Fingolimod Improves the Outcome of Experimental Graves' Disease and Associated Orbitopathy by Modulating the Autoimmune Response to the Thyroid-Stimulating Hormone Receptor
Abstract
Graves' disease (GD) and Graves' orbitopathy are associated with stimulating thyrotropin receptor (TSHR) autoantibodies and autoreactive T cells. Recent in vitro studies suggested that sphingosine-1-phosphate (S1P) signaling is involved in the pathogenesis of orbitopathy. In this study, we explored the immune modulatory potential of S1P receptor antagonist fingolimod in a murine model for GD. Fingolimod was orally administered preventively during disease onset or therapeutically after disease onset. Administration of fingolimod during disease onset completely prevented the formation of TSHR-stimulating autoantibodies. Intervention after disease onset rarely reduced TSHR-stimulating autoantibodies and blocking autoantibodies were induced in some animals. Consequently, autoimmune hyperthyroidism characterized by elevated serum thyroxin levels, hyperplastic thyroid morphology accompanied by T cell infiltration, weight gain, enhanced body temperature, and tachycardia did not manifest preventively and showed milder manifestation in therapeutically treated animals. Importantly, examination of orbital tissue showed significant amelioration of orbitopathy manifestations through reduction of T cell infiltration, adipogenesis, and hyaluronan deposition. Autoimmune hyperthyroidism and orbitopathy were accompanied by changes in peripheral and splenic T cell proportions with high CD3+, CD4+, and CD8+ T cells. Activated T cells CD4+CD25+ were elevated whereas regulatory T cells CD4+Foxp3+ cells remained unchanged in spleens. Fingolimod decreased elevated T cell levels and increased CD4+CD25+Foxp3+ regulatory T cell populations. Analysis of total disease outcome revealed that treatment during disease onset protected animals against autoimmune hyperthyroidism and orbitopathy. Of note, therapeutic intervention after disease onset suppressed disease in half of the animals and in the other half disease remained at mild stages. The results of this study support a clinical trial to investigate the immunologic and clinical benefits of early treatment with S1P-based drugs in GD.
Get full access to this article
View all available purchase options and get full access to this article.
References
1. Bahn RS 2010 Graves' ophthalmopathy. N Engl J Med 362:726–738.
2. Morshed SA, Latif R, Davies TF 2012 Delineating the autoimmune mechanisms in Graves' disease. Immunol Res 54:191–203.
3. Menconi F, Marcocci C, Marino M 2014 Diagnosis and classification of Graves' disease. Autoimmun Rev 13:398–402.
4. Enzmann DR, Donaldson SS, Kriss JP 1979 Appearance of Graves' disease on orbital computed tomography. J Comput Assist Tomogr 3:815–819.
5. Berta E, Bodor M, Galuska L, Paragh G, Erdei A, Gazdag A, Ujhelyi B, Berenyi E, Katko M, Gazso A, Nagy EV 2018 Early stage Graves' disease is uniformly accompanied by orbital immune activity even in patients who fail to develop orbithopathy during follow-up. Exp Clin Endocrinol Diabetes 126:628–631.
6. Leo M, Menconi F, Rocchi R, Latrofa F, Sisti E, Profilo MA, Mazzi B, Albano E, Nardi M, Vitti P, Marcocci C, Marino M 2015 Role of the underlying thyroid disease on the phenotype of Graves' orbitopathy in a tertiary referral center. Thyroid 25:347–351.
7. Eckstein AK, Plicht M, Lax H, Neuhauser M, Mann K, Lederbogen S, Heckmann C, Esser J, Morgenthaler NG 2006 Thyrotropin receptor autoantibodies are independent risk factors for Graves' ophthalmopathy and help to predict severity and outcome of the disease. J Clin Endocrinol Metab 91:3464–3470.
8. Stan MN, Bahn RS 2010 Risk factors for development or deterioration of Graves' ophthalmopathy. Thyroid 20:777–783.
9. Kim SE, Lee JH, Chae MK, Lee EJ, Yoon JS 2016 The role of sphingosine-1-phosphate in adipogenesis of Graves' orbitopathy. Invest Ophthalmol Vis Sci 57:301–311.
