Clinical Therapeutics/Volume ], Number ], 2017

Review
Integrins: Integrating the Biology and Therapy of
Cell–Cell Interactions
Franco Pandolfi, MD1; Laura Franza, MD1; Simona Altamura, PhD1;
Claudia Mandolini, PhD1; Cianci Rossella, MD1; Aftab Ansari, PhD2; and
James T. Kurnick, MD3,4
1
Institute of Internal Medicine, Catholic University, Rome, Italy; 2Department of Pathology and Laboratory
Medicine, Emory University School of Medicine, Atlanta, Georgia; 3CytoCure LLC, Beverly, Massachusetts;
and 4Department of Pathology, Massachusetts General Hospital, Harvard Medical School,
Boston, Massachusetts

ABSTRACT cancer, inflammatory diseases, HIv infection

Purpose: Although the role of integrins has been
described in a variety of diseases, these roles seem to
be distinct. To date, no study has attempted to provide
links to the various pathways by which such integrins
can be involved in these diverse disease settings. The
purpose of this review was to address this gap in our
knowledge with the hypothesis that there is, in fact, a
common pathway by which integrins may function.
Methods: This article provides an in-depth perspec-
tive on the discovery, development, and design of
therapeutics that modulate cellular function by target-
ing integrin:ligand interactions by reviewing the liter-
ature on this subject; the review included the most
recent results of clinical and subclinical studies.
A MEDLINE search was conducted for articles per-
taining to the various issues related to integrins, and the
most relevant articles are discussed (ie, not only those
published in journals with a higher impact factor).
Findings: It seems that the ligation of the integrins
with their cognate ligands plays a major role in
translating membrane dialogue into biological func-
tion. In addition, they also seem to play a major
regulatory role that can enhance or inhibit biological
function depending on the context within which such
receptor:ligand interactions occur and the organ and
tissues at which interactions occurs and is manipu-
lated. Those studies that used statistical analyses have
been included where appropriate.
Implications: Our findings show that anti-integrin
treatment has the potential to become a valid coad-
juvant in the treatment of several diseases including
and cardiovascular diseases. (Clin Ther. 2017;]:]]]–]]])
& 2017 Elsevier HS Journals, Inc. All rights reserved.
Key words: integrins, lymphocyte homing, T-lym-
phocytes, IBD, HIV.
INTRODUCTION
Integrins have been shown to play a pivotal role in the
activation and homing of a variety of hematopoietic cell
lineages. Cells can make contact with each other as well
as the extracellular matrix. The molecular mechanisms
involved in homing have come under extensive scrutiny
in recent years.1 Integrins are dimeric molecules
belonging to the immunoglobulin gene superfamily:
there are 18 α- and 8 β-subunits that combine into 24
αβ combinations.2 Of these, the integrins α4β1, α4β7,
αEβ7, and αLβ2 have been implicated as receptors that
contribute to leukocyte trafficking.
As is discussed later, integrins (which are sometimes
called addressins) play a crucial role in tissue homing
and consequent pathology. For example, alpha 4 beta 7
and cluster of differentiation (CD) 103 bind to mucosal
addressin cell adhesion molecule-1 (MAdCAM-1), thus
allowing lymphocyte migration to gut endothelium and
a relative role in inflammatory bowel diseases (IBDs);
Accepted for publication November 7, 2017.
https://doi.org/10.1016/j.clinthera.2017.11.002
0149-2918/$ - see front matter
& 2017 Elsevier HS Journals, Inc. All rights reserved.

] 2017 1
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Clinical Therapeutics
Table I. Summary of key integrins.
Integrin Alpha/Beta Subunits CD Ligand Expression Patterns Main Functions

LFA-1 Alpha L/beta 2 Cd11a/Cd18 ICAM-1-5, TLN, type I T cell, B cell, monocyte/ T-cell migration
collagen macrophage, NK cell, DC,
neutrophil, eosinophil
Alpha 1 Alpha 1 beta 2 CD49a/CD29 Collagen laminin Lymphocytes, stem cells Cell adhesion
Mac-1/CR3 Alpha M beta2 (Mac-1, Cd11b ICAM-1, ICAM-2, ICAM-4, Monocyte/macrophage, DC, Adhesion, activation and
CR3, CD11b/CD18) Cd18 iC3b, fibrinogen, factor neutrophil phagocytosis of macro
X, heparin, laminin, LPS phage, monocyte,
neutrophil, eosinophil
CR4 Alpha X beta 2 (p150/95, Cd11c C3bi, fibrinogen, collagen, Monocyte/macrophage Adhesion and phagocytosis of
CR4, CD11c/CD18) CD18 monocyte/macrophage and
neutrophil, adhesion
P150, 95 Alpha D beta 2 CD11d/ CD11d/CD18 ICAM-3, VCAM-1 Macrophage, eosinophil, Adhesion and migration
CD18) T cell, NK cell
CD103/alpha E Alpha E beta 7 (HML-1, D103 E-cadherin T cell, NK cell, DC, Adhesion and activation
CD103/CD-) macrophage
Alpha 4 beta1 (VLA-4, CD49d/CD29 VCAM-1, MAdCAM-1, Lymphocytes Homing of T and B cells
CD49d/CD29)
Alpha 4 beta 7 (LPAM-1, CD49d MAdCAM-1, VCAM-1 Lymphocytes, eosinophil Adhesion activation and
(CD49d/Act-1) macrophages recruitment
Alpha V beta 3 VD51/CD61 Vitronectin, ICAM-1, Monocyte, macrophage, Migration of monocyte,
VCAM-1, PECAM-1, DC, neutrophil macrophage and
fibrinogen, fibronectin neutrophil, phagocytosis
VLA-2, α2β1 CD49b/CD29 Laminin, collagen Epidermal keratinocytes Kinase signaling
Alpha 5/VLA-5 α5β1 CD49e/CD29 Fibronectin receptor

