Assignment

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Biotechnology IIMonoclonal antibody
Table of Contents
Monoclonal antibody ................................................................................................................................. 2
History of MAb development.................................................................................................................... 3
The types of mAb designed ....................................................................................................................... 3
Production of Monoclonal Antibodies ..................................................................................................... 3
Advantages .................................................................................................................................................. 6
Disadvantages ............................................................................................................................................. 6
Applications of Monoclonal Antibodies................................................................................................... 6
Monoclonal antibodies for cancer treatment ..................................................................................... 7
Monoclonal antibody therapy in rheumatoid arthritis...................................................................... 8
Pharmacology of some Monoclonal antibodies drugs ........................................................................13
Bevacizumab..........................................................................................................................................13
Brand Name : Avastin...............................................................................................................................13
Rituximab ...............................................................................................................................................18
Indication of Rituximab rheumatoid arthritis treatment ....................................................................19
Abciximab...............................................................................................................................................20
Palivizumab............................................................................................................................................21
Brand names: Synagis®
.........................................................................................................................21
Side effects of monoclonal antibodies...................................................................................................21
Side effects of licensed monoclonal antibodies ...................................................................................22
References .................................................................................................................................................26

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Antibodies
An antibody (Ab), also known as an immunoglobulin (Ig), is a large Y-shaped protein
produced by B cells that is used by the immune system to identify and neutralize foreign
objects such as bacteria and viruses.
“An antibody produced by a single clone of cells. Monoclonal antibody is therefore a
single pure type of antibody”
Each antibody recognizes a specific antigen unique to its target. Monoclonal antibodies
(mAb) are antibodies that are identical because they were produced by one type of immune
cell, all clones of a single parent cell. Polyclonal antibodies are antibodies that are derived
from different cell lines. They differ in amino acid sequence.
It is a protein used by the immune system to identify and neutralize foreign objects like
bacteria and viruses. Each monoclonal antibody recognizes a specific antigen.
Antibodies are secreted by a type of white blood cell called a plasma cell.
Monoclonal antibodies (mAb) are antibodies that are identical because they were
produced by one type of immune cell, all clones of a single parent cell.
Polyclonal antibodies are antibodies that are derived from different cell lines. They differ
in amino acid sequence
Monoclonal antibody
Figure 1: Structure of Monoclonal Antibody(Left) and their attachment with Antigen(right)

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History of MAb development
1890 Von Behring and kitasato discovered the serum of vaccinated persons contained
certain substances, termed antibodies
1900 Ehrlich proposed the “ side-chain theory”
1955 Jerne postulated natural selection theory. Frank Macfarlane Burnet expended.
Almost the same time, Porter isolated fragment of antigen binding (Fab) and fragment
crystalline (Fc) from rabbit y-globulin.
1964 Littlefield developed a way to isolate hybrid cells from 2 parent cell lines using the
hypoxanthine-aminopterin-thymidine (HAT) selection media.
1975 Kohler and Milstein provided the most outstanding proof of the clonal selection
theory by fusion of normal and malignant cells
1990 Milstein produced the first monoclonal antibodies.
The types ofmAb designed
A. Murine source mAbs: rodent mAbs with excellent affinities and specificities
generated using conventional hydrioma technology. Clinical efficacy compromised by
HAMA(human anti murine antibody) response, which lead to allergic or immune
complex hypersensitivities.
B. Chimeric mAbs: chimers combine the human constant regions with the intact rodent
variable regions. Affinity and specificity unchanged. Also cause human antichimeric
antibody response (30% murine resource)
C. Humanized mAbs: contained only the CDRs of the rodent variable region grafted
onto human variable region framework
Production of Monoclonal Antibodies
Process by which bulk quantities of targeted antibodies against a specific antigen are
produced.Monoclonal antibodies are produced via multiple/identical copies of a certain cell

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called a hybridoma. To create Hybridoma cells the fusion of 2 cells are needed in order to
combine the characteristics of the 2 cells into 1 cell. 1 of the cells is a producing cell
antibody which is a B-Lymphocyte used from a laboratory mouse and the other is a tumor
cell named myeloma. Tumor cells have the ability to grow indefinitely and at an exceeding
rate from normal cell growth. Laboratory produced Hybridoma cells replicate much faster
than normal antibody producing cells, and the individual hybridomas produce the specific
antibodies for an indefinite period of time.
Hybridoma cells manufacture the specific monoclonal antibody that was originally
produced by the B-Lymphocyte cell. The original B-Lymphocyte cell will produce the
Monoclonal antibody depending on the kind of antigen that was injected into the mouse just
prior to the harvesting of the B-Lymphocyte cells. A small example is, if the mice were
Figure 2: Production of Monoclonal Antibodies

