Monoclonal Antibodies (mAbs) – Structure, Engineering, and
Naming
Monoclonal Antibodies: The Backbone of Immunotherapy
• Therapeutic Revolution: mAbs are now the largest class of biotherapeutics,
with applications in oncology, autoimmunity, infectious diseases, and more.
Part 1: The Basic Structure of a Therapeutic mAb
• Your immune system produces different types (classes) of antibodies, like IgG,
IgM, IgA, IgD, and IgE, each with different functions.
• IgG (Immunoglobulin G): This is the most abundant antibody in your blood,
crucial for fighting infections, and has a long lifespan.
• Monoclonal Antibodies (mAbs): These are engineered to be identical
("mono-clonal") and target a single specific part (antigen) of a foreign
substance, like a cancer cell.
• Most clinically used mAbs are designed to mimic the natural IgG structure,
especially IgG1, because it's stable and effective. Researchers create these by
cloning a single B-cell that produces a desired antibody.
• Most therapeutic mAbs are based on the IgG isotype. It has a long serum half-
life and can engage the immune system.
ٮًﺎ# ﺴﻤﺎ ﻣﻀﺎ ًدا ﻣﺮﻋ& وً ﺣ# ٮﺞ1 &ٮ1 واﺣﺪة ٮB ﺔ7&ﺣﻠٮ
(cloning) ﺴﺎﺣﻬﺎ & ٮ &ٮ1 اﺳ
:ﺢ#ٮﺼٮ1 ٮًﺎ ﻟ7 ?ﻠﻬﺎ وراٮ7 ﻌﺪٮ1ٮ
أﻛ ?ٮﺮ أﻣﺎ &ٮًﺎ
ڡﻞ إﺣﺪاٮ?ًﺎ ﻟﻠﻤ &ٮﺎﻋﺔ1 أ
ﺸري#ٮﻌﻤﺎل اﻟٮ1 ﺔ ﻟﻼﺳ#ﻣ &ٮﺎﺳٮ
Dr. Mohammad Ali Khaleel Immunotherapy
26
• A detailed diagram of an IgG molecule.
.ﺎط#ٮ1ﻌﺪ اﻻرٮ#ﺔ ٮ7ﺔ اﻟﻤ &ٮﺎﻋٮ#ﺤﺎٮ# ٮ1 ﺤﺪد اﻻﺳ7 ﻞ ٮ#ٮ
# تواﺻﻞ ﻣﻊ1( ٮSignaling Module) ﻌﻤﻞ ﻛـ وﺣﺪة إﺷﺎرات7 ٮ
اﻟﺤﻬﺎز
:ﺮ#ﺎعى ﻋٮ
\ اﻟﻤ &ٮ
Fc receptors ﻋﲆ:
NK cells → ADCC
macrophages / neutrophils → ﻠﻌﻤﺔ#ٮ
Complement system → CDC
:ﺔ ﻣﻬﻤﺔ7إﺿﺎڡٮ & وﻃﺎﺋﻒ &
.(FcRn ﺮ#ﻟﻠﺤﺴﻢ اﻟﻤﻀﺎد )ﻋٮ # ﺼڡ \ى& ﺤﺪد اﻟﻌﻤﺮ اﻟ &ٮ7 ٮ
:ﻞ7ڡﻠٮ1 1ٮﻪ ﻟزيﺎدة أو ٮ1 ﻤﻜﻦ ﻫ &ٮﺪﺳ7 ٮ
Functional Anatomy of a mAb
• Two Functional Units in One Molecule:
1. The Fab (Antigen-Binding Fragment): What it binds to. Determines
the target (e.g., CD20 on B-cells, HER2 on breast cancer cells, TNF-α in
inflammation).
2. The Fc (Crystallizable Fragment): What it does after
ﺤﺪث7ﺤﺪد ﻣﺎذا ﺳٮ7 ٮ binding. Communicates with the immune system. It's a "signaling
.ﻌﺪ اﻟﻮﺻول ﻟﻠﻬﺪف#ٮ
module" that recruits immune cells (via Fc receptors) and complement
proteins.
