Gastroenterology

Gastroenterology

Volume 157, Issue 5, November 2019, Pages 1338-1351.e8
Gastroenterology

Original Research
Full Report: Basic and Translational—Alimentary Tract
Infliximab–Tumor Necrosis Factor Complexes Elicit Formation of Anti-Drug Antibodies

https://doi.org/10.1053/j.gastro.2019.08.009Get rights and content

Background & Aims

Some patients develop anti-drug antibodies (ADAs), which reduce the efficacy of infliximab, a monoclonal antibody against tumor necrosis factor (TNF), in the treatment of immune-mediated diseases, including inflammatory bowel diseases. ADAs arise inconsistently, and it is not clear what factors determine their formation. We investigated features of the immune system, the infliximab antibody, and its complex with TNF that might contribute to ADA generation.

Methods

C57BL/6 mice were given injections of infliximab and recombinant human TNF or infliximab F(ab′)2 fragments. Blood samples were collected every 2–3 days for 2 weeks and weekly thereafter for up to 6 weeks; infliximab-TNF complexes and ADAs were measured by enzyme-linked immunosorbent assay (ELISA). Intestinal biopsy and blood samples were obtained from patients having endoscopy who had received infliximab therapy for inflammatory bowel diseases; infliximab-TNF complexes were measured with ELISA. Infliximab-specific plasma cells were detected in patient tissue samples by using mass cytometry. We studied activation of innate immune cells in peripheral blood mononuclear cells (PBMCs) from healthy donors incubated with infliximab or infliximab-TNF complexes; toll-like receptors (TLRs) were blocked with antibodies, endocytosis was blocked with the inhibitor PitStop2, and cytokine expression was measured by real-time polymerase chain reaction and ELISAs. Uptake of infliximab and infliximab-TNF complexes by THP-1 cells was measured with confocal microscopy.

Results

Mice given increasing doses of infliximab produced increasing levels of ADAs. Blood samples from mice given injections of human TNF and infliximab contained infliximab-TNF complexes; complex formation was associated with ADA formation with an area under the curve of 0.944 (95% confidence interval, 0.851–1.000; P = .003). Intestinal tissues from patients, but not blood samples, contained infliximab-TNF complexes and infliximab-specific plasma cells. Incubation of PBMCs with infliximab-TNF complexes resulted in a 4.74-fold increase in level of interleukin (IL) 1β (IL1B) messenger RNA (P for comparison = .005), increased IL1B protein secretion, and a 2.69-fold increase in the expression of TNF messenger RNA (P for comparison = 0.013) compared with control PBMCs. Infliximab reduced only IL1B and TNF expression. Antibodies against TLR2 or TLR4 did not block the increases in IL1B or TNF expression, but endocytosis was required. THP-1 cells endocytosed higher levels of infliximab-TNF complexes than infliximab alone.

Conclusions

In mice, we found ADA formation to increase with dose of infliximab given and concentration of infliximab-TNF complexes detected in blood. Based on studies of human intestinal tissues and blood samples, we propose that infliximab-TNF complexes formed in the intestine are endocytosed by and activate innate immune cells, which increase expression of IL1B and TNF and production of antibodies against the drug complex. It is therefore important to optimize the infliximab dose to a level that is effective but does not activate an innate immune response against the drug-TNF complex.

Section snippets

Mice

Female C57BL/6 mice (6–8 weeks, 17–20 g) were obtained from Harlen (Rehovot, Israel) and acclimatized for ≥1 week before experimentation. Mice were fed a standard pellet diet and provided with tap water ad libitum. Blood was drawn at baseline and used as a matching control for each mouse. Mice were injected with infliximab by the intraperitoneal (IP) route (followed by intravenous [IV] injection of hTNF in some experiments) at the indicated concentrations (note pharmacokinetics of IP vs IV

Effect of Infliximab Concentration on Immunogenicity

Four to 5 mice in each dosing group were injected with infliximab at baseline, and blood was drawn at regular intervals.

Discussion

Our results suggest that local intestinal immune activation by infliximab-TNF complexes, differentially formed under different drug/target ratios, instigates intestinal production of ADA in an Fc-independent manner. This process involves endocytosis and more effective infliximab-TNF complex uptake compared with infliximab only by antigen-presenting cells, which thereafter secrete proinflammatory cytokines.

