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New modified coagulation factor VIII (FVIII) and factor IX (FIX) products have been designed to improve the treatment of individuals with hemophilia A and B by increasing the interval between dosing. Although these FVIII and FIX molecules have been structurally modified to improve the circulation time, the changes have also influenced their behavior in functional assays in comparison with traditional plasma-derived or recombinant coagulation factors. The assignment of potencies for these products can be problematic because discordance in factor activity values between the commonly used one-stage clotting (OC) and chromogenic substrate (CS) assays is often observed. Discrepancies in potency assay values also exist when different assay kits and reagents are used in the same assay type. Ideally, all FVIII and FIX products should be calibrated against the World Health Organization (WHO) International Standards (IS) because the assignment of potencies in International Units (IU) helps maintain treatment tradition and meaningful references for manufacturers, patients, and clinicians. The discrepant measurements, attributed to the modified structural and functional properties of these products, are manifested in their lack of commutability with the WHO IS for FVIII or FIX. Herein, we discuss the considerations upon which an assay is chosen for potency assignment and post-administration monitoring of a new factor product, which include the validity of the assay calibrated with the IS, the meaning of the potency values in IU, standards of care for patients, clinical relevance between the assigned potency value and recovery value from clinical labs, and patient safety.

Patients on immunosuppressive drugs have been excluded from studies of SARS-CoV-2 mRNA vaccines’ (mRNA-BNT162b2 and mRNA-1273) clinical trials that resulted in their Emergency Use Authorization in the USA and Europe. Since the initiation of the global vaccination campaign, it became apparent that patients on immunosuppressive drugs may not generate optimal immune response following vaccination.1 Prednisone and mycophenalate are potent inhibitors of immune responses. Prednisone acts at many levels of immunity including the innate and adaptive responses, whereas mycophenalate mainly targets T and B cells.2 These and other immunosuppressive drugs used to treat patients with autoimmune disorders and organ transplant patients were shown to significantly curtail antibody responses following SARS-CoV-2 mRNA vaccines.3–5 We report on a 75-year-old male patient with an underlying autoimmune disorder, myasthenia gravis, which was controlled after receiving high doses of prednisone and mycophenalate for 9 months. At his first SARS-CoV-2 vaccination, he was receiving 7.5 mg prednisone on alternate days and 3 g mycophenalate daily (figure 1A). He received two doses of Moderna mRNA-1273 vaccine with a 4-week interval between doses. Neutralisation titres were measured using a pseudovirus neutralisation assay (PsVNA) as described previously.6 No SARS-CoV-2 neutralising antibodies were detected in plasma at 4 weeks after the second mRNA-1273 …

The most challenging complication associated with Factor VIII (FVIII) replacement therapy is the development of neutralizing anti-drug antibodies, or inhibitors, which occur in 23-35% of severe (FVIII level via neonatal Fc receptor (FcRn) binding, other Fc-mediated interactions, including engagement with Fc gamma receptors (FcγR), may have immunological consequences. Several case reports and retrospective analyses suggest that rFVIIIFc offers superior outcomes with respect to ITI compared to other FVIII products. Previously we and others demonstrated rFVIIIFc interactions with activating FcγRIIIA/CD16. Here, we investigated if rFVIIIFc activates natural killer (NK) cells via CD16. We demonstrated rFVIIIFc signaling via CD16 independent of Von Willebrand Factor (VWF):FVIII complex formation. We established that rFVIIIFc potently activated NK cells in a CD16-dependent fashion resulting in IFNγ secretion and cytolytic perforin and granzyme B release. We also demonstrated an association between rFVIIIFc-mediated NK cell IFNγ secretion levels and the high-affinity (158V) CD16 genotype. Furthermore, we show that rFVIIIFc-activated CD16+ NK cells were able to lyse a B-cell clone (BO2C11) bearing an anti-FVIII B-cell receptor in an antibody-dependent cellular cytotoxicity (ADCC) assay. These in vitro findings provide an underlying molecular mechanism that may help explain clinical case reports and retrospective studies suggesting rFVIIIFc may be more effective in tolerizing HA patients with anti-FVIII inhibitors compared to FVIII not linked to Fc. Our in vitro findings suggest a potential use of Fc-fusion proteins acting via NK cells to target antigen-specific B-cells, in the management of unwanted immune responses directed against immunogenic self-antigens or therapeutic protein products.

