Adobe Systems Biological treatment - principles, technology, examples MUDr. Alena Máchalová, Ph.D., Department of Pharmacology Tato prezentace je autorským dílem vytvořeným zaměstnanci Masarykovy univerzity. Studenti předmětu ZLFA0722p mají právo pořídit si kopii prezentace pro potřeby vlastního studia Adobe Systems Biological drug ̶„Biodrugs, biologics, targeted treatment “ - recombinant proteins, peptides, antibodies, hormones substances derived from blood / plasma and recombination variants ̶„Biologicals, Biopharmacy, Biopharmaceuticals“ - recombinant proteins, peptides, antibodies, hormones + Stem cells, xenotransplantation, gene and antisense therapy [USEMAP] Adobe Systems Targeted effects of biologicals A specific effect of biologics is targeted - a specific target structure, antigen, enzyme, signal path (e.g. tumor cells). Biologics are able to identify the damaged cells for destruction by the immune system. Can prevent the growth and proliferation of cells that cause disease. Can deliver drug directly to the target which increases the effectiveness of treatment. Adobe Systems Traditional/Classical vs. Biological drug Large, complex molecules, commonly proteins> 50 kDa, similar or identical to endogenous Manufactured using living organisms / cells - risk contamination - own "inherited„ activity Complex heterogeneous structure matrix from which was drug isolated More difficult to characterize (3D conformation) Mechanism of action is complex, sometimes not fully understood, targeted action Usually immunogenic Mostly without interaction at P450 Small molecule <1kDa, different from endogenous substances Produced by chemical synthesis / isolation from plants Less critical steps in the synthesis, easier handling and formulation Very well characterized Molecular mechanism of action usually better described, linear dose-response relationship, affects the whole body Mostly non-immunogenic Usually with pharmacokinetic interactions at P450 [USEMAP] Adobe Systems Research and development of Biological drugs The development of biologics is 10 - 15 years, costs 1.5 billion USD Biologics are produced by the genetically modified host cells (bacterial, yeast, mammalian and plant) into which was inserted the genetic information stored in DNA. The first drug produced by biotechnological procedure was insulin (in 1978, registering 1982). The discovery of biotechnological production of pharmaceuticals, respectively monoclonal antibodies, was in 1984 awarded the Nobel Prize. [USEMAP] • 1972 - obtained recombinant deoxyribonucleic acid (rDNA) • 1975 - first monoclonal antibody (MAb). • This was followed by the establishment of the first biotech pharmaceutical companies. USA - Genentech Europe - Biotech • 1982 - The first biotech product was - recombinant insulin (Genentech, marketed by Eli Lilly) • 1986 monoclonal antibody OKT3 (OrthoCloneR) recombination. IFN Adobe Systems Examples of Biological drugs 1) Imunomodulating biologics MAb (Infliximab) and fusion proteins (etanercept), IFN 2) Hormones – insulin, GH 3) Vaccines – e.g. HVB, HPV 4) Growth factors – erytropoetin, trombopoetin, CSF 5) Enzymes for the treatment of hereditary diseases (monogenic) (e.g. Imiglucerase for the treatment of Gaucher disease) 6) Biologics influencing homeostasis- f. VII, F VIII, F IX, other inh. Of coaglation or activators of fibrinolysis 7) Gene therapy (e.g.. Alipogen tiparvovek – LPL gene) [USEMAP] Adobe Systems Advantages for the patients •better efficiency vs. "Classical" drugs • •biologicals are used under the supervision of experts in specialized centers. • •targeted, personalized treatment, which is always personalized • •the patient undergoes a more detailed examination before medication • •better understanding of the basic properties of the drug and its effects • •better solution of possible ADRs, their early detection [USEMAP] Adobe Systems Risks and disadvantages of biological drugs in general ̶carcinogenicity ̶ ̶allergenic potential ̶ ̶contaminants from the source cells ̶ ̶stabilizing