The Immunological Basis for Treatment Resistance to Anti-TNF Treatments
Phase: PHASE4
Conditions: Psoriasis
Sponsor: University of Michigan

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
 
 
 
 
 
 
 
 
 
 
 
The Immunological Basis for Treatment Resistance to Anti-TNF Treatments 
 
NCT01971346

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
The immunological basis for treatment resistance to anti-TNF 
treatments 
 
Rationale and Hypothesis 
Anti-TNF treatments such as etanercept are one of the most effective treatments 
available for psoriasis, but treatment response can vary substantially and a 
subgroup of patients may show minimal or no response even at high doses, 
despite having otherwise identical clinical features.   The biologic basis for the 
resistance to anti-TNF treatment is unknown but several separate lines of 
evidence indicate that it might be due to cross-regulation between tumor necrosis 
factor (TNF)-α and the type I interferon (IFN), IFN-α.     
The major source of type I IFNs are plasmacytoid dendritic cells (pDCs).  pDCs 
are rare in healthy skin but are often increased in psoriatic skin (4) and have 
been implicated in the pathogenesis of psoriasis, particularly in triggering plaque 
development, which has been shown to be dependent on IFN-α production in a 
xenograft mouse model.  Type I IFNs inhibit TNF-α production from monocyte-
derived inflammatory cells and anti-TNF pretreated pDCs have about a three-fold 
increase in IFN-α production. Furthermore, TNF blockade is consistently 
associated with an increased IFN-α signature in blood cells. In stark contrast, and 
consistent with the cross-regulation between these two cytokines, TNF-α inhibits 
the release of IFN-α from pDCs as well as generation of pDCs from 
hematopoietic precursors.    
The clinical evidence supporting this phenomenon has grown over the past few 
years.   The induction or exacerbation of psoriasis during anti-TNF therapy, 
which has now been reported in several hundred patients (9, 10) is one such 
example, and may occur in patients treated for inflammatory conditions other 
than psoriasis.   The psoriatic lesions of these patients have a greatly increased 
type I interferon signal, as determined by increased tell-tale Myxovirus 
Resistance Gene A (MxA) expression, compared with control psoriasis samples 
and similar observations have been made in patients exposed to the Toll-like 
receptor (TLR)-7 agonist imiquimod.  Imiquimod is a very effective inducer of 
type I interferon production by pDCs (15) and has been shown to exacerbate 
psoriasis both at the treated area as well as distant skin sites.  Similarly, to anti-
TNF exacerbated psoriasis, this reaction is accompanied by influx of pDCs and 
increased MxA expression.  Interestingly, but in line with the observations above, 
this reaction appears to be exacerbated in patients on anti-TNF treatment.  This 
cross-regulation is likely to extend beyond psoriasis as diseases characterized by 
increased type I IFN signal are frequently exacerbated or triggered by TNF 
treatments, including lichenoid skin reactions and the increased frequency of 
positive anti-double stranded DNA antibody titers  and less commonly clinical 
systemic lupus erythematosus, which are both reversible upon discontinuation of 
treatment. 
We have demonstrated that the inflammatory and cytokine network in chronic 
plaque psoriasis is heterogenous with large variation in the strength of the type I 

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
IFN-α and TNF-α signals between different patients.  Thus, about 35-40% of 
patients show an enriched IFN-α signature in lesional psoriatic skin, which, 
perhaps coincidentally, is around the same ratio of patients showing limited 
response to etanercept therapy.  Our analysis of a small cohort of patients (n=15) 
treated with etanercept indicated that those patients with increased IFN-α signal 
had poorer response to therapy and that the strength of the IFN-α signal was the 
main predictor of treatment response.   
These observations form the basis of our hypothesis that the balance between 
type I IFN and TNF determines the response to anti-TNF treatment. The goal 
of the proposed study is to address this hypothesis and demonstrate that the 
strength of the type I IFN signature in psoriatic skin is the major determinant of 
the clinical response to anti-TNF treatment.  
 
Proposed experiments 
Purpose: Determine the strength of the type I interferon and TNF signal in 
psoriatic skin prior to and during treatment with etanercept and correlate with 
degree of clinical improvement. 
 
