Interleukin 2

REVIEWS
The promise of low-dose interleukin2

therapy for autoimmune and
inflammatory diseases
David Klatzmann13 and Abul K.Abbas4
Abstract | Depletion of regulatory T (TReg) cells in otherwise healthy individuals leads to

multi-organ autoimmune disease and inflammation. This indicates that in a normal
immune system, there are self-specific effector Tcells that are ready to attack normal
tissue if they are not restrained by TReg cells. The data imply that there is a balance between
effector Tcells and TReg cells in health and suggest a therapeutic potential of TReg cells in
diseases in which this balance is altered. Proof-of-concept clinical trials, now supported
byrobust mechanistic studies, have shown that low-dose interleukin2 specifically
expandsand activates TReg cell populations and thus can control autoimmune diseases
andinflammation.
Sorbonne Universit,
UPMC Univ Paris 06,
UMRS 959, ImmunologyImmunopathologyImmunotherapy (i3),
F-75651 Paris, France.
2
INSERM, UMRS 959,
ImmunologyImmunopathologyImmunotherapy (i3),
F-75005 Paris, France.
3
Assistance Publique
Hpitaux de Paris, Hpital
Piti-Salptrire, Biotherapy
and Dpartement HospitaloUniversitaire InflammationImmunopathology-Biotherapy
(i2B), F-75651 Paris, France.
4
Department of Pathology,
University of California
San Francisco, California
941430511, USA.
e-mails:
david.klatzmann@upmc.fr;
Abul.Abbas@ucsf.edu
doi:10.1038/nri3823
Published online 17 April 2015
1
To avoid immune responses against self-antigens, most

self-reactive Tcells are eliminated during selection in
the thymus. However, this selection process is leaky,
and potentially harmful self-specific Tcells with possible effector activity are released from the thymus.
Self-specific Tcells do not usually mediate autoimmune
diseases because, in a normal immune system, they are
suppressed in the periphery by thymus-derived regulatory T (TReg) cells1,2. This TReg cell-mediated control
is exemplified by three observations: first, humans
and mice with a genetically determined TReg cell deficit
develop multiple organ-specific autoimmune diseases3,4;
second, a quantitative or qualitative defect in TReg cells
is present in many mouse and human autoimmune
diseases5; and third, efficient depletion of TReg cells in
healthy individuals at any time in life induces a rapid
autoimmune and inflammatory response that leads to
multi-organ autoimmunity 6. These observations have
led to the concept of a balance between TReg cells and
effector Tcells in health that is dysregulated in auto
immune diseases and inflammatory disorders, which
have a TReg cell insufficiency.
The discovery of TReg cells has opened up a new therapeutic possibility in terms of restoring a healthy balance
between TReg cells and effector Tcells through a qualitative and/or quantitative increase in TReg cell function.
Owing to a lack of drugs that were capable of enhancing TReg cell activity invivo, initial efforts at therapeutic intervention used adoptively transferred TReg cells.
Clinical improvements after TReg cell transfer have been
seen in many animal models of autoimmune diseases

and, recently, in humans with type1 diabetes7.
The discovery that interleukin2 (IL2) is a key
cytokine for TReg cell differentiation, survival and
function810 has led to new opportunities for tipping
the balance of TReg cells and effector Tcells towards
TReg cells. Proof-of-concept clinical trials have shown
that at low doses, IL2 specifically and safely activates
TRegcells in humans, and also improves autoimmune
and alloimmune inflammatory conditions11,12. These
data inspired a broad investigation of the effects of IL2
in diseases with an immune component, even beyond
the field of autoimmunity.
Here, we review historical and current developments
in IL2 therapy, discussing evidence from mechanistic
studies and clinical trials that has led to a shift in our
understanding of IL2 from a cytokine that activates
effector Tcells against cancer when used at a high
dose, to a cytokine that activates TReg cells to control
autoimmunity and inflammation at a lowdose.
IL2 and homeostasis

IL2 was the first cytokine to be molecularly cloned, and
based on its originally discovered action, it was named
Tcell growth factor (BOX1). Many studies in the 1970s
and 1980s convincingly showed that IL2 is an autocrine
survival and proliferation signal for Tcells, and stimulates
the differentiation of naive Tcells into effector Tcells13.
Thus, IL2 was established as the essential soluble mediator of Tcell-dependent effector immune responses and
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Box 1 | The discovery of interleukin2 as a Tcell growth factor
In the 1950s and 1960s, immunological studies were mostly focused on humoral
immune responses and on antibody function and structure, in part because such studies
were facilitated by the availability of assays for measuring antibody responses. Tcells
were studied in more detail from the 1960s onwards and much effort was put into
finding ways to culture them. Molecules capable of activating Tcells were sought from
the supernatant of cultured Tcells; they were first detected in supernatants of mixed
lymphocyte cultures115,116. It was another 10years before it was shown that media from
cultures of mitogen-activated cells could support the growth of Tcell clones, indicating
the presence of a growth factor in these cultures117. Of note, the authors concluded
their report of this discovery by stating that the possibility to grow Tcells invitro may
be relevant to immunotherapy. This protocol was then used to support the
proliferation of Tcell clones specific for tumour antigens that retained their functional
cytolytic activity118. Lymphocytes were rapidly identified as the source of what was
known at the time as Tcell growth factor. The interplay between Tcell growth factor
and another molecule produced by nonTcells that could activate Tcells, termed
lymphocyte activating factor (LAF), led to the development of the interleukin
terminology. LAF became known as interleukin1 (IL1) and Tcell growth factor became
known as IL2, as a result of the hypothesis now known to be largely incorrect that
Tcell growth factor was produced in response to LAF, which was thus put at the top of
the cytokine cascade. IL2 was the first interleukin to be cloned, in 1983 (REF.64). The
discovery of IL2 has been outlined in detail elsewhere119.
was thought to be required for the development of all

such responses.
T follicular regulatory cells

(TFR cells). Cells that are derived
from thymus-derived
regulatory T cells and share
phenotypic characteristics with
T follicular helper (TFH) cells,
including the expression of the
Bcell follicle-homing receptor
CXC-chemokine receptor 5.
TFHcells control germinal
centre Bcells undergoing
somatic hypermutation and
selection that results in
antibody affinity maturation.
TFR cells reduce TFH cell and
germinal centre Bcell numbers.
Type2 innate lymphoid cells