• Analogy: A Fab is like a highly specific GPS coordinate. The Fc is the radio
that calls in the specific strike (immune cells) once the target is locked.
Part 2: Antibody Engineering – The Humanization Journey
Immunogenicity :ﺔ7اﻟﻤﺸكﻠﺔ اﻷﺳﺎﺳٮ
The Immunogenicity Problem #
ٮًﺎ7 ﺪريﺤ1 & ﻞ اﻟﻤﻜوّن7ڡﻠٮ1 1 ٮ:اﻟﺤﻞ
اﻟڡﺄري ٮ
:ﺸريﺔ#كﻠﻤﺎ زادت اﻟٮ
• Concept: HAMA – Human Anti-Mouse Antibody Response.
ﺼڡ \ى& ↑ اﻟﻌﻤﺮ اﻟ &ٮ
& ↑
ﺔ7اﻟڡﻌﺎﻟٮ
ﻜوّن أﺿﺪاد ﻣﻀﺎدة ﻟﻠﺪواء1ٮﺤﺴﺲ وٮ1 ↓ اﻟ
Dr. Mohammad Ali Khaleel Immunotherapy
ٮّﻦ7 ٮﻌﺮّف ﻋﲆ دواء ﻣﻌ1 ﺎﻟ#ﺣﻬﺎز اﻟﻤ &ٮﺎﻋﺔ ٮ# ڡﻮم1 7 ﺤﺪث ﻋ &ٮﺪﻣﺎ ٮ1اﻟﻤﺸكﻠﺔ اﻟﱵ ٮ
27
#
.ٮﻪ1 ﻤﻬﺎﺣﻤ# ﺪأ ٮ#ٮٮ7 &ڡ،ﺣﺴﻢ ﻋ& ريﺐ# ﺔ( ﻋﲆ أٮ&ﻪ7ﻮﻟﻮﺣٮ7
# ٮٮ# اﻟ/ﺔ7ٮ &ٮٮ7 1روٮ#)ﺣﺼﻮﺻًﺎ اﻷدويﺔ اﻟٮ
&
• Problem: Early mAbs were made entirely from mouse proteins. The human
immune system recognizes them as foreign, leading to rapid clearance,
reduced efficacy, and potential allergic reactions.
• Engineering Goal: Reduce the mouse content to reduce immunogenicity,
while preserving the exquisite antigen-binding specificity.
Human Anti-Mouse Antibody Respons
Type Description % Immunogenicity Example (Generic)
Human Risk
Murine 100% mouse. 0% Very High Muromonab-CD3 (Historical,
(HAMA) mostly withdrawn) (-
momab)
Chimeric Mouse ~65% Lower Rituximab, Infliximab (-
Variable regions (for ximab)
binding) fused
to Human
Constant regions.
Humanized Only the mouse ~90- Very Low Trastuzumab,
CDRs are grafted onto 95% Pembrolizumab (-zumab)
a human antibody
framework.
Mouse antibody → ﺣ ًﺪا# ﺎعى
\ ﻣ &ٮ
Chimeric antibody → ﺸري#ﺣﺰء ٮ# + ﺣﺰء &ڡﺄري#
Humanized antibody → ڡﻂ1 &ڡCDRs ✔ &ڡﺄريﺔ
Dr. Mohammad Ali Khaleel antibody → ﺎﻟﲀﻣﻞ#ﺸري ٮ#ٮ
Fully human Immunotherapy 28
ﺎت7ﺎﻟﻌﺎٮ?ٮ#ﺔ اﻟﻌﺮض ٮ7ڡ &ٮٮ1 1ٮ &ﺤﺪام ٮ1 ﺎﺳ#ﺸريﺔ ٮ#ٮ &ٮﺎت ٮ7 ﺣ# ﺎت#ٮٮ1 هﺎ ﻣﻦ ﻣﻜ7ٮﻢ اﻟﺤﺼول ﻋﻠٮ1 7 ٮ
(Phage display)
ﺸر ًيﺎ#ٮًﺎ ٮ7 ﺣﻬﺎ ًزا ﻣ &ٮﺎﻋ# ٮﻠﻚ1 ﻤ1ٮًﺎ ٮ7 ?أو ﻣﻦ &ڡﺌران ﻣﻌﺪﻟﺔ وراٮ
Fully Derived from human 100% Minimal Adalimumab , Nivolumab (-
Human gene libraries (phage umab)
display) or transgenic
mice with human
immune systems.
