Acute Exercise and NK Cell Regulation in Tissue and Circulation After IL-6R Blockade

Study Overview
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Brief Summary
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The study is a randomized controlled trial studying the acute effect of intense aerobic exercise upon NK (Natural Killer) cell activation and appetite-regulation in human participants with or without concommitant IL-6R receptor blockade (Tocilizumab)

Detailed Description
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Objectives: Primary Objective: To explore the association between acute exercise, IL-6 blockade and NK regulation in circulation. To explore whether exercise activated NK-cells have a unique phenotype using single cell RNA sequencing. Secondary Objectives: To explore the effect of acute aerobic exercise on NK cell number and activity in circulation, muscle and adipose tissue, in healthy young males, in order to indirectly explore exercise as an anti-cancer remedy. To assess the kinetics of the NK-cell response and, if possible, chronologically investigate the appearance and whereabouts of the activated NK-cells. Explorative Objectives To establish a reproducible protocol for tracking various immune-cells and their involvement in the acute exercise response in humans To investigate novel signal molecules released from muscle during exercise with immunological importance. To investigate the possible role of exercise induced IL-6 on subjective feelings of hunger and satiety post exercise and food intake. • To explore the effect of IL-6 receptor blockade on the exercise proteome and metabolome, using mass spectrometry Methods: 30 healthy recreationally active young males will be included in this acute exercise study in which NK-cell kinetic and regulation will be studied in response to acute aerobic exercise and IL-6R blockade or placebo. The study consists of 2 visits. At inclusion (visit 1) all subjects will undergo assessment encompassing: baseline medical screening (auscultation, blood pressure, ECG), determination of body composition (DXA), cardiovascular fitness (VO2max) and standard fasting blood-biochemistry which will be analyzed immediately. Visit 2 will consist of a muscle and fat biopsy from the dominant leg and abdominal subcutaneous-fat depot respectively (both under resting conditions), which will then act as reference tissue for the further tissue analysis. Then, a 18G antecubital peripheral venous access will be secured prior to commencing with IL-6R infusion. 2 hours after the infusion procedure the subjects will undergo an acute exercise protocol. Subjects will then be challenged by a high intensity acute aerobic exercise bout, utilizing a bicycle ergometer. Blood samples will be drawn prior to the infusion and exercise, during exercise, as well as immediately, ½, 1, 1½ and 2h post exercise and up 4h post exercise in the appetite regulation substudy. Blood samples will immediately be analyzed for leucocyte count and differentiation as well as plasma biochemistry. In addition, blood samples will be utilized for NK cell isolation with subsequent single cell RNA sequencing, immune cell distribution and killing capacity towards cancer cells. Furthermore, plasma samples will be collected and frozen for later determination of cortisol, prolactin and circulating cytokines, including but not limited to IL-6 and G-CSF. Lastly, in the appetite substudy, insulin, GLP-1 and free fatty acids will be measured. Tissue samples will be obtained 2h post exercise for optimizing gene-expression analysis. Both muscle and adipose tissue samples will be analyzed for inflammatory and anti-inflammatory markers, NK cell content and phenotyping of these NK cells using markers obtained from single cell sequencing, conducted on the blood-borne NK-cells. Furthermore, immune cell infiltration will be assessed using histology. All tissue samples will be obtained using a Bergström needle under sterile conditions during local anesthesia in order to minimize any sample-related discomfort or infection. After the tissue sample, an ad libitum meal will be served, the subjects can eat as much can, but are instructed not to overconsume as any leftover food can be taken home. Paracetamol (1.5g) will be given to asses gastric emptying. All