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MONOCLONAL ANTIBIOTICS USAGE IN AUTO IMMUNE

DISORDERS

Praneeth Chandaluri1* and Ramesh Ganpisetti

2

1,2

Department of Pharmacy Practice, Malla Reddy College of Pharmacy (Affiliated to

Osmania University), Hyderabad, Telangana, India-500100.

ABSTRACT

Hybridoma technology is a method for producing large numbers of

identical antibodies (also called monoclonal antibodies). This process

starts by injecting a mouse with an antigen that provokes an immune

response. A type of white blood cell, the B cell that produces

antibodies that bind to the antigen are then harvested from the mouse.

These isolated B cells are in turn fused with immortal B cell cancer

cells, a myeloma, to produce a hybrid cell line called a hybridoma,

which has both the antibody-producing ability of the B-cell and the

exaggerated longevity and reproductively of the myeloma. Once

monoclonal antibodies for a given substance have been produced, they

can be used to detect the presence of this substance. The Western

blot test and immuno dot blottests detect the protein on a membrane.

They are also very useful in immunohistochemistry, which detect antigen in fixed tissue

sections and immunofluorescence test, which detect the substance in a frozen tissue section or

in live cells. Monoclonal antibody therapy is a form of immunotherapy that uses monoclonal

antibodies (mAb) to bind monospecifically to certaincells or proteins. This may then

stimulate the patient's immune system to attack those cells. Monoclonal antibodies used

for autoimmune diseases include infliximab and adalimumab, which are effective

in rheumatoid arthritis, Crohn's disease and ulcerative Colitis by their ability to bind to and

inhibit TNF-α. Basiliximab and daclizumab inhibit IL-2 on activated T cells and thereby help

preventing acute rejection of kidney transplants. Omalizumab inhibits human

immunoglobulin E (IgE) and is useful in moderate-to-severe allergic asthma.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 6.041

Volume 6, Issue 01, 266-285 Review Article ISSN 2278 – 4357

*Corresponding Author

Praneeth Chandaluri

Department of Pharmacy

Practice, Malla Reddy

College of Pharmacy

(Affiliated to Osmania

University), Hyderabad,

Telangana, India-500100.

Article Received on

24 Oct. 2016,

Revised on 14 Nov. 2016,

Accepted on 04 Dec. 2016

DOI: 10.20959/wjpps20171-8216

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KEYWORDS: Crohn's disease, myeloma, a hybridoma, rheumatoid arthritis,

immunofluorescence test, ulcerative Colitis.

INTRODUCTION

Hybridomas are cells that have been engineered to produce a desired antibody in large

amounts, to produce monoclonal antibodies. (1, 2) Monoclonal antibodies can be produced in

specialized cells through a technique now popularly known as hybridoma technology.[1]

Hybridoma technology was discovered in 1975 by two scientists, Georges Kohler of West

Germany and Cesar Milstein of Argentina (now working in U.K.), who jointly with Niels

Jerne of Denmark (now working in Germany) were awarded the 1984 Noble prize for

physiology and medicine.1 Generally, the production of one MAb, using the hybridoma

technology, costs between $8,000 and $12,000. The average reasonably SK can generate only

15 to 30 hybridoma fusions per year, but in an environment where the focus is on diagnostic-

or therapeutic-quality MAbs, there are additional significant limitations than can further

decrease throughput. Monoclonal antibodies is valuable for the analysis of parasites antigen

and appropriate that WHO should have organized a symposium (held at the national

university of Singapore, October 1981) which brought together those who have establish and

refined the technology and those who are using it, or intending to use it for the study of

organism responsible for some of the major diseases affecting mankind. Such monoclonal

antibodies, as they are known, have opened remarkable new approaches to preventing,

diagnosing and treating disease. Monoclonal antibodies are used, for instance, to distinguish

subsets of B cells and T cells. This knowledge is helpful not only for basic research but also

for identifying different types of leukemias and lymphomas and allowing physicians to tailor

treatment accordingly. Quantitating the number of B cells and helper T cells is all-important

in immune disorders such as AIDS. Monoclonal antibodies are being used to track cancer

antigens and alone or linked to anticancer agents, to attack cancer metastases. The

monoclonal antibody known as OKT3 is saving organ transplants threatened with rejection,

and preventing bone marrow transplants from setting off graft-versus-host disease (immune

system series).

