Given the sporadic occurrence of oseltamivir-resistant viruses, the characterization of zanamivir-resistant viruses and the lack of heterovariant vaccines, alternative treatment strategies for influenza are urgently needed. Immunotherapy with monoclonal antibodies represents a complementary strategy to current antivirals. The use of monoclonal antibodies for treatment of medical conditions, including viral diseases like hepatitis and respiratory syncytial virus, is well established.
Monoclonal antibody therapy could be employed alone for the treatment of influenza infections with strains that are resistant to current antivirals or in combination with antivirals in the case of terminal patients with severe influenza infections. Prophylactic administration of antibodies could be valuable in the case of a pandemic with a highly pathogenic virus like H5N1 especially for persons which are particular susceptible to illness like elderly and immunocompromised individuals, and people with a higher risk of getting infections as health-related and hospital workers.
Here, we review how cross-protection can be achieved, via passive immunotherapy or vaccination, against influenza, a representative viral infection. Recently, several bnAbs against the influenza virus that produce cross-protection have been isolated.
SAB Biotherapeutics: SAB-176
SAB-176 is being developed for several influenza indications, including treatment of high-risk patient populations, as well as pre- and post-exposure prophylaxis. The FDA’s Breakthrough Therapy designation confirms that the multi-epitope targeting modality of SAB-176 has a clear differentiation vs. monoclonal antibodies (mAb) that bind to a single epitope, and SAB’s treatment can sustain its efficacy over viral mutations and prevent or reduce the risk of emerging treatment-resistant influenza strains. Virus evolution driven by vaccines or treatments is a serious challenge and the use of therapeutics can create “escape mutants” or versions of a virus that have changed to escape pressure on virus survival driven by an antiviral treatment, whether it is a small molecule or monoclonal antibody modality.
SAB’s polyclonal antibodies exhibit broad neutralization across multiple epitopes of Influenza A and B viruses. SAB-176 has a half-life that allows long-term protection against a virus and its mutations with a single dose.
These fully human antibodies can neutralize many different variants of influenza A and B. SAB-176’s recently completed clinical proof-of-concept Phase 2A trial showed statistically significant reduction in viral load, confirming high cross-reactivity (the ability to recognize and react to strains it was not specifically produced against) to the pandemic influenza strain (not targeted with immunogen to produce SAB-176 treatment) in humans. SAB’s fully human polyclonal antibodies achieved both statistically significant reduction in viral load and statistically significant improvement in symptomology at Day 4, confirming SAB-176’s favorable safety and tolerability profile.
With funding for research provided by the Henry Jackson Foundation, this partnership will move forward a pharmacokinetic (PK), safety and tolerability study designed as a double-blinded, randomized study with intramuscular SAB-176 administered to healthy volunteers. The NMRC Clinical Trials Center, located in Bethesda, Maryland, will be conducting this PK study under the leadership of Cmdr. Nehkonti Adams, Director, NMRC Clinical Trials Center.
SAB has utilized its proprietary DiversitAb™ platform to manufacture SAB-176, fully human polyclonal antibodies targeting influenza from Transchromosomic (Tc) Bovine™. SAB-176 is a novel multi-target biologic that has shown sustained neutralization activity across multiple virus strains of Influenza A and B. In 2023, the U.S. Food and Drug Administration granted Breakthrough Therapy and Fast Track Designations to SAB-176 based on the results of the completed clinical proof-of-concept Phase 2 study in an influenza challenge model with intravenous (IV) formulation. SAB-176, along with several other fully human anti-infective immunoglobulins developed by SAB have been administered through IV to over 700 healthy volunteers and patients. This will be the first study to examine intramuscular administration of any DiversitAb™ platform product. The DiversitAb™ platform produces fully human target-specific biologics that can be delivered across a range of therapeutic areas, including infectious diseases and autoimmune conditions like type 1 diabetes (T1D).
SAB Chairman and CEO Samuel J. Reich stated that “we are pleased to continue our collaboration with the NMRC to explore new routes of administration for our products. (...)
Cidara Therapeutics: CD388
Cidara is developing a new generation of immunotherapeutic agents from its Cloudbreak platform that couple potent drugs to a human antibody fragment. These highly potent, long-acting drug-Fc conjugates (DFCs) are designed to inhibit specific disease targets while simultaneously engaging the immune system.
Cidara is developing CD388, a flu DFC, to achieve universal prevention of seasonal and pandemic influenza with a single dose. DFCs are not vaccines or monoclonal antibodies. Their targeting domains are small molecule antivirals that bind to a highly conserved target on the influenza cell surface, which is essential for viral proliferation and enables universal influenza coverage. These long-acting, bispecific DFCs are designed to directly inhibit viral proliferation while simultaneously directing immune-mediated clearance of the virus. The two distinct and complementary mechanisms are designed to maximize antiviral activity of DFCs.
