novel therapeutics for vitiligo - caldermsegmental vitiligo. •in non-segmental vitiligo, pigment...
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Novel Therapeutics for Vitiligo – What’s New and Exciting
Oma N. Agbai, M.D., FAAD
Assistant Clinical Professor Director of Multicultural Dermatology and
Hair Disorders University of California Davis, Department
of Dermatology
June 18, 2017
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Disclosures
Member of AbbVie Speaker Bureau
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Vitiligo
• Most common depigmentation disorder
• Worldwide with a prevalence of 1 to 2%
• Acquired disorder characterized by a chronic and progressive loss of functional epidermal and/or hair follicle melanocytes
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The Shame of Vitiligo
• Michael Jackson
• Lee Thomas
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Pathogenesis
• Multifactorial and polygenic
• Precise pathogenesis unknown
Halder RM, Chappell JL. Vitiligo Update. Semin Cutan Med Surg 2009; 28:86-92.
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Pathogenesis
• Autoimmune
• Oxidative Stress
• Neural
• Trauma
• Genetic
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Pathogenesis
Speeckaert, R. & van Geel, N. Am J Clin Dermatol (2017). doi:10.1007/s40257-017-
0298-5
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Vitiligo Subtypes
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Conventional treatments – Nonsegmental Vitiligo
• First line – Topical CS
– Topical Immunomodulators
• Extensive and/or recalcitrant disease – NB-UVB/Excimer laser
• Stable and focal disease – Pigment cell transplantation (limited availability)
• Active and extensive disease – Oral CS
• Very extensive disease – Depigmentation therapy (ex MBEH)
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Conventional treatments – Segmental Vitiligo
• Active disease
–Topical CS
–Topical immunomodulators
• Stable disease
–Pigment cell transplantation (limited availability)
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Novel/Nonconventional Treatment Options
• Afamelanotide
• Pigment cell transplantation – MKTP
– Blister grafts
• Newer immunomodulators – Tofacitinib/Ruxolitinib
• Other agents
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Novel/Nonconventional Treatment Options
• Afamelanotide
• Pigment cell transplantation – MKTP
– Blister grafts
• Newer immunomodulators – Tofacitinib/Ruxolitinib
• Other agents
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What is Afamelanotide?
• A synthetic analog of alpha-MSH, but more potent and long-lasting than alpha-MSH
• Clinical Trials:
– EPP
– Solar Urticaria
• Induces melanocyte proliferation and melanin synthesis
Haylett AK, Nie Z, Brownrigg M, Taylor R, Rhodes LE. Systemic photoprotection in solar urticaria with α-melanocyte-stimulating hormone analogue [Nle4-D-Phe7]-α-MSH. Br J Dermatol. 2011 Feb;164(2):407-14. doi: 10.1111/j.1365-2133.2010.10104.x.
Minder EI. Afamelanotide, an agonistic analog of α-melanocyte-stimulating hormone, in dermal phototoxicity of erythropoietic protoporphyria. Expert Opin Investig Drugs. 2010 Dec;19(12):1591-602. doi:10.1517/13543784.2010.535515. Epub 2010 Nov 13.
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Alpha-MSH in Vitiligo
• Reduced serum levels in vitiligo
• Role in stimulating eumelanogenesis and in protecting from oxidative damage:
– Reduction loss of functioning melanocytes in vitiligo, decreased melanin synthesis
Pichler R, Sfetsos K, Badics B, Gutenbrunner S, Auböck J (2006) Vitiligo patients present lower plasma levels of alpha-melanotropin immunoreactivities. Neuropeptides 40:177-183
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Question:
Would afamelanotide
enhance the therapeutic response of NB-UVB in
vitiligo?
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Afamelanotide + NB-UVB vs NB-UVB monotherapy
• A proof of concept study • SCENESSE® (afamelanotide), 16 mg;
subcutaneous implant • Phase 2 Pilot Clinical Trial • Generalized vitiligo
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Afamelanotide + NB-UVB vs NB-UVB monotherapy
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Study Protocol
Each subject assessed weekly for
signs of repigmentation
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Outcome Measures
• Serial Photography
• Time to onset of repigmentation
• Change in VASI (Vitiligo Area Scoring Index)
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How is Afamelanotide Implanted?
