Continuing Education Course: Clinical Pathology of Biotherapeutics

Toxicologic Pathology
2018, Vol. 46(8) 1013-1019

Immunogenicity and Immune Complex ª The Author(s) 2018

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Disease in Preclinical Safety Studies DOI: 10.1177/0192623318797070
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John L. Vahle1

Abstract
This article summarizes a continuing education presentation on immunogenicity that was part of a continuing education course
entitled, “Clinical Pathology of Biotherapeutics.” Immunogenicity of a biotherapeutic can have diverse impacts including altered
systemic exposure and pharmacologic responses and, in a fraction of the cases, safety concerns including cross-reactive neu-
tralization of endogenous proteins or sequela related to immune complex disease (ICD). In most cases, immune complexes are
readily cleared from circulation; however, based on physiochemical properties, insoluble complexes form, activate complement,
and deposit in tissues. Using published information and personal experience, a set of repeat-dose monkey toxicity studies with
manifestations suggestive of ICD was reviewed to summarize the spectrum of clinical and pathology findings. The most common
live-phase observation linked to ICD was an acute postdosing reaction following multiple dose administrations characterized by
generalized collapse and attributed to acute complement activation. Less common live-phase observations were related to syn-
dromes such as a consumptive coagulopathy or a protein losing nephropathy. The most common histologic change attributed to
ICD was multi-organ vascular/perivascular inflammation followed by glomerulonephritis. The presentation concluded with a
description of the challenges in assessing the relevance of immunogenicity-related reaction in monkey to human clinical use.

Keywords
immunogenicity, toxicity, immune complex disease, nonhuman primate, biotherapeutics

Introduction
This article summarizes one of the four presentations at a
Continuing Education Session held in association with the
Society of Toxicologic Pathology’s Thirty-seventh Annual
Symposium. The Continuing Education Session focused on the
clinical pathology evaluation of biotherapeutics in the context
of nonclinical safety studies. The primary objective of this
article was to review the potential impacts of immunogenicity
on the nonclinical safety assessment of biotherapeutics.
Following a brief introduction to the concepts of immunogeni-
city including mechanisms of formation of antidrug antibodies
(ADAs), the remainder of the presentation focused on the
various manifestation of immunogenicity in nonclinical safety
studies. Particular focus was placed on the development of
immune complex disease (ICD) in nonhuman primates admi-
nistered monoclonal antibody-based constructs. The review
concluded by addressing some of the challenges in understand-
ing the relevance of the immunogenicity findings in animals to
the safety of these agents in human clinical trials. This review
did not provide a detailed analysis of mechanisms of immuno-
genicity or immune complex formation and did not review
acute (type 1) hypersensitivity reactions. Several excellent
reviews on nonclinical and clinical immunogenicity were high-
lighted for the audience (Leach et al. 2014; Ponce et al. 2009;
Rojko et al. 2014; Mease, Kimzey, and Lansita 2017; De Groot
and Scott 2007; Krishna and Nadler 2016) and served as an
important basis for the presentation.
Immunogenicity: An Introduction
For the purposes of this review, immunogenicity was defined
as the ability of a therapeutic agent to induce an immune
response. Immunogenicity is most frequently a concern for
protein-based therapeutics (hereafter referred to as biothera-
peutics) and can occur in both animal and human settings
(Krishna and Nadler 2016; Ponce et al. 2009). The antibody
that is generated in response to a biotherapeutic has been
variably referred to as an ADA, antitherapeutic antibody,
primate antihuman antibody, or a human antihuman antibody,
and the general response has been referred to as an anti-
antibody response. The potential for immunogenicity to
limit the use of biotherapeutics, particularly monoclonal
1
Lilly Research Laboratories, Indianapolis, Indiana, USA
Corresponding Author:
John L. Vahle, Eli Lilly and Company, Lilly Corporate Center, Indianapolis,
IN 46285, USA.
