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Howard JF, Vu T, Li G, Korobko D, Smilowski M, Liu L, Gistelinck F, Steeland S, Noukens J, Van Hoorick B, Podhorna J, Borgions F, Li Y, Utsugisawa K, Wiendl H, De Bleecker JL, Mantegazza R. Subcutaneous efgartigimod PH20 in generalized myasthenia gravis: A phase 3 randomized noninferiority study (ADAPT-SC) and interim analyses of a long-term open-label extension study (ADAPT-SC+). Neurotherapeutics 2024:e00378. [PMID: 39227284 DOI: 10.1016/j.neurot.2024.e00378] [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: 11/14/2023] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 09/05/2024] Open
Abstract
ADAPT-SC (NCT04735432) was designed to evaluate noninferiority of subcutaneous (SC) efgartigimod PH20 to intravenous (IV) efgartigimod in participants with generalized myasthenia gravis (gMG). ADAPT-SC+ (NCT04818671) is an open-label extension study designed to assess long-term safety, tolerability, and efficacy of efgartigimod PH20 SC. Adult participants in ADAPT-SC were randomly assigned to receive a treatment cycle of 4 once-weekly administrations of efgartigimod PH20 SC 1000 mg or efgartigimod IV 10 mg/kg, followed by 7 weeks of follow-up. Primary endpoint was percentage change from baseline in total immunoglobulin G (IgG) level at week 4 (1 week after the fourth administration). Secondary efficacy endpoints assessed number and percentage of Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) responders and mean change from baseline in total score for each measure. The primary endpoint was met, demonstrating noninferiority in total IgG reduction between efgartigimod PH20 SC 1000 mg and efgartigimod IV 10 mg/kg. Clinically meaningful improvements were seen as early as 1 week following the first administration in both treatment arms, with maximal improvements at week 4. Continued treatment cycles of efgartigimod PH20 SC in ADAPT-SC+ have demonstrated long-term safety and consistent improvements in MG-ADL total score. Findings from ADAPT-SC and ADAPT-SC+ demonstrate similar safety and efficacy as observed in the placebo-controlled ADAPT study. Collectively, these findings support noninferiority between efgartigimod PH20 SC 1000 mg and efgartigimod IV 10 mg/kg, as well as long-term safety, tolerability, and efficacy of efgartigimod PH20 SC for treatment of a broad population of patients with gMG.
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Affiliation(s)
- James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - George Li
- Medsol Clinical Research Center, Port Charlotte, FL, USA
| | - Denis Korobko
- Regional Centre for Multiple Sclerosis and Other Autoimmune System Diseases of the Nervous System, State Novosibirsk Regional Clinical Hospital, Novosibirsk State Medical University, Novosibirsk, Russia
| | - Marek Smilowski
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | | | | | | | | | | | | | - Yuebing Li
- Neuromuscular Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Jan L De Bleecker
- Department of Neurology and Neuromuscular Reference Center, Ghent University Hospital, Ghent, Belgium
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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Howard JF, Bril V, Vu T, Karam C, Peric S, De Bleecker JL, Murai H, Meisel A, Beydoun SR, Pasnoor M, Guglietta A, Van Hoorick B, Steeland S, T’joen C, Utsugisawa K, Verschuuren J, Mantegazza R. Long-term safety, tolerability, and efficacy of efgartigimod (ADAPT+): interim results from a phase 3 open-label extension study in participants with generalized myasthenia gravis. Front Neurol 2024; 14:1284444. [PMID: 38318236 PMCID: PMC10842202 DOI: 10.3389/fneur.2023.1284444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/27/2023] [Indexed: 02/07/2024] Open
Abstract
Objective ADAPT+ assessed the long-term safety, tolerability, and efficacy of efgartigimod in adult participants with generalized myasthenia gravis (gMG). Methods ADAPT+ was an open-label, single-arm, multicenter, up to 3-year extension of the pivotal phase 3 ADAPT study. Efgartigimod was administered in treatment cycles of 4 intravenous infusions (one 10 mg/kg infusion per week). Initiation of subsequent treatment cycles was individualized based on clinical evaluation. Safety endpoints included incidence and severity of adverse events. Efficacy endpoints assessed disease severity using Myasthenia Gravis-Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Results As of January 2022, 151 participants had rolled over to ADAPT+ and 145 had received ≥1 dose of efgartigimod, of whom, 111 (76.6%) were AChR-Ab+ and 34 (23.4%) were AChR-Ab-. Mean study duration (treatment plus follow-up) was 548 days, and participants received up to 17 treatment cycles, corresponding to 217.6 participant-years of exposure. In the overall population, 123 (84.8%) participants reported ≥1 treatment-emergent adverse event; most frequent were headache (36 [24.8%]), COVID-19 (22 [15.2%]), and nasopharyngitis (20 [13.8%]). Clinically meaningful improvement (CMI) in mean MG-ADL and QMG scores was seen as early as 1 week following the first infusion across multiple cycles in AChR-Ab+ and AChR-Ab- participants. Maximal MG-ADL and QMG improvements aligned with onset and magnitude of total IgG and AChR-Ab reductions. For AChR-Ab+ participants at any time point in each of the first 10 treatment cycles, more than 90% had a maximum reduction of ≥2 points (CMI) in MG-ADL total score; across the 7 cycles in which QMG was measured, 69.4% to 91.3% of participants demonstrated a maximum reduction of ≥3 points (CMI) in QMG total score. Many participants demonstrated improvements well beyond CMI thresholds. In AChR-Ab+ participants with ≥1 year of combined follow-up between ADAPT and ADAPT+, mean number of annualized cycles was 4.7 per year (median [range] 5.0 [0.5-7.6]). Conclusion Results of ADAPT+ corroborate the substantial clinical improvements seen with efgartigimod in ADAPT and support its long-term safety, tolerability, and efficacy, as well as an individualized dosing regimen for treatment of gMG. Clinical trial registration https://classic.clinicaltrials.gov/ct2/show/NCT03770403, NCT03770403.
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Affiliation(s)
- James F. Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Stojan Peric
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jan L. De Bleecker
- Department of Neurology and Neuromuscular Reference Center, Ghent University Hospital, Ghent, Belgium
| | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Andreas Meisel
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Said R. Beydoun
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
| | | | | | | | | | | | - Jan Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Carlo Besta, Milan, Italy
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Bril V, Howard JF, Karam C, De Bleecker JL, Murai H, Utsugisawa K, Ulrichts P, Brauer E, Zhao S, Mantegazza R, Vu T. Effect of efgartigimod on muscle group subdomains in participants with generalized myasthenia gravis: post hoc analyses of the phase 3 pivotal ADAPT study. Eur J Neurol 2024; 31:e16098. [PMID: 37843174 PMCID: PMC11235734 DOI: 10.1111/ene.16098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) is a rare, chronic, neuromuscular autoimmune disease mediated by pathogenic immunoglobulin G (IgG) autoantibodies. Patients with gMG experience debilitating muscle weakness, resulting in impaired mobility, speech, swallowing, vision and respiratory function. Efgartigimod is a human IgG1 antibody Fc fragment engineered for increased binding affinity to neonatal Fc receptor. The neonatal Fc receptor blockade by efgartigimod competitively inhibits endogenous IgG binding, leading to decreased IgG recycling and increased degradation resulting in lower IgG concentration. METHODS The safety and efficacy of efgartigimod were evaluated in the ADAPT study. Key efficacy outcome measures included Myasthenia Gravis Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores. Efgartigimod demonstrated significant improvement in both the MG-ADL and QMG scores. This post hoc analysis aimed to determine whether all subdomains of MG-ADL and QMG improved with efgartigimod treatment. Individual items of MG-ADL and QMG were grouped into four subdomains: bulbar, ocular, limb/gross motor and respiratory. Change from baseline over 10 weeks in each subdomain was calculated for each group. RESULTS Greater improvements from baseline were seen across MG-ADL subdomains in participants treated with efgartigimod compared with placebo. These improvements were typically observed 1 to 2 weeks after the first infusion and correlated with reductions in IgG. Similar results were observed across most QMG subdomains. CONCLUSIONS These post hoc analyses of MG-ADL and QMG subdomain data from ADAPT suggest that efgartigimod is beneficial in improving muscle function and strength across all muscle groups, leading to the observed efficacy in participants with gMG.
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Affiliation(s)
- Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular DiseasesUniversity Health NetworkTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - James F. Howard
- Department of NeurologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Chafic Karam
- Penn Neuroscience Center–NeurologyHospital of the University of PennsylvaniaPennsylvaniaPhiladelphiaUSA
| | | | - Hiroyuki Murai
- Department of Neurology, School of MedicineInternational University of Health and WelfareTokyoJapan
| | | | | | | | | | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular DiseasesFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Tuan Vu
- Department of NeurologyUniversity of South Florida Morsani College of MedicineTampaFloridaUSA
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Crisafulli S, Boccanegra B, Carollo M, Bottani E, Mantuano P, Trifirò G, De Luca A. Myasthenia Gravis Treatment: From Old Drugs to Innovative Therapies with a Glimpse into the Future. CNS Drugs 2024; 38:15-32. [PMID: 38212553 DOI: 10.1007/s40263-023-01059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/13/2024]
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease that causes debilitating muscle weakness due to impaired neuromuscular transmission. Since most (about 80-90%) MG patients present autoantibodies against the acetylcholine receptor, standard medical therapy consists of symptomatic treatment with acetylcholinesterase inhibitors (e.g., pyridostigmine). In addition, considering the autoimmune basis of MG, standard therapy includes immunomodulating agents, such as corticosteroids, azathioprine, cyclosporine A, and cyclophosphamide. New strategies have been proposed for the treatment of MG and include complement blockade (i.e., eculizumab, ravulizumab, and zilucoplan) and neonatal Fc receptor antagonism (i.e., efgartigimod and rozanolixizumab). The aim of this review is to provide a detailed overview of the pre- and post-marketing evidence on the five pharmacological treatments most recently approved for the treatment of MG, by identifying both preclinical and clinical studies registered in clinicaltrials.gov. A description of the molecules currently under evaluation for the treatment of MG is also provided.
