Rh eumatology intern<'ltiona i.(IM) v 27, rto. 2. (.!m1 ?.fJ07)

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PFIZER EX. 1602 Page 1

Rheumatology International

Clinical and Ex peri menta I Investigations

Aims and Scope RHE UMATO LOGY INTERNATIONAL is an indc­p~ntknt jou rn al n.:lkcti ng world-wi~k progr:ss lll t h ~ n:scarc h. diagnosis and trca tm...: nt o l the \~anous ':ht!u­matic d iseases. It is <.h.:signcd to serve the II.Ih.: rnalton~d and intcrdi st..: iplinary group or wo rkers lll ~o l vcd Ill problems nr rheumatic diseases. Rl l EUMATOLOGY INTE RNATI ONAL will cover a ll nwdcrn trend s 111

diniL":t l und cxrx: rimcnt;.d rcsc:m..:h as. we ll as 11.1 tl~c ma na!.!C illC!ll o r rheumatic di sl..!aSL:S. Spec tal ~ mph <.lS I S wt ll he !..!. i \~ 11 to inll1lllllO-pathogcn...:tic ml!ch<.HliSlllS .. Jnlbn:­m alo ry reactions. co lla gen ntct:~ho li sn. t.. genetics. ~p t­tkmiology. thc rapcut ic m<~dui;II J O il o l 11lll1llll10 ioglc; tl

and in ll amnwto ry nh.::c hanJ sJl lS. and <.kvdopmcnt a~td eva luation of diagnostil: proccd un.:s cOJllh.:c t c~l wn_h rh~.:umat i ~..: d i s~as~s. Contribut ions to t h ~o:SI.! topll:S will aplx:a r in th t.: ro rm or o rigi nal puh_l ica tions: illl!wmat ive case n;po rb. short commun~t.:auons . ..:dllona ls, and r'.!V i'.!WS. " Lc\lers to the edi tor·· will he wdcome as an t.:: nhan<xment to discussion . Every dlUr~ wi l.l ~t.: made. to ensure speed of publil:ation whll_e mallltaJ ntng a IHgh '>ta ndard of content s and produ~..:tJon.

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Rheumatology International

Editor-in-Chief

Advisory Board

Honorary Editors

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Prof. Dr. E-M. Lemmel , Baden-Baden

L. Bonomo, Rome T. D. V. Cooke, Riyadh S. D. Deodhar, Chandigarh T. E. W. Feltkamp, Amsterdam H. Greiling, Aachen E. J. Holborow, London M. F. Kahn , Paris R. N. Maini, London D. G. Palmer, Dunedin

J. B. Natvig, Oslo

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Clinical and Experimental Investigations

P. A. Revell, London A. S. Russell , Edmonton, Alberta J. D. Stobo, San Francisco, CA N. Talal, New York, NY R. Timpl, Martinsried B. Vernon-Roberts, Adelaide M. Zembala, Cracow N. J. Zvaifler, San Diego, CA

A3

PFIZER EX. 1602 Page 3

Rheumatology I nternationa I

Clinical and Experimental Investigations

Volume 27 Number 3 January 2007

OR IG INAL ART ICLES

. akamura H . Ma suko K . Yudoh K. Kato T . Kanwd a T . K awa h<~ra T : Elfccts of J,! lucos:1rninl' :Himinis tratitm on Jla t icnts with rheumatoid arthr itis 2 13

Lee Ell. Lee YJ. Shin DH . C'hoi YM . l'ark M i l. Pandey JP. So ng YW: l mm uno~luhulin GM and K!\•1 ~cnol )' pcs in Knn.•an patients wi th S)'Sh.•mic hiJHIS

erythematosus 219

Lee EY . Lee C- K. Lee K-U. l'ark J Y. C ho K-.1 . C ho YS. Lee HR . Moo n SH . M oon 11-13 . Yoo B: Alpha-liJloic ac id SIIJ)Jlfl'SScs the dc ,•c lopmcnt nf coll aJ.!C n-induccd arthritis and protects a ga inst hnnc destruction in mice 225