Email: jvahle@lilly.com
1014
Figure 1. The types of impacts that an immunogenic response to a biotherapeutic can have on a toxicity study. In some cases, very little impact is
noted as there is not an appreciable impact on systemic exposure or pharmacologic or toxicologic effect. At the other end of the spectrum are
those cases where immunogenicity can have substantial impact including morbidity or mortality, including but not limited to hypersensitivity
reactions such as immune complex disease.
antibodies, was an early concern for the field (Kuus-Reichel
et al. 1994), and while immunogenicity remains an important
topic, a wide array of monoclonal antibody and related protein
constructs has proven to be highly effective therapeutics for a
variety of disease states. In the clinical setting, immunogeni-
city can cause a variety of effects including loss of systemic
exposure, loss of the desired therapeutic response, and less
frequently safety concerns such as infusion reactions, cross-
reactive neutralization of endogenous proteins that mediate
critical biologic functions, and ICD. When immunogenicity
issues arise late in the clinical development process, they are
extremely costly to drug developers. As such, methods to
predict and mitigate against clinical immunogenicity are
active areas of investigation (Yin et al. 2015).
It is important to recognize that many factors can affect
immunogenicity. Product-specific factors that affect immuno-
genic potential often focus on the protein sequence of the con-
struct; however, in many cases, the formulation, aggregates,
impurities, and therapeutic target play important roles.
Treatment-specific factors such as the dose, route, and fre-
quency of administration also influence immunogenic poten-
tial. Patient-specific factors such as the disease state,
concurrent illness or medications, and genetic background are
also important and underscore how challenging it can be to
predict immunogenic potential. While the production of ADAs
can occur via both T-cell-dependent and T-cell-independent
Toxicologic Pathology 46(8)
mechanisms (De Groot and Scott 2007), much of the focus
regarding predicting immunogenicity is centered on identifying
T-cell epitopes that drive T-cell help and antibody production.
Potential Impact of Immunogenicity
on Animal Toxicity Studies
Similar to the clinical setting, immunogenicity can have a vari-
ety of impacts in animal models including the toxicity studies
used to characterize the nonclinical safety profile of the
biotherapeutic (Figure 1). Because the biotherapeutic is a
human or humanized protein, the frequency and severity of the
immunogenic response can be greater in the animal model than
in the human clinical setting (Leach et al. 2014; Ponce et al.
2009). Despite the increased “foreignness” for the human pro-
tein in animals, in many cases, there may be no appreciable
immunogenicity in the animal model. While robust data are not
available on the frequency of immunogenicity in nonclinical
toxicity studies, pathologists frequently encounter studies of
biotherapeutics where there is essentially no impact of immu-
nogenicity on the overall study outcome. In these cases, sys-
temic exposures are maintained at adequate levels to assess
toxicity, there is no loss of intended pharmacologic effects, and
no sequela related to hypersensitivity or ICD.
Antibody-mediated changes in the pharmacokinetic profile
are one of the more common sequela of immunogenicity in
Vahle
toxicity studies. Antibodies that bind to the biotherapeutic and
increase their clearance from systemic circulation are referred
to as “clearing” antibodies and can markedly reduce systemic
exposure and interfere with the ability to assess toxicity in
either a single animal or entire dose groups. Various study
designs can be considered in an effort to “dose through” immu-
nogenicity including increasing administered dose or altering
dose frequency or route of administrations (Ponce et al. 2009).
While less common, there are clear examples where antibodies
to the therapeutic protein have decreased systemic clearance
resulting in increased systemic exposure (“sustaining anti-
bodies”). In these cases, prolonged circulation time may
increase pharmacologic activity and complicate assessments
of toxicity. In addition to altering systemic exposure, the anti-
body to the biotherapeutic can bind at or near the target-binding
epitope and inhibit the biotherapeutics ability to bind to the
desired target. These antibodies are referred to as “neutralizing
antibodies.” Both neutralizing and clearing antibodies, by
reducing the pharmacologic effects of the biotherapeutic, can
compromise the ability to assess the toxicity profile of the
therapeutic. To aid in the overall interpretation of the toxicity
study, it is important for the study pathologist to work with
colleagues in toxicokinetics and immunology to assure an
appropriate assay strategy is in place. These assays can include
the measurement of the active circulating biotherapeutic,
detection of circulating ADA levels, and measurement of phar-
macodynamic end points in either the periphery or tissues.
