Inflammation , antiinflammatory products

1. Inflammation,antiinflammatoryproducts Prof. Dr. Borvendég János

2. Main topics of the presentation: • What does it mean inflammation? • Synthtetic ( traditional) drugs with antiinflammatory actions. ( NSAIDs) • Biological products with antiinflammatory actions / synthetic moleculs with tyrosine kinase inhibiting effects. Biosimilar products.

3. Inflammation

4. Biological function of inflammation • Inflammation (Latin, inflammatio) is part of thecomplexbiologicalresponseof body tissuestoharmfulstimuli, suchaspathogens, damagedcells, orirritants . • Itsprotectiveresponseinvolvingimmunecells, bloodvessels, and molecularmediators. • The function of inflammationis toeliminatetheinitialcause of cellinjury, clear out necroticcells and tissuesdamagedfromtheoriginalinsultandtheinflammatoryprocess, andtoinitiatetissuerepair.

5. The classical signs of inflammation: • calor, dolor, rubor, tumor (heat, pain, redness and swelling) and loss of function. • Inflammation is a generic response,  innate immunity, as compared to  adaptive immunity, which is specific for each patogen.

6. Too little/too much inflammation: • Too little inflammation : may lead to progressive tissue destruction by the harmful stimulus In contrast, • chronic inflammation may lead to a host of diseases, such as hay fever, periodontitis, atherosclerosis, rheumatoid arthritis, and even cancer (e.g., gallbladder carcinoma). • Inflammation is therefore normally closely regulated by the body.

7. Phases of inflammation: • Acute phasesmediators of inflammation: histamine, serotonin, bradikinine, prostaglandins, leukotriens • Chronic phase mediators of inflammation : Interleukins 1,2,3 , TNF alpha , Interferon, PDFG( platelet derived grows factor)

8. The outcome of inflammation can be: • beneficial( defence activity of the organism) or • deleterious (Chronic inflammation may lead to serious tissue destruction).

9. Key factors in the process of inflammation: • lysosomal enzymes, (breaks down biomolecules,including peptides, nucleic acids, carbohydrates, and lipids). • prostaglandins ( produced by COX 1, and COX 2 enzymes), • leukotriens ( produced by lipoxigenase enzyme) • cytokines, hydroxyl radicals

10. Therapeutic strategies • relief of pain, • reducing the inflammation • slowing or arrest the tissue damage • helptherepearmechanism.

11. Anti inflammatory agents Classical products • NSAIDS ( Nonsteroidal anti-inflammatory drugs) • Glycocorticoids ( prednizolone, dexamethasone,triamcinolonetc.) • DMARDS ( Disease modifying anti rheumatic Drugs) like MTX( methotrexat), Chloroquine,Sulfasalazine.

12. New antiinflammatory agents. • Biological products:-Anti TNF alfa drugs, Etanercept, Infliximab , Adalimumab etc.-IL (Interleukin inhibitors : IL-1,IL-6, IL-12,IL-17,IL-23 etc). • Tyrosine kinase inhibitors ( JAK)

13. NSAIDS ( Nonsteroid Anti-inflammatory Agents): • Therapeutic effects: anti-inflammatory analgesic antipyretic platelet effect • Other effects of anti-inflammatory agents:Inhibits leukocyte migration, decreases oxygen radical production inhibit lymphocyte function • Side effects: gastrointstinal haemorrhage, upper GI bleeding, intolerance , vomiting tinnitus,

14. Mechanism of action of NSAIDs • Cyclooxygenase (COX), officiallyknownasprostaglandin-endoperoxidesynthase (PTGS), is an enzyme (specifically, a family of isozymes, that is responsibleforformation of prostanoids, includingthromboxane and prostaglandinssuchasprostacyclin. • There are two isozymes of COX encoded by distinct gene products: a constitutiveCOX-1and an inducibleCOX-2,ensymewhich differ in their regulation of expression and tissue distribution. .

