T N Medical College,

B Y L Nair Hospital, Mumbai

Department of
Pharmacology

Seminar Topic
Monoclonal Antibodies
Presented By
Dr. Jayesh U Patil
What are
The antibodies are gamma globulins, (called
immunoglobulins ) these are the products of differentiated
B cells and mediate the humoral arm of the immune
response. The primary functions of antibodies are to bind
specifically to antigen and bring about the inactivation or
removal of the offending toxin, microbe, parasite, or other
foreign substance from the body

Antibody
Polyclonal Monoclonal
Derived from different B
Lymphocytes cell lines
(recognize multiple epitopes
on single antigen)
Derived from a single B cell
clone (recognize one epitope
on single antigen)

Batch to Batch variation
affecting Ab reactivity & titer
mab offer Reproducible,
Predictable & Potentially
inexhaustible supply of Ab
with exquisite specificity
NOT Powerful tools for clinical
diagnostic tests

Enable the development of
secure immunoassay systems.

Inexpensive, low skills &
Technology required
Expensive , requires high
degree of skills & Technology
Different Ig Classes
Structure of Antibody
Dimer of Heavy & light chain

H & L chains joined by
disulphide bonds

Each chain has Variable &
Constant regions.

Variable region: Binds Antigen
(Complementary Determining
Region)(HYPERVARIABLE)

Constant Region: Effector
Function ( Interaction with
leucocytes, complement
binding)
How does an antibody act?
ADCC
Antibody-dependent
cell-mediated
cytotoxicity)


CDC
Complement Dependent
Cytotoxicity


Activation of apoptosis
Armed Antibodies
Radioimmunoconjugates
ADEPT
Immunotoxin
Immunocytokine
Immunoliposome
Cellular Immunoconjugate
Bispescific MABs


What are the of
Monoclonal Antibodies?
Murine
Chimeric
Humanized
Human
Genetically Engineered
Types of Monoclonal Antibodies
Genetically Engineered
Pharmacokinetics
Routes: IV , IM, SC ,
Inhalational (oral?)
Half life of IgG1,2,4 : 21 days
(IgA, IgD, IgE, and IgM)
have a shorter half-life 2.5
to 6 days
The half-life of mAbs :
murine (1.5 days)
chimeric (10 days)
humanized (12 to 20
days)
fully human (15 to 20
days)


Distribution :
mostly intravascular
Tissues /blood ratio : 0.1
to 1

Transport across
membranes
Classical endocytosis
(clathrin mediated)
Specific receptor
mediated

Metabolism/Elimination

Normal protein
catabolism
(lysosomal &
Proteosomal
degradation
Protective FcRn
Target mediated
elimination (
Human anti-Mouse
Antibodies(HAMA)
Renal/Hepatic
elimination

Adverse Drug Reactions

of
Stem & Sub stem
Example : AB-CI-XI-MAB
Here
Mab : Stem : Antibody/ fragment
Xi : Sub stem for Origin/Source
Ci : Sub Stem for Target

-a- rat
-e- hamster
-i- primate
-o- mouse
-u- human
-xi-
chimeric
(human/foreign)
-zu- humanized
-xizu-*
chimeric/humanized
hybrid
-axo-
rat/mouse hybrid

Sub stem: Origin/ Source
Sub Stem for Target
Old prefix New Meaning
-os- -s(o)- bone
-toxa- -tox(a)- toxin
-co(l)-
-t(u)-
colonic tumor
-go(t)- testicular tumor
-go(v)- ovarian tumor
-ma(r)-
mammary
tumor
-me(l)- melanoma
-pr(o)- prostate tumor
-tu(m)-
miscellaneous
tumor
-vi(r)- -v(i)- virus
Old prefix New Meaning
-Anibi-
Angiogenesis
Inhibitor
ba(c)-
-
b(a)-
bacterium
-ci(r)- -c(i)- circulatory system
-fung- -f(u)- fungus
-ki(n)- -k(i)- interleukin
-les-
inflammatory
lesions
-li(m)- -l(i)- immune system
-mul-
musculoskeletal
system
-ne(u)(r)- -n(e)- nervous system
Importance

Market has grown
exponentially

The Big 5 antibodies
in US market are
Infliximab
Bevacizumab
Trastuzumab
Adalimumab
Rituximab

