Challenges and Opportunities for the Subcutaneous Delivery of Therapeutic Proteins.

Biotherapeutics is a rapidly growing drug class, and over 200 biotherapeutics have already obtained approval, with about 50 of these being approved in 2015 and 2016 alone. Several hundred protein therapeutic products are still in the pipeline, including interesting new approaches to treatment. Owing to patients' convenience of at home administration and reduced number of hospital visits as well as the reduction in treatment costs, subcutaneous (SC) administration of biologics is of increasing interest. Although several avenues for treatment using biotherapeutics are being explored, there is still a sufficient gap in knowledge regarding the interplay of formulation conditions, immunogenicity, and pharmacokinetics (PK) of the absorption of these compounds when they are given SC. This review seeks to highlight the major concerns and important factors governing this route of administration and suggest a holistic approach for effective SC delivery.

[1]  Kiran Mukhyala,et al.  Effects of charge on antibody tissue distribution and pharmacokinetics. , 2010, Bioconjugate chemistry.

[2]  D. Muchmore,et al.  Accelerating and Improving the Consistency of Rapid-Acting Analog Insulin Absorption and Action for Both Subcutaneous Injection and Continuous Subcutaneous Infusion Using Recombinant Human Hyaluronidase , 2012, Journal of diabetes science and technology.

[3]  Sanjeev Kumar,et al.  Lymphatic Absorption, Metabolism, and Excretion of a Therapeutic Peptide in Dogs and Rats , 2013, Drug Metabolism And Disposition.

[4]  A. Supersaxo,et al.  Effect of Molecular Weight on the Lymphatic Absorption of Water-Soluble Compounds Following Subcutaneous Administration , 1990, Pharmaceutical Research.

[5]  Huub Schellekens,et al.  Bioequivalence and the immunogenicity of biopharmaceuticals , 2002, Nature Reviews Drug Discovery.

[6]  V. Harvey,et al.  Comparison of Subcutaneous and Intravenous Administration of Trastuzumab: A Phase I/Ib Trial in Healthy Male Volunteers and Patients With HER2‐Positive Breast Cancer , 2013, Journal of clinical pharmacology.

[7]  R. Steinman,et al.  Dendritic cells and the control of immunity , 1998, Nature.

[8]  W. Huisinga,et al.  Magnitude of Increased Infliximab Clearance Imposed by Anti-infliximab Antibodies in Crohn’s Disease Is Determined by Their Concentration , 2016, The AAPS Journal.

[9]  A. Mire-Sluis,et al.  Immune responses to therapeutic proteins in humans--clinical significance, assessment and prediction. , 2002, Current pharmaceutical biotechnology.

[10]  J S Patton,et al.  A recombinant human enzyme for enhanced interstitial transport of therapeutics. , 2006, Journal of controlled release : official journal of the Controlled Release Society.

[11]  Tim J Kamerzell,et al.  Using empirical phase diagrams to understand the role of intramolecular dynamics in immunoglobulin G stability. , 2009, Journal of pharmaceutical sciences.

[12]  P. Rutgeerts,et al.  Influence of trough serum levels and immunogenicity on long-term outcome of adalimumab therapy in Crohn's disease. , 2009, Gastroenterology.

[13]  M. Sanford Subcutaneous trastuzumab: a review of its use in HER2-positive breast cancer , 2014, Targeted Oncology.

[14]  Ian Kimber,et al.  Immunogenicity of therapeutic proteins: Influence of aggregation , 2013, Journal of immunotoxicology.

[15]  S. Rule,et al.  Subcutaneous vs intravenous rituximab in patients with non-Hodgkin lymphoma: a time and motion study in the United Kingdom , 2014, Journal of medical economics.

[16]  W Wang,et al.  Monoclonal Antibody Pharmacokinetics and Pharmacodynamics , 2008, Clinical pharmacology and therapeutics.

[17]  Jochem Alsenz,et al.  Protein Aggregates Seem to Play a Key Role Among the Parameters Influencing the Antigenicity of Interferon Alpha (IFN-α) in Normal and Transgenic Mice , 1997, Pharmaceutical Research.

[18]  Daniela Bumbaca,et al.  Physiochemical and Biochemical Factors Influencing the Pharmacokinetics of Antibody Therapeutics , 2012, The AAPS Journal.