K:tsht..: f S. G l1<1 t.:dian fv1M . Raja l.!c /\ . Cihadcri A: Dyslipoprotcinl'lllia durinJ.! the actin• course of sysh:mic lupus c rylhl•nw tosus in assnc ia tin n wit h an ti-dnuhlc-s lr<Hltlcd DNA (anti-dsONA) antibodies 235

h nwuch i M . Shimadzu H. Tamak i C. Yamagata T . Noz: tk i Y. S ugiya ma M . lko ma S. K inosh i1:1 K : S un'i\':.t l s tudy by organ disorders in 306 Jat>:mcsc tJati ('nf s with S)'Stcmic lupus c.:rythcm:ttosus: n..•su lt s frurn a single center 243

Pcnni .. ;j P. Tro mhelli A. G ios tra E. M e ntha G. Rizzoli R. Fiore CE: J>:unid ro n:lle ami usteoporosis pn..•n·n tion in lh'Cr tr:ms pl:.111t rcl'i JJi cn ts 251

Kim T~ l l . Paynt: U. Zlwng X. lwana ga Y. Da vt:y M P. R osen baum J l '. Inman RD : Alh.·rcd host:JJ ;.ttho~cn inter:u.· rions confe rred by till' Hlau synd rome mutation nf NOD2 257

A rdcn iz 6. Vat ttnst:vc r S. Musahak U. Aks u K . Sin A . Kok uluda i! A : A rthritis :IS~~ presenting syntJJiom in :1 hypngammaglnhulinl' lllic JJ:Itient with thy~u:ctnm y 263

lkndcr NK. 1-lt.:ilig CE. Drdll B. \Vo h lgt:muth .1 . /\rmhru stc r F~ P. ll c ilig B: lnununc,gcnicit y, dlicacy nnd :ul\'(:rst• C\'Cnts nf adalimum :1 h in I~ A 1•at ients 269

Ala ~c hirli B. Ocmi ryii rc k ~- Anca E. Gn rsoy S. Dcm iryl"1rr.:k !\ T : No C\'idencc fu r an :1ssnc iation hc twecn the Glu29HAsp poi)' IHOrphism of the t•ndotheli :ll nitric oxide synth:tst gene :.1nd l ihrcuny:1l~ia syndrome 275

CASE REPORTS

Bas kin E. i\g ras P l. M cnc k )c N. Ozdr.:mir II. Cc ng iz N: Full~huusc ncJ•hrnpat hy in :1 (l:tlit·nt with nc~:lti \'C serolnJ.!)' fur hiJUIS 281

G<~rthwa i t t.: EA . Borde r 0.1 . .l o nt.:s C ll. \Vorth JJP: /Uunlocot·t·u.\· equi infrc tion durin !.! rrc;.~ tm('nt nf a (.' ~ANCA JIIISi ti n· ' ':IStuliti s: a co1sc repo rt 285

Klumb EM . d~: Andrad~ MC .. k:s t't s NR. Camp:tni C. Campos C l< Lcvy RA . 1\ lbuqu r.: rquc.: E. C\: r va nt c.:s V: Primar)' antiphnsphulipid ll('phrnJl:lthy ht.•J,!inning durin J.! J•rcJ.! n:mcy 289

llc r M ~Y. Kim T -11. C hang 1·1- K . Lcc W~S . Yoo D- 11 : S uccl•ssful treatment of :1ccruired ~llll l'J.!:Ik:tryucyti c thrumhncy tufJCnia wi th cyclos pnrinc in ;ulult o nse t S till 's diseose 295

Koz OC i . l\t c.:~ /\ . Nu man /\lp M . Gult;ul E. Karaas lan Y. Kur;li (i : Bilatcrnl ucu l:1r isd 1cm ic syrulruml' :1s an initiollmanift•st:ll iun uf T akayo1su's artt•ritis associ :~ ted with c :~rutid stea l syndrumt 299 .