Engineering in Detail
• Chimeric: "Cut and Paste." The Fab's variable domains are mouse, the rest is
human. Major improvement, but mouse V regions can still cause reactions.
• Humanized: "CDR Grafting." Like transplanting only the tip of the key (CDR)
onto a human key blank. Requires careful "back-mutations" to maintain
binding affinity.
• Fully Human: The gold standard for minimizing immunogenicity in chronic
therapies.
The CDR stands for Complementarity Determining Region. These are loops at the
very tip of the antibody. They are highly variable and are the only part that actually
touches and binds to the target.
• The Mouse Antibody is a key made of brass (mouse protein). It unlocks the
door perfectly, but the human body hates brass.
• The Human Antibody is a key made of silver (human protein). The body loves
silver, but this key doesn't fit the lock.
• Grafting: Moving the specific binding loops (CDRs) from a mouse antibody to
a human antibody scaffold.
• Goal: To keep the binding power of the mouse but the safety of the human.
• Back-Mutations: Fine-tuning the human scaffold by reverting tiny parts of it
to the mouse version to ensure the CDRs hold the correct shape.
(Key Analogy) ٮﺎح1 ﺎﻟﻤڡ# & ﻪ ٮ7ٮٮ# ٮﺸ1 اﻟ
Mouse antibody = ٮﺎح ﻣﻦ ٮ&ﺤﺎس1 ﻣڡ &
ً ڡ &ڡﻞ ٮ1 ٮﺢ اﻟ1 ڡ7& ✔ ٮ
ﻤﺎﻣﺎ1
ﺮڡﺾ اﻟ &ٮﺤﺎس7 & اﻟﺤﺴﻢ ٮ
# ❌
Human antibody = ٮﺎح ﻣﻦ &ڡﻀﺔ1 ﻣڡ &
ٮّﻠﻪ# ڡ1 ٮ1 7 اﻟﺤﺴﻢ ٮ
# ✔
ڡ &ڡﻞ1 ٮﺢ اﻟ1 ڡ7& ❌ ﻻ ٮ
CDR Grafting = اﻟڡﻀﺔ & ڡﻂ ﻣﻦ اﻟ &ٮﺤﺎس إﻟﻰ1 ٮﺎح &ڡ1 اﻟﻤڡ
& ڡﻞ أﺳ &ٮﺎن1 &ٮ
ڡ &ڡﻞ1 ٮﺢ اﻟ1 ڡ7& ✔ ٮ
ٮّﻠﻪ# ڡ1 ٮ1 7 اﻟﺤﺴﻢ ٮ
# ✔
Dr. Mohammad Ali Khaleel
Back-mutations & ﻖ ﻟﺸكﻞ7ڡٮ1 ﻞ د7 ﻌﺪٮ1ٮ
= اﻟڡﻀﺔ
Immunotherapy
ﻮﺿﻌﻬﺎ اﻟﺼﺤيﺢ#ﻤﺴﻚ اﻷﺳ &ٮﺎن ٮ1→ ﺣﱴ ٮ
29
Part 3: Decoding the Name – The USAN Scheme
USAN Naming – A Structured Vocabulary
• Purpose: The United States Adopted Name (USAN) provides a unique,
standardized name that conveys drug substance information.
