Tulane University, Fall 2017, Foundations of Pharmacology

1. Adalimumab: Clinical Use &
Development
Leo Williams
Tulane University
Foundations of
Pharmacology

2. Tumor Necrosis Factor Alpha (TNFα)
• TNFα: Naturally occurring cytokine
(immune system signaling molecule) &
inflammation mediator
• normal inflammatory & immune
signaling
• elevated levels in patients with
autoimmune disorders – rheumatoid
arthritis synovial fluid; psoriasis
plaques; Crohn’s disease patient
serum
PDB ID: 2AZ5

3. Adalimumab
• Adalimumab: recombinant human IgG1
monoclonal antibody (mAb) specific for
tumor necrosis factor alpha (TNFα)
• Blocks TNF interaction with TNF
receptors – reduces inflammation
• 1330 amino acids
• MW = 140kDa
• World’s best-selling drug in 2016: $16
billion
• Pharmacokinetics – Single 40mg
subcutaneous injection
• 𝐶 𝑚𝑎𝑥 = 4.7 ± 1.6
µ𝑔
𝑚𝐿
• 𝑇 𝑚𝑎𝑥 = 131 ± 56 ℎ
• 𝐹 = 64%
PDB ID: 3WD5

4. TNF Signaling

5. Clinical Use of
Adalimumab

6. Indications
• Rheumatoid arthritis (RA): reducing
signs/symptoms; induce/maintain clinical
remission for moderate to severe active RA;
inhibit structural damage; improve physical
function
• Adult Crohn’s Disease (CD): reduce
signs/symptoms; induce/maintain clinical
remission for moderate to severe active CD &
poor response to conventional therapy or
infliximab;
• Many others: juvenile idiopathic arthritis,
psoriatic arthritis, ankylosing spondylitis,
pedatric Crohn’s disease, ulcerative colitis,
plaque psoriasis, hidradentitis suppurativa,
uveitis

7. Dosage & Forms
• Forms
• Auto-injecting pen, pre-filled syringe, or glass
vial (institutional use)
• Dose ranges from 80mg/0.8mL to 40mg/0.8mL
• Also in proportional fractions thereof
• Amounts:
• RA: 40mg biweekly
• CD: 160mg loading dose; 80mg at 2 weeks;
begin biweekly 40mg maintenance dose at 4
weeks
• Others: mostly mimic CD regimen; special
doses (i.e. less) for juvenile/pediatric diseases

8. Side Effects
• Serious infections: new or recurrent
tuberculosis, sepsis, invasive fungi,
hepatitis B reactivation, opportunistic
pathogens
• Cancer: all TNF blockers = increased risk
of many cancers, especially lymphomas
• Very rare but fatal hepatosplenic T-cell
lymphoma (HSTCL) in adolescents and
young adults
• Other: lupus-like syndrome, demyelinating
disease, cytopenias, heart failure
• Minor: upper respiratory infection, sinusitis,
headache, rash, injection site reaction

9. Adalimumab Development

10. Adalimumab
Development
Timeline

11. Adalimumab
Corporate
Timeline
• 1993: BASF Bioresearch Corp. & Cambridge
Antibody Technology partnership
• 1997: clinical trials begin
• 2000: Abbott Labs buys BASF Knoll
• 2002: adalimumab FDA approval for RA (5
clin. trials)
• 2005– : more approvals, each with clinical
trials
• 2007: approval for CD (3 specific trials – safety
already established)
• 2013: AbbVie Inc. splits from Abbott Labs &
takes ownership
• 2016: PATENT EXPIRES – generics!

12. Clinical
Trial
Results

13. mAb Generation – Phage
Display
1. DNA sequences for heavy and light
chains of antibody variable fraction (Fv)
randomized into phage (bacterial virus)
library – fused to phage coat protein
2. Phage library expanded in E. coli,
displaying billions of different Ab binding
fragments on phage surface

14. mAb Generation
– Phage Display
3. Phages undergo
‘biopanning’ against
immobilized antigen
(TNF) to select for
affinity/specificty
4. Rinse & repeat!
• ‘D2E7’ = adalimumab
• Defining attribute: all
inclusive physical link
between structure and
sequence

15. Manufacturing
Process
1. Combine Fv sequence with constant
fraction (Fc) for full Ab sequence  insert
into Chinese hamster ovary (CHO) cells
(similar glycosylation profile to human)
2. Most productive CHO clone propagated
3. Transfer to bioreactor to scale
4. Isolate & purify protein via multiple
chromatography steps, acid treatment, &
nanofiltration to remove viruses
5. Combine with reagents for final
pharmaceutical mixture, dose, & package
6. $ Profit $

16. Immunogenicity: human < chimeric

17. References
1. AbbVie Inc. Humira – Full Prescribing Information. (2017).
2. Kumar, Vinay . Abbas, Abdul K. Aster, jon C. Robbins and Cotrans Basic Pathology of Disease,
9th ed. Elsevier Saunders (2015). doi:10.1007/s13398-014-0173-7.2
3. Azevedo, V. F. et al. Adalimumab : a review of the reference product and biosimilars. Biosimilars
6, 29–44 (2016).
4. Philipidis, A. The Top 15 Best-Selling Drugs of 2016. Genetic Engineering & Biotechnology News
(2017).
5. Bain, B. & Brazil, M. Fresh from the Pipeline: Adalimumab. Nat. Rev. Drug Discov. 2, 693–694
(2003).
6. He, M. M. Small-Molecule Inhibition of TNF- . Science (80-. ). 310, 1022–1025 (2005).
7. Hu, S. et al. Comparison of the inhibition mechanisms of Adalimumab and Infliximab in treating
tumor necrosis factor α-associated diseases from a molecular view. J. Biol. Chem. 288, 27059–
27067 (2013).
8. Chan, C. E. Z., Lim, A. P. C., MacAry, P. A. & Hanson, B. J. The role of phage display in
therapeutic antibody discovery. Int. Immunol. 26, 649–657 (2014).
9. Avgerinos, G. Extended Reports from the 3rd International Symposium on Downstream
Processing of Genetically Engineered Antibodies and Related Molecules. in HUMIRA
manufacturing: challenges and the path taken 15–16 (GE Healthcare, 2004).