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Antonucci L, Thurman JM, Vivarelli M. Complement inhibitors in pediatric kidney diseases: new therapeutic opportunities. Pediatr Nephrol 2024; 39:1387-1404. [PMID: 37733095 DOI: 10.1007/s00467-023-06120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 09/22/2023]
Abstract
Historically, the complement system (classical, lectin, alternative, and terminal pathways) is known to play a crucial role in the etiopathogenesis of many kidney diseases. Direct or indirect activation in these settings is revealed by consumption of complement proteins at the serum level and kidney tissue deposition seen by immunofluorescence and electron microscopy. The advent of eculizumab has shown that complement inhibitors may improve the natural history of certain kidney diseases. Since then, the number of available therapeutic molecules and experimental studies on complement inhibition has increased exponentially. In our narrative review, we give a summary of the main complement inhibitors that have completed phase II and phase III studies or are currently used in adult and pediatric nephrology. The relevant full-text works, abstracts, and ongoing trials (clinicaltrials.gov site) are discussed. Data and key clinical features are reported for eculizumab, ravulizumab, crovalimab, avacopan, danicopan, iptacopan, pegcetacoplan, and narsoplimab. Many of these molecules have been shown to be effective in reducing proteinuria and stabilizing kidney function in different complement-mediated kidney diseases. Thanks to their efficacy and target specificity, these novel drugs may radically improve the outcome of complement-mediated kidney diseases, contributing to an improvement in our understanding of their underlying pathophysiology.
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Affiliation(s)
- Luca Antonucci
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
- Ph.D. Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
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2
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Tulika T, Pedersen RW, Rimbault C, Ahmadi S, Rivera‐de‐Torre E, Fernández‐Quintero ML, Loeffler JR, Bohn M, Ljungars A, Ledsgaard L, Voldborg BG, Ruso‐Julve F, Andersen JT, Laustsen AH. Phage display assisted discovery of a pH-dependent anti-α-cobratoxin antibody from a natural variable domain library. Protein Sci 2023; 32:e4821. [PMID: 37897425 PMCID: PMC10659949 DOI: 10.1002/pro.4821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/28/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023]
Abstract
Recycling IgG antibodies bind to their target antigen at physiological pH in the blood stream and release them upon endocytosis when pH levels drop, allowing the IgG antibodies to be recycled into circulation via FcRn-mediated cellular pathways, while the antigens undergo lysosomal degradation. This enables recycling antibodies to achieve comparable therapeutic effect at lower doses than their non-recycling counterparts. The development of such antibodies is typically achieved by histidine doping of their variable regions or by performing in vitro antibody selection campaigns utilizing histidine doped libraries. Both are strategies that may introduce sequence liabilities. Here, we present a methodology that employs a naïve antibody phage display library, consisting of natural variable domains, to discover antibodies that bind α-cobratoxin from the venom of Naja kaouthia in a pH-dependent manner. As a result, an antibody was discovered that exhibits a 7-fold higher off-rate at pH 5.5 than pH 7.4 in bio-layer interferometry experiments. Interestingly, no histidine residues were found in its variable domains, and in addition, the antibody showed pH-dependent binding to a histidine-devoid antigen mutant. As such, the results demonstrate that pH-dependent antigen-antibody binding may not always be driven by histidine residues. By employing molecular dynamics simulations, different protonation states of titratable residues were found, which potentially could be responsible for the observed pH-dependent antigen binding properties of the antibody. Finally, given the typically high diversity of naïve antibody libraries, the methodology presented here can likely be applied to discover recycling antibodies against different targets ab initio without the need for histidine doping.
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Affiliation(s)
- Tulika Tulika
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Rasmus W. Pedersen
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Charlotte Rimbault
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Shirin Ahmadi
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | | | - Monica L. Fernández‐Quintero
- Center for Molecular Biosciences Innsbruck, Department of GeneralInorganic and Theoretical Chemistry, University of InnsbruckInnsbruckAustria
| | - Johannes R. Loeffler
- Center for Molecular Biosciences Innsbruck, Department of GeneralInorganic and Theoretical Chemistry, University of InnsbruckInnsbruckAustria
| | - Markus‐Frederik Bohn
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Anne Ljungars
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Line Ledsgaard
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Bjørn G. Voldborg
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
| | - Fulgencio Ruso‐Julve
- Department of PharmacologyUniversity of OsloOsloNorway
- Department of ImmunologyOslo University Hospital RikshospitaletOsloNorway
- Precision Immunotherapy AllianceUniversity of OsloOsloNorway
| | - Jan Terje Andersen
- Department of PharmacologyUniversity of OsloOsloNorway
- Department of ImmunologyOslo University Hospital RikshospitaletOsloNorway
- Precision Immunotherapy AllianceUniversity of OsloOsloNorway
| | - Andreas H. Laustsen
- Department of Biotechnology and BiomedicineTechnical University of DenmarkLyngbyDenmark
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3
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Liu X, Tan Q, Wen J, Wang X, Yang G, Li Y, Lu M, Ye W, Si A, Ma S, Ding T, Sun L, Liu F, Zhang M, Jiang T, Gao W. Improving the cytotoxicity of immunotoxins by reducing the affinity of the antibody in acidic pH. J Transl Med 2023; 21:572. [PMID: 37626430 PMCID: PMC10463491 DOI: 10.1186/s12967-023-04210-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 05/19/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Immunotoxins are antibody-toxin conjugates that bind to surface antigens and exert effective cytotoxic activity after internalization into tumor cells. Immunotoxins exhibit effective cytotoxicity and have been approved by the FDA to treat multiple hematological malignancies, such as hairy cell leukemia and cutaneous T-cell lymphoma. However, most of the internalized immunotoxin is degraded in lysosomes, and only approximately 5% of free toxin escapes into the cytosol to exert cytotoxicity. Many studies have improved immunotoxins by engineering the toxin fragment to reduce immunogenicity or increase stability, but how the antibody fragment contributes to the activity of immunotoxins has not been well demonstrated. METHODS In the current study, we used 32A9 and 42A1, two anti-GPC3 antibodies with similar antigen-binding capabilities and internalization rates, to construct scFv-mPE24 immunotoxins and evaluated their in vitro and in vivo antitumor activities. Next, the antigen-binding capacity, trafficking, intracellular protein stability and release of free toxin of 32A9 scFv-mPE24 and 42A1 scFv-mPE24 were compared to elucidate their different antitumor activities. Furthermore, we used a lysosome inhibitor to evaluate the degradation behavior of 32A9 scFv-mPE24 and 42A1 scFv-mPE24. Finally, the antigen-binding patterns of 32A9 and 42A1 were compared under neutral and acidic pH conditions. RESULTS Although 32A9 and 42A1 had similar antigen binding capacities and internalization rates, 32A9 scFv-mPE24 had superior antitumor activity compared to 42A1 scFv-mPE24. We found that 32A9 scFv-mPE24 exhibited faster degradation and drove efficient free toxin release compared to 42A1 scFv-mPE24. These phenomena were determined by the different degradation behaviors of 32A9 scFv-mPE24 and 42A1 scFv-mPE24 in lysosomes. Moreover, 32A9 was sensitive to the low-pH environment, which made the 32A9 conjugate easily lose antigen binding and undergo degradation in lysosomes, and the free toxin was then efficiently produced to exert cytotoxicity, whereas 42A1 was resistant to the acidic environment, which kept the 42A1 conjugate relatively stable in lysosomes and delayed the release of free toxin. CONCLUSIONS These results showed that a low pH-sensitive antibody-based immunotoxin degraded faster in lysosomes, caused effective free toxin release, and led to improved cytotoxicity compared to an immunotoxin based on a normal antibody. Our findings suggested that a low pH-sensitive antibody might have an advantage in the design of immunotoxins and other lysosomal degradation-dependent antibody conjugate drugs.
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Affiliation(s)
- Xiaoyu Liu
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Qingqing Tan
- Department of Gynecology Oncology, Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, China
| | - Jiaqi Wen
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Xufei Wang
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Gang Yang
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Yuxiao Li
- Department of Endocrinology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Ming Lu
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Wei Ye
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Anfeng Si
- Department of Surgical Oncology, Jinling Hospital, Medical School of Nanjing University, 34 Yanggongjing Road, Nanjing, 210000, Jiangsu, People's Republic of China
| | - Sujuan Ma
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Tong Ding
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Luan Sun
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Fang Liu
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China
| | - Mei Zhang
- Department of Endocrinology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
| | - Tao Jiang
- Department of Surgical Oncology, Jinling Hospital, Medical School of Nanjing University, 34 Yanggongjing Road, Nanjing, 210000, Jiangsu, People's Republic of China.
| | - Wei Gao
- School of Basic Medical Sciences and Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing Medical University, 101 Longmian Road, Xuehai Building, Nanjing, 211166, Jiangsu, People's Republic of China.
- The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou Second People's Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, China.
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4
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Tang GQ, Tang Y, Dhamnaskar K, Hoarty MD, Vyasamneni R, Vadysirisack DD, Ma Z, Zhu N, Wang JG, Bu C, Cong B, Palmer E, Duda PW, Sayegh C, Ricardo A. Zilucoplan, a macrocyclic peptide inhibitor of human complement component 5, uses a dual mode of action to prevent terminal complement pathway activation. Front Immunol 2023; 14:1213920. [PMID: 37622108 PMCID: PMC10446491 DOI: 10.3389/fimmu.2023.1213920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Introduction The complement system is a key component of the innate immune system, and its aberrant activation underlies the pathophysiology of various diseases. Zilucoplan is a macrocyclic peptide that binds and inhibits the cleavage/activation of human complement component 5 (C5). We present in vitro and ex vivo data on the mechanism of action of zilucoplan for the inhibition of C5 activation, including two clinically relevant C5 polymorphisms at R885. Methods The interaction of zilucoplan with C5, including for clinical C5 R885 variants, was investigated using surface plasmon resonance (SPR), hemolysis assays, and ELISA. The interference of C5b6 formation by zilucoplan was investigated by native gel analysis and hemolysis assay. The permeability of zilucoplan in a reconstituted basement membrane was assessed by the partition of zilucoplan on Matrigel-coated transwell chambers. Results Zilucoplan specifically bound human complement C5 with high affinity, competitively inhibited the binding of C5 to C3b, and blocked C5 cleavage by C5 convertases and the assembly of the cytolytic membrane attack complex (MAC, or C5b9). Zilucoplan fully prevented the in vitro activation of C5 clinical variants at R885 that have been previously reported to respond poorly to eculizumab treatment. Zilucoplan was further demonstrated to interfere with the formation of C5b6 and inhibit red blood cell (RBC) hemolysis induced by plasmin-mediated non-canonical C5 activation. Zilucoplan demonstrated greater permeability than a monoclonal C5 antibody in a reconstituted basement membrane model, providing a rationale for the rapid onset of action of zilucoplan observed in clinical studies. Conclusion Our findings demonstrate that zilucoplan uses a dual mode of action to potently inhibit the activation of C5 and terminal complement pathway including wild-type and clinical R885 variants that do not respond to eculizumab treatment. These data may be relevant to the clinically demonstrated benefits of zilucoplan.