(ILC2s). ILCs are rare cells from
the lymphoid lineage
comprising the ILC1, ILC2 and
ILC3 subsets that produce
many of the same cytokines as
Tcells but lack Tcell antigen
receptors. They have diverse
roles in immune responses and
inflammation. ILC2s produce
type2 cytokines, such as
interleukin5 (IL5) and IL13,
and have key roles in
anthelminthic responses and
allergic lung inflammation.
The birth of an IL2 paradox. The aforementioned

dogma was not challenged until 1993, when it was discovered that knockout of the gene encoding IL2 in mice
led to severe lymphoproliferation and autoimmunity,
rather than the predicted immune deficiency 14. This
finding was soon followed by the description of similar phenotypes of mice with a knockout of the gene
encoding the -chain of the IL2 receptor (IL2R;
hereafter referred to as CD122)15 or IL2R (hereafter
referred to as CD25)16. The description of CD25 as
the canonical phenotypic marker of TReg cells17 suggested that IL2 signalling defects might affect TRegcells
and lead to autoimmunity. This was confirmed by
showing that TReg cells are absent in IL2deficient
or IL2Rdeficient mice, and that adoptive transfer
of these cells from normal mice could prevent auto
immunity in the deficient mice18. The surprising conclusion of these knockout mouse studies is that the
dominant role of IL2 is the maintenance of TRegcells,
and not the development of effector and memory
Tcells, because loss of IL2 signalling leads to a breakdown of immune tolerance and homeostasis. Thus, an
agent that had been used for decades to stimulate effector Tcells turned out to be dispensable for these cells,
and instead is required for activation of the TReg cells
that suppress effector Tcells.
Pleiotropic effects of IL2. IL2 is predominantly produced by activated CD4+ Tcells and, to a lesser extent, by
activated CD8+ Tcells, activated dendritic cells, natural
killer (NK) cells and NKT cells10. IL2 production following activation of CD4+ Tcells is transient; it involves
increased transcription and stability of IL2 mRNA, followed by transcriptional silencing and degradation of
IL2mRNA8.
Three polypeptide chains CD25, CD122

and IL2R (CD132) together form the highaffinity IL2R (dissociation constant (Kd)=1011M)10.
TheIL2induced oligomerization of IL2R initiates signal transduction, which is mediated only by the -chain
and -chain, through Janus kinase 1 (JAK1)-mediated and
JAK3mediated activation of signal transducer and activator of transcription 5 (STAT5), as well as the phosphoinositide 3kinase (PI3K) and mitogen-activated
protein kinase (MAPK) pathways. The CD122CD132
dimer can also signal in the absence of CD25, but has
a lower binding affinity for IL2 (Kd=109 M)10. The
high-affinity trimeric IL2R is constitutively expressed
by TRegcells, whereas other types of Tcell only acquire
CD25 upon activation10.
IL2 has pleiotropic functions (FIG.1). It supports
the development of TReg cells in the thymus, although
it may be dispensable for this role19. It is a key survival
factor for TReg cells in the periphery, and is required
for the functional competence and stability of TReg
cell populations 20,21. The molecular mechanism of
IL2induced TReg cell stability involves, at least in
part, epigenetic changes in the FOXP3 locus (which
encodes forkhead box P3)22,23. One canonical feature
of FOXP3+ TReg cells is their inability to produce IL2
(REFS22,23).
Aside from its role in supporting TReg cells, the other
main functions of IL2 are to support the proliferation
of CD4+ Tcells, and to support the terminal differentiation of CD8+ Tcells. In the absence of IL2 signalling,
CD8+ Tcells respond to a primary infection but fail to
respond to secondary antigen exposure24. Prolonged
CD25 expression on CD8+ Tcells favours terminal
effector differentiation invivo25,26. However, IL2 neutralization induces autoimmune diseases such as gastritis, diabetes, thyroiditis and neuropathy, which could
be adoptively transferred by CD4+ and CD8+ Tcells27,
suggesting that the differentiation of effector Tcells
can occur even in the absence of IL2.
IL2 has been shown to promote the development of
naive CD4+ Tcells into peripherally derived TReg cells28,
T helper 2 (TH2) cells29, TH9 cells30 and, in some studies,
TH1 cells31. By contrast, IL2 suppresses the differentiation of CD4+ Tcells into TH17 cells32 and T follicular
helper (TFH) cells33 by a STAT5dependent mechanism.
Thus, IL2 may suppress germinal centre formation
and create a regulatory environment in germinal centres by altering the balance of T follicular regulatory cells
(TFR cells)3436 and TFHcells.
NK cells express high levels of the CD122CD132
dimeric IL2R8. IL2 mainly stimulates the proliferation
of NK cells, and also increases their cytotoxic activity
and cytokine production, although to a lesser extent
than does IL12. Type2 innate lymphoid cells (ILC2s)
express high levels of CD25 (REF.37) and therefore proliferate in response to IL2 through activation of the
trimeric IL2R38. This proliferation is accompanied
by the production of IL5, which can, in turn, expand
eosinophil populations39. Following stimulation with
IL2, Tcells acquire interferon- production and
cytolytic activity40.
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In summary, although many studies show multiple
effects of IL2 on a range of immune cell populations,
the most consistent finding of studies in which IL2 is
administered or inhibited is an effect on TReg cells, and
this is the main focus of the remainder of this Review.
High sensitivity of TReg cells to IL2. One of the most

important results that has contributed to our understanding of the biology and therapeutic effects of IL2
is the demonstration that IL2induced signalling and
downstream gene activation occur at markedly lower
Antigen-mediated activation
CD122
CD132
CD25
expression
Naive CD4+
T cell
CD25
expression
IL-2
CD4+ T cell
IL-2
CD25
Trimeric IL-2R
CD8+ T cell
CD4+ T cell dierentiation
pTReg cell
TH1 cell
TH2 cell
TH9 cell
Naive CD8+
T cell
IL-2R signal strength
TH17 cell
TFH cell
Fate-orienting
cytokine milieu
Eector memory
CD8+ T cell
Central memory
CD8+ T cell
?
TH9 cells
TH2 cells
TFH cell
Activated
CD4+ TReg cell
TFR cells
TH1 cells
Activated
CD8+ TReg cell
c Control of T cell-mediated
b Control of autoantibody
TH17 cell
Activated TReg cells
production
autoimmunity
CD25
upregulation
CD25
upregulation
IL-2
pTReg cells
Activated
CD4+
TReg cells
CD4+ TReg cell
CD8+ TReg cell
a Control of local inammation

Figure 1 | Pleiotropic effects of interleukin2 in controlling
autoimmunity. Upon T cell receptor ligation and costimulation, naive
CD4+ or CD8+ Tcells transiently express CD25 and respond to interleukin2
(IL2) through the high-affinity trimeric IL2 receptor (IL2R). The
differentiation fate of CD4+ Tcells depends on the cytokine milieu: IL12 and
IL18 favour the differentiation of T helper 1 (TH1) cells; IL4 and IL33 favour
TH2 cells; transforming growth factor- (TGF) and IL4 favour TH9cells; TGF,
IL1, IL6 and IL23 favour TH17 cells; TGF favours peripherally induced
regulatory T (pTReg) cells; and IL6 and IL21 favour Tfollicular helper (TFH)
cells. As part of the fate-orienting milieu, IL2 favours the differentiation
of TH1, TH2, TH9 and pTReg cells, and inhibits the differentiation of TH17 and
TFH cells. The differentiation fate of CD4+ and CD8+ T cells is influenced by
the strength of IL2 signalling, with greater signal strength favouring
differentiation into pTReg cells and effectorNature

memory
T cells,| respectively.
Reviews
Immunology
TReg cells constitutively express CD25 and respond vigorously to IL2 by
upregulating CD25 and becoming more potent (activated) suppressor
cells. Some of these cells migrate to lymph node germinal centres where
they are known as Tfollicular regulatory (T FR) cells. Together, these
changes contribute to tipping the immune balance towards regulation
rather than inflammation, notably by: favouring the differentiation of
naive CD4+ T cells into pTReg cells rather than TH17 cells (part a); helping to
control autoantibody production by favouring the differentiation of
TFR cells over TFH cells (part b); and helping to control autoreactive CD8+
effector Tcells by increasing the number and function of TReg cells (part c).
The mechanisms of the suppressive activity of CD8+ TRegcells in vivo remain
to be determined.
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a
APC
APC
MHC class II
CD80
or CD86
Antigen
TCR
IL-2R
MAPK
AKT
NFAT
AP-1
mTOR
PI3K
Ca2+
MAPK
AKT
NFAT
AP-1
STAT5
Ca2+
JAK1 JAK3
STAT5
PI3K
STAT5
JAK1 JAK3
Eector T cell
STAT5 phosphorylation (%)
40
20
0
0.01
0.1
IL-2
10
IU ml1
100
80
60
40
20
100 1,000
Fold increase in the number

