Table 1.

Biotherapeutics approved by the FDA and EMA between 2004 and 2016, with reported nonclinical infusion reactions.^a

Productb Approval Datec	Target/Enzyme Isotype Molecule Type	Occurrenced Dosing	Finding (Direct Quote from Pharmacology Review)	Cytokines/Complement Examinatione	ADA/Immune Complex	Pretreatment/Interventionf
Daratumumab (Daralex) FDA 2015 EMA 2016	CD38 Human IgG1 kappa mAb	1st Dose (not observed at subsequent doses) Weekly, 6 doses (5, 25 mg/kg); IV infusion	“There was one mortality at 5 mg/kg immediately following dosing (1.5 h) in a female chimpanzee due to cytokine release response with overinflation, edema of the lungs following dosing with detectable levels of cytokines TNF-α, IL-6 and IFN-γ in the serum prior to necropsy.” “In addition to the death of the female chimpanzee in the 5 mg/kg dose group, two additional group 1 animals (at 5 mg/kg) exhibited a cytokine release response, including increased tracheal and nasal mucous production … Both Group 2 animals showed a reaction to the initial 25 mg/kg dose. Clinical signs included sneezing and mucous production was noted in A96A017 approximately 15 min (25 mL) into the dosing; this activity subsided and mucous membrane pallor was noted following administration of 44 mL of the dose (26 min).”	Cytokines reported for animal that died.	Not reported	“conditioning dose, of 10 mg was administered 24 h prior to first infusion of high dose following cytokine response reaction in first dosing of two low dose animals”
Blinatumomab (Blincyto) FDA 2014 EMA 2015	Bi-specific CD19 CD3 N/A BiTE	1st Dose (also at all subsequent doses) Weekly, 5 doses (0.1 μg/kg); 2-h IV infusion	“Infusion of chimpanzees with blinatumomab was associated with T-cell activation and increases in body temperature and heart rate and decreases in blood pressure, in addition to increases in cytokines IL-2, IL-6, and INF-γ. These finding are consistent with the cytokine release syndrome observed in the clinical trial in patients …”g	Increased cytokines in vivo and in vitro (human and chimpanzee cells)	Not reportedh	Not reported
Siltuximab (Slyvant) FDA 2014 EMA 2014	IL-6 Chimeric IgG1 mAb	1st Dose Weekly, 25 weeks (9.2, 46 mg/kg); IV infusion	“Although not common, first-dose infusion reaction occurred in a monkey (in 1 out of 52i) and included moderate facial swelling. The swelling resolved after the infusion ended and no other instances occurred.”	Not reported	Drug interference with ADA assay proposed	Not reported
Reslizumab (Cinqair) FDA 2016 EMA 2016	IL-5 Humanized IgG4 kappa mAb	Delayed (Doses 5–7) monthly, 7 doses (1, 5, 25 mg/kg); IV	“Immunogenicity noted in 3 in the pivotal toxicity study … One of the animals had repeated infusion reactions consistent with hypersensitivity (salivation, emesis, recumbency within 10 min of doses 5–7).”	Not reported	ADA detected in a “few animals”; drug interference with ADA assay reported Possible ADA related vasculitis	Not reported
Atezolizumab (Tecentriq) FDA 2016 EMA not yet approved	PDL-1 Humanized IgG1 mAb	Delayed (Day 133 and 141) Weekly; 26 weeks (5, 15, 50 mg/kg); IV infusion	“One male in the 5 and 15 mg/kg dose groups experienced infusion-related reactions after dosing on Day 113 and 141, respectively. Clinical signs included severe hypoactivity, staggered movements, and increased heart rate (15 mg/kg male). Animals recovered after receiving glucose and sodium chloride.”	Cytokines examined in vivo; unremarkable; cytokines were not induced in vitro (human cells)	ADA detected; drug interference with ADA assay reported	Supportive care (glucose and sodium chloride)
Obinutuzumab (Gazyva) FDA 2013 EMA 2014	CD20 Humanized IgG1 mAb	Delayed (3 died during dosing (Day 63–181); 4 died during recoveryj (Recovery Day 85–141)k Weekly; 26 weeks; IV bolus (5, 25 mg/kg), 30 min IV infusion (50 mg/kg)	“Hypersensitivity reactions were noted at all doses … in the 26-week study and were attributed to cross-species reactivity to a foreign protein. Clinical observations included acute anaphylactic/anaphalactoid reactions (clinical signs consisted of excessive salivation, facial erythema that progressed to the arms, with evident pruritus). Microscopic findings included an increased prevalence of systemic inflammation and infiltrates consistent with immune-complex mediated hypersensitivity reactions including glomerulonephritis, and arteritis/periarteritis and serosal/adventitial inflammation in multiple tissues. These reactions led to the unscheduled deaths of 6 (possibly 7) monkeys during the 26-week study …. Immune-complex deposition in glomeruli of some animals was confirmed by detection of electron dense deposits by immunohistochemistry or transmission electron microscopy.”	Cytokines examined in vivo (results not reported); cytokines elevated in vitro (human cells)l	ADA confirmed Immune complexes detected both in tissue by IHC and TEM and as circulating complexes	Intervention: Diphenhydramine treatment and prophylactic diphenhydra- minem