S rikulmont rcc.: T . Massey 1-1 D . Ro bc.: n s W N: Tre<~ tmcnt of skelet a l Erdhcim­(;hes te r disease with zuledrnnic :1cid : case rt.'Jmrt and jJrHflOScd mech:111isrns nf ac lion 303

LETTERS TO THE EDITOR

13ir..;in 6 z..;akar z. Yiik scl S. Ensa ri A. Ekim M. Yah;mka ya J~·: ,\cule renal failure

in a p:1 ticnt wit h f:uuili:1l i\'lcdit rrra ncan fC\'e r 309

Din lcr M . Ka sikciog lu E. Akin A . Sa yli 0 . /\ ksoy C. O ncd A , Bcrkt.:r E: Excrcist~ capacit)' ;md o xygrn rccm•ery half times of skeletal muscle in patients with

lihrnmya lgi:1 311

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PFIZER EX. 1602 Page 4

Rhe um ato llnt (2007) 27:269-274

DO l 10.1007 ls00296-006-0 L83-7

ORIGINAL ARTICLE

lmmunogenicity, efficacy and adverse events of adalimumab in RA patients

Niko K. Bender · Christoph E. Heilig· Benjamin Droll . Jessica Wohlgemuth· Franz-Paul Armbruster· Bernhard Heilig

Received : I .Jul y 2006 I Accepted: 23 July 2006 I Pu blished online : 28 Septembe r 2006 © Springer-Ve rl ag 2006

Abstract To assess the immunogenicity of ada­limum ab, a human anti-TN F-cr mAb, we evaluated the fo rma tio n of antibodies to ad alimumab, efficacy and adverse events amo ng 15 patients with highly active rhe uma to id a rthritis. Four patients were trea ted with ada limumab as monothe rapy, and t I pa ti ents with con­comitant DMARDs. Disease activity was measured by DAS28. The antibodies we re de tected by E LISA. Thirteen (87 % ) patients withdrew from the rapy within 45 weeks and overall 13 (87 % ) pati ents showed antibodies to ada limumab including 11 pati ents who withdrew from therapy. In fo ur pa ti ents without concomitant DMA RDs and in nine patients with con­comi ta nt DM A RDs, we de tected anti -adalimumab a ntibodies. Overall , fi ve o f seven pa tients with adve rse drug reactio ns and all nine pa ti ents with lack of e fficacy were assoc iated with the fo rma tion o f antibodies. Two a ntibody-positive patients deve loped an exantheme. Th e results indica te that ada limumab is, in spite of its full y human sequences, immun ogenic and induces anti­bodies in a high rate of ada limumab-treated pa ti ents.

Keywords lmmunogenicity · Anti -adalimumab a ntibodies· Adverse eve nts · C linica l response

N . K. Be nde r ( l8J ) · C. E . H e ilig· B. H e ilig Rh e um apraxis H e id e lbe rg, Wie la nclstr . 20 , 69 120 H e ide lbe rg, Ge rma ny e-ma il : n. bencler@rhe um apraxis- he iclelbe rg.de

B. D ro ll · J . Wo hlgemuth · F. -P. A rmb ruste r lmmundiagnosti k AG , Stu benwa lcl -A llee Sa, 64625 Benshe im , Germ a ny e-m ail : inl'o@immuncl iagnos tik .com

Introduction

T he tumor necrosis factor cr-blocking monoclonal anti­body adalimumab is described as safe and we ll tole rated and shows clinica l efficacy with o r without the concomi­tant use of methotrexa te in contro lled clinica l trials among patients with RA . A dalimumab is gene tica ll y engineered by phage-display technique and beca use o f its full y human sequences it is supposed to be less immu­nogenic than murine or chimeric monoclonal antibodies. However, the formation of human anti-human antibod­ies (H AH A) has been reported by several authors (1-3]. It still remains unclear which part of adalimumab induces H A HA response. Lmmunogenicity of ada­limumab and its clinica l significance in dail y clinical practice is poorly investiga ted compared to the immuno­genicity of in fli ximab and may dille r from that shown in previous controlled studies [ L -3]. The aim o f this tria l was to assess the immunogenicity of adalimumab and the correlation o f efficacy and adverse events among a sma ll number of patients in regular clinica l settings.

