31. Immunogenicity of Biologicals: Clinical Consequences
Immunogenicity of Biologicals:Clinical ConsequencesDr. S.К. ZyryanovProfessor, Chair of Clinical Pharmacology,N.I. Pirogov Russian National Research MedicalUniversity (RNRMU)
Main DefinitionsBiologicalA drug, the active substance of which is abiological substance derived or extracted froma biological source, including using one ormore of the above mentioned biotechnologicalmethods: rDNA technology; controlledexpression of genes encoding bioactive proteinproduction; hybrid and monoclonal antibodymethods
What is the difference between biologicals andlow-molecular drugs?• Molecular weights• Structure complexity• Features:– Structural and physical & chemical properties– Protein purification degree– Biological activity• Stability• Immunogenicity!Crommelin DJA, et al. Int J Pharm 2003;266:3-16.
Reported Frequencies of β-1a InterferonAntibody FormationExtract from the article by Bertolotto et al J Neurology 2004Study Determination of positive response toneutralizing antibodies (Нат)AnalysismethodDosage (IM,weekly)Share of Нат-positive patients(%)Jacobs et al. (1996)  Not reported N/A 30 mcg 22*Herden et al. (1999)  Min. 1 out of 20 titres CEA 30 mcg 5Rudick et al. (1998)  Min. 1 out of 20 titres CEA 30 mcg 6Jacobs et al. (2000)  Min. 1 out of 20 titres CEA 30 mcg 2Clanet et al. (2002)  Min. 1 out of 20 titres CEA 30 mcg60 mcg2,35,8IM – intramuscular; CEA – cytopathic effect analysis* Нат frequency was higher than in earlier studies because Jacobs et al.  had conducted studies using a non-commercial drug beforethe production process was improved.
r-protein Indications ImmunogenicityInsulin Diabetes Approx. 44% of patients (5%IgE)Growth hormone GH-deficiency 3%-16% of patientsErythropoietin Anaemia 1:10 000 patientsVIII factor Haemophilia Approx. 35% of patientsIFN- Hepatitis etc. Approx. 25% of patientsIL-2 Certain tumors 20%-100% of patientsImmunogenicity of Recombinant TherapeuticProteins(H.Schellekens, 2002)
Antibody Formation Consequences• Efficacy loss– Interferon alpha 2– Interferon beta– TNF inhibitors– Beta agalsydase– And many others• Cross-neutralization of endogenous factors– Erythropoietin (EPO)– Growth and megakaryocyte development factor (GMDF)• Anaphylaxis reaction; serum reaction– Monoclonal antibodies
Antibody analysis method Interferon drugEfficacy reduction (relapses, NMR orbio markers)PRISMS 4 (2005) CEA Rebif® YesIFNβ research group (1996) CEA Betaferon® YesIFNβ European ResearchGroup (1998) and (1999)CEA Betaferon®Deisenhammer et al. (1999)MxA protein interferon alphatestBetaferon® YesCook et al. (2001) CEA; neopterin test Avonex®; Betaferon® YesVallittu et al. (2002) CEA; MxA protein test Rebif® 22 YesBertolotto et al. (2005) CEA; MxA protein i-RNA test Avonex®; Rebif® 22; Betaferon® YesPachner et al. (2003)CEA; MxA protein i-RNA test;ОАСNot reported Biomarker reductionMalucchi et al. (2004) CEA Avonex®; Rebif® 22; Betaferon® YesPetkau et al. (2004) CEA; MxA protein test Betaferon® YesPerini et al. (2004) CEA Avonex®; Rebif® 22; Betaferon® YesKappos et al. (2005) CEAAvonex® 30 mcg;Avonex® 60 mcgYesSorensen et al. (2003) CEAAvonex® 30 mcg OW; Rebif® 22mcg OW; Rebif® 22 mcg TTW;Betaferon® 8 ММЕ/2daysInterferon neutralization.Extract from the article by R.A. Farrell and G. Giovannoni, Measuring and management of anti-interferon beta antibodies in subjects with multiplesclerosis, Mult. Scler. 13 (5) (Jun 2007), pp. 567–577.ß-interferon neutralizing antibodies reduce the multiple sclerosis treatment efficacy
Fig. 5. States of stable disease activity and remissionin patients with and without adalimumab(ААА) antibodiesBartelds, G. M. et al. JAMA 2011;305:1460-1468Copyright restrictions may apply.Weeks Weeks WeeksStable remissionStable minimum activityStable minimum activityPatientsharePatientsharePatientshareNumber of persons at risk Number of persons at risk Number of persons at riskUI/mlUI/ml
Impact of Antibodies on Beta-Agalsidase Efficacy in Fabry DiseaseBenichou et al. Molecular tools and genetics (2008)Shareofpatientswithnon-zeroscoreSerum negative Low titers Medium titers High titers
Biosimilar = generic‘Biosimilar’ is a biological that is similar to the originatorbiological but is not its generic due to differences in the initialraw materials and manufacturing of the originator biologicaland of the biosimilar…Source: translated from Article 10 (2) b of Directive 2001/83 as amendedWhy should we be cautious speaking aboutsubstitutability of biologicals?
