Stability of Protein Pharmaceuticals: Recent Advances.

There have been significant advances in the formulation and stabilization of proteins in the liquid state over the past years since our previous review. Our mechanistic understanding of protein-excipient interactions has increased, allowing one to develop formulations in a more rational fashion. The field has moved towards more complex and challenging formulations, such as high concentration formulations to allow for subcutaneous administration and co-formulation. While much of the published work has focused on mAbs, the principles appear to apply to any therapeutic protein, although mAbs clearly have some distinctive features. In this review, we first discuss chemical degradation reactions. This is followed by a section on physical instability issues. Then, more specific topics are addressed: instability induced by interactions with interfaces, predictive methods for physical stability and interplay between chemical and physical instability. The final parts are devoted to discussions how all the above impacts (co-)formulation strategies, in particular for high protein concentration solutions.'

Depression Is Associated With Non-Home Discharge After Coronary Artery Bypass Graft.

INTRODUCTION: Depression is disproportionately high in patients with coronary artery disease and has been associated with adverse outcomes following coronary artery bypass graft (CABG). One quality metric, non-home discharge (NHD), can have substantial implications for patients and health care resource utilization. Depression increases the risk of NHD after many operations, but it has not been studied after CABG. We hypothesized that a history of depression would be associated with an increased risk of NHD following CABG. METHODS: CABG cases were identified from the 2018 National Inpatient Sample using ICD-10 codes. Depression, demographic data, comorbidities, length of stay (LOS), rate of NHD were analyzed using appropriate statistical tests where a P-value < 0.05 was defined as statistically significant. Adjusted multivariable logistic regression models were used to assess independent association between depression and NHD as well as LOS while controlling for confounders. RESULTS: There were 31,309 patients, of which 2743 (8.8%) had depression. Depressed patients were younger, females, in a lower income quartile, and more medically complex. They also demonstrated more frequent NHD and prolonged LOS. After adjusted multivariable analysis, depressed patients had a 70% increased odds of NHD (adjusted odds ratio: 1.70 [1.52-1.89] P < 0.001) and a 24% increased odds of prolonged LOS (AOR: 1.24 [1.12-1.38] P < 0.001). CONCLUSIONS: From a national sample, depressed patients were associated with more frequent NHD following CABG. To our knowledge, this is the first study to demonstrate this, and it highlights the need for improved preoperative identification in order to improve risk stratification and timely allocation of discharge services.

A Systematic Review and Meta-Analysis to Assess the Impact of Pre-existing Comorbidities on the 30-Day Readmission after Lower Extremity Bypass Surgery for Peripheral Artery Occlusive Disease.

BACKGROUND: Unplanned hospital readmissions after surgical operations are considered a marker for suboptimal care during index hospitalizations and are associated with poor patient outcomes and increased healthcare resource utilization. Patients undergoing lower extremity bypass (LEB) operations for severe peripheral arterial disease (PAD) have one of the highest readmission rates, among all the vascular and nonvascular surgical operations. This review is meant to evaluate the impact of pre-existing comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), and coronary artery disease (CAD))-on the 30-day readmission rates among patients who underwent LEB for severe PAD. METHODS: The review protocol was registered to the PROSPERO database (CRD42021261067). A systematic review of the English literature was performed using PubMed, Scopus, and the Cochrane Library databases from inception till April 2022. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting on 30-day readmission following LEB for occlusive PAD. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and was reported as high, moderate, or low. The risk of bias was evaluated utilizing the Risk of Bias in Nonrandomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for each study was computed, and a P-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS: Five studies reported data on 30-day readmission after LEB for occlusive PAD. A total of 19,739 patients were included. Readmission occurred among 3,559 (18%) patients. DM and COPD were reported by all 5 selected studies, and CHF and HTN were reported by 4 studies. CAD was least reported among the selected 5 pre-existing conditions, with only 2 studies mentioning it. HTN (OR, 1.35; 95% confidence interval (CI), 1.10-1.64; P ≤ 0.001; I2 = 52.20%), DM (OR, 1.52; 95% CI, 1.30-1.79; P ≤ 0.001; I2 = 74.51%), and CHF (OR, 1.85; 95% CI, 1.51-2.25; P ≤ 0.001; I2 = 50.48%) were all found to be associated with an increased risk of 30-day readmission, while the presence of COPD (OR, 1.16; 95% CI, 0.98-1.36; P = 0.09; I2 = 61.93%) and CAD (OR, 1.30; 95% CI, 0.94-1.78; P = 0.11; I2 = 51.01%) was not associated with early readmission on meta-analysis of the available studies. CONCLUSIONS: The pre-existing comorbidities HTN, DM, and CHF increase the risk of 30-day readmission after LEB for occlusive PAD. The identification of these risk factors can help stratify the patients and further guide in understanding the variety of factors that contribute in hospital readmissions.

