# Patent

## Title
Methods and systems for reducing inflammation by neuromodulation and administration of an anti-inflammatory drug

## Abstract

Described herein are devices, systems and method of treating inflammation by vagus nerve stimulation and the delivery of an anti-inflammatory drug. In particular, described herein are methods of treating inflammation including the steps of stimulating a subject's inflammatory reflex to inhibit the immune response and administering an anti-inflammatory drug.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This patent application is a continuation-in-part of U.S. patent application Ser. No. 12/415,671, filed Mar. 31, 2009, titled “METHODS AND SYSTEMS FOR REDUCING INFLAMMATION BY NEUROMODULATION OF T-CELL ACTIVITY,” now U.S. Pat. No. 9,211,409, which claims the benefit of U.S. Provisional Patent Application No. 61/072,603, titled “DEVICES AND METHODS FOR NEUROMODULATOIN OF T-CELL ACTIVITY,” filed Mar. 31, 2008, each of which is herein incorporated by reference in its entirety.


STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH
This invention was made with government support under grant(s) R01 GM057226 and R01 GM062508 awarded by the National Institutes of Health. The government has certain rights in the invention.


BACKGROUND OF THE INVENTION
Cytokine production is counter-regulated by evolutionarily ancient mechanisms. The cholinergic anti-inflammatory pathway is an anti-inflammatory neural mechanism for suppressing cytokine release by the immune system. It functions by signals carried via the vagus nerve that suppress cytokine release through a molecular mechanism that requires the alpha7 nicotinic acetylcholine receptor subunit (alpha7 nAChR). Direct electrical (or mechanical) stimulation of the vagus nerve attenuates cytokine release and prevents tissue injury in experimental animals with cytokine mediated diseases, including endotoxemia, hemorrhagic shock, ischemia-reperfusion, sepsis, colitis, and arthritis. The functional integrity of this pathway is critical for modulating the innate immune response to endotoxins, because eliminating the function, by either cutting the vagus nerve, or removing the alpha7 nAChR gene, renders animals exquisitely sensitive to otherwise innocuous quantities of endotoxins.
Early observations into the anatomic and functional basis of the cholinergic anti-inflammatory pathway implicate neural input to spleen as essential for vagus nerve mediated decreases of TNF during endotoxemia. Electrical stimulation of the vagus nerve in the neck attenuates TNF mRNA and protein levels in spleen, a major source of TNF in endotoxemia. Surgical ablation of the vagus nerve branches to the celiac ganglion disrupts the TNF-suppressive activity of cervical vagus nerve stimulation. Innervation to the spleen is provided by the splenic nerve, a catecholaminergic nerve that originates in the celiac ganglion. Since the cholinergic antiiflammatory pathway requires alpha7 nAChR signals, we examined how signals originating in vagus nerve reach the TNF-producing cells in spleen. Here we show that the splenic nerve is required for vagus nerve stimulation control of TNF production. Splenic nerve endings culminate adjacent to TNF producing macrophages and adjacent to T cells. Surprisingly, T cells are required for the functional integrity of the neural signals that inhibit TNF in spleen. As a result, we suggest methods and devices for treatment of disorders by stimulation of the inflammatory reflex (including the vagus nerve) in combination with modulation of T-Cells. Modulation of T-Cells, which may (in part) mediate the inflammatory reflex may help in further controlling the inflammatory reflex.
This application is related to U.S. Pat. No. 6,610,713; U.S. patent application Ser. No. 10/990,938, titled “Inhibition of Inflammatory Cytokine Production by Cholinergic Agonists and Vagus Nerve Stimulation,” filed Nov. 17, 2004; and U.S. patent application Ser. No. 11/318,075, titled “Treating Inflammatory Disorders by Electrical Vagus Nerve Stimulation,” filed Dec. 23, 2005. Each of these patents and pending applications is herein incorporated by reference in its entirety.
SUMMARY OF THE INVENTION
Described herein are devices, systems and method of treating an inflammatory response, including a method of treating a T-cell mediated disease. For example, described herein is a method of treating an inflammatory response comprising: stimulating a subject's inflammatory reflex to inhibit the immune response; and administering a T-cell modifying agent.
Inflammatory responses to pathogens and tissue injury are precisely controlled to prevent excessive tissue injury. Signals in the cholinergic anti-inflammatory pathway, in which efferent vagus nerve signals inhibit cytokine production, require the alpha7 nicotinic acetylcholine receptor subunit (alpha7 nAChR), which binds acetylcholine and suppresses the nuclear translocation of NFkB. Despite the importance of this pathway in controlling cytokine production, the cellular target of the neural signals during endotoxemia was previously unknown. Here, immunohistochemical staining of spleen during endotoxemia revealed that splenic nerve endings terminate adjacent to discrete macrophage populations producing TNF, and next to T cells that produce acetylcholine. Application of either vagus nerve stimulation, or administration of nicotine, an alpha7 agonist, significantly attenuates TNF production by the subpopulation TNF-producing splenic macrophages. Surprisingly, however, vagus nerve stimulation of nude mice failed to inhibit TNF production. Administration of nicotine to nude mice did significantly inhibit TNF production, indicating that T cells are essential for the neural, but not molecular activation of the cholinergic anti-inflammatory pathway. Together these results indicate that T cells are required for regulation of TNF by vagus nerve signals to spleen, and identify a previously unknown role for T cells in the function of the cholinergic anti-inflammatory pathway.
In the methods, systems and devices described herein, the stimulation of the subject's inflammatory reflex may be electrical stimulation, mechanical stimulation, or any other appropriate method of stimulation. In particular, long-term stimulation methods (e.g., non-contact, non-desensitizing methods) may be preferred.
Any appropriate T-cell modifying agent may be used with the methods, systems and devices described herein. For example, the T-Cell modifying agent may be selected from the group consisting of: glucocorticoids, antibody agents, peptide agents, drugs, and pro-drugs.
The step of stimulating the subject's inflammatory reflex may comprise stimulating the subject's vagus nerve (and/or afferent or efferents of the vagus nerve). In some variations the step of stimulating the subject's inflammatory reflex comprises stimulating one or more of: the vagus nerve, the splenic nerve, the hepatic nerve and the trigeminal nerve, and their afferents and efferents.
The step of administering a T-cell modifying agent may comprises systemic administration of the T-cell modifying agent, or local administration of the T-cell modifying agent (e.g., to the spleen or general splenic region). A T-cell modifying anent may be administered at any time in the method, for example, before, during and/or after stimulating the subject's inflammatory reflex.
In some variations, the step of stimulating the inflammatory reflex comprises repeatedly and periodically stimulating the subject's inflammatory reflex. For example, a subject's vagus nerve may be stimulated every 4 hours, every 8 hours, every 12 hours, every 24 hours, every 2 days, etc. The method may also included additional administration of T-cell modifying agents. For example, a T-cell modifying agent may be applied at various times during the treatment method.
Also described herein are methods of treating T cell-mediated diseases comprising the steps of identifying a patient suffering from a condition mediated by T-cell cells, stimulating the subject's inflammatory reflex, and administering a T-cell modifying agent. The T-cell mediated disease may be selected from the group consisting of: transplant rejection, rheumatoid arthritis, Psoriasis, or multiple sclerosis.
INCORPORATION BY REFERENCE
All publications and patent applications mentioned in this specification are herein incorporated by reference in their entirety to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 shows the loss of inhibition the inflammatory reflex (measured by serum TNF) after cutting the splenic nerve (right side) compared to control (sham, left side). Inhibition of the inflammatory reflex is caused by VNS (vagus nerve stimulation), as previously described.
FIGS. 2A and 2B shows immunohistochmeical staining for synaptophysin (SYN) either before (FIG. 2A) or after (FIG. 2B) cutting the splenic nerve.
FIGS. 2C and 2D shows immunohistochemical staining for catecholaminergic neurons (CAT) before (FIG. 2C) or after (FIG. 2D) cutting the splenic nerve.
FIGS. 3A-3D show immunohistochemical staining with specific markers of macrophage subpopulations and TNF. MZM (marginal zone macrophages) and MMM (marginal metallophilic macrophages) and red pulp macrophages are indicated from this splenic section. TNF staining overlapped with marginal zone and the red pulp regions.
FIGS. 4A-4D are immunohistochemical staining of rats (through the spleen) after cutting the splenic nerve (FIGS. 4C and 4D) and in sham-operated rats, whose splenic nerve was left intact (FIGS. 4A and 4B); all rats were first subjected to vagus nerve stimulation and endotoxemia. Spleen sections were stained for TNF expression.
FIGS. 5A-5B show spleen sections stained for synaptophysin (SYN), TNF, and red pulp macrophages (RPM) in sham-operated (control) rats.
FIGS. 5C and 5D show spleen sections stained for synaptophysin (SYN) and CD3 (a T cell marker).
FIGS. 5E and 5F show spleen sections expressing eGFP placed under the control of endogenous ChAT transcriptional regulatory elements (eGFT-ChAT) and stained for synaptophysin (SYN).
FIG. 6A shows the effect of serum TNF levels in wild-type (left) and nude (right) mice (mice devoid of T cells) after vagus nerve stimulation during endotoxemia. “SHAM” mice were not stimulated.
FIG. 6B shows the effect of serum TNF levels in wild-type (left) and nude (right) mice during endotoxemia after application of either saline (PBS) or nicotine.
FIG. 7A shows the effect of a cholinesterase inhibitor, Paraoxon, on TNF production by LPS-stimulated spleen cells, indicating a dose-dependent inhibition of TNF. FIG. 7B indicates that here is no significant toxicity correlated to these levels of Paraoxon.
FIG. 8A illustrates a schematic of a general system for modulating an inflammatory reflex. FIG. 8B is a schematic illustration of one variation of system for modulating an inflammatory reflex.