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Affiliation(s)
| | - Brigida Boccanegra
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
| | - Massimo Carollo
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy
| | - Emanuela Bottani
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy
| | - Paola Mantuano
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, P.le L.A. Scuro 10, 37124, Verona, Italy.
| | - Annamaria De Luca
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Bari, Italy
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Kawama K, Warabi Y, Bokuda K, Kimura H, Takahashi K. Exacerbation of Thymoma-Associated Myasthenia Gravis Following Efgartigimod Treatment Related to Anti-acetylcholine Receptor Antibody Overshoot: A Report of Two Cases. Cureus 2023; 15:e50692. [PMID: 38229781 PMCID: PMC10791222 DOI: 10.7759/cureus.50692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/18/2024] Open
Abstract
Myasthenia gravis (MG), a chronic, autoimmune disease affecting the neuromuscular junction, arises from various autoantibodies, including those against the acetylcholine receptor (AChR). Recently, efgartigimod, a human IgG1 antibody Fc fragment engineered to reduce the pathogenic IgG autoantibody level, was developed as a treatment for MG. However, the long-term effects of the treatment are still unclear. The present report describes two novel cases of thymoma-associated MG exacerbation following efgartigimod treatment related to anti-AChR antibody overshoot. Both cases shared certain characteristics, including anti-AChR antibody positivity and post-thymectomy status. After a few cycles of efgartigimod treatment, their MG deteriorated, and their anti-AChR antibody titer exceeded the level before efgartigimod therapy. Prior studies show that anti-AChR antibody titer does not correlate with the disease severity of MG. However, previous studies have reported antibody overshoot following plasma exchange, which, like efgartigimod, reduces the level of plasma IgG and autoantibodies. Thus, MG exacerbation with anti-AChR antibody overshoot may be an adverse effect of both efgartigimod and plasma exchange. When clinical symptoms in patients with thymoma-associated MG receiving efgartigimod deteriorate despite low IgG, assessing the anti-AChR antibody level can be important for reconsidering the treatment strategy.
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Affiliation(s)
- Kentaro Kawama
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Yoko Warabi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Kota Bokuda
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Hideki Kimura
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, JPN
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Wilcke H, Glaubitz S, Kück F, Anten C, Liebetanz D, Schmidt J, Zschüntzsch J. Female sex and overweight are associated with a lower quality of life in patients with myasthenia gravis: a single center cohort study. BMC Neurol 2023; 23:366. [PMID: 37817097 PMCID: PMC10563278 DOI: 10.1186/s12883-023-03406-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/27/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) affects individuals as a chronic autoimmune disease for many years. Commonly, chronic diseases significantly reduce the patients' quality of life. Aiming to improve the future quality of life in MG, this study assessed the factors impacting quality of life. As gender-specific medicine is becoming increasingly important, this study also focused on understanding gender differences in the outcome of MG. METHODS The study is a combined monocentric, retrospective and prospective database analysis of patient records based on 2,370 presentations of 165 patients with clinically, serologically and/or electrophysiologically confirmed MG over an observation period of up to 47 years. The data collection included the following parameters: antibody status, disease severity, age, medication use, gender, and disease duration. In addition, a prospective survey was conducted on the quality of life using the Myasthenia gravis-specific 15-item Quality of Life scale (MG-QoL15) and on the activities of daily living using the MG-specific Activities of Daily Living scale (MG-ADL). RESULTS Of the 165 patients, 85 were male (51.5%) and 80 were female (48.5%). The remaining baseline characteristics (e.g. age and antibody status) were consistent with other myasthenia gravis cohorts. A high body mass index (BMI) (p = 0.005) and a high disease severity (p < 0.001) were significantly associated with lower disease-specific quality of life. Additionally, the quality of life in women with MG was significantly reduced compared to male patients (19.7 vs. 13.0 points in the MG-QoL15, p = 0.024). Gender differences were also observable in terms of the period between initial manifestation and initial diagnosis and women were significantly more impaired in their activities of daily living (MG-ADL) than men (4.8 vs. 3.0 points, p = 0.032). CONCLUSION Women with MG had significantly poorer disease specific quality of life compared to men as well as patients with a higher BMI. In order to improve the quality of life, gender-specific medicine and further investigation regarding a modification of the quality of life by lowering the BMI are essential and necessary. TRIAL REGISTRATION Study approval by the Ethics Committee of the University Medical Center Göttingen was granted (number 6/5/18).
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Affiliation(s)
- Hannah Wilcke
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Stefanie Glaubitz
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - Christoph Anten
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - David Liebetanz
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Jens Schmidt
- Department of Neurology, University Medical Center, Göttingen, Germany
- Department of Neurology and Pain Treatment, Immanuel Clinic Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Jana Zschüntzsch
- Department of Neurology, University Medical Center, Göttingen, Germany.
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Haraya K, Tachibana T. Translational Approach for Predicting Human Pharmacokinetics of Engineered Therapeutic Monoclonal Antibodies with Increased FcRn-Binding Mutations. BioDrugs 2023; 37:99-108. [PMID: 36449140 PMCID: PMC9709760 DOI: 10.1007/s40259-022-00566-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Recently, increasing FcRn binding by Fc engineering has become a promising approach for prolonging the half-life of therapeutic monoclonal antibodies (mAbs). This study is the first to investigate the optimization of an allometric scaling approach for engineered mAbs based on cynomolgus monkey data to predict human pharmacokinetics. METHODS Linear two-compartmental model parameters (clearance [CL]; volume of distribution in the central compartment [Vc]; inter-compartmental clearance [Q]; volume of distribution in the peripheral compartment [Vp]) after the intravenous (IV) injection of engineered mAbs (M252Y/S254T/T256E or M428L/N434S mutations) in cynomolgus monkeys and humans were collected from published data. We explored the optimal exponent for allometric scaling to predict parameters in humans based on cynomolgus monkey data. Moreover, the plasma concentration-time profile of engineered mAbs after IV injection in humans was predicted using parameters estimated based on an optimized exponent. RESULTS For engineered mAbs, a significant positive correlation between cynomolgus monkeys and humans was observed for CL, but not for other parameters. Whereas conventional exponents (CL: 0.8, Q: 0.75, Vc: 1.0, Vp: 0.95) previously established for normal mAbs showed poor prediction accuracy for CL and Q of engineered mAbs, the newly optimized exponents (CL: 0.55, Q: 0.6, Vc: 0.95, Vp: 0.95) achieved superior predictability for engineered mAbs. Moreover, the optimized exponents accurately predicted plasma mAb concentration-time profiles after IV injection of engineered mAbs in humans. CONCLUSIONS We found that engineered mAbs require specially optimized exponents to accurately predict pharmacokinetic parameters and plasma concentration-time profiles after IV injections in humans based on cynomolgus monkey data. This optimized approach can contribute to a more accurate prediction of human pharmacokinetics in the development of engineered mAbs.
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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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Kussini J, Kaisers T, Sequeira Santos AM, Eming R, Didona D. [Pemphigus: current and future treatment strategies]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 74:915-926. [PMID: 37902884 DOI: 10.1007/s00105-023-05246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/01/2023]
Abstract
Pemphigus diseases are a group of organ-specific autoimmune diseases which are characterised by the production of autoantibodies against intra-epidermal adhesion molecules and structural proteins of skin and mucosae. Depending on the entity, patients develop blisters and erosions on the skin and/or mucosae. According to the AWMF S2k guidelines for diagnosis and therapy of pemphigus diseases, a systemic therapy is recommended. Initially, high-dose, oral corticosteroids in combination with immunosuppressive drugs as corticosteroid-sparing agent, usually azathioprine or mycophenolate mofetil, can be used. Furthermore, rituximab, a monoclonal antibody directed against CD20 on B cells, was recently approved for pemphigus vulgaris and moderate or severe pemphigus foliaceus.
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Affiliation(s)
- Jacqueline Kussini
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - Tabea Kaisers
- Klinik III Dermatologie, Venerologie & Allergologie, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | | | - Rüdiger Eming
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland
- Klinik III Dermatologie, Venerologie & Allergologie, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - Dario Didona
- Klinik für Dermatologie und Allergologie, Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland.
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Guptill JT, Sleasman JW, Steeland S, Sips M, Gelinas D, de Haard H, Azar A, Winthrop KL. Effect of FcRn antagonism on protective antibodies and to vaccines in IgG-mediated autoimmune diseases pemphigus and generalised myasthenia gravis. Autoimmunity 2022; 55:620-631. [PMID: 36036539 DOI: 10.1080/08916934.2022.2104261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antagonism of the neonatal Fc receptor (FcRn) by efgartigimod has been studied in several autoimmune diseases mediated by immunoglobulin G (IgG) as a therapeutic approach to remove pathogenic IgGs. Whereas reduction of pathogenic titres has demonstrated efficacy in multiple autoimmune diseases, reducing total IgG could potentially increase infection risk in patients receiving FcRn antagonists. The objective of this study was to analyse the effect of FcRn antagonism with efgartigimod on existing protective antibody titres and the ability to mount an immune response after vaccine challenge. Serum levels of total IgG and protective antibodies against tetanus toxoid (TT), varicella zoster virus (VZV), and pneumococcal capsular polysaccharide (PCP) were measured in all patients enrolled in an open-label trial of efgartigimod for the treatment of pemphigus. Vaccine specific-responses were assessed by measuring changes in IgG titres in patients with generalised myasthenia gravis (gMG) who were treated with efgartigimod and who received influenza, pneumococcal, or coronavirus disease 2019 (COVID-19) vaccines during participation in the double-blind trial ADAPT or open-label extension, ADAPT+ (n = 17). FcRn antagonism reduced levels of protective anti-TT, anti-VZV, and anti-PCP antibodies and total IgG to a similar extent; anti-TT and anti-VZV titres remained above minimally protective thresholds for the majority of patients, (10/12) 83% and (14/15) 93% respectively. Protective antibodies returned to baseline values upon treatment cessation. Antigen-specific IgG responses to influenza, pneumococcal, and COVID-19 immunisation were detected in patients with gMG who received these vaccines while undergoing therapy with efgartigimod. In conclusion, FcRn antagonism with efgartigimod did not hamper generation of IgG responses but did transiently reduce IgG titres of all specificities.
