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Bialer M, Johannessen SI, Koepp MJ, Perucca E, Perucca P, Tomson T, White HS. Progress report on new medications for seizures and epilepsy: A summary of the 17th Eilat Conference on New Antiepileptic Drugs and Devices (EILAT XVII). I. Drugs in preclinical and early clinical development. Epilepsia 2024. [PMID: 39008349 DOI: 10.1111/epi.18056] [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: 05/16/2024] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024]
Abstract
For >30 years, the Eilat Conference on New Antiepileptic Drugs and Devices has provided a forum for the discussion of advances in the development of new therapies for seizures and epilepsy. The EILAT XVII conference took place in Madrid, Spain, on May 5-8, 2024. Participants included basic scientists and clinical investigators from industry and academia, other health care professionals, and representatives from lay organizations. We summarize in this article information on treatments in preclinical and in early clinical development discussed at the conference. These include AMT-260, a gene therapy designed to downregulate the expression of Glu2K subunits of kainate receptors, in development for the treatment of drug-resistant seizures associated with mesial temporal sclerosis; BHV-7000, a selective activator of heteromeric Kv7.2/7.3 potassium channels, in development for the treatment of focal epilepsy; ETX101, a recombinant adeno-associated virus serotype 9 designed to increase NaV1.1 channel density in inhibitory γ-aminobutyric acidergic (GABAergic) neurons, in development for the treatment of SCN1A-positive Dravet syndrome; GAO-3-02, a compound structurally related to synaptamide, which exerts antiseizure activity at least in part through an action on cannabinoid type 2 receptors; LRP-661, a structural analogue of cannabidiol, in development for the treatment of seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex; OV329, a selective inactivator of GABA aminotransferase, in development for the treatment of drug-resistant seizures; PRAX-628, a functionally selective potent sodium channel modulator with preference for the hyperexcitable state of sodium channels, in development for the treatment of focal seizures; RAP-219, a selective negative allosteric modulator of transmembrane α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor regulatory protein γ-8, in development for the treatment of focal seizures; and rozanolixizumab, a humanized anti-neonatal Fc receptor monoclonal antibody, in development for the treatment of LGI1 autoimmune encephalitis. Treatments in more advanced development are summarized in Part II of this report.
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Affiliation(s)
- Meir Bialer
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine and David R. Bloom Center for Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Svein I Johannessen
- National Center for Epilepsy, Sandvika, Norway
- Member of European Reference Network EpiCARE, Oslo University Hospital, Oslo, Norway
- Section for Clinical Pharmacology, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, University College London (UCL), Queen Square Institute of Neurology, London, UK
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
- Department of Neuroscience, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H Steve White
- Center for Epilepsy Drug Discovery, Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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Cavalcante P, Mantegazza R, Antozzi C. Targeting autoimmune mechanisms by precision medicine in Myasthenia Gravis. Front Immunol 2024; 15:1404191. [PMID: 38903526 PMCID: PMC11187261 DOI: 10.3389/fimmu.2024.1404191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/24/2024] [Indexed: 06/22/2024] Open
Abstract
Myasthenia Gravis (MG) is a chronic disabling autoimmune disease caused by autoantibodies to the neuromuscular junction (NMJ), characterized clinically by fluctuating weakness and early fatigability of ocular, skeletal and bulbar muscles. Despite being commonly considered a prototypic autoimmune disorder, MG is a complex and heterogeneous condition, presenting with variable clinical phenotypes, likely due to distinct pathophysiological settings related with different immunoreactivities, symptoms' distribution, disease severity, age at onset, thymic histopathology and response to therapies. Current treatment of MG based on international consensus guidelines allows to effectively control symptoms, but most patients do not reach complete stable remission and require life-long immunosuppressive (IS) therapies. Moreover, a proportion of them is refractory to conventional IS treatment, highlighting the need for more specific and tailored strategies. Precision medicine is a new frontier of medicine that promises to greatly increase therapeutic success in several diseases, including autoimmune conditions. In MG, B cell activation, antibody recycling and NMJ damage by the complement system are crucial mechanisms, and their targeting by innovative biological drugs has been proven to be effective and safe in clinical trials. The switch from conventional IS to novel precision medicine approaches based on these drugs could prospectively and significantly improve MG care. In this review, we provide an overview of key immunopathogenetic processes underlying MG, and discuss on emerging biological drugs targeting them. We also discuss on future direction of research to address the need for patients' stratification in endotypes according with genetic and molecular biomarkers for successful clinical decision making within precision medicine workflow.
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Affiliation(s)
- Paola Cavalcante
- Neurology 4 – Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Renato Mantegazza
- Neurology 4 – Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Carlo Antozzi
- Neurology 4 – Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Immunotherapy and Apheresis Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Ma G, Crowley AR, Heyndrickx L, Rogiers I, Parthoens E, Van Santbergen J, Ober RJ, Bobkov V, de Haard H, Ulrichts P, Hofman E, Louagie E, Balbino B, Ward ES. Differential effects of FcRn antagonists on the subcellular trafficking of FcRn and albumin. JCI Insight 2024; 9:e176166. [PMID: 38713534 PMCID: PMC11141909 DOI: 10.1172/jci.insight.176166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 04/10/2024] [Indexed: 05/09/2024] Open
Abstract
The homeostasis of IgG is maintained by the neonatal Fc receptor, FcRn. Consequently, antagonism of FcRn to reduce endogenous IgG levels is an emerging strategy for treating antibody-mediated autoimmune disorders using either FcRn-specific antibodies or an engineered Fc fragment. For certain FcRn-specific antibodies, this approach has resulted in reductions in the levels of serum albumin, the other major ligand transported by FcRn. Cellular and molecular analyses of a panel of FcRn antagonists have been carried out to elucidate the mechanisms leading to their differential effects on albumin homeostasis. These analyses have identified 2 processes underlying decreases in albumin levels during FcRn blockade: increased degradation of FcRn and competition between antagonist and albumin for FcRn binding. These findings have potential implications for the design of drugs to modulate FcRn function.
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Affiliation(s)
- Guanglong Ma
- Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Andrew R. Crowley
- Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | | | - Eef Parthoens
- VIB BioImaging Core, Center for Inflammation Research, Ghent, Belgium
| | | | - Raimund J. Ober
- Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | | | | | | | | | | | - E. Sally Ward
- Centre for Cancer Immunology, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Antozzi C, Guptill J, Bril V, Gamez J, Meuth SG, Nowak RJ, Quan D, Sevilla T, Jouvin MH, Jin J, Karcher K, Ramchandren S, Sun H, Ling L, Zhu Y, Arroyo S. Safety and Efficacy of Nipocalimab in Patients With Generalized Myasthenia Gravis: Results From the Randomized Phase 2 Vivacity-MG Study. Neurology 2024; 102:e207937. [PMID: 38165333 PMCID: PMC10962909 DOI: 10.1212/wnl.0000000000207937] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To evaluate in a phase 2 study the safety and efficacy of IV nipocalimab, a fully human, antineonatal Fc receptor monoclonal antibody, in patients with generalized myasthenia gravis (gMG). METHODS Patients with gMG with inadequate response to stable standard-of-care (SOC) therapy were randomized 1:1:1:1:1 to receive either IV placebo every 2 weeks (Q2W) or one of 4 IV nipocalimab treatments: 5 mg/kg once every 4 weeks (Q4W), 30 mg/kg Q4W, 60 mg/kg Q2W each for 8 weeks, or a 60 mg/kg single dose, in addition to their background SOC therapy. Infusions (placebo or nipocalimab) were Q2W in all groups to maintain blinding. The primary safety endpoint was incidence of treatment-emergent adverse events (TEAEs), including serious adverse events and adverse events of special interest. The primary efficacy endpoint was change from baseline to day 57 in Myasthenia Gravis-Activities of Daily Living (MG-ADL) total scores. Dose response of change at day 57 was analyzed with a linear trend test over the placebo, nipocalimab 5 mg/kg Q4W, nipocalimab 30 mg/kg Q4W, and nipocalimab 60 mg/kg Q2W groups. RESULTS Sixty-eight patients (nipocalimab: n = 54; placebo, n = 14) were randomized; 64 patients (94.1%) were positive for antiacetylcholine receptor autoantibodies, and 4 patients (6%) were positive for antimuscle-specific tyrosine kinase autoantibodies. Fifty-seven patients (83.8%) completed treatment through day 57. The combined nipocalimab group compared with the placebo group demonstrated similar incidences of TEAEs (83.3% vs 78.6%, respectively) and infections (33.3% vs 21.4%, respectively). No deaths or discontinuations due to TEAEs and no TEAEs of special interest (grade ≥3 infection or hypoalbuminemia) were observed with nipocalimab treatment. A statistically significant dose response was observed for change from baseline in MG-ADL at day 57 (p = 0.031, test of linear trend). DISCUSSION Nipocalimab was generally safe, well-tolerated, and showed evidence of dose-dependent reduction in MG-ADL scores at day 57 in this phase 2 study. These results support further evaluation of nipocalimab for the treatment of gMG. TRIAL REGISTRATION INFORMATION Clinical Trials Registration: NCT03772587; first submitted December 10, 2018; EudraCT Number: 2018-002247-28; first submitted November 30, 2018; date of first patient dosed April 10, 2019. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with gMG, nipocalimab was well-tolerated, and it did not significantly improve MG-ADL at any individual dose but demonstrated a significant dose response for improved MG-ADL across doses.