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injected with a certain virus, the mouse will have B-Lymphocytes that produce those
specific virual antibodies. Fusion with a tumor cell to make the hybridoma, result in the
production of monoclonal antibodies against the specific virus.
The hybridoma cells are placed into media that can help them grow and produce the bulk
quantities of monoclonal antibodies. There are 2 ways for growing monoclonal antibodies, 1
is to grow them in laboratory flasks meaning In Vitro, and the other is to grow them in the
stomach lining of mice. Injecting the hybridomas into the mice is the familiar method of
harvesting monoclonal antibodies. This method is done by mixing spleen cells from the
mouse that has been immunized with the desired antigen with myeloma cells.The myeloma
cells need to have lost their ability to synthesize HGPRT enzyme (hypoxanthine-guanine-
phosphoribosyltransferase) which enables the cells to synthesize purines using an
extracellular source of hypoxanthine as a precursor. Cells have another pathway that they
synthesize purines so lack of HGPRT is not a problem for the cell but when cells are exposed
to aminopterin they are unable to use this other pathway and are fully dependent on HGPRT
for their survival. So to summarize, unfused myeloma cells can’t grow since they lack
HGPRT and unfused normal spleen cells can’t grow since they have a limited life-span.
Hybridoma cells are grow indefinitely since the spleen-cell copartner supplies HGPRT and
the myeloma partner is immortal.
The first step is transferring of the cell fusion mixture to HAT culture medium which
contains hypoxanthine, aminopterin& pyrimidine thymidine. The 2nd step is testing the
supernatants from each culture in order to locate the producing the desired antibody. One
must isolate the single cells from each antibody-positive culture and subculture them, this
represents the clone which its antibodies are monoclonal. Every single cell culture secretes
a specific kind of antibody that is directed against a certain determinant/selected antigen.
The 3rd step is scaling up the size of the cultures of the successful clones. Hybridoma
cultures can be grown indefinitely in vitro in culture vessels which yield 15-65 µg/ml and in
vivo using mouse, where the antibody concentration in the serum 0.5-15 mg/ml. In the past
years, animal welfare activists in worldwide are trying to limit the use of mice for the
production of monoclonal antibodies. When the monoclonal antibody is produced it can be
used as a probe to track down, bind to and purify the specific protein that induced its
formation.

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Advantages
1) Homogeneity: Monoclonal antibody represents a single antibody molecule that
binds to antigens with the same affinity and promote the same effectors functions.
2) Specificity: The product of a single hybridoma reacts with the same epitope on
antigens.
3) Immunizing Antigen: Need not be pure or characterized and is ultimately not
needed to produce large quantities of antibody.
4) Selection: It is possible to select for specific epitope specificities and generate
antibodies against a wider range of antigenic determinants.
5) Antibody Production: Unlimited quantities of a single well-defined monospecific
reagent.
Disadvantages
1) Affinity: Average affinity of monoclonal antibodies are generally lower than
polyclonal antibodies.
2) Effector Functions: Because antibody is monoclonal, it may not produce the desired
biologic response.
3) Specificity: Monoclonals against conformational epitopes on native proteins may
lose reactivity with antigens.
4) Cross reactions: Antibodies sometimes display unexpected crossreactions with
unrelated antigens.
5) Time and effort commitment: Very Large.
Applications of Monoclonal Antibodies
Applications of Monoclonal Antibodies Diagnostic ApplicationsBiosensors & Microarrays
Therapeutic Applications Transplant rejection Cardiovascular disease Cancer Infectious
Diseases Inflammatory disease Clinical Applications. Purification of drugs, imaging the
target Future Applications Fight against Bioterrorism

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Autoimmune diseases
Monoclonal antibodies used for autoimmune diseases include infliximab and adalimumab,
which are effective in rheumatoid arthritis, Crohn's disease and ulcerative Colitis by their
ability to bind to and inhibit TNF-α.[31] Basiliximab and daclizumab inhibit IL-2 on
activated T cells and thereby help prevent acute rejection of kidney
transplants. Omalizumab inhibits human immunoglobulin E (IgE) and is useful in moderate-
to-severe allergic asthma.
Monoclonal antibodies for cancer treatment
Three mechanisms that could be responsible for the cancer treatment.
A. mAbs act directly when binding to a cancer specific antigen and induce
immunological response to cancer cells. Such as inducing cancer cell apoptosis,
inhibiting growth, or interfering with a key function.
B. mAbs was modified for delivery of a toxin, radioisotope, cytokine or other active
conjugates.
C. it is also possible to design bispecific antibodies that can bind with their Fab regions
both to target antigen and to a conjugate or effector cell
Figure 3 : action of Monoclonal antibodies for cancer treatment
ADEPT- antibody directed
enzyme prodrug therapy;
ADCC- antibody
dependentcell-mediated
cytotoxicity;
CDC- complement
dependentcytotoxicity;
MAb- monoclonal
antibody;
ScFv- single-chainFv
fragment

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Strategy of a direct or in direct induction of apoptosis in targeted cancer cells
1. mAbs target growth factor receptors to exert a direct effect on the growth and
survival of the cancer cells by antagonizing ligand-receptor signaling.
2. mAbs can target to cell surface antigens and directly elicit apoptotic signaling.
Until Feb 28, 2005, 18 mAbs were approved by FDA, which were applied in the treatment of
organ transplant, Cancer, Asthma, Hematopoietic malignancies and psoriasis.
The first approved mAbs was OKT-3, which is a murine IgGa2 protein to deplete T cells in
patients with acute rejection of renal allotransplant.
Monoclonal antibody therapy in rheumatoid arthritis
Rheumatoid arthritis (RA) is a systemic disease and the most prevalent of all autoimmune
disorders. Here we review recent advances in the development and availability of biologic
agents with a focus on monoclonal antibody or smaller formats of targeted engineered
therapeutics including novel, non-antibody-based therapeutics.
Monoclonal antibodies bind to their targets with high specificity and therefore have
excellent potential as therapeutic agents. Biotechnological advances have allowed the
production of large quantities of engineered monoclonal antibodies for therapeutic use.
Recent research in rheumatoid arthritis has identified important mediators of synovitis.
Monoclonal antibodies targeting these have been tested in clinical trials over the last
decade. Anti-cytokine therapies, in particular anti-tumour necrosis factor alpha monoclonal
antibodies, suppressed inflammation and produced rapid symptomatic improvement. Anti-
lymphocyte monoclonal antibodies produced long-lasting disease suppression in animal
models of rheumatoid arthritis. The use of depleting anti-lymphocyte monoclonal
antibodies in rheumatoid arthritis had been disappointing as they did not penetrate the
synovial joint in sufficient quantity to suppress disease without producing severe and
protracted peripheral blood lymphopenia. Consequently, their use in rheumatoid arthritis
had been abandoned. In contrast, clinical trials of non-depleting anti-CD4 monoclonal