DETAILED DESCRIPTION OF THE INVENTION
To study whether TNF-inhibiting signals in the vagus traverses the splenic nerve, the splenic nerve was surgically ablated in rats exposed to endotoxemia and vagus nerve stimulation. Splenic neurectomy prevented the TNF-suppressing activity of vagus nerve stimulation, indicating that the neural signals originating in the cervical vagus nerve traverse the splenic nerve (FIG. 1). Complete ablation of the splenic nerve was confirmed, because immunohistochemical staining for synaptophysin, a synaptic vesicle protein and marker of nerve terminals, was absent after the splenic nerve was cut (FIGS. 2A and 2B). Moreover, and as expected, review of sections stained using glyoxylic acid to reveal catecholaminergic neurons revealed that it was completely depleted in animals subjected to splenic neurectomy (FIGS. 2C and 2D). In agreement with previous studies, we observed synaptophysin-positive staining in the regions of the central artery, white pulp, red pulp, and splenic capsule. Sequential sections showed synaptophysin staining following a similar distribution pattern to that of the neural network visualized with glyoxylic acid.
To continue studying the functional and cellular anatomy of these nerves, it was necessary to characterize the cell source of spleen TNF during endotoxemia. Previous evidence suggested that the major source of TNF in endotoxemia is cells of the rethiculoendothelial system (Cano, G., A. F. Sved, L. Rinaman, B. S. Rabin, and J. P. Card. 2001. Characterization of the central nervous system innervation of the rat spleen using viral transneuronal tracing. J. Comp Neurol. 439:1-18.1), but the specific cell type was unknown. Accordingly, sections studied by immunohistochemistry revealed that TNF production occurred in the marginal zone and the red pulp regions, the areas where spleen macrophages reside. Immunohistochemistry with specific markers of macrophage subpopulations revealed the TNF-producing cells to be the marginal metallophilic macrophages, the marginal zone macrophages, and the red pulp macrophages (FIG. 3A-3D). We did not observe TNF-positive staining in either T lymphocytes or dendritic cells. These findings indicated that macrophages in the marginal zone and red pulp are the major source of spleen TNF in endotoxemia. In order to confirm the functional connection between vagus nerve signals and these TNF-producing macrophages, rats were subjected to vagus nerve stimulation and endotoxemia. TNF expression in spleen was significantly abolished by vagus nerve stimulation (FIG. 4A-4D). Together these results indicate that signals originating in the vagus nerve attenuate TNF in spleen via the splenic nerve.
We next undertook to understand the cellular basis for this control of cytokine production by specific nerves in discrete populations of macrophages. We performed a systematic search for points of contact between the splenic nerve endings and the TNF producing macrophages. Triple staining of spleen sections from sham-operated rats revealed nerve terminals adjacent to, and apparently contacting, the TNF-producing macrophages (FIGS. 5A and 5B). Nonetheless, these points of contact were difficult to visualize, and largely limited to the red pulp macrophages. Most important, not all of the TNF producing cells received neural input. Instead, it was clear that the major cells contacting the neurons were the T cell in the white pulp. Serial sections through white pulp areas revealed that synaptophysin-positive neurons provided abundant contact to T cells (FIGS. 5C and 5D). Previous investigators have shown that catecholaminergic neurons contact T cells in spleen, and that T cells express choline acetyltransferase, the enzyme required for acetylcholine production. BAC-transgenic mice, in which eGFP was placed under the control of endogenous ChAT transcriptional regulatory elements were used. Examination of eGFP-ChAT in spleen confirmed that T cells are the major source of acetylcholine synthesis in spleen. Moreover, nerve terminals made contact with some of these eGFP-ChAT-positive cells (FIGS. 5 E and 5F).
Accordingly, we reasoned that the T cells might participate in the neural regulation of TNF in the spleen. Consistent with this, we discovered that vagus nerve stimulation of nude mice (mice devoid of T cells) failed to inhibit TNF production during endotoxemia (FIG. 6A). We (and others) have previously shown that the alpha7 nAChR is essential for the functional integrity of the cholinergic anti-inflammatory pathway. Administration of nicotine to nude mice significantly inhibited the production of TNF (FIG. 6B) indicating the absence of T cells does not impair the ability of the TNF producing macrophages to respond to the alpha7 nAChR agonist. Thus, we have shown the surprising result that T cells provide a critical role in transducing neural signals from the splenic nerve to the TNF-producing macrophages to control cytokine production via the cholinergic anti-inflammatory pathway.
These surprising results described herein expand our knowledge of the anatomical basis of the cholinergic anti-inflammatory pathway by showing that macrophage subpopulations in spleen produce TNF in endotoxemia, and that electrical stimulation of the vagus nerve controls TNF production by these cells via a mechanism that is dependent on an intact splenic nerve.
Previously, we found that vagus nerve stimulation attenuates spleen TNF, an effect that is dependent on the celiac branches of the vagus nerve. However, neuronal tracing studies and the lack of splenic cholinergic fibers indicate that primary vagus nerve fibers do not innervate the spleen. Our results show that suppression of TNF by vagus nerve stimulation requires an intact splenic nerve, a finding that indicates a functional connection between the vagus nerve and splenic TNF-producing cells. The spleen is innervated by nerve fibers that originate in the celiac ganglion. Efferent fibers of the vagus nerve, through its celiac branches, terminate in synaptic-like structures around principal cells of the celiac ganglion. Our data raise the possibility that an anti-inflammatory signal conveyed by the vagus nerve attains splenic immune cells through a system of two serially-connected neurons: one preganglionic that originates in the dorsal motor nucleus of the vagus embodied in the vagus nerve, and other postganglionic that originates in the celiac ganglion whose axons travel along the splenic nerve.