Psoriatic patients will receive 100 mg etanercept per week (2 separate single-use 
pre-filled 50 mg subcutaneous injections taken on two separate days) for 3 
months. Inclusion and exclusion criteria will be identical to the previous EASE 
trial (with the exception of the highlighted items), as follows: 
 
Inclusion: 
1. At least 18 years of age at screening. 
2. Clinically stable moderate to severe plaque psoriasis at screening and 
baseline. 
3. Subject must be: 
 A man or 
 A woman who is surgically sterile or at least 3 years 
postmenopausal or 
 A woman of childbearing potential who has had a negative 
pregnancy test within 7 days before the first dose of study drug. 
4. If the subject is sexually active, (s)he must agree to use a medically 
acceptable form of contraception during screening and throughout the 
study. 
Exclusion: 
1. Grade 3 or 4 adverse events or infections within 28 days before screening, 
or between the screening visit and drug initiation. 
2. Active or chronic infection within 4 weeks before screening visit, or 
between the screening and baseline visits.  
3. Evidence of skin conditions other than psoriasis that would interfere with 
the evaluations of the effect of study medication on psoriasis. 

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
4. Use of oral psoralen with ultraviolet A (PUVA), oral retinoids, cyclosporine, 
alefacept, or any other systemic anti-psoriasis therapy within 28 days 
study drug initiation.  
5. Use of ultraviolet B (UVB) therapy, topical steroids at no higher than 
moderate strength, topical vitamin A or D analog preparations, or anthralin 
with 14 days of study initiation. 
6. Prior or concurrent use of cyclophosphamide therapy  
7. Concurrent sulfasalazine therapy. 
8. Known hypersensitivity to Enbrel® (etanercept) or any of its components 
or known to have antibodies to etanercept. 
9. Current enrollment in any other investigational device or investigational 
drug trial(s), or receipt of any other investigational agent(s) within 28 days 
before baseline visit. 
10. Use of any biologic drugs within 28 days of study drug initiation. 
11. Concurrent use of Anakinra. 
12. Severe comorbidities (diabetes mellitus requiring insulin; congestive heart 
failure (CHF) of any severity or myocardial infarction or cerebrovascular 
accident or transient ischemic attack within 3 months of screening visit; 
unstable angina pectoris, uncontrolled hypertension (sitting systolic BP 
<80 mm Hg or > 160 or diastolic BP > 100 mm Hg), oxygen-dependent 
severe pulmonary disease, history of cancer within 5 years (other than 
resected cutaneous basal or squamous cell carcinoma of the skin or in 
situ cervical cancer)  
13. Known history of tuberculosis (TB), or previous positive purified protein 
derivative (PPD) test. Any mycobacterial disease or high risk factors for 
tuberculosis (TB), such as family member with TB, positive purified protein 
derivative (PPD) or taking anti-tuberculosis medication. 
14. Known HIV-positive status or known history of any other immuno-
suppressing disease.  
15. Concurrent or history of psychiatric disease that would interfere with ability 
to comply with study protocol or give informed consent. 
16. History of alcohol or drug abuse within 12 months of screening visit. 
17. Latex sensitivity [Nota Bene: only applicable if they are using prefilled 
syringe or prefilled SureClick™ autoinjector presentations] 
18. Exposure to hepatitis B or hepatitis C or to high risk factors for hepatitis B 
or C, such as intravenous drug use in patient. 
19. Systemic lupus erythematosus, history of multiple sclerosis, transverse 
myelitis, optic neuritis or seizure disorder.  
20. Use of a live vaccine 90 days prior to screening visit, or concurrent use of 
a live vaccine.   
21. Any condition or circumstances judged by the patient’s physician[or the 
investigator or medically qualified study staff] to render this clinical trial 
detrimental or otherwise unsuitable for the patient’s participation.  
22. History of non-compliance with other therapies. 
23. Pregnant or nursing females. 

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
24. Diagnosis of multiple sclerosis in first degree family relationship (parent, 
sibling or child)  
 
 
 
Flow Chart of visits: 
Visits 
Screening 
BL 
Week2 
Week 6 
Week 12 
ICF 
X 
 
 
 
 
Med/Hx 
X 
 
 
 
 
Con Meds 
X 
X 
X 
X 
X 
Biopsies 
 
X 
X 
X 
X 
Inc/exc 
X 
 
 
 
 
Screening labs 
(CBC, metabolic 
panel) 
X 
 
 
 
 
TB Test* 
X 
 
 
 
 
Blood 
 
X 
X 
X 
X 
Dispense Drug 
 
X 
X 
X 
 
Urine Pregnancy 
Test 
X 
X 
 
X 
 
Photos 
 
X 
X 
X 
X 
Injection 
Instruction 
 
X 
 
 
 
Physical Exam 
X 
X 
 
 
 
PASI/PGA/BSA/ 
Itch 
Assessment** 
X 
X 
X 
X 
X 
*Subjects will be tested for TB at the screening visit and will return to research 
clinic 2 days later so that the area can be examined and the result documented.  
**Subjects will be asked to verbally indicate their level of itch on a scale of  0 to 
10 at each visit.  
  
