TREatment of ATopic eczema (TREAT) Registry Taskforce: an international Delphi exercise to identify a core set of domains and domain items for national atopic eczema photo- and systemic therapy registries.

BACKGROUND: Evidence of immunomodulatory therapies to guide clinical management of atopic eczema (AE) is scarce, despite frequent and often off-label use. Patient registries provide valuable evidence for the effects of treatments under real-world conditions that can inform treatment guidelines, give the opportunity for health economic evaluation and the evaluation of quality of care, as well as pharmacogenetic and dynamic research, which cannot be adequately addressed in clinical trials. OBJECTIVES: The TREatment of ATopic eczema (TREAT) Registry Taskforce aims to seek international consensus on a core set of domains and items ('what to measure') for AE research registries, using a Delphi approach. METHODS: Participants from six stakeholder groups were included: doctors, nurses, nonclinical researchers, patients, industry and regulatory body representatives. The eDelphi comprised three sequential online rounds, requesting participants to rate the importance of each proposed domain item. Participants could add domain items to the proposed list in round 1. A final consensus meeting was held to ratify the core set. RESULTS: Participants (n = 479) from 36 countries accessed the eDelphi platform, of whom 86%, 79% and 74% completed rounds 1, 2 and 3, respectively. At the face-to-face consensus meeting attended by 42 participants the final core set was established containing 19 domains with 69 domain items (49 baseline and 20 follow-up items). CONCLUSIONS: This core set of domains and items to be captured by national AE systemic therapy registries will standardize data collection and thereby allow direct comparability across registries and facilitate data pooling between countries. Ultimately, it will provide greater insight into the effectiveness, safety and cost-effectiveness of photo- and systemic immunomodulatory therapies.

[Pemphigoid diseases. Autoimmune diseases in the elderly]. / Pemphigoiderkrankungen. Autoimmunerkrankungen des Alters.

BACKGROUND: The incidence and thereby also the relevance of pemphigoid diseases have significantly increased in elderly patients. METHODS: The clinical features, diagnostic workup, and therapy of pemphigoid diseases based on the recently published German guidelines and expert opinions are described. RESULTS: The diagnosis is based on medical history, clinical manifestations, histopathology, and autoimmune serology. Treatment options depend on the diagnosis and disease severity. Both local and systemic immunosuppressive or immunomodulatory strategies have been proven to be effective. CONCLUSIONS: Chronic, itchy, inflammatory skin disorders in elderly patients are generally suspicious for pemphigoid diseases. The prognosis is usually good. For decisions about (local or systemic) immunosuppressive therapy, gerontological aspects should be taken into consideration.

[Official testing of immunological veterinary medicinal products]. / Unabhängige Prüfung von immunologischen Tierarzneimitteln.

The testing of immunological veterinary medicinal products (IVMPs) by official medicines control laboratories (OMCLs) is an important contribution to the control of quality, safety and efficacy of these products. Based on the legislation of the European Union (EU) and with the support of the European Directorate for the Quality of Medicines & HealthCare (EDQM) a network of OMCLs of the EU member states and Switzerland has been built. This network has established its own rules allowing the mutual recognition of test results and rapid communication of details regarding batch release or rejection. Annual reports, OMCL meetings and collaborative studies help to foster confidence between the OMCLs. The procedure for official testing is described and an overview of deficits found at testing is presented in the paper. The testing of selected batches of centrally authorized products is also performed by OMCLs and is briefly described. Communication both among OMCLs and with pharmaceutical industry is an important part of the OMCLs' work to compare test results and to optimize existing or develop new test methods. Several OMCLs are also pursuing the development of new test methods, primarily for the reduction, refinement and replacement of animal experiments in routine testing.

COVID-19 and 'immune boosting' on the internet: a content analysis of Google search results.

OBJECTIVE: The spread of misinformation has accompanied the coronavirus pandemic, including topics such as immune boosting to prevent COVID-19. This study explores how immune boosting is portrayed on the internet during the COVID-19 pandemic. DESIGN: Content analysis. METHODS: We compiled a dataset of 227 webpages from Google searches in Canada and the USA using the phrase 'boost immunity' AND 'coronavirus' on 1 April 2020. We coded webpages for typology and portrayal of immune boosting and supplements. We recorded mentions of microbiome, whether the webpage was selling or advertising an immune boosting product or service, and suggested strategies for boosting immunity. RESULTS: No significant differences were found between webpages that appeared in the searches in Canada and the USA. The most common types of webpages were from news (40.5%) and commercial (24.7%) websites. The concept of immune boosting was portrayed as beneficial for avoiding COVID-19 in 85.5% of webpages and supplements were portrayed as beneficial in 40% of the webpages, but commercial sites were more likely to have these portrayals. The top immune boosting strategies were vitamin C (34.8%), diet (34.4%), sleep (34.4%), exercise (30.8%) and zinc (26.9%). Less than 10% of the webpages provide any critique of the concept of immune boosting. CONCLUSIONS: Pairing evidence-based advice for maintaining one's health (eg, healthy diet, exercise, sleep) with the phrase immune boosting and strategies lacking in evidence may inadvertently help to legitimise the concept, making it a powerful marketing tool. Results demonstrate how the spread of misinformation is complex and often more subtle than blatant fraudulent claims.