of cells over baseline
In vivo sensitivity to IL-2
Baseline
5 days of
low-dose IL-2
TReg cells
Eector T cells
In vitro sensitivity to IL-2
60
Response
TReg cell
80
Fold increase in the number

of cells over baseline
STAT5 phosphorylation (%)
100
mTOR
Response
STAT5
CD28
0
0.01
0.1
10
IL-2 IU ml1
100
1,000
0
Baseline
5 days of
low-dose IL-2
Figure 2 | Effector T cells and regulatory T cells show differential use of signalling
Nature Reviews | Immunology
pathways and differential sensitivity to interleukin2. The activation of effector
Tcells and regulatory T (TReg) cells is mediated by combined signalling through the T cell
receptor (TCR) and costimulatory molecules such as CD28, and through the
interleukin2 receptor (IL2R). a | It is hypothesized that TReg cells have evolved to depend
more heavily on signal transducer and activator of transcription 5 (STAT5)dependent
IL2R signalling than on TCR and CD28 signalling compared with effector Tcells.
Dashed arrows and thick arrows indicate reduced and increased signalling, respectively.
b | Effector Tcells are poorly sensitive to invitro IL2 stimulation as measured by
downstream STAT5 phosphorylation and they do not proliferate following invivo
treatment with low-dose IL2.By contrast, TReg cells are highly sensitive to invitro IL2
stimulation and proliferate following low-dose IL2 treatment invivo. Data generated
from cells obtained from patients with type 1 diabetes treated with low-dose IL-2
(REFS82,85). Error bars indicate standard error of the mean. AP1, activator protein 1;
APC, antigen-presenting cell; IU, international unit; JAK, Janus kinase; MAPK,
mitogen-activated protein kinase; mTOR, mammalian target of rapamycin; NFAT, nuclear
factor of activated T cells; PI3K,phosphoinositide 3kinase.
concentrations of IL2 in TReg cells than in effector

Tcells or NK cells41 (FIG.2). TReg cells have a 1020fold
lower activation threshold for IL2 than effector Tcells
when measured in terms of the level of phosphorylated
STAT5 (pSTAT5). Moreover, downstream of pSTAT5,
the activation of numerous genes that are important for
cell function requires IL2 doses that are 100-times lower
for TReg cells than for effector Tcells42.
Importantly, this greater sensitivity to IL2 is not
solely due to a higher level of expression of CD25 on
TReg cells compared with effector Tcells, as Tcell blasts
that have even higher levels of CD25 are less sensitive to
IL2mediated activation than are TReg cells42. The exquisite sensitivity of TReg cells to IL2 could thus also be
due to IL2R signalling specificity. Whereas the MAPK,
PI3KAKT and STAT5 pathways are all activated in
effector Tcells in response to antigen, costimulation
and IL2, TReg cells in which high PTEN expression
levels inhibit the PI3Kdependent signalling pathway 43,44 may be more dependent on IL2STAT5
signalling(FIG.2).
Invivo experiments in mice confirmed these findings. At doses of IL2 of approximately 20,00050,000
IL2 international units (IU) per day, TReg cell populations
are expanded compared with those from control mice,
and they express higher levels of activation markers and
are more suppressive. At these doses of IL2, neither
clonal expansion nor activation of CD4+ or CD8+ effector
Tcells or of NK cells can be detected (see below).
IL2 in pathophysiology
The inflammatory disease that develops in mice lacking IL2 or functional IL2R is characterized by colitis
and the production of multiple autoantibodies1416,
but the specific effects can vary depending on the
mouse strain. On the BALB/c background, the dominant phenotype is autoimmune haemolytic anaemia
caused by erythrocyte-specific antibodies, whereas in
C57BL/6 mice, the dominant phenotype is colitis. Over
time, all Il2knockout mouse strains produce autoanti
bodies that are specific for nucleoproteins and other
self-antigens. Interestingly, the autoantibodies are produced even in germ-free Il2knockout mice, whereas
the colitis is largely abolished when these knockout
mice are made germ free45,46. These data indicate that
the defect in IL2dependent FOXP3+ TReg cells results
in immune responses against self-antigens (leading to
autoantibody production and true autoimmunity),
and perhaps also responses against commensal microorganisms in the gut (which may lead to colitis). In all of
these models, the disease can be corrected by providing
normal TRegcells.
Humans with rare mutations in CD25 also develop
autoimmunity 47. The disease caused by IL2 or IL2R
deficiency is not as severe as that caused by mutations in FOXP3 in humans with immune dysregulation
polyendocrinopathy enteropathy Xlinked syndrome3 (IPEX
syndrome) or in scurfy mice4. This might imply that
some TReg cells are relatively IL2 independent 48,49. In line
with this, it has been shown that IL15 can substitute for
IL2 to support and expand TReg cell populations50.
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IL2 international units

(IL-2 IU). The interleukin2
(IL2) IU is a biological activity
determined by the ability to
support the growth of an
IL2dependent cell line. In
practice, as the manufacture of
IL2 is standardized, 1.1mg
of IL2 corresponds to
18millionIU.
Immune dysregulation
polyendocrinopathy
enteropathy Xlinked
syndrome
(IPEX syndrome). This rare
genetic autoimmune disease is
caused by mutations in the
FOXP3 gene (which encodes
forkhead box P3). Affected
males present with early-onset
severe enteropathy that is
usually accompanied by
insulin-dependent diabetes
(type 1). Other autoimmune
manifestations include
hypothyroidism, anaemia,
thrombocytopenia and
neutropenia. Increased serum
IgE levels and dermatitis are
often also present.
IL2antibody complex
(IL2c). A complex of
interleukin2 (IL2) and
IL2specific antibody that has
a prolonged half-life compared
with IL2. Its biological activity
depends on the antibody.
Some complexes preferentially
stimulate effector Tcells,
whereas others preferentially
stimulate regulatory T cells.
Vascular leak syndrome

(VLS). VLS (also known as
capillary leak syndrome,
systemic capillary leak
syndrome or Clarkson disease)
is characterized by a leakage of
fluid from the circulatory
system into the interstitial
space, resulting in hypotension,
haemoconcentration and
hypoalbuminaemia.
Cytokine storm
Also known as
hypercytokinaemia. The
systemic expression of a
vigorous immune response
resulting in the release of
inflammatory mediators into
the bloodstream, including
cytokines, oxygen free radicals
and coagulation factors. The
primary symptoms of a
cytokine storm are high fever,
swelling and redness caused by
vascular leak, extreme fatigue
and nausea.
In many individuals with autoimmune disease, IL2

production is low compared with healthy individuals,
and this could result in the instability and defective function of TReg cells. This is the case for autoimmune diseases such as type1 diabetes51, rheumatoid arthritis52 and
systemic lupus erythematosus (SLE)53. However, these
findings are not typical of all patients with these diseases, and decreased IL2 production or IL2R expression is not considered to be a hallmark of most human
autoimmune diseases.
Nonetheless, most autoimmune diseases involve
a dysregulated balance between TReg cells and effector
Tcells, and thus, providing more IL2dependent signalling may help to correct the disease by increasing
TReg cell number and function, even in the absence of
a pre-existing TReg cell defect. This idea is highlighted
by the therapeutic efficacy of IL2 in mouse models
in which there is not necessarily a measurable IL2 or
IL2R defect. IL2 and IL2antibody complex (IL2c)54
have been administered in various experimental autoimmune diseases5560 or other inflammatory settings6163,
and in all cases showed some (often remarkable) efficacy.
The ups and downs of IL2 therapy

