PY365 - Autoimmune Diseases Cluster

Ali AlAttar 20800061
L0) Immunology Revision (Not Examined) –

PT. 1 The Adaptive Immune System & Tolerance:
ANTIBODY-BASED BIOLOGICS ANTIBODY STRUCTURE
Many of the BIOLOGICS used to treat These antibodies work by blocking
AiDs/autoimmune diseases are based receptors or binding to (or
on the component of the adaptive inactivating) their ligands
immune system known as interacting with those receptors.
ANTIBODIES They can be either responds to or
are cytokines (key in autoimmune
diseases)
Thus you need to You need to know about the STRUCTURE of an antibody, as:-
revise the STRUCTURE
of antibodies and how
they can be MODIFIED • The FUNCTION of Therapeutic Antibodies depends on their STRUCTURE
to reduce side effects • Some Therapeutic Antibodies only comprise PART of the entire antibody
molecule, so, you need to know the pieces
THE IgG MOLECULE - STRUCTURE • We will concentrate on the IgG antibody, as this is the major serum antibody
and represents the overwhelming majority of therapeutic antibodies
The IgG molecule is comprised of
TWO HEAVY and
Autoimmunity
TWOCase PY365
LIGHT – Case 3.4
polypeptide Therapeutics
- Autoimmune Disease
“chains” VH Cluster 1
1 1 THE IgG MOLECULE – THE Fab FRAGMENT
VL
The HEAVY chains (H) are made of FOUR The Fab (Fragment Antibody Binding) Binds to EPITOPE
CH
DOMAINS (3 “constant”, 1 “variable”), and is the TOP PART
CL
the LIGHT (L) chains of TWO DOMAINS Of the IgG molecule (the “arms” VH
(1 “constant”, 1 “variable”) VL
Of the Y-shaped IgG molecule) PARATOPE
CH
The domains are either genetically very CH
similar to each other (= C ‘constant’) The VARIABLE DOMAINS (VH and VL) CL
or are very different from each other (= V are called the PARATOPE
‘variable’) – note the naming of each
domain The PARATOPE binds to the EPITOPE
CH
on the ANTIGEN molecule:
DISULPHIDE BONDS link one OR each “arm” can bind one
heavy chain to the other and the Additional antibody molecule
light chains to the
Heavy chains
- Antibodies - a blood protein produced in response to and counteracting a

specific antigen, they combine chemically with substances which the body
recognizes as ‘alien’, such as bacteria, viruses, and foreign substances in the
blood.
- The fragment antigen-binding region (Fab region) is a region on an
antibody that binds to antigens. It’s composed of one constant and one
variable domain of each of the heavy and the light chain. The variable
domain contains the paratope (the antigen-binding site), comprising a set
of complementarity-determining regions, at the amino terminal end of
1
the monomer where each arm of the Y thus binds an epitope on the
antigen.
- A paratope, also known as an antigen-binding site, is the part of an
antibody which recognizes and binds to an antigen – it’s a small region at
the tip of the antibody's antigen-binding fragment and contains parts of the
antibody's heavy and light chains.
- An epitope, also known as antigenic determinant, is the part of an antigen
that is recognized by the immune system, specifically by antibodies, B cells,
or T cells. The epitope is the specific piece of the antigen to which an
antibody binds where the part of an antibody that binds to the epitope is
called a paratope.
- T cells – a type of white blood cell where T lymphocytes are part of the
immune system and develop from stem cells in the bone marrow.
Additionally, helper T-cells stimulate B-cells to make antibodies and help
killer cells develop whereas killer T-cells directly kill cells that have already
been infected by a foreign invader.
- B cells – also called B lymphocytes, , create a type of protein called an
antibody – these antibodies bind to pathogens or to foreign substances,
such as toxins, to neutralize them e.g., an antibody can bind to a virus,
which prevents it from entering a normal cell and causing infection.
WHAT IS AN EPITOPE?
THE IgG MOLECULE –FURTHER Fab FRAGMENTS
VL
1. F(ab’)2
(i.e.,: CERTOLIZUMAB CH
ALL of these fragments
PEGOL CL have therapeutic activity –
Can be derived from MURINE
mAbs = “Chimaeric Abs”
An EPITOPE, also known as ANTIGENIC DETERMINANT, is the part of an

antigen that is recognized by the immune system, specifically by
ANTIBODIES, B cells, or T cells. The part of an antibody that binds to the or
epitope is called a PARATOPE (previous slide)
An antigen (Ag - abbreviation of antibody generator), is any structural
substance which serves as a target for the receptors of an adaptive immune 2. Fab 3. scFv (single-chain 4. sdAb (single-domain
response, T- or B-cell receptors or ANTIBODIES variable fragment) Antibody)
Antigens are nearly always polypeptides (strings of amino acids) or
polysaccharides (rarely, lipids)
2
The IgG Molecule – The Fc Fragment “HYPERVARIABLE REGIONS”

Comparisons of genetic data from a lot of IgG molecules suggested that
The Fc Fragment is the BOTTOM PART short regions were extremely variable - became known as HYPERVARIABLE
Of the IgG molecule (the “stalk” REGIONS – these protrude/extend beyond from the tips of the Fab
VH
Of the Y-shaped IgG molecule VL
PARATOPE as loops and bind to epitopes/other antibody molecules
- It has BIOLOGICAL FUNCTIONS
CH
• The Fc Fragment binds to CELLULAR
CL
(Fc) RECEPTORS on cells and pathogens and
triggers PHAGOCYTOSIS which is the the
ingestion of bacteria or other material by
CH
phagocytes of antibody-coated cells by
macrophages etc.
• It also activates COMPLEMENT
• The Fc Fragment also provides STABILITY
to FUSION PROTEINS such as ETANERCEPT
• Usually from HUMAN IgG – seen as SELF
Etanercept is a tumor necrosis factor (TNF)
blocker that is used in adults to prevent joint Binds to Fc receptors These can be derived from MURINE mAbs = “Humanized Antibodies”
damage caused by rheumatoid arthritis Activates Complement
ACTIVATION OF IMMUNE RESPONSES

Basically, if you’re a bacteria and you want to
get to a site where you can replicate, you've Natural Barriers
got to get past the natural barriers e.g., if
you’re swallow something, you've got to get
through the lysosome in the saliva & the
acidic pH in the stomach and an abrasion
through the skin and if the bloodstream Invasion
avoid phagocytes. & infection
Produces
cytokines
Assuming you can invade and get to the site
where you want to start reproducing and Inflammation
proliferating - this sets up the infection
whereas soon as an infection is detected by
your body, inflammatory responses start
hence inflammation is the second stage of
stopping something to cause trouble. If the Immunity
inflammatory responses don't work out or
other components of the innate immune If something goes wrong, the immune system can either overreact to a
pathogen and cause chronic inflammatory response or it can turn on
system then adaptive immunity is then cells of the own body known as (autoimmunity)
triggered. 1
- Based on visual observation, the ancients characterised inflammation by

five cardinal signs, namely redness (rubor), swelling (tumour), heat (calor;
only applicable to the body'
extremities), pain (dolor) and
loss of function (functio THE “NORMAL”
HUMAN IMMUNE
laesa).
SYSTEM - I
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Autoimmunity CasePY365 – Case 3.4 Therapeutics
- Autoimmune Disease Cluster 1 1
THE “NORMAL” HUMAN IMMUNE SYSTEM - II

REGARDING ADAPTIVE IMMUNE SYSTEM
The immune system functions to prevent and retard the local establishment or systemic dissemination of PATHOGENS
(bacteria, viruses, fungi, protozoa and helminths). It must accomplish this task without excessive inflammation or the
development of autoimmunity. The immune system has four primary components:
1. B cells producing antibodies

ANTIBODY-MEDIATED IMMUNITY (humoral or B cell immunity) - mediated by bone marrow-derived B lymphocytes and
plasma cells (differentiated antibody-producing cells). These release antibodies (immunoglobulins) into secretions,
plasma, and interstitial spaces. Antibodies work to opsonize and promote phagocytosis of organisms, neutralize toxins,
and lyse pathogens (with the aid of complement). B-cells can also form MEMORY cells
2. Two types = CD8 – killer cells, CD4 – control in adaptive immune system
CELL-MEDIATED IMMUNITY (T cell immunity) - mediated by thymus-derived T lymphocytes (i.e., CD4 and CD8 T cells)
that are activated by antigen-presenting cells (e.g., dendritic cells, macrophages) and antigens. Although T cells do not
produce immunoglobulin, CD4 T cells are necessary for optimal B cell function. CD4 T cells also express cytokines that
activate phagocytes to efficiently clear intracellular pathogens. CD8 T cells lyse virally infected cells [MEMORY]
3.
The PHAGOCYTIC SYSTEM consists of tissue macrophages and dendritic cells, as well as blood-borne monocytes and
neutrophils. In response to specific signals, phagocytes ingest and kill invading microorganisms. Dendritic cells also serve
as antigen-presenting cells for T cells to start self-mediated antibody immunity
4.
REGARDING INNATE IMMUNE SYSTEM
The COMPLEMENT SYSTEM acts synergistically with antibodies and the remainder of the immune system to help clear
microbial infections both directly (complement-mediated cytolysis) and indirectly (recruitment of phagocytic cells,
opsonization of microbes).
THE ROLES OF CD4+ TCase

HELPER THE ADAPTIVE IMMUNE SYSTEM1 – CD4 LINEAGE
Autoimmunity PY364 CELLS
– Case 3.2 Therapeutics
CD4 T cells e.g., Naive T cells when activated by a specific antigen can: • APCs/antigen presenting cell T-cell Effector Th
which is the dendritic cell activation cells
see foreign antigen (e.g., Intracellular
IFN-ϒ
bacterial pathogen) which pathogens
chop it up and present it as Naïve C
peptides with MHCII to CD4+ Th0 cell Y CD4+ Th1 Macrophage
naïve CD4+ T-helper cells T
IL-2,
Antibodies
ies
O Extracellular
which become effector T- 4
od
Pathogens
ti b
cells of FOUR basic types TCR K
(inc. helminths)
An
I CD4+ Th2
MHCII N B-cell
E IL-17 Extracellular
B-cells Antigen S Pathogens
Presenting (inc. fungi)
Th0 Cell CD4+ Th17
In
•
terms of
Naïve cells are T 0. Activated by CYTOKINES to become subgroups T 1, T 2, T 17 depending on their MOA
h h h h
Neutrophils,
maintenance Monocytes
T 1 cells deploy “cell-mediated” immune responses (mostly against intracellular viruses and parasites); T 2 cells use
• h
Activates B cells to h
“antibody-mediated” immunity (mostly against extracellular bacteria and allergens); T 17 promote inflammatory responses,
h
particularly neutrophils [important in RA] produce antibodies CATEGORY: CELLS
CD4+ Treg NATURAL KILLER CEL
• In autoimmune conditions, Th cellular responses can be mistakenly directed towards one’s own cells and tissues, sparking
unnecessary immune reactions, such as that seen in Hashimoto’s or RA
Natural Killer Cells
Killer Cells: CD8+ Cytotoxic T-Lymphocytes 1
1
(CTLs) and Natural Killer Cells Natural Killer (NK) Cells represent one of the three subsets of lymphocytes, besides T- and B- cells. In comparison to the latter, NK
cells belong to the innate immune system and form a first line of defence against a wide variety of pathological challenges. Particularly,
they provide protection against viral and bacterial infections and they help to detect and limit the development of cancer.
In this regard, NK cells were first described as cells that have the ability to kill tumour cells without any priming or prior activation
(remember that e.g. cytotoxic T cells need priming by antigen presenting cells) and their name is ultimately connected to this ‘natural’
ability to kill. Additionally, NK cells secrete cytokines, as for example INFg and TNFa, which constitute a second important defence
mechanism during an immune reaction.
One could imagine that cells which display a natural ability to kill
Target Cell
need to be controlled very strictly to protect healthy cells from
attack. Therefore, in addition to a variety of different activating Activating
MHC I
receptors, NK cells express inhibitory receptors that Ligand
recognize cognate MHC class I (this is also referred to as Inhibitory Activating
Receptor Receptor
recognition of ‘self’).This is a very efficient mechanism of control
as almost all ‘normal’ cells express MHC class I and are NK Cell
therefore protected from unwanted attack.
While on patrol NK cells constantly contact other cells. During these interactions a balance of activating and inhibitory signals
determines whether NK cells attack or not.
Inhibition Activation
Reduced inhibition Strong activation
Strong inhibition Transformed or infected cells sometimes

Tumour cells or cells infected by viruses
often downregulate MHC class I increase the expression of molecules that
Healthy, ‘normal’ cells express enough are recognised by activating NK cell
MHC class I molecules to induce a molecules. These cells can no longer
deliver a strong inhibitory signal. NK receptors (activating ligands). NK cells now
strong inhibitory signal in NK cells. receive a much stronger activating signal than
These cells are therefore protected cells will therefore attack and eliminate
these cells. usually. This may override the inhibitory signal
from NK cell attack. and allow NK cells to attack.
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- Autoimmune Disease Cluster 1
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T REGULATORY CELLS (TREGS) – PROTECTORS T REGULATORY CELLS (TREGS) – PROTECTORS

AGAINST AUTOIMMUNITY -1 AGAINST AUTOIMMUNITY -2
• They are immunosuppressants secreting cytokines in which their main

role is stopping the activity of T helper cells, natural killer cells &
cytotoxic T lymphocytes and can kill off dendtritic cells calming the • The antigenic peptides recognized by the TCRs of Treg cells tend to be
immune system down as in autoimmunity the body can overdo it SELF-PEPTIDES (“autoantigens”)
• About 10% of human CD4+ T-cells are “T regulatory cells” (Tregs). Tregs • Thus, major function of Tregs is to inhibit CD4+ Th1, Th2 and Th17 and CD8+
express a transcription factor (Foxp3) – this alters the expression of many CTLs from mounting an immune attack against self components; that is,
genes. When activated, Tregs express large quantities of the cytokines
to protect the body against AUTOIMMUNITY
TGFβ and IL-10 - These are IMMUNOSUPPRESSANTS that inhibit the
activity of Th cells, NK cells and CD8+ CTLs. Tregs also have a powerful, • In people and animal models where there is a lack of Tregs (Foxp3
destructive effect on APCs such as (dendritic cells). mutations or nude mice), SEVERE AUTOIMMUNE CONDITIONS ARISE
MODES OF ACTION AND INHIBITION OF CYTOKINES 1

1 1
AutoimmunityCasePY365 – Case 3.4 Therapeutics
- Autoimmune Disease Cluster
What normally happens is

that a cytokine will interact
with a receptor, send a signal
and you'll get a production of
some kind of mediator. But
what happens in a situation
with autoimmune diseases,
you get too many cytokines
and too many inflammatory
signals hence get an over-the-
top inflammatory response
and escalates to pathology.
PT. 2 1
- Our immune system also generates lymphocytes capable of recognizing

self-antigens, known as auto-reactive (self-reactive) lymphocytes.
- Immune tolerance is the state of unresponsiveness of the immune system
to antigens whereas self-tolerance is the state of unresponsiveness of the
immune system to self-antigens. HOW IS AUTOIMMUNITY MANIFESTED
IMMUNOLOGICALLY
When cells of the adaptive immune system (e.g., T and B
cells) BREAK self-tolerance, the resulting condition is
characterised as AUTOIMMUNITY, where native host cells
are recognised as foreign, and the adaptive immune cells
target them for destruction
“The responses to self antigens or antigens

associated with the microbiota that led to tissue
damage and disease are broadly referred to as
AUTOIMMUNITY” (Janeway 2017)
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1
HOWS DOES A LYMPHOCYTE DISTINGUISH BETWEEN

SELF AND NON-SELF? THE CONCEPT OF “TOLERANCE”
• Mechanisms that prevent
autoimmunity like CHECKPOINTS
• Each PARTIALLY effective in TWO major groups of checkpoints:
preventing antiself responses
• Both mechanisms together act • CENTRAL tolerance mechanisms
synergistically to prevent (in Thymus/where T cells are
autoimmunity WITHOUT ablating produced and Bone marrow/B cells)
protection against PATHOGENS – knocks them out once they develop
to not cause trouble further, but if
• Ultimate aim is IMMUNOLOGICAL
they escape to periphery then:
TOLERANCE - mechanisms that
• PERIPHERAL tolerance
prevent an immune response mechanisms
being mounted against the body’s (in secondary lymphoid tissue/sites
own tissues (“self”) of inflammation)
• This is manifested by
immunological non- reactivity of
B- and T-cells to self antigens
(don’t become auto-reactive)
THE FIRST CHECKPOINT - CENTRAL TOLERANCE

• In the thymus, all tissues specific antigens are expressed under the control of a specific MECHANISMS OF PERIPHERAL TOLERANCE-DELETION
gene where any T cells that react with these self-antigens will be deleted hence get a
DELETION: T- and B-cells commit suicide (apoptosis) - usually as a result
weak binding of most non-self antigens to a Naïve T cell and will proliferate of repeated antigen stimulation or BCR: autoantigen binding
• REMOVES (or silences) strongly autoreactive lymphocytes
• Without central tolerance, immune system would be very self-reactive and lethal
autoimmunity would occur early in life
• Nearly ALL tissue-specific antigens expressed in thymus under control of AIRE
gene (so tissue-reactive T-cells can be deleted)
We don’t
want a strong
binding
where it’ll be SELF-
recognized
and taken out TOLERANCE
POSITIVE SELECTION NEGATIVE SELECTION BUT some

• Lymphocyte receptors • Lymphocyte receptors lymphocytes
bind self-antigens WEAKLY bind self-antigens STRONGLY escape to the
• SURVIVE and proliferate • MOST ELIMINATED to prevent periphery (2nd
to effector (memory) cells checkpoint)
autoimmune reactions
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1AutoimmunityCasePY365 – Case 3.4 Therapeutics
AutoimmunityCasePY365 – Case 3.42Therapeutics
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MECHANISMS OF PERIPHERAL TOLERANCE -ANERGY MECHANISMS OF PERIPHERAL TOLERANCE – SUPPRESSION

absence of the normal immune response to a
SUPPRESSION: Usually facilitated by Tregs
particular antigen or allergen
ANERGY: Usually due to a lack of co-stimulatory molecules during antigen
presentation (stops presentation of antigens by ‘resting’ APCs - especially of self)
They stop
macrophage
activation & T
cell proliferation
1
1
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L1) AiDs Case Introduction:

OVERVIEW:
- Gout isn’t an autoimmune disease (caused by uric acid build up in the form
of crystals causing inflammation).
- Arthritis = inflammation of the joints hence both joints inflammation with
gout & joints inflammation with arthritis looks the same, but the cause is
difference hence different drug used.
- Lupus is an autoimmune disease which means the body's natural defence
system (immune system) attacks healthy parts of the body.
- Most treatments are self-injectable pens (similar to insulin pens).
- Osteoarthritis is a degenerative disease (not inflammatory) where it causes
joints to become painful and stiff.
- Main drug for RA is methotrexate which is quite toxic in overdose hence
used carefully. Full Case Notes
• GP referred patient to consultant rheumatologist
The patient-Rachel Smith • Patient is positive for rheumatoid factor and strongly anti-CCP
antibody positive after measuring the blood.
• A 55-year-old female who presents to her GP • Diagnosed with rheumatoid arthritis
with swollen and tender small joints of hands • Started on oral methotrexate 10 mg weekly with Folic acid 5 mg
and feet. weekly with methotrexate titrated up to 20 mg per week
• GI intolerance resulted in a change to methotrexate 20 mg per
• She has been taking Ibuprofen 200 mg tds week sc/subcutaneous form resulting in disease attenuation
(prescribed by GP) for 6 weeks and feels (dose-related effect)
constantly tired (chronic fatigue)
• Highlighted = indicators of AiD. • Re-presented several months later with inflammatory markers
(e.g., we are measuring white blood cells for chronic
inflammation whereas for acute we look out for CRP/C-reactive
protein & ESR/Erythrocyte Sedimentation Rate where both go
up) again starting to rise and symptoms returned.
Autoimmune Diseases Cluster 1
- The last point could be due to e.g., stop using the medicine (check
adherence). However, if adhered then could be due to the disease getting
worse hence the drugs aren’t working, and this is quite common (relapsing
is common with methotrexate) hence we want to maximize the amount of
time the patient is in remission (the reduction or disappearance of
8
the signs and symptoms of a disease) and that stopping flaring (worsening
of the disease process).
- Methotrexate is almost always given for those with rheumatoid arthritis.
It’s a type of medicine called an immunosuppressant that slows down the
body’s immune system and help reduce inflammation. Additionally,
Immunosuppressants interfere with cell turnover, slowing them down so
we don’t make cytokines as quickly, but this can also have an effect on the
mucous membranes of the body which can lead to ulceration (folate can
help with this). Interventions / Pharmacist job list
• Rheumatoid arthritis is a long-term • From diagnosis, we have 12 weeks/3 weeks to get
autoimmune condition that causes pain, them on good quality therapy otherwise the
swelling and stiffness in the joints. joints will be destroyed (stiffness is observed).
• Seen primarily in the joints of the hands and • X-ray can be used where if erosion/loss of bone
can become destroyed overtime (doesn’t observed = no point of treatment.
work), if not fixed it’ll be a permanent damage • Identification of possible RA and referral to GP
where the joints won’t function at all • Management of RA therapy to minimise disease
flare ups
To consider
• Management of therapy complications e.g., in
• Age methotrexate
• Gender (higher in women)
• Current drug therapy Autoimmune Diseases Cluster
Formative SAQs 1
Autoimmune Diseases Cluster 1
• Concerning Rheumatoid Arthritis treatment (5 marks)
• Side effects
a. What is the main adverse drug reaction that can occur
• Our patient have an active disease, failed dose of methotrexate
with hydroxychloroquine therapy? Works by
therefore what we can be done next is to add (not switch)
biologic drugs e.g., Infliximab (first used, not used often), supressing the immune system but it can cause ocular
Adalimumab (Humira) or targeted specific DMARD (oral drugs) toxicity in high prolonged doses.
• Biologic drugs for the treatment of rheumatoid arthritis (RA) b. How can this adverse event be avoided/managed? By
are made from proteins. They work by blocking the activity of a doing regular eye tests, if it happened to a patient then
key chemical or cell or protein involved in inflammation that stop the medication and switch to a different drug.
gives rise to joint swelling and other symptoms. They are c. If a patient did experience this adverse event what
powerful and specific therapies that target very particular parts would your advice be?
of the immune system.
Formative SAQs
• Concerning Gout (5 marks)
a. Name a drug that is contraindicated in the
treatment of gout? (2 marks) - Diuretics e.g.,
thiazides
b. Explain mechanistically why this is the case?(3
marks) – it works by increasing the amount of uric
acid by affecting the reabsorption of urate in the
kidney hence hold on to more urate and due to less
volume through diuretics hence concentration of
urate goes up causing crystals formation
Autoimmune Diseases Cluster 9 1

L2) Immunology of Autoimmunity:

PART 1 - Inflammation:
WHAT YOU ALSO NEED TO KNOW - 2
WHAT YOU NEED TO KNOW - 1 Many AiDs manifest Thus, it is necessary to
• AiDs occurs when components of the human as chronic revise
inflammatory diseases INFLAMMATION –
immune system become PERTURBED (including RA) we'll do this in Part 1
• Some factors (but by no means all) involved
with this are known (covered later and by Dr
Glaspole)
• Many of the biologics used to treat AiDs work
Cytokines secreted
by interacting and modulating with components by macrophages are
of the innate and adaptive immune system... the main focus
• … so, AiDs can be treated by either dampening
down these ADAPTIVE immune Any biologic CYTOKINES (particularly IL-1, IL-6 This predominantly
responses (through production mostly of based drug can and TNFα) secreted by involve components
autoreactive B- and T-cells) or INNATE responses deal with issues MACROPHAGES (including the of the INNATE
(mostly pro-inflammatory cytokines – small like antibodies bone form – OSTEOCYTES) are immune response
particularly important here
proteins that signal components of the adaptive production as the
immune system where some are havioly body is most Macrophages are a type of white blood cell of the immune system that engulfs and
involved in autoimmune disease due to likely to consider digests pathogens, such as cancer cells, microbes, cellular debris, and foreign substances,
overproduction hence instead of signalling, it it foreign which do not have proteins that are specific to healthy body cells on their surface. The
promotes inflammation) process is called phagocytosis, which acts to defend the host against infection and injury. 1
1
WHAT YOU ALSO, ALSO NEED TO KNOW - 3 INNATE –V- ADAPTIVE IMMUNITY
Specific, designed
present at all times, develops in response to infection,
These work by either blocking protective against specific pathogens, to identify a
reacts immediately,
cellular receptors or direct First line of activates the adaptive leverages components of the innate particular
Many of the defense, non- response, develops memory.
binding to (and inactivating) system organism or
BIOLOGICS used to specific hence
their ligands (something that protein
treat AiDs are based why it can go
interacts with a receptor in this
on ANTIBODIES wrong
case IL-6 and TNFα reducing BOTH required for
level of inflammation Normal immune function
Thus you may need to

revise the STRUCTURE of
N
Myeloid
IO
Cells* Cytokines
AT
antibodies and how they

M
can be MODIFIED to
AM
reduce side effects

FL
Cytokines
IN
("Immunogenicity") *neutrophils, basophils,

mast cells, eosinophils
Mast cells
INFLAMMATION 1
causes Hayfever
1
Call tissues with good blood supply
Like Hayfever
INNATE IMMUNE CELLS

1
Main two
1
NETs: Neutrophil
extracellular traps

10 1
1 1
MONOCYTES POLYMORPHONUCLEAR NEUTROPHILS

• Derived from hematopoietic stem cells in bone
50-70% of circulating white cells (4 to 10 million per ml of blood). Infection
marrow
activates cytokines that stimulate the bone marrow to produce up to 20
• Blood: 1-6% leukocyte million neutrophils per ml of blood.
Blood monocyte • Migrate into the tissues and differentiate into
Macrophages
• Phagocytose microorganisms
• Differentiate to macrophages
• Present antigens to T cells
Tissue macrophage
• The name of monocyte-derived cells depends upon
the tissue they reside in:
Neutrophils are active phagocytic cells. They circulate in peripheral blood
Liver - Kupffer cells
for 7-10h and migrate by extravasation into tissues, where they have a
Lung – Alveolar Mf
life-span of a few days.
CNS - Microglial cells
Neutrophils are attracted to tissues by chemotactic factors.
Osteoclast Bone – Osteoclasts (often involved in
secreting cytokines causing issues with arthritis) INFLAMMATION: 1
1
SOLUBLE MEDIATORS
1 1 VASCULAR REACTION AND CELL RESPONSE
Cytokines (e.g., IL1, IL6, TNFα) change the
Autoimmunity Case
PY365 – Case 3.4 -Therapeutics
Autoimmune
morphology, Disease
adhesive Cluster
properties and permeability 1
of endothelial cells – KEY PLAYERS IN RA!
Secretion of
CYTOKINES & CHEMOKINES
A collection of small proteins made by
cells that affect the behaviour
(e.g., activation/migration)
of other cells.
The balance & level of cytokines and
Inflammation
chemokines secreted affects the
outcome of the response
• Alert to infection (or tumour etc.) Post capillary endothelial cells are
• Recruit cells to site impermeable to cells and plasma
• Activate further immune response (vasodilation, increase in vascular
permeability)
Inflammation
By permission of Dr N. Terrazzini, UoB
CHRONIC
Autoimmunity INFLAMMATORY
CasePY365 RESPONSES
– Case 3.4 Therapeutics
- Autoimmune Disease Cluster- GENERAL1 1 1 - In RA, there’s a trigger factor
1 1
where cells are recruited e.g.,

neutrophils and inflammatory
macrophages and dendritic cells where
the innate immune response is
activated in which under normal
Activation, resolution, and the process leading to chronicity of inflammation. Time course of
the inflammatory response with activation phase, peak phase, and resolution phase. Failure circumstances = tons of activity then it
of resolution leads to chronic inflammatory diseases. Key cells of the activation and
resolution phase are shown in the gray squares. ILC innate lymphoid cells, TH17 T helper
cells 17, MΦ macrophages 1 dies off. However, when it goes chronic
this resolution doesn’t occur hence = chronic inflammation.
- From acute to chronic inflammation = causes tissue damage.
- Arthritis in knee or joints = inflammation in such area where it’ll lead to
tissue damage due to mass cytokines released so the body goes over the
top clearing the inflammation and start damaging the cells.
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AUTOIMMUNITY → AUTOINFLAMMATION
• When adaptive cells break self-tolerance = Autoimmunity (host cells recognised as
foreign and adaptive immune cells target them for destruction
• When innate immune cells become activated, due to dysregulated secretion of pro-
inflammatory cytokines and consequent damage to host tissues = Autoinflammation
• When tolerance occur = autoimmunity
The Autoinflammation/Autoimmunity spectrum of diseases and their immune mechanisms.

