Background: Tumour necrosis factor α (TNFα) neutralising antibody constructs are increasingly being used to treat rheumatoid arthritis (RA).
Objective: To determine potential differences in clinical responses, soluble drug levels and antibody formation between patients with RA receiving infliximab and adalimumab.
Methods: 69 patients with RA fulfilling the 1987 American College of Rheumatology criteria and about to start treatment with infliximab or adalimumab, were enrolled consecutively. All patients had active disease (28-joint count Disease Activity Score >3.2). Infliximab was given intravenously at 3 mg/kg at baseline and after 2, 6 and 14 weeks. Adalimumab was administered as 40 mg biweekly subcutaneously. Concomitant drug treatment was monitored and continued at constant dosage during the study. All serum samples were tested for infliximab/adalimumab levels and anti-infliximab/anti-adalimumab antibodies.
Results: 35 patients received infliximab, 34 received adalimumab. At 6 months, 15 (43%), 6 (17%) and 14 (40%) of the infliximab-treated patients fulfilled the EULAR criteria for good, moderate and non-responders, respectively, whereas the corresponding figures for adalimumab-treated patients were 16 (47%), 8 (24%) and 10 (29%). Clinical responses correlated with the levels of S-infliximab/adalimumab and the formation of anti-infliximab/anti-adalimumab antibodies.
Conclusion: The clinical response to two anti-TNFα biological agents closely follows the trough drug levels and the presence of antibodies directed against the drugs. Further studies that focus on the underlying pathways leading to antibody formation are warranted to predict immunogenicity of these expensive biological agents and treatment outcomes.
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Rheumatoid arthritis (RA) is an autoimmune condition characterised by joint inflammation and destruction. The development of protein therapeutics, of which tumour necrosis factor α (TNFα)-neutralising therapies currently provide the best example, has resulted in far better control of disease activity accompanied by decreased rate of joint damage and improvement of physical functions.1 2 3 4 5 Besides the TNFα receptor antagonist, etanercept, two monoclonal antibodies directed against TNFα itself have been developed. Infliximab, a chimeric (mouse–human) monoclonal antibody against TNFα, and adalimumab, a fully human antibody against TNFα have been proved to be efficacious and safe in several randomised, controlled clinical trials aimed at treating RA.3 5 6
Despite these advances, TNFα-neutralising therapies still fail to produce a response in a substantial proportion of patients with RA or they lose their initial response over time. Various studies have also demonstrated that intensification of treatment or switching to another TNFα-binding agent often improves the level of response,7 8 9 10 and the clinical importance of antibody formation against infliximab and adalimumab has therefore attracted attention. Recently, two groups have demonstrated that antibodies against infliximab correlate with trough levels of circulating infliximab and, subsequently, with response failure.11 12 13 14 15 16 These studies provide strong support for the value of individualised drug monitoring of infliximab treatment. Less is known about the occurrence of antibodies against adalimumab. Previous reports have suggested that antibodies against adalimumab are found in 12% of patients receiving monotherapy. However, contradictory results have been reported regarding the correlation between these antibodies and clinical response.17 A case report shows a relation between antibody formation, trough levels of adalimumab and response to treatment at least underlining the existence of such antibodies.12 18 More recently, Bartelds and colleagues demonstrated that anti-adalimumab antibodies are present in 34% of patients with RA not responding to adalimumab monotherapy, whereas these antibodies are present in only 5% of the good responders.11
Differences in antibody formation between patients treated with infliximab or adalimumab might provide information on the mechanisms involved and also improve our potential to design patient-specific treatment programmes. We therefore tested patients with RA receiving infliximab and adalimumab and showed that both groups form antibodies to the anti-TNFα drugs that are closely related to trough levels of the biological agents and to clinical response to treatment.