CD ¼ cluster of differentiation; CR ¼ complement receptor; DC ¼ dendritic cell; ICAM ¼ intracellular adhesion molecule; LFA-1 ¼ lymphocyte function antigen-1;
LPS ¼ lipopolysaccharide; MAdCAM ¼ mucosal addressin cell adhesion molecule; NK ¼ natural killer; PECAM-1 ¼ platelet endothelial cell adhesion molecule-1;
Volume ] Number ]

VLA ¼ very late antigen; VCAM-1 ¼ vascular cell adhesion molecule 1.


lymphocyte function antigen-1 (LFA-1) binds to colla-
gen with a role in several diseases, including inflamma-
tory skin diseases. In addition, very late antigen 4
(VLA4) controls homing to the central nervous system
(CNS). Thus, targeting these integrins may yield clinical
beneficial effects (Table I).
A series of monoclonal antibodies (mAbs) have
been described with specificity for either the α- or the
β-subunit and, in selected cases, the heterodimeric
form of the integrin. These monoclonals include the
mAb CD103, specific for the αE subunit of the αEβ7
integrin that binds to E-cadherin an adhesion molecule
important for T-cell homing to the intestinal mucosa.3
Thus, CD103 has been used to detect peripheral blood
lymphocytes that are homing to the gut mucosa.4,5
The homing process is a multistep phenomenon6 in
which inflammation, damage-associated molecular
patterns,7 chemokines, and cytokines (particularly
inflammatory cytokines such as interleukin [IL]-158
and IL-329) are involved. Adhesion is started by
activation of endothelial cells through an
extravascular stimulus followed by lymphocyte
rolling, firm adhesion, and extravasation of the
lymphocytes. The initial phases of adhesion are
mediated by leukocyte L-selectin and endothelial P-
and E-selectins. Integrins initiate the second phase of
adhesion (or firm binding) to endothelial cells.10 The
adhesion of the cell after extravasation can be targeted
by anti-integrin mAbs.11
Different integrins bind to different ligands, thus
contributing to directing cells in different tissues. For
instance, in addition to the gut homing molecules
mentioned earlier, skin homing lymphocytes express
cutaneous lymphocyte-associated antigen, a ligand for
E-selectin.12 E-selectin is also referred to as ELAM-1
and is an inducible adhesion molecule for skin homing
of neutrophils and skin homing memory T cells.
The integrin family of heterodimeric receptors plays
a 2-fold role: (1) cell adhesion by binding to cognate
extracellular matrix proteins, which allows cells with
a given surface integrin to home to specific tissues; and
2) signal transduction initiating a particular intra-
cellular signaling pathway (usually referred to as
“inside-out signaling”), which allows the cell to
modify its integrinic profile according to its intra-
cellular status. Exogenous integrin-activating reagents
act on the integrin extracellular domains to induce
integrin activation regardless of integrin transmem-
brane and cytoplasmic interactions.13
] 2017
F. Pandolfi et al.
After activation, integrins initiate ligand-dependent
intracellular signaling pathway(s), a process that is
called “outside‑in” signaling because it is initiated by
the binding of extracellular ligands to the integrins.
Outside‑in signaling implicates ligand-dependent in-
tegrin clustering, which brings the signaling domains
of integrin-proximal proteins close enough together to
start intracellular signals.14
Recent proteomic studies show that adhesion of
cells to the extracellular matrix is mediated by
adaptors regulating the adhesion site dynamics, the
so-called “adhesome.”15 Such studies indicate that
what is currently known of adhesome complexity is
an overly simplified view of the more intricate picture,
which is being revealed by focal adhesion research.
Studies on T cells, antibodies on antigen-presenting
cells, and the accessory molecules that facilitate both
on and off signaling have greatly expanded our
understanding of immune response initiation and
regulation. In addition, as the anatomy of the
immune response reminds us, most lymphocytes
reside in tissues, whether they are lymph nodes or
spleen or epithelial-associated structures, such as the
gut-associated lymphatic tissue (GALT), bone
marrow, liver, lung, and skin. Not only are such
tissues structured to arrange the reacting cellular and
matrix elements to allow efficient immune function,
but these very structures depend on an array of tissue-
distributed elements that depend heavily on integrins.
In humans, the ready access to lymphocytes ob-
tained from the peripheral blood has determined that
most studies will focus on these circulating cells.
However, we are well aware that lymphocytes per-
form most of their activities in the tissues. Thus, the
study of tissue-infiltrating lymphocytes can provide a
better insight into the pathogenesis of diseases.16
Recruitment of lymphocytes into the tissues where
they perform their activities involves complex
biological events that are all part of a phenomenon
termed lymphocyte homing. Adhesion molecules
expressed on lymphocytes, such as integrins, play a
crucial role in lymphocyte homing. Different integrins
