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Bodaghi B, Souied EH, Tadayoni R, Weber M, Ponthieux A, Kodjikian L. Detection and Management of Intraocular Inflammation after Brolucizumab Treatment for Neovascular Age-Related Macular Degeneration. Ophthalmol Retina 2023; 7:879-891. [PMID: 37343623 DOI: 10.1016/j.oret.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
PURPOSE To present interim descriptive insights from the OCTOPUS and SWIFT studies on incidence, clinical features, management, and outcomes of intraocular inflammation (IOI), vasculitis, and occlusive vasculitis with brolucizumab treatment (Beovu, Novartis) in patients with neovascular age-related macular degeneration (nAMD) who were anti-VEGF naive or pretreated with anti-VEGFs (ranibizumab or aflibercept). DESIGN OCTOPUS (NCT04239027) and SWIFT (NCT04264819) studies are prospective phase IIIb single-arm, open-label, multicenter studies assessing brolucizumab. SUBJECTS Anti-VEGF naive (OCTOPUS) and pretreated (SWIFT) patients with nAMD. METHODS Interim prespecified analysis on the efficacy end point provided an opportunity to analyze IOI-related safety. Reports of IOI-related adverse events (AEs) were reviewed, and AE images and clinical features and outcomes of each case were analyzed by a review committee. RESULTS Of 505 brolucizumab-treated eyes/patients with median brolucizumab treatment of 8.8 months, 53 eyes demonstrated at least 1 IOI-related AE. The incidence of overall IOI-related AEs was 10.5%; among these events, the incidence was 7.1% for IOI only without retinal involvement and 3.4% for IOI with retinal involvement (2.0% with vasculitis, 1.4% with vascular occlusion with or without vasculitis). Incidence was similar in naive and pretreated patients. Before the onset of the first IOI-related AE, eyes received a median of 2 brolucizumab injections; 81.1% of IOI-related AEs occurred during the loading phase (median, 25.0 days from the last brolucizumab injection). At AE onset, most frequently reported symptoms were floaters (52.8%) and blurred or decreased vision (37.8%). Of the 86.8% of AEs that were treated, most were treated with topical corticosteroids (75.5%), 28.3% by systemic corticosteroids, and 26.8% by intraocular corticosteroids. No severe vision loss was reported for the 7 nontreated AEs. Overall, the median best-corrected visual acuity (BCVA) change at IOI-related AEs resolution from baseline was 1 letter (range, -74 to +32 letters), and 2 patients with occlusive vasculitis had BCVA loss ≥ 15 letters due to IOI-related AEs. All eyes permanently discontinued brolucizumab after the first IOI-related AE. CONCLUSIONS This analysis highlights the need for monitoring and education of patients to report any signs of IOI-related events immediately when being treated with brolucizumab. IOI should be treated promptly and intensely with corticosteroids. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Bahram Bodaghi
- Department of Ophthalmology, IHU FOReSIGHT, Sorbonne University, APHP, Paris, France
| | - Eric H Souied
- Department of Ophthalmology, Centre Hospitalier Intercommunal de Créteil, Université de Paris Est Créteil, Créteil, France
| | - Ramin Tadayoni
- Université Paris Cité, AP-HP, Lariboisière, St Louis and Fondation Adolphe de Rothschild hospitals, Paris, France
| | - Michel Weber
- Clinique Ophtalmologique, CHU de Nantes, 1, place Alexis Ricordeau, 44093 Nantes
| | - Anne Ponthieux
- Novartis Pharma SAS, Rueil-Malmaison, Malmaison, France.