The biologic significance of immunogenicity is heightened
when the ADA neutralizes not only the administered biother-
apeutic but also the biologic function of a critical endogenous
protein (cross-reactive antibodies). For example, thrombocyto-
penia and pancytopenia have been reported in patients follow-
ing the administration of recombinant human thrombopoietin
(Basser et al. 2002; Li et al. 2001). Clearly, in both animal and
human settings, the development of cross-reactive antibodies to
endogenous proteins can have life-threatening consequences.
Finally, as discussed in more detail below, the formation of
immune complexes and sequela can have major impact on the
interpretation of toxicity studies.
ICD—Overview of Mechanisms
A thorough review of the mechanisms of immune complex
formation, clearance, measurement, and pathophysiology was
outside the scope of the presentation. The audience was
referred to reviews of the topic by Rojko et al. (2014), an
investigation of anti-infliximab immune complexes by Rojas
et al. (2005), and methods to measure circulating immune com-
plexes by Pierog et al. (2015). Key concepts discussed include
the fact that in health, levels of circulating immune complexes
are relatively low due to two primary clearance mechanisms.
One mechanism consists of clearance via the FcgRIIa receptor
on platelets, monocytes, and macrophages and is present across
rodent and primates. The other mechanism, which is specific to
primates, involves shuttling of immune complexes via the com-
plement receptor 1on red blood cells. A variety of factors
1015
influence the physiochemical properties of immune complexes
and dramatically effect clearance and deposition of immune
complexes. Lattice size is one of the key factors, and the large
lattices can form when there is antigen: Antibody equivalence
is often insoluble and can lead to tissue deposition. Antigen and
antibody ratios are not the sole determinant, as
the concentration, valence, and charge of both antigen and
antibody can influence immune complex formation and clear-
ance. While these are useful concepts to understand, multiple
factors can influence immune complex formation, clearance,
and deposition, and it is not possible to predict the potential for
a given biotherapeutic at a given dose and dose frequency to
induce ICD in animals.
Immune complex formation leading to systemic and tissue
effects is generally considered a type III hypersensitivity reac-
tion in the classical Gel-Coombs classification scheme (Leach
et al. 2014); however, the pathophysiology is much more com-
plex than simple intravascular deposition of insoluble immune
complexes. As summarized by Krishna and Nadler (2016),
three key interrelated mechanisms contribute the reaction: (1)
deposition of immune complexes in vasculature and sites of
hyperfiltration leading to inflammation, (2) activation of com-
plement by the immune complex, and (3) cross-linking of FcgR
and complement receptor on the surface of a variety of immune
cells leading the release of inflammatory mediators and che-
motactive substances. Complement activation plays a key role
in both the systemic and the tissue effects noted in ICD, and
key mediators are the generation of the anaphylatoxins C3a,
C4a, and C5a (Krishna and Nadler 2016).
Findings Attributed to ICD in Nonhuman
Primate Toxicity Studies
To summarize the range of live-phase, laboratory, and mor-
phologic findings that have been associated with ICD follow-
ing the administration of biotherapeutics to nonhuman
primates in toxicity studies, a group of 23 repeat-dose nonhu-
man primate studies was reviewed for this presentation. The
level of detail available for each study varied greatly as the
information was derived from publications, workshop presen-
tations, personal communications, and personal experience.
Key publications that either review a series of cases or present
detailed results from a single-case experience include (Rojko
et al. 2014), (Heyen et al. 2014), Husar et al. ( 2017), and
Kronenberg et al. (2017). From the information available
across the studies reviewed, key study design elements, live
phase-findings, laboratory findings, and anatomic pathology
findings were summarized.