[19]  M. Tan,et al.  Hyaluronidase-incorporated hyaluronic acid-tyramine hydrogels for the sustained release of trastuzumab. , 2015, Journal of controlled release : official journal of the Controlled Release Society.

[20]  Hanns-Christian Mahler,et al.  Protein aggregation: pathways, induction factors and analysis. , 2009, Journal of pharmaceutical sciences.

[21]  A. Fathallah,et al.  Anatomical, physiological, and experimental factors affecting the bioavailability of sc-administered large biotherapeutics. , 2015, Journal of pharmaceutical sciences.

[22]  Ronald N. Germain,et al.  MHC-dependent antigen processing and peptide presentation: Providing ligands for T lymphocyte activation , 1994, Cell.

[23]  L. Khawli,et al.  Charge variants in IgG1 , 2010, mAbs.

[24]  G. Edwards,et al.  Lymphatic Absorption Is a Significant Contributor to the Subcutaneous Bioavailability of Insulin in a Sheep Model , 2001, Pharmaceutical Research.

[25]  Michael S. Roberts,et al.  Dermal blood flow, lymphatics, and binding as determinants of topical absorption, clearance and distribution , 2006 .

[26]  R. Tamura,et al.  Comparison of the immunogenicity of recombinant and pituitary human growth hormone in rhesus monkeys. , 1991, Fundamental and applied toxicology : official journal of the Society of Toxicology.

[27]  S. Polumuri,et al.  In Vivo Effect of Innate Immune Response Modulating Impurities on the Skin Milieu Using a Macaque Model: Impact on Product Immunogenicity. , 2017, Journal of pharmaceutical sciences.

[28]  B. Dijkmans,et al.  Clinical response to adalimumab: relationship to anti-adalimumab antibodies and serum adalimumab concentrations in rheumatoid arthritis , 2007, Annals of the rheumatic diseases.

[29]  R. Mrsny,et al.  Improving the outcomes of biopharmaceutical delivery via the subcutaneous route by understanding the chemical, physical and physiological properties of the subcutaneous injection site. , 2014, Journal of controlled release : official journal of the Controlled Release Society.

[30]  R. Germain,et al.  Antigen-unspecific B Cells and Lymphoid Dendritic Cells Both Show Extensive Surface Expression of Processed Antigen–Major Histocompatibility Complex Class II Complexes after Soluble Protein Exposure In Vivo or In Vitro , 1997, The Journal of experimental medicine.

[31]  Marisa K Joubert,et al.  Classification and Characterization of Therapeutic Antibody Aggregates , 2011, The Journal of Biological Chemistry.

[32]  C. Kapitza,et al.  Impact of Injection Speed, Volume, and Site on Pain Sensation , 2018, Journal of diabetes science and technology.

[33]  Paul A. J. Kolarsick,et al.  Anatomy and Physiology of the Skin , 2011 .

[34]  Yong‐jun Liu,et al.  Mouse and human dendritic cell subtypes , 2002, Nature Reviews Immunology.

[35]  S. Singh,et al.  Impact of product-related factors on immunogenicity of biotherapeutics. , 2011, Journal of pharmaceutical sciences.

[36]  Paolo Gallo,et al.  Immunogenicity of interferon beta: differences among products , 2004, Journal of Neurology.

[37]  Thomayant Prueksaritanont,et al.  Impact of methionine oxidation on the binding of human IgG1 to Fc Rn and Fc gamma receptors. , 2009, Molecular immunology.

[38]  T. Singer,et al.  Minipig as a potential translatable model for monoclonal antibody pharmacokinetics after intravenous and subcutaneous administration , 2012, mAbs.

[39]  A. Datta-Mannan,et al.  Application of FcRn Binding Assays to Guide mAb Development , 2014, Drug Metabolism and Disposition.

[40]  N. Cnubben,et al.  The minipig as an alternative non-rodent model for immunogenicity testing using the TNFα blockers adalimumab and infliximab , 2014, Journal of immunotoxicology.

[41]  Jürgen Hubbuch,et al.  Characterization of highly concentrated antibody solution - A toolbox for the description of protein long-term solution stability , 2017, mAbs.

[42]  D. Mager,et al.  Effects of hypertonic buffer composition on lymph node uptake and bioavailability of rituximab, after subcutaneous administration , 2015, Biopharmaceutics & drug disposition.

