Envelopment polyprotein

疫苗在预防传染病传播方面已被证明具有显著的功效，每年挽救了无数人的生命。近几十年来，疫苗的广泛应用使天花得以消灭，脊髓灰质炎、麻疹和其他传染病的发病率极低。世界卫生组织报告说，接种疫苗每年可以防止大约200万人死于麻疹、流感、百日咳和破伤风。此外，在癌症管理中使用疫苗在临床前试验中显示出强大的功效，成为免疫肿瘤学领域最有前途的治疗方法之一，并获得更多的关注。传统疫苗有几个缺点，可能会限制它们在疾病预防和治疗中的应用。例如，开发树突状细胞(DC)疫苗的基本程序涉及一个劳动密集型和耗时的过程，需要制备患者自身细胞。基于微生物的疫苗的工程和制造需要复杂而复杂的过程。肽疫苗表现出MHC限制，选择性地激活单克隆T细胞，因此具有较高的免疫逃逸风险DNA疫苗存在基因组改变、长期表达和产生抗DNA自身抗体的风险，这可能阻碍其在人类中的应用。因此，选择一种对疾病预防和治疗有前景价值的合适疫苗至关重要。与传统疫苗相比，使用信使RNA (mRNA)的疫苗具有多种有益的特征，mRNA是一种作为蛋白质翻译模板的单核苷酸序列。mRNA疫苗使用体细胞作为自然诱导先天免疫和适应性免疫的核心设施，实现蛋白质产物的翻译后修饰和全部功能，允许在生物反应器中不能产生的多聚体和多用途蛋白质在宿主细胞中正确的翻译折叠和组装，并将产生的细胞内和跨膜蛋白质转移到合适的细胞位置。mRNA疫苗可以根据疾病的独特属性设计编码任何抗原。此外，与DNA疫苗相比，mRNA疫苗避免了宿主基因组插入突变的潜在风险，并可调节所选抗原的表达。从商业角度来看，mRNA疫苗可以通过无细胞过程快速开发和大规模生产，因为它在体外的转录反应效率高，成本效益高。尽管与其他疫苗形式相比，mRNA本身也有一些缺点，例如稳定性差和免疫原性强，这限制了mRNA疫苗在体内的使用，但在修饰和递送方面的改进在很大程度上解决了这些障碍，确保了体内稳定性的维持，以及在启动强大的免疫反应和持久功能引起的不可逆不良反应之间的平衡。因此，mRNA疫苗已成为预防和治疗许多疾病的一种有希望的方式。图1 mRNA疫苗对免疫激活的双重作用mRNA疫苗研制mRNA疫苗的开发是几十年来广泛研究的成果。mRNA的发现可追溯到1961年，并于1969年首次实现了其体外蛋白表达的分离。1990年，体外转录的mRNA被成功验证为在小鼠骨骼肌细胞体内合成蛋白质的模板，标志着mRNA在体内表达的突破，为mRNA疫苗的开发奠定了基础。然而，mRNA疫苗的开发最初面临有限的投资，主要是由于对其不稳定性、体内运输效率低下和可能的先天免疫原性。但仍因其安全性、直接设计和简单制造，mRNA的研究一直在持续。最终，这些疫苗在当前控制大流行的努力中发挥了关键作用。迄今为止，已经建立了一个开发mRNA疫苗的综合框架，包括设计、合成和递送技术。图2 开发mRNA疫苗的流程mRNA设计由于mRNA的不稳定性和翻译效率低下，mRNA疫苗的发展面临着一个主要障碍。在体外，转录的mRNA包括5' cap, ORF, 3'非编码区(3' UTR), 5'非编码区(5' UTR)和a poly(A) tail五个主要元素，它们都模拟了内源性mRNA的结构。为了提高mRNA的翻译效率，科学家们设计了各种技术来修饰这些成分并优化mRNA的设计。 5' cap是一种位于成熟mRNA分子5'末端的修饰的核苷酸结构，包括一个通过三磷酸链与mRNA连接的鸟嘌呤核苷酸，在鸟嘌呤的第7位和/或第一个转录核苷酸的2'位置有额外的甲基化。5' cap在mRNA稳定性和功能的几个方面起着至关重要的作用，包括保护mRNA免受外切酶的侵害，提高mRNA的翻译效率，促进细胞核到细胞质的运输。在mRNA疫苗中，包含 5' cap结构对于mRNA分子的稳定和促进对编码蛋白的有效翻译至关重要。poly(A) tail是mRNA的一个关键的转录后修饰，对mRNA的稳定性、输出和翻译有重要作用。在真核细胞中，mRNA的成熟过程涉及在mRNA分子的3'端添加一个长链的腺嘌呤核苷酸，其典型长度范围为50-250个核苷酸。poly(A) tail一个关键功能是保护mRNA免受外切酶的侵害。此外，poly(A) tail促进mRNA从细胞核输出到细胞质，在细胞质中它可以被翻译成蛋白质，还参与蛋白质合成的起始。在mRNA疫苗中引入poly(A) tail有两个关键目的：第一，稳定mRNA分子并保护其免受细胞酶的降解。第二，提高mRNA的翻译效率，导致抗原表达增加和更有效的免疫反应。UTR在mRNA基因表达调控中起着至关重要的作用。具体来说，5' UTR在调节mRNA稳定性和翻译效率方面至关重要，5' UTR的选择性剪接可以改变mRNA的翻译效率。同样，3' UTR通过结合调控蛋白和microrna来调节mRNA的稳定性，这些蛋白和microrna可以破坏或稳定mRNA。在mRNA疫苗设计中，UTR被精心设计以优化蛋白质表达和免疫反应对5' UTR进行修饰可提高翻译效率，对3' UTR进行修饰可稳定mRNA并延长蛋白表达，从而提高mRNA疫苗的免疫原性和有效性。ORF以起始密码子开始，以终止密码子结束，是mRNA被核糖体翻译成蛋白质的关键片段。ORF的长度从几百到几千个核苷酸不等。ORF的序列决定了合成蛋白的身份和结构，因此对mRNA的有效性起着关键作用。在mRNA疫苗的背景下，ORF设计直接影响目标抗原的产生。mRNA疫苗技术的进步促进了它们针对新出现的传染病的快速设计和生产。ORF序列已被优化，以提高mRNA的稳定性和翻译效率。此外，在ORF中使用非天然氨基酸可以扩大抗原呈递的表位库，从而潜在地诱导更广泛的免疫反应。开发高效的ORF设计策略对mRNA疫苗的成功至关重要。这些努力有望开发出更有效、更通用的mRNA疫苗，在疾病预防和治疗方面具有广阔的应用前景。值得注意的是，由于修饰核苷能够提高mRNA分子的稳定性、翻译效率和免疫原性，它们在mRNA技术中得到了广泛的应用。这些核苷类似物可以在体外转录中整合到mRNA序列中，从而形成相对于未修饰的mRNA分子具有优越性能的修饰mRNA分子。在mRNA中最常用的修饰核苷有假尿嘧啶、5-甲基胞嘧啶和2-硫尿嘧啶。假尿嘧啶提高mRNA的稳定性和翻译效率，同时降低先天免疫反应的激活。5-甲基胞苷提高蛋白表达水平，而2-硫脲通过增加mRNA与核糖体的结合亲和力来提高翻译精度其他修饰，包括Nl -甲基伪尿嘧啶和5-甲氧基尿嘧啶，也被用来提高mRNA的稳定性和翻译效率在mRNA技术中掺入修饰核苷为开发更有效和更安全的基于mRNA的疗法，包括针对各种人类疾病的疫苗和基因疗法带来了巨大的希望。mRNA疫苗合成通过体外转录产生mRNA涉及使用RNA聚合酶从活细胞外的DNA模板合成mRNA。上游过程需要使用质粒作为模板，并使用T7, SP6或T3 RNA聚合酶将其转录成初级mRNA。这个反应只需要几个小时，每毫升反应产生几毫克的初级mRNA。随后，在转录过程中使用Cap类似物代替天然底物或通过使用RNA 2' - o-核糖转移酶、RNA甲基转移酶和甲基供体底物的两步酶促反应对初级mRNA进行反应。尽管利用Cap类似物是一种快速而实用的方法，但其使用受到相对较高的成本和由此产生的m7GpppN帽结构相关的不稳定性的阻碍。相反，两步酶促反应产生更稳定的m7GpppN帽结构，这还需要额外的步骤和酶反应，以及对合适的酶和甲基供体底物的精心选择为了达到临床质量标准，上游产生的mRNA需要经过多个纯化步骤才能从反应混合物中分离纯化。大小排斥色谱法是一种常用的方法，用于分离mRNA分子基于其大小和形状。这种方法既简单又温和，可以有效地去除杂质，包括残留的DNA、RNA和蛋白质。反相高效液相色谱法根据mRNA分子的疏水性分离mRNA分子，从而提供高分辨率和纯度，但费时且需要昂贵的设备。亲和层析是另一种纯化mRNA疫苗的策略，利用特异性配体捕获和纯化用于疾病预防和治疗的mRNA疫苗。这种方法可以提供高特异性和产率，但可能需要额外的配体固定步骤，并且可能昂贵。离子交换色谱法是另一种常见的mRNA纯化方法，它根据分子的电荷分离分子纯化mRNA分子结构与。尽管该方法收率和纯度高，但可能需要多个步骤和仔细优化才能获得最佳结果。除了基于色谱的方法外，基于沉淀的方法，包括异丙醇或乙醇沉淀，也可用于纯化mRNA疫苗这些方法简单且具有成本效益，但在去除杂质方面效果较差，并且可能需要再悬浮和质量控制的额外步骤。