Materials and methods
Patient inclusion and exclusion criteria
Patients with RA, fulfilling the 1987 American College of Rheumatology criteria for RA and about to start treatment with infliximab were enrolled consecutively in this open, prospective observational study. All patients were cared for at the department of rheumatology at the Radboud University Nijmegen Medical Centre and Sint Maartenskliniek, Nijmegen, and all gave informed consent before inclusion; the local ethics committee approved this study. Patients were excluded from this study if they used disease-modifying antirheumatic drugs other than methotrexate (MTX), had another coinciding autoimmune disease, used high doses of glucocorticoids (>10 mg daily) or had severe infections. Treatment of the patients was in accordance with the consensus statement on the initiation and continuation of TNFα blocking therapy in RA.19
Before starting infliximab/adalimumab treatment all patients had evidence of active disease as indicated by a 28-joint count Disease Activity Score (DAS28,20) of >3.2 taking into account that monotherapy with at least two disease-modifying antirheumatic drugs, including MTX, 25 mg weekly, had failed. All patients were given intravenous infusions of 3 mg/kg infliximab at baseline, 2, 6 and 14 weeks. At week 14 the treating rheumatologist was allowed to increase the dosage of infliximab to 5 mg/kg in patients for whom treatment had produced an inadequate response. Thereafter, dosing intervals were kept stable at 8-week intervals. The patients with RA receiving adalimumab originated either from a clinical trial (Abbott DE018, n = 20) or our outpatient clinics (n = 14). All patients started with a dosing regimen of 40 mg biweekly subcutaneously (SC). Only for those patients not included in the clinical trial could the dosage be increased to 40 mg SC weekly when response to treatment was judged inadequate by the rheumatologist. During the study, concomitant medication was monitored, and non-steroidal anti-inflammatory drugs and MTX were continued at constant dosage. Fourteen of 20 adalimumab-treated patients with RA in the clinical trial were receiving adalimumab monotherapy.
Functional serum levels of infliximab/adalimumab
One hour before each infusion or SC injection, 10 ml serum was collected and stored at −80°C. All sera were tested under blinded conditions at BioMonitor A/S, Copenhagen, Denmark (http://www.biomonitor.dk, accessed 20 June 2009). Functional infliximab/adalimumab levels, measured as TNFα binding capacity of serum IgG, were obtained by a standardised procedure described previously.13 16 Briefly, 1% patient serum was incubated with 125I-TNFα (Perkin Elmer, Boston, Massachusetts, USA), and after separation of the tracer using rabbit anti-human Fcγ antibody (Dako, Glostrup, Denmark), the pellet activity was measured using a Wallac1470 automatic gamma counter. S-infliximab/adalimumab were assessed as the levels of infliximab (Schering-Plough, Farum, Denmark) and adalimumab (Abbott, Gentofte, Denmark), respectively, which in a pool of normal serum bound equivalent amounts of radiolabelled TNFα; the inter- and intra-assay variations were <20 and <10%, respectively.
Antibodies to infliximab/adalimumab
The fact that infliximab and adalimumab are IgG constructs consisting only of κ light chains makes it possible to use anti-human λ light-chain antibody to distinguish between free infliximab/adalimumab and infliximab/adalimumab in complex with any class of λ-containing human immunoglobulin.13 16 The assays were carried out in a blinded fashion at BioMonitor ApS using 1% serum with an added 4000 cpm/100 μl of 125I-infliximab and 125I-adalimumab, respectively. After incubation, free and immunoglobulin-bound (any isotype) tracer were separated by affinity chromatography using small columns of matrix-bound anti-human immunoglobulin λ-chain antibody (Dako) (fig 1). The data are given as percentage bound cpm/total cpm added; the backgrounds were 3%, and the inter- and intra-assay variations were <20 and <10%, respectively. Interference by rheumatoid factor was tested by cross titrations with five known RF-positive sera without anti-infliximab or anti-adalimumab antibodies. None of these influenced the antibody measurements.
Descriptive statistics were provided using mean (SD). The disease activity between groups (independent samples) and between study start and study end (paired samples) was compared using a Student t test or paired t test, respectively. Non-normally distributed data were analysed using the Mann–Whitney U test (independent samples) and the Wilcoxon signed-ranks test (paired samples). Associations between δ DAS and S-drug levels and/or presence/absence of antibodies were quantified by Pearson’s correlation, and the corresponding p values were calculated.
Characteristics of patient groups
A total of 69 patients entered the study, of whom 35 were treated with infliximab and 34 with adalimumab. At baseline no differences were apparent between the patient groups (table 1).