[43]  D. Kalonia,et al.  Nature and consequences of protein-protein interactions in high protein concentration solutions. , 2008, International journal of pharmaceutics.

[44]  Huub Schellekens,et al.  Structural Characterization and Immunogenicity in Wild-Type and Immune Tolerant Mice of Degraded Recombinant Human Interferon Alpha2b , 2005, Pharmaceutical Research.

[45]  Leonid Kagan,et al.  The role of the lymphatic system in subcutaneous absorption of macromolecules in the rat model. , 2007, European journal of pharmaceutics and biopharmaceutics : official journal of Arbeitsgemeinschaft fur Pharmazeutische Verfahrenstechnik e.V.

[46]  N. Casadevall,et al.  Immunogenicity of recombinant human proteins: causes and consequences , 2004, Journal of Neurology.

[47]  C. Porter,et al.  The lymphatic system plays a major role in the intravenous and subcutaneous pharmacokinetics of trastuzumab in rats. , 2014, Molecular pharmaceutics.

[48]  Thomas A McDonald,et al.  Subcutaneous administration of biotherapeutics: current experience in animal models. , 2010, Current opinion in molecular therapeutics.

[49]  L. Khawli,et al.  A novel in vitro method to model the fate of subcutaneously administered biopharmaceuticals and associated formulation components. , 2015, Journal of controlled release : official journal of the Controlled Release Society.

[50]  R. Reed,et al.  Interstitial-lymphatic mechanisms in the control of extracellular fluid volume. , 1993, Physiological reviews.

[51]  J. Kanitakis,et al.  Anatomy, histology and immunohistochemistry of normal human skin. , 2002, European journal of dermatology : EJD.

[52]  B. Meibohm,et al.  Population Pharmacokinetics of Therapeutic Monoclonal Antibodies , 2010, Clinical pharmacokinetics.

[53]  Scott E. Fauty,et al.  Lymphatic Transport and Catabolism of Therapeutic Proteins after Subcutaneous Administration to Rats and Dogs , 2012, Drug Metabolism and Disposition.

[54]  A. D. Nielsen,et al.  Stability of monoclonal antibodies at high-concentration: head-to-head comparison of the IgG1 and IgG4 subclass. , 2014, Journal of pharmaceutical sciences.

[55]  Susan Gibbs,et al.  Technical Advance: Langerhans cells derived from a human cell line in a full‐thickness skin equivalent undergo allergen‐induced maturation and migration , 2011, Journal of leukocyte biology.

[56]  N. Chirmule,et al.  Considerations for optimization and validation of an in vitro PBMC derived T cell assay for immunogenicity prediction of biotherapeutics. , 2010, Clinical immunology.

[57]  B. Kerwin Polysorbates 20 and 80 used in the formulation of protein biotherapeutics: structure and degradation pathways. , 2008, Journal of pharmaceutical sciences.

[58]  Huub Schellekens,et al.  Factors influencing the immunogenicity of therapeutic proteins. , 2005, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[59]  P. Emery,et al.  The efficacy and safety of rituximab in patients with active rheumatoid arthritis despite methotrexate treatment: results of a phase IIB randomized, double-blind, placebo-controlled, dose-ranging trial. , 2006, Arthritis and rheumatism.

[60]  S. Akilesh,et al.  FcRn: the neonatal Fc receptor comes of age , 2007, Nature Reviews Immunology.

[61]  F. Nestle,et al.  Mechanisms regulating skin immunity and inflammation , 2014, Nature Reviews Immunology.

[62]  Christopher J Roberts,et al.  Therapeutic protein aggregation: mechanisms, design, and control. , 2014, Trends in biotechnology.

[63]  Linda O Narhi,et al.  Classification of protein aggregates. , 2012, Journal of pharmaceutical sciences.

[64]  P. Cremer,et al.  Interactions between macromolecules and ions: The Hofmeister series. , 2006, Current opinion in chemical biology.

[65]  H. Kazazian,et al.  Inhibitor Antibody Development and T Cell Response to Human Factor VIII in Murine Hemophilia A , 1999, Thrombosis and Haemostasis.

[66]  Satoshi Ohtake,et al.  Interactions of formulation excipients with proteins in solution and in the dried state. , 2011, Advanced drug delivery reviews.