最终，选择mRNA疫苗的纯化方法取决于各种因素，包括所需的纯度水平、可扩展性、成本和下游应用。mRNA疫苗递送由于RNA固有的不稳定性和需要保护其在细胞外环境中不被降解，将mRNA疫苗递送到细胞中提出了重大挑战。在过去的几十年里，研究人员探索了各种递送系统来克服这些挑战并增强mRNA疫苗的功效。最早的方法之一是使用裸mRNA分子，直接注射到细胞或组织中。在此，mRNA在没有载体的情况下递送，允许其在细胞内被翻译成抗原蛋白。虽然裸mRNA疫苗相对容易生产，并且在临床前研究中显示出前景，但它们的稳定性较差，并且可能比携带载体的mRNA疫苗引起的免疫反应更弱。另一种早期方法是mRNA-DC疫苗，它涉及在DCs上装载编码所需抗原的mRNA。然后DCs将抗原呈递给免疫系统，导致强大的免疫应答。这种方法在治疗癌症和传染病的临床前研究中显示出前景。近年来，脂质纳米颗粒(LNPs)和多聚复合物/聚合物纳米颗粒是两种最常用的mRNA疫苗递送系统。LNPs由于其生物相容性、稳定性和保护mRNA免受降解的能力，被广泛用作mRNA疫苗的递送系统。LNPs可以根据其脂质成分的性质、表面电荷和表面修饰进行分类。一类是阳离子LNPs，带正电的脂质成分与带负电的mRNA磷酸主链相互作用，促进后者进入靶细胞以前的研究已经提供了证据，证明了可电离LNP疫苗对不同传染病的有效性。作为基于mRNA的疫苗的递送载体，可电离LNPs具有巨大的潜力。这些纳米颗粒由一个由脂质双分子层包裹的mRNA核心组成，脂质双分子层包含可电离的脂质，可以有效地封装mRNA并防止其在细胞外环境中降解。此外，可电离的脂质有助于促进mRNA货物的内体释放和细胞质运输，这对有效的蛋白质表达至关重要。聚乙二醇(PEG)修饰的LNPs表面有一层聚乙二醇亲水性涂层，提高了生物相容性，降低了毒性。多聚体和聚合纳米颗粒是用于mRNA疫苗的多用途递送系统，已被广泛研究。多聚物是由带正电的聚合物(如聚乙烯亚胺)和带负电的mRNA分子之间的静电相互作用形成的它们有效地保护mRNA免受降解，促进细胞摄取，并由于它们的阳离子电荷而增强免疫原性聚合物纳米颗粒可以由多种聚合物形成，包括聚乳酸-羟基乙酸和聚乙二醇，mRNA可以通过多种机制被封装，包括静电相互作用、疏水相互作用和共价键。与多聚物和LNPs相比，它们具有较低的免疫原性和毒性，可以通过工程设计来增强其稳定性和靶向特异性。然而，它们的转染效率可能低于LNPs，并且它们的生产可能更加复杂和昂贵。一般来说，递送系统的选择取决于几个因素，包括mRNA疫苗的特异性和所需的转染效率、安全性、稳定性和靶特异性。mRNA疫苗佐剂免疫原性调节是mRNA疫苗开发中一个不可忽视的问题。尽管体外转录mRNA显示出一定的自我辅助潜力，但通常不足以引发全面的保护性免疫，需要强化重复/加强方案才能达到最佳效果多种策略已被应用于mRNA疫苗佐剂来调节其免疫原性。TriMix是一种mRNA的组合，编码三种不同的免疫刺激蛋白:CD40配体(CD40L)， CD70，以及组成活性Toll样受体4 (TLR4)。由于其改善DC活化和增强CD8+ T细胞反应的能力，TriMix已被纳入许多疫苗接种研究。此外，阳离子脂质的利用被广泛认为具有改善RNA摄取和促进其内体逃逸的能力，从而增加mRNA疫苗的佐剂活性。此外，合成mRNA序列与聚合载体的结合已被证明可增强各种亚基疫苗的佐剂性。研究人员开发了一种混合纳米颗粒系统，该系统包括聚乳酸-乙醇酸核和脂质壳，用于同时递送mRNA和疏水性TLR7佐剂。聚乳酸-羟基乙酸促进了细胞核内佐剂的整合，而脂质壳通过静电相互作用使mRNA的装载成为可能。这种方法已经证明了针对特定抗原的有效免疫反应和高度有效的抗肿瘤活性。传染病中的mRNA疫苗mRNA疫苗是通过编码疾病特异性抗原来预防传染病的。迄今为止，许多使用mRNA疫苗诱导抗病毒免疫的临床前和临床试验已经在多种传染病中进行，包括严重急性呼吸综合征冠状病毒2、寨卡病毒、人类免疫缺陷病毒、流感病毒、巨细胞病毒、呼吸道合胞病毒、水痘带状疱疹病毒和狂犬病毒。图3 mRNA疫苗在传染病中的应用前景严重急性呼吸综合征冠状病毒mRNA疫苗自2021年初以来，严重急性呼吸综合征冠状病毒2 (SARS-CoV-2)已在全球感染了无数人，并造成数百万人死亡。大多数SARS-CoV2感染不会对先前没有疾病的人构成威胁生命的风险。然而，在严重感染的情况下，肺部会引发不受控制的免疫反应，破坏上皮细胞和肺泡，导致肺水肿，血管通透性的危险增加和死亡。在SARS-CoV-2表面发现的刺突蛋白，通过与宿主细胞表面的血管紧张素转换酶2受体结合，促进病毒进入宿主细胞。因此，刺突蛋白代表了编码受体结合域或全长刺突蛋白的SARS-CoV-2 mRNA疫苗的主要靶标。迄今为止，两种针对2019冠状病毒病(COVID-19)刺突蛋白的mRNA疫苗已获得批准并在全球广泛使用。这些疫苗包括Moderna开发的mRNA-1273和BioNTech/ Pfizer开发的BNT162b2。与此同时，其他几种靶向刺突蛋白的mRNA疫苗目前正在进行临床试验，以评估其安全性和有效性。mRNA疫苗的问题之一是需要极低温储存，这限制了它们在条件差和经济水平低的地区的应用。CVnCoV是由CureVac AG开发的一种化学未修饰的编码S-2P的mRNA疫苗，在±5°C下稳定至少3个月，于2020年4月首次报道。使用CVnCoV的临床前模型显示，该疫苗诱导了强大的体液反应和强大的T细胞反应，并有效诱导IFN-γ+ TNF+ T细胞。ARCoV是一种编码RBD蛋白的LNP mRNA疫苗，由Abogen公司于2020年开发。在接种疫苗的小鼠中进一步感染SARS-CoV-2表明，ARCoV保护小鼠免受SARS-CoV-2感染，在接种疫苗的小鼠的肺部没有可测量的病毒RNA。LUNAR-COV19是一种自我复制的mRNA疫苗，编码S-2P抗原，由Arcturus公司于2020年开发，目的是通过单次低剂量给药提供强大的免疫力用于临床前模型的LUNAR-COV19诱导了CD44+CD62L-效应/记忆亚群扩增的强大T细胞反应，增强了IFN-γ+ CD8+/CD4+ T细胞的比例，并导致高滴度的中和抗体的强效体液反应。总之，mRNA疫苗的批准不仅保护了许多人免受COVID-19的侵害，而且为开发针对其他疾病的mRNA疫苗提供了宝贵的经验。值得注意的是，尽管已经制备出多种抗SARS-CoV-2 mRNA疫苗并用于人体，但仍存在未解决的问题，其作用机制尚不清楚。例如，mRNA疫苗对人类COVID-19提供保护的持续时间，以及如何增加主要保护上呼吸道的IgA抗体的水平，目前尚不清楚。如何降低不良反应的发生率，以往的临床试验表明，mRNA疫苗诱导的全身性不良事件发生率仍高于灭活病毒疫苗或蛋白质亚基引发的全身性不良事件发生率。寨卡病毒mRNA疫苗寨卡病毒(ZIKV)是一种具有阳性的RNA病毒，单链基因组长度为11000个。碱基感染寨卡病毒的人通常会出现持续两到七天的发烧、头痛、皮疹、不适和结膜炎。然而，它对祖神经细胞的偏向性在少数情况下导致神经发育性出生缺陷和先天性畸形。预防接种疫苗是预防寨卡病毒感染并发症的唯一选择，因为目前为止还没有出现针对这种病毒的药物。膜蛋白和包膜蛋白是寨卡病毒mRNA疫苗的常见抗原。迄今为止，基于mRNA平台开发的几种寨卡病毒疫苗已在临床前模型中进行了测试。一项挑战研究表明，用mRNA疫苗治疗的小鼠和非人灵长类动物对寨卡病毒感染具有保护作用。同年，Richner等人开发了一种lnp封闭的mRNA疫苗，编码原始型和变体ZIKV膜糖蛋白。两剂mRNA疫苗增强了对寨卡病毒的血清中和反应，并保护小鼠免受寨卡病毒感染。mRNA疫苗的有效性也在小鼠妊娠模型中进行了评估。尽管寨卡病毒mRNA疫苗在临床前研究中的结果很有希望，但还需要进一步的人体临床试验。人类免疫缺陷病毒mRNA疫苗人类免疫缺陷病毒(HIV)是逆转录病毒科慢病毒属的一员，分为HIV-1和HIV- 2两种类型。HIV引起获得性免疫缺陷综合征(AIDS)，全球有7500万人感染，导致3200多万人死于艾滋病。尽管进行了30年的研究，但目前还没有有效的预防性疫苗，这主要是因为在HIV包膜中发现的蛋白质具有显著的抗原多样性，其密集的“聚糖屏蔽”隐藏了关键包膜蛋白的表位。迄今为止，已在临床研究中研究了多种mRNA疫苗。