Dinutuximab

Dinutuximab
Monoclonal antibody
TypeWhole antibody
SourceChimeric (mouse/human)
TargetGD2
Names
Trade namesUnituxin, Isquette, Qarziba, others
Other namesDinutuximab beta, Ch14.18, APN-311
Clinical data
Main usesNeuroblastoma[1]
Side effectsPain, fever, infusion reaction, low platelets, low white blood cells, low potassium, capillary leak syndrome, liver problems[2]
WHO AWaReUnlinkedWikibase error: ⧼unlinkedwikibase-error-statements-entity-not-set⧽
Pregnancy
category
  • AU: C[3]
  • US: N (Not classified yet)[4]
    Routes of
    use    		Intravenous
    External links
    AHFS/Drugs.comMonograph
    MedlinePlusa615022
    Legal
    License data
    Legal status
    Chemical and physical data
    FormulaC6422H9982N1722O2008S48
    Molar mass144981.42 g·mol−1

    Dinutuximab, sold under the trade name Unituxin among others, is a medication used to treat neuroblastoma.[1] It is used for children at high-risk who are still having problems despite other treatments.[6] It is given by injection into a vein.[1]

    Common side effects include pain, fever, infusion reaction, low platelets, low white blood cells, low potassium, capillary leak syndrome, and liver problems.[2] Other side effects may include reversible posterior leukoencephalopathy syndrome, transverse myelitis, eye problems, and infection.[2] Use in pregnancy may harm the baby.[2] It is a monoclonal antibody that attaches to GD2, commonly found on neuroblastoma cells.[6] This binding causes the body's immune system to destroy them.[6]

    Dinutuximab was approved for medical use in the United States in 2015.[1] While it was also approved in Europe in 2015, it was subsequently withdrawn in 2017.[7] Dinutuximab beta; however, received approval in Europe in 2017.[6] In the United States 17.5 mg costs about 14,000 USD as of 2021.[8]

    Medical use

    Dinutuximab is used as post-consolidation therapy for children with high-risk neuroblastoma, in combination with granulocyte-macrophage colony-stimulating factor, interleukin-2, 13-cis-retinoic acid. It is given in patients who have completed induction therapy and consolidation therapy (autologous bone marrow transplant and external beam radiation therapy), as part of standard-of-care therapy for newly-diagnosed high-risk neuroblastoma. It is given by intravenous infusion, over ten to twenty hours, four days in a row.[2] It is also used second-line for relapsed/refractory neuroblastoma in combination with chemotherapy and GM-CSF.

    Dinutuximab beta is also used as a second line treatment for children with high-risk neuroblastoma; it was tested and is used with a longer and slower dosing regime, and is given on its own, although it may be combined with IL-2 if a stronger immune response is needed.[9]

    Morphine is administered prior to, during, and for two hours after infusion of dinutuximab and dinutuximab beta to manage the severe pain that this drug causes. An antihistamine and an anti-inflammatory are also given before, during, and after to manage the infusion reaction.[2][9]

    Women who are pregnant or who might become pregnant should not take dinutuximab or dinutuximab beta, because it is very likely to cause harm to a fetus.[2][9]

    They differ in that dinutuximab is manufactured using mouse cells, and dinutuximab beta is manufactured using hamster cells. The dosing regime differs, and dinutuximab is given in combination with granulocyte-macrophage colony stimulating factor (GM-CSF), interleukin-2 (IL-2) and 13-cis-retinoic acid (RA), while dinutuximab beta can be given alone.

    Dosage

    It is used at a dose of 17.5 mg/m2/day for 4 days in a row.[2]

    Side effects

    Dinutuximab carries black box warnings for life-threatening infusion reactions and neurotoxicity, as it causes severe neuropathic pain, and can cause severe sensory neuropathy and severe peripheral motor neuropathy.[2] Dinutuximab beta also has these adverse effects.[9]

    More than 25% of children taking these drugs experienced pain, fever, hives, vomiting, diarrhea, bone marrow suppression causing loss of platelets, red blood cells, white blood cells, and albumin, hypotension, electrolyte imbalance including low sodium, potassium, and calcium, elevated transaminases, infusion reactions, and capillary leak syndrome.[2][9]

    Other common adverse effects include retention or urine for weeks to months after receiving the drugs, protein in urine, blurred vision or dilated pupils, infections, edema, high blood pressure, bleeding that won't stop, tachycardia, and weight gain.[2][9]

    Pharmacology

    Dinutuximab and dinutuximab beta each work by binding to GD2, a glycolipid found on cells originating from the neuroectoderm during prenatal development, including neurons in the central nervous system and in the peripheral nervous system. Neuroblastoma cells have this as well. When dinutuximab binds to any cell that has GD2, that cell is destroyed via cell-mediated cytotoxicity and complement-dependent cytotoxicity.[2]

    In clinical trials of dinutuximab, the maximum plasma concentration was 11.5 mcg/mL; the mean steady state volume distribution was 5.4 L; the clearance rate was 0.21 L/day; and the average half-life was 10 days.[2]

    Chemistry

    Ch14.18 is a chimeric monoclonal antibody in which the variable heavy and light chain regions come from a mouse, with a human constant region for the heavy chain IgG1 and light chain kappa.[2][10]

    The version of dinutuximab made by United Therapeutics, and marketed under the brand name Unituxin, is manufactured via industrial fermentation using a murine myeloma cell line, SP2/0.[2] The version marketed by EUSA for Apeiron is called generically dinutuximab beta and is marketed under the brand name Isquette, and is manufactured in Chinese hamster ovary cells.[11][12]