Flu DFCs have the potential to offer significant advantages over current flu vaccines:
- True universal protection, against all influenza strains and for all people, including those with a compromised immune system
- Near-immediate protective effects
CD388 Mouse study
Cidara Corporate Presentation
CD388 Publication referenced in the Cidara Corporate Presentation
Concurrent with the acquisition, Cidara closed a definitive agreement for the sale of preferred stock in a private placement led by RA Capital Management, with significant participation from Bain Capital Life Sciences, Biotech Value Fund (BVF), and Canaan Partners. The private placement provides $240 million in gross proceeds that will be used by Cidara to develop CD388 as a universal preventative against seasonal and pandemic influenza A and B, beginning with a Phase 2b clinical trial in the upcoming Northern Hemisphere influenza season. The proceeds from the private placement fund the upfront payment under the agreement with Johnson & Johnson and are expected to provide runway beyond topline data from CD388’s Phase 2b trial. (...)
Dr. Stein continued, “This reacquisition of CD388, along with the capital to advance it through Phase 2b development, is transformational for Cidara and especially for those who could benefit from a long-acting, universal preventative against all forms of influenza. In our Phase 2b study later this year, we will evaluate the efficacy and safety of CD388 in providing season-long, universal protection from influenza. We believe that CD388 may have significant advantages beyond and in addition to flu vaccines, with the potential for universal protection even in the absence of a robust immune response and without the requirement for seasonal influenza strain prediction.”
All responsibility for future development, manufacturing, and commercialization activities of CD388 will be assumed by Cidara. In exchange for reacquiring the exclusive global development and commercial rights to CD388, Johnson & Johnson has received from Cidara a one-time upfront payment of $85 million and is eligible to receive potential additional development, regulatory, and commercial milestone payments.
Vir Biotechnology: VIR-2482
A phase 2 study of VIR-2482 ended unsuccessfully. The final results have been published in April 2024 and can be found here.
VIR-2482 is an investigational intramuscularly administered influenza A-neutralizing monoclonal antibody. In vitro, it has been shown to cover all major strains of influenza A that have arisen since the 1918 Spanish flu pandemic. VIR-2482 is designed as a universal prophylactic for influenza A. It has the potential to overcome the limitations of current flu vaccines and lead to meaningfully higher levels of protection due to its broad strain coverage and because it does not rely on an individual to create their own protective antibody response. VIR-2482, which incorporates Xencor’s Xtend™ Technology, also has been half-life engineered so a single dose has the potential to last the entire flu season. Under the collaboration agreement signed with GlaxoSmithKline (GSK) in 2021, GSK has an exclusive option to lead post-Phase 2 development and commercialization of VIR-2482.
Vir Biotechnology: VIR-2981
Vir Biotechnology has discontinued the development of VIR-2981, which was in the pre-clinical stage.
VIR-2981 is an investigational neuraminidase-targeting monoclonal antibody against influenza viruses. It targets a region of the neuraminidase protein that is highly conserved across influenza A and B strains and is designed to inhibit the influenza neuraminidase, a key viral protein that facilitates release of new viruses in infected individuals. Preclinical data demonstrate the antibody’s breadth and potency against all major strains of seasonal and pandemic influenza viruses and support the potential of this antibody in the prevention of influenza illness.
Johnson & Johnson / Leyden Laboratories: CR9114
CR9114 is in a pre-clinical stage. It has been developed by Johnson & Johnson and was licensed to Leyden Laboratories to develop a nasal spray. CR9114 has shown promising results against a broad range of influenza strains including H5N1. Intranasal administration fully protected mice from H5N1 infections a low viral doses.
Johnson & Johnson / Scripps Research: MD3606
MD3606 is in a pre-clinical stage. It has been developed by Johnson & Johnson in cooperation with Scripps Research. The multidomain antibody MD2470 combines the four different variable domains SD36, SD38, SD83, and SD84. While MD2470 is derived from llamas, it is combined with a human Fc receptor and together they constitute MD3606.
Johnson & Johnson: CR6261 and CR8020
CR6261 has failed a phase 2 study. There are no published results regarding CR8020 in recent years, so it has probably failed too. They have been developed by Crucell, which is now part of Johnson & Johnson. Nonetheless, their failure has provided valuable data to learn from.
Roche / Genentech: MHAA4549A
MHAA4549A has failed a phase 2 study sponsored by Genentech. The results have been published and Genentech is now part of Roche.
Visterra: VIS410
VIS410 has successfully completed a phase 2 study. The results have been published and as of May 2024 VIS410 is still in the pipeline in phase 2.
Theraclone: TCN-032
TCN-032 has failed to reach the primary endpoint in a completed a phase 2 study. Nonetheless, the results were positive and have been published.
Universal Influenza Vaccine Technology Landscape
A great vaccine database with a different focus is the Universal Influenza Vaccine Technology Landscape by CIDRAP.