The splenic nerve, mainly composed of catecholaminergic fibers, is supplied by preganglionic sympathetic neurons located in the intermediolateral column of the thoracic spinal cord and the paravertebral ganglia (1). Our results indicate that the vagus nerve communicates with the splenic nerve. Vagal regulation of postganglionic catecholaminergic fibers has been demonstrated previously. In dogs, electrical stimulation of the cervical vagus nerve decreases pancreatic norepinephrine release induced by electrical stimulation of thoracic (catecholaminergic) nerves (2). In rats, cervical vagotomy increases splenic nerve discharge induced by IL-1β, suggesting that the vagus nerve exerts a tonic inhibitory control over splenic nerve activity (3). To our knowledge, preganglionic projections to postganglionic neurons in the celiac ganglion have not been characterized. For instance, it is unclear whether the splanchnic nerve (preganglionic sympathetic fiber) and the vagus innervate the same postganglionic neurons in the celiac ganglion.
Vagus nerve stimulation attenuates TNF mRNA and protein levels in spleens of endotoxemic animals but the target cell of this effect was unknown. Here we found that vagus nerve stimulation attenuated TNF in macrophages of the marginal zone and the red pulp. An earlier study using the perfused rat spleen ex vivo showed that electrical stimulation of the splenic nerve induces norepinephrine release from spleen, and attenuates LPS-induced TNF through a beta-adrenergic dependent mechanism (4). Given that electrical stimulation of the vagus nerve requires an intact splenic nerve in order to suppress TNF, it is plausible that vagus nerve stimulation induces release of norepinephrine from catecholaminergic splenic nerve terminals, whose presence has been previously revealed in the marginal zone and red pulp. Future experiments will aim to determine the effect of vagus nerve stimulation on the release of catecholamines and other neurotransmitters or neuropeptides (e.g. neuropeptide Y) in spleen.
One issue in the cholinergic anti-inflammatory pathway not addressed in this study is the anatomic location of the nicotinic acetylcholine receptor alpha7 subunit, which is required for vagus nerve control of TNF production. In vivo, we have observed that alpha7 knockout mice are insensitive to the TNF-suppressive effect of vagus nerve (5). In vitro, acetylcholine and other cholinergic agonists attenuate LPS-induced TNF in human and mouse macrophages, as well as in mouse splenocytes, through an alpha7-dependent mechanism (5,6). In view of the present findings it is possible that the alpha7 requirement observed in vivo is related to its functioning in autonomic ganglia, the alpha7 nicotinic subunit of the acetylcholine receptor is expressed in autonomic ganglia where it mediates fast synaptic transmission, and its expression has been documented in the superior cervical ganglion and the celiac ganglion (7,8). It is possible that acetylcholine released by the vagus nerve acts upon alpha7 expressed in neurons of the celiac ganglion to modulate splenic nerve function. Nevertheless, alpha7 involvement in cholinergic signaling in spleen, which contains and produces acetylcholine (9,10) and alpha7-expressing immune cells (11), has not been ruled out.
Here, we have found that several macrophage subpopulations are responsible for splenic TNF production in endotoxemia, and that their cytokine-producing capability is amenable to modulation by electrical stimulation of the vagus nerve, through a mechanism dependent on an intact splenic nerve. The spleen is a lymphoid organ where several leukocyte subtypes converge to initiate innate and adaptive immune responses, and splenic nerve endings are located in close proximity to macrophages and lymphocytes. Our finding that vagus nerve stimulation modulates splenic TNF production through the splenic nerve, suggest that vagus nerve stimulation could modulate adaptive immunity as well. Altogether, these findings extend our knowledge of the anatomical basis that allows control of cytokine production in the spleen by the vagus nerve.
Materials and Methods
Animals
Adult male BALB/c mice 8 to 12 weeks-old (20-25 g; Taconic) and adult male Sprague Dawley rats 8 to 12 weeks-old (250-300 g, Charles River Laboratories) were housed at 25° C. on a 12-hour light/dark cycle, and let acclimatize for one week before experiments were conducted. Water and regular rodent chow were available ad libitum. Experiments were performed under protocols approved by the Institutional Animal Care and Use Committee of the Feinstein Institute for Medical Research, North Shore-LIJ Health System.
Antibodies
Antibodies and dilutions used for immunofluorescence were as follows: Marginal zone macrophages: Biotinylated rat anti-mouse SIGN-R1 (clone ER-TR9, BMA Biomedicals); marginal metallophilic macrophages: Biotinylated rat anti-mouse sialoadhesin (clone MOMA-1, BMA Biomedicals); red pulp macrophages: Biotinylated rat anti-mouse F4/80 (clone A3-1, Serotec); neutrophils: Rat anti-mouse Gr-1 (clone RB6-8C5, R&D Systems); rat marginal zone macrophages: Mouse anti-rat CD169 (Clone ED3, Serotec); rat red pulp macrophages (Clone ED2, Serotec). Goat anti-mouse TNF (R&D Systems), and goat anti-rat TNF (R&D Systems). Secondary reagents: Cy3-conjugated Affinipure donkey anti-goat IgG (Jackson Immunoresearch Laboratories); FITC-conjugated Affinipure donkey anti-rabbit IgG (Jackson Immunoresearch Laboratories); Alexa Fluor 568-conjugated streptavidin (Molecular Probes); FITC-conjugated avidin (Molecular Probes).
Endotoxemia
Endotoxin (LPS from E. coli, 0111:B4, Sigma-Aldrich) was injected to animals (10 mg/kg, i.p. corresponding to a LD75 dose). Blood and spleens were harvested 10, 30, 60 or 120 minutes after LPS administration. We used ELISA to determine TNF concentration in serum (R&D Systems). Spleens were either snap frozen for further immunofluorescence analysis or disrupted in PBS plus protease inhibitor cocktail (Complete mini, Roche) with a tissue homogenizer (Polytron 3100, Kinematica). TNF content in spleen tissue was determined by ELISA and normalized to protein concentration (Protein Assay, BioRad). In some experiments, PBS or nicotine (Sigma-Aldrich) was injected 30 minutes (2 mg/kg, i.p.) prior to endotoxin administration. Animals were then euthanized 60 minutes later and spleens were harvested for TNF immunofluorescence or TNF quantification in tissue homogenates.
Electrical Stimulation of the Vagus Nerve