Hyperimmune immunoglobulin (hCoV-2IG) preparations generated from SARS-CoV-2 convalescent plasma (CP) are under evaluation in several clinical trials of hospitalized COVID-19 patients. Here we explored the antibody epitope repertoire, antibody binding and virus neutralizing capacity of six hCoV-2IG batches as well as nine convalescent plasma (CP) lots against SARS-CoV-2 and emerging variants of concern (VOC). The Gene-Fragment Phage display library spanning the SARS-CoV-2 spike demonstrated broad recognition of multiple antigenic sites spanning the entire spike including NTD, RBD, S1/S2 cleavage site, S2-fusion peptide and S2-heptad repeat regions. Antibody binding to the immunodominant epitopes was higher for hCoV-2IG than CP, with predominant binding to the fusion peptide. In the pseudovirus neutralization assay (PsVNA) and in the wild-type SARS-CoV-2 PRNT assay, hCoV-2IG lots showed higher titers against the WA-1 strain compared with CP. Neutralization of SARS-CoV-2 VOCs from around the globe were reduced to different levels by hCoV-2IG lots. The most significant loss of neutralizing activity was seen against the B.1.351 (9-fold) followed by P.1 (3.5-fold), with minimal loss of activity against the B.1.17 and B.1.429 (≤2-fold). Again, the CP showed more pronounced loss of cross-neutralization against the VOCs compared with hCoV-2IG. Significant reduction of hCoV-2IG binding was observed to the RBD-E484K followed by RBD-N501Y and minimal loss of binding to RBD-K417N compared with unmutated RBD. This study suggests that post-exposure treatment with hCoV-2IG is preferable to CP. In countries with co-circulating SARS-CoV-2 variants, identifying the infecting virus strain could inform optimal treatments, but would likely require administration of higher volumes or repeated infusions of hCOV-2IG or CP, in patients infected with the emerging SARS-CoV-2 variants.

Therapeutic proteins provide interventions for some of the most complex and intractable diseases and are an essential part of modern medicine. Immunogenicity is the development of immune responses, usually measured by antibodies, to therapeutic proteins. These responses can adversely affect the safety and efficacy of the therapeutic agent and may have the following consequences: neutralization of a life-saving biotherapeutic, crossreactivity to non-redundant endogenous proteins, and hypersensitivity responses. These concerns have been underscored by the discontinuation of development of several drugs in recent years owing to immunogenicity issues. We review here recent progress in technological approaches that are useful for the clinical and non-clinical risk assessment of immunogenicity as well as mitigation strategies including deimmunizing protein molecules and inducing immune tolerance to the therapeutic protein.

Background Immunoglobulins are widely used across multiple therapeutic areas such as immunodeficiency syndromes, infection and autoimmune diseases. The pharmacokinetics (PK) of immunoglobulins are well characterized in adults, but very little is known about the PK of immunoglobulins in neonates and infants. Objective The objective of the present study was to characterize the PK of Gammagard, an immunoglobulin, in very low birth weight preterm neonates. Method Gammagard concentration-time data from very low birth weight neonates (bodyweight range 0.78–1.38 kg, n = 20) following intravenous administration of 500 mg/kg and 750 mg/kg were obtained from the literature. The data were analyzed with and without baseline correction using extensive blood samples (8 blood samples). Model-independent (non-compartmental) analysis was used to characterize the PK of Gammagard. Results Based on uncorrected baseline concentration-time data, the clearance and half-life of Gammagard were 3.1 ± 0.7 mL/day and 22 ± 6 days, respectively. Based on corrected baseline concentration-time data, the clearance and half-life of Gammagard were 20.2 ± 7.4 mL/day and 5.3 ± 2.2 days, respectively. Conclusion The dose of immunoglobulins should be adjusted based on the PK of baseline corrected rather than baseline uncorrected profiles because baseline corrected PK parameters especially half-life reconciles with PK principles.