METHODOLOGY

Hybridoma technology is a method for producing large numbers of

identical antibodies (also called monoclonal antibodies). This process starts by injecting a

mouse with an antigen that provokes an immune response. A type of white blood cell, the B

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cell that produces antibodies that bind to the antigen are then harvested from the mouse.

These isolated B cells are in turn fused with immortal B cell cancer cells, a myeloma, to

produce a hybrid cell line called a hybridoma, which has both the antibody-producing ability

of the B-cell and the exaggerated longevity and reproductivity of the myeloma. The

hybridomas can be grown in culture, each culture starting with one viable hybridoma cell,

producing cultures each of which consists of genetically identical hybridomas which produce

one antibody per culture (monoclonal) rather than mixtures of different antibodies

(polyclonal). The myeloma cell line that is used in this process is selected for its ability to

grow in tissue culture and for an absence of antibody synthesis. In contrast to polyclonal

antibodies, which are mixtures of many different antibody molecules, the monoclonal

antibodies produced by each hybridoma line are all chemically identical.

A hybridoma, which can be considered as a harry cell, is produced by the injection of a

specific antigen into a mouse, procuring the antigen-specific plasma cells (antibody-

producing cell) from the mouse's spleen and the subsequent fusion of this cell with a

cancerous immune cell called a myeloma cell. The hybrid cell, which is thus produced, can

be cloned to produce many identical daughter clones. These daughter clones then secrete the

immune cell product. Since these antibodies come from only one type of cell (the hybridoma

cell) they are called monoclonal antibodies. The advantage of this process is that it can

combine the qualities of the two different types of cells; the ability to grow continually, and

to produce large amounts of pure antibody. HAT medium (Hypoxanthine Aminopetrin

Thymidine) is used for preparation of monoclonal antibodies. Laboratory animals (eg. mice)

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are first exposed to an antigen to which we are interested in isolating an antibody against.

Once splenocytes are isolated from the mammal, the B cells are fused with immortalized

myeloma cells - which lack the HGPRT (hypoxanthine-guanine phosphoribosyltransferase)

gene - using polyethylene glycol or the Sendai virus. Fused cells are incubated in the HAT

(Hypoxanthine Aminopetrin Thymidine) medium. Aminopterin in the myeloma cells die, as

they cannot produce nucleotides by the de novo or salvage medium blocks the pathway that

allows for nucleotide synthesis. Hence, unfused D cell die. Unfused B cells die as they have a

short life span. Only the B cell-myeloma hybrids survive, since the HGPRT gene coming

from the B cells is functional. These cells produce antibodies (a property of B cells) and are

immortal (a property of myeloma cells).[2]

The incubated medium is then diluted into

multiwell plates to such an extent that each well contains only 1 cell. Then the supernatant in

each well can be checked for desired antibody. Since the antibodies in a well are produced by

the same B cell, they will be directed towards the same epitope and are known as monoclonal

antibodies.[3]

Once a hybridoma colony is established, it will continually grow in culture

medium like RPMI-1640 (with antibiotics and foetal bovine serum) and produce antibody

(Nelson et al., 2000.)[3]

The next stage is a rapid primary screening process, which identifies

and selects only those hybridomas that produce antibodies of appropriate specificity. The

hybridoma culture supernatant, secondary enzyme labelled conjugate and chromogenic

substrate, is then incubated and the formation of a colored product indicates a positive

hybridoma. Alternatively, immunocytochemical screening can also be used (Nelson et al.,

2000.) Multiwell plates are used initially to grow the hybridomas and after selection, are

changed to larger tissue culture flasks. This maintains the well being of the hybridomas and

provides enough cells for cryopreservation and supernatant for subsequent investigations.