    History

    Dinutuximab (originally called Ch14.18) was discovered by a group at University of California San Diego led by Alice Yu; this antibody and several others were brought into clinical trials funded by the National Cancer Institute.[10][13] The NCI manufactured the mAbs for the Phase III trial[13] of Ch14.18 in combination with GM-CSF and IL-2, which was halted due to clear efficacy; the results published in 2009.[14] No company had offered by that time to get FDA approval and commercialize the drug, so the NCI kept manufacturing it and making it available under compassionate use.[13] In 2010, the NCI signed an agreement with United Therapeutics under which the company took over manufacturing and would bring the drug to market.[13]

    In the meantime in Europe, oncologists and patient advocates wanted to have the drug available in Europe, and made efforts to obtain the cell line used to make it from United Therapeutics and the originating lab at the NCI itself; when those efforts failed they reached out to a group at Memorial Sloan Kettering that had generated an anti-GD2 mAb and was making at MSK for administration to patients there, but this didn't work out either.[15] A lab at the Children's Cancer Research Institute in Vienna, in collaboration with a network of European oncologists, had developed an anti-GD2 mAb that it made in CHO cells, and by 2011, it was in Phase III clinical trials, and the institute licensed its rights to Apeiron, a local biotech company.[16][17]

    The FDA approved United Therapeutics application in March 2015,[18] as did the European Medicines Agency.[19]

    In 2017, United Therapeutics withdrew the European marketing authorization, and said that it was having trouble making enough of the drug to sell in Europe.[19]

    In October 2016, Apeiron licensed the rights to Ch14.18 to the UK biotech company, EUSA,[20] and in May 2017, Apeiron and EUSA obtained EMA approval to market Ch14.18, by then called dinutuximab beta.[9][6]

    References

    1. 1 2 3 4 "Dinutuximab Monograph for Professionals". Drugs.com. Archived from the original on 13 September 2021. Retrieved 26 December 2021.
    2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 "Unituxin- dinutuximab injection". DailyMed. 19 April 2019. Archived from the original on 4 August 2020. Retrieved 16 August 2020.
    3. 1 2 "Qarziba Australian prescription medicine decision summary". Therapeutic Goods Administration (TGA). 11 April 2020. Archived from the original on 28 August 2021. Retrieved 16 August 2020.
    4. ↑ "Dinutuximab (Unituxin) Use During Pregnancy". Drugs.com. 30 March 2020. Archived from the original on 23 January 2021. Retrieved 16 August 2020.
    5. ↑ "Qarziba (Dinutuximab beta) 4.5 mg/mL concentrate for solution for infusion - Summary of Product Characteristics (SmPC)". (emc). 27 November 2019. Archived from the original on 13 August 2020. Retrieved 16 August 2020.
    6. 1 2 3 4 5 6 "Qarziba EPAR". European Medicines Agency. 17 September 2018. Archived from the original on 30 December 2020. Retrieved 16 August 2020.
    7. ↑ "Unituxin EPAR". European Medicines Agency (EMA). Archived from the original on 14 August 2020. Retrieved 16 August 2020.
    8. ↑ "Unituxin Prices, Coupons & Patient Assistance Programs". Drugs.com. Archived from the original on 26 February 2021. Retrieved 26 December 2021.
    9. 1 2 3 4 5 6 7 "Summary of product characteristics:: Dinutuximab beta EUSA (formerly Dinutuximab beta Aperion)" (PDF). EMA. 8 May 2017. Archived (PDF) from the original on 18 March 2018. Retrieved 26 October 2020.
    10. 1 2 Matthay KK, George RE, Yu AL (May 2012). "Promising therapeutic targets in neuroblastoma". Clinical Cancer Research. 18 (10): 2740–53. doi:10.1158/1078-0432.CCR-11-1939. PMC 3382042. PMID 22589483.
    11. ↑ "Assessment report: Dinutuximab beta Apeiron" (PDF). EMA. 23 March 2017. Archived (PDF) from the original on 18 March 2018. Retrieved 26 October 2020.
    12. ↑ "Dinutuximab beta - Apeiron Biologics -". AdisInsight. Archived from the original on 20 July 2017. Retrieved 28 January 2018.
    13. 1 2 3 4 "Dinutuximab (Unituxin)". NCI Technology Transfer Center. Archived from the original on 18 November 2016. Retrieved 28 January 2018.
    14. ↑ Capitini CM, Mackall CL, Wayne AS (February 2010). "Immune-based therapeutics for pediatric cancer". Expert Opinion on Biological Therapy. 10 (2): 163–78. doi:10.1517/14712590903431022. PMC 2809805. PMID 19947897.
    15. ↑ "Anti-GD2 for the treatment of neuroblastoma". Cinderella Therapeutics. 15 January 2013. Archived from the original on 30 June 2016.
    16. ↑ "Apeiron Gains Rights to Phase III-Stage Neuroblastoma Treatment". GEN. 22 June 2011. Archived from the original on 28 January 2018. Retrieved 26 October 2020.
    17. ↑ "Press release: Oncology Alliance: Apeiron, CCRI and SIOPEN join forces against neuroblastoma". Bionity. 27 June 2011. Archived from the original on 20 November 2011. Retrieved 28 January 2018.
    18. ↑ "Unituxin New FDA Drug Approval". CenterWatch. Archived from the original on 29 January 2018. Retrieved 28 January 2018.
    19. 1 2 "Unituxin: Withdrawal of the marketing authorisation in the European Union" (PDF). EMA. 21 April 2017. Archived from the original (PDF) on 28 January 2018.
    20. ↑ "Apeiron licences neuroblastoma antibody". Biocom AG. 4 October 2016. Archived from the original on 31 October 2020. Retrieved 26 October 2020.
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