Immune Complex Anaphylaxis
`Induced by Dextran and Its Elimination
`by Hapten Inhibition
`
`A. W. Richter
`Department of Biomedical Research Pharmacia AB, 75182 Uppsala, Sweden and Department
`ofImmunology, University of Stockholm, 10401 Stockholm, Sweden
`
`Abstract
`
`Purpose: To elucidate the mechanism of the rare anaphylactic reactions elicited
`by i.v. infusion of Macrodex® and Rheomacrodex® and to find measures for
`their elimination.
`
`Methods: Hapten inhibition in vitro and in dextran anaphylaxis in guinea pigs
`and dogs.
`
`Human serology: Complement profiles; IgE assays: RAST, PCA in monkeys,
`RCLAAR *; estimation of dextran reactive antibodies (DRA) by gel diffusion,
`passive hemagglutination, RCLAAR for IgG and subclasses, 19A, IgM, IgD;
`ELISA for IgG. Histopathology of human lung specimens. Clinical trials in
`five countries to assess efficacy of hapten inhibition.
`
`Summary of results: Dextran anaphylaxis (incidence 0.05%) occurs upon the first
`infusion of a few ml of clinical dextran. Severity of anaphylaxis positively cor(cid:173)
`relates with IgG-DRA levels (especially IgG2) reaching conc of 1 mg/ml. High
`titers of specific IgA and IgM were also found but no IgE or IgD. C 1 q levels
`were low. Lung histopathology of fatal cases disclosed obstruction of vessels
`with globuli of fibrinlike material, aggregated platelets and leukocytes. The
`naturally occurring DRA which cause anaphylaxis originate from immuni(cid:173)
`zation with ingested wild type dextran or cross-reactive bacterial poly(cid:173)
`saccharides. Since dextran anaphylaxis in animals could be prevented or re(cid:173)
`duced by hapten inhibition, and a dextran fraction of Mw 1000 (Promit®)
`proved to be non-eliciting and safe, clinical trials were started. 130000 patients
`were treated with injection of 1.5 or 3 g of Promit® 2 min prior to clinical
`dextran infusion. The 3 g dose reduced the incidence of anaphylaxis about 20
`times. This was confirmed by a two years post-marketing surveillance period in
`Sweden.
`
`* Red cell linked antigen antibody reaction.
`
`J. Ring et al. (eds.), New Trends in Allergy II
`© Springer-Verlag Berlin Heidelberg 1986
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 1
`
`

`

`Immune Complex Anaphylaxis Induced by Dextran
`
`273
`
`Conclusions: Dextran anaphylaxis is an immediate type, IgG-mediated reaction
`comparable to anaphylaxis in patients with deficiency of IgA or factor VIII.
`Hapten inhibition could be successfully applied to eliminate life-threatening
`dextran reactions by injecting monovalent hapten-dextran (Promit®) prior to
`infusion of Macrodex® IRheomacrodes®.
`
`Introduction
`
`In recent years the worldwide use of pharmaceuticals with established medical
`value has imposed increased demands on their safety. Among plasma sub(cid:173)
`stitutes the efficacy of dextran is well documented. Its additional blood flow
`improving and thromboprophylactic effects are widely used. Although severe
`adverse reactions to clinical dextran preparations are rare [1], they occur with
`an estimated incidence of 1 :2000 patients [2]. The elimination of such reactions
`was therefore made the aim of studies begun in Uppsala in 1968. Since then,
`many workers have joined the research program and formed collaborating
`study groups in Munich, Uppsala, and Vienna. Many publications have reflect(cid:173)
`ed the progress of the project [3-24; for reviews see 14,21,22,24,43]. The
`stepwise elucidation of the mechanism of dextran anaphylaxis in man, the
`study of animal models of dextran anaphylaxis, and its successful prevention by
`hapten inhibition, as well as the production of monovalent hapten-dextran on a
`large scale [18] enabled us to begin clinical trials of hapten prophylaxis in hu(cid:173)
`mans in 1978. The trials grew into large multicenter multinational studies,
`which ended in 1982 and were published in a series of articles [24, 33 - 40]. Re(cid:173)
`sults show that the incidence of severe dextran-induced anaphylactic reactions
`(DIARs) is greatly reduced by preinjection of hapten-dextran in a dose-de(cid:173)
`pendent manner, conferring greater safety to dextran infusion therapy. In this
`chapter I shall outline the course of the research program and the present data
`from the combined clinical trials and subsequent postmarketing surveillance in
`Sweden (1983 -1984). The role of IgG-mediated anaphylactic reactions, as op(cid:173)
`posed to IgE-mediated ones, will also be discussed.
`
`Historical Background
`
`Dextran of Mw 70000 was introduced into medicine as plasma substitute in 1947
`by Ingelman and Gronwall [6]. It was prepared from a branched type of native
`dextran and quite frequently caused mild allergic reactions. Change to a more
`linear dextran reduced the incidence of allergic reactions [25]. This dextran pro(cid:173)
`duced by the Leuconostoc mesenteroides NRRL B 512 strain is still used today.
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 2
`
`