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Outcome Measures
• Serial Photography
• Time to onset of repigmentation
• Change in VASI (Vitiligo Area Scoring Index)
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D 0 - baseline
D 64 – 11 tx, 1 impl D 30 - 5 tx
D 99 - 18 tx,
2 impl
Afamelanotide/NB-UVB
D 0 (V1) - baseline D 60 (V3) - after 26 tx D 91 (V4) - after 36 tx
NB-UVB only
D 155 - 24 tx,
4th implant
D 119 (V5) - after 47 tx
V1 – no implants V2 – prior to impl 1 V3– prior to impl 2 V4 – prior to impl 3 V6 ~28 d after impl 4
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D 0 - baseline D 23 - 7 tx D 58 - 18 tx /1 impl D 68 - 22 tx /2 impl
Afamelanotide/NB-UVB
D 0 (V1) - baseline D 30 (V2) - 13 tx D 58 (V3) - 21 tx NB-UVB only
V1 – no implants V2 – prior to impl 1 V3 – prior to impl 2 10 days after impl 2
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Afamelanotide/NB-UVB
D 0 (V1) - baseline D 55 – 15 treatments/1 implant
Images courtesy of Mt Sinai School of Medicine Dept of Dermatology
Images cropped to maintain patient privacy but are otherwise unaltered
D 140 – 32 treatments/4 implants
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Outcome Measures
• Serial Photography
• Time to onset of repigmentation
• Change in VASI (Vitiligo Area Scoring Index)
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No. Days Until Repigmentation
FACE UPPER
EXT
Afamelanotide/
NB-UVB 41.0 46.0
NB-UVB Only 61.0 69.0
[P = .001] [P = .003]
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Change in VASI
(Vitiligo Area Scoring Index)
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Novel/Nonconventional Treatment Options
• Afamelanotide
• Pigment cell transplantation – Ex: Melanocyte Keratonocyte Transplant
Procedure
• Newer immunomodulators
• Other agents
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Melanocyte-Keratinocyte
Transplant Procedure
• Most effective in patients with stable segmental vitiligo.
• In non-segmental vitiligo, pigment cell transplantation has a higher chance of an acceptable repigmentation if the disease is stable for at least 1–2 years and no Koebner phenomenon is present
van Geel N, Wallaeys E, Goh BK, De Mil M, Lambert J. Longterm results of
noncultured epidermal cellular grafting in vitiligo, halo naevi, piebaldism and naevus
depigmentosus. Br J Dermatol. 2010;163:1186–93
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Melanocyte-Keratinocyte
Transplant Procedure
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Preparing Recipient Site
• Recipient site is dermabraded
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Cell Separation
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Cell Separation
Melanocytes and Keratinocytes ready for application
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Melanocyte-Keratinocyte Transplant Procedure
4 months post procedure Before procedure
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Novel/Nonconventional Treatment Options
• Afamelanotide
• Pigment cell transplantation – Ex: Melanocyte Keratonocyte Transplant
Procedure
• Newer immunomodulators – Tofacitinib/Ruxolitinib
• Other agents
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Strassner JP, Harris JE. Understanding mechanisms of autoimmunity through translational research in vitiligo.
Curr Opin Immunol. 2016 Dec;43:81-88. doi: 10.1016/j.coi.2016.09.008. Epub 2016 Oct 17.
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Strassner JP, Harris JE. Understanding mechanisms of autoimmunity through translational research in vitiligo.
Curr Opin Immunol. 2016 Dec;43:81-88. doi: 10.1016/j.coi.2016.09.008. Epub 2016 Oct 17.
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• After 5 months of treatment
• 5mg every other day
• After 3weeks, dosage increased to 5 mg/d (half the approved
dosage for rheumatoid arthritis, which is 5 mg twice daily).
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Oral Ruxolitinib Therapy for Vitiligo
Harris JE et al. Rapid skin repigmentation on oral ruxolitinib in a patient with coexistent
vitiligo and alopecia areata. J Am Acad Dermatol. 2016 Feb;74(2):370-1.
20 mg orally twice
daily for a total of 20
weeks
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Oral Ruxolitinib Therapy for Vitiligo
Recurrent depigmetation by week 32
Harris JE et al. Rapid skin repigmentation on oral ruxolitinib in a patient with coexistent
vitiligo and alopecia areata. J Am Acad Dermatol. 2016 Feb;74(2):370-1.
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Twice Daily Application
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Novel/Nonconventional Treatment Options
• Afamelanotide
• Pigment cell transplantation – Ex: Melanocyte Keratonocyte Transplant
Procedure
• Newer immunomodulators – Tofacitinib/Ruxolitinib
• Other agents
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Topical
latanoprost x
4 weeks
Topical
tacrolimus x 4
weeks
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QUESTIONS