Therapeutic use of IL2 in humans is often adjusted to
weight (dose per kg) or body surface area (dose per m2).
For ease of comparison of different studies, we have converted all dosing to a fixed dose corresponding to an
adult of 70kg and 1.8m2 in the following discussion70.
Initial clinical development: why high doses? The field of
IL2 therapy started with the use of IL2 purified from
cell culture supernatant and gained pace after the cloning of IL2 in 1983 (REF.64). Recombinant IL2 was initially used at high doses, probably because of its short
half-life, which was thought to explain the poor clinical
response in the early clinical trials carried out with purified IL2 (REFS65,66). The first clinical trial reporting
efficacy of IL2 in human cancer67 used escalating doses
of up to ~120 million IU (MIU), in three bolus infusions every 8hours, to ensure that serum levels were
continuously maintained at concentration necessary to
stimulate high affinity IL2 receptors (REF.70). Severe
side effects were noted, including a generalized vascular
leak syndrome (VLS), and increased serum creatinine and
bilirubin levels (indicating kidney and liver damage).
The maximum tolerated dose of IL2 was found to be
4250 MIU every 8hours (126150 MIU per day) and
at this dosage, some complete clinical responses were
observed in patients with renal cell carcinoma or melanoma68. Subsequent attempts to lower the IL2 dose to
reduce side effects resulted in decreased efficacy 69.
Thus, the paradigm was established that (very)
high doses of IL2 were necessary to achieve a clinical
response in patients with cancer, with the drawback of
severe side effects.
High-dose IL2 in cancer: lessons learnt. High doses
of IL2 were subsequently extensively used in patients
with cancer. Importantly, they brought the first proof of
concept that stimulation of immune responses could be
a therapeutic modality in cancer. Large studies showed

an ~15% response rate to IL2 treatment, with 79% of
patients with melanoma or renal cell carcinoma having complete and often long-lasting responses70. These
results led to the approval of IL2 therapy by the US Food
and Drug Administration for renal cell carcinoma and
metastatic melanoma in 1992 and 1998, respectively.
It is striking that more than 20years later, the mechanisms of the successful immune responses induced by
IL2 therapy in patients with cancer are still not understood, and it is not clear why only some patients respond
to high-dose IL2. The discovery that IL2 markedly
expands TReg cell populations could, in part, explain
treatment failures in some patients7174.
The clinical efficacy of high-dose IL2 in some
patients with cancer is with the drawback of a high toxicity of the treatment. One of the main complications
is VLS, which has recently been attributed to a direct
effect of IL2 on CD25expressing endothelial cells75, and
which leads to multi-organ dysfunction. Initial rates of
mortality with high-dose IL2 therapy were up to 4%,
with deaths mostly occurring as a result of severe bacterial infections; these were later prevented by antibiotic
therapy. Other common side effects of high-dose IL2
are malaise, nausea and a flu-like syndrome, which are
common manifestations of a cytokine storm, as is seen
in settings such as acute infection76 and graft-versus-host
disease (GVHD)77.
In summary, high-dose IL2 has a poor safety profile but a robust efficacy in only a fraction of patients
with a restricted set of cancers. High doses of IL2 are
still used in patients with these cancers, although the
severe side effects and the inability to identify potential
responders have severely restrained the use of high-dose
IL2 (REF.70).
The resurrection of IL2: proof of concept. IL2 has been
available as an approved drug (Proleukin, Novartis;
generic name aldesleukin) since 1992, and was thus
available for clinical investigations. The effect of IL2
on TReg cells was known since the mid1990s, but it was
more than 10years before the first trials investigating
the ability of IL2 to promote TReg cell activity in humans
with autoimmune and inflammatory diseases were initiated11,12. The common perception of IL2 among clinicians was that of a very toxic drug that could be useful
only in some late-stage cancers. In addition, IL2 was
considered to be a cytokine that primarily stimulates the
effector arm of the immune response, and thus could
aggravate autoimmune diseases. In fact, the Proleukin
drug brochure specifically warns that Proleukin has
been associated with exacerbation of pre-existing or
initial presentation of autoimmune disease and inflammatory disorders (REF.121). Thus, most clinicians were
not prepared to reconsider IL2 as a therapy that could
suppress immune responses in autoimmune diseases.
In 2006, researchers were searching for means by
which to stimulate TReg cells in patients with hepatitis C
virus-induced vasculitis (HCV-induced vasculitis). It
had previously been shown that patients with HCVinduced vasculitis had a deficiency in the number
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Graft-versus-host disease
(GVHD). A common
complication of allogeneic
stem cell transplantation, in
which immune cells from the
graft recognize the recipient
cells as foreign and attack
them. The main target tissues
are the liver, skin and
gastrointestinal tract. It can be
acute (within 100days of
transplantation) and
life-threatening, or chronic.
Hepatitis C virus-induced
vasculitis
(HCV-induced vasculitis).
1015% of patients with
chronic HCV infection develop
systemic cryoglobulinaemic
vasculitis. Cryoglobulins are
cold-insoluble immune
complexes containing
rheumatoid factor and
polyclonal IgG that deposit on
vascular endothelium, causing
vasculitis in organs such as the
skin and kidneys, and in
peripheral nerves.
of TReg cells78 and that the resolution of the vasculitis

after treatment with antivirals or rituximab was associated with a normalization of TReg cell numbers79,80.
IL2 was thus suggested as a potential therapy for
HCV-induced vasculitis, on the basis of a major TReg
cell population expansion that had been observed
in patients with cancer who were treated with highdose IL2 (REF.73). To avoid the severe side effects of
high-dose IL2 and also prevent, as far as possible, the
activation of effector Tcells, it was thought that using
low-dose IL2 could be the solution. Indeed, low-dose
IL2 had been well tolerated in other indications81 and
the constitutively high levels of expression of CD25 on
TReg cells could make them more sensitive than effector
Tcells to IL2 (although this had not been definitively
shown at thetime).
Patients with HCV-induced vasculitis were treated
with low-dose IL2, with doses ranging from 1.5 MIU
to 3 MIU per day. Patients received a cumulative
dose of 50MIU administered over 2months11, which
corresponds to one-third of the daily dose administered to some patients with cancer. The treatment
was well tolerated, and there was a greater than twofold expansion of activated TReg cell populations with
no detectable activation of effector Tcells. A marked
anti-inflammatory activity of IL2 was also observed.
Of note, a significant clinical improvement was seen
in eight out of ten patients11. IL2 was also shown to
have beneficial effects for the treatment of chronic
GVHD, an alloimmune inflammatory disease occurring after allogeneic haematopoietic stem cell transplantation (aHSCT)12. The results of these two trials
Box 2 | The main side effects of low-dose interleukin2