`

`274
`
`A. W. Richter
`
`Gelin and co-workers showed that dextran of Mw 40000 increased the suspen(cid:173)
`sion stability of blood and improved blood flow in the microcirculation [26].
`This led to the introduction of Rheomacrodex as a blood flow-improving agent
`[27]. In the 1960s an additional effect of dextran 70 was found, i.e., that it
`reduced the incidence of postoperative pulmonary embolism [28]. This
`thromboprophylactic effect is now the most frequent medical indication for
`dextran 70. The increased worldwide use of clinical dextran led to a consider(cid:173)
`able number of reported adverse reactions in spite of the low incidence of such
`reactions.
`
`Immunology of Dextran
`
`The immunogenicity of B 512 dextran in man is molecular weight dependent
`[29]. Whereas native and very high molecular weight dextrans are immunogenic
`in humans, dextran 70 and 40 are nonimmunogenic [21]. From the immunologi(cid:173)
`cal point of view, a dextran infusion with 30-100 g represents an "overwhelm(cid:173)
`ing" dose. In animals corresponding doses lead to immunological unresponsive(cid:173)
`ness. Like other polysaccharides, dextran induces a thymus-independent IgM
`response in mice [21]. However, dextran can be converted to a thymus-de(cid:173)
`pendent antigen by covalent coupling to protein [5]. Such conjugates elicit a
`strong IgG antidextran response upon immunization of carp, mice, guinea pigs,
`rabbits, sheep, and horses. We have utilized this fact to raise antidextrans in
`rabbits and dogs for use in our anaphylaxis models and for analytical purposes
`[5, 8]. Most people have natural dextran-reactive antibodies (DRAs) in their
`sera. They may have been induced by native, high molecular weight dextran in(cid:173)
`gested as food contaminant, produced by bacteria of the gastrointestinal tract,
`or produced by other cross-reactive microbial polysaccharides [30; for review
`see 21].
`
`Table 1. Scale of severity of clinical symptoms of adverse reactions to colloidal infusion solu(cid:173)
`tions (Rind and MeBmer (14], Laubenthal [36])
`
`Grade of
`severity
`
`Clinical symptoms
`
`II
`
`III
`
`IV
`
`Skin manifestations: flush, erythema, urticaria
`
`Measurable, but not life-threatening hemodynamic reaction (blood pressure fall,
`20-60 mmHg). Dyspnea, nausea, vomiting
`
`Shock (blood pressure fall exceeding 60 mmHg). Life-threatening
`bronchospasm
`
`Cardiac and/or respiratory arrest
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 3
`
`

`

`Immune Complex Anaphylaxis Induced by Dextran
`
`275
`
`Serology in Humans
`
`Antibodies
`
`Analysis of sera of dextran reactors and nonreactors, accumulated over many
`years, with various standardized procedures for measuring DRAs, gave the fol(cid:173)
`lowing results. Circulating DRAs occur in low titers in the majority of human
`populations; high titers are only found in a small percentage of individuals.
`Geographical variations in titer distribution do occur [23]. All patients with se(cid:173)
`vere DIAR of grades III and IV (see Table 1 for classification) have high or
`very high titers of circulating DRA before the reaction. No IgE class DRAs
`could be found in 100 dextran reactors with different methods [7]. When Ig
`classes and subgroups were studied by RCLAAR and ELISA in reactors and
`nonreactors to dextran, high titers of IgG, especially of IgG 2, usually ac(cid:173)
`companied by IgA and IgM, were found in reactors, whereas nonreactors had
`small amounts of mostly IgM class DRAs [11, 19]. An excellent correlation was
`found between the grade of severity of DIAR and the titer of IgG class DRAs,
`implying that large amounts of immune complexes are formed in the circu(cid:173)
`lation of patients with the most severe reactions [19].
`
`Complement
`
`Complement profiles were established in dextran reactors [7]. The most impor(cid:173)
`tant finding was a significant decrease in the levels of CIq in severe DIAR. Con(cid:173)
`centrations of the other complement proteins and of the anaphylatoxin inac(cid:173)
`tivator were normal. These results show that the classical pathway is activated
`in dextran reactors by immune complexes. The findings are in accord with the
`occurrence of high titers ofIgG class DRAs in patients with severe DIAR.
`
`Studies of the Chemical and Pharmaceutical
`Manufacturing Procedure
`
`the action of Leuconostoc
`is a polysaccharide produced by
`Dextran
`mesenteroides NRRL B 512 on sucrose in the presence of nutrients. Thus, a
`careful purification process is necessary to manufacture clinical dextran prep(cid:173)
`arations of defined molecular weight and molecular weight distribution. Since
`macromolecular contaminants may sensitize patients, we tested the immuno(cid:173)
`genicity of dextran from the early stages of the manufacturing process. No evi(cid:173)
`dence for immunogenic impurities could be demonstrated [5]. Later, it was
`found that a soluble macromolecular component of Leuconostoc bacteria react(cid:173)
`ed with anti-yeast mannan antibodies. As such a Leuconostoc-derived com(cid:173)
`ponent could be a potentially sensitizing agent in clinical dextran, an im-
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 4
`
`