Regulation of biosimilar manufacturing and application in ECAmended Directive 2001/83/EC(2003/63/EC, 2004/27/EC)Overarching Guidelines(CHMP/437/04)Quality Guidelines(CHMP/49348/05)Non-Clin & Clin Guidelines(CHMP/42832/05)r-Human Insulin Guidance(CHMP/42832/05)Somatropin Guidance(CHMP/94528/05)r-GCSF Guidance(CHMP/31329/05)r-Erythropoeitin Guidance(CHMP/94526/05)Immunogenicity Guidance(CHMP/14327/06)Low Molecular Weight HeparinGuidance (CHMP/118264/2007)r--Interferon Guidance(CHMP/102046/06)Guidelines under preparation
Findings of the Сomparative Alpha EpoietinDrug StudySingh A. K.Brigham and Women’s hospital & Harvard Medical School,Boston, USA.World Congress of Nephrology – Apr 22, 200747 samples from the following countries were tested: Argentine,Brazil, Columbia, India, Indonesia, Iran, Jordan, Korea, Lebanon,Nigeria, Philippines, Russia, Thailand, Venezuela, Viet Nam andYemenThe samples were tested according to the EuropeanPharmacopoeia quality requirements to alpha epoietin. Eprex®(alpha epoietin) was used as a reference product.Singh AK. Poster presented at the World Congress of Nephrology, 21-25 April 2007, Rio de Janeiro, Brazil
15Singh A. K. Study Findings pH 9 samples deviated from the specification requirements Osmosis 21 samples had greater osmosis Protein and erythropoietin content 1 sample did not meet the specification requirements as concerns theprotein content 8 samples had excess erythropoietin In vitro biological sample1 sample did not meet the specification requirements 18 samples deviated from the specification requirements In vivo efficacy48%-163% efficacy differences 9 samples did not meet the specification requirements 6 samples deviated from the specification requirements Bacterial endotoxin2 samples contained bacterial endotoxinSingh AK. Poster presented at the World Congress of Nephrology, 21-25 April 2007, Rio de Janeiro, Brazil
16 Aggregate content 29 samples exceeded the specification by the number of aggregates 7 samples had more than 1% and less than 2% aggregates 4 samples had 2%-4% aggregates 18 samples had more than 4% aggregates Isoform content 34 samples had excess isoforms, which may reduce the clinicaleffect 9 out of 34 samples had ≥ 3 additional isoformsSingh A. K. Study FindingsSingh AK. Poster presented at the World Congress of Nephrology, 21-25 April 2007, Rio de Janeiro, Brazil
Epokim 123Epokrin 123EporonEpovet 12Espogen 123GeerepoHemax 123Hypercryte 12VepoxZirop 12Alkali isoformsAcid isoforms0 1 2 3 4 5Total quantity of additional isoformsAlpha Epoietin Drug Comparative Study Findings(continued)
Conclusions on Alpha Epoietin drugComparative Study Findings: Several out of the tested epoietin biosimilars had variable quality and efficacy;42 out of 47 samples did not meet all European Requirements to alphaepoietin 34 samples contained additional alkali isoforms that may reduce clinical drugefficacy 2 samples contained bacterial endotoxin that poses risk for the patient’s safety 22 samples contained more than 2% aggregates that may influence the drugimmunological profile Detected differences lead to unpredictable adverse events in clinical practice Studied biosimilars had differences in various series of one and the same drugSpecialists applying epoietin generics in their practice should track theirefficacy and safety attentivelySingh AK. Poster presented at the World Congress of Nephrology, 21-25 April 2007, Rio de Janeiro, Brazil