participants will undergo the 2 study visits at the same approximate time of the day (9.00 a.m.) After completion of the study, any left-over material will be transferred to the CFAS biobank. Subjects: Included subjects will be 30 recreationally active, moderately trained, healthy young males aged 18-40 years. Exclusion criteria are: cardiovascular, rheumatologic and metabolic disease, elite sports or high aerobic training status. Chronic use of nonsteroidal anti-inflammatory drug (NSAID) or other immunosuppressants. Intervention: Subjects will be randomized to acute exercise, with (n=15) or without (n=15) prior IL-6R blockade. The exercise intervention will consist of a highly taxing ≈45 minutes interval based, aerobic exercise bout, conducted on a stationary bicycle ergometer. After an initial 5-minute warmup at 50-60% of HRmax, subjects will undergo seven, verbally encouraged, 3-minute intervals at above 90% HRmax, interspersed by 3 minutes of low intensity pedaling. Blood samples will be drawn before, during as well as immediately, ½, 1, 1½ and 2h post exercise together with tissue sampling at the 2h time-point. To assess appetite regulation, further blood samples will be drawn from 2h-4h post exercise. Statistical considerations: Based on data from our pilot study, we anticipate a ≈ 45 % lower maximal NK cell mobilization in the IL6R inhibition group compared to CON and a 29 % difference in NK cell nadir with the lowest values obtained in the IL6R inhibition group. Assuming a 5%-significance level in two-sided tests, we need to include 9 patients in each group to achieve 90% power for detecting a relative difference of 45 % in the intervention-group. To account for potential dropouts/excluded, due to the somewhat invasive setup, we will include a total of 30 patients (15 per group). Recruitment: Subjects will be recruited through forsøgsperson.dk or similar sites alongside advertising at relevant sites. Subjects will contact us at CFAS and will be given the choice whether to receive study information pr. telephone (thereby denying the option of a bystander) or a face to face meeting at CFAS. All this information will be given by the primary investigator. If the subject is interested in hearing more of the study, relevant documents will be emailed. If the subject is interested in joining the study after having received written or oral information, he will have 24h to consider study participation. When the subject has been informed either by telephone or face to face and accepts study participation, he will be invited to visit 1 where written and informed consent will be obtained (or signed and brought from home by the participant). Risks and adverse reactions: Subjects may experience minor discomfort with regard to blood and tissue samples. The blood volume drawn is negligible and will not be associated with any health risk. All sampling of tissues will be performed under sterile conditions during local anesthesia and will thus be associated with little pain or discomfort and very little risk of infection. During exercise testing, participants may experience shortness of breath. IL-6R inhibition is generally well tolerated with only few side-effects. The dose of paracetamol is low and is not associated with any risk. Contact information of the involved medical doctor will be given to participants at study inclusion, so that any adverse event can be reported and solved. Dissemination of study results: Both positive, negative and inconclusive results will be published in relevant international scientific journals. Ethical consideration: The project is expected to cause limited risks, side effects and discomfort. All procedures will be performed by experienced physicians and physiologists with relevant safety. Tocilizumab is generally well tolerated and the dose of paracetamol is low. Included subjects may at any time, and without justification, retract their consent of study participation. We believe that the project is important and will contribute with critical new information on the IL-6 modifiable NK-cell response to acute exercise both in circulation and in adipose and muscle tissue (as there is currently very limited knowledge on the latter). The study is considered a toolbox-study by Lægemiddelstyrelsen, and hence not at pharmaceutical study

