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Abstract
The development of antidrug antibodies (ADAs) is a major problem in several recombinant protein therapies used in the treatment of multiple sclerosis (MS). The etiology of ADAs is multifaceted. The predisposition for a breakdown of immune tolerance is probably genetically determined, and many factors may contribute to the immunogenicity, including structural properties, formation of aggregates, and presence of contaminants and impurities from the industrial manufacturing process. ADAs may have a neutralizing capacity and can reduce or abrogate the bioactivity and therapeutic efficacy of the drug and cause safety issues. Interferon (IFN)-β was the first drug approved for the treatment of MS, and-although it is generally recognized that neutralizing antibodies (NAbs) appear and potentially have a negative effect on therapeutic efficacy-the use of routine measurements of NAbs and the interpretation of the presence of NAbs has been debated at length. NAbs appear after 9-18 months of therapy in up to 40% of patients treated with IFNβ, and the frequency and titers of NAbs depend on the IFNβ preparation. Although all pivotal clinical trials of approved IFNβ products in MS exhibited a detrimental effect of NAbs after prolonged therapy, some subsequent studies did not observe clinical effects from NAbs, which led to the claim that NAbs did not matter. However, it is now largely agreed that persistently high titers of NAbs indicate an abrogation of the biological response and, hence, an absence of therapeutic efficacy, and this observation should lead to a change of therapy. Low and medium titers are ambiguous, and treatment decisions should be guided by determination of in vivo messenger RNA myxovirus resistance protein A induction after IFNβ administration and clinical disease activity. During treatment with glatiramer acetate, ADAs occur frequently but do not appear to adversely affect treatment efficacy or result in adverse events. ADAs occur in approximately 5% of patients treated with natalizumab within 6 months of therapy, and persistent NAbs are associated with a lack of efficacy and acute infusion-related reactions and should instigate a change of therapy. When using the anti-CD20 monoclonal antibodies ocrelizumab and ofatumumab in the treatment of MS, it is not necessary to test for NAbs as these occur very infrequently. Alemtuzumab is immunogenic, but routine measurements of ADAs are not recommended as the antibodies in the pivotal 2-year trials at the population level did not influence lymphocyte depletion or repopulation, efficacy, or safety. However, in some individuals, NAbs led to poor lymphocyte depletion.
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Marta M, Baker D, Creeke P, Pryce G, Gnanapavan S, Giovannoni G. Antigen-specific tolerization in human autoimmunity: Inhibition of interferon-beta1a anti-drug antibodies in multiple sclerosis: A case report. Mult Scler Relat Disord 2021; 56:103284. [PMID: 34624642 DOI: 10.1016/j.msard.2021.103284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/26/2021] [Accepted: 09/26/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antigen-specific tolerance in auto-immune diseases is the goal for effective treatment with minimal side-effects. Whilst this is achievable in animal models, notably via intravenous delivery of the model-specific autoantigen following transient CD4 T cell depletion, specific multiple sclerosis autoantigens remain unproven. However, anti-drug antibodies to human therapeutic proteins represent a model human autoimmune condition, which may be used to examine immune-tolerance induction. Some people with MS (PwMS) on interferon-beta1a (IFNβ1a) develop neutralizing antibodies to IFNβ1a that do not disappear in repeated tests over years. METHODS One PwMS was recruited, as part of a planned phase IIa trial (n = 15), who had developed neutralizing antibodies to subcutaneous IFNβ1a. Mitoxantrone (12 mg/m2) was administered as a lymphocyte depleting agent followed by four days of (88 μg/day + three 132 μg/day) intravenous IFNβ1a. Subcutaneous IFNβ1a three times a week was maintained during follow-up. IFNβ1a neutralizing antibody responses in serum were measured during treatment and three-monthly for 12 months. FINDINGS One participant was recruited and, within 6 months of tolerization, the neutralizing antibodies were undetectable. The tolerization treatment was well tolerated. However, the study was terminated after the first enrolment, on ethical grounds, as treatment alternatives became available and the potential risks of mitoxantrone use increased. INTERPRETATION The data suggest that it may be possible to induce antigen-specific tolerance by providing tolerogenic antigen following transient immune depletion. Further studies are warranted. FUNDING The study was supported by an unrestricted research grant from Merck-Serono.
