Antibody Therapeutics – a primer

Consideration of antibodies as a therapeutic modality isn’t new. Ever since the discovery of anti-toxin antibodies and the observation of their efficacy against certain bacterial toxins (e.g. tetanus toxin) in the early 1890s, the subsequent 40-odd years saw a rise in the therapeutic usage of antibody preparations (under the umbrella term ‘serum therapy’) for various infectious diseases (N.B. informative reviews at References 1, 2 and 3) – the name indicating the origin of these preparations: polyclonal serum collected from immunized animals (such as sheep) or pre-exposed immune human donors. Serum therapy worked, no doubt, but also gave rise to various side effects related to the presence of a complex foreign protein substance (e.g. animal serum in a human body), a condition known as ‘serum sickness’, accompanied by fever, chills, joint pain, allergy, and in extreme cases, anaphylaxis. Although this challenge was somewhat resolved by the 1930s through better-purified antibodies, the introduction of vastly superior, potent, and better tolerated antimicrobial chemotherapy (‘antibiotics’, starting with sulphonamides and then the β-lactam, penicillin) around 1935 sounded the death-knell for serum therapy. Within 5 years, antibacterial serum therapy fell into disuse, leaving only a niche area for those conditions that were not amenable to antibiotic treatment, namely, venoms, toxins (such as diphtheria and tetanus), and viral infections (such as, hepatitis A and polio) (1).

However, to appropriate a popular saying, one “cannot keep a good antibody down“. Research into the principles, technology and use of antibody preparations hadn’t stopped. At the same time, there was an increasing appreciation of the fact that, although antimicrobials work (and work well) by slowing down and/or killing the microbial pathogens, the totality of host defence is a dynamic process dependent upon host-pathogen interactions – because of which immune therapies, including antibody-associated therapies, had a definite and important role to play in clinical therapeutics. In modern times, this realization has become even more crucial in view of three pathogen-related observations:

  1. a notable increase in microbes resistant to specific antimicrobials (think of the antibiotic resistant bugs of recent times, such as methicillin resistant Staphylococcus aureus or MRSA),
  2. the increased use of invasive diagnostic and therapeutic techniques, which – while beneficial – have paradoxically made a subset of the patient population more vulnerable to ubiquitous microbes (think of catheters and catheter-associated infections), and
  3. a sharp increase in the patient subset with immune impairment, whether conditional (think of immune suppression prior to, say, organ transplant), metabolic (as in diabetes and certain cancers), genetic (such as ‘hypogammaglobulinemia’, a condition which results in very low levels of antibodies in the body), or disease-associated (as in HIV-infection and AIDS); in such patients, even otherwise-innocuous microbes can also cause disease.

Not surprisingly, this situation resulted in a renewed interest in immune-based therapies, including antibody therapy, aimed at combating disease by buttressing host immunity.

A historical example of antibody use is the intravenous immunoglobulin (IVIG) therapy developed in the 1980s; IVIG is a polyclonal antibody preparation derived from healthy donors (whose blood contains antibodies recognizing diphtheria toxin, measles and polio virus at the minimum, as a result of direct exposure, or vaccination) (2). It has been successfully used as replacement therapy in hypogammaglobulinemics, as well as prophylactically and therapeutically in many viral infections, such as hepatitis A and B, polio, rabies, measles, rubella (German measles), cytomegalovirus, and varicella (Chicken pox); IVIG is also indicated in immunosuppressed patients and newborns as therapy of acute infections, as well as post-exposure prophylaxis. In addition, polyclonal antibodies from hyperimmunized sheep, horses and rabbits are used as antidotes against envenomization (snake and spider venom), certain bacterial toxins (such as Clostridium botulinum neurotoxin), digitalis toxicity, as well as to cause immune suppression in organ transplant recipients to prevent rejection (3).

Given the unique characteristic of high antigen-specificity of Monoclonal Antibodies or MAb(s) (which I touched upon briefly in the previous post), it is expected that the practice of antibody therapeutics would embrace this technology. In fact, when Georges Köhler and César Milstein jointly described the technology in their seminal Nature paper in 1975 (Nature 256:495–497, 1975), MAbs were hailed as the ‘Magic Bullet’ that harnessed the therapeutic power of specific antibodies against specific diseases.

Unfortunately, the physiological system, in health and disease, is often too complex a system to be easily reduced to single components; it is truly greater than mere sum of its parts. A lack of appreciation of this in the early days of biology and medicine led to a lot of headaches. Thankfully, such is the nature of science, that from each such failure, as well as from the small measures of successes, scientists have learnt, reasoned, experimented and put that knowledge to good use.

