Assessing Physicochemical Stability of Monoclonal Antibodies in a Simulated Subcutaneous Environment.

Monoclonal antibodies (mAbs) are being increasingly administered by the subcutaneous (SC) route compared to the traditional intravenous route. Despite the growing popularity of the subcutaneous route, our current knowledge regarding the intricate mechanistic changes happening in the formulation after injection in the subcutaneous space, as well as the in vivo stability of administered mAbs, remains quite limited. Changes in the protein environment as it transitions from a stabilized, formulated drug product in an appropriate container closure to the SC tissue environment can drastically impact the structural stability and integrity of the injected protein. Interactions of the protein with components of the extracellular matrix can lead to changes in its structure, potentially impacting both safety and efficacy. Investigating protein stability in the SC space can enable early assessment of risk and performance of subcutaneously administered proteins influencing clinical decisions and formulation development strategies. The Subcutaneous Injection Site Simulator (SCISSOR) is a novel in vitro system that mimics the subcutaneous injection site and models the events that a protein goes through as it transitions from a stabilized formulation environment to the dynamic physiological space. In this paper, we utilize the SCISSOR to probe for biophysical and chemical changes in seven mAbs post SC injection using a variety of analytical techniques. After 24 h, all mAbs demonstrated a relative decrease in conformational stability, an increase in fragmentation, and elevated acidic species. Higher order structure analysis revealed a deviation in the secondary structure from the standard and an increase in the number of unordered species. Our findings suggest an overall reduced stability of mAbs after subcutaneous administration. This reduced stability could have a potential impact on safety and efficacy. In vitro systems such as the SCISSOR combined with downstream analyses have potential to provide valuable information for assessing the suitability of lead molecules and aid in formulation design optimized for administration in the intended body compartment, thus improving chances of clinical success.

Laser Measurement and Numerical Simulation of Elastomer Stopper Motion during High-Altitude Shipping of Pharmaceutical Syringes.

During high-altitude shipping of pre-filled syringes, pressure differentials can cause the elastomer stopper to move unintentionally. This motion represents a risk to container closure integrity and drug product sterility. To understand and quantitate this risk, we combined high-accuracy laser measurements and numerical simulations of stopper motion. We tested the effects of syringe barrel siliconization, stopper design, syringe orientation, and altitude rate on stopper displacement; only the siliconization factor had a significant effect. Our observations were compared with two mathematical models based on Boyle's Law and a force balance approach. For well-lubricated syringes, stopper motion was reasonably predicted by Boyle's Law (residual ≤ 10%). When the lubricant amount was reduced, Boyle's Law failed to accurately predict stopper motion (residual ≈ 40%). To simulate stopper motion more accurately, we developed a dynamic model in MATLAB-Simulink to incorporate the dry and viscous friction inherent to the lubricated interference fit. Using a Coulomb-viscous subroutine, deviations from Boyle's Law were successfully explained in terms of the displacement, but the system dynamics were not fully accurate. The combination of laser measurements and numerical simulation has yielded unique insight into stopper motion during high-altitude shipping. These tools can provide valuable input to a risk-based drug development strategy to enable global distribution of pre-filled syringes.

The Race to Develop the Pfizer-BioNTech COVID-19 Vaccine: From the Pharmaceutical Scientists' Perspective.

At the outset of the coronavirus disease 2019 (COVID-19) pandemic, it was clear that a vaccine would be crucial for global health efforts. The Pfizer and BioNTech teams came together in a race against the virus, working to design, test, manufacture, and distribute a safe and efficacious vaccine in record time for people around the world. Here, we provide backstory commentary from the pharmaceutical scientist perspective on the challenges and solutions encountered in the development of the Pfizer-BioNTech mRNA COVID-19 vaccine (BNT162b2; b2; Comirnaty®; tozinameran). We discuss the foundational science that led to the decision to use an mRNA-based approach. We also describe key challenges in the identification of an optimal vaccine candidate and testing in clinical trials, the continuous efforts to improve the vaccine formulation in response to changing global health priorities and facilitate vaccine accessibility, and how vast quantities of vaccine doses were manufactured and safely delivered to every corner of the globe, all without compromising quality, science, and safety. The key to successfully delivering a safe and efficacious vaccine within nine months was a result of extraordinary, real-time, parallel effort and across-the-board collaboration between stakeholders on a global scale.