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Affiliation(s)
- Monica Marta
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
| | - David Baker
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
| | - Paul Creeke
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Gareth Pryce
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Sharmilee Gnanapavan
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
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Buron MD, Magyari M, Chalmer TA, Sørensen PS, Sellebjerg F. Effectiveness of glatiramer acetate in neutralizing antibody-positive patients previously treated with interferon-β. Mult Scler Relat Disord 2020; 39:101894. [PMID: 31884382 DOI: 10.1016/j.msard.2019.101894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/30/2019] [Accepted: 12/14/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Some patients with multiple sclerosis who are treated with interferon-β(IFNβ) develop neutralizing antibodies (NAbs), which reduce or abolish the therapeutic effects of the treatment. These patients are usually switched to a non-IFNβ treatment, such as glatiramer acetate (GA). It is unknown whether a patient's previous disease activity in combination with their NAb-status can provide further insights on their risk of future disease activity. Consequently, we investigated treatment outcomes in patients switching from IFNβ to GA according to NAb-status and clinical disease activity, while on IFNβ. METHODS We identified all patients switching from IFNβ to GA and having information on NAb-status from the Danish Multiple Sclerosis Registry and compared treatment outcomes while on GA according to previous disease activity and the presence of NAbs. RESULTS We included 568 patients in the study: 107 NAb-negative patients switched due to adverse events (group 1), 24 NAb-negative patients switched with disease activity (group 2), 397 NAb-positive patients switched without disease activity (group 3) and 40 NAb-positive patients switched with disease activity (group 4). Compared to the reference (group 1), group 2 had an increased risk of future relapses (HR 1.79 95% Confidence interval (CI): 1.00-3.19). Group 3 showed a trend of a lower risk of future relapses (HR 0.74, 95%CI: 0.53-1.04). Group 4 had, on average, a similar risk of future relapses (HR 1.15 95% CI: 0.69-1.92). Similarly, group 2 had a higher probability of treatment discontinuation due to disease activity compared to the other groups. CONCLUSION While on GA, patients switched from IFNβ in the context of disease activity and no NAbs had the highest risk of future disease activity, while NAb positive patients without previous activity had the lowest. We did not find any average difference between NAb-positive patients switching in a context of disease activity and NAb-negative patients switched due to adverse events, although carefulness in the interpretation of this result is advised.
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Affiliation(s)
- Mathias Due Buron
- Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, 2600 Glostrup, Denmark; Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark.
| | - Melinda Magyari
- Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, 2600 Glostrup, Denmark; Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark.
| | - Thor Ameri Chalmer
- Danish Multiple Sclerosis Registry, Department of Neurology, Rigshospitalet, 2600 Glostrup, Denmark; Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark.
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark.
| | - Finn Sellebjerg
- Danish Multiple Sclerosis Center, Department of Neurology, Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark.
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Freedman MS, Abdoli M. Evaluating response to disease-modifying therapy in relapsing multiple sclerosis. Expert Rev Neurother 2015; 15:407-23. [DOI: 10.1586/14737175.2015.1023711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
The Canadian Multiple Sclerosis Working Group (CMSWG) developed practical recommendations in 2004 to assist clinicians in optimizing the use of disease-modifying therapies (DMT) in patients with relapsing multiple sclerosis. The CMSWG convened to review how disease activity is assessed, propose a more current approach for assessing suboptimal response, and to suggest a scheme for switching or escalating treatment. Practical criteria for relapses, Expanded Disability Status Scale (EDSS) progression and MRI were developed to classify the clinical level of concern as Low, Medium and High. The group concluded that a change in treatment may be considered in any RRMS patient if there is a high level of concern in any one domain (relapses, progression or MRI), a medium level of concern in any two domains, or a low level of concern in all three domains. These recommendations for assessing treatment response should assist clinicians in making more rational choices in their management of relapsing MS patients.