ADA production during the time course of infliximab treatment occurs in approximately 50%

Acknowledgments

Author contributions: Guarantor of article: Haggai Bar-Yoseph. Specific author contributions: Haggai Bar-Yoseph, Sigal Pressman, Alexandra Blatt, Shiran Gerassy, and Naama Maimon performed the study. Haggai Bar-Yoseph, Sigal Pressman, Shomron Ben-Horin, and Yehuda Chowers conceived the study. Haggai Bar-Yoseph, Sigal Pressman, and Yehuda Chowers wrote the paper. Haggai Bar-Yoseph, Sigal Pressman, Alexandra Blatt, Shiran Gerassy, Naama Maimon, Elina Starosvetsky, Bella Ungar, Shomron Ben-Horin,

References (38)

  • F. Baert et al.

    Influence of immunogenicity on the long-term efficacy of infliximab in Crohn’s disease

    N Engl J Med

    (2003)
  • M.A. Ainsworth et al.

    Tumor necrosis factor-alpha binding capacity and anti-infliximab antibodies measured by fluid-phase radioimmunoassays as predictors of clinical efficacy of infliximab in Crohn’s disease

    Am J Gastroenterol

    (2008)
  • E. Louis et al.

    A positive response to infliximab in Crohn disease: association with a higher systemic inflammation before treatment but not with -308 TNF gene polymorphism

    Scand J Gastroenterol

    (2002)
  • B. Ungar et al.

    The temporal evolution of antidrug antibodies in patients with inflammatory bowel disease treated with infliximab

    Gut

    (2014)
  • S. Vermeire et al.

    Effectiveness of concomitant immunosuppressive therapy in suppressing the formation of antibodies to infliximab in Crohn’s disease

    Gut

    (2007)
  • E. Ducourau et al.

    Antibodies toward infliximab are associated with low infliximab concentration at treatment initiation and poor infliximab maintenance in rheumatic diseases

    Arthritis Res Ther

    (2011)
  • C. Steenholdt et al.

    Clinical implications of variations in anti-infliximab antibody levels in patients with inflammatory bowel disease

    Inflamm Bowel Dis

    (2012)
  • U.S. Department of Health and Human Services, Food and Drug Administration Center for Drug Evaluation and Research (CDER), Pharmacology and Toxicology. Guidance for industry estimating the maximum safe starting dose in initial clinical trials for therapeutics in adult healthy volunteers pharmacology and toxicology guidance for industry estimating the maximum safe starting dose in initial clinical trials for therapeutics in adult healthy volunteers

    (2005)
  • U. Kopylov et al.

    Clinical utility of antihuman lambda chain-based enzyme-linked immunosorbent assay (ELISA) versus double antigen ELISA for the detection of anti-infliximab antibodies

    Inflamm Bowel Dis

    (2012)
  • Cited by (24)

    • Oral delivery of infliximab using nano-in-microparticles for the treatment of inflammatory bowel disease

      2021, Carbohydrate Polymers
      Citation Excerpt :

      Taking these into consideration, oral targeted administration of anti-TNF-α antibodies seems a promising alternative to systemic treatment. However, most studies about IFX are given by intravenously until now (Bar-Yoseph et al., 2019; Bezzio et al., 2021 & Zhang et al., 2017). So, it is urgent and necessary to develop an oral delivery system for IFX and estimate the efficacy of oral administration of IFX in treating IBD.

    • Randomized Controlled Trial: Subcutaneous vs Intravenous Infliximab CT-P13 Maintenance in Inflammatory Bowel Disease

      2021, Gastroenterology
      Citation Excerpt :

      Similar immunogenicity was also observed with SC- and IV-administered vedolizumab in the VISIBLE 1 study.33 Various explanations are possible, including high zone tolerance, designating immune tolerance induced by high concentrations of the antigen (here the monoclonal antibody) and/or favorable drug–TNF ratios leading to reduced immune complex formation and diminished ADA generation.34–36 Nevertheless, our findings suggest that switching from CT-P13 IV to CT-P13 SC during maintenance therapy does not result in increased immunogenicity relative to continuing maintenance therapy with CT-P13 SC.

    View all citing articles on Scopus

    Conflicts of interest These authors disclose the following: Shomron Ben-Horin received consulting and advisory board fees and/or research support from AbbVie, MSD, Janssen, Takeda, Pfizer, GSK, and CellTrion. Yehuda Chowers received consulting fees from AbbVie, Janssen, Takeda, Pfizer, Eli Lilli, Medtronics, Neopharm, Protalix; speaker fees from AbbVie, Janssen, and Takeda; and grants from AbbVie and Takeda. Bella Ungar has received consultation/lecture fees from Takeda, AbbVie, Jannsen, and Neopharm. The remaining authors disclose no conflicts.

    Funding This study was supported by a generous grant from the Leona M. and Harry B. Helmsley Charitable Trust.

    Authors share co-first authorship.

    View full text