The journey of a lifetime - development of Pfizer's COVID-19 vaccine.

It would be apt to say that one of the greatest accomplishments in modern medicine has been the development of vaccines against COVID-19, which had paralyzed the entire world for more than a year. Pfizer and BioNTech codeveloped the first COVID-19 vaccine that was granted emergency-use authorization or conditional approval in several regions globally. This article is an attempt to go 'behind-the-scenes' of this development process and highlight key factors that allowed us to move with this unprecedented speed, while adhering to normal vaccine-development requirements to generate the information the regulatory authorities needed to assess the safety and effectiveness of a vaccine to prevent an infectious disease, including quality and manufacturing standards. This is also a story of how Pfizer and BioNTech leveraged our combined skill sets and experience to respond to the global health crisis to progress this program swiftly while ensuring the compliance with our high-quality standards and keeping patient safety at the forefront. We will also highlight multiple other factors that were instrumental in our success.

Subcutaneous Delivery of High-Dose/Volume Biologics: Current Status and Prospect for Future Advancements.

Subcutaneous (SC) delivery of biologics has traditionally been limited to fluid volumes of 1-2 mL, with recent increases to volumes of about 3 mL. This injection volume limitation poses challenges for high-dose biologics, as these formulations may also require increased solution concentration in many cases, resulting in high viscosities which can affect the stability, manufacturability, and delivery/administration of therapeutic drugs. Currently, there are technologies that can help to overcome these challenges and facilitate the delivery of larger amounts of drug through the SC route. This can be achieved either by enabling biologic molecules to be formulated or delivered as high-concentration injectables (>100 mg/mL for antibodies) or through facilitating the delivery of larger volumes of fluid (>3 mL). The SC Drug Delivery and Development Consortium, which was established in 2018, aims to identify and address critical gaps and issues in the SC delivery of high-dose/volume products to help expand this delivery landscape. Identified as a high priority out of the Consortium's eight problem statements, it highlights the need to shift perceptions of the capabilities of technologies that enable the SC delivery of large-volume (>3 mL) and/or high-dose biologics. The Consortium emphasizes a patient-focused approach towards the adoption of SC delivery of large-volume/high-concentration dosing products to facilitate the continued expansion of the capabilities of novel SC technologies. To raise awareness of the critical issues and gaps in high-dose/volume SC drug development, this review article provides a generalized overview of currently available and emerging technologies and devices that could facilitate SC delivery of high-dose/volume drug formulations. In addition, it discusses the challenges, gaps, and future outlook in high-dose/volume SC delivery as well as potential solutions to exploit the full value of the SC route of administration.

Accelerating the development of novel technologies and tools for the subcutaneous delivery of biotherapeutics.

Subcutaneous (SC) delivery of biotherapeutics is well established as a route of administration across many therapeutic areas and has been shown to be effective and well-tolerated. It can offer several advantages over intravenous administration. This notwithstanding, there remain critical development issues and knowledge gaps in SC drug delivery. To articulate and address these issues, the SC Drug Delivery and Development Consortium was convened in 2018 as a pre-competitive collaboration of industry experts in drug delivery, device development, and commercialization. In this review, we outline the Consortium's vision and mission in advancing the development of patient-centered biotherapeutics and establishing a collaborative organization that facilitates open sharing of information and gives voice to diverse viewpoints from SC experts across industries and disciplines. Additionally, we describe the current landscape and challenges associated with SC administration of therapeutic proteins (specifically monoclonal antibodies) and offer insights into potential solutions to these challenges within the context of 8 problem statements developed by the Consortium to highlight key gaps, unmet needs, and actionable issues. Current and future opportunities to accelerate progress in the field through technological advances and the development of drug delivery tools are also discussed.

Transcending the skin barrier to deliver peptides and proteins using active technologies.

Peptides and proteins have been investigated as promising therapeutic agents over the past decade. These macromolecules are conventionally administered by the parenteral route because oral delivery is associated with degradation in the gastrointestinal tract. Transdermal delivery presents a promising alternative route of drug delivery, avoiding pain associated with parenteral administration and degradation issues associated with oral delivery. However, the barrier properties of skin limit delivery to only small, moderately lipophilic molecules. Hence, hydrophilic macromolecules like peptides and proteins cannot passively permeate across skin. Active physical enhancement approaches such as iontophoresis electroporation, microneedles treatment, and sonophoresis have been developed to assist transdermal delivery of peptides and proteins. This review describes active physical transdermal enhancement approaches for transdermal delivery of peptides and proteins. The mechanisms associated with each technique and important parameters governing transdermal delivery of peptides and proteins are discussed in detail. Combinations of enhancement techniques for synergistic enhancement in protein and peptide delivery are also discussed.