Ipilimumab (Yervoy) FDA 2011 EMA 2011	CTLA-4 Human IgG1 kappa mAb	Delayed (Day 58) Weekly; 13 weeks; IV (10 mg/kg), Combination Studyn weeks 5–13	“One monkey exhibited an infusion-like reaction (signs of shock [Cyanotic, thread pulse, muffled heart sounds], requiring supportive care).”	Cytokines examined in vitro; weak induction seen under some assay conditions (human cells)	ADA response first detected on D16. ADA response exceed assay limits by D44 in the animal with reaction	Supportive care (oxygen, IV fluid, diphenhydramine, dexamethasone); drug holiday
Ofatumumab (Arzerra)o FDA 2009 EMA 2010	CD20 Human IgG1 kappa mAb	Delayed (Onset Day 78–134) Weekly; 8 dose, followed by 5 monthly doses; (20, 100 mg/kg), 30-min IV infusion	“Ofatumumab-treated cynomolgus monkeys only exhibited signs of infusion reactions after repeated dosing; these events resolved without treatment. No clinical observations of infusion reactions were detected in the short-term studies (i.e. 4 weeks or less of dosing). In the 7-month toxicity study, signs were observed in high-dose animals from D78 onward (the 1st monthly maintenance dose) and in low dose animals from Dl06 onward (the 2nd monthly dose). The effect manifested as transient increases in heart rate and heart force (variable range, usually beginning during the 30-minute infusion, and resolving within a few hours of the end of infusion) and occurred sporadically for particular animals. Transient trembling was observed in 3/28 animals (11%).”	Complement was investigated in a short 2-dose follow up study. The data was “difficult to interpret”. Coombs Test Positive Day 122–176	Reduced ADA detection compared to short term studies Immune complex data were “not informative”	Not reported
		Delayed (Day 148 & 162 (second cycle of dosing)) Cycled repeat dose (20, 100 mg/kg)p; 30-min IV infusion	“An exploratory study in cynomolgus monkeys confirmed that ofatumumab treatment caused transient (15 min–4 h post-treatment) increases in serum levels of activated complement and interleukin-6 (IL-6), and neutrophil degranulation.”	Coombs Test positive D15-D267 Activated complement and interleukin-6 (IL-6),	Not reported	Not reported
Panitumumab (Vectibix) FDA 2006 EMA 2009	EGFR Human IgG2 mAb	Delayed (Day 29–141) Weekly; 13 weeks (7.5, 15, 30 mg/kg); IV bolus	“Infusion reactions - dose-related peri-infusion emesis, lethargy, prostration, excessive salivation, pallor to skin, gums, and/or muscle spasms observed in 5 monkeys … Monkey #33F in the 15 mg/kg/dose group died of apparent anaphylactic reaction on SD-l34, shortly after completion of dosing”	Not reported	ADA detected in some animals	Pre-treated with prophylactic diphenhydramine
Natalizumab (Tysabri) FDA 2004 EMA 2006	α4- integrin Humanized IgG4 mAb	Delayed (Day 64 and 71) Weekly; 6-month juvenile (3, 10, 30, 60 mg/kg); 30-min IV infusion	“Infusion reaction was observed in two studies using cynomolgus monkeys and these reactions appeared to be immune mediated and correlated with high levels of anti-drug antibodies.; One female in the high dose group exhibited adverse reactions to the test article approximately 2.5–3 h following infusion on Days 64 and 71. The reactions were characterized by generalized petechial hemorrhages, severe bruising/ecchymotic hemorrhages around the face, bruising of the arms and femoral area, and on Day 71, swelling of the left side of the face.”	Complement activation observed in vivo	ADA inverse relationship to dose Development of CIC-Raji-reactive immune complexes (IC) immediately post dose @ Day 85 & 176	Dexamethasone and benadryl; drug holiday
		Delayed (Day 43–155) Weekly; 6 months, adult (3, 10, 30, 60 mg/kg); 30–60 min IV infusion	“Infusion-related incidences were observed in three animals from different dose groups, which appeared to be due to a hypersensitivity response to the study drug … In addition, minimal to moderate glomerulonephritis was observed in the kidneys of 4 animals at Week 26 and glomerulosclerosis (chronic manifestation of glomerulonephritis) was observed in 1 animal at the end of the recovery period. The glomerulonephritis findings are believed to be the result of immune complex deposition or other antibody-dependent phenomena, which is likely related to the immunogenicity of the test article in the monkey.”	Complement activation observed in vivo	ADA identified in some animals correlates with complement and immune complexes	Not reported
Rilonacept (Arcalyst) FDA 2008 EMA 2009q	IL-1β; IL-1α Fc IgG1 Fusion protein	Delayed Weekly; 3-weeks (5, 20, 50 mg/kg); 30 min IV infusion	“The timing for the adverse reaction [emesis, lethargy] observed … correlated with formation of the anti product antibody after the IV administration of lL-1 Trap. Interestingly, the number animals showing such incidence were higher in the low dose group. This coincides with the observation that the increase in the quantity of the anti product antibody formation was higher in the animals at the low dose group. The intolerance of the immune complex formation in the animals might have been revealed by the clinical signs of lethargy and emesis.”	Increase in CRP; no change in complement	ADA - All animals @Day 16; large individual variation	None reported
