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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Monoclonal Antibodies

Last Update: July 12, 2022.

OVERVIEW

Monoclonal antibodies are immunoglobulins that have a high degree of specificity (mono-specificity) for an antigen or epitope. Monoclonal antibodies are typically derived from a clonal expansion of antibody producing malignant human plasma cells. The initial monoclonal antibodies were created by fusing spleen cells from an immunized mouse with human or mouse myeloma cells (malignant self-perpetuating antibody producing cells), and selecting out and cloning the hybrid cells (hybridomas) that produced the desired antibody reactivity. These initial monoclonal products were mouse antibodies and were very valuable in laboratory and animal research and diagnostic assays, but were problematic as therapeutic agents because of immune reactions to the foreign mouse protein. Subsequently, production of chimeric mouse-human monoclonal antibodies and means of further “humanizing” them and producing fully human recombinant monoclonal antibodies were developed. The conventions used in nomenclature of monoclonal antibodies indicate whether they are mouse dervied (-omab), chimeric (-ximab), humanized (-zumab) or fully human (-umab).

Monoclonal antibodies have broad clinical and experimental medical uses. Many of the initial monoclonal antibodies used in clinical medicine were immunomodulatory agents with activity against specific immune cells, such as CD4 or CD3 lymphocytes, which are important in the pathogenesis of rejection after solid organ transplantation. Subsequently, monoclonal antibodies were prepared against specific cytokines (anti-cytokines), which were believed to play a role in cell and tissue damage in immunologically mediated diseases such as rheumatoid arthritis, alkylosing spondylitis, inflammatory bowel disease, multiple sclerosis and psoriasis, among others. In addition, therapeutic monoclonal antibodies were developed, aimed at blocking or inhibiting the activity of specific enzymes, cell surface transporters or signaling molecules and have been used in cancer chemotherapy and to treat severe viral infections. Use of monoclonal antibodies is currently broadening to therapy of other severe, nonmalignant conditions including asthma, atopic dermatitis, migraine headaches, hypercholesterolemia, osteoporosis, bacterial diseases (such as anthrax) and viral infections (such as COVID-19). Thus, the therapeutic monoclonal antibodies do not fall into a single class and have broad therapeutic uses. As of 2022, more than 80 therapeutic monoclonal antibodies have been approved for use in the United States.

Monoclonal antibodies are generally well tolerated. Because they are large proteins (typically 150-200,000 daltons in size) they require parenteral, often intravenous, administration. Circulating proteins are metabolized by many cells, but particularly by hepatocytes. Proteins undergo hepatic uptake by endocytosis and are either degraded or recycled to the cell surface for secretion. The hepatic metabolism of antibodies often determines their half-life. Proteins are broken down by cellular proteases into small peptides and amino acids that can used to synthesize other proteins. Metabolism of proteins does not generate toxic intermediates and, therefore, monoclonal antibodies are unlikely to induce drug induced liver injury via production of toxic metabolites. On the other hand, the peptides that are generated by the metabolism of the exogenously administered protein may ultimately be presented as foreign epitopes and generate an immune response. In addition, the primary effect of the monoclonal antibody may generate a response, either immune or otherwise, that leads to an immune mediate hepatic injury. Finally, monoclonal antibodies that suppress the immune system may cause reactivation of latent infections, including tuberculosis, herpes simplex, varicella zoster (shingles) and hepatitis B.

Among the monoclonal antibodies that have been used in clinical medicine, only a few have been linked to drug induced liver injury and, in many situations, the cause of the hepatic adverse event is often unclear. The monoclonal antibodies most clearly linked to drug induced liver injury include the antibodies to tumor necrosis factor (anti-TNF such as infliximab, adalimumab, certolizumab and golimumab) and antibodies to checkpoint proteins (anti-CTLA4 such as ipilimumab; anti-PD1 such as cemiplimab, dostarlimab, nivolumab and pembrolizumab; and anti-PD-L1 such as atezolizumab, avelumab and durvalumab) and to antibodies to B cell markers and activation signals (anti-CD20 such as rituximab, ofatumumab and tositumomab). The liver injury caused by these products is usually attributed to induction of autoimmunity or to immune modulation and reactivation of hepatitis B.

