1
|
Luo Y, Acevedo D, Baños N, Pluma A, Castellanos-Moreira R, Moreno E, Rodríguez-García S, Deyà-Martínez A, García-García A, Quesada-Masachs E, Torres M, Casellas M, Grados D, Martí-Castellote C, Antón J, Vlagea A, Juan M, Esteve-Solé A, Alsina L. Expected impact of immunomodulatory agents during pregnancy: A newborn's perspective. Pediatr Allergy Immunol 2023; 34:e13911. [PMID: 36825745 DOI: 10.1111/pai.13911] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
The neonatal immune ontogeny begins during pregnancy to ensure that the neonate is well-suited for perinatal life. It prioritizes Th2/M2 and regulatory responses over Th/M1 activity to avoid excessive inflammatory responses and to ensure immune tolerance and homeostasis. Newborns also present increased Th17/Th22 responses providing effective anti-fungal immunity and mucosal protection. Intrauterine exposure to immune modulatory drugs with the placental transfer may influence the natural course of the fetal immune development. The vertical transfer of both biological therapy and small molecules begins during the first trimester through neonatal Fc receptor or placental diffusion, respectively, reaching its maximum transfer potential during the third trimester of pregnancy. Most of the biological therapy have a prolonged half-life in newborn's blood, being detectable in infants up to 12 months after birth (usually 6-9 months). The use of immunomodulators during pregnancy is gaining global interest. Current evidence mainly reports birth-related outcomes without exhaustive analysis of the on-target side effect on the perinatal immune system ontogeny, the infection risk, or the immune dysregulation. The present review will focus on: (1) the main characteristics of the perinatal immune system to understand its specific features and vulnerabilities to immune modulation; (2) the mechanisms of placental transfer of immunomodulators; and (3) the immune changes reported to date in newborns exposed to immunomodulators with emphasis on the current concerns and gaps in knowledge.
Collapse
Affiliation(s)
- Yiyi Luo
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Daniel Acevedo
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Núria Baños
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Andrea Pluma
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Estefania Moreno
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Angela Deyà-Martínez
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Ana García-García
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | | | - Mireia Torres
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manel Casellas
- High Risk Obstetric Unit, Gynecology and Obstetrics Department, Vall de Hebron Hospital Campus, Universitat Autónoma of Barcelona (UAB), Barcelona, Spain
| | - Dolors Grados
- Rheumatology Department, Hospital Universitari d'Igualada, Igualada, Spain
| | - Celia Martí-Castellote
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Jordi Antón
- Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Pediatric Rheumatology, Hospital Sant Joan de Déu, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - Alexandru Vlagea
- Immunology Department, Biomedic Diagnostic Center (CDB), Hospital Clínic of Barcelona, Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic de Barcelona, Barcelona, Spain
| | - Manel Juan
- Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain.,Immunology Department, Biomedic Diagnostic Center (CDB), Hospital Clínic of Barcelona, Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Esteve-Solé
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Laia Alsina
- Clinical Immunology and Primary Immunodeficiencies Unit, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain.,Clinical Immunology Unit, Hospital Sant Joan de Déu-Hospital Clínic, Barcelona, Spain.,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
2
|
Beltagy A, Aghamajidi A, Trespidi L, Ossola W, Meroni PL. Biologics During Pregnancy and Breastfeeding Among Women With Rheumatic Diseases: Safety Clinical Evidence on the Road. Front Pharmacol 2021; 12:621247. [PMID: 34122062 PMCID: PMC8189556 DOI: 10.3389/fphar.2021.621247] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/04/2021] [Indexed: 12/31/2022] Open
Abstract
Females are generally more affected by autoimmune diseases, a fact that underlines the relationship with pregnancy and the safety of anti-rheumatic drugs in pregnancy and lactation. Biologic therapies are increasingly prescribed to treat and maintain remission in a significant number of systemic autoimmune rheumatic diseases. The experience with the use of biologics during gestation is extremely lacking because of the observational nature of the available studies and the difficulty in designing proper clinical trials in pregnancy. Among the studied biologics, more information was published on TNFα inhibitors and, in particular, on their potential passage through the placenta and impact on the fetus. Currently, a fragment of anti-TNFα monoclonal IgG, certolizumab pegol, is considered safe with almost no placental transfer. Subsequent observations are suggesting a comparable safety for the soluble TNFα receptor etanercept. Another biologic, eculizumab, the anti-C5a antibody used to treat complement-mediated microangiopathies, is also considered safe due to the unique engineered IgG2/4κ formulation that limits its passage through the placental barrier. Still, long-term data about children born to women treated with biologics in pregnancy are not attainable. Data on breastfeeding are currently available for several biologics. This article reviews the literature available about which drugs are considered safe during pregnancy and lactation, which are not, and on future prospects.