		Delayed 3-times/week; 26-week (15, 25, 40, 60 mg/kg); SC NOAEL not identified due to findings @ low dose	“There were two unscheduled deaths in this study; one male (#46) from 40 mg/kg showed clinical signs of discomfort at Day 40, dosing was discontinued, the animals continue to show discomfort, therefore, sacrificed at Day 45, histopathology showed myocarditis; another male (#54) died after dosing on Day 108, histopathology showed congestion in several organs like kidney etc., this animals [sic] also showed congestion in lung due to granuloma as indicated by edema and perivascular lung blockage. Both of these animals did show high antibody titer, and the sponsor believes that the cause of deaths resulted from immune mediated hypersensitivity reaction. The reviewer agrees with sponsor analysis of data from these unscheduled deaths.”	CRP detected in individual animals; dose-dependent complement increase was observed in males only	ADA present in most but not all animals	Periodic epinephrine
		Delayed Every 2nd week; 26-weeks (14 doses) (3, 10, 30, 100 mg/kg); IV infusion	“There was an increased incidence of emesis/retching in the treatment group with the increase in the duration of the study indicating poor tolerance of the compound after IV administration.” “One female (# 43) in the 30 mg/kg dose group was observed to assume recumbent position at approximately one hour after the infusion of the 5th dosing, the animal recovered spontaneously within 7–12 mins. Another male from the high dose group become non responsive during the drug infusion of the 12th dose, the animal had dorsiflexed head position, with constricted pupils and pale gums. The animal, however, recovered within 10 mins post infusion.”	Slight increase in CRP at high dose; no changes in complement identified	ADA present in most but not all animals	None reported
Algucosidase Alpha (Myozyme) FDA 2006 EMA 2006	Alpha-Glucosidase N/A ERT	Delayed Rodent pharmacology studies (rat, mice and knockout mice); multiple dosing regimens	“Several unscheduled animal deaths occurred during the pharmacology studies with no details regarding cause of death provided. Some of these deaths can be accounted for by hypersensitivity reactions that are a common response of rodents to the rhGAA. However, some of the deaths could not be accounted for by hypersensitivity and no data on the potential cause are provided. Due to the concern about hypersensitivity, rodents were routinely pre-treated with diphenhydraminc (DPH), usually at 5 mg/kg, 20 min prior to infusion of the rhGAA.”	Complement not detectedr	ADA detected, but not tested in all studies	Prophylactic diphenhydramine
		Delayed Weekly (1, 10, 100 mg/kg); 4-weeks; IV NOAEL 10 mg/kg	“Hypersensitivity response was observed in one and one[sic] male from group 4 after the third dose.”	Not reported	Not performed	Prophylactic diphenhydramine based on earlier pharmacology work
Galsulfase (Naglazyme) FDA 2005 EMA 2006	N-acetylgalactosamine 4-sulfatase N/A ERT	First Dose and Delayed Weekly (1–2 mg/kg):IV NOAEL not reported	“In the acute single dose toxicity studies, rats and dogs had swelling of the mouth, nose or paws … anaphylactic or anaphylactoid reactions …” “Trembling and coughing were often detected during infusion. A number of episodes of vomiting, defecation, and fever were also observed.” “Three types of microscopic findings were identified: 1) pulmonary perivascular inflammation, 2) interstitial pneumonia, and 3) glomerulonephropathy. Based on the present observations, we cannot rule out the possibility that they are interrelated, and may have a common immunological etiology … In addition, anti-rhASB immune complex deposition may also lead to the … pulmonary and renal pathology.”	Complement activation observed in 2/5	ADA detected	Not reported diphenhydramine used in subsequent fertility/EFD study
Evolocumab (Repatha) FDA 2015 EMA 2015	PCSK9 Human IgG2	Not reported, but interpreted to be a delayed effect. Every 2 weeks; lifetime; SC	“Pale appearance, ataxic behavior and skin, cold to touch, could indicate an immune response to this human IgG protein [in hamsters].”	Not reported	Pharmacodynamics used as a surrogate – no significant ADA	Not reported
Abatacept (Orencia) FDA 2005 EMA 2007	CD80/86 Fc IgG1 Fusion protein	Not reported but interpreted to be a delayed effect. Studies during which this reaction occurred were not identified.	“In mice and dogs, when drug levels fell below immunomodulatory levels and the animals were subsequently administered an IV challenge dose of abatacept, the presence of circulating abatacept-specific antibodies was associated with clinical signs of hypersensitivity“	Not reported	ADA detected	Not reported

