An unmet Need
Hypersensitivity Reactions (HSRs), stemming from drug infusion and medical device usage can range in severity from minor skin rash to anaphylactic shock and death. Globally, more than 3% of patients develop HSRs to marketed therapies, and the occurrence of HSRs in clinical trials can be not only dangerous for patients, but project ending and often bankrupting for companies. With the development of new and more complex therapies that are highly susceptible to HSRs, the need for preclinical HSR testing is growing. World leading health authorities, such as the FDA, EMA and WHO, acknowledge the adverse nature of these events and the need for improved prevention and management.
The CARPA Assay
SeroScience’s professional suite of immunotoxicology services center on complement activation, the innate immune system’s first-line defense against foreign objects and a system capable of eliciting anaphylaxis. The assay is named Complement Activation Related Pseudoallergy (CARPA); it is a pseudoallergic reactions because it is not IgE mediated. Our proprietary porcine model and testing protocols enable high-resolution studies of complement activation pathway-mediated HSR and the associated physiologic read-outs, providing detailed insight into the intensity with which the human complement system will react to a foreign object (drug or device). More than 20 years of supporting in vivo studies have demonstrated our proprietary system to be extremely accurate in quantifying the level of reaction expected to occur in a human as well as to develop clear guidance on appropriate dose concentration, allowing us to create custom administration protocols to mitigate undesired reactions.
In partnership with Dartmouth College, Semmelweis University and Aurigon GmbH, the SeroScience Group offers the CARPA Assay under GLP, GLP-like, or non-GLP standards depending on your needs and budget. The experiment is usually conducted on minipigs or juvenile domestic pigs (the most sensitive platforms), but may also be conducted in dogs, rats and mice depending on experiment design and purpose.
During the experiment the following parameters are acquired and analyzed:
Pulmonary Arterial Pressure (PAP)
Systemic Arterial Pressure (SAP)
Cardiac Output (CO)
Heart rate (HR)
Expiratory/end-tidal Carbon Dioxide pressure (pCO2)
All Blood Cell Counts
White Blood Cell (WBC) differential
Skin reactions (rash, flushing)
Complement measurements are recommended and widely applied for the hemocompatibility testing of medical devices, as regulated in ISO 10993-4. ISO-1093
The U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research (CDER) lists testing for complement activation among the recommended immunotoxicological as follows:
"A pseudoallergic reaction can result from activation of inflammatory or anaphylactic mechanisms independent of antigen-specific immune responses. Pseudoallergy is known to have several causes, including but not limited to direct histamine release and complement activation (Descotes, 1986; Szebeni, 2001). This reaction is likely to be dose-related. If signs of anaphylaxis are observed in animal studies, follow-up studies should be considered. Anaphylactoid reaction can be differentiated from true IgE mediated anaphylaxis by various methods, including in vitro testing (e.g., drug-induced histamine release using a mast cell line) (Baxter et al., 1993; Toyoguchi et al., 2000). Biochemical markers of an anaphylactoid reaction can be observed in nonclinical toxicology studies (e.g., detection of serum anaphylactic complement products in animals showing signs of anaphylaxis) (Szebeni, 2001). Careful evaluation of these reactions has resulted in valuable information on biochemical markers used in clinical trials.” See Guidance for Industry 2002.
A peer-reviewed publication referencing the above guideline also specifically comments on the phenomenon (Hastings KL 2002 Int Immunopharmacol).
The EMA refers to complement activation as a potential mechanism when adverse reactions occur upon administration of biotechnology-derived products in ICH guideline S6 (R1): "incidence and/or severity of adverse effects, complement activation, or the emergence of new toxic effects should be considered when interpreting the data.” See EMA CHMP ICH 731268 1998.
ISO 10993-4: Biological evaluation of medical devices — Part 4: selection of tests for interaction with blood, ANSI/AAMI/ISO 10993-4:2002/(R) 10 March 2009, 2009.
Guidance for Industry, Immunotoxicology Evaluation of Investigational New Drugs”, October 2002. https://www.fda.gov/media/72228/download
Hastings KL, Center for Drug Evaluation and Research, US Food and Drug Administration. Implications of the new FDA/CDER immunotoxicology guidance for drugs. Int Immunopharmacol. 2002 Oct;2(11):1613-8.
Preclinical safety evaluation of biotechnology-derived pharmaceuticals EMA/CHMP/ICH/731268/1998; Committee for medicinal products for human use (CHMP); June 2011)
Rampton D, Folkersen J, Fishbane S, Hedenus M, Howaldt S, Locatelli F, Patni S, Szebeni J, Weiss G. Hypersensitivity reactions to intravenous iron: guidance for risk minimization and management. Haematologica. 2014;99(11):1671-6.