Collapse
Affiliation(s)
- Asmaa Beltagy
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy.,Rheumatology and Clinical Immunology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Azin Aghamajidi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Laura Trespidi
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Wally Ossola
- Department of Obstetrics and Gynaecology, Fondazione Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Pier Luigi Meroni
- Istituto Auxologico Italiano, IRCCS, Immunorheumatology Research Laboratory, Milan, Italy
| |
Collapse
|
3
|
Lund T, Thomsen SF. Use of TNF-inhibitors and ustekinumab for psoriasis during pregnancy: A patient series. Dermatol Ther 2017; 30. [PMID: 28071837 DOI: 10.1111/dth.12454] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023]
Abstract
From 2002 to 2016 a total of seven women with severe refractory psoriasis were exposed to the TNF-inhibitors infliximab and adalimumab or to the IL12/23 inhibitor ustekinumab during one or more pregnancies. Maternal, fetal or teratogenic toxicity were not detected during pregnancy and puerperium. All pregnancies were uneventful and resulted in delivery of 10 healthy children in total, one of the women is due February 2017. Postpartum, five of the women were lactating, but none of the women or newborns developed adverse reactions. Data on safety of treatment during breastfeeding are sparse, but so far appears to be safe due to the lack of absorption across the gastrointestinal lining. Currently biological therapy with either TNF-inhibitors or ustekinumab is not recommended during pregnancy, however in selected women with severe psoriasis these treatment modalities may be considered.
Collapse
Affiliation(s)
- Tamara Lund
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
4
|
Yarur A, Kane SV. Update on pregnancy and breastfeeding in the era of biologics. Dig Liver Dis 2013; 45:787-94. [PMID: 23474350 DOI: 10.1016/j.dld.2013.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/01/2013] [Indexed: 12/11/2022]
Abstract
Inflammatory bowel diseases are chronic conditions that frequently affect patients during their childbearing years. Considering the characteristics of disease and the medications used to treat it, several issues arise in the care of these patients when they attempt or achieve conception. We review the most current evidence concerning fertility and pregnancy outcomes in patients with inflammatory bowel diseases. With the exception of those women who undergo pelvic surgery, patients with inflammatory bowel diseases have no decreased fertility. Sulfasalazine decreases fertility in men. When looking at obstetrical outcomes, active disease at conception is associated with an increased risk of preterm delivery and low birth weight. While most medications used to treat inflammatory bowel diseases are low risk, some precautions need to be taken and the risk-to-benefit ratio needs to be considered on an individualized basis. In general, aminosalicylates and thiopurines should be continued, but methotrexate is contraindicated. Anti-tumour necrosis factor agents are considered safe to continue but full monoclonal antibodies do cross the placenta. As a general rule, the it is important to counsel women that conception is optimal when disease is in remission, as adverse obstetrical outcomes are directly associated with disease activity. Clinicians need to educate patients before, during and after conception, emphasizing treatment compliance.
Collapse
Affiliation(s)
- Andres Yarur
- Department of Medicine, University of Florida, USA
| | | |
Collapse
|
5
|
Everds N, Li N, Bailey K, Fort M, Stevenson R, Jawando R, Salyers K, Jawa V, Narayanan P, Stevens E, He C, Nguyen MP, Tran S, Doyle N, Poitout-Belissent F, Jolette J, Xu C, Sprugel K. Unexpected Thrombocytopenia and Anemia in Cynomolgus Monkeys Induced by a Therapeutic Human Monoclonal Antibody. Toxicol Pathol 2013; 41:951-69. [DOI: 10.1177/0192623312474727] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cynomolgus monkeys dosed with a therapeutic monoclonal antibody (mAbY.1) at ≥50 mg/kg had unexpected acute thrombocytopenia (nadir ∼3,000 platelets/µl), sometimes with decreases in red cell mass. Increased activated macrophages, mitotic figures, and erythrophagocytosis were observed in the spleen. Binding of mAbY.1 to cynomolgus peripheral blood cells could not be detected in vitro. mAbY.1 induced phagocytosis of platelets by peripheral blood monocytes from cynomolgus monkeys, but not from humans. mAbs sharing the same constant domain (Fc) sequences, but differing from mAbY.1 in their variable domains, bound competitively to and had similar biological activity against the intended target. None of these antibodies had hematologic liabilities in vitro or in vivo. Neither the F(ab’)2 portion of mAbY.1 nor the F(ab’)2 portion on an aglycosylated Fc (IgG1) framework caused phagocytosis of platelets in vitro. These data suggest that the hematologic effects of mAbY.1 in cynomolgus monkeys likely occurred through an off-target mechanism, shown to be driven by 1 to 3 amino acid differences in the light chain. The hematologic effects made mAbY.1 an unsuitable candidate for further development as a therapeutic agent. This example demonstrates that nonclinical safety studies may be essential for understanding off-target effects of mAbs prior to clinical trials.