• Format: Prefix + Target/Substem 1 + Source/Substem 2 + Suffix
o Prefix: Unique, coined for distinction (e.g., Ritu- , Trastu- , Ada-).
o Infix/Substem 1 (Disease/Target): Indicates the drug's therapeutic
area.
▪ -vi(r)- = viral
▪ -ba(c)- = bacterial
▪ -tu(m)- = tumor
▪ -li(m)- = immunomodulator
▪ -ci(r)- = cardiovascular
o Infix/Substem 2 (Source): THIS IS OUR ENGINEERING STORY.
▪ -o- = mouse (old)
▪ -xi- = chimeric
▪ -zu- = humanized
▪ -mu- = fully human
o Suffix: -mab for all monoclonal antibodies.
Name Breakdown – Practice
• Ritux *-im-* ab? .
o Ritu- (prefix)
o -t(u)- (target: tumor)
o -x(i)- (source: chimeric)
o -mab (suffix)
o Correct Breakdown: Ritu-xi-mab.
• Trastu-zu-mab: -t(u)- (tumor), *-zu-* (humanized).
• Adali-mu-mab: No distinct target substem, *-mu-* (fully human).
Dr. Mohammad Ali Khaleel Immunotherapy
30
• Bevaci-zu-mab: -ci(r)- (cardiovascular, targets VEGF in angiogenesis), *-zu-
* (humanized). No oral – IV/SC only – Slow SC – Small Vd – No BB
Part 4: Pharmacokinetics (PK) of Biologics
• The PK of mAbs is fundamentally different from small molecules. Forget about
CYP450 metabolism and renal filtration.
• 1. Absorption
• Oral Bioavailability is Zero: mAbs are large proteins (~150 kDa). If
swallowed, gastric acid and proteolytic enzymes digest them, and they are too
large to cross the GI epithelium.
• Routes: IV (100% bioavailability) or Subcutaneous (SC).
• SC Absorption: Because capillaries have tight junctions, mAbs injected SC
enter the systemic circulation via the lymphatic system. This is a slow process;
𝑇𝑚𝑎𝑥 (time to peak concentration) can take 1 to 8 days.
• 2. Distribution
• Volume of Distribution (Vd): Very small (3–8 L).
• Why? mAbs are large and hydrophilic. They generally stay in the plasma and
extracellular fluid. They do not cross the Blood-Brain Barrier (BBB) passively.
• 3. Elimination
• This is the most complex concept. Elimination occurs via two distinct
pathways:
• A. Non-specific Catabolism (Linear PK)
• The mAb is taken up by cells (via pinocytosis) and degraded by lysosomes into
amino acids. This happens in the Reticuloendothelial System (RES).
• B. Target-Mediated Drug Disposition - TMDD (Non-linear PK)
• The mAb binds to its specific target (antigen).
• The complex is internalized and degraded.
• Clinical Implication: If the dose is low, most drug binds the target and is
eliminated quickly (short half-life). If the dose is high, the target gets
saturated, and the drug clears more slowly. This causes non-linear
pharmacokinetics.
• 4. The FcRn Salvage Pathway (The "Long Half-Life" Secret)
• Why is the half-life of IgG mAbs 21 days, while other proteins last only hours?
Dr. Mohammad Ali Khaleel Immunotherapy
31
FcRn saves IgG → long half-life → infrequent dosing
• Mechanism: The Neonatal Fc Receptor (FcRn) acts as a recycling bin.
• When endothelial cells engulf IgG, the acidic environment of the endosome
causes the IgG to bind to FcRn.
• Instead of going to the lysosome to be destroyed, FcRn transports the IgG
back to the cell surface and releases it back into the blood.
• Result: This recycling protects mAbs from degradation, allowing for once-
monthly or bi-weekly dosing.