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Affiliation(s)
- Carlo Antozzi
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Jeffrey Guptill
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Vera Bril
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Josep Gamez
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Sven G Meuth
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Richard J Nowak
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Dianna Quan
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Teresa Sevilla
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Marie-Helene Jouvin
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Jim Jin
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Keith Karcher
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Sindhu Ramchandren
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Hong Sun
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Leona Ling
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Yaowei Zhu
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
| | - Santiago Arroyo
- From the Neurological Institute Foundation C. Besta (C.A.), Milan, Italy; Duke University School of Medicine (J. Guptill), Durham, NC; Argenx US Inc. (J. Guptill), Boston, MA; University of Toronto (V.B.), ON, Canada; Universitat Autonoma de Barcelona, (J. Gamez), Spain; Medical Faculty (S.G.M.), Heinrich-Heine-University, Düsseldorf, Germany; Yale University School of Medicine (R.J.N.), New Haven, CT; University of Colorado School of Medicine (D.Q.), Aurora; Hospital Universitari i Politécnic La Fe (T.S.), Universitat de Valencia, Spain; Pharvaris, Inc. (M.-H.J.), Boston, MA; Janssen Research & Development, LLC, (J.J., K.K., S.R.,H.S., L.L., Y.Z.), Titusville, NJ; Marinus Pharmaceuticals, Inc. Radnor, PA; Fulcrum Therapeutics (S.A.), Cambridge, MA
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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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Saito A, Matsui S, Chino A, Sato S, Takeshita N. Discovery and pharmacological characterization of novel positive allosteric modulators acting on skeletal muscle-type nicotinic acetylcholine receptors. Biochem Biophys Res Commun 2023; 668:27-34. [PMID: 37235916 DOI: 10.1016/j.bbrc.2023.04.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
Skeletal muscle-type nicotinic acetylcholine receptors (m-nAChRs) are ligand-gated ion channels that open after activation by ACh and whose signals cause muscle contraction. Defects in neurotransmission are reported in disorders such as myasthenia gravis (MG) and congenital myasthenia syndromes (CMS). Although treatments for these disorders exist, therapies which significantly increase muscle strength have yet to be reported. Positive allosteric modulators (PAMs), which promote ACh signaling through AChRs, are expected to be promising therapeutic agents. In this study, we identified an m-nAChR PAM called AS3513678 by high-throughput screening using human myotube cells and modified it to obtain novel compounds (AS3566987 and AS3580239) that showed even stronger PAM activity. AS3580239 caused a leftward shift in the ACh concentration-response curve and was 14.0-fold potent at 10 μM compared with vehicle. Next, we examined the effect of AS3580239 on electrically-induced isometric contraction of the extensor digitorum longus (EDL) muscle in wild-type (WT) and MG model rats. AS3580239 enhanced EDL muscle contraction in both WT and MG model rats at 30 μM. These data suggest that AS3580239 improved neurotransmission and enhanced muscle strength. Thus, m-nAChR PAMs may be a useful treatment for neuromuscular diseases.
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Affiliation(s)
- Asako Saito
- Astellas Pharma Inc, 21, Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan.
| | - Shigeo Matsui
- Astellas Pharma Inc, 21, Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
| | - Ayaka Chino
- Astellas Pharma Inc, 21, Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
| | - Shota Sato
- Astellas Pharma Inc, 21, Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
| | - Nobuaki Takeshita
- Astellas Pharma Inc, 21, Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
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7
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Bhandari V, Bril V. FcRN receptor antagonists in the management of myasthenia gravis. Front Neurol 2023; 14:1229112. [PMID: 37602255 PMCID: PMC10439012 DOI: 10.3389/fneur.2023.1229112] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder characterized by autoantibodies specifically directed against proteins located within the postsynaptic membrane of the neuromuscular junction. These pathogenic autoantibodies can be reduced by therapies such as plasma exchange, IVIG infusions and other immunosuppressive agents. However, there are significant side effects associated with most of these therapies. Since there is a better understanding of the molecular structure and the biological properties of the neonatal Fc receptors (FcRn), it possesses an attractive profile in treating myasthenia gravis. FcRn receptors prevent the catabolism of IgG by impeding their lysosomal degradation and facilitating their extracellular release at physiological pH, consequently extending the IgG half-life. Thus, the catabolism of IgG can be enhanced by blocking the FcRn, leading to outcomes similar to those achieved through plasma exchange with no significant safety concerns. The available studies suggest that FcRn holds promise as a versatile therapeutic intervention, capable of delivering beneficial outcomes in patients with distinct characteristics and varying degrees of MG severity. Efgartigimod is already approved for the treatment of generalized MG, rozanolixizumab is under review by health authorities, and phase 3 trials of nipocalimab and batoclimab are underway. Here, we will review the available data on FcRn therapeutic agents in the management of MG.
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Affiliation(s)
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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Pyzik M, Kozicky LK, Gandhi AK, Blumberg RS. The therapeutic age of the neonatal Fc receptor. Nat Rev Immunol 2023; 23:415-432. [PMID: 36726033 PMCID: PMC9891766 DOI: 10.1038/s41577-022-00821-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 02/03/2023]
Abstract
IgGs are essential soluble components of the adaptive immune response that evolved to protect the body from infection. Compared with other immunoglobulins, the role of IgGs is distinguished and enhanced by their high circulating levels, long half-life and ability to transfer from mother to offspring, properties that are conferred by interactions with neonatal Fc receptor (FcRn). FcRn binds to the Fc portion of IgGs in a pH-dependent manner and protects them from intracellular degradation. It also allows their transport across polarized cells that separate tissue compartments, such as the endothelium and epithelium. Further, it is becoming apparent that FcRn functions to potentiate cellular immune responses when IgGs, bound to their antigens, form IgG immune complexes. Besides the protective role of IgG, IgG autoantibodies are associated with numerous pathological conditions. As such, FcRn blockade is a novel and effective strategy to reduce circulating levels of pathogenic IgG autoantibodies and curtail IgG-mediated diseases, with several FcRn-blocking strategies on the path to therapeutic use. Here, we describe the current state of knowledge of FcRn-IgG immunobiology, with an emphasis on the functional and pathological aspects, and an overview of FcRn-targeted therapy development.
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Affiliation(s)
- Michal Pyzik
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Lisa K Kozicky
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amit K Gandhi
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard S Blumberg
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Harvard Digestive Diseases Center, Boston, MA, USA.
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9
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Berentsen S, Fattizzo B, Barcellini W. The choice of new treatments in autoimmune hemolytic anemia: how to pick from the basket? Front Immunol 2023; 14:1180509. [PMID: 37168855 PMCID: PMC10165002 DOI: 10.3389/fimmu.2023.1180509] [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: 03/06/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is defined by increased erythrocyte turnover mediated by autoimmune mechanisms. While corticosteroids remain first-line therapy in most cases of warm-antibody AIHA, cold agglutinin disease is treated by targeting the underlying clonal B-cell proliferation or the classical complement activation pathway. Several new established or investigational drugs and treatment regimens have appeared during the last 1-2 decades, resulting in an improvement of therapy options but also raising challenges on how to select the best treatment in individual patients. In severe warm-antibody AIHA, there is evidence for the upfront addition of rituximab to prednisolone in the first line. Novel agents targeting B-cells, extravascular hemolysis, or removing IgG will offer further options in the acute and relapsed/refractory settings. In cold agglutinin disease, the development of complement inhibitors and B-cell targeting agents makes it possible to individualize therapy, based on the disease profile and patient characteristics. For most AIHAs, the optimal treatment remains to be found, and there is still a need for more evidence-based therapies. Therefore, prospective clinical trials should be encouraged.
