Biomaterials for Induction and Treatment

of Autoimmunity

Akhilesh Kumar Shakya and Kutty Selva Nandakumar

Abstract Use of biomaterials in autoimmunity research is widely explored, as an

adjuvant to induce antigen specific immune responses, for facilitating induction of
experimental models to study disease pathogenesis and for designing novel thera-
peutic targets. Similarly, polymeric biomaterials are explored as a delivery vehicle
for sustained and specific release of auto-antigens/drugs to treat autoimmune dis-
orders. Although considered as biocompatible, implantation/injection of polymers
like silica and metallic implants are associated with development of chronic
inflammation and autoimmunity. Despite these compatibility concerns, biomaterials
are still considered as favorable materials for several applications in the autoim-
munity field.

Keywords Autoimmunity

Biomaterials Polymer

Auto-antigen specific


immunotherapy Poly-N-isopropylacrylamide Arthritis

Abbreviations
APCs Antigen presenting cells
ASIA Adjuvant induced autoimmune syndrome
bFGF Basic fibroblast growth factor
CFA Complete Freund’s adjuvant
CIA Collagen induced arthritis
CII Collagen type II

A.K. Shakya (&)

Chemical Engineering Department, Texas Tech University,
Lubbock, TX 79409-3121, USA
e-mail: [Link]@[Link]
K.S. Nandakumar
Medical Immunopharmacology Research, Southern Medical University,
Guangzhou, China
e-mail: [Link]-Selva@[Link]
K.S. Nandakumar
Medical Inflammation Research, Medical Biochemistry and Biophysics,
Karolinska Institute, Stockholm, Sweden

© Springer Nature Singapore Pte Ltd. 2017 167

A. Tripathi and J.S. Melo (eds.), Advances in Biomaterials
for Biomedical Applications, Advanced Structured Materials 66,
DOI 10.1007/978-981-10-3328-5_4
168 A.K. Shakya and K.S. Nandakumar

CS Chitosan
DCs Dendritic cells
EAE Experimental autoimmune encephalomyelitis
EAU Experimental autoimmune uveoretinitis
HA Hyaluronic acid
LSECs Liver sinusoidal endothelial cells
MS Multiple sclerosis
NGF Nerve growth factor
NPs Nanoparticles
PHCCC N-Phenyl-7-(hydroxyimino)cyclopropa[b]chromen-1a-carboxamide
PLGA Poly(lactic-co-glycolic acid)
PNiPAAm Poly-N-isopropylacrylamide
Treqs T regulatory cells
TCR T cell receptor
VUR Vesicoureteral reflux

1 Introduction

Autoimmunity is a sign of imbalance between the regulatory and effector immune

responses, which mainly emerge as a result of either defective elimination or
improper control of self-reactive lymphocytes. This imbalance causes breakdown of
immunological tolerance against self-molecules or tissues resulting in autoimmune
disorders. In most of these clinical manifestations, the initiating events are
unknown. However, genetics, epigenetics and environmental factors are identified
as decisive factors in the establishment of autoimmunity. Prevalence of autoim-
mune disorders (multiple sclerosis, rheumatoid arthritis and type 1 diabetes) is
approximately 1% in the worldwide population (Cooper and Stroehla 2003). In
addition, inflammatory conditions like atherosclerosis (hardening and narrowing of
the arteries) (Hansson and Hermansson 2011; Ketelhuth and Hansson 2015) and
inflammatory bowel disease (inflammation in colon and small intestine) (Colia et al.
2016) may have autoimmune components (Ross 1990; Galperin and Gershwin
1997). Female preponderance in the development of chronic autoimmune diseases
is well documented with more than 75% autoimmune cases are reported in females.
Especially, young females at the age of or after puberty are ten times more sus-
ceptible for developing autoimmune diseases (Beeson 1994; Smith and Germolec
1999). Generally, these autoimmune disorders are characterized by systemic or
localized (tissue-specific) chronic inflammation, which leads to progressive
destruction of target tissues.
Autoimmune diseases are a major concern worldwide due to high economic
burden to the society and because of poor understanding of disease initiation and
pathogenic events. Patients usually visit the clinics at a later stage of the disease
Biomaterials for Induction and Treatment of Autoimmunity 169

development, making it difficult to intervene at the disease initiation stage.