are involved in homing to various tissues. Thus, the
integrins expressed by peripheral blood lymphocytes
represent the signature that indicates the destination
of lymphocytes. Differential display of integrins helps
to direct homing to different tissues.
The dynamic control of integrin-mediated cell
adhesion to extracellular matrix proteins is crucial
3
 Clinical Therapeutics
for several physiological and pathological and platelet
adhesion.17
As is discussed in the present review, integrins play a
role in an array of clinical conditions, and a number of
integrin-specific drugs are now being used in clinical
trials, and some have already reached the market.
Although we cannot claim to be comprehensive, the
present article highlights several important observa-
tions, both basic and clinical, that illustrate the utility
of integrins and the therapeutics that target them.
MATERIALS AND METHODS
We conducted a MEDLINE search, using the following
key words: “targeting integrins” “cancer integrins”
inflammation and integrins” integrins and SIV integ-
rings and cardiovascular diseases for the years 1995-
2016 for articles pertaining to the various issues related
to anti-integrin reagents, and we discuss the most
relevant articles in English especially (ie, not only those
published in journals with a higher impact factor).
APPLICATION OF ANTI-INTEGRIN MABS
INTO THERAPEUTIC TOOLS:
THE EXPERIENCE WITH IBD
Initial studies showed that leukocyte adherence to the
inflamed endothelium in the CNS is mediated by the
α4 (CD49d) β1-integrin/vascular cell adhesion mole-
cule 1 interaction; this view was consistent with the
finding that blockade of α4β1-integrin prevented the
development of experimental autoimmune encephalo-
myelitis in murine models.18
After the discovery of cell surface molecules that
promote the homing of lymphocytes to CNS and its
role in the pathogenesis of experimental autoimmune
encephalomyelitis, in 1992, Yednock et al19 were the
first to provide evidence to support this view. They
showed that the binding of lymphocytes to CNS tissue
could be inhibited by targeting the integrin molecule
α4β1. These landmark studies were subsequently
followed by a large number of studies that aimed to
use anti-integrin mAb as clinical tools for their
therapeutic effects in a variety of human studies (as
reviewed later in this article).20
Preclinical studies in the animal model described
the role of integrins in gut inflammation (reviewed in
Mitroulis et al21). A step forward was made with
the demonstration that blocking MAdCAM by
mAb reduced homing of lymphocytes to the
4 Volume ] Number ]
inflamed colon in mice.22 The administration of
anti-α4 mAbs yielded similar positive effects.23
Hence, targeting integrins was largely translated to
clinical use.20,24
A recombinant humanized mAb against the α4
integrin chain (natalizumab) improved the signs and
symptoms of patients with Crohn’s disease or ulcer-
ative colitis (UC) in 2 pilot trials.25,26 A computer-
assisted search of the Cochrane Central Register of
Controlled Trials showed that pooled data from 4
studies resulted in induction of clinical remission. The
authors stated that adverse events occurred infre-
quently and were experienced by a similar proportion
of treated patients and control subjects. However,
they also commented that “the included trials lacked
adequate statistical power to detect serious adverse
events that occur infrequently.”27
A humanized antibody against α4β7 was then
developed (vedolizumab) and proved itself useful in
the treatment of Crohn’s disease.28 A large (248
patients) randomized, placebo-controlled study of
patients with Crohn’s disease with infusions of 3 or
6 mg/kg of anti-α4β7 integrin (vedolizumab) followed.
Quality of life improved in all treated patients, with a
3% rate of adverse effects similar in all groups and no
severe adverse effects.29 An even larger placebo-
controlled study (368 patients) was performed later,
reinforcing evidence of the drug’s efficacy in Crohn’s
disease.30 Targeting α4β7 (vedolizumab or MLN-02)
thus proved safe and efficient in both Crohn’s
disease28,30 and UC.31–38 A couple of additional
human monoclonal anti-α4β7 (AMG) have also been
developed and tested in monkeys, and they have a
similar safety profile to vedolizumab in Phase I trials
in humans.39 Although the trial was suspended for not
well-defined reasons, it is due to be re-started shortly.
There are no data on double-blind clinical trials
regarding similarities or differences in binding
between the AMGEN (AMG 181) and Takeda
(vedolizumab) products, which are both presumably
directed against the α4β7 integrin. Vedolizumab seems
to be more selective because it binds to the
heterodimeric form of the α4β7 integrin and does
not bind to either of the 2 individual chains; in
addition, it has been shown to inhibit leukocyte
migration into the gut mucosa without off-target
effects such as binding to α4β1. Thus, vedolizumab
is currently the first-choice anti-integrin biologic drug
available for the treatment of patients with Crohn’s