additives (cryopreservation stabilizers) ̶ ̶sterility ̶ ̶stability, variability of drugs (biotechnology products) [USEMAP] Adobe Systems Production of biological drugs Historically isolation from natural sources: ̶ ̶insulin from the pancreas of cattle, pigs (recombinant today) ̶ ̶h-choriogonadotropin - from the urine of pregnant women (today recombinant) ̶ ̶hirudin - Medical leeches (H. officinalis) (today synthetic / recombinant) ̶ ̶ ̶ ̶ ̶ ̶ ̶ ̶ ̶ Adobe Systems 3 generation of biologicals 1 ) "copies" of human proteins 2 ) modified proteins (AAs substitution, glycosylation, PEGylation) - better pharmacokinetics, pharmacodynamics - e.g. glargine, PEG-IFN 3 ) de novo designed proteins / MAB The production of biological drugs - recombinant technology Adobe Systems Nomenclature ̶Derived from biochemical name (Pegasys -PEG IFN) ̶The name given by the manufacturer - unrelated to the effect of the origin ̶Hormone with different tradename (Serostim, Saizen, Zorbtive) ̶MAB- system root words and suffixes [USEMAP] Adobe Systems Nomenclature of MAB ̶Generally: suffix -mab ̶ ̶Letter before suffix: ̶o – of mice origin ̶a - rat origin ̶e - hamster origin ̶i - of primates ̶u – of human origin (human cell line production) ̶zu – humanized ̶xi – chimeric ̶mumab – fully human ̶ [USEMAP] Adobe Systems Mouse MAb 100% of the mice orig. Hypersensitivity High levels of Ab (not used clinically) Human MAb 100% human Hypersensitivity Low levels of Neutralizing Antibodies (panitumumab adalimumab) Humanized 5-10% mice orig. MAb Hypersensitivity Low levels of Neutralizing Antibodies (Trastuzumab Certolizumab) Chimeric MAb 34% of mice orig. Hypersensitivity Low levels of circulating Ab (rituximab infliximab) [USEMAP] Adobe Systems Nomenclature of MAB ̶ Sometimes encoding indication ̶lim - immune ̶bac - bacterial ̶cir- cardiovascular ̶tu - malignity ̶ E.g. rituximab - chimeric MAB to treat Non-Hodgkin. lymphomas alemtuzumab - humanized antibody to the CD52 glycoprotein CLL ̶ ̶ ̶ ̶ ̶ ̶ ̶ ̶ [USEMAP] Adobe Systems The production of biological drugs - recombinant technology ̶DNA extraction ̶product / synthesis according to library ̶transformation / DNA transfection into producer cells ̶production ̶purification ̶stabilization ̶testing (biological activity - CT I-III) ̶registration ( RCT + IV ) [USEMAP] Adobe Systems The production of biological drugs - recombinant technology ̶DNA extraction ̶product / synthesis according to library ̶transformation / DNA transfection into producer cells ̶production ̶purification ̶stabilization ̶testing (biological activity - CT I-III) ̶registration ( RCT + IV ) [USEMAP] Adobe Systems Contaminants from manufacture process ̶Microorganisms - antigenic structures, pyrogenicity , sepsis ̶Viruses ̶DNA - ? Consequences? ̶Custom product in improper 3D structure ̶Contaminating proteins ̶antigenicity ̶stability (protease ) ̶safety (growth factors, hormones, toxins) ̶ ̶ Purification - affinity gel / permeation chromatography Adobe Systems Contaminants from manufacture process ̶ Purification - affinity gel / permeation chromatography Purity ± 98-99 % Verification of the biological activity of each batch ! - Biochemical methods , cell lines or animal ( e.g. Epoetin ) = Time-consuming , cost , accuracy Adobe Systems ̶Microorganisms - bacteria - optimized E. coli strains (mutations of periplasmatic and membrane protease) - yeast - S. cerevisiae ̶ ̶Tissue cultures of higher organisms ̶ ̶Cell-free expression systems ̶ ̶Genetically modified animals, plants The production of biological drugs - recombinant technology [USEMAP] Adobe Systems E. Coli - The synthesis of proteins without posttranslational modifications - Cheap medium, mutated forms of E. coli with advantageous properties - increase the stability of the gene product ... - Modification of wall, transformation of plasmid (DNA product introduction) - thermal shock, electroporation -Selection - resistance to antibiotics / cell culture media - -Renaturation - E.g. IFN , GSM, insulin, growth hormone ... The production of biological drugs - recombinant technology [USEMAP] Adobe Systems S. Cerevisieae - synthesis of proteins with posttranslational modifications, possibility of hybridization -easy, economical cultivation, generation time of 2h, mutants with advantageous properties - increased stability of the gene product - - modification of cell wall, transformation of plasmid (various vectors) - selection - auxotrophic strains (disabled biosynthetic pathway for AA, NA); plasmid introduce this gene – only transformed yeast are viable in selection media (ATB) - renaturation - E.g. insulin, growth hormone ... The production of biological drugs - recombinant technology [USEMAP] Adobe Systems Tissue cultures of higher organisms - About 60% of recombinant proteins positives: same way of modifications as in humans a wide variety of products eliminates ethical / technical problems (isolation, animal cells, the lack of material) negatives: higher risk of contamination (rich medium, slower growth, expensive, difficult cultivation) The production of biological drugs - recombinant technology [USEMAP] Adobe Systems Tissue cultures of higher organisms Primary cultures (subculturing or passaging not possible)/ cell lines (tumor) mostly adherent cell lines - release trypsin Medium: ions , glucose, vitamins, nucleotides , lipids, calf serum (source of growth factors, hormones + PDGF, EGF, FGF, ... ) pH control, morphology Vectors (details are kept secret): plasmids , viral plasmids (retroviruses), polycations Part of the transfected DNA are regions of DNA increasing production Selection (principles similar to those of S. cerevisiae . ) The production of biological drugs - recombinant technology [USEMAP] epidermal growth factor (EGF), platelet-derived growth factor (PDGF) and fibroblast growth factor (FGF) DEAE diethylaminoethyl Adobe Systems Tissue cultures of higher organisms CHO – chinese hamster ovary NS0, Sp2/0-Ag14 – mouse plasmocytome cells (leukocytes) – auxotrophic for L-glutamine BHK 21 (baby hamster kidney – syrian hamster) The production of biological drugs - recombinant technology [USEMAP] Adobe Systems Sobotková M, Bartůňková J. Remedia 2008, 18 (5), 356-364 Participant:0 Voted:0 Tissue cultures of higher organisms production of „hybridomes“ [USEMAP] Nejprve je indukována imunitní odpověď na specifický antigen u experimentálního zvířete. Z jeho sleziny (nebo jiné lymfatické tkáně) je získána směs lymfocytů, z nichž některé tvoří protilátky specifické proti podanému antigenu. Tyto lymfocyty jsou v roztoku propylenglykolu smíchány s myelomovými buňkami. Takové myeolomové buňky postrádají enzym nutný pro metabolismus purinů (hypoxantin-guanin-fosforibosyl transferáza). Vlivem propylenglykolu dojde k fúzi obou typů buněk. Kromě těchto hybridů budou v médiu i nefúzované lymfocyty a myelomové buňky. Nefúzované lymfocyty rostou velmi pomalu nebo nerostou vůbec, a tak se postupně samy eliminují. Jestliže kulturu buněk přeneseme do média obsahujícího hypoxantin, aminopterin a thymidin (HAT médium), zahynou i nefúzované myelomové buňky, protože postrádají enzym nutný pro metabolizaci těchto látek. Proliferovat tak budou jen buňky hybridomové. Ty však kromě požadované monoklonální protilátky produkují i směs jiných protilátek. Dalším selektováním a klonováním pak postupně získáme buněčnou kulturu, která produkuje požadovanou monoklonální protilátku; podle [34] – Goetz, et al., 1995. Adobe Systems ANd9GcR947Nrim36PXxrUyzzeuOzltQ0Mf7Na6QR2Y9FpkMi3Rnt6q1U Transgenic plants „Edible vaccines " - production of the immunogenic protein (like the polio vaccine ) culturing plant tissue culture in agar Agrobacterium transfection (+ recombinant plasmid) selection, planting tobacco (Nicotiana tabacum ), Arabidopsis thaliana PRX - 112 - 06/2014 - 1st patient treated with recombinant protein from the plant ( Protalix Biotherapeutics ) Gaucher disease - deficit of glucocerebrosidase „…active recombinant proteins systemically through oral administration of plant cells expressing biotherapeutic proteins...