Etanercept

Etanercept, sold under the brand name Enbrel among others, is a biologic medical product that is used to treat autoimmune diseases by interfering with tumor necrosis factor (TNF), a soluble inflammatory cytokine, by acting as a TNF inhibitor. It has U.S. Food and Drug Administration (FDA) approval to treat rheumatoid arthritis, juvenile idiopathic arthritis and psoriatic arthritis, plaque psoriasis and ankylosing spondylitis. Tumor necrosis factor alpha (TNFα) is the "master regulator" of the inflammatory (immune) response in many organ systems. Autoimmune diseases are caused by an overactive immune response. Etanercept has the potential to treat these diseases by inhibiting TNF-alpha.[10]

Etanercept
Clinical data
Trade namesEnbrel, Benepali, Erelzi, others
Other namesetanercept-szzs, etanercept-ykro
AHFS/Drugs.comMonograph
MedlinePlusa602013
License data
Pregnancy
category
Routes of
administration		Subcutaneous injection
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability58–76% (SC)
MetabolismReticuloendothelial system (speculative)
Elimination half-life70–132 hours
Identifiers
CAS Number
PubChem SID
DrugBank
ChemSpider
  • None
UNII
KEGG
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.224.383
Chemical and physical data
FormulaC2224H3475N621O698S36
Molar mass51235.07 g·mol−1

Etanercept is a fusion protein produced by recombinant DNA. It fuses the TNF receptor to the constant end of the IgG1 antibody. First, the developers isolated the DNA sequence that codes the human gene for soluble TNF receptor 2, which is a receptor that binds to tumor necrosis factor-alpha. Second, they isolated the DNA sequence that codes the human gene for the Fc end of immunoglobulin G1 (IgG1). Third, they linked the DNA for TNF receptor 2 to the DNA for IgG1 Fc. Finally, they expressed the linked DNA to produce a protein that links the protein for TNF receptor 2 to the protein for IgG1 Fc.[11]

The prototypic fusion protein was first synthesized and shown to be highly active and unusually stable as a modality for blockade of TNF in vivo in the early 1990s by Bruce A. Beutler, an academic researcher then at the University of Texas Southwestern Medical Center at Dallas, and his colleagues.[12][13]

These investigators also patented the protein,[14] selling all rights to its use to Immunex, a biotechnology company that was acquired by Amgen in 2002.[15]

It is a large molecule, with a molecular weight of 150 kDa, that binds to TNFα and decreases its role in disorders involving excess inflammation in humans and other animals, including autoimmune diseases such as ankylosing spondylitis,[16] juvenile rheumatoid arthritis, psoriasis, psoriatic arthritis, rheumatoid arthritis, and, potentially, in a variety of other disorders mediated by excess TNFα. It is on the World Health Organization's List of Essential Medicines.[17]

Medical uses

In the United States, etanercept is indicated for:

In the European Union, etanercept is indicated to treat:

  • moderate to severe active rheumatoid arthritis[9]
  • severe, active and progressive rheumatoid arthritis[9]
  • juvenile idiopathic arthritis[9]
  • polyarthritis (rheumatoid-factor-positive or -negative) and extended oligoarthritis in children and adolescents[9]
  • active and progressive psoriatic arthritis[9]
  • enthesitis-related arthritis
  • axial spondyloarthritis[9]
  • severe active ankylosing spondylitis[9]
  • severe non-radiographic axial spondyloarthritis[9]
  • moderate to severe plaque psoriasis[9]
  • chronic severe plaque psoriasis pediatric plaque psoriasis[9]

Safety

On May 2, 2008, the U.S. Food and Drug Administration (FDA) placed a black box warning on etanercept due to a number of serious infections associated with the drug.[24] Serious infections and sepsis, including fatalities, have been reported with the use of etanercept including reactivation of latent tuberculosis and hepatitis B infections.[8][25]

Mechanism of action

Etanercept reduces the effect of naturally present TNF, and hence is a TNF inhibitor, functioning as a decoy receptor that binds to TNF.[26]

Tumor necrosis factor-alpha (TNFα) is a cytokine produced by lymphocytes and macrophages, two types of white blood cells. It mediates the immune response by attracting additional white blood cells to sites of inflammation and through additional molecular mechanisms that initiate and amplify inflammation. Inhibition of its action by etanercept reduces the inflammatory response, which is especially useful for treating autoimmune diseases.

There are two types of TNF receptors: those found embedded in white blood cells that respond to TNF by releasing other cytokines, and soluble TNF receptors that are used to deactivate TNF and blunt the immune response. In addition, TNF receptors are found on the surface of virtually all nucleated cells (red blood cells, which are not nucleated, do not contain TNF receptors on their surface). Etanercept mimics the inhibitory effects of naturally occurring soluble TNF receptors, the difference being that etanercept, because it is a fusion protein rather than a simple TNF receptor, has a greatly extended half-life in the bloodstream, and therefore a more profound and long-lasting biologic effect than a naturally occurring soluble TNF receptor.[27]