10. Ko J, Chae MK, Lee JH, Lee EJ, Yoon JS 2017 Sphingosine-1-phosphate mediates fibrosis in orbital fibroblasts in Graves' orbitopathy. Invest Ophthalmol Vis Sci 58:2544–2553.
11. Seo Y, Chae MK, Han SA, Lee EJ, Lee JH, Yoon JS 2017 Sphingosine-1-phosphate is involved in inflammatory reactions in patients with Graves' orbitopathy. Inflamm Res 66:535–545.
12. Plohn S, Edelmann B, Japtok L, He X, Hose M, Hansen W, Schuchman EH, Eckstein A, Berchner-Pfannschmidt U 2018 CD40 enhances sphingolipids in orbital fibroblasts: potential role of sphingosine-1-phosphate in inflammatory T-cell migration in Graves' orbitopathy. Invest Ophthalmol Vis Sci 59:5391–5397.
13. La Mantia L, Tramacere I, Firwana B, Pacchetti I, Palumbo R, Filippini G 2016 Fingolimod for relapsing-remitting multiple sclerosis. Cochrane Database Syst Rev 4:CD009371.
14. Tsai HC, Huang Y, Garris CS, Moreno MA, Griffin CW, Han MH 2016 Effects of sphingosine-1-phosphate receptor 1 phosphorylation in response to FTY720 during neuroinflammation. JCI Insight 1:e86462.
15. Kohno T, Tsuji T, Hirayama K, Iwatsuki R, Hirose M, Watabe K, Yoshikawa H, Kohno T, Matsumoto A, Fujita T, Hayashi M 2005 A novel immunomodulator, FTY720, prevents development of experimental autoimmune myasthenia gravis in C57BL/6 mice. Biol Pharm Bull 28:736–739.
16. Commodaro AG, Peron JP, Lopes CT, Arslanian C, Belfort R Jr., Rizzo LV, Bueno V 2010 Evaluation of experimental autoimmune uveitis in mice treated with FTY720. Invest Ophthalmol Vis Sci 51:2568–2574.
17. Morohoshi K, Osone M, Yoshida K, Nakagawa Y, Hoshikawa S, Ozaki H, Takahashi Y, Ito S, Mori K 2011 The sphingosine 1-phosphate receptor modulator FTY720 prevents iodide-induced autoimmune thyroiditis in non-obese diabetic mice. Autoimmunity 44:490–495.
18. Berchner-Pfannschmidt U, Moshkelgosha S, Diaz-Cano S, Edelmann B, Gortz GE, Horstmann M, Noble A, Hansen W, Eckstein A, Banga JP 2016 Comparative assessment of female mouse model of Graves' orbitopathy under different environments, accompanied by proinflammatory cytokine and T-cell responses to thyrotropin hormone receptor antigen. Endocrinology 157:1673–1682.
19. Schluter A, Horstmann M, Diaz-Cano S, Plohn S, Stahr K, Mattheis S, Oeverhaus M, Lang S, Flogel U, Berchner-Pfannschmidt U, Eckstein A, Banga JP 2018 Genetic immunization with mouse thyrotrophin hormone receptor plasmid breaks self-tolerance for a murine model of autoimmune thyroid disease and Graves' orbitopathy. Clin Exp Immunol 191:255–267.
20. Moshkelgosha S, So PW, Deasy N, Diaz-Cano S, Banga JP 2013 Cutting edge: retrobulbar inflammation, adipogenesis, and acute orbital congestion in a preclinical female mouse model of Graves' orbitopathy induced by thyrotropin receptor plasmid-in vivo electroporation. Endocrinology 154:3008–3015.
21. Chen CR, McLachlan SM, Rapoport B 2010 Thyrotropin (TSH) receptor residue E251 in the extracellular leucine-rich repeat domain is critical for linking TSH binding to receptor activation. Endocrinology 151:1940–1947.
22. Rammos C, Hendgen-Cotta UB, Totzeck M, Pohl J, Ludike P, Flogel U, Deenen R, Kohrer K, French BA, Godecke A, Kelm M, Rassaf T 2016 Impact of dietary nitrate on age-related diastolic dysfunction. Eur J Heart Fail 18:599–610.