候选疫苗利用启动和增强策略来引发靶向B细胞反应，目的是产生广泛中和的抗HIV抗体。值得注意的是，mRNA HIV疫苗的研制仍处于初级阶段。需要更多的研究来优化这种治疗策略，以获得持久的免疫反应。这些研究的重点是同时给药，帮助重新激活HIV储存库，使其对免疫系统可见，并可能最终提高mRNA HIV疫苗的功效。抗流感病毒mRNA疫苗流感病毒是正粘病毒科的成员，主要由四种流感病毒组成:A、B、C和D型;其中，A型和B型临床与人类疾病相关。抗流感病毒mRNA疫苗的典型靶标是病毒表面的糖蛋白血凝素(HA)，因为它介导病毒进入。然而，由于流感病毒的快速突变导致抗原漂移，mRNA疫苗的HA抗原成分需要每年审查和修改。这一特点使mRNA疫苗成为预防流感病毒感染和控制疾病传播的最合适方式。诱导的抗原特异性抗体反应已被发现与小鼠对病毒攻击的保护有效性相关。总的来说，生产速度快的mRNA疫苗可能成为治疗流感病毒的重要手段，但需要进一步的随机研究来证实mRNA流感疫苗的安全性和有效性。巨细胞病毒mRNA疫苗人巨细胞病毒(CMV)属于乙型疱疹病毒亚科，基因组大小为236千碱基。初次感染后，巨细胞病毒通常建立潜伏状态，在宿主体内持续存在而不引起活动性疾病。免疫功能低下个体的病毒再激活可导致危及生命的并发症，包括肺、胃肠道、肝脏、眼睛或中枢神经系统。巨细胞病毒被认为是先天性畸形最普遍的感染性原因，在10-15%的病例中会导致感音神经性听力损失、发育迟缓和胎儿死亡。病毒包膜糖蛋白(g) gB和gH/gL的存在促进了病毒进入宿主细胞的过程，细胞-细胞融合事件允许病毒传播。迄今为止还没有关于CMV mRNA疫苗的安全性、反应原性、安全性和免疫原性的临床数据报道。呼吸道合胞病毒(RSV)是一种包膜病毒，属于副粘病毒科肺炎病毒属，是婴幼儿中最常见的病原体，可引起急性下呼吸道感染，免疫力低下的老年人也容易感染呼吸道合胞病毒。融合蛋白(F蛋白)是人体免疫系统对抗RSV的靶标;因此，通常选择它作为疫苗开发的抗原。然而，当RSV附着在靶细胞上时，F蛋白被修饰为预融合形式，隐藏了有效的中和表位，导致RSV的免疫逃避。儿童经常被呼吸道合胞病毒感染，迄今为止在这一阶段进行的临床试验很少，但已针对成人开展了临床试验。尽管已经开展了多项临床研究，但几乎所有研究仍处于早期阶段，mRNA疫苗对下呼吸道急性感染的预防作用仍有待确定。抗水痘-带状疱疹病毒mRNA疫苗水痘带状疱疹病毒(VZV)，也称为人类疱疹病毒3型，是一种具有双链DNA基因组的甲型疱疹病毒，广泛分布于人群中原发性VZV感染导致水痘(水痘)，并在神经节神经元中潜伏。潜伏性VZV在严重者由于细胞对VZV的免疫力下降而被重新激活，引起疱疹后神经痛，可能导致持续数月的难以忍受的疼痛，影响患者的生活质量。VZV编码10种糖蛋白:ORFS/L、gK、gN、gC、gB、gH、gM、gL、gI和gE。mRNA疫苗是未来生产VZV疫苗的合适平台，尽管结果的可转译性很有希望，但仍然迫切需要更多的临床和临床前研究，重点关注疫苗的有效性和安全性。狂犬病毒mRNA疫苗狂犬病毒是横纹肌病毒科的一种负链RNA病毒，可引起狂犬病，狂犬病是一种人畜共患病毒性疾病，致死率接近100%狂犬病毒通过表面糖蛋白RABV-G与细胞靶标结合，进入周围神经和中枢神经系统。未来的研究应侧重于提高抗体滴度，诱导更长时间的免疫反应，从而可能有助于生产更便宜、更容易获得的狂犬病疫苗，以满足公共卫生需求。癌症mRNA疫苗癌症mRNA疫苗通常用于治疗，而不是用于传染病的预防。事实上，它通常被设计为编码肿瘤相关抗原(TAAs)或新抗原来激活抗肿瘤免疫反应。迄今为止，美国国家医学图书馆(ClinicalTrials.gov)已经注册了许多研究mRNA疫苗对各种癌症效果的临床试验，包括黑色素瘤、脑癌、非小细胞肺癌(NSCLC)、卵巢癌、前列腺癌、血液系统癌、消化系统癌和乳腺癌。图4 mRNA疫苗在癌症中的应用前景黑色素瘤mRNA疫苗黑色素瘤是由广泛分布于体内(如皮肤、粘膜、葡萄膜、内耳、直肠)的黑色素细胞恶性转化而产生的。皮肤黑色素瘤是最常见的类型，占所有新诊断的原发性恶性肿瘤的约1.7%，占全球所有癌症死亡率的约0.7%。基于DC的mRNA疫苗主要用于对抗黑色素瘤。早在1996年，Boczkowski等人就进行了过继性mRNA脉冲DC转移，发现编码卵清蛋白(OVA)的DC脉冲mRNA疫苗可以保护小鼠免受表达OVA的肿瘤细胞的侵袭，并显著减少B16/F10.9肿瘤模型中的肺转移。近年来，多种基于DC的mRNA疫苗已在黑色素瘤患者中进行了测试。免疫佐剂通常用于刺激和扩增对目标抗原的免疫应答，以调节mRNA疫苗的体内免疫原性。TriMix主要被用作一种基于DC的黑色素瘤mRNA疫苗，因为它编码激活刺激因子CD40L (CD4+ T细胞激活因子)、共刺激分子CD70 (CD8+T细胞激活因子)和组成型活性TLR4 (DC抗原呈递启动子)。尽管基于体外转录的形式不如基于DC的形式常见，但分子生物技术的发展使这种形式在癌症治疗中变得可行。个性化mRNA疫苗与其他抗癌方法相结合，可能为黑色素瘤的治疗铺平道路。多种mRNA疫苗已被开发用于治疗黑色素瘤，在临床研究中显示出潜在的治疗效果。然而，目前还没有mRNA疫苗被正式批准用于治疗黑色素瘤,mRNA疫苗与其他治疗策略的结合可能进一步提高其有效性并促进其获得批准的潜力。脑癌mRNA疫苗原发性脑癌在成人中较少见，占全世界所有癌症类型的1-2%。恶性胶质瘤是脑癌中最常见的亚型，胶质母细胞瘤是最具侵袭性的亚型脑癌。在美国，恶性胶质瘤的5年生存率约为32%，胶质母细胞瘤的5年生存率约为5%。DC脉冲肿瘤mRNA疫苗是最早应用于人类恶性胶质瘤的mRNA形式之一。两项研究涉及到自体肿瘤mRNA负载DC的应用。两项临床试验正在招募患者，以研究人类CMV pp65-LAMP在胶质母细胞瘤中的有效性，结果尚未披露。此外，一种装载pp65-LAMP mRNA的1,2-二油基-3-三甲基丙烷(DOTAP)脂质体疫苗正在高级别胶质瘤和胶质母细胞瘤的I期研究中进行测试，结果尚未公布。值得注意的是，恶性胶质瘤的mRNA疫苗主要编码TAAs，基于新抗原的mRNA疫苗与免疫检查点抑制剂是否在胶质瘤中表现出更好的疗效还有待研究。非小细胞肺癌mRNA疫苗肺癌是世界上第二常见的癌症，也是癌症死亡的主要原因，其中非小细胞肺癌占所有肺癌的85%,可切除疾病的5年生存率约为60%，不能切除的局部疾病的5年生存率约为33%，扩展性疾病伴转移的5年生存率为6.3%。CV9201和BI1361849 (CV9202)是在nsclc中进行临床试验的两种基于mRNA的疫苗。尽管一小部分NSCLC患者从mRNA疫苗治疗中获益，但据已发表的研究报道，总体生存率仍然有限。需要进一步优化mRNA疫苗，选择合适的联合治疗方案，以提高其疗效。此外，目前仅有少数研究完成并发表研究结果，未来mRNA疫苗在NSCLC中的应用还需要更多的临床试验。抗卵巢癌mRNA疫苗卵巢癌是最危险的妇科癌症之一，2020年全球约有31.4万例新病例和20.7万例死亡,它占女性癌症相关死亡的约5%，已成为全球女性癌症相关死亡的第五大原因。目前，一项首次人体开放标签I期研究正在招募卵巢癌患者，接受脂质聚合物配制的mRNA疫苗和neo辅助化疗。遗憾的是，在复发的敏感上皮性卵巢癌患者中使用装载扩增卵巢癌干细胞mRNA、hTERT和survivin的自体DC的I/II期试验于2021年终止，没有显示结果。mRNA疫苗在卵巢癌中的应用仍处于早期阶段，参加临床试验的患者数量仍然有限。mRNA疫苗对卵巢癌的疗效有待于在更多的患者中进一步探索，以更好地评价其疗效。抗前列腺癌mRNA疫苗前列腺癌是全球男性癌症相关死亡的第二大常见癌症和第五大原因，约有1000万男性被诊断出患有前列腺癌。每年在全世界造成40多万人死亡，预计到2040年每年死亡人数将达到80多万人。开发了一种佐剂脉冲mRNA疫苗纳米颗粒，其中含有OVA编码的mRNA和棕榈酸修饰的TLR7/8激动剂R848 (C16-R848)，并包裹在脂质-聚乙二醇外壳中该疫苗成功地保留了包封C16-R848的佐剂活性，且mRNA转染效率显著提高，转染率超过95%。这种高转染效率导致OVA mRNA衍生抗原在抗原呈递细胞的MHC I类分子上的呈递增强。