Top 4 Mab producing
companies
Roche
Genetech
J& J
Abott




Indian Scenario
Biocon was the first Indian pharma company to start production of
MAB in India( Biomab EGFR/ Nimotuzumab)

Dr reddys, Serum Institute of India, Intas Biopharmac ,Bharat
Serum & Vaccines , Aresthagen also have production units in india

Production of Biosimilar agents

Most of the MABs are imported.
3F8
Abagovomab[1]
Abciximab
Adalimumab
Adecatumumab
Afelimomab
Afutuzumab[3]
Alacizumab pegol[
ALD518[5]
Alemtuzuma
b
Altumomab pentetate
Anatumomab
mafenatox
Anrukinzumab[4] (=
IMA-638)[7]
Apolizumab[8]
Arcitumomab
Aselizumab[9]
Atlizumab (=
tocilizumab)
Atorolimumab
Bapineuzumab[10]
Basiliximab
Bavituximab[1]
Bectumomab
Belimumab
Benralizumab
Bertilimumab[9]
Besilesomab
Bevacizumab[6]
Biciromab
Bivatuzumab
mertansine
Blinatumomab
Brentuximab
vedotin[12]
Briakinumab[13]
Canakinumab[14]
Cantuzumab
mertansine
Capromab pendetide
Catumaxomab[10]
CC49
Cedelizumab
Certolizumab
pegol[2]
Cetuximab
Citatuzumab
bogatox[3]
Cixutumumab
Clenoliximab
Clivatuzumab
tetraxetan[15]
Conatumumab[3]
CR6261
Dacetuzumab[4]
Daclizumab
Daratumumab[16]
Denosumab[17]
Detumomab
Dorlimomab
aritox[18]
Dorlixizumab
Ecromeximab[8]
Eculizumab[8]
Edobacomab
Edrecolomab
Efalizumab[19]
Efungumab[1]
Elotuzumab
Elsilimomab
Enlimomab pegol[20]
Epitumomab
cituxetan[21]
Epratuzumab
Erlizumab[22]
Ertumaxomab[10]
Etaracizumab
Exbivirumab[23]
Fanolesomab[24]
Faralimomab
Farletuzumab
Felvizumab
Fezakinumab[25][26][
27]
Figitumumab
Fontolizumab[8]
Foravirumab[3]
Fresolimumab[28]
Galiximab
Gantenerumab[14]
Gavilimomab[22]
Gemtuzumab
ozogamicin
Girentuximab[16]
Glembatumumab
vedotin[30][31]
Golimumab[23]
Gomiliximab
Ibalizumab[14]
Ibritumomab
tiuxetan
Igovomab
Imciromab
Infliximab
Intetumumab[32][33][
34]
Inolimomab
Inotuzumab
ozogamicin[11]
Ipilimumab[17]
Iratumumab[17]
Keliximab
Labetuzumab[19]
Lebrikizumab[35]
Lemalesomab[22]
Lerdelimumab[6]
Lexatumumab[1]
Libivirumab[23]
Lintuzumab
Lorvotuzumab
mertansine
Lucatumumab[4]
Lumiliximab[2]
Mapatumumab[10]
Maslimomab
Matuzumab[9]
Mepolizumab
Metelimumab[24]
Milatuzumab[4]
Minretumomab
Mitumomab
Morolimumab
Motavizumab[1]
Muromonab-
CD3
Nacolomab tafenatox
Naptumomab
estafenatox[36]
Natalizumab
Nebacumab
Necitumumab[37]
Nerelimomab
Nimotuzumab[17][38]
Nofetumomab
merpentan
Ocrelizumab[17]
Odulimomab
Ofatumumab[10]
Olaratumab
Omalizumab[22]
Oportuzumab
monatox[37]
Oregovomab[24]
Otelixizumab[4]
Pagibaximab[10]
Palivizumab
Panitumumab[23
]
Panobacumab[37]
Pascolizumab[8]
Pemtumomab
Pertuzumab
Pexelizumab[19]
Pintumomab
Priliximab
Pritumumab
PRO 140
Rafivirumab[3]
Ramucirumab
Ranibizumab[2]
Raxibacumab[11]
Regavirumab
Reslizumab[19]
Rilotumumab[39]
Rituximab
Robatumumab
Rontalizumab[40]
Rovelizumab
Ruplizumab[6]
Satumomab
pendetide
Sevirumab
Sibrotuzumab
Sifalimumab[41]
Siltuximab
Siplizumab[8]
Solanezumab[37]
Sonepcizumab[42]
Sontuzumab[38]
Stamulumab[17][38]
Sulesomab
Tacatuzumab
tetraxetan
Tadocizumab[38]
Talizumab
Tanezumab[3]
Taplitumomab
paptox[22]
Tefibazumab[11]
Telimomab aritox
Tenatumomab[4]
Teneliximab[8]
Teplizumab[14]
TGN1412
Ticilimumab (=
tremelimumab)
Tigatuzumab[4]
TNX-650
Tocilizumab[2] (=
atlizumab)
Toralizumab[8]
Tositumomab
Trastuzumab
Tremelimumab
Tucotuzumab
celmoleukin[17][38]
Tuvirumab
Urtoxazumab[2]
Ustekinumab[3]
Vapaliximab[8]
Vedolizumab
Veltuzumab[4]
Vepalimomab
Visilizumab[22]
Volociximab[10]
Votumumab
Zalutumumab[10]
Zanolimumab[2]
Ziralimumab[22]
Zolimomab aritox
TOCILIZUMAB
OFATUMUMAB
BEVACIZUMAB
BELIMUMAB
TOSITUMOMAB
ALEMTUZUMAB
ARCITUMOMAB
CERTOLIZUMAB PEGOL
CETUXIMAB
TRASTUZUMAB
ADALIMUMAB
CANAKINUMAB
RANIBIZUMAB
GEMTUZUMAB
OZOGAMICIN
IMCIROMAB
DENOSUMAB
CAPROMAB INFLIXIMAB
ABCIXIMAB
RITUXIMAB
GOLIMUMAB
BASILIXIMAB
ECULIZUMAB
USTEKINUMAB
PALIVIZUMAB
FANOLESOMAB;
NEUTROSPEC
NATALIZUMAB
PANITUMUMAB
NOFETUMOMAB
DENOSUMAB
OMALIZUMAB
IPILIMUMAB
DACLIZUMAB
IBRITUMOMAB
TIUXETAN
Cost Issues
Drug Company Form Cost
Infliximab Remicade
Vial
10 mg x 1's 41,039 INR
Rituximab Dr. Reddys REDITUX vial 100 mg x 10 mL x 1's 9,999 INR
500 mg x 50 mL x 1's 39,996 INR