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Affiliation(s)
- Sigbjørn Berentsen
- Department of Research and Innovation, Haugesund Hospital, Helse Fonna Hospital Trust, Haugesund, Norway
- *Correspondence: Sigbjørn Berentsen,
| | - Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Abstract
CONTEXT Thyroid eye disease (TED), a vision-threatening and disfiguring autoimmune process, has thwarted our efforts to understand its pathogenesis and develop effective and safe treatments. Recent scientific advances have facilitated improved treatment options. OBJECTIVE Review historically remote and recent advances in understanding TED. DESIGN/SETTING/PARTICIPANTS PubMed was scanned using search terms including thyroid-associated ophthalmopathy, thyroid eye disease, Graves' orbitopathy, autoimmune thyroid disease, and orbital inflammation. MAIN OUTCOME MEASURES Strength of scientific evidence, size, scope, and controls of clinical trials/observations. RESULTS Glucocorticoid steroids are widely prescribed systemic medical therapy. They can lessen inflammation-related manifestations of TED but fail to reliably reduce proptosis and diplopia, 2 major causes of morbidity. Other current therapies include mycophenolate, rituximab (anti-CD20 B cell-depleting monoclonal antibody), tocilizumab (interleukin-6 receptor antagonist), and teprotumumab (IGF-I receptor inhibitor). Several new therapeutic approaches have been proposed including targeting prostaglandin receptors, vascular endothelial growth factor, mTOR, and cholesterol pathways. Of potentially greater long-term importance are attempts to restore immune tolerance. CONCLUSION Despite their current wide use, steroids may no longer enjoy first-tier status for TED as more effective and better tolerated medical options become available. Multiple current and emerging therapies, the rationales for which are rooted in theoretical and experimental science, promise better options. These include teprotumumab, rituximab, and tocilizumab. Restoration of immune tolerance could ultimately become the most effective and safe medical management for TED.
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Affiliation(s)
- Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
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11
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Novel treatment strategies for acetylcholine receptor antibody-positive myasthenia gravis and related disorders. Autoimmun Rev 2022; 21:103104. [PMID: 35452851 DOI: 10.1016/j.autrev.2022.103104] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022]
Abstract
The presence of autoantibodies directed against the muscle nicotinic acetylcholine receptor (AChR) is the most common cause of myasthenia gravis (MG). These antibodies damage the postsynaptic membrane of the neuromuscular junction and cause muscle weakness by depleting AChRs and thus impairing synaptic transmission. As one of the best-characterized antibody-mediated autoimmune diseases, AChR-MG has often served as a reference model for other autoimmune disorders. Classical pharmacological treatments, including broad-spectrum immunosuppressive drugs, are effective in many patients. However, complete remission cannot be achieved in all patients, and 10% of patients do not respond to currently used therapies. This may be attributed to production of autoantibodies by long-lived plasma cells which are resistant to conventional immunosuppressive drugs. Hence, novel therapies specifically targeting plasma cells might be a suitable therapeutic approach for selected patients. Additionally, in order to reduce side effects of broad-spectrum immunosuppression, targeted immunotherapies and symptomatic treatments will be required. This review presents established therapies as well as novel therapeutic approaches for MG and related conditions, with a focus on AChR-MG.
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12
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Principles and Guidelines of Immunotherapy in Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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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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14
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García-Serra A, Radosevic M, Ríos J, Aguilar E, Maudes E, Landa J, Sabater L, Martinez-Hernandez E, Planagumà J, Dalmau J. Blocking Placental Class G Immunoglobulin Transfer Prevents NMDA Receptor Antibody Effects in Newborn Mice. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/6/e1061. [PMID: 34580181 PMCID: PMC8477376 DOI: 10.1212/nxi.0000000000001061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/15/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES To determine in a mouse model whether neonatal Fc receptor (FcRn) blockade prevents the placental transfer of class G immunoglobulin (IgG) derived from patients with anti-NMDA receptor (NMDAR) encephalitis and their pathogenic effects on the fetuses and offspring. METHODS Pregnant C57BL/6J mice were administered via tail vein FcRn antibody (FcRn-ab) or saline solution 6 hours before administration of patients' or controls' IgG on days 14, 15, and 16 of gestation. Three experimental groups were established: mice receiving controls' IgG, patients' IgG, or patients' IgG along with pretreatment with FcRn-ab. Immunohistochemical staining, confocal microscopy, hippocampal long-term potentiation, and standardized developmental and behavioral tasks were used to assess the efficacy of treatment with FcRn-ab. RESULTS In pregnant mice that received patients' IgG, treatment with FcRn-ab prevented the IgG from reaching the fetal brain, abrogating the decrease of NMDAR clusters and the reduction of cortical plate thickness that were observed in fetuses from untreated pregnant mice. Moreover, among the offspring of mothers that received patients' IgG, those whose mothers were treated with FcRn-ab did not develop the alterations that occurred in offspring of untreated mothers, including impairment in hippocampal plasticity, delay in innate reflexes, and visuospatial memory deficits. DISCUSSION FcRn blockade prevents placental transfer of IgG from patients with anti-NMDAR encephalitis and abrogates the synaptic and neurodevelopmental alterations caused by patients' antibodies. This model has potential therapeutic implications for other antibody-mediated diseases of the CNS during pregnancy.
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Affiliation(s)
- Anna García-Serra
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Marija Radosevic
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - José Ríos
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Esther Aguilar
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Estibaliz Maudes
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Jon Landa
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Lidia Sabater
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Eugenia Martinez-Hernandez
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Jesús Planagumà
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain
| | - Josep Dalmau
- From the Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) (A.G.-S., M.R., E.A., E.M., J.L., L.S., E.M.-H., J.P., J.D.), Hospital Clínic, Universitat de Barcelona; Medical Statistics Core Facility (J.R.), IDIBAPS and Hospital Clínic; Biostatistics Unit (J.R.), School of Medicine, Universitat Autònoma de Barcelona, Spain; Department of Neurology (J.D.), University of Pennsylvania, Philadelphia; and Institució Catalana de Recerca i Estudis Avançats (ICREA) (J.D.), Barcelona, Spain.
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Menon D, Urra Pincheira A, Bril V. Emerging drugs for the treatment of myasthenia gravis. Expert Opin Emerg Drugs 2021; 26:259-270. [PMID: 34228579 DOI: 10.1080/14728214.2021.1952982] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Advances in understanding the immune pathomechanisms in myasthenia gravis (MG) allow for the development of novel targeted immune therapies. By working at specific points in the immunopathogenesis, these agents have the potential to provide rapid and efficacious responses compared to conventional immunosuppressive therapy (IST), addressing unmet needs and consequently are a research priority.Areas covered: This paper reviews the advances in MG treatment modalities with their scientific rationale. A search of clinicaltrials.gov and a literature search of PubMed from January 2015 to the end of June 2021 was done using the search terms: MG, treatment, immune targets to obtain information on recent developments of complement inhibitors, FcRn receptor inhibitors, direct and indirect B cell inhibitors, CAR and CAAR- T cell therapy, and hematopoietic stem cell transplantation. Specific agents in various phases of clinical development, evidence from ongoing trials and potential roadblocks are examined.Expert opinion: Despite several promising novel agents, existing data as to the timing of initiation and duration of treatment, long-term safety profile and utility in certain patient subsets are limited and require further research. Despite these considerations, the future of MG treatment is transitioning from broad-spectrum IST toward precise, target-driven and personalized immunotherapy.
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Affiliation(s)
- Deepak Menon
- Department of Medicine, Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Alejandra Urra Pincheira
- Department of Medicine, Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Vera Bril
- Department of Medicine, Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
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Choi AY, Manook M, Olaso D, Ezekian B, Park J, Freischlag K, Jackson A, Knechtle S, Kwun J. Emerging New Approaches in Desensitization: Targeted Therapies for HLA Sensitization. Front Immunol 2021; 12:694763. [PMID: 34177960 PMCID: PMC8226120 DOI: 10.3389/fimmu.2021.694763] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 01/11/2023] Open
Abstract
There is an urgent need for therapeutic interventions for desensitization and antibody-mediated rejection (AMR) in sensitized patients with preformed or de novo donor-specific HLA antibodies (DSA). The risk of AMR and allograft loss in sensitized patients is increased due to preformed DSA detected at time of transplant or the reactivation of HLA memory after transplantation, causing acute and chronic AMR. Alternatively, de novo DSA that develops post-transplant due to inadequate immunosuppression and again may lead to acute and chronic AMR or even allograft loss. Circulating antibody, the final product of the humoral immune response, has been the primary target of desensitization and AMR treatment. However, in many cases these protocols fail to achieve efficient removal of all DSA and long-term outcomes of patients with persistent DSA are far worse when compared to non-sensitized patients. We believe that targeting multiple components of humoral immunity will lead to improved outcomes for such patients. In this review, we will briefly discuss conventional desensitization methods targeting antibody or B cell removal and then present a mechanistically designed desensitization regimen targeting plasma cells and the humoral response.