23. Hendgen-Cotta UB, Esfeld S, Coman C, Ahrends R, Klein-Hitpass L, Flogel U, Rassaf T, Totzeck M 2017 A novel physiological role for cardiac myoglobin in lipid metabolism. Sci Rep 7:43219.
24. Johnson KT, Wiesweg B, Schott M, Ehlers M, Muller M, Minich WB, Nagayama Y, Gulbins E, Eckstein AK, Berchner-Pfannschmidt U 2013 Examination of orbital tissues in murine models of Graves' disease reveals expression of UCP-1 and the TSHR in retrobulbar adipose tissues. Horm Metab Res 45:401–407.
25. Abel S, Ueffing K, Tatura R, Hutzler M, Hose M, Matuschewski K, Kehrmann J, Westendorf AM, Buer J, Hansen W 2016 Plasmodium yoelii infection of BALB/c mice results in expansion rather than induction of CD4(+) Foxp3(+) regulatory T cells. Immunology 148:197–205.
26. Gamrad L, Rehbock C, Westendorf AM, Buer J, Barcikowski S, Hansen W 2016 Efficient nucleic acid delivery to murine regulatory T cells by gold nanoparticle conjugates. Sci Rep 6:28709.
27. Schluter A, Flogel U, Diaz-Cano S, Gortz GE, Stahr K, Oeverhaus M, Plohn S, Mattheis S, Moeller LC, Lang S, Bechrakis NE, Banga JP, Eckstein A, Berchner-Pfannschmidt U 2018 Graves' orbitopathy occurs sex-independently in an autoimmune hyperthyroid mouse model. Sci Rep 8:13096.
28. Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, Perros P, Salvi M, Wiersinga WM, European Group on Graves Orbitopathy 2016 The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy. Eur Thyroid J 5:9–26.
29. Kahaly GJ, Shimony O, Gellman YN, Lytton SD, Eshkar-Sebban L, Rosenblum N, Refaeli E, Kassem S, Ilany J, Naor D 2011 Regulatory T-cells in Graves' orbitopathy: baseline findings and immunomodulation by anti-T lymphocyte globulin. J Clin Endocrinol Metab 96:422–429.
30. Glick AB, Wodzinski A, Fu P, Levine AD, Wald DN 2013 Impairment of regulatory T-cell function in autoimmune thyroid disease. Thyroid 23:871–878.
31. Matsuzawa K, Izawa S, Okura T, Fujii S, Matsumoto K, Shoji K, Nakamura R, Sumi K, Fujioka Y, Yoshida A, Shigemasa C, Kato M, Yamamoto K, Taniguchi S 2016 Implications of FoxP3-positive and -negative CD4(+) CD25(+) T cells in Graves' ophthalmopathy. Endocr J 63:755–764.
32. Gonzalez-Amaro R, Marazuela M 2016 T regulatory (Treg) and T helper 17 (Th17) lymphocytes in thyroid autoimmunity. Endocrine 52:30–38.
33. Qin J, Zhou J, Fan C, Zhao N, Liu Y, Wang S, Cui X, Huang M, Guan H, Li Y, Shan Z, Teng W 2017 Increased circulating Th17 but decreased CD4(+)Foxp3(+) Treg and CD19(+)CD1d(hi)CD5(+) Breg subsets in new-onset Graves' disease. Biomed Res Int 2017:8431838.
34. Rydzewska M, Jaromin M, Pasierowska IE, Stozek K, Bossowski A 2018 Role of the T and B lymphocytes in pathogenesis of autoimmune thyroid diseases. Thyroid Res 11:2.
35. Zhou J, Bi M, Fan C, Song X, Yang R, Zhao S, Li L, Li Y, Teng W, Shan Z 2012 Regulatory T cells but not T helper 17 cells are modulated in an animal model of Graves' hyperthyroidism. Clin Exp Med 12:39–46.
36. Yuan Q, Zhao Y, Zhu X, Liu X 2017 Low regulatory T cell and high IL-17 mRNA expression in a mouse Graves' disease model. J Endocrinol Invest 40:397–407.
37. Saitoh O, Nagayama Y 2006 Regulation of Graves' hyperthyroidism with naturally occurring CD4+CD25+ regulatory T cells in a mouse model. Endocrinology 147:2417–2422.