TRAPS: TNF receptor associated periodic syndrome, FCAS: Familial cold autoinflammatory syndrome, HIDS: Hyperimmunoglobulinemia D syndrome,
IPEX: immunodysregulation polyendocrinopathy enteropathy X-linked syndrome.
https://www.immunology.org/public-information/bitesized-immunology/immune-dysfunction/autoinflammation
PART 2 – Tolerance:
1 1
HOW IS AUTOIMMUNITY MANIFESTED WHAT HAPPENS WHEN THINGS GO WRONG?

IMMUNOLOGICALLY? INFECTION (particularly
GENETIC FACTORS chronic) and
When cells of the adaptive immune system BREAK ENVIRONMENTAL EXPOSURE
self-tolerance, the resulting condition is
characterised as AUTOIMMUNITY, where native host
cells are recognised as foreign and the adaptive
immune cells target them for destruction IMMUNE
DYSREGULATION
“The responses to self antigens or antigens

associated with the microbiota that lead to tissue
damage and disease are broadly referred to as AUTOIMMUNITY/
AUTOINFLAMMATION
AUTOIMMUNITY” (Janeway 2017)
THE ADAPTIVE IMMUNE SYSTEM – CD4 LINEAGE
A CRITICAL FUNCTION OF THE IMMUNE SYSTEM IS AUTOREACTIVE 1
- Autoimmune
T-cell Disease
Effector Th Cluster 1 1
TO DISCRIMINATE SELF FROM NON-SELF T-CELLS
activation cells
IFN-ϒ Intracellular
• Autoimmune
Autoimmunity CasePY365 – Case responsesDisease
3.4 Therapeutics
- Autoimmune resemble NORMAL immune 1 1 1
Cluster “SELF” PEPTIDES pathogens
(AUTOANTIGENS) –
responses to pathogens… in that T- and B- lymphocytes produces e.g., T effector
Naïve C
Horror CD4+ Th0 cell Y CD4+ Th1 Macrophage
autotoxicus! are activated by ANTIGENS cells that attacks us T Attacks
IL-2,
s
• These are known as AUTOANTIGENS… “self”
Extracellular
An AUT odie
O 4
ti b Pathogens
↓
TCR K
ies
(inc. helminths)
ti b O
An
I CD4+ Th2 od Tissue

• …which give rise to AUTOREACTIVE EFFECTOR (T) CELLS MHCII N B-cell
Damage”
and AUTOANTIBODIES (from B-cells – that attacks us) E IL-17 Extracellular
Adaptive Antigen S
against the self-antigen immune Presenting
Pathogens
(inc. fungi)
system Cell CD4+ Th17
Neutrophils,
• Regulatory T cells (Tregs) may also fail to do their job of DISFUNCTIONAL Monocytes
keeping the immune system (adaptive) in line Tregs
• APCs see antigen (bacterial pathogen)… CD4+ Treg
• … which chop it up and present it as peptides with MHCII
• Such dysregulated immune responses to self tissues to naïve CD4+ T-helper cells …
lead to chronic syndromes = AUTOIMMUNE DISEASES • … which become effector T-cells of FOUR basic types
SOME COMMON AUTOIMMUNE DISEASES

AutoimmunityCase
- Therapeutics
Autoimmune Disease Cluster 1
1 1
1
Acts on an organ swollen neck
About 5% of population in West – immune system Synovium = membrane

pretty effective at distinguishing self from non-self around the joints
1
12
HOWS DOES A LYMPHOCYTE DISTINGUISH BETWEEN T REGULATORY CELLS (TREGS) – PROTECTORS

SELF AND NON-SELF? THE CONCEPT OF “TOLERANCE” AGAINST AUTOIMMUNITY -1
• Mechanisms that prevent autoimmunity
like CHECKPOINTS
• Each PARTIALLY effective in preventing
antiself responses
• Together act synergistically to prevent
autoimmunity WITHOUT ablating
protection against PATHOGENS
• Ultimate aim is IMMUNOLOGICAL • About 10% of human CD4+ T-cells are “T regulatory cells” (Tregs)
TOLERANCE - mechanisms that prevent TWO major groups of checkpoints: • Tregs express a transcription factor (Foxp3) – this alters the expression of
many genes
an immune response being mounted
• CENTRAL tolerance mechanisms • When activated, Tregs express large quantities of the cytokines
against the body’s own tissues (“self”)
(in Thymus/T cells and Bone marrow/B TGFβ/tissue growth factor beta and IL-10
• This is manifested by immunological
cells) • These are IMMUNOSUPPRESSANTS that inhibit the activity of Th cells,
non- reactivity of B- and T-cells to self NK cells and CD8+ CTLs that would theoretically attack the body
• PERIPHERAL tolerance mechanisms
antigens (in secondary lymphoid tissue/sites • Tregs also have a powerful, destructive effect on APCs/antigen
of inflammation) presenting cells such as dendritic cells
1
T REGULATORY CELLS (TREGS) – PROTECTORS WHAT HAPPENS WHEN THINGS GO WRONG?
AGAINST-AUTOIMMUNITY
Autoimmune Disease Cluster
-2
1
1 1 MECHANISMS
INFECTION and
GENETIC FACTORS ENVIRONMENTAL
EXPOSURE
IMMUNE BREAKDOWN
SYSTEMIC e.g., DYSREGULATION OF TOLERANCE
• The antigenic peptides recognized by the TCRs of Treg cells tend to be scleroderma, Lupus
erythematosus,
SELF-PEPTIDES (“autoantigens”) Rheumatoid Arthritis
• Thus, major function of Tregs is to inhibit CD4+ Th1, Th2 and Th17 and CD8+
CTLs from mounting an immune attack against self components; that is, ORGAN SPECIFIC e.g., AUTOIMMUNE INDUCTION OF
Hashimotos thyroiditis, DISEASE AUTOANTIBODIES/SELF
to protect the body against AUTOIMMUNITY
myasthenia gravis, (tissue damage) REACTIVE T-CELLS/LACK OF
• In people and animal models where there is a lack of Tregs (Foxp3 multiple sclerosis TREG FUNCTION/CHRONIC
mutations or nude mice), SEVERE AUTOIMMUNE CONDITIONS ARISE INFLAMMATION
AutoimmunitySYMPTOMS OF3.4
CasePY365 – Case Hashimoto's
- Autoimmune Thyroiditis/HD
Therapeutics Disease Cluster 1
1 1
HASHIMOTO’S DISEASE – AN EXAMPLE OF AN ORGAN- 1 • DIAGNOSTIC SIGN - enlarged thyroid (“goiter”).
SPECIFIC AUTOIMMUNE DISEASE • Makes front of neck to look swollen Hashimoto's symptoms may be mild
at first or take years to develop.
• May make swallowing difficult.
• Hashimoto's disease (HD) - a condition in
which your immune system attacks your • Weight gain
THYROID GLAND – located below your • fatigue
Adam’s Apple • paleness or puffiness of the face
• joint and muscle pain
• The thyroid gland is part of the endocrine Below • constipation
system. It produces hormones that • inability to get warm
coordinate many of the body's activities Treatment: daily (oral) use of the synthetic
• difficulty getting pregnant thyroid hormone levothyroxine – identical to
• joint and muscle pain human source – usually very successful
• Inflammation due to HD (“chronic
lymphocytic thyroiditis”) → underactive • Hair loss or thinning, brittle hair
thyroid gland (hypothyroidism) • irregular or heavy menstrual periods
• depression
• HD most common cause of hypothyroidism. • slowed heart rate
Primarily affects middle-aged women – but
can occur in men/women/children of any age
RHEUMATOID ARTHRITIS – 1
AN EXAMPLE OF SYSTEMIC AUTOIMMUNE DISEASE
1
High serum [Ab] to

1+ thyroid antigens;
Predominantly
thyroid-specific
B and T cells
Risk Factors
• Sex (women)
• Age (>45yo)
• Heritable Autoimmune priming, tissue attack and chronic inflammation
Destruction
— The three stages of rheumatoid arthritis
• Other AI of thyroid
The first sign of autoimmunity is the presence of rheumatoid factor and ACPA in the
diseases follicles
blood hence can be detected early. If not noticed, they’ll start targeting the joints.
1

13 1
1 1
AUTOINFLAMMATORY RESPONSES – AUTOINFLAMMATORY RESPONSES –

EXAMPLE OF RHEUMATOID ARTHRITIS EXAMPLE OF RHEUMATOID ARTHRITIS
Mutations in cells of the innate
RA shows Like many AIM conditions, there are immune system (monocytes and in RA, these cytokines are
characteristics of both a number of environmental and neutrophils), lead to elevated predominantly tumour
autoimmune (AIM) genetic risk factors associated levels of pro-inflammatory necrosis factor (TNFα) and
AND autoinflammatory with RA (smoking, obesity, cytokines - creating a positive Interleukin 6 (IL-6) plus (to a
vitamin D deficiency, changes in the feedback loop of lesser extent) IL-1β
(AIF) disease exacerbating inflammation
microbiota, HLA type, etc.)
By blocking these Thus, immunotherapies were

Once RA is triggered (stage 2), immune cells migrate aberrantly secreted developed to reduce the
into the joints where they produce large quantities of cytokines, the amount of circulating TNFα,
immune mediators (cytokines/chemokines) leading systemic inflammatory IL-6 and IL-1β. These drugs,
symptoms are (i.e.,: etanercept , tocilizumab,
to the activation and recruitment of more immune
alleviated anakinra) are able to bind to
cells into the tissue
and sequester these cytokines
or their receptors
MODES OF ACTION AND INHIBITION OF CYTOKINES TNFα
Normally, cytokines locks on
Autoimmunity CasePY365 – Case 3.4 Therapeutics a receptor
- Autoimmune Disease Clusterleading to an 1 1 Autoimmunity
1 CasePY365 – Case 3.4 Therapeutics
1 1
inflammatory signal. If
neutralized through an
antibody that sticks to the
cytokine hence can’t react
with its receptor of if there’s
soluble receptors in which
we neutralize them. Once
the cytokine can’t bind to a
soluble or cellular receptor
• Tumour necrosis factor alpha (cachexin/cachectin/TNFα) is a cytokine involved in
there’s no signaling hence no
systemic inflammation – secreted by macrophages
exaggerated inflammatory • As TNF promotes the pro-inflammatory response, amplified and disregulated
response. Therefore, lots of production of TNF is associated with autoimmune disorders such as RA, ankylosing
drugs used either bind to the spondylitis, inflammatory bowel disease, psoriasis
receptor, IL-6 or TNF-alpha • Thus, these disorders can be treated by using a TNF inhibitor where they modurate
the immune system hence immunomodulators
1
1 1 SUMMARY (PARTS 1 & 2)
INTERLEUKIN-6 (IL-6)
1. Rheumatoid Arthritis (RA) and many other autoimmune diseases ("AiDs") ultimately
result due to a perturbation of the human immune system where immune mediators
attack “self” cells and tissues = “immunopathology”
2. Normally, the adaptive immune system demonstrates “tolerance” – where the bodies
own cells and tissues are recognised as self.
3. In many cases (including RA) AiDs also show autoinflammatory responses. These are
predominantly provided by the cells and their secreted products of the innate immune
system (i.e.,: monocytes and cytokines)
4. AI is triggered by a number of factors – genetic (often specific HLA haplotypes),
• IL-6 REGULATES MANY PATHWAYS THAT COULD CONTRIBUTE TO ITS EFFECT ON environmental (smoking, obesity, some medications, pregnancy etc) or infection –
INFLAMMATORY DISEASE PROGRESSION. which lead to perturbation of the immune system and breakdown of tolerance (seen as
• During CD4 T cell differentiation, IL-6 promotes IL-17 and IL-21 production, and suppresses induction of autoantibodies/self reactive T-cells/lack of Treg function/chronic
regulatory T (Treg) cell function inflammation etc)
• IL-6 promotes neutrophil and macrophage recruitment and survival through induction of
IL-17 production. 5. There are TWO main families of AI diseases – organ specific (example of Hashimotos
• IL-6 also acts on nonimmune cells, altering the function of fibroblasts and osteoclasts Thyroiditis) and systemic (example of rheumatoid arthritis)
(found in the bone)
6. Treatment of AI diseases focuses on controlling the manifestations of such immune
• This all leads to deposition of matrix, antibody complexes and proteases in the targeted
tissue and, consequently, tissue destruction. perturbations. Such interventions can either remove or ablate T- and B-cells that have
Abbreviation: rANKL, receptor of nuclear factor kappa-B ligand. 1 broken tolerance or disable the ligands responsible for autoinflammatory responses
and/or their cellular receptors (IL-1, IL-6, TNFα). In organ-specific AI, control of immune
responses often comes too late, so function must be replaced by direct administration
of bioactive drugs (i.e.,: levothyroxine in HT, insulin in diabetes mellitus) 1
14
L3) Biologic DMARDs in the Treatment of Rheumatoid Arthritis - Structure,

Targets & MOA:
Biologic Disease-Modifying Anti-Rheumatic Drugs
(bDMARDs): TNFΑ ANTAGONISTS –
immunosuppressants & first-line drugs
NON- ORIGINATOR
CLASS/ MOLECULE
PROPRIETARY PROPRIETARY TARGET STRUCTURE
MODE OF ACTION DESCRIPTION
NAME NAME
TNFα receptor/
IMMUNOSUPPRESSANT
ETANERCEPT Enbrel* TNFα fusion protein fully-human IgG
TNFα inhibitor
Fc region
IMMUNOSUPPRESSANT Mu/Hu chimeric
INFLIXIMAB Remicade* TNFα Chimaeric mAb
TNFα inhibitor IgG mAb to TNFα
IMMUNOSUPPRESSANT Fully-human IgG mAb
ADALIMUMAB Humira* TNFα Fully human mAb
TNFα inhibitor to TNFα
PEGylated Fab
Humanized mAb
CERTOLIZUMAB IMMUNOSUPPRESSANT fragment
Cimzia TNFα (90% human, little
PEGOL TNFα inhibitor of humanized mAb
IMMUNOSUPPRESSANT
bit of mice)
to TNFα - DMARDs can improve symptoms such as
Fully-human IgG mAb
GOLIMUMAB Simponi TNFα TNFα inhibitor Fully human mAb
to TNFα
mAb = monoclonal antibody

pain, stiffness and swelling, but they may take
This lists ALL the bDMARDs used for RA therapy that block TNFα. All have been approved
for use by NICE in October 2022. Note the combination of chimaeric, humanized and fully- a few weeks or even months to fully take
human full-size
IgG antibodies, a modified Fab antibody fragment and a fusion protein (* - biosimilars
available)
effect. There are different types of DMARDs,
and they work in slightly different ways. The three main types are: conventional
synthetic DMARDs, including Methotrexate, biological therapies like Adalimumab &
targeted synthetic DMARDs, such as Baricitinib and Tofacitinib.
- Biological therapies are a relatively new class of medicines as they stop or block
particular cells in the immune system from triggering inflammation, and so target
the underlying cause of diseases - they tend to work more quickly than conventional
DMARDs. Some biological therapies are called anti-TNF drugs where they target a
protein called tumour necrosis factor, which increases inflammation when excess
amounts are present in the blood or joints. They are only given to people who have
already tried other treatments appropriate to their condition and not responded
well to them. Biological therapies are Biologic Disease-Modifying Anti-Rheumatic Drugs
(bDMARDs) OTHER TARGETS
often given in combination with a Overall effect on the adaptive immune system unlike the others targeting cytokines,
where RIT can bind to B cells and destruct them which leads to infection
NON- ORIGINATOR
CLASS/
conventional DMARD such as PROPRIETARY PROPRIETARY TARGET
MODE OF ACTION
STRUCTURE
MOLECULE
DESCRIPTION
NAME NAME
IMMUNOSUPPRESSANT Mu/Hu chimeric
Methotrexate. RITUXIMAB Mabthera* CD20
B-cell activation
Chimaeric mAb
IgG mAb to CD20 (B
inhibitor (that produces cell receptor that
Only give every 3-6 months antibodies) shows its active)
due to its pharmacokinetics IMMUNOSUPPRESSANT extracellular domain of
B7-1/-2 T-cell activation CTLA-4
ABATACEPT Orencia fusion protein
(CD80/86) inhibitor leading to fused with fully-human
infection IgG Fc region
IMMUNOSUPPRESSANT Humanized IgG mAb to
TOCILIZUMAB RoActemra IL-6R Humanized mAb
Interleukin inhibitor IL-6R
Fully human IgG mAb
IMMUNOSUPPRESSANT
SARILUMAB Kevzara IL-6R Fully human mAb to IL-6R
Interleukin inhibitor
Immunosuppressants that act on another cytokine that promotes inflammation (IL-6)

This lists ALL the bDMARDs approved used for RA therapy by NICE in 2022.
Note the combination of chimaeric (formed from animal parts, humanized and fully-
human full-size
IgG antibodies, a fusion protein and a recombinant protein (* - biosimilars available)
15
THE TNFα INHBITORS – TARGET = soluble TNFα or ADALIMUMAB (Humira), INFLIXIMAB AND GOLIMUMAB
cellular TNFα receptors
Structure of TNF α
These three TNFα inhibitors will be considered together as, structurally, they
are all produced as recombinant, glycosylated (due to containing sugar in the
ORIGINATOR IgG attached to the amino acids and proteins), full-length IgG1 (most
NON-PROPRIETARY CLASS/
NAME
PROPRIETARY TARGET
MODE OF ACTION
STRUCTURE MOLECULE DESCRIPTION antibody found in the blood and joints is IgG) monoclonal antibodies which
NAME
IMMUNOSUPPRESSA TNFα receptor/ are used to treat RA – they all work the same
TNFα
ETANERCEPT Enbrel NT fusion protein fully-human IgG
receptor
TNFα inhibitor Fc region In contrast to etanercept and certolizumab pegol, these three drugs
IMMUNOSUPPRESSA
Mu/Hu chimeric are all full-length IgG mAbs.
INFLIXIMAB Remicade TNFα NT Chimaeric mAb
IgG mAb to TNFα
TNFα inhibitor
IMMUNOSUPPRESSA
Fully-human IgG mAb But like etanercept and certolizumab pegol, they ALL bind to TNFα
ADALIMUMAB Humira TNFα NT Fully human mAb
TNFα inhibitor
to TNFα found in joints and prevent it signalling through its cellular TNF
IMMUNOSUPPRESSA PEGylated Fab fragment
CERTOLIZUMAB
Cimzia TNFα NT Humanized mAb of humanized mAb
receptors, TNFR1 (CD120a, p55) and TNFR2 (CD120b, p75)
PEGOL
TNFα inhibitor to TNFα
IMMUNOSUPPRESSA
Fully-human IgG mAb
GOLIMUMAB Simponi TNFα NT Fully human mAb
to TNFα
TNFα inhibitor
PY365 – Case 3.4 - Autoimmune Disease Cluster They block7

ADALIMUMAB, INFLIXIMAB AND GOLIMUMAB cytokine
effect then
blocks TNF-
alpha
Red = mouse
Blue = human
Chimaeric mAb Humanised mAb
100% Fully-human mAb
Murine variable Murine hypervariable
Murine mAb GOLIMUMAB,
domains (25%), rest regions (5%), rest
ADALIMUMAB
is human (75%) is human (95%)
INFLIXIMAB TOCILIZUMAB
• INFLIXIMAB is a purified, recombinant chimaeric human-mouse IgG mAb = mouse heavy and light chain
variable regions + human heavy (95%) and light chain constant regions –a chimaeric mAb – GREATER
RISK of inducing anti-drug antibodies that adalimumab/golimumab
• ADALIMUMAB and GOLIMUMAB are fully-human mAbs. Adalimumab = first fully-human mAb
approved for use by the FDA. Humira = “Human monoclonal antibody in rheumatoid arthritis” (World’s
best-selling drug - $18 billion of global sales in 2017!)
• TARGET and MOA: All these mAbs neutralise TNFα by binding with high affinity to both soluble and
transmembrane TNFα, PLUS TNF bound to the soluble form of the TNF receptors
• MOA: PRIMARY = blocking cytokine signalling ; SECONDARY (already reequipped by NK bc they think
there’s something wrong with the cell) = Fc domain binds to (a) bind Fcϒ receptors on immune cells,
thus signalling them for destruction by natural killer cells through Antibody-dependent cellular
cytotoxicity (ADCC) OR (b) fix complement, thus activating complement-mediated lysis
When we shift to fully human = side effects are witnessed due to antidrug antibodies reaction
- If 100% human = nasty immune response (not used anymore), variable

domain amount is used instead which is the bit that binds to the protein
(paratope) that binds to the epitope (part of the protein that have amino
acids) that is recognized.
- They can form immune complexes between the target and the antidrug
antibody which can deposit in joints forming RA hence this mechanism
should be avoided.
16
CERTOLIZUMAB PEGOL (“CIMZIA”) – A MODIFIED REVISION - PEGYLATION

ANTIBODY FRAGMENT (95% HUMAN, 5% MOUSE)
They just have the arms that are bound to PEG increasing plasma
half-life hence is injected by sc, much more stable, no need for Good for enhancing water
continuous injections, it doesn’t cross the placenta hence used for solubility and is not toxic
pregnancy and breastfeeding
Cimzia is unique amongst
the anti-TNF mAbs Like other TNF • PEGylation is the process of covalent or non-covalent attachment
antagonists, cimzia
It is composed of the
binds to soluble and of polyethylene glycol (PEG, “macrogol”) to a drug which is then
antibody binding fragment
(Fab) of a humanized membrane-bound described as PEGylated.
monoclonal antibody TNF-α, inhibiting its • Covalent attachment of PEG to a therapeutic protein such as
against TNF proinflammatory
actions certolizumab pegol can mask the drug from immune surveillance,
This is conjugated to
polyethylene glycol which thus reducing immunogenicity, and increases its hydrodynamic
• Increases its plasma
Has NO Fc domain, so size, prolonging its plasma half-life by reducing renal clearance.
half-life to c. 14 days,
allowing fortnightly cannot fix complement • PEG is an attractive polymer for conjugation as it enhances water
subcutaneous use or trigger ADCC (so, no
• Increase bioavailability secondary affect). Also
solubility of the conjugate, gives high drug mobility in solution
• Increases drug stability makes it less and has low inherent toxicity and immunogenicity
and retention time by immunogenic than the
decreasing renal
clearance, proteolysis Cimzia does not appear to cross the
placenta, so can be used by pregnant
full-length mAbs,
reducing immune-
ETANERCEPT (“ENBREL”) – the rabbit drug
and immunogenicity
women and whilst breastfeeding related side effects • Etanercept is a recombinant form of the soluble TNFR2 soluble
receptor (TNRF2 aka p75 – has 2 copies)
FULL LENGTH –V- ANTIBODY FRAGMENTS IN PY365
• It –binds
CaseTNFα
3.4 1000
- Autoimmune Diseasethan
times more strongly Cluster
the native REVISIO
THERAPY: THE DISTRIBUTION PROBLEM monomeric receptor (1 recaptor)
• Fusion of the IgG1 Fc domain with p75 greatly extended the
Single-domain antibodies accumulate much better and
drugs half-life in the bloodstream over p75 alone, and provided
treats faster than full length monoclonal antibodies a more profound and long-lasting biologic effect than the
BIG (150kDa) IgG naturally occurring soluble TNFα receptor
molecules may have But if a single-domain
equivalent (15kDa) • In addition, the dimeric form (2 receptors) of the TNFR2-based
trouble penetrating into an
used then has a 10X fusion protein had much enhanced activity compared to a
inflamed knee joint due to
their large size/distribution greater value! monomeric form
(0.3-0.5Kg/L)* - • Etanercept (only circulating TNF-alpha) will NOT bind to
problems
greater distribution transmembrane TNFα or TNFα bound to the soluble form of the
*in preclinical trials TNFα receptors or TNFβ. Unlike infliximab, adalimumab and
in animal models golimumab, it cannot target cells for lysis.
It prevents RA by binding to, and

And there is some inactivating, SOLUBLE TNFα in the circulation.
Full-size anti-TNF-α evidence that CIMZIA
Thus, TNFα cannot bind to its
IgG (150kDa) has a shows enhanced
Distribution Volume penetration cellular receptors and trigger pro-inflammatory
of 0.03-0.08L/Kg* responses, which may lead to RA
TOCILIZUMAB (“RoActemra”): TARGET = IL-6

RECEPTORS (NOT SOLUBLE IL-6/cytokines – targets SARILUMAB (“Kevzara”): TARGET = IL-6
the receptors not ligands) RECEPTORS (NOT SOLUBLE IL-6)
• Like Tocilizumab, Sarilumab (SRL) = full-size, IgG mAb w/
Tocilizumab is a • Tocilizumab is a full-size, humanized (95% human, 5% high affinity for interleukin-6 receptors but is FULLY-
Sarilumab is a
full-size IgG murine) IgG mAb with high affinity for interleukin-6 full-size IgG HUMAN
humanised mAb RECEPTORS (NOT the cytokine IL-6) human mAb • Authorised by the EMA June 2017 - IDENTICAL MOA TO
• Autoimmune diseases like RA are associated with TOCILIZUMAB. It can be used with or without MTX. A
abnormally high IL-6 levels and by binding to both meta-analysis comparing the efficacy and tolerability of
soluble (sIL-6R) and cell surface membrane bound (IL- TCZ and SRL suggests TCZ 8mg + MTX>TCZ 8mg>SRL
6R) RECEPTORS, tocilizumab prevents IL-6 from exerting 200mg> SRL 200mg + MTX to achieve the ACR50
its pro-inflammatory effects (SEE NEXT SLIDE) response rate
• Interestingly, it has been noted that IL-6R and sIL-6R • Treatment should be interrupted in patients who
operate differently in RA pathogenesis, with the develop serious infections until the infection is under
control. The dose may have to be lowered in patients
soluble form being more implicated in disease
with abnormal blood tests
progression.
• Generally, tocilizumab is only used after failure of one
or more of the TNF-inhibitor biologics
Rituximab, Abatacept, SarilumabPY365

and– Case 3.4 - Autoimmune Disease Cluster 21
tocilizumab act upon other cellular
targets, not TNFα.
17
TOCILIZUMAB/SARILUMAB – MODE OF ACTION RITUXIMAB: TARGET = CD20 that is found on

surface of the B-CELL RECEPTOR
• Rituximab is a mouse/human Chimaeric
Punches holes in the bacteria
antibody that binds to CD20
• CD20 is a receptor expressed on the surface
of mature B-cells
• Rituximab causes a selective
depletion/dispopulation of the CD20+ B-cell
population
• Role of B-cells in RA not fully understood, but By NKC
use of rituximab in combination with
Methotrexate led to sustained clinical
improvements in RA patients
• Mechanism of action is COMPLEX – kills
target CD20+ B-cells via complement and
antibody-mediated cytoxicity and induces First method is apoptosis then to
programmed cell death (“apoptosis”) trigger complement and finally
induce cytotoxicity
RITUXIMAB (A B-CELL TARGET) RITUXIMAB – MODE OF ACTION

