From Neuromodulation to Drug Discovery and Treatment Luis

From Neuromodulation to Drug Discovery and Treatment Luis Ulloa, Ph. D Luis. Ulloa@Rutgers. edu

SEPSIS • • • tre There atm ent is NO a for Sep vailab le sis Leading cause of death in ICUs Mortality rate 40 -70% Third leading cause of death in developed countries Equals the number of fatalities from acute myocardial infarction Affects over 18 million people worldwide Expected 1 -1. 5% increase of incidence per year 750, 000 US patients/year Kills over 250, 000 Americans/year Accounts for 9. 3% overall death in US More than 30 unsuccessful clinical trials

Sepsis is NOT only related to infections Antibiotics L Ulloa. Nature Rev DD (2005)

NEURONAL PATHWAY De. Jonge & Ulloa. Br J Pharm (2007)

MABP (%) Vagus Nerve Stimulation Attenuates ENDOTOXIC SHOCK Vagus Nerve Stimulation 100 Sham 50 0 VGX 0 20 40 Time (min) 60 Borovikova et al. , Nature (2000)

Pharmacological strategy to mimic VNS Nicotine α 7 -agonists L. Ulloa. Nature Rev DD (2005)

Borovikova et al. , Nature 2000

Nicotine Inhibits the NF-k. B signaling pathway. Confirmed in other cell types: Human Monocytic U 937 (Sugano et al. , BBR, 2004) Microvascular Endothelial Cells Hu. MVEC (Saeed et al. , JEM, 2005) Peritoneal Macrophages (De. Jonge et al. , Nat Imm, 2005) Wang & Ulloa. Nat Med (2004)

Nicotine Attenuates Systemic HMGB 1 and Prevents Lethal ENDOTOXEMIA. Clinical Trials: Clinical Trials in Ulcerative Colitis Wang & Ulloa. Nature Medicine (2004)

Vagus Nerve Stimulation Attenuates Systemic TNF Levels Spleen LPS + - + 20 LPS+Sham LPS+VNS 150 [TNF] (pg/ml) - TNF m. RNA 15 b-Actin m. RNA 100 50 10 5 ** ** ** 0 Heart Serum Huston & Ulloa. , J Exp Med (2006) Brain Heart * Lung Spleen Liver 0 [TNF] (ng/g Protein) 200 Liver

The SPLEEN mediates the anti-inflammatory potential of the vagus nerve. VNS C LPS TNF m. RNA b-Actin m. RNA [Serum TNF] (% rate) 100 50 0 Huston & Ulloa. , J Exp Med (2006) *L *R

SPLENIC NERVE mediates the effects of the VN Vida et al. , J Immunol (2011)

Vagal modulation AFTER the infection ? ? Peña et al. J Immunol (2011)

Does vagal modulation require lymphocytes? Peña et al. J Immunol (2011)

Splenic histology: Periarteriolar Lymphoid Sheath

Modulatory T lymphocytes reestablish neuromodulation Peña et al. J Immunol Jun 10 (2011)

Modulatory T lymphocytes reestablish neuromodulation AFTER THE INFECTION Peña et al. J Immunol Jun 10 (2011)

Identification of modulatory lymph 0 cytes. T supp Tmod CD 25 + - FOXP 3 + - ORIGEN Thymus Naïve Spleen Anti. Inflammation Constitutive inducible Mediator IL-10 CTLA 4 ? ? ?

Vagal Immune modulation! Central activation Afferent VN VGX VNS a 7 Ag GCM Efferent VN b 2 Ag ACh α 7 n. ACh. R CD 3+ CD 4+ CD 25 - Splenic Nerve NE β 2 AR TNF LPS m 0 HM 1 Spleen To be continued !

Vagus Nerve Clinical Significance Vagus Nerve Stimulators approved by the FDA 1997 Refractory Epilepsy 2005 Treatment-resistant Depression Groves-Neu&Biobeh Rev’ 05 Despite its recent identification, different investigators have already reported that the vagus nerve can modulate systemic inflammation in : Ischemia&Reperfusion Bernik -JVasc Surg’ 02; Altavilla-Shock ‘ 06. Hemorrhage and Resuscitation Cai-JCell. Mol Med’ 09 Pancreatitis Van Westerloo-Gastroenterology’ 06. Colitis Pullan -New England J Med’ 94 Endotoxemia Borovikova-Nature’ 00; Huston-JExp Med’ 06 Septic shock Bernik –JExp. Med’ 02 Severe sepsis Wang-Nat Med ‘ 04; Pena-JImmunol’ 11; Vida-FASEB J’ 11.

Neuronal Stimulation ELECTROACUPUNCTURE • No surgery or anesthesia • Repeated in chronic conditions • Endorsed by the NCCAM, NIH, and the WHO. • Electrical current allows to standardize the procedure Chronic pain Vickers-Arch Int Med’ 12 Postoperative Lee-Cochrane’ 04 ; Napadow-J Alt Comp Med’ 04 Stroke rehabilitation Zhang-Cochrane’ 05; Wu-Cochrane’ 06 DIRECT NERVE STIMULATION • Requires surgical nerve exposure • Anesthesia • Temporal effect • Lifetime of device & battery

ST 36 Zusanli acupoint Ø Most important acupuncture point. Ø Promotes general wellness by balancing most viscera and critical response to food and water and strengthens the lung, liver, spleen, GI. Ø Potential role in anxiety, depression and manic behaviors. Tibial Sural Peroneal

ST 36 controls systemic inflammation Torres & Ulloa, Nat Med(2014)

Electroacupuncture improves survival in POLYMICROBIAL PERITONITIS Endotoxemia INFLAMMATION Cecal Ligation and Puncture INFECTION NECROSIS & INFLAMMATION Torres & Ulloa, Nat Med (2014)

Role of the Adrenal Glands SPX or ADX EA Serum Blood LPS Serum TNF EA LPS EA

b 2 AR and NE are not required for EA Vida & Ulloa, FASEB J (2012) Reserpine Fusaric acid Torres & Ulloa, Nat Med(2014)

Heo-Jun International Award 2016

What PLACEBO In anesthetized patients? He Gu (LI-4), Qu Chi (LI-11), Zu San Li (ST-36) 2 x 30’ – 10 Hz clinicaltrials. gov : code NCT 01937520

Electroacupuncture decreased the request for pain killer Grech et al & L. Ulloa JAMS (2016)

Electroacupuncture induces TGFb, and prevents ACTH and hyperglycemia Grech et al & L. Ulloa JAMS (2016)

e h T f O s n o i t a Limit Study Ø Ø Ø Pilot Study : Small Cohort Acupoints : He Gu (LI-4), Qu Chi (LI-11), Zu San Li (ST-36). 2 x 30’ – 10 Hz INDUCES TGFb : ELDERLY > 45 y, Under < 75 Kg bw ACTH : ELDERLY > 45 y, OVER > 75 Kg bw HYPERGLYCEMIA: ELDERLY > 45 y, OVER > 75 Kg bw Grech et al & L. Ulloa JAMS (2016)

Vagal Immune modulation! Central activation Afferent VN VGX VNS a 7 Ag GCM Efferent VN b 2 Ag ACh α 7 n. ACh. R CD 3+ CD 4+ CD 25 - Splenic Nerve NE β 2 AR TNF LPS m 0 HM 1 Spleen To be continued !

Acknowledges Faculty Program, Rutgers University AHA National#06352230 N Funding: USAMRMC #05308004 NJ Health Foundation NIH RO 1 GM 084125 RO 1 GM 082436