BIOLOGICALS

RASHID MAHMOOD ARSHADPHARMACISTUNIVERSAL HOSPITAL

WHAT ARE BIOLOGIC MEDICINE?

• A large Protein molecule typically derived from living cells & used in the treatment or prevention of diseases.

• Include therapeutic proteins, DNA, Monoclonal antibodies & fusion proteins.

• Often 200 to 1000 times of the small molecule & far more complex structurally.

Examples : Human growth hormone Human insulin Erythropoietin Vaccines Monoclonal antibodies

BILOGICALS Vs CONVENTIONAL

BIOLGOCIALS Vs CONVENTIONAL

MONOCLONAL ANTIBODIESWHAT IS AN ANTIBODY?

• An antibody is a protein used by immune system to identify & neutralize foreign objects like bacteria & viruses. Each antibody identifies a specific antigen unique to its target.

• Monoclonal antibodies (mAb) are the antibodies which are identical because they are produced by one type of immune cells, all clones of single parent cell.

• Polyclonal antibodies are antibodies that are derived from different cell lines. They differ in amino acid sequences.

MONOCLONAL Vs POLYCLONAL

MONOCLONAL Vs POLYCLONAL

DEVELOPMENT OF MONOCLONAL

• In the 1970s, the B-Cell cancer MYELOMA was known, & it was understood that these B-cells produce a single type of antibody. This was used to study the structure of antibodies, but it was not possible to produce identical antibodies specific to a single antigen.

DEVELOMPMENT OF MONOCLONAL

Fusion of mice spleen cells with myeloma cells

HYBRIDOMA creates monoclonal antibodies

MONOCLONAL ANTIBODIES

HYBRIDOMA METHOD• Inject the antigen into mouse.• Remove the spleen• Identify spleen cells which are

producing antibodies.• Separate these cells & grow

them in tissue culture tubes.• Search each antibody for cross

reactivity.• Select the Ab which don’t cross

react with any other protein.

HYBRIDOMA METHOD

LIMITATIONS WITH MOUSE MONOCLONALS

• Problem in medical applications is that the standard procedure for the production of monoclonal antibodies yields mouse antibodies & these are rejected by human immune system.

MONOCLONAL ANTIBODIES

Finding solution for human use

• In one approach, one takes the DNA that encodes the binding portions of mouse monoclonal antibodies & merges it with human antibody producing DNA, in order to make bacteria produce the antibodies which are half mouse & half human.

TYPES OF MONOCLONAL

IST GENERATION• Murine or rat proteins are purified after immunization with

the antigens so called Murine antibodies.

SECOND GENERATION• Recombinant DNA technology or Genetic engineering is used

to produce the hybrid composed of human Abs regions with murine

CHIMERIC Abs HUMANIZED Abs HUMAN Abs

MONOCLONAL TYPES

HUMAN MONOCLONAL ANTIODY

MONOCLONAL Abs TYPES

MURINE• Derived from Mice.• Patients treated with

murine mAbs produce a Human Antimouse Antibody(HAMA) response.

• Rapid clearance of mAb• Poor tumor prevention• Hypersensitivity reaction MUROMOMAB TOSITUMOMAB

CHIMERIC• Antigens binding

parts(variable region) is of mouse origin.

• Effector parts(constant region) is of human origin.

• Infliximab• Rituximab• Abciximab

MONOCLONAL Abs TYPES

HUMANIZED• Human antibodies with

complementary determining region(CDR) or hypervariable region from non human source.

• Daclizumab• Trastuzumab

HUMAN• Recombinant DNA

technology.• Genes for variable Fab

portions of human Abs is inserted in genome of bacteriophages & replicated

• Adalimumab

CRITICAL DIFFERNCE

NOMENCLATURE

SUFFIX MURINE

CHIMERIC

HUMANIZED

HUMAN

MOMAB

XIMAB

ZUMAB

UMAB

NOMENCLATURE OF mAbs

NOMENCLATURE

EXAMPLES• AB-CI-XI-MAB: Chimeric mAb

used on cardiovascular system.

• TRAS-TU-ZU-MAB: Humanized mAb used against tumor.

• ADA-LI-MU-MAB: Human antibody used against immune system.

• PALI-VI-ZU-MAB: Humanized mAb used against virus(RSV).

• INF-LI-XI-MAB: Chimeric mAb used against immune system.