Collapse
Affiliation(s)
| | - Nianyu Li
- Amgen Inc., Seattle, Washington, USA
| | - Keith Bailey
- Oklahoma State University, Stillwater, Oklahoma, USA
| | | | | | | | - Kevin Salyers
- Amgen Inc., Thousand Oaks, California, USA
- Kevin Salyers is deceased
| | - Vibha Jawa
- Amgen Inc., Thousand Oaks, California, USA
| | | | | | - Ching He
- Amgen Inc., Seattle, Washington, USA
| | | | - Sam Tran
- Amgen Inc., Seattle, Washington, USA
| | - Nancy Doyle
- Charles River Preclinical Services Montreal, Senneville, Quebec, Canada
| | | | - Jacquelin Jolette
- Charles River Preclinical Services Montreal, Senneville, Quebec, Canada
| | - Cen Xu
- Amgen Inc., Thousand Oaks, California, USA
| | | |
Collapse
|
6
|
Martin PL, Bugelski PJ. Concordance of preclinical and clinical pharmacology and toxicology of monoclonal antibodies and fusion proteins: soluble targets. Br J Pharmacol 2012; 166:806-22. [PMID: 22168335 DOI: 10.1111/j.1476-5381.2011.01812.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Monoclonal antibodies (mAbs) and fusion proteins directed towards soluble targets make an important contribution to the treatment of disease. The purpose of this review was to correlate the clinical and preclinical data on the 14 currently approved mAbs and fusion proteins targeted to soluble targets. The principal sources used to gather data were: the peer reviewed Literature; European Medicines Agency 'Scientific Discussions' and United States Food and Drug Administration 'Pharmacology/Toxicology Reviews' and package inserts (United States Prescribing Information). Data on the following approved biopharmaceuticals were included: adalimumab, anakinra, bevacizumab, canakinumab, certolizumab pegol, denosumab, eculizumab, etanercept, golimumab, infliximab, omalizumab, ranibizumab, rilonacept and ustekinumab. Some related biopharmaceuticals in late-stage development were also included for comparison. Good concordance with human pharmacodynamics was found for both non-human primates (NHPs) receiving the human biopharmaceutical and mice receiving rodent homologues (surrogates). In contrast, there was limited concordance for human adverse effects in genetically deficient mice, mice receiving surrogates or NHPs receiving the human pharmaceutical. In summary, the results of this survey show that although both mice and NHPs have good predictive value for human pharmacodynamics, neither species have good predictive value for human adverse effects. No evidence that NHPs have superior predictive value was found.
Collapse
Affiliation(s)
- Pauline L Martin
- Biologics Toxicology, Janssen Research & Development, Radnor, PA 19087, USA.
| | | |
Collapse
|
7
|
Vermeire S, Carbonnel F, Coulie PG, Geenen V, Hazes JMW, Masson PL, De Keyser F, Louis E. Management of inflammatory bowel disease in pregnancy. J Crohns Colitis 2012; 6:811-23. [PMID: 22595185 DOI: 10.1016/j.crohns.2012.04.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 04/13/2012] [Accepted: 04/13/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease (IBD) is a chronic disease affecting mainly young people in their reproductive years. IBD therefore has a major impact on patients' family planning decisions. Management of IBD in pregnancy requires a challenging balance between optimal disease control and drug safety considerations. This article aims to provide a framework for clinical decision making in IBD based on review of the literature on pregnancy-related topics. METHODS Medline searches with search terms 'IBD', 'Crohn's disease' or 'ulcerative colitis' in combination with keywords for the topics fertility, pregnancy, congenital abnormalities and drugs names of drugs used for treatment of IBD. RESULTS IBD patients have normal fertility, except for women after ileal pouch-anal anastomosis (IPAA) and men under sulfasalazine treatment. Achieving and maintaining disease remission is a key factor for successful pregnancy outcomes in this population, as active disease at conception carries an increased risk of preterm delivery and low birth weight. Clinicians should discuss the need for drug therapy to maintain remission with their patients in order to ensure therapy compliance. Most IBD drugs are compatible with pregnancy, except for methotrexate and thalidomide. If possible, anti-TNF therapy should be stopped by the end of the second trimester and the choice of delivery route should be discussed with the patient. CONCLUSIONS Disease control prior to conception and throughout pregnancy is the cornerstone of successful pregnancy management in IBD patients.