Structure

Etanercept is made from the combination of two naturally occurring soluble human 75-kilodalton TNF receptors linked to an Fc portion of an IgG1.[28] The effect is an artificially engineered dimeric fusion protein.[28] Etanercept is a complex molecule containing 6 N-glycans, up to 14 O-glycans and 29 disulfide bridge structures.[29][30][31]

History

The fusion protein was developed by Bruce A. Beutler, an academic researcher then at the University of Texas Southwestern Medical Center at Dallas, and colleagues, who patented it and sold the rights to Immunex. The first etanercept-related patent was filed by Immunex on September 5, 1989.[32]

Etanercept was approved for use in the United States in November 1998.[8][33]

Etanercept was approved for use in the European Union in February 2000.[9]

Society and culture

Marketing

In North America, etanercept is marketed by Amgen under the trade name Enbrel in two separate formulations, one in powder form, the other as a pre-mixed liquid. Wyeth (part of Pfizer) was the sole marketer of etanercept outside North America excluding Japan where Takeda Pharmaceuticals markets the drug.

Economics

The U.S. retail price of etanercept has risen over time. In 2008, the cost of etanercept was $1,500 per month or $18,000 per year.[34] By 2011, the cost had exceeded $20,000 per year.[35][36] In 2013, a survey by the International Federation of Health Plans (IFHP) found that the average U.S. cost for etanercept was $2,225 per month, or $26,700 per year.[37] The IFHP report also found wide variation in prices charged to various U.S. health plans, between $1,946 per month at the 25th percentile and $4,006 per month at the 95th percentile.[37]

Etanercept is more expensive in the U.S. than in other countries.[37] As of 2013, average monthly costs in surveyed nations ranged from $1,017 in Switzerland to $1,646 in Canada, compared to an average monthly cost of $2,225 per month in the U.S.[37]

Amgen sells etanercept within the U.S. and Canada, while Pfizer, Inc. sells the drug outside of the U.S. and Canada.[35] Sales within the U.S. and Canada were $3.5 billion in 2010.[35] Sales of etanercept outside the U.S. and Canada were $3.3 billion in 2010.[38]

Patents

The patent on etanercept was set to expire on October 23, 2012,[39] but, in the United States, a second patent, granting exclusivity for another 16 years, has been granted.[40]

Before the extension it seemed unlikely that a generic would have been available. As a biologic, etanercept is subject to different laws from those applicable to chemical formulations. Currently many countries do not permit the manufacture of generic biologics. However, the European Union and the United States (Biologics Price Competition and Innovation Act of 2009) do currently have in place a system to approve generic biologics (biosimilars) which "requires mandatory clinical testing and periodic review".[41]

In April 2013, the Indian pharma major Cipla made an announcement about launching the first biosimilar of Etanercept in India under the brand name 'Etacept' for the treatment of rheumatic disorders. The company's April 17, 2013 press release claimed that the biosimilar will cost 30% less as compared to the innovator.[42]

In January 2015, Samsung and Biogen's joint venture "Samsung Bioepis" successfully submitted Benepali, a biosimilar version of the drug, for review to the European Medicines Agency (EMA), and announced that it will seek regulatory approvals in other territories as well. Later the same year, the European Medicines Agency also accepted Sandoz's application for review of its etanercept biosimilar Erelzi which will be marketed by Novartis.[43]

In the U.S., Sandoz submitted a biologics license application (BLA) for the proposed etanercept product "GP2015" in July 2016. Upon acceptance of the first application process, the U.S. FDA reviewed data from European clinical trials and bio-analytical investigations, demonstrating the biosimilarity of GP2015 to the US-licensed Enbrel. Sandoz in 2009 tried to invalidate the patents held by Hoffman-La Roche/Immunex and exclusively licensed to Amgen but lost in federal court. Sandoz was then countersued by Amgen for patent infringements related to the methods of treating psoriasis and/or psoriatic arthritis. The case Immunex Corp. et al. vs. Sandoz Inc. et al., 16-cv-01118-CCC-JBC (D.N.J.) is pending.[44]

An American physician, Edward Tobinick, has attempted to use etanercept to treat chronic neurological dysfunction after stroke and brain injury[45] and issued U.S.[46] and foreign patents. Writing for Science-Based Medicine, Steven Novella said that it was "unethical for physicians to practice outside of their area of competence and expertise". Tobinick attempted unsuccessfully to sue Novella in response.[47] Subsequently, Tobinick's treatment was evaluated in a double-blind, randomized, placebo-controlled trial at Griffith University in Australia. The researchers concluded, "Perispinal etanercept can provide significant and ongoing benefits for the chronic post-stroke management of pain and greater shoulder flexion by the paretic arm. Effects are rapid and highly significant, supporting direct action on brain function."[48]

Biosimilars

In January 2016, Benepali was approved for use in the European Union.[49]

In February 2017, Lifmior was approved for use in the European Union.[50] It was withdrawn from the market in February 2020.[51]

In June 2017, Erelzi was approved for use in the European Union.[52]

In March 2019, YLB113 (Etanercept biosimilar by YL Biologics) was approved in Japan.[53]

In May 2020, Nepexto was approved for use in the European Union.[54]

Rymti and Etera were approved for medical use in Australia in October 2020.[1][55][3][4]

Similar agents

References
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