| | - Laurent Kodjikian
- Department of Ophthalmology, Croix-Rousse teaching Hospital, Hospices Civils de Lyon, 69004 Lyon, France; UMR5510 MATEIS, CNRS, INSA Lyon, Université Lyon 1, 69100 Villeurbanne, France
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Kim ES, Kwon Y, Choe YH, Kim MJ. Free antibodies-to-infliximab are biomarker for predicting the effect of dose intensification in pediatric Crohn's disease patients with secondary loss of response. Therap Adv Gastroenterol 2023; 16:17562848231170948. [PMID: 37168401 PMCID: PMC10164862 DOI: 10.1177/17562848231170948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/04/2023] [Indexed: 05/13/2023] Open
Abstract
Background Immunogenicity to antitumor necrosis factor alpha agents, such as infliximab (IFX), may lead to therapeutic failure. Objectives This study evaluated the relationship between free and total antibodies-to-infliximab (ATIs), trough levels (TLs) of IFX, and the response to dose intensification. Design We performed a prospective, observational study including pediatric patients with Crohn's disease (CD) receiving IFX maintenance therapy without dose intensification. Methods We compared clinical and laboratory outcomes according to the presence of free and total ATIs. Factors associated with response to IFX dose intensification were investigated by analyzing IFX TLs and free and total ATIs. Results Of the 98 patients, 9 patients had detectable free ATIs and 38 patients had total ATIs. Patients with free ATIs had significantly lower TLs (0.7 versus 5.1 µg/mL, p < 0.001) than patients without free ATIs. However, there was no difference in the IFX TLs according to the presence of total ATIs (p = 0.2523). Analysis of the 38 samples with total ATIs showed that response to dose intensification was significantly lower in patients with free ATIs than those without free ATIs (22.2% versus 65.5%, p < 0.001). In addition, free ATIs were the only factor with poor response to dose intensification [odds ratio (OR): 14.15, 95% confidence interval (CI): 1.31-151.97, p = 0.0140]. According to the receiver operating characteristic analysis, the optimal cutoff level indicating non-response to IFX dose intensification was 30.0 AU/mL for free ATIs concentration (area under curve, 0.792; 95% CI: 0.590-0.942; sensitivity, 60.0%; specificity, 96.7%; p = 0.0241). Conclusion Free ATIs, but not total ATIs, have a negative impact on the course of CD. Free ATIs are potential reliable biomarker for predicting the effect of dose intensification in patients with loss of response to IFX. Future studies based on serial and proactive therapeutic drug monitoring are required in the future.
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Affiliation(s)
- Eun Sil Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yiyoung Kwon
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul 06351, Korea
| | - Mi Jin Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul 06351, Korea
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Karle AC, Wrobel MB, Koepke S, Gutknecht M, Gottlieb S, Christen B, Rubic-Schneider T, Pruimboom-Brees I, Leber XC, Scharenberg M, Maciejewski B, Turner O, Saravanan C, Huet F, Littlewood-Evans A, Clemens A, Grosskreutz CL, Kearns JD, Mehan P, Schmouder RL, Sasseville V, Brees D. Anti-brolucizumab immune response as one prerequisite for rare retinal vasculitis/retinal vascular occlusion adverse events. Sci Transl Med 2023; 15:eabq5241. [PMID: 36724238 DOI: 10.1126/scitranslmed.abq5241] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In October 2019, Novartis launched brolucizumab, a single-chain variable fragment molecule targeting vascular endothelial growth factor A, for the treatment of neovascular age-related macular degeneration. In 2020, rare cases of retinal vasculitis and/or retinal vascular occlusion (RV/RO) were reported, often during the first few months after treatment initiation, consistent with a possible immunologic pathobiology. This finding was inconsistent with preclinical studies in cynomolgus monkeys that demonstrated no drug-related intraocular inflammation, or RV/RO, despite the presence of preexisting and treatment-emergent antidrug antibodies (ADAs) in some animals. In this study, the immune response against brolucizumab in humans was assessed using samples from clinical trials and clinical practice. In the brolucizumab-naïve population, anti-brolucizumab ADA responses were detected before any treatment, which was supported by the finding that healthy donors can harbor brolucizumab-specific B cells. This suggested prior exposure of the immune system to proteins with structural similarity. Experiments on samples showed that naïve and brolucizumab-treated ADA-positive patients developed a class-switched, high-affinity immune response, with several linear epitopes being recognized by ADAs. Only patients with RV/RO showed a meaningful T cell response upon recall with brolucizumab. Further studies in cynomolgus monkeys preimmunized against brolucizumab with adjuvant followed by intravitreal brolucizumab challenge demonstrated that high ADA titers were required to generate ocular inflammation and vasculitis/vascular thrombosis, comparable to RV/RO in humans. Immunogenicity therefore seems to be a prerequisite to develop RV/RO. However, because only 2.1% of patients with ADA develop RV/RO, additional factors must play a role in the development of RV/RO.