`

`276
`
`A. W. Richter
`
`munochemical test for its detection and quantitation was developed [31]. By im(cid:173)
`proved purification, its concentration in clinical dextran was reduced to 10 ppm
`or less. Comparison of the incidence of adverse reactions to clinical dextran be(cid:173)
`fore and after introduction of the Leuconostoc RSRI purity test provided no
`evidence for a causal role of this contaminant in eliciting DIAR, but suggested
`an elicitor role of the dextran molecule itself.
`
`Hapten Inhibition In Vitro
`
`Haptens cannot induce antibody formation but do bind to antibodies of cor(cid:173)
`responding specificity. They may be poly-lor monovalent with regard to the
`number of antigenic determinants. Whereas a polyvalent hapten forms immune
`complexes with antibodies, a monovalent hapten binds to individual combining
`sites of antibodies only, and cannot join together antibodies by bridging. In the
`B 512 dextran-anti dextran system, monovalent isomalto-oligosaccharides (lOS)
`inhibit the precipitation of antidextran by large dextran molecules [32]. Their
`inhibitory power increases strongly from isomaltose to isomaltopentaose with
`little further increase for isomalto-hexaose and isomalto-heptaose. These results
`were confirmed by indirect single radial immunodiffusion [5]. A dextran frag(cid:173)
`ment of 6 glucose units (Mw 990) was judged suitable as a monovalent hapten
`for in vivo experiments. Thus, dextran 1 with Mw 1000 was prepared on a large
`scale by prolonged acid hydrolysis of B 512 dextran with subsequent fractiona(cid:173)
`tion and purification [18]. It is a mixture of lOS with 2-13 glucose units. Its
`molecular size distribution is controlled by gel chromatography. Dextran 1 IS
`used clinically as a sterile 15% solution delivered in 20-ml vials.
`
`Animal Experiments on Anaphylactic Shock
`
`Hapten Inhibition of Cytotropic Passive Dextran Anaphylaxis
`in Guinea Pigs
`
`The most important findings show that 100% protection from anaphylactic
`death can be achieved by admixture of low molecular hapten-dextran to the
`challenging high molecular dextran or by injection of hapten-dextran prior to
`challenge [3]. The protective effect is dose dependent and a significant re(cid:173)
`duction in mortality is observed when the hapten is present in a molar excess of
`3 - 7, corresponding to an admixture of 10% - 50% w Iw to the challenging
`dextran [3, 4]. For the hapten, a Mw range of 1000 was found to be optimal in
`terms of both protective effect and safety requirements [5]. No elicitor action is
`present upon challenge with such a hapten, even at maximal degrees of sensiti-
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 5
`
`