15. Selevtive COX-2 inhibitors ? •  The impetus for development of selective COX-2 inhibitors was the adverse gastrointestinal side effects of nonselective NSAIDs. •  After a short time, it became evident that there was a fivefold higher risk of myocardial infarction in the rofecoxib (selective COX2 inhib.) group compared to the group that received naproxen

16. NSAID drugs • Products: aspirin diclofenac naproxen, ibuprofen, meloxicam, piroxicam, sulindac indometacin etc.COX 2 selective : Celecoxib, Rofecocib ( withdrown) • Chemical structures: acetyl salicylic acid propionic acid derivatives, phenylpropionic acid , iodole derivatives naphthylpropionic acid oxicams

17. Tyrosine kinase inhibitors. • Protein kinases mediate protein phosphorylation, which is a fundamental component of cell signalling, with crucial roles in most signal transduction cascades: from controlling cell growth and proliferation to the initiation and regulation of immunological responses. • Janus kinase (JAK), mitogen-activated protein kinase (MAPK) and spleen tyrosine kinase (Syk) inhibitors. JAK3 expression, as well as STAT-4, -5 and -6 expression, was increased in the synovium of patients with RA, This finding was confirmed in other studies, leading to selective inhibition of JAK kinases becoming a therapeutic strategy for the treatment of RA, as well as other inflammatory-mediated diseases

18. Registered tyrosin kinase inhibitor: • TofacitinibJAK3 , JAK2 , JAK1 inhibitor (Pfizer ) syntheticsmallmoleculfororalteatment. • FDA-approved (November 2012). EMA( 2016) • Indications: RheumatoidarthritisPsoriasisInflammaroryBowelDiseases • To date, the US FDA has approved about 30small-molecule kinase inhibitors, halfof which were approved in the past 5years. 

19. Baricitinib JAK1/JAK2 inhibitor (EliLilly) • EMA-approved 2017.syntheticsmallmoleculfororalteatment.ofpatients with moderate to severe rheumatoid arthritis when standard treatment with disease-modifying anti-rheumatic drugs has not worked well enough or if patients cannot tolerate them.

20. Biological medicinal products

21. Biologicalmedicinalproducts(EMA definition) Medicinalproductscontainingbiotechnology-derivedproteinsasactivesubstance, immunologicalssuchasvaccines, blood-derivedproducts, monoclonalantibodies, etc.

22. The significance of biologicalproducts (BP) • The majority of BP-s is important medicine, • The price of the innovator BP-s is extremely high, • To curb the healthcare spending is in the interest of the society and also of the insurance agencies • The potential for BP manufacturers is great (currently $US 30 bn annual sales in the US)

23. Major kinds of biopharmaceuticals: Importantendogenesligands of theorganism: Bloodfactors (Factor VIII and IX) Tissueplasminogenactivator (thrombolyticagens) Hormones: insulin, growthhormone, gonadotropins (FSH) Haematopoieticfactors: erythropoitin, colonystimulatingfactors

24. Major kinds of biopharmaceuticals: Monoclonal antibodies (mab) blocking the activities of: Tu. Necrosis Factor (TNFalfa), Interferons, Interleukins (ILs), enzymes Additional products (therapeutic enzymes, vaccins ,etc.)

25. Biopharmaceuticals ProducedbyrecombinantDNA technic: 1.) Substances ≈ identicaltothe body’s ownkeysignallingproteins. (e.g. insulin, growthhormone) 2.) Monoclonalantibodies (toblockthefunction of anygivensubstance, enzymes, specificcelltypes) 3.) Receptor constructs (fusionproteins) (receptor linked to immunglobulin)

26. Production of biologicalproducts:

27. Possibledifferencesinthemanufacturingprocess:

28. Main indications of the biological products today • Chronic inflammatory diseases: • Rheumatoid Arthritis, ostheoarthritis, spondylarthritis, chronic inflammatory boweldiseases Psoriasis. • Other incations for diseases in: oncology, haematology endocrinology, neurology

29. Biologicalmedicinesforthetreatment of inflammatoryconditions etanercepthuman fusion protein → TNFα (Enbrel) antagonist • RheumatoidArthitis (RA) •ankylosingspondylitis • psoriasis adalimumabmab→ TNFα (Humira) • RA •ankylosingspondylitis • Crohn’s disease (chronicbowelinflammation) •psoriasis

30. Biologicalmedicinesforthetreatment of inflammatoryconditions Infliximabchimericmab → TNFα (Remicade) • RA •ankylosingspondylitis • Crohn’s disease •psoriasis

31. Biologicalmedicinesforthetreatment of inflammatoryconditions rituximabchimericmab → CD20 protein or B cells (Rituxan) • RA tocilizumabhumanisedmab→ IL-6 (Actemra) • RA anakinra→ blocks IL-1 („mastercytokine”) (Kinaret) abatacept → blocksthefunction of a type of white (Orencia) bloodcell (Tcells)