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Affiliation(s)
| | | | | | | | | | | | | | - Stuart Knechtle
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Jean Kwun
- Duke Transplant Center, Department of Surgery, Duke University Medical Center, Durham, NC, United States
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Fc-Receptor Targeted Therapies for the Treatment of Myasthenia gravis. Int J Mol Sci 2021; 22:ijms22115755. [PMID: 34071155 PMCID: PMC8198115 DOI: 10.3390/ijms22115755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 12/16/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which immunoglobulin G (IgG) antibodies (Abs) bind to acetylcholine receptors (AChR) or to functionally related molecules in the postsynaptic membrane at the neuromuscular junction. IgG crystallizable fragment (Fc)-mediated effector functions, such as antibody-dependent complement deposition, contribute to disease development and progression. Despite progress in understanding Ab-mediated disease mechanisms, immunotherapy of MG remained rather unspecific with corticosteroids and maintenance with immunosuppressants as first choice drugs for most patients. More specific therapeutic IgG Fc-based platforms that reduce serum half-life or effector functions of pathogenic MG-related Abs are currently being developed, tested in clinical trials or have recently been successfully translated into the clinic. In this review, we illustrate mechanisms of action and clinical efficacies of emerging Fc-mediated therapeutics such as neonatal Fc receptor (FcRn)-targeting agents. Furthermore, we evaluate prospects of therapies targeting classical Fc receptors that have shown promising therapeutic efficacy in other antibody-mediated conditions. Increased availability of Fc- and Fc receptor-targeting biologics might foster the development of personalized immunotherapies with the potential to induce sustained disease remission in patients with MG.
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18
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Patel DD, Bussel JB. Neonatal Fc receptor in human immunity: Function and role in therapeutic intervention. J Allergy Clin Immunol 2021; 146:467-478. [PMID: 32896307 DOI: 10.1016/j.jaci.2020.07.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 02/08/2023]
Abstract
The humoral immune response provides specific, long-lived protection against invading pathogens, via immunoglobulin production and other memory functions. IgG, the most abundant immunoglobulin isotype, has the longest half-life and protects against bacterial and viral infections. The neonatal Fc receptor (FcRn) transports IgG across barriers, for example, the placenta, enhancing fetal humoral immunity to levels similar to their mothers'. Importantly, FcRn, by protecting IgG from intracellular degradation, results in an approximately 21-day circulating IgG half-life and high plasma levels; similarly, FcRn recycles albumin and is the portal of entry for enteric cytopathic human orphan (echo) virus infection. Dysregulated immune responses may lead to antibodies against self-antigens (autoantibodies), resulting in organ-specific or systemic autoimmune diseases. Autoantibody-mediated diseases have been treated by nonspecific immunoglobulin-lowering/modulating therapies, including immunoadsorption, plasma exchange, and high-dose intravenous immunoglobulin. However, targeting FcRn with specific inhibitors results in reduction in only IgG levels. The effectiveness of FcRn inhibitors in autoimmune diseases, including myasthenia gravis and immune thrombocytopenia, provides further evidence that IgG is a primary driver in these autoantibody-mediated diseases. We describe the role of FcRn in human biology, including insights that clinical testing of FcRn inhibitors have provided into FcRn biology and autoimmune disease mechanisms, allowing fact-based speculation on their therapeutic potential.
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Affiliation(s)
- Dhavalkumar D Patel
- UCB Pharma, Brussels, Belgium; University of North Carolina, Chapel Hill, NC.
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19
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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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20
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Lane LC, Cheetham TD, Perros P, Pearce SHS. New Therapeutic Horizons for Graves' Hyperthyroidism. Endocr Rev 2020; 41:5897403. [PMID: 32845332 PMCID: PMC7567404 DOI: 10.1210/endrev/bnaa022] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022]
Abstract
Graves' hyperthyroidism is characterized by the presence of autoantibodies that stimulate the thyroid-stimulating hormone receptor (TSHR), resulting in uncontrolled secretion of excessive thyroid hormone. Conventional treatments, including antithyroid medication, radioiodine, or surgery have remained largely unchanged for the past 70 years and either lack efficacy for many patients, or result in lifelong thyroid hormone replacement therapy, in the case of the latter 2 options. The demand for new therapeutic options, combined with greater insight into basic immunobiology, has led to the emergence of novel approaches to treat Graves' hyperthyroidism. The current therapies under investigation include biologics, small molecules, and peptide immunomodulation. There is a growing focus on TSHR-specific treatment modalities, which carry the advantage of eliciting a specific, targeted approach, with the aim of avoiding disruption of the functioning immune system. These therapies present a new opportunity to supersede the inadequate treatments currently available for some Graves' patients, offering hope of successful restoration of euthyroidism without the need for ongoing therapy. Several of these therapeutic options have the potential to translate into clinical practice in the near future. This review provides a comprehensive summary of the recent advances and various stages of development of the novel therapeutic approaches to treat Graves' hyperthyroidism.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Tim D Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Petros Perros
- Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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21
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Abstract
Pemphigus vulgaris (PV) is a severe chronic autoimmune blistering disease that affects the skin and mucous membranes. It is characterized by suprabasal acantholysis due to disruption of desmosomal connections between keratinocytes. Autoantibodies against desmosomal cadherins, desmoglein 3 and 1, have been shown to induce disease. Certain human leukocyte antigen (HLA) types and non-HLA foci confer genetic susceptibility. Until the discovery of corticosteroids in the 1950s, PV was 75% fatal. Since then, multiple PV treatments, such as systemic corticosteroids and adjunctive therapy with immunosuppressive medications (mycophenolate mofetil, azathioprine, cyclophosphamide, cyclosporine, methotrexate, gold, and others) have been introduced; however, none have led to long-term remissions and many have undesired adverse effects. Our growing understanding of the pathophysiologic mechanisms in PV is leading to development of new targeted therapies, such as intravenous immunoglobulin, anti-CD20 monoclonal antibodies, inhibitors of Bruton tyrosine kinase and neonatal Fc receptors, and adoptive cellular transfer, that may result in lasting control of this life-threatening disease.
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MESH Headings
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Agammaglobulinaemia Tyrosine Kinase/metabolism
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antigens, CD20/immunology
- Antigens, CD20/metabolism
- Autoantibodies/immunology
- Autoantibodies/metabolism
- Combined Modality Therapy/methods
- Drug Therapy, Combination/methods
- Genetic Predisposition to Disease
- HLA Antigens/genetics
- HLA Antigens/immunology
- Histocompatibility Antigens Class I/metabolism
- Humans
- Immunoglobulins, Intravenous/pharmacology
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/pharmacology
- Immunosuppressive Agents/therapeutic use
- Immunotherapy, Adoptive/methods
- Molecular Targeted Therapy/methods
- Pemphigus/genetics
- Pemphigus/immunology
- Pemphigus/therapy
- Plasmapheresis
- Receptors, Fc/antagonists & inhibitors
- Receptors, Fc/metabolism
- Remission Induction/methods
- Signal Transduction/drug effects
- Signal Transduction/immunology
- Treatment Outcome
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Affiliation(s)
- Emily M Altman
- Department of Dermatology, University of New Mexico, 1021 Medical Arts Avenue NE, Albuquerque, NM, 87102, USA.
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22
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Implications of Fc Neonatal Receptor (FcRn) Manipulations for Transplant Immunotherapeutics. Transplantation 2020; 104:17-23. [PMID: 31397806 DOI: 10.1097/tp.0000000000002912] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alloimmune injury to allografts is mediated by pathogenic donor-specific alloantibodies, usually of the IgG isotype. Currently, strategies used to reduce donor-specific alloantibodies are collectively called desensitization. Despite successes, these treatments have limited efficacy and can be associated with adverse events, infectious complications, and high cost. Fc neonatal receptor (FcRn) was originally discovered as a transport mechanism for IgG from maternal circulation to fetus. FcRn receptors are now known to be widely distributed in virtually all tissues. IgG and albumin binding to FcRn is pH-dependent, which results in a significant prolongation their half-life. Structural analysis shows FcRn is a nonclassical major histocompatibility complex Class I receptor, which is emerging as a novel target to significantly reduce the half-life of pathogenic antibodies or extend the half-life of therapeutic monoclonals. Manipulation of IgG-Fc/FcRn interactions has implications for treatment of virtually all IgG-mediated diseases. The use of monoclonals directed at the FcRn can rapidly enhance the turnover of total IgG, including pathogenic IgG. In this review, we highlight the aspects of FcRn biology responsible for development of FcRn targeted therapeutics aimed at pathogenic autoantibodies and alloantibodies. We also explore the novel modifications of therapeutic monoclonals that exploit FcRn functions to enhance therapeutic efficacy.