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Affiliation(s)
| | - Yalan Tang
- UCB Pharma, Cambridge, MA, United States
| | | | | | | | | | - Zhong Ma
- UCB Pharma/Ra Pharmaceuticals, Cambridge, MA, United States
| | - Nanqun Zhu
- UCB Pharma/Ra Pharmaceuticals, Cambridge, MA, United States
| | | | - Charlie Bu
- UCB Pharma, Cambridge, MA, United States
| | | | | | | | - Camil Sayegh
- UCB Pharma/Ra Pharmaceuticals, Cambridge, MA, United States
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5
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Röth A, Ichikawa S, Ito Y, Kim JS, Nagy Z, Obara N, Panse J, Schrezenmeier H, Sica S, Soret J, Usuki K, Yoon SS, Balachandran N, Buri M, Lundberg P, Patel H, Shinomiya K, Sostelly A, Nishimura JI. Crovalimab treatment in patients with paroxysmal nocturnal haemoglobinuria: Long-term results from the phase I/II COMPOSER trial. Eur J Haematol 2023. [PMID: 37321625 DOI: 10.1111/ejh.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES This study reports long-term outcomes from the open-label extension (OLE) period of the Phase I/II COMPOSER trial (NCT03157635) that evaluated crovalimab in patients with paroxysmal nocturnal haemoglobinuria, who were treatment-naive or switched from eculizumab at enrolment. METHODS COMPOSER consists of four sequential parts followed by the OLE. The primary OLE objective was to assess long-term crovalimab safety, with a secondary objective to assess crovalimab pharmacokinetics and pharmacodynamics. Exploratory efficacy endpoints included change in lactate dehydrogenase (LDH), transfusion avoidance, haemoglobin stabilisation and breakthrough haemolysis (BTH). RESULTS A total 43 of 44 patients entered the OLE after completing the primary treatment period. Overall, 14 of 44 (32%) experienced treatment-related adverse events. Steady state exposure levels of crovalimab and terminal complement inhibition were maintained over the OLE. During the OLE, mean normalised LDH was generally maintained at ≤1.5× upper limit of normal, transfusion avoidance was achieved in 83%-92% of patients and haemoglobin stabilisation was reached in 79%-88% of patients across each 24-week interval. Five BTH events occurred with none leading to withdrawal. CONCLUSIONS Over a 3-year median treatment duration, crovalimab was well tolerated and sustained C5 inhibition was achieved. Intravascular haemolysis control, haemoglobin stabilisation and transfusion avoidance were maintained, signifying long-term crovalimab efficacy.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Satoshi Ichikawa
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Yoshikazu Ito
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Zsolt Nagy
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Naoshi Obara
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Juliette Soret
- Centre d'Investigations Cliniques, Hôpital Saint-Louis, Paris, France
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | | | - Muriel Buri
- Biostatistics Oncology Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pontus Lundberg
- Oncology Biomarker Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Himika Patel
- Product Development Hematology, Genentech, Inc., South San Francisco, California, USA
| | - Kenji Shinomiya
- Primary Clinical Science and Strategy, Chugai Pharmaceutical Co., Tokyo, Japan
| | | | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
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Begum F, Khan N, Boisclair S, Malieckal DA, Chitty D. Complement Inhibitors in the Management of Complement-Mediated Hemolytic Uremic Syndrome and Paroxysmal Nocturnal Hemoglobinuria. Am J Ther 2023; 30:e209-e219. [PMID: 37104648 DOI: 10.1097/mjt.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND Complement-mediated HUS (CM-HUS) and paroxysmal nocturnal hemoglobinuria (PNH) are rare hematologic disorders that cause dysregulation and hyperactivation of the complement system. Historically, treatment of CM-HUS involved plasma exchange (PLEX), often with limited benefit and variable tolerance. Conversely, PNH was treated with supportive care or hemopoietic stem cell transplant. Within the last decade, monoclonal antibody therapies that block terminal complement pathway activation, have emerged as less invasive and more efficacious options for management of both disorders. This manuscript seeks to discuss a relevant clinical case of CM-HUS and the evolving landscape of complement inhibitor therapies for CM-HUS and PNH. AREAS OF UNCERTAINTY Eculizumab, the first humanized anti-C5 monoclonal antibody, has been the standard of care in treating CM-HUS and PNH for over a decade. Although eculizumab has remained an effective agent, the variability in ease and frequency of administration has remained an obstacle for patients. The development of novel complement inhibitor therapies with longer half-lives, has allowed for changes in frequency and route of administration, thus improving patient QOL. However, there are limited prospective clinical trial data given disease rarity, and limited information on variable infusion frequency and length of treatment. THERAPEUTIC ADVANCES Recently, there has been a push to formulate complement inhibitors that improve QOL while maintaining efficacy. Ravulizumab, a derivative of eculizumab, was developed to allow for less frequent administration, while remaining efficacious. In addition, the novel oral and subcutaneous therapies, danicopan and crovalimab, respectively, along with pegcetacoplan are currently undergoing active clinical trials, and poised to further reduce treatment burden. CONCLUSION Complement inhibitor therapies have changed the treatment landscape for CM-HUS and PNH. With a significant emphasis on patient QOL, novel therapies continue to emerge and require an in-depth review of their appropriate use and efficacy in these rare disorders. CLINICAL CASE A 47-year-old woman with hypertension and hyperlipidemia presented with shortness of breath and was found to have hypertensive emergency in the setting of acute renal failure. Her serum creatinine was 13.9 mg/dL; elevated from 1.43 mg/dL 2 years before. The differential diagnosis for her acute kidney injury (AKI) included infectious, autoimmune, and hematologic processes. Infectious work-up was negative. ADAMTS13 activity level was not low at 72.9%, ruling out thrombotic thrombocytopenic purpura (TTP). Patient underwent a renal biopsy, which revealed acute on chronic thrombotic microangiopathy (TMA). A trial of eculizumab was initiated with concurrent hemodialysis. The diagnosis of CM-HUS was later confirmed by a heterozygous mutation in complement factor I (CFI), resulting in increased membrane attack complex (MAC) cascade activation. The patient was maintained on biweekly eculizumab and was eventually transitioned to ravulizumab infusions as an outpatient. Her renal failure did not recover, and the patient remains on hemodialysis while awaiting kidney transplantation.
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Affiliation(s)
- Farhana Begum
- Department of Medicine, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030
| | - Nida Khan
- Department of Medicine, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030
| | - Stephanie Boisclair
- Department of Hematology and Oncology, Northwell Health Cancer Institute, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030; and
| | - Deepa A Malieckal
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030
| | - David Chitty
- Department of Hematology and Oncology, Northwell Health Cancer Institute, Zucker School of Medicine-Northwell NS/LIJ, Manhasset, NY 11030; and
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Cone J, Kimmel L, Zhang Y, Johnson K, Sheridan D, Tamburini P. Characterization of multivalent complexes formed in the presence of more than one conventional antibody to terminal complement component C5. PLoS One 2023; 18:e0284502. [PMID: 37079521 PMCID: PMC10118082 DOI: 10.1371/journal.pone.0284502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 04/02/2023] [Indexed: 04/21/2023] Open
Abstract
This study sought to understand the nature of the immune complexes that could be formed when a patient is exposed simultaneously to two different anti-complement component 5 (C5) antibodies, such as in patients converting from one bivalent, noncompetitive, C5-binding monoclonal antibody to another. Size exclusion chromatography (SEC) in combination with multiangle light scattering was used to assess the potential formation of multivalent complexes among eculizumab, C5, and each of two other anti-C5 bivalent antibodies, TPP-2799 or TP-3544, respectively having the same sequence as either crovalimab or pozelimab currently undergoing clinical trials. Each of these two antibodies bound C5 noncompetitively with eculizumab. In phosphate-buffered saline (PBS), C5-eculizumab in the absence of other antibodies measured <500 kDa; however, inclusion of other antibodies at levels ranging from equimolar and up to a fivefold excess over eculizumab and C5 yielded a series of complexes with some >1500 kDa in size, consistent with incorporation of multiple antibodies and C5 molecules. A similar pattern of complexes was also observed when fluorescently labeled eculizumab and either of the other two antibodies were spiked into human plasma, based on SEC monitored by fluorescence detection. A detailed characterization of the pharmacodynamic and pharmacokinetic properties of such complexes is warranted, as is the incorporation of mitigation processes to avoid their formation in patients converting from one bivalent, noncompetitive, C5-binding monoclonal antibody to another.
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Affiliation(s)
- Josh Cone
- Alexion, AstraZeneca Rare Disease, New Haven, CT, United States of America
| | - Lida Kimmel
- Alexion Pharmaceuticals, Inc., New Haven, CT, United States of America
| | - Yuchun Zhang
- Alexion, AstraZeneca Rare Disease, New Haven, CT, United States of America
| | - Krista Johnson
- Alexion, AstraZeneca Rare Disease, New Haven, CT, United States of America
| | - Douglas Sheridan
- Alexion Pharmaceuticals, Inc., New Haven, CT, United States of America
| | - Paul Tamburini
- Alexion, AstraZeneca Rare Disease, New Haven, CT, United States of America
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8
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Nishimura JI, Soubret A, Arase N, Buatois S, Hotta M, Charoin JE, Ito Y, Sreckovic S, Takamori H, Bucher C, Ueda Y, Hernández-Sánchez J, Gotanda K, Jordan G, Shinomiya K, Ramos J, Kim JS, Panse J, de Latour RP, Röth A, Morii E, Schrezenmeier H, Isaka Y, Sica S, Kanakura Y, Yoon SS, Kinoshita T, Paz-Priel I, Sostelly A. Mitigating Drug-Target-Drug Complexes in Patients With Paroxysmal Nocturnal Hemoglobinuria Who Switch C5 Inhibitors. Clin Pharmacol Ther 2023; 113:904-915. [PMID: 36660902 DOI: 10.1002/cpt.2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/06/2023] [Indexed: 01/21/2023]
Abstract
Drug-target-drug complexes (DTDCs) are phenomena newly observed in patients who switch from the complement component 5 (C5) inhibitor eculizumab to crovalimab, a novel, anti-C5 antibody in development for paroxysmal nocturnal hemoglobinuria (PNH), because these agents bind to different C5 epitopes. In Part 3 of the four-part, phase I/II COMPOSER study, 19 patients with PNH switching from eculizumab received 1,000-mg crovalimab intravenously, then subcutaneous maintenance doses from Day 8 (680 mg every 4 weeks (q4w), 340 mg every 2 weeks, or 170 mg every week). Crovalimab exposure was transiently reduced, and size-exclusion chromatography and crovalimab-specific enzyme-linked immunosorbent assays revealed DTDCs in all 19 patients' sera. Additionally, self-limiting mild to moderate symptoms suggestive of type III hypersensitivity reactions occurred in two patients. Mathematical modeling simulations of DTDC kinetics and effects of dosing on DTDC size distribution using Part 3 data predicted that increased crovalimab concentrations could reduce the proportion of large, slow-clearing DTDCs in the blood. A simulation-guided, optimized crovalimab regimen (1,000 mg intravenously; four weekly, subcutaneous 340-mg doses; then 680 mg q4w from Day 29) was evaluated in Part 4. Confirming the model's predictions, mean proportions of large DTDCs in patients who switched from eculizumab to this optimized regimen decreased by > 50% by Day 22, and target crovalimab concentrations were maintained. No type III hypersensitivity reactions occurred in Part 4. Optimizing crovalimab dosing thus reduced the proportion of large DTDCs, ensured adequate complement inhibition, and may improve safety. Model-based dosing optimization to mitigate DTDC formation offers a useful strategy for patients switching to novel antibody treatments targeting soluble epitopes.
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Affiliation(s)
- Jun-Ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Osaka, Japan
| | - Antoine Soubret
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Noriko Arase
- Department of Dermatology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Osaka, Japan
| | - Simon Buatois
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Masaki Hotta
- Department of Medical Technology, Osaka University Hospital, Osaka, Japan
| | - Jean-Eric Charoin
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Yoshikazu Ito
- Department of Hematology, Tokyo Medical University Hospital, Tokyo, Japan
| | | | - Hiroyuki Takamori
- Department of Hematology and Oncology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Osaka, Japan
| | - Christoph Bucher
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland
| | - Yasutaka Ueda
- Department of Hematology and Oncology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Osaka, Japan
| | | | | | - Gregor Jordan
- Roche Pharma Research and Early Development, Roche Innovation Center Munich, Munich, Germany
| | | | - Julia Ramos
- Genentech, Inc., South San Francisco, California, USA.,Spark Therapeutics, Inc., Philadelphia, Pennsylvania, USA
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | | | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Eiichi Morii
- Department of Pathology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Osaka, Japan
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Yoshitaka Isaka
- Department of Nephrology, Graduate School of Medicine, Faculty of Medicine, Osaka, Japan
| | - Simona Sica
- Fondazione Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Graduate School of Medicine, Faculty of Medicine, Osaka University, Osaka, Japan.,Department of Hematology, Sumitomo Hospital, Osaka, Japan
| | | | - Taroh Kinoshita
- Yabumoto Department of Intractable Disease Research, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Ido Paz-Priel
- Genentech, Inc., South San Francisco, California, USA.,Gilead Sciences, San Francisco, California, USA
| | - Alexandre Sostelly
- Roche Pharma Research and Early Development, Roche Innovation Center Basel, Basel, Switzerland.,Alnylam Pharmaceuticals, Basel, Switzerland
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9
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Panse J. Paroxysmal nocturnal hemoglobinuria: Where we stand. Am J Hematol 2023; 98 Suppl 4:S20-S32. [PMID: 36594182 DOI: 10.1002/ajh.26832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
For the last 20 years, therapy of paroxysmal nocturnal hemoglobinuria (PNH) relied-up until recently-on antibody based terminal complement inhibitionon. PNH pathophysiology-a mutational defect leading to partial or complete absence of complement-regulatory proteins on blood cells-leads to intravascular hemolysis and consequences such as thrombosis and other sequelae. A plethora of new drugs interfering with the proximal and terminal complement cascade are under recent development and the first "proof-of-pinciple" proximal complement inhibitor targeting C3 has been approved in 2021. "PNH: where we stand" will try to give a brief account on where we came from and where we stand focusing on approved therapeutic options. The associated improvements as well as potential consequences of actual and future treatments as well as their impact on the disease will continue to necessitate academic and scientific focus on improving treatment options as well as on side effects and outcomes relevant to individual patient lives and circumstances in order to develop effective, safe, and available treatment for all hemolytic PNH patients globally.