32. Biologicalproductsinoncology trastuzumab(Herceptin) → HER 2 breastcc. rituximab (MabThera) → anti-CD20 ab B-cellmalignancies (lymphoma) bevacizumab→ VEGF angiogenesis inhibitor

33. Biopharmaceuticalsaredifferentfromtraditionalmedicines: • Complexmanufacturingprocess • Highmolecularweight • Complex 3-D sturcture • Difficulttocharacterize • Instability -*- • Immunogenicity

34. Factorswhichmaychangethestructure of theproteins: Chemically: oxidation deamidation disulfide shuffling racemisation Physically: unfolding misfolding aggregation precipitation fragmentation

35. The complexity of the BP which has a great impact of characterising physicochemically/biologically of their structure/properties • BP have different levels of complexity • The methods and extent of analytical studies must have the ability to characterize in depth the BP in question • The complexity and extent at the subsequent level (pharm. tox. clinical) should be determined on case by base basis, taking account the results gained from the initial physicochemical/biological analysis.

36. Factorswhichmayinfluencetheimmunogenicity of biologicalproducts: Non-product related factors: underlying disease genetic background immun status co-medications Product related factors: source of proteins protein structure glycosilation impurity stability (degradation products) aggregation formulation/excipiens Application related factors: route of administration dose-dose internal duration of treatment

37. Types of reproduced drugs: • Generic products ( bioequivalent dugs) • Biosimilar products

38. What is a genericmedicine? - containsthesameactivesubstance of samequalityasthereferencemedicine, but - itsappearance (color/shape), - theinactiveingredients (excipients), - themanufacturingprocesscan be different, but - theinnovator and thegenericproduct must be bioequivalent (in PK parameters: AUC, Cmax) - efficacy / safetyhaveto be equal.

39. Generic drugs • They are equivalent with the original product in: • chemical structures, • bioequivalent in: • Pharmaco-kinetic properties, • Pharmacodynamic, and • Therapeutic effiects and in safety ( advers reactions)

40. BiosimilarProduct:(EMA definition) Biosimilar, orsimilarbiologicalmedicalproduct is „a newbiologicalproductsimilartoa licenced reference (biological) medicinalproduct”. US/FDA: „follow-on protein product”

41. Biosimilarity: - A biologicalmedicine is biosimilarto a referencebiologicalmedicineifsimilarin: - quality - efficacy - safety- Biosimilar and referencebiologicalmedicinesaresimilarbutnotidentical

42. SimilarBiologicalMedicinalProduct (SBMP) Basic principles: - SPMP-s are not generic productsThe „standard generic approach” is not acceptable due to the complexity of biological/biotechnology-derived aproducts. - „Similar biological approach” depends on the state of art of analytical procedures.

43. SimilarBiologicalMedicinalProduct (SBMP) Basic principles (cont.): They regulatory requirements are guided (on case by case basic) by the: - extent of the physicochemical/biological characterisation of the product, - nature or possible changes in the quality/structure of the biological product due the changes in the manufacturing process (and their unexpected outcomes) - clinical/regulatory experiences with the particular class of the product in question

44. Clinicalstudieswithbiosimilarproducts: • Requirements depend on- type/properties of the SBMP- data gained from physicochemical and preclinical analyses- therapeutic indication • Stepwise procedure- PK- PD- Therapeutic equivalence studies

45. Consequencies of immuneresponse: • Safety (allergy, anaphylaxis) • Efficacy:- loss (due to neutralising antibodies)- enhancement • Activity of endogenous (similar) proteins- loss (neutralisation) • PK clearance:- increase- decrease -*- Extent and significance of immune responseto clinical efficacy/safety!?

46. The most important patent expirations: somatropin recombinant insulin erythropoetin G-CSF tPA IL-2 IFN-alfa 2b IFN-gamma-1b Streptokinase - * - rituximab trastuzumab

47. Is it simple to make a biosimilar?

48. Are these animals biosimilar?

49. Are these animalsbiosimilar?

50. Hurdlesinthefastergrowth of biosimilar market • Biosimilarsarespecificproducts • Regulationsfor marketing approvalaremuchstricterthanthoseforconventionalgenerics • The requiredcapitalinvestment and cost of manufacturingaremuchhigherforbiosimilars and theprobability of succesfullaunch is lowerthanthoseforchemical-basedgenerics