The culture supernatant can yield 1to 60 ug/ml of monoclonal antibody, which is maintained

at 20°C or lower until required (Nelson et al., 2000.) By using culture supernatant or a

purified immunoglobulin preparation, further analysis of a potential monoclonal antibody

producing hybridoma can be made in terms of reactivity, specificity and crossreactivity

(Nelson et al., 2000.).

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(1) Immunisation of a mouse

(2) Isolation of B cells from the spleen

(3) Cultivation of myeloma cells

(4) Fusion of myeloma and B cells

(5) Separation of cell lines

(6) Screening of suitable cell lines

(7) in vitro (a) or in vivo

(b) multiplication

(8) Harvesting

Advancements OR Improvements in Hybridoma Technology

Considerable efforts during the last 10-15 years have been made to improve the yield of

monoclonal antibodies using hybridoma technology.[4,5]

These efforts included the

following:[6,7]

(1) The substitution of a chemical fusion promoter (P.E.G.) for the Sendai virus

initially used to promote fusion and (2) The use of myelomas that do not secrete their own

antibodies and that therefore do not interfere with the production of the required antibody (3)

A continuous cell line (Sp 2/0) was used as a fusion partner for the antibody producing B

cells. (4) Feeder layers consisting of extra cells to feed newly formed hybridomas were used

for optimal growth and hybridoma production. The most common feeder layers consisted

of[6,7]

murine peritoneal cells, marcrophages derived from mouse, rat or guinea pig extra

non immunized spleen cells, human fibroblasts, human peripheral blood monocytes or

thymus cells; these feeder cells had some limitations like depletion of nutrients meant for

hybridoma and contamination, so that other sources of hybridoma growth factors (HGF) like

interleukin-6 (II-6) derived from human cells were used.

Purification of Antibodies Monoclonal antibodies may need to be purified before they are

used for a variety of purposes. Before final purification, the cultures may be subjected to cell

fractionation for enrichment of the antibody protein. In E. coli, the antibodies may be

secreted in the periplasm, which may be used for enrichment of antibody, so that further

purification is simplified. Alternatively the antibodies may be purified from cell homogenate

or cell debris obtained from the medium.[6,7]

Antibodies can be purified by anyone of the

following techniques (I) ion-exchange chromatography; (ii) antigen affinity chromatography.

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Serum Free Media for Bulk Culture of Hybridoma Cells – The media for culturing a variety

of animal cells and discussed the significance of adding serum to basal nutrient media. Serum

is a highly complex and poorly defined mixture of components like albumin, transferrin,

lipoproteins and various hormones/growth factors. Nevertheless, serum makes an essential

component of media for culturing animal cells. The use of serum, however, leads to

difficulties in purification of antibodies. Furthers, it is an expensive technology for large scale

production of hybridoma cells for industrial production of monoclonal antibodies. In view of

these difficulties, serum free media are being increasingly used for culturing hybridoma

cells.[6,7]

Advantages of Serum Free Media in HybridomaCell Culture and Preparation of

Monoclonal Antibodies:[6,7]

1. Greatly simplified purification of antibodies due to increased

1.initial purity and absence of contaminating immunoglobulin. 2. Decreased variability of

culture medium. 3. Reduced risk of infectious agents. 4. Fewer variables for quality

control/quality assurance. 5. Increased control over bioreactor conditions. 6. Potential for

increased antibody secretion. 7. Low or no dependence on animals. 8. Cost effective. 9.

Overall enhanced efficiency.