Collapse
Affiliation(s)
- Séverine Vermeire
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Bowman C, King L, Stedman D. Embryo-fetal distribution of a biopharmaceutical IgG2 during rat organogenesis. Reprod Toxicol 2012; 34:66-72. [DOI: 10.1016/j.reprotox.2012.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 03/20/2012] [Accepted: 04/12/2012] [Indexed: 02/03/2023]
|
9
|
Off-Target Platelet Activation in Macaques Unique to a Therapeutic Monoclonal Antibody. Toxicol Pathol 2012; 40:899-917. [DOI: 10.1177/0192623312444029] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AMG X, a human neutralizing monoclonal antibody (mAb) against a soluble human protein, caused thrombocytopenia, platelet activation, reduced mean arterial pressure, and transient loss of consciousness in cynomolgus monkeys after first intravenous administration. In vitro, AMG X induced activation in platelets from macaque species but not from humans or baboons. Other similar mAbs against the same pharmacological target failed to induce these in vivo and in vitro effects. In addition, the target protein was known to not be expressed on platelets, suggesting that platelet activation occurred through an off-target mechanism. AMG X bound directly to cynomolgus platelets and required both the Fab and Fc portion of the mAb for platelet activation. Binding to platelets was inhibited by preincubation of AMG X with its pharmacological target or with anti-human Fc antibodies or by preincubation of platelets with AMG X F(ab′)2 or human immunoglobulin (IVIG). AMG X F(ab′)2 did not activate platelets. Thus, platelet activation required both recognition/binding of a platelet ligand with the Fab domain and interaction of platelet Fc receptors (i.e., FcγRIIa) with the Fc domain. These findings reflect the complexity of the mechanism of action of mAbs and the increasing awareness of potential for unintended effects in preclinical species.
Collapse
|
10
|
Hazes JM, Coulie PG, Geenen V, Vermeire S, Carbonnel F, Louis E, Masson P, De Keyser F. Rheumatoid arthritis and pregnancy: evolution of disease activity and pathophysiological considerations for drug use. Rheumatology (Oxford) 2011; 50:1955-68. [PMID: 21890617 PMCID: PMC3198908 DOI: 10.1093/rheumatology/ker302] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 07/19/2011] [Indexed: 12/13/2022] Open
Abstract
It has long been known that pregnancy and childbirth have a profound effect on the disease activity of rheumatic diseases. For clinicians, the management of patients with RA wishing to become pregnant involves the challenge of keeping disease activity under control and adequately adapting drug therapy during pregnancy and post-partum. This article aims to summarize the current evidence on the evolution of RA disease activity during and after pregnancy and the use of anti-rheumatic drugs around this period. Of recent interest is the potential use of anti-TNF compounds in the preconception period and during pregnancy. Accumulating experience with anti-TNF therapy in other immune-mediated inflammatory diseases, such as Crohn's disease, provides useful insights for the use of TNF blockade in pregnant women with RA, or RA patients wishing to become pregnant.