通过改善OVA特异性CD8+ T细胞在表达OVA的同种异体前列腺癌小鼠模型中的延伸和浸润，疫苗接种引发了有效的适应性免疫反应，并在移植后抑制肿瘤生长(与对照组相比减少60%)。然而，到目前为止还没有提供临床治疗结果。总之，针对前列腺癌的mRNA疫苗大多处于尝试阶段，对生存的潜在价值需要临床结果的更多支持。抗血液系统癌mRNA疫苗血液恶性肿瘤包括一系列与造血干细胞异常增殖有关的疾病，包括白血病、骨髓瘤和淋巴瘤。根据国际癌症研究机构发布的2020年全球癌症统计数据，白血病是血液病中癌症死亡的第一大原因，也是全球癌症死亡的第十大原因。常见的白血病类型包括急性髓性白血病(AML)、慢性髓性白血病、慢性髓单核细胞白血病、慢性中性粒细胞白血病和非典型慢性髓性白血病。迄今为止，mRNA疫苗主要应用于血液系统肿瘤的AML。总体而言，mRNA疫苗在临床试验中显示出对AML有希望的效果，尽管尚未被批准作为其标准治疗。除AML外，其他人类血液系统癌症的mRNA疫苗主要处于临床前阶段，需要更多的临床试验来研究其疗效。抗血液系统癌mRNA疫苗癌症可发生在胃肠道的任何组织，包括结肠、胃、食道、肝脏和胰腺。消化系统癌症是全世界癌症发病和死亡的主要原因，每年有300万新发病例和200万人死于胃肠道癌症。基于mRNA的疫苗mRNA 4650已被临床评估用于治疗各种消化系统癌症，包括胃肠道癌症和肝癌。接受肌肉注射mRNA 4650治疗的胃肠道癌症患者出现了针对肿瘤新抗原的CD4+和CD8+ t细胞反应。mRNA 4157被设计用于编码34种独特的新抗原，在结直肠癌和其他实体肿瘤患者中进行的I期临床研究正在进行中它诱导抗原特异性T细胞，当作为单一疗法或与派姆单抗联合使用时，耐受性良好，可导致完全或部分反应。在肿瘤浸润淋巴细胞中发现了作为mRNA疫苗靶点的特异性免疫原性突变。疫苗接种引发了针对预测的新表位的突变特异性T细胞反应，但在本试验中接受治疗的4名患者中没有发现客观的临床反应。总之，尽管使用mRNA疫苗对抗消化系统癌症的临床试验有限，但在一小部分患者中显示出一些有效性，为进一步开发有效的消化系统癌症治疗方法提供了基础。抗乳腺癌mRNA疫苗乳腺癌是妇女中最常见的癌症，也是全球癌症相关死亡的主要原因。《2020年全球癌症统计》报告称，女性乳腺癌已经超过肺癌，成为最常被诊断的癌症。乳腺癌包括三种主要亚型:ER+、HER2+和三阴性乳腺癌(TNBC)。与其他亚型相比，传统的内分泌或靶向药物对TNBC无效，超过50%的患者在诊断后的最初3至5年内复发，中位总生存期为10.2个月。尽管疫苗接种诱导了特异性T细胞应答，但存活数据仍未公布，mRNA疫苗的疗效尚不清楚。此外，只有一篇研究mRNA疫苗在疾病预防和治疗中的作用，需要更多的试验来促进其在临床实践中的应用。免疫疾病中的mRNA疫苗自身免疫性疾病的特点是由于对自身抗原的免疫反应失调而引起的慢性炎症。许多使用mRNA疫苗对抗癌症或传染病的临床研究表明，它们有可能引发自身免疫性疾病。然而，小鼠模型显示其治疗自身免疫性疾病的能力，尽管尚未进行临床应用。外周耐受性的生理诱导和维持主要是由抗原呈递细胞(APCs)呈递自身抗原决定的，其表面共刺激分子(如DC86)的表达减少。传统的mRNA疫苗通常会引起由TLR信号驱动的强I型T辅助细胞反应。疫苗接种不影响对不相关抗原的免疫应答，该方法在不同抗原(PLP、MBP和MOBP)诱导的模型中有效，这表明了该方法的重要方面，如优化mRNA疫苗以引发针对特定病理的保护性免疫应答和维持抗原特异性免疫耐受以治疗自身免疫性疾病的可能性。过敏是免疫系统对外来物质的超敏反应，通常对大多数人无害。这种被称为过敏原的外来物质会引发免疫反应，导致各种症状，如瘙痒、打喷嚏、流眼泪和皮疹。常见的过敏原包括花粉、尘螨、某些食物、药物和昆虫毒液。过敏可以从轻微到严重，在某些情况下，可能危及生命。与传统的过敏原提取物相比，mRNA疫苗通过编码过敏原和提供更纯净的免疫抗原，也提供了一种更安全的方法来预防过敏状况。在小鼠中，编码过敏原的mRNA疫苗已被发现通过激活Th1细胞反应有效地预防I型过敏免疫后，小鼠暴露于相应的过敏原，由此产生的炎症特征(如嗜酸性粒细胞，IL-4和IL-5)减少，而抗炎反应增强。更重要的是，mRNA疫苗在小鼠中产生长期记忆反应，在再次暴露于过敏原时导致有效的抗炎反应这些发现说明了mRNA疫苗在不需要加强疫苗接种的情况下靶向过敏的潜力。mRNA疫苗在组织损伤中的应用组织损伤是指发生在身体组织上的任何物理损伤或伤害。这可能是由多种因素造成的，如创伤、感染、炎症和暴露于有害物质或辐射。组织损伤可以影响身体的任何部位，包括皮肤、肌肉、骨骼、器官和神经。心血管疾病是世界范围内对人类健康的主要威胁它们包括但不限于冠心病、高血压、心力衰竭、血管钙化和心脏纤维化心血管损伤大多是不可逆的，只能控制。除心血管疾病外，mRNA疫苗已显示对多种软组织损伤有效。研究发现，含有核苷修饰的编码HGF和EGF的mRNA的mRNA- lnps可以刺激慢性胆碱缺乏的乙氨酸介导的肝损伤和急性对乙酰氨基酚诱导的肝毒性小鼠的肝脏再生。在糖尿病小鼠模型中，通过矿物包被微颗粒递送核苷修饰的编码FGF-2的mRNA，通过加速伤口完全愈合的过程，改善了皮肤伤口的愈合。mRNA疫苗在促进组织生成方面显示出很大的潜力。除了上述损伤外，mRNA疫苗还可能促进其他组织的生成。罕见疾病的mRNA疫苗罕见病被定义为影响一小部分人口的医疗状况，其特点是患病率低，而且由于罕见，对其的了解往往有限。患者可能难以找到适当的医疗护理和治疗。据报道，mRNA疫苗具有治疗多种罕见疾病的潜力。囊性纤维化是一种遗传性疾病，主要影响肺、胰腺和其他器官。它是由CFTR基因突变引起的，导致肺部和其他器官产生粘稠的粘液，这种粘液会堵塞气道，使呼吸困难，导致慢性肺部感染、肺损伤和呼吸衰竭。囊性纤维化还会影响胰腺，导致消化问题和营养不良，并可能导致其他并发症，如肝病、糖尿病和不孕症。囊性纤维化是一种目前无法治愈的终身疾病，而治疗有助于症状控制以及提高生活质量。2018年，Robinson等人报道了一种临床相关的脂质纳米颗粒填充化学修饰的编码CFTR的mRNA增加了CFTR的膜定位，并恢复了其在患者来源的支气管上皮细胞中作为氯离子通道的作用。一项I/II期临床研究目前正在进行中，该试验旨在评估MRT5005雾化治疗囊性纤维化成人患者的安全性、耐受性和生物活性。遗传性代谢紊乱是儿童疾病和死亡的重要原因这些疾病约占活产婴儿的1 / 800，通常源于常染色体隐性模式遗传的单个基因突变遗传性代谢性疾病占儿科急性肝衰竭病例的10-15%，死亡率在22-65%之间。mRNA疫苗已经在几种罕见的遗传性疾病中进行了测试，如遗传性酪氨酸血症1型、苯丙酮尿症(PKU)、甲基丙二酸血症(MMA)、丙酸血症(PA)、糖原储存病1a型(GSD1a)和鸟氨酸转氨基甲酰基酶(OTC)缺乏症。PKU是一种遗传性代谢疾病，由苯丙氨酸羟化酶(PAH)活性不足引起，导致患者血液和器官中苯丙氨酸(Phe)的积累。如果不进行治疗，患者会遭受严重的神经损伤。通过反复静脉注射PKU (Pahenu2)小鼠模型，给药LNPs包装的小鼠Pah mRNA产生治疗性Pah蛋白，降低肝脏、血清和脑中的Phe水平，逆转疾病进展。这些发现表明，LNPs中形成的Pah mRNA为PKU患者提供了一种替代治疗选择，无需终生限制Pah饮食。基于这种可能性，ModernaTx, Inc. (Cambridge, MA, USA)已将PAH PKU mRNA-3283纳入其产品开发管线。MMA是一种有机酸血症，具有很高的发病和死亡风险，目前还没有批准的治疗方法来解决其根本原因这种常染色体隐性遗传病阻碍了丙酸源自某些蛋白质和脂肪的代谢因此，甲基丙二酸在体液和组织中有显著的积累。这种疾病的主要原因通常归因于线粒体酶甲基丙二酰辅酶a (CoA)变异酶(MUT)的缺乏。将lnp包封的MUT mRNA反复静脉注射到小鼠中，可降低血浆MMA浓度，提高存活率。目前正在进行一项I/II期临床试验，以评估mRNA疫苗在疾病预防和治疗中的作用LNP包封的人MUT mRNA (mRNA-3705)用于诊断为分离性甲基丙二酸血的个体的安全性、药代动力学和药效学。总之，缺乏能够治愈这些罕见疾病的治疗药物。mRNA疫苗使长期控制这些疾病成为可能，尽管仍处于尝试阶段。需要更多的研究来证实它们对罕见疾病的疗效。