The majority of patients were women with mean age of disease onset of 57 years. About 71% were rheumatoid factor positive, which is similar to other recently published reports on TNFα-neutralising therapies.11 12 14 Infliximab in all cases was given at a dose of 3 mg/kg at baseline and after 2, 6 and 14 weeks. After this initiation regimen, infliximab was administered at 8-week intervals, which was continued throughout the study in all but one case that was increased to 5 mg/kg because of moderate response. The 8-week interval was shortened to 6 weeks in six cases: one of them was a moderate responder at 12 weeks (responder at 6 months), two were moderate responders at 3 and 6 months and three were non-responders throughout the whole study. Ten of 35 patients receiving infliximab used low-dose prednisolone varying between 5 mg and 10 mg daily. Although, there was a trend for more use of prednisolone in the non-responders (35%) and moderate responders (33%) compared with responders (20%), the mean levels of prednisolone per patient were comparable (data not shown).
Although all patients with RA who started treatment with adalimumab began with 40 mg every other week, only the patients not included in the clinical trial were allowed to increase the dose. From those 14 patients, five who were all moderate responders at 3 months, increased the dosage to 40 mg weekly upon which two of them evolved to good responders at 6 months. From the 20 patients included in the DE018 trial, six received MTX in a dose varying from 10 mg to 30 mg once weekly, the dose of which was kept stable during the trial. Nine out of 31 patients receiving adalimumab used low-dose prednisolone varying between 5 mg and 10 mg daily. A comparable trend for use of prednisolone was seen as in the patients receiving infliximab, being higher in the non-responders (50%) and moderate responders (43%) than in the responders (13%). Again, the mean levels of prednisolone between the groups were comparable (data not shown).
Clinical response and association with functional drug levels and antibodies against infliximab and adalimumab
Infliximab or adalimumab as well as antibodies against infliximab or adalimumab were undetectable in all patients at the start of treatment.
At 6 months, 43% of the infliximab-treated patients fulfilled the EULAR criteria for good responders, whereas 17% and 40% of the patients were moderate or non-responders (table 2).
Figure 2A and B show that all patients having a good response receiving infliximab had detectable drug levels after 3 (R = 0.54, p = 0.03) and 6 months. In the patients who were classified as moderate responders, only three patients had detectable levels of infliximab at 6 months, two of whom turned out to be good responders at 12 months (figs 2C and D) having a DAS28 of 3.2 and 3.1, respectively. In contrast, none of the patients who were classified as non-responders had detectable infliximab levels at 6 months, strongly suggesting that low trough levels of infliximab at 3 and 6 months predict treatment failure (figs 2E and F). This phenomenon is underlined by two patients who were responders at months 3, having high levels of S-infliximab but became non-responder at 6 months where infliximab levels were not detectable any more (figs 2E and F), all of which coincided with the formation of antibodies against infliximab at 3 months.
The formation of antibodies to infliximab was strongly associated with both response (R = 0.63, p = 0.008) to treatment and levels of soluble infliximab (R = 0.74, p = 0.01). For example, 14/15 (93%) patients who were good responders at 6 months had no detectable levels of anti-infliximab antibodies at that time, whereas 50% of the moderate responders had low levels (figs 3A and B). In contrast, all patients who were classified as non-responders at 6 months had detectable antibody formation either at low concentrations (7%), at moderate (36%) or high (57%) levels. With regard to the association between soluble levels of infliximab and anti-infliximab antibodies, none of the patients with detectable infliximab levels at any time point had circulating antibodies to the drug (fig 4). In contrast, in all but three patients with antibodies (regardless of level) soluble levels of infliximab were undetectable. In a total of six patients with RA classified as non-responders at 3 months, soluble infliximab levels were still detectable even though low levels of antibodies were measured. In all these cases, the levels of trough infliximab dropped below the level of detection and the anti-infliximab antibody levels rose to medium or high, suggesting that the absence of detectable levels of infliximab is accompanied by the formation of antibodies to the drug. The mean (SD) weekly dosage of MTX was 20.3 (3.5) mg, 20.8 (3.8) mg and 20.0 (3.4) mg for the responders, moderate responders and non-responders, respectively.
