Selective JAK Inhibition Reveals Paradoxical and Hierarchical Control of interferon-γ-driven Autoimmunity in AIRE Deficiency

Reviewer #1 (Public review):

Summary:

Heller et al use a murine model of AIRE deficiency, a disease that leads to systemic autoimmune disease, to demonstrate differential effects of selective JAK inhibitors. This group and others have previously demonstrated the efficacy of the JAK1/2 inhibitor ruxolitinib in patients with AIRE deficiency. Here, they focus on the ability of ruxolitinib versus drugs inhibiting either JAK1, JAK2, or JAK3 to alter organ pathology and accumulation of interferon-gamma producing immune cells in the lungs, which are important mediators of inflammation in patients with this disease. The current study provides evidence that selective JAK2 or JAK1 both reduce disease in this mouse model. There is potentially a more beneficial effect of selective JAK2 inhibition, although these differences are minor, and it is uncertain whether this is clinically relevant for patients. They demonstrate that inhibition of JAK3 alone in the mouse was clearly not beneficial for disease. Overall, this study provides evidence for consideration of more selective JAK inhibition in patients with AIRE deficiency.

Strengths:

(1) Robust model for investigating AIRE deficiency.

(2) They combine cellular studies (immune cell production of IFN-g) and robust organ pathology scoring to evaluate the effects of the drugs tested here.

(3) Data clearly demonstrates that JAK3 inhibition, at least as used here, may increase IFN-g production and does not reduce organ pathology.

Weaknesses:

(1) There is no direct comparison of the effects of JAK2 vs. JAK1 inhibition to support that JAK2 inhibition is clearly superior.

(2) They were not able to perform pharmacokinetic studies or measure the efficacy of JAK inhibition in their model, and it is uncertain how the doses of drug used here will translate to the treatment of patients.

(3) It is uncertain whether this study, performed in a murine model, will correspond to tissue/cell specificity of JAK inhibition in patients.

Reviewer #2 (Public review):

Summary:

This work from Heller et al. examines the differential responses of treatment with selective JAK inhibitors in Aire knockout mice, which develop several autoimmune diseases. The authors had previously shown efficacious responses in both mice and humans with a broader JAK-I, Ruxolitinib, that had Aire-deficiency. Because of the side effect profile, it may be better to determine if selective JAK-I therapy could continue to work with less of the side effects of Ruxolitinib. Here, they develop a protocol of treating mice for four weeks with JAK1,2, and 3 inhibitors and then examining tissues for infiltration of T cells and gamma-interferon-producing T cells. They also perform analyses of infiltration of the tissues versus intravascular localization of T cells. They find that JAK2 inhibition provided the most robust results for decreasing infiltrates and gamma interferon-producing T cells. All JAK-I's resulted in decreased T cell infiltration of tissues, and somewhat paradoxically, the JAK3 inhibitor caused an increased accumulation of gamma-interferon-producing T cells in tissues.

Strengths:

This is a nice set of studies that makes some inroads on a more refined approach to treating autoimmunity in the Aire knockout model. The work here will be important for developing the next clinical trial for patients with APS1 and represents an advance for efforts in that space.

Weaknesses:

The increase in gamma-interferon-producing cells in tissues with JAK3 inhibition is interesting, but essentially remains unanswered in any way. There is a minimal assessment of the broad STAT pathways that the selective JAK-i's could be hitting, and perhaps that could be assessed more systematically. Finally, there is no pharmacokinetic data, which makes comparisons between the treatments a bit limited.