Take, for example, serum sickness that I have mentioned above, which restricted the utility of serum therapy, especially in situations requiring prolonged use. Even purified polyclonal antibodies from animals, which have high specific activities, are not always immune from this shortcoming, especially on long-term use. Again, IVIG, made according to strict criteria, are in limited supply and have low capacity of recognizing specific antigen (which is not surprising, since they are pooled from healthy donors). MAbs offered a solution to some of these challenges, and became popular in biologic therapeutics; however, that is not to say that MAbs don’t have problems specific to their own (3).

The single-epitope specificity of MAbs is beneficial for targeted functions, such as (a) blocking of molecular interactions; and (b) targeting of specific components. The following is a (non-exhaustive) list of a few therapeutic MAbs currently approved by US FDA (4, 5, 6):

Common Name Cognate antigen Indication Mechanism
For various cancers (review in Ref. 6)
rituximab CD20 NHL, RA, CLL Sensitizes cells to chemotherapy; apoptosis, ADCC, CDC
ofatumumab CLL Recognizes different epitope than rituximab; CDC and ADCC
trastuzumab HER-2 breast cancer and some uterine cancer Binds target to prevent cell growth and proliferation; suppresses angiogenesis; ADCC
pertuzumab breast cancer Binds target to prevent cell growth and proliferation
Cetuximab EGFR Colorectal cancer; squamous cell carcinoma of head and neck Receptor binding and inactivation; prevents cell growth; CDC, ADCC
Panitumumab Colorectal cancer Receptor binding and inactivation; prevents cell growth
bevacizumab VEGF-A metastatic colorectal carcinoma; lung and renal cancers; glioblastoma multiforme of brain Ligand binding and receptor inactivation; prevents angiogenesis
ipilimumab CTLA-4 metastatic melanoma Binding and inactivation of CTLA-4, which allows CTLs to kill cancer cells
alemtuzumab CD52 CLL, T-cell lymphoma Specific targeting; ADCC
For autoimmune and inflammatory diseases (review in Ref. 4)
Natalizumab α4 subunit of α4β1 and α4β7 integrins MS; Crohn’s disease Receptor binding and antagonism; inhibits leukocyte adhesion to their counter receptor (or receptors)
infliximab TNF-α RA; Crohn’s Disease; plaque psoriasis; UC; AS; psoriatic arthritis Binds soluble and membrane-bound TNF; neutralizes TNF; inhibits binding to TNFRs; induces activated T cell and macrophage apoptosis
adalimumab RA; Crohn’s Disease; plaque psoriasis; JIA; AS; psoriatic arthritis Binds soluble and membrane-bound TNF; neutralizes TNF; inhibits binding to TNFRs; lyses TNF-producing cells;
Certolizumab RA; Crohn’s Disease Binds soluble and membrane-bound TNF; neutralizes TNF; inhibits binding to TNFRs
Golimumab RA; psoriatic arthritis; AS Binds soluble and membrane-bound TNF; neutralizes TNF; inhibits binding to TNFRs
rituximab CD20 TNF-inhibition resistant RA Sensitizes cells to chemotherapy; apoptosis, ADCC, CDC
Tocilizumab IL-6R RA Receptor binding and ligand blockade
Ustekinumab IL-12, IL-23 Plaque soriasis Ligand binding and receptor antagonism
Omalizumab IgE Moderate to severe persistent allergic asthma Ligand binding and receptor antagonism; reduces IgE binding to mast cells and basophils, preventing degranulation
basiliximab CD25 (IL-2R) Prophylaxis for rejection of kidney allografts Receptor antagonism; prevents binding of IL-2 to CD25 on B- and T-cell surface
Belimumab BAFF (a.k.a. BLyS) SLE Ligand binding and neutralization; induces apoptosis in B-cells with inactive BAFF
abciximab pro-thrombic glycoprotein factor IIb/IIIb prevention and resolution of intravascular blood clots Specific targeting; inhibits factor IIb/IIIa on platelet membrane, prevents platelet aggregation and thrombus (blood clot) within coronary artery
Eculizumab C5 (Complement) Paroxysmal nocturnal haemoglobinuria Binds C5, inhibiting complement cascade and CDC
Canakinumab IL-1β CAPS (including Muckle-Wells syndrome) Ligand binding and receptor antagonism; prevents IL-1β action
For other conditions, including infectious diseases (review in Ref. 5)
Denosumab RANK-L Bone loss; osteoporosis; bone metastases; giant cell tumor Ligand binding and receptor inactivation; leads to suppression of osteoclast (bone-destroying cell) maturation
Ranibizumab VEGF-A wet-type age-related macular degeneration Ligand binding and receptor inactivation; prevents angiogenesis, and resultant macular edema and choroidal neovascularization
Palivizumab epitope in the A antigenic site of the Fusion protein of RSV Prophylaxis against RSV Prevents RSV entry into the cell

