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CHAPTER 16

BIOLOGICS
PRESENTED BY:
13 GO, REAGAN TYLER L.
14 GONZALES, ROBERT
DOMINIC D.
15 GRANDE, MA. CLARMINA R.

WHAT ARE BIOLOGICS?


A biologic is a substance produced by a living source; it commonly
includes the following:

Antibiotics
Hormones
Vitamins
Others
Provision of immunity through the use of biologic is immunization.
Vaccination, a term which refers to the use of a biologic product (a
vaccine) to develop active immunity in the patient.

WHAT ARE BIOLOGICS?


The Food and Drug Administration (FDA) refers to immunizing agents
as biologics.

The Advisory Committee on Immunization Practices (ACIP) refers to


immunizing agents as immunobiologics.

According to the Code of Federal Regulations, a biologic product is any


virus, therapeutic serum, toxin, antitoxin, or analogous product
employed for prevention, treatment, or cure of diseases in humans.

DEFINITION OF TERMS
Antigen
Antibody
Immunogen
Immunological
Interleukin
Serum/Sera
Virion

PART I
TYPES OF
IMMUNITY

THERE ARE TWO MAIN CATEGORIES OF


IMMUNITY:

Natural Immunity
Species Immunity
Racial Immunity
Individual
Immunity

Acquired Immunity
Active Immunity
naturally acquired active immunity
artificially acquired active immunity

Passive Immunity
naturally acquired passive
immunity
artificially acquired passive
immunity

1.1 NATURAL IMMUNITY


Natural, innate, or native immunity depends on factors that are
inborn.

It can be classified as:


Species immunity
Racial immunity
Individual immunity

1.1.1 SPECIES IMMUNITY


In general, cold-blooded animals are not susceptible to diseases
common to warm-blooded animals.

Humans are not at all susceptible to certain diseases of lower


animals and correspondingly, many human diseases do not
naturally occur in animals.

1.1.2 RACIAL IMMUNITY


Human races differ in susceptibility to common infections.
Factors that determine racial immunity are elusive and not
well known.

1.1.3 INDIVIDUAL IMMUNITY


Individuals vary in the ability to resist common microbiologic
diseases.

The natural resistance of the same individual may vary from time
to time.

Health plays a vital role in resisting invasion by other species of


microorganisms capable of producing infection.

1.2 ACQUIRED IMMUNITY


T lymphocytes regulate cell-mediated immunity and are
responsible for controlling certain bacterial and viral infections.
They are responsible for mediating:

Graft vs Host disease


Allograft rejection
Delayed hypersensitivity reactions

1.2 ACQUIRED IMMUNITY


T lymphocytes augment the activity of B lymphocytes, which
are primarily involved with humoral immunity and antibody
production.

Once exposed to an antigen, the T and B lymphocytes


demonstrate memory that allows them to recognize and respond
to a specific antigen when exposed again.

1.2.1 ACTIVE IMMUNITY


Active immunity develops in response to antigenic substances
in the body.

This may occur by natural means, as by infection, in which case it


is termed naturally acquired active immunity.

It may also develop in response to administration of a specific


vaccine or toxoid, in which case it is artificially acquired active
immunity.

1.2.1 ACTIVE IMMUNITY


Vaccines are administered primarily for prophylactic action, to
develop acquired active immunity. These may contain living
attenuated (weakened) or killed microorganisms or fractions of
these microorganism.

Toxoids are bacterial toxins modified and detoxified with


moderate heat and chemical treatment so that the antigenic
properties remain while the substance is rendered nontoxic.

1.2.1 ACTIVE IMMUNITY


A problem with toxoids is that they produce inadequate
immunologic responses when administered alone. Therefore,
they are often combined with adjuvants such as alum, aluminum
phosphate, and aluminum hydroxide that enhance their
antigenicity,

The insoluble property of these adjuvants help in prolonging


immune response.

1.2.1 ACTIVE IMMUNITY


A vaccine composed of killed whole microorganisms is known as
inactivated vaccine.

Vaccine that contain live but significantly weakened microorganisms


are attenuated vaccines.

Both types are capable of producing immunity. However, the

attenuated vaccines typically have more antigenicity so are more likely


to confer permanent immunity. Inactivated vaccines, however, must be
administered again over time for maintenance.

1.2.1 ACTIVE IMMUNITY


With live vaccines, caution must be exercise with

immunocompromised patients. This group of patients includes those


with:
HIV infection
Thymic Abnormalities
Lymphoma
Leukemia
Generalized Malignancy
Advanced debilitating diseases
Or those receiving corticosteroids, alkylating agents, antimetabolites, or
radiation chemotherapy.

1.2.1 ACTIVE IMMUNITY


Immunization during pregnancy is another concern. Live
attenuated vaccines should be avoided for pregnant patients
because of the danger of transmission of the microorganism to
the fetus.