disease because it is relatively safe and has fewer side
effects.40
In short, although 2 large natalizumab trials (EN-
CORE [International Efficacy of Natalizumab in
Crohn's Disease Response and Remission] and EN-
ACT-2 [International Efficacy of Natalizumab as
Active Crohn's Therapy]) have shown clinical (ie,
patients with active Crohn’s disease were more likely
to go into using than patients receiving placebo)
results in Crohn’s disease, 2 large clinical trials
utilizing vedolizumab in patients with Crohn’s disease
induction and maintenance41 have shown clinical
benefit. Vedolizumab has also shown positive results
in 2 large (4300) trials in patients with ulcerative
colitis (UC) (for UC induction and maintenance).32
It is important to note that alicaforsen, an antisense
inhibitor of intracellular adhesion molecule 1 (ICAM-
1) also known as CD54, failed to show efficacy in a
placebo-controlled study of Crohn’s disease; the
primary end point of the study was clinical
remission by week 12, and no statistical differences
in response were observed between alicaforsen
and placebo.42 PF-00547659, a humanized anti–
MAdCAM Ab, is now being tested for efficacy in
Phase I trials in UC.43
Another anti-α4β7 (AMG 181) mAb has been
developed and tested in monkeys39,44 and has a safe
profile in Phase I trials in humans.39 There are no
double-blind trials directing data regarding similarities
or differences in binding between AMG 181 and
vedolizumab. A growing portion of patients with IBD
are elderly, and thus assessment of biological treatments
in this group of patients is crucial.45 Vedolizumab is
also safe and effective in pediatric patients.46
In summary, 3 strategies are now available to target
integrins in IBD (intended as Crohn’s disease and UC):
targeting of α4β7 (vedolizumab); targeting of α4
(natalizumab); and the targeting of β7 (etrolizumab).47
These have been reviewed further elsewhere.34,48,49
Vedolizumab is more selective than natalizumab, as
binding is directed against the α4β7 integrin, inhibit-
ing leukocyte migration into gut mucosa; this action
causes potentially fewer off-target effects than seen
with natalizumab, which binds to additional hetero-
dimers, including α4β1.44 However, no definitive data
on the differences between the antibodies are yet
available.50
Although antibodies to epitopes that are only present
in a heterodimer (eg, α4β7) should be more selective
] 2017
F. Pandolfi et al.
than an antibody against either the alpha or beta chain
alone, one should recall that the expression of α4β7 is
not limited to gut-associated lymphocytes. Although
there is a selective binding of α4β7 to MAdCAM , the
original anti-α4β7, Act-1, was not developed to target
gut-derived lymphocytes. In fact, the observation that
both CD4þ and CD8þ T cells will express α4β7 after
long-term culture, and that the anti-tetanus toxoid
specificity of the immunizing CD4þ T cells that also
gives rise to Act-1, suggests that there is not a limited
reactivity to the gut. In fact, it was reported that Act-1
stained cells in rheumatoid arthritis synovium51 before
it was recognized that the antibody was specific for
α4β7. Thus, without undercutting the important effects
of anti-α4β7 in IBD, it would be naive to ignore possible
other therapeutic uses of this antibody. Indeed, as
discussed later, anti-α4β7 has been shown to have a
role in preventing HIV infection. Although this role may
involve the homing of cells to the gut, the possible
impact on memory cells outside the gut could also play
a role in altering HIV infection of critically important
lymphocytes in the gut and elsewhere.
One major issue in the use of biological drugs in
general is their cost. Although the cost of vedolizumab is
comparable to the cost of other approved mAb therapies
in IBD, particularly the anti–tumor necrosis factor α
reactive antibodies, the murine antibody infliximab52
and the humanized antibody (adalimumab) are far more
expensive than other widely used anti-inflammatory
drugs. For example, the incremental cost-effectiveness
ratio for vedolizumab compared with the standard
of care (aminosalicylic acids, corticosteroids, and
immunosuppressant agents) is £21,620 per quality-
adjusted life-year.53 Therefore, the issue of cost benefit
of these new drugs remains open.
Another unanswered question, in our opinion, is the
lack of detailed studies of the gut mucosa to evaluate
the beneficial effects of therapy and the possible increase
rate of infections. This is obviously the case with all
drugs with an immunosuppressive effect, including the
anti–tumor necrosis factor α class. It is unclear whether
the more tissue-specific nature of the anti-integrin anti-
bodies will have a less generalized immunosuppressive
impact in patients, although, as previously noted,
neither α4 nor α4β7 expression is limited exclusively
to the brain or the gut, and thus the full range of their