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Affiliation(s)
- Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.,argenx, Ghent, Belgium
| | - John W Sleasman
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | | | | | - Antoine Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin L Winthrop
- Division of Infectious Disease, Oregon Health and Science University, Portland, Oregon, USA
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10
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Monoclonal Antibody Engineering and Design to Modulate FcRn Activities: A Comprehensive Review. Int J Mol Sci 2022; 23:ijms23179604. [PMID: 36077002 PMCID: PMC9455995 DOI: 10.3390/ijms23179604] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [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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11
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Sand KMK, Gruber MM, Sandlie I, Mathiesen L, Andersen JT, Wadsack C. Contribution of the ex vivo placental perfusion model in understanding transplacental immunoglobulin G transfer. Placenta 2022; 127:77-87. [PMID: 35981406 DOI: 10.1016/j.placenta.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The acquisition of humoral immunity in utero is essential for the fetus. The crucial protein, which is responsible for this part of immunity, is immunoglobulin-G (IgG). Immune functions of IgGs are mediated via the interaction of the crystallizable fragment (Fc) region of IgG with specific Fc γ receptors (FcγRs). However, an atypical FcγR, the neonatal Fc receptor (FcRn), is a key regulator of IgG transfer across the human placenta. During the last four decades ex vivo placental perfusion studies have contributed significantly to the study of mechanisms of IgG transfer across the multicellular placental barrier. METHOD A PubMed search was conducted by using specific keywords: placenta, perfusion and IgG to review manuscripts using human placental perfusion to study the transplacental transfer of IgG. Relevant studies found in reference lists of these manuscripts were also added to the review, and references were included that supported or gave nuance to the discussion of the mechanisms of IgG kinetics in the placenta. RESULTS AND DISCUSSION We found twenty publications on the study of transplacental transfer of IgG using human ex vivo placental perfusion, by research groups with partly different settings. This review summarizes knowledge about placental IgG transfer, with a strong focus on the contributions from ex vivo placental perfusion studies.
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Affiliation(s)
- Kine Marita Knudsen Sand
- Department of Biosciences, University of Oslo, 0371, Oslo, Norway; Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, 0424, Oslo, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, 0424, Oslo, Norway
| | - Michael M Gruber
- Department of Obstetrics and Gynaecology, Medical University of Graz, 8036, Graz, Austria
| | - Inger Sandlie
- Department of Biosciences, University of Oslo, 0371, Oslo, Norway; Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, 0424, Oslo, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, 0424, Oslo, Norway
| | - Line Mathiesen
- Section of Environmental Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, 0424, Oslo, Norway; Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, 0424, Oslo, Norway
| | - Christian Wadsack
- Department of Obstetrics and Gynaecology, Medical University of Graz, 8036, Graz, Austria; BioTechMed-Graz, Austria
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12
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Moise KJ, Oepkes D, Lopriore E, Bredius RGM. Targeting neonatal Fc receptor: potential clinical applications in pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:167-175. [PMID: 35229965 DOI: 10.1002/uog.24891] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 06/14/2023]
Abstract
The neonatal Fc receptor (FcRn) plays an important role in the transfer of the immunoglobulin G isotype (IgG) from the mother to the fetus. FcRn expressed on endothelial cells also binds to IgG and albumin, regulating the circulating half-lives of these proteins. Alloimmune and autoimmune IgG antibodies have been implicated in various perinatal immune-mediated diseases. FcRn-mediated placental transfer of pathogenic antibodies can result in cell and tissue injury in the fetus and neonate, with devastating outcomes. Thus, blockade of FcRn may be an effective treatment strategy in managing these conditions and could additionally reduce the concentration of pathogenic antibodies in the maternal circulation by preventing IgG recycling. In this review, we discuss the biology of FcRn, the rationale and considerations for development of FcRn-blocking agents, and their potential clinical applications in various perinatal immune-mediated diseases. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K J Moise
- Department of Women's Health, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - D Oepkes
- Department of Obstetrics and Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R G M Bredius
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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13
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Yuan H, Pan M, Chen H, Mao X. Immunotherapy for Pemphigus: Present and Future. Front Med (Lausanne) 2022; 9:901239. [PMID: 35783635 PMCID: PMC9240651 DOI: 10.3389/fmed.2022.901239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Pemphigus is a chronic and severe autoimmune bullous disease caused by autoantibodies targeting adhesion molecules between keratinocytes. It requires 2–3 years on average to manage the disease. To date, although Rituximab combined with short-term systemic glucocorticoids was accepted as first-line therapy, systemic glucocorticoids remain the primary therapeutic option for pemphigus patients, successfully decreasing morbidity and mortality from pemphigus. However, novel therapeutic strategies are desirable due to the low efficacy in some subset of patients and the long-term severe adverse effects of traditional therapies. Recently, immunotherapy has proved to be encouraging for disease control or cure. Based on the current understanding of the immune mechanisms of pemphigus, we review the immune targets and corresponding agents applied in practice or under clinical trials. The goals of the novel treatments are to improve the quality of life of pemphigus patients by improving efficacy and safety, minimizing side effects, achieving fast disease control, or curing the disease.
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Affiliation(s)
- Huijie Yuan
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Meng Pan
- Department of Dermatology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongxiang Chen
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuming Mao
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Xuming Mao
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14
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Provan D, Newland AC. Investigational drugs for immune thrombocytopenia. Expert Opin Investig Drugs 2022; 31:715-727. [DOI: 10.1080/13543784.2022.2075340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Drew Provan
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK
| | - Adrian C Newland
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK
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15
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Zakrzewicz A, Würth C, Beckert B, Feldhoff S, Vanderheyden K, Foss S, Andersen JT, de Haard H, Verheesen P, Bobkov V, Tikkanen R. Stabilization of Keratinocyte Monolayer Integrity in the Presence of Anti-Desmoglein-3 Antibodies through FcRn Blockade with Efgartigimod: Novel Treatment Paradigm for Pemphigus? Cells 2022; 11:cells11060942. [PMID: 35326398 PMCID: PMC8946243 DOI: 10.3390/cells11060942] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/21/2022] Open
Abstract
Pemphigus vulgaris is an autoimmune blistering disease of the epidermis, caused by autoantibodies against desmosomal proteins, mainly desmogleins 1 and 3, which induce an impairment of desmosomal adhesion and blister formation. Recent findings have shown that inhibition of immunoglobulin G binding on the neonatal Fc receptor, FcRn, results in reduced autoantibody recycling and shortens their half-life, providing a valid treatment option for PV. We have here analyzed the role of FcRn in human keratinocytes treated with antibodies isolated from pemphigus vulgaris patient or with recombinant anti-desmoglein-3 antibodies that induce pathogenic changes in desmosomes, such as loss of monolayer integrity, aberrant desmoglein-3 localization and degradation of desmoglein-3. We show that blocking IgG binding on FcRn by efgartigimod, a recombinant Fc fragment undergoing clinical studies for pemphigus, stabilizes the keratinocyte monolayer, whereas the loss of desmoglein-3 is not prevented by efgartigimod. Our data show that FcRn may play a direct role in the pathogenesis of pemphigus at the level of the autoantibody target cells, the epidermal keratinocytes. Our data suggest that in keratinocytes, FcRn may have functions different from its known function in IgG recycling. Therefore, stabilization of keratinocyte adhesion by FcRn blocking entities may provide a novel treatment paradigm for pemphigus.
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Affiliation(s)
- Anna Zakrzewicz
- Institute of Biochemistry, Medical Faculty, University of Giessen, Friedrichstrasse 24, 35392 Giessen, Germany; (A.Z.); (C.W.); (B.B.); (S.F.)
| | - Celina Würth
- Institute of Biochemistry, Medical Faculty, University of Giessen, Friedrichstrasse 24, 35392 Giessen, Germany; (A.Z.); (C.W.); (B.B.); (S.F.)
| | - Benedikt Beckert
- Institute of Biochemistry, Medical Faculty, University of Giessen, Friedrichstrasse 24, 35392 Giessen, Germany; (A.Z.); (C.W.); (B.B.); (S.F.)
| | - Simon Feldhoff
- Institute of Biochemistry, Medical Faculty, University of Giessen, Friedrichstrasse 24, 35392 Giessen, Germany; (A.Z.); (C.W.); (B.B.); (S.F.)
| | - Katrien Vanderheyden
- Argenx BV, Industriepark Zwijnaarde 7, 9052 Ghent, Belgium; (K.V.); (H.d.H.); (P.V.); (V.B.)
| | - Stian Foss
- Department of Immunology, University of Oslo and Oslo University Hospital, Rikshospitalet, 0372 Oslo, Norway; (S.F.); (J.T.A.)
- Institute of Clinical Medicine and Department of Pharmacology, University of Oslo and Oslo University Hospital, 0372 Oslo, Norway
| | - Jan Terje Andersen
- Department of Immunology, University of Oslo and Oslo University Hospital, Rikshospitalet, 0372 Oslo, Norway; (S.F.); (J.T.A.)
- Institute of Clinical Medicine and Department of Pharmacology, University of Oslo and Oslo University Hospital, 0372 Oslo, Norway
| | - Hans de Haard
- Argenx BV, Industriepark Zwijnaarde 7, 9052 Ghent, Belgium; (K.V.); (H.d.H.); (P.V.); (V.B.)
| | - Peter Verheesen
- Argenx BV, Industriepark Zwijnaarde 7, 9052 Ghent, Belgium; (K.V.); (H.d.H.); (P.V.); (V.B.)
| | - Vladimir Bobkov
- Argenx BV, Industriepark Zwijnaarde 7, 9052 Ghent, Belgium; (K.V.); (H.d.H.); (P.V.); (V.B.)
| | - Ritva Tikkanen
- Institute of Biochemistry, Medical Faculty, University of Giessen, Friedrichstrasse 24, 35392 Giessen, Germany; (A.Z.); (C.W.); (B.B.); (S.F.)
- Correspondence:
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16
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Wolfe GI, Ward ES, de Haard H, Ulrichts P, Mozaffar T, Pasnoor M, Vidarsson G. IgG regulation through FcRn blocking: A novel mechanism for the treatment of myasthenia gravis. J Neurol Sci 2021; 430:118074. [PMID: 34563918 DOI: 10.1016/j.jns.2021.118074] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/04/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
The neonatal Fc receptor (FcRn) is an MHC class I-like molecule that is widely distributed in mammalian organs, tissues, and cells. FcRn is critical to maintaining immunoglobulin G (IgG) and albumin levels through rescuing these molecules from lysosomal degradation. IgG autoantibodies are associated with many autoimmune diseases, including myasthenia gravis (MG), a rare neuromuscular autoimmune disease that causes debilitating and, in its generalized form (gMG), potentially life-threatening muscle weakness. IgG autoantibodies are directly pathogenic in MG and target neuromuscular junction proteins, causing neuromuscular transmission failure. Treatment approaches that reduce autoantibody levels, such as therapeutic plasma exchange and intravenous immunoglobulin, have been shown to be effective for gMG patients but are not indicated as ongoing maintenance therapies and can be associated with burdensome side effects. Agents that block FcRn-mediated recycling of IgG represent a rational and promising approach for the treatment of gMG. Blocking FcRn allows targeted reduction of all IgG subtypes without decreasing concentrations of other Ig isotypes; therefore, FcRn blocking could be a safe and effective treatment strategy for a broad population of gMG patients. Several FcRn-blocking antibodies and one antibody Fc fragment have been developed and are currently in various stages of clinical development. This article describes the mechanism of FcRn blockade as a novel approach for IgG-mediated disease therapy and reviews promising clinical data using such FcRn blockers for the treatment of gMG.