[67]  L. Khawli,et al.  Key factors influencing ADME properties of therapeutic proteins: A need for ADME characterization in drug discovery and development , 2015, mAbs.

[68]  A. Larregina,et al.  Professional antigen-presenting cells of the skin , 2006, Immunologic research.

[69]  R. Straubinger,et al.  Phosphatidylserine reduces immune response against human recombinant Factor VIII in Hemophilia A mice by regulation of dendritic cell function. , 2011, Clinical immunology.

[70]  J. Esko,et al.  Proteoglycans and Sulfated Glycosaminoglycans , 2009 .

[71]  G. E. Macallum,et al.  Applications and optimization of immunization procedures. , 2005, ILAR journal.

[72]  Donald E. Mager,et al.  Receptor-Mediated Pharmacokinetic/Pharmacodynamic Model of Interferon-β 1a in Humans , 2002, Pharmaceutical Research.

[73]  R. Wasserman Overview of recombinant human hyaluronidase-facilitated subcutaneous infusion of IgG in primary immunodeficiencies. , 2014, Immunotherapy.

[74]  M. Swartz,et al.  The physiology of the lymphatic system. , 2001, Advanced drug delivery reviews.

[75]  E. Menzel,et al.  Hyaluronidase and its substrate hyaluronan: biochemistry, biological activities and therapeutic uses. , 1998, Cancer letters.

[76]  I. Cook Evidence based route of administration of vaccines , 2008, Human vaccines.

[77]  J. Saint-Remy,et al.  Von Willebrand Factor Modulates Factor VIII Immunogenicity: Comparative Study of Different Factor VIII Concentrates in a Haemophilia A Mouse Model , 2002, Thrombosis and Haemostasis.

[78]  V. Schacht,et al.  Anatomy of the Subcutaneous Lymph Vascular Network of the Human Leg in Relation to the Great Saphenous Vein , 2009, Anatomical record.

[79]  A. Fathallah,et al.  Immunogenicity of Subcutaneously Administered Therapeutic Proteins—a Mechanistic Perspective , 2013, The AAPS Journal.

[80]  W. Richter,et al.  Subcutaneous Absorption of Biotherapeutics: Knowns and Unknowns , 2014, Drug Metabolism and Disposition.

[81]  D. Johnston,et al.  The effect of subcutaneous injection site on absorption of human growth hormone: abdomen versus thigh , 1991, Clinical endocrinology.

[82]  E. Mosekilde,et al.  Bioavailability and variability of biphasic insulin mixtures. , 2012, European journal of pharmaceutical sciences : official journal of the European Federation for Pharmaceutical Sciences.

[83]  E. Kimby,et al.  Strategies in the management of alemtuzumab-related side effects. , 2006, Seminars in oncology.

[84]  P. Cremer,et al.  Specific ion effects on the water solubility of macromolecules: PNIPAM and the Hofmeister series. , 2005, Journal of the American Chemical Society.

[85]  J. Bantle,et al.  Effects of the Anatomical Region Used for Insulin Injections on Glycemia in Type I Diabetes Subjects , 1993, Diabetes Care.

[86]  R. Bhat,et al.  Stabilization of yeast hexokinase A by polyol osmolytes: correlation with the physicochemical properties of aqueous solutions. , 2006, Biophysical chemistry.

[87]  N. Fineberg,et al.  Immunogenicity of recombinant DNA human insulin , 1983, Diabetologia.

[88]  E. Kimby,et al.  Phase II trial of subcutaneous anti-CD52 monoclonal antibody alemtuzumab (Campath-1H) as first-line treatment for patients with B-cell chronic lymphocytic leukemia (B-CLL). , 2002, Blood.

[89]  Jared S. Bee,et al.  Fate of Multimeric Oligomers, Submicron, and Micron Size Aggregates of Monoclonal Antibodies Upon Subcutaneous Injection in Mice. , 2016, Journal of pharmaceutical sciences.

[90]  D. Kalonia,et al.  Determination of second virial coefficient of proteins using a dual-detector cell for simultaneous measurement of scattered light intensity and concentration in SEC-HPLC. , 2004, Biophysical journal.

[91]  A. Salar,et al.  Comparison of subcutaneous versus intravenous administration of rituximab as maintenance treatment for follicular lymphoma: results from a two-stage, phase IB study. , 2014, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[92]  A. Rosenberg,et al.  Effects of protein aggregates: An immunologic perspective , 2006, The AAPS Journal.