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Affiliation(s)
- Anette C Karle
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Matthias B Wrobel
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Stephan Koepke
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Michael Gutknecht
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Sascha Gottlieb
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Brigitte Christen
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | | | | | - Meike Scharenberg
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - Oliver Turner
- Novartis Institutes for BioMedical Research, East Hanover, NJ 07960, USA
| | - Chandra Saravanan
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Francois Huet
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - Andreas Clemens
- Medical Affairs Region Europe, Novartis Pharma AG, Basel CH-4056, Switzerland
| | | | - Jeffrey D Kearns
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Pawan Mehan
- TRD Biologics & CGT, Novartis Pharma AG, Basel CH-4056, Switzerland
| | - Robert L Schmouder
- Novartis Institutes for BioMedical Research, East Hanover, NJ 07960, USA
| | - Vito Sasseville
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Dominique Brees
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
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Kearns JD, Wassmann P, Olgac U, Fichter M, Christen B, Rubic-Schneider T, Koepke S, Cochin de Billy B, Ledieu D, Andre C, Hawtin S, Fischer B, Moretti F, Hug C, Bepperling A, Brannetti B, Mendez-Garcia C, Littlewood-Evans A, Clemens A, Grosskreutz CL, Mehan P, Schmouder RL, Sasseville V, Brees D, Karle AC. A root cause analysis to identify the mechanistic drivers of immunogenicity against the anti-VEGF biotherapeutic brolucizumab. Sci Transl Med 2023; 15:eabq5068. [PMID: 36724241 DOI: 10.1126/scitranslmed.abq5068] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Immunogenicity against intravitreally administered brolucizumab has been previously described and associated with cases of severe intraocular inflammation, including retinal vasculitis/retinal vascular occlusion (RV/RO). The presence of antidrug antibodies (ADAs) in these patients led to the initial hypothesis that immune complexes could be key mediators. Although the formation of ADAs and immune complexes may be a prerequisite, other factors likely contribute to some patients having RV/RO, whereas the vast majority do not. To identify and characterize the mechanistic drivers underlying the immunogenicity of brolucizumab and the consequence of subsequent ADA-induced immune complex formation, a translational approach was performed to bridge physicochemical characterization, structural modeling, sequence analysis, immunological assays, and a quantitative systems pharmacology model that mimics physiological conditions within the eye. This approach revealed that multiple factors contributed to the increased immunogenic potential of brolucizumab, including a linear epitope shared with bacteria, non-natural surfaces due to the single-chain variable fragment format, and non-native drug species that may form over prolonged time in the eye. Consideration of intraocular drug pharmacology and disease state in a quantitative systems pharmacology model suggested that immune complexes could form at immunologically relevant concentrations modulated by dose intensity. Assays using circulating immune cells from treated patients or treatment-naïve healthy volunteers revealed the capacity of immune complexes to trigger cellular responses such as enhanced antigen presentation, platelet aggregation, endothelial cell activation, and cytokine release. Together, these studies informed a mechanistic understanding of the clinically observed immunogenicity of brolucizumab and associated cases of RV/RO.