However, disease specific clinical manifestations start long time before the clinical
symptoms appear. For example, presence of anti-citrullinated protein/peptide
specific antibodies (ACPAs) is observed several years before the onset of
Rheumatoid arthritis (Rantapaa-Dahlqvist et al. 2003). To understand the patho-
genic pathways in autoimmune diseases, several animal models are used that can
either be induced or spontaneously developed (Kannan et al. 2005; Asquith et al.
2009). Conventional therapies for autoimmune disorders are based on
immuno-suppressive, antiviral or antibacterial treatments. Currently, patients are
treated with biologicals or drugs that can block the pro-inflammatory cytokines, B
and/or T cells. Moreover, oral medications like angiotensin and statins are also
being used in the clinics. Despite the effectiveness of these medications, specificity
of the treatments and side effects of the drugs are major concerns that should be
taken into consideration while developing future novel immunotherapies
(Fairweather 2007).
Biomaterials have been well explored in immunology for the development of
new vaccines, therapeutics, tissue regeneration and in the induction of diseases in
animal models to study the inflammatory pathogenic pathways. Biomaterials can be
used in different ways: as suppressors to inhibit the immune response against
therapeutics, as an adjuvant for sustained release and enhancing immunogenicity of
an antigen or as attenuators to modulate the immune responses. As an immune
system attenuator, they can reduce the immune responses against the delivered
drugs or therapeutic protein(s). For example, in blood transfusion studies, polymers
can minimize the chances of rejection. Covalent conjugation of monomethoxy
polyethylene glycol (mPEG) to the cells or tissues significantly reduced the pos-
sibility of rejection by inducing a state of tolerance (Scott et al. 1997; Scott and
Murad 1998). Moreover, attachment of PEG to the egg white lysozyme antigen also
reported to diminish T cell responses (So et al. 1996). As the immune system
suppressor, they can be an alternate to conventional immunosuppressive drugs like
cyclosporine, which is associated with undesirable side effects (Descotes 2004).
Similarly, multiwall carbon nanotubes (CNTs) suppressed the systemic immune
responses in mice (Mitchell et al. 2009). Inhibitory effect of polyhydroxy C60
(fullerene) was also reported on type 1 hypersensitive reactions (Ryan et al. 2007).
Others biomaterials like chitosan, PLGA particles and dendrosomes have also been
shown to have suppressive role in type I and III hypersensitive reactions (Balenga
et al. 2006; Gomez et al. 2008). Biomaterial polymers are well explored as a
delivery system and/or as an adjuvant in designing several methods of delivery
system for slow release of the antigen and for the induction of antigen-specific
immune responses. In this context, apart from sustained release, polymers can also
stabilize the antigen for eliciting an effective immune resonse. For example,
polymeric system based on 1,6-bis(pcarboxyphenoxy) hexane and 1, 8-bis
(p-carboxyphenoxy)- 3,6-dioxaoctane significantly stabilized the Bacillus anthra-
cis antigen (Petersen et al. 2012). Adjuvant property of polymers depends on the
charge, format, chemistry and the balance between their hydrophobicity and
hydrophilicity properties (Shakya and Nandakumar 2012a). Apart from being used
170 A.K. Shakya and K.S. Nandakumar

for antigen delivery, during last decade, biomaterials are also tested in the
autoimmunity field as an adjuvant for induction of autoimmune responses and as
therapeutics for treatment of autoimmune diseases.
Failure of tolerance towards self-antigens is a crucial component in the induction
of autoimmunity. Both central and peripheral tolerance mechanisms that are
essential to control self-reactive immune cells are compromised. In healthy indi-
viduals, these tolerance mechanisms inhibit induction of autoimmune responses.
However, when tolerance is breached, immune cells become hyperactive towards
self-proteins leading to destruction of tissue organization and organ structure.
Hence, to design and develop protective strategies against development of
autoimmunity, to explore disease mechanisms and treat them successfully, bio-
materials have been widely explored. This chapter updates use of such biomaterials
in autoimmunity research.