Disadvantages of Serum Free Media in Hybridoma Cell Culture and Preparation of

Monoclonal Antibodies- 1. Not all serum free media are applicable to all cell lines. 2. Cells

may not grow to as high densities and may be more fragile than cells in serum 3. Media may

take longer to prepare. Bypassing Hybridomas and Cloning of mab Genes – The VH and VL

genes for antibodies can be amplified through polymerase chain reaction (PCR) using

'universal primers' (universal primers will carry conserved sequences for most antibodies). By

building restriction sites in the above primers, the amplified VH and VL genes can also be

cloned directly for expression in mammalian cells or bacteria. The raw material for PCR may

be hybridomas or B cells, which may be homogeneous (if derived from single cells) or

heterogeneous. In the latter case, a variety of VH and VL genes will be amplified and will

combine at random to produce as many as 106 clones for antibody genes (from 1000 different

VH and 1000 different VL genes). These genes will be cloned in a phage and their products

(particularly Fab fragments) can be screened for antigen binding activities. From such a large

number of combinations in a combatorial library, it is very difficult to recover the original

pairs of V genes (e.g. VHa.VLa or VHx.VLx is an original pair: VLy is a new combination

VHa). However, the complexity may be reduced by using antigen-selected B lymphocytes

(filters coated with antigen can be used for screening).[7]

Designing and Building of mab

Genes – The antigen binding sites of antibodies have been studied in some detail in recent

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years. This led to modelling of entirely new antibodies, sometimes for their use as enzymes.

This modelling through computer graphics can be used for alteration of antibody genes or for

synthesis of entirely genes. These genes can be cloned and expressed in bacteria. The

antibodies produced can be tested for their specificity and affinity for specific antigen.[7]

Primary and Secondary Libraries for Antibody Genes – In this method a repertoire of

antibody genes can be prepared by using genes that can be obtained from a number of

different sources including the following (i) Rearranged V genes from animals obtained

through the use of PCR (with universal primers) (ii) New V genes obtained through gene

conversion, a process adopted in birds (iii) Rearranged genes obtained from mRNA through

reverse transcription (iv) Designing entirely new V genes or D segments. The next step is to

allow the expression of library in bacteria and screen antibodies for antigen binding activities.

Thescreening can be done on membrane filters coated with antigen. In future, the screening

procedures may be replaced by methods of selection. In either case the selected VH and VL

genes can be subjected to mutations to increase the affinity of an antibody for a specific

antigen. A variety of methods for the above strategy are being developed, so that in future

monoclonal antibodies will be produced without hybridomas and lymphocytes gens.[6,7]

DIAGNOSTIC TESTS

Once monoclonal antibodies for a given substance have been produced, they can be used to

detect the presence of this substance. The Western blot test and immuno dot blottests detect

the protein on a membrane. They are also very useful in immunohistochemistry, which detect

antigen in fixed tissue sections and immunofluorescence test, which detect the substance in a

frozen tissue section or in live cells.[8,9]

ANALYTIC AND CHEMICAL USES

Antibodies can also be used to purify their target compounds from mixtures, using the

method of immunoprecipitation.

List of therapeutic, Diagnostic and Preventive Monoclonal Antibodies

Antibodies that are clones of a single parent cell. When used as drugs, the International

Nonproprietary Names (INNs) end in -mab. The remaining syllables of the INNs, as well as

the column Source, are explained in Nomenclature of monoclonal antibodies.[9,10,11]

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Types of monoclonal antibodies with other structures than naturally occurring

antibodies.

The abbreviations in the column Type are as follows:

mab: whole monoclonal antibody

Fab: fragment, antigen-binding (one arm)

F(ab')2: fragment, antigen-binding, including hinge region (both arms)

Fab': fragment, antigen-binding, including hinge region (one arm)

Variable fragments:

scFv: single-chain variable fragment

di-scFv: dimeric single-chain variable fragment

sdAb: single-domain antibody

Bispecific monoclonal antibodies:

3funct: trifunctional antibody

BiTE: bi-specific T-cell engager

THERAPEUTIC TREATMENT

Monoclonal antibody therapy is a form of immunotherapy that uses monoclonal

antibodies (mAb) to bind monospecifically to certaincells or proteins. This may then

stimulate the patient's immune system to attack those cells. Alternatively,

in radioimmunotherapy a radioactive dose localizes on a target cell line, delivering lethal

chemical doses.[11]

More recently antibodies have been used to bind to molecules involved

in T-cell regulation to remove inhibitory pathways that block T-cell responses, known as

immune checkpoint therapy.[12]

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It is possible to create a mAb specific to almost any extracellular/ cell surface target.