Patients and methods

Pa tients

Fifteen eligible pati ents had rheumato id a rthriti s (RA) diagnosed according to the 1987 revised criti e ria of the American College of Rheumatology (4] with a di sease activity score (DAS 28) of more than 4.0 who were tak­ing adalimumab with o r without concomitant metho­trexa te o r le flunomide. All participants were trea ted with corti coste ro ids and had previo usly received more than one DMARD witho ut clinica l e fficacy.

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Exclusion criteria consisted of the British Society for Rheumatology guidelines for prescribing TN Fa blockers in adults with RA [5].

Study protocol

We assessed 15 patients between November 2003 and January 2006 at a single center in Germany. Eleve n patients were tak ing adalimumab with concomitant methotrexa te or leflunomide and four patients were taking adalimumab as monotherapy. Informed consent was obtained fro m all patients enrolled. After screen­ing for tuberculosis, which included chest radiographs and tuberculin skin testing, base line assessment which included measurement of DAS28 and medical history were perfo rmed. Study visits were conducted every month to every 3 months in most cases. Every patient received ada limumab at a dosage of 40 mg subcutane­ously every other week . Pa tients were instructed about se lf- injection techniques.

Assessment

OAS28 and morning stiffness were measured at base­line, after 3, 6, 12 and 18 months thereafter. A change in the OAS 28 of >1.2 (twice the measurement error) is a clinically significant change [6].

Safety was assessed on the basis of adverse events reported by patients and findings on physical examina­tion and laboratory evaluations.

lmmunogenicity assessment

Serum levels of anti-adalimum ab antibodi es were mon­itored at base line and every other time on follow-up (i.e. , in most cases between 4 weeks and 3 months thereafter) . According to the optical density (OD) of the HAHA serum level, we divided the antibody-positive pa tients into three groups: patients with low serum lev­els (0.02 ::: 00 < 0.2), intermediate levels (0.2 S 00 < 1.0), and high levels of antibodies aga inst adalimumab (OD =:: 1.0). Serum levels of anti-adalimum ab antibod­ies were measured by sandwich enzyme linked immu­nosorbent assay (EUSA; Immundiagnostik AG, Bensheim, Germany). Ninety-six-well microtite r plates were coated with 100 f.ll/we ll of solution containing 3 ~tg/ml F(ab')2 fragments of adalimumab (Abbott, Wiesbaden, Germany) buffered with 50 mM of sodium carbonate (pH 9.6). After incubation overnight at 4°C, the plates were blocked with 2% BSA in PBS for l h at room temperature. Patient serum and control sa mples diluted 1:200 in 2% BSA in PBS , pH 7.2, were added to the appropria te well in duplicate and incubated

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overnight at 4°C. After washing, horseradish peroxy­dase-conjuga ted adalimumab was added and the prep­arations were incubated for l h at room temperature. Color reaction was induced by incubation with th e substrate solution (TMB) for 30 min . The reaction was stopped by addition of 0.4 M sulfuric acid and a micro­plate reader was used to measure the OD at a wave­length o f 450 nm. The results were de termined by cuto ff.