1.2.2 PASSIVE IMMUNITY


Passive acquired immunity occurs by introduction of the
immunoglobulin produced in another individual (human or
animal) into the host, who is not involved in their production.

It can also be classified as natural or artificial, just like active


immunity.

1.2.2 PASSIVE IMMUNITY


Naturally acquired passive immunity occurs by placental
transmission of immunoglobulin gamma (IgG) from the mother
to the fetus.

Artificially acquired passive immunity include several biologic


products containing immunoglobulins. These are limited to
provision of temporary prophylaxis to susceptible individuals.
Notable in this category are the anti-venins for the treatment of
snakebite and spiders.

PART II
PRODUCTION OF
BIOLOGICS

PRODUCTION OF BIOLOGICS
Biologics are produced by manufacturers licensed to do so in
accordance with the terms of the federal Public Health Service
Act approved July 1, 1944, and;

Each product must meet specified standard as administered by


the Center for Biologics Evaluation and Research of the FDA.

PRODUCTION OF BIOLOGICS

Provisions generally applicable to biologic products include tests for:

Potency
General safety
Sterility
Purity
Water (residual moisture)
Pyrogens
Identity
Constituent materials (preservatives, diluents, adjuvants)
Additional safety tests on live vaccines and certain other items are also required.

PRODUCTION OF BIOLOGICS
The label of a biologic product must include:
Title or Proper Name (the name under which the product is licensed)
Name, address, and license number of the manufacturer
Expiration date
Recommended individual dose for multiple-dose containers
Preservative/s used and the amount
Number of containers (if more than one)
Amount of product in the container
Recommended storage temperature
Auxiliary statements (e.g. freezing is to be avoided)
Other information as FDA regulations may require to ensure safe and effective use
of the product.

PRODUCTION OF BIOLOGICS
Most biologics are stored in a refrigerator (2 C to 8 C, or 35 F to 46 F), and
freezing is to be avoided.

Diluents packaged with biologics should not be frozen.


Beside the biologic substance that is harmed by freezing, the container may
be broken due to the expansion of an aqueous vehicle resulting in loss of
product.

The expiration date for biologic products varies with the product and the
storage temperature. Most biologic products have an expiration date of a
year or longer after the date of manufacture or issue.

PART III
STORAGE, HANDLING,
AND SHIPPING OF
BIOLOGICS

STORAGE, HANDLING, AND SHIPPING OF


BIOLOGICS
Biologics are sensitive to extreme temperatures, and exposure to heat or
freezing can decrease their potency and dramatically reduce their
effectiveness.

Biologics are expensive and can add significantly to ones inventory


costs.

A real danger is that if damaged products are administered, the person


may get little or none of the intended benefit. Worse, the person may
not be able to build up immunity and may result in an infection or
inadequate protection from the disease.

STORAGE, HANDLING, AND SHIPPING OF


BIOLOGICS
The overriding theme for the pharmacist in storage, handling, and
shipping of biologic products is to maintain the cold chain.

This implies continuity from the manufacturers refrigerator to ones


pharmacy, clinic, or office to the point of administration. If this cold chain
is to be maintained, the pharmacist can be assured that the quality of the
product will not be diminished.

STORAGE, HANDLING, AND SHIPPING OF


BIOLOGICS
For small-volume biologics, a standard refrigerator-freezer should be used. Frost-free
freezers should be used because ice buildup interferes with the freezers ability to
maintain very low temperatures. Also, defrosting requires that the product be removed
to temporary storage.

A separate refrigerator dedicated to biologics is preferable to minimize the time the


refrigerator door is opened. The WHO recommends that the door not be opened
more frequently that four times per day.

The door shelving can be used to store diluents or bottles of water. This helps provide
insulation and a thermal reserve.

Refrigerator temperatures should range between 2 C and 8 C, and freezers should stay
well below 0 C. Usually, an optimal temperature is 15 C (5 F).

STORAGE, HANDLING, AND SHIPPING OF


BIOLOGICS
Store containers of the same vaccine together.
To avoid selecting the wrong product or one having a similar sounding
name or packaging, separate the product.

Look-alike packaging as well as sound-alike names can easily confuse


any conscientious practitioner.

The use of a mishandled or poorly stored biologic could have


devastating consequences on the person who receives it.

PART IV
BIOLOGICS FOR ACTIVE
IMMUNITY

THERE ARE FOUR TYPES OF BIOLOGICS FOR


ACTIVE IMMUNITY:

Bacterial Vaccines
Viral Vaccines
Cancer Vaccines

Autologous tumor vaccines


Allogeneic tumor vaccines
Anti-iodotypic vaccines
Gene therapy derived vaccines

Toxoids

4.1 BACTERIAL VACCINES


Originally, organisms are grown in a suitable broth medium in a
controlled environment of temperature, pH, and oxygen tension.