• RI-TU-XI-MAB: Chimeric antibody used against tumor

MONOCLONAL ANTIBODY TYPES

CONJUGATED/LABELED/LOADED: COUPLED WITH DRUGS/TOXINS, RADIOACTIVE ITEMS

• CHEMO LABELED ANTIBODIES• MABs coupled with chemotherapeutic agents e.g.,

Brentuximab vedotin & Ado-trastuzumab emtansine.• Brentuximam vedotin is targeting to CD30 antigen on T & B-

cells in the treatment of hodgkin lymphoma.• Ado-trastuzumab emtansine , targets the HER2 protein antigen

used for curing advanced breast cancer patients.

• IMMUNE TOXINS: CONJUGATED WITH TOXINS• E.g., Denileukin diftitox• Used to treat some cancer(T-cell Lymphoma)• Consist of IL-2 protein attached with toxin derived from the

germ causing diphteria• IL-2 normally attaches to cells those express CD25 antigen &

helps in delivering the toxin to those cells.• RADIO IMMUNE MABs: IBRITUMOMAB• An MAB against CD20 antigen on B cells• Conjugated with the radioactive isotopes like Indium-

111(111in) or Yttrium-90(90Y) for treatment of Lymphoma patients.

PHARMACOKINETICS ROUTE OF ADMINISTRATION:• Subcutaneously (Rituximab, Trastuzumab, Adalimumab)• Intramuscularly (Palivizumab)• Intravenously• IV route is preferred for 100% bioavailability. ROUTE OF ELIMINATION:• Via uptake & catabolism by reticuloendothelial system &

target tissue. HALF LIFE:• Chimeric: 4-15 days• Humanized: 3-24 days• Human: 11-24 days

Human antimouse antibody(HAMA) response develops 7-10 days following exposure to murine antibodies.

MECHANISM OF ACTION

1. BLOCKING THE ACTION OF MOLECULAR TARGESTS Can work antagonistically by binding a receptor to prevent

activation Can also bind to antigen & prevent activation

2. MAGIC BULLET Compound with target specificity is coupled with various

effector groups e.g., toxins, radionuclei, enzymens, DNA

3. SIGNAL MOLECULES Coupled to mediators of apoptosis, cell division, phagocytosis.

MECHANISM OF ACTION

MECHANISM OF ACTION

ADVERSE EFFECTS OF mAbs

Mechanisms involved• Exogenic nature of mAb

used.• Suppression of physiological

function• Activation of inflammatory

cells or mediators after binding of mAb to its target antigen.

General Side Effects• Fever, chills• Weakness• Headache• Nausea• Diarrhea• Rashes• Changes in blood pressure• Flushes & faintness

ADVERSE EFFECTS OF mAbs

NAKED MABs• Mild; often allergenic on ist infusion• Cytokine release syndrome• Infusion toxicity, cytopenia CONJUGATE MABs• More A/Es; depends upon the substance attached ANTILYMPHOCYTE MABs• Immunosuppression (increased risk of infection) ANTI- TNF MABs• Reactivation of TB• Lymphomas

THERAPEUTIC USES OF MABs

• Immunosuppression

• Autoimmune diseases

• Malignancies

• Antiplatelet therapy

• Infectious diseases

• Lymphomas

• Asthma

• Osteoporosis

• Graft rejection

• Leukemias

ECONOMICS

• Monoclonal antibodies (MABs) is the fastest growing segment of pharmaceutical industry.

• 65 Billion $ in sales for year 2014.• 5 Monoclonal antibody drugs in top 10 best selling drugs of

2014.• #1= Abbvie’s HUMIRA(Adalimumab), US$13.2 Billion• #3= Roche’s MABTHERA(Rituximab), US$8.5 Billion• #5= Roche’s HERCEPTIN(Trastuzumab), US$6.79 Billion• #7= Johnson’s REMICADE(Infliximab),US$6.13 Billion• #8= Roche’s AVASTIN(Bevacizumab), US$6.01 Billion

FDA APPROVED MABs

FDA APPROVED MABs

FDA APPROVED MABs

FDA APPROVED MABs

ACTEMRA(TOCILIZUMAB)

Binds to IL-6 receptors & inhibits IL-6 mediated signaling.IL-6 is proinflamatory cytokine produced by T & B Cell lymphocytes & monocytes.Speical target is IL-6 produced by synovial & endothelial cells.

• Rheumatoid arthirits• Polyarticular juvenile arthiritis• Systemic juvenile arthiritis• Dosage: Monotherapy or with

methotrexate• 60 minute single iv infusion drip

once in a 4 weeks (RA)• If SC , then 162mg(0.9ml) is given

every other week or every week• PJA dose is same as RA• SJA dose is 60 min single iv

infusion drip every 2 weeks

PROLIA(DENOSUMAB)

Binds to RNKL,a protein essential for formation, function &survival of osteoclasts.Decresing bone resorption, increasing osteoblast activity, bone mass & strength.