efficacy and side effects remains to be determined.
Recent data show that targeting αEβ7 (by etrolizu-
mab) integrin suppresses accumulation of CD8þ
5
 Clinical Therapeutics
T helper 9 and T helper 17 cells,54 which are
characteristic of an inflammatory subset. After
activation, the fate of naive T cells depends mostly
on the cytokines presented in the microenvironment
surrounding them. This leads to the production of T
cells with different patterns of cytokine production.55
SIMIAN IMMUNODEFICIENCY VIRUS/HIV
One of the most promising therapeutic applications of
anti-integrin mAbs has been the more recent experi-
ments that examined the effect of the anti-α4β7
integrin antibody on the pathogenesis of simian
immunodeficiency virus (SIV) infection in the non-
human primate model of human AIDS. Thus, these
studies used the experimental infection of rhesus
macaques with SIV that is accepted as the most
relevant animal model to study HIV-induced patho-
genesis.56 SIV infection, much like HIV, targets the
gastrointestinal tissues (GIT) that contain the largest
numbers of activated CD4þ T cells.57–59 Both HIV
and SIV predominantly target activated CCR5-ex-
pressing CD4þ T cells because the CD4 molecule
and CCR5 serve as the major receptor/co-receptor for
HIV/SIV. A large body of previously published data
indicated that the α4β7 integrin expressed by various
hematopoietic cell lineages serves as a GIT “homing
marker,” both in the murine system and subsequent
human studies.60 Thus, the α4β7 integrin served as a
“zip code” for cells homing to the GIT, primarily
because the cognate ligand for the α4β7 integrin
is MAdCAM-1, expressed by high endothelial
venules and epithelial cells of the GIT.61 During
acute HIV/SIV infection, the GIT thus becomes
the primary target of pathogenesis, with a massive
depletion of the CD4þ T-cell lineage and the initiation
of a breech between the intestinal wall and
the systemic circulation; this action results in the
leakage of gut microbiota into the systemic circulation,
a phenomenon known as “bacterial translocation.”62
The depletion of CD4þ T cells leads to the rapid
replenishment of new CD4þ T cells from the periphery
that traffic to the GIT via the expression of the
α4β7integrin and localize to the GIT, where once again
they become targets of HIV/SIV infection and depletion,
and the cycle continues.
What is of further interest is the finding that the
α4β7-expressing CD4þ T-cell subset is the preferential
target of HIV/SIV infection,63,64 probably because the
6 Volume ] Number ]
α4β7 molecule seems to have variable levels of affinity
for a discrete region of the V2 regions of envelopes of
select HIV/SIV.65 The chronic cycles of homing of the
α4β7-expressing CD4þ T cells and their depletion in
the GIT leads to considerable inflammation, which
determines a breech between the intestinal wall and
the systemic circulation. The constant inflammation,
followed by macrophage-mediated repair mechanisms
that normally occur during wound healing, results in
fibrosis. It is now becoming clear that bowel fibrosis is
to a large extent irreversible even if highly effective
antiretroviral therapy is instituted early during HIV/
SIV infection.
The question being posed is whether inhibition of
trafficking of CD4þ T cells would have any therapeu-
tic benefit in HIV/SIV infection.66 A summary of the
results is as follows:
1. The administration of anti-α4β7 for blockade dur-
ing acute SIV infection did not inhibit the acute
CD4 depletion in the gut but led to subsequent
restoration of CD4þ T cells in gut and lymphoid
organs with long-term prevention of disease
development.
2. The temporary short-term blockade of α4β7 in the
context of antiretroviral chemotherapy interruption
led to potent and durable control of virus repli-
cation up to 418 months’ posttherapy and resto-
ration of GI CD4þ T cells without the requirement
of any additional antiretroviral chemotherapy
or anti-α4β7 therapy. The precise mechanisms
underlying such potent and long-lasting control
(Z2 years and counting) induced by α4β7 blockade
remains to be elucidated. During the latter studies,
several key observations were also made:
o Using immuno–positron emission tomography/
computed tomography technology67 to detect
the in vivo distribution of SIV and CD4þ T cells
in α4β7-mAb, virus was predominantly localized
to the small intestine and there was restoration
of CD4þ T cells in the GI tract and other
lymphoid compartments (eg, lymph nodes,
spleen). In contrast, in animals not treated with
anti-α4β7, virus was localized extensively to the
large intestine, and CD4 cells were significantly
depleted in all tissues examined.
o Somewhat unexpectedly, all anti-α4β7–treated
monkeys developed markedly higher antibody
levels to the second variable region of SIV env
(V2), linked to mucosal protection in the RV144
trial.