Adverse events will be reported in accordance with the guidelines of the 
Institutional Review Board (IRB) and the Food and Drug Administration (FDA). 
Concomitant medications will be recorded. All serious adverse events, regardless 
of causation, will be reported to the IRB and Amgen Global Safety (see below) 
within one working day. All serious and medically significant adverse events 
considered related to etanercept by the investigator will be followed until resolved 
or considered stable.  Unexpected and fatal or life-threatening events will be 
reported to the FDA by phone or FAX within 7 calendar days. Written reports will 
be sent to the FDA within 15 calendar days for any serious unexpected adverse 
events for which there is reasonable possibility that the event may have been 
caused by the study drug. Any pregnancies occurring on study must also be 
reported to Amgen Global Safety (see below). Within 24 hours of FDA 
notification, a copy of all FDA submitted reports will be sent to Amgen by 
facsimile or mail at the following address:  

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
 
Amgen Global Safety 
c/o Amgen 
One Amgen Center Dr. 
Mail Stop 17-1-A 
Thousand Oaks, CA  91320-1799 
Fax: 1-888-814-8653 
 
At the screening visit, subjects will have a TB test performed, as well as skin 
exams, physical exams, medical history review, etc. as documented in the study 
flow sheet to determine if they meet the entrance requirements.  
Peripheral blood and biopsies will be obtained from 50 psoriatic patients with 
active lesions, who have not received any systemic treatment for four weeks, or 
any topical treatment other than bland emollients for two weeks. Peripheral blood 
mononuclear cells (PBMC) will be isolated from blood (approximately 4-6 tubes) 
taken from psoriatic patients prior to treatment and at every visit of etanercept 
treatment (see flow chart).  The isolated PBMCs will be cryopreserved and stored 
in liquid nitrogen, or used immediately for experiments. Serum will be stored for 
future cytokine measurements and levels of anti-nuclear antibodies (ANA) by 
ELISAs. Cellular staining will be determined by twelve-color BD LSR II flow-
cytometer.  Two biopsies will be taken at baseline (uninvolved and lesional 
psoriatic skin) and at each visit (lesional only) at week 2, 6 and 12. Gene and 
protein expression may be analyzed in whole-biopsies, or certain cell populations 
may be isolated from biopsies to perform flow cytometry, gene expression 
studies, protein expression studies, and other laboratory studies.  
 
1. 
Demonstrate that the strength of type I IFN signature in psoriatic skin 
predicts treatment response. 
Fifty individuals with moderate to severe psoriasis with high dose etanercept 
(50mg twice weekly), and the composition of the lesional psoriatic cytokine 
network will be tracked at the onset (day 0), early (week 2), during the middle 
(week 6) and at the end of treatment (week 12).  Serum samples and PBMC 
isolation will be done at each time-point for later analyses. Biopsies of uninvolved 
and lesional skin will be performed before initiation of treatment and then lesional 
biopsies taken at week 2, week 6 and week 12.  Skin will be anaesthetized with 
1% lidocaine with epinephrine and 6mm punch biopsies will be taken.  
Photographs of patients will be obtained and the anatomical location of biopsies 
recorded. Biopsies will be bisected, with one-half snap frozen in liquid nitrogen 
and stored at -80° until RNA and protein processing and the other half fixed in 
4% formalin for paraffin embedding and immunohistochemistry. Processing will 
be performed as previously described by our team and only high quality RNA, as 
determined by Agilent 2100 Bioanalyzer will be used .   

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
Next-generation sequencing of RNA (RNAseq) will be performed on the samples 
according to Illumina’s protocol using 2µg of RNA.  Immunohistochemistry will be 
performed to validate findings with MXA staining used to confirm presence of 
type I interferon signal. H&E staining will be used to assess the degree of 
epidermal hyperplasia and response to treatment and immunohistochemical 
detection of keratin 16, CD3, CD11c, CD163, Ki67 used to validate the degree of 
histologic response in context of the clinical response.    QRT-PCR will be 
performed for selected gene transcripts to validate the findings of RNAseq.   
 