Male Sprague Dawley rats were anesthetized with urethane (4 g, i.p.) and xylazine (15 mg/kg, i.m.). Vagus nerve stimulation was performed as described previously (11). Briefly, a bipolar platinum electrode (Plastics One) was placed across the isolated cervical vagus nerve. Electrical stimulation (1V, 2 ms, 5 Hz) was generated by a stimulation module (STM100A) under the control of the AcqKnowledge software (Biopac Systems). Rats underwent 10 minutes of vagus nerve stimulation before and after endotoxin injection. In rats subjected to sham surgery, the vagus nerve was only exposed.
Immunofluorescence
All samples were fresh-frozen with dry ice, embedded in O.C.T, compound (Tissue-Tek) and kept at −20° C. until processing. Ten μm-thick spleen slices were cut using a cryostat and mounted on glass slides and air-dried for five minutes. The tissue was then permeabilized with PBS-saponin 0.1% for 30 minutes. All incubation periods were performed at room temperature in a humid chamber. The primary antibodies were diluted in PBS-saponin 0.1% at the following concentrations: TNF (1:6 dilution), MOMA-1 (1:1000 dilution), ER-TR9 (1:100 dilution), F4/80 (1:50). After a 2-hour incubation period, the slides were washed 3 times in washing buffer (PBS, tween 20 0.02%), incubated with avidin-FITC and Cy3-labeled rat anti-goat IgG, both diluted 1:250 in PBS-saponin 0.1% for 30 minutes. Finally, the slides were washed, dried, mounted (Vectashield) and observed through a Zeiss Axiovert 20 inverted microscope. Images were analyzed using the AxioVision V5 software (Carl Zeiss).
Methods of Treatment
In general, an inflammatory response may be treated based on this new discovery. In particular, an inflammatory reflex may be treated by stimulating a subject's inflammatory reflex to inhibit the immune response, and administering a T-cell modifying agent.
The inflammatory reflex may include the vagus nerve, the splenic nerve, the hepatic nerve and the trigeminal nerve, and their afferents and efferents. For example, Tracey et. al., have previously reported that the nervous system regulates systemic inflammation through a vagus nerve pathway. This pathway may involve the regulation of inflammatory cytokines and/or activation of granulocytes. Thus, it is believed that appropriate modulation of the vagus nerve may help regulate inflammation. In some variations the inflammatory reflex may be limited to one or more of these nerves (or its afferents or efferents), such as the vagus nerve.
The inflammatory reflex may be stimulated by any appropriate method, particularly electrical or mechanical stimulation. Other forms of stimulation include magnetic stimulation, thermal stimulation, etc. When electric and mechanical stimulation is used, this stimulation may be performed without desensitizing the inflammatory reflex. For example, the stimulation may be performed by an electrode or actuator that does not directly contact the nerve. Any appropriate stimulation may be used, particularly stimulation which results in a long-lasting (and repeatable) inhibition of inflammation, including cytokine levels. Examples of such stimulation are provided in the documents incorporated by reference, but may include stimulation at extremely low duty-cycle such as stimulation for less than 5 minutes once every 6 hours, every 12 hours, every 24 hours, or longer. An exemplary electrical stimulation may be stimulation at in the range of 10 mV to 5 V at a frequency of 0.1 Hz to 100 Hz, with a duration of stimulation between from 1 ms to 10 min.
In some variations, the stimulation is modified by the addition of the T-cell modification agent. For example, stimulation may be reduced in intensity (e.g., voltage, pressure, etc.) or in duration (e.g., frequency within stimulation pulse) or in regularity (e.g., duration between stimulation pulses), or the like. Feedback (open loop or closed loop) may be used to set the intensity, duration, and/or regularity of stimulation.
The stimulation of the inflammatory pathway may be provided by an external device, an internal (e.g., implanted) device, or a device having both internal and external components. For example, a stimulation device may include a non-contact electrode that does not contact a nerve of the inflammatory reflex, an energy source to apply energy to the electrode(s) and a controller. The controller may control the application of energy to the electrode(s). For example, the controller may initially cause the stimulator to apply stimulation once or twice a day for 1 minute of 0.1 V stimulation having a frequency of 1 Hz and a duration of 50 ms. The stimulator may be part of a system for treating the inflammatory reflex, which may also include one or more sensors, including feedback sensors. Feedback sensors may help control the system, including the application of stimulation to the inflammatory pathway, and/or the administration of one or more T-cell modulating agents.
Agents that modulate T-cells may include immunosuppressants and immunomodulators. For example, agents such as glucocorticoids (e.g., dexamethasone, hydrocortisone, prednisone, prednisolone, etc.), antibody agents (e.g., antibodies or fragments directed against the CD3 molecule of the T-cell antigen receptor complex, such as Muromonab CD3(0KT-3), etc.), peptide agents (e.g., immunosuppressive agents including Cyclosporine, etc.). Drugs (e.g., tacrolimus, Aspirin-like drugs (ALD), etc.) and “pro-drugs” (such as Azathioprine, Mycophenolate Mofetil, Methotrexate, etc.) are also included. Agents may act directly on T-cells or indirectly to affect T-cells. For example, agents may interact with receptors on the surface of the T-cell (e.g., caspase 8 inhibitor c-FLIP(L), and related agents), and may modulate (e.g., inhibit or enhance) T-cell response and/or proliferation. The examples provided above are not exhaustive, and any agent which may be used to modulate T-cells (e.g., T-cell activity or proliferation) may be used.
The modulation of T-cells may include potentiating activity, including potentiating acetylcholine (ACh) activity. For example, a T-cell modifying agent may include an agent that potentiates release of acetylcholine. Such agents may include small molecules, antibodies, peptides, or the like. For example, anti-CD11a antibodies have been shown in some circumstances to enhance or trigger release of acetylcholine (e.g., T. Fujii, K. Masuyama, K. Kawashima, “Simvastatin regulates non-neuronal cholinergic activity in T lymphocytes via CD11a-mediated pathways” J Neuroimmunol. 2006 October; 179(1-2):101-7. Epub 2006 Jul. 10). In some variations, the T-cell modifying agent may potentiate the stability of ACh, for example, by preventing uptake and/or breakdown of ACh. For example, the activity of the T-cell may be modulated by inhibiting acetylcholine esterase. Alternatively, the activity of the T-cell may be modulated by destabilizing (e.g., removing) acetylcholine; for example, by adding esterase.