A methodology for the selection of a routine purity test for insoluble beta(1-->3)glucan.

Beta(1-->3)glucan isolated from the cell wall of Saccharomyces cerevisiae is a biological response modifier (BRM) stimulating resistance against bacterial, viral, fungal and protozoal diseases. This polysaccharide has a high molecular weight, which makes it very difficult to achieve a purity test. A comparative study of different analytical procedures for beta(1-->3)glucan from S. cerevisiae was conducted in order to establish a reliable routine analytical methodology for quality control of this active ingredient in pharmaceutical products. With this aim, different combinations of the analytical procedure steps were tested, including three alternatives for the acid hydrolysis step, three for neutralization, two for gas-liquid chromatographic derivatization and two internal standards. The glucose yield, precision, time consumption and reagent cost per sample were determined for 10 sample replicates. All gas chromatographic determinations were conducted using packed GLC columns and an FID detector. The selected analytical method showed 83.61 +/- 3.48% glucose yield, the shortest relative time consumption (54.2%) and the lowest cost of reagents (7.4%) and consisted of a combination of 72% sulfuric acid hydrolysis, 25% ammonium hydroxide neutralization and alditol acetate derivatization using xylose as internal standard.

Systematic Review: Cost-effective Strategies of Optimizing Anti-tumor Necrosis and Immunomodulators in Inflammatory Bowel Disease.

BACKGROUND: Medication costs in inflammatory bowel disease (IBD) are now the principal driver of health care costs. Cost-effective strategies to optimize and rationalize treatment are therefore necessary. METHODS: A systematic review until April 30, 2018, was performed to identify economic evaluations of strategies to optimize infliximab, adalimumab, and immunomodulators for the treatment of IBD in adults. A qualitative synthesis of the identified studies was performed. RESULTS: Seventy articles were identified that met the inclusion criteria. Adalimumab seems cost-effective compared with infliximab as maintenance therapy for moderate to severe Crohn's disease (CD). Infusion costs are a significant additional treatment cost with infliximab. However, other studies found biosimilar infliximab more cost-effective than alternative biologics in fistulizing and moderate-severe luminal CD-although the latter did not reach a willingness-to-pay threshold of <$50,000. In moderate-severe ulcerative colitis, infliximab seems more cost-effective than adalimumab. Multiple tailored approaches to treatment based on objective markers of disease activity or efficacy have been shown to be cost-effective in CD, including following secondary loss of response to anti-TNF therapy for postoperative recurrence and in escalating treatment. For immunomodulator treatment, both thiopurine methyltransferase (TPMT) testing before commencing thiopurines and thiopurine metabolite testing for dose optimization seem cost-effective. CONCLUSION: In a win-win for patients and payers, several potential avenues to achieve cost-effectiveness-but also therapeutic optimization of anti-TNF therapies-were elucidated in this review with comparatively sparse data for immunomodulators. Optimizing immunomodulator and anti-tumor necrosis factor alpha therapy to achieve objective disease control seems to be cost-effective at conventional willingness-to-pay thresholds in a number of clinical settings.

Easy and effective method to generate endotoxin-free chitosan particles for immunotoxicology and immunopharmacology studies.

OBJECTIVES: The cationic biopolymer chitosan (CH) has emerged as a promising candidate adjuvant due to its safety profile and immunostimulatory properties. The presence of endotoxin contamination in biomaterials is generally underappreciated and can generate misleading results. It is important to establish a convenient methodology to obtain large amounts of high quality chitosan nanoparticles for biomedical applications. METHODS: We developed an easy method to generate endotoxin-free chitosan and assessed its purity using the Limulus amebocyte lysate assay and by measuring dendritic cell activation. KEY FINDINGS: Purified chitosan-based formulations alone failed to induce production of the proinflammatory cytokines tumour necrosis factor alpha (TNF-α) and interleukin (IL)-6 in bone marrow-derived dendritic cells (BMDCs) generated from C57BL/6 mice, while maintaining its ability to promote IL-1ß secretion in combination with the Toll-like receptor (TLR)-9 agonist, CpG. Moreover, BMDCs from C3H/HeN and TLR4-deficient mice, C3H/HeJ were stimulated with endotoxin-free chitosan-based formulations and no differences were observed in IL-6 and IL-1ß secretion, excluding the involvement of TLR-4 in the immunomodulatory effects of chitosan. CONCLUSIONS: The developed method provides simple guidelines for the production of endotoxin-free chitosan, ideal for biomedical applications.