Characterization of Oligomer Formation of Surfactant Protein-D (SP-D) Using AF4-MALLS.

BACKGROUND: Surfactant protein-S (SP-D) is a naturally occurring lung protein with the potential to treat pulmonary infections. A recombinant surfactant protein-D (SP-D) has been produced and was previously found to exist in multiple oligomeric states. INTRODUCTION: Separation and characterization of interconverting oligomeric states of a protein can be difficult using chromatographic methods, so an alternative separation technique was employed for SPD to characterize the different association states that exist. METHODS: Samples of SP-D were analyzed using asymmetrical flow field-flow fractionation (AF4) using UV and multi-angle laser light scattering (MALLS) detection. The AF4 method appears to be able to separate species as small as the monomer up to the dodecamer (the dominant species) to much larger species with a molar mass greater than 5 MDa. RESULTS: Consistent elution of four distinct peaks was observed after repeated injections. The largest species observed under the last peak (labeled as Peak 4) were termed "unstructured multimers" and were resolved fairly well from the other species. The AF4-MALLS data suggest that only a small fraction of Peak 4 truly corresponds to high molar mass unstructured multimers. All other peaks demonstrated significant molar mass homogeneity consistent with AFM results. CONCLUSION: AF4-MALLS technology appears to be a powerful analytical approach to characterize the complex and dynamic interplay among different protein oligomeric species of SP-D in an aqueous solution.

A Randomized Clinical Trial of Perfusion Modalities in Pediatric Congenital Heart Surgery Patients.

BACKGROUND: The objective of this randomized clinical trial was to investigate the effects of perfusion modalities on cerebral hemodynamics, vital organ injury, quantified by the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score, and clinical outcomes in risk-stratified congenital cardiac surgery patients. METHODS: This randomized clinical trial included 159 consecutive congenital cardiac surgery patients in whom pulsatile (n = 83) or nonpulsatile (n = 76) perfusion was used. Cerebral hemodynamics were assessed using transcranial Doppler ultrasound. Multiple organ injury was quantified using the PELOD-2 score at 24, 48, and 72 hours. Clinical outcomes, including intubation time, intensive care unit length of stay (LOS), hospital LOS, and mortality, were also evaluated. RESULTS: The Pulsatility Index at the middle cerebral artery and in the arterial line during aortic cross-clamping was consistently better maintained in the pulsatile group. Demographics and cardiopulmonary bypass characteristics were similar between the 2 groups. While risk stratification with The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Categories was similar between the groups, Mortality Categories 1 to 3 demonstrated more patients than Mortality Categories 4 and 5. There were no differences in clinical outcomes between the groups. The PELOD-2 scores showed a progressive improvement from 24 hours to 72 hours, but the results were not statistically different between the groups. CONCLUSIONS: The Pulsatillity Index for the pulsatile group demonstrated a more physiologic pattern compared with the nonpulsatile group. While pulsatile perfusion did not increase plasma-free hemoglobin levels or microemboli delivery, it also did not demonstrate any improvements in clinical outcomes or PELOD-2 scores, suggesting that while pulsatile perfusion is a safe method, it not a "magic bullet" for congenital cardiac operations.

Are outcomes in congenital cardiac surgery better than ever?