Any evaluation of the safety and clinical tolerance of low-dose interleukin2 (IL2)
should bear in mind that relatively few patients have been treated for a long period of
time, and that studies have mainly been carried out with no placebo control and often
in patients receiving additional potentially toxic treatments. The only serious adverse
events that have been reported so far for low-dose IL2 occurred during the treatment
of patients with chronic graft-versus-host disease, who received relatively high
cumulative doses of IL2 together with other immunosuppressants and corticosteroids
(see Supplementary information S1 (table)). Most reported adverse events of IL2
treatment are of mild or moderate severity (grade 1 or 2)120. The most frequent adverse
events reported in all trials of low-dose IL-2 are injection site reactions and
constitutional symptoms (such as fatigue, fever, malaise and arthralgia).
In the only double-blind, placebo-controlled study of low-dose IL2 reported so far
(see Supplementary information S1 (table)), 12, 12, 13 and 19 adverse events were
reported in patients who received 0, 0.3, 1 and 3 MIU of IL2 per day, respectively.
Injection site reactions occurred in approximately 30% of the IL2treated patients, but
these were irrespective of the dose and were not seen for all injections in a given
patient. This remains unexplained and might be related to the propensity of IL2 to form
aggregates. Constitutional symptoms seemed to be more dose dependent. However,
fatigue was observed more frequently in the placebo group. In total, the number of days
during which patients declared adverse events was higher for patients receiving
placebo than for patients receiving any dose of IL2.
In another study, IL2 was well tolerated in 18 children (712years old) with type1
diabetes who were treated with IL2 at a dose of 0.251 MIU per day for a mean
treatment duration of more than 6months (D.K., unpublished observations).
No significant abnormalities in patient biochemistry have been reported as a
consequence of low-dose IL2 therapy. Eosinophilia seems to be dependent on the IL2
dose and scheme of administration. It does not occur in all patients and, for those
patients with eosinophilia, it does not occur during all courses of treatment.
showed that low-dose IL2 could be a novel class of

immunoregulatory drug that functions by inducing
the expansion and/or activation of TReg cells. The door
was thus opened for IL2 therapy to be resurrected
into clinical use in the form of low-dose IL2 to control
autoimmunity and inflammation.
Clinical development of low-dose IL2

The terminology low-dose IL2 requires clarification. Of note, mouse models are not useful for defining
low doses of IL2 as applicable to humans because the
IL2 doses that stimulate TReg cells without stimulating effector Tcells in mice (~20,000 IU) correspond
to very high equivalent doses by weight for humans. In
the cancer field, the term low-dose IL2 has been used
for doses of ~5 MIU per injection. However, these were
given three times a day for long treatment periods, with
the total amount of IL2 administered to each patient
being in excess of 100 MIU. In evaluating the safety and
biological effects of low-dose IL2, it is therefore important to consider both single and cumulative dosage.
In the trials of low-dose IL2 reviewed here, the single
dose varies from 0.09 to 5.4 MIU and the cumulative dose
ranges from 1.5 to 52.5 MIU, except for a few patients
with chronic GVHD who received up to 320 MIU
(see Supplementary information S1 (table)).
Safety. The safety of low-dose IL2 was initially an
important concern, but several trials have now established that low doses of IL2 are well tolerated. Local
reactions at injection sites and flu-like syndromes were
the most frequent mild to moderate adverse events
in patients or healthy volunteers receiving between
0.18MIU and 3 MIU of IL2 per day 11,8284(BOX2;FIG.3).
Of note, in a double-blind, randomized, placebo-controlled trial, the total number of days on which adverse
events were reported during the study was higher in
the placebo group than in the IL2treated groups82.
Together, these studies show that at doses that stimulate
TReg cells, IL2 is well tolerated.
Main biological findings. The trials of low-dose IL2 that
have been reported so far have used different doses and
different schedules of administration. However, the main
conclusions are that IL2 induces robust expansion of
the TReg cell population, and that the maximum magnitude82 and duration85 of TReg cell population expansion
are dose dependent. Some effects could be detected at
an IL2 dose as low as 0.18 MIU per day in healthy volunteers86. Although there are so far no descriptions of
patients who do not respond to low-dose IL2, one study
has shown significant variations in the TReg cell response,
with some patients who received the lowest dose of IL2
(0.33 MIU per day) responding better than patients who
received the highest dose (3 MIU per day)82. Of note, the
minimum dose of IL2 necessary to stimulate TReg cells
has not yet been established, and may vary according to
the patient and the disease.
The TReg cell response to IL2 has mostly been studied in peripheral blood mononuclear cells (PBMCs).
In one study, IL2 induced a marked increase in the
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REVIEWS
Potential adverse eects
Potential benecial eects
Mild to moderate
constitutional symptoms
such as asthenia, myalgia,
fever and arthralgia
Atherosclerosis
By boosting TReg cells, IL-2
could help to control local
inammation to reduce
plaque formation
Type 1 diabetes
By boosting TReg cells, IL-2
could suppress eector
T cell-mediated killing of
insulin-producing cells
Systemic lupus
erythematosus
By blocking TFH cells and
stimulating TFR cell
dierentiation, IL-2 could
reduce autoantibody
formation and immune
complex deposition
Local reaction
at injection site
Rheumatoid arthritis
By boosting TReg cells,
blocking TH17 cells and
favouring pTReg cells, IL-2
could help to control
inammation-dependent
joint destruction
Figure 3 | Effects of interleukin2 in patients with autoimmune or inflammatory

Naturereactions
Reviews to
| Immunology
diseases. At low doses, there are only mild to moderate adverse
interleukin2 (IL2), including reactions of unknown cause at the site of injection and
constitutional symptoms that are possibly triggered by cytokine release. The potential
beneficial effects are indicated relative to paradigmatic diseases: atherosclerosis as an
inflammatory disease; type1 diabetes as a T cell-mediated autoimmune disease;
systemic lupus erythematosus as an autoantibody-mediated autoimmune disease; and
rheumatoid arthritis as an autoimmune inflammatory disease. pTReg, peripherally induced
regulatory T; TFH, T follicular helper; TFR, T follicular regulatory;TH, T helper.
Adverse events
Medical occurrences that are
temporally (but not necessarily
causally) associated with the
use of a medicinal product.
The severity of adverse events
is graded from 1 to 4, with the
grades representing mild,
moderate, severe and
potentially life-threatening
events, respectively. Any
adverse event that causes
death, is life threatening,
requires hospitalization, or
results in persistent or
significant disability or
incapacity is considered a
serious adverse event.
number of TReg cells that was accompanied by a marked

decrease in the number of infiltrating CD8+ effector
Tcells in scalp biopsies of patients with autoimmune
alopecia areata (see below); these patients markedly
improved during treatment 83. Thus, in line with observations made in animal models, the IL2dependent
increase in the number of TReg cells that is mostly documented in peripheral blood is also seen at the site of the
autoimmune manifestation.
The expansion of TReg cell populations is accompanied by a marked increase in their expression of activation markers, such as CD25, glucocorticoid-induced
TNFR-related protein (GITR; also known as TNFRSF18)
and cytotoxic T lymphocyte antigen 4 (CTLA4)85,87. In
addition, the suppressive activity of these activated TReg
cells is greater than that of control TReg cells11,12,88. Thus,
we conclude that IL2 induces the robust proliferation
and activation of TReg cells, but its doseresponse relationship in health and disease seems to be complex and
needs to be investigated further to optimize IL2use.
A major proliferative response of CD8+CD25+FOXP3+