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23
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Menon D, Barnett C, Bril V. Novel Treatments in Myasthenia Gravis. Front Neurol 2020; 11:538. [PMID: 32714266 PMCID: PMC7344308 DOI: 10.3389/fneur.2020.00538] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/14/2020] [Indexed: 01/08/2023] Open
Abstract
Myasthenia gravis (MG) is the prototypical autoimmune disorder caused by specific autoantibodies at the neuromuscular junction. Broad-based immunotherapies, such as corticosteroids, azathioprine, mycophenolate, tacrolimus, and cyclosporine, have been effective in controlling symptoms of myasthenia. While being effective in a majority of MG patients many of these immunosuppressive agents are associated with long-term side effects, often intolerable for patients, and take several months to be effective. With advances in translational research and drug development capabilities, more directed therapeutic agents that can alter the future of MG treatment have been developed. This review focuses on the aberrant immunological processes in MG, the novel agents that target them along with the clinical evidence for efficacy and safety. These agents include terminal complement C5 inhibitors, Fc receptor inhibitors, B cell depleting agents (anti CD 19 and 20 and B cell activating factor [BAFF)]inhibitors), proteosome inhibitors, T cells and cytokine based therapies (chimeric antigen receptor T [CART-T] cell therapy), autologous stem cell transplantation, and subcutaneous immunoglobulin (SCIG). Most of these new agents have advantages over conventional immunosuppressive treatment (IST) for MG therapy in terms of faster onset of action, favourable side effect profile and the potential for a sustained and long-term remission.
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Affiliation(s)
| | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
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24
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Kasprick A, Hofrichter M, Smith B, Ward P, Bieber K, Shock A, Ludwig RJ, Schmidt E. Treatment with anti-neonatal Fc receptor (FcRn) antibody ameliorates experimental epidermolysis bullosa acquisita in mice. Br J Pharmacol 2020; 177:2381-2392. [PMID: 31975370 PMCID: PMC7174883 DOI: 10.1111/bph.14986] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/04/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background and Purpose Pemphigus and pemphigoid diseases are characterized and caused predominantly by IgG autoantibodies targeting structural proteins of the skin. Their current treatment relies on general and prolonged immunosuppression that causes severe adverse events, including death. Hence, novel safe and more effective treatments are urgently needed. Due to its' physiological functions, the neonatal Fc receptor (FcRn) has emerged as a potential therapeutic target for pemphigus and pemphigoid, primarily because IgG is protected from proteolysis after uptake into endothelial cells. Thus, blockade of FcRn would reduce circulating autoantibody concentrations. However, long‐term effects of pharmacological FcRn inhibition in therapeutic settings of autoimmune diseases are unknown. Experimental Approach Therapeutic effects of FcRn blockade were investigated in a murine model of the prototypical autoantibody‐mediated pemphigoid disease, epidermolysis bullosa acquisita (EBA). B6.SJL‐H2s C3c/1CyJ mice with clinically active disease were randomized to receive either an anti‐FcRn monoclonal antibody (4470) or an isotype control over 4 weeks. Key Results While clinical disease continued to worsen in isotype control‐treated mice, overall disease severity continuously decreased in mice injected with 4470, leading to almost complete remission in over 25% of treated mice. These clinical findings were paralleled by a reduction of autoantibody concentrations. Reduction of autoantibody concentrations, rather than modulating neutrophil activation, was responsible for the observed therapeutic effects. Conclusion and Implications The clinical efficacy of anti‐FcRn treatment in this prototypical autoantibody‐mediated disease encourages further development of anti‐FcRn antibodies for clinical use in pemphigoid diseases and potentially in other autoantibody mediated diseases.
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Affiliation(s)
- Anika Kasprick
- Lübeck Institute of Experimental Dermatology, and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Maxi Hofrichter
- Lübeck Institute of Experimental Dermatology, and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | | | | | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | | | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology, and Center for Research on Inflammation of the Skin, University of Lübeck, Lübeck, Germany
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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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Abstract
Maternal alloimmunization to paternally inherited antigens on fetal/neonatal platelets can cause fetal/neonatal alloimmune thrombocytopenia (FNAIT) after antibody-mediated removal of platelets from the fetal circulation. The complications vary from mild bleeding symptoms to severe intracranial hemorrhage and subsequent neurological impairment or death. Studies on in vivo mechanisms are challenging to measure directly in pregnant women, rendering murine models as valuable and attractive alternatives, despite some critical differences between mice and men affecting the translational value. Here we present and discuss, the different murine models that substantially have increased our knowledge and understanding of FNAIT pathogenesis - as well as pre-clinical evaluation of therapeutic and preventive strategies.
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Affiliation(s)
- Trude Victoria Rasmussen
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway; Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Maria Therese Ahlen
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.
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27
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Diagnosis and treatment of autoimmune hemolytic anemia in adults: Recommendations from the First International Consensus Meeting. Blood Rev 2019; 41:100648. [PMID: 31839434 DOI: 10.1016/j.blre.2019.100648] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
Autoimmune hemolytic anemias (AIHAs) are rare and heterogeneous disorders characterized by the destruction of red blood cells through warm or cold antibodies. There is currently no licensed treatment for AIHA. Due to the paucity of clinical trials, recommendations on diagnosis and therapy have often been based on expert opinions and some national guidelines. Here we report the recommendations of the First International Consensus Group, who met with the aim to review currently available data and to provide standardized diagnostic criteria and therapeutic approaches as well as an overview of novel therapies. Exact diagnostic workup is important because symptoms, course of disease, and therapeutic management relate to the type of antibody involved. Monospecific direct antiglobulin test is considered mandatory in the diagnostic workup, and any causes of secondary AIHA have to be diagnosed. Corticosteroids remain first-line therapy for warm-AIHA, while the addition of rituximab should be considered early in severe cases and if no prompt response to steroids is achieved. Rituximab with or without bendamustine should be used in the first line for patients with cold agglutinin disease requiring therapy. We identified a need to establish an international AIHA network. Future recommendations should be based on prospective clinical trials whenever possible.
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28
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Blumberg LJ, Humphries JE, Jones SD, Pearce LB, Holgate R, Hearn A, Cheung J, Mahmood A, Del Tito B, Graydon JS, Stolz LE, Bitonti A, Purohit S, de Graaf D, Kacena K, Andersen JT, Christianson GJ, Roopenian DC, Hubbard JJ, Gandhi AK, Lasseter K, Pyzik M, Blumberg RS. Blocking FcRn in humans reduces circulating IgG levels and inhibits IgG immune complex-mediated immune responses. SCIENCE ADVANCES 2019; 5:eaax9586. [PMID: 31897428 PMCID: PMC6920022 DOI: 10.1126/sciadv.aax9586] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
The neonatal crystallizable fragment receptor (FcRn) functions as an intracellular protection receptor for immunoglobulin G (IgG). Recently, several clinical studies have reported the lowering of circulating monomeric IgG levels through FcRn blockade for the potential treatment of autoimmune diseases. Many autoimmune diseases, however, are derived from the effects of IgG immune complexes (ICs). We generated, characterized, and assessed the effects of SYNT001, a FcRn-blocking monoclonal antibody, in mice, nonhuman primates (NHPs), and humans. SYNT001 decreased all IgG subtypes and IgG ICs in the circulation of humans, as we show in a first-in-human phase 1, single ascending dose study. In addition, IgG IC induction of inflammatory pathways was dependent on FcRn and inhibited by SYNT001. These studies expand the role of FcRn in humans by showing that it controls not only IgG protection from catabolism but also inflammatory pathways associated with IgG ICs involved in a variety of autoimmune diseases.