Research and development is underway to create antibodies for diseases (such as rheumatoid

arthritis, multiple sclerosis, Alzheimer's disease, Ebola[13]

and different types of cancers).

Each antibody binds only one specific antigen.

Immunoglobulin G (IgG) antibodies are large heterodimeric molecules, approximately

150 kDa and are composed of two kinds of polypeptide chain, called the heavy (~50kDa) and

the light chain (~25kDa). The two types of light chains are kappa (κ) and lambda (λ). By

cleavage with enzyme papain, the Fab (fragment-antigen binding) part can be separated from

the Fc (fragment constant) part of the molecule. The Fab fragments contain the variable

domains, which consist of three antibody hypervariable amino aciddomains responsible for

the antibody specificity embedded into constant regions. The four known IgG subclasses are

involved in antibody-dependent cellular cytotoxicity.[14]

STRUCTURE OF ANTIBODY AND ANTIGEN

The immune system responds to the environmental factors it encounters on the basis of

discrimination between "self" and "non-self". Tumor cells are generally not specifically

targeted by the immune system, since tumor cells are the patient's own cells. Tumor cells,

however are highly abnormal and many display unusual antigens.

Some such antigens are inappropriate for the cell type or its environment. Some normally

present only during the organisms' development (e.g. fetal antigens).[4]

Some are rare

or absent in healthy cells and are responsible for activating cellular signal

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transduction pathways that cause unregulated tumor growth. Examples include ErbB2, a

constitutively active cell surface receptor that is produced at abnormally high levels on the

surface of approximately 30% of breast cancer tumor cells. Such breast cancer is known

as HER2-positive breast cancer.[5]

Antibodies are a key component of the adaptive immune response, playing a central role in

both in the recognition of foreign antigens and the stimulation of an immune response to

them. The advent of monoclonal antibody technology has made it possible to raise antibodies

against specific antigens presented on the surfaces of tumors.[15-17]

USES OF MONOCLONAL ANTIBODIES

Cancer

Anti-cancer monoclonal antibodies can be targeted against malignant cells by several

mechanisms. Ramucirumab is a recombinant human monoclonal antibody and is used in the

treatment of advanced malignancies.[18]

Radioimmunotherapy

Radioimmunotherapy (RIT) involves the use of radioactively-conjugated murine antibodies

against cellular antigens. Most research involves their application to lymphomas, as these are

highly radio-sensitive malignancies. To limit radiation exposure, murine antibodies were

chosen, as their high immunogenicity promotes rapid tumor clearance. Tositumomab is an

example used for non-Hodgkins lymphoma.

Antibody-directed enzyme prodrug therapy

Antibody-directed enzyme prodrug therapy (ADEPT) involves the application of cancer-

associated monoclonal antibodies that are linked to a drug-activating enzyme. Systemic

administration of a non-toxic agent results in the antibody's conversion to a toxic drug,

resulting in a cytotoxic effect that can be targeted at malignant cells. The clinical success of

ADEPT treatments is limited.[19]

Immunoliposome therapy

Immunoliposomes are antibody-conjugated liposomes. Liposomes can carry drugs or

therapeutic nucleotides and when conjugated with monoclonal antibodies, may be directed

against malignant cells. Immunoliposomes have been successfully used in vivo to convey

tumour-suppressing genes into tumours, using an antibody fragment against the

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human transferrin receptor. Tissue-specific gene delivery using immunoliposomes has been

achieved in brain and breast cancer tissue.[20]

Checkpoint therapy

Checkpoint therapy uses antibodies and other techniques to circumvent the defenses that

tumors use to suppress the immune system. Each defense is known as a checkpoint.