Tcells to IL2 has also been observed11,82. This increase in
the number of CD8+ regulatory T cells is twofold to fivefold greater than the corresponding increase in the number of CD4+ TReg cells11,82; similar observations have been
made in mice122 and macaques88. As CD8+CD25+FOXP3+
Tcells are highly suppressive invitro 8890,122, further
studies are warranted to evaluate whether they have
therapeutic effects in the context of disease.
NK cells also respond to low-dose IL2, although
much less so than TReg cells. In patients with chronic
GVHD who received continuous treatment with IL2,
the number of blood NK cells doubled over the course
of 8weeks, whereas the number of TReg cells increased
sixfold to eightfold12. In patients with type1 diabetes,
there was only a non-significant trend for a moderate
increase in the number of NK cells at the highest dose
of IL2 used (3 MIU per day)82,85. In healthy volunteers,
no effect of IL2 on total NK cell number was reported.
The non-cytotoxic CD56hi NK cells seemed to be most
sensitive to IL2 (REFS11,86,87). Thus, low-dose IL2 may
in some cases expand NK cell populations, but in a daily
and cumulative dose-dependent manner, and mostly for
doses of more than 1 MIU perday.
In patients receiving continuous low-dose IL2, a significant but asymptomatic eosinophilia peaked at 10% of
white cells in the blood after 4weeks of treatment, and
subsequently declined12. In patients with HCV-induced
vasculitis, there was a non-significant increase in the
mean number of eosinophils after IL2 treatment, with
only some patients having increased values, and often not
for all courses of IL2 (REF.39). A modest but significant
increase in the number of eosinophils was also seen in
healthy volunteers who received IL2. In summary, IL2
does expand eosinophil populations, but in a daily and
cumulative dose-dependent manner. At doses of less than
or equal to 1 MIU per day, the effect seems to be minimal.
An intriguing and significant dose-dependent
decrease in the number of CD19+ Bcells, which also
affected marginal zone Bcells, has been reported in two
trials of low-dose IL2 (REFS11,82), with a strong unexpected correlation between an increase in the number
of TReg cells and a decrease in the number of Bcells82.
This effect could be linked to an inhibition of TFH cells
and/or a stimulation of TFR cells. The clinical relevance
of these findings remains to be clarified, particularly
because Bcell inhibition could be advantageous in the
case of antibody-mediated autoimmune diseases for
which Bcell-depleting agents can be efficacious. Along
these lines, three ongoing trials of low-dose IL2 in
patients with SLE have noted decreased levels of DNAspecific antibodies following IL2 administration (see
Supplementary information S1 (table)).
Immunomonitoring of patients with type1 diabetes receiving increasing doses of low-dose IL2 showed
the dose-dependent induction of a regulatory milieu,
as assessed by TReg cell to effector Tcell ratios, TReg cell
activation markers, plasma cytokine and chemokine
levels, and transcriptomics85. This study also showed
that low-dose IL-2 therapy did not induce IL-2-specific
antibodies.
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REVIEWS
Altogether, doses of IL2 below or equal to 1 MIU
per day seem to specifically induce TReg cell expansion
and activation, and a decrease in the number of Bcells,
both of which are desirable effects for the treatment of
autoimmune diseases. At doses of more than 1 MIU
per day, the effects on TReg cells are more marked, but
some expansion of NK cell and eosinophil populations
can be observed, which might be unwanted in some
clinical settings.
Alopecia areata
A prevalent autoimmune
disease (affecting 1.7% of the
general population) that leads
to hair loss on the scalp and
other areas of the body.
Infiltration of CD4+ and CD8+
Tcells around hair follicles is
associated with the condition.
TRANSREG clinical trial

An open-label PhaseII clinical
trial investigating the
stimulation of regulatory T cells
by low-dose interleukin2 in 11
autoimmune diseases:
rheumatoid arthritis,
ankylosing spondylitis,
systemic lupus erythematosus,
psoriasis, Behcet disease,
Wegener granulomatosis,
Takayasu disease, Crohn
disease, ulcerative colitis,
autoimmune hepatitis and
sclerosing cholangitis
(ClinicalTrials.gov identifier:
NCT01988506).
Efficacy in human autoimmune and inflammatory

diseases. Patients with HCV-induced vasculitis have a
set of symptoms including fatigue, arthralgia, purpura,
kidney involvement and neuropathy. In eight out of
ten patients treated with low-dose IL2, these symptoms progressively disappeared11. In most cases, clinical
improvements started to be observed after the second or
third course of IL2 therapy11. In patients with alopecia
areata, regrowth of the scalp and/or body hair was noted
in all of the five patients treated with IL-2, and four had
a regrowth of scalp hair 83. Recently, early clinical results
of low-dose IL2 in patients with SLE that have been
presented at meetings have reported marked improvement in clinical scores (see Supplementary information
S1 (table)). In one patient with refractory SLE, a rapid
induction of clinical remission was reported90.
In chronic GVHD, of the 23 patients who were
evaluated all of whom were refractory to systemic
glucocorticoid therapy 12 had a partial response to
IL2 and 11 had stable disease after IL2 therapy 12. In
responding patients, extended therapy led to sustained
clinical responses and a lowering of the corticosteroid
doses administered, which is an indication of treatment
efficacy. Low-dose IL2 was also investigated for the
prevention of GVHD in patients receiving aHSCT84.
The IL2 treatment not only reduced the frequency and
severity of acute GVHD, but was also accompanied by
a reduction in the number of infectious episodes, which
are a major post-transplantation complication84.
Thus, although the dosing and timing of IL2 administration may not have been optimal in these preliminary studies, they concordantly show some biological
and clinical efficacy of low-dose IL2 that correlates with
the expansion and activation of TReg cell populations.
The promise of low-dose IL2

By demonstrating the specificity of the effects of lowdose IL2 on TReg cells and by reporting data that indicate a clinical benefit for patients, the preliminary studies
discussed above have given optimism for further investigation. This has also been reinforced by mechanistic
studies showing that, at least in theory, low-dose IL2
should have therapeutic effects on both Tcell-mediated
and antibody-mediated autoimmune diseases.
The issue of dose and schedule. The current assumption
is that the therapeutic potential of low-dose IL2 is in
large part linked to the stimulation of TReg cells, which
are thus a surrogate marker of efficacy. Therefore, the
question is how much TReg cell stimulation is required,
and for how long, to have significant therapeutic effects
in diseases that are often chronic in nature? The initial