Analysis/Statistics: RNAseq reads will be mapped using the TopHat algorithm 
and gene expression levels will be expressed as reads per kilobase of region per 
million mapped reads (RPKM).  Based on prior experience, we estimate that we 
will obtain around 3 gigabases of sequence for each sample.  Inflammation 
profiles and cytokine signature scores will be calculated as described by our 
group1-3.  Estimating that around 50% of patients will achieve a 75% reduction in 
Psoriasis Area and Severity Index (PASI) (PASI75) at 12 weeks; this should 
allow us to determine if effective treatment is associated with complete 
neutralization of the TNF signal in lesional psoriatic skin and elucidate the effect 
of the strength of the type I IFN signal on treatment response.  For our statistical 
analyses, we are interested in one outcome variable (PASI score) and two 
continuous covariates (RNAseq-generated TNF-α signal and IFN-α signal). We 
anticipate that these data will be analyzed in two ways.  
 
(1) First, we will test whether temporal change in PASI score is significantly 
associated with baseline TNF-α signal, baseline IFN-α signal, and/or an 
interaction between these two baseline signals. Along these lines, a cumulative 
score reflecting change in PASI during the course of etanercept treatment will be 
calculated for each patient. This score will then be treated as a continuous 
response variable, and we will use robust linear modeling to test whether scores 
are significantly associated with baseline TNF-α signal, baseline IFN-α signal, 
and/or an interaction between these two signals. In addition, we expect that it will 
be possible to unambiguously classify 30% of patients as non-responders, with 
an equal percentage showing clear improvement in PASI score, and the 
remainder showing an intermediate response. Accordingly, we will also 
categorize patients according to improvement in PASI score (i.e., responders, 
intermediate-responders, and non-responders), and use cross-validation to 
calculate AUC statistics to directly quantify the capacity of baseline TNF-α and 
IFN-α signals to predict patient response status.  Based upon preliminary data (n 
= 15 patients), we anticipate that improved PASI score will be associated with a 
heightened baseline TNF-α signal and weakened baseline IFN-α signal. The 
proposed study design will allow us to not only confirm this expectation, but will 
provide increased power to assess a possible TNF-α/IFN-α interaction effect, and 
to better characterize quantitative thresholds associated with response and non-
response.  
 

Derm 652: Enbrel for Psoriasis                                                         Protocol Version: 4  
 
                      March 29, 2016 
(2) Second, we will test whether TNF-α and/or IFN-α signals are significantly 
altered during the course of etanercept therapy, and whether such changes differ 
between subjects with different PASI response profiles. In these analyses, TNF-α 
or IFN-α signal will be treated as a response variable in a univariate repeated 
measures analysis of variance, with subject and time as covariates. In this 
framework, a shift in TNF-α or IFN-α signal during the course of etanercept 
treatment will be indicated by a significant time effect. In follow-up analyses, 
models will include 0-1 covariates indicating specific PASI response profiles 
(e.g., non-responder, intermediate-responder, or responder), which will allow us 
to test whether temporal shifts in TNF-α or IFN-α signals differ according to the 
effectiveness of etanercept treatment (i.e., by evaluating interaction effects 
involving time and 0-1 covariates denoting PASI response patterns). We 
anticipate that etanercept treatment will more strongly attenuate TNF-α signals in 
responders compared to intermediate-responders or non-responders (possibly 
due to disparities in baseline TNF-α and IFN-α signals). Conversely, we expect 
that non-responders will be characterized by high IFN-α signals, which remain 
high during the course of etanercept treatment. All analyses performed using 
PASI scores will be repeated using physician global assessment scores as the 
response variable, although we expect results from these two analyses to be 
consistent.  With 50 patients recruited and treated, we estimate that we will have 
>95% statistical power to detect significant effects in the proposed design (Type I 
error rate of 0.05). Although the analysis will be primarily focused on TNF and 
IFN signatures, this dataset will also provide us with opportunities to determine 
contribution of other inflammatory cellular and cytokine contribution to the clinical 
response. 
Anticipated Results: We expect that patients with strong IFN-α signature in 
psoriatic skin along with weak TNF-α signature will have minimal response to 
anti-TNF treatment, while patients with the opposite pattern, weak IFN and strong 
TNF signature, will have significant clinical improvement.