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Affiliation(s)
- Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Center for Integrated Oncology (CIO), Aachen Bonn Cologne Düsseldorf (ABCD), Aachen, Germany
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10
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Gurevich E, Landau D. Pharmacological Management of Atypical Hemolytic Uremic Syndrome in Pediatric Patients: Current and Future. Paediatr Drugs 2023; 25:193-202. [PMID: 36637720 DOI: 10.1007/s40272-022-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/14/2023]
Abstract
Atypical hemolytic uremic syndrome is a thrombotic microangiopathy characterized by hemolysis, thrombocytopenia, and acute kidney injury, usually caused by alternative complement system overactivation due to pathogenic genetic variants or antibodies to components or regulatory factors in this pathway. Previously, a lack of effective treatment for this condition was associated with mortality, end-stage kidney disease, and the risk of disease recurrence after kidney transplantation. Plasma therapy has been used for atypical hemolytic uremic syndrome treatment with inconsistent results. Complement-blocking treatment changed the outcome and prognosis of patients with atypical hemolytic uremic syndrome. Early administration of eculizumab, a monoclonal C5 antibody, leads to improvements in hematologic, kidney, and systemic manifestations in patients with atypical hemolytic uremic syndrome, even with apparent dialysis dependency. Pre- and post-transplant use of eculizumab is effective in the prevention of atypical hemolytic uremic syndrome recurrence. Evidence on eculizumab use in secondary hemolytic uremic syndrome cases is controversial. Recent data favor the restrictive use of eculizumab in carefully selected atypical hemolytic uremic syndrome cases, but close monitoring for relapse after drug discontinuation is emphasized. Prophylaxis for meningococcal infection is important. The long-acting C5 monoclonal antibody ravulizumab is now approved for atypical hemolytic uremic syndrome treatment, enabling a reduction in the dosing frequency and improving the quality of life in patients with atypical hemolytic uremic syndrome. New strategies for additional and novel complement blockage medications in atypical hemolytic uremic syndrome are under investigation.
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11
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Schmidt CQ, Smith RJH. Protein therapeutics and their lessons: Expect the unexpected when inhibiting the multi-protein cascade of the complement system. Immunol Rev 2023; 313:376-401. [PMID: 36398537 PMCID: PMC9852015 DOI: 10.1111/imr.13164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Over a century after the discovery of the complement system, the first complement therapeutic was approved for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). It was a long-acting monoclonal antibody (aka 5G1-1, 5G1.1, h5G1.1, and now known as eculizumab) that targets C5, specifically preventing the generation of C5a, a potent anaphylatoxin, and C5b, the first step in the eventual formation of membrane attack complex. The enormous clinical and financial success of eculizumab across four diseases (PNH, atypical hemolytic uremic syndrome (aHUS), myasthenia gravis (MG), and anti-aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorder (NMOSD)) has fueled a surge in complement therapeutics, especially targeting diseases with an underlying complement pathophysiology for which anti-C5 therapy is ineffective. Intensive research has also uncovered challenges that arise from C5 blockade. For example, PNH patients can still face extravascular hemolysis or pharmacodynamic breakthrough of complement suppression during complement-amplifying conditions. These "side" effects of a stoichiometric inhibitor like eculizumab were unexpected and are incompatible with some of our accepted knowledge of the complement cascade. And they are not unique to C5 inhibition. Indeed, "exceptions" to the rules of complement biology abound and have led to unprecedented and surprising insights. In this review, we will describe initial, present and future aspects of protein inhibitors of the complement cascade, highlighting unexpected findings that are redefining some of the mechanistic foundations upon which the complement cascade is organized.
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Affiliation(s)
- Christoph Q. Schmidt
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany
| | - Richard J. H. Smith
- Departments of Internal Medicine and Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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12
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Banik SSR, Kushnir N, Doranz BJ, Chambers R. Breaking barriers in antibody discovery: harnessing divergent species for accessing difficult and conserved drug targets. MAbs 2023; 15:2273018. [PMID: 38050985 DOI: 10.1080/19420862.2023.2273018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 12/07/2023] Open
Abstract
To exploit highly conserved and difficult drug targets, including multipass membrane proteins, monoclonal antibody discovery efforts increasingly rely on the advantages offered by divergent species such as rabbits, camelids, and chickens. Here, we provide an overview of antibody discovery technologies, analyze gaps in therapeutic antibodies that stem from the historic use of mice, and examine opportunities to exploit previously inaccessible targets through discovery now possible in alternate species. We summarize the clinical development of antibodies raised from divergent species, discussing how these animals enable robust immune responses against highly conserved binding sites and yield antibodies capable of penetrating functional pockets via long HCDR3 regions. We also discuss the value of pan-reactive molecules often produced by these hosts, and how these antibodies can be tested in accessible animal models, offering a faster path to clinical development.
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13
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Ramdani Y, Lamamy J, Watier H, Gouilleux-gruart V. Monoclonal Antibody Engineering and Design to Modulate FcRn Activities: A Comprehensive Review. Int J Mol Sci 2022; 23:9604. [PMID: 36077002 PMCID: PMC9455995 DOI: 10.3390/ijms23179604] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/03/2023] Open
Abstract
Understanding the biological mechanisms underlying the pH-dependent nature of FcRn binding, as well as the various factors influencing the affinity to FcRn, was concurrent with the arrival of the first recombinant IgG monoclonal antibodies (mAbs) and IgG Fc-fusion proteins in clinical practice. IgG Fc–FcRn became a central subject of interest for the development of these drugs for the comfort of patients and good clinical responses. In this review, we describe (i) mAb mutations close to and outside the FcRn binding site, increasing the affinity for FcRn at acidic pH and leading to enhanced mAb half-life and biodistribution, and (ii) mAb mutations increasing the affinity for FcRn at acidic and neutral pH, blocking FcRn binding and resulting, in vivo, in endogenous IgG degradation. Mutations modifying FcRn binding are discussed in association with pH-dependent modulation of antigen binding and (iii) anti-FcRn mAbs, two of the latest innovations in anti-FcRn mAbs leading to endogenous IgG depletion. We discuss the pharmacological effects, the biological consequences, and advantages of targeting IgG–FcRn interactions and their application in human therapeutics.
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14
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Nishidate M, Shibahara N, Hayasaka A, Staack RF, Miyayama T, Terao K, Jordan G. Validation of a method to analyze size distribution of crovalimab-complement C5-eculizumab complexes in human serum. Bioanalysis 2022. [PMID: 35904159 DOI: 10.4155/bio-2022-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Crovalimab is a humanized monoclonal antibody targeting human complement C5. Patients switching from eculizumab to crovalimab are expected to form drug-target-drug complexes (DTDCs), since these antibodies each bind to a different epitope on complement C5. An analytical method to evaluate the size distribution of these DTDCs was developed and validated. Methods: Human serum samples were separated by size-exclusion chromatography (SEC) into eight fractions, and the concentration of crovalimab in each fraction was measured by ELISA. We evaluated SEC, ELISA and the combination of both methods (SEC-ELISA). Results: Predetermined validation acceptance criteria were met. Conclusion: The DTDC assay method was successfully validated. It enables us to evaluate the impact of DTDCs on clinical outcomes.
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15
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Jordan G, Moheysen-Zadeh M, Dahl U, Staack RF. Novel isoelectric target depletion (ITaD) protocol reduces the need for specific reagents for immunogenicity testing. Bioanalysis 2022. [PMID: 35642540 DOI: 10.4155/bio-2022-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The development of immunogenicity assays for clinical drug candidates targeting soluble proteins is challenging when the soluble target might produce either false-positive or false-negative signals in bridging anti-drug antibody screening assays. A generic soluble target removal protocol that uses a pH-dependent depletion was evaluated. Results: An anti-drug antibody bridging assay with a pH-dependent soluble target depletion step was successfully developed. Endogenous target levels of ∼600 nM could be depleted below 8 pM. The assay was highly drug tolerant and met regulatory requirements. Conclusion: A reagent-independent target depletion protocol can be used for immunogenicity testing in the presence of a soluble target. The generic protocol circumvents common depletion or masking protocols.
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16
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Kulasekararaj AG, Brodsky RA, Nishimura JI, Patriquin CJ, Schrezenmeier H. The importance of terminal complement inhibition in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221091046. [PMID: 35663504 PMCID: PMC9160915 DOI: 10.1177/20406207221091046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic hematologic disorder associated with inappropriate terminal complement activity on blood cells that can result in intravascular hemolysis (IVH), thromboembolic events (TEs), and organ damage. Untreated individuals with PNH have an increased risk of morbidity and mortality. Patients with PNH experiencing IVH often present with an elevated lactate dehydrogenase (LDH; ⩾ 1.5 × the upper limit of normal) level which is associated with a significantly higher risk of TEs, one of the leading causes of death in PNH. LDH is therefore used as a biomarker for IVH in PNH. The main objective of PNH treatment should therefore be prevention of morbidity and mortality due to terminal complement activation, with the aim of improving patient outcomes. Approval of the first terminal complement inhibitor, eculizumab, greatly changed the treatment landscape of PNH by giving patients an effective therapy and demonstrated the critical role of terminal complement and the possibility of modulating it therapeutically. The current mainstays of treatment for PNH are the terminal complement component 5 (C5) inhibitors, eculizumab and ravulizumab, which have shown efficacy in controlling terminal complement-mediated IVH, reducing TEs and organ damage, and improving health-related quality of life in patients with PNH since their approval by the United States Food and Drug Administration in 2007 and 2018, respectively. Moreover, the use of eculizumab has been shown to reduce mortality due to PNH. More recently, interest has arisen in developing additional complement inhibitors with different modes of administration and therapeutics targeting other components of the complement cascade. This review focuses on the pathophysiology of clinical complications in PNH and explores why sustained inhibition of terminal complement activity through the use of complement inhibitors is essential for the management of patients with this chronic and debilitating disease.
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Affiliation(s)
- Austin G. Kulasekararaj
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
- National Institute of Health Research/Wellcome King’s Clinical Research Facility and King’s College London, London, UK
| | | | - Jun-ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Christopher J. Patriquin
- Division of Medical Oncology & Hematology, University Health Network – Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, and University Hospital Ulm, Ulm, Germany
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17
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Nishimura JI, Usuki K, Ramos J, Ichikawa S, Buri M, Kiialainen A, Sostelly A, Peffault de Latour R, Paz-Priel I, Röth A. Crovalimab for treatment of patients with paroxysmal nocturnal haemoglobinuria and complement C5 polymorphism: Subanalysis of the phase 1/2 COMPOSER study. Br J Haematol 2022; 198:e46-e50. [PMID: 35608260 DOI: 10.1111/bjh.18274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jun-Ichi Nishimura
- Department of Haematology and Oncology, Osaka University Graduate School of Medicine C9, Suita, Osaka, Japan
| | - Kensuke Usuki
- Department of Haematology, NTT Medical Centre Tokyo, Shinagawa-ku, Tokyo, Japan
| | - Julia Ramos
- Genentech, a Member of the Roche Group, South San Francisco, California, USA
| | - Satoshi Ichikawa
- Department of Haematology, Tohoku University Hospital, Aoba-ku, Sendai, Japan
| | - Muriel Buri
- F. Hoffmann-La Roche, Ltd, Basel, Switzerland
| | | | | | - Régis Peffault de Latour
- Department of Haematology and Bone Marrow Transplant Department, CHU Paris GH St Louis Lariboisière et Fernand-Widal Hospital, Paris, France
| | - Ido Paz-Priel
- Genentech, a Member of the Roche Group, South San Francisco, California, USA
| | - Alexander Röth
- Department of Haematology and Stem Cell Transplantation, West German Cancer Centre, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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18
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Sun X, Liu C, Lu X, Ling Z, Yi C, Zhang Z, Li Z, Jin M, Wang W, Tang S, Wang F, Wang F, Wangmo S, Chen S, Li L, Ma L, Zhang Y, Yang Z, Dong X, Qian Z, Ding J, Wang D, Cong Y, Sun B. Unique binding pattern for a lineage of human antibodies with broad reactivity against influenza A virus. Nat Commun 2022; 13. [PMID: 35501328 PMCID: PMC9061721 DOI: 10.1038/s41467-022-29950-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 04/06/2022] [Indexed: 01/04/2023] Open
Abstract
Most structurally characterized broadly neutralizing antibodies (bnAbs) against influenza A viruses (IAVs) target the conserved conformational epitopes of hemagglutinin (HA). Here, we report a lineage of naturally occurring human antibodies sharing the same germline gene, VH3-48/VK1-12. These antibodies broadly neutralize the major circulating strains of IAV in vitro and in vivo mainly by binding a contiguous epitope of H3N2 HA, but a conformational epitope of H1N1 HA, respectively. Our structural and functional studies of antibody 28-12 revealed that the continuous amino acids in helix A, particularly N49HA2 of H3 HA, are critical to determine the binding feature with 28-12. In contrast, the conformational epitope feature is dependent on the discontinuous segments involving helix A, the fusion peptide, and several HA1 residues within H1N1 HA. We report that this antibody was initially selected by H3 (group 2) viruses and evolved via somatic hypermutation to enhance the reactivity to H3 and acquire cross-neutralization to H1 (group 1) virus. These findings enrich our understanding of different antigenic determinants of heterosubtypic influenza viruses for the recognition of bnAbs and provide a reference for the design of influenza vaccines and more effective antiviral drugs. While most broadly neutralizing antibodies (bnAb) against Influenza virus target conserved conformational epitopes of the glycoprotein hemagglutinin (HA), Sun et al. characterize a lineage of bnAbs that neutralize group 1 and 2 strains. Structural characterization shows that antibody 28-12 binds a continuous epitope within H3 (group 2) but requires a conformational epitope for H1 (group 1) binding. Comparison of germline-reverted Ab and intermediate mutants provides evidence for an evolutionary adaptation from group 2 to group 1 strain.