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Affiliation(s)
- Gil I Wolfe
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, SUNY, Buffalo, NY, USA.
| | - E Sally Ward
- Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, SO16 6YD, UK
| | - Hans de Haard
- argenx, Zwijnaarde, Belgium, University of California, Irvine, CA, USA
| | - Peter Ulrichts
- argenx, Zwijnaarde, Belgium, University of California, Irvine, CA, USA
| | - Tahseen Mozaffar
- Department of Neurology, University of California, Irvine, CA, USA
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gestur Vidarsson
- Sanquin Research, and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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17
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Yang Y, Nian S, Li L, Wen X, Liu Q, Zhang B, Lan Y, Yuan Q, Ye Y. Fully human recombinant antibodies against EphA2 from a multi-tumor patient immune library suitable for tumor-targeted therapy. Bioengineered 2021; 12:10379-10400. [PMID: 34709992 PMCID: PMC8810047 DOI: 10.1080/21655979.2021.1996807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Enhanced EphA2 expression is observed in a variety of epithelial-derived malignancies and is an important target for anti-tumor therapy. Currently, Therapeutic monoclonal antibodies against immune checkpoints have shown good efficacy for tumor treatment. In this study, we constructed an immune single-chain fragment variable (scFv) library using peripheral blood mononuclear cells (PBMCs) from 200 patients with a variety of malignant tumors. High affinity scFvs against EphA2 can be easily screened from the immune library using phage display technology. Anti-EphA2 scFvs can be modified into any form of recombinant antibody, including scFv-Fc and full-length IgG1 antibodies, and the recombinant antibody affinity was improved following modification. Among the modified anti-EphA2 antibodies the affinity of 77-IgG1 was significantly increased, reaching a pmol affinity level (10−12). We further demonstrated the binding activity of recombinant antibodies to the EphA2 protein, tumor cells, and tumor tissues using macromolecular interaction techniques, flow cytometry and immunohistochemistry. Most importantly, both the constructed scFvs-Fc, as well as the IgG1 antibodies against EphA2 were able to inhibit the growth of tumor cells to some extent. These results suggest that the immune libraries from patients with malignant tumors are more likely to screen for antibodies with high affinity and therapeutic effect. The constructed fully human scFv immune library has broad application prospects for specific antibody screening. The screened scFv-Fc and IgG1 antibodies against EphA2 can be used for the further study of tumor immunotherapy.
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Affiliation(s)
- Yaqi Yang
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Siji Nian
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Lin Li
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Xue Wen
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China.,Department of Laboratory Medicine, the Affiliated Hospital of Southwest Medical University, Sichuan 646000, P.R. China
| | - Qin Liu
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Bo Zhang
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Yu Lan
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Qing Yuan
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
| | - Yingchun Ye
- Public Center of Experimental Technology, The school of Basic medical science, Southwest medical university, Luzhou, Sichuan Province, 646000, China
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18
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Howard JF, Bril V, Vu T, Karam C, Peric S, Margania T, Murai H, Bilinska M, Shakarishvili R, Smilowski M, Guglietta A, Ulrichts P, Vangeneugden T, Utsugisawa K, Verschuuren J, Mantegazza R. Safety, efficacy, and tolerability of efgartigimod in patients with generalised myasthenia gravis (ADAPT): a multicentre, randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2021; 20:526-536. [PMID: 34146511 DOI: 10.1016/s1474-4422(21)00159-9] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/23/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is an unmet need for treatment options for generalised myasthenia gravis that are effective, targeted, well tolerated, and can be used in a broad population of patients. We aimed to assess the safety and efficacy of efgartigimod (ARGX-113), a human IgG1 antibody Fc fragment engineered to reduce pathogenic IgG autoantibody levels, in patients with generalised myasthenia gravis. METHODS ADAPT was a randomised, double-blind, placebo-controlled, phase 3 trial done at 56 neuromuscular academic and community centres in 15 countries in North America, Europe, and Japan. Patients aged at least 18 years with generalised myasthenia gravis were eligible to participate in the study, regardless of anti-acetylcholine receptor antibody status, if they had a Myasthenia Gravis Activities of Daily Living (MG-ADL) score of at least 5 (>50% non-ocular), and were on a stable dose of at least one treatment for generalised myasthenia gravis. Patients were randomly assigned by interactive response technology (1:1) to efgartigimod (10 mg/kg) or matching placebo, administered as four infusions per cycle (one infusion per week), repeated as needed depending on clinical response no sooner than 8 weeks after initiation of the previous cycle. Patients, investigators, and clinical site staff were all masked to treatment allocation. The primary endpoint was proportion of acetylcholine receptor antibody-positive patients who were MG-ADL responders (≥2-point MG-ADL improvement sustained for ≥4 weeks) in the first treatment cycle. The primary analysis was done in the modified intention-to-treat population of all acetylcholine receptor antibody-positive patients who had a valid baseline MG-ADL assessment and at least one post-baseline MG-ADL assessment. The safety analysis included all randomly assigned patients who received at least one dose or part dose of efgartigimod or placebo. This trial is registered at ClinicalTrials.gov (NCT03669588); an open-label extension is ongoing (ADAPT+, NCT03770403). FINDINGS Between Sept 5, 2018, and Nov 26, 2019, 167 patients (84 in the efgartigimod group and 83 in the placebo group) were enrolled, randomly assigned, and treated. 129 (77%) were acetylcholine receptor antibody-positive. Of these patients, more of those in the efgartigimod group were MG-ADL responders (44 [68%] of 65) in cycle 1 than in the placebo group (19 [30%] of 64), with an odds ratio of 4·95 (95% CI 2·21-11·53, p<0·0001). 65 (77%) of 84 patients in the efgartigimod group and 70 (84%) of 83 in the placebo group had treatment-emergent adverse events, with the most frequent being headache (efgartigimod 24 [29%] vs placebo 23 [28%]) and nasopharyngitis (efgartigimod ten [12%] vs placebo 15 [18%]). Four (5%) efgartigimod-treated patients and seven (8%) patients in the placebo group had a serious adverse event. Three patients in each treatment group (4%) discontinued treatment during the study. There were no deaths. INTERPRETATION Efgartigimod was well tolerated and efficacious in patients with generalised myasthenia gravis. The individualised dosing based on clinical response was a unique feature of ADAPT, and translation to clinical practice with longer term safety and efficacy data will be further informed by the ongoing open-label extension. FUNDING argenx.
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Affiliation(s)
- James F Howard
- Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tuan Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Chafic Karam
- Penn Neuroscience Center-Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stojan Peric
- Neurology Clinic, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Temur Margania
- Department of Neurology and Neurorehabilitation, New Hospitals, Tbilisi, Georgia
| | - Hiroyuki Murai
- Department of Neurology, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Malgorzata Bilinska
- Department and Clinic of Neurology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Marek Smilowski
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | | | | | | | | | - Jan Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Renato Mantegazza
- Department of Neuroimmunology and Neuromuscular Diseases, Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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19
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Hubbard JJ, Pyzik M, Rath T, Kozicky LK, Sand KMK, Gandhi AK, Grevys A, Foss S, Menzies SC, Glickman JN, Fiebiger E, Roopenian DC, Sandlie I, Andersen JT, Sly LM, Baker K, Blumberg RS. FcRn is a CD32a coreceptor that determines susceptibility to IgG immune complex-driven autoimmunity. J Exp Med 2021; 217:151942. [PMID: 32658257 PMCID: PMC7537387 DOI: 10.1084/jem.20200359] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/21/2020] [Accepted: 05/29/2020] [Indexed: 12/18/2022] Open
Abstract
IgG immune complexes (ICs) promote autoimmunity through binding fragment crystallizable (Fc) γ-receptors (FcγRs). Of these, the highly prevalent FcγRIIa (CD32a) histidine (H)-131 variant (CD32aH) is strongly linked to human autoimmune diseases through unclear mechanisms. We show that, relative to the CD32a arginine (R)-131 (CD32aR) variant, CD32aH more avidly bound human (h) IgG1 IC and formed a ternary complex with the neonatal Fc receptor (FcRn) under acidic conditions. In primary human and mouse cells, both CD32a variants required FcRn to induce innate and adaptive immune responses to hIgG1 ICs, which were augmented in the setting of CD32aH. Conversely, FcRn induced responses to IgG IC independently of classical FcγR, but optimal responses required FcRn and FcγR. Finally, FcRn blockade decreased inflammation in a rheumatoid arthritis model without reducing circulating autoantibody levels, providing support for FcRn’s direct role in IgG IC-associated inflammation. Thus, CD32a and FcRn coregulate IgG IC-mediated immunity in a manner favoring the CD32aH variant, providing a novel mechanism for its disease association.
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Affiliation(s)
- Jonathan J Hubbard
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Michal Pyzik
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Timo Rath
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lisa K Kozicky
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kine M K Sand
- Department of Biosciences, Centre for Immune Regulation, University of Oslo, Oslo, Norway.,Department of Immunology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Amit K Gandhi
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Algirdas Grevys
- Department of Biosciences, Centre for Immune Regulation, University of Oslo, Oslo, Norway.,Department of Immunology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Stian Foss
- Department of Biosciences, Centre for Immune Regulation, University of Oslo, Oslo, Norway.,Department of Immunology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Susan C Menzies
- Division of Gastroenterology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan N Glickman
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Edda Fiebiger
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Inger Sandlie
- Department of Biosciences, Centre for Immune Regulation, University of Oslo, Oslo, Norway.,Department of Immunology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Jan Terje Andersen
- Department of Biosciences, Centre for Immune Regulation, University of Oslo, Oslo, Norway.,Department of Immunology, Centre for Immune Regulation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Laura M Sly
- Division of Gastroenterology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kristi Baker
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard S Blumberg
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Harvard Digestive Diseases Center, Boston, MA
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20
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Vesco G, Lualdi M, Fasano M, Nardo L, Alberio T. Demonstration of fibrinogen-FcRn binding at acidic pH by means of Fluorescence Correlation Spectroscopy. Biochem Biophys Res Commun 2020; 536:32-37. [PMID: 33360096 DOI: 10.1016/j.bbrc.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/09/2020] [Indexed: 11/16/2022]
Abstract
The neonatal Fc receptor (FcRn) interacts with IgG and albumin at acidic pH within endosomes, thus protecting these plasma proteins from degradation. Recently, we proposed fibrinogen as a new binding partner of FcRn. This work was aimed at providing a direct demonstration of FcRn-fibrinogen binding at acidic pH by Fluorescence Correlation Spectroscopy. The increase in diffusion time between free and fibrinogen-bound FITC-labelled FcRn was assumed as the binding indicator. We observed that, at acidic pH (pH = 5.3), FcRn diffusion time shifted from ≈730 μs (FITC-labelled FcRn alone) to >1200 μs (FITC-labelled FcRn added with fibrinogen). A similar trend was exhibited by albumin, a known FcRn interactor, while no significant variations in diffusion time were observed upon incubation with catalase as negative control. Our results demonstrate a binding interaction between fibrinogen, one of the most abundant plasma proteins, and FcRn, a receptor involved in the regulation of the levels of IgG and albumin. This interaction is likely responsible for fibrinogen protection from intracellular degradation and recycling in plasma. Fibrinogen is crucial not only in haemostasis but also in acute inflammatory response and in some pathological conditions. The interaction with FcRn can influence not only the levels of fibrinogen in plasma and other tissues, but also the levels of other FcRn binding partners, among which are some plasma proteins of clinical relevance.