`

`Immune Complex Anaphylaxis Induced by Dextran
`
`277
`
`zation. Since the basic bridging (elicitor) mechanism in anaphylaxis appears to
`be shared by all mammals, these considerations should also apply to humans,
`both for IgE- and IgG-mediated reactions.
`
`Hapten Inhibition of Active Dextran Anaphylaxis, i.e.,
`Immune Complex (Aggregate, IgG-Mediated) Anaphylaxis in Dogs
`
`Most important is the fact that in this active anaphylaxis model circulating
`DRAs are induced (by immunization with edestin-dextran) in a titer pattern
`roughly comparable to that of humans [8]. In both conscious [9, 15] and anes(cid:173)
`thetized dogs [13], DIARs of varying degree of severity could be elicited and
`followed by measurements of hemodynamics, blood cell numbers, and DRA
`titers. Hapten-dextran of Mw 1000 given either before or admixed to the chal(cid:173)
`lenging dextran 60 significantly reduced both the number and the severity of
`DIAR [13].
`
`Comparison of Cytotropic and Aggregate or Immune
`Complex Anaphylaxis in Monkeys
`
`Different cardiorespiratory patterns of shock were observed in aggregate ana(cid:173)
`phylaxis (AA) and cytotropic anaphylaxis (CA), reflecting different biological
`actions of IgE and IgG class antibodies. A decrease in cardiac output and con(cid:173)
`comitant hypotension was seen in AA and CA. During AA, intense pulmonary
`vasoconstriction was initially important in depressing cardiac output; periph(cid:173)
`eral blood pooling was the main mechanism in CA. The respiratory reaction
`limited gas transport over the lungs greatly in CA but not in AA. Decreased
`pulmonary compliance in AA was due to pulmonary congestion, whereas in CA
`it was due to constriction of bronchial smooth muscle. The differences between
`AA and CA might be explained by the fact that platelets were activated only in
`AA. Apparently, vasoconstricting mediators predominate in AA and vasodilat(cid:173)
`ing ones in CA [12, 16].
`
`Multicenter Clinical Trials of Hapten Prophylaxis
`in Five Countries
`
`Prospective open clinical trials began in 1978 and ended in 1982. Physicians at
`80 clinics in Finland, Sweden, Norway, Germany, and Switzerland participat(cid:173)
`ed. It was apparent that a large number of patients would be required to assess
`a reduction in the incidence of severe DIAR. From a large amount of historical
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 6
`
`

`

`278
`
`A. W. Richter
`
`control material comprising reports on DIAR in Sweden [2], the incidence of
`severe DIAR (grades III and IV) was estimated to 0.05%, i.e., I: 2000 pa(cid:173)
`tients. This represents a minimum figure, and thus the number of severe DIARs
`expected to occur in 100000 patients infused with dextran 70 and hapten could
`be about 50. Therefore, the inclusion of a large control group was considered
`unethical. Results of clinical trials in Germany [24, 33, 36], Switzerland [34, 35],
`and Scandinavia [37 -40] have been reported elsewhere. For combined clinical
`trials, see Table 2. Among 37626 patients receiving dextran 70 after injection of
`10 ml hapten-dextran, 0.029% (i.e., 29 per 100000) reacted with severe DIAR.
`This was not satisfactory, and in further trials the hapten dose was doubled to
`20 ml, since hapten inhibition in animal models is a dose- dependent phenom(cid:173)
`enon. And indeed, among 79951 patients receiving dextran 70 after injection of
`20 ml hapten-dextran, only 0.00375% reacted with severe DIAR (grade III on(cid:173)
`ly). This would correspond to 3.75 per 100000. The protective effect of the
`20 ml dose is 7.8 times better than that of the 10 ml dose. With regard to the
`"historical" control figure for severe DIAR (0.05% per patient), the 10 ml dose
`decreased the incidence by 42% and the 20 ml dose by 93%. Instead of an inci(cid:173)
`dence of severe DIAR of 1 : 2000 patients before use of hapten-dextran, we now
`have an incidence of 1 : 27000 according to results of 80000 protocolled pa(cid:173)
`tients receiving preinjection of 20 ml dextran 1.
`
`Table 2. Prophylaxis against DIARs by administration of dextran 70 after injection of either
`10 ml or 20 ml hapten-dextran
`
`Country
`
`Patients
`
`DIARs
`
`No. ofDIARs, grade of severity
`
`(n)
`
`(total no.)
`
`II
`
`III
`
`IV V*
`
`10-m1 studies
`Germany
`Switzerland
`Scandinavia
`
`20 ml studies
`Germany
`Switzerland
`Scandinavia
`
`6 I13
`2280
`29233
`
`37626
`
`24513
`14339
`41099
`
`79951
`
`I3
`3
`61
`
`77
`
`24
`14
`72
`
`110
`
`* grade V = lethal outcome
`
`8
`I
`41
`
`50
`
`16
`9
`56
`
`81
`
`3
`0
`I3
`
`16
`
`6
`5
`15
`
`26
`
`0
`0
`I
`
`2
`2
`6
`
`10
`
`0
`0
`0
`
`0
`
`'--0.0292%--' I of 3421
`patients
`
`2
`0
`I
`
`3
`
`0
`0
`0
`
`0
`
`0
`0
`0
`
`0
`
`0.0038%--' I of27000
`patients
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 7
`
`