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19
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Anliker M, Drees D, Loacker L, Hafner S, Griesmacher A, Hoermann G, Fux V, Schennach H, Hörtnagl P, Dopler A, Schmidt S, Bellmann-Weiler R, Weiss G, Marx-Hofmann A, Körper S, Höchsmann B, Schrezenmeier H, Schmidt CQ. Upregulation of Checkpoint Ligand Programmed Death-Ligand 1 in Patients with Paroxysmal Nocturnal Hemoglobinuria Explained by Proximal Complement Activation. J Immunol 2022; 208:1248-1258. [PMID: 35173033 DOI: 10.4049/jimmunol.2100031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 12/17/2021] [Indexed: 12/12/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hemolytic disease driven by impaired complement regulation. Mutations in genes encoding the enzymes that build the GPI anchors are causative, with somatic mutations in the PIG-A gene occurring most frequently. As a result, the important membrane-bound complement regulators CD55 and CD59 are missing on the affected hematopoietic stem cells and their progeny, rendering those cells vulnerable to complement attack. Immune escape mechanisms sparing affected PNH stem cells from removal are suspected in the PNH pathogenesis, but molecular mechanisms have not been elucidated. We hypothesized that exuberant complement activity in PNH results in enhanced immune checkpoint interactions, providing a molecular basis for the potential immune escape in PNH. In a series of PNH patients, we found increased expression levels of the checkpoint ligand programmed death-ligand 1 (PD-L1) on granulocytes and monocytes, as well as in the plasma of PNH patients. Mechanistically, we demonstrate that complement activation leading to the decoration of particles/cells with C3- and/or C4-opsonins increased PD-L1 expression on neutrophils and monocytes as shown for different in vitro models of classical or alternative pathway activation. We further establish in vitro that complement inhibition at the level of C3, but not C5, inhibits the alternative pathway-mediated upregulation of PD-L1 and show by means of soluble PD-L1 that this observation translates into the clinical situation when PNH patients are treated with either C3 or C5 inhibitors. Together, the presented data show that the checkpoint ligand PD-L1 is increased in PNH patients, which correlates with proximal complement activation.
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Affiliation(s)
- Markus Anliker
- Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital, Innsbruck, Austria
| | - Daniela Drees
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany.,Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Lorin Loacker
- Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital, Innsbruck, Austria
| | - Susanne Hafner
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany
| | - Andrea Griesmacher
- Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital, Innsbruck, Austria
| | - Gregor Hoermann
- Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital, Innsbruck, Austria.,MLL Munich Leukemia Laboratory, Munich, Germany
| | - Vilmos Fux
- Central Institute for Medical and Chemical Laboratory Diagnosis, University Hospital, Innsbruck, Austria
| | - Harald Schennach
- Central Institute of Blood Transfusion and Immunology, University Hospital Innsbruck, Innsbruck, Austria
| | - Paul Hörtnagl
- Central Institute of Blood Transfusion and Immunology, University Hospital Innsbruck, Innsbruck, Austria
| | - Arthur Dopler
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany
| | - Stefan Schmidt
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria; and
| | - Rosa Bellmann-Weiler
- Department of Internal Medicine II, Innsbruck Medical University, Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Innsbruck Medical University, Innsbruck, Austria
| | - Astrid Marx-Hofmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany.,Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Sixten Körper
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany.,Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany.,Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, Ulm, Germany; .,Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden-Württemberg-Hessen and University Hospital of Ulm, Ulm, Germany
| | - Christoph Q Schmidt
- Institute of Pharmacology of Natural Products and Clinical Pharmacology, Ulm University, Ulm, Germany;
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20
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Lee PS, MacDonald KG, Massi E, Chew PV, Bee C, Perkins P, Chau B, Thudium K, Lohre J, Nandi P, Deyanova EG, Barman I, Gudmundsson O, Dollinger G, Sproul T, Engelhardt JJ, Strop P, Rajpal A. Improved therapeutic index of an acidic pH-selective antibody. MAbs 2022; 14:2024642. [PMID: 35192429 PMCID: PMC8865267 DOI: 10.1080/19420862.2021.2024642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although therapeutically efficacious, ipilimumab can exhibit dose-limiting toxicity that prevents maximal efficacious clinical outcomes and can lead to discontinuation of treatment. We hypothesized that an acidic pH-selective ipilimumab (pH Ipi), which preferentially and reversibly targets the acidic tumor microenvironment over the neutral periphery, may have a more favorable therapeutic index. While ipilimumab has pH-independent CTLA-4 affinity, pH Ipi variants have been engineered to have up to 50-fold enhanced affinity to CTLA-4 at pH 6.0 compared to pH 7.4. In hCTLA-4 knock-in mice, these variants have maintained anti-tumor activity and reduced peripheral activation, a surrogate marker for toxicity. pH-sensitive therapeutic antibodies may be a differentiating paradigm and a novel modality for enhanced tumor targeting and improved safety profiles.
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Affiliation(s)
- Peter S Lee
- Discovery Biotherapeutics, Bristol Myers Squibb, Redwood City, CA, USA
| | | | - Evan Massi
- Immuno-Oncology Research, Bristol Myers Squibb, Redwood City, CA, USA
| | - Pamela V Chew
- Oncology Biology, Gilead Sciences, Foster City, CA, USA
| | - Christine Bee
- Discovery Biology, Frontier Medicines, South San Francisco, CA, USA
| | - Padma Perkins
- Immuno-Oncology Research, Bristol Myers Squibb, Redwood City, CA, USA
| | - Bryant Chau
- Kyverna, Synthetic Biology, Emeryville, CA, USA
| | - Kent Thudium
- Immuno-Oncology Research, Bristol Myers Squibb, Redwood City, CA, USA
| | - Jack Lohre
- In Vivo Pharmacology, Bristol Myers Squibb, Redwood City, CA, USA
| | - Pradyot Nandi
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb, Lawrenceville, NJ, USA
| | - Ekaterina G Deyanova
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb, Lawrenceville, NJ, USA
| | - Ishita Barman
- Therapeutic Discovery, 3T Biosciences, South San Francisco, CA, USA
| | - Olafur Gudmundsson
- Pharmaceutical Candidate Optimization, Bristol Myers Squibb, Lawrenceville, NJ, USA
| | - Gavin Dollinger
- Discovery Biotherapeutics, Bristol Myers Squibb, Redwood City, CA, USA
| | - Tim Sproul
- In Vivo Pharmacology, UNITY Biotechnology, South San Francisco, CA, USA
| | | | - Pavel Strop
- Biologics Discovery, Tallac Therapeutics, Burlingame, CA, USA
| | - Arvind Rajpal
- Large Molecule Drug Discovery, Genentech Research and Early Development, South San Francisco, CA, USA
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21
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Abstract
INTRODUCTION Eculizumab, the first anti-C5 monoclonal antibody approved for patients with paroxysmal nocturnal hemoglobinuria (PNH), has revolutionized the natural history of this disease, blocking intravascular hemolysis, reducing the risk of thrombo-embolic events, resulting in a significant improvement in survival and quality of life. However, the hematological response to eculizumab is extremely heterogeneous, with only one-third of PNH patients reaching normal hemoglobin levels. AREAS COVERED This article reviews the current new drugs being investigated in phase II and III trials for adult PNH patients. Literature search was performed using Medline and Clinicaltrials.org databases. EXPERT OPINION The new molecules have been classified according to the target of the complement system on which they act; we have novel terminal complement inhibitors, which target C5, and proximal complement inhibitors, which interfere with C3 or even further upstream (factor B and D). Ravulizumab is the first next-generation C5 inhibitor, approved by FDA and EMA, which reproduced the excellent results achieved with eculizumab, trying to improve the convenience of patients. However, unresolved issues remain, such as C3-mediated extravascular hemolysis, on which novel proximal complement inhibitors are showing their efficacy. Pegcetacoplan is the first C3-inihibitor approved by FDA. Long-term safety data for novel complement inhibitors are needed.
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Affiliation(s)
- Camilla Frieri
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital, Paris, France.,University Paris Diderot, Paris, France.,Federico II University of Naples, Department of Clinical Medicine and Surgery, Naples, Italy
| | - Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital, Paris, France.,University Paris Diderot, Paris, France.,Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, Netherlands
| | - Flore Sicre De Fontbrune
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital, Paris, France.,University Paris Diderot, Paris, France
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22
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Abstract
pH-dependent antigen binding has proven useful in engineering next-generation therapeutics specifically via antibody recycling technology. This technology allows for half-life extension, thereby lowering the amount and frequency of dosing of therapeutics. Cell sorting, coupled with display techniques, has been used extensively for the selection of high-affinity binders. Herein, we describe a cell sorting methodology utilizing yeast surface display for selection of binding proteins with strong binding at physiological pH and weak to no binding at acidic pH. This methodology can be readily applied to engineer proteins and/or antibodies that do not have pH-dependent binding or for selection of de novo pH-dependent binders using library-based methods.
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Affiliation(s)
- Jenna N Meanor
- Department of Chemical and Biomolecular Engineering, North Carolina State University, Raleigh, NC, USA
| | - Albert J Keung
- Department of Chemical and Biomolecular Engineering, North Carolina State University, Raleigh, NC, USA
| | - Balaji M Rao
- Department of Chemical and Biomolecular Engineering, North Carolina State University, Raleigh, NC, USA
- Golden LEAF Biomanufacturing Training and Education Center (BTEC), North Carolina State University, Raleigh, NC, USA
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23
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Hori Y, Ohmine K, Katada H, Noguchi Y, Sato K, Nambu T, Adeline LR, Wan GS, Haraya K, Ozeki K, Nanami M, Tachibana T, Sampei Z, Kuramochi T, Nezu J, Hattori K, Igawa T. Elimination of plasma soluble antigen in cynomolgus monkeys by combining pH-dependent antigen binding and novel Fc engineering. MAbs 2022; 14:2068213. [PMID: 35482905 PMCID: PMC9067469 DOI: 10.1080/19420862.2022.2068213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A conventional antibody targeting a soluble antigen in circulation typically requires a huge dosage and frequent intravenous administration to neutralize the antigen. This is because antigen degradation is reduced by the formation of antigen–antibody immune complexes, which escape from lysosomal degradation using neonatal Fc receptor (FcRn)-mediated recycling. To address this, we developed an antigen-sweeping antibody that combines pH-dependent antigen binding and Fc engineering to enhance Fc receptor binding. The sweeping antibody actively eliminates the plasma antigens by increasing the cellular uptake of the immune complex and dissociating the antigens in the acidic endosome for degradation. Strong antigen sweeping can reduce the dosage, potentially achieve higher efficacy, and expand the scope of antigen space available for targeting by antibodies. In this study, to further improve the sweeping efficacy, we developed a novel antibody Fc variant by enhancing Fcγ receptor IIb (FcγRIIb) binding and modulating charge characteristics for increased cellular uptake of the immune complex, together with enhancing FcRn binding for efficient salvage of the antigen-free antibodies. Our Fc variant achieved strong antigen sweeping in cynomolgus monkeys with antibody pharmacokinetics comparable to a wild-type human IgG1 antibody. The positive-charge substitutions enhanced uptake of the immune complex by FcγRIIb-expressing cells in vitro, which was completely inhibited by an anti-FcγRIIb antibody. This suggests that the strong in vivo sweeping efficacy improved by the charge engineering is more likely achieved by FcγRIIb-dependent uptake of the immune complex rather than nonspecific uptake. We expect this novel Fc engineering can maximize the antigen sweeping efficacy even in humans and create novel therapeutic antibodies that meet unmet medical needs for patients.