Abbreviations: ADCC, antibody-dependent cellular cytotoxicity; AS, ankylosing spondylitis; BAFF, B-cell activating factor; CAPS, Cryopyrin-associated periodic syndromes; CDC, complement-dependent cytotoxicity; CLL, chronic lymphocytic leukemia; CTL, cytotoxic T lymphocyte; CTLA4, cytotoxic T lymphocyte antigen 4; EGFR, epidermal growth factor receptor; HER2, human epidermal growth factor receptor 2; IL, interleukin; JIA, juvenile idiopathic arthritis; MS, multiple sclerosis; NHL, non-Hodgkin’s Lymphoma; R, receptor; RA, rheumatoid arthritis; RANK-L, receptor activator of NFkb ligand; RSV, respiratory syncytial virus; SLE, systemic lupus erythematosus; TNF,tumour necrosis factor; UC, ulcerative colitis; VEGF-A, vascular endothelial growth factor A.

In addition to above, certain MAbs have been used as targeting agents for specific delivery of a toxic payload to cancer cells; for example, (a) Ibritumomab tiuxetan and Tositumomab-I131 (both recognize CD20 on normal and malignant B-cells) are used in NHL to deliver a radioactive isotope (Yttrium-90, Indium-111, or Iodine-131) which kills B-cells, leaving the void to be filled by a fresh batch of healthy B-cells from bone marrow; (b) Brentuximab vedotin (anti-CD30 present on T- and B-cells) is used in Hodgkin’s lymphoma and anaplastic large cell lymphoma to deliver the anti-mitotic drug vedotin, which inhibits the proliferation of cancer cells.

I don’t know about you, but I am fascinated by the power of the MAb technology. However, the same characteristic of specificity may cause restricted functionality of the MAbs; they cannot bind to multiple epitopes, and therefore, are not very effective against complex epitopes (as in certain bacterial toxins), nor in situations in which there are too many targets (due to heterogeneous cell populations, as in many cancers) or the density/availability of targets are low (due to low target expression, as in certain tumors). A related but different problem arises because of low levels of targets present elsewhere in the body; binding of the MAb to those molecules outside of the target tissue may cause unintended toxicities and side effects (7), which has over time led to the withdrawal of certain approved MAbs from the market. In addition, having been made in vitro, MAb also fail when the targets change (mutate or evolve). This has been the single most important difficulty that has prevented generation of MAb therapeutics against infectious diseases, because pathogens often evolve to adapt to the host body.

A timeline of evolution of Antibody Therapeutics in the US:

Evolution of antibody therapeutics in US

In the totality of Antibody Therapeutics, MAbs have had several iterations of importance, which I shall discuss in the next post.

References for further reading:

  1. Casadevall, et al.(2004) Passive antibody therapy for infectious diseases. Nature Reviews Microbiology 2, 695-703; doi:10.1038/nrmicro974.
  2. Buchwald and Pirofski (2003) Immune therapy for infectious diseases at the dawn of the 21st century: the past, present and future role of antibody therapy, therapeutic vaccination and biological response modifiers. Current Pharmaceutical Design 9(12), 945-68.
  3. Buelow and Schooten (2006) The Future of Antibody Therapy. In: Radbruch, et al. (Eds) Immunotherapy in 2020: Ernst Schering Foundation Symposium Proceedings, pp.83-106. Springer Berlin Heidelberg, Germany. Doi: 10.1007/2789_2007_040.
  4. Chan and Carter (2010) Therapeutic antibodies for autoimmunity and inflammation. Nature Reviews Immunology 10, 301-316; doi:10.1038/nri2761
  5. Antibody Society: list of Approved MAbs, as of June 9, 2012 page, last accessed: November 8, 2012.
  6. Weiner et al. (2010) Monoclonal antibodies: versatile platforms for cancer immunotherapy. Nature Reviews Immunology 10, 317-327; doi:10.1038/nri2744.
  7. Hansel et al. (2010) The safety and side effects of monoclonal antibodies. Nature Reviews Drug Discovery 9, 325-338; doi:10.1038/nrd3003.

This is the SECOND PART of a multipart series on exciting new developments in the world of antibodies.

1 Comment

  1. Rituximab has been used in a small placebo controlled trial to treat ME.

    http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0026358

    Although the cause is unknown their have been a number of results suggesting abnormalities in the immune system. The trial happened after a patient with ME and Lymphoma was treated with Rituximab and the ME symptoms went. Some time later they came back though.

    There has been much hope in the ME community that this offers a potential treatment as well as helping understand the pathology of the disease

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