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Noel JC, Lagassé D, Golding B, Sauna ZE. Emerging approaches to induce immune tolerance to therapeutic proteins. Trends Pharmacol Sci 2023; 44:1028-1042. [PMID: 37903706 DOI: 10.1016/j.tips.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 11/01/2023]
Abstract
Immunogenicity affects the safety and efficacy of therapeutic proteins. This review is focused on approaches for inducing immunological tolerance to circumvent the immunogenicity of therapeutic proteins in the clinic. The few immune tolerance strategies that are used in the clinic tend to be inefficient and expensive and typically involve global immunosuppression, putting patients at risk of infections. The hallmark of a desirable immune tolerance regimen is the specific alleviation of immune responses to the therapeutic protein. In the past decade, proof-of-principle studies have demonstrated that emerging technologies, including nanoparticle-based delivery of immunomodulators, cellular targeting and depletion, cellular engineering, gene therapy, and gene editing, can be leveraged to promote tolerance to therapeutic proteins. We discuss the potential of these novel approaches and the barriers that need to be overcome for translation into the clinic.
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Affiliation(s)
- Justine C Noel
- Division of Hemostasis, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel Lagassé
- Division of Hemostasis, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Basil Golding
- Division of Plasma Derivatives, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Zuben E Sauna
- Division of Hemostasis, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
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Mizuno T, Kiyosawa J, Fukuda A, Watanabe S, Kurose N, Nojima T, Kanda T. Infective endocarditis following tumor necrosis factor-α antagonist therapy for management of psoriatic erythroderma: a case report. J Med Case Rep 2017; 11:35. [PMID: 28179019 PMCID: PMC5299640 DOI: 10.1186/s13256-016-1130-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 11/02/2016] [Indexed: 11/10/2022] Open
Abstract
Background The introduction of biological agents, such as infliximab, which act against tumor necrosis factor-α was a major advance for the treatment of an increasing number of chronic diseases. Tumor necrosis factor-α antagonists represent a major therapeutic advance for the management of chronic inflammatory diseases, such as psoriasis. Previous studies have reported that the use of tumor necrosis factor-α antagonists increased the risk of opportunistic infections and reactivation of latent bacterial infections. Cardiac involvement, such as infective endocarditis, is very rare in the literature. Case presentation A 77-year-old Asian man with a 10-year history of psoriatic erythroderma was referred due to high fever and general malaise. He was treated with Predonine (prednisolone) and infliximab. After treatment, cardiac echography showed mitral valve vegetation and brain magnetic resonance imaging indicated multiple fresh infarctions. He died from large brain infarction in October 2013. An autopsy showed fresh thrombosis in his left middle cerebral artery, mitral valve vegetations, and septic micro-embolisms in multiple organs. Conclusions Lethal bacterial endocarditis was revealed after administration of tumor necrosis factor-α inhibitor, infliximab, for the treatment of psoriatic erythroderma. An autopsy showed vegetation in his mitral valve and brain infarction with fresh purulent embolism in his left middle cerebral artery and septic micro-embolisms.
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Affiliation(s)
- Takuro Mizuno
- Department of Cardiovascular Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi, Toyama, 935-8531, Japan
| | - Jun Kiyosawa
- Department of Cardiovascular Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi, Toyama, 935-8531, Japan
| | - Akihiro Fukuda
- Department of Cardiovascular Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi, Toyama, 935-8531, Japan
| | - Seiji Watanabe
- Department of Dermatology, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi, Toyama, 935-8531, Japan
| | - Nozomu Kurose
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, 1-1 Uchinada, Ishikawa, 920-0293, Japan
| | - Takayuki Nojima
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, 1-1 Uchinada, Ishikawa, 920-0293, Japan
| | - Tsugiyasu Kanda
- Department of Community Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi, Toyama, 935-8531, Japan.