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antibodies in rheumatoid arthritis showed that they could suppress synovitis. However, it
remains unclear whether they could lead to prolonged disease improvement.
Although current therapies can reduce the signs and symptoms of RA for many patients, the
quest for a cure (or a more complete blockade of the structural damage) in RA is still
ongoing and will need treatment approaches, which are not exclusively confined to blocking
a particular cytokine, receptor, or autoreactive B or T cell involved in disease progression.
To this end exciting treatment alternatives and drug targets are on the horizon that may
become available to patients in the future.
The human monoclonal antibodies adalimumab and golimumab; infliximab (a chimeric
IgG1 monoclonal antibody); etanercept (a TNF receptor–Fc fusion protein); and
certolizumabpegol (a pegylated humanized antibody Fab' fragment). Agents with other
targets are the IL-1R antagonist anakinra; abatacept (a CTLA-4–Fc fusion protein), which
modulates the T-cell co-stimulatory pathway; the humanized antibody tocilizumab, which
binds IL-6R; and rituximab, a chimeric anti-CD20 monoclonal antibody that depletes B-cell
populations. Abbreviation: CTLA-4, cytotoxic T lymphocyte antigen 4.

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Figure 4: Summary of biologic therapies used in the treatment of rheumatoid arthritis
Evolution of monoclonal anybody
Figure 5 : Generation of TNA antibodies

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Chimeric mAbs: chimers combine the human constant regions with the intact rodent
variable regions. Affinity and specificity unchanged. Also cause human antichimeric
antibody response (30% murine resource)
Humanized mAbs: contained only the CDRs of the rodent variable region grafted
onto human variable region framework
Recombinant monoclonal antibodies: Recombinant antibody engineering involves
the use of viruses or yeast to create antibodies, rather than mice. Phage display
library: construction of VH and VL gene libraries and expression of them on a
filamentous bacteriophage. The phage expressing an antigen-bonding domain specific
for a particular antigen to screen the mAbs
List of FDA’s Approved Monoclonal antibody
The first approved mAbs was OKT-3 [1986], which is a murine IgGa2 protein to deplete T
cells in patients with acute rejection of renal allotransplant.
Until Feb 24, 2013, 312 mAbs were approved by FDA, which were applied in the treatment
of organ transplant, Cancer, Asthma, Hematopoietic malignancies and psoriasis.
Figure 6 : FDA’s Approved Monoclonal antibody

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Antibody Brand name Type Indication
Abciximab ReoPro chimeric Cardiovascular disease
Adalimumab Humira human Several auto-immune disorders
Alemtuzumab Campath humanized Chronic lymphocytic leukemia
Basiliximab Simulect chimeric Transplant rejection
Belimumab Benlysta human Systemic lupus erythematosus
Bevacizumab Avastin humanized Colorectal cancer, Age related macular degeneration
BrentuximabVedot
in
Adcetris Chimeric Hodgkin lymphoma
Canakinumab Ilaris Human
Cetuximab Erbitux chimeric Colorectal cancer, Head and neck cancer
Certolizumabpeg
ol
Cimzia humanized Crohn's disease
Daclizumab Zenapax humanized Transplant rejection
Denosumab Prolia , Xgeva Human Postmenopausal osteoporosis
Eculizumab Soliris humanized Paroxysmal nocturnal hemoglobinuria
Efalizumab Raptiva humanized Psoriasis
Palivizumab Synagis humanized Respiratory Syncytial Virus
Panitumumab Vectibix human Colorectal cancer
Ranibizumab Lucentis humanized Macular degeneration
Rituximab Rituxan, Mabthera chimeric Non-Hodgkin lymphoma
Tocilizumab Actemra Humanised Rheumatoid arthritis
Tositumomab Bexxar murine Non-Hodgkin lymphoma
Trastuzumab Herceptin humanized Breast cancer

