Combination therapy for inhibitor reversal in haemophilia A using monoclonal anti-CD20 and rapamycin.
Development of antibodies (inhibitors) against coagulation factor VIII (FVIII) is a major complication of intravenous replacement therapy in haemophilia A (HA). Current immune tolerance induction (ITI) regimens are not universally effective. Rituximab, a B cell-depleting antibody against CD20, has shown mixed results for inhibitor reversal in patients. This study aims to develop a combinatorial therapy for inhibitor reversal in HA, using anti-murine CD20 (anti-mCD20) antibody and rapamycin, which targets both B and T cell responses. Additionally, it extensively characterises the role of the IgG backbone in B cell depletion by anti-CD20 antibodies. For this, inhibitors were generated in BALB/c-HA mice by weekly IV injection of FVIII. Subsequently, anti-mCD20 (18B12) with IgG2a or IgG1 backbone was injected IV in two doses three weeks apart and B cell depletion and recovery was characterised. Rapamycin was administered orally 3x/week (for 1 month) while continuing FVIII injections. Altering the IgG backbone of anti-mCD20 from IgG2a to IgG1 reduced overall depletion of B cells (including memory B cells), and marginal zone, B-10, and B-1b cells were specifically unaffected. While neither antibody was effective alone, in combination with rapamycin, anti-mCD20 IgG2a but not IgG1 was able to reverse inhibitors in HA mice. This regimen was particularly effective for starting titres of ~10 BU. Although IgG1 anti-mCD20 spared potentially tolerogenic B cell subsets, IgG2a directed sustained hyporesponsiveness when administered in conjunction with rapamycin. This regimen represents a promising treatment for inhibitor reversal in HA, as both of these compounds have been extensively used in human patients.
Moanaro
M
Biswas
Geoffrey L
GL
Rogers
Alexandra
A
Sherman
Barry J
BJ
Byrne
David M
DM
Markusic
Haiyan
H
Jiang
Roland W. Herzog, PhD, University of Florida, Cancer and Genetics Research Complex, 2033 Mowry Road, Gainesville, FL 32610, USA, Tel.: +1 352 273 8113, Fax: +1 352 273 8342, E-mail: rherzog@ufl.edu.
Roland W
RW
Herzog
D000284:Administration, Oral; D019264:Adoptive Transfer / Q000379:methods; D000818:Animals; D000906:Antibodies / Q000097:blood*; D000911:Antibodies, Monoclonal / Q000008:administration & dosage*; D018951:Antigens, CD20 / Q000276:immunology*; D001402:B-Lymphocytes / Q000187:drug effects / Q000276:immunology; D003029:Coagulants / Q000008:administration & dosage / Q000276:immunology*; D004195:Disease Models, Animal; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005169:Factor VIII / Q000008:administration & dosage / Q000235:genetics / Q000276:immunology*; D006467:Hemophilia A / Q000097:blood / Q000188:drug therapy* / Q000235:genetics / Q000276:immunology; D007108:Immune Tolerance / Q000187:drug effects; D007074:Immunoglobulin G / Q000008:administration & dosage*; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D007275:Injections, Intravenous; D008297:Male; D008807:Mice, Inbred BALB C; D018345:Mice, Knockout; D020123:Sirolimus / Q000008:administration & dosage*; D050378:T-Lymphocytes, Regulatory / Q000276:immunology / Q000637:transplantation; D013997:Time Factors
D000906:Antibodies; D000911:Antibodies, Monoclonal; D018951:Antigens, CD20; D003029:Coagulants; D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; C078147:F8 protein, human; D005169:Factor VIII; D020123:Sirolimus
Anti-mCD20; factor VIII; haemophilia; inhibitor; rapamycin
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