Clinical Oncology Society of Australia Position Statement: 2022 update to the safe handling of monoclonal antibodies in healthcare settings

A Human Skin Explant Test as a Novel In Vitro Assay for the Detection of Skin Sensitization to Aggregated Monoclonal Antibodies

Introduction: Monoclonal antibodies (mAbs) are important therapeutics. However, the enhanced potential for aggregation has become a critical quality parameter during the production of mAbs. Furthermore, mAb aggregation may also present a potential health risk in a clinical setting during the administration of mAb therapeutics to patients. While the extent of immunotoxicity in patient populations is uncertain, reports show it can lead to immune responses via cell activation and cytokine release. In this study, an autologous in vitro skin test designed to predict adverse immune events, including skin sensitization, was used as a novel assay for the assessment of immunotoxicity caused by mAb aggregation. Material and Methods: Aggregation of mAbs was induced by a heat stress protocol, followed by characterization of protein content by analytical ultra-centrifugation and transmission electron microscopy, revealing a 4% aggregation level of total protein content. Immunotoxicity and potential skin sensitization caused by the aggregates, were then tested in a skin explant assay. Results: Aggregated Herceptin and Rituximab caused skin sensitization, as shown by histopathological damage (grade II-III positive response) together with positive staining for Heat Shock Protein 70 (HSP70). Changes in T cell proliferation were not observed. Cytokine analysis revealed a significant increase of IL-10 for the most extreme condition of aggregation (65 °C at pH3) and a trend for an overall increase of IFN-γ, especially in response to Rituximab. Conclusions: The skin explant assay demonstrated that aggregated mAbs showed adverse immune reactions, as demonstrated as skin sensitization, with histopathological grades II-III. The assay may, therefore, be a novel tool for assessing immunotoxicity and skin sensitization caused by mAb aggregation.

Influences Shaping Clinicians' Monoclonal Antibody and Immune Checkpoint Inhibitor Preparation and Administration Management Practices: A Systematic Review

OBJECTIVES

In 30 years, monoclonal antibodies (mAbs) and immune checkpoint inhibitors (ICPIs) have enhanced cancer survival and quality of life. Limited knowledge exists regarding the long-term risks of repeated exposure, especially for cancer nurses, who prepare and administer them. This systematic review aimed to identify influences shaping clinicians' awareness and practices in the safe preparation and administration of mAbs and ICPIs.

DATA SOURCES

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases CINAHL, EMBASE, Joanna Briggs Institute, OVID, MEDLINE, and Cochrane were searched. Eligibility and risk of bias were assessed by four reviewers.

RESULTS

Of 7301 identified studies, 481 duplicates were removed, and 6673 were excluded after title and abstract review. A full-text review was conducted on 147 studies; six studies were included. A narrative synthesis generated two themes: (1) ambiguity contributes to variation in handling practices and (2) continuing professional development (CPD) is vital but hard to implement without evidence.

CONCLUSION

Lack of evidence regarding long-term risks and consensus creates uncertainty about the hazardous nature of unconjugated mAbs and ICPIs. Resulting in varied risk reduction strategies during preparation and administration, and inconsistent CPD. Protecting the long-term health of clinicians necessitates consensus on risk reduction strategies. This will be challenging without compelling evidence or international agreement on their hazardous classification.

IMPLICATIONS FOR NURSING PRACTICE

In nursing, policy gaps and inconsistent CPD related to unconjugated mAbs and ICPIs may expose nurses to risks. Understanding the educational needs of nurses and global standardized guidelines are urgently needed.