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Affiliation(s)
- Guglielmo Vesco
- University of Insubria, Department of Science and High Technology, Via Valleggio 11, Como, Italy
| | - Marta Lualdi
- University of Insubria, Department of Science and High Technology, Via Valleggio 11, Como, Italy
| | - Mauro Fasano
- University of Insubria, Department of Science and High Technology, Via Valleggio 11, Como, Italy
| | - Luca Nardo
- University of Insubria, Department of Science and High Technology, Via Valleggio 11, Como, Italy
| | - Tiziana Alberio
- University of Insubria, Department of Science and High Technology, Via Valleggio 11, Como, Italy.
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21
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Sun W, Khare P, Wang X, Challa DK, Greenberg BM, Ober RJ, Ward ES. Selective Depletion of Antigen-Specific Antibodies for the Treatment of Demyelinating Disease. Mol Ther 2020; 29:1312-1323. [PMID: 33212299 PMCID: PMC7934575 DOI: 10.1016/j.ymthe.2020.11.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/09/2020] [Accepted: 11/11/2020] [Indexed: 11/19/2022] Open
Abstract
Current treatments for antibody-mediated autoimmunity are associated with lack of specificity, leading to immunosuppressive effects. To overcome this limitation, we have developed a class of antibody-based therapeutics for the treatment of autoimmunity involving antibodies that recognize the autoantigen, myelin oligodendrocyte glycoprotein (MOG). These agents ("Seldegs," for selective degradation) selectively eliminate antigen (MOG)-specific antibodies without affecting the levels of antibodies of other specificities. Seldeg treatment of mice during antibody-mediated exacerbation of experimental autoimmune encephalomyelitis by patient-derived MOG-specific antibodies results in disease amelioration. Consistent with their therapeutic effects, Seldegs deliver their targeted antibodies to Kupffer and liver sinusoidal endothelial cells that are known to have tolerogenic effects. Our results show that Seldegs can ameliorate disease mediated by MOG-specific antibodies and indicate that this approach also has the potential to treat other autoimmune diseases where the specific clearance of antibodies is required.
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MESH Headings
- Animals
- Antibodies, Monoclonal/metabolism
- Autoantibodies/immunology
- Autoantigens/immunology
- Encephalomyelitis, Autoimmune, Experimental/etiology
- Encephalomyelitis, Autoimmune, Experimental/metabolism
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Encephalomyelitis, Autoimmune, Experimental/therapy
- Endothelial Cells/immunology
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
- Female
- Humans
- Macrophages/immunology
- Macrophages/metabolism
- Macrophages/pathology
- Male
- Mice
- Mice, Inbred C57BL
- Mice, Transgenic
- Multiple Sclerosis/immunology
- Myelin-Oligodendrocyte Glycoprotein/immunology
- Receptors, IgG/metabolism
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Affiliation(s)
- Wei Sun
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, TX 77843, USA
| | - Priyanka Khare
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, TX 77843, USA
| | - Xiaoli Wang
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, TX 77843, USA
| | - Dilip K Challa
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, TX 77843, USA
| | - Benjamin M Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Raimund J Ober
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, TX 77843, USA; Department of Biomedical Engineering, Texas A&M University, 5045 Emerging Technologies Building, 3120 TAMU, College Station, TX 77843, USA; Cancer Sciences Unit, Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK.
| | - E Sally Ward
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, TX 77843, USA; Cancer Sciences Unit, Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, 3107 Medical Research & Education Building, 8447 State Highway 47, Bryan, TX 77807, USA.
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22
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Lozoya OA, McClelland KS, Papas BN, Li JL, Yao HHC. Patterns, Profiles, and Parsimony: Dissecting Transcriptional Signatures From Minimal Single-Cell RNA-Seq Output With SALSA. Front Genet 2020; 11:511286. [PMID: 33193599 PMCID: PMC7586319 DOI: 10.3389/fgene.2020.511286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 09/18/2020] [Indexed: 11/23/2022] Open
Abstract
Single-cell RNA sequencing (scRNA-seq) technologies have precipitated the development of bioinformatic tools to reconstruct cell lineage specification and differentiation processes with single-cell precision. However, current start-up costs and recommended data volumes for statistical analysis remain prohibitively expensive, preventing scRNA-seq technologies from becoming mainstream. Here, we introduce single-cell amalgamation by latent semantic analysis (SALSA), a versatile workflow that combines measurement reliability metrics with latent variable extraction to infer robust expression profiles from ultra-sparse sc-RNAseq data. SALSA uses a matrix focusing approach that starts by identifying facultative genes with expression levels greater than experimental measurement precision and ends with cell clustering based on a minimal set of Profiler genes, each one a putative biomarker of cluster-specific expression profiles. To benchmark how SALSA performs in experimental settings, we used the publicly available 10X Genomics PBMC 3K dataset, a pre-curated silver standard from human frozen peripheral blood comprising 2,700 single-cell barcodes, and identified 7 major cell groups matching transcriptional profiles of peripheral blood cell types and driven agnostically by < 500 Profiler genes. Finally, we demonstrate successful implementation of SALSA in a replicative scRNA-seq scenario by using previously published DropSeq data from a multi-batch mouse retina experimental design, thereby identifying 10 transcriptionally distinct cell types from > 64,000 single cells across 7 independent biological replicates based on < 630 Profiler genes. With these results, SALSA demonstrates that robust pattern detection from scRNA-seq expression matrices only requires a fraction of the accrued data, suggesting that single-cell sequencing technologies can become affordable and widespread if meant as hypothesis-generation tools to extract large-scale differential expression effects.
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Affiliation(s)
- Oswaldo A. Lozoya
- Genomic Integrity & Structural Biology Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - Kathryn S. McClelland
- Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - Brian N. Papas
- Integrative Bioinformatics Support Group, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - Jian-Liang Li
- Integrative Bioinformatics Support Group, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - Humphrey H.-C. Yao
- Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
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23
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Castleman JS, Moise KJ, Kilby MD. Medical therapy to attenuate fetal anaemia in severe maternal red cell alloimmunisation. Br J Haematol 2020; 192:425-432. [PMID: 32794242 DOI: 10.1111/bjh.17041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 12/01/2022]
Abstract
Haemolytic disease of the fetus and newborn (HDFN) remains an important cause of fetal mortality with potential neonatal and longer-term morbidity. HDFN is caused by maternal red cell alloimmunisation, with IgG antibodies crossing the placenta to destroy fetal erythroid cells expressing the involved antigen. Intrauterine fetal blood transfusion is the therapy of choice for severe fetal anaemia. Despite a strong evidence base and technical advances, invasive fetal therapy carries risk of miscarriage and preterm birth. Procedure-related risks are increased when invasive, in utero transfusion is instituted prior to 22 weeks to treat severe early-onset fetal anaemia. This review focuses upon this cohort of HDFN and discusses intravenous immunoglobin (IVIg) and novel monoclonal antibody (M281, nipocalimab) treatments which, if started at the end of the first trimester, may attenuate the transplacental passage and fetal effects of IgG antibodies. Such therapy has the ability to improve fetal survival in this severe presentation of HDFN when early in utero transfusion may be required and may have wider implications for the perinatal management in general.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kenneth J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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24
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Habib AA, Ahmadi Jazi G, Mozaffar T. Update on immune-mediated therapies for myasthenia gravis. Muscle Nerve 2020; 62:579-592. [PMID: 32462710 DOI: 10.1002/mus.26919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 11/05/2022]
Abstract
With the exception of thymectomy, immune modulatory treatment strategies and clinical trials in myasthenia gravis over the past 50 y were mainly borrowed from experience in other nonneurologic autoimmune disorders. The current experimental therapy paradigm has significantly changed such that treatments directed against the pathological mechanisms specific to myasthenia gravis are being tested, in some cases as the initial disease indication. Key advances have been made in three areas: (i) the expanded role and long-term benefits of thymectomy, (ii) complement inhibition to prevent antibody-mediated postsynaptic membrane damage, and (iii) neonatal Fc receptor (FcRn) inhibition as in vivo apheresis, removing pathogenic antibodies. Herein, we discuss these advances and the potential for these newer therapies to significantly influence the current treatment paradigms. While these therapies provide exciting new options with rapid efficacy, there are anticipated challenges to their use, especially in terms of a dramatic increase in cost of care for some patients with myasthenia gravis.
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Affiliation(s)
- Ali Aamer Habib
- Department of Neurology, University of California, Irvine, California
| | | | - Tahseen Mozaffar
- Department of Neurology, University of California, Irvine, California.,Department of Orthopedic Surgery, University of California, Irvine, California.,Departments of Pathology and Laboratory Medicine, University of California, Irvine, California
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25
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Gable KL, Guptill JT. Antagonism of the Neonatal Fc Receptor as an Emerging Treatment for Myasthenia Gravis. Front Immunol 2020; 10:3052. [PMID: 31998320 PMCID: PMC6965493 DOI: 10.3389/fimmu.2019.03052] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/12/2019] [Indexed: 12/30/2022] Open
Abstract
Myasthenia gravis is an autoimmune disease in which immunoglobulin G (IgG) autoantibodies are formed against the nicotinic acetylcholine receptor (AChR) or other components of the neuromuscular junction. Though effective treatments are currently available, many commonly used therapies have important limitations and alternative therapeutic options are needed for patients. A novel treatment approach currently in clinical trials for myasthenia gravis targets the neonatal Fc receptor (FcRn). This receptor plays a central role in prolonging the half–life of IgG molecules. The primary function of FcRn is salvage of IgG and albumin from lysosomal degradation through the recycling and transcytosis of IgG within cells. Antagonism of this receptor causes IgG catabolism, resulting in reduced overall IgG and pathogenic autoantibody levels. This treatment approach is particularly intriguing as it does not result in widespread immune suppression, in contrast to many therapies in routine clinical use. Experience with plasma exchange and emerging phase 2 clinical trial data of FcRn antagonists provide proof of concept for IgG lowering in myasthenia gravis. Here we review the IgG lifecycle and the relevance of IgG lowering to myasthenia gravis treatment and summarize the available data on FcRn targeted therapeutics in clinical trials for myasthenia gravis.