In general, the methods and systems described herein are directed to the treatment of inflammation by modulating T-Cell activity, in some variations the activity of acetylcholine is directly modulated, so that sources of acetylcholine or agonists and antagonists implicated in the acetylcholine signaling pathway (e.g., acetylcholine receptors, etc.) including non-T-cell sources may also be manipulated as part of the methods and systems described herein. For example, the method may include a method of coordinating stimulation of the subject's inflammatory reflex to inhibit the inflammatory response and administering an agent that modulates or potentiates splenic acetylcholine, which may include acetylcholine released by T-cells.
Agents or drugs may be delivered systemically to the subject, or they may be delivered locally. For example, agents may be delivered orally, intraveneously, intramuscularly, etc. In some variations, the agent may be delivered by an implant. For example, the implant may be part of a system for stimulating (e.g., electrically, mechanically, etc.) the inflammatory reflex. In some variations the T-cell modifying agent is applied locally to the spleen, including the region communicating with the spleen (e.g., splenic region).
The method of treating an inflammatory response may be used to treat any inflammatory response, including an inflammatory disorder. Any inflammatory disorder may be treated in this manner. For example, disorders mediated by a cytokine response may be treated as described herein.
Examples of inflammatory disorders may include (but are not limited to): transplant rejection, rheumatoid arthritis, Psoriasis, or multiple sclerosis. Inflammatory disease that include T-cell mediated diseases may include: inflammatory bowel disease, systemic lupus erythematosis, rheumatoid arthritis, juvenile chronic arthritis, spondyloarthropathies, systemic sclerosis (scleroderma), idiopathic inflammatory myopathies (dermatomyositis, polymyositis), Sjogren's syndrome, systemic vaculitis, sarcoidosis, autoimmune hemolytic anemia (immune pancytopenia, paroxysmal nocturnal hemoglobinuria), autoimmune thrombocytopenia (idiopathic thrombocytopenic purpura, immune-mediated thrombocytopenia), thyroiditis (Grave's disease, Hashimoto's thyroiditis, juvenile lymphocytic thyroiditis, atrophic thyroiditis), diabetes mellitus, immune-mediated renal disease (glomerulonephritis, tubulointerstitial nephritis), demyelinating diseases of the central and peripheral nervous systems such as multiple sclerosis, idiopathic polyneuropathy, hepatobiliary diseases such as infectious hepatitis (hepatitis A, B, C, D, E and other nonhepatotropic viruses), autoimmune chronic active hepatitis, primary biliary cirrhosis, granulomatous hepatitis, and sclerosing cholangitis, inflammatory and fibrotic lung diseases (e.g., cystic fibrosis), gluten-sensitive enteropathy, Whipple's disease, autoimmune or immune-mediated skin diseases including bullous skin diseases, erythema multiforme and contact dermatitis, psoriasis, allergic diseases of the lung such as eosinophilic pneumonia, idiopathic pulmonary fibrosis and hypersensitivity pneumonitis, transplantation associated diseases including graft rejection and graft-versus host disease, Psoriasis and other skin disorders.
The step of administering a T-cell modifying agent may be performed at any point in the methods described herein, as appropriate. For example, in some variations, the T-cell modifying agent is administered concurrent with the stimulation of the inflammatory reflex. In some variations the T-cell modifying agent is given before stimulation of the inflammatory reflex (e.g., seconds, minutes, hours, or days before). In some variations, the T-cell modifying agent is given after stimulation of the inflammatory reflex (e.g., seconds, minutes, hours, or days after). Multiple administrations of T-cell modifying agents may be given. In some variations, multiple T-cell modifying agents may be given either simultaneously or at different times.
The benefit of both administration of T-cell modifying agents and stimulation of the inflammatory reflex may result in an enhanced effect that would otherwise be seen with either stimulation or administration alone. This may allow a decreased amount of stimulation or administration to be provided. In some instances the effect may be further enhanced by the combination. For example, a T-cell modifying agent that does not significantly inhibit inflammation may be effective to inhibit an inflammatory response when combined with stimulation of the vagus nerve or some other component of the inflammatory reflex.
In some variations, an agent that modifies T-cell activity may be applied to inhibit the inflammatory reflex, which may otherwise be stimulated. For example, an agent that inhibits T-cell activity (and/or proliferation) may be provided to inhibit the inflammatory reflex, which may enhance inflammation, or may remove an inhibition on inflammation.
A method of treating a T cell-mediated diseases may include the steps of identifying a patient suffering from a condition mediated by T-cell cells, stimulating the subject's inflammatory reflex, and administering a T-cell modifying agent.
A “T-cell mediated” disease means a disease in which T cells directly or indirectly mediate or otherwise contribute to the morbidity in a mammal. The T cell mediated disease by be associated with cell mediated effects, lymphokine mediated effects, etc. and even effects associated with B cells if the B cells are stimulated, for example, by the lymphokines secreted by T cells.
Compounds that modify the Acetylcholine response of the T-cells are one class of T-cell modifying agents that may be used herein. For example, a T-cell modifying agent may include a material that effects either the release, the update, or the breakdown of acetylcholine in the spleen, and particularly by the T-cells in proximity to the splenic nerve endings. For example, FIGS. 7A and 7B illustrates the effect of Paraoxon on spleen cells. Paraoxon is a cholinesterase inhibitor. FIG. 7A shows that increasing the amount of AChE inhibitor in whole spleen cell cultures stimulated with LPS results in a blunted TNF response. As mentioned above, the source of TNF in LPS-stimulated spleen cell cultures is thought to be the splenic macrophage population. Based on the data provided herein (e.g., FIG. 7A), there is an endogenous source of acetylcholine in the whole spleen cell preparation, and if the activity of ACh is increased in these cultures by inhibiting AChE, the TNF response is effectively blunted.