`

`Immune Complex Anaphylaxis Induced by Dextran
`
`279
`
`Postmarketing Surveillance of Hapten Prophylaxis in Sweden,
`1983-1984
`
`The Scandinavian multicenter clinical trials of hapten prophylaxis of DIAR
`ended in September 1981. They showed a 14-fold reduction in the incidence of
`severe DIAR. In November 1982 hapten-dextran was registered as a drug in
`Sweden under the name of Promiten (dextran 1, Pharmacia AB, Uppsala,
`Sweden) for the prophylaxis of severe DIAR. A preliminary survey based on
`spontaneous reports of DIAR to the health authorities and the producer has
`been compiled [41] and is presented here (Table 3). As in the clinical trials,
`each case report has been evaluated regarding causality and severity. The no(cid:173)
`menclature used by the health authorities was adapted for causality classifi(cid:173)
`cation: P = dextran is the probable or possible cause, N = the elicitation of the
`reaction by dextran is not probable or not assessable. In many instances, classi(cid:173)
`fication was facilitated by access to serum samples taken before the reaction
`and estimation of DRAs by passive hemagglutination or ELISA. The use of
`clinical dextran in Sweden has increased: during 1983 - 84, 424858 units were
`sold, as well as 205408 units of Promiten. This suggests that the prophylaxis
`concept has been accepted by the great majority of physicians, since for each
`dextran 1 unit, about 2.1 units of clinical dextran have been used. Therefore
`prerequisites are fulfilled for a valid estimation of the efficacy of Promiten
`prophylaxis during this time period, especially since the reporting of severe and
`lethal drug reactions is mandatory in Sweden (see Table 3). Compared to the
`control period of 1975 -79, when clinical dextran was used without hapten [2],
`the incidence of severe DIAR (grades III, IV, and V) was reduced at least 16
`times. One fatal reaction occurred in a patient with sepsis accompanied by an
`
`Table 3. Findings regarding postmarketing surveillance of hapten prophylaxis in Sweden,
`1983-1984 [41]
`
`Period
`
`1975-1979
`(no hapten)
`Incidence (%):
`
`1983-1984
`(with hapten)
`Incidence (%):
`
`No. of dextran DIARs
`(total no.)
`bott! es used
`
`DIARs, grade of severity
`
`II
`
`III
`
`IV
`
`V
`
`647756
`
`300
`
`61
`
`94
`
`424858
`
`53
`
`34
`
`13
`
`78
`44
`~0.0224
`~0.0103--'
`
`23
`
`0
`5
`I
`~ 0.0014 -----'
`~0.0002--'
`
`Decrease of incidence in %:
`Reduction of incidence:
`
`74
`
`15
`
`79
`
`90
`
`100
`
`94
`~15 times-'
`45 times
`~16 times
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 8
`
`

`

`280
`
`A. W. Richter
`
`Table 4. Mitigated severe DIAR reflecting a beneficial hapten effect (suspected DIAR in post-
`marketing study 1983-1984)
`
`2
`
`3
`
`4
`
`5
`
`68
`
`7b
`
`8
`
`P,
`Code Sev-
`erity NP
`
`DRA titer IgGDRA
`pass hem
`assay
`titer
`
`ELISA
`(OD,
`4lOnm)
`
`Prec. DRA Classification
`(mg/ml)
`(clin. and immun. data)
`
`E
`G
`H
`K
`M
`0
`P
`Q
`R
`
`I
`I
`V
`II
`I
`III
`II
`V
`III
`
`P
`P
`NP
`P
`P
`P
`P
`P
`P
`
`512
`512
`128
`512
`128
`2048
`512
`2048
`1024
`
`800
`50000
`1000
`400000
`400
`200000
`1600
`1600000
`400000
`
`0.163
`>2.000
`0.134
`>2.000 0.5
`0.047
`>2.000 0.7
`0.175
`>2.000 2.4
`l.l
`>2.000
`
`8 Column 6: All sera screened at a dilution 1:400
`b Column 7: Estimation of precipitating DRA by RSRI
`
`True grade I DIAR
`Mitigated severe DIAR
`Not antibody mediated
`Mitigated severe DIAR
`True grade I DIAR
`Mitigated severe DIAR
`True grade II DIAR
`True grade V DIAR
`Mitigated severe DIAR
`
`extremely high titer of ORA of IgG class (2.4 mg IgG/ml serum) (see Table 4).
`In this patient the hapten dose was not sufficient or was not distributed evenly
`in the circulation due to circulatory insufficiency.
`The incidence of severe DIAR in the surveillance period is 1 : 33000 pa(cid:173)
`tients, a figure well in accord with that of the combined 20 ml clinical trials of
`dextran 1. The effect of hapten is also exemplified in Table 4, showing cases
`from the surveillance study with mild DIAR exhibiting extremely high titers of
`IgG class DRAs. These cases have been classified by clinical and immunologi(cid:173)
`cal data as "mitigated severe DIAR," contrasting to "true" mild reactions ac(cid:173)
`companied by low titers ofIgG class DRAs.
`
`Conclusions
`
`Dextran-induced anaphylactic reactions in humans are classified as IgG-me(cid:173)
`diated immune complex anaphylaxis. This is evident from the presence of mg/
`ml concentrations of specific antibody, complement activation via the classical
`pathway, and pathological changes in lungs conforming to the picture of im(cid:173)
`mune complex (lgG) but not cytotropic (lgE) anaphylaxis in monkeys. Severe
`DIARs occur upon the first infusion of a few milliliters of clinical dextran.
`Dextran reactors have thus not been sensitized by clinical dextran but they are
`high responders to dextran and have high titers of preformed naturally occur(cid:173)
`ring ORA in their sera. Though IgE anaphylaxis appears to dominate in hu(cid:173)
`mans, DIARs are not the only example of IgG-mediated anaphylactic reactions.
`Another well documented example is anaphylaxis in IgA-deficient patients
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 9
`
`