“ The production of biological drugs - recombinant technology PRX-106 is the Company's orally administered, plant cell-expressed recombinant anti-TNF fusion protein that successfully concluded Phase I clinical trial. In preclinical studies, PRX-106 alleviated immune-mediated hepatitis and reduced interferon gamma levels in a concanavalin A (ConA) inflammatory mouse model. Furthermore, the drug was shown to alleviate liver damage and reducing liver necrosis and reduction of liver enzymes, ALT and AST, thus leading to an improvement in liver biopsies. Adobe Systems The risk of functional damage of biologicals ̶denaturation ̶precipitation ̶deamination ̶mismatch of SH groups ( = incorrect 3D ) ̶oligomerization, aggregation, covalent binding ̶hydrolysis ̶isomerization ̶racemisation ̶formation imides ̶oxidation ̶ Multiple stabilizers cryopreservation metal chelation checking the pH, osmolarity , strengthening the hydrophobic bonds Adobe Systems Costs of the treatment ̶Biological therapy is more expensive than "traditional" drugs ̶ ̶Reasons - significantly higher development costs - Demanding and complex testing - The nature of products and higher costs after launch - Higher costs for production, storage, transportation, shorter expiration consequences: lower numbers of treated patients (up to 2 orders !!! ) Despite that: - effective and in many cases can save money in terms of direct and indirect costs direct costs: shorter hospitalization, reducing the number of surgical procedures, reduce the cost of follow-up treatment , ... indirect costs : accelerating the patient's self-sufficiency, reducing the costs of absenteeism, cost reductions in social support and care allowances , reducing the cost of informal care and nursing [USEMAP] Adobe Systems BIOSIMILARS [USEMAP] Adobe Systems BIOSIMILARS " Copy" of biotechnology drugs • produced after the expiry of patent protection on the original biotechnology drugs • In the US, for the same group uses the term „Follow –on Biologics“ , abbreviated „fobs“ The standard procedure for the registration of generic medicines with defined structure (ie . bioequivalence study) is inapplicable Adobe Systems •Biosimilars drugs are similar, but not identical with the original biological drug. • •Biosimilars are not automatically therapeutically interchangeable with the original biological drug . • •small change process in biosimilars may cause an entirely different drug. • •Biosimilars pass before entering the market or shorter simplified clinical trials , but disproportionately more complex than with generics BIOSIMILARS [USEMAP] Adobe Systems Biological drugs in a broader context 1. Gene therapy 2. Anti-sense therapy 3. Immunization with vaccines Adobe Systems Biological drugs in a broader context 1. Gene therapy ̶incorporation of a gene sequence into a target tissue by an appropriate vector ̶treating or preventing gene-related illnesses by changing the expression human genes AE, risks: ̶Adverse immune response ̶Infections vector - natural activation of virus ̶Genetic influence on gametes ̶Risk of malignity- activation of protooncogenes , suppression of regulatory genes [USEMAP] Adobe Systems Biological drugs in a broader context 2. Anti-sense therapy ̶Incorporation of complementary oligonucleotides to the initiation codon / promoter to DNA ̶block the effects of action of proteins that are not transcribed ̶ ̶Olimersen - lowering expression of Bcl -2 (overexpressed in many cancer) - withdrawn from registration [USEMAP] Adobe Systems The antisense and gene therapy in practice ̶Fomivirsen - antisense sequences to the mRNA of human CMV - Ophthalmic applications for pac . HIV + to reduce CMV infection ̶Pegaptanib - oligonucleotide binding to the VEGF protein - for the treatment of wet AMD ̶Glybera - 3 x 1012 genome copies of human lipoprotein lipase in a viral vector (adeno- associated virus serotype 1 (AAV1 ) to treat hyperlipoproteinemia I [USEMAP] Gencidin spinocelulární karcinom hlavy a krku… Adobe Systems Zápatí prezentace 36 Biological/targeted treatment of selected