Because of their fine specificity, monoclonal antibodies can also be used to direct more conventional therapeutic agents to specific organs, tissues or cells. Several monoclonal antibody conjugates have been developed, largely in the therapy of cancer, the conjugated drug being an antineoplastic or cytotoxic agent. Five such agents are gemtuzumab ozogamicin, brentuximab vedotin, trastuzumab emtansine, inotuzumab ozogamicin and moxetumomab pasudotox. These products combine a monoclonal antibody (anti-CD33, anti-CD30, anti-HER2, anti-CD22) to a microtubule inhibitor (ozogamicin, vedotin, emtansine, pasudotox). These agents have been associated with serum enzyme elevations during therapy, and several have been linked to hepatic vascular damage, sinusoidal obstruction syndrome and nodular regenerative hyperplasia. These forms of hepatotoxicity are likely due to the conjugate (the "payload") rather than the monoclonal antibody (the targeting vehicle).

Monoclonal antibodies approved for clinical use in the United States are listed below with their brand name followed by the type of monoclonal and specific antigen targeted, the year of initial approval, likelihood score of causing liver injury, and major uses. Those monoclonal antibodies with specific chapters in LiverTox are underlined and have a link to the corresponding record. COVID-19-related monoclonal antibodies, which are typically granted Emergency Use Authorization (EUA) and are often subsequently withdrawn because of antiviral resistance, are not listed in this table but can be found in the chapter “COVID-19 Monoclonal Antibodies.”

MONOCLONAL ANTIBODIES

Underlined Generic Names link to a LiverTox record.

CANCER
Generic Name
Brand Name
Type
Antigenic Target
Year of Initial Approval Likelihood
Score†
Major Uses
Alemtuzumab
Campath
Humanized
CD52
2001CChronic lymphocytic leukemia
Atezolizumab
Tecentriq
Humanized
PD-L1
2016BUrothelial carcinoma
Non-small cell lung cancer

Small cell lung cancer

Hepatocellular carcinoma

Avelumab
Bavencio
Human
PD-L1
2017BMerkel cell carcinoma
Urothelial carcinoma

Renal cell carcinoma

Bevacizumab
Avastin
Humanized
VEGF
2004EColorectal cancer
Renal, Ovarian, and Non-small cell lung cancer
Macular degeneration (off lbl)
Blinatumomab
Blincyto
Mouse
CD3, CD19
2014E*Acute lymphoblastic leukemia
Brentuximab
Adcetris
Chimeric
CD30
2011E*Hodgkin lymphoma
Peripheral T-cell lymphoma

Cemiplimab
Libtayo
Human
PD-1
2018CSquamous cell carcinoma

Basal cell carcinoma

Non-small cell lung cancer

Cetuximab
Erbitux
Chimeric
EGFR
2004EHead and neck cancer
Colorectal cancer
Daratumumab
Darzalex
Human
CD38
2015EMultiple myeloma
Dinutuximab
Unituxin
Chimeric
GD2
2015E*Neuroblastoma
Dostarlimab
Jemperli
Human
PD-1
2021CEndometrial carcinoma
Durvalumab
Imfinzi
Human
PD-L1
2017BNon-small cell lung cancer
Small cell lung cancer
Elotuzumab
Empliciti
Humanized
SLAMF7
2015DMultiple myeloma
Gemtuzumab
Mylotarg
Humanized
CD33
2000
2017
AAcute myelogenous leukemia
Inotuzumab
Besponsa
Humanized
CD22
2017BAcute lymphoblastic leukemia
Ipilimumab
Yervoy
Human
CTLA4
2009AMalignant melanoma