•
• Part 5: The Clinical Impact of Immunogenicity
• Immunogenicity is the ability of a biotherapeutic to provoke an immune
response, leading to the formation of Anti-Drug Antibodies (ADAs).
• Types of ADAs
• Binding Antibodies (Non-neutralizing): Bind to the drug but may not block
efficacy directly. However, they form immune complexes that the body clears
rapidly (increasing clearance).
• Neutralizing Antibodies (NAbs): Bind directly to the antigen-binding site
(Fab), preventing the drug from locking onto its target. This renders the drug
useless.
• Clinical Consequences
• Loss of Efficacy (Secondary Failure): A patient responds well to Infliximab
for 6 months, then their symptoms return despite continued dosing. Trough
levels will be undetectable because ADAs are clearing the drug.
• Hypersensitivity: Infusion reactions (fever, chills, rash) or serum sickness.
• Pharmacokinetic Alteration: ADAs usually increase clearance, shortening the
half-life.
Dr. Mohammad Ali Khaleel Immunotherapy
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Module: Immune Checkpoint Inhibitors (ICIs)
Part 1: Mechanism of Action (The "Brakes" Analogy)
To understand these drugs, you must understand where the immune system is being
inhibited. T-cells have natural "checkpoints" to prevent autoimmunity. Cancers hijack these
checkpoints to hide.
1. CTLA-4 Inhibition (The "Parking Brake")
• Drug: Ipilimumab (Yervoy).
• Location: Lymph Nodes (Priming Phase).
• Mechanism: When a naive T-cell is presented with an antigen by a Dendritic Cell,
CTLA-4 competes with CD28 for the co-stimulatory signal (B7).
• Action: Ipilimumab blocks CTLA-4. It allows the T-cell to get "primed" and activated
in the lymph node before it even travels to the tumor.
• Analogy: Releasing the parking brake before the car (T-cell) leaves the garage
(Lymph Node).
2. PD-1 Inhibition (The "Foot Brake")
• Drugs: Pembrolizumab (Keytruda), Nivolumab (Opdivo).
• Location: Tumor Microenvironment (Effector Phase).
• Target: The PD-1 receptor on the T-Cell.
• Mechanism: The tumor cell expresses PD-L1 (the ligand). When PD-L1 shakes hands
with PD-1 on the T-cell, the T-cell turns off (exhaustion).
• Action: These drugs cap the PD-1 receptor on the T-cell so it cannot "see" the
tumor's stop signal.
• Analogy: Releasing the foot brake so the car (T-cell) can run over the target (Tumor).
3. PD-L1 Inhibition (The "Ligand Block")
• Drugs: Atezolizumab (Tecentriq), Durvalumab (Imfinzi), Avelumab (Bavencio).
• Location: Tumor Microenvironment.
• Target: The PD-L1 protein on the Tumor Cell.
• Action: Instead of capping the T-cell, these drugs cap the tumor cell's signal.
• Clinical Note: Theoretically similar to PD-1 inhibitors, but PD-L1 inhibitors leave the
PD-L2 pathway intact, which may result in slightly less pneumonitis (though clinical
data varies).
Part 2: Dosing Strategies (The Shift to Flat Dosing)
Historically, we dosed these by weight ($mg/kg$). You will now see a massive shift toward
Flat Dosing.
Why the shift?
Dr. Mohammad Ali Khaleel Immunotherapy
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1. Wide Therapeutic Index: Unlike chemotherapy, higher doses of mAbs do not
necessarily equal higher toxicity. The receptors become saturated at low doses.
2. Pharmacokinetics: Population PK models showed that a flat dose (e.g., 200 mg)
provides equivalent exposure to weight-based dosing for the vast majority of
patients.
3. Safety & Pharmacy Workflow: Reduces calculation errors and preparation time in
the cleanroom.
Common Flat Dose Regimens (Memorize These):
• Pembrolizumab: 200 mg IV Q3W or 400 mg IV Q6W.