2 Biomaterials for the Induction of Experimental

Autoimmunity

For dissecting the complexity of autoimmune diseases, validation of existing

therapies and identifying novel therapeutic targets, animal models (also called as
disease models) are a pre-requisite (Kannan et al. 2005; Asquith et al. 2009). These
disease models can be induced with a self-antigen and an appropriate adjuvant.
However, these models may reflect either part of the clinical disease or represent the
clinical spectrum of a sub-population of the patients. Hence, the induced models are
often chosen based on the scientific question and therapeutic targets. Nevertheless,
very few studies reported the use of biomaterials with an auto-antigen for induction
of autoimmunity.

2.1 Experimental Arthritis

Rheumatoid arthritis (RA) is an autoimmune disorder, characterized by chronic

inflammation of articular joints and associated with progressive depletion of extra-
cellular matrices, cartilage and bone. Various chronic and acute models have been
developed by immunization with joint-specific as well as ubiquitously expressed
antigens with an adjuvant. For example, collagen type II (CII) is a major protein
present in the articular cartilage, target for autoimmune attack in arthritis. When CII
is mixed with an adjuvant and immunized to susceptible animals having a permis-
sible genetic background, it induces polyarthritis so called collagen induced arthritis
(CIA), a classical model for arthritis. Commonly used adjuvants in the induction of
autoimmunity are Freund’s adjuvants, which are oil based with or without
mycobacterial derivatives. However, use of these type of adjuvants tend to induce a
Biomaterials for Induction and Treatment of Autoimmunity 171

biased immune response, especially by inducing a particular T helper (Th) cell

signaling pathways and thereby masking the actual response towards a particular
antigen (Petrovsky and Aguilar 2004; Shakya and Nandakumar et al. 2012b).
Moreover, they are also associated with localized and systemic toxicities. Therefore,
there is a need for biocompatible and immunologically inert adjuvant for the
development of an animal model to study the development of autoimmune diseases
in detail. Very recently, our group demonstrated the adjuvant potential of temper-
ature responsive poly-N-isopropylacrylamide (PNiPAAm) based polymers for the
development of collagen induced arthritis (CIA) in mice (Shakya et al. 2011; Shakya
and Nandakumar 2015). PNiPAAm in solution phase can easily be mixed with CII at
room temperature (25 °C) but above its lower critical solution temperature (LCST)
at 32 °C, PNiPAAm precipitates along with CII and act as a depot for slow release of
CII (Fig. 1). Thus, CII mixed with PNiPAAm induced arthritis that is independent of
any particular Th-type immune response. After mixing with PNiPAAm, CII retained
its native epitopes, an essential factor in arthritis development (Shakya et al. 2011)
because denatured CII did not induce disease development. Autoimmune responses
induced by PNiPAAm-CII mixture were found to be toll like receptors (TLRs)
independent. Presence of CII specific T cell receptor (TCR) or mutation in Ncf1
subunit of mitochondrial NADPH complex induced severe arthritis after
PNiPAAm-CII immunization (Shakya et al. 2011). Interestingly,
hydrophilic-hydrophobic balance of a polymer was found to be an important factor
in determining its adjuvant property (Shakya et al. 2016). Similar to this
homopolymer PNiPAAm, adjuvant property of copolymers poly-N-

>32.5°C <32.5°C)

Polymer-antigen mixture Polymer-antigen mixture

in solution form in precipitation form

Antigen release

Prolonged immune response

Fig. 1 Schematic representation of temperature dependent phase transition of stimuli-responsive

polymer, PNiPAAm with collagen type II (CII) molecules. Below the cloud point (*32.5 °C),
polymer and CII are in solution form however they precipitate at body temperature. Polymer
generates a depot effect and release CII slowly to get a prolonged immune response
172 A.K. Shakya and K.S. Nandakumar

(a) (b)
H2 H H2 H H2 H H2 H H2 H
* C C C C * * C C C C C C *
m n m n o
CO CO CO
NH NH O
CH CH CH2
H3C CH3 B H3C CH3 B CH2
HO OH HO OH
N
H3C CH3
PNiPAAm-co-VPBA PNiPAAm-co-VPBA-co-DMAEMA

(c) (d) (e)

Fig. 2 Chemical structure of copolymers poly-N-isopropylacrylamide-co-vinylphenylboronic acid