o Control of viral replication in anti-α4β7–treated
monkeys was associated with a marked expan-
sion of cytokine-producing natural killer cells.
Although no major changes in SIV-specific CD4
or CD8 T cell–mediated immune responses were
noted between anti-α4β7–treated monkeys and
control monkeys, the sustained antiviral control
seen in anti-α4β7–treated monkeys relative to
control animals was associated with a marked
decrease in the levels of plasma pro-inflamma-
tory cytokines and chemokines; conversely,
levels of IL-10, IL-35, interferon-α, and retinoic
acid were elevated. Of importance, increases in
IL-10 and interferon-α were identified as predic-
tors of disease progression in SIV infection in the
context of other studies. According to our data,
however, this association may have to be revis-
ited, which at least for interferon-α concurs with
a couple of recent reports.
In summary, there have clearly been some remark-
able findings with the use of antibodies against the
integrin α4β7 that have tremendous value for the
future therapy of HIV infection in humans. However,
several words of caution regarding these findings are
needed. First, these findings must be repeated using
different SIV stocks to ensure that this outcome is not
unique to the virus that was used. Second, whether all
these findings can be reproduced in humans awaits
results of some important clinical human studies.
Third, it is important to note that such anti-α4β7
therapy is not a cure. It did not eliminate virus from
the infected monkeys but merely regulated its repli-
cation for a prolonged period of time. Finally, the
mechanisms by which these results were obtained will
require a new series of studies, some of which have
already been initiated.
Thus said, even though it is important to be
cautious, the initial findings of these experiments show
that integrin signaling plays a pivotal role in the
development and maintenance of HIV infection. Tar-
geting such a pathway may help radically change the
natural history of such disease.
TARGETING INTEGRINS IN THROMBOTIC
AND ISCHEMIC DISEASES
Although there has been an emphasis on the role of
integrins in inflammation and cell trafficking, there are
structural associations that suggest a role for integrins
in other processes. Of note, 9 of the 24 human
] 2017
F. Pandolfi et al.
integrins contain an “inserted” domain (I-domain)
that has homology to the domain A of the von
Willebrand factor and is found in the extracellular
portion of the α-subunit.68 Of these, αIIb/β3 and αV/
β3 integrins are expressed by platelets and have an
important part in platelet aggregation, fibrinogen
binding, and clot formation. Clearly, thrombosis
and platelet-related events play a critical role in
cardiovascular disease, and the role of integrins
has been the target of several clinical trials in
cardiovascular diseases. Indeed, platelets are pivotal
in hemostasis, and thus any abnormality could result
in stroke and ischemic heart disease, as well as a
variety of bleeding disorders. In resting platelets, αIIb/
β3 integrin shows a bent conformation that prevents
contact with the ligand. It is only at the end
of the activation pathway that the integrin switches
from a bent to an open conformation,69 allowing
fibrinogen-binding clot formation. For this reason,
αIIb/β3 integrin has been studied for antiplatelet
drug production. Currently, there are 3 different
drugs targeting this integrin: abciximab, tirofiban,
and eptifibatide. A recent summary of trials in
cardiovascular diseases has been published
elsewhere.70
The inhibitory mAb 7E3 binds to β3 chain71 and
blocks the adhesion to fibrinogen and ICAM-1. The
EPIC (Evaluation of 7E3 for the Prevention of
Ischemic Complications) study showed that a 7E3
bolus-only strategy in percutaneous coronary
intervention is associated with an early protective
anti-ischemic effect.72 Platelets also express α2/β1,73
a collagen receptor that can be targeted by a small
molecule (sMo), BTT-3016. It has been shown that
this new α2β1 inhibitor exerts collagen-specific
antiplatelet activity and regulates thrombus growth
in vivo without compromising primary hemostasis
more than aspirin.74
Abciximab is an engineered antibody fragment that
targets glycoprotein IIb/IIIa (GpIIb/IIIa) (an integrin
platelet surface receptor ligand of fibrinogen), enhanc-
ing the effects of aspirin and heparin in patients with
acute coronary syndromes, and is effective in revascu-
larization treatments in acute ischemic infarction with
immunologic modifications.75–77 However, abciximab
is not recommended for the treatment of patients with
acute ischemic stroke, as shown by the negative result
of the AbESTT-II (Abciximab in Emergency
Treatment of Stroke Trial) Phase III study.78
7
 Clinical Therapeutics
Abciximab was shown to be effective in 4 large trials:
EPIC,79 EPILOG (Evaluation of Percutaneous
Transluminal Coronary Angioplasty to Improve
Long-term Outcome of c7E3 GpIIb/IIIa Receptor
Blockade),80 CAPTURE (c7E3 Fab Antiplatelet
Therapy in Unstable Refractory Angina),81 and
EPISTENT (Evaluation of Platelet IIb/IIIa Inhibitor
for Stenting).82
Tirofiban, an sMo targeting GpIIb/IIIa, has been
shown to reduce ischemic events compared with
aspirin in unstable angina.83 Similar effects can be
obtained with tirofiban and intrifiban,84 sMos
targeting GpIIb/IIIa.85
Eptifibatide is a disulfide-linked cyclic heptapeptide
that blocks the binding of αIIbβ3 integrin to fibrino-
gen and other arginine-glycine-aspartic acid (RGD)-
containing ligands. It has proven safe and useful in
patients with cardiovascular conditions through sev-
eral trials (IMPACT-II [Integrilin to Minimise Platelet
Aggregation and Coronary Thrombosis-II],86
87
PURSUIT, and ESPRIT [Enhanced Suppression of
the Platelet IIb/IIIa Receptor with Integrilin
Therapy]88) in a total of 415,0000 patients.
MULTIPLE SCLEROSIS
VLA4 is a heterodimeric integrin that comprises an α4
chain (CD49d) and a β1 chain (CD29). It is important
for the trafficking of lymphocytes through the blood–
brain barrier to the CNS tissues and is involved in the
pathogenesis of multiple sclerosis.89 Targeting of the α4
chain can also be achieved via the oral administration of
firategrast, an sMo,90 and has proven useful in the
treatment of multiple sclerosis.91,92 A large trial, involv-
ing 627 patients, showed that natalizumab reduced the
risk of the sustained progression of disability and the
rate of clinical relapse.93–96 However, natalizumab’s
therapeutic efficacy is limited due to its association with
the reactivation of John Cunningham polyomavirus and
the development of progressive multifocal leukoence-
phalopathy (PML).97 As consequences of several PML
cases, these trials were stopped, and natalizumab was
withdrawn in 2009.98 However, in a 2010 reevaluation,
the European Medicines Agency determined that the
benefits exceeded the risks for patients treated with
natalizumab, and the drug was used again in patients
not receiving other immunosuppressive drugs.
However, more cases of PML have been reported
since its return to the market.99
8 Volume ] Number ]
Several additional severe side effects have been
reported with the use of anti-integrins as therapeutics.
For instance, cryptococcal meningitis has been re-
ported in association with natalizumab treat-
ment.100,101 The association of natalizumab and
cryptococcal infection is probably linked to the im-
mune reconstitution inflammatory syndrome.101 The
side effects are also associated with the effects of
natalizumab on a subpopulation of T cells termed
regulatory T cells that are characterized as CD4þ
CD25þ Foxp3 þ cells with strong regulatory effects.
This subset is functionally impaired in multiple
sclerosis102 and can be modified by treatment:
interferon-β increases the number of functional
regulatory T cells. Natalizumab may also function
through modification of the regulatory T-cell
subpopulation, but conclusive data are not yet
available.
PSORIASIS
Psoriasis is presumably an autoimmune disease in
which the immune system senses selected autoantigens
presented by skin Langerhans cells. It is generally
accepted that Langerhan cells upon activation migrate
to local lymph nodes and initiate dialogue with
cognate T cells, and the T cells subsequently migrate
to the skin where the Langerhans cells reside, and a
chronic inflammatory response is initiated. The T cells
present in such lesions express an integrin molecule
termed LFA-1 whose natural ligand is ICAM-1. LFA-
1 is an integrin consisting of CD11a as the alpha chain
and CD18 as the beta chain (CD11a/CD18). It has
been shown that LFA-1 is involved in transendothelial
migration of T cells from the blood to the lymph
nodes via a sequence of events that include arrest after
LFA-1 is activated by ligation of chemokine receptors
and firm adhesion, followed by diapedesis. LFA-1
plays a key role in T-cell migration and regulates T-
cell activation; in addition to psoriasis, it has a role in
the pathogenesis of several inflammatory diseases,
especially autoimmune diseases.103
Such knowledge has led to studies to find inhibitors
of the interaction between LFA-1 and ICAM-1, which
should reasonably inhibit the inflammatory process. A
number of mAbs against LFA-1 have thus been
described to inhibit the adhesion of lymphocytes to
endothelium, providing the rationale for targeting
integrins in psoriasis.104 One such reagent is
odulimomab, an mAb with specificity for the CD11a