Of the 23 studies examined, 22 used different biotherapeu-
tics (two studies were reported for one of the biotherapeutics),
and as expected, these were primarily monoclonal antibody-
based biotherapeutics. In many cases, only general descriptions
of the biotherapeutic were disclosed, so it was not possible to
identify clear trends; however, ICD was reported in studies of
both monospecific and bispecific antibodies and occurred
across various isotypes of antibody (IgG1, IgG2, and IgG4).
1016
There were insufficient data to determine whether a certain
type of antibody construct was more prone to developing ICD.
In terms of methods of dose administration, manifestations of
ICD were reported across both intravenous and subcutaneous
administrations and in studies using weekly, twice-weekly, and
once-monthly dose administrations. Although the administered
dose on a milligram per kilogram basis was not reported for
many studies, most studies reported the dose level (low, mid-
dle, and high) at which ICD was reported. Manifestations of
ICD were observed across all dose levels and in various dose-
level combinations. While it was difficult to assess the true
dose response in all the studies due to limited individual animal
reporting, ICD did not generally present in a dose-responsive
manner. The incidence of ICD within a given study also varied
widely, and in 36% of the studies, only a single animal was
affected, whereas in 64% of the studies, multiple animals were
affected.
In 13 of the 23 studies (57%), findings attributable to ICD
were reported during the live phase. While the clinical signs
and laboratory findings reported were quite varied, for the
purposes of this Continuing Education Session, live-phase
findings were grouped into broad syndromes. The most com-
mon presentation or syndrome was designated an acute post-
dose reaction. These reactions occurred shortly after dose
administration and most frequently occurred following the
fourth or fifth dose administration. Clinical signs reported in
nonhuman primates included hypoactivity, retching, emesis,
excessive salivation, altered respiration, pallor, hypothermia,
and pruritus. As discussed in Rojko et al. (2014), these may be
a form of a generalized type III hypersensitivity reaction asso-
ciated with acute complement activation. The clinical course
for these animals varied widely with some showing sponta-
neous recovery, other requiring veterinary intervention with
supportive case, and in other cases progressing to morbidity
requiring early euthanasia. While the type and timing of labora-
tory data obtained in these animals was variable, the more
common observations included transient decreases in neutro-
phil and platelet counts, increased fibrinogen and triglyceride
concentrations, and decreases in albumin concentration. Com-
plement data were reported in five of the 23 studies, and while
the specific complement components analyzed varied,
increases in C3a, C4a, C4d, and SC5b-9 were reported. Cyto-
kine determinations were only reported in two of the 23 studies,
and increased MCP1, Il-10, and IL6 were reported in one of
these studies.
Although likely part of a continuum associated with acute
complement activation, there were two additional acute live-
phase syndromes identified in this case series. A subgroup of
animals developed a consumptive coagulopathy. While many
of these animals had clinical signs similar to those of the post-
dose reaction described above, additional live-phase observa-
tions included failure to clot at the phlebotomy site and/or
petechial hemorrhage. While the laboratory data collected var-
ied according to the specific study, laboratory findings reported
in these animals included reductions in platelet counts, pro-
longed coagulation times, decreased fibrinogen concentration,
Toxicologic Pathology 46(8)
and, in a single case, d-dimers were analyzed and reported as
increased in concentration. Another syndrome that is likely
associated with these acute postdose reactions included a sub-
set of animals that had acute collapse postdosing, and the only
histologic change identified was acute thrombosis. The level
of detail reported in these studies did not allow a determina-
tion whether these animals also had laboratory data that would
have been consistent with a consumptive coagulopathy and
disseminated intravascular coagulation. The live-phase obser-
vations described above occurred shortly postdose. This is in
contrast to the other important live-phase syndrome, nephro-
tic syndrome, in which there was a gradual onset of clinical
signs and laboratory findings. These animals were often first
detected based on live-phase observations of dependent
edema, decreased body weight, and decreased food consump-
tion and/or laboratory data of decreased serum albumins and
increased urinary proteins. In each of these cases, histologic
examination revealed glomerular disease attributed to
immune complex deposition.