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Affiliation(s)
- Yuji Hori
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | - Ken Ohmine
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | | | - Yuki Noguchi
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | - Kazuki Sato
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | | | | | | | - Kenta Haraya
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | - Kazuhisa Ozeki
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | - Masahiko Nanami
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | | | - Zenjiro Sampei
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | - Taichi Kuramochi
- Research Division, Chugai Pharmaceutical Co, Ltd, Gotemba, Japan
| | - Junichi Nezu
- Research Division, Chugai Pharmaceutical Co, Ltd, Chuo-ku, Tokyo, Japan
| | - Kunihiro Hattori
- Research Division, Chugai Pharmaceutical Co, Ltd, Kamakura, Japan
| | - Tomoyuki Igawa
- Research Division, Chugai Pharmaceutical Co, Ltd, Chuo-ku, Tokyo, Japan
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24
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Grevys A, Frick R, Mester S, Flem-Karlsen K, Nilsen J, Foss S, Sand KMK, Emrich T, Fischer JAA, Greiff V, Sandlie I, Schlothauer T, Andersen JT. Antibody variable sequences have a pronounced effect on cellular transport and plasma half-life. iScience 2022; 25:103746. [PMID: 35118359 PMCID: PMC8800109 DOI: 10.1016/j.isci.2022.103746] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/11/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022] Open
Abstract
Monoclonal IgG antibodies are the fastest growing class of biologics, but large differences exist in their plasma half-life in humans. Thus, to design IgG antibodies with favorable pharmacokinetics, it is crucial to identify the determinants of such differences. Here, we demonstrate that the variable region sequences of IgG antibodies greatly affect cellular uptake and subsequent recycling and rescue from intracellular degradation by endothelial cells. When the variable sequences are masked by the cognate antigen, it influences both their transport behavior and binding to the neonatal Fc receptor (FcRn), a key regulator of IgG plasma half-life. Furthermore, we show how charge patch differences in the variable domains modulate both binding and transport properties and that a short plasma half-life, due to unfavorable charge patches, may partly be overcome by Fc-engineering for improved FcRn binding. IgG variable region sequences greatly affect cellular uptake and recycling Variable region charge patches affect FcRn binding and transport The presence of cognate antigen modulates cellular transport and FcRn binding Fc-engineering for improved FcRn binding can overcome unfavorable charge patches
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Affiliation(s)
- Algirdas Grevys
- Centre for Immune Regulation (CIR) and Department of Biosciences, University of Oslo, 0371 Oslo, Norway
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
- Roche Pharma Research and Early Development (pRED), Roche Innovation Center Munich, 82377 Penzberg, Germany
- Corresponding author
| | - Rahel Frick
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Simone Mester
- Centre for Immune Regulation (CIR) and Department of Biosciences, University of Oslo, 0371 Oslo, Norway
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Karine Flem-Karlsen
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Jeannette Nilsen
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Stian Foss
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Kine Marita Knudsen Sand
- Centre for Immune Regulation (CIR) and Department of Biosciences, University of Oslo, 0371 Oslo, Norway
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Thomas Emrich
- Roche Pharma Research and Early Development (pRED), Roche Innovation Center Munich, 82377 Penzberg, Germany
| | | | - Victor Greiff
- Department of Immunology, Institute of Clinical Medicine, University of Oslo, 0424 Oslo, Norway
| | - Inger Sandlie
- Centre for Immune Regulation (CIR) and Department of Biosciences, University of Oslo, 0371 Oslo, Norway
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Tilman Schlothauer
- Roche Pharma Research and Early Development (pRED), Roche Innovation Center Munich, 82377 Penzberg, Germany
| | - Jan Terje Andersen
- CIR and Department of Immunology, Oslo University Hospital Rikshospitalet, 0372 Oslo, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
- Corresponding author
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25
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Ruck T, Nimmerjahn F, Wiendl H, Lünemann JD. Next generation antibody-based therapies in neurology. Brain 2021; 145:1229-1241. [PMID: 34928330 DOI: 10.1093/brain/awab465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Antibody (Ab)-based therapeutics are now standard in the treatment of neuroinflammatory diseases, and the spectrum of neurological diseases targeted by those approaches continues to grow. The efficacy of Ab-based drug-platforms is largely determined by the specificity-conferring antigen-binding fragment (Fab) and the crystallizable fragment (Fc) driving antibody function. The latter provides specific instructions to the immune system by interacting with cellular Fc receptors and complement components. Extensive engineering efforts enabled tuning of Fc functions to modulate effector functions and to prolong or reduce Ab serum half-lives. Technologies that improve bioavailability of Ab-based treatment platforms within the central nervous system parenchyma are being developed and could invigorate drug discovery for a number of brain diseases for which current therapeutic options are limited. These powerful approaches are currently being tested in clinical trials or have been successfully translated into the clinic. Here, we review recent developments in the design and implementation of Ab-based treatment modalities in neurological diseases.
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Affiliation(s)
- Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany.,Department of Neurology, Heinrich-Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Falk Nimmerjahn
- Department of Biology, Division of Genetics, University of Erlangen-Nuremberg, 91058 Erlangen, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, 48149 Münster, Germany
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26
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Raina R, Vijayvargiya N, Khooblall A, Melachuri M, Deshpande S, Sharma D, Mathur K, Arora M, Sethi SK, Sandhu S. Pediatric Atypical Hemolytic Uremic Syndrome Advances. Cells 2021; 10:3580. [PMID: 34944087 PMCID: PMC8700093 DOI: 10.3390/cells10123580] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 12/30/2022] Open
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare disorder characterized by dysregulation of the alternate pathway. The diagnosis of aHUS is one of exclusion, which complicates its early detection and corresponding intervention to mitigate its high rate of mortality and associated morbidity. Heterozygous mutations in complement regulatory proteins linked to aHUS are not always phenotypically active, and may require a particular trigger for the disease to manifest. This list of triggers continues to expand as more data is aggregated, particularly centered around COVID-19 and pediatric vaccinations. Novel genetic mutations continue to be identified though advancements in technology as well as greater access to cohorts of interest, as in diacylglycerol kinase epsilon (DGKE). DGKE mutations associated with aHUS are the first non-complement regulatory proteins associated with the disease, drastically changing the established framework. Additional markers that are less understood, but continue to be acknowledged, include the unique autoantibodies to complement factor H and complement factor I which are pathogenic drivers in aHUS. Interventional therapeutics have undergone the most advancements, as pharmacokinetic and pharmacodynamic properties are modified as needed in addition to their as biosimilar counterparts. As data continues to be gathered in this field, future advancements will optimally decrease the mortality and morbidity of this disease in children.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA; (N.V.); (A.K.); (S.D.); (K.M.); (M.A.)
- Department of Nephrology, Akron Children’s Hospital, Akron, OH 44308, USA
| | - Nina Vijayvargiya
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA; (N.V.); (A.K.); (S.D.); (K.M.); (M.A.)
| | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA; (N.V.); (A.K.); (S.D.); (K.M.); (M.A.)
| | - Manasa Melachuri
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA; (M.M.); (D.S.)
| | - Shweta Deshpande
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA; (N.V.); (A.K.); (S.D.); (K.M.); (M.A.)
| | - Divya Sharma
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA; (M.M.); (D.S.)
| | - Kashin Mathur
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA; (N.V.); (A.K.); (S.D.); (K.M.); (M.A.)
| | - Manav Arora
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA; (N.V.); (A.K.); (S.D.); (K.M.); (M.A.)
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon 122007, India;
| | - Sonia Sandhu
- Hematology and Oncology, Cleveland Clinic Akron General Medical Center, Akron, OH 44307, USA;
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27
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Gurnari C, Nautiyal I, Pagliuca S. Current Opinions on the Clinical Utility of Ravulizumab for the Treatment of Paroxysmal Nocturnal Hemoglobinuria. Ther Clin Risk Manag 2021; 17:1343-1351. [PMID: 34934322 PMCID: PMC8684432 DOI: 10.2147/tcrm.s273360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/28/2021] [Indexed: 01/15/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder of hematopoietic stem cells genetically defined by the acquisition of somatic mutations in the X-linked phosphatidylinositol glycan anchor biosynthesis, class A (PIGA) gene. PIGA is essential for the synthesis of glycosyl phosphatidylinositol (GPI) anchor proteins and its mutations result in a deficiency of such molecules on the membrane of blood cells derived from the mutant clone. In particular, the lack of the GPI-linked complement regulatory proteins CD55 and CD59 is responsible for the increased sensitivity of PNH erythrocytes to complement-mediated destruction. Indeed, the classical clinical picture of PNH includes signs and symptoms of intravascular hemolysis along with variable degrees of cytopenia and a strong tendency to thrombosis, hallmarks of the disease. Before the introduction of anti-complement inhibitors, PNH was characterized by a high mortality primarily due to thrombotic events. The approval of the terminal anti-complement inhibitor eculizumab in 2007 introduced a paradigm shift in the treatment of the disease with improvement of the chronic hemolytic process and dramatic reduction of the thrombotic rate. However, eculizumab has a relatively short half-life when considering a life-long treatment, with obvious consequences as to the quality of life of treated patients necessitating relatively frequent drug administrations. Moreover, up to 30% of PNH patients undergoing eculizumab therapy show a suboptimal response, continuing to require red cell transfusions because of extravascular hemolysis or breakthrough hemolytic episodes. In 2019, the FDA approved the second-generation C5 inhibitor ravulizumab, a long-lasting agent with a better control of disease manifestations. Herein, we discuss the use of ravulizumab in PNH, its differences with first-generation C5 inhibitors, the research evidence supporting the safety and efficacy of this drug and its impact on costs for health systems and quality of life of PNH patients.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Ishani Nautiyal
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
- ED561 Hematology, Oncogenesis and Biotherapies, University of Paris, Paris, France
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28
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Gavriilaki E, Peffault de Latour R, Risitano AM. Advancing therapeutic complement inhibition in hematologic diseases: PNH and beyond. Blood 2021:blood. [PMID: 34482398 DOI: 10.1182/blood.2021012860] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/11/2021] [Indexed: 11/20/2022] Open
Abstract
Complement is an elaborate system of the innate immunity. Genetic variants and autoantibodies leading to excessive complement activation are implicated in a variety of human diseases. Among them, the hematologic disease paroxysmal nocturnal hemoglobinuria (PNH) remains the prototype model of complement activation and inhibition. Eculizumab, the first-in-class complement inhibitor, was approved for PNH in 2007. Addressing some of the unmet needs, a long-acting C5 inhibitor, ravulizumab, and a C3 inhibitor, pegcetacoplan have been also now approved with PNH. Novel agents, such as factor B and factor D inhibitors, are under study with very promising results. In this era of several approved targeted complement therapeutics, selection of the proper drug needs to be based on a personalized approach. Beyond PNH, complement inhibition has also shown efficacy and safety in cold agglutinin disease (CAD), primarily with the C1s inhibitor of the classical complement pathway, sutimlimab, but also with pegcetacoplan. Furthermore, C5 inhibition with eculizumab and ravulizumab, as well as inhibition of the lectin pathway with narsoplimab, are investigated in transplant-associated thrombotic microangiopathy (TA-TMA). With this revolution of next-generation complement therapeutics, additional hematologic entities, such as delayed hemolytic transfusion reaction (DHTR) or immune thrombocytopenia (ITP), might also benefit from complement inhibitors. Therefore, this review aims to describe state-of-the-art knowledge of targeting complement in hematologic diseases focusing on: a) complement biology for the clinician, b) complement activation and therapeutic inhibition in prototypical complement-mediated hematologic diseases, c) hematologic entities under investigation for complement inhibition, and d) other complement-related disorders of potential interest to hematologists.
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29
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Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by complement-mediated intravascular haemolysis, severe thrombophilia and bone marrow failure. While for patients with bone marrow failure the treatment follows that of immune-mediated aplastic anaemia, that of classic, haemolytic PNH is based on anti-complement medication. The anti-C5 monoclonal antibody eculizumab has revolutionized treatment, resulting in control of intravascular haemolysis and thromboembolic risk, with improved long-term survival. Novel strategies of complement inhibition are emerging. New anti-C5 agents reproduce the safety and efficacy of eculizumab, with improved patient convenience. Proximal complement inhibitors have been developed to address C3-mediated extra-vascular haemolysis and seem to improve haematological response.
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Affiliation(s)
- Antonio Maria Risitano
- Department of Onco-Hematology, AORN San Giuseppe Moscati Avellino, Avellino, Italy.,Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.,Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands
| | - Régis Peffault de Latour
- Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands.,French Reference Centre for Aplastic Anaemia and Paroxysmal Nocturnal Haemoglobinuria, Assistance Publique - Hôpitaux de Paris, Saint-Louis Hospital, Paris, France.,Bone Marrow Transplant Unit, Université de Paris, Denis Diderot, Paris, France
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30
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Sultan EY, Rizk DE, Kenawy HI, Hassan R. A small fragment of factor B as a potential inhibitor of complement alternative pathway activity. Immunobiology 2021; 226:152106. [PMID: 34147816 DOI: 10.1016/j.imbio.2021.152106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The complement system is a key player in innate immunity and a modulator of the adaptive immune system. Among the three pathways of complement, the alternative pathway (AP) accounts for most of the complement activation. Factor B (FB) is a major protease of the AP, making it a promising target to inhibit the AP activity in conditions of uncontrolled complement activation. METHODS Based on the data obtained from sequence analysis and conformational changes associated with FB, we expressed and purified a recombinant FB fragment (FBfr). We tested the inhibitory activity of the protein against the AP by in vitro assays. RESULTS FBfr protein was proven to inhibit the complement AP activity when tested by C3b deposition assay and rabbit erythrocyte hemolytic assay. CONCLUSION Our recombinant FBfr was able to compete with the native human FB, which allowed it to inhibit the AP activity. This novel compound is a good candidate for further characterization and testing to be used in complement diagnostic tests and as a drug lead in the field of complement therapeutics.