development of IL2 therapy in patients with cancer was
based on the assumption that constant detection of IL2
in the serum was necessary for efficacy 70, but it is not
known whether constant TReg cell stimulation would be
required in autoimmune diseases, or for howlong.
By modelling the pharmacokinetics of TReg cells during and after a 5day treatment of IL2, we defined a
5day induction course of 1 MIU of IL-2 per day as a
scheme that will approximately double the percentage
of TReg cells in PBMCs, to be followed by a fortnightly
injection of 1MIU of IL2 as a maintenance treatment
that should support an increased number of TReg cells at
2060% above baseline values. This treatment modality
is used in our current studies, and preliminary results
from 36 patients in the TRANSREG clinical trial have confirmed these predictions. Importantly, we found that this
treatment course is well tolerated in the long term (more
than 6months) and does not significantly modify the
number of effector Tcells, NK cells or eosinophils.
Further clinical trials will be required to better decipher the IL2 doseresponse relationship in terms of the
specificity of TReg cell stimulation and treatment efficacy
(FIG.4). It should also be mentioned that continuous
administration of IL2 achieved by gene transfer is a
possible treatment modality; this has been a convenient
approach to use in experimental models9193 but it would
be less easy to adjust treatment over time if applied
tohumans.
Immunoregulation without immunosuppression. The
main complications of immunosuppression are related
to infection. As there is normally a balance between
TReg cells and effector Tcells, and because TReg cells also
control immune responses to infection that are mediated by effector Tcells, the question thus arises as to
whether protective antimicrobial immunity would be
compromised when enhancing TReg cell function in a
non-antigen-specific manner. Preclinical and clinical
data available so far indicate that this is not the case.
The administration of an IL2expressing adeno-associated virus vector in mice maintained IL2 production
and the associated increase in the number of TReg cells
for more than a year 93. Under such conditions, which
permanently increase the proportion of TReg cells to
150200% of baseline values, no effects were observed
on mouse lifespan, clinical signs or tissue histology.
Furthermore, when challenged with an influenza virus
vaccine or a lethal dose of a mouse-adapted influenza
virus, mice receiving long-term administration of IL2
mounted normal protective immune responses93.
In patients with chronic HCV infection, no increase
in viral load was observed during IL2 treatment despite
increased TReg cell numbers, and there was even a small
but significant decrease in the viral load at the end of
the followup period11. In the GVHD-prevention trial, the
recovery of invitro immune responses against recall antigens was identical in the IL2treated and control groups,
and, importantly, a marked decrease in the number of
infectious episodes was observed in the treated group as
compared with controls84. Nevertheless, given the effects
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Fold increase in the

number of TReg cells
a Repeated courses
The dose of IL-2 and the timing

of courses determine the AUC
and eects on other cells
AUC
Baseline number
of TReg cells
Time
IL-2 administration
b Daily continuous administration

IL-2 dose determines the AUC
(with a possible plateau eect)
and eects on other cells; with
time, this scheme may induce
signicant eects on NK cells,
eector T cells and eosinophils
c Induction and maintenance

Emax
Induction
IL-2 dose determines the

amplitude of the induction
eect (Emax); the repetition
frequency determines the AUC
Maintenance
d Repeated single injections
IL-2 dose determines the

amplitude of the eect, which
rapidly returns to baseline
e Biomarker-dened administration
IL-2 dose and spacing are
dened based on biomarkers of
ecacy (possibly, but not
necessarily, related to TReg cells)
Figure 4 | Possible administration schemes for

interleukin2. The number of regulatory T (TReg) cells
and their expression of activation markers are
currently the best surrogate markers of the biological
activity of interleukin2 (IL2). The efficacy of low-dose
IL2 treatment will probably depend on the extent and
duration of these effects on TReg cells. Treatment
efficacy can be characterized by the maximum effect
gained (Emax) and the overall effect over time, which is
defined by the area under the curve (AUC; compared
with baseline). The dose and schedule of IL2
administration will have a major influence on these
parameters, as well as on the specificity of the effect
for TReg cells as opposed to effector Tcells, natural
killer (NK) cells and eosinophils. a|Repeated courses
of IL2 (indicated by the red arrows) at defined
intervals11,83,90 will produce an increase in the number
of TReg cells at the end of each course, followed by a
decrease in their number to a level that depends on
the dose administered85 and the timing of the next
course11. b|Daily continuous administration of IL2
will produce the greatest overall effects (highest
AUC), but with the side effect of some expansion of
NK cell, effector Tcell and eosinophil populations12.
c|Ashort induction course followed by maintenance
treatment with IL2 will enable a desired Emax to be
reached, and then a desired AUC to be maintained by
repeated single injections, the timing of which will
determine the long-term AUC. d|Repeated single
administration of IL2 will provide transient boosts to
TReg cell numbers. e | Personalized biomarker-defined
administration will be the ultimate treatment modality
when (or if) biomarkers of efficacy are identified. At
present (in the absence of an ideal personalized
biomarker-controlled administration schedule), the
induction course followed by maintenance treatment
with IL2, or repeated courses of IL2, might be
appropriate for settings in which the disease is
moderate and there is a need for long-term support of
TReg cells (for example, in patients with recently
diagnosed type1 diabetes). In more severe or more
inflammatory settings, daily continuous
administration of IL2 might be favourable (for
example, in patients with chronic graft-versus-host
disease). Finally, repeated single administration of IL2
might be more appropriate for treatments that aim to
support the suppressive activity of TReg cells over long
periods of time in conditions in which this activity may
be defective owing to IL-2 deprivation (for example,
for the prevention of type1 diabetes).
Nature Reviews | Immunology
of IL2 on TFH cells and TFR cells, and the striking decrease
in the number of Bcells that has been reported in some
trials of IL2 (REFS11,82), further studies of humoral
responses in individuals treated with IL2 are warranted.
In the trial of low-dose IL2 therapy for chronic
GVHD, three patients had bacterial infections of grade 3
or higher 12, but these findings are difficult to interpret
in light of the other immunosuppressive drugs or corticosteroids that these patients received. Of note, in a trial
investigating the adoptive transfer of exvivo-expanded
TReg cells in children with type1 diabetes, one patient
contracted an influenza virus infection immediately after
the TReg cell infusion. The infection resolved normally
within a few days, indicating that increased TReg cell

number did not induce systemic immune suppression7.
The apparent preservation of a normal immune
response to infection during IL2 therapy is, in fact, not
surprising. Inflammation is controlled by TReg cells but
it also controls TReg cells94. At high levels of inflammation, TReg cells become less efficient 95. It is thus expected
that a moderate increase in the number of TReg cells or
their functionality should not affect effector immune
responses that are triggered by highly inflammatory
events, such as infection or vaccination, as the inflammation would be expected to constrain the TReg cell
response.
VOLUME 15 | MAY 2015 | 291

REVIEWS
IL2 and inflammation. On the one hand, TReg cells tend
to lose their functional capacity in highly inflammatory
environments94. They might even become unstable, losing FOXP3 expression and converting to a phenotype
that is more characteristic of effector CD4+ Tcells (these
converted cells have been termed exTReg cells), although
such a process is much debated96. Different mechanisms
can regulate the susceptibility of TReg cells to inflammation-induced FOXP3 destabilization: FOXP3 expression
is downregulated by polyubiquitylation97 mediated by
the E3 ubiquitin ligase STUB1, which is induced by proinflammatory cytokines and lipopolysaccharides98; PIM1
kinase phosphorylates a serine residue of human FOXP3,
thereby impairing its function99; and binding of methyl
CpG-binding protein 2 (MeCP2) to FOXP3 stabilizes its
expression100.
On the other hand, TReg cells suppress inflammation by
multiple mechanisms, including reducing co-stimulation
to activate effector Tcells, consuming IL2 and secreting
immunosuppressive cytokines such as IL10. The antiinflammatory effects of TReg cells have been observed
in various models of inflammatory diseases in mice. In
a model of atherosclerosis that spontaneously develops in low-density lipoprotein receptor-knockout mice,
TReg cell depletion aggravated atherosclerosis and TReg
cell repletion improved it 61. In line with these observations, treatment with IL2 also improved atherosclerotic
lesions101,102. Recent reports confirmed that TReg cells can
improve other inflammatory conditions, such as acute
lung injury103, muscular dystrophy63 or beryllium-induced
granulomatous inflammation62. In the muscular dystrophy model, treatment with IL2c increased the number
of TReg cells and the IL10 concentration in muscle, resulting in decreased myofibre injury. In humans treated with
IL2, the analysis of the entire transcriptome of PBMCs
suggested a major anti-inflammatory role of low-dose
IL2 (REF.11).
These results warrant the investigation of low-dose
IL2 in inflammatory diseases or conditions that are not
caused by autoimmune or alloimmune reactions (FIG.3).
IL2 in other indications. TReg cells have a role in controlling allergy, as indicated by the presence of this symptom
in the IPEX syndrome. IL2c has been shown to improve
an experimental form of allergy in mice104. Thus, IL2 also
has some potential for the treatment of allergy. However,
the dose-dependent eosinophilia that can be induced by
IL2 should be carefully considered in terms of the application of this therapy to asthma, in which the harmful role
of eosinophils is still debated105. Furthermore, ILC2s can
respond to IL2 by producing IL13, which is detrimental
in allergy and asthma106. IL2 has already been evaluated,
with some success, in the fields of HSCT12,84 and solid
organ transplantation107.
Ageing of the immune system is associated with
abnormalities of the Tcell repertoire, with the appearance
of oligoclonal expansions108. Injection of TReg cells into old
mice or the treatment of these mice with IL2 prevented
such oligoclonal T cell expansions109. The role of IL2 in
preserving Tcell homeostasis during ageing should be
more thoroughly investigated.
Second-generation IL2 and combination therapies.