(PNiPAAm-co-VPBA) (a) and poly-N-isopropylacrylamide-co-vinylphenylboronic acid-co-
dimethylaminoethylmethacrylate (PNiPAAm-co-VPBA-co-DMAEMA) (b). Histology analysis
of paws of arthritis mice received which injection of CII protein with CFA (c), PNiPAAm-co-
VPBA-co-DMAEMA–CII (d) and phosphate buffer saline alone (e). All the images were captured
at 20  magnification (Reproduced from permission Shakya et al. 2013; Vaccine 31(35):3519–3527)

isopropylacrylamide-co-vinylphenylboronic acid (PNiPAAm-co-VPBA) and

poly-N-isopropylacrylamide-co-vinylphenylboronic acid-co-dimethylami-
noethylmethacrylate (PNiPAAm-co-VPBA-co-DMAEMA) were also demonstrated
with CII antigen. These copolymers were synthesized through free radical poly-
merization process and characterized by gel permeation chromatography to deter-
mine their molecular weights. These polymers were found to be biocompatible under
in vitro conditions and did not show any detectable systemic and localized toxicity
in vivo. Mice injected with these copolymers and CII developed significant level of
CII specific antibody response, which mainly consists of all IgG subtypes (Shakya
et al. 2013) (Fig. 2). Macrophages are the major infiltrating cells found at the
injection site of PNiAAm-CII mixture. Exacerbation of arthritis in the absence of
reactive oxygen species (ROS) in rodents was reported earlier (Holmdahl et al.
2016). In this context, it is of interest to note that ROS produced by macrophages
attenuated the autoimmune response and development of arthritis (Gelderman et al.
2007; Pizzolla et al. 2011; Shakya et al. 2016).

2.2 Experimental Autoimmune Encephalomyelitis

Multiple sclerosis (MS) is a well known chronic autoimmune neurological disorder,

associated with multiple patches of inflammation and demyelination of the central
Biomaterials for Induction and Treatment of Autoimmunity 173

nervous system. To understand the pathogenesis of MS, experimental autoimmune

encephalomyelitis (EAE) is the most commonly used animal model. EAE is T cell
driven autoimmune disorder, with a characteristic infiltration of mononuclear cells
like macrophages and B cells into the inflammatory site. EAE mimics several
clinical features of MS patients like demyelinating lesions of central nervous system
(CNS) white matter and foam like myelin debris in active lesions (Getts et al. 2012).
In mice, EAE can be induced either by immunization with myelin antigens or by
adoptive transfer of myelin specific T cells. Immunization with myelin antigens in
genetically susceptible rodents involves use of an adjuvant and characterized by
demyelination primarily in the spinal cord mediated by the immune system.
Immunization with myelin proteins breaks down the peripheral tolerance mecha-
nisms leading to activation and differentiation of myelin specific T cells in the
secondary lymphoid organs (Yednock et al. 1992). Then the activated T cells cross
the blood brain barrier where they get reactivated by CNS antigens presented by
tissue resident antigen presenting cells (Kawakami et al. 2004). This reactivation of
T cells induces expression of pro-inflammatory cytokines (TNF-a, IL-17 and
GM-CSF), which may cause nervous tissue injury either directly or by activating
immune cells present in the vicinity. Moreover, adjuvants used for such disease
development are also associated with toxicity problems. As an alternate, recently
organotypic slice culture based model was developed. For example, to understand
the role of pro-inflammatory cytokines in MS, a non viral polymer poly
(2-dimethylaminoethylmethacrylate) based gene delivery approach and an ex vivo
organotypic slice cultures were developed to transduce the cells with genes encoding
the pro-inflammatory cytokines. Polymer based biocompatible system has efficiently
transduced different cell types in organotypic brain slice system through delivery of
TNF and IFN-c genes. Expression and release of TNF and IFN-c cytokines induced
inflammation-mediated myelin loss in cerebellar slices, which represents an ex vivo
system for studying the pathogenesis of MS (Mathew et al. 2013).