Rojka et al. (2014) provided a thorough review of the his-
tologic findings associated with ICD as well as the immuno-
histochemical localization of various immune component with
tissues. In the current series of studies, the general pattern of
histologic changes was consistent with that reported by Rojko
et al. Two of the 23 studies described clinical signs or labora-
tory findings that were attributed to ICD and acute complement
activation but that did not have histologic lesions indicative of
ICD. In the remaining 21 studies, in which histologic changes
were attributed to ICD, perivascular and/or vascular inflamma-
tion was the most common histologic change occurring in 49%
of the studies. Within a given study, the individual animal
incidence of this change varied, and within an animal, the
number of tissues affected was also highly variable ranging
from a single vessel affected to widespread multi-organ invol-
vement. Consistent with the sites of predilection for immune
complex deposition, common sites were small to medium ves-
sels in the serosa or mesentery, tortuous vessels in the urogen-
ital tract, sites of hyperfiltration (choroid plexus, glomerulus),
and the aortic root and coronary artery of the heart. In some
cases, immunohistochemistry for immune components was
used to confirm a diagnosis of immune complex vasculitis.
Glomerulonephritis was less common than vasculitis in this
series of cases and was reported in 16% of those studies in
which histologic lesions attributable to immune complex
occurred. The morphology of immune complex glomerulone-
phritis has been well described previously, and in this case
series, key histologic findings reported were glomerular hyper-
cellularity with hypersegmentation, increased mesangial
matrix, thickened peripheral capillary loops, and, in more
severe cases, synechia. Additional diagnostic methods were
used in several of the studies and included localization of
immune components within the lesion and electron microscopy
to identify electron-dense deposits and further characterize the
glomerular change. Other changes reported but not described in
detail included fibrin thrombi in vessels not associated with
vascular/perivascular inflammation and an increase in the size
Vahle
Figure 2. Various end points and approaches study teams can consider in developing a weight-of-evidence assessment regarding immune
complex disease in animal toxicity studies. The author emphasized a case-by-case approach to determining which end points are most appropriate
for a given animal or study.
and/or number of Kupffer cells in the liver. In more advanced
cases with severe vasculitis, a variety of secondary changes
were reported including edema, hemorrhage, and necrosis of
adjacent tissue.
Diagnostic Approach to ICD
The author provided a brief overview of the diagnostic tools
that can be used to investigate findings that may be attributable
to ICD (Figure 2). For many of the laboratory alterations that
may be of interest such as detection of acute phase responses or
acute complement activation, sampling timing is critical. As
such, during the study design phase, the study team can con-
sider a sample banking strategy where the appropriate matrix
(serum and/or plasma) is banked both prestudy (to establish
individual animal baseline values) and at various intervals both
pre- and postdose during the study. In those cases where there
are unexpected events and prospective samples were not
obtained, residual samples from toxicokinetic or routine clin-
ical pathology samples may be available. An advantage of the
toxicokinetic samples, if available and in the appropriate
matrix, is that they are typically obtained at multiple intervals
postdose. In addition to laboratory data, having timely and
consistent recording of live-phase observations is important
in those situations where one or more animals develop clinical
signs postdose administration. The live-phase observer should
strive to use consistent terminology across the study to allow
1017
study personnel to determine whether different animals are
having similar presentations.
The routine end points included in standard repeat-dose
toxicity studies (live-phase observation, hematology, clinical
chemistry, urinalysis, coagulation panels, anatomic pathol-
ogy, and toxicokinetic data) provide a strong database and
in some cases may be sufficient to provide a high index of
suspicion that immunogenicity and ICD are present. Other
assays that are often critical in the overall weight-of-
evidence assessment include ADA analysis, assessment of
pharmacodynamic markers to assess whether active drug is
present, detection of circulating immune complex levels,
complement and cytokine determinations, and an expanded
panel of acute phase reactants.
