Journal of Clinical Apheresis 6:122-123 (1991)
Passive Hyperimmune Therapy in the Treatment of AIDS and ARC Joshua Levy HemaCare Corporation, Sherman Oaks, California
The observation that some patients with HIV infection have a much more benign course and maintain good health for much longer periods caused investigators to look at what might be protective factors in these patients. One significant observation has been that these patients with milder disease have very high titers of neutralizing antibodies against the HIV virus [1,2]. Patients with frank AIDS have low titers of these antibodies, and as disease progresses high titer patients show significant decrease in their antibody titer 131. Moreover, in a recent study by Devash et al. [4] in pregnant HIV-positive women who delivered infants with and without HIV infection. mothers who had high titers of certain HIV antibodies were found not to transfer the HIV infection in utero. Passive transfer of high titer p24 antibody into patients with AIDS and ARC has in two previous studies shown to clear p24 circulating antigen and to have possible clinical benefit [5,6]. Clearance of HIV by passive transfer of antibody was validated by even the sensitive method of PCR [7]. In 1988, Dr. Abraham Karpas, of Cambridge University, published in the Proceedings of’the National Academy of Science [ 5 ]preliminary results of a study in which 10 patients were treated in an open fashion. The objectives of that study was to determine the toxicity of passive transfer of immune plasma, to determine the effect on p24 antigen and antibody titers, and to determine the effects on circulating CD4+ cell counts. The treatment protocol consisted of monthly infusion of 500 ml of immune plasma infused over 1 to 2 hours. The results observed included the clearance of viral p24 antigen after infusion with patients maintained free of p24 antigen for the entire length of the study. Most of the patients showed increase in anti-viral antibody titers. Two ARC patients. in particular, showed dramatic increases in their own anti-viral titer. CD4 cell counts remained stable, particularly in patients with ARC. Clinical appraisal has revealed in a more recent evaluation of 2 years’ duration the demise of 6 AIDS patients, but with a longer than expected survival. and a better quality of life. Three ARC patients have remained stable, and have shown no worsening immune deficiency over a 24 month period. p24 antigen levels in these patients disappeared after the
+
0 1991 Wiley-Liss, Inc.
infusion of the immune plasma and maintained this antigen negative state with monthly infusions. Dr. George Jackson, in the Lancet in 1987 [6], reported on 6 advanced AIDS patients treated with high antibody plasma from to 2 HIV infected, high titer asymptomatic donors. Four of the patients were HIV antigen positive and 2 were not. The treatment protocol consisted with infusions of 55 to 550 ml of immune plasma. The dose was determined based on the formula of 1 ml per estimated picogram of p24 antigenemia, or in the absence of antigenemia 100 ml of plasma. The results of Dr. Jackson’s study revealed that HIV antigen was cleared immediately following passive immune therapy. The recipient’s serum acquired the HIV antibody profile of the donor together with HIV neutralizing activity. Passive antibody persisted up to 11 weeks depending on the volume of plasma given. Patients improved with fewer opportunistic infections, a transient increase in T lymphocytes, and improved Karnofsky index functional scores. No toxicity was demonstrated in either the Karpas or Jackson studies. Based on these previous studies it was felt that a larger double-blind controlled study was needed to clarify the safety and efficacy of passive immune therapy in the treatment of AIDS and ARC. HemaCare Corporation, in association with MediCorp, developed the donor facilities and manufacturing facilities for the performance of a clinical trial and together with 12 different physician groups, as co-investigators, located in both Southern and Northern California, applied to the California Food and Drug Branch for an IND to perform this study. The IND has been approved and the study initiated with the following protocol. The protocol is a double-blind controlled study in which 75 patients will receive 500 ml of placebo (5% human albumin), 75 patients will receive 500 ml of hyperimmune plasma, and 75 patients will receive 250 ml of hyperimmune plasma mixed with 250 ml of 5 % human albumin. Patients will be computer randomized to
Address reprint requests to Joshua Levy, M.D.. 4954 Van Nuys Boulevard. Shcrman Oaks. CA 91403.