3 Adjuvant Induced Autoimmune Syndrome

The concept of adjuvant induced autoimmune syndrome (ASIA) was first recog-
nized in 2011, although patients having diverse symptoms after treatment with
silicone or paraffin fillers were reported by Miyoshi in 1964 (Alijotas-Reig 2015).
According to ASIA concept, chronic systemic inflammation and autoimmune dis-
orders can develop by repeated exposure to biomaterials especially to the materials
used in plastic surgeries such as silicone implant used for breast augmentation
(Hajdu et al. 2011). Silicone is a polymer of dimethylsiloxane that has been
extensively explored in biomedical applications due to its variable degree of vis-
cosity, which depends on the length of polymer used. Silicone mainly gained its
popularity in breast implants despite its wide usage in other implantable products
like ventriculo-peritoneal and heart valves (Hajdu et al. 2011). Today breast, but-
tock and face augmentation by the use of liquid silicone is most commonly adopted
174 A.K. Shakya and K.S. Nandakumar

plastic surgery method in USA and other countries. However, capsular fibrosis and
contracture, scleroderma, local adverse reactions and other autoimmune disorders
are associated with silicone implants despite its acceptable biocompatibility nature
(Gabriel et al. 1994; Sanchez-Guerrero et al. 1995; Hajdu et al. 2011; Franca et al.
2013). Association of silicone with autoimmune disorders was first reported in
1984, when a spectrum of autoimmune diseases like rheumatoid arthritis, systemic
lupus erythematosus (SLE), polymyositis and sclerosis were reported in 24 patients
who had received silicone injection (Kumagai et al. 1984). In another study, one out
of three silicone implanted patients developed RA symptoms, second patient
developed symptoms like SLE, and third one developed connective tissues
abnormality (van Nunen et al. 1982). During last few years many cases of con-
nective tissue disorders have been documented with silicone implants (Spiera et al.
1994; Holmich et al. 2007; Nesher et al. 2015; Singh et al. 2016). Besides silicone,
other biomaterials like alum and hyaluronic acid may also be responsible for ASIA
(Alijotas-Reig et al. 2012) (Alijotas-Reig 2015). Causative factors and symptoms
identified for ASIA syndrome include repeated biomaterials injection, development
of local chronic inflammation, systemic symptoms such as joint pain, fever, fatigue
and vasculitis. Risk factors for the development of ASIA include family history of
autoimmunity, autoimmune reaction against implants and allergic reaction against
the injected materials (Goren et al. 2015). Very recently a case of adjuvant induced
autoimmune syndrome was reported when dextranomer/hyaluronic acid copolymer
(Deflux) was used for the injection to treat vesicoureteral reflux (VUR). Deflux
injections cure about 85% primary VUR abnormalities in females however
0.6–0.7% of patients are refractory to the treatment. Suda et al., from Japan reported
occurrence of autoimmune disease in a female patient having ureteral obstruction,
who has received repeated injections of Deflux (Suda et al. 2016). Besides the
polymeric biomaterials, ASIA has also been reported with metallic implants. Most
common type of metals reported for induction of autoimmunity is nickel and
titanium. In a case study, 23 year old female had nickel titanium chain implant for
cosmetic purpose. After 1 year post implantation she developed autoimmune
symptoms like thrombocytopenia, anemia and neutropenia (Loyo et al. 2013).

4 Biomaterials for Delivery of Drug/Antigen(S)

for Treatment of Autoimmune Diseases

Generally treatments are often initiated either before or around the onset of disease to
block its development as well as revert an established disease by intervention therapy.
However, in many common autoimmune diseases in fact the disease starts many
years, maybe decades, before the clinical diagnosis. Hence, establishing tolerance
towards self-antigens by vaccination is needed and efforts are being made to develop
such vaccines for autoimmune diseases (Correale et al. 2008; Nicholas et al. 2011;
Lernmark and Larsson 2013; Rosenthal et al. 2015). In this context, use of
Biomaterials for Induction and Treatment of Autoimmunity 175

well-defined, biodegradable materials as delivery vehicles for drugs and vaccines are
highly useful for optimized target delivery (Hunter et al. 2014).