• Rituximab, like infliximab, is a chimaeric human-mouse IgG Sticks an
3 MODES FOR CELL DEATH antibody to
mAb = mouse heavy and light chain variable regions + human it to signal
heavy and light chain constant regions the
• Like abatacept, rituximab modulates the immune system by immune
targeting and destroying normal or malignant immune cells Antibody-
system
• RTX targets the surface CD20 receptor of B- cells dependent cellular
• Like infliximab, adalimumab and golimumab, RTX has a Fc cytotoxicity
domain that can fix complement and bind to cell surface Fcϒ
receptors to trigger antibody-dependent (ADCC) or
complement-dependent cytotoxicity (CDC) in vivo of CD20+ B-
cells. It also down-regulates the B-cell receptor (‘BCR’ = CD79 Complement is a
+ Ig antibody), which abrogates signalling through the NF-κB component of the innate complement-
immune system which
pathway and hence a reduced recruitment of immune triggers a cascade which
dependent
cytotoxicity
effectors leads to lysis of the cell
• RTX also induces apoptosis of CD20+ B-cells
• This eliminates B-cells from the body, allowing a new
population of healthy B-cells to arise from lymphoid stem cells Apoptosis
• BUT may make patient prone to opportunistic infections or
the re-emergence of latent infections – RTX use must be
carefully monitored PY365 – Case 3.4 - Autoimmune Disease Cluster 26
ABATACEPT (“ORENCIA” – TARGETS RECEPTORS ON APCs)

ABATACEPT – MODE OF ACTION
External Will see a bacteria &
domain phagocytose it
Cell
membrane
Heavy chain
Fc domain
Binds to a co- Internal
domain
stimulatory
receptor Human IgG1
CTLA-4 Abatacept
Binds to CD28
• Naïve T-cells are activated by TWO signals provided by the antigen presenting cell (APC)
• The first (signal 1) is that between the Major Histocompatibility Complex (MHC – Class I
• Structurally, abatacept is a fusion protein consisting of the external domain of CTLA-4 or II) on the surface of the APC which presents a polypeptide fragment (red square) to
(Cytotoxic T-Lymphocyte Associated protein 4, aka CD152) fused to fully-human IgG Fc the T-cell receptor (TCR)
• CTLA-4 is an antagonist of the T-cell costimulatory molecule CD28 and, when bound to • The second (signal 2) is a co-stimulatory signal provided when the CD80/86 ligand on the
CD80/86, down regulates T-cell activation (see over) APC binds to the CD28 (aka “B7”) on the T-cell
• Activated T cells are implicated in the pathogenesis of RA and are found in the • ABATACEPT binds to the CD80/86 ligand, preventing its interaction with CD28. Thus, the
synovium/joints membrane of patients with RA costimulatory signal is not provided, the T-cell is not activated and the adaptive immune
• In vitro, abatacept has been shown to decrease T-cell proliferation with a concomitant system damped-down
inhibition of the proinflammatory cytokines TNFα, interferon-γ, and interleukin-2
18
PHARMACOKINETICS OF bDMARDs – KEY POINTS PHARMACOKINETICS – TNFα ANTAGONISTS

MOLECULE Bio- Serum Volume of
• The pharmacokinetic properties of bDMARDs differ markedly from non-biologics – this has DRUG
DESCRIPTION
Dose Route Frequency
availability half life Distribution*
Cmax* Tmax Clearance
important clinical implications as they’re big and can’t be taken orally TNFα receptor/
2.4ug/ml
• bDMARDs can be administered intravenously, intramuscularly or subcutaneously (mostly) ETANERCEPT fully-human IgG 50 mg1 sc1 1 per week 76% 3.3d 7.6 L
(50mg sc)
2 days 0.066L/h
Fc region
• Oral administration is precluded by their large size, hydrophilicity and, (obviously) gastric Baseline then
Mu/Hu chimeric 77ug/ml
degradation of these proteinaceous drugs. INFLIXIMAB*
IgG mAb to TNFα
3-5mg/kg3 iv3 infusions at 6–8 92% 9d 3-4.1L
(3mg/kg iv)
2 days -
• subcutaneously, bDMARDs are slowly absorbed from the site of injection because they’re big - tend Fully-human IgG
weekly intervals
8ug/ml 0.011-
to reach maximum serum concentration in around 48h. ADALIMUMAB
mAb to TNFα
40mg1 sc1 2 weeks 64% 12-14d 5-6L
(with MTX)
5 days
0.015L/h
• bDMARDs are LARGE, hydrophilic molecules that have difficulty entering their target tissues (joints) PEGylated Fab 200mg eow
CERTOLIZUMAB fragment or 400mg 2.5-7
and cells (endothelial cells, monocytes, and synovial fibroblasts). PEGOL of humanized each 4th
sc1 2-4 weeks 80% 14d 8.01L 17ug/ml
days
0.021L/h
• Due to their large size, glomerular filtration in the kidneys or metabolism in the liver contributes mAb to TNFα week1
very little to their removal from circulation. GOLIMUMAB
Fully-human IgG 50mg-
sc1 Monthly 51% 12d 8.05L 3.1ug/ml
2-6
0.069L/h
mAb to TNFα 100mg1** days
• Thus, volumes of distribution are generally low and lie between that of plasma (4L) and the
extracellular space (23L). PHARMACOKINETICS (based on 70-75kg adult). Data is for sc injection using autoinjectors1,
• One might predict that bDMARDs would be rapidly endocytosed and metabolized by proteolytic where given. Alternatively, if sc autoinjector not available, use of pre-filled syringe2 for sc
enzymes within tissues, circulating phagocytic cells or target cells, leading to their rapid elimination. injection or intravenous infusion3 –
Due to the Fc domain, their degradation is limited. * at steady state; **100mg dose of golimumab if patient weighs >100kg
• However, bDMARDs based on full-size antibodies (infliximab, adalimumab, golimumab, tocilizumab
and rituximab) and the fusion proteins etanercept and abatacept all contain a glycosylated IgG1 Fc
domain which binds to the cellular neonatal Fc-receptor (FcRn) and limits degradation. PHARMACOKINETICS - DON’T PANIC!
• Such protection is enhanced by the glycosylation of the IgG1 domain or PEGylation in the case of
certolizumab pegol, which makes such proteins poor targets for proteolysis and decreases their PY365 – Case 3.4 - Autoimmune Disease Cluster 30
access to metabolising enzymes . I don’t expect you to
• Taking all this together, it explains the long elimination half-lives (up to 4 weeks) and slow clearance remember ALL the data in
(0.01-0.07L/h) seen with most of these bDMARDs. that table! Just note the
29 following broad trends…
PHARMACOKINETICS – OTHER TARGETS
Bio-
MOLECULE Serum Volume of
DRUG Dose Route Frequency availabilit Cmax* Tmax Clearance
DESCRIPTION half life Distribution*
y
1000mg3 Day 1 & 15, • The time taken (Tmax) to reach peak serum concentration (Cmax) is
RITUXIMAB – Mu/Hu chimeric (given as a then at 6 c.200ug/ml 3
every 6 months IgG mAb to CD20 loading
iv3
monthly
71% 21d 4.6L
days
0.010L/h measured in days, rather than hours. These drugs distribute slowly
dose) intervals • Cmax values for sc administration at Tmax, vary between 2-50ug/ml,
extracellular
domain of CTLA-4 • Bioavailability for sc administration of mAbs and fusion proteins (not
1.5-
ABATACEPT fused with fully- 125mg1 sc1 Weekly 79% 13d 8.25L 48ug/ml
2d
0.021L/h anakinra) is between 51% and 80%
human
IgG Fc region • With the exception of etanercept (1-2 times per week), the long serum
TOCILIZUMAB
Humanized IgG
162mg2 sc2 4 weekly 79% 8-14d 7.07L 43ug/ml
2.8
0.010L/h half-lives and slow clearance of these drugs mean that most can be
mAb to IL-6R days
Human IgG mAb administered sc every 2-4 weeks or longer. Etanercept can thus be
SARILUMAB 150/200mg sc 2 weeks 80% 8-10d 8.3L 35.4ug/ml _ -
to !L-6R “washed out” rapidly which is an advantage as the others are hard to get
4-6h (not
Recombinant
used rid off
modified IL1
ANAKINRA 100mg2 sc2 daily 95% anymore 18.5L 3.6ug/ml 3-7h 0.63L/h
Receptor
antagonist
due to short REVISION - MONOCLONAL
PY365 ANTIBODY
– Case 3.2 - Autoimmune (mAb)
Disease Cluster
half-life)
NOMENCLATURE
PHARMACOKINETICS (based on 70-75kg adult). Data is for sc injection using autoinjectors1,
where given. Alternatively, if sc autoinjector not available, use of pre-filled syringe2 for sc • Fully murine mAbs indicated by -o-
injection or intravenous infusion3 – * at steady state; inserted into the non-proprietary
name (ie: Ibritum-o-mab)
• If murine constant region (Fc)
KEY POINTS
PY365 – Case 3.4 - Autoimmune Disease Cluster 31 replaced by human Fc to form a
CHIMAERIC antibody, -xi- is inserted
1. Antibody nomenclature: xxx –xi- mab = chimaeric; xxx – zu – mab = “humanised”; xxx –u-
into the non-proprietary name (e.g.,
mab = fully-human Infli-xi-mab; Retu-xi-mab)
2. NINE therapeutic mAbs are currently (2022) approved by NICE to treat RA. Several structures
• If parts of the variable domains are
are represented – full-length IgGs, antibody fragments and fusion proteins; chimaeric,
also replaced by human portions,
humanised and fully-human HUMANIZED antibodies are obtained.
3. FIVE act by inhibiting the activity of the proinflammatory cytokine TNFα [Certolizumab These are indicated using -zu- (e.g., Human parts are shown in
red, non-human parts in blue.
pegol, Adalimumab, Golimumab, Etanercept and Infliximab] tocili-zu-mab).
4. Adalimumab and Golimumab are full-length, fully-human IgGs. Infliximab is a mouse/human • A FULLY HUMAN mAb is indicated
chimaera using -u- (e.g., Adalim-u-mab)
5. Certolizumab pegol is a modified antibody fragment formed of a humanised Fab fragment 1
which binds to TNFα linked to polyethylene glycol ROLE OF ANTIBODY Fc FRAGMENT IN IMMUNE RESPONSES
6. Etanercept is a fusion protein consisting of two copies of the human soluble TNFα receptor
fused to an antibody Fc fragment (for stability). It binds to, and literally “mops-up” TNFα in • The Fc fragment of a full-length antibody
the circulation binds to various cell receptors (FcR) and
complement proteins
7. Tocilizumab/Sarilumab are humanised and fully-human IgGs respectively that bind to the IL- • In this way, it mediates the different
6 receptor, IL-6 being another component of the pro-inflammatory response that is physiological effects of antibodies
associated with RA • Key Examples:
8. Rituximab is a mouse/human chimaeric IgG that binds to, and selectively-depletes, CD20+ B- 1. IgG binds to pathogens via Fab =
cells “opsonisation”; binding of Fc to FcΥR on
macrophage activates that cell to engulf
9. Finally, abatacept is another fusion protein like etanercept – Cytotoxic T-lymphocyte
and kill the pathogen
Antigen-4 (CTLA-4) stabilised with a human antibody Fc fragment. By binding to receptors 2. Fc of IgG opsonising microbes (or tumour “opsonised” (antibody-coated)
(CD80/86) on antigen-presenting cells, it prevents the activation of T-effector cells, cells) can bind to FcγRIII on Natural Killer microbe recognised by effector
systematically dampening-down the adaptive immune system cell by binding of Fc to cellular receptor
cells (or cytotoxic CD8+ T-cells) that then
release cytotoxic granules that kill the
microbe = “Antibody-Dependent Cellular
Cytotoxicity” (ADCC)
PY365 – Case 3.4 - Autoimmune Disease Cluster REVISION

19
ADALIMUMAB FLASH CARD INFLIXIMAB FLASH CARDS

Biologic Biologic
DMARD
ADALIMUMAB (“Humira”) INFLIXIMAB (“Remicade” – biosimilars “Remsima”, “Inflectra “, “Fixabi”)
DMARD
Structure
144kDa Structure 144kDa
Full-length IgG1
Fully-human IgG1 Chimaeric mAb
Full-length mAb (murine Fv, fully-human Fc)
Common Indications
Common Indications • Moderate to severe active RA (+ MTX ONLY)
• Moderate to severe active RA (+ MTX, or alone if MTX inappropriate) when response to other non- • Severe plaque psoriasis
biologic DMARDS (including MTX) inadequate • Active and progressive psoriatic arthritis (+ MTX)
• Severe plaque psoriasis • Severe active ankylosing spondylitis/axial spondyloarthritis
• Active and progressive psoriatic arthritis • Severe active Crohn’s disease and fistulating Crohn’s disease
• Severe active ankylosing spondylitis/axial spondyloarthritis • Severe active ulcerative colitis
• Severe active Crohn’s disease Mode of Action
• Severe active ulcerative colitis • Suppression of TNFα activity
Contra-Indications
• Active moderate to severe acne inversa
• Moderate or severe heart failure
Mode of Action
• Active Tuberculosis and other severe infections
• Suppression of TNFα activity
Common Side Effects
Contra-Indications
• The summary of product characteristics notes the following adverse reactions as very common: viral
• Moderate to severe heart failure
infection, headache, upper respiratory tract infection, sinusitis, abdominal pain, nausea, infusion‑
• Active tuberculosis or other severe active infections
related reaction and pain (NICE, 2016); Associations with infection (TB, septicaemia, HBV reactivation)
Common Side Effects
Formulations
• The summary of product characteristics notes the following adverse reactions as very common:
• Intravenous infusion (no injectable pen yet available)
respiratory tract infections, leukopenia, anaemia, increased lipids, headache, abdominal pain, nausea
Dose
and vomiting, elevated liver enzymes, rash, musculoskeletal pain and injection site reaction (NICE,
• Infliximab is administered as an intravenous infusion at a dose of 3 mg/kg, with initial doses at 0, 2
2016): Associations with infection (TB, septicaemia, HBV reactivation) and 6 weeks, and then every 8 weeks thereafter. For disease that has an inadequate response or loss
Formulations of response after 12 weeks of treatment, consideration may be given to increasing the dose step‑
• Subcutaneous injection ONLY – can be self-administered wise by approximately 1.5 mg/kg up to a maximum of 7.5 mg/kg every 8 weeks. Alternatively,
Dose administration of 3 mg/kg as often as every 4 weeks may be considered. The NHS list price of
• Adalimumab is administered subcutaneously as a 40‑mg dose every other week. The net price of originator infliximab (Remicade) is £419.62 per 100‑mg vial (BNF, July 2015). Assuming a weight per
adalimumab is £352.14 per 40‑mg prefilled pen or prefilled syringe, or £352.14 per 40‑mg/0.8‑ml person of 70 kg, vial wastage and 3 initial doses followed by treatment every 8 weeks, the cost in the
first year is £10,070.88, and then £8812.02 per year. Costs may vary in different settings because of
vial ( BNF, July 2015). Assuming 26 doses per year, the annual cost of adalimumab is £9155.64. For
negotiated procurement discounts. The NHS list price of infliximab biosimilars (Remsima, Inflectra) is
adalimumab monotherapy, the dose may be increased up to 40 mg per week for people who have a
£377.66 per 100‑mg vial (BNF, December 2015). Assuming a weight per person of 70 kg, vial wastage,
decrease in response. Costs may vary in different settings because of negotiated procurement and 3 initial doses in the first year followed by treatment every 8 weeks, the cost in the first year is
discounts (NICE, 2016). £9063.84, and then £7930.86 per year. The infliximab biosimilars are available to the NHS at contract
Points of Interest/Information prices negotiated through the Commercial Medicines Unit. These prices are lower than the list price
• CAUTIONS: demyelinating disorders; development of malignancy; mild heart failure; predisposition to but are commercial in confidence (NICE, 2016)
infection Points of Interest/Information
• DO NOT INITIATE until active infections controlled and discontinue if severe infection develops • Only given by intravenous infusion; adequate resuscitation facilities MUST be available when
• TUBERCULOSIS: Patients with active TB should be treated for 2mo before starting on adalimumab; infliximab used due to risk of anaphylaxis
st
patients successfully treated for TB can start adalimumab but must be monitored every 3mo for • HYPERSENSITIVITY REACTIONS reported during or within 1-2h after infusion, particularly during 1 or
nd
possible recurrence 2 treatment – prophylactic antipyretics, antihistamines or hydrocortisone may be administered
• Avoid in pregnancy; use contraception during treatment and for 5mo after; Avoid during • TB: As for Adalimumab
•
breastfeeding and for 5mo after treatment
THREE biosimilars now (2017) available
•
•
REVISION
CAUTIONS: Long list – see BNF
Use only if essential in pregnancy; use contraception during treatment and for 6mo after treatment;
amount used probably too small to be harmful during breast feeding
GOLIMUMAB FLASH CARD CERTOLIZUMAB PEGOL FLASH CARD ETANERCERPT FLASH CARD
Biologic Biologic Biologic
GOLIMUMAB (“Simponi”) CERTOLIZUMAB PEGOL (“Cimzia”) ETANERCEPT (“Enbrel”)
DMARD DMARD DMARD
Structure 4348kDa Structure 51 kDa

Structure 147kDa 2 copies soluble human TNFα
Full-length IgG1 Fab fragment
receptor 2 (“p75”) linked
Humanized (from mouse)
Fully-human mAb to fully-human Fc region of IgG1
Common Indications
• Moderate to severe active RA (+ MTX, or alone if MTX inappropriate) when response to other non-
biologic DMARDS (including MTX) inadequate
Common Indications Common Indications
• Active and progressive psoriatic arthritis
• Moderate to severe active RA (+ MTX, or alone if MTX inappropriate) when response to other non- • Moderate to severe active RA (+ MTX, or alone if MTX inappropriate) when response to other non-
• Severe active ankylosing spondylitis
biologic DMARDS (including MTX) inadequate biologic DMARDS (including MTX) inadequate
• Severe plaque psoriasis
• Active and progressive psoriatic arthritis
• Active and progressive psoriatic arthritis Mode of Action
• Severe active ankylosing spondylitis/axial spondyloarthritis • Suppression of TNFα activity
• Severe active ankylosing spondylitis Mode of Action
• Severe active ulcerative colitis Contra-Indications
• Suppression of TNFα activity
Mode of Action • Sepsis or patients who are at risk of sepsis
Contra-Indications • Active infections including chronic or localised infections
• Suppression of TNFα activity • Moderate to severe heart failure
Contra-Indications • Active Tuberculosis and other severe active infections
Common Side Effects
• The summary of product characteristics notes the following adverse reactions as very common:
• Moderate to severe heart failure Common Side Effects
infections and injection site reactions NICE, 2016). Associations with infection (TB, septicaemia, HBV
• Active Tuberculosis and other severe active infections • The summary of product characteristics lists no adverse reactions as very common but notes that in
reactivation)
Common Side Effects clinical trials the most common adverse reactions were bacterial and viral infections (NICE, 2016);
Formulations
• The summary of product characteristics notes that upper respiratory tract infections are very Associations with infection (TB, septicaemia, HBV reactivation) • Subcutaneous injection – can be self-administered (“Enbrel”, “Benepali”, “Enbrel MyClic” pens)
common adverse events (NICE, 2016); Associations with infection (TB, septicaemia, HBV reactivation) Formulations • Powder and solvent for injection (inc. paediatric dose)
• Subcutaneous injection ONLY – can be self-administered (“Cimzia” pen) Dose
Formulations Dose • Etanercept is administered subcutaneously as a 25‑mg dose twice weekly or alternatively as a 50‑mg
• Subcutaneous injection ONLY – can be self-administered using SIMPONI pen • Certolizumab pegol is administered subcutaneously as initial 400‑mg doses at 0, 2 and 4 weeks, dose every week. The net price of etanercept is £89.38 per 25‑mg prefilled syringe, or £178.75 per 50
Dose followed by maintenance doses of 200 mg every 2 weeks. Alternatively, administration of 400 mg ‑mg prefilled pen or prefilled syringe (BNF, July 2015). Assuming 52 doses per year, the annual cost of
every 4 weeks can be considered, once clinical response is confirmed. The net price of certolizumab etanercept is £9295. Costs may vary in different settings because of negotiated procurement
• Golimumab is administered subcutaneously as a 50‑mg dose every month on the same day each
pegol is £357.50 per 200‑mg prefilled syringe (BNF, July 2015). Assuming 3 initial doses of 400 mg discounts
month. For people weighing more than 100 kg, a dose of 100 mg may be considered if the disease has followed by maintenance doses every 2 weeks, the cost (without the patient access scheme) in the Points of Interest/Information
an inadequate clinical response after 3–4 doses. The net price of golimumab is £762.97 per 50‑mg first year is £10,367.50, (or with the patient access scheme, £6793) and then £9295 per year. Costs • THREE PRODUCTS (Enbrel, Benepali, Enbrel MyClic) available as pen injections – good practice to use
prefilled pen or prefilled syringe (BNF, July 2015). For people weighing less than 100 kg and assuming may vary in different settings because of negotiated procurement discounts (NICE, 2016) same brand name throughout treatment
12 doses per year, the annual cost of golimumab is £9155.64. Costs may vary in different settings Points of Interest/Information • CAUTIONS: Development/history of malignancy; development/history of demyelinating disorders;
because of negotiated procurement discounts (NICE, 2016) • Loading dose 10X higher than adalimumab, golimumab diabetes mellitus; heart failure risk; history of blood disorders; hepatitis B and C infection;
Points of Interest/Information • CAUTIONS: demyelinating disorders; development of malignancy; mild heart failure; predisposition to predisposition to infection; exposure to herpes zoster virus – stop treatment
• CAUTIONS: As Adalimumab PLUS risk factor for dysplasia or carcinoma of colon – check regularly infection • TUBERCULOSIS: Patients with active TB should be treated for 2mo before starting on etanercept;
• DO NOT INITIATE until active infections controlled and discontinue if severe infection develops
• TB: As for Adalimumab patients successfully treated for TB can start etanercept but must be monitored every 3mo for
• TUBERCULOSIS: Patients with active TB should be treated for 2mo before starting on certolizumab
• Similar to adalimumab, but with less side effects possible recurrence
pegol; patients successfully treated for TB can start certolizumab pegol but must be monitored every
• Avoid in pregnancy; use contraception during treatment and for 3 weeks after treatment; avoid
• Use only if essential in pregnancy; use contraception during treatment and for 6mo after treatment; 3mo for possible recurrence
during breast feeding
• Can be used during pregnancy and breastfeeding – reduced placental transit
avoid during breast feeding and for least 6mo after treatment
REVISION REVISION
TOCILIZUMAB FLASH CARD RITUXIMAB FLASH CARD ABATACEPT FLASH CARD
Biologic
Biologic Biologic ABATACEPT (“Orencia”)
TOCILIZUMAB (“RoActemra”) RITUXIMAB (“Mabthera” – biosimilar Truxima) DMARD
DMARD DMARD
Structure 92kDa
Structure 145kDa Structure 144kDa 2 copies of extracellular
Full-length IgG1 domain of human CTLA-4
Full-length IgG1 receptor (CD152) fused to human
Humanised mAb
chimaeric mAb IgG1 Fc
(murine Fv, fully-human Fc)
Common Indications
• Moderate to severe active RA (+ MTX, or alone if MTX inappropriate) in patients unresponsive to
Common Indications Common Indications
other DMARDs ( including MTX or a TNFα inhibitor) or in those intolerant to these drugs
• Severe active RA when response to other non-biologic and biologic DMARDS (including 1 or more • Moderate to severe active RA (+ MTX) in patients unresponsive to other DMARDs (including MTX or a
Mode of Action TNFα inhibitors) inadequate or who are intolerant of them (in combination with methotrexate) TNFα inhibitor)
• Tocilizumab binds soluble as well as membrane bound interleukin-6 receptors, hindering IL-6 from Mode of Action
• Stage III-IV follicular lymphomas, non-Hodgkins lymphomas, lymphocytic leukemia; granulomatosis
exerting its pro-inflammatory effects • Abatacept prevents antigen-presenting cells (APCs) from delivering the co-stimulatory signal to the
with polyangiltis naïve T-cell
Contra-Indications
9
• Do not initiate if absolute neutrophil count < 2 x 10 /litre Mode of Action Contra-Indications
• Severe active infection • Binds to CD20 on normal and malignant B-cells, targeting them for destruction • Severe and uncontrolled infection
Contra-Indications Common Side Effects
Common Side Effects
• Severe heart failure; severe, uncontrolled heart disease • The summary of product characteristics notes that upper respiratory tract infections are very
• The summary of product characteristics notes the following adverse reactions as very common: upper
common adverse events (NICE, 2016)
respiratory tract infections and hypercholesterolaemia (NICE, 2016) • Active Tuberculosis and other severe infections
9 3 Formulations
• Discontinue if absolute neutrophil count <0.5 x 10 /litre or platelet count <50 x 10 /microlitre Common Side Effects • Powder to form solution for intravenous infusion (follow reconstitution and administration guidelines
Formulations • Many – see BNF; Associations with infection (TB, septicaemia, HBV reactivation) carefully using silicon-free syringe provided); subcutaneous injection pen available (“Orencia Pen”)
• Solution for intravenous infusion • Progressive multifocal leucoencephalopathy (PML) has been reported – monitor patients and suspend Dose
Dose • Abatacept is given by intravenous infusion at a dose of 500 mg for a person weighing less than 60 kg,
treatment if PML develops
• Tocilizumab is administered as a dose of 8 mg/kg every 4 weeks. The net price of tocilizumab is 750 mg for a person weighing between 60 kg and 100 kg, and 1000 mg for a person weighing more
£102.40 per 4‑ml (80‑mg) vial, £256.00 per 10‑ml (200 mg) vial, or £512.00 per 20‑ml (400‑mg) vial Formulations
than 100 kg. It is given initially at 0, 2 and 4 weeks, then every 4 weeks thereafter. The net price of
(BNF, July 2015). Assuming a weight per person of 70 kg, vial wastage, and 13 doses each year, the • Solution for intravenous infusion abatacept for intravenous infusion is £302.40 per 250 mg vial (BNF, July 2015). For people weighing
annual cost (without the patient access scheme) of tocilizumab is £9318.40. Costs may vary in Points of Interest/Information between 60 and 100 kg, the cost of treatment for the first year is £12,700.80 and then £11,793.60 per
different settings because of negotiated procurement discounts (NICE, 2016) • CAUTIONS: Long list – see BNF; when used for RA, predisposition to infection year (without the patient access scheme). Costs may vary in different settings because of negotiated
Points of Interest/Information procurement discounts (NICE, 2016)
• Hepatitis B infection and reactivation (including fatal cases) – do not commence rituximab treatment Points of Interest/Information
• Dose adjustment may be required for patients with low absolute neutrophil or platelet count or with
liver enzyme disorders until evidence HBV successfully-treated and monitor for HBV during treatment and for 12mo • CAUTIONS: Do not initiate until active infections controlled; elderly patients (increased risk of side
thereafter effects); predisposition to infection (screen for latent TB and viral hepatitis); Progressive multifocal
• CAUTIONS: History of diverticulitis, intestinal ulceration or recurrent/chronic infection (discontinue
leucoencephalopathy (PML) has been reported – monitor patients and suspend treatment if PML
treatment if serious infection occurs) • Avoid in pregnancy unless potential benefit to mother outweighs risk of B-cell depletion if foetus; use
develops
• Avoid unless essential in pregnancy; use contraception during treatment and for 3mo after treatment; contraception (both sexes) during treatment and for 12 mo after treatment; avoid breast feeding • Use only if essential in pregnancy; use contraception during treatment and for 14 weeks after
during breast feeding, use only if potential benefit outweighs risk during and for 12mo after treatment REVISION
treatment; avoid during breast feeding and for least 14 weeks after treatment
REVISION
20
L4) bDMARDs Immunogenicity:

WHAT IS IMMUNOGENICITY?
• IMMUNOGENICITY is the ability of any molecule to
provoke an adaptive immune response • Immunogenicity is the
• This is always mediated by T-cells (affected by ability of a foreign
adaptive immune response and is centered around substance, such as an
immunogenicity) antigen, to provoke an CONTRIBUTION OF CONTRIBUTION OF
immune response in the BIOLOGICAL SYSTEM ANTIGEN
• Such responses are vital to protect ourselves from
body of a human
disease or are induced by vaccination
(activation of T cell is the Immune system properties: Physicochemical properties:
• BUT the body can also respond to biologics as it issue which signals to b 1. Immune tolerance 1. Delivery and Treatment
doesn’t know the difference between infectious cells to produce antibodies 2. MHC Class II Haplotype 2. Manufacturing
organism and normal proteins that’ll target the drugs) 3. Patient immunosuppression 3. Storage
• This leads to responses AGAINST the drug, usually • Anti-drug Antibodies e.g., HIV 4. Formulation
manifested as ANTI-DRUG ANTIBODIES (ADAs) (ADAs) is a big problem 5. Expression system
with using biologics
• ADAs cause the biologic to be less-effective or can
even provoke immunopathology!
IMMUNOGENICITY is the outcome of the interplay between BIOLOGICAL
• So, in the context of biologics, Immunogenicity is SYSTEMS (our immune responses to a therapeutic protein) and the
an UNWANTED immune response and must be BIOPHYSICAL/CHEMICAL properties of the protein itself
avoided as much as possible!
REVISION: REGULATORY T-CELLS (“TREG”), CAN ALSO
REVISION: THE KEY ROLE OF THE EFFECTOR T-CELL IMPACT PY365
ON IMMUNOGENICITY
– Case 3.4 - Autoimmune Disease Cluster 3
T-cell Effector Th
activation cells
Naïve
CD4+ Th cell
CD4+ Th1 Macrophage
IL-2
TCR
MHC2 CD4+ Th2 B-cell Antibodies

X
Antigen
Presenting
Cell
They can affect the T cells effects where they’re made
CD8+ cytotoxic
T-cell in the bone marrow and has a receptor FOXP3 where
they are immunomodulators where they stop basic
The three immune system properties are tolerance, naïve T cells to become infective
MHC II haplotype, Immunosuppression)
1: What we are after is
IMMUNOGENECITY IS THE BALANCE BETWEEN T-
PY365 – Case 3.4 - Autoimmune Disease Cluster REVISION “T-CELL MEDIATED
PY365 – CaseIMMUNE TOLERANCE”
3.4 - Autoimmune Disease Cluster REVISION
EFFECTOR AND T-REGULATORY CELLS THAT CONTROL Immune tolerance can be defined as a state
This contrasts with
IMMUNOGENICITY in which a T cell CAN NO LONGER respond to
the conventional
antigen. The T cell "tolerates" the antigen
immune-mediated
e.g., protein-based food but if foreign is
response to
detected (by non-self) to be eliminated
eliminate pathogens
Immune tolerance – allows

one to distinguish SELF from
If our biologic does not induce
effector T-cells, or induces NON-SELF and prevents
regulatory T-cells, we don’t REACTIONS to environmental
antigens (gut microbes,
2: PRESENCE OF SPECIFIC HLA ALLELES get immunogenicity problems!
allergens)
3: IMPACT OF IMMUNOSUPPRESSION ON
PY365 – Case 3.4 - Autoimmune Disease Cluster4 6
IMMUNOGENICITY If patient is IMMUNOSUPPRESSED due to:-
PY365 – Case 3.4 - Autoimmune Disease Cluster 5 • Age
• Taking immunosuppressive medication
• Undergoing chemo/radiotherapy
• HIV
• autoimmune disease
• HLA genes encode MHC II structures that present bits of therapeutic
protein peptides (which can represent immunodominant epitopes) on the there is a HIGH RISK of immunogenicity
surface of an antigen-presenting cell to a T-cell due to their compromised immune system
• Some HLA genes are associated with immunogenicity as they encode where the body will recognize them as non-self
MHCs that bind these immunodominant epitopes very tightly i.e.,: HLA-DR But this doesn’t mean they have NO T-cells, needed to
• The MHC II/peptides bind with high affinity to the naïve T-cell receptor recognize self and non-self!
and induce OVER activation and OVER proliferation of that T-cell
• The population of T-effector cells thus created will induce antibody The whole immune system just doesn’t operate
responses against that therapeutic protein (= Immunogenicity) normally during immunosuppression
PY365 – Case 3.4 - Autoimmune Disease Cluster 7

21
PHYSICOCHEMICAL ASPECTS OF IMMUNOGENICITY

THE ROLE OF THE IMMUNE SYSTEM IN
IMMUNOGENICITY – KEY POINTS
1. The key effector in immunogenicity is the T- cell, due to its role in inducing
the production of anti-drug antibodies (ADAs) against the therapeutic mAb 2. MANUFACTURING
ISSUES
2. However, it is the BALANCE between the activities of EFFECTOR T-cells 3. STORAGE
(which induce antibodies) and REGULATORY T-cells (which supress the
induction of effector T-cells) which determines the severity of
Immunogenic responses
3. Ideally, our therapeutic protein will NOT induce the production of effector
T-cells (or just induces Tregs) – so that the drug is effectively not recognised
by the immune system – a state of IMMUNE TOLERANCE
4. If the patient is IMMUNOSUPRESSED, they may respond aberrantly to a 1. TREATMENT RELATED 4. EXPRESSION
FACTORS (how to deliver 5. FORMULATION SYSTEM
therapeutic protein with a strong likelihood of inducing immunogenicity the drug)
5. Equally, the presence of certain HLA genes encoding specific MHC II
structures are associated with a higher risk of immunogenicity 1:PY365
ROUTE OF ADMINISTRATION
– Case 3.4 - Autoimmune Disease Cluster 10
• Skin/mucosal surfaces show MARKED

1. TREATMENT-RELATED FACTORS DIFFERENCES compared to blood where they’re the
first point in terms of pathogens entry
Several factors • Route of administration
• -Drug dose • They have a lot of antigen presenting cells (such as
related to treatment
PY365 – Case 3.4 Autoimmune Disease Cluster 9 Langerhans cells) plus extra types of T-cells (i.e.,: gd
can impact on • Frequency of administration
immunogenicity • Duration of treatment T-cells)
Hence why bDMARDs are carefully monitored • Thus, injecting therapeutic proteins
subcutaneously or intradermally is MORE LIKELY to
induce immunogenicity
• Thus, therapeutic proteins are often administered
intravenously if other risk factors are apparent
2. MANUFACTURING ISSUES
1: EFFECTS OF DRUG DOSE, FREQUENCY AND
DURATION OF TREATMENT
• Short-term treatment less likely to cause an immune
response than long-term treatment
• Products given continuously less likely to be
immunogenic than if given intermittently
• 3-dimensional structure of mAb/biologic may CHANGE during
(maintenance of trough levels)
PY365 – Case 3.4 - Autoimmune Disease Cluster 11 manufacturing process hence the drug won’t work or cause
• Re-exposure after a long interval is often associated
pathological effects
with an enhanced immune response (rather like a
• CONTAMINANTS (such as endotoxins, host-cell
vaccine as that’s what’s wanted, but memory B cells
proteins/lipids/DNA or breakdown products) can become
can respond when this drug is given after a period of incorporated into the product
time hence the interval needs to be given correctly) • ALL contaminants can act as ADJUVANTS, altering the immune
• Lower dose of Infliximab (3mg/kg) more response to the therapeutic mAb in an uncontrolled manner
immunogenic than higher dose (5mg/kg) (wanted in vaccines to be more effective but not with biologics)
3. AGGREGATION DURING STORAGE (mAbs) 4. EXPRESSION SYSTEM USED
Expression systems are genetic constructs (a gene encoded by DNA) that are
• Therapeutic mAbs are VERY PRONE TO AGGREGATION can be prevented by PY365a–protein,
designed to produce Case 3.4
or -an
Autoimmune Disease
RNA (ribonucleic acid),Cluster
either inside or
serum albuminPY365 – Case 3.4 - Autoimmune Disease Cluster 13 outside a cell. Expression systems are used in research and in the commercial
• This can be caused by manufacturing process and/or storage production of enzymes or therapeutics
• mAbs must be VERY CAREFULLY STORED (see below)
• Aggregated mAbs reveal/create NEW epitopes (a part of the antigen in which Bacterial – will NOT link heavy and light antibody chains,
the antibody attaches to) and may become HIGHLY IMMUNOGENIC so can only be used to provide antibody FRAGMENTS
Aqueous 4 C 25-50% Frozen at Lyophilised
hence not used (scFV, Fab)
glycerol @-20 C -20 or -80 C
Shelf Life 1 month 1 year > 1 year > 1 year
Carrier Yes - BSA Yes - BSA Yes - BSA No Mammalian cells (such as CHO or NSO) – will express
protein full-size, correctly-folded, glycosylated IgG at high yield
required?
(2g/L) FULLY BIOLOGICALLY ACTIVE
Sterile? Yes Usually No No
MAJORITY OF APPROVED HumAbs EXPRESSED IN CHO
pH range 7.2-7.6 7.2-7.6 None None
Multiple use? Yes Yes No Not Transgenic animals (goats) - will express full-size,
applicable correctly-folded, biologically active, glycosylated IgG in
[Ab] mg/ml 1-5 1-5 1-5 1-5 milk
PY365 – Case 3.4 - Autoimmune Disease Cluster 15 PY365 – Case 3.4 - Autoimmune Disease Cluster 16
22
5. FORMULATION The real “take-home” message from the preceding slides

is that therapeutic proteins are complex,
The nature of
excipients/buffers/adjuvants This can impact on
three-dimensional structures and just about ANYTHING
used with a therapeutic protein immunogenicity can affect this and cause immunogenicity!
can CHANGE ITS STRUCTURE
An adjuvant is an
ingredient used in some
vaccines that helps
create a stronger
immune response in
people receiving the
vaccine.
Silicon leaching from a vial

Thus, validation and testing of all steps of the manufacturing
Even the infusion diluent
closure altered structure of process, purification, storage and formulation must be strictly
and infusion device
an experimental HIV material can have an controlled! If any step is changed, the product must be
therapeutic vaccine! effect! rigorously re-tested. [biosimilars]
PY365 (also
– Caseknown
3.4 -asAutoimmune
follow-on biologic or subsequent
Disease Cluster entry 17
PHYSICOCHEMICAL ASPECTS OF
BIOSIMILARS biologic) is a biologic medical product that is almost an IMMUNOGENICITY – KEY POINTS
identical copy of an original product that is manufactured
by a different company. • In clinical use, the route, frequency, duration and dose of the biologic can
impact on the degree of immunogenicity noted
Although theoretically Rigorous retesting of all steps • Because therapeutic proteins are complex, 3-dimensional structures which
“identical” to the parent in the manufacturing can be easily altered by manufacturing processes, purification, storage or
drug, there can be process, purification, storage formulation, ALL of these factors can cause immunogenicity
differences which impact and formulation must be • The expression system employed to produce a biologic can impact not only
on immunogenicity undertaken before regulatory on the efficacy of the therapeutic protein but also its potential to cause
approval for use is granted immunogenicity
• Post-translational modifications, such as glycosylation, and aggregation of
the product during manufacture or storage have particular impact
• Careful testing at all stages of the manufacture, formulation and storage of a
therapeutic protein is essential to minimise structure alterations and
subsequent immunogenicity
bDMARDs: IMMUNOGENICITY • If ANY detail of the manufacture, formulation and storage of a therapeutic
protein is changed, the product must be rigorously re-tested!
• As all bDMARDs are proteins • MUST take possibility of
• Can be recognised by adaptive immunogenicity into
immune system (T-cells) account before starting REACTIVITY TO Fab FRAGMENT OF bDMARDs
• Impacts on PK/PD properties treatment
• IMG can not only effect
ADAs →Fab
ADAs →Fab or PY365 – Case 3.4 - Autoimmune•Disease fragment of
Cluster 20
of these drugs
treatment efficacy.. Fc fragment of infliximab, adalimumab,
PY365 – Case 3.4 - Autoimmune Disease• Cluster
.. but may also cause 19 Antibody golimumab certolizumab have
serious side FX a neutralizing capacity
• They interfere with binding of
ab/antibody to TNFα
Explanations:
• Anti-idiotype reactivity • Expected with the
(reaction of immune chimaeric
system to any novel
infliximab, or
antibody)
• In most cases, immunogenicity evidenced by • Balance of Teffector and humanized
development of anti-drug antibodies (ADAs) – screened Tregulatory epitopes within certolizumab pegol..
before treatment a biologic → may • .. but not expected
• ADAs observed previously with other biologics suppress or enhance fully-human
(erythropoietin, insulins, enzymes) immune tolerance adalimumab and
golimumab
Annoyingly suggests humanisation not sole answer to control
immune reactivity of mAb!
23
REACTIVITY TO Fc FRAGMENT OF bDMARDs HUMANISATION – NOT A UNIVERSAL PANACEA!

• ADAs →Fc fragment/junction portion between the two There are drugs in • Studies show clear relationship between successful RA treatment with
(“anti-hinge”) - do not normally affect drugs which you get ADAs infliximab/adalimumab and the presence of ADAs
neutralizing ability as the fab fragment is still exposed against the Fc • Meta-analysis (12 studies) = development of ADAs reduced the anti-TNF
and can still bind to TNF-alpha fragment or the
• But can still form immune complexes with the drugs → junction between the
response rate (RR) by 68%
enhance the rate of clearance by scavenging Fc fragment and the • Also, patients with ADAs to infliximab/adalimumab required higher doses
macrophages etc. antibody fragment of drug and/or shorter intervals between infusions to achieve or maintain
a good clinical response →treatment failure
• NO association between ADAs and clinical response for etanercept,
• ADAs can develop abatacept abatacept, certolizumab or golimumab as much lower risk of ADAs being
and etanercept
• Neutralizing ADAs →CTLA-4
induced (2-5%, 1-3%, 5-8%, 6%, respectively)
antigen or complexing ADAs • Similarly, only 3.8% of tocilizumab/3-4% of rituximab RA patients
→Fc/hinge domain of developed ADAs - no correlation to clinical events
abatacept
• ADAs →etanercept are not
neutralising hence making • Two clear messages emerge
etanercept less problematic 1. First, infliximab/adalimumab more immunogenic than other bDMARDs
when producing ADs
23 2. Humanisation is not a universal panacea for preventing immunogenicity
OTHER FACTORS INDUCING ADAs DURING SUMMARY OF FACTORS INFLUENCING ADA
bDMARD THERAPY DEVELOPMENT DURING bDMARD TREATMENT 24
1. High amount of TNF targets at baseline (reflected by the CRP level) can
consume a large proportion of the bDMARD → low trough levels of the
drug → occurrence of ADAs
2. Use of methotrexate reduced proportion of patients with ADAs on
infliximab/adalimumab by ∼41%
3. Maintenance of A CONSTANT TROUGH LEVEL of the biologic = best
guarantee of disease control + best method for preventing ADA
development
4. In line with the “discontinuity theory” of the immune response = novel (but
persistent) antigen induces initial immune response, followed by tolerance
IFF the antigen persists at constant levels
5. But intermittent appearance of antigen → persistent immunogenic response
(as seen in vaccine and vaccine recall)
6. Temporary withdrawal of treatment favour immunogenicity. Ie use of
abatacept observed that patients who discontinued treatment → higher Factors affecting induction of ADAs, which impact on serum trough concentration of
incidence of immunogenicity than patients who did not discontinue (7.4% vs bDMARDs. Some factors (obesity, inflammation status) depend on the patient, others
2.6%, respectively) are linked to the treatment strategy (concomitant use of immunomodulator
7. Obese patients have a far higher incidence of ADAs 25 (methotrexate), bDMARD dosage schedule). Low trough concentrations are thought
to play a role in the development of ADAs.
TESTING AND PREDICTING
…and we must test
Immunogenicity can any new therapeutic YOU CANNOT USE ANIMAL MODELS TO PREDICT
mAb (or after any
be caused by many
factors… change in manufacture IMMUNOGENICITY IN HUMANS
or reformulation etc)
for immunogenicity
From the EMEA guidelines
As we are interested in human recombinant proteins,

This saves both time The field is now mature Even though there is
and money in drug enough for SOME no one clear signal these will almost certainly be immunogenic in any animal.
development and has predictions to be made, and that can be used to
the potential to subsequent changes predict
reduce immunogenicity incorporated, to minimise it immunogenicity
27
HUMAN CLINICAL TRIALS ARE THE “GOLD STANDARD” AND details of immune systems vary between species-
TO DETECT AND CHARACTERISE ADAs what happens in a rat may well not happen in us, and vice
versa - remember TGN1412! (Google this…)
Samples need to be taken
Testing in double-blind for a period after the
randomised trials must therapeutic protein has
be designed to detect
immunogenicity as well
been eliminated: highest
affinity antibodies will be
IMMUNOGENICITY TESTING AND PREDICTING –28
as safety and efficacy bound to the drug first,
lower affinity ones later
KEY POINTS
• ALL new therapeutic mAbs and any reformulations of therapeutic
mAbs MUST be tested for Immunogenicity by human Clinical Trials,
following EMEA guidelines
Trials should • In vitro testing of humanised mAbs in animals is not acceptable, as
continue for 6-12
months to monitor these will always be seen as foreign proteins and induce anti-drug
variation in immune antibodies (ADAs)
responses.
24
L5) Biosimilars:
BIOSIMILARS. WHAT’S THE POINT? THAT’S THE JOB OF THE MEDICINES REGULATORY AUTHORITIES
The medicines regulatory
These biologics But patent expiry authorities ENSURE that We ALSO demand
are amazing is coming-up on biosimilars are as effective retesting is done
drugs but so some of them. Can as the Reference Biologc when a manufacturing
expensive! we make them (drug which it is copying) process changes…
cheaper? before we license them!
Biosimilars doesn’t really need

… by applying (in both
clinical trials making it cheaper cases) the International
but need to ensure the source as In both cases, Conference on
cheaper doesn’t always = quality this is termed a Harmonisation (ICH) Q5e
SIMILARITY guidelines
EVALUATION
Well, yes, as
Cheaper drugs there are lower FDA; EMA; WHO
would improve development
healthcare (and costs OR to test if the process These outline the
we could make a change has had an adverse necessary steps
lot of money!) Similarity Evaluation is taking key parts of effect on product quality , required to compare
the molecule to see how similar the biosimilar efficacy or safety (including biosimilars with the
reference biologic
is compared to the original drug immunogenicity)
KEY POINTS – make sure you know these! THE SIMILARITY EVALUATION/”COMPARABILITY EXERCISE”
Even if manufactured under
1. The term ‘biosimilar’ is used to As biologics are produced in living IDENTICAL CONDITIONS,
describe a biologic that is 3. Because they are not identical, cells, there will ALWAYS be batch- characteristics of biologics can
considered ‘highly similar to a biosimilars cannot be considered to-batch variation STILL change – termed ‘DRIFT’
reference biologic product generic versions of their reference
notwithstanding minor biologic products ALSO, any changes in
differences in clinically inactive manufacturing process can alter
components’… characteristics – legal requirement
Best example is RITUXIMAB (knocks
to carry-out a pre-clinical (always)
down CD20 B cells) – ADCC/antibody
and clinical re-evaluation
4. And we also know that changes dependent cellular cytotoxicity activity
2 …and for which there are ‘no (sometimes) of the product =
in manufacturing process will alter increased 10-20% over time! Due to “COMPARABILITY EXERCISE” –
clinically meaningful differences changes in GLYCANS/sugars on the
between the biologic product and the characteristics (“drift”) of a there have been 35 changes in
antibody. Important as this is major MOA
biosimilar which means they Infliximab manufacturing!
the reference product in terms of of RTX when used to treat non-Hodgkins
the safety, purity, and potency of MUST be compared to the Lymphoma (a type of cancer that
the product’ originator biologic develops in the lymphatic system)
BIOLOGICS AND SMALL-MOLECULE DRUGS ARE NOT THE SAME BIOLOGICS –V- BIOSIMILARS: 1 Clinical Trials
• A reference biologics molecule must go through a “standalone” application
• This contains all data, including CLINICAL TRIALS demonstrating its safety and
Not possible to make an exact copy of it unlike generics effectiveness
• When the patent on an original biological medicine expires, other competing companies
can apply for marketing approvals for a corresponding biosimilar product
• The ultimate goal of a biosimilar development program is to prove “bio-similarity” with
the reference drug, rather than establish a standalone safety or efficacy profile
• Thus, instead of going through a conventional clinical trial, the biosimilar undergoes a
comparative clinical trial to prove a lack of clinical difference from the reference
molecule
• The biosimilar molecule can piggyback on the safety and efficacy knowledge gathered
from the years of usage of the reference molecule.
BIOLOGICS –V- BIOSIMILARS: 2 Regulatory Aspects
• From a regulatory standpoint, the biosimilar development program need not BIOSIMILAR DEVELOPMENT IN A NUTSHELL
repeat the entire clinical development program as the original reference (ACCORDING TO THE FDA…)
PY365 – Case 3.2 - Autoimmune Disease Cluster
biologics molecule 8
• This advantage reduces the costs incurred by both: the manufacturers as well
as the consumers
• Moreover, it saves a lot of volunteers and patients from engaging in
unnecessary trials 2. Rigorously define the key 3. Develop a manufacturing,
quality attributes (“QTPP”) Purification and formulation process
• Overall, the approval pathway for biosimilars is much more streamlined, 1. Select your reference
biologic
of that reference biologic (things that mustn't to match the QTPPs of the reference
change much, if changed = doesn’t work) biologic
simpler and cheaper than the branded original biologics
• Consequently, biosimilars enable patients to access medical innovations
-V- 4. Then do your SIMILARITY EVALUATION
sooner and cheaper, without compromising on the efficacy or safety
PY365 – Case 3.2 - Autoimmune Disease Cluster 8 PY365 – Case 3.2 - Autoimmune Disease Cluster 9
25
COMPARING BIOLOGIC AND BIOSIMILAR BIOSIMILARS MUST BE TESTED WITH REFERENCE TO THE
DEVELOPMENT PATHWAYS ORIGINATOR (“REFERENCE”) BIOLOGIC =
• In the BIOLOGIC pathway, more CLINICAL “SIMILARITY EVALUATION”
data is required
• But for the BIOSIMILAR pathway, the PRE- SIMILARITY EVALUATION:-
CLINICAL stage is more extensive We’ll use the example of
• If adequate similarity can be established • Physicochemical properties THERAPEUTIC
between the reference biologic and the • In vitro/in vivo biological MONOCLONAL ANTIBODIES
activity and function to see how this is done,
biosimilar in the pre-clinical phase….
using the EMA (2012)
• …. much less clinical testing is required • PK and PD properties
stepwise assessment
• This accelerates biosimilar development • Preclinical in vivo safety and
and cuts cost (clinical trials are expensive!) toxicity profile
PRECLINICAL TESTING OF THERAPEUTIC mAb BIOSIMILARS: EXAMPLES OF FUNCTIONAL ASSAYS –ADCC & CELL GROWTH
BASED
PY365 ON
– Case 3.2EMA 2012 GUIDELINES:
- Autoimmune Disease Cluster step 1 10 PY365 – Case 3.2 - Autoimmune Disease Cluster 11
• Note the KEY functional assessments based
on IMMUNE PARAMETERS:-
Ø Target antigen binding (say, TNFα for a
bDMARD) – specificity/affinity
Ø Recognition of and binding to all Fc gamma
receptors
EC50
Ø Fab effector functions (i.e.,: does mAb EC50
neutralise its ligand and prevent its activity;
does receptor activation or blockade occur)
Ø FC fragment associated functions (is
complement bound/activated; degree of
antibody and/or complement-dependent
cytotoxicity
• All parameters MUST be comparable to

those obtained with reference biologic under
the same experimental conditions
DEFINING THE REFERENCE BIOLOGIC PY365 – Case 3.2 - Autoimmune Disease Cluster 14
• DRIFT = characteristics of reference biologic can Indicates a GLYCOSYLATION – A KEY MODIFICATION
change over time change in The controlled
• Thus, “key quality attributes” of this must be polypeptides enzymatic
hence this drift modification of an
rigorously characterised
could have an organic molecule,
• These provide a QUALITY TARGET PRODUCT effect on efficacy especially a
PROFILE (QTPP) for the reference biologic protein, by addition
• To address QTPP DRIFT, “goalposts” can be defined of a sugar
• These provide “established variations” over time molecule.
• If physicochemical/functional parameters of the Glycosylation can modify:
product fit within the reference biologic • Protein folding
“goalposts”, it can be considered to be ‘highly • Cellular localisation
• Protein activity
similar’ – product can be a new Biosimilar, or after
change in manufacturing Many therapeutic proteins are glycosylated when produced naturally in the body:
• i.e.,: cytokines (interleukins and interferons), gonadotrophins, blood factors, tissue plasminogen activator, full-length
• Examples of QTPP drift = changes in aa of IgG monoclonal antibodies
polypeptide (Fig 3, right) or glycan profile (figure 4) Lack of glycosylation is deleterious to the function of most of these proteins! As is aberrent glycosylation
PY365 – Case 3.2 - Autoimmune Disease Cluster REVISION

GLYCOSYLATION – A POST-TRANSLATIONAL Introduction to Pharmacy Therapeutics
1
MODIFICATION THAT IMPACTS ON IMMUNOGENICITY PRECLINICAL TESTING OF THERAPEUTIC mAb BIOSIMILARS:

BASED ON EMA 2012 GUIDELINES
• Note that if similarity within QTPP
(quality test product profile) goalposts
has been established in Step 1, in vivo
testing may not be required
Big changes = big
issues with the protein
• Be aware of the limitations of animal
models! If a mouse is used, it will
• ALL full-length mAbs are GLYCOPROTEINS – they contain chains of carbohydrates called GLYCANS always raise anti-drug antibodies
• GLYCANS can be altered both quantitatively (number of glycans) and qualitatively (structure of
glycans) depending on EXPRESSION SYSTEM USED – this can DRIFT during manufacture against a fully-human mAb!
• Three structures – COMPLEX, HYBRID and HIGH MANNOSE
• HUMAN CELL LINE like BHK gives different glycan structure to CHO cell line, which is from a hamster
• This can impact on therapeutic efficacy/immunogenicity of product
• mAb CAMPATH (Alemtuzumab) which pull out cytotoxic T cell where it has DIFFERENT glycans if made
in NSO cells or CHO cells – the latter being more therapeutically-active and less immunogenic
26 PY365 – Case 3.2 - Autoimmune Disease Cluster 16