Iontophoresis of a 13 kDa protein monitored by subcutaneous microdialysis in vivo.

BACKGROUND: The purpose of this study was to optimize parameters pertaining to microdialysis technique so as to make this method feasible for evaluating transdermal transport of macromolecules. RESULTS: Microdialysis experiments were performed in vivo using hairless rats with daniplestim as the model protein. Two perfusion fluids - phosphate-buffered saline (PBS) and 3% dextran in PBS - were evaluated with respect to their effect on sample volume retrieval and recovery of the target protein from the microdialysis probe. Incorporation of dextran-60 in the perfusion fluid reduced fluid loss to 10% as opposed to 34% in the absence of dextran-60. Improvement in daniplestim recovery was also seen with dextran-PBS (56.5 ± 10.3%) as the perfusion fluid than with PBS alone (26.7±4.5%). CONCLUSION: Subcutaneous levels of daniplestim were measured following iontophoresis after improving recovery and minimizing fluid loss from the microdialysis probe.

Development of biotechnology products in pre-filled syringes: technical considerations and approaches.

A monoclonal antibody (mAb) product development case study is presented to address some of the issues faced during developing a pre-filled syringe (PFS) product for a biotherapeutic. In particular, issues involving incompatibility with silicone oil and a stability-based approach for selection of PFS barrel and tip cap components have been discussed. Silicone spiking studies followed by exposure to agitation stress or accelerated temperature conditions were used to check for incompatibilities of the mAb with silicone oil, a necessary product contact material in PFS. In addition, screening studies to compare various closure materials as well as syringe barrel processing methods were used to select the optimum closure materials as well as the correct syringe processing method. Results indicate that the model mAb formulation used was sensitive to high levels of silicone oil especially under accelerated temperature conditions resulting in formation of protein-silicone particles in the solution for samples that were spiked with the silicone oil. Agitation stress did not have any significant impact on the quality attributes tested. Samples stored in syringe barrels that were processed with sprayed-on silicone had higher levels of subvisible particles as compared to those that were processed with the baked-on process. The tip cap comparability study resulted in one tip cap material having superior compatibility among the three that were tested. The quality attribute that was most impacted by the tip cap materials was mAb oxidation. An approach for evaluation of primary packaging components during the development of pre-filled syringe presentations for biotechnology-based compounds has been highlighted.

Protein and solute distribution in drug substance containers during frozen storage and post-thawing: a tool to understand and define freezing-thawing parameters in biotechnology process development.

Active pharmaceutical ingredient for biotechnology-based drugs, commonly known as drug substance (DS), is often stored frozen for longer shelf-life. Freezing DS enhances stability by slowing down reaction rates that lead to protein instability, minimizes the risk of microbial growth, and eliminates the risk of transport-related stress. High density polyethylene bottles are commonly used for storing monoclonal antibody DS due to good mechanical stress/strain resistant properties even at low temperatures. Despite the aforementioned advantages for frozen storage of DS, this is not devoid of risks. Proteins are known to undergo ice-water surface denaturation, cryoconcentration, and cold denaturation during freezing. A systematic investigation was performed to better understand the protein and solute distribution along with potential of aggregate formation during freeze and thaw process. A significant solute and protein concentration gradient was observed for both frozen and thawed DS bottles. In case of thawed DS, cryoconcentration was localized in the bottom layer and a linear increase in concentration as a function of liquid depth was observed. On the other hand, for frozen DS, a "bell shaped" cryoconcentration distribution was observed between the bottom layers and centre position. A cryoconcentration of almost three-fold was observed for frozen DS in the most concentrated part when freezing was conducted at -20 and -40 °C and 2.5-fold cryoconcentration was observed in the thawed DS before mixing. The information obtained in this study is critical to design freeze thaw experiments, storage condition determination, and process improvement in manufacturing environment.

Transdermal delivery of a approximately 13 kDa protein--an in vivo comparison of physical enhancement methods.