Passive Hyperimmune Therapy
either treatment or placebo groups. The treatment will consist of the infusion of placebo or hyperimmune plasma on a monthly basis over a 12 month period. Plasma preparation will be as follows: approximately 750 ml of HIV positive plasma will be collected from donors, by automated plasmapheresis. Plasmapheresis of donors will be performed twice a month. Plasma will undergo freeze thawing to achieve cell membrane disruption of any residual cells. Viral inactivation will be accomplished by mixing the preparation for 10 minutes at room temperature, after adding beta-propiolactone at a final concentration of .25%. The plasma from 20 donors will be pooled and aliquoted into 500 cc containers that are identical to the placebo containers. The safety and efficacy of B-propiolactone (BPL) has been reviewed in number of publications [ 8- 131. Asymptomatic HIV donors will be selected based on a p24 titers of at least 1 :256. Donors will be excluded, or suspended from donating for any of the following reasons: opportunistic infections or malignancy predictive of immune deficiency; any exclusion criteria for blood donation defined by the California Health and Safety Code and our protocol; any lab test, including ALT, suggestive of impaired hepatic function. Donors will be suspended from donating if their p24 antibody level drops by more than 2 titers from their previous donation. Patient safety end points will be carefully monitored, looking for allergic reactions despite ABO matching. We will also monitor these patients for any evidence of toxicity in liver, renal, or hematologic measurements. Donor safety will be monitored by following the donors clinically, looking for opportunistic infections, malignancy, weight loss, decreased p24 antibody titers, or any abnormality in lab studies. The donors will be followed up for 3 years after donation, including a semiannual physical exam and questionnaire. The major end points for efficacy in this study will be the frequency of new or first AIDS defining opportunistic infections over the study period, the length of time until the development of a third ARC symptom, the interval until the onset of a new opportunistic infection, and the length of survival. Other end points for efficacy will include weight gain or loss over 1 year; the Karnofsky index rating; the presence or concentration of p24 antigen; HIV DNA or RNA by quantitative PCR, percent of T-4 cells; sedimentation rate; and the level of serum beta 2 microglobulin. The data will be analyzed with a statistical evaluation of the efficacy parameters at 6 month intervals and safety parameters at 2 month intervals. The analysis will be provided by an oversight patient safety monitoring
123
board, which is made up of 4 scientists and physicians from the UCLA School of Medicine. In conclusion, while we do not look upon passive hyperimmune therapy as a cure for AIDS or ARC, this treatment may well be an excellent adjunct to other drugs including anti-virals and future immune stimulants. If safety and efficiency is demonstrated by this and other studies, the next steps would be the preparation of hyperimmune IV gammaglobulins and even monoclonal antibodies.
REFERENCES I , Weiss RA. Clapham PR, Cheingsons-Popov R, et al.: Neutralization of human T lymphocytic virus type 111 by sera of AIDS and AlDS-risk patients. Nature 316:71, 1985. 2. Guroff M , Brown M. Gallo RC: HTLV-Ill neutralizing antibodies in patients with AIDS and AIDS-related complex. Nature 316:72, 1985. 3. Weber JN. Clapham PR, Seiss RA, et al.: Human immunodcficicncy virus infcction in two cohorts of homosexual mcn: neutralizing sera and association of anti-GAG antibody with prognosis. Lancet i:119-121. 1987. 4. Devash Y . et al.: Vcrtical transmission of human immunodcticiency virus is correlated with the absence of' high-affinity/avidity maternal antibodies to the gp120 principal neutralizing domain. Proc Natl Acad Sci USA 87:3445-3449, 1990. 5. Karpas A. ct al.: Effects of passive immunization in paticnts with acquired immunodeticicncy syndrome-related complex and acquired immunodeficiency syndromc. Proc Natl Acad Sci USA 95~9234-9237, 1988. 6. Jackson GG. et al: Passive immunoneutralization of Human Imniunodeficicncy virus in patients with advanced AIDS. Lancct ii:647-65 I , 1987. 7. Karpas A, ct al.: Polymerasc chain reaction cvidencc for human immunodeficiency virus 1 neutralization by passivc immunization in patients with AIDS and AIDS-relatcd complex. Proc Natl Acad Sci USA 85:7613-7617, 1990 8. Ball MJ Spriggs V. Sutton PM: Effcct of B-propiolactone-an Inhibitor of HTLV IIliLAC activity-on immunological analyses. J Immunol Methods 95: 113- 116. 1986. 9. Prince. AM, Horowitz. B, ct al: Quantitdtivc assays for evaluation of HTLV Ill inactivation procedures: tri (N-butyl) phosphate: sodium cholatc and B-propiolactone, Cancer Rca [Suppl] 45:4592~-4594s, 1985. 10. Pruggmayer D. Stcphan W: Gas chromatographic tracc analysis of B-propiolactonc in sterilized serum protcins. Vox Sang 31 : 191- 198. 1976. I I , Spirc B. Montagnicr L, et al.: Inactivation of lymphadenopathyassociated virus by chcmical disinfectants. Lancct ii:899-901, 1984. 12. Stephan W: Inactivation of hepatitis viruses and HIV in plasma and plasma derivatives by treatment with B-propiolactonciUV irradiation. Curr Stud Heniatol Blood Transfus 56: 122-127. 1989. 13. Dichtelmuller H . et al.: Inactivation of HIV in plasma derivativc by B-propiolactone and UV irradiation. lnfcction I5:63/367-65/ 369. 1987.