Following a suitable amount of time for bacterial growth, the cell culture
is processed in two steps:
Step 1: If the vaccine is to be inactivated, the organisms are treated with phenol or
formaldehyde. (Heat and phenol or heat and acetone are employed for typhoid
fever vaccine).

Step 2: Next, the organisms are separated from the medium through centrifugation
and suspended in sterile water or 0.9% sodium chloride for injection.

4.1 BACTERIAL VACCINES

A live attenuated vaccine can also be produced by genetic alteration of the


pathogenic organisms. This allows the organism to survive and multiply but not
produce the disease.

Another way to create a vaccine is to employ purified antigen subunits produced


with the use of recombinant DNA. With subunit vaccines, the genes that code for
the desired antigen are introduced into the nonpathogenic organisms.

Subunit vaccines have had limited clinical utility because of the inability to produce
a sufficient, specific immune response.

Alternative biotechnologic strategies have been employed to produce subunit


vaccine immunogens and adjuvant-active compounds that can be added to
enhance the immune response.

4.1 BACTERIAL VACCINES

The final vaccine may contain one single immunogen (monovalent) or it may
contain multiple immunogens (polyvalent, trivalent) to promote immunity
against the same disease.

The strength of a bacterial vaccine may be expressed as:

total number of organisms


total protective units per milliliter or dose
micrograms of immunogen in each milliliter or in each dose of vaccine.

4.2 VIRAL VACCINES

Viruses cannot be grown on inanimate media employed to grow bacteria and thus,
are propagated on one of several types of animate media.

Embryonic egg
Cell cultures of chick embryo
Human diploid cell culture
Monkey cell culture
Skin of living calves
Intact mice

After the growth of the culture, various techniques are employed to separate the
virus from the host cell. Purification steps are taken to reduce incidence of
hypersensitivity reactions to animate media or host cells.

4.2 VIRAL VACCINES

The final viral product may contain a single immunogen (monovalent) or it


may contain multiple immunogens (polyvalent) to elicit immunity against the
same disease.

The vaccine may remain as the whole virion or be further chemically processed
to split into a subvirion vaccine.

To prolong stimulation of antibodies, the virion may be adsorbed onto


aluminum phosphate, as is the case with rabies vaccine (adsorbed).

Typically, viral vaccines are available as lyophilized (freeze-dried) products that


required reconstitution prior to administration with the provided diluent.

4.2 VIRAL VACCINES

The strength of viral vaccines can be provided in:

tissue culture infection doses, the quantity of virus estimated to infect 50%
of inoculated cultures

Micrograms of immunogen
International units
D-antigen units
Plaque-forming units for yellow fever vaccine

4.3 CANCER VACCINES

Cancer vaccines in development are intended to increase recognition of cancer


cells by the immune system.

This approach to cancer treatment is exciting, as it offers another modality to


complement surgery, radiation therapy, and chemotherapy. Another is that the
development of these vaccines may play a role in preventing cancer in patients
at high risk because of familial diseases.

A goal of cancer vaccine development is to increase antigen awareness of the


immune cells or increase costimulatory signals that induce an immune
response.

4.3 CANCER VACCINES

T cells, lymphokine-activated killer cells, and natural killer cells have antitumor
activity. Thus, tumor vaccine development is to stimulate these immune cells
instead of antibody-producing cells, the operational model used to protect one
from an infection.

Tumor-killing cells recognize tumor-associated antigens (TAAs) on the surface of


the tumor cells.

Four types of cancer vaccines are under investigation:

Autologous tumor vaccines


Allogeneic tumor vaccines
Anti-iodotypic vaccines
Gene therapy-derived vaccines

4.3.1 AUTOLOGOUS TUMOR VACCINES

Autologous tumor vaccines are developed from antigenic material procured


from the tumor of the patient. Tumor cells are isolated from the tissue procured
during biopsy or surgery.

These cells are killed or attenuated and reinfused into the patient.

Typically, to enhance immunogenicity, they are combined with an adjuvant, such


as bacilli Calmette-Guerin (BCG) or C. parvum.

A major problem with this approach is the work and cost associated with the
production of vaccine for the individual patient. Also, some tumors escape the
immune system because their antigens are not expressed on the tumor surface.

4.3.2 ALLOGENEIC TUMOR VACCINES

Allogeneic tumor vaccines use the concept of shared or tumor-specific


antigens.

These vaccines are produced from cell lines that express tumor-specific or
shared TAAs.

To induce an immune response, either the fragment of the allogeneic tumor cell
or the whole cell is injected.

The beneficial aspect of this vaccine is that it can be used in a wide population
of patients.