mRNA疫苗已成为疾病预防和治疗的热点，在临床前和临床试验中占据主导地位，特别是在传染病和癌症方面。然而，迄今为止，除了抗新冠病毒mRNA疫苗外，很少有疫苗被批准用于疾病治疗。一些可能限制mRNA疫苗应用的挑战尚未完全解决。在实现最佳抗原生产和确保充分的佐剂效果之间取得平衡是一项重大挑战。mRNA疫苗的佐剂作用促进先天免疫和适应性免疫，但过度的先天免疫抑制mRNA的翻译。此外，疫苗可能无法对某些人群(如免疫功能低下的个体或老年人)提供强有力或持久的保护。有几种方法可以提高疫苗的整体有效性并延长其持续时间，包括按特定时间间隔对mRNA疫苗进行加强注射，使用不同类型的疫苗(例如mRNA和传统疫苗的组合)，以及优化mRNA疫苗的储存和运输条件。总之，mRNA疫苗的制备和应用技术尚不完善，有待进一步改进。除了mRNA疫苗潜在的这些普遍问题之外，在不同的疾病中还存在特定的挑战。鉴于mRNA疫苗在免疫性疾病、罕见病和组织损伤方面的应用仍处于早期阶段，在这些疾病背景下评估其疗效和挑战的研究仍然存在不足。文献来源：mRNA vaccines in disease prevention and treatment识别微信二维码，添加生物制品圈小编，符合条件者即可加入生物制品微信群！请注明：姓名+研究方向！版权声明本公众号所有转载文章系出于传递更多信息之目的，且明确注明来源和作者，不希望被转载的媒体或个人可与我们联系(cbplib@163.com)，我们将立即进行删除处理。所有文章仅代表作者观点，不代表本站立场。

中文摘要水痘和带状疱疹（herpes zoster，HZ）是由水痘-带状疱疹病毒（varicella-zoster virus，VZV）感染引起的两种不同疾病。VZV初次感染后潜伏于脊髓或脑神经节中。HZ是机体免疫力降低、潜伏的VZV被激活后产生的疱疹样疾病，并导致神经组织、皮肤组织的损害。目前尚无治疗HZ的特效药，HZ疫苗可有效降低HZ发生率、复发率，减少相关后遗症和并发症。此文对已上市和开发中的HZ疫苗现状进行综述，为新型HZ疫苗研发提供参考。正文水痘-带状疱疹病毒（varicella-zoster virus，VZV）属于疱疹病毒科α亚科，具有嗜神经、嗜表皮和嗜T细胞特性[1]。VZV初次感染后，感染的VZV会潜伏于脊髓或脑神经节的神经元内；在发热、肿瘤、免疫力低下等多种诱发因素作用下，VZV会被再次激活，并沿外周神经扩散，引起带状疱疹（herpes zoster，HZ）。其后遗症和并发症包括疱疹后神经痛（postherpetic neuralgia，PHN）、脑膜炎等[2]。虽然阿昔洛韦、泛昔洛韦和伐昔洛韦对HZ有一定的疗效，但是仍无针对HZ治疗的特效药。上市的HZ疫苗主要包括2种减毒活疫苗（Zostavax®、NBP608）和1种重组亚单位疫苗（Shingrix），还有多个减毒活疫苗和重组亚单位疫苗进入临床研究，多个DNA疫苗和mRNA疫苗正处于临床前研究阶段。1HZ病原学和流行病学VZV基因组为约125 kb的双链DNA，GC含量为46%，含73个开放阅读框（open reading frame，ORF），至少编码69种蛋白。已知的包膜糖蛋白（glycoprotein，g）有gE、gB、gH、gI、gC、gL、gK、gM、gN，均与病毒的致病性和免疫原性密切相关。其中，gC与VZV毒力相关，gI、gL、gK、gM、gN与病毒传播复制和细胞融合能力呈现不同程度相关性，gE、gB、gH能诱导机体产生中和抗体[2-3]。gE在病毒囊膜和宿主细胞膜上含量最丰富，是细胞免疫和体液免疫应答的重要靶点[4-5]，也是开发HZ疫苗的重要候选抗原。HZ多为散发性，无季节流行性，且发病率与年龄及细胞免疫功能状态相关。以全年龄组人群或特定地域居民HZ发病率为基础的流行病学研究发现，根据HZ累积发病率，估计发生至少1次由VZV再激活引发HZ的终生风险为10%〜30%，且发病率随着年龄的增长而显著增加[6]。2017年北京通州区抽样调查结果显示，曾患水痘的人群占5.70%，抗VZV IgG抗体阳性率为66.78%[7]。2018年温州龙湾区60岁以下人群抽样调查结果显示，男性和女性抗VZV IgG抗体阳性率分别为72.14%、82.89% ；15岁以下人群抗VZV IgG抗体阳性率为58.68%，而15〜59岁人群抗VZV IgG抗体阳性率高达91.23%[8]；2017—2018年，安徽蚌埠20〜70岁人群抽样调查结果显示，20〜29、30〜39、40〜49、50〜59、60〜70岁人群抗VZV IgG抗体阳性率分别为96.15%、97.06%、93.55%、83.93%、80.00%[9]。美国每年约有100万HZ病例，发病率随年龄增长而增加，0~14、15~29、30~39、40~49、50~59、60~69、70~79、≥80岁人群HZ发生率分别为1.1‰、1.4‰、2.0‰、2.9‰、4.6‰、6.9‰、9.5‰、10.9‰[10]。Kridin与Cohen[11]研究表明，确诊HZ后3个月内HZ导致神经、眼部、皮肤和内脏并发症的风险分别增加0.48%、1.33%、0.29%和 0.78%，HZ 特异性并发症导致住院和死亡的绝对风险分别为0.97%和0.04%。PHN为HZ的临床症状中最复杂且最常见的一种，以持续性疼痛、跳痛为主，甚至还伴有痛觉过敏或是异常性疼痛，对患者生活质量产生严重影响[12]。大多数国家往往根据PHN和HZ相关住院费用来制定HZ疫苗接种策略，目前看来，这远远低估了 HZ的实际疾病负担。2VZV感染与免疫应答VZV在机体内潜伏和晚期基因的沉默，可能与微RNA的缺乏相关[13]。VZV潜伏再激活的机制相对比较复杂：（1）VZV感染的靶细胞神经元和角质形成细胞也是APC，其表面的MHC I、MHC Ⅱ及胞间黏附分子1可介导细胞免疫应答[14]。（2）VZV再激活后被模式识别受体识别，结合VZV病原相关分子模式，激活下游信号通路Toll样受体途径、髓样分化因子88途径等，分泌细胞因子IFN-γ、IL-10、IL-4、IL-12等和活化T淋巴细胞亚群产生免疫应答，因而在急性期HZ会伴有细胞免疫失衡的现象，如CD4+ T、CD3+ T细胞明显降低，CD8+ T细胞升高，CD4+ T/CD8+ T比值降低，最后导致神经、皮肤组织的损害[14-15]；（3）CD4+ T细胞和CD8+ T细胞在VZV的感染及激活过程中发挥重要作用[16]。当抗原特异性T细胞减少和功能低下，导致机体内VZV再激活，致使HZ的发生[17]。研究者们提出，早期监测CD4+ T细胞及观测T细胞亚群的变化有助于对病情的判定[15]。2010年，韩科等[18]对不同年龄段的HZ患者外周血检测结果显示，HZ患者的T细胞亚群（CD3+、CD4+、CD8+ ）以及CD4+ /CD8+ 比值均低于正常人群，其中Th与抑制性T细胞的比值（CD4+ /CD8+）明显降低。（4）CD4+ T细胞在呈递病毒抗原后，能成熟分化为Th1和Th2两个细胞亚群，Th1主要分泌IL-2和IFN-γ，能有效刺激、介导细胞免疫，参与炎症反应；Th2主要分泌IL-4、IL-5、IL-13，参与调控体液免疫应答。Th17和Treg同属独立于Th1和Th2的独特CD4+ T细胞亚群，Th17与Treg及其相关细胞因子可通过多种机制参与机体的抗病毒免疫应答，在HZ发病机制中发挥重要作用[19-20]。赵阳等[21-22]对Th17、CD4+CD25+ Foxp3+ Treg及相关细胞因子IL-6、IL-17、转化生长因子β1在HZ病程中治疗前后变化进行研究，结果显示，Th17、Treg水平在HZ患者外周血中显著增高，在治疗后显著下降，与二者相关的细胞因子水平也发生相应变化。3目前批准上市的HZ疫苗3.1Zostavax®Zostavax®由美国Merck&Co开发，于2006年5月被美国FDA批准上市，是首个上市的1剂量接种HZ疫苗，用于60岁及以上人群预防HZ，2011年3月获准在50〜59岁人群中使用。其疫苗毒株为Oka/Merck株，每剂病毒含量至少为19 400 PFU，是水痘减毒活疫苗病毒量的10倍。目前已在60多个国家获准使用[23-24]。在美国大约38 000名60岁及以上人群中开展的Zostavax®预防HZ的临床试验研究结果显示，Zostavax®对60~69、70~79、≥80岁人群保护效力分别为64%、41%、18%。