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Affiliation(s)
- Karissa L Gable
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Durham, NC, United States
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26
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Pyzik M, Sand KMK, Hubbard JJ, Andersen JT, Sandlie I, Blumberg RS. The Neonatal Fc Receptor (FcRn): A Misnomer? Front Immunol 2019; 10:1540. [PMID: 31354709 PMCID: PMC6636548 DOI: 10.3389/fimmu.2019.01540] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022] Open
Abstract
Antibodies are essential components of an adaptive immune response. Immunoglobulin G (IgG) is the most common type of antibody found in circulation and extracellular fluids. Although IgG alone can directly protect the body from infection through the activities of its antigen binding region, the majority of IgG immune functions are mediated via proteins and receptors expressed by specialized cell subsets that bind to the fragment crystallizable (Fc) region of IgG. Fc gamma (γ) receptors (FcγR) belong to a broad family of proteins that presently include classical membrane-bound surface receptors as well as atypical intracellular receptors and cytoplasmic glycoproteins. Among the atypical FcγRs, the neonatal Fc receptor (FcRn) has increasingly gained notoriety given its intimate influence on IgG biology and its ability to also bind to albumin. FcRn functions as a recycling or transcytosis receptor that is responsible for maintaining IgG and albumin in the circulation, and bidirectionally transporting these two ligands across polarized cellular barriers. More recently, it has been appreciated that FcRn acts as an immune receptor by interacting with and facilitating antigen presentation of peptides derived from IgG immune complexes (IC). Here we review FcRn biology and focus on newer advances including how emerging FcRn-targeted therapies may affect the immune responses to IgG and IgG IC.
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Affiliation(s)
- Michal Pyzik
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Kine M K Sand
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Department of Biosciences, University of Oslo, Oslo, Norway
| | - Jonathan J Hubbard
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Pharmacology, Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Inger Sandlie
- Department of Biosciences, University of Oslo, Oslo, Norway
| | - Richard S Blumberg
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.,Harvard Digestive Diseases Center, Boston, MA, United States
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27
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Baldwin WM, Valujskikh A, Fairchild RL. The neonatal Fc receptor: Key to homeostasic control of IgG and IgG-related biopharmaceuticals. Am J Transplant 2019; 19:1881-1887. [PMID: 30903736 PMCID: PMC6591018 DOI: 10.1111/ajt.15366] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/15/2019] [Accepted: 03/15/2019] [Indexed: 01/25/2023]
Abstract
IgG and albumin are the most abundant proteins in the circulation and have the longest half-lives. These properties are due to a unique receptor, the neonatal Fc receptor (FcRn). Although FcRn is named for its function of transferring IgG across the placenta from maternal to fetal circulation, FcRn functions throughout life to maintain IgG and albumin concentrations. FcRn protects IgG and albumin from intracellular degradation and recycles them back into the circulation. Clinical trials have confirmed that pathogenic antibodies can be depleted by blocking this homeostatic function of FcRn. Moreover, understanding the molecular interactions between IgG and FcRn has resulted in the design of therapeutic monoclonal antibodies with more efficacious pharmacokinetics. As a result of genetic engineering these monoclonals can be delivered at lower doses and at longer intervals. More recent findings have demonstrated that FcRn enhances phagocytosis by neutrophils, immune complex clearance by podocytes and antigen presentation by dendritic cells, macrophages, and B cells. This minireview highlights the relevance of FcRn to transplantation.
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Affiliation(s)
- William M. Baldwin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anna Valujskikh
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert L. Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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28
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Bilgic Temel A, Murrell DF. Pharmacological advances in pemphigus. Curr Opin Pharmacol 2019; 46:44-49. [PMID: 30974409 DOI: 10.1016/j.coph.2019.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/26/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023]
Abstract
This is an updated review of the literature on the emerging therapeutic options for the treatment of pemphigus to provide better care for patients. There is an increasing range of molecules targeted for pemphigus therapy against CD20, Bruton tyrosine kinase, chimeric antigen receptor, T-cell immune components, B-cell activating factor, proliferation-inducing ligand (APRIL), CD25, p38 mitogen-activated protein kinase (p38MAPK) and cytokine modulation therapies (anti-IL-4, anti-IL-6). The main aim of the current new therapies is to provide specific pathology-focused therapeutic options which have long-term sustainable therapeutic effects on disease progress, cause less side effects without systemic immunosuppression, and have less risk of getting antibodies against the medication during treatment.
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Affiliation(s)
- Asli Bilgic Temel
- St George Hospital, UNSW Department of Dermatology, Kogarah, Sydney, NSW 2217, Australia
| | - Dedee F Murrell
- St George Hospital, UNSW Department of Dermatology, Kogarah, Sydney, NSW 2217, Australia.
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29
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Huijbers MG, Plomp JJ, van Es IE, Fillié-Grijpma YE, Kamar-Al Majidi S, Ulrichts P, de Haard H, Hofman E, van der Maarel SM, Verschuuren JJ. Efgartigimod improves muscle weakness in a mouse model for muscle-specific kinase myasthenia gravis. Exp Neurol 2019; 317:133-143. [PMID: 30851266 DOI: 10.1016/j.expneurol.2019.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/24/2019] [Accepted: 03/04/2019] [Indexed: 12/30/2022]
Abstract
Myasthenia gravis is hallmarked by fatigable muscle weakness resulting from neuromuscular synapse dysfunction caused by IgG autoantibodies. The variant with muscle-specific kinase (MuSK) autoantibodies is characterized by prominent cranial and bulbar weakness and a high frequency of respiratory crises. The majority of MuSK MG patients requires long-term immunosuppressive treatment, but the result of these treatments is considered less satisfactory than in MG with acetylcholine receptor antibodies. Emergency treatments are more frequently needed, and many patients develop permanent facial weakness and nasal speech. Therefore, new treatment options would be welcome. The neonatal Fc receptor protects IgG from lysosomal breakdown, thus prolonging IgG serum half-life. Neonatal Fc receptor antagonism lowers serum IgG levels and thus may act therapeutically in autoantibody-mediated disorders. In MuSK MG, IgG4 anti-MuSK titres closely correlate with disease severity. We therefore tested efgartigimod (ARGX-113), a new neonatal Fc receptor blocker, in a mouse model for MuSK myasthenia gravis. This model involves 11 daily injections of purified IgG4 from MuSK myasthenia gravis patients, resulting in overt myasthenic muscle weakness and, consequently, body weight loss. Daily treatment with 0.5 mg efgartigimod, starting at the fifth passive transfer day, reduced the human IgG4 titres about 8-fold, despite continued daily injection. In muscle strength and fatigability tests, efgartigimod-treated myasthenic mice outperformed control myasthenic mice. Electromyography in calf muscles at endpoint demonstrated less myasthenic decrement of compound muscle action potentials in efgartigimod-treated mice. These substantial in vivo improvements of efgartigimod-treated MuSK MG mice following a limited drug exposure period were paralleled by a tendency of recovery at neuromuscular synaptic level (in various muscles), as demonstrated by ex vivo functional studies. These synaptic improvements may well become more explicit upon longer drug exposure. In conclusion, our study shows that efgartigimod has clear therapeutic potential in MuSK myasthenia gravis and forms an exciting candidate drug for many autoantibody-mediated neurological and other disorders.
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Affiliation(s)
- Maartje G Huijbers
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Department of Human Genetics, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Jaap J Plomp
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Inge E van Es
- Department of Human Genetics, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Samar Kamar-Al Majidi
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; Department of Human Genetics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Peter Ulrichts
- argenx BVBA, Industriepark Zwijnaarde 7, 9052, Zwijnaarde, Gent, Belgium
| | - Hans de Haard
- argenx BVBA, Industriepark Zwijnaarde 7, 9052, Zwijnaarde, Gent, Belgium
| | - Erik Hofman
- argenx BVBA, Industriepark Zwijnaarde 7, 9052, Zwijnaarde, Gent, Belgium
| | | | - Jan J Verschuuren
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
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30
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Ling LE, Hillson JL, Tiessen RG, Bosje T, van Iersel MP, Nix DJ, Markowitz L, Cilfone NA, Duffner J, Streisand JB, Manning AM, Arroyo S. M281, an Anti-FcRn Antibody: Pharmacodynamics, Pharmacokinetics, and Safety Across the Full Range of IgG Reduction in a First-in-Human Study. Clin Pharmacol Ther 2018; 105:1031-1039. [PMID: 30402880 PMCID: PMC6587432 DOI: 10.1002/cpt.1276] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
M281 is a fully human, anti-neonatal Fc receptor (FcRn) antibody that inhibits FcRn-mediated immunoglobulin G (IgG) recycling to decrease pathogenic IgG while preserving IgG production. A randomized, double-blind, placebo-controlled, first-in-human study with 50 normal healthy volunteers was designed to probe safety and the physiological maximum for reduction of IgG. Intravenous infusion of single ascending doses up to 60 mg/kg induced dose-dependent serum IgG reductions, which were similar across all IgG subclasses. Multiple weekly doses of 15 or 30 mg/kg achieved mean IgG reductions of ≈85% from baseline and maintained IgG reductions ≥75% from baseline for up to 24 days. M281 was well tolerated, with no serious or severe adverse events (AEs), few moderate AEs, and a low incidence of infection-related AEs similar to placebo treatment. The tolerability and consistency of M281 pharmacokinetics and pharmacodynamics support further evaluation of M281 in diseases mediated by pathogenic IgG.