Roche MABTHERA
vial
100 mg x 10 mL x 1's 16,000 INR
500 mg x 50 mL x 1's 76,000 INR

Trastuzumab Roche HERCEPTIN
vial
440 mg x 50 mL x 1's 1,24,000 INR
Cetuximab Merck ERBITUX vial 5 mg x 1 mL x 100ml 87,920 INR
5 mg x 1 mL x 20ml 18,465 INR
Bevacizumab Roche Avastin Vial 25 mg /mL x 4ml 28,000 INR

Production of MABs
Hybridoma Technology

Phage Display ( Bacterial display ,
Yeast Display, Ribosomal Display)

Transgenic Mice Hybridoma
Hybridoma Technology
Fusion of antibody producing
murine splenocytes with
immortal myeloma cells

Selection of appropriate cells
with HAT medium

Selection of specific clone with
high affinity and specificity

Immortal clone used to
produce MURINE antibodies

Phage Display
VHVL genes fused with
gene coding tail protein
of phage.

Antibodies are
DISPLAYED on phage
surface

Affinity maturation &
selection of appropriate
phage

E. Coli infected with the
phage

VHVL production

Modification of VHVL
chains to form antibody
Transgenic Mice

Murine Immunoglobulin
gene knocked and
replaced by Human
Immunoglobulin gene.

Antibodies formed are
HUMAN
Purification
Cells, cell debris, lipids, and
clotted material are first
removed, typically by filtration
with a 0.45 um filter.

