical signals
  • a sensor that senses a physiological parameter associated with immune function can be utilized.
  • incorporating the therapy delivery device as part of a closed- loop system can include placing or implanting a therapy delivery device on or within a mammal at a nerve target site, sensing a physiological parameter associated with immune function, and then activating the therapy delivery device to apply a therapy signal to adjust application of the therapy signal to the nerve target site in response to the sensor signal to modulate immune function.
  • the physiological parameter is associated with a deficient or abnormal immune system such as a hypoactive or hyperactive immune system.
  • a deficient or abnormal immune system such as a hypoactive or hyperactive immune system.
  • physiological parameters can include any characteristic or function associated with immune function, such skin temperature, protein concentrations, heart rate, blood pressure, biomarkers of the immune system or autonomic nervous system, electrochemical gradients, electrolytes, laboratory values, body temperature, and vital signs.
  • Sensors to measure physiological parameters can be external of the patient's body, or on the patient's body.
  • the parameters can be measured, for example, from blood, saliva, or sweat biomarkers.
  • physiological parameters include vital signs; EEG, EMG; FNIRS; heart rate variability; immune and hormonal markers, IL-6, TNF, other inflammatory mediators; sedimentation rate such as ESR for example, CRP, CBC and differential ratios of cell; circadian rhythms; and other means of feedback linked to stimulation modulation.
  • Physiological parameters that are biomarkers include but are not limited to BDNF, Neuropeptide Y, Cortisol, orexin, oxytocin, epinepherine, melatonin norepinephrine, DHEA, IL-6, IL-1, IL-4, TNF.
  • Other physiological parameters include eye tracking, pupil tracking, facial expression, thermography, and cognitive and behavioral measures such as stress, anxiety or hyperactivity.
  • the GI tract and enteric nervous system may be locations where a closed-loop system could be employed to improve GI inflammation.
  • a therapy delivery signal is delivered to the spinal cord, a prevertebral ganglion or vagus nerve, a receiving electrode or a biosensor (e.g., a biomaterial coated with detection surfaces for specific neurotransmitters) can be implanted into an enteric plexus or ganglion.
  • a biosensor e.g., a biomaterial coated with detection surfaces for specific neurotransmitters
  • the biosensor can be programmed to shut off the efferent/afferent signal.
  • the present disclosure provides another method 500 for improving an immune disorder, such as autoimmune disorders, hypersensitivity syndromes, or immune deficiency disorders, in a subject.
  • a method comprises determining the level of a physiological parameter that is indicative of immune activity 502 of the subject and predicting dysfunction of the subject's immune system by comparing the determined level of the physiological parameter with a control value 504.
  • the method further includes placing a therapy delivery device into communication with a neural target site that contributes to immune activity if the subject suffers from immune system dysfunction 506.
  • the method further includes activating the therapy delivery device to deliver a therapy signal to the neural target site to improve the subject's immune disorder 508.
  • non-limiting physiological parameters include: leukocyte subset ratios, such as the CD4/CD8 ratio;immunoglobulin (antibody) levels or antigen-specific antibody levels (e.g., antibodies directed against specific proteins in the body); NK lysis; granulocyte, neutrophil or monocytic activation; levels of biomarkers of inflammation such as, for example, C-reactive protein; levels of biomarkers of infection such as, for example, procalcitonin; or levels of lymphocytes or leukocytes.
  • leukocyte subset ratios such as the CD4/CD8 ratio
  • immunoglobulin (antibody) levels or antigen-specific antibody levels e.g., antibodies directed against specific proteins in the body
  • NK lysis granulocyte, neutrophil or monocytic activation
  • biomarkers of inflammation such as, for example, C-reactive protein
  • levels of biomarkers of infection such as, for example, procalcitonin
  • levels of lymphocytes or leukocytes include lymphocytes or
  • Various assays, tests and procedures can be employed to determine the level of a physiological parameter indicative of immune activity.