BACKGROUND AND AIM OF THE STUDY: Congenital heart disease is the most common congenital defect among infants born in the United States. Within the first year of life, 1 in 4 of these infants will need surgery. Only one generation removed from an overall mortality of 14%, many changes have been introduced into the field. Have these changes measurably improved outcomes? METHODS: The literature search was conducted through PubMed MEDLINE and Google Scholar from inception to October 31, 2021. Ultimately, 78 publications were chosen for inclusion. RESULTS: The outcome of overall mortality has experienced continuous improvements in the modern era of the specialty despite the performance of more technically demanding surgeries on patients with complex comorbidities. This modality does not account for case-mix, however. In turn, clinical outcomes have not been consistent from center to center. Furthermore, variation in practice between institutions has also been documented. A recurring theme in the literature is a movement toward standardization and universalization. Examples include mortality risk-stratification that has allowed direct comparison of outcomes between programs and improved definitions of morbidities which provide an enhanced framework for diagnosis and management. CONCLUSIONS: Overall mortality is now below 3%, which suggests that more patients are surviving their interventions than in any previous era in congenital cardiac surgery. Focus has transitioned from survival to improving the quality of life in the survivors by decreasing the incidence of morbidity and associated long-term effects. With the transformation toward standardization and interinstitutional collaboration, future advancements are expected.

Analysis of Peptides using Asymmetrical Flow Field-flow Fractionation (AF4).

While asymmetrical flow field-flow fractionation (AF4) has been widely used for separation of high molecular weight species and even particles, its ability to resolve lower molecular weight species has rarely been explored. Over the course of many projects, we have discovered that AF4 can be an effective analytical method for separating peptides from oligomers and higher molecular weight aggregates. The methodology can be used even for peptides as small as 2 kD in molecular weight. Using multi-angle laser light scattering (MALLS) detection, accurate masses of the parent peptide can be obtained, provided accurate extinction coefficients are provided. It was shown that AF4 can be stability-indicating, suggesting that AF4-MALLS may be a suitable alternative to the use of SEC to monitor the aggregation of peptides.

Denaturation and Aggregation of Interferon-τ in Aqueous Solution.

PURPOSE: To evaluate the different degrees of residual structure in the unfolded state of interferon-τ using chemical denaturation as a function of temperature by both urea and guanidinium hydrochloride. METHODS: Asymmetrical flow field-flow fractionation (AF4) using both UV and multi-angle laser light scattering (MALLS). Flow Microscopy. All subvisible particle imaging measurements were made using a FlowCAM flow imaging system. RESULTS: The two different denaturants provided different estimates of the conformational stability of the protein when extrapolated back to zero denaturant concentration. This suggests that urea and guanidinium hydrochloride (GnHCl) produce different degrees of residual structure in the unfolded state of interferon-τ. The differences were most pronounced at low temperature, suggesting that the residual structure in the denatured state is progressively lost when samples are heated above 25°C. The extent of expansion in the unfolded states was estimated from the m-values and was also measured using AF4. In contrast, the overall size of interferon-τ was determined by AF4 to decrease in the presence of histidine, which is known to bind to the native state, thereby providing conformational stabilization. Addition of histidine as the buffer resulted in formation of fewer subvisible particles over time at 50°C. Finally, the thermal aggregation was monitored using AF4 and the rate constants were found to be comparable to those determined previously by SEC and DLS. The thermal aggregation appears to be consistent with a nucleation-dependent mechanism with a critical nucleus size of 4 ± 1. CONCLUSION: Chemical denaturation of interferon-τ by urea or GnHCl produces differing amounts of residual structure in the denatured state, leading to differing estimates of conformational stability. AF4 was used to determine changes in size, both upon ligand binding as well as upon denaturation with GnHCl. Histidine appears to be the preferred buffer for interferon-τ, as shown by slower formation of soluble aggregates and reduced levels of subvisible particles when heated at 50°C.

Rational Design of Liquid Formulations of Proteins.

Twenty years ago, a number of eminent pharmaceutical scientists collaborated on an article describing a rational approach to developing stable lyophilized protein formulations (Carpenter, Pikal, Chang, & Randolph, 1997). Since that time, no corresponding document for rational development of liquid formulations of proteins has appeared. Certainly, many of the principles underpinning rational protein formulation have been known for some time, but no overarching scheme has ever been described in the literature. Now the time has come to provide a framework for the rational design of protein formulations as aqueous solutions. The objective of this review is to lay out four concepts that will guide one to obtaining a stable liquid protein formulation. Additionally, the aim will be to identify factors that are intrinsic to the stabilization of any protein, not just a particular class of proteins, such as monoclonal antibodies (Uchiyama, 2014; Wang, Singh, Zeng, King, & Nema, 2007) and to provide guidelines aiming to effect stabilization. Noting that all approaches to stabilization face validation that must be performed empirically, it is hoped that the rational strategies described here will help the formulation scientist in their daily tasks and inspire continued advancement of the science involved in protein formulation.