The availability of several enhancement techniques has made it possible to study delivery of macromolecules through skin. This study was conducted to evaluate the transdermal delivery of a ~13 kDa protein using iontophoresis, sonophoresis, and microneedles alone or in combination. In vivo delivery experiments were carried out using hairless rats with daniplestim (DP) as the model protein (molecular weight: 12.760 kDa; isoelectric point, 6.2). Delivery enhancement abilities of the above techniques were evaluated at two different drug concentrations in the patch: 2 mg/mL and 5 mg/mL. At a drug loading concentration of 2 mg/mL maximum delivery was seen with the combination of microneedles and iontophoresis. At 5 mg/mL, sonophoresis alone gave a C(max) of 8.22 +/- 5.9 ng/mL and a combination of sonophoresis and iontophoresis gave a C(max) of 4.9 +/- 1.8 ng/mL. The results of this study suggest that combination of microneedles and iontophoresis was the most effective approach in delivering a 13 kDa protein through the skin.

Microchannels created by sugar and metal microneedles: characterization by microscopy, macromolecular flux and other techniques.

The objective of this study was to investigate the feasibility of using microneedle technology to enhance transcutaneous permeation of human immunoglobulin G (IgG) across hairless rat skin. Microchannels created by maltose and metal (DermaRoller) microneedles were characterized by techniques such as methylene blue staining, histological examination, and calcein imaging. Methylene blue staining and histological sections of treated skin showed that maltose microneedles and DermaRoller breached the skin barrier by creating microchannels in the skin with an average depth of approximately 150 microm, as imaged by confocal microscopy. Calcein imaging and pore permeability index values suggested the uniformity of the created pores in microneedle-treated skin. Transdermal studies with IgG indicated a flux rate of 45.96 ng/cm(2)/h, in vitro, and a C(max) of 7.27 ng/mL, in vivo, for maltose microneedles-treated skin while a flux rate of 353.17 ng/cm(2)/h, in vitro, and a C(max) of 9.33 ng/mL, in vivo, was achieved for DermaRoller-treated skin. Transepidermal water loss measurements and methylene blue staining, in vivo, indicated the presence of microchannels for upto 24 h, when occluded. In conclusion, the microchannels created by maltose microneedles and DermaRoller resulted in the percutaneous enhancement of a macromolecule, human IgG.

Long- and short-range electrostatic interactions affect the rheology of highly concentrated antibody solutions.

PURPOSE: To explain the differences in protein-protein interactions (PPI) of concentrated versus dilute formulations of a model antibody. METHODS: High frequency rheological measurements from pH 3.0 to 12.0 quantitated viscoelasticity and PPI at high concentrations. Dynamic light scattering (DLS) characterized PPI in dilute solutions. RESULTS: For concentrated solutions at low ionic strength, the storage modulus, a viscosity component and a measure of PPI, is highest at the isoelectric point (pH 9.0) and lowest at pH 5.4. This profile flattens at higher ionic strength but not completely, indicating PPI consist of long-range electrostatics and other short-range attractions. At low concentrations, PPI are near zero at pI but become repulsive as the pH is shifted. Higher salt concentrations completely flatten this profile to zero, indicating that these PPI are mainly electrostatic. CONCLUSIONS: This discrepancy occurs because long-range interactions are significant at low concentrations, whereas both long- and short-range interactions are significant at higher concentrations. Computer modeling was used to calculate antibody properties responsible for long- and short-range interactions, i.e. net charge and dipole moment. Charge-charge interactions are repulsive while dipole-dipole interactions are attractive. Their net effect correlated with the storage modulus profile. However, only charge-charge repulsions correlated with PPI determined by DLS.

Molecular charge mediated transport of a 13 kD protein across microporated skin.

Transport of proteins across the skin is highly limited owing to their hydrophilic nature and large molecular size. This study was conducted to assess the skin transport abilities of a model protein across hairless rat skin during iontophoresis alone and in combination with microneedles as a function of molecular charge. The effect of microneedle pretreatment on electroosmotic flow was also investigated. Skin permeation experiments were carried out in vitro using daniplestim (DP) (MW, 12.76 kD; isoelectric point, 6.2) as a model protein molecule. The effect of molecular charge on protein transport was evaluated by performing studies in two different buffers--TRIS (pH 7.5) and acetate (pH 4.0). Iontophoretic transport mechanisms of DP varied with respect to molecular charge on the protein. The combination approach (iontophoresis and microneedles) gave much higher flux values compared to iontophoresis alone at both pH 4.0 and pH 7.5, however, the delivery in this case was also found to be charge dependent. The findings of this study indicate that electroosmosis persisted upon microporation, thus retaining skin's permselective properties. This enables us to explore the combination of microneedles and iontophoresis as a potential approach for delivery of proteins.