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Affiliation(s)
- Leona E Ling
- Momenta Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Jan L Hillson
- Momenta Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | | | - Tjerk Bosje
- PRA Health Sciences, Groningen, The Netherlands
| | | | - Darrell J Nix
- Drug Development Consulting, North New Portland, Maine, USA
| | - Lynn Markowitz
- Momenta Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | | | - Jay Duffner
- Momenta Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | | | | | - Santiago Arroyo
- Momenta Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
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31
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Li T, Balthasar JP. Development and Evaluation of a Physiologically Based Pharmacokinetic Model for Predicting the Effects of Anti-FcRn Therapy on the Disposition of Endogenous IgG in Humans. J Pharm Sci 2018; 108:714-724. [PMID: 30471293 DOI: 10.1016/j.xphs.2018.10.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/28/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022]
Abstract
This work scaled up a previously developed physiologically based pharmacokinetic model to predict the effects of anti-FcRn agents on the disposition of endogenous IgG in human subjects. Simulations were performed with the scaled model to predict the effects of single- and multiple-dose administration of anti-FcRn monoclonal antibodies (1-256 mg/kg) and high-dose intravenous immune globulin (0.4-2 g/kg). The model was evaluated for prediction accuracy through comparison to the effects of rozanolixizumab, an anti-FcRn monoclonal antibodies under current clinical evaluation, on the disposition of endogenous IgG in healthy human subjects. The model provided reasonably accurate predictions of the effects of rozanolixizumab. Prediction errors for the maximum reduction in endogenous IgG concentrations were -8.50% (90% model prediction interval: -14.0% to 1.44%), 3.33% (90% model prediction interval: -13.9% to 21.2%), and 6.85% (90% model prediction interval: -35.2% to 10.5%) for rozanolixizumab doses of 1, 4, and 7 mg/kg, respectively. Model simulations predict that anti-FcRn therapies will exhibit greater dose potency in healthy volunteers than in patients with elevated IgG production rates (e.g., as typically found in autoimmune disease). The model appears to have potential for use in assessing and predicting novel dosing strategies for anti-FcRn therapies.
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Affiliation(s)
- Tommy Li
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York 14214
| | - Joseph P Balthasar
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York 14214.
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Li T, Balthasar JP. Application of Physiologically Based Pharmacokinetic Modeling to Predict the Effects of FcRn Inhibitors in Mice, Rats, and Monkeys. J Pharm Sci 2018; 108:701-713. [PMID: 30423340 DOI: 10.1016/j.xphs.2018.10.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/28/2018] [Accepted: 10/30/2018] [Indexed: 01/06/2023]
Abstract
There is a growing interest in developing inhibitors of the neonatal Fc-receptor, FcRn, for use in the treatment for humoral autoimmune conditions. We have developed a new physiologically based pharmacokinetic model that is capable of characterizing the pharmacokinetics and pharmacodynamics of anti-FcRn monoclonal antibodies (mAb) in mice, rats, and monkeys. The model includes incorporation of FcRn recycling of immune gamma globulin (IgG) in hematopoietic cells in addition to FcRn recycling of IgG in vascular endothelial cells and considers FcRn turnover and intracellular cycling. The model captured antibody disposition in wild-type and FcRn-knockout mice and rats, and also predicted the effects of intravenous immune globulin and anti-FcRn mAb on IgG disposition. Simulations predicted the change in IgG clearance in response to intravenous immune globulin with good accuracy in rats (mean prediction error of 7.15% ± 7.67%). In monkeys, prediction windows for simulated IgG concentration versus time data, as generated through Monte Carlo simulation, were able to capture the effects of anti-FcRn mAb on endogenous IgG. The model may have utility in guiding preclinical evaluations of anti-FcRn therapies in development, potentially assisting in the identification of optimal dosing strategies for this emerging class of immunosuppressive drugs.
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Affiliation(s)
- Tommy Li
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York 14214
| | - Joseph P Balthasar
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York 14214.
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33
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Li T, Balthasar JP. FcRn Expression in Wildtype Mice, Transgenic Mice, and in Human Tissues. Biomolecules 2018; 8:biom8040115. [PMID: 30326650 PMCID: PMC6316262 DOI: 10.3390/biom8040115] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/29/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022] Open
Abstract
Quantitative real-time PCR and Western blot methods were developed to assess neonatal Fc-receptor (FcRn) mRNA and protein expression in human FcRn transgenic mice, Swiss Webster mice, and in select human tissues. Additionally, FcRn turnover was evaluated via pulse-chase. FcRn mRNA expression was significantly higher in transgenic mice when compared to mouse FcRn mRNA in Swiss Webster mice and it ranged from 184-fold higher in the kidney to 109,000-fold higher in the skin. FcRn protein expression was found to be 13-fold lower in kidney to 5.6-fold higher in lung obtained from transgenic mice compared to FcRn protein expression in lung samples obtained from Swiss Webster mice. FcRn protein expression in human liver and small intestine tissues matched more closely with FcRn expression in Swiss Webster mice but were significantly lower when compared to values found from Swiss Webster and transgenic mice. Although FcRn mRNA expression correlated significantly with protein expression (p < 0.0005), the correlation coefficient was only 0.113. As such, the measurement of FcRn protein may be preferred to FcRn mRNA for quantitative applications. Significant differences were found in FcRn expression in transgenic mice, Swiss Webster mice, and human tissues, which may have implications for the use of mouse models in the assessment of monoclonal antibody disposition, efficacy, and safety.
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Affiliation(s)
- Tommy Li
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA.
| | - Joseph P Balthasar
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA.
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Smith B, Kiessling A, Lledo-Garcia R, Dixon KL, Christodoulou L, Catley MC, Atherfold P, D'Hooghe LE, Finney H, Greenslade K, Hailu H, Kevorkian L, Lightwood D, Meier C, Munro R, Qureshi O, Sarkar K, Shaw SP, Tewari R, Turner A, Tyson K, West S, Shaw S, Brennan FR. Generation and characterization of a high affinity anti-human FcRn antibody, rozanolixizumab, and the effects of different molecular formats on the reduction of plasma IgG concentration. MAbs 2018; 10:1111-1130. [PMID: 30130439 PMCID: PMC6291300 DOI: 10.1080/19420862.2018.1505464] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rozanolixizumab (UCB7665), a humanized high-affinity anti-human neonatal Fc receptor (FcRn) monoclonal antibody (IgG4P), has been developed to reduce pathogenic IgG in autoimmune and alloimmune diseases. We document the antibody isolation and compare rozanolixizumab with the same variable region expressed in various mono-, bi- and trivalent formats. We report activity data for rozanolixizumab and the different molecular formats in human cells, FcRn-transgenic mice, and cynomolgus monkeys. Rozanolixizumab, considered the most effective molecular format, dose-dependently and selectively reduced plasma IgG concentrations in an FcRn-transgenic mouse model (no effect on albumin). Intravenous (IV) rozanolixizumab dosing in cynomolgus monkeys demonstrated non-linear pharmacokinetics indicative of target-mediated drug disposition; single IV rozanolixizumab doses (30 mg/kg) in cynomolgus monkeys reduced plasma IgG concentration by 69% by Day 7 post-administration. Daily IV administration of rozanolixizumab (initial 30 mg/kg loading dose; 5 mg/kg daily thereafter) reduced plasma IgG concentrations in all cynomolgus monkeys, with low concentrations maintained throughout the treatment period (42 days). In a 13-week toxicology study in cynomolgus monkeys, supra-pharmacological subcutaneous and IV doses of rozanolixizumab (≤ 150 mg/kg every 3 days) were well tolerated, inducing sustained (but reversible) reductions in IgG concentrations by up to 85%, with no adverse events observed. We have demonstrated accelerated natural catabolism of IgG through inhibition of IgG:FcRn interactions in mice and cynomolgus monkeys. Inhibition of FcRn with rozanolixizumab may provide a novel therapeutic approach to reduce pathogenic IgG in human autoimmune disease. Rozanolixizumab is being investigated in patients with immune thrombocytopenia (NCT02718716) and myasthenia gravis (NCT03052751).
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Targeting FcRn to Generate Antibody-Based Therapeutics. Trends Pharmacol Sci 2018; 39:892-904. [PMID: 30143244 DOI: 10.1016/j.tips.2018.07.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/24/2018] [Accepted: 07/27/2018] [Indexed: 01/01/2023]
Abstract
The MHC class I-related receptor FcRn serves multiple roles ranging from the regulation of levels of IgG isotype antibodies and albumin throughout the body to the delivery of antigen into antigen loading compartments in specialized antigen-presenting cells. In parallel with studies directed towards understanding FcRn at the molecular and cellular levels, there has been an enormous expansion in the development of engineering strategies involving FcRn to modulate the dynamic behavior of antibodies, antigens, and albumin. In this review article, we focus on a discussion of FcRn-targeted approaches that have resulted in the production of novel antibody-based platforms with considerable potential for use in the clinic.