4.3.3 ANTI-IODOTYPIC VACCINES

Anti-iodotypic vaccines are three-dimensional immunogenic regions on the


antibody that binds antigen.

Antibodies that bind TAAs are isolated and injected into mice. The resulting
antibodies are harvested and used to vaccinate another mouse. The resulting
anti-bodies have a three-dimensional binding site that mimics the original
structure of the TAA.

Because the anti-iodotypic antibody closely resembles the antigen, these can be
used to induce immune responses (cellular, antibody-antigen) to a given
antigen.

4.3.4 GENE THERAPY DERIVED


VACCINES
Gene therapy allows a DNA template to be placed within a cell, transcribed
into messenger RNA, and expressed as a costimulatory protein. One can
then induce a cell to synthesize this proteins as part of its normal function.

A gene that encodes interleukins or other costimulatory proteins can be


placed in cells expressing TAAs. This stimulates the immune response.

4.4 TOXOIDS
Bacteria are propagated, and after the required growth is achieved, the culture is filtered
through a sterilizing membrane filter. The filtrate that contains the toxin (exotoxin) is
then processed.

Processing involves addition of a concentrated salt solution to precipitate the toxin


from the filtrate. After the precipitated toxin is washed and dialyzed to purify it, the
toxin is detoxified with formaldehyde.

The detoxified toxin (toxoid) may be plain or contain an adjuvant. The product may
also contain single, multiple, or mixed immunogens.

A mixed biologic has two toxoids and a vaccine in single dosage form for active
immunization against different toxicities and infection.

Their advantage is broad immunization coverage and minimum number of injections.

4.4 TOXOIDS
The strength of a toxoid is in flocculating (Lf)) units.
e.g. Tetanus toxoid, 4 to 5 Lf U/0.5 mL dose

A flocculating unit is the smallest amount of toxin that flocculates most


rapidly one unit of standard antitoxin in a series of mixtures containing
fixed amounts of antitoxin and varying amounts of toxin.

PART V
BIOLOGICS FOR PASSIVE
IMMUNITY

THERE ARE FOUR TYPES OF BIOLOGICS FOR


ACTIVE IMMUNITY:

Human Immune Sera and Globulins


(Homologous Sera)
Animal Immune Sera
(Heterologous Sera)

5.1 HUMAN IMMUNE SERA AND


GLOBULINS
(HOMOLOGOUS SERA)

They include immunoglobulin and hyperimmune sera for specific diseases.


These contain the specific antibodies obtained from the blood of humans
and produced as a result of having had the specific disease or having been
immunized against it with a specific biologic product.

The source of homologous sera is the pooled plasma of adult donors:


General population for immunoglobulins
Hyperimmunized donors for immunoglobulins for specific
diseases

5.1 HUMAN IMMUNE SERA AND


GLOBULINS
(HOMOLOGOUS SERA)

The pooled plasma from adult donors must be free of hepatitis B antigen and
antibodies to HIV.
Processing steps include:

Fractional precipitation (e.g., with cold ethanol)


Maintaining rigorous control of pH; and
Ionic strength

Further purification takes place with a finished biologic product that contains
n.l.t 15% and n.m.t 18% protein. There are exceptions such as the varicella-zoster
immunoglobulins (VZIGs) which contain n.l.t 10% proteins.

5.1 HUMAN IMMUNE SERA AND


GLOBULINS
(HOMOLOGOUS SERA)
Sera have the greatest value for the treatment of acute disease, although
they are also useful in some instances to prevent illness when immediate
protection is needed.

Immunity resulting from the injection of an immune serum is brief (just


for a few weeks).

5.2 ANIMAL IMMUNE SERA


(HETEROLOGOUS SERA)

Most commonly employed immune sera are prepared by immunization of


horses against the specific immunogen (e.g., toxin, venom).

After the plasma is harvested, it is separated by fractional precipitation into two


components:

Immunologically active (immunoglobulins)


Immunologically inactive (albumins, clotting factors)

The immunologically active component is treated with pepsin to remove the


complement-activating component of the molecules and render it less
immunogenic. Then, the active component is recovered through dialysis and
fractional precipitation or centrifugation.

5.2 ANIMAL IMMUNE SERA


(HETEROLOGOUS SERA)

This category includes the antitoxins and antivenins.

Antitoxins are produced by inoculating horses with increasing doses of the


toxoids and exotoxins.

Antivenins are produced similarly, by inoculating horses with the venom of


selected species and harvesting the plasma.

Before using these products, precautions must be taken to ensure the safety of
the patient, who may be sensitive to horse protein. Sensitivity tests may be
undertaken to detect any dangerous hypersensitivity.

EXAMPLES OF OFFICIAL BIOLOGIC


PRODUCTS

See TABLE 16.1 for


EXAMPLES OF OFFICIAL BIOLOGIC PRODUCTS.