`

`Immune Complex Anaphylaxis Induced by Dextran
`
`281
`
`upon repeated infusion of IgA-containing blood or plasma [42]. The regular oc(cid:173)
`scale pro(cid:173)
`currence of DRA in severe DIAR and the possibility of large -
`duction of a monovalent hapten [18] led to the successful application of hapten
`inhibition in preventing dextran anaphylaxis. In the era before hapten prophy(cid:173)
`laxis, the estimated incidence of severe DIAR was I : 2000 patients [2]. In clini(cid:173)
`cal trials with 10 and 20 ml Promiten the incidence was I : 3400 and 1 : 27 000
`respectively. In the postmarketing surveillance of about 200000 patients the
`incidence was I: 33000 patients. The incidence of lethal DIAR was I: 15000
`patients without hapten and I : 200000 with 20 ml hapten-dextran.
`It should be pointed out that an estimated number of 2000000 patients have
`hitherto received hapten-dextran worldwide. The risk of giving dextran should
`be compared with its beneficial effect when used as a thromboprophylactic
`agent [28]. In Sweden an estimated number of at least 200 patients were protect(cid:173)
`ed from fatal lung embolism in a 2-year period, compared with one fatal ana(cid:173)
`phylactic dextran reaction [41].
`
`Participants in the Research Program
`
`Sweden: Richter W, Hedin H, Granath K, Ingelman B, Perlman P, Stalenheim
`G, Smedegard G, Ljungstrom KG, Renck H, Revenas B, Saldeen T
`Germany: Messmer K, Ring J, Seemann-Mendler C, Laubenthal H, Peter K,
`Selbmann HK, Schwartz JA, Gregori M
`Austria: Kraft D, Rumpold H, Scheiner 0, Steinbereithner K
`Great Britain: Devey M, Stanworth D
`USA: Muller-Eberhard HJ et al.
`Switzerland: Gruber U, Allemann U, Gerber H, Wettier H
`Japan: Takamoto H
`
`Acknowledgments. Thanks are due to our laboratory technicians and to the staff and personnel
`of the 80 hospitals which made possible the successful performance of the clinical trials.
`
`References
`
`I. Furhoff AK (1977) Anaphylactoid reactions to dextran - a report of 133 cases. Acta
`Anaesth Scand 21:161-167
`2. Ljungstrom KG, Renck H, Strandberg K, Hedin H, Richter W, WiderlofE (1983) Adverse
`reactions to dextran in Sweden 1970-1979. Acta Chir Scand 149:253-262
`3. Richter W (1971) Hapten inhibition of passive antidextran dextran anaphylaxis in guinea
`pigs. Int Arch Allergy 41 :826 - 844
`4. Richter W (1973) Built-in hapten inhibition of anaphylaxis by the low molecular weight
`subfractions of a B 512 dextran fraction of l\\, 3400. Int Arch Allergy 45:930- 936
`5. Richter W (1973) Immunological in vivo and in vitro studies of the dextran antidextran
`system. Thesis, University of Uppsala
`6. Ingelman B (1947) Dextran and its use as a plasma substitute. Acta Chern Scand
`1:731-738
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 10
`
`

