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Thromb Haemost 2017; 117(01): 33-43
DOI: 10.1160/TH16-05-0404
Coagulation and Fibrinolysis
Schattauer GmbH

Combination therapy for inhibitor reversal in haemophilia A using monoclonal anti-CD20 and rapamycin

Moanaro Biswas   *
1   University of Florida, Department of Pediatrics, Division of Cellular and Molecular Therapy, Gainesville, Florida, USA
,
Geoffrey L. Rogers   *
1   University of Florida, Department of Pediatrics, Division of Cellular and Molecular Therapy, Gainesville, Florida, USA
,
Alexandra Sherman
1   University of Florida, Department of Pediatrics, Division of Cellular and Molecular Therapy, Gainesville, Florida, USA
,
Barry J. Byrne
1   University of Florida, Department of Pediatrics, Division of Cellular and Molecular Therapy, Gainesville, Florida, USA
,
David M. Markusic
1   University of Florida, Department of Pediatrics, Division of Cellular and Molecular Therapy, Gainesville, Florida, USA
,
Haiyan Jiang
2   Biogen, Cambridge, Massachusetts, USA
,
Roland W. Herzog
1   University of Florida, Department of Pediatrics, Division of Cellular and Molecular Therapy, Gainesville, Florida, USA
› Author Affiliations Financial support: This work was supported by a sponsored research agreement with Biogen and by NIH grant R01 AI51390 (to RWH).
Further Information

Publication History

Received: 25 May 2016

Accepted after major revision: 12 September 2016

Publication Date:
01 December 2017 (online)

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Summary

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.

Supplementary Material to this article is available at www.thrombosis-online.com.

Keywords

Anti-mCD20 - factor VIII - haemophilia - inhibitor - rapamycin

* These authors contributed equally to this work.


 

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