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Affiliation(s)
- Enas Yasser Sultan
- Department of Microbiology & Immunology, Faculty of Pharmacy, Mansoura University, Egypt
| | - Dina Eid Rizk
- Department of Microbiology & Immunology, Faculty of Pharmacy, Mansoura University, Egypt
| | - Hany Ibrahim Kenawy
- Department of Microbiology & Immunology, Faculty of Pharmacy, Mansoura University, Egypt.
| | - Ramadan Hassan
- Department of Microbiology & Immunology, Faculty of Pharmacy, Mansoura University, Egypt
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31
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Haraya K, Tachibana T. Estimation of Clearance and Bioavailability of Therapeutic Monoclonal Antibodies from Only Subcutaneous Injection Data in Humans Based on Comprehensive Analysis of Clinical Data. Clin Pharmacokinet 2021; 60:1325-1334. [PMID: 33954956 PMCID: PMC8505369 DOI: 10.1007/s40262-021-01023-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 01/03/2023]
Abstract
Introduction Theoretically, the separate estimation of clearance (CL) and bioavailability (F) requires both intravenous and extravascular injection data. This study investigated whether CL and subcutaneous F of therapeutic monoclonal antibodies (mAbs) in humans can be separately estimated from subcutaneous injection data only. Methods First, the geometric mean of linear pharmacokinetic parameters (CL, intercompartmental CL [Q], volume of distribution in the central compartment [Vc], and volume of distribution in the peripheral compartment [Vp]) after intravenous injection for mAbs in humans that have been reported in public data sources was estimated from 103 mAbs with linear pharmacokinetics and 44 mAbs with nonlinear pharmacokinetics. Next, we estimated the CL and F of 25 mAbs with linear pharmacokinetics from plasma/serum mAb concentration–time profiles after subcutaneous injection in humans by fixing the geometric mean of Q, Vc, and Vp based on the public data. Moreover, the plasma/serum concentration–time profile of 25 mAbs after intravenous injection was simulated using the estimated CL and the geometric mean of Q, Vc, and Vp. Results There were no significant differences in parameters among subclasses (immunoglobulin [Ig] G1, 2, and 4) or in linearity (derivation from linear and nonlinear pharmacokinetics). Using only subcutaneous injection data, we successfully estimated the CL of 23/25 mAbs (92%) and F of all 25 mAbs (100%) within 1.5-fold of the observed value. Moreover, overall, the simulated concentration–time profiles were largely consistent with observed data (90.8% within 1.5-fold of the observed values). Conclusions This approach does not require intravenous injection data to separately estimate CL and F after subcutaneous injection in humans and can therefore accelerate the clinical development of mAbs. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01023-z.
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Affiliation(s)
- Kenta Haraya
- Chugai Pharmaceutical Co., Ltd, 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan.
| | - Tatsuhiko Tachibana
- Chugai Pharmaceutical Co., Ltd, 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
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32
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Höchsmann B, Körper S, Schrezenmeier H. Komplementinhibitoren: neue Therapeutika – neue Indikationen. Transfusionsmedizin 2021. [DOI: 10.1055/a-1145-5522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungDas Komplementsystem, ein klassisch transfusionsmedizinisches Thema, hat in den letzten Jahren in allen Bereichen der Medizin an Bedeutung gewonnen. Komplementinhibitoren werden aufgrund eines besseren Verständnisses der Pathophysiologie unterschiedlicher Erkrankungen in einem sich stetig erweiternden Krankheitsspektrum eingesetzt. Dieses reicht von typisch komplementassoziierten Erkrankungen wie der PNH (paroxysmale nächtliche Hämoglobinurie) bis hin zu akuten Krankheitsbildern mit einer Fehlregulation des Komplementsystems, wie COVID-19.
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Affiliation(s)
- Britta Höchsmann
- Institut für Klinische Transfusionsmedizin und Immungenetik Ulm, DRK-Blutspendedienst Baden-Württemberg-Hessen und Universitätsklinikum Ulm; Institut für Transfusionsmedizin, Universität Ulm
| | - Sixten Körper
- Institut für Klinische Transfusionsmedizin und Immungenetik Ulm, DRK-Blutspendedienst Baden-Württemberg-Hessen und Universitätsklinikum Ulm; Institut für Transfusionsmedizin, Universität Ulm
| | - Hubert Schrezenmeier
- Institut für Klinische Transfusionsmedizin und Immungenetik Ulm, DRK-Blutspendedienst Baden-Württemberg-Hessen und Universitätsklinikum Ulm; Institut für Transfusionsmedizin, Universität Ulm
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33
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Wang B, Gallolu Kankanamalage S, Dong J, Liu Y. Optimization of therapeutic antibodies. Antib Ther 2021; 4:45-54. [PMID: 33928235 PMCID: PMC7944496 DOI: 10.1093/abt/tbab003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/15/2021] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
In this review, we have summarized the current landscape of therapeutic antibody optimization for successful development. By engineering antibodies with display technology, computer-aided design and site mutagenesis, various properties of the therapeutic antibody candidates can be improved with the purpose of enhancing their safety, efficacy and developability. These properties include antigen binding affinity and specificity, biological efficacy, pharmacokinetics and pharmacodynamics, immunogenicity and physicochemical developability features. A best-in-class strategy may require the optimization of all these properties to generate a good therapeutic antibody.
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Affiliation(s)
- Bo Wang
- Ab Studio, Inc. Hayward, CA 94545, USA
| | | | | | - Yue Liu
- Ab Studio, Inc. Hayward, CA 94545, USA
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34
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Abstract
As an essential modulator of IgG disposition, the neonatal Fc receptor (FcRn) governs the pharmacokinetics and functions many therapeutic modalities. In this review, we thoroughly reexamine the hitherto elucidated biological and thermodynamic properties of FcRn to provide context for our assessment of more recent advances, which covers antigen-binding fragment (Fab) determinants of FcRn affinity, transgenic preclinical models, and FcRn targeting as an immune-complex (IC)-clearing strategy. We further comment on therapeutic antibodies authorized for treating SARS-CoV-2 (bamlanivimab, casirivimab, and imdevimab) and evaluate their potential to saturate FcRn-mediated recycling. Finally, we discuss modeling and simulation studies that probe the quantitative relationship between in vivo IgG persistence and in vitro FcRn binding, emphasizing the importance of endosomal transit parameters.
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Affiliation(s)
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA;
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35
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Macpherson A, Laabei M, Ahdash Z, Graewert MA, Birtley JR, Schulze MSE, Crennell S, Robinson SA, Holmes B, Oleinikovas V, Nilsson PH, Snowden J, Ellis V, Mollnes TE, Deane CM, Svergun D, Lawson AD, van den Elsen JM. The allosteric modulation of complement C5 by knob domain peptides. eLife 2021; 10:63586. [PMID: 33570492 PMCID: PMC7972453 DOI: 10.7554/elife.63586] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/11/2021] [Indexed: 12/22/2022] Open
Abstract
Bovines have evolved a subset of antibodies with ultra-long heavy chain complementarity determining regions that harbour cysteine-rich knob domains. To produce high-affinity peptides, we previously isolated autonomous 3–6 kDa knob domains from bovine antibodies. Here, we show that binding of four knob domain peptides elicits a range of effects on the clinically validated drug target complement C5. Allosteric mechanisms predominated, with one peptide selectively inhibiting C5 cleavage by the alternative pathway C5 convertase, revealing a targetable mechanistic difference between the classical and alternative pathway C5 convertases. Taking a hybrid biophysical approach, we present C5-knob domain co-crystal structures and, by solution methods, observed allosteric effects propagating >50 Å from the binding sites. This study expands the therapeutic scope of C5, presents new inhibitors, and introduces knob domains as new, low molecular weight antibody fragments, with therapeutic potential. Antibodies are proteins produced by the immune system that can selectively bind to other molecules and modify their behaviour. Cows are highly equipped at fighting-off disease-causing microbes due to the unique shape of some of their antibodies. Unlike other jawed vertebrates, cows’ antibodies contain an ultra-long loop region that contains a ‘knob domain’ which sticks out from the rest of the antibody. Recent research has shown that when detached, the knob domain behaves like an antibody fragment, and can independently bind to a range of different proteins. Antibody fragments are commonly developed in the laboratory to target proteins associated with certain diseases, such as arthritis and cancer. But it was unclear whether the knob domains from cows’ antibodies could also have therapeutic potential. To investigate this, Macpherson et al. studied how knob domains attach to complement C5, a protein in the inflammatory pathway which is a drug target for various diseases, including severe COVID-19. The experiments identified various knob domains that bind to complement C5 and inhibits its activity by altering its structure or movement. Further tests studying the structure of these interactions, led to the discovery of a common mechanism by which inhibitors can modify the behaviour of this inflammatory protein. Complement C5 is involved in numerous molecular pathways in the immune system, which means many of the drugs developed to inhibit its activity can also leave patients vulnerable to infection. However, one of the knob domains identified by Macpherson et al. was found to reduce the activity of complement C5 in some pathways, whilst leaving other pathways intact. This could potentially reduce the risk of bacterial infections which sometimes arise following treatment with these types of inhibitors. These findings highlight a new approach for developing drug inhibitors for complement C5. Furthermore, the ability of knob domains to bind to multiple sites of complement C5 suggests that this fragment could be used to target proteins associated with other diseases.
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Affiliation(s)
- Alex Macpherson
- UCB, Slough, United Kingdom.,Department of Biology and Biochemistry, University of Bath, Bath, United Kingdom
| | - Maisem Laabei
- Department of Biology and Biochemistry, University of Bath, Bath, United Kingdom
| | | | | | | | | | - Susan Crennell
- Department of Biology and Biochemistry, University of Bath, Bath, United Kingdom
| | - Sarah A Robinson
- Department of Statistics, University of Oxford, Oxford, United Kingdom
| | | | | | - Per H Nilsson
- UCB, Slough, United Kingdom.,Department of Chemistry and Biomedicine, Linnaeus University, Kalmar, Sweden.,Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway
| | | | | | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital, University of Oslo, Oslo, Norway.,Research Laboratory, Bodø Hospital, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway.,Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Charlotte M Deane
- Department of Statistics, University of Oxford, Oxford, United Kingdom
| | - Dmitri Svergun
- European Molecular Biology Laboratory, Hamburg Unit, Hamburg, Germany
| | | | - Jean Mh van den Elsen
- Department of Biology and Biochemistry, University of Bath, Bath, United Kingdom.,Centre for Therapeutic Innovation, University of Bath, Bath, United Kingdom
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36
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Ozen A, Kasap N, Vujkovic-Cvijin I, Apps R, Cheung F, Karakoc-Aydiner E, Akkelle B, Sari S, Tutar E, Ozcay F, Uygun DK, Islek A, Akgun G, Selcuk M, Sezer OB, Zhang Y, Kutluk G, Topal E, Sayar E, Celikel C, Houwen RHJ, Bingol A, Ogulur I, Eltan SB, Snow AL, Lake C, Fantoni G, Alba C, Sellers B, Chauvin SD, Dalgard CL, Harari O, Ni YG, Wang MD, Devalaraja-Narashimha K, Subramanian P, Ergelen R, Artan R, Guner SN, Dalgic B, Tsang J, Belkaid Y, Ertem D, Baris S, Lenardo MJ. Broadly effective metabolic and immune recovery with C5 inhibition in CHAPLE disease. Nat Immunol 2021; 22:128-39. [PMID: 33398182 DOI: 10.1038/s41590-020-00830-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/28/2020] [Indexed: 01/29/2023]
Abstract
Complement hyperactivation, angiopathic thrombosis and protein-losing enteropathy (CHAPLE disease) is a lethal disease caused by genetic loss of the complement regulatory protein CD55, leading to overactivation of complement and innate immunity together with immunodeficiency due to immunoglobulin wasting in the intestine. We report in vivo human data accumulated using the complement C5 inhibitor eculizumab for the medical treatment of patients with CHAPLE disease. We observed cessation of gastrointestinal pathology together with restoration of normal immunity and metabolism. We found that patients rapidly renormalized immunoglobulin concentrations and other serum proteins as revealed by aptamer profiling, re-established a healthy gut microbiome, discontinued immunoglobulin replacement and other treatments and exhibited catch-up growth. Thus, we show that blockade of C5 by eculizumab effectively re-establishes regulation of the innate immune complement system to substantially reduce the pathophysiological manifestations of CD55 deficiency in humans.
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Abstract
The C5 targeting monoclonal antibody eculizumab has changed the natural history of paroxysmal nocturnal hemoglobinuria (PNH) in the last 10 years. However, some unmet clinical needs persist, including persistent anemia with some patients requiring transfusions, incomplete C5 inhibition with breakthrough hemolysis (because of pharmacokinetic or pharmacodynamic issues such as infections, as well as conditions increasing complement activity), the underlying bone marrow failure, and the significant burden on patient quality of life (intravenous route of administration and frequency of infusions). Moreover, a subclass of patients carries C5 polymorphisms resistant to eculizumab inhibition. Several second-generation C5 inhibitors are under active study to overcome unmet clinical needs with eculizumab. Current strategies encompass increasing drug half-life, developing small molecule inhibitors of C5, and exploring new routes of administration (including subcutaneous and oral agents). In this review, we summarize available data on second-generation C5 inhibitors in PNH, including novel monoclonal antibodies, a small interfering RNA, and small molecules.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano e Università degli studi di Milano, Milan, Italy
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, National Institute of Health Research/Wellcome King's Clinical Research Facility, London, SE5 9RS, UK.