Role of Buffers in Protein Formulations.

Buffers comprise an integral component of protein formulations. Not only do they function to regulate shifts in pH, they also can stabilize proteins by a variety of mechanisms. The ability of buffers to stabilize therapeutic proteins whether in liquid formulations, frozen solutions, or the solid state is highlighted in this review. Addition of buffers can result in increased conformational stability of proteins, whether by ligand binding or by an excluded solute mechanism. In addition, they can alter the colloidal stability of proteins and modulate interfacial damage. Buffers can also lead to destabilization of proteins, and the stability of buffers themselves is presented. Furthermore, the potential safety and toxicity issues of buffers are discussed, with a special emphasis on the influence of buffers on the perceived pain upon injection. Finally, the interaction of buffers with other excipients is examined.

Culturing and investigation of stress-induced lipid accumulation in microalgae using a microfluidic device.

There is increasing interest in using microalgae as a lipid feedstock for the production of biofuels. Lipids used for these purposes are triacylglycerols that can be converted to fatty acid methyl esters (biodiesel) or decarboxylated to "green diesel." Lipid accumulation in most microalgal species is dependent on environmental stress and culturing conditions, and these conditions are currently optimized using slow, labor-intensive screening processes. Increasing the screening throughput would help reduce the development cost and time to commercial production. Here, we demonstrated an initial step towards this goal in the development of a glass/poly(dimethylsiloxane) (PDMS) microfluidic device capable of screening microalgal culturing and stress conditions. The device contained power-free valves to isolate microalgae in a microfluidic growth chamber for culturing and stress experiments. Initial experiments involved determining the biocompatibility and culturing capability of the device using the microalga Tetraselmis chuii. With this device, T. chuii could be successfully cultured for up to 3 weeks on-chip. Following these experiments, the device was used to investigate lipid accumulation in the microalga Neochloris oleabundans. It was shown that this microalga could be stressed to accumulate cytosolic lipids in a microfluidic environment, as evidenced with fluorescence lipid staining. This work represents the first example of microalgal culturing in a microfluidic device and signifies an important expansion of microfluidics into the biofuels research arena.

Review: Microfluidic applications in metabolomics and metabolic profiling.

Metabolomics is an emerging area of research focused on measuring small molecules in biological samples. There are a number of different types of metabolomics, ranging from global profiling of all metabolites in a single sample to measurement of a selected group of analytes. Microfluidics and related technologies have been used in this research area with good success. The aim of this review article is to summarize the use of microfluidics in metabolomics. Direct application of microfluidics to the determination of small molecules is covered first. Next, important sample preparation methods developed for microfluidics and applicable to metabolomics are covered. Finally, a summary of metabolomic work as it relates to analysis of cellular events using microfluidics is covered.

Electrode array detector for microchip capillary electrophoresis.

Selectivity and resolution for analyses conducted using microfluidic devices can be improved by increasing the total number of individual detection elements in the device. Here, a poly(dimethylsiloxane) capillary electrophoresis microchip was fabricated with an integrated electrode array for selective detection of small molecules. Eight individually addressable gold electrodes were incorporated in series after a palladium current decoupler in the separation channel of an electrophoresis microchip. The electrode array device was characterized using a mixture of biologically relevant analytes and xenobiotics: norepinephrine, 4-aminophenol, acetaminophen, uric acid, and 3,4-dihydroxyphenylacetic acid. Separation efficiencies as high as 9000 +/- 1000 plates (n = 3) for 3,4-dihydroxyphenylacetic acid and limits of detection as low as 2.6 +/- 1.2 microM (n = 3) for norepinephrine were obtained using this device. After characterizing the performance of the device, potential step detection was conducted at the array electrodes and selective detection achieved based upon differences in redox potentials for individual analytes. Utilization of potential step detection was particularly advantageous for resolving co-migrating species; resolution of 3,4-dihydroxy-l-phenylalanine from acetaminophen using potential control was demonstrated. Finally, a human urine sample was analyzed using potential step detection to demonstrate the applicability of this device for complex sample analysis.