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Joost I, Steinfurt J, Meyer PT, Kern WV, Rieg S. Staphylococcus aureus bacteremia with iliac artery endarteritis in a patient receiving ustekinumab. BMC Infect Dis 2016; 16:586. [PMID: 27765025 PMCID: PMC5072319 DOI: 10.1186/s12879-016-1912-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 10/11/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Ustekinumab (Stelara®), a human monoclonal antibody targeting the p40-subunit of interleukin (IL)-12 and IL-23, is indicated for moderate to severe plaque psoriasis and psoriatic arthritis. In large multicenter, prospective trials assessing efficacy and safety of ustekinumab increased rates of severe infections have not been observed so far. CASE PRESENTATION Here, we report the case of a 64-year old woman presenting with chills, pain and swelling of her right foot with dark maculae at the sole, and elevated inflammatory markers. She had received a third dose of ustekinumab due to psoriatic arthritis three days before admission. Blood cultures revealed growth of Staphylococcus aureus and imaging showed a thickening of the aortic wall ventral the bifurcation above the right internal iliac artery, resembling an acute bacterial endarteritis. Without the evidence of aneurysms and in absence of foreign bodies, the decision for conservative management was made. The patient received four weeks of antibiotic therapy with intravenous flucloxacillin, followed by an oral regime with levofloxacin and rifampicin for an additional four weeks. Inflammatory markers resolved promptly and the patient was discharged in good health. CONCLUSION To our knowledge, this is the first report of a severe S. aureus infection in a patient receiving ustekinumab. Albeit ustekinumab is generally regarded as a safe drug, severe bacterial infections should always be included in the differential diagnosis of elevated inflammatory markers in patients receiving biologicals as these might present with nonspecific symptoms and fever might be absent. Any effort to detect deep-seated or metastatic infections should be made to prevent complications and to secure appropriate treatment. Although other risk factors for an invasive staphylococcal infection like psoriasis, recent corticosteroid injection, or prior hospitalisations were present, and therefore a directive causative link between the S. aureus bacteraemia and ustekinumab can not be drawn, we considered the reporting of this case worthwhile to alert clinicians as we believe that ongoing pharmacovigilance to detect increased risks for rare but severe infections beyond phase II and phase III trials in patients treated with biologicals is essential.
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Affiliation(s)
- Insa Joost
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106 Germany
| | - Johannes Steinfurt
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Hugstetter Strasse 55, Freiburg, 79106 Germany
| | - Philipp T. Meyer
- Department of Nuclear Medicine, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106 Germany
| | - Winfried V. Kern
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106 Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, Freiburg, 79106 Germany
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Wiese AD, Griffin MR, Stein CM, Mitchel EF, Grijalva CG. Opioid Analgesics and the Risk of Serious Infections Among Patients With Rheumatoid Arthritis: A Self-Controlled Case Series Study. Arthritis Rheumatol 2016; 68:323-31. [PMID: 26473742 DOI: 10.1002/art.39462] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/01/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Animal studies and in vitro human studies suggest that certain opioid analgesics impair crucial immune functions. This study was undertaken to determine whether opioid use is associated with increased risk of serious infection in patients with rheumatoid arthritis (RA). METHODS We conducted a self-controlled case series analysis on a retrospective cohort of 13,796 patients with RA enrolled in Tennessee Medicaid in 1995-2009. Within-person comparisons of the risk of hospitalization for serious infection during periods of opioid use versus non-use were performed using conditional Poisson regression. Fixed confounders were accounted for by design; time-varying confounders included age and use of disease-modifying antirheumatic drugs, glucocorticoids, and proton-pump inhibitors. In additional analyses, risks associated with new opioid use, use of opioids known to have immunosuppressive properties, use of long-acting opioids, and different opioid dosages were assessed. Sensitivity analyses were performed to account for potential protopathic bias and confounding by indication. RESULTS Among 1,790 patients with RA who had at least 1 hospitalization for serious infection, the adjusted incidence rate of serious infection was higher during periods of current opioid use compared to non-use, with an incidence rate ratio (IRR) of 1.39 (95% confidence interval [95% CI] 1.19-1.62). The incidence rate was also higher during periods of long-acting opioid use, immunosuppressive opioid use, and new opioid use compared to non-use (IRR 2.01 [95% CI 1.52-2.66], IRR 1.72 [95% CI 1.33-2.23], and IRR 2.38 [95% CI 1.65-3.42], respectively). Results of sensitivity analyses were consistent with the main findings. CONCLUSION In within-person comparisons of patients with RA, opioid use was associated with an increased risk of hospitalization for serious infection.