In vitro transdermal delivery of therapeutic antibodies using maltose microneedles.

This paper investigates the microneedle-mediated in vitro transdermal delivery of human IgG as a model protein and demonstrates its applicability to deliver a monoclonal antibody. Microchannels created by the treatment of maltose microneedles in full thickness hairless rat skin were visualized using methylene blue staining. Cryostat sections were prepared and stained using hematoxylin and eosin to locate the depth of penetration. In vitro penetration studies were conducted using freshly excised full thickness hairless rat skin and various parameters like needle length, number of needles and effect of donor concentration were examined. Pathway of IgG transport across skin was confirmed by immunohistochemical (IHC) studies. A monoclonal antibody was delivered under optimized conditions. Methylene blue was taken up by microchannels indicating disruption of the stratum corneum and cryosections showed that microneedles just reached the dermis. Human IgG delivery increased with increase in arrays of microneedles, concentration and length of microneedles. IHC studies demonstrated that IgG follows microchannels for transport across the skin. Transdermal delivery was also demonstrated for the monoclonal antibody. In conclusion, maltose microneedles provide a means for the transdermal delivery of macromolecules.

Ultrasonic rheology of a monoclonal antibody (IgG2) solution: implications for physical stability of proteins in high concentration formulations.

The purpose of this work was to investigate if physical stability of a model monoclonal antibody (IgG(2)), as determined by extent of aggregation, was related to rheology of its solutions. Storage stability of the model protein was assessed at 25 degrees C and 37 degrees C for three months in solutions ranging from pH 4.0 to 9.0 and ionic strengths of 4 mM and 300 mM. The rheology of IgG(2) solutions has been characterized at 25 degrees C in our previous work and correlation of solution storage modulus (G') with protein-protein interactions established. The extent of aggregation was consistent with solution rheology as understood in terms of changes in G' with protein concentration. Thermodynamic stability of native IgG(2) conformation increased with increasing pH. The correlation between rheology and aggregation was also assessed at increased ionic strengths. The decrease in aggregation was consistent with change in solution rheology profile at pH 7.4 and 9.0. The results provide evidence of a relationship between solution rheology and extent of aggregation for the model protein studied. The implications of this relationship for formulation and physical stability assessment in high concentration protein solutions are discussed.

Transdermal delivery of interferon alpha-2B using microporation and iontophoresis in hairless rats.

PURPOSE: To demonstrate transdermal delivery of interferon alpha-2b (IFNalpha2b) in hairless rats through aqueous microchannels (micropores) created in the skin and enhanced by iontophoresis. MATERIALS AND METHODS: The Altea Therapeutics PassPort System was configured to form an array of micropores (2.0 cm(2); 72 micropores/cm(2)) on the rat abdomen. The transdermal patch (Iomed TransQ1-GS-hydrogel) was saturated with an IFNalpha2b solution (600 microg/ml) and applied for 4 h. Delivery was evaluated with and without cathodic iontophoresis (0.1 mA/cm(2)). Intravenous delivery (0.4 microg/100 g body weight) was performed to support pharmacokinetic calculations. RESULTS: IFNalpha2b was not delivered through intact skin by itself (passive delivery) or during iontophoresis. However, passive delivery through micropores was achieved in vivo in rats. A dose of 397 +/- 67 ng was delivered over 6 h, with steady state serum concentrations reaching a plateau at 1 h post-patch application. These levels dropped rapidly after patch removal, and returned to baseline within 2 h of patch removal. Iontophoresis-enhanced delivery through micropores resulted in a two-fold increase in the dose delivered (722 +/- 169 ng) in the hairless rat. CONCLUSIONS: In vivo delivery of IFNalpha2b was demonstrated through micropores created in the outer layer of the skin. Iontophoresis enhanced delivery through microporated skin in hairless rats.

Ultrasonic storage modulus as a novel parameter for analyzing protein-protein interactions in high protein concentration solutions: correlation with static and dynamic light scattering measurements.