[93]  S. Singh,et al.  Monitoring of subvisible particles in therapeutic proteins. , 2012, Methods in molecular biology.

[94]  Y. Nakanishi,et al.  Lymphatic transport of recombinant human tumor necrosis factor in rats. , 1988, Journal of pharmacobio-dynamics.

[95]  C. Porter,et al.  Subcutaneous drug delivery and the role of the lymphatics. , 2005, Drug discovery today. Technologies.

[96]  Chen Yanover,et al.  Polymorphisms in the F8 Gene and MHC-II Variants as Risk Factors for the Development of Inhibitory Anti-Factor VIII Antibodies during the Treatment of Hemophilia A: A Computational Assessment , 2013, PLoS Comput. Biol..

[97]  M. Genovese,et al.  Subcutaneous Abatacept vErsus Intravenous Abatacept: A Phase IIIb Noninferiority Study in Patients With an Inadequate Response to Methotrexate , 2011, Arthritis and rheumatism.

[98]  Stephanie H Mathes,et al.  The use of skin models in drug development. , 2014, Advanced drug delivery reviews.

[99]  Meng Chen,et al.  The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection , 2015, Patient preference and adherence.

[100]  M. Muscettola,et al.  The lymphatic route. 1) Albumin and hyaluronidase modify the normal distribution of interferon in lymph and plasma , 1986, Experientia.

[101]  D. Driver,et al.  FcRn Affinity-Pharmacokinetic Relationship of Five Human IgG4 Antibodies Engineered for Improved In Vitro FcRn Binding Properties in Cynomolgus Monkeys , 2012, Drug Metabolism and Disposition.

[102]  Leonid Kagan,et al.  Subcutaneous Absorption of Monoclonal Antibodies: Role of Dose, Site of Injection, and Injection Volume on Rituximab Pharmacokinetics in Rats , 2011, Pharmaceutical Research.

[103]  M. Genovese,et al.  Immunogenicity, Safety, and Efficacy of Abatacept Administered Subcutaneously With or Without Background Methotrexate in Patients With Rheumatoid Arthritis: Results From a Phase III, International, Multicenter, Parallel‐Arm, Open‐Label Study , 2013, Arthritis care & research.

[104]  Hong Ding,et al.  PEGylation of a Factor VIII–Phosphatidylinositol Complex: Pharmacokinetics and Immunogenicity in Hemophilia A Mice , 2011, The AAPS Journal.

[105]  M. Swartz,et al.  Interstitial flow and its effects in soft tissues. , 2007, Annual review of biomedical engineering.

[106]  J. M. Wilson,et al.  Intravenous versus subcutaneous dosing of epoetin: a review of the literature. , 1993, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[107]  P. Giangrande,et al.  Safety and pharmacokinetics of subcutaneously administered recombinant activated factor VII (rFVIIa) , 2011, Journal of thrombosis and haemostasis : JTH.

[108]  Vibha Jawa,et al.  T-cell dependent immunogenicity of protein therapeutics: Preclinical assessment and mitigation. , 2013, Clinical immunology.

[109]  W. Jiskoot,et al.  Immunogenicity of Therapeutic Proteins: The Use of Animal Models , 2011, Pharmaceutical Research.

[110]  E. Kuipers,et al.  Immunogenicity negatively influences the outcome of adalimumab treatment in Crohn’s disease , 2008, Alimentary pharmacology & therapeutics.

[111]  J L Cleland,et al.  A specific molar ratio of stabilizer to protein is required for storage stability of a lyophilized monoclonal antibody. , 2001, Journal of pharmaceutical sciences.

[112]  W R Mayr,et al.  Immunogenicity of human insulin (Novo) or pork monocomponent insulin in HLA-DR-typed insulin-dependent diabetic individuals. , 1983, Diabetes care.

[113]  Valerie M. Weaver,et al.  The extracellular matrix at a glance , 2010, Journal of Cell Science.

[114]  M. Swindle,et al.  The development of swine models in drug discovery and development. , 2012, Future medicinal chemistry.

[115]  B. Sugarman,et al.  Clinical Immunogenicity of rHuPH20, a Hyaluronidase Enabling Subcutaneous Drug Administration , 2015, The AAPS Journal.