Although the spleen is innervated by catecholaminergic nerve fibers, neural cholinergic input is absent. However, the spleen contains acetylcholine and releases it upon electrical stimulation of the splenic nerve. In order to characterize the source of acetylcholine in spleen, we used transgenic mice in which enhanced green fluorescent protein (eGFP) is expressed under control of transcriptional regulatory elements of choline acetyltransferase, the enzyme that synthesizes acetylcholine. eGFP was detected in spleen B and T cells, some of which were located in close proximity to nerve endings in the parenchyma of the white pulp. Paraoxon, a cholinesterase inhibitor that enhances cholinergic transmission by preventing hydrolysis of acetylcholine, dose-dependently attenuated TNF levels in spleen cell suspensions stimulated with LPS without affecting cell viability, suggesting that acetylcholine derived from lymphocytes is involved in regulation of spleen TNF.
For example, FIG. 7A illustrates the effect of increasing concentrations of Paraoxon on TNF production by LPS-stimulated spleen cells of BALB/c 18 week old mice. As mentioned above, as the amount of Paraoxon is increased (thereby increasing the amount of acetylcholine by increasing the inhibition of AChE), the greater the inhibition of TNF. In this example, differing concentrations of Paraoxon were included in various individual wells (having 5×106 cell/well) with a total volume of 250 microliters/well, and stimulated for 4 hours with LPS (500 ng/mL). FIG. 7B illustrates that for the concentrations of Paraoxon used in FIG. 7A, there was no significant loss of viability, so the effect was not likely due to a reduction in macrophages or other cells producing TNF, but is instead the result of inhibition of TNF production due to acetylcholine.
Thus, inflammation may be inhibited by stimulating the inflammatory reflex and by administering a T-cell modifying agent, as mentioned above. In some variations, the inflammatory response may be inhibited by stimulating a subject's inflammatory reflex and administering a T-cell modifying agent that enhances the ACh component of the inflammatory reflex (either before, during, or after stimulation of the inflammatory reflex).
In some variations a system for modulating an inflammatory response by modifying a subject's T-cells includes one or more components for stimulating a portion of the inflammatory reflex (e.g., the vagus nerve), and one or more components for applying a T-cell modifying agent. The component for stimulating the T-cell modifying agent may be an implant that releases one or more compounds that modify the activity of a T-cell. For example, the system may include an implantable drug delivery system that releases a compound. The implantable drug delivery system may be configured to be implanted in or near the spleen, so that the drug may be delivered to the spleen, and particularly near the terminals of the splenic nerve adjacent to T-cells and/or macrophages. In general the component for applying a T-cell modifying agent (e.g., a drug-delivery system or sub-system) and the component for stimulating a portion of the inflammatory reflex (e.g., a vagus nerve stimulator) communicate so that the stimulation of the inflammatory reflex may be coordinated with the modification of the T-cells. Thus, the system may be configured so that the T-cell modifying agent is applied either before or during (or in some cases, after) the stimulation of one or more portion of the inflammatory reflex.
FIG. 8A illustrates a schematic of one variation of a general system for modulating an inflammatory reflex, as described herein, including an inflammatory reflex stimulation module 801 and a T-cell modification module 803. These two modules may communicate (e.g., wirelessly or via direct connection 805). In some variations, the system includes a controller for coordinating the activity of these modules. FIG. 8B is a schematic illustration of one variation of this system. In FIG. 8B, the inflammatory reflex stimulation module includes an implantable electrode for stimulating the vagus nerve 811, a controller for coordinating the stimulation from the electrode 813, and a power supply 815 for providing the power (e.g., battery). The power supply and/or controller may be implantable with the electrode, or they may be external. The T-cell modification module includes an implantable drug depot 821, and a delivery controller 823 for controlling the release of drug from the implantable drug depot 823. The drug depot is configured to be implanted (e.g., in or near the spleen) and to deliver drugs to reach the T-cells (or a subpopulation of the T-cells) in the spleen and modify their activity. Any of the agents mentioned herein for modifying the T-cell response may be used. The drug depot may be powered or passive. The delivery controller for the drug depot may communicate directly or indirectly (e.g., wirelessly) 825 with the controller for the vagus nerve stimulator. Any of these systems may include a controller for coordinating the stimulation between the inflammatory reflex stimulation module and the T-cell modifying agent module.
In some embodiments, the drugs delivered in conjunction with vagus nerve stimulation include anti-inflammatory drugs such as TNF blockers or IL-6 inhibitors. This treatment may combine two independent therapies for treating inflammation. Other drugs include drugs which suppress immune function by blocking one or more immune mediators, or immune cell function, or alternatively, target an immune cell for destruction, thereby suppressing immune function. The drugs may be administered as described herein. For example, the drugs may be injected into the patient's blood or muscle or under the skin. Alternatively, the drugs can be delivered using a drug depot or other implantable drug delivery device. In some embodiments, the drugs can be encapsulated in an extended release formulation to provide long term release of the drug. Table 2 below provides examples of these drugs, the immune mediator or cell that is inhibited by these drugs, and the indications in which these drugs are used.