Chromatography

Trastuzumab
(Herceptin)
humanized mAb directed against the extracellular
domain of human epidermal growth factor receptor 2,
HER2

Use: Ca Breast ( Patients with HER2/neu-amplified
tumors)

ADRs:

Infusion reaction
Cardiotoxicity (Before initializing therapy, baseline
electrocardiogram and cardiac ejection fraction measurement
should be obtained)





Anti EGFR, Chimeric (Human, Mouse)

Uses:
Head & Neck Cancer
Colorectal Ca

Adverse Effects:
Acneform Rash
Diarrhea
Cardiopulmonary Arrest
Interstitial Lung Disease
Hypomagnesaemia
Anaphylactoid Reaction
Cetuximab
Chimeric Anti CD20

Use :

non-Hodgkin's lymphomas (NHLs), including
Diffuse large B-cell lymphoma
CLL,
mantle cell lymphoma,
Waldenstrm macroglobulinemia,
marginal zone lymphomas
Thrombotic thrombocytopenic purpura,
Autoimmune hemolytic anemias,
cryoglobulin-induced renal disease
multiple sclerosis
Rituximab
Rituximab Toxicity:
Infusion reaction
Possible Tumor lysis syndrome
severe mucocutaneous skin reactions
Reactivation of hepatitis B virus or rarely, JC
virus (with progressive multifocal
leukoencephalopathy)

Hypogammaglobulinemia and autoimmune
syndromes (idiopathic thrombocytopenic
purpura, thrombotic thrombocytopenic
purpura, autoimmune hemolytic anemia,
pure red cell aplasia, and delayed
neutropenia)
Fully humanized IgG
2
antibody
Binds specifically to the
extracellular domain of EGFR.

Therapeutic Uses
Metastatic colorectal carcinoma

Adverse Effects
Rash and dermatological toxicity
Severe infusion reactions
Pulmonary fibrosis
Electrolyte abnormalities
Panitumumab
Alemtuzumab
Humanized IgG- monoclonal antibody.
binds to CD52 antigen


Uses

B- and T-cell low-grade lymphomas

CLL



Toxicity
Acute infusion reaction
Myelosuppression
Risk of fungal, viral, and other
opportunistic infections (Listeria)
Binds to CD20 at site distinct from the site targeted by rituximab.

Theraputic Uses:
CLL after failure of fludarabine and alemtuzumab.

Toxicities:
Immunosuppression and opportunistic infection
Hypersensitivity reactions during antibody infusion, and
Myelosuppression, which may be prolonged.
Reactivation of viral infections, leading to progressive
multifocal leukoencephalopathy or hepatitis B progression.

Ofatumumab
Gemtuzumab Ozogamicin
Humanized monoclonal antibody
against CD33

Covalently linked to a semisynthetic
derivative of calicheamicin, a potent
enediyne antitumor antibiotic.


Use: AML

Adverse Effects:
Myelosuppression
Hepatocellular damage
Hyperbilirubinemia and
enzyme elevations
Bevacizumab
Anti VEGF-A
Fully Humanized

ADRs
Infusion reaction
Bleeding(hemoptysis) ,HTN,
Poor wound healing, GI Perforation
Thromboembolic Event (stroke, MI)
Nephrotic Syndrome
Posterior Leukoencephelopathy



Uses
Renal cell Ca (Clear cell Type)
Colorectal Ca
Glioblastoma Multiforme
Non Small cell Lung Ca
Metastatic Breast Ca
Age Related Macular Degeneration
Deafness in NF2
Ranibizumab
Anti VEGF-A
Fc fragment removed

Used in : Wet Age Related
Macular Degeneration
Fully human antibody that binds to
CTLA-4 (cytotoxic T lymphocyte-
associated antigen 4)

Used to Treat patients with late-
stage melanoma that has spread or
cannot be removed by surgery
Ipilimumab
Monoclonal Antibodies
used in
Anti TNF Agents
effects on endothelial cells
(1) increased secretion of prostacyclin, which, in turn, favors
increased blood flow by causing local vasodilation
(2) increased expression of P-E-selectins, adhesion molecules
that promote attachment of the passing lymphocytes and
monocytes
(3) induction and secretion of chemokines such as IL-8.
Together, all these changes in the endothelium facilitate the
extravasation of lymphocytes and monocytes at the site of
the delayed hypersensitivity reaction
Other effects
Activation of fibroblasts ( increase synthesis of matrix
metalloproteinases and IL1,IL8 secreation)
Recruitment of T cells through IL1 (secreted by
macrophages)
TNF-lpha
Infliximab
Human-mouse chimeric IgG
1

monoclonal antibody

Use:
Crohn's disease,
Ulcerative colitis,
Rheumatoid arthritis,
Ankylosing spondylitis, and
Psoriatic arthritis
Adalimumab
Anti-TNF
This Recombinant human
IgG
1