The Untapped Pharmacopeic Potential of Helminths.

The dramatic rise in immunological disorders that occurs with socioeconomic development is associated with alterations in microbial colonization and reduced exposure to helminths. Excretory-secretory (E/S) helminth products contain a mixture of proteins and low-molecular-weight molecules representing the primary interface between parasite and host. Research has shown great pharmacopeic potential for helminth-derived products in animal disease models and even in clinical trials. Although in its infancy, the translation of worm-derived products into therapeutics is highly promising. Here, we focus on important key aspects in the development of immunomodulatory drugs, also highlighting novel approaches that hold great promise for future development of innovative research strategies.

Assessment of structural and functional similarity of biosimilar products: Rituximab as a case study.

Biosimilars are products that are similar in terms of quality, safety, and efficacy to an already licensed reference/ innovator product and are expected to offer improved affordability. The most significant source of reduction in the cost of development of a biosimilar is the reduced clinical examination that it is expected to undergo as compared to the innovator product. However, this clinical relief is predicated on the assumption that there is analytical similarity between the biosimilar and the innovator product. As a result, establishing analytical similarity is arguably the most important step towards successful development of a biosimilar. Here, we present results from an analytical similarity exercise that was performed with five biosimilars of rituximab (Ristova®, Roche), a chimeric mouse/ human monoclonal antibody biotherapeutic, that are available on the Indian market. The results show that, while the biosimilars exhibited similarity with respect to protein structure and function, there were significant differences with respect to size heterogeneity, charge heterogeneity and glycosylation pattern.

International standards for monoclonal antibodies to support pre- and post-marketing product consistency: Evaluation of a candidate international standard for the bioactivities of rituximab.

The intrinsic complexity and heterogeneity of therapeutic monoclonal antibodies is built into the biosimilarity paradigm where critical quality attributes are controlled in exhaustive comparability studies with the reference medicinal product. The long-term success of biosimilars will depend on reassuring healthcare professionals and patients of consistent product quality, safety and efficacy. With this aim, the World Health Organization has endorsed the need for public bioactivity standards for therapeutic monoclonal antibodies in support of current controls. We have developed a candidate international potency standard for rituximab that was evaluated in a multi-center collaborative study using participants' own qualified Fc-effector function and cell-based binding bioassays. Dose-response curve model parameters were shown to reflect similar behavior amongst rituximab preparations, albeit with some differences in potency. In the absence of a common reference standard, potency estimates were in poor agreement amongst laboratories, but the use of the candidate preparation significantly reduced this variability. Our results suggest that the candidate rituximab standard can support bioassay performance and improve data harmonization, which when implemented will promote consistency of rituximab products over their life-cycles. This data provides the first scientific evidence that a classical standardization exercise allowing traceability of bioassay data to an international standard is also applicable to rituximab. However, we submit that this new type of international standard needs to be used appropriately and its role not to be mistaken with that of the reference medicinal product.

Bovine colostrum as a biologic in clinical medicine: a review. Part I: biotechnological standards, pharmacodynamic and pharmacokinetic characteristics and principles of treatment.

Mammals supply their newborn before birth, at birth or shortly after birth with antibodies, immunocytes and humoral constituents. This "borrowed immunity" is a form of passive immunization to protect the newborn against environmental pathogens until it establishes its own pathogen recognition and disposal systems. In cows, goats, horses and some other animal species, most immunoglobulins are obtained from the colostrum, the first milk after birth, via the gut but in humans the majority of immunoglobulins, and those of the IgG-class in particular, are acquired from the mother by placental transport in the weeks prior to parturition. It has long been known that the consumption of bovine colostrum by humans has therapeutic effects e.g. in gastrointestinal infections, but only since the second half of the last century has it been possible to prepare stable, standardized preparations of colostrum. These biologics are administered to patients in combination with standard therapies as so-called balanced supportive diets. Investigations with standardized colostrum preparations in animal models of human disease and estimates of bovine IgG activity in the human GI-tract, described in this review, have provided preclinical data supporting the use of bovine colostrum in human diseases. On the other hand, the number of bovine colostrum products with a sufficiently large and reliable database is limited and the precise nature of the therapeutic targets is still being evaluated.

