Elsevier

Cellular Immunology

Volume 301, March 2016, Pages 40-48
Cellular Immunology

Review article
Immunogenicity of long-lasting recombinant factor VIII products

https://doi.org/10.1016/j.cellimm.2015.12.006Get rights and content

Highlights

  • Results of different approaches developed to enhance FVIII half-life.

  • Strategies include fusion to IgG1 Fc fragment, serum albumin, or polyethylene glycol.

  • Identification of potential benefits or risks in terms of immunogenicity.

Abstract

Replacement therapy for patients with hemophilia A using plasma-derived or recombinant factor VIII (FVIII) is complicated by the short half-life of the FVIII products and by the occurrence of neutralizing antibodies in a substantial number of patients. In the recent years, enormous efforts have been invested to develop new generations of coagulation factors with extended half-lives. Presumably, the use of long-lasting FVIII products should reduce the frequency of administration to the patients and drastically improve their quality of life. The question of their immunogenicity remains however unanswered as yet. The present review proposes a summary of the different strategies developed to enhance the half-life of FVIII, including fusion of FVIII to the Fc fragment of the human IgG1 or to human serum albumin, or attachment of polyethylene glycol. Based on the available literature, we hypothesize on the potential benefits or risks associated with each of the latter strategies in terms of immunogenicity of the newly derived hemostatic drugs.

Introduction

The past decades have witnessed extraordinary improvement in the treatment of bleeding disorders. Progressing from the Stone Age, with the use of whole blood and cryoprecipitate infusion, we have evolved to a modern time where recombinant coagulation factors are administered. Congenital disorders such as hemophilia A, that display life-threatening bleeding manifestations, have benefitted utmost from the development of new generation therapeutic factor VIII (FVIII), owing to the implication and commitment of the pharmaceutical field. Simultaneously, clinical studies as well as the implication of clinicians and basic researchers have promoted new treatment regimens (prophylaxis rather than “on-demand” treatment) that reduce the risks for hemarthrosis and arthropathy episodes and have improved the quality of life of hemophilic patients.

Despite the quality of FVIII in terms of efficacy and viral safety, the short half-life of FVIII imposes frequent administrations to provide an optimal protection of the patients from bleeding episodes. This is understandably associated with a limited adherence of the patients to prophylaxis regimen, thereby resulting in a lack of complete protection and higher treatment costs. Accordingly, the most recent developments for therapeutic coagulation factors have focused on extending their half-life in the blood: recombinant factors with longer residual time in circulation would cumulate the benefice of reducing the frequency of administration, thus improving the compliance of patients, and increasing the bleed-free time-span of the patients, thus reducing the risks for minor arthropathy-prone joint bleeds. In this context, several strategies are being exploited to optimize the pharmacokinetics of therapeutic FVIII, that include coupling of the effector protein to dimeric Fc fragments of human immunoglobulin G, to polyethylene glycol (PEG) or to human serum albumin (HSA).

The treatment of patients with hemophilia A using exogenous FVIII is complicated by the immunogenicity of the infused FVIII. Indeed, up to 30% of patients with severe hemophilia A, and up to 5% of patients with mild/moderate forms of the disease, develop anti-FVIII IgG antibodies following replacement therapy. The induced anti-FVIII IgG presumably affect the pharmacokinetics of the exogenously administered coagulation factors but, more critically, inhibit their pro-coagulant activity. The development of inhibitory anti-FVIII IgG, or ‘FVIII inhibitors’, represents a major clinical burden as well as a major societal concern owing to the additional costs that are associated with inhibitor management. To our knowledge, there is no available study that clearly establishes a correlation between the residual time of a molecule and its immunogenicity in humans. It is thus hazardous to predict the immunogenicity of long-acting FVIII products. Besides, FVIII exhibits a degree of immunogenicity that is unexpected given the fact that FVIII has no known pro-inflammatory role. In this review, we summarize the rationale for the different strategies developed to enhance the half-life of FVIII. Based on the available evidence, we further anticipate the consequences and limitations of coupling FVIII to ‘half-life enhancers’ for its immunogenicity in hemophilia A patients.