4.1 Rheumatoid Arthritis

Administration of autoantigen through oral route is a well-known strategy to

achieve peripheral immune tolerance against autoimmune diseases like rheumatoid
arthritis, diabetes and experimental uveitis. Effectiveness of oral tolerance depends
on several factors such as the nature, dose, frequency of the administered antigen,
genetic background of the recipient and the degree of antigen uptake by antigen
presenting cells of gastrointestinal tract (GI). In the harsh environment of GI tract,
the amount of antigen delivered to the mucosa is extremely small. Therefore,
efficient antigen delivery systems are justified with a controlled release of antigens
at mucosal sites, while providing protection to the antigen against GI environment.
In this context, particulate systems in nano and micron size ranges have been
explored to achieve optimal level of peripheral immune tolerance. For example,
poly(lactide-co-glycolide) (PLGA) nanoparticles encapsulated with CII were syn-
thesized by water in oil in water emulsion (w/o/w) by a solvent evaporation method.
Mice fed with single dose of CII encapsulated PLGA particles, which contained
40 µg of CII, noticeably had reduced clinical symptoms of arthritis with low level
of anti-CII antibodies in the serum (Kim et al. 2002).
For RA, a delivery system that can deliver the drug at the effector site (articular
cartilage) is more beneficial than the systemic delivery. Most of the developed
systems do not have specificity to deliver the drug at the site of interest, therefore
significantly large amount of drugs are required, which cause severe toxicity
problems. Therefore to balance between effectiveness and minimizing the side
effects, several systems like liposome, soft gels, micro-emulsion, topical formula-
tions, nano-dispersions and pellets have been developed (Fig. 3). Among them,
liposome based delivery system is widely explored for targeted delivery of
anti-rheumatic drugs. These delivery systems are biocompatible, degradable,
immunologically inert and can encapsulate significant amount of drugs (Kapoor
et al. 2014).
Another strategy to enhance the bioavailability of drug/protein is PEGylation,
which is the covalent attachment of polyethylene glycol polymer to the
drug/antigen. This strategy has been successfully explored for increasing the
therapeutic potential of anti-rheumatic drugs like TNF-related apoptosis inducing
ligand (TRAIL). In a study, site specific N-terminal PEGylation of TRAIL induced
13-fold higher stability, however, this procedure has slightly reduced TRAIL
functionality. Therefore to improve the bioactivity of TRAIL in other study,
nano-sized complexes of PEGylated TRAIL protein were synthesized by using
negatively charged hyaluronic acid (HA). These nanocomplexes were shown
promising therapeutic potential to treat arthritis in mice, possibly due to sustained
release of TRAIL or good stability of proteins under in vivo system (Kim et al.
176 A.K. Shakya and K.S. Nandakumar

Water

Liposome Microsphere Polymeric Nanoparticles

Liquid Solid
lipid lipid

Nanoemulsion Lipid Nanoparticles Bioadhesive gel

Fig. 3 Different vehicle systems used for delivery of antigens or drugs used in immunotherapy

2010). Furthermore, PEGylation enhances in vivo shelf life of the proteins by

reducing their renal clearance. PEG also improves drug solubility, stability and
minimizes immune reaction against the therapeutic proteins by shielding proteins
from water molecules (Fig. 4).

4.2 Multiple Sclerosis

Transplantation of cells is an attractive therapeutic approach to treat demyelinating

diseases like MS. Neuronal precursor cells have shown promising results in
remyelination due to their differentiation ability into neural cells. Various delivery
systems have been demonstrated for effective delivery of these precursor cells into
the central nervous system. For example, three dimensional nano-fiber based poly
(glycolic-co-lactide)/chitosan (PLGA/CS) scaffold was able to induce the precursor
cells (PC12) into neural cell differentiation in the presence of nerve growth factor
(NGF) and basic fibroblast growth factor (bFGF). Enhanced expression of nestin,
b-tubulin and microtubule associated protein were observed in PC12 cells seeded
on PLGA/CS scaffold. Moreover, PC12 seeded scaffolds transplanted into lateral
ventricles of EAE affected mice reduced the clinical signs of the disease signifi-
cantly (Hoveizi et al. 2015). Another vaccine controlled release system based on
colloidal gel containing the immunomodulating peptide was also demonstrated for
the treatment of EAE. Colloidal gel from alginate-chitosan and PLGA polymers
was able to deliver the Ac-PLP-BPI-NH2-2 peptide in a controlled manner. This
peptide was designed to bind the MHCII and intracellular adhesion molecule
(ICAM)-I simultaneously. Colloidal gel based vaccine, when administrated sub-
cutaneously into mice having encephalomyelitis, suppressed and delayed the
severity of EAE symptoms compared to the control group. Expression of IL-6 and
IL-17 was found to be lower in vaccinated mice than in control mice, which
Biomaterials for Induction and Treatment of Autoimmunity 177