Fusions of IL2 with carrier proteins, such as the Fc
domain of IgG, have improved its short half-life110. In
addition, several mutant forms of IL2 have been produced in attempts to alter its ability to bind to different
components of the IL2R, and thus to change its range
of activity. One of the earliest such mutant forms of IL2
was designed to reduce binding to the CD122CD132
IL2R dimer (to reduce activation of NK cells and
cytokine-mediated toxicity), while preserving its ability to bind to CD25 and hence the trimeric high-affinity
IL2R111. This mutant IL2 protein retained the ability to
activate Tcells and mediate antitumour effects, but its
effect on TReg cells has not yet been reported. A different
IL2 mutant has been produced that shows increased
binding to CD122 and thus has an increased ability
to activate CD8+ Tcells and NKcells112. Complexes
of specific monoclonal antibodies bound to IL2
have modified the interaction with IL2R complexes.
Depending on the antibody-binding site on IL2, the
IL2c preferentially activates cells expressing high levels
of CD122, such as memory CD8+ Tcells and NK cells,
or CD25expressing cells such as TReg cells54,113.
Although this field is extremely active and worth pursuing, it should be kept in mind that modified IL2 or
IL2c with preferential activity for TReg cells has not yet
been evaluated in patients. It will be many years before
an optimized TReg cell-focused form of IL2 is at the same
stage of development as plain IL2, with its 30years of
clinical use. Thus, it is reasonable to propose that clinical development of plain IL2 should be pursued without waiting for the promises of more effective variants;
also, the experience gained with plain IL2 will help to
develop second-generation versions of IL2.
Combination therapy is often superior to single
therapy for complex diseases. High-dose IL2 is already
being tested in combination with checkpoint inhibitors
for the immunotherapy of cancer 114. Similarly, combinations of low-dose IL2 with other immune modulators will be worth evaluating in autoimmune diseases.
For example, combining low-dose IL2 with antibodies
targeting inflammatory cytokines such as IL1, IL6,
IL17 or IL23 could prove to have synergistic effects in
controlling immune-triggered inflammation.
Finally, the possibility to combine the use of IL2
with antigens to induce specific tolerance is extremely
attractive and should be explored.
Conclusions and perspectives

Independent clinical trials have now shown the safety
of low-dose IL2, at least for treatment lengths ranging from several months to a year, which overcomes
the most frequent barrier in the development of novel
therapies. Moreover, these trials have provided preliminary indications of significant biological and clinical
efficacy. Without waiting for a comprehensive understanding of its mechanisms of action, the promises of
low-dose IL2 therapy already warrant broad clinical
investigations. These should be aimed at exploring
the large field of potential target diseases, but also at
transforming current indications of efficacy into proof
292 | MAY 2015 | VOLUME 15
REVIEWS
of efficacy that can only be obtained from state of the
art, double-blind, placebo-controlled randomized trials. Comprehensive ancillary studies embedded in these
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Acknowledgements
The work of D.K. is funded by French state funds within the

Investissements dAvenir programme (ANR11-IDEX-000402;
LabEx Transimmunom); the European Research Council
Advanced Grant (ERC2012AdG, TRiPoD, Agreement number 322856); the Assistance Publique Hopitaux de Paris,
France; the Sorbonne University, Pierre and Marie Curie
Medical School, Paris, France; the Institut National de la
Sant et de la Recherche Mdicale (INSERM); and Le Centre
National de la Recherche Scientifique (CNRS).
Competing interests statement
The authors declare competing interests: see Web version for

details.
DATABASES
ClinicalTrials.gov: http://clinicaltrials.gov/
SUPPLEMENTARY INFORMATION
See online article: S1 (table)
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REVIEWS

The promise of low-dose interleukin2

Abstract | Depletion of regulatory T (TReg) cells in otherwise healthy individuals leads to

To avoid immune responses against self-antigens, most

seen in many animal models of autoimmune diseases

IL2 and homeostasis

NATURE REVIEWS | IMMUNOLOGY

VOLUME 15 | MAY 2015 | 283

was thought to be required for the development of all

T follicular regulatory cells

Type2 innate lymphoid cells

The birth of an IL2 paradox. The aforementioned

Three polypeptide chains CD25, CD122

284 | MAY 2015 | VOLUME 15

High sensitivity of TReg cells to IL2. One of the most

CD4+ T cell dierentiation

IL-2R signal strength

Activated TReg cells

CD4+ TReg cell

CD8+ TReg cell

a Control of local inammation

differentiation into pTReg cells and effectorNature

NATURE REVIEWS | IMMUNOLOGY

VOLUME 15 | MAY 2015 | 285

STAT5 phosphorylation (%)

Fold increase in the number

In vivo sensitivity to IL-2

In vitro sensitivity to IL-2

Fold increase in the number

STAT5 phosphorylation (%)

concentrations of IL2 in TReg cells than in effector

286 | MAY 2015 | VOLUME 15

IL2 international units

Vascular leak syndrome

In many individuals with autoimmune disease, IL2

The ups and downs of IL2 therapy

a therapeutic modality in cancer. Large studies showed

NATURE REVIEWS | IMMUNOLOGY

VOLUME 15 | MAY 2015 | 287

of TReg cells78 and that the resolution of the vasculitis

Box 2 | The main side effects of low-dose interleukin2

showed that low-dose IL2 could be a novel class of

Clinical development of low-dose IL2

288 | MAY 2015 | VOLUME 15

Potential benecial eects

Figure 3 | Effects of interleukin2 in patients with autoimmune or inflammatory

number of TReg cells that was accompanied by a marked

A major proliferative response of CD8+CD25+FOXP3+

NATURE REVIEWS | IMMUNOLOGY

VOLUME 15 | MAY 2015 | 289

TRANSREG clinical trial

Efficacy in human autoimmune and inflammatory

The promise of low-dose IL2

in diseases that are often chronic in nature? The initial

290 | MAY 2015 | VOLUME 15

Fold increase in the

The dose of IL-2 and the timing

b Daily continuous administration

c Induction and maintenance

IL-2 dose determines the

d Repeated single injections

IL-2 dose determines the

Figure 4 | Possible administration schemes for