PLEASE FIND BELOW OUR TEAM’S PUBLISHING RECORD ON THE SUBJECT OF HYPERSENSITIVITY REACTIONS AND SPECIFICALLY THE CARPA PHENOMENON:
Szebeni, J. et al. (2018). “Roadmap and strategy for overcoming infusion reactions to nanomedicines” Nat Nanotechnol <Link>
Mészáros, T. et al. (2018). “Involvement of complement activation in the pulmonary vasoactivity of polystyrene nanoparticles in pigs: unique surface properties underlying alternative pathway activation and instant opsonization.” Int J Nanomedicine 13: 6345-6357. <Link>
Zamboni, WC. et al. (2018). “Animal models for analysis of immunological responses to nanomaterials: Challenges and considerations” Adv Drug Deliv Rev. <Link>
Neun, BW. et al. (2018). “Understanding the Role of Anti-PEG Antibodies in the Complement Activation by Doxil in Vitro” Molecules 23(7) 1700. <Link>
Szebeni, J. et al. (2018). “A porcine model of complement activation-related pseudoallergy to nano-pharmaceuticals: Pros and cons of translation to a preclinical safety test” Prec Nanomedicine 1(1): 63-73. <Link>
Matviykiv , S. et al. (2018). “Immunocompatibility of Rad-PC-Rad liposomes in vitro, based on human complement activation and cytokine release” Prec Nanomedicine 1(1): 43-62. <Link>
Unterweger , H. et al. (2018). “Dextran-coated superparamagnetic iron oxide nanoparticles for magnetic resonance imaging: evaluation of size-dependent imaging properties, storage stability and safety” Int J Nanomedicine 13:1899-1915. <Link>
Szebeni, J. (2018). “Mechanism of nanoparticle-induced hypersensitivity in pigs: complement or not complement?” Drug Discov Today 23(3): 487-492. <Link>
Fülöp, T. et al. (2018). “Complement activation in vitro and reactogenicity of low-molecular weight dextran-coated SPIONs in the pig CARPA model correlation with physicochemical features and clinical information” Journal of Controlled Release 270: 268-274. <Link>
Cedrone, E. et al. (2017). “Anticoagulants Influence the Performance of In Vitro Assays Intended for Characterization of Nanotechnology-Based Formulations” Molecules 23(1), 12. <Link>
Buscema, M. et al. (2017). “Immunological response to nitroglycerin-loaded shear-responsive liposomes in vitro and in vivo” Journal of Controlled Release 264: 14-23. <Link>
Unterweger, H. et al. (2017). “Non-immunogenic dextran-coated superparamagnetic iron oxide nanoparticles: a biocompatible, size-tunable contrast agent for magnetic resonance imaging” International Journal of Nanomedicine 12: 5223–5238. <Link>
Wibroe, PP. et al. (2017). “Bypassing adverse injection reactions to nanoparticles through shape modification and attachment to erythrocytes.” Nat Nanotechnol. 12(6):589-594. <Link>
Fülöp, T. et al. (2017). “The role of thromboxane A2 in complement activation-related pseudoallergy.” Eur Journal of Nanomedicine 9(2): 59. <Link>
Őrfi, E. and Szebeni, J. (2016). “The immune system of the gut and potential adverse effects of oral nanocarriers on its function.” Adv Drug Deliv Rev 106: 402-409. <Link>
Bozó, T.; Mészáros, T. et al. (2016). “Aggregation of PEGylated liposomes driven by hydrophobic forces.”Colloids and Surfaces B: Biointerfaces 147: 467-474. <Link>
Jackman, J. et al. (2016). “Comparison of complement activation-related pseudoallergy in miniature and domestic pigs: foundation of a validatable immune toxicity model.” Nanomedicine 12(4): 933-943. <Link>
Mészáros, T. et al. (2016). “Factor H inhibits complement activation induced by liposomal and micellar drugs and the therapeutic antibody rituximab in vitro.” Nanomedicine 12(4): 1023-1031. <Link>
Matuszak, J. et al. (2016). “Nanoparticles for intravascular applications: physicochemical characterization and cytotoxicity testing.” Nanomedicine (Lond) 11(6): 597-616. <Link>
Szebeni, J. and G. Storm (2015). “Complement activation as a bioequivalence issue relevant to the development of generic liposomes and other nanoparticulate drugs.” Biochem Biophys Res Commun 468(3): 490-497. <Link>
Csukas, D. et al. (2015). “AC5 Surgical Hemostat as an effective hemostatic agent in an anticoagulated rat liver punch biopsy model.” Nanomedicine 11(8): 2025-2031. <Link>
Milosevits, G. et al. (2015). “Exosomes: potential model for complement-stealth delivery systemss.” Eur Journal of Nanomedicine 7(3): 207-218. <Link>
Dezsi, L. et al. (2015). “Rodent models of complement activation-related pseudoallergy: Inducers, symptoms, inhibitors and reaction mechanisms.” Eur Journal of Nanomedicine 7(1): 15-25. <Link>