20July 09ASHAbstract &Poster #Immunogenicity of Low Molecular Weight Heparins and TheirBiosimilarsW.P.JeskeJ.WalengaHIT Antibodies Synthesis InductionIn Vitro Cross-Reactivity of Branded LMWHs (1 g/mL) withHIT Antibodies in the Platelet Aggregation Assay1 2 3 4 5 6 7 8%Aggregation02 55 07 51. Saline 5. Reviparin2. Dalteparin 6. Parnaparin3. Enoxaparin 7. Tinzaparin4. Nadroparin 8. HeparinIn Vitro Cross-Reactivity of Branded LMWHs (1 g/mL) withHIT Antibodies in the Platelet Aggregation Assay1 2 3 4 5 6 7 8%Aggregation02 55 07 51. Saline 5. Reviparin2. Dalteparin 6. Parnaparin3. Enoxaparin 7. Tinzaparin4. Nadroparin 8. HeparinIn Vitro Cross-Reactivity of Biosimilar Versions of Enoxaparin andDalteparin (1 g/mL) with HIT Antibodies in thePlatelet Aggregation Assay1 2 3 4 5 6 7%Aggregation02 55 07 51. Saline 5. Dilutol2. Clenox 6. Lupenox3. Cutenox 7. Daltehep4. DripaninaIn Vitro Cross-Reactivity of Biosimilar Versions of Enoxaparin andDalteparin (1 g/mL) with HIT Antibodies in thePlatelet Aggregation Assay1 2 3 4 5 6 7%Aggregation02 55 07 51. Saline 5. Dilutol2. Clenox 6. Lupenox3. Cutenox 7. Daltehep4. Dripanina
Clinical case: Clexansubstitution with a genericA patient had taken Clexan for 4 yearswithout complications. Upon transitionto the enoxaparin biosimilar, thepatient experienced 2 life-threatening haemorrhages within 4months from the onset of use.This case suggests that FDA should followEMA recommendation to have a morestringent biosimilar approval procedure:bioequivalency and the studies that displaysafety and efficacy similar to those of theoriginator before approval of thebiosimilar.Biologicals and BiosimilarsClinical Case
М.V. Belov, A.S. Petrochenko, E.M. Pozdnyakova, V.V. Yakusevich. Efficacy of different tromboembolic complication prevention methods in clinical practice(retrospective study). Clinical Pharmacology and Treatment, 2012, 21 (4)Biologicals and BiosimilarsClinical Pre-Surgical Practice FindingsGoal. Assessing the efficacy of tromboembolicconsequences prevention in the pre-surgeryperiod using unfractionated heparin andenoxaparin biosimilar.Findings. Frequency of LLVT did not reliably differin the patients receiving unfractionated heparinand enoxaparin biosimilar.Opinion. Lack of pronounced advantages ofenoxaparin biosimilar to unfractionated heparinmay be due to heterogeneity of the raw materialsused for manufacturing of the originator andenoxaparin and biosimilar.Enoxaparin biosimilar did not differ fromunfractionated heparin in terms of LLVT preventionefficacy.Frequency (%) of lower limb venous thrombosisbefore surgery (LLVT)Enoxaparin biosimilarUnfractionatedheparin
Immunogenicity Forecasting Establishment of physical and chemicalproperties Epitope analysis (in silico/in vitro) Reactions with the patient’s serum Animal tests• Conventionally used animals (relativeimmunogenicity?)• Subprimates• Immune tolerant transgenic mice
Biosimilar Immunogenicity Issues The existing analysis methods do not fully predictbiological properties The immune system is able to notice changes in adrug, which are not detected using analytical methods Immunogenicity of biologicals may have significantclinical consequences24
Immunogenicity and BiosimilarAspects Immunogenicity can only be detected in clinicalstudies Problems of trackability and substitutability withsimilars Substitution must not be there the immunogenicityrisk factor is Immunogenicity may make a patient immune to awhole drug class Standardization