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Affiliation(s)
- Jeffrey D Kearns
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Paul Wassmann
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Ufuk Olgac
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Marie Fichter
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Brigitte Christen
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - Stephan Koepke
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - David Ledieu
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Cedric Andre
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Stuart Hawtin
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Benoit Fischer
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Francesca Moretti
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Christian Hug
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - Barbara Brannetti
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | | | | | - Andreas Clemens
- Medical Affairs Region Europe, Novartis Pharma AG, Basel CH-4056, Switzerland
| | | | - Pawan Mehan
- TRD Biologics and CGT, Novartis Pharma AG, Basel CH-4056, Switzerland
| | - Robert L Schmouder
- Novartis Institutes for BioMedical Research, East Hanover, NJ 07960, USA
| | - Vito Sasseville
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Dominique Brees
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Anette C Karle
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
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Jiang AL, Breder CD, Chang LC. Investigation of Factors Associated with Immunogenicity Labeling Updates and Characteristics of Biologics License Applications. Clin Pharmacol Ther 2021; 110:1381-1388. [PMID: 34383294 DOI: 10.1002/cpt.2393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/26/2021] [Indexed: 11/12/2022]
Abstract
Immunogenicity, the potential to elicit an anti-drug immune response, is a critical concern in developing biological products, but its consequences are difficult to predict with animal studies. The aims of the present study are to investigate the evolution of immunogenicity information in labeling and to identify attributes associated with immunogenicity labeling updates. Biologics License Applications (BLAs) approved by the Center for Drug Evaluation and Research, United States Food and Drug Administration between 2008 and 2017 were studied. A majority of BLAs described the incidence/prevalence of anti-drug antibodies (ADAs) (94.9%) and neutralizing antibodies (NAbs) (68.4%) in their original labeling documents. However, less than one-third of the BLAs mentioned the impact of ADAs/NAbs in the original (20.3%) and most recent (29.1%) labeling documents. BLAs with a priority review status (57.4% versus 33.3%), orphan designation (61.5% versus 34.2%), or a mention of ADA impact in the latest label (69.6% versus 38.9%) had higher percentages of applications with postmarketing requirements (PMRs) directly related to immunogenicity concerns in comparison with applications without those characteristics. Among the BLAs with updated immunogenicity information, the mean time to the first update was 1077 days, while that for BLAs with accelerated approval was shorter (709.1 ± 492.2 days versus 1173.8 ± 661.8 days). The results suggest that there is a substantial amount of critical information lacking in the original labeling documents and an overdependence on PMRs for more evidence. Additional efforts should be made to investigate the impact of ADAs to provide timely information for improved patient care.
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Affiliation(s)
- Ai-Lei Jiang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Christopher D Breder
- Advanced Academic Programs, Krieger School of Arts and Sciences, Johns Hopkins University, Washington, DC, USA
| | - Lin-Chau Chang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
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Valenzuela F, Flores R. Immunogenicity to biological drugs in psoriasis and psoriatic arthritis. Clinics (Sao Paulo) 2021; 76:e3015. [PMID: 34614113 PMCID: PMC8449932 DOI: 10.6061/clinics/2021/e3015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/10/2021] [Indexed: 01/15/2023] Open
Abstract
Monoclonal antibodies or fusion proteins, defined as biological drugs, have modified the natural history of numerous immune-mediated disorders, allowing the development of therapies aimed at blocking the pathophysiological pathways of the disease, providing greater efficacy and safety than conventional treatment strategies. Virtually all therapeutic proteins elicit an immune response, producing anti-drug antibodies (ADAs) against hypervariable regions of immunoglobulins. Immunogenicity against biological drugs can alter their pharmacokinetic and pharmacodynamic properties, thereby reducing the efficacy of these drugs. In more severe cases, ADAs can neutralize the therapeutic effects of the drug or cause serious adverse effects, mainly hypersensitivity reactions. The prevalence of ADAs varies widely depending on the type of test used, occurrence of false-negative results, and non-specific binding to the drug, making it difficult to accurately assess their clinical impact. Concomitant use of immunosuppressors efficiently reduces the immunogenicity in a dose-dependent manner, either by decreasing the frequency of detectable ADAs or by delaying their appearance, thereby enhancing the effectiveness of biological therapies. Among the new therapeutic strategies for the management of psoriasis, biological agents have gained increasing importance in recent years as they interrupt key inflammation pathways involved in the physiopathology of the disease. Reports regarding ADA in new biologics are still scarce, but the most recent evidence tends to show little impact on the clinical response to the drug, even with prolonged treatment. It is therefore essential to standardize laboratory tests to determine the presence and titles of ADAs to establish their administration and management guidelines that allow the determination of the real clinical impact of these drugs.
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Affiliation(s)
- Fernando Valenzuela
- Department of Dermatology, School of Medicine, University of Chile, Santiago-Chile
- Department of Dermatology, Clínica Las Condes, Santiago-Chile
| | - Rodrigo Flores
- Department of Dermatology, School of Medicine, University of Chile, Santiago-Chile
- Corresponding author. E-mail:
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