Passive Hyperimmune Therapy in the Treatment of AIDS and ARC Joshua Levy HemaCare Corporation, Sherman Oaks, California
The observation that some patients with HIV infection have a much more benign course and maintain good health for much longer periods caused investigators to look at what might be protective factors in these patients. One significant observation has been that these patients with milder disease have very high titers of neutralizing antibodies against the HIV virus [1,2]. Patients with frank AIDS have low titers of these antibodies, and as disease progresses high titer patients show significant decrease in their antibody titer 131. Moreover, in a recent study by Devash et al. [4] in pregnant HIV-positive women who delivered infants with and without HIV infection. mothers who had high titers of certain HIV antibodies were found not to transfer the HIV infection in utero. Passive transfer of high titer p24 antibody into patients with AIDS and ARC has in two previous studies shown to clear p24 circulating antigen and to have possible clinical benefit [5,6]. Clearance of HIV by passive transfer of antibody was validated by even the sensitive method of PCR [7]. In 1988, Dr. Abraham Karpas, of Cambridge University, published in the Proceedings of’the National Academy of Science [ 5 ]preliminary results of a study in which 10 patients were treated in an open fashion. The objectives of that study was to determine the toxicity of passive transfer of immune plasma, to determine the effect on p24 antigen and antibody titers, and to determine the effects on circulating CD4+ cell counts. The treatment protocol consisted of monthly infusion of 500 ml of immune plasma infused over 1 to 2 hours. The results observed included the clearance of viral p24 antigen after infusion with patients maintained free of p24 antigen for the entire length of the study. Most of the patients showed increase in anti-viral antibody titers. Two ARC patients. in particular, showed dramatic increases in their own anti-viral titer. CD4 cell counts remained stable, particularly in patients with ARC. Clinical appraisal has revealed in a more recent evaluation of 2 years’ duration the demise of 6 AIDS patients, but with a longer than expected survival. and a better quality of life. Three ARC patients have remained stable, and have shown no worsening immune deficiency over a 24 month period. p24 antigen levels in these patients disappeared after the
+
0 1991 Wiley-Liss, Inc.
infusion of the immune plasma and maintained this antigen negative state with monthly infusions. Dr. George Jackson, in the Lancet in 1987 [6], reported on 6 advanced AIDS patients treated with high antibody plasma from to 2 HIV infected, high titer asymptomatic donors. Four of the patients were HIV antigen positive and 2 were not. The treatment protocol consisted with infusions of 55 to 550 ml of immune plasma. The dose was determined based on the formula of 1 ml per estimated picogram of p24 antigenemia, or in the absence of antigenemia 100 ml of plasma. The results of Dr. Jackson’s study revealed that HIV antigen was cleared immediately following passive immune therapy. The recipient’s serum acquired the HIV antibody profile of the donor together with HIV neutralizing activity. Passive antibody persisted up to 11 weeks depending on the volume of plasma given. Patients improved with fewer opportunistic infections, a transient increase in T lymphocytes, and improved Karnofsky index functional scores. No toxicity was demonstrated in either the Karpas or Jackson studies. Based on these previous studies it was felt that a larger double-blind controlled study was needed to clarify the safety and efficacy of passive immune therapy in the treatment of AIDS and ARC. HemaCare Corporation, in association with MediCorp, developed the donor facilities and manufacturing facilities for the performance of a clinical trial and together with 12 different physician groups, as co-investigators, located in both Southern and Northern California, applied to the California Food and Drug Branch for an IND to perform this study. The IND has been approved and the study initiated with the following protocol. The protocol is a double-blind controlled study in which 75 patients will receive 500 ml of placebo (5% human albumin), 75 patients will receive 500 ml of hyperimmune plasma, and 75 patients will receive 250 ml of hyperimmune plasma mixed with 250 ml of 5 % human albumin. Patients will be computer randomized to
Address reprint requests to Joshua Levy, M.D.. 4954 Van Nuys Boulevard. Shcrman Oaks. CA 91403.