对于22 000名50~59岁人群的临床研究显示，与安慰剂组相比，Zostavax®组HZ发生风险降低70%。Zostavax®上市后安全性和长期有效性研究结果显示，60岁以上人群接种Zostavax®后，HZ发病率可降低51%。在北美和欧洲开展的Ⅲ期临床试验中，22 439名50~59岁的受试者按1：1的比例随机分为疫苗组和安慰剂对照组，疫苗组接种1剂Zostavax®，保护效力可达69.8%[25]。Zostavax®接种已被证明具有较高的成本效益，长达10年的上市后监测已证实其具有中等程度的有效性和较好的安全性[26-27]。3.2NBP608韩国SK Bioscience公司开发的HZ减毒活疫苗NBP608采用与Zostavax®相同的MRC-5细胞系与Oka病毒株进行生产，旨在提供与Zostavax®对HZ相当保护力的疫苗。2019年，Choi等[28]在824名50岁或以上健康成年人中进行了NBP608临床试验，比较NBP608与Zostavax®免疫原性和安全性。接种后6周，g特异性ELISA检测结果显示，NBP608与Zostavax®组血清抗体几何平均滴度分别为1 346.37和1 674.94；酶联免疫吸附斑点检测结果显示，NBP608组和Zostavax®组IFN-γ的几何平均斑点数（geometric mean number of spot，GMSN）分别为95.60、91.11斑点形成细胞/106外周血单个核细胞，IL-2的GMSN分别为17.37、13.59斑点形成细胞/106外周血单个核细胞；不良事件发生率总体为49.82%，NBP608组为50.73%，Zostavax®组为48.91%。HZ减毒活疫苗的保护效果随年龄增长而逐渐降低，且接种部位常伴随炎症反应，如红斑、肿胀和疼痛等症状，急需更加安全高效的HZ疫苗。3.3Shingrix2017年10月，美国FDA批准英国葛兰素史克（GSK）公司的重组亚单位疫苗Shingrix上市，用于50岁及以上成年人预防HZ。Shingrix由冻干重组VZV gE抗原和佐剂 AS01B组成，使用前混合，肌内注射接种2剂（间隔2~6个月）。其中重组VZV gE通过中国仓鼠卵巢细胞表达，AS01B佐剂悬浮液成分包含3-O-脱乙酰基-4'-单磷酰脂质A和三萜苷（QS-21）。2017年，美国免疫实践咨询委员会建议将其作为50岁及以上人群首选HZ疫苗[29-30]。1项多中心、随机、安慰剂对照Ⅲ期临床试验对50岁及以上人群接种2剂Shingrix后的安全性和有效性进行了研究，50~59、60~69和≥70岁3个年龄组共15 411名受试者，其中疫苗组7 698人，安慰剂组7 713人，接种后平均随访3.2年，疫苗保护效力可达97.2%，不同年龄组保护效力相当[31]。Cunningham等[32]对70岁及以上人群接种2剂Shingrix的安全性和有效性进行了研究。13 900名受试者（平均年龄75.6岁）随机分为疫苗或安慰剂组，接种后平均随访3.7年，疫苗保护效力为89.8%。汇总分析结果显示，Shingrix对50岁以上人群HZ保护效力为91.3%，对PHN保护效力为88.8%。疫苗接种后7 d内，局部和全身不良反应发生率分别为79.0%和29.5%。4研发中的新型HZ疫苗HZ减毒活疫苗在预防HZ中发挥重要作用，但其保护效率随年龄增长而降低，而HZ重组亚单位疫苗在50岁及以上年龄段均有较高的免疫保护效率。目前HZ疫苗的研发主要集中于新型HZ疫苗。4.1新型重组亚单位疫苗重组亚单位疫苗利用不同表达系统表达抗原蛋白，辅以佐剂注射至机体后产生相应的免疫应答，具有安全性好、成本低等特点，成为疫苗研发的热点之一[33]。重组亚单位疫苗研发的关键问题有[34-36]：（1）候选抗原的筛选。候选抗原主要具有免疫原性强、抗原稳定性强等特点。从病原学角度来看，gE、gB、gH均能诱导机体产生相应的中和抗体，其中gE是免疫原性和反应原性最强的糖蛋白，也是HZ疫苗研发重要的候选抗原。gB在膜融合中起着至关重要的作用，是抗病毒治疗的潜在新靶点，也是HZ疫苗潜在的候选抗原[37]；（2）佐剂系统应用。目前，有5个成熟的疫苗佐剂平台[38]：矿物盐类佐剂（如明矾）、油乳佐剂（如MF59、QS-21）、微生物和植物提取物以及衍生物类佐剂（如CpG DNA）、微粒抗原呈递系统佐剂（如脂质体、聚乙交酯、免疫刺激复合物ISCOMS、免疫刺激分子）、细胞因子类佐剂（如粒细胞巨噬细胞集落刺激因子）。2021年，贺蕾[4]构建可表达VZV gE的pcDNA3.4-gE-his质粒后，选择3种复合佐剂（MF59、CpG、QS-21）与gE共同免疫小鼠。结果发现，MF59佐剂、MF59与QS-21或CpG 2006构成的复合佐剂均可以诱导较高水平的gE特异性抗体，可以作为HZ重组亚单位疫苗理想的候选佐剂。此外，植物源多糖联合铝佐剂[39]、铝佐剂等也都是重组亚单位疫苗理想的候选佐剂。4.2腺病毒（adenovirus，Ad）载体疫苗Ad载体疫苗将抗原基因通过Ad载体呈递到宿主细胞，诱导免疫应答[33]。相较于其他病毒载体，Ad载体具有基因毒性小、安全性好、可被改造为复制缺陷病毒载体和选择性复制的溶瘤病毒载体等优点[40-42]。陈伟伟等[40]采用AdEasy系统构建携带gE基因的重组腺病毒质粒pAdEasy-gE，分别以病毒滴度3.3×106、1×107、3×107感染单位（infectious unit，IFU）/ml剂量的质粒单针肌内注射免疫NIH小鼠。结果发现，免疫剂量为1×107和3×107 IFU/ml时，在第4周和第6周，均可引起较高水平的体液免疫应答。4.3DNA疫苗DNA疫苗通过将目的抗原基因构建至质粒免疫宿主，从而获得免疫应答[33]。DNA疫苗具有安全性高、构建周期短、能诱导较强T细胞免疫应答的特点，也是具有潜力的疫苗研发路径[43]。研究发现，单独注射DNA疫苗免疫原性相对较低，特别是在大型动物模型和人类中更明显。为改善这种情况，现在已经开发出了能够增强DNA摄取、表达和免疫原性的其他接种方式，包括各种递送装置，例如基因枪、无针注射装置和体内电穿孔装置[44]。周旭等[45]分别构建了gH和gL重组真核表达质粒，于第0、3、5周用质粒单独或与CpG1826佐剂共同免疫小鼠。结果发现，仅双质粒与佐剂共免疫组小鼠血清显示出中和活性，即gH-gL复合物具有一定的免疫原性，同时gH也是HZ疫苗潜在的候选抗原。林俊杨[43]采用pcDNA3.1质粒构建3种含有gE和IE63基因序列的DNA疫苗，以50 μg CpG寡聚脱氧核苷酸1826（CpG-ODN1826）为佐剂，肌内注射接种小鼠，可诱导产生较高水平的gE特异性IgG抗体。Kim等[44]用插入VZV gE、IE63或IE62基因的重组DNA质粒免疫C57BL/6小鼠发现，3种DNA疫苗均可诱导产生较强的VZV特异性CD4+ T细胞免疫应答；与编码IL-7或IL-33的DNA质粒共接种，VZV特异性CD4+ T细胞应答明显增强。在单剂量免疫质粒后2周，用1×107 PFU表达gE的痘苗病毒（VV-gE）对小鼠进行攻毒，攻毒后第2天和第5天，小鼠卵巢VV-gE滴度分别下降至4×103、1×102 PFU。4.4mRNA 疫苗mRNA疫苗将外源目的基因通过体外转录技术制备的mRNA以特定的递送系统递送至宿主细胞，表达目的蛋白，进而产生特异性免疫应答。相较于DNA疫苗，mRNA疫苗具有高安全性、高免疫应答性等优势，是疫苗研发方向的亮点[35]。同时，mRNA疫苗研发具有几大挑战[46]：（1）mRNA序列设计及稳定性。由于mRNA极易被RNA酶水解代谢失活，因此mRNA序列设计及稳定性是mRNA疫苗研发和生产的挑战之一；（2）递送系统。人体内环境复杂，mRNA能否被安全准确递送至胞内也是mRNA疫苗有效性的关键，故而递送系统是否有效也极为关键；（3）质量控制。模板DNA的残留和mRNA不完全合成表达，也是mRNA疫苗研发的难题。Monslow等[47]将预免疫28 d VZV减毒活疫苗（19 400 PFU）的成年健康恒河猴随机分为2组，第1组比较不同类型疫苗接种后免疫原性：脂质纳米颗粒（lipid nanoparticle，LNP）包裹编码VZV gE 抗原的 mRNA 疫苗（VZV gE mRNA/LNP）50、100、200 μg 接种各 5 只，19 400 PFU VZV减毒活疫苗接种4只，50 μg VZV gE亚单位佐剂疫苗接种5只（间隔28 d加强接种2剂）；第2组比较不同剂量VZV gE mRNA/LNP接种后免疫原性：100、200、400 μg接种各5只，间隔28 d，加强接种2剂。