Collapse
Affiliation(s)
- Johanna M.W. Hazes
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Pierre G. Coulie
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Vincent Geenen
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Séverine Vermeire
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Franck Carbonnel
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Edouard Louis
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Pierre Masson
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| | - Filip De Keyser
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, de Duve Institute, Université Catholique de Louvain, Brussels, Center of Immunology, Institute of Pathology, University of Liège, Liège, Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium, Gastroentérologie, Hôpital du Bicetre, Paris, France, Gastroenterology, CHU and University of Liege, Liège and Department of Rheumatology, Ghent University, Ghent, Belgium
| |
Collapse
|
11
|
Djokanovic N, Klieger-Grossmann C, Pupco A, Koren G. Safety of infliximab use during pregnancy. Reprod Toxicol 2011; 32:93-7. [PMID: 21621603 DOI: 10.1016/j.reprotox.2011.05.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/26/2011] [Accepted: 05/12/2011] [Indexed: 12/16/2022]
Abstract
Infliximab is a chimeric IgG1 monoclonal antibody to tumor necrosis factor alpha (TNF)-α used in the treatment of inflammatory bowel disease and rheumatoid arthritis. Infliximab does not actively cross the placenta during the first trimester, but undergoes efficient placental transfer during the late second and third trimesters and is detectable in the infant's serum for several months after birth. This raises concerns about immunological risks of infection and response to vaccines. Available evidence from registry studies and case reports involving more than 300 pregnancy outcomes suggest that infliximab carries low fetal risk and is compatible with use during conception and the first two trimesters of pregnancy. The long-term effects of infliximab exposure on the developing immune system are yet unknown. Based on limited data from several case reports, infants born with detectable levels of infliximab do not seem to have an increased risk of infections in their first year of life and have normal responses to nonlive vaccines. However, a fatal case of disseminated mycobacterial infection has been reported in an infant who received BCG vaccine at 3 months of age, to a mother who had been treated with infliximab throughout her pregnancy. Vaccination with live viruses should be postponed in infants exposed to infliximab in utero, until serum levels are undetectable which may require more than 6 months. Discontinuing infliximab early in the third trimester should be considered in order to minimize late fetal exposure.
Collapse
Affiliation(s)
- Nada Djokanovic
- The Motherisk Program, Department of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University Ave 555, Toronto M5G 1X8, Canada
| | | | | | | |
Collapse
|
12
|
Abstract
Over the past years, biological therapies, especially anti-TNF-α antibody therapy has emerged as a treatment approach in patients who have failed to achieve or maintain remission with tradional DMARDs. Women suffering from inflammatory arthritis may need to continue therapy throughout pregnancy and/or in the lactation period, hence the increased concern over the safety of antirheumatic drugs during pregnancy. Anti-TNF agents fall within the US FDA category B concerning fetal risk, indicating that no adequate and well-controlled studies have been conducted in pregnant or lactating women. However, in the last decade, numerous case series and registry data of pregnancies exposed to anti-TNF therapy have accumulated in the literature. According to these data, TNF inhibitor therapies appear to be safe in pregnancy, since no increased risk of malformations has been demonstrated. Ceasing therapy after conception should be considered, but treatment may be continued during pregnancy when indicated.The use of these agents is likely compatible with breast-feeding. The extent of fetal risk is not clarified for exposure to other biologics, such as Rituximab.
Collapse
Affiliation(s)
- R E Fischer-Betz
- Klinik für Endokrinolologie, Diabetologie und Rheumatologie, Rheumazentrum Rhein-Ruhr, Moorenstr. 5, 40225, Düsseldorf.
| | | |
Collapse
|
13
|
Effects of CNTO 530, an erythropoietin mimetic-IgG4 fusion protein, on embryofetal development in rats and rabbits. ACTA ACUST UNITED AC 2010; 89:87-96. [PMID: 20077575 DOI: 10.1002/bdrb.20227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND CNTO 530is a biopharmaceutical consisting of a novel peptide that mimics the actions of erythropoietin, fused to the Fc fragment of human IgG4. Pharmacokinetic and pharmacodynamic studies showed that CNTO 530 produced sustained increases in red blood cell parameters in rats and rabbits and that the serum half life of CNTO 530 was 2 days in rabbits and 3 days in rats. METHODS For the evaluation of embryofetal development, CNTO 530 was injected at loading doses of 0, 0.9/1, 6, or 60 mg/kg subcutaneously (SC) on gestation day (GD)7 followed by maintenance doses of 0, 0.3, 2, or 20 mg/kg SC every 3 days through GD16 in rats and every 2 days through GD19 in rabbits (GD0 was the day of mating). Rats were Caesarean sectioned on GD21, rabbits on GD29. RESULTS Administration of CNTO 530 was associated with an increase in hematocrit at all dose levels and a decrease in maternal body weight gains. Fetuses exhibited reduced body weight and delayed ossification. Soft tissue changes were limited to cardiovascular alterations in the high-dose rabbits only. Rat and rabbit fetuses were exposed to CNTO 530 in all dose groups. CONCLUSIONS These studies show that the embryo/fetal development effects observed following CNTO 530 treatment during organogenesis are qualitatively similar to those seen with other erythropoietin agonists and are likely a secondary consequence of increased hematocrit in the dams. Unlike other erythropoietin receptor agonists, CNTO 530 was able to cross the placental barrier, which was considered likely the result of FcRn-mediated transcytosis.