Pharmacological, pharmacokinetic, and primate analgesic efficacy profile of the novel bradykinin B1 Receptor antagonist ELN441958.

The bradykinin B(1) receptor plays a critical role in chronic pain and inflammation, although efforts to demonstrate efficacy of receptor antagonists have been hampered by species-dependent potency differences, metabolic instability, and low oral exposure of current agents. The pharmacology, pharmacokinetics, and analgesic efficacy of the novel benzamide B(1) receptor antagonist 7-chloro-2-[3-(9-pyridin-4-yl-3,9-diazaspiro[5.5]undecanecarbonyl)phenyl]-2,3-dihydro-isoindol-1-one (ELN441958) is described. ELN441958 competitively inhibited the binding of the B(1) agonist ligand [(3)H]desArg(10)-kallidin ([(3)H]DAKD) to IMR-90 human fibroblast membranes with high affinity (K(i) = 0.26 +/- 0.02 nM). ELN441958 potently antagonized DAKD (but not bradykinin)-induced calcium mobilization in IMR-90 cells, indicating that it is highly selective for B(1) over B(2) receptors. Antagonism of agonist-induced calcium responses at B(1) receptors from different species indicated that ELN441958 is selective for primate over rodent B(1) receptors with a rank order potency (K(B), nanomolar) of human (0.12 +/- 0.02) approximately rhesus monkey (0.24 +/- 0.01) > rat (1.5 +/- 0.4) > mouse (14 +/- 4). ELN441958 had good permeability and metabolic stability in vitro consistent with high oral exposure and moderate plasma half-lives in rats and rhesus monkeys. Because ELN441958 is up to 120-fold more potent at primate than at rodent B(1) receptors, it was evaluated in a primate pain model. ELN441958 dose-dependently reduced carrageenan-induced thermal hyperalgesia in a rhesus monkey tail-withdrawal model, with an ED(50) approximately 3 mg/kg s.c. Naltrexone had no effect on the antihyperalgesia produced by ELN441958, indicating a lack of involvement of opioid receptors. ELN441958 is a novel small molecule bradykinin B(1) receptor antagonist exhibiting high oral bioavailability and potent systemic efficacy in rhesus monkey inflammatory pain.

Gemtuzumab ozogamicin, a potent and selective anti-CD33 antibody-calicheamicin conjugate for treatment of acute myeloid leukemia.

CD33 is expressed by acute myeloid leukemia (AML) cells in >80% of patients but not by normal hematopoietic stem cells, suggesting that elimination of CD33(+) cells may be therapeutically beneficial. A conjugate of a calicheamicin hydrazide derivative attached via hydrazone formation to the oxidized carbohydrates of the anti-CD33 murine antibody P67.6 had been chosen for use in AML prior to humanization of this antibody. However, the CDR-grafted humanized P67.6 could not be used to make the carbohydrate conjugate because of the unexpected sensitivity of this antibody to periodate oxidation. Exploration of a series of bifunctional linkers resulted in a new class of calicheamicin conjugates, termed the hybrid conjugates, that allows for the attachment of the calicheamicin to lysines but incorporates the site of hydrolytic release, a hydrazone, previously shown to be required for activity. The optimized conjugate chosen for clinical trials, gemtuzumab ozogamicin ("gem-ozo", Mylotarg, formerly designated CMA-676), was significantly more potent and selective than the carbohydrate conjugate it replaced. It was selectively cytotoxic to HL-60 leukemia cells in tissue culture with an IC(50) in the low to sub-pg cal/mL range (cal = calicheamicin equivalents). Doses of gem-ozo as low as 50 microg cal/kg given three times to mice bearing HL-60 xenografts routinely resulted in long-term, tumor-free survivors, while a nonbinding control conjugate was relatively inactive. Gem-ozo at a concentration of 2 to 10 ng cal/mL selectively inhibited leukemia colony formation by marrow cells from a significant proportion of AML patients. Gem-ozo has also shown significant activity against AML in Phase II trials and is the first antibody-targeted chemotherapeutic agent approved by the FDA.