With respect to tissue-based end points, immunohistochem-
ical or immunofluorescent detection of immune components in
the tissue of interest can be helpful and in some cases can
provide a definitive diagnosis of ICD. Methods are available
to detect not only various immunoglobulin and complement
components from the monkey (e.g., monkey IgG, IgM, C3) but
also to localize the therapeutic antibody within the tissue of
interest. Other morphologic approaches that may be warranted
include electron microscopy and special stains (e.g., Periodic
Acid Schiff [PAS] on thin sections) to better characterize glo-
merular disease.
One of the most important aspects of the diagnostic or inves-
tigative approach is, for the study team and the study
1018
pathologists in particular, to bring a strong diagnostic skill set
and differential diagnostic approach to the study. While it can
be tempting to default to a diagnosis of ICD for any postdose
reaction or vascular change that occurs in a monkey that has
developed an immunogenic response, the study team needs to
carefully rule out, as best as possible, that the changes are not
either (a) directly attributable to the test article or (b) a sponta-
neous event unassociated with the test article. Another impor-
tant challenge for the study team to deal with is the fact that in
many cases, not all of the individual end points will correlate
for a given animal. Because no single diagnostic test has per-
fect specificity and ICD manifests in a variety of ways, these
cases often remain diagnostic and interpretive challenges. A
relatively straightforward case might present with multiple epi-
sodes of acute postdose reactions, significant loss of systemic
exposure, high titers of ADA, postdose complement activation,
and histologic evidence of vasculitis and glomerulonephritis. In
the studies summarized above, this type of “perfect con-
cordance” was relatively rare. For example, at the high doses
administered in some toxicity studies in an effort to overcome
immunogenicity (“dosing through strategy” [Ponce et al.
2009]), despite considerable immunogenicity and accelerated
clearance of the biotherapeutic, systemic exposure may not be
dramatically impacted. In addition, assays for ADA may not be
positive due to the design of the assay with respect to drug
tolerance. Although not clearly reported in the case series
examined, in the author’s experience, there is often not a direct
correlation between ADA titer and the presence and/or severity
of ICD. Some biotherapeutics can induce high ADA levels with
marked reduction in systemic exposure and did not result in any
evidence of ICD in the toxicity study.
Given these challenges, it can be difficult to determine the
appropriate diagnostic approach for any given study. Labora-
tories and sponsors appear to vary widely in the intensity in
which they investigate these findings. The author encouraged a
case-by-case determination and suggested the study team con-
sider a variety of factors in determining what level of evidence
is warranted. Key questions for consideration are:
 What is the severity of the findings?
 Did the findings result in morbidity or mortality?
 What are the incidence and dose responsiveness of the
findings across the study?
 What is the overall anatomic distribution of the findings
(e.g., single vessel vs. widespread vasculitis)?
 What is the overall weight of evidence with the existing
data?
 What additional data are more likely to be informative?
For example, in a study where a single animal presents with
a minimal to slight vascular lesion and the systemic exposure
was markedly reduced, it may be warranted to indicate in the
study report that the finding was potentially due to ICD rather
than representing a direct test-article effect and not to pursue
further evaluation. In contrast, a study with a high incidence of
postdose reactions and vascular disease that resulted in
Toxicologic Pathology 46(8)
morbidity and lacked a consistent correlation to altered sys-
temic exposure might warrant additional analysis such as asses-
sing complement activation or attempting to localize immune
components in the tissue.
