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Kearns JD, Wassmann P, Olgac U, Fichter M, Christen B, Rubic-Schneider T, Koepke S, Cochin de Billy B, Ledieu D, Andre C, Hawtin S, Fischer B, Moretti F, Hug C, Bepperling A, Brannetti B, Mendez-Garcia C, Littlewood-Evans A, Clemens A, Grosskreutz CL, Mehan P, Schmouder RL, Sasseville V, Brees D, Karle AC. A root cause analysis to identify the mechanistic drivers of immunogenicity against the anti-VEGF biotherapeutic brolucizumab. Sci Transl Med 2023; 15:eabq5068. [PMID: 36724241 DOI: 10.1126/scitranslmed.abq5068] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Immunogenicity against intravitreally administered brolucizumab has been previously described and associated with cases of severe intraocular inflammation, including retinal vasculitis/retinal vascular occlusion (RV/RO). The presence of antidrug antibodies (ADAs) in these patients led to the initial hypothesis that immune complexes could be key mediators. Although the formation of ADAs and immune complexes may be a prerequisite, other factors likely contribute to some patients having RV/RO, whereas the vast majority do not. To identify and characterize the mechanistic drivers underlying the immunogenicity of brolucizumab and the consequence of subsequent ADA-induced immune complex formation, a translational approach was performed to bridge physicochemical characterization, structural modeling, sequence analysis, immunological assays, and a quantitative systems pharmacology model that mimics physiological conditions within the eye. This approach revealed that multiple factors contributed to the increased immunogenic potential of brolucizumab, including a linear epitope shared with bacteria, non-natural surfaces due to the single-chain variable fragment format, and non-native drug species that may form over prolonged time in the eye. Consideration of intraocular drug pharmacology and disease state in a quantitative systems pharmacology model suggested that immune complexes could form at immunologically relevant concentrations modulated by dose intensity. Assays using circulating immune cells from treated patients or treatment-naïve healthy volunteers revealed the capacity of immune complexes to trigger cellular responses such as enhanced antigen presentation, platelet aggregation, endothelial cell activation, and cytokine release. Together, these studies informed a mechanistic understanding of the clinically observed immunogenicity of brolucizumab and associated cases of RV/RO.
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Affiliation(s)
- Jeffrey D Kearns
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Paul Wassmann
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Ufuk Olgac
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Marie Fichter
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Brigitte Christen
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - Stephan Koepke
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - David Ledieu
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Cedric Andre
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Stuart Hawtin
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Benoit Fischer
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Francesca Moretti
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Christian Hug
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | | | - Barbara Brannetti
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | | | | | - Andreas Clemens
- Medical Affairs Region Europe, Novartis Pharma AG, Basel CH-4056, Switzerland
| | | | - Pawan Mehan
- TRD Biologics and CGT, Novartis Pharma AG, Basel CH-4056, Switzerland
| | - Robert L Schmouder
- Novartis Institutes for BioMedical Research, East Hanover, NJ 07960, USA
| | - Vito Sasseville
- Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Dominique Brees
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
| | - Anette C Karle
- Novartis Institutes for BioMedical Research, Basel CH-4056, Switzerland
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