Compound therapies combine antibodies to suppress multiple defensive layers. Known

checkpoints include CTLA-4 targeted by ipilimumab, PD-1 targeted by nivolumab and

pembrolizumab and the tumor microenvironment.[21]

The tumor microenvironment (TME) features prevents the recruitment of T cells to the

tumor. Ways include chemokine CCL2 nitration, which traps T cells in the stroma. Tumor

vasculature helps tumors preferentially recruit other immune cells over T cells, in part

through endothelial cell (EC)–specific expression of FasL, ETBR and B7H3.

Myelomonocytic and tumor cells can up-regulate expression of PD-L1, partly driven by

hypoxic conditions and cytokine production, such as IFNβ. Aberrant metabolite production in

the TME, such as the pathway regulation by IDO, can affect T cell functions directly and

indirectly via cells such as Treg cells. CD8 cells can be suppressed by B cells regulation of

TAM phenotypes. Cancer-associated fibroblasts (CAFs) have multiple TME functions, in

part through extracellular matrix (ECM)–mediated T cell trapping andCXCL12-regulated T

cell exclusion.[21]

Autoimmune diseases

Monoclonal antibodies used for autoimmune diseases include infliximab and adalimumab,

which are effective in rheumatoid arthritis, Crohn's disease and ulcerative Colitis by their

ability to bind to and inhibit TNF-α.[22]

Basiliximab and daclizumab inhibit IL-2 on

activated T cells and thereby help preventing acute rejection of kidney transplants.[22]

Omalizumab inhibits human immunoglobulin E (IgE) and is useful in moderate-to-severe

allergic asthma.

TNF INHIBITORS OF MONOCLONAL ANTIBODIES

A TNF inhibitor is a pharmaceutical drug that suppresses the physiologic response to tumor

necrosis factor (TNF), which is part of the inflammatory response. TNF is involved in

autoimmune and immune-mediated disorders such as rheumatoid arthritis, ankylosing

spondylitis, inflammatory bowel disease, psoriasis, hidradenitis suppurativa and

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refractory asthma, so TNF inhibitors may be used in their treatment. The important side

effects of TNF inhibitors include lymphomas, infections (especially reactivation of

latenttuberculosis), congestive heart failure, demyelinating disease, a lupus-like syndrome,

induction of auto-antibodies, injection site reactions and systemic side effects.[1]

Tumor

necrosis factor-α (TNF-α) is a cytokine central to many aspects of the inflammatory response.

Macrophages, mast cells and activated TH cells (especially TH1 cells) secrete TNF-α. TNF-α

stimulates macrophages to produce cytotoxic metabolites, thereby increasing phagocytic

killing activity.[23-25]

TNF-α has been implicated in numerous autoimmune diseases. Rheumatoid arthritis,

psoriasis and Crohn’s disease are three disorders in which inhibition of TNF-α has

demonstrated therapeutic efficacy. Rheumatoid arthritis illustrates the central role of TNF-α

in the pathophysiology of autoimmune diseases. Although the initial stimulus for joint

inflammation is still debated, it is thought that macrophages in a diseased joint secrete TNF-

α, which activates endothelial cells, other monocytes and synovial fibroblasts. Activated

endothelial cells up-regulate adhesion molecule expression, resulting in recruitment of

inflammatory cells to the joint. Monocyte activation has a positive feedback effect on T-cell

and synovial fibroblast activation. Activated synovial fibroblasts secrete interleukins, which

recruit additional inflammatory cells. With time, the synovium hypertrophies and forms a

pannus that leads to destruction of bone and cartilage in the joint, causing the characteristic

deformity and pain of rheumatoid arthritis.[26,27]

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Anti TNF agents molecular characteristics

Etanercept (Enbrel): Soluble TNF receptor fusion protein. As you can see in the image,

etanercept molecule consists of 2 extracellular domains of human soluble TNF receptor p75

that binds to TNF and a Fc fragment of human IgG that serves as a stabilizer.

Infliximab (Remicade): chimeric human-mouse anti-TNF alpha. This drug is 25% murinal

(mouse) derived and 75% human. The binding epitope for TNF is of murine origin while the

IgG fragment is of human origin.