Challenges in Assessing Human Relevance
The presentation concluded with a brief discussion on how to
assess the clinical relevance of immunogenicity-related find-
ings in animal toxicity studies. To frame the discussion, three
divergent approaches were reviewed. On one end of the spec-
trum was an approach that considers animal immunogenicity-
related findings as not relevant to humans, since an immune
response to a human or humanized protein is expected to be
greater in animals than in humans. In this approach, the animal
findings may not be used in the determination of a study no-
observed-adverse-effect level and summary clinical regulatory,
and clinical documents might not discuss the animal findings in
detail. A downside of this approach is that it may be overly
definitive in using language such as “not relevant” and may not
provide the appropriate degree of transparency and interpreta-
tion of this complex phenomenon. At the other end of the
spectrum is an approach that suggests since humans can
develop immune responses to human or humanized protein
therapeutics and since ICD can occur in humans, the animal
findings are a key safety finding and should be used to deter-
mine human dose levels and drive clinical safety monitoring
strategies. A downside of this approach is that it does not
incorporate sufficient perspective regarding the generally poor
predictive value animals have with respect to immunogenicity
in general, and it may create greater clinical and/or regulatory
concern for the findings than is warranted.
The author suggested an intermediate approach that indicates
that while animal studies are often not predictive of immuno-
genicity and sequelae related to immunogenicity in humans, the
animal findings should be carefully considered as part of the
overall safety assessment. For example, if there is an on-target
mechanistic basis for enhanced immunogenicity in animals, the
findings might be considered more predictive for humans. In
addition, for novel constructs that may be considered more
“foreign” to both animals and human and for which there is
limited clinical experience, additional caution might be war-
ranted. One important point to keep in mind with this approach
is that because immunogenicity does not generally occur in a
dose-responsive manner, the animal findings should be consid-
ered more in terms of hazard identification, and it is likely not
appropriate to set clinical dose ranges based on immunogenicity-
related findings. In both the study and clinical regulatory
documents describing immunogenicity-related findings, it is
important to distinguish between immunogenicity-related find-
ing, which have questionable translation for human, and direct
on-target pharmacologic and toxicologic effects, which are more
likely translatable to the human setting. In the author’s preferred
approach, these direct on-target effects are most appropriate for
setting the clinical dose range. Ultimately, the goal is to provide
clinicians and regulators the transparency and perspective on the
Vahle
immunogenicity-related findings while providing clear descrip-
tions on the nature and dose response of direct on-target effects.
The field currently lacks robust data to either definitively
confirm or refute the statement that ICD in animals does not
predict for similar effects in man. Certainly, there are examples
in summary basis of approval documents where the findings in
nonhuman primates did not predict for an increased immuno-
genicity or immune complex in humans. In an important paper
discussing both animal and human data, Hussar et al. (2017)
describe a high incidence and severity of ICD in monkeys
administered an anti-CD20 monoclonal antibody; however, the
accumulated clinical data have not identified an increased risk
of events attributable to ICD.
The author closed the presentation by emphasizing to the
audience that immunogenicity in nonclinical safety study is
challenging to predict, and the sequelae associated with
immunogenicity are diverse. Study teams mostly keep an
open mind and use a weight-of-evidence approach when
describing and interpreting findings that may be attributable
to immunogenicity.
Acknowledgments
The author greatly benefited from collaborative discussions with
pathology, toxicology and immunology colleagues over the years
including Nancy Everds, William Siska, Charley Dean, Sven Kronen-
berg, Frank Brenan, Michael Leach, Jennifer Rojko, Rafael Ponce,
Mark Evans, Heather Dale, Tara Arndt, Jamie Blackbourne, and Mer-
edith Steeves. These discussions greatly aided the preparation of the
continuing education presentation upon which this article was based.
Author Contributions
The author (JV) contributed to conception or design; data acquisition,
analysis, or interpretation; drafting the manuscript; and critically
revising the manuscript. The author gave final approval and agreed
to be accountable for all aspects of work in ensuring that questions
relating to the accuracy or integrity of any part of the work are appro-
priately investigated and resolved.
Declaration of Conflicting Interests
The author(s) declared no potential, real, or perceived conflicts of
interest with respect to the research, authorship, and/or publication
of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
1019
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