PRECLINICAL TESTING OF THERAPEUTIC mAb BIOSIMILARS: KEY PHYSICOCHEMICAL PARAMETERS

BASED ON EMA 2012 GUIDELINES The Biosimilar MUST be “Post-translational
produced in same cell line as modifications” seen in
Reference Biologic – cannot reference biologic are vital
• Note key use of animals in this step – when developing a biosimilar
change from CHO to yeast cells!
to establish pharmacodynamic/kinetic – in particular, the GLYCAN
parameters (rather than predicting profile of a glycoprotein (ie:
immunogenicity!) IgG mAb) – glycan profiling
Is essential!
• New FORMULATIONS/excipients, may
cause unwanted immune responses The biosimilar final dosage
form must be assessed to Structural characterisations must
determine the functional be robust – from primary amino
impact of formulation and acid structure to quaternary
excipients structure and other potential
changes (ie: amino acid
deamidation/oxidation)
Benefits of Biosimilars - 1
Clinical studies (if required) CLINICAL STUDIES? PY365 –by
CHEAPER Case 3.2hence
half - Autoimmune Disease Cluster
more patients can be treated 18
are NOT used to recreatePY365 – Case 3.2 - Autoimmune Disease Cluster 17

efficacy/safety data…
Ultimately, a robust
similarity exercise allows
for a more streamlined in
vivo preclinical/clinical
study and faster approval
… but to eliminate any which should increase
residual doubts that may patient access
exist over the DEGREE OF
SIMILARITY
bDMARD Biosimilars
Benefits of Biosimilars - 2 As of June 2020, biosimilars based on INLIXIMAB, ADALIMUMAB, ETANERCEPT and
RITUXIMAB had been approved for use in RA treatment in the EU/UK
SB4 (“Benpali”)
is the approved
etanercept biosimilar
CT-P13 (“Remsima” and “Inflectra”) “Rixathon”, a rituximab
SB2 (“Flixabi”) “GP2015” submitted biosimilar from Novartis
are the infliximab biosimilars for approval Dec 2015 gained approval
in June 2017
• The use of these drugs has been increasing especially patient

self-administering the drug subcutaneously
• It saves time & money + keep trough levels high

THE BIG ONE – HUMIRA (ADALIMUMAB)
BIOSIMILARS – FOR/ADVANTAGES
Cost reduction by competition (much cheaper = more assessable to patients)
• Biologic medicines can be really expensive. For example, a biologic cancer drug may cost
hundreds and thousands of dollars per patient annually. Having multiple biosimilars in
the market will break the reference drug monopoly and help bring down the costs.
Enhanced patient accessibility
• >46,000 patients on Humira
From 2012, till US patent Arrival of FOUR biosimilars • With more biosimilars in circulation, more patients worldwide can have access to these
• NHS England guidance to Trusts – 9 of 10 new
Expiry in 2016, EU in 2017, Amgevita, Hyrimoz,
patients should be started on best value treatment options.
Humira was WORLD’S Hulio, Imraldi
medicine within three months of biosimilar
TOP-SELLING DRUG enable BIG savings to NHS! launch Incentive for innovation
($18 billion globally in 2017). Deal struck for these in Nov 2018
• At least 80% of existing patients • Biosimilars cannot be marketed until the patent on reference medicine expires. Having
BIGGEST SPEND in NHS reduces annual Humira cost should be switched to the best value biologic innovative, patentable new biologic products maybe necessary to maintain a large
In 2017 (£400 million pa!) by £150 million pa
within 12 months
marketshare hold, in the wake of expiring patents. Thus, pharmaceutical companies
• NHS Business Services Authority aims to cut
prescribing variation through its Medicines would be encouraged to invest more into cutting edge R&D sectors to foster innovation
Optimisation Dashboard
27
BIOSIMILARS – AGAINST/DISADVENTAGES
Despite their affordability, biosimilars face numerous challenges in finding acceptance. Some of the ongoing challenges include:
Patient and prescriber education
• According to a survey in 2014, almost 30% of people living with a diagnosis said that their medicinal choice was highly influenced by the drug
manufacturer’s identity. Mass education is needed in both the health sector as well as the pharmaceutical industry. Prescribers may see
biosimilars as extra work: review clinical data, discuss substitution with pharmacists, and so forth. The situation is further complicated by the
agreeability of insurers to mandate the switch to biosimilars. The physicians, pharmacist and patients, all need to be enlightened and
subsequently, convinced of the benefits of switching to biosimilars.
Extrapolation issue
• Extrapolation used for off-label things where it’s “The process of granting a clinical indication to a medication without its own or new clinical
safety and efficacy studies to support that indication”. Whether biosimilars can be prescribed for off-label indications, that are okayed for the
reference drug, is a grey area. Appropriate guidelines must be set in place for these indications. If not, hospitals and pharmacies will be forced
to carry both the reference molecule as well as the biosimilar counterpart; nullifying the cost benefits from prescribing the biosimilar.
The interchangeability question
• Interchangeability indicates whether switching back and forth between two products does not influence the efficacy or safety when compared
to each product alone. While there are some guidelines in place to determine this, there is uncertainty, prevalent at local prescriber and
pharmacy levels. Whether a pharmacist can “substitute” a reference molecule with an interchangeable biosimilar or vice versa, without an
explicit prescription, is another avenue seeking reconciliation.
Rare diseases
• Rare disease treatments often utilize “orphan drugs” that are associated with high costs. While there are biosimilars being developed for these
orphan drugs, they face many practical hurdles. First, it is difficult to obtain a large enough, non-heterogeneous population for phase I and III
trials. Furthermore, the cost of manufacturing enough batches of the biosimilar to run batch-to-batch variability studies to build extensive
comparability data, can be disproportionately high.
SUMMARY AND KEY POINTS

1. Biosimilars are defined as a biologic product considered ‘highly similar’ but not identical to its reference biologic product.
2. Regulatory bodies have established guidelines for the development of biosimilars based on the Comparability Exercise
guidelines applicable to a biologic which registers a change in manufacturing process
3. This is termed a Similarity Evaluation, where the physicochemical properties, in vitro/in vivo biological activity and function,
PK and PD properties and preclinical in vivo safety and toxicity profile of the biosimilar are established
4. For biosimilar mAbs, the EMA 2012 guidelines indicate a three-step process. The first step involves in vitro examination of
(mostly) immune parameters. If similarity is established, in vivo studies may not be required
5. Biosimilarity testing involves comparison to the originator (“reference”) biologic. The key attributes of the reference
biologic, the “Quality Target Product Profile” (QTPP) must be established
6. However, the QTPP may change over time (known as “drift”) so goalposts must be defined to provide established variations
– the biosimilar’s characteristics must fit between these “goalposts”
7. The biosimilar manufacturing process cannot deviate extensively from that of the originator biologic and must be tested in
its final dosage form to ensure that formulation/excipients do not impact on its efficacy and safety
8. Clinical trials may still be required for licensure, but should not be designed to recreate the efficacy/safety data of the
originator biologic but to establish any residual doubts concerning the biosimilar
9. As of June 2020, infliximab, etanercept, adalimumab and rituximab biosimilars have been approved by the EU for use
against RA in Europe – massive savings for NHS – guidance indicates most patients should switch to biosimilars
10. There are major advantages in the use of biosimilars (cost reduction, enhanced patient accessibility, incentives for
innovation) but continuing challenges (lack of familiarity, “extrapolation” (off label use), interchangeability issues, use as
“orphan drugs”)
GLOSSARY GLOSSARY (CONTINUED..)

• Biologic therapeutic agents (e.g., proteins defined by the FDA as greater than 40 amino acids) that
are manufactured in living systems, typically through recombinant DNA technology. Because the • Preclinical evaluation the phase of study occurring before clinical evaluation. This can
manufacturing process for biologics is inherently subject to variation, identical copies cannot be include analytical and/or physicochemical characterization; chemistry, manufacturing and
produced. Other guidelines, such as those by the EMA and WHO, do not provide a definition for what control (CMC) evaluation in vitro and/or in vivo functional, PK, PD, toxicologic or
constitutes a protein immunogenicity assessment
• Biosimilar a biologic product considered ‘highly similar’ but not identical to its reference biologic • Reference biologic the existing, licensed and marketed product against which a proposed
product. The FDA further defines a biosimilar as highly similar ‘notwithstanding minor differences in
biosimilar product will be compared WHO uses the terminology ‘reference biotherapeutic
clinically inactive components’, and having ‘no clinically meaningful differences between the biologic
product and the reference product in terms of the safety, purity, and potency of the product’ product’, the EMA uses ‘reference medicinal product’ and the FDA uses ‘reference product’
• Comparability exercise usually an exercise to characterize a biologic product before and after a when referring to a reference biologic
manufacturing process change, with the goal of ruling out any adverse impact on quality, efficacy or • Similarity evaluation the process of demonstrating biosimilarity between a proposed
safety. The EMA regards this exercise as broadly similar to a biosimilarity assessment biosimilar and its reference biologic product.
• Comparable usually the biologic product being equivalent in terms of efficacy and safety, including • Second-generation biological (“biobetter”) A structurally/functionally altered biological
immunogenicity, before and after a manufacturing process change product resulting in improved or different biological activity from the reference
• Drift the process by which biologic drugs can change over time and exhibit differences between lots • Me-too biological (“Non-innovator biological “) A biological product developed with the
or batches of product
• Generic drug copies of small-molecule drugs (e.g., ibuprofen). Because identical versions of most
same target antigen but without demonstrated comparability to the reference product
small-molecule drugs can be produced through chemical synthesis, they can be substituted for the
branded product

28
L6) Formulation & Delivery of Monoclonal Antibodies (mAbs):

Year 3 cases and mAbs Antibodies
(monoclonal antibodies) • Proteins, macromolecules
• 4 polypeptide chains (2 heavy big chains ~50 kDa each; 2
• This case - Rachel Smith light chains that are also big ~25 kDa each); compared to
molecular weight of insulin (5 kDa hence 10x bigger),
• She was started on subcutaneous certolizumab
doesn’t cross membranes hence why injected
pegol at a dose of 400 mg at week 0, 2, 4 and 200
• Not very stable compared to small drug molecules
mg every 2 weeks thereafter.
• They’re injected because otherwise they’re too big to get
Revision of protein structure into the blood
PY365 Advanced Pharmacy 1 3.4 Autoimmune Disease Cluster

Routes of administration of mAbs
• Infliximab – IV infusion
• Rituximab – IV infusion
• Tocilizumab – IV infusion, SC injection
• Abatacept – IV infusion
A peptide/protein is the polymer where they can link with amino acids Often if SC it’s then
in any order to form a structure which fold up more to tertiary and • Adalimumab – SC injection injected into the abdomen
finally the functional assembly chains in quaternary • Golimumab – SC injection (similar to diabetes)
• Certolizumab pegol – SC injection (Rachel Smith)
Advantages of SC route • Etanercept – SC injection
- for delivery of mAbs – Infliximab is a humanized mouse monoclonal antibody,
• Can self-administer treatment following training – Adalimumab a fully human monoclonal antibody
• Better self-management (no need for hospitals or clinics – Etanercept a construct comprising two human p75 TNF-α
hence manage their own condition) receptors coupled to the Fc portion of a monoclonal
• Useful to treat chronic diseases with frequent human antibody.
dosing as it can be life-long
Disadvantages of SC route
• Can use pre-filled syringes/pens/autoinjectors
• Better patient comfort than IV infusion - for delivery of mAbs
• Longer dosing interval • Limited volume can be delivered to SC space (< 2 mL e.g.,
• Decrease healthcare costs in mg where it’s not potent to use micrograms, if more =
• Decreased hospital/clinic visits painful)
• Increase compliance/adherence • Relatively high dose required ~200 mg
Is it like injecting syrup?
PY365 Advanced Pharmacy 1
Not quite.
3.4 Autoimmune Disease Cluster • So, need stable, highly concentrated antibody formulation
• Adalimumab (Humira) - • Can have high viscosity
• 148 kDa • Can increase injection force (push harder), time (takes more time
to come out of the needle) and pain at injection site
• C6428H9912N1694O1987S46
• Can decrease compliance/adherence
• Viscosity of syrup • Can also adversely affect bioprocessing during

• ~ 3000 mPas manufacture due to having to be careful
• Viscosity of mAb PY365 Advanced Pharmacy 1 3.4 Autoimmune Disease Cluster
• ≤ 20 mPas – hence problem
when it comes to pushing it out
the needle
29
Challenges of high concentration Viscosity

formulation development • Macroscopic level
• High concentration • Rate of transfer of momentum in a liquid (how readily it
• ≥0.1 (one tenth) of the solution volume is occupied by the pours) – it’s what we can actually see
solute
• Molecular size and distance between Van der Waal surfaces is of • Microscopic level
a similar magnitude to the size of molecule (distance between • Resistance to solute mobility (how the solute molecules
each monoclonal antibody is the size of one of those molecules
hence close together) move around relative to the solvent molecules)
• ^ Refers to molecular proximity (how close they are

together)
• Can result in interaction between proteins due to
being close:
• Reversible self-association, increase in viscosity as they’re able
to stick together, opalescence (not transparent), even
aggregation as we can get participates
PY365 Advanced Pharmacy 1 Dilute solutions
3.4 Autoimmune Disease Cluster
Dilute solution Concentrated solution
Y
Y
Y
YY
Y
Y YY
Y
Y Y
Y
Y Y
Y The equations above describe viscosity behaviours of dilute solutions
with the assumption that the solute molecules do not experience the
presence of one another. That is, the effects due to molecular crowding
Less than 10% of the volume equipped by monoclonal antibody hence and solute-solute interactions are ignored.
diffuse around and are unlikely to come in contact with each other Difference in viscosity due to different intermolecular interactions.
unlike when it’s concentrated which can occupy more than 10% Which is most suitable for development into a product?
Concentration-dependent viscosity curves of two
Concentrated solutions antibody solutions under identical formulation conditions

(i.e., same formulation buffer, pH, temperature, and
excipients). At 150 mg per mL, mAb2 has significantly
• Need to consider higher viscosity than mAb1. From the drug product
development perspective, mAb1 is suitable for
development as a high concentration drug product
– Molecular crowding (depends on the because its solution shows low viscosities at high
concentrations. Because experimental conditions for both
concentration put – not much control) the mAbs are identical, the differences in their solution
viscosity behaviours must arise from differences in the
intermolecular interactions, antibody networks and
– Intermolecular interactions higher-order structures formed by the mAbs in their
respective solutions. The intermolecular interactions
• Depend on characteristics of solute molecules e.g., can among antibody molecules include both pairwise and
higher-order interactions involving multiple molecules.
Shows the difference between two different
depend on amino acids sequence monoclonal antibodies where both
The pairwise intermolecular interactions, expected to
prevail at dilute concentrations, are related to
formulations are identical where we can see
experimentally measurable quantities such as osmotic
the one in blue has its viscosity higher as the
second virial coefficients (B22) and diffusion interaction
concentration isn’t compared to that in red
Pairwise intermolecular interaction (the better is the red due to lower viscosity
hence go through a needle easier)
parameter (kD). However, as the concentrations rise, the
higher-order interactions are also expected to contribute
significantly toward solution viscosity.
• Considers behaviour of pairs of molecules interacting DVLO revision

with each other DVLO theory is applicable to nanoparticles and to larger colloidal
material and describes the balance between van der Waals
• DVLOPharmacy
PY365 Advanced – revision
1 3.4 Autoimmune Disease Cluster attractions and electrostatic repulsions in a liquid medium
When they’re far =

repulsion is low
• Dependent on: Charge - repulsion
Attraction = they don’t
interact much due to the
– overall charge on solute molecule and charge distribution Energy potential
when the two
distance
(as we don’t only have tiny ions that can be negative or Charge
lines are added
together – once
positive but a big protein/globular protein which contains they get close
together = they
variety of charges hence is complex) stuck
Van der Waal - attraction
– Proximity (how close solute molecules are to each other)
30
Higher order intermolecular interactions Approaches to avoid high viscosity

• Considers behaviour of groups of molecules = high viscocity • Predict or study concentration-dependent viscosity of
mAb (the blue & red graph)
• Could reconsider use of mAb if early enough in development
process and alternatives exist - if blue = use an alternative
• Understand effect of sequence and structure of mAb
Network formation
on viscosity at high concentrations – depends on the
These studies found formation of antibody clusters, networks and higher-order oligomers to
order of amino acids in the chain
be consistent with increased viscosity of antibody solutions. Moreover, the simulations were • Optimise sequence while still retaining activity where the
able to pin-point the underlying cause. The presence of domain level electrostatic antibodies are still clinically active but loses viscosity
complementarities among the antibody molecules leads to formation of the antibody
networks and higher-order structures. Such networks impart “solid-like” properties to the
highly concentrated antibody solutions. The density to saturation ratios of these networks are
• Understand role of excipients (to change them) in
conceptually related to modulus of elasticity. Therefore, antibody molecules capable of controlling viscosity
forming these networks are able to resist solution deformation under shear stress and
demonstrate increased viscosities at high concentrations.
Use of Excipients PY365 Advanced Pharmacy 1 3.4 Autoimmune Disease Cluster

Rapid Formulation Development for mAbs
• pH optimisation through use of buffers
• Formulate at pH away from pI (slightly acidic - neutral)
J Kang, X Lin and J Penera 2016
• Generally formulated at slightly acidic pHs
• Salts and charged amino acids (to the solution Summarized 37 formulations that have been
successfully (due to not being viscous) used
around the monoclonal)
in commercial mAbs, including fragment
• Reduce tendency for proteins to self-associate with eachother
antigen-binding (Fab) and antibody – drug
• Surfactants conjugates (ADCs).
• Replace proteins at interfaces due to both being surface-active Among them, 12 are lyophilized
formulations and 25 are liquid formulations,
• Stabilizers
with their concentration ranging from
• Anti-oxidant, metal chelator, cryoprotectant
2 mg/mL to 200 mg/mL. Table 1 lists
Reminder: excipients used in these mAb formulations.
In proteins the isoelectric point (pI) is defined as the pH at which a protein
Understands whether they are amino
has no net charge. When the pH > pI, a protein has a net negative charge
acids, sugars or a surfactant etc.
(repel) and when the pH < pI, a protein has a net positive charge (repel)
Six categories of excipients Six categories of excipients

1. Six commonly used buffers keep pH levels between 4.7PY365
and Advanced Pharmacy 1used included ascorbic3.4
5. Antioxidants AutoimmuneC,Disease Cluster
acid/Vitamin
7.4 (acidic): acetate, citrate, histidine, succinate, phosphate, methionine, and ethylenediaminetetraacetic acid (EDTA). Used
and hydroxymethylaminomethane (Tris). Histidine and
infrequently, with each of the three antioxidants found in only
phosphate dominate (used in 35% and 33% formulations,
respectively). one formulation.
2. Most (80%) formulations used one of three surfactants: 6. All lyophilized (freeze-dried as they contain sugar) formulations
polysorbate 80 (Tween 80), polysorbate 20 (Tween 20), and used one or a mixture of polyol/disaccharide/polysaccharide
poloxamer 188. Among those, 72% used polysorbate 80. (e.g., mannitol, sorbitol, sucrose, trehalose, and dextran 40).
3. Sodium chloride (NaCl) is commonly used. Found in about Sucrose most popular excipient (> 80% of these formulations).
50% of formulations.
Sugars provide bulk for lyophilized formulations and serve as
4. Two amino acids (glycine and arginine) were used in about
stabilizing agents for therapeutic proteins. This category of
20% of the MAb formulations.
excipients also is used in liquid formulations (found in 30%).
Is it like injecting syrup? Not quite.
PY365 Advanced Pharmacy 1• What are the problems with Disease
3.4 Autoimmune injecting
Cluster Combination product
something that’s viscous?
Conventional needle and syringe - these • DrugPharmacy
PY365 Advanced plus device
1 3.4 Autoimmune Disease Cluster
are usually quite thin, and therefore • Must be compatible
require a lot of force to push a viscous
fluid out of it. Also, it would be really • Drug solution – in water + excipients
quite challenging for someone with • Viscous
arthritis to set up the needle and use it.
It can be painful due to the need • Device
to use more force/pressure and
it takes longer all due to it being • Needle technology (not too thick or thin)
viscous • What’s helpful to the patient
With RA limited dexterity (performing tasks with the hand) • Ergonomic design (size, shape, actuation mechanism)
31
Requirements Certolizumab pegol

• Made as bolus injector – not multi-use • Cimzia
(used once only) • Pre-filled pen
• Pre-filled plastic syringe • Pre-filled syringe
• Silicon oil was used to lubricate glass syringes but
Cimzia pre-filled syringe
increased aggregation
What’s useful is the large
• Concerns regarding leachates from plastics thumb pad as the liquid is
• Needle safety device quite viscous and needs force

so if can’t use hands a big
thing to push is easier to push
AutoClicks® prefilled Pen against something where it

also has a finger grip to help,
and instead a skinny cap it can
(Click, click, done) have a loop to help yank it off.
Also not made round to help
with grip.
Click, click, done (auto). A wide non-slip grip, a viewing

The second product we developed for CIMZIA, the AutoClicks® Prefilled Pen, was window which helps e.g., when
designed to appeal to people who don’t like needles. The disposable, autoinjector to take the device away from
pen, which comes prefilled with CIMZIA, eliminates the need to deal with the abdomen and it clicks to
medication or needles. It’s a button-free delivery system with a wide nonslip grip. demonstrate injection (up to
Patients can follow their injection progress through a large viewing window, giving 15s later) – all due to viscosity
them even more control knowing they’ve safely injected their medication. as it takes a long time. The
band shows when it’s ready to
Adalimumab be operated.
• Humira A cap protecting the

needle (easy to remove), a
PY365 Advanced Pharmacy 1 Golimumab3.4 Autoimmune Disease Cluster
• Pre-filled pen window that fills with a • Simponi
yellow indicator during
• Pre-filled syringes injection (takes up to 10s), • Pre-filled pen
cap to not accidently • Pre-filled disposable devices
• Injection vials press the button before • Pre-filled syringes
being ready
Simponi pre-filled syringe
Helps with
needle phobia
Etanercept
• Benepali Summary
• Pre-filled disposable injection
• For self administration mAbs need to be given SC due to it
• Enbrel being big and proteins that can be digested hence avoid PO
• Pre-filled disposable injection and it doesn’t need an HCP hence SC rather than IV
• Powder and solvent for solution for injection vials • Limited volume available SC (about <2mL)
• Erelzi • High dose of mAb required due to not being potent therefore
• Pre-filled disposable injection go to mg not mcg. Therefore, high viscosity solutions (which
indicates its issues)
• Information on why they have high viscosity and how this can
be minimised (by e.g., using excipients, changing amino acid
sequence and changing monoclonal antibody)
• Devices for administering high viscosity solutions to this
patient group
32
L7) Autoimmune Cluster - Rheumatic Disease 1:

Classification Classification
Joints are observed first
for RA (or articular things that happen
system where a diseases Articular naturally with ageing, not Affects other body
in it affects the joint) driven by inflammation systems or organs Non-Articular
Inflammatory Degenerative
Generalized Local
RA SpA Other Hand Large Spine
All over the body but not To one particular area
Joints
primary affect the joints
Take most of the Inflammatory
time in terms of syndrome of e.g., osteoarthritis in knees and hips, if in
looking for hands = similar to RA but not the same
the spine
medicines and their
diseases
Autoimmune clusterArticular Inflammatory 1

RA is the classic syndrome Autoimmune cluster 1
• 1% of population
• F:M 3:1 - could be due to female hormones e.g., RA disappears
after the third trimester in most pregnant women
• Bimodal presentation:
• Younger onset 30 – 50’s (uncontrollable, intense therapy
needed)
• Older onset >60 years (different presentation, not as severe
and progressive, less joint damaging)
• Often symmetrical Involvement (with joint assessment both
hands are observed)
• First Test - What joints are affected, as it gets to smaller joints = more points towards the
• Small joints (hands & feet) always + large joints (rare e.g., diagnosis.
shoulders, hips & knees) • Serology - the scientific study or diagnostic examination of blood serum, especially with
• Historical Features (e.g., early morning stiffness like a super glue regard to the response of the immune system to pathogens or introduced substances.
in their joints which takes 30 mins to get out of bed) We measure ACCP antibodies/ACPA/Anti–Citrullinated Protein Antibody & rheumatoid
factor, if positive to both = more points.
• ^ EMS > 30 min, pain with activity (to a point). “Gel phenomenon”
• Last Test – based on CRP/C-reactive protein and ESR/Erythrocyte Sedimentation Rate
• Soft tissue swelling (red, inflamed and swollen)
Rheumatoid arthritis RA non joint features
• Rheumatoid arthritis usually has a slow, insidious Primarily affects the joints but not only, but it also affects:
onset over weeks to months – by the time people • Rheumatoid nodules (no harm, most won’t remove
them as they get scar tissues and come back again where
know, it would’ve been ongoing for a while
it’ll be underneath it, can shrink with treatment)
• About 15-20% of individuals have a more rapid • Sicca/Dry eyes syndrome (due to an inflammatory
onset that develops over days to weeks reaction on the tear ducts where they don’t produce
RHEUMATOID ARTHRITIS –
• About 8-15% have acute onset of symptoms that
AN EXAMPLE OF SYSTEMIC AUTOIMMUNE DISEASE much tears)
develop over days • Inflammation of blood vessels leading to clots,
hypertension leading to a cardiovascular disease like a
stroke or heart attack (10% risk to have CVE)
Autoimmune priming, tissue attack and chronic inflammation

— The three stages of rheumatoid arthritis
The first sign of autoimmunity is the presence of rheumatoid factor and ACPA in the
blood hence can be detected early. If not noticed, they’ll start targeting the joints.
Causation
Autoimmunity Case
PY365 – Case 3.4 Therapeutics
1 1
Natural History (untreated)
• Genetic and environmental (e.g., smoking, accident § Disability
injury, vaccines etc.) § Damage
• Complex and poorly understood § Deformity
• HLA/human leukocyte antigen (a complex of genes § Death (mainly from cardiovascular
on chromosome 6) determines severity of disease complications)
and involves different gene systems Joint destruction in RA
(irreversible)
• Trigger could be Presents subluxation
which is the joints being
injury/virus/infection/smoking/alcohol etc. collapsed on itself
33
Autoimmune cluster 1
Hand X-Ray of a finger joints – Erosions Mortality Graph in RA –

(loss of bone) More if a women with RA
Risk of Mortality (Standardized Ratio)

1.5
0.5
0
Men Women Overall
Gap becomes bigger over a period of 2 years
Treatment and Prognosis Surgical intervention (don’t work much

• NSAIDs as a starter with small joints, better with large)
Autoimmune cluster When RA unknown/not 1
• Steroids diagnosed yet – first-line • Removal of inflamed synovium/joint
membrane
• Conventional synthetic disease modifying • Arthroplasty (a surgical procedure
antirheumatic drugs (csDMARDs) – within 12 weeks to restore the function of the joints
by e.g., resurfacing the bones or use
e.g., Methotrexate an artificial joint)
• If above doesn’t work, use either: • Reconstruction/fusion
• High risk procedure
– Targeted synthetic disease modifying antirheumatic
• Questionable outcomes
drugs (tsDMARDs) e.g., Toricetemab Mostly for pain relief by removing the
– Biologic disease modifying antirheumatic drugs inflammation but not to improve function
as it’ll be poor hence not done much
(bDMARDs) – normal pathway as we have more
experience in it e.g., Rituximab & Abatacept etc. Lupus
1
Autoimmune cluster 1 Autoimmune cluster
• Systemic lupus erythematosus is an
Other Inflammatory Rheumatic Diseases autoimmune disease of the body's
connective tissues. Not seen as
Uncommon: much as RA.
• Significant impact (not seen much) • SLE affects tissues throughout the
body. Five times as many women as
• Arthritis (only in some) men get SLE.
• Examples include: • Most people develop the disease
• Systemic lupus erythematosus between the ages of 15 and 40,
although it can show up at any age.
• Scleroderma (hardening of skin) Big autoimmune complexes blocking small
blood vessels causing inflammation and is
• Myositis (inflammation of muscles) mainly found in the kidneys causing e.g.,
• Vasculitis (inflammation of blood vessel walls) scars (can be organ threatening)
Lupus Anatomy (cont.)