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Pharmacology ofsome Monoclonal antibodies drugs
Bevacizumab
Brand Name :Avastin
Bevacizumab is a humanized monoclonal antibody that recognizes and blocks vascular
endothelial growth factor A (VEGF-A). VEGF-A is a chemical signal that stimulates the
growth of new blood vessels (angiogenesis).
Bevacizumab was the first commercially available angiogenesis inhibitor. It stops tumor
growth by preventing the formation of new blood vessels by targeting and inhibiting the
function of a natural protein called vascular endothelial growth factor (VEGF) that
stimulates new blood vessel formation.
The drug was first developed as a genetically engineered version of a mouse antibody that
contains both human and mouse components. Genentech is able to produce the antibody in
production-scale quantities.
Blood vessels grow uncontrollably in cancer, retinal proliferation of diabetes in the eye, and
other diseases. Bevacizumab can block VEGF-A from creating new blood vessels.
Bevacizumab was the first clinically available angiogenesis inhibitor in the United States.
Bevacizumab is currently approved by the U.S. Food and Drug Administration (FDA) for
cancers that are metastatic (have spread to other parts of the body). It received its first
approval in 2004 for combination use with standard chemotherapy for metastatic colon
cancer and non-small cell lung cancer. In 2008, it was approved by the FDA for use in
metastatic breast cancer, a decision that generated some controversy as it went against the
recommendation of its advisory panel, who objected because it only slowed tumor growth
but failed to extend survival.
Clinical studies are underway in non-metastatic breast cancer, renal cell carcinoma,
glioblastomamultiforme, ovarian cancer, castrate-resistant (formally called hormone
refractory) prostate cancer, non-metastatic unresectable liver cancer and metastatic or
unresectable locally advanced pancreatic cancer. A study released in April 2009 found that
bevacizumab is not effective at preventing recurrences of non-metastatic colon cancer
following surgery. In May 2009, it received FDA approval for treatment of recurring
glioblastomamultiforme, while treatment for initial growth is still in phase III clinical trial.

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Indications of Avastin
Colorectal cancer
Bevacizumab was approved by the FDA in February 2004 for use in metastatic colorectal
cancer when used with standard chemotherapy treatment (as first-line treatment) and with
5-fluorouracil-based therapy for second-line metastatic colorectal cancer. This
recommendation was based on the E3200 trial — addition of bevacizumab to oxaliplatin/5-
FU/leucovorin (FOLFOX4) therapy.
In adjuvant colon cancer, data from two large randomized studies have shown no significant
benefit and a potential to cause harm in this setting.
It was approved by the EMEA in January 2005 for use in colorectal cancer.
Lung cancer
In 2006, the FDA approved bevacizumab for use in first-line advanced nonsquamous non-
small cell lung cancer in combination with carboplatin/paclitaxel chemotherapy. The
approval was based on the pivotal study E4599 (conducted by the Eastern Cooperative
Oncology Group), which demonstrated a 2-month improvement in overall survival in
patients treated with bevacizumab (Sandler, et al. NEJM 2004). A preplanned analysis of
histology in E4599 demonstrated a 4-month median survival benefit with bevacizumab for
patients with adenocarcinoma (Sandler, et al. JTO 2010); adenocarcinoma represents
approximately 85% of all non-squamous cell carcinomas of the lung.
A subsequent European clinical trial, AVAiL, was first reported in 2009 and confirmed the
significant improvement in progression-free survival shown in E4599 (Reck, et al. Ann.
Oncol. 2010). An overall survival benefit was not demonstrated in patients treated with
bevacizumab; however, this may be due to the more limited use of bevacizumab as
maintenance treatment in AVAiL versus E4599 (this differential effect is also apparent in
the European vs US trials of bevacizumab in colorectal cancer: Tyagi and Grothey, Clin
Colorectal Cancer, 2006). As an anti-angiogenic agent, there is no mechanistic rationale for
stopping bevacizumab before disease progression. Stated another way, the survival benefits
achieved with bevacizumab can only be expected when used in accordance with the clinical
evidence: continued until disease progression or treatment-limiting side effects.
Another large European-based clinical trial with bevacizumab in lung cancer, AVAPERL, was
reported in October 2011 (Barlesi, et al. ECCM 2011). First-line patients were treated with
bevacizumab plus cisplatin/pemetrexed for four cycles, and then randomized to receive
maintenance treatment with either bevacizumab/pemetrexed or bevacizumab alone until

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disease progression. Maintenance treatment with bevacizumab/pemetrexed demonstrated
a 50% reduction in risk of progression vs bevacizumab alone (median PFS: 10.2 vs 6.6
months, HR 0.50, p<0.001).
The National Comprehensive Cancer Network recommends bevacizumab as standard first-
line treatment in combination with any platinum-based chemotherapy, followed by
maintenance bevacizumab until disease progression. Bevacizumab is given as an
intravenous infusion every three weeks at the dose of either 15 mg/kg or 7.5 mg/kg. The
higher dose is usually given with carboplatin-based chemotherapy, whereas the lower dose
is usually given with cisplatin-based chemotherapy.
Breast cancer
In December 2010, the FDA removed the breast cancer indication from bevacizumab, saying
that it had not been shown to be safe and effective in breast cancer patients. The combined
data from four different clinical trials showed that bevacizumab neither prolonged overall
survival nor slowed disease progression sufficiently to outweigh the risk it presents to
patients. This only prevented Genentech from marketing bevacizumab for breast cancer.
Doctors are free to prescribe bevacizumab off label, although insurance companies are less
likely to approve off-label treatments. In June 2011, an FDA panel unanimously rejected an
appeal by Roche. A panel of cancer experts ruled for a second time that Avastin, the best-
selling cancer drug in the world, should no longer be used in breast cancer patients, clearing
the way for the U.S. government to remove its endorsement from the drug. The June 2011
meeting of the FDA's oncologic drug advisory committee was the last step in an appeal by
the drug's maker. The committee concluded that breast cancer clinical studies of patients
taking Avastin have shown no advantage in survival rates, no improvement in quality of life,
and significant side effects. Patient support groups were disappointed by the committee's
decision.
Avastin will still remain on the market as an approved treatment for certain types of colon,
lung, kidney and brain cancer (glioblastomamultiforme).
Renal cancers
In certain renal (kidney) cancers, Bevacizumab improves the progression free survival time
but not survival time. In 2009, the FDA approved bevacizumab for use in metastatic renal
cell cancer (a form of kidney cancer).following earlier reports of activity EU approval was
granted in 2007.
Brain cancers