Results

Antibodies to adalimumab

The baseline characteristics of the patients are shown in Table 1. Overall , 13 (87%) patients had low serum levels up to high serum levels of antibodies against ada­limumab (Fig. 1 ). All four patients with adalimumab monotherapy and nine pa tients with additiona l DMARDs had elevated serum levels (Fig. 1). Three patients had high levels of antibodies (00 2': 1.0) , two patients had intermedia te levels, and eight patients had low levels (0.02 ::: 00 < 0.2). One patient with high levels of anti-adalimumab antibodies was taking ada­limumab without concomitant DMARD and withdrew from therapy owing to the development of a drug­related exantheme. The other two patients dropped out owing to lack of etficacy- one ta king concomitant le flunomide, one concomitant methotrexa te.

The two patients with inte rmedi ate serum levels of anti-adalimumab antibodies had to discontinue owing to adverse events, including one with exantheme and one with herpes zoster. Among the eight patients with low levels, six had to discontinue trea tment, four owing to lack of e f1icacy , two owing to adverse drug reactions, and two patients are still taking adalimumab without lack of etficacy or adverse events.

Dropouts and antibody formation

In 13 (86%) patients adalimumab treatment failed and led to withdrawal from therapy (Table 2). Six patients discontinued treatment owing to lack o f efiicacy, six owing to adve rse drug react ions, one because of bon e surgery (Table 2). Of those patients with side effects , three discontinued trea tment owing to hypersensitivity reactions (two with monotherapy) , one owing to th e developme nt of herpes zoste r, and one owing to short­ness breath , both were taking adalimumab with con­comitant methotrexate (Table 3). Of three RA patients who did not reach the third month of therapy we had no further DAS28 a fter base line. On ly one patient

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Table 1 Base lin e characteristics o f I 5 patie nts with R A trea ted with adalimumab

Variables

Age , yea rs Female sex Disease duration , yea rs Numbe r of previous DMARDs DAS 28 at baselin e Mo rnin g stiffness, minutes Se ropositivity

Indi ca tion fo r ada limum a b

High disease ac ti vity AEs to othe r biologicals R efractory to other biologica ls

Concomitant medication

Corti costeroids Me th otrexa te Le nuno mide 20 mg/day

Dosage (mg)

Prednisone, mg/clay Me thotrexate, mg/week

Mea n ± SEM (ra nge)/n (%)

55.9 ± 8.1 (34- 73) 10 (67) 12.2 ± 8.2 (2.5-40) 3.1 ± l.l (1- 5) 6.5 ± 1.2 (4.0- 8.5) 132 ± 121 (0-480) 9 (60)

11 (%)

14 (93) 1 (7) 6 (40)

n (%)

15 ( 100) 10 (67) J (7)

Mean ± SEM (range

7.7 ± 2.7 (2.5-15) 13. 1 ± 2.3 (7.5-20)

SEM standa rd e rror of the mean , n number o f patients

Overal I

Drop out

Adverse events

Exantheme

Concomitant DMARDs

Without concomitant DMARDs

Lack of efficacy

2

2

2

~ 2

I

I I

., 1"':1.'-

~1~'

• lloHAHA neg. aHAHA pos.

Fig. 1 Numbe r o f patients with/without HAHA response in rela­tion to clinica l pa rameters among J 5 acla limumab-treated pa tients

reached 45 weeks of treatment and one reached 28 weeks of trea tment before dropout. The other l1 patients discontinued adalimumab treatment within 15 weeks including three patients with adverse events who had to drop out after 3 weeks.

Eleven dropout patients had elevated serum levels of anti-adalimumab antibodies; two patients were neg­a tive (Fig. 1).