• The inflammation of SLE can be seen in the lining,
Autoimmune cluster Lupus - Anatomy 1 covering, and muscles of the heart. The heart can be
affected even if you are not feeling any heart symptoms.
• SLE causes tissue inflammation The most common problem is bumps and swelling of the
and blood vessel problems pretty endocardium,
much anywhere in the body. • SLE also causes inflammation and breakdown in the skin.
Rashes can appear anywhere, but the most common
• Note the granular appearance of spot is across the cheeks and nose.
the cortex of these lupus affected • People with SLE are very sensitive to sunlight. Being in Butterfly rash –
skin-related lupus
kidneys – it’s across the entire the sun for even a short time can cause a painful rash.
surface of both kidneys Some people with SLE can even get a rash from
fluorescent lights.
suggesting a chronic condition.
• Rashes caused by SLE are red, itchy, and painful. The
most typical SLE rash is called the butterfly rash, which
appears on the face – particularly the cheeks and across
the nose. SLE can also causes hair loss. The hair usually
grows back once the disease is under control.
34
Lupus Anatomy (joints) Lupus Anatomy

• Almost everyone with SLE has joint pain or • Lupus can also affect the nervous system causing
inflammation. Any joint can be affected, but headaches, seizures, and organic brain syndrome.
the most common spots are the hands,
wrists, and knees. • It can cause anemia due to blood loss or from the
• Usually, the same joints on both sides of the kidney disease (it does not directly affect the red
body are affected. The pain can come and blood cells).
go, or it can be long lasting. The soft tissues • Pregnancy: the chances of miscarriage, premature
around the joints are often swollen, but
there is usually no excess fluid in the joint.
birth, and death of the baby in the uterus are high.
Many SLE patients describe muscle pain and
weakness, and the muscle tissue can swell.
SAQ
• A patient scores 7 on the 2010 ACR/EULAR
classification. Describe theAutoimmune
components
cluster of this 1
classification system and why is this score

important in diagnosis (5 marks).
Involves serology, joint distribution, symptom duration
and acute phase reactants where it’s important for
quicker diagnosis leading to better choice of
treatment to start hence this score can help us
construct a plan rapidly as this is important to treat
those with RA before it becomes uncontrollable
35

Spondyloarthropathies (SpA) - Seropositive RA refers to the presence
refers to any joint disease
• Consist of a group of related disorders that of RF/rheumatoid factor and/or anti-CCP
include lots of autoimmune diseases where of the vertebral column.
some affects joints and some don’t e.g.,
Reiter's syndrome (joins the
antibodies (also called ACCP & ACPA) in a
eyes/conjunctivitis, skin & joints), ankylosing
spondylitis, psoriatic arthritis, and arthritis in person diagnosed with RA/rheumatoid
association with inflammatory bowel disease Predominant disease that
e.g., Crohns disease effects the spine arthritis. It has more cytokines hence more
• Occurs more age at diagnosis in the third
decade and a peak commonly among young joint damage e.g., RA.
men, with a mean incidence between ages
25 and 34 - Seronegative RA refers to the situation
• The prevalence appears to be about 1%
• The male-to-female ratio approaches 4 to 1 where both antibodies are not elevated,
among adult Caucasians
• Genetic factors play an important role in the and it doesn’t cause much destruction due
susceptibility to each disease
to not many cytokines produced e.g., SpA
like ankylosing spondylitis. The difference between them is simply SEVERITY.
- Reactive arthritis/Reiter’s syndrome is usually preceded by an infection caused by
bacteria, such as Chlamydia trachomatis (a sexually transmitted disease) or
Salmonella (a bacteria that can contaminate foods) where this condition may cause
arthritis symptoms, such as joint pain and inflammation. Also, it may also cause
symptoms in the urinary tract and eyes.
- Ankylosing spondylitis is a type of arthritis that causes inflammation in the joints
and ligaments of the spine. Normally, the joints and ligaments in the spine help us
move and bend. If you have ankylosing spondylitis, over time, the inflammation in
the joints and tissues of the spine can cause stiffness.
- Psoriatic arthritis is a type of arthritis that affects some people with the skin
condition psoriasis (a skin disease that causes a rash with itchiness/dry skin lesions)
where it typically causes affected joints to become swollen, stiff, and painful.
- Inflammatory bowel disease (IBD) is a term for Spondyloarthropathies (SpA)
(Crohn's disease and ulcerative colitis) that are • The cause is unclear, but there is strong evidence
that the initial event involved interaction
characterized by chronic inflammation of the between genetic factors and environment
factors, particularly bacterial infections
gastrointestinal (GI) tract where prolonged
• Reiter’s syndrome may follow a wide range of GI
inflammation results in damage to the GIT. infections
• Bowel inflammation has been implicated in the
pathogenesis of endemic Reiter’s syndrome (eye
& skin involved), psoriatic arthritis, and
ankylosing spondylitis
36
Spondyloarthropathies (SpA) Sacroiliitis

• The spondyloarthropathies share certain common • Sacroiliitis is an inflammation of
features, including the absence of serum rheumatoid the sacroiliac joint in the hip (the
factor, an oligoarthritis (arthritis affecting 2-4 joints connective tissue which gets
during the first 6 months of disease) commonly involving inflamed)
large joints in the lower extremities, frequent • Picture on the bottom right shows
involvement of the axial skeleton (bits attached to spine an individual with – sacroiliitis and
& hips), familial clustering, and linkage to HLA-B27 which Ankylosing Spondylitis.
can lead to SpA • The arrows point to the inflamed
and narrowed SI joints and infused
• These disorders are characterized by inflammation at bones.
sites of attachment of ligament, tendon, fascia, or joint • They are white due to bony
capsule to bone (enthesopathy – disorder involving the sclerosis around the joints
attachment of a tendon or ligament to a bone)
Ankylosing Spondylitis Autoimmune cluster Ankylosing Spondylitis 1

• Chronic disease that primarily • Treatment options:
affects the spine and may lead to Ankylose is infusing two things Found
stiffness of the back. together, this what happens in the – With early diagnosis and treatment, pain and
spine due to being inflamed often in
• The joints and ligaments that stiffness can be controlled and may reduce
young men,
normally permit the back to move fusing. In women, AS is usually mild and hard
some gets
become inflamed. to diagnose.
uveitis
• The joints and bones may grow – Exercise (inflammat
(fuse) together. – Medications: NSAIDs, sulfasalazine (DMARD) ion of the
• The effects are inflammation and & and anti TNF agents middle
chronic pain and stiffness in the – Posture management layer of the
lower back that usually starts – Self-help aids eye) where
where the lower spine is joined to all can be
the pelvis or hip. – Surgery as an intervention to remove fusion
markers
• Diagnosis is made through: (a) of the bone reducing inflammation &
medical history including stabilizing the joints
symptoms, (b) X-rays, and possibly
(c) blood tests for HLA-B27 gene
Reiter's Syndrome Reiter's Syndrome
• It’s zero negative.
• Reiter's often begins following inflammation
• Arthritis that produces pain, swelling, redness and heat of the intestinal or urinary tract.
in the joints.
• It sets off a disease process involving the
• It can affect the spine and commonly involves the joints joints, eyes, urinary tract, and skin.
of the spine and sacroiliac joints. • Many people have periodic attacks that last
• It can also affect many other parts of the body such as from three to six months where some people
arms and legs. have repeated attacks, which are usually
• Main characteristic features are inflammation of the followed by symptom-free periods.
joints, urinary tract, eyes, and ulceration of skin and • Diagnosis is made through a physical exam,
mouth. skin lesions, and a test for the HLA-B27 gene
• The symptoms are fever, weight loss, skin rash,
inflammation, sores, and pain.
Reiter's Syndrome
• For different parts of the body,
Autoimmune different
cluster 1
treatments are used:
– Medications: NSAIDs, antibiotics, topical skin
medications
– Eye drops
– Joint protection
37
Psoriatic Arthritis Psoriatic Arthritis

• Causes pain and swelling in some joints • Diagnosis may involve X-rays, blood tests, and joint
and scaly skin patches on some areas of fluid tests.
the body. • Treatment options:
• The symptoms are: – Skin care
– About 95% of those with psoriatic arthritis have – Light treatment (UVB or PUVA)
swelling in joints outside the spine, and more – Corrective cosmetics
than 80% of people with psoriatic arthritis have – Medications: glucocorticoids, NSAIDs, DMARDs
nail lesions. The course of psoriatic arthritis
– Exercise
varies, with most doing reasonably well.
– Rest
– Silver or grey scaly spots on the scalp, elbows,
knees and/or lower end of the spine. – Heat and cold
‘Sausage toes’ – Splints
– Pitting of fingernails/toenails
– Pain and swelling in one or more joints – Surgery (rarely)
– Swelling of fingers/toes that gives them a
"sausage" appearance. Autoimmune cluster 1
Inflammatory Bowel Disease Inflammatory Bowel Disease

• IBD, an autoimmune disease • The amount of the bowel disease usually influences
(also e.g., diabetes), consists the severity of arthritis symptoms. Other areas of the
of two separate diseases that body affected by inflammatory bowel disease include
cause inflammation of the ankles, knees, bowel, liver, digestive tract, skin, eyes,
bowel and can cause arthritis spine, and hips.
or inflammation in joints: • Treatment options:
– Crohn's Disease involves – Diet
inflammation of the colon or – Exercise
small intestines.
– Medication: Corticosteroids, Immunosuppressants, NSAIDs,
– Ulcerative Colitis is characterized Sulfasalazine
by ulcers and inflammation of the
– Surgery
lining of the colon.
Functional Presentation and disability of1 Autoimmune cluster

the Spondylarthropathies
• When the axial skeleton/spine is
involved, the initial symptom is morning SAQ
stiffness and lower back pain
• Which body structure is predominantly affected by
• As the disease worsens, there is
progressive diminution of motion of the
ankylosing spondylitis? What symptoms are most
spine affecting movement and skills like common and what causes these problems? (5 marks)
driving. Affect those in their 30-40s. The axial spine is affected (vertebra) affecting the
• Eventually, the sacroiliac joints, lumbar, connective tissues surrounding it where it’s noticed as pain
thoracic, and cervical spine become fused and stiffness in the lower back of the spine caused by
• At this stage, the spine is no longer inflammation of the connective tissues leading to ankylosis
painful, but the person has lost all ability
to flex or rotate the spine and generally
develops a hunched-over posture with
fused flexion of the cervical spine and
flexion contracture of the hips to
compensate for the loss of the lordosis
curvature in the lumbar spine
38

Degenerative articular rheumatic Degenerative Joint Disease (OA)
disease (Osteoarthritis) • Cause is unclear (mainly due to ageing, the ageing
• Not inflammatory in nature (not as swollen and red) joints, but generally has biological
• Most common rheumatic disease (those with RA have components/background)
OA in their joints) and is characterized by progressive
loss of cartilage in the joint capsule as it provides a • Considered to be a “wear and tear” arthritis (over-
natural shock absorber and reactive changes at the using the joints)
margins of the joint and in the subchondral bone • Obesity is frequently associated with it
• The disease usually begins in one’s 40s
• Prevalence increases with age and the disease becomes
• Genetic factors play a role in the development that is
almost universal in individuals aged 65 and older sex-influenced and dominant in females, resulting in an
• Primarily affects weight-bearing joints such as the incidence 10 times greater than in men
knees, hips (both easily replaced, lasts about 10 years, • The final outcome is full-thickness loss of cartilage
it means more treatment options as the target are down to bone
bigger joints), and lumbosacral spine (joint between the
last lumber vertebra & the first sacral segment of the Degenerative Joint Disease (OA)
vertebral column)
• In early
Autoimmune disease,
cluster pain occurs only 1
Prevalence after joint use and is relieved by
Commonest form of arthritis joint rest where the weight is
§ F>M taken off
§ Increases with age • As the disease progresses, pain
occurs with minimal
§ Begins often in youth (40s)
motion/activity or even at rest
§ Creates cause of medical disability due to the joints
not working as there’s no fluid moving around • Nocturnal pain (night) is
(mainly larger joints) commonly associated with
severe disease
Functional Limitations of Degenerative Knee & Hip (OA)
Joint Disease (OA) There should be bigger gaps between where the bones
meet (can’t be seen due to narrowing of joints space)
• Limited use of the involved joint affected by the
generative disease
• Walking and transfer activities may be impaired
• Generally, ADLs (activates of daily living) will not be
significantly impaired as it affects the larger joints
mainly (hips and knees)
Treatment and Prognosis of
Degenerative Joint Disease
• Meds (generally, don’t use NSAIDs as their risk outweighs the
benefit in non-inflammatory diseases) e.g., mainly weak opioids With reduced joint space/fluid = erosions at bone surface due to fluids
or Paracetamol
Autoimmune cluster used then stronger ones as we want to reduce1 compressed causing microfractures at the bone surface due to high pressure
their use but if needed start with NSAID for analgesic effect to hence the osteoclasts gets push aside forming bone spurs which is overgrowth
delay opioid use (careful especially with elderly) of bone that occurs at the joints where bones meet (impair movement)
• For NSAID check for ulceration due to increased prostaglandins
(GIT risk e.g., bleeding affecting the potency of gastric mucous), Hip & Knee Replacement
risk of cardiovascular events increased and acute kidney injury
• Early PT/exercises
Titanium implants used
• Heat (hot bath)/cold therapy
• Joint protection
• Surgery
Chop the ends off and
• Osteoarthritis is a slowly progressive disease add a metal for the hip
• The eventual outcome is complete destruction of the joint, and
ultimately surgical intervention is required
39
Common Localized Non-Articular Disorders Generalized Non-articular Disorders

Fibromyalgia syndrome
• A chronic musculoskeletal syndrome characterized by
diffuse pain mainly in the joints with the absence of
synovitis (joint swelling) or myositis (muscle
inflammation) where treatments are limited
FMS
• 10-12% general population (2% adults)
• Strong female preponderance
Autoimmune in nature, little parts of the body affected
but mainly big joint symptoms or things around them Associated Complaints
• Diffusecluster
aching/stiffness,
worse in am (may mimic RA)
Autoimmune cluster Presentation 1
Autoimmune 1
• Pain like shooting needles
• Normal physical • Fatigue/exhaustion/sleep disturbance
examination (no
abnormalities) • Sensation of swelling of hands/feet (examination
• No significant normal)
abnormalities on joint • Paresthesias (normal EMGs) – it’s an abnormal
examination sensation of the skin (tingling, pricking, chilling,
• Characteristic finding is burning, numbness) with no apparent physical cause
tenderness upon • Tension headaches / migraines
palpation of discrete
anatomical locations • Symptoms of irritable bowel syndrome
termed tender points • Anxiety/depression
Areas in red are generally painful and tender • Weight gain (++)
FMS Local non-articular disease
• Working model: • Doesn’t affect the joints,
– A disorder of pain processing organ specific, affects the
pancreas = diabetes
– Central nervous system “sensitization”
• The typical example if
– Makes usually non-painful stimuli feel painful IDDM, but Hashimoto
thyroiditis is also a good
Hashimoto’s thyroiditis example of an organ
• Characterized by the destruction of thyroid cells by specific (localised) not
various cell- and antibody-mediated immune articular autoimmune
processes disease
• Presence of typically anti-TPO (anti-thyroid
peroxidase) and anti-Tg (anti-thyroglobulin) SAQ
Autoimmune 1
antibodies suggests Hashimoto thyroiditis however, • cluster
Fibromyalgia syndrome is a generalised non
10-15% of patients with Hashimoto thyroiditis may articular disorder. What are the characteristics of
be antibody negative the clinical presentation and why do psychological
therapies have such an important role to play in
Treatment treating this disease? (5 marks).
• Just like any other hypothyroid state supplements Normal physical examination as there’s no
are given
abnormalities in the joints as well and also look for
• The treatment of choice for Hashimoto thyroiditis hypersensitivity in the tender points.
is thyroid hormone replacement
Also, large psychological therapies like CBT (cognitive
• The drug of choice is individually tailored, and
titrated levothyroxine sodium administered orally, behavioural therapy) helps corrects it as it can work
usually for life. better than the drugs.
40
L10) Autoimmune Cluster - Rheumatoid Arthritis Treatment 1:
Classification and epidemiology of Classification and epidemiology of

rheumatoid arthritis rheumatoid arthritis
• Rheumatoid arthritis (RA) has an annual incidence of • Childhood and current low socioeconomic status are
approximately 0.4 per 1000 in females and 0.2 per 1000 associated (e.g., due to low air quality and they’re
in males; recent evidence indicates that the incidence more likely to smoke or be around smokers) with
may be rising. increased risk of RA.
• A prevalence of 0.4% to 1% is reported in diverse • Hormonal and reproductive factors contribute to
populations worldwide with evidence for geographic the female predominance in RA; parity,
variation. breastfeeding, and exogenous hormones.
• Cigarette smoking remains the strongest environmental Geographic variation
risk factor for triggering RA; other lifestyle factors and
exposures such as alcohol use may be inversely
associated with RA. Autoimmune cluster 1
Looking for score >6

ACR/EULAR criteria for RA
Time trends
There’s a general
Autoimmune cluster
decline in the 1
incidence of RA due
to e.g., when
smoking stops
The increased trend
might relate to e.g.,
smoking, increased
diagnosis and change
in diet/eating habits
due to rise in obesity
oimmune cluster 1
Nutrition Medication influence
Conflicting results with some showing: Influence
•Autoimmune in terms of anti-inflammation
cluster 1
• Protective link between olive oil/fish • Statins have modest anti-inflammatory activity
(Mediterranean diet)
• Studies show RA risk possibly reduced by up to 40%
• Higher risk between red meat and protein
in those taking statins due to reducing cardiovascular
• However, neither proven in large cohort studies
risks hence patients with RA should take statins
• Low Vit. D and C and possibly copper and
selenium may have a role • Ongoing research in progress to assess their anti-
inflammatory effects
41
Infectious agents Socioeconomic status

• Can raise inflammatory markers • The data is varied
• These are potential associations, although • Most recent data suggests lower education level and
epidemiological confirmation has not been possible occupational class favours RA
• Epstein-Barr virus (member of human herpesvirus) • A study in Sweden suggests that those without a
• Human Parvovirus B19 (can cause anaemia) university degree have a 40% higher risk of RA
Reproductive and endocrine Birth weight

factors (hormones) • Higher birth weight has been shown to link to RA
• Pregnancy seems to affect the onset of RA as that’s a • Babies > 4.5kg have double the risk of developing RA
big hormonal change • Probably a hypothalamic-pituitary axis dysfunction
• One study showed that the risk of RA during
pregnancy is reduced, but increases in the 12 months The hypothalamic–pituitary–adrenal (HPA) axis
1 is a hormone-based system that regulates the
after
Autoimmune delivery
cluster
body’s reaction to stress – this ensures that the
• Some hormonal factors are in play, possibly androgen body can respond immediately to stressful events
(synthetic steroid hormone) although yet unknown and return to a normal state just as quickly.
Preclinical features of RA Development of autoimmunity Natural history of the disease

• Happens before presenting with problem
Autoantibodies
• Autoimmune cluster
precede disease (can be detected 1 Autoimmune cluster 1
early)
Crucial period
• Can be 5-10 years before symptoms where we want to
alternate disease
• Levels rise as symptoms emerge
• Rheumatoid factor (RF) Building up with a trigger Like ESR & CRP
triggering the genetic switch
• Anti-cyclic citrullinated peptide antibodies (Anti- e.g., smoking or infection
CCP) where they’re antibodies that are directed

against circulating peptides and proteins
Predicting onset and possible
Antibody formation changes Autoimmune cluster 1
prevention
Autoimmune cluster
Autoimmune cluster 1 • Currently being investigated

• Aim is to ID the high-risk RA autoantibodies and
address the preclinical phase before it transitions
e.g., Seronegative = risk-reduced
• ? Role for statins
• ? (Anti) Anti-CCP
Helps predict the disease state SAQ

ESR or CRP • In the preclinical phase of RA, what three markers of
the disease become apparent and why is this
• They go up with inflammation important as a prognostic (= predicting the likely
• An erhyrocyte sedimentation rate (ESR) is a type of course/outcome of a medical condition) indicator? (5
blood
utoimmune clustertest that measures how quickly an erythrocyte 1 marks).
(red blood cells) settle at the bottom of a test tube that In the pre-clinical phase of RA/rheumatoid arthritis, the
contains a blood sample. Normally, red blood cells three markers for the disease that become apparent are
settle relatively slowly where a faster than normal rate RF/rheumatoid factor, Anti-CCP & inflammatory
markers/acute phase reactants e.g., ESR & CRP.
may indicate an inflammation in the body
It’s important as it’s leads to early diagnosis and if
• A high level of CRP (C-reactive protein) in the blood is a positive hence more likely to experience damage due to
marker of inflammation where it can be caused by high inflammation levels and have a bad outcome hence
variety of conditions e.g., from infection to cancer more aggressive treatments will be needed.
Autoimmune cluster 1 42

Clinical features of RA Joint changes
• Inflammatory polyarthritis (where more than 1 joint is • Synovial membrane covers the
affected) is central inside of the synovial joint
(articular joints) where this
• Particularly the small joints of hands and feet membrane is covered by
• 80% of RA patients have high levels of RF and Anti- synoviocytes cells which gets
CCP Abs attacked where they try to replace
themselves hence overgrow - issue
• Inflammatory markers are also raised (acute phase with that, we get damage in the
reactants - ESR & CRP) tissue hence inflammation and lots
of activity of those inflammatory
• Joint erosion and destruction can occur hence no
mediators causes the joint swelling
longer function and tenders
• Joints become swollen and tender (synovitis – joint • Then if left unchecked, cytokines
capsule becomes swollen, and tender hence inflamed) are released, and they will reduce
the balance between osteoclasts
Early disease MCPs and PIPs swollen and osteoblasts leading to erosion
Autoimmune cluster 1 Check your joints!
• Four-point technique used for
detection
Metacarpophalangeal joint – • Synovitis (inflamed synovium)
muscle joints (MCP)
feels ‘spongy’ – normally it
should be hard
Proximal interphalangeal joint (PIP) • Valleys (bumps at the end of
hand) are filled in between
Distal interphalangeal joint (DIP) MCPs (as the knuckles are flat)
• Can use ultrasounds
Progressive disease (when the 1
Autoimmune cluster
joints start to become destroyed) Ulnar drift A hand deformity in which the swelling
Autoimmune cluster of the metacarpophalangeal joints 1
causes the fingers to become displaced,
tending towards the little finger.
The joint nearest the knuckle is
permanently bent toward the
palm while the farthest joint is
bent back away.
Ulnar bone
Fixed flexion in the joints drifting to
the side
The joint closest to the

fingertip is permanently
bent toward the palm
while the nearest joint to
the palm is bent away
Joints looks like a swan neck from it.
Autoimmune cluster Patterns of onset 1 Patters of progression

• Gradual (80%) • Lotscluster
Autoimmune of inter
patient variability
– Most common, small joints, EMS (early morning
• Brief/self limited
stiffness, super-glue feeling) prominent, symmetrical
• Palindronic (on/off disease, happens and then
• Slow, monoarticular
disappears for a while where it happens
– Less common, larger joints spreading to smaller over
around the body)
weeks
• Prolonged and progressive
• Abrupt, acute polyarthritis
– Widespread affecting small and large joints leading to
incapacity All of the above can range from mild to severe
43
Assessing disease activity HAQ-DI score –

• DAS 28 (disease activity score Quality of life measurement (how the disease affects
looking at 28 joints)
the patient, looks at the global health)
• Count number of tender joints
Health Assessment Questionnaire Disability Index
in specific places (28 sites) and
we look at how many of them 0 = no disability
are tender and swollen 3 = unable to
• Look at ESR or CRP (acute carry out tasks
phase reactants)
• Then, do a global health Change of 0.22
assessment from (0-100) is significant
• Add it all together to get the
disease activity score High HAQ-DI
• DAS can help show progression scores = more
of disease and its differences erosions
between time periods
Prognosis Extra articular features of RA

• HAQ score at baseline is a predictor of outcome

• Radiographic changes at baseline are a poor indicator
• Acute phase reactants e.g., ESR & CRP predict damage
• Early treatment, tight control (get them into remission,
if changes = act quickly as there’s only 12 weeks to do
so) is the key to prevent erosions and such
Nodules • Fibrous growth caused by pooling of

RF immune complexes Pulmonary involvement
• They don’t do anything bad, just
bad looking • Occurs frequently – often missed
• After surgery, they often grow back • Pulmonary nodules
Autoimmune
in the same place, so we removed • cluster
Interstitial lung disease (ILD) happens in about 7% of
the nodule and now we have a scar RA patients, but they have a three-fold increase in
tissue as they can have reduced risk of death
elasticity where if the nodule grows
• Methotrexate – an anchor drug given for most
again underneath the scar tissue,
patients but can cause pulmonary pneumonitis
we’ve made the problem worse
(inflammation in the lungs), hence needs to stop
• We can inject them with steroids
which can impact the efficacy of treatment
(may shrink)
• Nodules may also shrink/decrease Cardiac disease
in size if the patient is on optimal
• RA may lead to generalised vascular disease hence 1
drug therapy Autoimmune cluster
calculate the Q-risk as one of the risk factors is RA
Autoimmune cluster Ocular involvement 1
• Pericarditits is often seen (inflammation of the
• Episcleritis – sudden onset of redness pericardium – a sac-like structure with two thin layers
and pain where it’s an inflammation of of tissue that surround the heart to hold it in place and
the episclera becoming red where it’s a help it work)
thin layer of clear tissue on top of the • Cardiovascular disease is common, and risk of cardiac
white part of the eye/sclera death is high (inflammation of blood vessels)
• Sicca syndrome/dry eyes also common
due to an inflammation in the tear ducts • Important to treat risk i.e., antiplatelet/statin/anti-
hence don’t produce tears as much hypertensive
• DMARD therapy significantly lowers risk
44
Genetic links The contribution of genetic