The purpose of this work was to establish ultrasonic storage modulus (G') as a novel parameter for characterizing protein-protein interactions (PPI) in high concentration protein solutions. Using an indigenously developed ultrasonic shear rheometer, G' for 20-120 mg/ml solutions of a monoclonal antibody (IgG(2)), between pH 3.0 and 9.0 at 4 mM ionic strength, was measured at frequency of 10 MHz. Our understanding of ultrasonic rheology indicated decrease in repulsive and increase in attractive PPI with increasing solution pH. To confirm this behavior, dynamic (DLS) and static (SLS) light scattering measurements were conducted in dilute solutions. Due to technical limitations, light scattering measurements could not be conducted in concentrated solutions. Mutual-diffusion coefficient, measured by DLS, increased with IgG(2) concentration at pH 4.0 and this trend reversed as pH was increased to 9.0. Second virial coefficient, measured by SLS, decreased with increasing pH. These observations were consistent with the nature of PPI understood from G' measurements. Ultrasonic rheology, DLS, and SLS measurements were also conducted under conditions of increased ionic strength. The consistency between rheology and light scattering analysis under various solution conditions established the utility of ultrasonic G' measurements as a novel tool for analyzing PPI in high protein concentration systems.

Application of high-frequency rheology measurements for analyzing protein-protein interactions in high protein concentration solutions using a model monoclonal antibody (IgG2).

The purpose of this work was to explore the utilization of high-frequency rheology analysis for assessing protein-protein interactions in high protein concentration solutions. Rheology analysis of a model monoclonal immunoglobulin G2 solutions was conducted on indigenously developed ultrasonic shear rheometer at frequency of 10 MHz. Solutions at pH 9.0 behaved as most viscous and viscoelastic whereas those at pH 4.0 and 5.4 exhibited lower viscosity and viscoelasticity, respectively. Intrinsic viscosity, hydrophobicity, and conformational analysis could not account for the rheological behavior of IgG2 solutions. Zeta potential and light scattering measurements showed the significance of electroviscous and specific protein-protein interactions in governing rheology of IgG2 solutions. Specific protein-protein interactions resulted in formation of reversible higher order species of monomer. Solution storage modulus (G'), and not loss modulus or complex viscosity, was the more reliable parameter for predicting protein-protein interactions. Predictions about the nature of protein-protein interactions made on the basis of solution G' were found to be consistent with observed effect of pH and ionic strength on zeta potential and scattered intensity of IgG2 solutions. Results demonstrated the potential of high-frequency storage modulus measurements for understanding behavior of proteins in solutions and predicting the nature of protein-protein interactions.

Protein structural conformation and not second virial coefficient relates to long-term irreversible aggregation of a monoclonal antibody and ovalbumin in solution.

PURPOSE: The purpose of the study was to investigate the relationship of the second virial coefficient, B22, to the extent of irreversible protein aggregation upon storage. METHODS: A monoclonal antibody and ovalbumin were incubated at 37 degrees C (3 months) under various solution conditions to monitor the extent of aggregation. The B22 values of these proteins were determined under similar solution conditions by a modified method of flow-mode static light scattering. The conformation of these proteins was studied using circular dichroism (CD) spectroscopy and second-derivative Fourier transform infrared spectroscopy. RESULTS: Both proteins readily aggregated at pH 4.0 (no aggregation observed at pH 7.4); the extent of aggregation varied with the ionic strength and the presence of cosolutes (sucrose, glycine, and Tween 80). Debye plots of the monoclonal antibody showed moderate attractive interactions at pH 7.4, whereas, at pH 4.0, nonlinear plots were obtained, indicating self-association. CD studies showed partially unfolded structure of antibody at pH 4.0 compared with that at pH 7.4. In the case of ovalbumin, similar B22 values were obtained in all solution conditions irrespective of whether the protein aggregated or not. CD studies of ovalbumin indicated the presence of a fraction of completely unfolded as well as partially unfolded species at pH 4.0 compared with that at pH 7.4. CONCLUSIONS: The formation of a structurally altered state is a must for irreversible aggregation to proceed. Because this aggregation-prone species could be an unfolded species present in a small fraction compared with that of the native state or it could be a partially unfolded state whose net interactions are not significantly different compared with those of the native state, yet the structural changes are sufficient to lead to long-term aggregation, it is unlikely that B22 will correlate with long-term aggregation.