38. Bail K, Notz Q, Rovituso DM, Schampel A, Wunsch M, Koeniger T, Schropp V, Bharti R, Scholz CJ, Foerstner KU, Kleinschnitz C, Kuerten S 2017 Differential effects of FTY720 on the B cell compartment in a mouse model of multiple sclerosis. J Neuroinflammation 14:148.
39. Rakov H, Engels K, Hones GS, Brix K, Kohrle J, Moeller LC, Zwanziger D, Fuhrer D 2017 Sex-specific phenotypes of hyperthyroidism and hypothyroidism in aged mice. Biol Sex Differ 8:38.
40. Holthoff HP, Goebel S, Li Z, Fassbender J, Reimann A, Zeibig S, Lohse MJ, Munch G, Ungerer M 2015 Prolonged TSH receptor A subunit immunization of female mice leads to a long-term model of Graves' disease, tachycardia, and cardiac hypertrophy. Endocrinology 156:1577–1589.
41. Kappos L, Radue EW, O'Connor P, Polman C, Hohlfeld R, Calabresi P, Selmaj K, Agoropoulou C, Leyk M, Zhang-Auberson L, Burtin P, Group FS 2010 A placebo-controlled trial of oral fingolimod in relapsing multiple sclerosis. N Engl J Med 362:387–401.
42. Cohen JA, Barkhof F, Comi G, Hartung HP, Khatri BO, Montalban X, Pelletier J, Capra R, Gallo P, Izquierdo G, Tiel-Wilck K, de Vera A, Jin J, Stites T, Wu S, Aradhye S, Kappos L, Group TS 2010 Oral fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med 362:402–415.
43. Calabresi PA, Radue EW, Goodin D, Jeffery D, Rammohan KW, Reder AT, Vollmer T, Agius MA, Kappos L, Stites T, Li B, Cappiello L, von Rosenstiel P, Lublin FD 2014 Safety and efficacy of fingolimod in patients with relapsing-remitting multiple sclerosis (FREEDOMS II): a double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Neurol 13:545–556.
44. Holthoff HP, Li Z, Fassbender J, Reimann A, Adler K, Munch G, Ungerer M 2017 Cyclic peptides for effective treatment in a long-term model of graves disease and orbitopathy in female mice. Endocrinology 158:2376–2390.
45. Fassbender J, Holthoff HP, Li Z, Ungerer M 2019 Therapeutic effects of short cyclic and combined epitope peptides in a long-term model of Graves' disease and orbitopathy. Thyroid 29:258–267.
46. Draman MS, Stechman M, Scott-Coombes D, Dayan CM, Rees DA, Ludgate M, Zhang L 2017 The role of thyrotropin receptor activation in adipogenesis and modulation of fat phenotype. Front Endocrinol (Lausanne) 8:83.
47. Lahesmaa M, Orava J, Schalin-Jantti C, Soinio M, Hannukainen JC, Noponen T, Kirjavainen A, Iida H, Kudomi N, Enerback S, Virtanen KA, Nuutila P 2014 Hyperthyroidism increases brown fat metabolism in humans. J Clin Endocrinol Metab 99:E28–E35.
48. Christoffersen C, Federspiel CK, Borup A, Christensen PM, Madsen AN, Heine M, Nielsen CH, Kjaer A, Holst B, Heeren J, Nielsen LB 2018 The apolipoprotein M/S1P axis controls triglyceride metabolism and brown fat activity. Cell Rep 22:175–188.
49. Moon MH, Jeong JK, Lee JH, Park YG, Lee YJ, Seol JW, Park SY 2012 Antiobesity activity of a sphingosine 1-phosphate analogue FTY720 observed in adipocytes and obese mouse model. Exp Mol Med 44:603–614.
50. Hozumi Y, Kobayashi E, Miyata M, Fujimura A 1999 Immunotherapy for experimental rat autoimmune thyroiditis using a novel immunosuppressant, FTY720. Life Sci 65:1739–1745.
51. Pelz A, Schaffert H, Diallo R, Hiepe F, Meisel A, Kohler S 2018 S1P receptor antagonists fingolimod and siponimod do not improve the outcome of experimental autoimmune myasthenia gravis mice after disease onset. Eur J Immunol 48:498–508.