Use:
Rheumatoid arthritis
Ankylosing spondylitis
Crohn's disease
juvenile idiopathic arthritis
plaque psoriasis
psoriatic arthritis
Certolizumab
pegol


Humanized
FAB
fragment
Anti TNF Crohn's disease ,
Rheumatoid arthritis


Golimumab


Human Anti TNF once monthly subcutaneous
treatment for adults with
moderately to severely active
rheumatoid arthritis,
psoriatic arthritis, and
ankylosing spondylitis
Toxicities of Anti TNF
agents
Increased risk of serious infections. (tuberculosis)
Increase the risk of lymphoma and possibly other
malignancies.
Can also induce the development of anti-DNA
antibodies
Infusion or injection site reactions
Demyelinating central nervous system disease.
Muromonab(OKT-3)
Mouse IgG2 against CD3 antigen
first mAb approved for clinical use in humans
Suppressing, enhancing, or redirecting T-cell responses to
antigens

USE: Treatment of acute organ transplant rejection

Toxicity
cytokine release syndrome
Aseptic meningitis
Pulmonary edema,
Acute respiratory distress syndrome,
Cardiovascular collapse, cardiac arrest, and arrhythmia
Skin reactions
infections and neoplasms associated with immunosuppressive
"Rebound" rejection




Eculizumab
Humanized IgG
Binds the C5 complement component, inhibiting its
cleavage into C5a and C5b thereby inhibiting the
terminal pore-forming lytic activity of complement.

Use : Paroxysmal nocturnal hemoglobinuria (PNH)
ADRs: Increased risk of meningococcal infection
Natalizumab
Natalizumab is Humanized monoclonal antibody against 4-integrin (also known as VLA-4).
Binding of the antibody to this adhesion molecule will reduce extravasation of certain leukocytes (e.g.,
lymphocytes), preventing them from migrating to sites of inflammation where they may exacerbate tissue
injury.

Use : Crohn's disease.
Multiple Sclerosis
Increased risk of progressive multifocal leukoencephalopathy (PML).
Drug Type Target Approved Use
TOCILIZUMAB humanized
monoclonal antibody


against the
interleukin-6 receptor
(IL-6R)



Castleman's disease

Rheumatoid arthritis


Belimumab


Human

BLyS (or B-lymphocyte
stimulator)

SLE
Rheumatoid Arthritis

Basiliximab

chimeric mouse-
human monoclonal
antibody

chain (CD25) of the
IL-2 receptor




prevent rejection in organ
transplantation, especially in
kidney transplants


Daclizumab


humanized
monoclonal antibody



alpha subunit of the
IL-2 receptor of T cells



prevent rejection in organ
transplantation, especially in
kidney transplants


Ustekinumab


human monoclonal
antibody



against interleukin 12
and interleukin 23



severe plaque psoriasis
multiple sclerosis and sarcoidosis

Monoclonal Antibodies used in

Drug Possible use
Efungumab
(Fungus)
invasive Candida
infection in
combination with
amphotericin B
Exbivirumab Hepatitis
Foravirimab Prophylaxis of
Rabies
Libivirumab Hepatitis B
Rafivirumab prophylaxis of
rabies
Regavirumab infections with
cytomegalovirus
Sevirumab infections with
cytomegalovirus in
patients with AIDS
Tuvirumab Hepatitis B
Felvizumab respiratory
syncytial virus
Drug Possible Use
Motavizumab respiratory
syncytial virus
Palivizumab respiratory
syncytial virus
Nebacumab Sepsis
Panobacumab against
Pseudomonas
aeruginosa
Raxibacumab Prophylaxis against
Anthrax
Edobacomab Sepsis due to Gram
-ve Bacteria
Pagibaximab Staphylococcal
Sepsis
Tefibazumab Severe
Staphylococcal
infections, MRSA
Utoxazumab Diarrhoea due to E
coli O121
Palivizumab
Prevents entry of RSV into respiratory epithelium
Blocks protein involved in the fusion
Thus prevents occurrence of infection