Colorectal, Esophageal, Hepato-cellular and Renal cell cancer

Non-small cell lung cancer

Mogamulizumab
Poteligeo
Humanized
CCR4
2018CMycosis fungoides
Sézary syndrome
Moxetumomab
Lumoxiti
Mouse
CD22
2018E*Hairy cell leukemia
Necitumumab
Portrazza
Human
EGFR
2015ENon-small cell lung cancer
Nivolumab
Opdivo
Human
PD-1
2015AMalignant melanoma
Colorectal, Esophageal, Hepato-cellular and Renal cell cancer
Non-small cell lung cancer
Ofatumumab
Arzerra
Human
CD20
2009E*Chronic lymphocytic leukemia
Olaratumab
Lartruvo
Human
PDGF
2016ESoft tissue sarcoma
Panitumumab
Vectibix
Human
EGFR
2006EColorectal cancer
Pembrolizumab
Keytruda
Humanized
PD-1
2014AMalignant melanoma
Non-small cell lung cancer
Advanced cervical cancer
Pertuzumab
Perjeta
Humanized
HER2
2012EBreast cancer
Ramucirumab
Cyramza
Human
VEGF
2014E*Gastric, non-small cell lung cancer
Colorectal cancer
Rituximab
Rituxan
Chimeric
CD20
1997AChronic lymphocytic leukemia
Non-Hodgkin lymphoma
Rheumatoid arthritis
Tositumomab
Bexxar
Mouse
CD20
2003

Withdrawn

E*Non-Hodgkin lymphoma
Trastuzumab
Herceptin
Humanized
HER2
1998DBreast and gastric cancer
AUTOIMMUNE DISEASES
Generic Name
Brand Name
Type
Antigenic Target
Initial
Approval
Likelihood
Score†
Major Uses
Adalimumab
Humira
Human
TNFα
2002BInflammatory bowel disease
Rheumatoid, Psoriatic arthritis
Severe psoriasis
Alemtuzumab
Lemtrada
Humanized
CD52
2014CMultiple sclerosis
Belimumab
Benlysta
Human
B cell activity factor
2011

2020

ESystemic lupus erythematosus

Lupus nephritis

Brodalumab
Siliq
Human
IL-17A
2017EPlaque psoriasis
Canakinumab
Ilaris
Human
IL1β
2009E*Autoinflammatory diseases
Certolizumab
Cimzia
Humanized
TNFα
2008E*Inflammatory bowel disease
Rheumatoid arthritis
Daclizumab
Zinbryta
Humanized
CD25
2016CMultiple sclerosis
Dupilumab
Dupixent
Human
IL-4α
2017EAtopic dermatitis
Efalizumab
Raptiva
Humanized
CD11a
2003
Withdrawn
DPlaque psoriasis
Golimumab
Simponi
Human
TNFα
2009E*Inflammatory bowel disease
Rheumatoid, Psoriatic arthritis
Guselkumab
Tremfya
Human
IL-23
2017E*Plaque psoriasis
Infliximab
Remicade
Chimeric
TNFα
1998AInflammatory bowel disease
Rheumatoid arthritis
Severe psoriasis
Ixekizumab
Taltz
Humanized
IL-17A
2016EPlaque psoriasis
Psoriatic arthritis
Ocrelizumab
Ocrevus
Humanized
CD20
2017DMultiple sclerosis
Omalizumab
Xolair
Humanized
IgE
2003EEosinophilic asthma

Chronic idiopathic urticaria

Risankizumab
Skyrizi
Humanized
IL-23
2019EPlaque psoriasis
Rituximab
Rituxan
Chimeric
CD20
1997AChronic lymphocytic leukemia
Non-Hodgkin lymphoma
Rheumatoid arthritis
Sarilumab
Kevzara
Human
IL6R
2017E*Rheumatoid arthritis
Secukinumab
Cosentyx
Human
IL-17A
2015E*Plaque psoriasis
Psoriatic arthritis, Ankylosing spondylitis, Scalp psoriasis

Axial spondylarthritis

Siltuximab
Sylvant
Chimeric
IL6
2014ECastleman disease
Tildrakizumab
Ilumya
Humanized
IL-23
2018E*Plaque psoriasis
Tocilizumab
Actemra
Humanized
IL6R
2010CRheumatoid arthritis