Yorulmaz S et al. (2015). “Membrane attack complex formation on a supported lipid bilayer: initial steps towards a CARPA predictor nanodevice.” Eur Journal of Nanomedicine 7(3): 245-255. <Link>
Csukas, D. et al. (2015). “Pulmonary intravascular macrophages: prime suspects as cellular mediators of porcine CARPA.” Eur Journal of Nanomedicine 7(1): 27-36. <Link>
Urbanics, R. et al. (2015). “Lessons learned from the porcine CARPA model: constant and variable responses to different nanomedicines and administration protocols.” Eur Journal of Nanomedicine 7(3): 219-231. <Link>
Kozma, G. T. et al. (2015). “Variable association of complement activation by rituximab and paclitaxel in cancer patients in vivo and in their screening serum in vitro with clinical manifestations of hypersensitivity: a pilot study.”Eur Journal of Nanomedicine 7(4): 289-301. <Link>
Mészáros, T. et al. (2015). “Paradoxical rise of hemolytic complement in the blood of mice during zymosan- and liposome-induced CARPA: a pilot study.” Eur Journal of Nanomedicine 7(3): 257-262. <Link>
Dezsi, L. et al. (2014). “Features of complement activation-related pseudoallergy to liposomes with different surface charge and PEGylation: comparison of the porcine and rat responses.” J Control Release 195: 2-10. <Link>
Bedocs, P. et al. (2014). “Hypersensitivity reactions to intravenous lipid emulsion in swine: relevance for lipid resuscitation studies.” Anesth Analg 119(5): 1094-1101. <Link>
Szebeni, J. (2014). “Complement activation-related pseudoallergy: a stress reaction in blood triggered by nanomedicines and biologicals.” Mol Immunol 61(2): 163-173. <Link>
Szebeni, J. and P. Haima (2013). “Hemocompatibility of medical devices, blood products, nanomedicines and biologicals” TECOmedical Clinical & Technical Review <Link>
Moghimi, S. M. et al. (2013). “Surfactant-mediated complement activation in beagle dogs.” Int Immunopharmacol 17(1): 33-34. <Link>
Dezsi, L. et al. (2013). “Cardiopulmonary and hemodynamic changes in complement activation-related pseudoallergy” Health 5(6): 1032-1038. <Link>
Szebeni, J. et al. (2013). “Plasma Proteome Profiling with Monoclonal Antibody Libraries: A Pilot Biomarker Analysis for Nanomedicine-Induced Complement Activation.” Advances in Nanoparticles 2(2): 133-144. <Link>
Szebeni, J. et al. (2012). “A porcine model of complement-mediated infusion reactions to drug carrier nanosystems and other medicines.” Adv Drug Deliv Rev 64(15): 1706-1716. <Link>
Szebeni, J. et al. (2012). “Prevention of infusion reactions to PEGylated liposomal doxorubicin via tachyphylaxis induction by placebo vesicles: a porcine model.” J Control Release 160(2): 382-387. <Link>
Milosevits, G. et al. (2012). “Flow cytometric analysis of supravesicular structures in doxorubicin-containing pegylated liposomes.” Chem Phys Lipids 165(4): 482-487. <Link>
Weiszhár, Z. et al. (2012). “Complement activation by polyethoxylated pharmaceutical surfactants: Cremophor-EL, Tween-80 and Tween-20.” Eur J Pharm Sci 45(4): 492-498. <Link>
Szebeni, J. et al. (2012). “Liposome-induced complement activation and related cardiopulmonary distress in pigs: factors promoting reactogenicity of Doxil and AmBisome.” Nanomedicine 8(2): 176-184. <Link>
Szebeni, J. et al. (2011). “Activation of complement by therapeutic liposomes and other lipid excipient-based therapeutic products: prediction and prevention.” Adv Drug Deliv Rev 63(12): 1020-1030. <Link>
Merkel, O. et al. (2011). “In vitro and in vivo complement activation and related anaphylactic effects associated with polyethylenimine and polyethylenimine-graft-poly(ethylene glycol) block copolymers.” Biomaterials 32(21): 4936-4942. <Link>
Moghimi, S. M. et al. (2010). “Complement activation cascade triggered by PEG-PL engineered nanomedicines and carbon nanotubes: the challenges ahead.” J Control Release 146(2): 175-181. <Link>
Epstein-Barash, H. et al. (2010). “Physicochemical parameters affecting liposomal bisphosphonates bioactivity for restenosis therapy: internalization, cell inhibition, activation of cytokines and complement, and mechanism of cell death.” J Control Release 146(2): 182-195. <Link>
Racz, Z. et al. (2010). “Sugar-free, glycine-stabilized intravenous immunoglobulin prevents skin but not renal disease in the MRL/lpr mouse model of systemic lupus.” Lupus 19(5): 599-612. <Link>
Szebeni, J. and Moghimi, S. M.(2009). “Liposome triggering of innate immune responses: a perspective on benefits and adverse reactions.” J Liposome Research 19(2): 85-90. <Link>