Use : in high risk neonates
(premature babies, infants with congenital heart
disease , pulmonary HTN, Chronic lung disease
requiring oxygen, cystic fibrosis , Immunodeficiency
states)
Drug Type Target Radioisotope Use
Arcitumomab
murine
F(ab')
fragment
anti-
carcinoembr
yonic antigen
(CEA)
antibody
technetium 99m
(99mTc)

imaging patients with
metastatic colorectal
carcinoma
(immunoscintigraphy)
Ibritumomab
tiuxetan
murine anti-CD20

isotopic yttrium
(90Y) or 111In
follicular, or
B-cell non-Hodgkin's
lymphoma
Tositomomab
anti-D20

iodine 131
(131I)
CD20-positive, follicular
non-Hodgkin's
lymphoma
Capromab
Pendetide
murine

Anti prostate
specific
membrane
antigen

indium (111In)

immunoscintigraphy for
patients with biopsy-
confirmed prostate
cancer
Nofetumomab
Murine 40 KD tumor
protein

99m Tc
to stage patients with
small cell lung cancer

fanolesomab
Murine CD15
technetium-99m
(
99m
Tc).

diagnosis of appendicitis
Abciximab (REOPRO) is the Fab fragment of a humanized
monoclonal antibody directed against the
IIb3
receptor.

Use:
Patients undergoing percutaneous angioplasty for
coronary thromboses

Adverse Effects:
Bleeding (GI Bleed)
Thrombocytopenia
Allergic reactions
Abciximab
Omalizumab
Humanized monoclonal antibody
Blocks the binding of IgE to high-affinity IgE receptors
(FcR1) on mast cells and thus prevents their activation by
allergens. Omalizumab also reduces levels of circulating
IgE

administered by subcutaneous injection every 2-4 weeks

Clinical Use
Asthma prophylaxis
Allergic rhinitis
protection against anaphylaxis during specific
immunotherapy

ADRs:
anaphylactic response, which is uncommon (<0.1%)

Human antibody,
binds with RANKL,
Denosumab blocks osteoclast formation
and activation.
It increases BMD and decreases bone
turnover markers
Use: Osteoporosis

Denosumab
Genetically Engineered MABs
Bispescific
Two ScFvs , amino acid sequence coded from four different
genes on single peptide.
BiTEs form a link between T cells and tumor cells
One of the scFvs binds to T cells via the CD3 receptor, and the
other to a tumor cell via a tumor specific molecule

Blinatumomab (MT103): for the treatment of non-Hodgkins
lymphoma and acute lymphoblastic leukemia; directed
towards CD19, a surface molecule expressed on B cells.

MT110: for the treatment of gastrointestinal and lung cancers;
directed towards the EpCAM antigen
Bi-specific T-cell
engagers (BiTEs)
Has binding sites for two different antigens, typically CD3 and
a tumor antigen, making it a type of bispecific monoclonal
antibody. In addition, its intact Fc-part can bind to an Fc
receptor on accessory cells like conventional monospecific
antibodies.

Catumaxomab : (Fc, CD3, EpCAM)
The drug is approved (EMA) for the treatment of malignant
ascites in patients with EpCAM-positive cancer if a standard
therapy is not available

Ertumaxomab : (Fc,CD3, HER2/Neu)
In Phase II clinical trial evaluating the treatment of breast
cancer



Trifunctional antibody
Single-domain antibody
Consists of a single monomeric variable antibody domain(VH)
Relatively low molecular wt.(12-15 kDa Vs 120-150kDa)
better permeability in tissues

short plasma half-life since they are eliminated renally
they do not show complement system triggered cytotoxicity because they lack an Fc region
Possible oral administration.

Single-domain antibodies are being researched for multiple pharmaceutical applications
and have potential for use in the treatment of acute coronary syndrome, cancer and
Alzheimer's disease

ALX-0081
a single-domain antibody targeting von Willebrand factor is in clinical trials for the
prevention of thrombosis in patients with acute coronary syndrome
Have a nice day !