Fusing the human immunoglobulin G1 (IgG1) constant region (Fc-domain) to therapeutic proteins or peptides increases their circulating plasma half-life via neonatal Fc receptor (FcRn) binding and recycling. However, Fc-mediated interactions with other molecules including complement C1q and Fc gamma receptors (FcγRs) can have immunological consequences and the potential to modulate the immunogenicity of Fc-fusion therapeutics. In a comparative study, we carried out a comprehensive assessment of Fc-mediated interactions for five FDA-approved Fc-fusion therapeutics. C1q binding and complement activation were measured by ELISA, while FcγR binding and signaling were evaluated using BW5147:FcγR-ζ reporter cell lines. We demonstrate that FIX-Fc and FVIII-Fc bound C1q as well as activating and inhibitory FcγRs (I, IIA, IIB, IIIA). These coagulation factor Fc-fusions also signaled via FcγRIIIA, and to a lesser extent via FcγRI and FcγRIIB. TNFR-Fc and CTLA4-Fc bound FcγRI, while TNFR-Fc also bound FcγRIIIA, but these interactions did not result in FcγR signaling. Our comprehensive assessment demonstrates that (i) different Fc-fusion drugs have distinct C1q/FcγR binding and signaling properties, (ii) FcγR binding does not predict signaling, and (iii) the fusion partner (effector molecule) can influence Fc-mediated interactions.

To study bacterial co-infection following 1918 H1N1 influenza virus infection, mice were inoculated with the 1918 influenza virus, followed by Streptococcus pneumoniae (SP) 72 h later. Co-infected mice exhibited markedly more severe disease, shortened survival time and more severe lung pathology, including widespread thrombi. Transcriptional profiling revealed activation of coagulation only in co-infected mice, consistent with the extensive thrombogenesis observed. Immunohistochemistry showed extensive expression of tissue factor (F3) and prominent deposition of neutrophil elastase on endothelial and epithelial cells in co-infected mice. Lung sections of SP-positive 1918 autopsy cases showed extensive thrombi and prominent staining for F3 in alveolar macrophages, monocytes, neutrophils, endothelial and epithelial cells, in contrast to co-infection-positive 2009 pandemic H1N1 autopsy cases. This study reveals that a distinctive feature of 1918 influenza virus and SP co-infection in mice and humans is extensive expression of tissue factor and activation of the extrinsic coagulation pathway leading to widespread pulmonary thrombosis. Copyright © 2015 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Essentials Fc-fusion increases a therapeutic's half-life, but FcγR interactions may impact immunogenicity. Species-specific Fc-FcγR interactions allow for mechanistic in vivo studies using mouse models. Fc fusion modulates the immune response to factor IX in hemophilia B mice by eliciting Th1 bias. This model could inform future studies of IgE-associated anaphylaxis in hemophilia B patients. SummaryBackground Fc fusion is a platform technology used to increase the circulating half-life of protein and peptide therapeutics. However, there are potential immunological consequences with this approach, such as changes in the molecule's immunogenicity as well as possible interactions with a repertoire of Fc receptors (FcR) that can modulate immune responses. Objectives/Methods Using a mouse hemophilia B (HB) model, we compared the immune responses to infusions of recombinant human factor IX (hFIX) and hFIX fused to mouse IgG2a-Fc (hFIX-mFc). The mFc was employed to allow species-specific Fc–FcγR interactions. Results Although treatment with hFIX-mFc altered the early development of anti-FIX IgG, no significant differences in anti-FIX antibody titers were observed at the end of the treatment regimen (5 weeks) or upon anamnestic response (5 months). However, treatment with hFIX-mFc elicited higher FIX-neutralizing antibody levels and resulted in reduced IgE titers compared with the hFIX-treated group. Additionally, differences in plasma cytokine levels and in vitro CD4+ T-cell responses suggest that whereas hFIX treatment triggered a Th2-biased immune response, hFIX-mFc treatment induced Th1-biased CD4+ T cells. We also show that hFIX-mFc bound to soluble FcγRs and engaged with FcγRs on different cell types, which may impact antigen presentation. Conclusions These studies provide a model system to study how Fc-fusion proteins may affect immune mechanisms. We used this model to demonstrate a plausible mechanism by which Fc fusion may modulate the IgE response to hFIX. This model may be appropriate for investigating the rare but severe IgE-mediated anaphylaxis reaction to hFIX infusions in HB patients.