[116]  C E Wheeler,et al.  The epidermal-dermal junction. , 1975, The Journal of investigative dermatology.

[117]  J. Mahlangu,et al.  Recombinant factor VIIa analog in the management of hemophilia with inhibitors: results from a multicenter, randomized, controlled trial of vatreptacog alfa , 2014, Journal of thrombosis and haemostasis : JTH.

[118]  W Wang,et al.  Instability, stabilization, and formulation of liquid protein pharmaceuticals. , 1999, International journal of pharmaceutics.

[119]  D. McFarlin,et al.  Lymph node function and lymphocyte circulation in the pig. , 1973, Advances in experimental medicine and biology.

[120]  L. Leak Electron microscopic observations on lymphatic capillaries and the structural components of the connective tissue-lymph interface. , 1970, Microvascular research.

[121]  S. Gregory,et al.  Electrostatic interactions of monoclonal antibodies with subcutaneous tissue. , 2011, Therapeutic delivery.

[122]  Tetsuji Sato,et al.  Factor VIII-Mimetic Function of Humanized Bispecific Antibody in Hemophilia A. , 2016, The New England journal of medicine.

[123]  L. Jensen,et al.  The pharmacokinetics of recombinant human erythropoietin after subcutaneous injection at different sites , 2004, European Journal of Clinical Pharmacology.

[124]  Jos H. Beijnen,et al.  Clinical Pharmacokinetics of Therapeutic Monoclonal Antibodies , 2010, Clinical pharmacokinetics.

[125]  B. Frederick,et al.  Subcutaneous Bioavailability of Golimumab at 3 Different Injection Sites in Healthy Subjects , 2010, Journal of clinical pharmacology.

[126]  W. Jiskoot,et al.  Reversible NaCl-induced aggregation of a monoclonal antibody at low pH: Characterization of aggregates and factors affecting aggregation. , 2016, European journal of pharmaceutics and biopharmaceutics : official journal of Arbeitsgemeinschaft fur Pharmazeutische Verfahrenstechnik e.V.

[127]  Anne S De Groot,et al.  Reducing risk, improving outcomes: bioengineering less immunogenic protein therapeutics. , 2009, Clinical immunology.

[128]  M. Skobe,et al.  Structure, function, and molecular control of the skin lymphatic system. , 2000, The journal of investigative dermatology. Symposium proceedings.

[129]  G. Edwards,et al.  Lymphatic Absorption of Subcutaneously Administered Proteins: Influence of Different Injection Sites on the Absorption of Darbepoetin Alfa Using a Sheep Model , 2007, Drug Metabolism and Disposition.

[130]  C. Porter,et al.  Lymphatic transport of proteins after subcutaneous administration. , 2000, Journal of pharmaceutical sciences.

[131]  S. Balu-Iyer,et al.  Native-like aggregates of factor VIII are immunogenic in von Willebrand factor deficient and hemophilia a mice. , 2012, Journal of pharmaceutical sciences.

[132]  K. Yoneyama,et al.  A first-in-human phase 1 study of ACE910, a novel factor VIII-mimetic bispecific antibody, in healthy subjects. , 2016, Blood.

[133]  M. Joubert,et al.  Use of In Vitro Assays to Assess Immunogenicity Risk of Antibody-Based Biotherapeutics , 2016, PloS one.

[134]  Marisa K Joubert,et al.  Immunogenicity of Therapeutic Protein Aggregates. , 2016, Journal of pharmaceutical sciences.

[135]  L. Khawli,et al.  Evaluating the Use of Antibody Variable Region (Fv) Charge as a Risk Assessment Tool for Predicting Typical Cynomolgus Monkey Pharmacokinetics* , 2015, The Journal of Biological Chemistry.

[136]  Brian M. Murphy,et al.  Stability of Protein Pharmaceuticals: An Update , 2010, Pharmaceutical Research.

[137]  Shawn M. Sweeney,et al.  Mapping the Ligand-binding Sites and Disease-associated Mutations on the Most Abundant Protein in the Human, Type I Collagen* , 2002, The Journal of Biological Chemistry.

[138]  Huub Schellekens,et al.  Immunogenicity of therapeutic proteins: clinical implications and future prospects. , 2002, Clinical therapeutics.