• Treatment of Postmenopausal women with osteoporosis

• Treatment to increase bone mass in men with osteoporosis

• Dosage: 2 shots per year• 1000mg calcium & 400 iu

vitamin D daily• Hypocalcaemia C/I• S/E: Hypocalcaemia,serious

infections, dermatological infections,osteonecrosis of jaw.

LUCENTIS(RANIBIZUMAB)

Binds to active forms of VEGF-A which causes neovascularization & leakage.Reduces the endothelial cell proliferation,vascular leakage & new blood vessel formation.

• Diabetic macular edema• Central retinal vein occlusion• Wet AMD• Ophthalmic intravitreal injection

only• Dosage: once a month usually or• Once in a 3 months after ist 4

monthly injections• S/E: Dry eye, double vision, eye

pain, night blindness• C/I: ocular or periocular infections

CIMZIA(CERTOLIZUMAB)

A TNF inhibitor, key pro inflamtory cytokine involoved in inflamtory processes.Also inhibits IL-1B in monocytes.

• Rheumatoid arthritis• Psoriatic arthritis• Chrone’s disease• Dosage: Subcutaneous injections• Loading dose=2 injections of

200mg/ml at week 0, 2 & 4 weeks.• Maintenance dose= 400 mg every 4

weeks.• S/E: UTIs, & URTIs most common.• Eleveted liver enzymes & hepatitis

REMICADE(INFLIXIMAB)

NeutralizesTNF by binding with high affinity.Tnf induces production of pro inflamatory cytokines like IL 1,6 & migration of leucocytes &activation of neutrophil & eosinophils.

• Rheumatoid & psoriatic arthritis• Ankylosis spondylitis• Chron’s disease• Ulcerative colitis• Plaque psoriasis• Dosage: 5mg/kg given as iv infusion at

week 0,2 & 6 weeks• Followed by 5mg/kg every 8 weeks• In RA dose is often given 10mg/kg every

4 weeks as a maintenance dose but chances of serious infection is increased at higher dose

HUMIRA(ADALIMUMAB)

Inhibits the tumor necrotic factor alpha (TNF) in synovial fluids of RA patientsIncreased levels of TNF also found in plaque psoriasis

• Rhematoid & psoriatic arthritis• Ankylosing spondylitis• Chron’s disease• Ulcerative colitis• Plaque Psoriasis• Dosage:combined with methotrexat• Joint issue:40 mg every other week• GI issue:160mg-day1, 80mg-day15,

from day29-40mg every other week.• Skin issue: initial dose-80mg & then

maintenance dose 40 mg every other week.

MABTHERA(RITUXIMAB)

Binds to CD20 antigen(B-lymphocyte antigen).CD20 regulates cell cycle initiation & differentiation.Possible mechanisms of cell lysis include CDC, ADCC & APOPTOSIS.

• Non-Hodgkin Lymphoma• Chronic Lymphocytic Leukopenia• Rheumatoid arthiritis• Dosage: IV infusion only, don’t use

as IV push or bolus• Initate at 50mg/hr, if no toxicity

then increase 50mg per every 30 min to maximum 400 mg/hr

• Dosing inerval depends upon chemotherapy sessions

• In RA, two 1000mg Iv infusions seperated by 2 weeks then every 16-24 weeks subsequently.

ENBREL(ETANERCEPT)

Cytokine inhibitor mainly TNF, its activation depends on binding to 2 of the recepotors TNFRs.Etanercept is dimeric form of TNF receptor, so binds to TNF & makes it inactive so no signaling occurs

• Genetically engineered FUSION PROTEIN.

• Rhematoid arthritis• Psoriatic arthritis• Polyarticular juvenile arthritis• Ankylosing spondylitis• Dosage: 50mg once

weekly(standard)• Severe cases: 50 mg twice weekly

for 3 months & then maintenance as 50 mg once weekly (increased side effect )

ORENCIA(ABATCEPT)

Abatacept decreases the T cell proliferation & inhibits production of cytokines like TNF alpha, Interlekuin-2 & Interferon.

• Rheumatoid arthritis• Juvenile arthritis• Dosage forms: two forms available• 250mg vial for iv use & 125mg/ml for

SC use.• IV Dose: depends upon body weight• Less then 60kg-500mg• 60-100kg-750 mg• More than 100kg-1000mg• Repeat at week 2,4 & every 4 weeks .• SC Dose: 125mg once weekly