Official Title
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Acute Exercise and NK Cell Regulation in Tissue and Circulation After IL-6R Blockade - a Randomized Controlled Trial

Conditions
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Interleukin-6 Inhibition, Physical Stress, Appetitive Behavior

Intervention / Treatment
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* Drug: Tocilizumab Injectable Product
* Other: Saline 0.9% 100 ml NaCl 0.9% will be infused over 1 hour


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: recreationally active moderately trained healthy young males aged 18-40 years BMI from 18-30 kg·m2 Exclusion Criteria: Cardiovascular disease Rheumatologic disease Metabolic disease, Elite sports or high aerobically training status (VO2max>60ml O2/min/kg), Frequent/chronic use of medications affecting physical performance or inflammation (NSAIDS, DMARDS)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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Male

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: CON<br>This group will do intense aerobic exercise without concomitant IL-6R blockade | Other: Saline 0.9% 100 ml NaCl 0.9% will be infused over 1 hour<br>* The control group will undergo intense aerobic exercise with saline infusion for 1h prior to the exercise bout<br>|
| Active Comparator: BLOCK<br>This group will do intense aerobic exercise with concomitant IL-6R blockade | Drug: Tocilizumab Injectable Product<br>* The intervention group will undergo intense aerobic exercise with prior IL-6R infusion for 1h prior to the exercise bout.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Kinetics and regulation of NK (Natural Killer) cells during and following acute exercise | Change in NK cell and NK cell subset count in circulation before and after acute aerobic exercise with or without IL-6R blockade. | Up to 1 day | 
| NK cell phenotype in response to acute exercise with or without IL-6R blockade | Change in NK-cell phenotype using single cell RNA sequencing. Here, within-group changes of baseline vs. post exercise timepoints as well as between group differences between IL-6 blockade and placebo will be investigated. The focus will be on markers of cytotoxicity, cell adhesion and adrenergic signaling. | Up to 1 day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in NK cell count in adipose tissue | Using a combination of histology, western blot and gene-expression analysis for CD56, CD57 and other NK-cell markers, the principal investigator will identify and count the number of NK cells in adipose tissue | 3 hours after intervention | 
| Change in NK cell phenotype in adipose tissue | Using a combination of histology, western blot and gene-expression analysis for CD56, CD57 and other NK-cell markers, the principal investigator will identify the phenotype of NK cells in adipose tissue | 3 hours after intervention | 
| Change in NK cell count in muscle tissue | Using a combination of histology, western blot and gene-expression analysis for CD56, CD57 and other NK-cell markers, the principal investigator will identify and count the number of NK cells in muscle tissue | 3 hours after intervention | 
| Change in NK cell phenotype in muscle tissue | Using a combination of histology, western blot and gene-expression analysis for CD56, CD57 and other NK-cell markers, the principal investigator will identify the phenotype of NK cells in muscle tissue | 3 hours after intervention | 
| Change in macrophage count in muscle tissue | Using a combination of histology, western blot and gene-expression analysis for CD68, CD163, CD206, TNF-alpha and other macrophage markers, the principal investigator will identify and count the number of macrophages in muscle tissue | 3 hours after intervention | 
| Change in macrophage phenotype in muscle tissue | Using a combination of histology, western blot and gene-expression analysis for CD68, CD163, CD206, TNF-alpha and other macrophage markers, the principal investigator will phenotype (M1/M2) macrophages in muscle tissue | 3 hours after intervention | 
| Change in macrophage count in adipose tissue | Using a combination of histology, western blot and gene-expression analysis for CD68, CD163, CD206, TNF-alpha and other macrophage markers, the principal investigator will identify and count the number of macrophages in adipose tissue | 3 hours after intervention | 
| Change in macrophage phenotype in adipose tissue | Using a combination of histology, western blot and gene-expression analysis for CD68, CD163, CD206, TNF-alpha and other macrophage markers, the principal investigator will phenotype (M1/M2) macrophages in adipose tissue | 3 hours after intervention | 
| Change in T-cell count in adipose tissue | Using a combination of histology, western blot and gene-expression analysis for CD3, CD8, and other T-cell markers, the principal investigator will count the number of T-cells in adipose tissue | 3 hours after intervention | 
| Change in T-cell phenotype in adipose tissue | Using a combination of histology, western blot and gene-expression analysis for CD3, CD8, and other T-cell markers, the principal investigator will phenotype the T-cells in adipose (CD3+/CD8+) tissue | 3 hours after intervention | 
| Change in T-cell count in muscle tissue | Using a combination of histology, western blot and gene-expression analysis for CD3, CD8, and other T-cell markers, the principal investigator will count the number of T-cells in muscle tissue | 3 hours after intervention | 
| Change in T-cell phenotype in muscle tissue | Using a combination of histology, western blot and gene-expression analysis for CD3, CD8, and other T-cell markers, the principal investigator will phenotype (CD3+/CD8+) the T-cells in muscle tissue | 3 hours after intervention | 