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The FDA granted accelerated approval of Avastin for the treatment of recurrent
glioblastomamultiforme in May 2009. Treatment for initial growth is still in phase III clinical
trial.
In the September 2009 issue of the Journal of Clinical Oncology, UCLA researchers reported
that Avastin improves response and survival in patients with recurrent glioblastoma in
comparison to historical controls. That study also found that it may be useful in the
treatment of radiation necrosis, since it reduces edema and mass effect and diminishes
blood-brain-barrier leakage.
In a Phase I clinical trial conducted in 2009–2010, John A. Boockvar's team at Weill Cornell
Medical College administered bevacizumab intra-arterially directly into the brain tumors of
fourteen patients with recurrent glioblastomamultiforme. Results were sufficiently
encouraging to propose a Phase II trial of the technique. Preliminary data of a large
multicenter trial reported at the ASCO meeting 2013 suggest that patients with newly
diagnosed glioblastoma do not benefit from the addition of bevacizumab to chemoradiation
therapy.
Investigational uses
Bevacizumab did not meet its primary endpoint of extending overall survival (OS) in a
recent phase III trial in unresectable gastric cancer (in combination with paclitaxel / Taxol),
but it did demonstrate a positive result in treatment of ovarian cancer.
A study released in April 2009 found that bevacizumab is not effective at preventing
recurrences of non-metastatic colon cancer following surgery.
Bevacizumab has demonstrated activity in ovarian cancer,and glioblastomamultiform, a
type of brain tumour, when used as a single agent.
In 2010 two phase III trials showed a 27% and 54% increase in progression-free survival in
ovarian cancer.
Bevacizumab has been investigated as a possible treatment of pancreatic cancer, as an
addition to chemotherapy, but studies have shown no improvement in survival. It may also
cause higher rates of high blood pressure, bleeding in the stomach and intestine, and
intestinal perforations.
The drug is also undergoing initial trials as an addition to established chemotherapy
protocols and surgery in the treatment of pediatric osteosarcoma and other sarcomas, such
as leiomyosarcoma.
Uses in eye disease

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Many diseases of the eye, such as age-related macular degeneration (AMD) and diabetic
retinopathy, damage the retina and cause blindness when blood vessels around the retina
grow abnormally and leak fluid, causing the layers of the retina to separate. This abnormal
growth is caused by VEGF, so bevacizumab has been successfully used to inhibit VEGF and
slow this growth.
Bevacizumab has recently been used by ophthalmologists in an off-label use as an
intravitreal agent in the treatment of proliferative (neovascular) eye diseases, particularly
for choroidal neovascular membrane (CNV) in AMD. Although not currently approved by
the FDA for such use, the injection of 1.25-2.5 mg of bevacizumab into the vitreous cavity
has been performed without significant intraocular toxicity. Many retina specialists have
noted impressive results in the setting of CNV, proliferative diabetic retinopathy,
neovascular glaucoma, diabetic macular edema, retinopathy of prematurity and macular
edema secondary to retinal vein occlusions.
When bevacizumab is used in the treatment of macular degeneration, only tiny and
relatively inexpensive doses (compared to amounts used in colon and other cancers) are
required. Some investigators believe that bevacizumab at a cost of around $42 a dose is as
effective as ranibizumab at a cost of over $1,593 a dose.
The primary pharmacokinetic difference between intraocular Bevacizumab and
Ranibizumab is the very large difference in systemic half-lives, i.e. 2 hours for Ranibizumab
versus 20 days for Bevacizumab. Since Bevacizumab was designed as a cancer treatment,
the long systemic half-life is considered to be a positive feature (allowing greater exposure
time of the tumor to the drug), while the same long half-life is a negative feature in
intraocular treatment, since it has no benefit outside of the eye and may in fact be
detrimental. Although the systemic exposure with both drugs is very low, Ranibizumab has
a much lower average systemic exposure (area under the curve), so it may be conjectured to
have a commensurately lesser chance of systemic adverse events.
The National Eye Institute (NEI) of the National Institutes of Health (NIH) announced in
October 2006 that it would fund a comparative study trial of ranibizumab (Lucentis) and
bevacizumab (Avastin) to assess the relative safety and effectiveness in treating AMD.This
study, called the Comparison of Age-Related Macular Degeneration Treatment Trials (CATT
Study), enrolled about 1,200 patients with newly diagnosed wet AMD, randomly assigning
the patients to one of four treatment groups. The CATT Study was conducted at 47 clinical
sites throughout the United States, following the patients for 2 years. Initial results of the
study showing essentially similar outcomes using either drug at one year were formally
published after peer review in the New England Journal of Medicine on May 19, 2011.
Similar results in this cohort were maintained at two years, with bevacizumab showing non-