52. Tsuji T, Yoshida Y, Fujita T, Kohno T 2012 Oral therapy for type 1 diabetes mellitus using a novel immunomodulator, FTY720 (fingolimod), in combination with sitagliptin, a dipeptidyl peptidase-4 inhibitor, examined in non-obese diabetic mice. J Diabetes Investig 3:441–448.
53. Brinkmann V, Lynch KR 2002 FTY720: targeting G-protein-coupled receptors for sphingosine 1-phosphate in transplantation and autoimmunity. Curr Opin Immunol 14:569–575.
54. Fujino M, Funeshima N, Kitazawa Y, Kimura H, Amemiya H, Suzuki S, Li XK 2003 Amelioration of experimental autoimmune encephalomyelitis in Lewis rats by FTY720 treatment. J Pharmacol Exp Ther 305:70–77.
55. Webb M, Tham CS, Lin FF, Lariosa-Willingham K, Yu N, Hale J, Mandala S, Chun J, Rao TS 2004 Sphingosine 1-phosphate receptor agonists attenuate relapsing-remitting experimental autoimmune encephalitis in SJL mice. J Neuroimmunol 153:108–121.
56. Chiba K 2005 FTY720, a new class of immunomodulator, inhibits lymphocyte egress from secondary lymphoid tissues and thymus by agonistic activity at sphingosine 1-phosphate receptors. Pharmacol Ther 108:308–319.
57. Brinkmann V 2007 Sphingosine 1-phosphate receptors in health and disease: mechanistic insights from gene deletion studies and reverse pharmacology. Pharmacol Ther 115:84–105.
58. Kataoka H, Sugahara K, Shimano K, Teshima K, Koyama M, Fukunari A, Chiba K 2005 FTY720, sphingosine 1-phosphate receptor modulator, ameliorates experimental autoimmune encephalomyelitis by inhibition of T cell infiltration. Cell Mol Immunol 2:439–448.
59. Jansson L, Vrolix K, Jahraus A, Martin KF, Wraith DC 2018 Immunotherapy with apitopes blocks the immune response to TSH receptor in HLA-DR transgenic mice. Endocrinology 159:3446–3457.
60. Salvi M, Vannucchi G, Curro N, Campi I, Covelli D, Dazzi D, Simonetta S, Guastella C, Pignataro L, Avignone S, Beck-Peccoz P 2015 Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves' orbitopathy: a randomized controlled study. J Clin Endocrinol Metab 100:422–431.
61. Stan MN, Salvi M 2017 Management of endocrine disease: rituximab therapy for Graves' orbitopathy—lessons from randomized control trials. Eur J Endocrinol 176:R101–R109.
62. Silkiss RZ, Reier A, Coleman M, Lauer SA 2010 Rituximab for thyroid eye disease. Ophthalmic Plast Reconstr Surg 26:310–314.
63. Ostrowski RA, Bussey MR, Shayesteh Y, Jay WM 2015 Rituximab in the treatment of thyroid eye disease: a review. Neuroophthalmology 39:109–115.
64. McCoy AN, Kim DS, Gillespie EF, Atkins SJ, Smith TJ, Douglas RS 2014 Rituximab (Rituxan) therapy for severe thyroid-associated ophthalmopathy diminishes IGF-1R(+) T cells. J Clin Endocrinol Metab 99:E1294–E1299.
65. Wiersinga WM 2017 Advances in treatment of active, moderate-to-severe Graves' ophthalmopathy. Lancet Diabetes Endocrinol 5:134–142.
Information & Authors
Information
Published In
Copyright
Copyright 2019, Mary Ann Liebert, Inc., publishers.
History
Published online: 17 September 2019
Published in print: September 2019
Published ahead of production: 25 June 2019
Topics
Authors
Author Disclosure Statement
All authors disclose any commercial association that might create a conflict of interest in connection with this article.
Metrics & Citations
Metrics
Citations
Export Citation
Export citation
Select the format you want to export the citations of this publication.
View Options
Get Access
Access content
To read the fulltext, please use one of the options below to sign in or purchase access.⚠ Society Access
If you are a member of a society that has access to this content please log in via your society website and then return to this publication.