PEG-TRAIL Hyaluronic acid (HA)

- - -
- - --
- -
- - PEG-TRAIL/HA
nanocomplex
- -
- -
- - -
- --
Addition of 1% HA

Network of PEG-TRAIL/HA
nanocomplex

Fig. 4 Schematic representation of nanocomplex release system formation through ionic

interaction between PEG-TRAIL molecules and hyaluronic acid (HA). HA exist in anionic form
in biological fluids which formed the complex with cationic charged PEG-TRAIL molecules
(Reproduced from permission Kim et al. 2010 Biomaterials 31(34):9057–9064)

demonstrates long term suppression of the disease (Buyuktimkin et al. 2012). In

another study, antigen loaded micron-sized PLGA particles were demonstrated to
deliver the encephalitogenic peptides through intravenous infusion to prevent the
onset of disease, thereby ameliorating the clinical symptoms of EAE. Peptide
loaded micron size particles (MPs) were taken up by marginal zone macrophages
expressing the MARCO receptors that modulate the activity of T regulatory cells
(Tregs) (Getts et al. 2012). In a different study, capability of PLGA nanoparticles has
been demonstrated to treat EAE in mice. Myelin antigen coupled nanoparticles
were able to prevent and treat the established experimental encephalomyelitis
(Hunter et al. 2014).
178 A.K. Shakya and K.S. Nandakumar

Table 1 Delivery systems and administrative routes of anti-rheumatic drugs/biomolecules

Anti-rheumatic Delivery systems References
drug/molecule
Ketoprofen Bioadhesive gels Transdermal delivery (Singh et al. 2009)
Eudragit based Oral delivery (El-Kamel et al. 2001)
microparticles
Methotraxate Polylactic acid based Intra-articular (Liang et al. 2004)
microspheres delivery
Solid in oil nano-carrier Transdermal delivery (Yang et al. 2012)
Prednisolone Cyclodextrins Intravenous (Hwang et al. 2008)
Diclofenac Solid lipid nanoparticles Transdermal delivery (Liu et al. 2010)
Indomethacin Liposomes Oral delivery (Soehngen et al. 1988)
Prostaglandin E1 Lipid microspheres Intravenous delivery (Moriuchi-Murakami
et al. 2000)
Collagen type II PLGA nanoparticles Oral delivery (Kim et al. 2002)

Immune tolerance capacity of liver has also been utilized for the treatment of
autoimmune disorders. A recent study has shown that liver sinusoidal endothelial
cells (LSECs) can induce Tregs to achieve hepatic tolerance. Polymeric nanoparti-
cles encapsulated with auto-antigenic peptide can selectively deliver the peptide to
LSECs for the induction of Tregs. Thus, NPs based on auto-antigen peptide delivery
can effectively prevent the onset of clinical symptoms of EAE in mice.
Interestingly, a single dose of NP significantly improved the established EAE due to
the activation of Tregs (Carambia et al. 2015). Other than the vaccine approaches,
drugs encapsulated in polymeric NPs were tried to treat EAE. For example, N-
Phenyl-7-(hydroxyimino)cyclopropa[b]chromen-1a-carboxamide (PHCCC) mole-
cule encapsulated PLGA NPs target the DCs to skew the inflammatory Th17
response towards protective Treg response. PHCCC molecules can easily be
encapsulated into NPs and 89% of the drug was found to be released within 3 days.
Moreover, DHCCC encapsulated NPs were 36 fold less cytotoxic compared to the
soluble drug. Treatment of EAE mice with DHCCC encapsulated NPs adminis-
trated at 3 days interval significantly delayed the onset of disease and improved the
clinical score compared to the soluble drug of same dose and frequency (Gammon
et al. 2015) (Table 1).