Effects of Education and Information on Vaccination Behavior in Patients with Inflammatory Bowel Disease.

BACKGROUND: Despite the existence of international guidelines, vaccination in patients with inflammatory bowel disease (IBD) has not been integrated optimally. We developed a thorough education program, and compared its influence on vaccination rates with routine clinical practice in a tertiary IBD center. METHODS: Between December 2014 and March 2015, we included 505 consecutive patients with IBD visiting our outpatient clinic (53% men, 72% Crohn's disease, median age 44 years). Vaccination data, including hepatitis B, influenza, pneumococcus, tetanus, and varicella zoster virus, as well as demographic data, were collected by a fellow in training or a certified gastroenterologist. Thereafter, patients were randomly assigned to group A receiving routine clinical practice or intervention group B receiving additional education by the IBD nurse with help of an information brochure and vaccination card. Vaccination status was reassessed 8 months later. RESULTS: At baseline, 32% of patients were vaccinated according to the guidelines. The remaining 346 patients were randomized to group A (n = 206) or intervention group B (n = 140). Eight months after randomization, 33% of intervention group B versus 6% of group A followed vaccination recommendations and differences were significant for each vaccine (all P < 0.001). A higher educational level was independently associated with better compliance to pneumococcal vaccination (P = 0.008) and to the guidelines overall (P < 0.001). However, the educational intervention was the only consistent factor independently associated with improved compliance to each individual vaccination recommendation (all P ≤ 0.023). CONCLUSIONS: Introduction of thorough vaccination education significantly increased compliance to vaccination guidelines. However, further education of patients and health care providers remains necessary.

Developments in immunological standardization.

In the century since Paul Erlich's innovative immunological standardization work with diphtheria anti-toxin, the field of immunological standardization has expanded dramatically. Biological standards for a diverse range of immunological substances have been produced e.g. immunoglobulins, complement components, autoantibodies and blood group reagents. The concept of calibration of such materials in biological units of potency is now widely accepted for many such substances. Most recently much effort has been devoted to producing biological standards for cytokines which can be used to calibrate and validate biological assays for these analytes. Immunoassays have been found to be particularly problematical from the standardization view point although provision of a single international standard for distribution world-wide is clearly advantageous and helps reduce assay variability. It is hoped that the considerable progress with immunological standardization achieved during the past century will continue and expand to ensure the validity of existing and new immunological assays which will be required in the future.

FDA regulations for growth factors and related products.

Biological products, including the majority of growth factors, are regulated by the Center for Biologics Evaluation and Research (CBER) in the U.S. Food and Drug Administration (U.S.FDA) under two statutes; U.S. Federal Food Drug and Cosmetics (FDC) act and the U.S. Public Health Service act. As stipulated in the U.S. Code of Federal Regulations (21 CFR) under the FDC act, the testing of new products in humans is conducted under an Investigational New Drug (IND) application. The primary objective of the FDA in all Phases of an investigation is assure safety of human subjects. During phase II and phase III studies, additional assurance regarding the scientific quality of the clinical investigation is required. A marketing approval is granted by CBER following the review of Product License Applications (PLA) and Establishment License Applications (ELA). CBER's review process provides guidance to the manufacturers of biological products towards the development of safe and effective biological products for human use. Information pertinent to preclinical issues and clinical trial design is presented here with a special emphasis on the non-hematopoietic growth factors.

Fragments of truth: T-cell targets of polyclonal immunoglobulins in autoimmune diseases.

The expanding therapeutic use of high-dose intravenous immunoglobulin (IVIg) in autoimmune diseases has raised important practical and conceptual issues over the last few years. These have prompted a number of research efforts aimed at characterizing aspects of the mechanism of action of current IVIg preparations, which might lead to the development of standardized, more cost-effective agents. Although polyclonal IgG in these preparations are mostly thought to act via direct interference with disease-specific, pathogenic autoantibodies, evidence from clinical and experimental work points to the involvement of crucial checkpoints upstream of self-reactive B-cell activation and autoantibody production. Reviewed herein are the results of the most recent studies documenting the crucial role of regulatory T cells (Treg) in the immunomodulatory activity of IVIg, and the molecular mechanisms mediating the effect of specific IgG fragments and glycoforms on Treg activity and the ensuing downregulation of T-cell effector responses of different sign and magnitude. Further progress in this area of translational research may lead to the development of innovative strategies aimed at restoring tolerance in autoimmune diseases.