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Link J, Lundkvist Ryner M, Fink K, Hermanrud C, Lima I, Brynedal B, Kockum I, Hillert J, Fogdell-Hahn A. Human leukocyte antigen genes and interferon beta preparations influence risk of developing neutralizing anti-drug antibodies in multiple sclerosis. PLoS One 2014; 9:e90479. [PMID: 24608124 PMCID: PMC3946519 DOI: 10.1371/journal.pone.0090479] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 02/01/2014] [Indexed: 11/18/2022] Open
Abstract
A significant proportion of patients with multiple sclerosis who receive interferon beta (IFNβ) therapy develop neutralizing antibodies (NAbs) that reduce drug efficacy. To investigate if HLA class I and II alleles are associated with development of NAbs against IFNβ we analyzed whether NAb status and development of NAb titers high enough to be biologically relevant (>150 tenfold reduction units/ml) correlated with the HLA allele group carriage in a cohort of 903 Swedish patients with multiple sclerosis treated with either intramuscular IFNβ-1a, subcutaneous IFNβ-1a or subcutaneous IFNβ-1b. Carriage of HLA-DRB1*15 was associated with increased risk of developing NAbs and high NAb titers. After stratification based on type of IFNβ preparation, HLA-DRB1*15 carriage was observed to increase the risk of developing NAbs as well as high NAb titers against both subcutaneous and intramuscular IFNβ-1a. Furthermore, in patients receiving subcutaneous IFNβ-1a carriage of HLA-DQA1*05 decreased the risk for high NAb titers. In IFNβ-1b treated patients, HLA-DRB1*04 increased the risk of developing high NAb titers, and in a subgroup analysis of DRB1*04 alleles the risk for NAbs was increased in DRB1*04:01 carriers. In conclusion, there is a preparation-specific genetically determined risk to develop NAbs against IFNβ high enough to be clinically relevant in treatment decisions for patients with multiple sclerosis if confirmed in future studies. However, choice of IFNβ preparation still remains the single most significant determinant for the risk of developing NAbs.
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Affiliation(s)
- Jenny Link
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Malin Lundkvist Ryner
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Katharina Fink
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Christina Hermanrud
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Izaura Lima
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Boel Brynedal
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jan Hillert
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Fogdell-Hahn
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Development and characterization of a non-cell-based assay to assess the presence of neutralizing antibodies to interferon-beta in clinical samples. J Immunol Methods 2013; 395:37-44. [DOI: 10.1016/j.jim.2013.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/11/2013] [Accepted: 06/17/2013] [Indexed: 11/22/2022]
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Wadhwa M, Subramanyam M, Goelz S, Goyal J, Jethwa V, Jones W, Files JG, Kramer D, Bird C, Dilger P, Tovey M, Lallemand C, Thorpe R. Use of a standardized MxA protein measurement-based assay for validation of assays for the assessment of neutralizing antibodies against interferon-β. J Interferon Cytokine Res 2013; 33:660-71. [PMID: 23848523 DOI: 10.1089/jir.2012.0079] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Effective monitoring of the development of neutralizing antibodies (NAbs) against IFN-β in multiple sclerosis (MS) patients on IFN-β therapy is important for clinical decision making and disease management. To date, antiviral assays have been the favored approach for NAb determination, but variations in assay conditions between laboratories and the increasing use of novel assays have contributed to the reporting of inconsistent antibody data between laboratories and between products. This study, undertaken at the request of the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA), is a joint effort by manufacturers of IFN-β products (approved in Europe) towards harmonization of a NAb assay that facilitates generation of comparable NAb data, which, in conjunction with clinical outcomes, should prove useful for clinicians treating MS patients with IFN-β products. This article describes the standardized cellular myxovirus resistance protein A (MxA) protein measurement-based assay for detection of IFN-β NAbs and its use for the validation of assays used for the quantitative determination of such antibodies. Although titers varied between laboratories and the products used, utilization of IFN-β1a rather than IFN-β1b as the challenge antigen produced more consistent results in the NAb assay. Adoption of the standardized assay improves comparability between laboratories circumventing problems that arise when different, nonstandardized assays are employed for immunogenicity assessment. Based on the data, the EMA recommended for standardization purposes, the use of IFN-β1a in NAb assays, independent of the therapeutic product used for therapy and validation of new NAb procedures against the standardized assay described.