`

`282
`
`A. W. Richter
`
`7. Hedin H (1977) Dextran-induced anaphylactoid reactions in man. Immunological in vitro
`and in vivo studies. Thesis, University of Uppsala
`8. Seeman C, Hedin H, Richter W, Ring J, Stippig S, Messmer K (1978) Haptenhemmung
`der Dextran-induzierten anaphylaktischen Reaktion beim Hund. Allergologie 1:185
`9. Schwarz JA, Raschack M (1978) Verhinderung Antikorperbedingter Dextran-Nebenwir(cid:173)
`kungen durch Hapten-Hemmung - eine experimentelle Pilotstudie am wachen Hund.
`Allergologie I: 184
`10. Hedin H, Smedegard G (1979) Complement profiles in monkeys subjected to aggregate
`(immune complex) anaphylaxis and following injection of soluble and particulate poly(cid:173)
`saccharides. Int Arch Allergy Appl Immunol 60:286- 294
`11. Hedin H, Kraft D, Richter W, Scheiner 0, Devey M (1979) Dextran-reactive antibodies in
`patients with anaphylactoid reactions to dextran. Immunobiology 156:289 - 290
`12. Smedegard G (1980) Anaphylactic shock. Pathophysiology of aggregate and cytotropic
`anaphylaxis in the monkey. Thesis, Acta Univers Upsala, p 548
`13. Mendler C (1980) Hapten-Hemmung der Dextran-induzierten anaphylaktischen Reaktion
`beim Hund. Thesis, Ludwig-Maximilians-University Munich
`14. Ring J (1976) Anaphylaktoide Reaktionen nach Infusion naturlicher und kunstlicher Kol(cid:173)
`loide. Thesis for habilitation, Ludwig-Maximilian-University Munich
`15. Schwarz JA, Rother U, Koch W, Raschack M, Till G (1981) Verhinderung Antikorper-be(cid:173)
`dingter Dextran-Nebenwirkungen durch Haptenhemmung mit Dextran 1 am Hund.
`Anaesthesist 30:297 - 303
`16. Revenas B, Smedegard G, Saldeen T, Fredholm BB, Strandberg K (1981) Anaphylactic
`shock in monkeys passively sensitized with human reaginic serum. II. Respiratory mechan(cid:173)
`ics, hematology and metabolism. Acta Physiol Scand 111:249-257
`17. Schwarz JA, Koch W, Buhler V, Kaumeier S (1981) Pharmacokinetics of low molecular
`(monovalent) dextran (Dx 1) in volunteers. Int J Clin Pharmacol Ther Toxicol 19:358 - 367
`18. Richter A W, Ingelman B, Granath K (1982) An isomalto-oligosaccharide product for
`medical use. Abstract, poster presentation, 11th international carbohyd symposium, Van(cid:173)
`couver, BC
`19. Kraft D, Hedin H, Richter W, Scheiner 0, Rumpold H, Devey ME (1982) Im(cid:173)
`munoglobulin class and subclass distribution of dextran reactive antibodies in human re(cid:173)
`actors and nonreactors to clinical dextran. Allergy 37:481-489
`20. Hedin H, Richter W (1982) Pathomechanism of dextran-induced anyphylactoid/anaphy(cid:173)
`lactic reactions in man. Int Arch Allergy Appl Immunol 68: 122-126
`21. Richter A W, Hedin HI (1982) Dextran hypersensitivity (a review). Immunol Today
`3:132-138
`22. Richter W, Hedin H (1983) Solutions and emulsions used for intravenous infusions. In: de
`Weck AL, Bundgaard H (eds) Allergic reaction to drugs. Springer, Berlin Heidelberg New
`York Tokyo (Handbook of experimental pharmacology, vol 63)
`23. Messmer K, Richter W, Takaori M (1984) Prinzip der Haptenhemmung zur Prophylaxe
`der Dextrananaphylaxie: immunologische Aspekte. Beitr Anaesth Intensivmed 3: 15 - 27
`24. Laubenthal H, Peter K, Richter W, Kraft D, Selbmann HK, Messmer K (1983) Ana(cid:173)
`phylaktoide/anaphylaktische Reaktionen auf Dextran. Pathomechanismus und Prophy(cid:173)
`laxe. Diagnostik Intensivtherapie 8:4-14
`25. Kabat EA, Turino GM, Tarrow AB, Maurer PH (1957) Studies on the immunochemical
`basis of allergic reactions to dextran in man. J Clin Invest 36: 1160 - 1170
`26. Gelin LE (1956) Studies in anemia of injury. Thesis, University of Gothenburg. Acta Chir
`Scand Suppl 210
`27. Gelin LE, Ingelman B (1961) Rheomacrodex - a new dextran solution for rheological
`treatment of impaired capillary flow. Acta Chir Scand 122:294- 302
`28. Bergentz SE (1978) Dextran in the prophylaxis of pulmonary embolism. World J Surg
`2:19-25
`29. Kabat EA, Bezer AE (1958) The effect of variation in molecular weight on the antigenicity
`of dextran in man. Arch Biochem Biophys 78:306 - 318
`30. Hehre EJ, Neill JM (1946) Formation of serologically reactive dextrans by streptococci
`from subacute bacterial endocarditis. J Exp Med 83:147-163
`
`PGR2020-00009
`Pharmacosmos A/S v. American Regent, Inc.
`Petitioner Ex. 1073 - Page 11
`
`