Many chronic inflammatory factors to RA
diseases have been shown to occur • Twin (due to identical genetic structure) and
preferentially in individuals carrying family studies show a contribution of genetic
certain variants of genes in the factors to RA
MHC (major histocompatibility
complex) on human chromosome 6
• HLA-DRB1 region is the most likely genetic link
• HLA-DRB1 region is modified by smoking and
other environmental factors
Rheumatoid factor
Autoantibodies in RA (not usually measured)
• Autoantibodies recognise antigens on IgG
• Leads to compliment fixation (i.e., turbocharges the
Autoimmuneformation
cluster of immune) 1
• Detected in 50-80% of RA patients depending on
stage of disease
• High titre is more specific (>40 IU/mL), the higher
positivity = the more specific to the disease
• RF predicts disease, high titre = more severe RA,
rapid progression, worse outcome
Anti-citrullinated peptide Autoantibodies and

radiographic progression
antibodies (ACPAs)
• RA patients have epitopes which is the part of an Are they’re going to
antigen that an antibody attaches itself to, that come get an erosion and is
from citrulline, recognised by autoantibodies it going to be worse
as the time progress
• Anti-cyclic citrullinated peptide antibody test is the
way we check for these antibodies (Anti-CCP The more = the worst
antibodies)
• Highly specific (>95% for RA)
SAQAutoimmune cluster 1
• What are the two most common PIP/DIP deformities

often seen in RA (in the fingers)? Why is avoiding
these deformities in particular, important in any
treatment plan? (5 marks).
The most common PIP-DIP deformities often seen in RA
are the boutonniere deformity and swan neck deformity.
It’s important to avoid them as they can cause complex
disabilities and have an impact on activities of daily living.
Autoimmune cluster 45 1

The RA joint: Inflammatory response
synovitis and tissue destruction • We want to primarily avoid TNF-
• Chronic inflammation of the synovium alpha and interlukin-6 or IL-12 where
(layer tissue that lines the inside of the those cytokines that causes tissue
synovial joint) – that lining becomes damage and joint destruction are
infiltrated with inflammatory cytokines produced through T and B cells
• Leads to destruction of cartilage and • They can affect the balance of
bone osteoclasts and osteoblasts which
• Macrophage looking-like synoviocytes can lead to erosion
are recruited and retained into the joints • Drugs can be TNF-alpha &
space interleukins inhibitors/antagonists, B
• Inflammation leads to increase in T and cell depilators (Rituximab) and T cells
B cells which drives auto-antibody co-stimulation inhibitors (Abatacept)
production where we’re trying to stop which reduces cytokine
cytokines
Cytokines form a complex network
Inflammation in the joint leads to Autoimmune cluster
TNF-alpha and IL-6 mediate a bunch of things 1
cytokine production TNF-alpha activates osteoclasts and chondrocytes (a cell which

secretes the matrix of cartilage and become embedded in it)
Also, prostaglandins are involved (management of pain required)
Management of RA: Synovitis

Autoimmune cluster 1 Autoimmune cluster 1
• Synovitis causes the joint swelling and joint

destruction
• Complete remission (reduction or disappearance of
the sign and symptoms of disease) is the goal
• Aggressive therapy is important
• Erosions possible in 2 years without good
Tx/therapy
• Prognostic indicators (high anti-CCP, RF, acute
phase reactants and poor DAS 28 & HAQ-DI)
should drive most aggressive therapy
• Step-up paradigm most common a class of targeted
synthetic DMARDs
csDMARDs, tsDMARDs & bDMARDs
• Cs = conventional synthetic which includes
traditional DMARDs like Methotrexate
• Ts = targeted synthetic, they’re not biological, small
molecules, taken orally e.g., Tofacitinb & Baricitinib
• B = biologic e.g., Etanercept & Adalimumab
• Targets are generally TNF-alpha & IL-6
Autoimmune cluster
46
Step up paradigm csDMARDs tsDMARDs bDMARDs

cs b
• Use an anchor drug first (MTX – Methotrexate, dose
reduction if we get sustained remission)
• Then add another drug (mostly another conventional
synthetic DMARD e.g., Sulfasalazine, if doesn’t work
then a biologic DMARD e.g., Adalimumab)
• Permits graded escalation of therapy with minimum
number of medicines that can be used
• When traditional DMARDs ineffective (generally TsDMARDs - Janus-associated Mechanism of Action
avoided as it can be toxic) – add a ts/targeted synthetic kinase inhibitors
Tofacitinib Inhibits the JAK-STAT signalling
drug or bDMARD pathway responsible for
Baricitinib
• Glucocorticoids are useful to dampen down and flares inflammatory response
for acute presentations Autoimmune cluster 1
MD/multi-disciplinary approach to RA
ts/bDMARDs are expensive
• A team approach
• About £10,000 per year per patient
improves outcome
• NICE limits access to these medicines
– Disease is severe, that is, a disease activity score
• Many different
(DAS28) greater than 5.1 and professions are
– Disease has not responded to intensive therapy involved in the care
with a combination of conventional of an RA patient
disease-modifying antirheumatic drugs (DMARDs)
• Pharmacists are
Principles of opioid treatment of important in that
chronic musculoskeletal pain team
• MSK (musculoskeletal) pain significantly impacts
quality of life
• Opioids are often spared because of the worry of Problems with opioids
tolerance and ADRs/adverse drug reactions Autoimmune cluster 1
• Have been abused in the past hence why there’s a
• A proactive approach when applying the pain ladder push to use Paracetamol and NSAIDs
is advocated when it comes to opioids use
• Oxycodone one of the most widely abused
• ADRs like constipation can be managed with good
pharmaceutical care as it’s mostly ignored prescription drugs in the US which can cause
severe damages
The opioid risk tool
• 13,000 deaths a year from opioid OD
(mainly for strong opioids)
Autoimmune cluster 1 • Correct patient selection is imperative
• Right patient, right drug, right time
Choice of agent and titration

• In naïve patients use short acting agents first
• Start at the lowest dose
• Titrate by 30-50% and assess pain
• Once stable, convert total daily dose of short acting
to a long-acting preparation
47
Converting opioids Potential problems

• Beware of renal impairment with morphine, easy for
patients with AKI/acute kidney injury to accumulate
morphine and become toxic
• Role for naloxone protocols (reverses an opioid
overdose)
• Constipation managed proactively with softener and
stimulant laxative
SAQ
• A patient presents with a DAS score of 5.3 despite
intensive therapy with a combination of DMARDs.
Describe what this score means and why it
Autoimmuneinfluences
cluster the decision around next steps in the 1
treatment plan. (5 marks).
ne cluster Beware of interactions The DAS 1 28 score is used to detect disease activity
score looking at 28 joints where this DAS score of 5.3
indicates a severe active disease.
The DAS score of 5.3 influence decisions around next
steps in the treatment plan because the current
therapy is no longer working hence use the next step
which is e.g., bDMARDs
48

NSAIDS Kinetics and MOA
• Useful as a background anti-inflammatory (used first • Well absorbed
when gone to a GP e.g., when a swelling is observed, • Highly protein bound
• Metabolized by liver
effective, 6 weeks course)
• Excreted by GF/glomerular
• There is inter patient variability between response to filtration or TS/tubular
each NSAID (not every NSAID work to everyone) secretion
• Peak plasma 1-4 hrs
• Beware of the potential side effects – consider the
• Accumulation at site of
risk/benefit of each of (age increases the risks) inflammation hence useful
– CV risk for inflammatory diseases
• Short half lives - repeated
– GI risk in terms of bleeding and ulceration dosing necessary
Focuses on prostaglandins
– Renal risk to reduce inflammation
COX/cyclooxygenase inhibition
Bleeding
Unfortunately, no matter which drug chosen, it will always lead to

decreased PGI2 production which can lead to a prothrombotic effect - all
NSAIDs therefore have a bad reputation for increasing cardiovascular risk
- Cyclooxygenases (COX-1
and COX-2) are key enzymes in
the conversion of arachidonic
acid to prostaglandins and
other lipid mediators.
- COX-2 – new NSAIDs, by
blocking it we reduce serious
side effects as the difference is
in the minor adverse reactions e.g., helps avoiding serious GI bleeding
hence they’re more tolerated.
49
- COX-2 inhibitors target pain and inflammation with fewer

gastrointestinal side effects. They also don't seem to affect platelets
the way non-selective NSAIDs do, which means that COX-2 inhibitors
may not increase bleeding risk as much as COX-1 inhibitors when
used with blood thinners, like warfarin.
COX 2 inhibition Efficacy

• No difference in efficacy between tNSAID/traditional
All NSAIDs have NSAID and COX2I
different selectivity for
• Particularly useful in acute inflammation that leads
COX 2 which are useful
for acute inflammation
to swelling in the area
• Choice varies between patients
Right of the line shows • If no effect in 2/52 (2 weeks) switch to an alternative
progressively greater
COX-2 specificity • No rationale for combo therapy
Naproxen has a potent antiplatelet effect hence it
counteracts some of the prothrombotic COX-2 inhibition in
terms of a cardiovascular risk
GI effects Autoimmune cluster

CV effects 1
Naproxen used when
when we’re worried
Highest risk of CV for a cardiovascular
risk. If not available,
Serious GI
then Ibuprofen is used
effects when it’s
closer to the
right/increased
risk
Odds ratios and 95 % confidence
intervals for cardiovascular death
Systemic glucocorticoids/steroids in Glucocorticoids

rheumatology/disorders in joints
immune cluster Autoimmune
1 cluster
Glucocorticoids inhibit
many inflammation-
1
• After diagnosis, given first with MXT or the associated molecules
alternative/sulfasalazine, but for short-term only - if all such as cytokines,
doesn’t work, give bDMARDs chemokines, arachidonic
• Various systemic effects that have an effect on disease acid metabolites, and
modification adhesion molecules. In
• Decrease pro-inflammatory cytokines e.g., IL-6 & TNF-
Most used
orally contrast, anti-
alpha and enzymes inflammatory mediators
often are up-regulated
• Inhibit transcription factors, decrease T cell function and Available
by glucocorticoids.
Fc receptor expression IV
• Adverse events common, short courses only (~less than 2

weeks) as the patient can crash hence avoid long-term
use
50
Dose timing Mechanism of action

• Clearance varies by time of day because of the Stop production of pro-
disruption of normal cortisol production inflammatory cytokines through
transactivation and transrepression
• Very early am/in morning admin results in more
The important anti-
profound reduction of inflammation
inflammatory and
immunomodulatory effects of
A biological GCs are mediated
rhythm that
primarily express a
predominantly by genomic
periodicity during mechanisms. By binding to
daylight hours. cytosolic GC receptors (cGCR),
we induce (“transactivation”)
or inhibit (“transrepression”)
the synthesis of regulator
Efficacy proteins.
Adverse events
Long
treatment
courses of
high dose
are generally
a bad idea
with steroids
Practical recommendations
Autoimmune cluster 1 ACR response rates
• The ACR is reported as % improvement, comparing
• Use the lowest dose for the shortest time
disease
Autoimmune activity at two discrete time points (usually at
cluster 1
• Discuss risk and benefit start baseline and post-baseline comparison when
• Use in combination with a DMARD treatment is finished) to indicate efficacy
• Offer adequate bone protection as e.g., most post- • ACR20 is ≥ 20% improvement in patient’s symptoms
menopausal women with high risk of osteoporosis (clinically significant)
which is affected by steroids hence provide vitamin C • ACR50 is ≥ 50% improvement
& D supplements and give Alendronic acid – ACR50 responders include ACR20 responders
• ACR70 is ≥ 70% improvement
– ACR70 responders include ACR20 & ACR50 responders
Non-immunosuppressive disease Parenteral gold

modifying anti rheumatic drugs Autoimmune cluster
• Rapidly absorbed and highly protein bound like NSAIDs1
• Old school drugs but still very useful, can be used as • Very slowly eliminated via kidney
combination agents • MOA unknown, probably reduces oxidative stress and
• Gold as an antirheumatic drug affects macrophages and cytokines
• Sulfasalazine • IM gold as effective as oral MTX
Used rarely • Higher ADR rate than MTX
• Hydroxychloroquine
Oxidative stress reflects an imbalance between the systemic
manifestation of reactive oxygen species and a biological
• SSZ and HCQ used in the UK gold very rarely system's ability to readily detoxify the reactive
intermediates or to repair the resulting damage.
51Autoimmune cluster 1
Gold ADRs Sulfasalazine

• Can be used for IBD/inflammatory bowel disease
• Prodrug, metabolized by bacteria to 5ASA and
sulfapyridine – only the latter is absorbed
• MOA unclear, probably reduces oxidative damage
• Effective as lower doses of MTX
• Generally, well tolerated
• Can cause oligospermia (deficiency of sperm cells in
the semen/low sperm count)
Hydroxychloroquine Autoimmune cluster 1
• Antimalarial drug found by chance to improve Hydroxychloroquine SE

oimmunesymptoms
cluster of RA, used in combination • 1 Moderate effect alone, better
• T ½ is 40 days but LDs/loading doses not normally used in combo
as increase in ADRs • Can cause retinal changes,
• Cpss takes 3 months i.e., slow acting drugs hence takes must have regular eye testing
time to reach steady state (OCT/optical coherence
tomography screening at
• Often used in lupus (SLE) as its ‘anchor’ drug – baseline and every 5 years)
especially those that are skin-related
• If occurs, stop drug and
• Inhibits Toll-like receptors affecting cytokine signalling switch to alternative DMARD
Steady-state concentration (Css) occurs when the amount of a drug being
absorbed is the same amount that's being cleared from the body when the
drug is given continuously or repeatedly. Steady-state concentration is the time
during which the concentration of the drug in the body stays consistent. Autoimmune cluster 1
SAQ
• Rank ibuprofen, naproxen, and diclofenac in terms
of their relative risk of cardiovascular thrombotic
events starting with the highest risk. Why is the
dose of drug important and how does this affect
your risk ranking? (5 marks).
Starting with the highest risk, the relative risk of
cardiovascular thrombotic effects is firstly observed in
Diclofenac and then ibuprofen and then Naproxen.
The dose of drug is important in terms of affecting the
risk ranking in terms of their chances of getting a
cardiovascular risk/heart attack as this risk is dose-
related hence it’s the maximum amount of drug that
can be taken which affects the ranking as the risk
changes based on it.
52
Methotrexate Patient safety concerns

• Anchor drug in RA • Can be toxic in high doses and life-threatening as it
affects the blood cells specifically those that are white
• Structural analogue of folic acid, but it isn’t an hence increased risk of infection
antagonist • Given WEEKLY, if not = don’t dispense
• Adenosine theory increasingly accepted • Use folic acid to decrease ADRs such as stomach upset
& mouth ulcers
• Can be extremely effective against RA • Only use 2.5mg tablets because we want to reduce
• Must be monitored properly probability of overdose and give us flexibility
https://geekymedics.com/methotrexate- • Patients must have regular blood tests to avoid toxic
side effects hence check full blood count, if dropped =
counselling-osce-guide/ stop the drug
• Patients must be counselled on the medicine
Adenosine theory – MXT use Leflunomide
Autoimmune cluster
• That intercellular adenosine 1
will move out of the cell into the • Marketed as a ‘safer’
extracellular space against its Methotrexate, but can be
concentration gradient where it used in combination
is free to circulate in the blood • Inhibits pyrimidine
Pyrimidine
plasma and is increased by the synthesis and T cell pathway
dose of MXT proliferation
• When it does, it can bind to • Inhibits dihydroorotate
receptors on the cell membrane dehydrogenase
(A2a, A2b receptors)
• This causes an increase in • T ½ of 2 weeks so should
intracellular cyclic AMP - this require LD (rarely used)
causes an anti-inflammatory • Stops building blocks and
effect at regular doses and at proliferation of these cells
high doses we get to grow that are adding to
immunosuppression the inflammatory processes
Efficacy Immunosuppressives:
Ciclosporin, cyclophosphamide,
azathioprine, mycophenolate mofetil
• No commonly used in RA
• Can be used with MXT, but not great for
immunosuppressant because of side effects
• Only Azathioprine used in RA usually
Better response
• Cyclophosphamide, ciclosporin and mycophenolate
MOA more associated with severe ADRs compared to
azathioprine
oimmune cluster 1 Efficacy in RA

53
Azathioprine AZA metabolism

• Cleaved to 6MP when it’s metabolized – this is the active • 6MP can be converted in the body to active 6-TGNs or
element in the drug inactive 6-MMP
• 6MP can either go down a route where it becomes inactive – • The enzyme responsible for inactivation is TPMT
this route is catalysed by an enzyme/TMPT; the rest go down an
active route which have different enzyme controlling it • If this enzyme is low, less 6MP is inactivated and therefore
• 6MP turns to inactive 6-MMP catalysed by thiopurine more is available to be converted to active 6-TGNs
methyltransferase (TPMT) • Therefore, if we give someone the same dose with very
• If low TPMT more 6MP is available to form 6-TGNs/active form low TPMT levels, they’re going to have a higher availability
• 89% have high TPMT 11% have moderate 0.3% have no TPMT
of the drug and therefore the dose will be higher – this
activity
can cause a lot of adverse side effects
• When TPMT levels are low, higher levels of 6-TGNs are produced
and this is associated with a greater risk of myelosuppression. AZA metabolism
• Must measure TPMT activity before starting to ensure correct Autoimmune cluster Always end up with both
1
dose hence need to check the
proportion of the active and
inactive form to give a dosage
6MP under the influence of TMPT = inactive 6-MMP
Decreased TPMT = 6MP = Active 6-TGN
6-MP= 6-mercaptopurine
6-MMP= 6-methylmercaptopurine
6-TGNs= 6-thioguanine nucleotides Inactivated
by TMPT
TPMT=thiopurine methyltransferase
T-Cell co-stimulation and other T Cell co-stimulation

Autoimmune cluster
directed therapies 1
and other-directed therapies
• T Cell activation sustains synovitis/inflammation in • T Cell activation sustains synovitis
the joints, removing them = decreases synovitis • Activation requires costimulatory
signals
• Activation requires costimulatory signals • If we can cut off this T cell co-
• Abatacept blocks these co-stimulatory signals and stimulation, we can dampen down
prevents T cell activation the no. of T cells that are activated
and therefore you can attenuate
the synovitis
Abatacept Binds to receptor & stops the
conjugation of T cell stimulator
• Abatacept blocks these
costimulatory signals and prevents
T cell activation
• Soluble human
recombinant fusion
protein
Autoimmune cluster 1 Efficacy
• CTL4/FC conjugate • Comparable to other biologics
• Prevents co-stimulation • Mild infusion related reactions
• IV but now available as • Low immunogenicity due to being a fusion protein,
sub cut not an antibody
54
B Cell depletion Rituximab

• B cells are required for antigen presentation • Chimeric human mouse
monoclonal antibody
• This leads to RF and Anti-CCP autoantibody • Targets the CD20
production receptor on B cells – if
• If reactive B cells can be destroyed, then antigen we bind to CD20 we can
production can not take place hence no cytokines signal cell death
• IV infusion 2 doses of
Efficacy and safety 1000mg 14 days apart
repeated every 6
• Most studies show better outcome compared to months
MTX monotherapy
• Infection rates remain low IL 6 inhibition
• 1 in 25,000 risk of progressive multifocal • Multifunctional
Autoimmune cluster cytokine important in RA 1
leukoencephalopathy
Autoimmune cluster – life-threatening adverse 1
• Produced by T cells B cells and many other cells
reaction but low risk to occur floating around rheumatoid joints
• No increase in malignancy/cancer as B cells can • Wide range of effects including inflammation
control tumour cell growth supressing it
Tocilizumab Efficacy
• Humanised monoclonal • Good efficacy
antibody which targets IL-6 • Comparable to other
Autoimmune cluster
• Competitively blocks IL-6 1 biologics
from binding to its cell
bound receptor to have its
inflammatory effects Autoimmune cluster
• Can be given as a sub cut

injection
Structure
Tumour necrosis factor
blocking therapies
Autoimmune been the major target for biologic RA 1
clusterhas
• TNF-a
therapies and are first line after DMARD failure
(csDMARDs), then IL-6 inhibitors and finally T cell
depilator and B cell receptor antagonist.
• Wide ranging attenuation of inflammatory effects
cause profound disease modification
Has a synergistic reaction with MXT in terms
• More effective when combined with MTX of anti-drug antibody effect
Efficacy
• All agents follow a Autoimmune cluster 1
similar pattern with
Autoimmune cluster regard to/wrt ACR 1
response
• Better activity with
Etanercept alone
than MXT, but
together = more
effective
Autoimmune cluster
55 1
Safety Certolizumab pegol – Fragments of the receptor

which induces positive effects
(a pegylated Fab‘)
• Generally safe but a few things to remember
1. Humanized - less anti-drug antibodies
• Can reactivate latent TB/tuberculosis where TB must 8% immunogenicity rate vs up to 50% chimeric
infliximab (HACA) vs about 10% fully human
be kept latent because of an inflammatory capsule adalimumab (HAHA).
around the mycobacterium in the lungs, reduced
inflammation in the body can reduce that protective 2. Monovalent – no cross-linking
Does not cross-link antigens to form large
inflammatory capsule and the mycobacterium can be supramolecular complexes. Better tissue penetration.
reactivated action – must have CXR/chest x-ray to
3. Pegylated – hands around the body
check any latent TB which could be activated Improves drug pharmacokinetics and bioavailability.
• Slight increase in infection rate but not serious

4. Fragment
• All are sub cut injections, patient must be trained to Minimizes potential Fc-mediated effects such as
complement-dependent cytotoxicity (CDC) or
inject their device antibody dependent cell-mediated cytotoxicity
(ADCC).
Autoimmune cluster
Order of use of bDMARDs 1
tsDMARDs - The Janus Kinase (JAK)
• Offer Anti-TNFa 1st (usually Adalimumab)

Family – NOT biologic
• Switch to different anti-TNFa or use IL6 • Oral agents, better than MXT, same as bDMARDs &
no need for injection
(tocilizumab)/T-cell blocker (abatacept)
• Janus kinases is important in signaling promoting
• B Cell depletor (rituximab) cytokines
1. Cytokine binding to the • Currently, there are four known Janus kinases -
surface
JAK1, JAK2, JAK3, and TYK2 (JAK INHIBITORS)
• JAK3 is restricted to the immune system and is
2. JAK STAT interaction
involved in signal transduction of cytokines via
3. Gene transcription signal transducers and activators of transcription.
This what would normally
happen cluster
Autoimmune 1 Tofacitinib, an oral JAK inhibitor
If we inhibit JAK, when the Autoimmune cluster 1
cytokine binds to the cell
to cause that destruction,
we will stop that from
happening
• Tofacitinib interferes with the JAK STAT pathway, so we don’t get gene
transcription
Autoimmune comes to the cell receptor but because Tofacitinib is there we don’t 1
cluster
• Cytokine
get JAK STAT gene transcription
• If we can reduce the production and proliferation of these cytokines, we have
a profound effect on the amount of inflammation in the body
Cytokine Effects on the immune system
Cytokine Tofacitinib blocks Stimulate the proliferation and differentiation of Th, Tc,
IL-2
α β γ phosphorylation of B, and natural killer (NK) cells
STAT and
downstream IL-4
Induce the differentiation of Thelper0 to Thelper2
Induce immunoglobulin switching
Trial data for those who can’t tolerate MXT
activation
JAK JAK
P P Promote the development, proliferation and survival of T,
IL-7
P P B, and NK cells
STAT
STAT
STAT
STAT
IL-9 Stimulate intrathymic T cell development
P Promote the proliferation, cytotoxicity and cytokine

IL-15
production of NK cells
mRNA IL-21 Enhance T and B cell function
• Tofacitinib inhibits JAK1, JAK2, and JAK3 in vitro with functional cellular specificity for JAK1
and JAK3 over JAK2. Importantly, tofacitinib directly or indirectly modulates signaling for an
important subset of pro-inflammatory cytokines including IL-2, -4, -7, -9, -15, and -21
56
Biosimilars – like generics Biosimilar Manufacturing Process

• The biological product is “highly similar” to the • The manufacturing process and environmental
referenced product (which differs from the original) conditions used for a “referenced product” difficult
notwithstanding minor differences in inactive to duplicate
components • “Biosimilars are highly unlikely to be identical to the
• No clinically meaningful differences between the “referenced product” but may not affect clinical
biological product and the referenced product in terms outcome
of safety, purity and potency. • 30% cheaper (£7,700 vs £11,000 for infliximab)
SAQ
• In general, it is best to limit the use of a range of
strengths of methotrexate. Explain why this is
important and briefly describe the current
Autoimmune cluster recommendations to reduce 1 clinical risk. (5 marks).
It’s best to limit the use of a range of strengths of MXT (2.5mg
and 10mg) due to issues with toxicity mainly but limiting the
range of doses avoids the risk of overdose therefore we can
undergo a consultation and make sure the patient
distinguishes between the packs/packaging and takes them
once weekly. Also, a shelf that indicates high-risk drugs and
finally using a methotrexate counselling booklet.
Avoid use of MXT with Trimethoprim/an antibiotic for UTI
which can increase risk of nephrotoxicity.
57
58
L15) Introduction to Sandy Jones - SLE with Gout Differential Diagnosis:
Context What is Lupus?