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inferiority to ranibizumab, although a statistically non-significant trend to improved visual
outcomes from injections given monthly rather than as required was noted with both drugs.
Rituximab
Brand names:Rituxan and MabThera
Rituximab is a chimeric monoclonal antibody against the protein CD20, which is primarily
found on the surface of immune system B cells. Rituximab destroys B cells and is therefore
used to treat diseases which are characterized by excessive numbers of B cells, overactive B
cells, or dysfunctional B cells. This includes many lymphomas, leukemia’s, transplant
rejection, and autoimmune disorders.
Mechanism of Action
Rituximab binds specifically to the antigen CD20 (human B-lymphocyte-restricted
differentiation antigen, Bp35), a hydrophobic transmembrane protein with a molecular
weight of approximately 35 kD located on pre-B and mature B lymphocytes. The antigen is
expressed on > 90% of B-cell non-Hodgkin's lymphomas (NHL), but the antigen is not found
on hematopoietic stem cells, pro-B-cells, normal plasma cells or other normal tissues. CD20
regulates an early step(s) in the activation process for cell cycle initiation and
differentiation, and possibly functions as a calcium ion channel. CD20 is not shed from the
cell surface and does not internalize upon antibody binding. Free CD20 antigen is not found
in the circulation.
B cells are believed to play a role in the pathogenesis of rheumatoid arthritis (RA) and
associated chronic synovitis. In this setting, B cells may be acting at multiple sites in the
autoimmune/inflammatory process, including through production of rheumatoid factor
(RF) and other autoantibodies, antigen presentation, T-cell activation, and/or
proinflammatory cytokine production.
Mechanism of Action: The Fab domain of rituximab binds to the CD20 antigen on B
lymphocytes, and the Fc domain recruits immune effector functions to mediate B-cell lysis
in vitro. Possible mechanisms of cell lysis include complement-dependent cytotoxicity

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(CDC) and antibody-dependent cell mediated cytotoxicity (ADCC). The antibody has been
shown to induce apoptosis in the DHL-4 human B-cell lymphoma line.
Normal Tissue Cross-reactivity: Rituximab binding was observed on lymphoid cells in the
thymus, the white pulp of the spleen, and a majority of B lymphocytes in peripheral blood
and lymph nodes. Little or no binding was observed in the non-lymphoid tissues examined.
Indication of Rituximab rheumatoid arthritis treatment
This study characterized the relationship between clinical response, serum rituximab
concentrations, and peripheral B-cell levels in patients with rheumatoid arthritis treated
with rituximab. Data were analyzed from a double-blind, phase IIa trial in which 161
patients with active rheumatoid arthritis despite continuing methotrexate were randomized
to methotrexate alone (10-25 mg/wk), rituximab alone (single course: 1000 mg
administered intravenously on days 1 and 15), rituximab plus cyclophosphamide (750 mg
administered intravenously on days 3 and 17), or rituximab plus methotrexate. Serum
samples for pharmacokinetic analysis were collected through 24 weeks, and peripheral
circulating CD19+ B-cell levels were measured through 48 weeks. All treatments were
generally well tolerated, with no clinically relevant excess of adverse events leading to
withdrawal among patients who received rituximab compared with those who received
methotrexate alone. The proportions of patients who achieved an American College of
Rheumatology score of 50 at week 24 were 13% (methotrexate alone), 33% (rituximab
alone), 41% (rituximab plus cyclophosphamide), and 43% (rituximab plus methotrexate).
Peripheral B-cell depletion occurred by day 15 in all patients treated with rituximab. There
was no relationship between B-cell depletion and clinical response. Recovery of peripheral
B cells was variable and showed no relationship with return of disease activity in patients
who responded to rituximab. The mean terminal half-life of rituximab was 19 to 22 days;
pharmacokinetic parameters were similar whether rituximab was administered alone or
with methotrexate or cyclophosphamide. Because the level of peripherally circulating B
cells does not appear to correlate with a maintained clinical response in patients with
rheumatoid arthritis, the timing of rituximab retreatment should be based on clinical
symptoms rather than peripheral B-cell levels.

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Abciximab
Brand Name :ReoPro
Abciximab is a type of "blood thinner" used to prevent blood clots during certain
procedures used to open up the blood vessels in the heart (e.g., balloon angioplasty,
coronary stent placement, percutaneous coronary intervention-PCI). It is usually used with
heparin and aspirin.Abciximab works by preventing platelets in the blood from sticking to
each other. When platelets stick to each other, they may form blood clots that may cause a
heart attack or cause the opened blood vessel in the heart to close back up.
Indications for use
Abciximab is indicated for use in individuals undergoing percutaneous coronary
intervention (angioplasty with or without stent placement). The use of abciximab in this
setting is associated with a decreased incidence of ischemic complications due to the
procedure and a decreased need for repeated coronary artery revascularization in the first
month following the procedure.[4] Research also shows that this drug can be of use for
patients with diabetes and chronic renal insufficiency. It is not the appropriate drug of
choice if a patient is scheduled for an emergency surgery (i.e., heart surgery) because
bleeding time may take about 12 hours to normalize.
Pharmacokinetics
Abciximab has a plasma half-life of about ten minutes, with a second phase half-life of about
30 minutes. However, its effects on platelet function can be seen for up to 48 hours after the
infusion has been terminated, and low levels of glycoprotein IIb/IIIa receptor blockade are
present for up to 15 days after the infusion is terminated. Abciximab does not require renal
dose adjustment.