chain of LFA-1,105 and it is also being used in human
bone marrow and organ transplantation.
The blockade of CD11a with a humanized mAb
that binds to the α subunit of LFA-1 seems to be useful
in psoriasis. However, 8 of 20 patients relapsed after
12 weeks of treatment. In an effort to understand
the mechanism related to relapse, it was shown
that relapse was due to an increase in CD11c-
positive inflammatory myeloid dendritic cells and
CD8-positive interferon-secreting T cells. Unfortu-
nately, the investigators did not evaluate T helper 17
cells because their role in autoimmune diseases was
not fully appreciated at the time.106 Efalizumab
has also yielded positive results in plaque
psoriasis.107 However, it was withdrawn from
the market because it was associated with the
development of PML.98
CANCER
A new field of application is emerging in the therapy
of cancer, directed at the targeting of integrins. This
therapy is termed “tumor-targeted drug delivery treat-
ment.” Targeted drug delivery methods thus use sMo,
mAbs, or specific photoreceptors that are abnormally
overexpressed in tumors.108
In addition to drug delivery, anti-integrin targeting is
a new avenue for the treatment of cancer. Integrins are
involved in tumor angiogenesis, and their blockade has
been shown to be efficient in inhibiting tumor growth,
angiogenesis, and metastasis. The most relevant mole-
cule during tumor angiogenesis seems to be αvβ3.
The most important integrin during tumor angio-
genesis seems to be αVβ3. The inhibition of this integrin
signaling with antibodies, peptides, peptide-mimetic mol-
ecules, and other antagonists has great potential in the
treatment of cancer. Alpha(v)beta(3) is highly expressed
on activated endothelial cells, new-born vessels, and some
tumor cells but is not present in resting endothelial cells
and most normal organ systems, making it a suitable
target for antiangiogenic therapy. The inhibition of
integrin αvβ3 signaling with antibodies (cilengitide) is a
potential strategy in cancer treatment.109
Recent evidence suggests that there is a synergistic
effect of combined therapeutic approaches (ie, chemo-
therapy, radiotherapy) and antiangiogenic treatment
over a single modality alone.110,111 αvβ3 integrin is
also involved in intracellular signaling and regulates
cell proliferation. Some mAbs targeting this integrin
] 2017
F. Pandolfi et al.
(etaracizumab and intetumumab) are being tested for
therapeutic efficacy in metastatic melanoma.112,113
Along these lines, a new trial with an anti-α5β1 (PF-
04605412) has been proven safe in nonhematologic
malignancies.114 A fully human mAb with specificity for
anti-αV integrins (CNTO 95) has been shown to inhibit
angiogenesis and tumor growth in preclinical studies.
Results are promising in various human tumors: solid
tumors, melanoma, and prostate cancer.115
These therapeutics have shown encouraging activity in
Phase II clinical trials, and cilengitide is currently being
tested in a Phase III trial in patients with glioblastoma.116
In addition, ATN-161, a noncompetitive inhibitor of the
fibronectin PHSRN sequence, is in early development
studies for cancer.117
Integrins are also involved in different stages of
cancer development, including maintenance of cancer
stem cells and cancer resistance.118 Drug-resistant acute
lymphoblastic leukemia represents a therapeutic
challenge. It has been reported that interference with
α4-mediated adhesion of acute lymphoblastic leukemia
cells can sensitize them to chemotherapy.119,120
Volociximab is a high-affinity chimeric antibody
directed against human endothelial α5β1 integrin and
is being tested in resistant cancer and primary peri-
toneal cancer.121
TARGETING INTEGRINS WITH SMALL ORALLY
ADMINISTERED MOLECULES
Orally available sMos inhibiting integrins have
actively been investigated since the 1990s.
The first molecules to be studied were αIIbβ3 (GpIIb/
IIIa) inhibitors.122 Originally, the intravenous
formulations were more effective than the oral
formulations. The following studies have shown that
the lack of efficacy of the orally available sMos was
possibly due to low concentration in the plasma.123
The sMos imitate the integrin-binding properties of
the glycine/aspartic acid (RGD) peptide in terms of
overall geometry and the presence of a basic moiety
and free carboxyl group.124 These drugs are pro-
drugs; the R group (ethyl) and R1 group (OH) are
cleaved to form the active drug.123 The nature of the
R groups has not yet been disclosed.
Even though this first class of orally available sMos
were not effective, pharmaceutical companies continued
research among this field because of the severe side
effects of the intravenous integrin inhibitors. The correct
9
10