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MESH Headings
- Animals
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/pharmacokinetics
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antigen-Antibody Complex/immunology
- Autoantibodies/drug effects
- Autoimmune Diseases/drug therapy
- Cohort Studies
- Double-Blind Method
- Female
- Healthy Volunteers
- Histocompatibility Antigens Class I
- Humans
- Immunity, Humoral/immunology
- Immunoglobulin G/blood
- Immunoglobulin G/immunology
- Macaca fascicularis
- Male
- Mice
- Protein Binding
- Receptors, Fc/antagonists & inhibitors
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Affiliation(s)
| | | | - S. D. Jones
- BioProcess Technology Consultants, Woburn, MA 01801, USA
| | | | - R. Holgate
- Abzena, Babraham, Cambridge, CB22 3AT, UK
| | - A. Hearn
- Abzena, Babraham, Cambridge, CB22 3AT, UK
| | - J. Cheung
- New York Structural Biology Center, New York, NY 10027, USA
| | - A. Mahmood
- New York Structural Biology Center, New York, NY 10027, USA
| | - B. Del Tito
- Biologics Consulting, Alexandria, VA 22314, USA
| | | | | | | | - S. Purohit
- BioProcess Technology Consultants, Woburn, MA 01801, USA
| | | | - K. Kacena
- BioBridges, Wellesley, MA 02481, USA
| | - J. T. Andersen
- Department of Immunology and Centre for Immune Regulation, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo 0424, Norway
- Department of Pharmacology, Institute of Clinical Medicine, University of Oslo, Oslo 0424, Norway
| | | | | | - J. J. Hubbard
- Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA 02115, USA
| | - A. K. Gandhi
- Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - K. Lasseter
- Clinical Pharmacology of Miami, Miami, FL 33014, USA
| | - M. Pyzik
- Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - R. S. Blumberg
- Department of Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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29
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Beecher G, Putko BN, Wagner AN, Siddiqi ZA. Therapies Directed Against B-Cells and Downstream Effectors in Generalized Autoimmune Myasthenia Gravis: Current Status. Drugs 2019; 79:353-364. [PMID: 30762205 DOI: 10.1007/s40265-019-1065-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Myasthenia gravis is a rare, heterogeneous, classical autoimmune disease characterized by fatigable skeletal muscle weakness, which is directly mediated by autoantibodies targeting various components of the neuromuscular junction, including the acetylcholine receptor, muscle specific tyrosine kinase, and lipoprotein-related protein 4. Subgrouping of myasthenia gravis is dependent on the age of onset, pattern of clinical weakness, autoantibody detected, type of thymic pathology, and response to immunotherapy. Generalized immunosuppressive therapies are effective in all subgroups of myasthenia gravis; however, approximately 15% remain refractory and more effective treatments with improved safety profiles are needed. In recent years, successful utilization of targeted B-cell therapies in this disease has triggered renewed focus in unraveling the underlying immunopathology in attempts to identify newer therapeutic targets. While myasthenia gravis is predominantly B-cell mediated, T cells, T cell-B cell interactions, and B-cell-related factors are increasingly recognized to play key roles in its immunopathology, particularly in autoantibody production, and novel therapies have focused on targeting these specific immune system components. This overview describes the current understanding of myasthenia gravis immunopathology before discussing B-cell-related therapies, their therapeutic targets, and the rationale and evidence for their use. Several prospective studies demonstrated efficacy of rituximab in various myasthenia gravis subtypes, particularly that characterized by antibodies against muscle-specific tyrosine kinase. However, a recent randomized control trial in patients with acetylcholine receptor antibodies was negative. Eculizumab, a complement inhibitor, has recently gained regulatory approval for myasthenia gravis based on a phase III trial that narrowly missed its primary endpoint while achieving robust results in all secondary endpoints. Zilucoplan is a subcutaneously administered terminal complement inhibitor that recently demonstrated significant improvements in functional outcome measures in a phase II trial. Rozanolixizumab, CFZ533, belimumab, and bortezomib are B-cell-related therapies that are in the early stages of evaluation in treating myasthenia gravis. The rarity of myasthenia gravis, heterogeneity in its clinical manifestations, and variability in immunosuppressive regimens are challenges to conducting successful trials. Nonetheless, these are promising times for myasthenia gravis, as renewed research efforts provide novel insights into its immunopathology, allowing for development of targeted therapies with increased efficacy and safety.
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Affiliation(s)
- Grayson Beecher
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Brendan Nicholas Putko
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Amanda Nicole Wagner
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Zaeem Azfer Siddiqi
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada.
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30
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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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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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32
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Challa DK, Wang X, Montoyo HP, Velmurugan R, Ober RJ, Ward ES. Neonatal Fc receptor expression in macrophages is indispensable for IgG homeostasis. MAbs 2019; 11:848-860. [PMID: 30964743 PMCID: PMC6601554 DOI: 10.1080/19420862.2019.1602459] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The maintenance of the homeostasis of immunoglobulin G (IgG) represents a fundamental aspect of humoral immunity that has direct relevance to the successful delivery of antibody-based therapeutics. The ubiquitously expressed neonatal Fc receptor (FcRn) salvages IgG from cellular degradation following pinocytic uptake into cells, conferring prolonged in vivo persistence on IgG. However, the cellular sites of FcRn function are poorly defined. Pinocytic uptake is a prerequisite for FcRn-mediated IgG salvage, prompting us to investigate the consequences of IgG uptake and catabolism by macrophages, which represent both abundant and highly pinocytic cells in the body. Site-specific deletion of FcRn to generate mice harboring FcRn-deficient macrophages results in IgG hypercatabolism and ~threefold reductions in serum IgG levels, whereas these effects were not observed in mice that lack functional FcRn in B cells and dendritic cells. Consistent with the degradative activity of FcRn-deficient macrophages, depletion of these cells in FcRn-deficient mice leads to increased persistence and serum levels of IgG. These studies demonstrate a pivotal role for FcRn-mediated salvage in compensating for the high pinocytic and degradative activities of macrophages to maintain IgG homeostasis.
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Affiliation(s)
- Dilip K Challa
- a Department of Molecular and Cellular Medicine , Texas A&M University Health Science Center , College Station , TX , USA
| | - Xiaoli Wang
- a Department of Molecular and Cellular Medicine , Texas A&M University Health Science Center , College Station , TX , USA
| | - Héctor Pérez Montoyo
- b Department of Immunology , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Ramraj Velmurugan
- a Department of Molecular and Cellular Medicine , Texas A&M University Health Science Center , College Station , TX , USA
| | - Raimund J Ober
- a Department of Molecular and Cellular Medicine , Texas A&M University Health Science Center , College Station , TX , USA.,c Department of Biomedical Engineering , Texas A&M University , College Station , TX , USA.,d Cancer Sciences Unit, Centre for Cancer Immunology, Faculty of Medicine , University of Southampton , Southampton , UK
| | - E Sally Ward
- a Department of Molecular and Cellular Medicine , Texas A&M University Health Science Center , College Station , TX , USA.,d Cancer Sciences Unit, Centre for Cancer Immunology, Faculty of Medicine , University of Southampton , Southampton , UK.,e Department of Microbial Pathogenesis and Immunology , Texas A&M University Health Science Center , Bryan , TX , USA
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33
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Ben Mkaddem S, Benhamou M, Monteiro RC. Understanding Fc Receptor Involvement in Inflammatory Diseases: From Mechanisms to New Therapeutic Tools. Front Immunol 2019; 10:811. [PMID: 31057544 PMCID: PMC6481281 DOI: 10.3389/fimmu.2019.00811] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 03/27/2019] [Indexed: 12/21/2022] Open
Abstract
Fc receptors (FcRs) belong to the ITAM-associated receptor family. FcRs control the humoral and innate immunity which are essential for appropriate responses to infections and prevention of chronic inflammation or auto-immune diseases. Following their crosslinking by immune complexes, FcRs play various roles such as modulation of the immune response by released cytokines or of phagocytosis. Here, we review FcR involvement in pathologies leading notably to altered intracellular signaling with functionally relevant consequences to the host, and targeting of Fc receptors as therapeutic approaches. Special emphasis will be given to some FcRs, such as the FcαRI, the FcγRIIA and the FcγRIIIA, which behave like the ancient god Janus depending on the ITAM motif to inhibit or activate immune responses depending on their targeting by monomeric/dimeric immunoglobulins or by immune complexes. This ITAM duality has been recently defined as inhibitory or activating ITAM (ITAMi or ITAMa) which are controlled by Src family kinases. Involvement of various ITAM-bearing FcRs observed during infectious or autoimmune diseases is associated with allelic variants, changes in ligand binding ability responsible for host defense perturbation. During auto-immune diseases such as rheumatoid arthritis, lupus or immune thrombocytopenia, the autoantibodies and immune complexes lead to inflammation through FcR aggregation. We will discuss the role of FcRs in autoimmune diseases, and focus on novel approaches to target FcRs for resolution of antibody-mediated autoimmunity. We will finally also discuss the down-regulation of FcR functionality as a therapeutic approach for autoimmune diseases.