TABLE 2





Immune mediator 




or cell inhibited
Examples of drugs
Indications







TNF
etanercept, 
Crohn's, psoriasis, 



adalimumab,
rheumatoid arthritis,



infliximab,
ankylosing



golimumab,
spondylitis,



certolizumab 
psoriatic arthritis



pegol



IL-6 or IL-6
tocilizumab
Rheumatoid


receptor

arthritis


T cell-antigen 
abatacept
Rheumatoid 


presenting cell

arthritis


interaction




Janus-Activated 
tofacitinib
Rheumatoid 


Kinase (JAK)

arthritis


Spleen-Associated 
fostamatinib
investigational


Kinase (SyK)




B-cell (CD20)
rituximab
Rheumatoid 




arthritis


IL-1
anakinra
Rheumatoid 




arthritis,




CAPS 




syndrome


B-cell (BAFF/
belimumab
Systemic lupus 


BLySS))

erythematosus


T cell (CD25/IL-2R)
daclizumab
Multiple 




sclerosis


α4-integrin 
natalizumab
Multiple 


(cell adhesion)

sclerosis


T, B, NK 
alemtuzumab
Multiple 


cell lysis (CD52)

sclerosis


sphingosine-1-phosphate
fingolimod
Multiple 


receptor modulator, 

sclerosis


sequesters




lymphocytes in




lymph nodes




Nuclear factor (erythroid-
dimethyl fumarate
Multiple 


derived 2)-
(DMF)
sclerosis


like 2 (Nrf2) pathway




activator




α4β7 integrin 
vedolizumab
Crohn's


(cell adhesion) 