Of the patients who started treatment with adalimumab, 17 (50%) patients fulfilled the criteria for good response, whereas 7 (21%) and 10 (29%) were classified as moderate and non-responders at 3 months, respectively (table 2). As observed in patients receiving infliximab, the levels of soluble adalimumab were also associated with response to treatment (R = 0.64, p = 0.01) (fig 3). For instance, all responders and moderate responders had detectable levels of soluble adalimumab, which were higher in responders than in moderate responders (table 2). In contrast, non-response was clearly associated with undetectable (n = 9) or very low serum levels (n = 1) of adalimumab. In line with that seen in patients treated with infliximab, antibody formation against adalimumab also correlated with response to treatment (fig 4B). None of the responders had antibodies to adalimumab at 3 and 6 months (and thus circulating levels of drug). In sharp contrast, all non-responders had detectable antibodies against adalimumab both at 3 and 6 months. Interestingly and in contrast with the moderate responders treated with infliximab, where 20% and 30% already had circulating antibodies at 3 and 6 months, respectively, none of the adalimumab patients had detectable antibody levels. Of the patients who had a response to treatment at 3 months, seven (41%) originated from the DE018 trial as did five (71%) who were considered as moderate responders and eight (80%) non-responders. From those patients 42%, 40% and 13% concomitantly used MTX in the responder, moderate and non-responders, respectively.
Response failure due to generation of antibodies against biopharmaceutical agents is increasingly appreciated as one of the mechanisms of drug failure.21 Hitherto, dose- or dose frequency adjustments of anti-TNFα neutralising therapies owing to insufficient responses are a frequent necessity in patients with RA.22 23 For example, secondary response failure has been reported in patients receiving infliximab treatment.12 13 22 Furthermore, many patients with secondary response failure to one anti-TNFα drug benefit from a switch to other anti-TNFα drugs, suggesting a role of neutralising antibodies directed specifically against the protein used for treatment.24 25 26 Several studies have shown that secondary response failure is associated with low trough levels of anti-TNFα biological agents and development of antibodies against these drugs.11 12 13 14 27 Indeed, trough level assessments of anti-TNFα drugs and measurements of antibodies against these biological agents are among the measures that best predict the response of individual patients with RA.12 14 16 28 29 In the most recent report from Bartelds et al an anti-adalimumab antibody frequency of 34% in non-responders and 5% in good responders was found, an observation that closely resembles our results.11
Here we demonstrate that response to anti-TNFα antibodies, both infliximab and adalimumab, is closely related to the formation of antibodies to the constructs and, in turn, the trough levels of neutralising anti-anti-TNFα antibodies. Interestingly, patients treated with adalimumab demonstrated a 10% higher response rate than their counterparts treated with infliximab, which mirrored the percentage of patients who formed antibodies to the drug. The latter finding corroborate findings from two recent studies, which found comparable responses.30 31 32
An interesting observation from this study is that the moderate responders still have circulating levels of drug and do not have detectable levels of antibodies, which is especially remarkable in the patients treated with adalimumab. Several mechanisms may explain this phenomenon. At first, very small amounts of anti-TNF antibodies might be already present that cannot be detected by our assays. This is unlikely since the presence of very low concentrations of antibodies correlated well with measurable drug levels and clinical response in the non-responders. Finally, other mechanisms may cause the moderate response in these patients that are unconnected with response to the treatment itself. Perhaps, the patients with a very high baseline DAS28 represent a different RA phenotype that is simply not responsive or only moderately responsive to TNFα neutralising therapy.
We have shown that response to two anti-TNFα therapies closely follows the trough levels of the drugs and the presence of antibodies directed against the drugs. Additionally, we have provided a rationale for the recent observation that response to treatment with adalimumab is greater than that seen after treatment with infliximab. Further studies that focus on the underlying pathways leading to antibody formation are warranted since it would be helpful to predict response to anti-TNF therapies.
We are indebted to all the people from the Maartenskliniek who contributed to the collection and storage of the patient samples. We thank Dr W Kievit for his input on statistical analysis used throughout the study. We thank Mrs Pia Grothe Meinke and Marianna Thomsen at IIR, Rigshospitalet and BioMonitor A/S for excellent technical assistance.
Funding The study was partly funded by Abbott Immunology Inc, Chicago, USA.
Competing interests None.
Ethics approval Approval from the local ethics committee.
Abbott Inc did not have any influence on the set-up of the study, the interpretation of the data or the writing of the paper.