• Nivolumab: 240 mg IV Q2W or 480 mg IV Q4W.
Dr. Mohammad Ali Khaleel Immunotherapy
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اﻟﺤﻠٮ7ﺔ اﻟٮ#ﻄﺎ &ٮٮ7ﺔ ﻋٮ#ﺮ pinocytosis دﺣﻞ #
اﻟﺤﺴﻢ اﻟﻤﻀﺎد ) (IgGإﻟﻰ & &
داﺣﻞ endosomeﺣﺎﻣﴤ )(acidic pH & #
$ٮ 7ﺮٮ1ٮ#ﻂ Fc regionﻣﻦ IgGﻣﻊ FcRn
%ٮ#ﺪل أن ٮ & ُ7ٮ 1ڡﻞ إﻟﻰ lysosomeﻟ 7ٮ 1ٮﺤﻄﻢ
اﻟﺤﻠٮ7ﺔ
#ﺈرﺣﺎع IgGإﻟﻰ ﺳﻄﺢ & & ٮ 1 7ڡﻮم FcRnٮ #
7عى
أﺣرى إﻟﻰ اﻟﺪم ﻋ &ٮﺪ pHﻃ #ٮٮ \ ' ٮُ7ﻄﻠﻖ ﻣﺮة &
أﺣﺴﺎم ﻣﻀﺎدة ﺿﺪ 1ﺤڡٮ7ﺰ #ﺣﻬﺎز اﻟﻤ &ٮﺎﻋﺔ وإ &ٮ 1ٮﺎج # #
7ﻮﻟﻮح \ى ﻋﲆ ٮ & هى 1ڡﺪرة اﻟﺪواء اﻟ #ٮٮ
\
اﻟﺪواء ).(ADAs
:ٮ&ﻮﻋﺎن ADAs
ٮ1ﺮٮ1ٮ#ﻂ ٮ#ﺎﻟﺪواء ،ٮ1زيﺪ ﺳﺮﻋﺔ اﻟ 1ٮ &ﺤﻠﺺ ﻣ &ٮﻪ ،ﻻ ٮ1ﻤ &ٮﻊ &ڡﻌﺎﻟ 7ٮ 1ٮﻪ Non-neutralizing:
.ﻣٮ#ﺎﺷﺮة
ٮ1ﺮٮ1ٮ#ﻂ ٮ#ﻤﻮ 1ڡﻊ ﻋﻤﻞ اﻟﺪواء ،ٮ1ﻤ &ٮﻌﻪ ﻣﻦ اﻟﻌﻤﻞ وٮ 1#ﺤﻌﻞ اﻟﺪواء ﻋ& ٮ7ﺮ Neutralizing:
&
.ڡﻌﺎل
اﻟﻌوا 1ڡﺐ اﻟﺴريريﺔ:
&ڡ 1ڡﺪان &ڡﻌﺎﻟٮ7ﺔ اﻟﺪواء ).(Secondary failure
اﻟﻄڡﺢ ،أو ﻣﺮض اﻟﻤﺼﻞ. & ٮ &1ڡﺎﻋﻼت &ڡﺮط اﻟﺤﺴﺎﺳٮ7ﺔ ﻣ ?ٮﻞ اﻟﺤﻤﻰ ،اﻟ 1ڡﺸﻌريﺮة،
ٮ1ﻌ7 ïٮّﺮ &ڡ \ى &ﺣﺼﺎﺋﺺ اﻟﺪواء اﻟﺪواﺋٮ7ﺔ )↑ ﺳﺮﻋﺔ اﻟ 1ٮ &ﺤﻠﺺ(.
ﺎﺣون ﻟٮ1ﻌ ïٮ7يﺮ اﻟﻌﻼج إذا &ﻃﻬﺮت 1 ADAsڡويﺔ. اﻟﻤﺮﴇ 1ڡﺪ ٮ 7ﺤ 1ٮ #