Fusion of the IgG1 constant region domain (Fc) to therapeutic proteins increases the plasma half-life of drugs via binding to the neonatal Fc receptor (FcRn). However, potential interactions with Fc gamma-receptors (FcγR) expressed by immune cells may effect the immunogenicity of these drugs. The coagulation factors VIII (FVIII) and IX (FIX) for the treatment of hemophilia A & B (HA & HB) are the only drugs available with and without Fc fusion and offer an opportunity to experimentally study the effect of Fc fusion. Anti FVIII & FIX antibodies (ADAs) and rare cases of anaphylaxis in HB patients, are serious safety concerns. Using a mouse model for HB, we compared the immune responses to infusions of recombinant human FIX (hFIX) and hFIX fused to mouse IgG2a-Fc (hFIX-mFc). The mFc allowed species-specific Fc-FcγR interactions and prevented immune response to the foreign hFc. Treatment with hFIX-mFc caused earlier onset of anti-FIX IgG and elicited higher FIX-neutralizing antibody levels. Treatment with hFIX triggered Th2 biased immunity i.e., elevated plasma IgE titers, and Th2 cytokine profile of FIX-specific CD4 T cells and a few anaphylactic events. The fusion of Fc altered the response to a Th1 type with increased plasma IFN-γ levels, and IFN-γ secretion by effector CD4 T cells. hFIX-mFc binds to soluble FcγRs and FcγRs on natural killer cells (which also secrete IFNγ) and antigen presenting cells (dendritic cells, and macrophages source of IL-12). We show that Fc fusion enhances the presentation of hFIX to CD4 T cells. We propose that high plasma availability and targeting of APC provide plausible mechanisms by which the Fc fusion may modulate the CD4 T cell response to hFIX towards a Th1 like response, thus avoiding allergic responses.

Fusing the IgG1 constant region (Fc-domain) to therapeutic proteins increases their plasma half-life via neonatal Fc receptor (FcRn) binding. However, potential interactions with other Fc-binding molecules including complement C1q and Fc gamma receptors (FcγR) can have immunological consequences. Our previous studies in a mouse model suggest that engagement of the Fc-Factor IX (FIX) to FcγR on APC and NKT cells could alter the immunogenicity of the FIX moiety. Here, we conducted a comparative study of FDA-approved Fc-fusion proteins to assess their potential for C1q binding as well as FcγR binding and signaling. Binding of soluble drug to C1q was measured by ELISA, and FcγR binding and signaling was evaluated using BW5147:FcγR-ζ reporter cell lines. We demonstrate that rFIXFc and rFVIIIFc bound C1q as well as activating and inhibitory FcγRs (I, IIA, IIB, IIIA). These therapeutic proteins also signaled via FcγRIIIA, and to a lesser extent via FcγRI and FcγRIIB. Other Fc-fusion drugs (TNFR-Fc; CTLA4-Fc) bound FcγRI (TNFR-Fc also bound FcγRIIIA), but did not result in FcγR signaling. As predicted, a control anti-CD20 monoclonal antibody modified for enhanced FcγRIIIA engagement, bound and signaled via FcγRIIIA, while the parent molecule did not; supporting our use of BW5147: FcγR-ζ reporter cells for the assessment of Fc:FcγR interactions. Our studies show that Fc-fusion drugs have distinct C1q/FcγR binding and signaling properties. Moreover, FcγR binding does not predict signaling. Our studies suggest that Fc-FcγR engagement can influence the immunogenicity to Fc-fusion drugs as both fusion partners influence this interaction. Future investigations will elucidate the underlying molecular mechanisms.

The fusion of a protein with the Fc-region of an antibody is used to increase the circulating half-life of therapeutic proteins. Using a mouse hemophilia B (HB) model we compared the immune responses to infusions of recombinant human FIX (rFIX) and human FIX-mouse Fc (hFIX-mFc) fusion protein. HB mice received weekly IV injection of rFIX or hFIX-mFc for 5 weeks. Anti-FIX IgG, IgE and cytokines were measured. Splenic cells were used to determine FIX-specific T and B cell functional and memory responses. Our results showed that, following IV treatment with rFIX or hFIX-mFc, there are no statistically significant differences in the titers of anti-FIX IgG Ab and numbers of long term memory B cells. However, a significantly larger proportion of mice treated with rFIX developed elevated titers of total IgE which correlated with a Th2 bias following rFIX. In contrast, hFIX-mFc induced a Th1-like response and no detectable IgE. Our study suggests, that in mice, hFIX-mFc fusion protein promotes a Th1-like response and is less likely than rFIX to induce an IgE response, which may lead to anaphylaxis, a rare severe adverse event associated with the treatment of HB patients.