27 1

Table 2 Dropouts, treatment duration a nd disease activ ity in the course o f trea tme nt

Dropout patients (week 2-45)

A ll Owing to lack o f e iTicacy Owing to AEs Exantheme Other AEs

Needed surgery

Treatment duration

Numbe r of inj ections until drop out Number o f weeks until d rop out

Mea n disease ac tivity

DAS28 at baseline DAS28 three months la te r

R esults II(%)

13 (87) 6 (40) 6 (40) 3 (20) 3 (20) I (7)

Mea n ± SEM (ra nge)

7.8 ± 4.2 (2-23)

13.2 ± 7.8 (2-45)

Mean± SEM (ra nge)

6.5 ± 1.2 (4.0-8.5) 6. 1 ± 0.6 (4.5-7.2)

Table 3 Adve rse events amon g 15 adalimumab-trea ted pati ents

Variable

Patients with adverse events Adverse events leading to withdrawa l Exantheme Herpes zos ter Edema Nausea Headache Dyspnea Abnormal menses Diarrhea

Efficacy and antibody formation

Results 11 (%)

7 (47) 6 (40) 3 (20) I (7) 1 (7) 1 (7) 1 (7) 2 ( 13) 1 (7) 1 (7)

At baseline we measured a mea n DAS28 of 6.5 and 3 months thereafter a mean OAS28 of 6.1 (Table 2). No clinically significant change in the DAS28 was observed in nine (60%) patients. These nine patie nts showed elevated levels of anti-adalimumab antibodies. The duration of morning stilli1ess afte r 3 months could not be evaluated in five patients because they dropped out before the 3-month follow-up .

The two antibody-negative patients showed clinical response to adalimumab.

Adverse events and antibody formation

Seven ( 47 %) patients showed adverse drug reactions (Table 3). Five patients with adverse events were anti­body posi tive (Fig. 1). Three patients developed an

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ada limumab-re lated exa ntheme, including two patients with antibodies to ada limumab in the ir se rum (Fig. 1). Two patients without anti-adalimumab antibodies in their se rum showed adve rse events, including one case with exantheme and one with local inflammation at the

inj ection site.

Methotrexate and antibody formation

A ll four pati ents without concomitant DMARDs had to discontinue adalimumab trea tment and all were tested positive on antibodies aga inst the TNF-cx­blocke r (Fig. 1). One pat ient dropped out owing to lack o f ellicacy , one owing to lack of efficacy and drug­related exa ntheme, one owing to drug-re lated exan­theme, and one owing to herpes zoster. Of the 11 pa tients with concomitant DMARDs, nine were tested positive for antibodies aga inst aclalimumab (Fig. 1). In this group nine patients had to discontinue the anti­TNFcx therapy, including seven patients with antibod­ies against aclalimumab. A ll seven antibody-positive patients were associa ted with an inadequate response to ada limumab and two patients showed adverse drug reactions.

Antibody titers in the course of treatment

Seven patients with a nega tive base line titer of anti­adalimumab antibodi es showed a n increas ing OD of th e a ntibody titer after the fir st ada limum ab inj ec­tions. After withdrawal from aclalimumab treatment we obse rved a decrease of th e OD to base line anti­body serum levels in mos t cases. The o th e r s ix patients showed antibodies to ada lim umab in the further course of therapy. Examples are shown in F igs. 2 and 3.

Discussion

In this regular clinical se tting, o ur investiga tion indi­cates that in spite of its full y human sequences ada­limumab induces HAHA responses in a high rate of aclalimumab-trea ted patients with or without the con­comitant use of DMARDs. Previous trials described an incidence of anti-adalimumab antibodies of about 12% among patients treated with acla limumab as monothe r­apy [1] and about 1% among patients who had taken concomitant methotrexa te [2] . There seems to be no difference in the pattern or frequence of adverse events between pati ents with or without th ese antibodies [ 1 ]. The corre lation between HAHA response and reduced clinica l efficacy is reported clifl"erent ly [l-3]. Van de

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0 ,06

0,07

0,06

0,05

c 0,04

0 0 ,03

0,02

0,01

~075

I ~ -/ ~

I ~7

I ""'0,034

I \ -I \

I \ 0

, -0,004 1 2 3 4 5 6 6 ~.oos

-om Time (months)

Fig. 2 Optica l de nsity (OD) o r the antibody se rum leve l ( !lli~1 lin e) in th e co urse or trea tme nt with adalimumab (!luck llll e) of" 54- year-o ld fe mal e pati ent who had to stop ada limumab-mo no­the rapy within 2 months owin g to lack of e !Ticacy

