Monika Stadler

Degradation products of factor VIII which can lead to increased immunogenicity.

The biochemical and immunochemical aspects of the development of inhibitors with a plasma–derived, double–virus inactivated factor VIII (FVIII) concentrate (marketed as Octavi SDPlus in Germany and Bisinact in Belgium) are described. A total of 12 cases of inhibitor formation (predominantly type II) were reported in Germany, 8 in Belgium but none in Portugal. Initially, the only difference between the non–pasteurised, SD virus–inactivated product Octavi and the pasteurised product Octavi SDPlus appeared to be pasteurisation, though subsequently, the quality of source material for the product was found to differ in different countries. Separation studies revealed the presence of a 40 kDa peptide fragment in some batches. It was subsequently shown that there was a strong correlation between inhibitor development and batches containing the 40 kDa marker, and a relationship between elevated markers of coagulation activation (FPA in particular) and the occurrence of the 40 kDa marker. Further work revealed that analytical methods commonly used for quality control were not suitable to highlight batch–to–batch differences. It was concluded that inhibitor potential (neoantigenicity) in Octavi SDPlus arose due to two effects; degradation of FVIII already present in source material; and heating of unstable FVIII degradation products. In this case, inhibitors were not caused by the overall production process, nor by GMP failures. The problem of inhibitor potential can be avoided if appropriate preventive measures are taken. Further work is needed to prove non–neoantigenicity and to reinforce the scientific findings, and to characterise pilot batches.

Molecular modifications in factor VIII concentrates produced from different plasma pools.

We defined the main cause for the increased immunogenicity of the commercial factor VIII (fVIII) plasma-derived concentrates reported to induce formation of inhibitory antibodies in haemophilia A patients in Germany and Belgium. Formation of these antibodies directed against the C2 domain of fVIII was previously attributed to the use of solvent/detergent (S/D) treatment and pasteurisation for virus inactivation of fVIII concentrate. Since fVIII concentrates associated with increased immunogenicity were prepared from plasma pools characterised by elevated levels of coagulation markers, we examined whether the plasma source or S/D treatment and pasteurisation are responsible for structural changes within the C2 domain causing its abnormal immunogenicity. We found that samples of fVIII concentrate that originated from the abnormal plasma pool had a reduced ability to bind to phospholipid and conformationally sensitive anti-C2 domain antibodies, this effect being mostly pronounced in the samples that underwent both S/D treatment and pasteurisation. Thus, our study suggests that insufficient quality of the starting plasma pools is the major factor determining the structural alterations in the C2 domain of fVIII, whereas combination of S/D treatment and pasteurisation aggravates these changes.