mAb = monoclonal antibody, ERT = enzyme replacement therapy.

^aData from FDA Pharmacology Toxicology Reviews ^{10, 11, 12, 13, 14, 15, 16, 18, 19, 20},[17],^{21, 22, 23, 24, 25}and the ofatumumab product label [59].

^bInfusion reactions were also reported for golimumab; however, they were only seen with a murine surrogate used for reproductive and developmental hazard identification and were not observed with golimumab itself [60].

^cData from FDA and EMA websites ^{61, 62}.

^dSeen at 1st dose or delayed (following multiple doses).

^eBased on study report summarized in the FDA Pharmacology Review. Investigations may have taken place that are not included in the summary.

^fBased on study report summarized in the FDA Pharmacology Review. Interventions may have taken place that are not included in the summary.

^gExpected effect due to pharmacology of the drug.

^hNot a terminal study.

ⁱThe reference 1/52, refers to all monkey studies conducted.

^jRecovery animals died from glomerulonephritis associated with immune complex deposition.

^kSix of seven mortalities were related to the hypersensitivity described in this table.

^lComplement cascade activated by drug pharmacology.

^mThe intervention was successful for one animal, but for another animal, the intervention was successful at first but, over time, failed to prevent the reaction. This type of variability in response is consistent with the author's experience.

ⁿCombination study with multiple regimens Drug (8 intermittent IV doses over 88 days) + SIV vaccine (IM Days 1,2,29,30,56,58,85,85).

^oAdditionally, hemolytic anemia attributed to monkey-specific humoral immune response was observed at 7 weeks.

^pTotal of 4 doses. Each cycle consisted for 2 doses given 2 weeks apart; Dosing Days 1, 15, 148, 162 (only selected endpoints were reported).

^qNo longer authorized in Europe.

^rWhen histamine was measured, moderate histamine elevation was observed after the 3rd dose and significantly elevated histamine was observed after the 8th dose. Histamine was not measured in all studies.