Juvenile idiopathic arthritis

Giant cell arteritis

Ustekinumab
Stelara
Human
IL-12, IL-23
2010E*Plaque psoriasis
Psoriatic arthritis
Vedolizumab
Entyvio
Humanized
Integrin α4β7
2014DInflammatory bowel disease
LIVER TRANSPLANTATION
Generic Name
Brand Name
Type
Antigenic Target
Initial
Approval
Likelihood
Score†
Major Uses
Basiliximab
Simulect
Chimeric
IL-2Rα
1998EPrevention of transplant rejection
Daclizumab
Zenapax
Humanized
IL-2
1997
Withdrawn
CPrevention of transplant rejection
Muromonab-CD3
OKT3
Mouse
CD3 T cells
1985

Withdrawn

EPrevention of transplant rejection
MISCELLANEOUS
Generic Name
Brand Name
Type
Antigenic Target
Initial
Approval
Likelihood
Score†
Major Uses
Abciximab
Reopro
Chimeric
GpIIb/IIIa
1993Inhibition of platelet aggregation
Aducanumab
Aduhelm
Human
Amyloid β
2021EAlzheimer disease
Alirocumab
Praluent
Human
PCSK9
2015EHypercholesterolemia
Benralizumab
Fasenra
Humanized
IL5
2017EEosinophilic asthma
Bezlotoxumab
Zinplava
Human
C. difficile toxin B
2016EPrevention of recurrence
of C. difficile infection
Burosumab
Crysvita
Human
FGF 23
2018EX-linked Hypophosphatemia

Caplacizumab
Cablivi
Humanized
vWF
2019EAcquired thrombotic thrombocytopenic purpura
Crizanlizumab
Adakveo
Humanized
P-selectin
2019ESickle cell disease
Denosumab
Prolia, Zgeva
Human
RANKL
2010E*Osteoporosis
Bone metastases
Eculizumab
Soliris
Humanized
C5
2007DParoxysmal nocturnal hemoglobinuria
Emapalumab
Gamifant
Human
Interferon Gamma
2018EHemophagocytic lymphohistiocytosis
Emicizumab
Hemlibra
Humanized
Factor IXa & X
2017EHemophilia A
Eptinezumab
Vyepti
Humanized
CGRP
2019EMigraine headache
Erenumab
Aimovig
Human
CGRP
2018EMigraine headache
Evinacumab
Evkeeza
Human
ANGPTL3
2021EHypercholesterolemia
Evolocumab
Repatha
Human
PCSK9
2015EHypercholesterolemia
Fremanezumab
Ajovy
Humanized
CGRP
2018EMigraine headache
Galcanezumab
Emgality
Humanized
CGRP
2018EMigraine headache
Ibalizumab
Trogarzo
Humanized
CD4
2018EHIV infection
Lanadelumab
Takhzyro
Human
Kallikrein
2018EHereditary angioneurotic edema
Mepolizumab
Nucala
Humanized
IL15
2015EEosinophilic asthma
Hypereosinophilic syndrome
Natalizumab
Tysabri
Humanized
Integrin α4β7
2004BMultiple sclerosis
Inflammatory bowel disease
Obiltoxaximab
Anthim
Chimeric
Anthrax toxin
2016EInhalational anthrax
Omalizumab
Xolair
Humanized
IgE
2003EEosinophilic asthma

Chronic idiopathic urticaria

Palivizumab
Synagis
Humanized
RSV fusion protein
1998ERespiratory syncytial virus infection
Ranibizumab
Lucentis
Humanized
VEGF-A
2006EMacular degeneration
Ravulizumab
Ultomiris
Humanized Complement C52018E*Paroxysmal noctural hemoglobinuria
Raxibacumab Human
Anthrax toxin
2012EInhalational anthrax
Reslizumab
Cinqair
Humanized
IL5
2016EEosinophilic asthma
Romosozumab
Evenity
Humanized
Sclerostin
2019EOsteoporosis
Teprotumumab
Tepezza
Human
IGF1R
2019EGraves ophthalmopathy

Likelihood Score indicates the likelihood of association with drug induced liver injury,

based upon the known potential of the drug to cause such injury.

Updated: November 29, 2021

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