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Affiliation(s)
- Sanae Ben Mkaddem
- INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France.,CNRS ERL8252, Paris, France.,Faculté de Médecine, Université Paris Diderot, Sorbonne Paris Cité, Site Xavier Bichat, Paris, France.,Inflamex Laboratory of Excellence, Paris, France
| | - Marc Benhamou
- INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France.,CNRS ERL8252, Paris, France.,Faculté de Médecine, Université Paris Diderot, Sorbonne Paris Cité, Site Xavier Bichat, Paris, France.,Inflamex Laboratory of Excellence, Paris, France
| | - Renato C Monteiro
- INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France.,CNRS ERL8252, Paris, France.,Faculté de Médecine, Université Paris Diderot, Sorbonne Paris Cité, Site Xavier Bichat, Paris, France.,Inflamex Laboratory of Excellence, Paris, France.,Service d'Immunologie, DHU Fire, Hôpital Bichat-Claude Bernard, Assistance Publique de Paris, Paris, France
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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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35
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Smith B, Christodoulou L, Clargo A, Eddleston A, Greenslade K, Lightwood D, Shock A, Tyson K, Brennan FR. Generation of two high affinity anti-mouse FcRn antibodies: Inhibition of IgG recycling in wild type mice and effect in a mouse model of immune thrombocytopenia. Int Immunopharmacol 2018; 66:362-365. [PMID: 30529500 DOI: 10.1016/j.intimp.2018.11.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/26/2018] [Accepted: 11/25/2018] [Indexed: 12/25/2022]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disease characterized by pathogenic immunoglobulin G (IgG) autoantibodies that bind to platelets, causing their phagocytic removal and leading to reductions in platelet number. The neonatal Fc receptor (FcRn) selectively salvages and recycles IgG, including pathogenic IgG, thereby extending the half-life of IgG in plasma. Two anti-mouse FcRn monoclonal antibodies (mAb) (4470 and 4464) were generated to evaluate the effect of inhibiting IgG recycling. Statistically significant reductions in plasma IgG concentration were observed upon administration of 4470 (10, 30 and 100 mg/kg) in wild-type mice. In a passive mouse model of ITP, 4464 alleviated the reduction in platelet number and/or preserved newly produced platelets when dosed prophylactically as well as in a therapeutic dosing regimen once platelet numbers had already been reduced. These results support the investigation of anti-FcRn therapy as a potential treatment for ITP.
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Affiliation(s)
- Bryan Smith
- UCB Pharma, 208 Bath Road, Slough SL1 3WE, UK.
| | | | | | | | | | | | | | - Kerry Tyson
- UCB Pharma, 208 Bath Road, Slough SL1 3WE, UK.
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36
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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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37
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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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38
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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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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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40
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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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41
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Bayry J, Kaveri SV. Kill 'Em All: Efgartigimod Immunotherapy for Autoimmune Diseases. Trends Pharmacol Sci 2018; 39:919-922. [PMID: 30201270 DOI: 10.1016/j.tips.2018.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/13/2022]
Abstract
Neonatal Fc receptors (FcRns) recycle IgGs by preventing their lysosome degradation. As this process also enhances half-life of pathogenic auto-IgG, inspired from the mechanisms of intravenous immunoglobulin, several inhibitors of IgG-FcRn interface have been conceived for treating autoimmune diseases. Among them, the high-affinity FcRn-binding engineered Fc molecule efgartigimod has recently completed phase I clinical trial.
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Affiliation(s)
- Jagadeesh Bayry
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Equipe-Immunopathologie et Immunointervention Thérapeutique, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, F-75006, France.
| | - Srini V Kaveri
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Equipe-Immunopathologie et Immunointervention Thérapeutique, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, F-75006, France
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42
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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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43
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Zhao P, Wang Y, Wu A, Rao Y, Huang Y. Roles of Albumin-Binding Proteins in Cancer Progression and Biomimetic Targeted Drug Delivery. Chembiochem 2018; 19:1796-1805. [PMID: 29920893 DOI: 10.1002/cbic.201800201] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 12/18/2022]
Abstract
Nutrient transporters have attracted significant attention for their promising application in biomimetic delivery. Due to the active consumption of nutrients, cancer cells generally overexpress nutrient transporters to meet their increased need for energy and materials. For example, albumin-binding proteins (ABPs) are highly overexpressed in malignant cells, stromal cells, and tumor vessel endothelial cells responsible for albumin uptake. ABP (e.g., SPARC) is a promising target for tumor-specific drug delivery, and albumin has been widely used as a biomimetic delivery carrier. Apart from the transportation function, ABPs are closely associated with neoplasia, invasion, and metastasis. Herein, a summary of the roles of ABP in cancer progression and the application of albumin-based biomimetic tumor-targeted delivery through the ABP pathway is presented.
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Affiliation(s)
- Pengfei Zhao
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 501 Haike Road, Shanghai, 201203, P.R. China.,Zhejiang Academy of Medical Science, 182 Tianmushan Road, Hangzhou, 310013, P.R. China
| | - Yonghui Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 501 Haike Road, Shanghai, 201203, P.R. China
| | - Aihua Wu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 501 Haike Road, Shanghai, 201203, P.R. China
| | - Yuefeng Rao
- The First Affiliated Hospital of the College of Medicine, Zhejiang University, Hangzhou, 310003, P.R. China
| | - Yongzhuo Huang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 501 Haike Road, Shanghai, 201203, P.R. China.,University of Chinese Academy of Sciences, Beijing, 100049, P.R. China
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44
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Stöppler D, Macpherson A, Smith-Penzel S, Basse N, Lecomte F, Deboves H, Taylor RD, Norman T, Porter J, Waters LC, Westwood M, Cossins B, Cain K, White J, Griffin R, Prosser C, Kelm S, Sullivan AH, Fox D, Carr MD, Henry A, Taylor R, Meier BH, Oschkinat H, Lawson AD. Insight into small molecule binding to the neonatal Fc receptor by X-ray crystallography and 100 kHz magic-angle-spinning NMR. PLoS Biol 2018; 16:e2006192. [PMID: 29782488 PMCID: PMC5983862 DOI: 10.1371/journal.pbio.2006192] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/01/2018] [Accepted: 05/02/2018] [Indexed: 01/09/2023] Open
Abstract
Aiming at the design of an allosteric modulator of the neonatal Fc receptor (FcRn)-Immunoglobulin G (IgG) interaction, we developed a new methodology including NMR fragment screening, X-ray crystallography, and magic-angle-spinning (MAS) NMR at 100 kHz after sedimentation, exploiting very fast spinning of the nondeuterated soluble 42 kDa receptor construct to obtain resolved proton-detected 2D and 3D NMR spectra. FcRn plays a crucial role in regulation of IgG and serum albumin catabolism. It is a clinically validated drug target for the treatment of autoimmune diseases caused by pathogenic antibodies via the inhibition of its interaction with IgG. We herein present the discovery of a small molecule that binds into a conserved cavity of the heterodimeric, extracellular domain composed of an α-chain and β2-microglobulin (β2m) (FcRnECD, 373 residues). X-ray crystallography was used alongside NMR at 100 kHz MAS with sedimented soluble protein to explore possibilities for refining the compound as an allosteric modulator. Proton-detected MAS NMR experiments on fully protonated [13C,15N]-labeled FcRnECD yielded ligand-induced chemical-shift perturbations (CSPs) for residues in the binding pocket and allosteric changes close to the interface of the two receptor heterodimers present in the asymmetric unit as well as potentially in the albumin interaction site. X-ray structures with and without ligand suggest the need for an optimized ligand to displace the α-chain with respect to β2m, both of which participate in the FcRnECD-IgG interaction site. Our investigation establishes a method to characterize structurally small molecule binding to nondeuterated large proteins by NMR, even in their glycosylated form, which may prove highly valuable for structure-based drug discovery campaigns.