Adalimumab (HUMIRA- Human Monoclonal Antibody in Rheumatoid Arthritis-): fully

human anti-tumor necrosis factor alpha monoclonal antibody produced by phage-display

technology.

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Potential mechanisms of action of the TNF-α blockers in immune-mediated

inflammatorydiseases.

MAC: Macrophage; sTNF: Soluble TNF-α; T: T cell; TCD: CD4+ T cell; tmTNF:

Transmembrane TNF-α; Treg: T regulatory cell.

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SIDE EFFECTS OF TNF-α MONOCLONAL ANTIBODIES

Rheumatoid arthritis

The role of TNF as a key player in the development of rheumatoid arthritis was originally

demonstrated by Kollias and colleagues in proof of principle studies in transgenic animal

models.[28,29,30]

Clinical application of anti-TNF drugs in rheumatoid arthritis was demonstrated by Marc

Feldmann and Ravinder N. Maini, who won the 2003 Lasker Award for their work.[31]

Anti-

TNF compounds help eliminate abnormal B cell activity.[17][18]

Skin disease

Clinical trials regarding the effectiveness of these drugs on hidradenitis suppurativa are

ongoing.[31]

The National Institute of Clinical Excellence (NICE) has issued guidelines for the treatment

of severe psoriasis using the anti-TNF drugs etanercept (Enbrel) and adalimumab (Humira) as

well as the anti-IL12/23 biological treatment ustekinumab (Stelara). In cases where more

conventional systemic treatments such as psoralen combined with ultraviolet A treatment

(PUVA), methotrexate and ciclosporin have failed or can not be tolerated, these newer

biological agents may be prescribed. Infliximab (Remicade) may be used to treat severe

plaque psoriasis if aforementioned treatments fail or can not be tolerated.[32]

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Cancer

The U.S. Food and Drug Administration continues to receive reports of a rare cancer of white

blood cells (known as Hepatosplenic T-Cell Lymphoma or HSTCL), primarily in adolescents

and young adults being treated for Crohn’s disease and ulcerative colitis with TNF blockers,

as well as with azathioprine and/or mercaptopurine.[33]

Opportunistic infections

TNF inhibitors put patients at increased risk of certain opportunistic infections. The FDA has

warned about the risk of infection from two bacterial pathogens, Legionella and Listeria.

People taking TNF blockers are at increased risk for developing serious infections that may

lead to hospitalization or death due to certain bacterial, mycobacterial, fungal, viral and

parasitic opportunistic pathogens.[34]

Tuberculosis

In patients with latent Mycobacterium tuberculosis infection, active tuberculosis (TB) may

develop soon after the initiation of treatment with infliximab.[35]

Before prescribing a TNF

inhibitor, physicians should screen patients for latent tuberculosis. The anti-TNF monoclonal

antibody biologics infliximab, golimumab, certolizumab and adalimumab and the fusion

protein etanercept, which are all currently approved by the FDA for human use, have

warnings which state that patients should be evaluated for latent TB infection, and if it is

detected, preventive treatment should be initiated prior to starting therapy with these

medications. dealy the wound healing also may not cause TB.

Fungal infections

The FDA issued a warning on September 4, 2008, that patients on TNF inhibitors are at

increased risk of opportunistic fungal infections such as pulmonary and disseminated

histoplasmosis, coccidioidomycosis, and blastomycosis. They encourage clinicians to

consider empiric antifungal therapy in certain circumstances to all patients at risk until the

pathogen is identified.[36]

CONCLUSION

These antibodies targeted the variable region gene products of T-cell receptors that were

involved in autoimmune disease. It is remarkable that a limited heterogeneity of T-cell

receptors is responsible for autoimmune conditions. However, in certain instances the T-

cell receptor repertoire is more diverse and may require a cocktail of monoclonal antibody

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reagents. Other approaches to treatment of autoimmune disease based on targeting the

variable region of the T-cell receptor involve active molecular vaccination.

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