IL-23
ustekinumab
psoriasis


IL-17
brodalumab and 
Rheumatoid 



ixekizumab
arthritis, 




psoriasis









While the devices, systems, and methods of using them have been described in some detail here by way of illustration and example, such illustration and example is for purposes of clarity of understanding only. It will be readily apparent to those of ordinary skill in the art in light of the teachings herein that certain changes and modifications may be made thereto without departing from the spirit and scope of the invention.
REFERENCES


    
    
        1. Cano, G., A. F. Sved, L. Rinaman, B. S. Rabin, and J. P. Card. 2001. Characterization of the central nervous system innervation of the rat spleen using viral transneuronal tracing. J. Comp Neurol. 439:1-18.
        2. Benthem, L., T. O. Mundinger, and G. J. Taborsky, Jr. 2001. Parasympathetic inhibition of sympathetic neural activity to the pancreas. Am. J. Physiol Endocrinol. Metab 280:E378-E381.
        3. Saindon, C. S., F. Blecha, T. I. Musch, D. A. Morgan, R. J. Fels, and M. J. Kenney. 2001. Effect of cervical vagotomy on sympathetic nerve responses to peripheral interleukin-1beta. Auton. Neurosci. 87:243-248.
        4. Kees, M. G., G. Pongratz, F. Kees, J. Scholmerich, and R. H. Straub. 2003. Via beta-adrenoceptors, stimulation of extrasplenic sympathetic nerve fibers inhibits lipopolysaccharide-induced TNF secretion in perfused rat spleen. J. Neuroimmunol. 145:77-85.
        5. Wang, H., M. Yu, M. Ochani, C. A. Amelia, M. Tanovic, S. Susarla, J. H. Li, H. Wang, H. Yang, L. Ulloa, Y. Al-Abed, C. J. Czura, and K. J. Tracey. 2003. Nicotinic acetylcholine receptor alpha7 subunit is an essential regulator of inflammation. Nature 421:384-388.
        6. Borovikova, L. V., S. Ivanova, M. Zhang, H. Yang, G. I. Botchkina, L. R. Watkins, H. Wang, N. Abumrad, J. W. Eaton, and K. J. Tracey. 2000. Vagus nerve stimulation attenuates the systemic inflammatory response to endotoxin. Nature 405:458-462.
        7. Del Signore, A., C. Gotti, A. Rizzo, M. Moretti, and P. Paggi. 2004. Nicotinic acetylcholine receptor subtypes in the rat sympathetic ganglion: pharmacological characterization, subcellular distribution and effect of pre- and postganglionic nerve crush. J. Neuropathol. Exp. Neurol. 63:138-150.
        8. Lips, K. S., P. Konig, K. Schatzle, U. Pfeil, G. Krasteva, M. Spies, R. V. Haberberger, S. A. Grando, and W. Kummer. 2006. Coexpression and spatial association of nicotinic acetylcholine receptor subunits alpha7 and alpha 10 in rat sympathetic neurons. J. Mol. Neurosci. 30:15-16.
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## Claims

1. A method of treating an inflammatory response, the method comprising:
stimulating a subject's inflammatory reflex to inhibit the inflammatory response by stimulating the subject's vagus nerve, wherein the stimulation is selected from the group consisting of electrical stimulation of the vagus nerve and mechanical stimulation of the vagus nerve, wherein the step of stimulating the subject's inflammatory reflex is repeated at regular intervals of at least about 4 hours; and
administering an anti-inflammatory drug.

2. The method of claim 1, wherein the step of stimulating the subject's inflammatory reflex comprises electrically stimulating the subject's inflammatory reflex to inhibit the immune response.

3. The method of claim 1, wherein the step of administering the anti-inflammatory drug comprises systemic administration of the anti-inflammatory drug.

4. The method of claim 1, wherein the step of administering the anti-inflammatory drug comprises administering the anti-inflammatory drug before stimulating the inflammatory reflex.

5. The method of claim 1, wherein the step of stimulating the inflammatory reflex comprises repeatedly and periodically stimulating the subject's inflammatory reflex.

6. The method of claim 1, wherein the anti-inflammatory drug is a TNF blocker or an IL-6 inhibitor.

7. The method of claim 1, wherein the inflammatory response is due to rheumatoid arthritis, psoriasis, multiple sclerosis, or Crohn's disease.

8. A method of treating an inflammatory response, the method comprising:
stimulating a subject's inflammatory reflex to inhibit the inflammatory response by stimulating the subject's vagus nerve, wherein the stimulation is selected from the group consisting of electrical stimulation of the vagus nerve and mechanical stimulation of the vagus nerve, wherein the step of stimulating the subject's inflammatory reflex is repeated at regular intervals of at least about 4 hours; and
administering a drug that suppresses immune function by blocking one or more immune mediators, wherein the immune mediator is selected from the group consisting of TNF, IL-6, IL-6 receptor, janus-activated kinase, spleen-associated kinase, CD20, B-cell activating factor, B lymphocyte stimulator, CD25, IL-2R, IL-1, α4-integin, CD52, sphingosine-1-phosphate receptor modulator, nuclear factor (erythroid-derived 2)-like 2 pathway activator, α4β7 integrin, IL-23, and IL-17.

9. The method of claim 8, wherein the step of stimulating the subject's inflammatory reflex comprises electrically stimulating the subject's inflammatory reflex to inhibit the immune response.

10. The method of claim 8, wherein the step of administering the drug comprises systemic administration of the drug.

11. The method of claim 8, wherein the inflammatory response is due to rheumatoid arthritis, psoriasis, multiple sclerosis, or Crohn's disease.