diseases 1.Oncology 2.Rheumatic diseases 3.Psoriasis 4.Inflammatory bowel disease 5.Asthma 6.Multiple sclerosis 7.Ophtalmology 8.Hyperlipidemia [USEMAP] Adobe Systems Zápatí prezentace 37 Pharmacokinetics of biodrugs -different than in „classic“ drugs (ADME) - -administration parenteral, absorption via lymphatic system, low bioavailability -s.c. administration (not mAb) -i.v. only in specialised centers, higher risk of immune reaction -Tmax - several days! -big molecules – slow and limited distribution, low Vd, binding to carrier proteins, no albumin! - [USEMAP] Adobe Systems Zápatí prezentace 38 Pharmacokinetics of biodrugs -different than in „classic“ drugs (ADME) - -elimination – not liver, mostly katabolism, intensive elimination via neutralising Ab (saturable) - -kidneys – small peptides, active tubular transport - Binding to target influences PK - The higher the dose, the lower Vd The higher the dose, the lower Cl [USEMAP] Adobe Systems Zápatí prezentace 39 Adverse effects in general mAb: 1.Reaction to foreign protein - allergic reaction, anaphylaxis (prevention – premedication, slow administration of the 1st dose) 2. 2.Tumor lysis syndrome – typical for hematological malignities – ion dysbalance (hyperuricaemia, hyperkalaemia, hyperphosphataemia and hypocalcaemia) 3. 3.Effect on healthy cells - rash, diaorrhea, tiredness, neurological symptoms, heart and lungs may be affected [USEMAP] Adobe Systems Zápatí prezentace 40 Adverse effects in general TKI: decreased haematopoiesis, oedemas, fever, nauzea, vomiting, hematomas, rash, hair loss, bain in joints and muscles, changes in perception of taste and vision, dyslipidaemia… In case of toxicity it is usually possible to decerase dosing without loss of clinical effect. [USEMAP] Adobe Systems 1. Biological (targeted) treatment in oncology „target“ may be localised in tumor cells - membrane receptor – extracellular part or/ intracellular signalling pathway - immune system (specific T-cells) - cancer immunotherapy - Immune check-point inhibitors (anti-CTLA-4 or anti-PD(L)1) [USEMAP] checkpoints are designed to protect normal body cells from immune damage during the immune reaction to the pathogens Adobe Systems Target on tumor cells The most common targets ̶EGFR (epidermal growth factor receptor) – trastuzumab, pertuzumab, erlotinib, lapatinib ̶VEGF(vascular endothelial growth factor receptor)- bevacizumab, sunitinib ̶PDGF (platelet derived growth factor receptor) ̶FGF (fibroblast growth factor receptor) ̶SCGF = c-KIT (stem cell growth factor) - imatinib MoA: -antagonization of extracelullar part of receptor or endogenous ligand - monoclonal antibodies (-mabs) - -inhibition of intracellular pathway – proteinkinase inhibitors (-nibs) 1. Biological (targeted) treatment in oncology [USEMAP] Adobe Systems Targeted therapy – „mAbs and –nibs“ Cell membrane Ligand bindingl Receptor´s activation Proliferation Migration Tumor growth and matastases Survival Signal transduction Receptors with TKI activities Tyrosin- Kinases domain (TKI) Monoclonal antibodies Tyrozin-kinases inhibitors B-Raf [USEMAP] Adobe Systems HER-2 - 1985 – identification of the human Her-2/neu gene as a negative prognostic marker I: treatment of HER-2 positive breast cancer or adjuvant therapy of breast Ca AE: allergic reaction, fever, chills, hypotension cardiotoxicity diarrhea, nausea, vomiting, rash muscle and joint pain pulmonary infiltrates, penumonitis Trastuzumab (HERCEPTIN ®) Target on tumor cells [USEMAP] Adobe Systems HER2 HER1-4 Trastuzumab binds to subdomain IV and inhibits downstream signalling Mechanisms of Action Cell membrane Franklin MC, et al. Cancer Cell. 2004;5(4):317-328. Trastuzumab (HERCEPTIN ®) Target on tumor cells [USEMAP] Adobe Systems HER2 HER1-4 Pertuzumab binds to a specific domain II and inhibits ligand-activated dimerization Trastuzumab binds to subdomain IV and inhibits downstream signalling Pertuzumab (PERJETA) Mechanisms of Action The combined regimen of pertuzumab and trastuzumab offers the potential for a more comprehensive