Clinical Therapeutics
Table II. Role of integrins in various disorders.
Drug Target Indication Drug Class Status Reference

Natalizumab α4β1, α4β7 IBD, MS huMoAb Marketed for the treatment of 34,35,54,62

MS and IBD
Vedolizumab α4β7 IBD huMoAb Phase III trials 36–43
42
Alicaforsen ICAM-1 Crohn’s disease Antisense inhibitor Failed
43
F-00547659 MAdCAM UC mAB Preliminary efficacy
Etrolizumab α4β7 β7 UC humAb Investigational 44

AMG 181 α4β7 UC huMoAB Phase II trials in UC 54,55

71
7E3 IIb/IIIa Percutaneous coronary intervention mAb (Fab fragment) Prevention ischemic complications
Cilengitide αVβ3 Cancer Cyclic peptide Phase II trial in patients with 73

advanced non–small-cell lung

carcinoma
BTT-3016 Α2β1 Platelet inhibitor sMo To be developed 76

Volociximab α5β1 Ovarian and peritoneal cancer Chimeric Phase II 83

84
Intrifiban GpIIb/IIIa Unstable angina sMo Marketed in unstable angina
85
Tirofiban GpIIb/IIIa Unstable angina sMo Marketed in unstable angina
Firategrast α4 MS sMo 90
105
Odulimomab LFA-1 Immunosuppression mAb
106
GW559090X VLA-4 Asthma sMo
118–121
Abciximab GpIIb/IIIa MI huMoAb Marketed in MI
Etaracizumab αVβ3 Cancer humAb Investigational 112,113

PF-04605412 Α5β1 Nonhematologic malignancies 114

AJM 300 α5 IBD 127

Valategrast α4β1 Asthma sMo 133

L-000845704 αv β3 Osteoporosis sMo 135

Intetumumab αV Cancer humAb Investigational 136

ATN-161 Α5β1 Solid tumors sMo 137

Lifitegrast αLβ2 Eye sMo 138

Eptifibatide αIIbβ3 Percutaneous coronary intervention sMo 139

140
Tirofiban GpIIb/IIIa Unstable angina sMo
Omalizumab α4β7 Eosinophilic esophagitis Ongoing 141

NCT01040598
Volume ] Number ]

GpIIb/IIIa ¼ glycoprotein IIb/IIIa; huMoAb ¼ human monoclonal antibody; IAM ¼ intracellular adhesion molecule; IBD ¼ inflammatory bowel disease; LFA-1 ¼
lymphocyte function antigen-1; mAb ¼ monoclonal antibody; MAdCAM ¼ mucosal addressin cell adhesion molecule; MI ¼ myocardial infarction; MS ¼ multiple
sclerosis; sMo ¼ small molecule; UC ¼ ulcerative colitis.

dosing of the orally available sMos is one of the major
problems to overcome because it has been seen that at
low doses, they do not work as antagonists but as
agonists.125 Another aspect currently being investigated
is if orally available sMos have a better safety profile
than the intravenous formulations.126 At the moment,
the safety profiles of the oral compounds are being
verified, and the first results are encouraging.127 It is
important to note that several integrins, including αvβ3
and αvβ5, recognize the RGD sequence shared by a
number of extracellular matrix ligands. Accordingly,
RGD mimetic peptides or sMos bind to these integrins
on the surface of cells to block specific αV integrin-
mediated signaling pathways and act as anticancer and
antiangiogenic agents.
An updated table of selected structures of small
nonpeptide inhibitors for integrins can be found in the
article by Cox et al.126
Key motifs for the binding of α4β7 and α4β1 to
their ligands have been defined, and sMos targeting
such binding were developed.128
Pretreatment with multiple doses of an VLA4 orally
administered receptor antagonist, HMR 103, protects
against allergen-induced airway responses and airway
inflammation129 in humans,130,131 and its antagonist
GW559090X was useful, even with a single inhaled
dose, in asthma, a disease with potential severe
complications.132 This is probably due to their
action on T-lymphocyte homing to the vessels133
(reviewed by Metzger131). Other inhaled sMos are
being developed with anti-inflammatory activity.134
Valategrast, an orally administered sMo targeting
α4β1, is currently being used in trials in asthma.
AJ 300 is a phenylalanine-based sMo antagonist
of α4 integrins. It has proven effective in patients
with UC.127
CONCLUSIONS
The targeting of integrins is already a new avenue of
treatment in a vast array of human diseases, from
thrombosis to allergic diseases, to multiple sclerosis
(Table II). Because GALT is possibly the largest
immune organ, specifically targeting GALT may
prove beneficial not only in IBD but also in other
diseases such as HIV infection. In the treatment of
cancer, anti-integrins already represent a potential
alternative for several tumors resistant to
conventional treatments. Moreover, new trials are
] 2017
F. Pandolfi et al.
now needed to combine integrin targeting to other
immunologic interventions, such as checkpoint
targeting (PDL1), vaccinations, and other immuno-
logic therapeutics. We are confident that the new
arsenal of immunologic therapeutics may bring
remarkable results in patients for whom there are
currently no available treatments.
In addition to the specific examples we have
discussed in detail in this review, there is a wide array
of integrin-directed therapeutics that have the poten-
tial to play a role in many other disorders that one can
anticipate on the basis of the initial description of
integrins, as shown in Table II. These diseases have
very different etiologies, such as osteoporosis,
eosinophilic esophagitis, and dry eye. Presently, 80
trials with anti-integrin drugs are reported at
ClinicalTrials.gov registers.
Such drugs include both mAbs and sMos, which
have the potential to play a role in many more diseases
than one can anticipate thoroughly on the initial
description of integrins.
ACKNOWLEDGMENTS
The study was supported in part by a grant from the
Catholic University (Internal Funding-Linea D1). All
authors contributed equally. There were no study
sponsors.
CONFLICTS OF INTEREST
Dr. Kurnick receives royalties from the sales of
vedolizumab (Takeda) from his role in the creation
of the original murine mAb. The authors have in-
dicated that they have no other conflicts of interest
regarding the content of this article.
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Address correspondence to: Franco Pandolfi, MD, Institute of Internal

Medicine, Catholic University, Rome, Italy. E-mail: franco.pandolfi@
unicatt.it

] 2017 17