Section snippets

Coupling therapeutic FVIII to human Fc fragments

The interaction of the Fc domain of immunoglobulins with the neonatal Fc receptor (FcRn) has been known for years as a physiological mechanism that protects IgGs from catabolism and confers them a long half-life in the blood [1]. Therefore, IgGs of the IgG1, IgG2 and IgG4 sub-classes are known to circulate in the body with a half-life of 3 weeks. The FcRn is expressed at many sites and by different cell types in mammals, where it mediates IgG transcytosis and IgG recycling in a pH-dependent

Coupling therapeutic FVIII to human albumin

Accounting for 50% of total plasma proteins, albumin is the most prominent protein circulating in the blood. Serum albumin is a natural carrier for several endogenous hydrophobic molecules, such as fatty acids or thyroid hormones; it is also involved in scavenging free radical species that may be released in the blood. Albumin displays a long half-life of 20 days in vivo. This persistence is attributed to both a high hydrodynamic size, which prevents glomerular filtration by kidneys, and

PEGylation of therapeutic FVIII

PEGylation consists in a covalent conjugation of polymers of ethylene glycol (PEG) to a carrier. PEGylation was found to extend the residence time of derivatized proteins [39], [40], and was therefore considered as an efficient strategy to improve drug delivery and has been applied to enhance the lifespan of a large number of drugs over the last decades. PEG conjugation affects the physicochemical features of the target protein, without altering its structure. In particular, the hydrophilic

Conclusions

The development of a new generation of therapeutic coagulation factors is revolutionizing the treatment of patients with hemophilia. Specifically, novel products with extended half-lives should facilitate patient management, resulting in a drastically improved quality of life. Indeed, the reduced frequency of drug administration and the prolonged circulation time of the hemostatic drugs should provide a longer protection of the patients from micro-bleeds in joints, thus minimizing co-morbidity.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgments

This work was supported by Institut national de la santé et de la recherche médicale (Inserm), Centre National de la Recherche Scientifique (CNRS), Université Pierre et Marie Curie (UPMC) Paris 6, and the Innovative Medicines Initiative Joint Undertaking under grant agreement n. 115303, with resources from the European Union’s Seventh Framework Programme (FP7/2007-2013) and EFPIA companies’ in kind contribution. Mathieu Ing is the recipient of a fellowship from Ministère de l’enseignement

References (83)

  • F. Nimmerjahn et al.

    Fc gamma receptors: old friends and new family members

    Immunity

    (2006)
  • D.J. Hui et al.

    Modulation of CD8+ T cell responses to AAV vectors with IgG-derived MHC class II epitopes

    Mol. Ther. J. Am. Soc. Gene Ther.

    (2013)
  • J.J. Neumiller

    Clinical pharmacology of incretin therapies for type 2 diabetes mellitus: implications for treatment

    Clin. Ther.

    (2011)
  • R.E. Pratley et al.

    Once-weekly albiglutide versus once-daily liraglutide in patients with type 2 diabetes inadequately controlled on oral drugs (HARMONY 7): a randomised, open-label, multicentre, non-inferiority phase 3 study

    Lancet Diab. Endocrinol.

    (2014)
  • S. Schulte

    Innovative coagulation factors: albumin fusion technology and recombinant single-chain factor VIII

    Thromb. Res.

    (2013)
  • G. Golor et al.

    Safety and pharmacokinetics of a recombinant fusion protein linking coagulation factor VIIa with albumin in healthy volunteers

    J. Thromb. Haemost.

    (2013)
  • S.I. Lim et al.

    Site-specific albumination of a therapeutic protein with multi-subunit to prolong activity in vivo

    J. Control. Release

    (2015)
  • C.A. Weber et al.

    T cell epitope: friend or foe? Immunogenicity of biologics in context

    Adv. Drug Deliv. Rev.

    (2009)
  • D. Kolbus et al.

    Immunization with cationized BSA inhibits progression of disease in ApoBec-1/LDL receptor deficient mice with manifest atherosclerosis

    Immunobiology

    (2011)
  • F.M. Veronese

    Peptide and protein PEGylation: a review of problems and solutions

    Biomaterials

    (2001)
  • B. Mei et al.