HER blockade Cell membrane Franklin MC, et al. Cancer Cell. 2004;5(4):317-328. Target on tumor cells [USEMAP] Adobe Systems MoA: HER1 (EGFR – 1) TKI I: non-small-cell lung carcinoma (NSCLC) pancreatic cancer Erlotinib Target on tumor cells [USEMAP] Adobe Systems Bevacizumab (AVASTIN ®) MoA: mAb against VEGF preventing it from binding to receptors inhibition of angiogenesis and regression of tumor vasculature 1. The growth of malignant tumor needs the continuous supply of oxygen and nutrients. Simple diffusion and not enough nutrition to the cells under the influence of hypoxia. Tumor produced a series mediators, particularly VEGF (vascular endothelial factor). Target on tumor cells [USEMAP] Adobe Systems Bevacizumab (AVASTIN ®) ̶ I: Metastatic colorectal Ca Metastatic breast Ca, renal Ca, non-small-cell lung Ca AE: acceleration of hypertenzion proteinuria trombembolic complications poor wound healing ̶ 1. Target on tumor cells [USEMAP] Adobe Systems MoA: Multikinase inhibitor (anti VEGF, PDGF, c-KIT) I: GIST – gastrointestinal stromal tumor mRCC – renal cell carcinoma pNET – pancreatic neuroendocrine tumors Sunitinib Target on tumor cells [USEMAP] Adobe Systems ̶Bcr-abl inhibitor – CML ̶c-KIT inhibitor – 1st line treatment of GIST (mutation c-KIT in 85% pts.) – 70% of the pts. Are responders!!! AE: -neutropenia, trombocytopenia ̶diarrhoea, vomiting -joint pain Imatinib mesylate (GLIVEC ®) fig_53-01-001 (BCR-ABL Translocation) Target on tumor cells [USEMAP] Adobe Systems Zápatí prezentace 52 Rituximab 1997 - fhe first registered mAB approved by FDA for the treatment of lymphomas MoA: binding to the transmembrane antigen CD20 (on pre-B and mature B lymphocytes), which is expressed on> 95% of all non-Hodgkin lymphomas of B cell origin I: NHL, CLL, autoimmune disesases AE: rash, itchiness, hypotension severe – infection, toxic epidermal necrolysis ̶ Target on B cells [USEMAP] Adobe Systems Checkpoints – provide protection from immune destruction even during an immune reaction - may have stimulatory on inhibitory function anti-CTLA-4 (cytotoxic T-lymphocyte antigen 4) – co-inhibitory – ipilimumab - melanoma anti-PD-1 (programmed death-1 receptor) - nivolumab, pembrolizumab - melanoma, RCCa, NSCLC anti-PD-L1 – atezolizumab ̶ ̶ „Checkpoint inhibitors“ Target on T cells [USEMAP] Adobe Systems Activation of T lymfocytes through TCR and co-stimulating molecule CD28 yellow_inner green_inner cd28_MONDAY mhcII_MONDAY tcr_MONDAY Dendritic cell T lymfocyte MHC B7 TCR CD28 antigen_MONDAY b7_MONDAY Antigen CTLA-4 ctla4_MONDAY ctla4_MONDAY green_outer yellow_outer Adobe Systems Up-regulation of CTLA-4 receptors after T- cell activation yellow_inner green_inner cd28_MONDAY mhcII_MONDAY tcr_MONDAY Dendritic cell T lymfocyte MHC B7 TCR CD28 antigen_MONDAY b7_MONDAY Antigen ctla4_MONDAY CTLA-4 ctla4_MONDAY ctla4_MONDAY green_outer yellow_outer Adobe Systems CTLA-4 receptor inhibition yellow_inner green_inner cd28_MONDAY mhcII_MONDAY tcr_MONDAY Dendritic cell T lymfocyte MHC B7 TCR CD28 antigen_MONDAY b7_MONDAY Antigen ctla4_MONDAY CTLA-4 green_outer yellow_outer Adobe Systems Antagonisation of CTLA-4 receptors Ipilimumab yellow_inner green_inner cd28_MONDAY mhcII_MONDAY tcr_MONDAY Dendritic cell T lymfocyte MHC B7 TCR CD28 antigen_MONDAY b7_MONDAY Antigen ctla4_MONDAY CTLA-4 green_outer yellow_outer antibody Leach DR, Science 1996;271:1734-1736. Ipilimumab • Gajewski TF, et al. Curr Opin Immunol. 2011;23:286-292. Spranger S, Gajewski T. J Immunother cancer. 