[139]  F. Theil,et al.  Pharmacokinetics of Humanized Monoclonal Anti-Tumor Necrosis Factor-α Antibody and Its Neonatal Fc Receptor Variants in Mice and Cynomolgus Monkeys , 2010, Drug Metabolism and Disposition.

[140]  Steven J Shire,et al.  Challenges in the development of high protein concentration formulations. , 2004, Journal of pharmaceutical sciences.

[141]  Sri H. Ramarathinam,et al.  A Systems Approach to Understand Antigen Presentation and the Immune Response. , 2016, Methods in molecular biology.

[142]  W. Jusko,et al.  Pharmacokinetic and pharmacodynamic modeling of recombinant human erythropoietin after multiple subcutaneous doses in healthy subjects. , 2005, European journal of pharmaceutical sciences : official journal of the European Federation for Pharmaceutical Sciences.

[143]  M. Morris,et al.  Mechanistic Determinants of Biotherapeutics Absorption Following SC Administration , 2012, The AAPS Journal.

[144]  G. Ebers,et al.  Randomised double-blind placebo-controlled study of interferon β-1a in relapsing/remitting multiple sclerosis , 1998, The Lancet.

[145]  S. Antonarakis,et al.  Targeted disruption of the mouse factor VIII gene produces a model of haemophilia A , 1995, Nature Genetics.

[146]  Z. Sauna,et al.  Immunogenicity assessment during the development of protein therapeutics , 2018, The Journal of pharmacy and pharmacology.

[147]  L. Schaefer,et al.  Proteoglycans: from structural compounds to signaling molecules , 2009, Cell and Tissue Research.

[148]  A. Coles Alemtuzumab Therapy for Multiple Sclerosis , 2012, Neurotherapeutics.

[149]  P. Mortimer,et al.  Lymphatics of the Skin , 1986, International journal of dermatology.

[150]  W. Jiskoot,et al.  Hybrid transgenic immune tolerant mouse model for assessing the breaking of B cell tolerance by human interferon beta. , 2010, Journal of immunological methods.

[151]  Christopher J Roberts,et al.  Comparative effects of pH and ionic strength on protein-protein interactions, unfolding, and aggregation for IgG1 antibodies. , 2010, Journal of pharmaceutical sciences.

[152]  R Seitz,et al.  Taking immunogenicity assessment of therapeutic proteins to the next level. , 2011, Biologicals : journal of the International Association of Biological Standardization.

[153]  Vandana Iyer,et al.  Use of a folding model and in situ spectroscopic techniques for rational formulation development and stability testing of monoclonal antibody therapeutics. , 2010, Journal of pharmaceutical sciences.

[154]  G. Edwards,et al.  Lymphatic transport of proteins after s.c. injection: implications of animal model selection. , 2001, Advanced drug delivery reviews.

[155]  Sandeep Kumar,et al.  The Effect of Small Oligomeric Protein Aggregates on the Immunogenicity of Intravenous and Subcutaneous Administered Antibodies. , 2015, Journal of pharmaceutical sciences.

[156]  J. Balthasar,et al.  Mechanistic considerations for the use of monoclonal antibodies for cancer therapy , 2014, Cancer biology & medicine.

[157]  Steven Kozlowski,et al.  Overlooking subvisible particles in therapeutic protein products: gaps that may compromise product quality. , 2009, Journal of pharmaceutical sciences.

[158]  F. Theil,et al.  Subcutaneous bioavailability of therapeutic antibodies as a function 
of FcRn binding affinity in mice , 2012, mAbs.

[159]  R. Hansen,et al.  Antibody pharmacokinetics and pharmacodynamics. , 2004, Journal of pharmaceutical sciences.

[160]  Fakhereh Mirrashed,et al.  In vivo morphological characterisation of skin by MRI micro‐imaging methods , 2004, Skin research and technology : official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging.

[161]  M. Jenkins,et al.  CD4+ T cells that enter the draining lymph nodes after antigen injection participate in the primary response and become central–memory cells , 2006, The Journal of experimental medicine.

[162]  S. Mercadal,et al.  Efficacy and safety of subcutaneous rituximab versus intravenous rituximab for first-line treatment of follicular lymphoma (SABRINA): a randomised, open-label, phase 3 trial. , 2017, The Lancet. Haematology.