21 | P a g e
Palivizumab
Brand names: Synagis®
Palivizumab is a monoclonal antibody produced by recombinant DNA technology. It is used
in the prevention of respiratory syncytial virus (RSV) infections. It is recommended for
infants that are high-risk because of prematurity or other medical problems such as
congenital heart disease.
Palivizumab is a humanized monoclonal antibody (IgG) directed against an epitope in the A
antigenic site of the F protein of RSV. In two Phase III clinical trials in the pediatric
population, palivizumab reduced the risk of hospitalization due to RSV infection by 55% and
45%. Palivizumab is dosed once a month via intramuscular (IM) injection, to be
administered throughout the duration of the RSV season.
Palivizumab targets the fusion protein of RSV, inhibiting its entry into the cell and thereby
preventing infection.
Uses of Palivizumab
Palivizumab is used in certain infants and young children to prevent infections of the breathing
tubes and lungs that are caused by a certain virus (respiratory syncytial virus-RSV). It is known as
a monoclonal antibody, and it works by preventing the growth of RSV. This medication is not
used to treat RSV infection
Side effects of monoclonal antibodies
Monoclonal antibodies are given intravenously (injected into a vein). Compared with the
side effects of chemotherapy, the side effects of naked mAbs are usually fairly mild and are
often more like an allergic reaction. These are more common while the drug is first being
given. Possible side effects can include:Anaphylaxis
anaphylactic reactions
Malignancy
Serious infections
Abnormal liver function,
Fever
Chills
Weakness
Headache
Nausea
Vomiting
Diarrhea
Low blood pressure
Rashes
Hypersensitivity
neutropaenia and lipid deregulation

22 | P a g e
Some mAbs can also have other side effects that are related to the antigens they target. For
example, bevacizumab (Avastin®), an mAb that targets tumor blood vessel growth, can
cause side effects such as high blood pressure, bleeding, poor wound healing, blood clots,
and kidney damage.
Side effectsof licensed monoclonal antibodies
The safety and side effects of monoclonal antibodies
Target mAb Type FDA
approv
al
Indications* Selected side effects
Platelet
glycopr
otein
IIb/IIIa
Abciximab
(ReoPro;
Centocor Ortho
Biotech,EliLilly)
Chimeric
antibody
fragment:
c7E3 Fab
1994 Prevention of
ischaemic cardiac
complications of
percutaneous
coronary
interventions and
unstable angina
• Hypersensitivity and
immunogenicity
• Increased risk of bleeding
•Thrombocytopaenia
Tumour
necrosis
factor-α
Adalimumab
(Humira;
Abbott)
Fully
human
2002 •Rheumatoid
arthritis
• Ankylosing
spondylitis
• Psoriasis
• Psoriatic
arthritis
• Crohn's disease
• Ulcerative
colitis
• Infusion reactions and
immunogenicity
• Hypersensitivity reactions
•Immunosuppression and
infections (tuberculosis)
• Anaemia, leukopaenia and
thrombocytopenia
• Worsening heart failure
• Malignancy, lymphoma
and lymph proliferative
disorders
• Increased nuclear-specific
antibodies
Certolizumab
(Cimzia; UCB)
Humanized
pegylated
2008
Infliximab
(Remicade;
Centocor Ortho
Biotech)
Chimeric 1998
CD52 on
mature
B, T and
natural
killer
cells
Alemtuzumab
(Campath;
Genzyme)
Humanized 2001 • B cell chronic
lymphocytic
leukaemia
• Graft-versus-
host disease
• Multiple
myeloma
• Multiple
sclerosis
• Vasculitis
• Behçet's disease
• Infusion reactions
immunogenicity
• CRS
• Tumourlysis syndrome
• Immunosuppression and
opportunistic infections
• Cytopaenias:
pancytopaenia,
lymphopaenia and
thrombocytopaenia
• Autoimmune
haemolyticanaemia
• Thyroid disorders

23 | P a g e
• Cardiotoxicity
Interleu
kin-2
receptor
-α on
activate
d
lympho
cytes
Basiliximab
(Simulect;
Novartis)
Chimeric 1998 • Prophylaxis of
renal transplant
allograft rejection
• Severe acute
hypersensitivity reactions
• CRS and immunogenicity
infections
• Local skin reactions
• Warnings when combined
with other
immunosuppressives
Daclizumab
(Zenapax;
Roche)
Humanized 1997
Disconti
nued in
Europe
Vascula
r
endothe
lial
growth
factor
Bevacizumab
(Avastin;
Genentech)
Humanized 2004 • Metastatic
colorectal cancer
• Non-small-cell
lung carcinoma
• Metastatic
breast carcinoma
• Metastatic renal
carcinoma
• Infusion reactions and
immunogenicity
• Local complications at
tumour site
• Arterial and venous
thromboembolicevents
• Haemorrhage
• Severe hypertension
• Cardiac failure
• Reversible posterior
leukoencephalopathy
syndrome
• Slower wound healing and
GI perforation
Ranibizumab
(Lucentis;
Genentech,
Novartis)
Humanized
(Fab
fragment
from
bevacizuma
b)
2006 • Injected
intravitreally for
neovascular
(wet) age-related
macular
degeneration
• Conjunctivalhaemorrhage
• Intraocular inflammation
• Increased intraocular
pressure
• Retinal detachment
• Endophthalmitis
Comple
ment C5
Eculizumab
(Soliris;
Alexion)
Humanized 2007 • Paroxysmal
nocturnal
haemoglobinuria
• Meningococcal
andNeisseria infection
• Intravascular haemolysis
CD11a Efalizumab
(Raptiva;
Genentech)
Humanized 2003
Recentl
y
disconti
nued
• No longer
licensed for
chronic plaque
psoriasis
• First-dose reaction
complex
• Immunosuppression
• Serious opportunistic
infections
• PML
• Guillain–Barré syndrome,
encephalitis, meningitis
• Immune
haemolyticanaemia
• Immune
thrombocytopaenia
CD3
antigen
on T
Muromonab-
CD3
(OrthocloneOK
Mouse 1986
(no
Europe
• Acute resistant
allograft rejection
in renal, cardiac
• Severe acute infusion
reactions