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Affiliation(s)
- Meenu Wadhwa
- 1 Biotherapeutics Group, National Institute for Biological Standards and Control , Hertfordshire, United Kingdom
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Yamout B, Alroughani R, Al-Jumah M, Khoury S, Abouzeid N, Dahdaleh M, Alsharoqi I, Inshasi J, Hashem S, Zakaria M, ElKallab K, Alsaadi T, Tawfeek T, Bohlega S. Consensus guidelines for the diagnosis and treatment of multiple sclerosis. Curr Med Res Opin 2013; 29:611-21. [PMID: 23514115 DOI: 10.1185/03007995.2013.787979] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The diagnosis of multiple sclerosis (MS) is dependent on the presence of clinical and paraclinical evidence demonstrating dissemination of central nervous system lesions in both space and time, as well as the exclusion of other disorders. Diagnostic criteria were originally promulgated in 1965 by the Schumacher committee and modified subsequently by the Poser committee to include paraclinical evidence. The most recent criteria are the 2010 modifications of the 2001 McDonald criteria, which are focused on making an earlier diagnosis of MS. This article provides guidelines, derived from clinical experience as well as evidence-based medicine, for the diagnosis and management of MS with special emphasis on practices in the Middle East.
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Affiliation(s)
- B Yamout
- American University of Beirut Medical Center, Beirut, Lebanon.
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Martins TB, Rose JW, Gardiner GL, Kusukawa N, Husebye D, Hill HR. Cell-Based Reporter Gene Assay for Therapy-Induced Neutralizing Antibodies to Interferon-Beta in Multiple Sclerosis. J Interferon Cytokine Res 2013; 33:52-7. [DOI: 10.1089/jir.2012.0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas B. Martins
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah
| | - John W. Rose
- Neurovirology Research Laboratory and the Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gareth L. Gardiner
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah
| | - Noriko Kusukawa
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah
| | - Dee Husebye
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Harry R. Hill
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah
- Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Creeke PI, Farrell RA. Clinical testing for neutralizing antibodies to interferon-β in multiple sclerosis. Ther Adv Neurol Disord 2013; 6:3-17. [PMID: 23277789 PMCID: PMC3526949 DOI: 10.1177/1756285612469264] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Biopharmaceuticals are drugs which are based on naturally occurring proteins (antibodies, receptors, cytokines, enzymes, toxins), nucleic acids (DNA, RNA) or attenuated microorganisms. Immunogenicity of these agents has been commonly described and refers to a specific antidrug antibody response. Such immunogenicity represents a major factor impairing the efficacy of biopharmaceuticals due to biopharmaceutical neutralization. Indeed, clinical experience has shown that induction of antidrug antibodies is associated with a loss of response to biopharmaceuticals and also with hypersensitivity reactions. The first disease-specific agent licensed to treat multiple sclerosis (MS) was interferon-β (IFNβ). In its various preparations, it remains the most commonly used first-line agent. The occurrence of antidrug antibodies has been extensively researched in MS, particularly in relation to IFNβ. However, much controversy remains regarding the significance of these antibodies and incorporation of testing into clinical practice. Between 2% and 45% of people treated with IFNβ will develop neutralizing antibodies, and this is dependent on the specific drug and dosing regimen. The aim of this review is to discuss the use of IFNβ in MS, the biological and clinical relevance of anti-IFNβ antibodies (binding and neutralizing antibodies), the incorporation of testing in clinical practice and ongoing research in the field.
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