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Affiliation(s)
- Andrew D Wiese
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie R Griffin
- Vanderbilt University Medical Center, Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville Campus, Nashville, Tennessee
| | | | | | - Carlos G Grijalva
- Vanderbilt University Medical Center, Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville Campus, Nashville, Tennessee
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Sams M, Olsen MA, Joshi R, Ranganathan P. Staphylococcus aureus sepsis in rheumatoid arthritis. Rheumatol Int 2015; 35:1503-10. [PMID: 25758228 DOI: 10.1007/s00296-015-3239-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/27/2015] [Indexed: 11/26/2022]
Abstract
Patients with rheumatoid arthritis (RA) are at increased risk of infection. In this study, we determined the risk of and risk factors for Staphyococcus aureus (S. aureus) sepsis in RA. We assembled a retrospective nested case-control subset of RA patients with S. aureus sepsis from the Barnes-Jewish Hospital Medical Informatics database, confirmed the diagnoses, and collected data electronically and by chart review. We used multivariate logistic regression to identify independent risk factors for S. aureus sepsis, with risk expressed as odds ratios (ORs). We extracted data on the length of hospitalization and 30-day and 1-year mortality from the Medical Informatics database for all cases and controls. There were 48 confirmed S. aureus sepsis cases and 232 confirmed controls in the RA cohort. In multivariate analysis, indwelling central venous catheter (OR 15.97; 95 % CI 5.09-50.10; p < 0.01) and congestive heart failure (OR 2.89; 95 % CI 1.26-6.63; p = 0.01) were independently associated with risk of S. aureus sepsis, while treatment with disease-modifying anti-rheumatic drugs (DMARDs), both biologic and non-biologic, was not. S. aureus sepsis was associated with increased 30-day and 1-year mortality (OR 7.37; 95 % CI 2.86-19.0; p < 0.01 for 30-day and OR 5.24; 95 % CI 2.51-10.94; p < 0.01 for 1-year mortality) and longer hospitalization (p < 0.01). Treatment with biologic DMARDs was not associated with longer hospitalization (p = 0.89). Indwelling central venous catheters and congestive heart failure increased the risk of S. aureus sepsis in this observational cohort of patients with RA. Treatment with biologic and non-biologic DMARDs did not increase this risk.
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Affiliation(s)
- Michael Sams
- Dupage Medical Group Rheumatology, Naperville, IL, USA
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Guerrero C, Tort J, Pérez J, Andrés M, Espejo E. Rhodococcus equi infection in a patient with Crohn's disease treated with infliximab. J Infect 2014; 70:689-90. [PMID: 25546345 DOI: 10.1016/j.jinf.2014.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 12/15/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Carolina Guerrero
- Internal Medicine Service, Consorci Sanitari de Terrassa, Ctra. Torrebonica s/n, 08227 Terrassa, Spain
| | - Joan Tort
- Internal Medicine Service, Consorci Sanitari de Terrassa, Ctra. Torrebonica s/n, 08227 Terrassa, Spain
| | - Josefa Pérez
- Microbiology Laboratory, Catlab, Vial Sant Jordi s/n, Pol. Ind. Can Mitjans, 08232 Viladecavalls, Spain
| | - Marta Andrés
- Infectious Diseases Unit, Internal Medicine Service, Consorci Sanitari de Terrassa, Ctra. Torrebonica s/n, 08227 Terrassa, Spain
| | - Elena Espejo
- Infectious Diseases Unit, Internal Medicine Service, Consorci Sanitari de Terrassa, Ctra. Torrebonica s/n, 08227 Terrassa, Spain.
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