| Change in monocyte count in circulation | Using flow cytometry we will identify and count monocytes in circulation | Up to 1 day | 
| Change in T-cell count in circulation | Using flow cytometry the investigators will count T-cells in circulation | Up to 1 day | 
| Change in B-cell count in circulation | Using flow cytometry the investigators will count B-cells in circulation | Up to 1 day | 
| Change in IL-6 receptor expression on NK-cells in circulation | The change in IL-6 receptor surface expression on circulating NK-cells using flow cytometry | Up to 1 day | 
| Change in circulating IL-6 | Plasma IL-6 conc. using ELISA assay | Up to 1 day | 
| Change in circulating IL-2 | Plasma IL-2 conc. using ELISA assay | Up to 1 day | 
| Change in circulating IL-1 | Plasma IL-1 conc. using ELISA assay | Up to 1 day | 
| Change in circulating IL-10 | Plasma IL-10 conc. using ELISA assay | Up to 1 day | 
| Change in circulating TNF-alpha | Plasma TNF-alpha conc.using ELISA assay | Up to 1 day | 
| Change in circulating G-CSF | Plasma TNF-alpha conc. using ELISA assay | Up to 1 day | 
| Change in circulating epinephrine | Blood epinephrine conc. using ELISA assay | Up to 1 day | 
| Change in circulating norepinephrine | Blood norepinephrine conc. using ELISA assay | Up to 1 day | 
| Change in circulating total leucocytes | Blood leucocyte count using sysmex XN | Up to 1 day | 
| Change in circulating neutrophils | Blood neutrophil count.using sysmex XN | Up to 1 day | 
| Change in circulating reticulocytes | Blood reticulocytes count.using sysmex XN | Up to 1 day | 
| Change in circulating eosinophils | Blood eosinophil count.using sysmex XN | Up to 1 day | 
| Change in circulating basofile leucocytes | Blood basofile leucocytes count.using sysmex XN | Up to 1 day | 
| Change in circulating total lymphocytes | Blood lymphocyte count.using sysmex XN | Up to 1 day | 
| Change in circulating Prolactin | Plasma Prolactin conc. using sysmex XN | Up to 1 day | 
| Change in cortisol | Plasma cortisol conc. using sysmex XN | Up to 1 day | 
| Change in metamyelocytes | Blood metamyelocyte count using sysmex XN | Up to 1 day | 
| Change in ACTH | Plasma ACTH conc. using sysmex XN | Up to 1 day | 
| Change in circulating lactate | Blood lactate using ABL | Up to 1 day | 
| Change in CRP | Plasma CRP conc. using sysmex XN | Up to 1 day | 
| Change in hsCRP | Plasma CRP conc. using ELISA | Up to 1 day | 
| Novel myokines during acute exercise | As an explorative outcome the investigators will investigate possible novel signal molecules released during exercise with immunological importance, either in circulation or in tissue (i.e. GDNF [Glial cell Derived Neurotrophic Factor]) | Immediately after acute bout of exercise | 
| VO2max | VO2max using bicycle ergometer and Oxicon Online system | Baseline | 
| Lean Body mass | Lean body mass using dual-energy x-ray absorptiometry (DXA) | Baseline | 
| Fat mass | Fat mass using dual-energy x-ray absorptiometry (DXA) | Baseline | 
| Bone Mineral Density | Bone Mineral Density using dual-energy x-ray absorptiometry (DXA) | Baseline | 
| Appetite assessment | Hunger, satiety, fullness, and prospective food consumption will be rated using a visual analog scales (VAS). A line of 20 cm is drawn from left to right on A4 paper starting at 0 cm with  not hungry at all ending at 20 cm with never been more hungry in my life. The subject mark somewhere in between according to his subjective feeling, The length is reported and indicates the degree of hunger, eg. the longer the line the more hunger. In general the longer to right the person marks the line, the stronger is the subjective felling within the given question | 4 hours after intervention | 
| Ad libitum caloric intake | Caloric intake will be determined by providing meal consisting of a hot pot of homogeneous pasta Bolognese (1,440 g, 1,912 kcal, 55 E percent carbohydrate, 30 E percent fat, 15 E percent protein; homogeneous composition) served with a glass of water of 150 ml 1 h after exercise. Participants will sit quietly on their own and are asked to eat until comfortably full/satiated and to drink all of the water. The duration of the meal is sat to 30 minutes | 4 hours after intervention | 
| Gastric emptying | Gastric emptying will be assessed by the participants drinking 100 ml in which 1,5 g paracetamol is dissolved. The Paracetamol concentration will be determined by Sandwich Electro-Chemiluminescence-Immunoassay (ECLIA) | 4 hours after intervention | 
| Change in GLP1 | Plasma GLP1 conc. using ELISA assay | 4 hours after intervention | 
| Change in PYY | Plasma PYY conc. using ELISA assay | 4 hours after intervention | 
| Change in CCK | Plasma CCK conc. using ELISA assay | 4 hours after intervention | 
| Change in Glucose | Plasma Glucose conc. using using sysmex XN | 4 hours after intervention | 
| Change in Insulin | Plasma insulin conc. using using sysmex XN | 4 hours after intervention | 
| Change in C-peptide | Plasma C-peptide conc. using using sysmex XN | 4 hours after intervention | 
| Change in free fatty acids | Plasma free fatty acids conc. using sysmex XN | 4 hours after intervention | 
| Change in acetoacetate | Plasma acetoacetate conc. using mass spectrometry | 4 hours after intervention | 
| Change in betahydroxybutyrate | Plasma betahydroxybutyrate conc. using mass spectrometry | 4 hours after intervention | 
| Change in CRH | Plasma CRH conc. using ELISA | 4 hours after intervention | 
| Change in AVP | Plasma AVP conc. using ELISA | 4 hours after intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Natural Killer cells, Aerobic exercise, IL-6R blockade, Human, Appetite