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Affiliation(s)
- Daniel Stöppler
- Leibniz-Forschungsinstitut für Molekulare Pharmakologie, Berlin, Germany
| | | | | | | | | | | | | | | | | | - Lorna C. Waters
- Leicester Institute of Structural and Chemical Biology, University of Leicester, Leicester, United Kingdom
| | | | | | | | | | | | | | | | - Amy H. Sullivan
- Beryllium Discovery, Bedford, Massachusetts, United States of America
| | - David Fox
- Beryllium Discovery, Bedford, Massachusetts, United States of America
| | - Mark D. Carr
- Leicester Institute of Structural and Chemical Biology, University of Leicester, Leicester, United Kingdom
| | | | | | - Beat H. Meier
- Laboratory of Physical Chemistry, ETH Zürich, Zürich, Switzerland
| | - Hartmut Oschkinat
- Leibniz-Forschungsinstitut für Molekulare Pharmakologie, Berlin, Germany
- * E-mail: (HO); (ADL)
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45
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Seijsing J, Yu S, Frejd FY, Höiden-Guthenberg I, Gräslund T. In vivo depletion of serum IgG by an affibody molecule binding the neonatal Fc receptor. Sci Rep 2018; 8:5141. [PMID: 29572538 PMCID: PMC5865129 DOI: 10.1038/s41598-018-23481-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/12/2018] [Indexed: 12/28/2022] Open
Abstract
Lowering the total level of Immunoglobulin G (IgG) in circulation is a promising general treatment option for many autoimmune diseases driven by pathogenic autoantibodies. The half-life of IgG in circulation is unusually long as a consequence of its interaction with the neonatal Fc receptor (FcRn), which protects it from lysosomal degradation by cells in contact with blood. Blocking the IgG/FcRn interaction prevents FcRn-mediated rescue, which may lead to increased catabolism and a lowering of the total IgG level. Here, we find that an engineered alternative scaffold protein, an affibody molecule, interacting specifically with FcRn, is able to block the IgG/FcRn interaction in vitro. The affibody molecule (ZFcRn) was expressed alone or as a fusion to an albumin binding domain (ABD), to extend its half-life in circulation, in both cases with retained affinity and blocking potential. Repeated i.v. injections in mice of ZFcRn and ZFcRn-ABD were found to result in an up to 40% reduction of the IgG serum-level after 5 days. Potential applications of ZFcRn as a general treatment modality for autoimmune diseases are discussed.
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Affiliation(s)
- Johan Seijsing
- School of Biotechnology, KTH Royal Institute of Technology, Roslagstullsbacken 21, 11417, Stockholm, Sweden.,Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Shengze Yu
- School of Biotechnology, KTH Royal Institute of Technology, Roslagstullsbacken 21, 11417, Stockholm, Sweden
| | | | | | - Torbjörn Gräslund
- School of Biotechnology, KTH Royal Institute of Technology, Roslagstullsbacken 21, 11417, Stockholm, Sweden.
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46
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Ahmed AR, Carrozzo M, Caux F, Cirillo N, Dmochowski M, Alonso AE, Gniadecki R, Hertl M, López-Zabalza MJ, Lotti R, Pincelli C, Pittelkow M, Schmidt E, Sinha AA, Sprecher E, Grando SA. Monopathogenic vs multipathogenic explanations of pemphigus pathophysiology. Exp Dermatol 2018; 25:839-846. [PMID: 27305362 DOI: 10.1111/exd.13106] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2016] [Indexed: 01/31/2023]
Abstract
This viewpoint highlights major, partly controversial concepts about the pathogenesis of pemphigus. The monopathogenic theory explains intra-epidermal blistering through the "desmoglein (Dsg) compensation" hypothesis, according to which an antibody-dependent disabling of Dsg 1- and/or Dsg 3-mediated cell-cell attachments of keratinocytes (KCs) is sufficient to disrupt epidermal integrity and cause blistering. The multipathogenic theory explains intra-epidermal blistering through the "multiple hit" hypothesis stating that a simultaneous and synchronized inactivation of the physiological mechanisms regulating and/or mediating intercellular adhesion of KCs is necessary to disrupt epidermal integrity. The major premise for a multipathogenic theory is that a single type of autoantibody induces only reversible changes, so that affected KCs can recover due to a self-repair. The damage, however, becomes irreversible when the salvage pathway and/or other cell functions are altered by a partnering autoantibody and/or other pathogenic factors. Future studies are needed to (i) corroborate these findings, (ii) characterize in detail patient populations with non-Dsg-specific autoantibodies, and (iii) determine the extent of the contribution of non-Dsg antibodies in disease pathophysiology.
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Affiliation(s)
- A Razzaque Ahmed
- Department of Dermatology of Tufts University and Center for Blistering Diseases, Boston, MA, USA
| | - Marco Carrozzo
- School of Dental Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Frédéric Caux
- Department of Dermatology, University Paris 13, Avicenne Hospital, APHP, Bobigny, France
| | - Nicola Cirillo
- Melbourne Dental School and Oral Health CRC, The University of Melbourne, Melbourne, Vic., Australia
| | - Marian Dmochowski
- Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agustín España Alonso
- Department of Dermatology, School of Medicine, University Clinic of Navarra, University of Navarra, Navarra, Spain
| | - Robert Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - Michael Hertl
- Department of Dermatology and Allergology, Philipps University, Marburg, Germany
| | | | - Roberta Lotti
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Pincelli
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Mark Pittelkow
- Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Enno Schmidt
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Animesh A Sinha
- Department of Dermatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Eli Sprecher
- Department of Dermatology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Sergei A Grando
- Institute for Immunology and Departments of Dermatology and Biological Chemistry, University of California, Irvine, CA, USA.
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47
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Liu L. Pharmacokinetics of monoclonal antibodies and Fc-fusion proteins. Protein Cell 2018; 9:15-32. [PMID: 28421387 PMCID: PMC5777971 DOI: 10.1007/s13238-017-0408-4] [Citation(s) in RCA: 199] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/23/2017] [Indexed: 12/11/2022] Open
Abstract
There are many factors that can influence the pharmacokinetics (PK) of a mAb or Fc-fusion molecule with the primary determinant being FcRn-mediated recycling. Through Fab or Fc engineering, IgG-FcRn interaction can be used to generate a variety of therapeutic antibodies with significantly enhanced half-life or ability to remove unwanted antigen from circulation. Glycosylation of a mAb or Fc-fusion protein can have a significant impact on the PK of these molecules. mAb charge can be important and variants with pI values of 1-2 unit difference are likely to impact PK with lower pI values being favorable for a longer half-life. Most mAbs display target mediated drug disposition (TMDD), which can have significant consequences on the study designs of preclinical and clinical studies. The PK of mAb can also be influenced by anti-drug antibody (ADA) response and off-target binding, which require careful consideration during the discovery stage. mAbs are primarily absorbed through the lymphatics via convection and can be conveniently administered by the subcutaneous (sc) route in large doses/volumes with co-formulation of hyaluronidase. The human PK of a mAb can be reasonably estimated using cynomolgus monkey data and allometric scaling methods.
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Affiliation(s)
- Liming Liu
- Department of Pharmacokinetics, Pharmacodynamics and Drug Metabolism, MRL, West Point, PA, 19486, USA.
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48
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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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49
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Devanaboyina SC, Khare P, Challa DK, Ober RJ, Ward ES. Engineered clearing agents for the selective depletion of antigen-specific antibodies. Nat Commun 2017; 8:15314. [PMID: 28561044 PMCID: PMC5460014 DOI: 10.1038/ncomms15314] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/20/2017] [Indexed: 12/03/2022] Open
Abstract
Here we have designed a novel class of engineered antibody-based reagents (‘Seldegs') that induce the selective degradation of antigen-specific antibodies. We demonstrate the rapid and specific clearance of antibodies recognizing the autoantigen, myelin oligodendrocyte glycoprotein and tumour target, HER2. Seldegs have considerable potential in multiple areas, including the treatment of antibody-mediated autoimmunity and diagnostic imaging. The depletion of antigen-specific, deleterious antibodies during therapy and diagnosis remains an unsolved challenge. Here the authors develop ‘Seldegs', antigens linked to human Fc fragments with high affinity for the neonatal Fc receptor FcRn, to deplete MOG- and HER2-specific antibodies in mice.
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Affiliation(s)
- Siva Charan Devanaboyina
- Department of Molecular and Cellular Medicine, Texas A&M University Health Science Center, 469 Joe H. Reynolds Medical Sciences Building, 1114 TAMU, College Station, Texas 77843, USA.,Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, 3107 Medical Research &Education Building, 8447 State Highway 47, Bryan, Texas 77807, 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, Texas 77843, USA.,Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, 3107 Medical Research &Education Building, 8447 State Highway 47, Bryan, Texas 77807, 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, Texas 77843, USA.,Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, 3107 Medical Research &Education Building, 8447 State Highway 47, Bryan, Texas 77807, 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, Texas 77843, USA.,Department of Biomedical Engineering, Texas A&M University, 5045 Emerging Technologies Building, 3120 TAMU, College Station, Texas 77843, USA
| | - 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, Texas 77843, USA.,Department of Microbial Pathogenesis and Immunology, Texas A&M University Health Science Center, 3107 Medical Research &Education Building, 8447 State Highway 47, Bryan, Texas 77807, USA
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50
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Nosrati M, Solbak S, Nordesjö O, Nissbeck M, Dourado DFAR, Andersson KG, Housaindokht MR, Löfblom J, Virtanen A, Danielson UH, Flores SC. Insights from engineering the Affibody-Fc interaction with a computational-experimental method. Protein Eng Des Sel 2017; 30:593-601. [DOI: 10.1093/protein/gzx023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 04/12/2017] [Indexed: 01/25/2023] Open
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