    Rational design of a fully active, long-acting PEGylated factor VIII for hemophilia A treatment

    Blood

    (2010)
  • T.E. Coyle et al.

    Phase I study of BAY 94–9027, a PEGylated B-domain-deleted recombinant factor VIII with an extended half-life, in subjects with hemophilia A

    J. Thromb. Haemost.

    (2014)
  • B.A. Konkle et al.

    Pegylated, full-length, recombinant factor VIII for prophylactic and on-demand treatment of severe hemophilia A

    Blood

    (2015)
  • H.R. Stennicke et al.

    A novel B-domain O-glycoPEGylated FVIII (N8-GP) demonstrates full efficacy and prolonged effect in hemophilic mice models

    Blood

    (2013)
  • A. Tiede et al.

    Enhancing the pharmacokinetic properties of recombinant factor VIII: first-in-human trial of glycoPEGylated recombinant factor VIII in patients with hemophilia A

    J. Thromb. Haemost.

    (2013)
  • A. Abuchowski et al.

    Effect of covalent attachment of polyethylene glycol on immunogenicity and circulating life of bovine liver catalase

    J. Biol. Chem.

    (1977)
  • A. Bendele et al.

    Short communication: renal tubular vacuolation in animals treated with polyethylene-glycol-conjugated proteins

    Toxicol. Sci.

    (1998)
  • A. Baumann et al.

    Pharmacokinetics, metabolism and distribution of PEGs and PEGylated proteins: quo vadis?

    Drug Discov. Today

    (2014)
  • A.T. Viau et al.

    Safety evaluation of free radical scavengers PEG-catalase and PEG-superoxide dismutase

    J. Free Radic. Biol. Med.

    (1986)
  • M.A. Young et al.

    Toxicity and hemodynamic effects after single dose administration of MalPEG-hemoglobin (MP4) in rhesus monkeys

    Trans. Res. J. Lab. Clin. Med.

    (2007)
  • H. Tillmann et al.

    High prevalence of pre-existing antibodies against polyethylene glycol (PEG) in hepatitis C (HCV) patients which is not associated with impaired response to PEG-interferon

    J. Hepatol.

    (2010)
  • T. Shimizu et al.

    Anti-PEG IgM and complement system are required for the association of second doses of PEGylated liposomes with splenic marginal zone B cells

    Immunobiology

    (2015)
  • T. Ishida et al.

    Accelerated blood clearance of PEGylated liposomes following preceding liposome injection: effects of lipid dose and PEG surface-density and chain length of the first-dose liposomes

    J. Control. Release

    (2005)
  • A.S. Abu Lila et al.

    The accelerated blood clearance (ABC) phenomenon: clinical challenge and approaches to manage

    J. Control. Release

    (2013)
  • T. Ishida et al.

    Spleen plays an important role in the induction of accelerated blood clearance of PEGylated liposomes

    J. Control. Release

    (2006)
  • H. Koide et al.

    T cell-independent B cell response is responsible for ABC phenomenon induced by repeated injection of PEGylated liposomes

    Int. J. Pharm.

    (2010)
  • I. Hamad et al.

    Poly(ethylene glycol)s generate complement activation products in human serum through increased alternative pathway turnover and a MASP-2-dependent process

    Mol. Immunol.

    (2008)
  • J. Szebeni et al.

    Activation of complement by therapeutic liposomes and other lipid excipient-based therapeutic products: prediction and prevention

    Adv. Drug Deliv. Rev.

    (2011)
  • A. Chanan-Khan et al.

    Complement activation following first exposure to pegylated liposomal doxorubicin (Doxil): possible role in hypersensitivity reactions

    Ann. Oncol.

    (2003)
  • P.M. van Helden et al.

    Maintenance and break of immune tolerance against human factor VIII in a new transgenic hemophilic mouse model

    Blood

    (2011)
  • L. Castro-Núñez et al.

    Shear stress is required for the endocytic uptake of the factor VIII-von Willebrand factor complex by macrophages

    J. Thromb. Haemost.

    (2012)
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