Passive Hyperimmune Therapy
either treatment or placebo groups. The treatment will consist of the infusion of placebo or hyperimmune plasma on a monthly basis over a 12 month period. Plasma preparation will be as follows: approximately 750 ml of HIV positive plasma will be collected from donors, by automated plasmapheresis. Plasmapheresis of donors will be performed twice a month. Plasma will undergo freeze thawing to achieve cell membrane disruption of any residual cells. Viral inactivation will be accomplished by mixing the preparation for 10 minutes at room temperature, after adding beta-propiolactone at a final concentration of .25%. The plasma from 20 donors will be pooled and aliquoted into 500 cc containers that are identical to the placebo containers. The safety and efficacy of B-propiolactone (BPL) has been reviewed in number of publications [ 8- 131. Asymptomatic HIV donors will be selected based on a p24 titers of at least 1 :256. Donors will be excluded, or suspended from donating for any of the following reasons: opportunistic infections or malignancy predictive of immune deficiency; any exclusion criteria for blood donation defined by the California Health and Safety Code and our protocol; any lab test, including ALT, suggestive of impaired hepatic function. Donors will be suspended from donating if their p24 antibody level drops by more than 2 titers from their previous donation. Patient safety end points will be carefully monitored, looking for allergic reactions despite ABO matching. We will also monitor these patients for any evidence of toxicity in liver, renal, or hematologic measurements. Donor safety will be monitored by following the donors clinically, looking for opportunistic infections, malignancy, weight loss, decreased p24 antibody titers, or any abnormality in lab studies. The donors will be followed up for 3 years after donation, including a semiannual physical exam and questionnaire. The major end points for efficacy in this study will be the frequency of new or first AIDS defining opportunistic infections over the study period, the length of time until the development of a third ARC symptom, the interval until the onset of a new opportunistic infection, and the length of survival. Other end points for efficacy will include weight gain or loss over 1 year; the Karnofsky index rating; the presence or concentration of p24 antigen; HIV DNA or RNA by quantitative PCR, percent of T-4 cells; sedimentation rate; and the level of serum beta 2 microglobulin. The data will be analyzed with a statistical evaluation of the efficacy parameters at 6 month intervals and safety parameters at 2 month intervals. The analysis will be provided by an oversight patient safety monitoring
123
board, which is made up of 4 scientists and physicians from the UCLA School of Medicine. In conclusion, while we do not look upon passive hyperimmune therapy as a cure for AIDS or ARC, this treatment may well be an excellent adjunct to other drugs including anti-virals and future immune stimulants. If safety and efficiency is demonstrated by this and other studies, the next steps would be the preparation of hyperimmune IV gammaglobulins and even monoclonal antibodies.
REFERENCES I , Weiss RA. Clapham PR, Cheingsons-Popov R, et al.: Neutralization of human T lymphocytic virus type 111 by sera of AIDS and AlDS-risk patients. Nature 316:71, 1985. 2. Guroff M , Brown M. Gallo RC: HTLV-Ill neutralizing antibodies in patients with AIDS and AIDS-related complex. Nature 316:72, 1985. 3. Weber JN. Clapham PR, Seiss RA, et al.: Human immunodcficicncy virus infcction in two cohorts of homosexual mcn: neutralizing sera and association of anti-GAG antibody with prognosis. Lancet i:119-121. 1987. 4. Devash Y . et al.: Vcrtical transmission of human immunodcticiency virus is correlated with the absence of' high-affinity/avidity maternal antibodies to the gp120 principal neutralizing domain. Proc Natl Acad Sci USA 87:3445-3449, 1990. 5. Karpas A. ct al.: Effects of passive immunization in paticnts with acquired immunodeticicncy syndrome-related complex and acquired immunodeficiency syndromc. Proc Natl Acad Sci USA 95~9234-9237, 1988. 6. Jackson GG. et al: Passive immunoneutralization of Human Imniunodeficicncy virus in patients with advanced AIDS. Lancct ii:647-65 I , 1987. 7. Karpas A, ct al.: Polymerasc chain reaction cvidencc for human immunodeficiency virus 1 neutralization by passivc immunization in patients with AIDS and AIDS-relatcd complex. Proc Natl Acad Sci USA 85:7613-7617, 1990 8. Ball MJ Spriggs V. Sutton PM: Effcct of B-propiolactone-an Inhibitor of HTLV IIliLAC activity-on immunological analyses. J Immunol Methods 95: 113- 116. 1986. 9. Prince. AM, Horowitz. B, ct al: Quantitdtivc assays for evaluation of HTLV Ill inactivation procedures: tri (N-butyl) phosphate: sodium cholatc and B-propiolactone, Cancer Rca [Suppl] 45:4592~-4594s, 1985. 10. Pruggmayer D. Stcphan W: Gas chromatographic tracc analysis of B-propiolactonc in sterilized serum protcins. Vox Sang 31 : 191- 198. 1976. I I , Spirc B. Montagnicr L, et al.: Inactivation of lymphadenopathyassociated virus by chcmical disinfectants. Lancct ii:899-901, 1984. 12. Stephan W: Inactivation of hepatitis viruses and HIV in plasma and plasma derivatives by treatment with B-propiolactonciUV irradiation. Curr Stud Heniatol Blood Transfus 56: 122-127. 1989. 13. Dichtelmuller H . et al.: Inactivation of HIV in plasma derivativc by B-propiolactone and UV irradiation. lnfcction I5:63/367-65/ 369. 1987.