2013;1:16. Checkpoint inhibitors – PD-(L)-1 T cell recruitment Blocking PD1:PD-L1 binding might activate immunity within the tumor microenvironment Cytotoxic T cell Chemokines Migration T reg • • • • • • • Tumor • PD-L1 Anergy • MDSC PD1 • Adobe Systems 2. Biological treatment of rheumatic diseases Anti-TNF drugs – Ab (infliximab, adalimumab) - receptor etanercept Anti IL drugs - anakinra, tocilizumab Immunomodulants – adalimumab, rituximab [USEMAP] Adobe Systems 2. Biological treatment of rheumatic diseases Anti-TNF drugs - Ab Infliximab – chimeric mAbs, IgG, 75 % of human, 25% of the murine antibody high affinity binding to human TNFα Adalimumab - human MAB binds specifically to TNF and neutralizes the biological function of TNF by blocking its interaction with the p55 and p75 cell surface TNF receptors Certolizumab – humanized Fab fragment of TNFα antibody, conjugated with PEG Golimumab - the same mechanism action as infliximab, not registered in EU [USEMAP] Adobe Systems 2. Biological treatment of rheumatic diseases Anti-TNF drugs - receptor Etanercept – soluble dimeric fusion protein – extracelular domain of receptor for TNFα and Fc chain of human IgG1 Mechanism of action: competitive inhibition of TNFα, decreased effect of TNFβ does not bind complement, but leads to the disintegration of granulomas [USEMAP] Adobe Systems 2. Biological treatment of rheumatic diseases Anti-TNF drugs – adverse effects Opportunistic infections – increased risk in combination of immunosuppressive drugs (with 2 - combined to 14x ! ), malnutrition, age > 50 years - mycobacteria , listeria , fungal , viral infections Paradoxical autoimmune reactions Anti-idiotypic antibodies (in addition prevents binding of the antibody to TNF) TB –activation of latent forms Late carcinogenicity - lymphoproliferative disease (2-3 times higher versus the healthy population) , inconsistent data Others - specific AE for specific substances [USEMAP] Adobe Systems 2. Biological treatment of rheumatic diseases Anti IL treatment Anakinra – IL1 receptor antagonist weaker effect than anti-TNF drugs Tocilizumab - humanized mAb against IL6 AE: (infection ) + increase in lipids ( CHOL , LDL, TAG) [USEMAP] Adobe Systems 2. Biological treatment of rheumatic diseases Immunomodulants Abatacept - recombinant fusion protein from composed of Fc region of IgG and extracellular domain of CTLA4 ( receptor expressed in T-cells); competitively binds to CD80, preventing T cell activation proliferation Rituximab - binds to the transmembrane antigen CD20 (on pre-B and mature B lymphocytes) expressed on> 95% of all non-Hodgkin lymphomas of B cell origin [USEMAP] Adobe Systems 3. The biological treatment of psoriasis Anti-TNF drugs Etanercept - see above -Only one biological treatment of psoriasis for children 8-18 years Infliximab - see above Anti IL drugs Ustekinumab - fully human MAb IgG1 anti-IL -12/ 23 (important in the pathogenesis of psoriasis), inhibition of cytokine cascade AE : nasopharyngitis, headache, arthralgia, local irritation at the injection site [USEMAP] Adobe Systems 4. Biological treatment of inflammatory bowel disease (Crohn's disease, ulcerative colitis ) Anti-TNF drugs (see above) infliximab adalimumab certolizumab Selective adhesion molecule inhibitors Natalizumab – humanized IgG4 mAb against integrin α (prevents migration of leukocytes across the capillary wall) Vedolizumab - humanized IgG1 mAb against α4β1 integrin (on activated leukocytes, provides adhesion to the endothelium and the penetration into the circulation from the gastrointestinal tract ) [USEMAP] Adobe Systems 5. Biological treatment of bronchial asthma Adjunctive/supplementary treatment in patients with more serious desease which do not respond to other treatments Mepolizumab - anti IL-5 Ab Omalizumab – humanized Ab anti IgE [USEMAP] Adobe Systems 6. Biological treatment of multiple sclerosis IF β – 1a – antiinflammatory, immunomodulatory effects, supresses Th1 T lymphocytes activity and HEB permeability AE: flu-like syndrome, inhibition of hematopoiesis Natalizumab – see above Anti-CD20 mAb (B cells) - rituximab (see above), ocrelizumab, alemtuzumab Anti-IL-2 - daclizumab humanized mAb [USEMAP] Adobe Systems 7. Biological treatment in ophtalmplogy Monoclonal antibody against VEGF - A Bevacizumab (see above) - was developed for the treatment of colorectal cancer, off-label use in wet age-related macular degeneration (AMD) Ranibizumab Indications : AMD, CNV (chorioidal neovascularization) ̶ ̶ [USEMAP] Adobe Systems Zápatí prezentace 70 Thanks for your attention ̶ [USEMAP]