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Ulrichts P, Guglietta A, Dreier T, van Bragt T, Hanssens V, Hofman E, Vankerckhoven B, Verheesen P, Ongenae N, Lykhopiy V, Enriquez FJ, Cho J, Ober RJ, Ward ES, de Haard H, Leupin N. Neonatal Fc receptor antagonist efgartigimod safely and sustainably reduces IgGs in humans. J Clin Invest 2018; 128:4372-4386. [PMID: 30040076 DOI: 10.1172/jci97911] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 07/03/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Intravenous Ig (IVIg), plasma exchange, and immunoadsorption are frequently used in the management of severe autoimmune diseases mediated by pathogenic IgG autoantibodies. These approaches modulating IgG levels can, however, be associated with some severe adverse reactions and a substantial burden to patients. Targeting the neonatal Fc receptor (FcRn) presents an innovative and potentially more effective, safer, and more convenient alternative for clearing pathogenic IgGs. METHODS A randomized, double-blind, placebo-controlled first-in-human study was conducted in 62 healthy volunteers to explore single and multiple ascending intravenous doses of the FcRn antagonist efgartigimod. The study objectives were to assess safety, tolerability, pharmacokinetics, pharmacodynamics, and immunogenicity. The findings of this study were compared with the pharmacodynamics profile elicited by efgartigimod in cynomolgus monkeys. RESULTS Efgartigimod treatment resulted in a rapid and specific clearance of serum IgG levels in both cynomolgus monkeys and healthy volunteers. In humans, single administration of efgartigimod reduced IgG levels up to 50%, while multiple dosing further lowered IgGs on average by 75% of baseline levels. Approximately 8 weeks following the last administration, IgG levels returned to baseline. Efgartigimod did not alter the homeostasis of albumin or Igs other than IgG, and no serious adverse events related to efgartigimod infusion were observed. CONCLUSION Antagonizing FcRn using efgartigimod is safe and results in a specific, profound, and sustained reduction of serum IgG levels. These results warrant further evaluation of this therapeutic approach in IgG-driven autoimmune diseases. TRIAL REGISTRATION Clinicaltrials.gov NCT03457649. FUNDING argenx BVBA.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - JunHaeng Cho
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, College Station, Texas, USA
| | - Raimund J Ober
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, College Station, Texas, USA.,Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - E Sally Ward
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, College Station, Texas, USA.,Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, Bryan, Texas, USA
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Kiessling P, Lledo-Garcia R, Watanabe S, Langdon G, Tran D, Bari M, Christodoulou L, Jones E, Price G, Smith B, Brennan F, White I, Jolles S. The FcRn inhibitor rozanolixizumab reduces human serum IgG concentration: A randomized phase 1 study. Sci Transl Med 2018; 9:9/414/eaan1208. [PMID: 29093180 DOI: 10.1126/scitranslmed.aan1208] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/28/2017] [Accepted: 09/27/2017] [Indexed: 12/13/2022]
Abstract
Pathogenic immunoglobulin G (IgG) autoantibodies characterize some human autoimmune diseases; their high concentration and long half-life are dependent on recycling by the neonatal Fc receptor (FcRn). Inhibition of FcRn is an attractive new treatment concept for IgG-mediated autoimmune diseases. Rozanolixizumab (UCB7665; CA170_01519.g57 IgG4P) is an anti-human FcRn monoclonal antibody. In cynomolgus monkeys, rozanolixizumab reduced IgG (maximum 75 to 90% by about day 10), was well tolerated, and did not increase risk of infection. We also report a first-in-human, randomized, double-blind, placebo-controlled, dose-escalating study of intravenous (IV) or subcutaneous (SC) rozanolixizumab in healthy subjects (NCT02220153). The primary objective was to evaluate safety and tolerability. Secondary objectives were assessment of rozanolixizumab pharmacokinetics and pharmacodynamics, including effects on circulating IgG concentrations. Forty-nine subjects were randomized to receive rozanolixizumab (n = 36) or placebo (n = 13) across six cohorts. The first three cohorts received IV doses, and the subsequent three cohorts received SC doses, of rozanolixizumab 1, 4, or 7 mg/kg (n = 6 for each cohort; plus n = 7 or 6 for placebo, respectively). The most frequent treatment-emergent adverse event [TEAE; headache, 14 of 36 (38.9%) subjects] was dose-dependent and more prominent after IV administration. Severe TEAEs occurred in four subjects, all in the highest-dose IV group [headache (n = 3) and back pain (n = 1)]. Rozanolixizumab pharmacokinetics demonstrated nonlinear increases with dose. There were sustained dose-dependent reductions in serum IgG concentrations (IV and SC rozanolixizumab). These data provide clinical evidence for the therapeutic potential of rozanolixizumab.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Stephen Jolles
- Department of Immunology, University Hospital of Wales, Cardiff CF14 4XW, UK
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38
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A short review of the pharmacokinetic behavior of biological medicinal agents for the clinical practice. Microchem J 2018. [DOI: 10.1016/j.microc.2017.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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39
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Kenniston JA, Taylor BM, Conley GP, Cosic J, Kopacz KJ, Lindberg AP, Comeau SR, Atkins K, Bullen J, TenHoor C, Adelman BA, Sexton DJ, Edwards TE, Nixon AE. Structural basis for pH-insensitive inhibition of immunoglobulin G recycling by an anti-neonatal Fc receptor antibody. J Biol Chem 2017; 292:17449-17460. [PMID: 28878017 DOI: 10.1074/jbc.m117.807396] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/17/2017] [Indexed: 11/06/2022] Open
Abstract
The neonatal Fc receptor FcRn plays a critical role in the trafficking of IgGs across tissue barriers and in retaining high circulating concentrations of both IgG and albumin. Although generally beneficial from an immunological perspective in maintaining IgG populations, FcRn can contribute to the pathogenesis of autoimmune disorders when an abnormal immune response targets normal biological components. We previously described a monoclonal antibody (DX-2507) that binds to FcRn with high affinity at both neutral and acidic pH, prevents the simultaneous binding of IgG, and reduces circulating IgG levels in preclinical animal models. Here, we report a 2.5 Å resolution X-ray crystal structure of an FcRn-DX-2507 Fab complex, revealing a nearly complete overlap of the IgG-Fc binding site in FcRn by complementarity-determining regions in DX-2507. This overlap explains how DX-2507 blocks IgG binding to FcRn and thereby shortens IgG half-life by preventing IgGs from recycling back into circulation. Moreover, the complex structure explains how the DX-2507 interaction is pH-insensitive unlike normal Fc interactions and how serum albumin levels are unaffected by DX-2507 binding. These structural studies could inform antibody-based therapeutic approaches for limiting the effects of IgG-mediated autoimmune disease.
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Affiliation(s)
- Jon A Kenniston
- From Shire, Lexington, Massachusetts 02421, .,Dyax Corp., Burlington, Massachusetts 01803
| | - Brandy M Taylor
- Beryllium Discovery Corp., Bainbridge Island, Washington 98110, and
| | | | | | | | | | | | - Kateri Atkins
- Beryllium Discovery Corp., Bainbridge Island, Washington 98110, and
| | - Jameson Bullen
- Beryllium Discovery Corp., Bainbridge Island, Washington 98110, and
| | | | | | | | - Thomas E Edwards
- Beryllium Discovery Corp., Bainbridge Island, Washington 98110, and
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Yang D, Giragossian C, Castellano S, Lasaro M, Xiao H, Saraf H, Hess Kenny C, Rybina I, Huang ZF, Ahlberg J, Bigwarfe T, Myzithras M, Waltz E, Roberts S, Kroe-Barrett R, Singh S. Maximizing in vivo target clearance by design of pH-dependent target binding antibodies with altered affinity to FcRn. MAbs 2017; 9:1105-1117. [PMID: 28786732 PMCID: PMC5627591 DOI: 10.1080/19420862.2017.1359455] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Antibodies with pH-dependent binding to both target antigens and neonatal Fc receptor (FcRn) provide an alternative tool to conventional neutralizing antibodies, particularly for therapies where reduction in antigen level is challenging due to high target burden. However, the requirements for optimal binding kinetic framework and extent of pH dependence for these antibodies to maximize target clearance from circulation are not well understood. We have identified a series of naturally-occurring high affinity antibodies with pH-dependent target binding properties. By in vivo studies in cynomolgus monkeys, we show that pH-dependent binding to the target alone is not sufficient for effective target removal from circulation, but requires Fc mutations that increase antibody binding to FcRn. Affinity-enhanced pH-dependent FcRn binding that is double-digit nM at pH 7.4 and single-digit nM at pH 6 achieved maximal target reduction when combined with similar target binding affinities in reverse pH directions. Sustained target clearance below the baseline level was achieved 3 weeks after single-dose administration at 1.5 mg/kg. Using the experimentally derived mechanistic model, we demonstrate the essential kinetic interplay between target turnover and antibody pH-dependent binding during the FcRn recycling, and identify the key components for achieving maximal target clearance. These results bridge the demand for improved patient dosing convenience with the “know-how” of therapeutic modality by design.
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Affiliation(s)
- Danlin Yang
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Craig Giragossian
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Steven Castellano
- b Duke University School of Medicine , Marilee Glen Court, Durham , North Carolina , USA
| | - Marcio Lasaro
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Haiguang Xiao
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Himanshu Saraf
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Cynthia Hess Kenny
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Irina Rybina
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Zhong-Fu Huang
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Jennifer Ahlberg
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Tammy Bigwarfe
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Maria Myzithras
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Erica Waltz
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Simon Roberts
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Rachel Kroe-Barrett
- a Biotherapeutics Discovery Research , Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield , Connecticut , USA
| | - Sanjaya Singh
- c Janssen BioTherapeutics , Janssen Research & Development , LLC, Spring House, Pennsylvania , USA
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Hepatic FcRn regulates albumin homeostasis and susceptibility to liver injury. Proc Natl Acad Sci U S A 2017; 114:E2862-E2871. [PMID: 28330995 DOI: 10.1073/pnas.1618291114] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The neonatal crystallizable fragment receptor (FcRn) is responsible for maintaining the long half-life and high levels of the two most abundant circulating proteins, albumin and IgG. In the latter case, the protective mechanism derives from FcRn binding to IgG in the weakly acidic environment contained within endosomes of hematopoietic and parenchymal cells, whereupon IgG is diverted from degradation in lysosomes and is recycled. The cellular location and mechanism by which FcRn protects albumin are partially understood. Here we demonstrate that mice with global or liver-specific FcRn deletion exhibit hypoalbuminemia, albumin loss into the bile, and increased albumin levels in the hepatocyte. In vitro models with polarized cells illustrate that FcRn mediates basal recycling and bidirectional transcytosis of albumin and uniquely determines the physiologic release of newly synthesized albumin into the basal milieu. These properties allow hepatic FcRn to mediate albumin delivery and maintenance in the circulation, but they also enhance sensitivity to the albumin-bound hepatotoxin, acetaminophen (APAP). As such, global or liver-specific deletion of FcRn results in resistance to APAP-induced liver injury through increased albumin loss into the bile and increased intracellular albumin scavenging of reactive oxygen species. Further, protection from injury is achieved by pharmacologic blockade of FcRn-albumin interactions with monoclonal antibodies or peptide mimetics, which cause hypoalbuminemia, biliary loss of albumin, and increased intracellular accumulation of albumin in the hepatocyte. Together, these studies demonstrate that the main function of hepatic FcRn is to direct albumin into the circulation, thereby also increasing hepatocyte sensitivity to toxicity.
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Qiu Y, Lv W, Xu M, Xu Y. Single chain antibody fragments with pH dependent binding to FcRn enabled prolonged circulation of therapeutic peptide in vivo. J Control Release 2016; 229:37-47. [DOI: 10.1016/j.jconrel.2016.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/07/2016] [Accepted: 03/12/2016] [Indexed: 12/25/2022]
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Witte M, Koga H, Hashimoto T, Ludwig RJ, Bieber K. Discovering potential drug-targets for personalized treatment of autoimmune disorders - what we learn from epidermolysis bullosa acquisita. Expert Opin Ther Targets 2016; 20:985-98. [DOI: 10.1517/14728222.2016.1148686] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mareike Witte
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Hiroshi Koga
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Takashi Hashimoto
- Institute of Cutaneous Cell Biology, Kurume University, Kurume, Japan
| | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
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Igawa T, Haraya K, Hattori K. Sweeping antibody as a novel therapeutic antibody modality capable of eliminating soluble antigens from circulation. Immunol Rev 2016; 270:132-51. [DOI: 10.1111/imr.12392] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tomoyuki Igawa
- Research Division; Chugai Pharmaceutical Co. Ltd.; Shizuoka Japan
| | - Kenta Haraya
- Chugai Pharmabody Research Pte. Ltd.; Synapse Singapore
| | - Kunihiro Hattori
- Research Division; Chugai Pharmaceutical Co. Ltd.; Shizuoka Japan
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