Collapse
|
14
|
Cassina M, Fabris L, Okolicsanyi L, Gervasi MT, Memmo A, Tiboni GM, Di Gianantonio E, Clementi M. Therapy of inflammatory bowel diseases in pregnancy and lactation. Expert Opin Drug Saf 2009; 8:695-707. [DOI: 10.1517/14740330903357463] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
15
|
Warren MA, Shoemaker SF, Shealy DJ, Bshar W, Ip MM. Tumor necrosis factor deficiency inhibits mammary tumorigenesis and a tumor necrosis factor neutralizing antibody decreases mammary tumor growth in neu/erbB2 transgenic mice. Mol Cancer Ther 2009; 8:2655-63. [PMID: 19755514 DOI: 10.1158/1535-7163.mct-09-0358] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tumor necrosis factor-alpha (TNF-alpha) is a pleiotropic cytokine that is synthesized and secreted by cells of the immune system, as well as by certain epithelia and stroma. Based on our previous studies demonstrating TNF-stimulated proliferation of normal and malignant mammary epithelial cells, we hypothesized that TNF might promote the growth of breast cancer in vivo. To test this, we generated bigenic mice that overexpressed activated neu/erbB2 in the mammary epithelium and whose TNF status was wild-type, heterozygous, or null. Mammary tumorigenesis was significantly decreased in TNF-/- mice (n = 30) compared with that in TNF+/+ mice (n = 27), with a palpable tumor incidence of 10.0% and 44.4%, and palpable tumors/mouse of 0.10 +/- 0.06 and 0.67 +/- 0.17, respectively. Tumorigenesis in the heterozygous group fell between that in the TNF+/+ and TNF-/- groups, but was not significantly different from either of the homozygous groups. The decreased tumor development in the TNF-/- mice was associated with a decreased proliferative index in the lobular and ductal mammary epithelium. To further investigate the role of TNF in breast cancer, mammary tumor-bearing mice whose tumors overexpressed wild-type neu/erbB2 were treated with a TNF-neutralizing antibody or a control antibody for 4 weeks (n = 20/group). Mammary tumor growth was significantly inhibited in mice treated with the anti-TNF antibody compared with the control antibody. Together, these data show a stimulatory role for TNF in the growth of breast tumors and suggest that TNF antagonists may be effective in a subset of patients with breast cancer.
Collapse
Affiliation(s)
- Mary Ann Warren
- Department of Pharmacology and Therapeutics, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
| | | | | | | | | |
Collapse
|
16
|
Bussiere JL, Martin P, Horner M, Couch J, Flaherty M, Andrews L, Beyer J, Horvath C. Alternative Strategies for Toxicity Testing of Species-Specific Biopharmaceuticals. Int J Toxicol 2009; 28:230-53. [DOI: 10.1177/1091581809337262] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although toxicology studies should always be conducted in pharmacologically relevant species, the specificity of many biopharmaceuticals can present challenges in identification of a relevant species. In certain cases, that is, when the clinical product is active only in humans or chimpanzees, or if the clinical candidate is active in other species but immunogenicity limits the ability to conduct a thorough safety assessment, alternative approaches to evaluating the safety of a biopharmaceutical must be considered. Alternative approaches, including animal models of disease, genetically modified mice, or use of surrogate molecules, may improve the predictive value of preclinical safety assessments of species-specific biopharmaceuticals, although many caveats associated with these models must be considered. Because of the many caveats that are discussed in this article, alternative approaches should only be used to evaluate safety when the clinical candidate cannot be readily tested in at least one relevant species to identify potential hazards.
Collapse
Affiliation(s)
- Jeanine L. Bussiere
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Pauline Martin
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Michelle Horner
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Jessica Couch
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Meghan Flaherty
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Laura Andrews
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Joseph Beyer
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| | - Christopher Horvath
- From Amgen Inc, Thousand Oaks, California; Centocor Research & Development, Inc, Radnor, Pennsylvania; Genzyme, Framingham, Massachusetts; Genentech Inc, South San Francisco, California; and Taligen Therapeutics, Cambridge, Massachusetts
| |
Collapse
|
17
|
Martin PL, Breslin W, Rocca M, Wright D, Cavagnaro J. Considerations in assessing the developmental and reproductive toxicity potential of biopharmaceuticals. ACTA ACUST UNITED AC 2009; 86:176-203. [DOI: 10.1002/bdrb.20197] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|