24 | P a g e
cells T3; Ortho
Biotech)
an
Medicin
es
Authori
ty
authori
zation)
and hepatic
transplant
patients
infections
• Immunogenicity
• Cardiovascular side
effects
• Hepatitis
α4
integrin
Natalizumab
(Tysabri;
Biogen-Idec,
Elan
Pharmaceutical
s)
Humanized 2004 • Highly active
relapsing-
remitting
multiple sclerosis
• Infusion and
hypersensitivity reactions
• Immunogenicity
• PML (0.1%) with
immunosuppressives
• Hepatotoxicity
Immuno
globulin
E (IgE)
Omalizumab
(Xolair;
Genentech,
Novartis)
Humanized 2003 • Severe allergic
asthma
unresponsive to
conventional
therapy and with
acute
exacerbations
• Anaphylaxis (0.1%)
• Injection site reactions
• Immunogenicity
• URTI
• Churg–Strauss syndrome
(rare)
Fusion
protein
on RSV
Palivizumab
(Synagis;
Medimmune)
Humanized 1998 • Prevention of
RSV
complications in
high-risk infants
• Anaphylaxis and apnoea
(rare)
• Fever, injection site
reactions
CD20 on
B cells
Rituximab
(Rituxan/Mabth
era; Genentech,
Biogen Idec)
Chimeric 1997 • Follicular non-
Hodgkin's
lymphoma
• CD20+ diffuse
large B cell non-
Hodgkin's
lymphoma
• Autoimmune
haematological
disorders
• Prominent acute infusion
reactions
• CRS
• Tumourlysis syndrome
• Transient hypotension
• Immunogenicity
• Serum sickness
• Severe mucocutaneous
reactions
• Immunosuppression
• Hepatitis B reactivation
with fulminant hepatitis
• PML
• Renal toxicity
• Cardiac arrhythmias
EGFR Panitumumab
(Vectibix;
Amgen)
Fully
human
2006 • Monotherapy
for EGFR-positive
metastatic
colorectal
carcinoma with
non-mutated
(wild-
type) KRAS after
failure of
• Infusion reactions
• Skin rashes in most
patients (90%)
• Diarrhoea (60%), nausea
and vomiting
• Hypomagnesaemia (2%)

25 | P a g e
conventional
chemotherapy
Cetuximab
(Erbitux;
Bristol–Myers
Squibb, ImClone
Systems, Merck
Serono)
Chimeric 2004 • EGFR-positive
metastatic
colorectal cancer
• Squamous cell
carcinoma of
head and neck
• Severe infusion reactions
• IgE against
oligosaccharide and HAMA
• Urticaria and
dermatological toxicity
• Bronchospasm and
pulmonary toxicity
• Hypomagnesaemia
Trastuzumab
(Herceptin;
Genentech)
Humanized 1998 • ERBB2-positive
breast carcinoma
infusion reactions
• Cardiotoxicity with
anthracyclines
• Skin reactions
• Pulmonary toxicity
• Hypomagnesaemia
Interleu
kin-6
receptor
Tocilizumab
(Actemra;
Roche, Chugai)
Humanized 2009 • Unresponsive
active
rheumatoid
arthritis
• Castleman's
disease
• Anaphylaxis and
anaphylactoid reactions
• UTRI
• Headache
• Serious infections
• Abnormal liver function,
neutropaenia and lipid
deregulation
CRS, cytokine release syndrome; EGFR, epidermal growth factor receptor; ERBB2, also known as
HER2/neu; FDA, Food and Drug Administration; GI, gastrointestinal; HAMA, human anti-mouse
antibodies; KRAS, v-Ki-ras2 Kirsten rat sarcoma viral oncogene homologue; PML, progressive
multifocal leukoencephalopathy; RSV, respiratory syncytial virus; URTI, upper respiratory tract
infection.*Some of these indications are not currently licensed.

26 | P a g e
References
Carter P: Improving the efficacy of antibody-based cancer therapies. Nat Rev Cancer
2001;1:118-129
Dale L Ludwig, et. al. Oncogene(2003) 22, 9097-9106
Jancie, M Recheit, etal. Nature biotechnology, 2005, Sep,Vol. 23, No.9Stamatis-Nick C. J
Allergy Clin. Immunol, Oct. 2005
Schwaber, J; Cohen, EP (1973). "Human x mouse somatic cell hybrid clone secreting
immunoglobulins of both parental types". Nature244 (5416): 444–7.
doi:10.1038/244444a0. PMID 4200460. edit
Köhler, G.; Milstein, C. (1975). "Continuous cultures of fused cells secreting antibody of
predefined specificity". Nature256 (5517): 495. doi:10.1038/256495a0. PMID 1172191. edit

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