0,1

0,06

0,06

0,04

c 0 ,02 0

~0,075

=---------=--= /0,037

I -o,02

0 I 1 2 3 4

-0,04 I 1-0,051

-o,06

Time (months)

Fig. 3 Op tica l density (00) o f th e a ntibody serum level (1 /Iin line) in the course o f trea tme nt with acla limumab (1/Iick OITOII' ) o f a 56-yea r-old male pati ent. He sta rted acla limumab treatme nt with conco mita nt metho trexate a fte r discontinuing inniximab be­ca use o r lack o f c lllcacy. T he th erapy with adal imumab is still ongoing; no adve rse drug reacti ons we re o bserved un t il prese nt

Putte e t al. [1] found no statisti ca l clifTe rence in A C R20 response rates between HAHA-positive and HAHA­negative patients trea ted with the recommended close of 40 mg every o ther week. In the ARMADA trial no correlation between the presence of anti-aclalimumab antibodies and a reduced respo nse to treatment was observed [2] but other trials reported a lower rate in the ACR20 response among antibody-positive patie nts [3]. In our trial it is difficult to correlate HAHA response and clinica l parameters because we observed an overa ll high incide nce of anti-adalimumab antibod­ies and dropo uts owing to adve rse events and lack o f etlicacy. Moreover, we could not compare antibody­positive with antibody-negative patients because th ere were o nly two patients without de tected HAHA . Fur­the rmore, we did not evalua te the concentration of

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ada limumab in the serum , so we could not assess the clearance o f Humira® from the serum.

The ELISA, which used F(ab'h fragments of ada­limumab for HAHA binding, is supposed to be highly specific because binding of unspecific antibodies to the Fe part of ada limumab is prevented. Antibodies against ada limumab detected in our assay could be spe­cific to any part of this F(ab')2 fragment. We assume that the H AHA reactivity is either directed against non-human glycosylated sites on the surface of the antibody expressed in CHO cells or against the anti­genic determinants in VL and VH regions of ada­limumab that include the CDRs (complementary determining region). The latter was reported by Ritter et al. [7] who characterized the HAHA response aga inst a humanized monoclonal antibody for the treatment of colon ca ncer with the use of the highly sensitive BlACORE method . He detected , despite humaniza tion , HAHA responses in 63% of the treated patients [7]. A further evidence for the development of anti- idiotype antibodies against ada limumab might be the very low incidence of antibodies against etaner­cept, a recombinant human TNF-receptor fusion pro­tein, between 0.5 and 3% [8-12].

ln contrast to ada limumab and etanercept, the clin­ical significance of antibodies aga inst infliximab, a chimeric monoclonal antibody to TNFcx, is well described among patients with Crohn's disease [13 , 14] . lnflixim ab is highly immunogenic and treatment is associated with a high incidence of human anti-chi­meric antibod ies (HACA) between 14 and 61% [1 3-17]. Among patients with rheumatoid arthritis HACA incidence is lower, probably beca use of the concomi­tant use of methotrexate in all study patients, and the clinica l signifi ca nce is less investigated [18, 19]. Patients with detectable HACA are more likely to have infusion reactions and insufficient clinical response than those without antibodies aga inst inflix­imab. The concomitant use of immun omod ulato rs red uces the incidence of HACA formation [13-15]. Furthermore, after induction therapy at week 0, 4 and 6, sched uled treatment every 8 weeks is associated with lower HACA incidence [17]. Because inl'liximab in the serum interfe res with the assays for HACA detection [13- 19] , the incidence of anti-inHiximab antibodies could be underestimated in most trials described above. The interference of ada limumab with our and previously used assays is unknown and not yet investigated.

Because of the small number of patients, our data must be handled with caution and suggests that further trials of regular clinical settings with a higher number of patients have to be performed.

273

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