4.3 Type1 Diabetes

Type1 diabetes (T1D) is a chronic autoimmune disorder characterized by devas-

tation of insulin secreting beta cells by autoreactive T cells. Lack of insulin
secretion from beta cells leads to hyperglycemia and abnormal glucose metabolism
(Nicholas et al. 2011) (Fig. 5). Similar to most of the autoimmune diseases, both
genetic and environmental factors contribute to the development of type 1 diabetes.
Especially, contribution of autoreactive T lymphocytes is well recognized in the
Biomaterials for Induction and Treatment of Autoimmunity 179

Auto-antigen specific immunotherapy

In presence of exogenous
Dendritic cell autoantigen

Th cell

T regulatory cell Th2 cell

β cell

Th1 cell
Insulin secretion
Cytotoxic T cell

Fig. 5 Mechanism of auto-antigen specific immunotherapy. During antigen specific immunother-

apy DCs process the antigen and present to naïve Th cells through secretion of IL-10 cytokine. In
this context, activated Th cells activate the Tregs and Th2 cells, which block the proliferation of
auto-reactive Th1 and CTL cells through secretion of IL-10. Activation of Tregs leads to the
prevention of beta cell death and this way immuno-tolerance is achieved against the auto-antigen
(Nicholas et al. 2011)

establishment of T1D (van Belle et al. 2011). Therefore immunomodulation of

autoreactive T cell response is one of the major strategies to treat the disease. For a
successful immunotherapy, selection of suitable vaccine and its efficient delivery
are major concerns. Various biomaterials are explored for design and effective
delivery of drug/vaccine against T1D. For example, PLGA polymeric nanoparticles
(NPs) were used to encapsulate insulin as an autoantigen and CpG
oligodeoxynucleotides as an adjuvant. The antigen loaded NPs were embedded in
PuraMatrix peptide hydrogel for sustained release of the antigen. PuraMatrix is
biodegradable, biocompatible and self-assembling peptides based material, which
can form 3-D matrix in the presence of physiologic medium with 5–200 nm pore
size. Antigen loaded PuraMatrix based hydrogel was injected subcutaneously in
non-obese diabetic (NOD) mice in order to evaluate the vaccine efficacy. Although,
this vaccine has induced formation of temporary granuloma, which had huge fil-
tration of lymphocytes and macrophages, overall, this approach represents
promising immuno tolerance model for the treatment of T1D (Yoon et al. 2015).
180 A.K. Shakya and K.S. Nandakumar

Another strategy to control the development of autoimmune diabetes is by min-

imizing the autoimmune reactions by induction of immunological tolerance. In
steady state, beta cells, which undergoes apoptosis is recognized by antigen pre-
senting cells (efferocytosis) for the induction of immunological tolerance. However at
the time of abnormal efferocytosis, APCs are unable to recognize apoptotic beta cells,
which result in the induction of autoimmune T1D or other disorders. Therefore to
help APCs for better recognition, researchers have synthesized and used micron-sized
particles containing beta-cell antigens as an alternate source of apoptotic beta cells.
For example, phosphatidylserine-liposomes encapsulated with insulin peptides when
administrated into NOD mice induced tolerogenic dendritic cells and attenuated the
autoreactive immune responses. Liposomal-based immunotherapy minimized the
development of autoimmunity and thereby reduced the symptoms of diabetes. Using
liposomes for immunotherapy has several advantages in terms of easy preparation
methods and administering protocols compared to the existing immunotherapy
regimen. Liposomes are also able to protect the antigen from degradation under
in vivo conditions (Pujol-Autonell et al. 2015).

4.4 Autoimmune Uveitis

Uveitis is the most common autoimmune ocular disorder, which is one of the major
causes for blindness in developing countries. Currently, uveitis is treated by
repeated intraocular injection of corticosteroids, which are associated with side
effects and patient inconvenience. Alternatively immunosuppressive therapies are
also in use to treat chronic autoimmune uveoretinitis, which make patients more
susceptible for infections. Therefore, biodegradable polymers based delivery sys-
tems in the form of implants have been studied for effective and localized delivery
of the drugs (Gammon et al. 2015). For example, ability of polymeric nanoparticles
for slow release of drugs to treat autoimmune uveoretinitis has been demonstrated.
A single dose of poly(lactic) acid NPs encapsulated with betamethasone phosphate
drug administrated intravenously into Lewis rats was able to improve the clinical
score of EAU with significantly reduced infiltration of macrophages, auto-reactive
T cells and hypertrophic morphology of muller cells (Sakai et al. 2006).

5 Conclusion

In conclusion, biomaterials in autoimmunity are attractive resources for induction

and treatment of autoimmune disorders. However, their biocompatibility properties
should be studied in detail before their long-term use.
Biomaterials for Induction and Treatment of Autoimmunity 181

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