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38
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Abstract
Therapeutic antibodies are instrumental in improving the treatment outcome for certain disease conditions. However, to enhance their efficacy and specificity, many efforts are continuously made. One of the approaches that are increasingly explored in this field are pH-responsive antibodies capable of binding target antigens in a pH-dependent manner. We reviewed suitability and examples of these antibodies that are functionally modulated by the tumor microenvironment. Provided in this review is an update about antigens targeted by pH-responsive, sweeping, and recycling antibodies. Applicability of the pH-responsive antibodies in the engineering of chimeric antigen receptor T-cells (CAR-T) and in improving drug delivery to the brain by the enhanced crossing of the blood-brain barrier is also discussed. The pH-responsive antibodies possess strong treatment potential. They emerge as next-generation programmable engineered biologic drugs that are active only within the targeted biological space. Thus, they are valuable in targeting acidified tumor microenvironment because of improved spatial persistence and reduced on-target off-tumor toxicities. We predict that the programmable pH-dependent antibodies become powerful tools in therapies of cancer.
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Affiliation(s)
- Tomasz Klaus
- Research and Development Department, Pure Biologics, Inc., Dunska 11, 54427, Wrocław, Poland
| | - Sameer Deshmukh
- Research and Development Department, Pure Biologics, Inc., Dunska 11, 54427, Wrocław, Poland.
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39
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Agostinis C, Balduit A, Mangogna A, Zito G, Romano F, Ricci G, Kishore U, Bulla R. Immunological Basis of the Endometriosis: The Complement System as a Potential Therapeutic Target. Front Immunol 2021; 11:599117. [PMID: 33505394 PMCID: PMC7829336 DOI: 10.3389/fimmu.2020.599117] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022] Open
Abstract
Endometriosis (EM) is a chronic disease characterized by the presence and proliferation of functional endometrial glands and stroma outside the uterine cavity. Ovaries and pelvic peritoneum are the most common locations for endometrial ectopic tissue, followed by deep infiltrating EM sites. The cyclic and recurrent bleeding, the progressive fibrosis and the peritoneal adhesions of ectopic endometrial glands, may cause different symptoms depending on the origin involved. EM is a frequent clinical condition affecting around 10% of women of mainly reproductive age, as well as in post-menopausal women and adolescents, especially with uterine anomalies. The risk of developing EM depends on a complex interaction between genetic, immunological, hormonal, and environmental factors. It is largely considered to arise due to a dysfunction of immunological surveillance. In fact, women with EM exhibit altered functions of peritoneal macrophages, lymphocytes and natural killer cells, as well as levels of inflammatory mediators and growth factors in the peritoneal fluid. In EM patients, peritoneal macrophages are preponderant and highly active compared to healthy women. Peritoneal macrophages are able to regulate the events that determine the production of cytokines, prostaglandins, growth factors and complement components. Several studies have shown alteration in the regulation of the complement activation, leading to chronic inflammation characteristic of EM. Aberrant regulation/activation of the complement system has been observed in the peritoneal cavity of women affected by EM. Thus, complement inhibition may represent a new approach for the treatment of EM, given that a number of complement inhibitors are under pre-clinical and clinical development. Such an intervention may provide a broader therapeutic control of complement-mediated inflammatory damage in EM patients. This review will focus on our current understanding of the role of complement activation in EM and possible modalities available for complement-based therapy.
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Affiliation(s)
- Chiara Agostinis
- Institute for Maternal and Child Health, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) "Burlo Garofolo", Trieste, Italy
| | - Andrea Balduit
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Alessandro Mangogna
- Institute for Maternal and Child Health, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) "Burlo Garofolo", Trieste, Italy
| | - Gabriella Zito
- Institute for Maternal and Child Health, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) "Burlo Garofolo", Trieste, Italy
| | - Federico Romano
- Institute for Maternal and Child Health, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) "Burlo Garofolo", Trieste, Italy
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) "Burlo Garofolo", Trieste, Italy.,Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Uday Kishore
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, United Kingdom
| | - Roberta Bulla
- Department of Life Sciences, University of Trieste, Trieste, Italy
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40
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Watanabe H, Shibuya M, Shibahara N, Ruike Y, Sampei Z, Haraya K, Tachibana T, Wakabayashi T, Sakamoto A, Tsunoda H, Murao N. A Novel Total Drug Assay for Quantification of Anti-C5 Therapeutic Monoclonal Antibody in the Presence of Abundant Target. AAPS J 2021; 23:21. [PMID: 33415498 DOI: 10.1208/s12248-020-00539-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
SKY59 or RO7112689 is a humanized monoclonal antibody against complement protein C5 with pH-dependent C5-binding and neonatal Fc receptor-mediated recycling capabilities, which result in long-lasting neutralization of C5. We developed and validated a novel total drug assay for quantification of target-binding competent SKY59 in the presence of endogenous C5 in cynomolgus monkey plasma. The target-binding competent SKY59 was determined after complex formation by the addition of recombinant monkey C5 using goat anti-human IgG-heavy chain monkey-adsorbed polyclonal antibody as a capture antibody and rabbit anti-C5 monoclonal antibody (mAb) non-competing with SKY59 for detection. The total SKY59 assay was shown to be accurate and precise over the range of 0.05-3.2 μg/mL as well as be tolerant to more than 400 μg/mL of C5 (~ 3000-fold molar excess of target). We also developed and validated a total C5 assay, confirmed selectivity and parallelism, and verified the utility of recombinant monkey C5 for the total C5 assay as well as the total SKY59 assay. Furthermore, we used these validated methods to measure SKY59 and C5 concentrations in cynomolgus monkey plasma samples in a toxicology study. This total drug assay can be applied not only to other antibody therapeutics against shed/soluble targets when a non-competing reagent mAb is available but also for clinical studies when a reagent mAb specific for engineered Fc region on a therapeutic mAb is available.
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Affiliation(s)
- Hiroo Watanabe
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan.
| | - Mitsuko Shibuya
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Norihito Shibahara
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Yoshinao Ruike
- Research Division, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Zenjiro Sampei
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Kenta Haraya
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Tatsuhiko Tachibana
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Tetsuya Wakabayashi
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Akihisa Sakamoto
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
| | - Hiroyuki Tsunoda
- Research Division, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Naoaki Murao
- Research Division, Chugai Pharmaceutical Co., Ltd., 1-135 Komakado, Gotemba, Shizuoka, 412-8513, Japan
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Ort M, Dingemanse J, van den Anker J, Kaufmann P. Treatment of Rare Inflammatory Kidney Diseases: Drugs Targeting the Terminal Complement Pathway. Front Immunol 2020; 11:599417. [PMID: 33362783 PMCID: PMC7758461 DOI: 10.3389/fimmu.2020.599417] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/09/2020] [Indexed: 12/15/2022] Open
Abstract
The complement system comprises the frontline of the innate immune system. Triggered by pathogenic surface patterns in different pathways, the cascade concludes with the formation of a membrane attack complex (MAC; complement components C5b to C9) and C5a, a potent anaphylatoxin that elicits various inflammatory signals through binding to C5a receptor 1 (C5aR1). Despite its important role in pathogen elimination, priming and recruitment of myeloid cells from the immune system, as well as crosstalk with other physiological systems, inadvertent activation of the complement system can result in self-attack and overreaction in autoinflammatory diseases. Consequently, it constitutes an interesting target for specialized therapies. The paradigm of safe and efficacious terminal complement pathway inhibition has been demonstrated by the approval of eculizumab in paroxysmal nocturnal hematuria. In addition, complement contribution in rare kidney diseases, such as lupus nephritis, IgA nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, or antineutrophil cytoplasmic antibody-associated vasculitis has been demonstrated. This review summarizes the involvement of the terminal effector agents of the complement system in these diseases and provides an overview of inhibitors for complement components C5, C5a, C5aR1, and MAC that are currently in clinical development. Furthermore, a link between increased complement activity and lung damage in severe COVID-19 patients is discussed and the potential for use of complement inhibitors in COVID-19 is presented.
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Affiliation(s)
- Marion Ort
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, United States
| | - Priska Kaufmann
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
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Röth A, Nishimura JI, Nagy Z, Gaàl-Weisinger J, Panse J, Yoon SS, Egyed M, Ichikawa S, Ito Y, Kim JS, Ninomiya H, Schrezenmeier H, Sica S, Usuki K, Sicre de Fontbrune F, Soret J, Sostelly A, Higginson J, Dieckmann A, Gentile B, Anzures-Cabrera J, Shinomiya K, Jordan G, Biedzka-Sarek M, Klughammer B, Jahreis A, Bucher C, Peffault de Latour R. The complement C5 inhibitor crovalimab in paroxysmal nocturnal hemoglobinuria. Blood 2020; 135:912-20. [PMID: 31978221 DOI: 10.1182/blood.2019003399] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/20/2019] [Indexed: 12/31/2022] Open
Abstract
Complement C5 inhibition is the standard of care (SoC) for patients with paroxysmal nocturnal hemoglobinuria (PNH) with significant clinical symptoms. Constant and complete suppression of the terminal complement pathway and the high serum concentration of C5 pose challenges to drug development that result in IV-only treatment options. Crovalimab, a sequential monoclonal antibody recycling technology antibody was engineered for extended self-administered subcutaneous dosing of small volumes in diseases amenable for C5 inhibition. A 3-part open-label adaptive phase 1/2 trial was conducted to assess safety, pharmacokinetics, pharmacodynamics, and exploratory efficacy in healthy volunteers (part 1), as well as in complement blockade-naive (part 2) and C5 inhibitor-treated (part 3) PNH patients. Twenty-nine patients were included in part 2 (n = 10) and part 3 (n = 19). Crovalimab concentrations exceeded the prespecified 100-µg/mL level and resulted in complete and sustained terminal complement pathway inhibition in treatment-naive and C5 inhibitor-pretreated PNH patients. Hemolytic activity and free C5 levels were suppressed below clinically relevant thresholds (liposome assay <10 U/mL and <50 ng/mL, respectively). Safety was consistent with the known profile of C5 inhibition. As expected, formation of drug-target-drug complexes was observed in all 19 patients switching to crovalimab, manifesting as transient mild or moderate vasculitic skin reactions in 2 of 19 participants. Both events resolved under continued treatment with crovalimab. Subcutaneous crovalimab (680 mg; 4 mL), administered once every 4 weeks, provides complete and sustained terminal complement pathway inhibition in patients with PNH, warranting further clinical development (ClinicalTrials.gov identifier, NCT03157635).
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Fukuzawa T, Nezu J. SKY59, A Novel Recycling Antibody for Complement-mediated Diseases. Curr Med Chem 2020; 27:4157-4164. [PMID: 31622197 DOI: 10.2174/0929867326666191016115853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The complement system usually helps protect against microbial infection, but it could also be involved in the onset of various diseases. Inhibition of complement component 5 (C5) with eculizumab has resulted in a significant reduction of hemolysis, reduction of thromboembolic events, and increased survival in patients with Paroxysmal Nocturnal Hemoglobinuria (PNH). However, eculizumab requires frequent intravenous infusions due to the abundance of C5 in plasma and some patients may still experience breakthrough hemolysis. This review introduces the recent body of knowledge on recycling technology and discusses the likely therapeutic benefits of SKY59, a novel recycling antibody, for PNH and complement-mediated disorders. METHODS By using recycling technology, we created a novel anti-C5 antibody, SKY59, capable of binding to C5 pH-dependently. RESULTS In cynomolgus monkeys, SKY59 robustly inhibited C5 and complement activity for significantly longer than a conventional antibody. SKY59 also showed an inhibitory effect on C5 variant p.Arg885His, whereas eculizumab does not suppress complement activity in patients with this type of mutation. CONCLUSION SKY59 is a promising anti-C5 biologic agent that has significant advantages over current therapies such as long duration of action and efficacy against C5 variants.