  • flow cytometry analysis can be used to determine the ratio of leukocyte subsets, such as the CD4/CD8 ratio; blood analysis can be used to determine antibody levels or antigen-specific antibody levels; immune cell function assays (e.g., mitogen stimulation of whole blood cells or lymphocytes with cytokine readouts or proliferation; K cell lysis assays; or radiological testing, such as Tl/T2-weighted imaging of the brain or spinal cord with gadolinium chloride enhancement to identify regions of vascular compromise which are either caused by aberrant inflammation or cause it to develop.
  • the above-described assays, tests and procedures are exemplary.
  • Other techniques can be used to determine the level of a physiological parameter indicative of immune activity depending on various factors. Such factors include, for example, the specific immune disorder being treated, the subject's age, the body organs affected, the duration or phase of the disorder, and other factors.
  • the detected level can be compared to a control value to determine if the detected level is abnormal, thereby indicating that the subject suffers from an immune system dysfunction.
  • Control values can be based upon the level of a corresponding physiological parameter obtained from a control population.
  • the control population can be the general population or a select population.
  • the select population can be a group of healthy subjects, a group of subjects that are at risk of immune system dysfunction, or a group of subjects that suffer from immune system dysfunction.
  • the control value can be based upon the units of the particular biomarker per ml of blood in subjects of the general or select population.
  • an increased level of the detected physiological parameter (as compared to the control value) can be indicated of immune system dysfunction.
  • a decreased level of the detected physiological parameter (as compared to the control value) can be indicative of immune system dysfunction.
  • CD4/CD8 ratios are often used as indicators of "adaptive immune health" with a normal ratio of greater than 2.0. Values lower than 2.0 are often used clinically as a diagnostic criteria for various suspected immune diseases including HIV, AIDS, anemia, multiple sclerosis, and chronic infections. A ratio higher 2.0 could indicate the presence of an infection.
  • inflammatory markers such as a C-reactive protein level greater than 5mg/l
  • prolonged elevation of markers of infection such as a procalcitonin level greater than 0.5 ng/ml or a leukocyte level greater than 9nl
  • prolonged suppression of lymphocytes such as a lymphocyte level less than 1.5/nl or a leukocyte level of less than 4/nl, is often associated with exacerbated immune-suppression or impaired host defense.
  • IL-2 immune system dysfunction
  • pathogenic antibodies include the presence of pathogenic antibodies; excessive NK lysis; the presence of innate cell respiratory burst function such as granulocyte, neutrophil and monocytic activation; enhanced lesions indicating a break-down of the blood-brain barrier; or the presence of sustained leucopenia, leukocytosis, lymphopenia, lymphocytosis, monocytosis, monopenia, neutrophilia, or neutropenia.
  • NK lysis the presence of innate cell respiratory burst function such as granulocyte, neutrophil and monocytic activation
  • enhanced lesions indicating a break-down of the blood-brain barrier
  • sustained leucopenia leukocytosis, lymphopenia, lymphocytosis, monocytosis, monopenia, neutrophilia, or neutropenia.
  • an additional step of methods of the present disclosure includes identify a patient suffering from an immune disorder, such as an autoimmune disorder, a hypersensitivity syndrome, or an immune deficiency disorder.
  • an immune disorder such as an autoimmune disorder, a hypersensitivity syndrome, or an immune deficiency disorder.

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Abstract

L'invention concerne des procédés destinés à atténuer un trouble immunitaire chez un sujet. Le trouble immunitaire peut être un trouble auto-immun, un syndrome d'hypersensibilité ou un syndrome d'immunodéficience. Les procédés consistent à positionner un dispositif d'administration de traitement sur un site cible neuronal qui contribue à l'activité immunitaire du sujet. Le dispositif d'administration de traitement est activé en vue de délivrer un signal de traitement au site cible neuronal en vue d'atténuer le trouble immunitaire du sujet.
PCT/US2017/067213 2016-12-19 2017-12-19 Systèmes et procédés d'atténuation d'un trouble immunitaire WO2018118857A1 (fr)

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