`

`Immune Complex Anaphylaxis Induced by Dextran
`
`283
`
`31. Richter AW (1980) A new immunochemical purity test for clinical dextran. Methodology
`and studies on clinical dextran preparations. Int Arch Allergy Appl Immunol 61 :457 - 466
`32. Kabat EA (1961) Inhibition reactions. In: Kabat EA, Mayer MM (eds) Experimental im(cid:173)
`munochemistry, 2nd edn. Thomas, Springfield
`33. Messmer K, Ljungstrom KG, Gruber UF, Richter W, Hedin H (1980) Prevention of
`dextran-induced anaphylactoid reactions by hapten inhibition. Lancet 1:975
`34. Gruber UF, Allemann U, Gerber H, Wetder H (1982) Erster direkter Vergleich der aller(cid:173)
`gischen Nebenwirkungen des Dextrans mit und ohne Hapten. Schweiz Med Wochenschr
`112:605-612
`35. Gruber UF, Wetder H, Allemann U, Gerber H, Laubenthal H, Messmer K (1982) Pro(cid:173)
`phylaxe allergischer Dextran-Reaktionen durch Vorinjektion von 20 ml Hapten bei 12000
`Patienten in der Schweiz. Schweiz Rundschau Med (Praxis) 71:1092-1100
`36. Laubenthal H (1983) Dextrananaphylaxie. Pathomechanismus und Prophylaxe durch
`Haptenhemmung. Ergebnisse einer multizentrischen, klinischen Studie. Thesis for habili(cid:173)
`tation, Ludwig-Maximilian-University, Munich
`37. Ljungstrom KG, Renck H, Hedin H, Richter W, Rosberg B (1983) Prevention of dextran(cid:173)
`induced anaphylactic reactions by hapten inhibition. I. A Scandinavian multicenter study
`on the effects of 10 ml dextran, 15%, administered before dextran 70 or dextran 40. Acta
`Chir Scand 149:341 - 348
`38. Renck H, Ljungstrom KG, Rosberg B, Dhuner KG, Dahl S (1983) Prevention of dextran(cid:173)
`induced anaphylactic reactions by hapten inhibition. II. A comparison of the effects of
`20 ml Dextran 1, 15%, administered either admixed to or before dextran 70 or dextran 40.
`Acta Chir Scand 149:349- 353
`39. Renck H, Ljungstrom KG, Hedin H, Richter W (1983) Prevention of dextran-induced
`anaphylactic reactions by hapten inhibition. III. A Scandinavian multicenter study on the
`effects of 20 ml Dextran 1, 15%, administered before dextran 70 or dextran 40. Acta Chir
`Scand 149:355 - 360
`40. Ljungstrom KG, Renck H (1983) Sakrare dextranterapi med hapteninhibition. Stor skan(cid:173)
`dinavisk studie. Liikartidningen 80 (1- 2):26 - 27
`41. Ljungstrom KG, Renck H, Hedin H, Richter W, Wiholm BE (1985) Hapteninhibition
`minskade biverkningama vid dextran-anvandning. Liikartidningen 82:2772 - 2773
`42. Leikola J, Koistinen J, Lethinen M, Virolainen M (1973) IgA-induced anaphylactic trans(cid:173)
`fusion reactions: a report of four cases. Blood 42: 111 - 119
`43. Ring J (1982) Zur Problematik der Dextran-Unvertraglichkeit und ihrer spezifischen Pro(cid:173)
`phylaxe durch H