• Sandy Jones is a 28-year-old female of Afro- • Lupus is a generalised inflammatory autoimmune
Caribbean descent who presents to her GP with a disease
diffuse malar/butterfly rash for 6 months and joint • Affects practically all organ systems infiltrated
pain. Since then, her disease has progressed rapidly. with immune complexes
• Autoantibodies are detected against DNA/dsDNA
Malar rash is a red or purplish
facial rash with a “butterfly”
which affect a lot of connective tissues
pattern. It covers your cheeks • Connective
and the bridge of your nose, but tissue/joints/kidneys/skin/brain/blood cells
usually not the rest of the face.
The rash can be flat or raised. • End organ damage is possible
Lupus presents in many different ways One symptom of lupus is arthritis & also one symptom of
gout is arthritis
Autoimmune Cluster – lupus can often be confused with gout
1
Autoimmune Cluster for 1• These are both inflammatory conditions,
• Often mistaken
other diseases, the
with similar joint related symptoms but
only one is autoimmune in origin, if
more organs
someone presents with arthritis but
affected = more
doesn’t present any of the other lupus
chance of problems symptoms, it can be commonly confused
in terms of patient
with gout.
outcome
• Mainly affects the • In RA, we see symmetrical involvement, in
skin, the joints & the
other types of inflammatory diseases we
would see other systems involved
kidneys
• SLE/Systemic lupus erythematosus is a
particular in that we can get just a singular
What is it like to live with lupus presentation of one aspect of the disease
Autoimmune
• AffectsCluster
mainly young women 1 • Gout is driven by predisposition of urate
crystals in the joints – these cause
• “I’m not a big fan of the meds, as they come with all sorts of side inflammation
effects, some as bad as the symptom itself. But sometimes they
are necessary, and I will take them if I have to.” Gout is Painful!
• “Fatigue is a big factor in lupus, so I’m careful about where I’m
spending my energy. Weekends are sometimes about recovery
from the working week. I have to say no to some social events
because I know I can’t handle too much in one day or go out in
the evening as I’ll be exhausted. Some days I am so tired all I can
think about is having a nap.”
• “The last time my Lupus flared, the doctors said it might be time
to discuss a kidney transplant. I’m only 28 and it was the scariest
Percentage of those suffering from gout in the U.S. who stated
thing I have ever heard”
Formative SAQs gout is more painful than select experiences in 2019
• Concerning Gout (5 marks)

Autoimmune Cluster 1
a. Name a drug that is contraindicated in the treatment
of gout? (2 marks) – Diuretics e.g., thiazides
b. Explain mechanistically why this is the case? (3
marks) – thiazide diuretics works by increasing the
amount of uric acid by affecting the re-absorption of
urate in the kidney hence hold on to more urate and
due to less volume through the use of diuretics hence
the concentration of urate goes up causing crystals
formation
59
L16) Autoimmune Cluster - Systemic Lupus Erythematosus 1:

Introduction Classification Of Systemic Lupus
• SLE/Systemic Lupus Erythematosus is an autoimmune Erythematosus
rheumatic disease, considered seronegative
• Unknown etiology/cause
This wide
• Is a systemic disease involving connective tissue
variety of
• Autoantibodies have intracellular targets (parts of the symptoms make
cells involved with DNA replication) SLE difficult to
• Antinuclear antibodies (ANAs) are present in at least diagnose and
95% of patients with SLE. easy to
miscategorise
• Anti–double-stranded DNA (dsDNA), anti-smith
(anti-Sm), anti-Ro, and anti-La antibodies are
examples of these ANAs, if positive = SLE
• 12:1 female to male ratio
How race affects incidence

Autoimmune Cluster
Lupus development 1
Genetics
Normal immunity > environmental trigger >

autoantibodies production
Clinical presentation - skin

utoimmune Cluster Clinical progression 1
• Autoantibodies and clinical features appear Butterfly/malar rash
years before the diagnosis of SLE due to the
variety of symptoms
• Many patients with SLE spend time with
symptoms before meeting the ACR criteria
• A wide variety of symptoms, with equally different
severity between patients makes SLE difficult to
diagnose
• SLE can be organ, and life threatening e.g., losing
the kidneys
60
Joint involvement Clinical presentation - joints

• Joint inflammation and
destruction can occur (rare
& slow progression)
• Its course is different to
typical inflammatory joint
disease like RA
• The systemic nature can
lead to the incorrect primary
Swelling in the MCPs and looks similar to boutonniere deformity
diagnosis
SAQ
• Name three types of anti-nuclear antibodies that can
often be detected in a patient with SLE and why are
these important at arriving at a differential diagnosis?
(5 marks).
The three type of anti-nuclear antibodies that can be detected
in a patient with SLE are where they’re anti–double-stranded
DNA (dsDNA), anti-smith (anti-Sm), anti-Ro, and anti-La.
They’re important as it gives the idea that a patient could be
misdiagnosed e.g., with gout but the anti-nuclear antibodies
will indicate SLE - this helps us arrive at a confirmation of
diagnosis which is important to get better, faster and proper
treatment.
61
L17) Autoimmune Cluster - Systemic Lupus Erythematosus 2:

Lupus nephritis Renal damage
• Renal involvement is a severe complication of SLE, • Filters/vessels become blocked with vast number of
most common is LN immune complexes/antibodies due to lots of
inflammation happening
• Lupus nephritis causes scarring and destruction of • Scarring starts to happen meaning the filters don’t
renal tissue decreasing kidney function and can lead function anymore hence the kidneys can’t filter things out
to renal failure as it’s full of toxins hence it’s life-
threatening e.g., especially in those in their 20s and
might need an organ transplant
• Classified as class I-VI indicating amount of damage
in the kidney
Neuropsychiatric complications Autoimmune Cluster

Iatrogenic lupus 2
• Big immune
Autoimmune Cluster complexes/antibodies get lodged into the • 1 It’s usually mild, check drug
little arteries in the brain in the CNS – lots of history
inflammation and areas in the CNS don’t function as well • Caused by drugs causing
• Can lead to confusion and fits – can commonly be lupus-like syndrome, hence
confused with epilepsy or mental health disorders even check the ANA’s (anti-nuclear
antibodies)
though it’s an organ disease
• These drugs cause an
autoimmune response in
which the body attacks its
own cells producing
symptoms similar to those of
systemic lupus
erythematosus (SLE)
Management of non-renal and

non–central nervous system lupus
• Mainly the skin and joints
Score for each body
• NSAIDS – if the patient has renal damage, NSAIDs can
area that can be make it worse hence monitor Check the GI and any renal risks
affected, we’re looking • Hydroxychloroquine – anchor drug in SLE reducing it
for a reduction scoring symptoms, especially those with skin conditions
after a period of time because the drug is distributed across the skin quite
which shows if there’s well
a response in terms of • Glucocorticoids – steroids can be given to help manage
symptoms improving flares but be careful with it use as it can reduce the
bone density hence given for a short period
62
Treatment of neuropsychiatric lupus Classification of renal involvement
FOR SEIZURES
Not imp. due to

possibly lost of
renal function
Treatment of lupus nephritis
toimmune Cluster 7 Azathioprine,
• Tends to be acute & acute phase reactions increased Mycophenolate & Ciclosporin
• IV cyclophosphamide pulse therapy in combination • Have been studied as remission inducing and
with glucocorticoids is the gold standard for the maintenance therapies - maintain the patient in terms
treatment of severe lupus nephritis of flares
• Can quickly establish remission and prevent organ failure • For induction therapies we generally want to use
as the scarring could be severe causing renal failure done cyclophosphamide and glucocorticoids as they’re the
with the treatment above ^ most effective
• Must also include a maintenance strategy once remission • If used correctly can maintain remission at high rates
is established to stop it from happening again
• Seldom used for induction and IV cyclophosphamide
• We want to try and minimize cyclophosphamide therapy is the standard therapy as these agents aren’t fast-
because its quite toxic (it can also affect fertility in women) acting hence get the patient under control
9
Recommended treatment of LN
Autoimmune Cluster
Autoimmune Cluster
Summary 10
• Multi system disease

• Autoantibodies to intracellular targets
• Skin, brain, joints, kidney
• Treatment involves induction of remission and
maintenance of that remission to prevent organ damage
SAQ
• Describe the two phases of treatment of lupus
nephritis. How does having two treatment phases
affect treatment choice? (5 marks).
The two phases of treatment of lupus nephritis are induction12
Autoimmune Cluster
Autoimmune Cluster 11of remission and maintenance of remission. Having two
phases affect the treatment choice as one drug can’t be used
for both phases but for induction of remission, we want it to
be fast acting like cyclophosphamide therapy whereas for
maintenance of remission we want it to be slow, lasts longer
and less toxic as cyclophosphamide can be toxic hence e.g.,
Azathioprine can be given or Mycophenolate & Ciclosporin.
63
L18) Gout 1:
Gout club What is gout?
I’ve had crushed bones. I’ve shattered my ankles. I’ve • Not an autoimmune disease
torn out my knees. I’ve dislocated and torn my • An inflammatory arthritis caused by precipitation of
shoulder. I’ve been shot. I’ve been stabbed. I’ve been uric acid crystals in the joint which forms needles on
bitten by snake, dog, human, and cat. I’ve been sucker the joints causing joint inflammation
punched. Tasered. I’ve been hit in the head with a beer
bottle. I’ve been kicked in the junk. None of that pain…
none of it… comes close to what gout is like.
Gout X ray findings Two possible mechanisms

• Under excretion of urate where the amount of urate
accumulates
Autoimmune Case in the body and crystalises out
Not a good way to
Autoimmune Case 1 • Over production of urate so can’t get it out fast
detect gout as it enough
doesn’t show crystals
• > 90% of patients with primary gout are
Calcification area which is the underexcreters (their kidneys do not get rid of
build up of calcium in body tissue
enough urate)
- With purine metabolism, we want to try

Purine metabolism
and reduce the amount of urate.
Autoimmune Case 4
Autoimmune CasePurine nucleoside 3
metabolism - Normally, we intake purines which are
Xanthine Found in bird’s white poop the building blocks of protein responsible for
Xanthine oxidase Allantoin
In birds, used to be protein metabolism – these get converted to
Uric acid
Uricosurics Uricase in humans but noy
anymore xanthine in which xanthine is then converted
GI tract Excess urate in
Renal excretion excretion plasma to uric acid - that conversion is controlled by
IL-1
xanthine oxidase where to produce uric acid,
Urate
Neutrophil
Tophi deposition in
joint
activation we need xanthine oxidase to work.
- Normally, some of the uric acid goes through renal extraction, some goes
oimmune Case 5
through the gut, rest is circulating in the plasma where if we have too much
circulating in the plasma, the rate will come out of solution/plasma and start to
crystalize/deposit in the joint causing localized inflammation causing the pain in
the area.
- When urate gets deposited in the joint, we get an inflammatory reaction - that
inflammatory reaction activates neutrophils, this leads to the inflammation and
64
pain. If this carries on for a long period of time, we can get solidified elements of
urate (called tophi) that build up in the joint space.
- Uricosurics help increase the amount of uric acid that is pushed through the renal
excretion route OR we could stop xanthine oxidase from working - this would
prevent the uric acid from building up in the first place (can use a Xanthine
oxidase inhibitor like Allopurinol).
- Lastly, we could try and prevent the neutrophils from being activated - part of
the activation is driven by IL-1, so we could design a drug to block IL-1 which will
help stop interleukin activation.
- Uricase is an enzyme which will convert excess rate in the plasma into an
insoluble compound called allantoin - however this enzyme is missing in humans.
Prevalence and incidence Risk factors
Men • Male/post menopausal women
• Metabolic syndrome
Combined • Obesity
Women
• Diet
– High purine intake
Risk factors are – Alcohol
related to diet or – Fructose
lifestyle, or any • Drugs, including:
particular types of – Diuretics
medicines taken – Low dose aspirin
– Ciclosporin
• Increased cell turnover (malignant disease)
Drugs which decrease renal excretion • Genetic predisposition
Autoimmune Case 1
of urate (holding more urate in the Gout phases
body causing its build-up) Autoimmune Case
1. Urate concentration is raised
• CAN’T LEAP but is not enough to come out of
• Ciclosporin solution and for the crystals to
• Alcohol form
2. Person will get flares and
• Nicotinic acid
period of gout that come and go
• Thiazides 3. Body is trying to get rid of the
• Loop diuretics crystals and put them back into
• Ethambutol solution
• Aspirin (LD) 4. More than one joint affected
• Pyrazinamide & deposition of rate masses in
the joints due to high urate, try
2015 ACR-EULAR Gout classification
Autoimmune Case 1 to get urate under control before
that period
If you have a score equal or is > 8 = classified as gout

Autoimmune Case 1
Autoimmune Case 2
65
Expressing Urate concentration Urate lowering drugs (ULDs)

Ideal range is to get • Xanthine oxidase inhibitors lower the production of
below 300 Urate stays in
micromoles/L or
solution and won’t urate in the body as they stop the conversion
below 0.3 millimoles/L
crystalize through inhibition e.g., Allopurinol
Also Also
expressed expressed as
• Uricosuric drugs increase the excretion of uric acid in

as 4mg/dl 0.24mmol/l
the urine and thereby reduce plasma concentration

e.g., Probenecid
Beware what unit's urate is expressed
in – easy to make a mistake
Autoimmune Case 1 - Usually start with

Naproxen
Autoimmune Case 1
NSAIDs then review 4-6
weeks/month later.
Next, think about lifestyle
BSR 2017
interventions and lastly,
Management Serum urate
an over rate lowering
of gout
therapy. But if they do
have continued problems
with their urate, then
think about starting urate
lowering drugs.
- First line is Allopurinol, start low and titrate up, measure urate at the
start. However, if can't use Allopurinol e.g., renal problems then use
Febuxostat where if that 2016 EULAR Treat to target
Recommendations
doesn't work either, might 1
Serum urate must be measured regularly, and urate-lowering therapy should
be adjusted to attain the therapeutic target.
A serum urate level <6 mg/dl (<360 micromol/l) should be targeted and
consider switching to 2
maintained in all patients with gout
In patients with severe gout, such as those with tophi or frequent attacks, the
3 target should be a serum urate level <5 mg/dl (<300 micromol/l) until clinical
uricosuric drug. remission is achieved
Acute attacks should be treated promptly with anti-inflammatory medications,
4
taking safety issues into consideration
Prophylaxis against attacks should be initiated and continued for at least
5
6 months after starting urate-lowering therapy.
In all patients with gout, renal function should be assessed at the time of
6
diagnosis and then monitored regularly.
Comorbidities associated with gout may influence therapy and outcomes and
7
should be assessed regularly and managed
Modifiable risk factors should be addressed primarily through patient
8
education and support.
Information about gout and its management should be made readily available
9
to patients by their healthcare professionals.
66
Dietary modification Acute gout diagnosis

• DO NOT EAT HIGH PURINE CONTENT Joint fluid examination under
– Oily fish, shellfish
polarized microscopy
– Game
– Offal
– Marmite/yeast extract
• EAT SMALL AMOUNTS OF MODERATE PURINE CONTENT
– Meat/chicken
– Beans/legumes/peas
– Spinach/cauliflower/asparagus
– Mushrooms
– Wholegrains
Crystals of urate found in joints birefringent needle shaped crystals
• EAT MORE LOW PURINE CONTENT
– Bread/pasta
– Milk (milk protein – maybe uricosuric) Aspirate the joints (stick a needle in it, pull fluid it and have a look at it
– Eggs
– Other fruit and vegetables
under the microscope)
– Butter, cheese, ice cream, chocolate, cake (beware comorbidities…) • Crystals shaped like needles
– Cherries & Vitamin C (maybe uricosuric) • Sometimes if you aspirate joints and find crystals, sometimes the
• AVOID ALCOHOL ENTIRELY patient doesn't have any problems - you can have crystals and no gout
Description of acute attack Intervals between attacks

• Rapid development of warmth, swelling,
erythema/abnormal redness of skin or mucous
membranes and pain in the affected joint
• Pain escalates to most intense level in 8-12 hrs
• Initial attack is usually monoarticular and >50% cases
involve the 1st MTP joint/big toe, not symmetrical like RA
• Other joints involved in early stage: midfoot, ankles,
heels and knees. Less commonly wrists , fingers and If there’s a single attack in 1 year, we
elbows. usually don’t initiate therapy but started if
there’s a second attack
Acute gout treatment Autoimmune Case

Colchicine 1
Autoimmune Case 1 – Anti inflammatory activating when it comes to gout in
terms of those crystals, not well tolerated as it can
cause GI disturbances & diarrhoea
– Blocks microtubule assembly in neutrophils reducing
Naproxen mainly
phagocytosis and transport of MSU crystals.
– Affects neutrophil migration into joints by reducing
But they can be painful for the patient, used adhesion molecules on endothelial cells and
to reduce inflammation and gout flares
neutrophils in response to IL-1 or TNF-a
– Reduces inflammasome-driven activation by
microtubule inhibition which decreases MSU delivery
SAQ
• Describe the four phases of gout. Why is aCase
Autoimmune knowledge of 1
four phases important when selecting appropriate
Autoimmune Case pharmacotherapy? (5 marks). 1
The four phases of gout are acute flares, asymptomatic
hyperuricemia, chronic polyarthropathy with tophus
formation and painless intercritical segments.
Because we would mobilize lots of the urate in the body
hence Allopurinol/urate lowering therapy is not given in the
acute flare phase as it gives a re-bound effect in terms of
when Allopurinol decreases uric acid the body gets the
stored urate of the joint gout whereas NSAIDs or Colchicine
are given for prevention in the first 4-6 weeks/month.
Autoimmune Case 1
67
L19) Gout 2:
Chronic gout QoL impact –
goes down with more severe form of gout
• Destructive polyarticular involvement with low-grade
joint inflammation, joint deformity, and
tophi/deposit of monosodium urate crystals
• Tophaceous gout which is the most severe form of
gout develops within 5 years of onset of gout in 30%
of untreated patients
• Tophi growths are painless and rarely become
infected but function and health-related QoL can be
severely affected with chronic gout
Tophi – a sign of chronic gout
Chronic gout treatment
Autoimmune Case
• Build up of uric acid crystals under Autoimmune
1 Case 2
the skin Reducing impact =
helps excrete
• Often painless urate more renally
• Large tophi can reduce joint

movement/mobility depending on
where they are and may be
surgically removed which won’t
cause scarring like nodules
• Anti-gout treatment can gradually To help with the spikes associated with urate mobilizing
hence an NSAID & PPI can be used for a couple of weeks
shrink tophi
Allopurinol toxicity
Autoimmune Case
Allopurinol therapy 1 • Careful use in patients with renal failure
Autoimmune Case 1
• Start low no more than 100 mg/day – Metabolites are renally cleared hence can accumulate with RI
– hypersensitivity reactions are more common in patients with
• Dose reduce ALL patients with moderate to severe renal insufficiency – probably better options are alternatives.
renal insufficiency or use alternative which is mainly • Purine-associated hypersensitivity syndrome is DIFFERENT
the go to e.g., Febuxostat from allergic rash
• Gradually up-titrate the dose, which in some cases, – Systemic and sometimes life-threatening illness
can be more than 300 mg/day if needed. Max – Fever, hepatitis, marrow suppression, nephritis, DRESS (Drug
Rash with Eosinophila and Systemic Symptoms)
600mg/day
• The Role of HLA B5801 and allopurinol hypersensitivity is
• Treat to Target: serum urate concentration <360 unquestioned
micromole/l, and <300 micromole/l if treating tophi. • All patients from populations with a high allele frequency
for HLA B5801 and high hazard ratio for developing
Allopurinol – a purine derivative hypersensitivity should be screened (Asian populations)
Autoimmune Case 1 Second/third line therapies
• Looks a bit like hypoxanthine which is a substrate of xanthine

Febuxostat is not renally cleared hence is
oxidase more helpful, usually a second-line drug
• We want to stop our xanthines from being converted into uric acid whereas Allopurinol is first-line generally but
• Allopurinol competes with the hypoxanthine for xanthine oxidase, stopped if we can’t control the urate even at
so you're not able to convert your xanthines into uric acid the maximum dose or can’t tolerate it
Autoimmune Case 1
1
68 Autoimmune Case
Febuxostat - a non-purine selective Febuxostat use

inhibitor of xanthine oxidase. • First treatment in 40 years for chronic gout
• NON-PURINE inhibitor of xanthine oxidase
• Theoretically safe to use in patients with allopurinol
sensitivity reactions
• Been studied in patients with mild renal insufficiency
• Dosed at 40-80mg/once daily
Renal excretion of uric acid
No purine-associated hypersensitivity
Autoimmune Case
Febuxostat benefits 1
Autoimmune Case 1
• More potent than 300 mg/day allopurinol
• Not a purine: appropriate for patients with
allopurinol hypersensitivity
• Can be used safely in patients with mild renal • Uric acids comes into the glomerulus for filtration
• 90% of that uric acid is reabsorbed hence small amounts are
insufficiency (unlike allopurinol) excreted (8-12%) therefore uricosuric drugs try to stop some of that
reabsorption so more urate can be excreted
Uricosuric agents – blocking URAT 1

reduces uric acid reabsorption Sulfinpyrazone
• If we block URAT 1, • Inhibits URAT-1
then we block the
reabsorption of the • Can cause GI upset
Autoimmune Case
urate back into the • 1Needs to be taken with large quantities of water to
glomerulus
• This means that we prevent kidney stones
will stop the • There are better alternatives
reabsorption so more
will be available for • Worldwide shortage now
excretion
URAT1 (Urate 1 transporter) is a member of the OAT (organic anion

transporter) family, and an anion-exchanging uptake transporter
Probenecid
Autoimmune Case 1
Autoimmune Case Benzbromarone 1
• Uricosuric agent blocks tubular re-absorption of uric acid
• Useful in patients who under-excrete uric acid (90%) • Unlicensed in the UK needs to be imported even
though it was the alternative for Allopurinol
• If need be, confirm under-excretion with 24 hr. uric acid
<800 mg/24 hrs. • Non competitive inhibitor of XO
• Can be used in renal impairment (vs allopurinol)
Do not use in: • Withdrawn from several markets because of
hepatotoxicity causing liver problems & death
• Tophi
• Must have regular LFTs/liver function tests if used
• Renal impairment
• Clear overproduction syndrome - rare
Autoimmune Case 1
Autoimmune Case 1
69
Lesinurad Renal Complications

• Used in combination with a xanthine oxidase • Nephrolithiasis (kidney stones)
inhibitor where this alone doesn’t achieve target – Risk factors: increased uric acid excretion, reduced urine volume,
• Inhibits URAT-1 and so reduces reabsorption of uric and low urine pH
acid in the kidneys
• 200mg od with XO • Chronic urate nephropathy
• NICE rejected in 2018 – ICER/QALY £62,298 – Urate crystals can deposit in renal medullary interstitium
producing inflammatory changes and fibrosis
– Clinical features are non-specific: renal function impairment, bland
Severe refractory urinary sediment, mild proteinuria and serum urate concentrations
tophaceous gout often higher than expected for the degree of renal impairment.
– Biopsy confirms diagnosis
Due to a very low urate metabolism
Autoimmune Case 1
Autoimmune Case Uricase would be the answer 1
• Enzyme that converts insoluble uric acid to more soluble

metabolite allantoin which helps with gout BUT humans
have lost the gene function to produce uricase
• Rasburicase – can be used instead: a drug derived from
aspergillus used to treat tumor lysis syndrome which is a
complication that can occur from cancer treatment where
large amounts of tumor cells are killed off lysed from the
treatment, releasing their contents into the bloodstream
Autoimmune Case
Pegloticase 1 • Rasburicase is extremely immunogenic where it’s almost
immediately inactivated by the body, which limits its half
• Mammalian uricase
life and its use in chronic diseases due to production of
• Pegylated antidrug antibodies
– Increases half life
– Reduces immunogenicity as it Pegloticase adverse events
covers the immune system
triggers and antidrug • Infusion reactions (not human, even with PEG)
antibodies • Many patients develop antibodies to drug that
increases its clearance
• Administered by IV infusion • Anaphylaxis
every 2 weeks • 80% patients had gout flares despite prophylaxis
• Contraindicated in G6PD deficient patients
Autoimmune Case 1
IL-1 and urate driven inflammation • May exacerbate heart failure
• IL-1 drives the inflammation in gout whereas IL-6 drives the

inflammation in RA
Biologic targets in gout therapy
• Inflammatory cells can innately recognize common microbial Gout pathogenesis:
features as danger signals Autoimmune
• SuperCase
saturated serum levels of uric acid which leads 1
– Flagella, viral RNA, etc… to crystal formation and deposits in joints
– Excess uric acid and associated crystals recognised in the • Crystals are engulfed by macrophages
same way • Macrophages release inflammatory cytokines
• Leads to rapid inflammation
• Recruit more inflammatory cells and perpetuate joint
• Microbial patterns bind to Toll-like receptors and lead to inflammation
increase in pro IL-1
70
Autoimmune Case 1Autoimmune Case 1
IL-1 blockers (canakinumab)

• IL-1 Receptor antagonist (anakinra, commercially available for
Rheumatoid Arthritis)
IL-1 production • Anti IL-1 antibody (canakinumab, commercially available to
• Pro-IL 1 is inactive, but capable of being rapidly treat certain periodic fevers)
metabolized to active IL-1 • IL-1 decoy receptor fusion protein (rilanocept, commercially
available to treat certain periodic fevers)
• Machinery that cleaves pro IL-1 to active IL-1 is called
the inflammasome
Several pilot studies show promising results:
• Uric acid is capable of activating the inflammasome
• Single dose of Canakinumab superior to triamcinolone injection
(has long half life)
• Not approved as studies were only 16-weeks
• But can be very expensive due to small groups treated
Summary Autoimmune Case SAQ 1
1. Asymptomatic hyperuricemia • In patients with mild renal insufficiency, what

Autoimmune Case
2. Acute intermittent gout 1 would be an appropriate ULD regime, and why can
standard first line therapies not be used? (5 marks).
3. Advanced gout (chronic tophaceous gout)
In patients with mild renal insufficiency, an appropriate
ULD regime would be Febuxostat.
Treatment to target urate levels
Acute – NSAIDs etc.
Standard first line therapies like Allopurinol can’t be
used as its metabolite is renally cleared hence its
Chronic/more than 1 attack in a year – ULTs + lifestyle
amount will build up leading to toxicity in those
modification
patientd with renal insufficiency.
Autoimmune Case 1
Autoimmune Case 1
71

PY365 - Autoimmune Diseases Cluster

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PY365 - Autoimmune Diseases Cluster

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Ali AlAttar 20800061

L0) Immunology Revision (Not Examined) –

- Antibodies - a blood protein produced in response to and counteracting a

An EPITOPE, also known as ANTIGENIC DETERMINANT, is the part of an

The IgG Molecule – The Fc Fragment “HYPERVARIABLE REGIONS”

ACTIVATION OF IMMUNE RESPONSES

- Based on visual observation, the ancients characterised inflammation by

THE “NORMAL” HUMAN IMMUNE SYSTEM - II

1. B cells producing antibodies

THE ROLES OF CD4+ TCase

Reduced inhibition Strong activation

Strong inhibition Transformed or infected cells sometimes

T REGULATORY CELLS (TREGS) – PROTECTORS T REGULATORY CELLS (TREGS) – PROTECTORS

• They are immunosuppressants secreting cytokines in which their main

MODES OF ACTION AND INHIBITION OF CYTOKINES 1

What normally happens is

- Our immune system also generates lymphocytes capable of recognizing

“The responses to self antigens or antigens

HOWS DOES A LYMPHOCYTE DISTINGUISH BETWEEN

THE FIRST CHECKPOINT - CENTRAL TOLERANCE

POSITIVE SELECTION NEGATIVE SELECTION BUT some

MECHANISMS OF PERIPHERAL TOLERANCE -ANERGY MECHANISMS OF PERIPHERAL TOLERANCE – SUPPRESSION

L1) AiDs Case Introduction:

Autoimmune Diseases Cluster 9 1

L2) Immunology of Autoimmunity:

Thus you may need to

antibodies and how they

reduce side effects

("Immunogenicity") *neutrophils, basophils,

Call tissues with good blood supply

INNATE IMMUNE CELLS

Autoimmunity CasePY365 – Case 3.4 Therapeutics

MONOCYTES POLYMORPHONUCLEAR NEUTROPHILS

where cells are recruited e.g.,

The Autoinflammation/Autoimmunity spectrum of diseases and their immune mechanisms.

HOW IS AUTOIMMUNITY MANIFESTED WHAT HAPPENS WHEN THINGS GO WRONG?

“The responses to self antigens or antigens

I CD4+ Th2 od Tissue

SOME COMMON AUTOIMMUNE DISEASES

Acts on an organ swollen neck

About 5% of population in West – immune system Synovium = membrane

HOWS DOES A LYMPHOCYTE DISTINGUISH BETWEEN T REGULATORY CELLS (TREGS) – PROTECTORS

High serum [Ab] to

Autoimmunity CasePY365 – Case 3.4 Therapeutics

AUTOINFLAMMATORY RESPONSES – AUTOINFLAMMATORY RESPONSES –

By blocking these Thus, immunotherapies were

L3) Biologic DMARDs in the Treatment of Rheumatoid Arthritis - Structure,

mAb = monoclonal antibody

Immunosuppressants that act on another cytokine that promotes inflammation (IL-6)

PY365 – Case 3.4 - Autoimmune Disease Cluster They block7

- If 100% human = nasty immune response (not used anymore), variable

CERTOLIZUMAB PEGOL (“CIMZIA”) – A MODIFIED REVISION - PEGYLATION

It prevents RA by binding to, and

TOCILIZUMAB (“RoActemra”): TARGET = IL-6

Rituximab, Abatacept, SarilumabPY365

TOCILIZUMAB/SARILUMAB – MODE OF ACTION RITUXIMAB: TARGET = CD20 that is found on

RITUXIMAB (A B-CELL TARGET) RITUXIMAB – MODE OF ACTION

ABATACEPT (“ORENCIA” – TARGETS RECEPTORS ON APCs)

PHARMACOKINETICS OF bDMARDs – KEY POINTS PHARMACOKINETICS – TNFα ANTAGONISTS

PY365 – Case 3.4 - Autoimmune Disease Cluster REVISION

ADALIMUMAB FLASH CARD INFLIXIMAB FLASH CARDS

Structure 4348kDa Structure 51 kDa

L4) bDMARDs Immunogenicity:

MHC2 CD4+ Th2 B-cell Antibodies