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Affiliation(s)
- Taku Fukuzawa
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Junichi Nezu
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
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Van de Walle I, Silence K, Budding K, Van de Ven L, Dijkxhoorn K, de Zeeuw E, Yildiz C, Gabriels S, Percier JM, Wildemann J, Meeldijk J, Simons PJ, Boon L, Cox L, Holgate R, Urbanus R, Otten HG, Leusen JHW, Blanchetot C, de Haard H, Hack CE, Boross P. ARGX-117, a therapeutic complement inhibiting antibody targeting C2. J Allergy Clin Immunol 2020; 147:1420-1429.e7. [PMID: 32926878 PMCID: PMC7485568 DOI: 10.1016/j.jaci.2020.08.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
Background Activation of the classical and lectin pathway of complement may contribute to tissue damage and organ dysfunction of antibody-mediated diseases and ischemia-reperfusion conditions. Complement factors are being considered as targets for therapeutic intervention. Objective We sought to characterize ARGX-117, a humanized inhibitory monoclonal antibody against complement C2. Methods The mode-of-action and binding characteristics of ARGX-117 were investigated in detail. Furthermore, its efficacy was analyzed in in vitro complement cytotoxicity assays. Finally, a pharmacokinetic/pharmacodynamic study was conducted in cynomolgus monkeys. Results Through binding to the Sushi-2 domain of C2, ARGX-117 prevents the formation of the C3 proconvertase and inhibits classical and lectin pathway activation upstream of C3 activation. As ARGX-117 does not inhibit the alternative pathway, it is expected not to affect the antimicrobial activity of this complement pathway. ARGX-117 prevents complement-mediated cytotoxicity in in vitro models for autoimmune hemolytic anemia and antibody-mediated rejection of organ transplants. ARGX-117 exhibits pH- and calcium-dependent target binding and is Fc-engineered to increase affinity at acidic pH to the neonatal Fc receptor, and to reduce effector functions. In cynomolgus monkeys, ARGX-117 dose-dependently reduces free C2 levels and classical pathway activity. A 2-dose regimen of 80 and 20 mg/kg separated by a week, resulted in profound reduction of classical pathway activity lasting for at least 7 weeks. Conclusions ARGX-117 is a promising new complement inhibitor that is uniquely positioned to target both the classical and lectin pathways while leaving the alternative pathway intact.
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Affiliation(s)
| | | | - Kevin Budding
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Kim Dijkxhoorn
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elisabeth de Zeeuw
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cafer Yildiz
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | - Johanna Wildemann
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan Meeldijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | - Linda Cox
- Bioceros BV, Utrecht, The Netherlands
| | | | - Rolf Urbanus
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Henny G Otten
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeanette H W Leusen
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | - C Erik Hack
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Prothix BV, Leiden, The Netherlands
| | - Peter Boross
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Prothix BV, Leiden, The Netherlands.
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45
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Jodele S, Köhl J. Tackling COVID-19 infection through complement-targeted immunotherapy. Br J Pharmacol 2020; 178:2832-2848. [PMID: 32643798 PMCID: PMC7361469 DOI: 10.1111/bph.15187] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/09/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
The complement system is an ancient part of innate immunity sensing highly pathogenic coronaviruses by mannan‐binding lectin (MBL) resulting in lectin pathway activation and subsequent generation of the anaphylatoxins (ATs) C3a and C5a as important effector molecules. Complement deposition on endothelial cells and high blood C5a serum levels have been reported in COVID‐19 patients with severe illness, suggesting vigorous complement activation leading to systemic thrombotic microangiopathy (TMA). Complement regulator gene variants prevalent in African‐Americans have been associated with a higher risk for severe TMA and multi‐organ injury. Strikingly, severe acute respiratory syndrome Coronavirus 2 (SARS‐CoV‐2)‐infected African‐Americans suffer from high mortality. These findings allow us to apply our knowledge from other complement‐mediated diseases to COVID‐19 infection to better understand severe disease pathogenesis. Here, we discuss the multiple aspects of complement activation, regulation, crosstalk with other parts of the immune system, and the options to target complement in COVID‐19 patients to halt disease progression and death.
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Affiliation(s)
- Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jörg Köhl
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
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46
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Gembillo G, Siligato R, Cernaro V, Santoro D. Complement Inhibition Therapy and Dialytic Strategies in Paroxysmal Nocturnal Hemoglobinuria: The Nephrologist's Opinion. J Clin Med 2020; 9:E1261. [PMID: 32357555 PMCID: PMC7287718 DOI: 10.3390/jcm9051261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 12/24/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease that presents an estimated incidence of 1.3 cases per million per year, with a prevalence of 15.9 cases per million. It is characterized by hemolysis, bone marrow dysfunction with peripheral blood cytopenia, hypercoagulability, thrombosis, renal impairment and arterial and pulmonary hypertension. Hemolysis and subsequent hemosiderin accumulation in tubular epithelium cells induce tubular atrophy and interstitial fibrosis. The origin of PNH is the somatic mutation in the X-linked phosphatidylinositol glycan class A (PIG-A) gene located on Xp22: this condition leads to the production of clonal blood cells with a deficiency in those surface proteins that protect against the lytic action of the activated complement system. Despite the increased knowledge of this syndrome, therapies for PNH were still only experimental and symptomatic, until the introduction of the C5 complement blockade agent Eculizumab. A second generation of anti-complement agents is currently under investigation, representing future promising therapeutic strategies for patients affected by PNH. In the case of chronic hemolysis and renal iron deposition, a multidisciplinary approach should be considered to avoid or treat acute tubular injury or acute kidney injury (AKI). New promising perspectives derive from complement inhibitors and iron chelators, as well as more invasive treatments such as immunoadsorption or the use of dedicated hemodialysis filters in the presence of AKI.
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Affiliation(s)
- Guido Gembillo
- Unit of Nephrology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (R.S.); (V.C.); (D.S.)
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Patriquin CJ, Kuo KHM. Eculizumab and Beyond: The Past, Present, and Future of Complement Therapeutics. Transfus Med Rev 2019; 33:256-265. [PMID: 31703946 DOI: 10.1016/j.tmrv.2019.09.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/18/2022]
Abstract
Dysregulation of the complement system underlies the pathophysiology of many diseases. Renewed interest in complement occurred with the recognition that its therapeutic inhibition was possible. Terminal complement blockade with the anti-C5 monoclonal antibody eculizumab significantly changed management and clinical outcomes of patients with paroxysmal nocturnal hemoglobinuria, and served as a proof of concept for other complement-mediated diseases. Eculizumab is also approved for atypical hemolytic uremic syndrome and myasthenia gravis. Multiple new disease indications have been identified, and novel complement inhibitors are in various stages of development, with several currently in human trials. Beyond C5, these new drugs block proximal complement, pathway-specific targets, convertase activity, and anaphylatoxin function. Though monoclonal antibodies are still common, peptides, RNAi, and small molecule inhibitors provide the opportunity for different administration routes and schedules. Several challenges still exist or will soon present themselves, including mitigation of infection risk, effective monitoring strategies, and how to choose between therapeutics when more than one is available. In this review, we will describe the lessons learned from the "eculizumab era," present many of the novel therapeutics currently or soon to be in trials, and highlight some of the challenges that will require attention as the field progresses.
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Affiliation(s)
- Christopher J Patriquin
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada; Divison of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada.
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada; Divison of Medical Oncology & Hematology, University Health Network, Toronto, Ontario, Canada
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48
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Zelek WM, Xie L, Morgan BP, Harris CL. Compendium of current complement therapeutics. Mol Immunol 2019; 114:341-352. [PMID: 31446305 DOI: 10.1016/j.molimm.2019.07.030] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022]
Abstract
The complement system is well known for its role in innate immunity and in maintenance of tissue homeostasis, providing a first line of defence against infection and playing a key role in flagging apoptotic cells and debris for disposal. Unfortunately, complement also contributes to pathogenesis of many diseases, in some cases driving pathology, and in others amplifying or exacerbating the inflammatory and damaging impact of non-complement disease triggers. The driving role of complement in a single disease, paroxysmal nocturnal hemoglobinuria (PNH), provoked the development and eventual FDA (US Food and Drug Administration) approval of eculizumab (Soliris™), an anti-C5 antibody, for therapy. Although PNH is very rare, eculizumab provided clinical validation and demonstrated that inhibiting the complement system was not only well-tolerated, but also provided rapid therapy and saved lives. This clinical validation, together with advances in genetic analyses that demonstrated strong associations between complement and common diseases, drove new drug discovery programmes in both academic laboratories and large pharmaceutical companies. Numerous drugs have entered clinical development and several are in phase 3 trials; however, many have fallen by the wayside. Despite this high attrition rate, crucial lessons have been learnt and hurdles to development have become clear. These insights have driven development of next generation anti-complement drugs designed to avoid pitfalls and facilitate patient access. In this article, we do not set out to provide a text-heavy review of complement therapeutics but instead will simply highlight the targets, modalities and current status of the plethora of drugs approved or in clinical development. With such a fast-moving drug development landscape, such a compendium will inevitably become out-dated; however, we provide a snapshot of the current field and illustrate the increased choice that clinicians might enjoy in the future in selecting the best drug for their application, decisions based not only on efficacy but also cost, mechanistic target, modality and route of delivery.
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Affiliation(s)
- Wioleta M Zelek
- Systems Immunity Research Institute and Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, CF14 4XN, UK
| | - Long Xie
- Complement Therapeutics Research Group, Institute of Cellular Medicine, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - B Paul Morgan
- Systems Immunity Research Institute and Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, CF14 4XN, UK
| | - Claire L Harris
- Complement Therapeutics Research Group, Institute of Cellular Medicine, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
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Nagarajah S, Tepel M, Nielsen C, Assing K, Palarasah Y, Andersen LLT, Lange LB, Bistrup C. Reduced membrane attack complex formation in umbilical cord blood during Eculizumab treatment of the mother: a case report. BMC Nephrol 2019; 20:307. [PMID: 31390992 PMCID: PMC6686417 DOI: 10.1186/s12882-019-1469-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 07/19/2019] [Indexed: 02/07/2023] Open
Abstract
Background Atypical hemolytic uremic syndrome (aHUS) is a disorder of the microvasculature with hemolytic anemia, thrombocytopenia and acute kidney injury. Nowadays, aHUS is successfully treated with eculizumab, a humanized, chimeric IgG2/4 kappa antibody, which binds human complement C5 and blocks generation of C5a and membrane-attack-complex. Case presentation A 25-year-old woman with end stage renal disease due to relapsing atypical hemolytic uremic syndrome had a relapse of the disease during pregnancy. She was treated with eculizumab. We measured reduced formation of the membrane-attack complex in newborn’s umbilical cord vein blood using the sensitive and specific Palarasah-Nielsen-ELISA. Conclusions Eculizumab treatment of the mother with end stage renal disease may cause reduced innate immunity which could render newborns more susceptible to infections.
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Affiliation(s)
- Subagini Nagarajah
- Department of Nephrology, Odense University Hospital, 5000, Odense C, Denmark.,Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Martin Tepel
- Department of Nephrology, Odense University Hospital, 5000, Odense C, Denmark. .,Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Christian Nielsen
- Department of Immunology, Odense University Hospital, Odense, Denmark
| | - Kristian Assing
- Department of Immunology, Odense University Hospital, Odense, Denmark
| | - Yaseelan Palarasah
- Research Unit of Immunology and Microbiology, University of Southern Denmark, Odense, Denmark
| | | | - Lotte Borg Lange
- Department of Nephrology, Odense University Hospital, 5000, Odense C, Denmark
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, 5000, Odense C, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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50
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Zelek WM, Taylor PR, Morgan BP. Development and characterization of novel anti-C5 monoclonal antibodies capable of inhibiting complement in multiple species. Immunology 2019; 157:283-295. [PMID: 31120547 PMCID: PMC6620185 DOI: 10.1111/imm.13083] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/23/2019] [Accepted: 05/14/2019] [Indexed: 12/29/2022] Open
Abstract
Over the last decade there has been an explosion in complement therapies; one-third of the drugs in the clinic or in development target C5 protein. Eculizumab, a monoclonal antibody (mAb) that binds C5 and blocks its cleavage by the convertase, is the current reference standard treatment for atypical haemolytic uraemic syndrome (aHUS) and paroxysmal nocturnal haemoglobinuria (PNH) and in clinical trials for many other diseases. Here we describe a panel of novel anti-C5 mAb, including mAb that, like Eculizumab, are efficient inhibitors of complement but, unlike Eculizumab, inhibit across species, including human, rat, rabbit and guinea pig. Several inhibitory anti-C5 mAb were identified and characterized for C5 binding and lytic inhibitory capacity in comparison to current therapeutic anti-C5 mAb; three clones, 4G2, 7D4 and 10B6, were selected and further characterized for ligand specificity and affinity and cross-species inhibitory activity. The mAb 10B6 was human-specific whereas mAb 4G2 and 7D4 efficiently inhibited lysis by human, rabbit and rat serum, and weakly inhibited guinea pig complement; 7D4 also weakly inhibited mouse complement in vitro The rat C5-cross-reactive mAb 4G2, when administered intraperitoneally in a rat model of myasthenia gravis, effectively blocked the disease and protected muscle endplates from destruction. To our knowledge this is the first report of an anti-C5 function blocking mAb that permits preclinical studies in rats.
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Affiliation(s)
- Wioleta M. Zelek
- Division of Infection and ImmunitySchool of MedicineSystems Immunity Research InstituteCardiff UniversityWalesUK
| | - Philip R. Taylor
- Division of Infection and ImmunitySchool of MedicineSystems Immunity Research InstituteCardiff UniversityWalesUK
| | - B. Paul Morgan
- Division of Infection and ImmunitySchool of MedicineSystems Immunity Research InstituteCardiff UniversityWalesUK
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