Extracellular Vesicle Biomarkers Reveal Inhibition of Neuroinflammation by Infliximab in Association with Antidepressant Response in Adults with Bipolar Depression

Abstract

Accumulating evidence suggests that neuroinflammation is involved in bipolar disorder (BD) pathogenesis. The tumor necrosis factor-alpha (TNF-α) antagonist infliximab was recently reported to improve depressive symptoms in a subpopulation of individuals with BD and history of childhood maltreatment. To explore the mechanistic mediators of infliximab's effects, we investigated its engagement with biomarkers of cellular response to inflammation derived from plasma extracellular vesicles enriched for neuronal origin (NEVs). We hypothesized that infliximab, compared to placebo, would decrease TNF-α receptors (TNFRs) and nuclear factor-kappa B (NF-κB) pathway signaling biomarkers, and that history of childhood abuse would moderate infliximab's effects. We immunocaptured NEVs from plasma samples collected at baseline and at weeks 2, 6, and 12 (endpoint) from 55 participants of this clinical trial and measured NEV biomarkers using immunoassays. A subset of participants (n = 27) also underwent whole-brain magnetic resonance imaging at baseline and endpoint. Childhood physical abuse moderated treatment by time interactions for TNFR1 (χ² = 9.275, p = 0.026), NF-κB (χ² = 13.825, p = 0.003), and inhibitor of NF-κB (IκBα) (χ² = 7.990, p = 0.046), indicating that higher levels of physical abuse were associated with larger biomarker decreases over time. Moreover, the antidepressant response to infliximab was moderated by TNFR1 (χ² = 7.997, p = 0.046). In infliximab-treated participants, reductions in TNFR1 levels were associated with improvement of depressive symptoms, an effect not detected in the placebo group. Conversely, reductions in TNFR1 levels were associated with increased global cortical thickness in infliximab- (r = -0.581, p = 0.029), but not placebo-treated, patients (r = 0.196, p = 0.501). In conclusion, we report that NEVs revealed that infliximab engaged the TNFR/NF-κB neuro-inflammatory pathway in individuals with BD, in a childhood trauma-dependent manner, which was associated with clinical response and brain structural changes.

Keywords: bipolar disorder; childhood trauma; cytokines; depression; inflammation.

Figure 1

Least squares mean changes in biomarkers levels from baseline to week 12 in infliximab- or placebo-treated individuals with bipolar disorder with or without clinically significant history of physical abuse (PA). Results from an intent-to-treat generalized estimating equation analysis of 55 participants with bipolar disorder who were administered three infusions of infliximab (n = 27) or placebo (n = 28) at baseline and at weeks 2 and 6 of a 12-week trial. Error bars indicate standard errors (SE). Abbreviations: TNFR1: Tumour necrosis factor-alpha receptor-1; NF-κB: nuclear factor-kappa B; PA: with clinically significant history of physical abuse; No PA: without clinically significant history of physical abuse.

Figure 2

Association between changes in TNFR1 levels, adjusted for Alix concentration, and changes in MADRS scores, in the placebo and infliximab treated groups, at week 6.

Figure 3

Association between changes in TNFR1 levels, adjusted for Alix concentration, and changes in cortical thickness, in the placebo and infliximab treated groups, at endpoint.