结果显示：（1）不同类型疫苗接种70 d后，抗体水平以大致相同的速度衰减，但仍高于接种前；（2）在接种后第42天和第70天，100和200 μg剂量的mRNA疫苗、50 μg剂量的VZV gE亚单位佐剂疫苗组的抗体亲和力分别为0.18、0.20、0.18和0.30、0.32、0.25，明显高于减毒活疫苗（0.12、0.21）；（3）VZV gE mRNA/LNP 疫苗接种后抗体水平与剂量呈正相关；（4）在加强接种后第70天检测IFN-γ、IL-2、TNF，发现50、100、200 μg剂量的VZV gE mRNA/LNP组和减毒活疫苗组的小鼠血清CD4+ T细胞中IFN-γ阳性率分别为35%、40%、75%、10%，IL-2阳性率分别为55%、45%、62%、2%，TNF阳性率分别为52%、50%、83%、10%。由此可见，50、100、200 μg剂量的VZV gE mRNA/LNP诱导的细胞免疫水平高于VZV减毒活疫苗。5展望HZ造成的疾病负担引起全球极大的关注，安全、有效、可及的HZ疫苗也成为全球研发热点。已上市的HZ减毒活疫苗免疫效果低于亚单位疫苗，且病毒含量是水痘减毒活疫苗的10倍左右，产量受到一定限制；已上市的亚单位疫苗中佐剂虽然会提高疫苗的免疫原性，但佐剂本身存在的免疫刺激和接种依从性问题，一定程度上也会限制亚单位疫苗的使用。mRNA疫苗可诱导产生较强的细胞免疫应答，其进入机体后可以直接表达抗原，不存在DNA疫苗有可能整合至宿主基因组的风险，具有较大的研究应用前景，值得关注。另外，合适的动物模型选择和感染模型的建立对于HZ疫苗临床前评价研究十分重要。作者孙惠敏1 综述    李秀玲2 审校1上海生物制品研究所有限责任公司第四研究室，上海 200051；2上海生物制品研究所有限责任公司，上海 201403通信作者：李秀玲，Email：lixiuling@sinopharm.com引用本文：孙惠敏，李秀玲. 带状疱疹疫苗研究开发进展 [J]. 国际生物制品学杂志，2023，46(1)：55-60.  DOI：10.3760/cma.j.cn311962-20220610-00030

RARITAN, N.J., Nov. 4, 2021 /PRNewswire/ -- The Janssen Pharmaceutical Companies of Johnson & Johnson announced today that more than 45 company-sponsored abstracts, including 11 oral presentations, plus more than 35 investigator-initiated studies will be featured at the American Society of Hematology (ASH) Annual Meeting and Exposition. ASH is taking place at the Georgia World Congress Center in Atlanta and virtually from December 11-14, 2021. "We are committed to advancing the science and treatment of hematologic malignancies and look forward to presenting the latest research from our robust portfolio and pipeline during ASH 2021," said Peter Lebowitz, M.D., Ph.D., Global Therapeutic Area Head, Oncology, Janssen Research & Development, LLC. "We continue to deepen and accelerate our understanding of blood cancers as we strive toward our vision – the elimination of cancer." "As evidenced by our presence at ASH, we are continuously pushing boundaries to treat cancer," said Serge Messerlian, U.S. President, Oncology, Janssen Biotech, Inc. "At ASH, we look forward to working with the oncology community to advance the understanding and use of novel treatments and address unmet patient needs, with the ultimate goal of developing curative therapies. Our commitment to the blood cancer community is driven and inspired by our mission to reimagine care so patients can redefine living." Transforming treatment paradigms for patients with multiple myeloma Through years of research and community engagement, Janssen continues to build upon its knowledge of multiple myeloma and the challenges faced by patients at all stages of this complex disease. During ASH 2021, Janssen will present data that represents its multipronged approach to treating multiple myeloma in both the frontline and relapsed or refractory settings through the development of cell and biologic therapies. Featured data on CAR-T and Bispecific therapies Updated, longer-term results from the pivotal Phase 1b/2 CARTITUDE-1 study evaluating the B-cell maturation antigen (BCMA)-targeted chimeric antigen receptor T-cell (CAR-T) therapy ciltacabtagene autoleucel (cilta-cel) in heavily pre-treated patients who have relapsed and/or become refractory will be featured in an oral presentation (Abstract #549). Another oral presentation will report comparisons of patient outcomes with cilta-cel in the CARTITUDE-1 study with standard-of-care therapies from real-world clinical practice (Abstract #550). Other data from the CARTITUDE program at ASH 2021 will provide data on the earlier use of cilta-cel, with updated results from Cohort A of the Phase 2 CARTITUDE-2 study, which included patients who were refractory to lenalidomide with progressive multiple myeloma after 1-3 lines of therapy (Abstract #3866) and the first data from Cohort B of the Phase 2 CARTITUDE-2 study which enrolled patients following early relapse after initial therapy that included proteasome inhibitors and immunomodulatory drugs (Abstract #2910). Both sets of results will be featured in poster presentations. Separately, data being presented as a poster presentation will highlight the potential use of anakinra as a treatment for cytokine release syndrome associated with CAR-T therapy treatment (Abstract #2812). Janssen will present the results from the Phase 1 and 2 MajesTEC-1 (Abstract #896) studies evaluating teclistamab (BCMAxCD3), an investigational, off-the-shelf, T-cell redirecting bispecific antibody in heavily pre-treated patients with multiple myeloma. Updated results from the Phase 1 MonumenTAL-1 (Abstract #158) study, evaluating talquetamab (GPRC5DxCD3) – an investigational, off-the-shelf, T-cell redirecting bispecific antibody and the first directed at this novel target for heavily pre-treated patients with multiple myeloma – will be featured in an oral presentation. In addition, results from the TRiMM-2 study of talquetamab (Abstract #161) and teclistamab (Abstract #1647) in combination with DARZALEX FASPRO® (daratumumab and hyaluronidase-fihj) will also be presented. DARZALEX® and DARZALEX FASPRO® featured data Janssen continues to explore treatment combinations in newly diagnosed multiple myeloma. An oral presentation of updated results from the randomized Phase 2 GRIFFIN trial (Abstract #79) will present updated response rates, including minimal residual disease (MRD), as well as progression-free survival (PFS), with DARZALEX® as part of an investigational quadruplet therapy regimen; a second oral presentation (Abstract #118) will examine the impact that clinical sequencing scenarios with DARZALEX®-based combinations in frontline versus second-line. In the maintenance setting, an oral presentation (Abstract #82) will share updated MRD results from the two-part Phase 3 CASSIOPEIA study of DARZALEX® in combination with bortezomib, thalidomide and dexamethasone (VTd) and autologous stem cell transplant (ASCT) followed by DARZALEX® maintenance therapy. In real-world evidence, a poster presentation (Abstract #1965) examining potential healthcare disparities will highlight patient characteristics, treatment patterns and outcomes for Black and White patients with multiple myeloma who initiated treatment with DARZALEX®. Janssen also continues to evolve the treatment approaches for rare hematologic diseases including newly diagnosed light chain (AL) amyloidosis. An oral presentation will feature updated data from the Phase 3 ANDROMEDA study (Abstract #159), which supported the accelerated approval of DARZALEX FASPRO® in combination with bortezomib, cyclophosphamide and dexamethasone (D-VCd) as the first U.S. FDA-approved treatment for this rare and serious blood cell disorder. Exploring new regimens in CLL/SLL treatment to address unmet patient needs Through a comprehensive development program, Janssen continues to research additional IMBRUVICA®-based regimens to meet the range of needs of patients with chronic lymphocytic leukemia (CLL), including options that have the potential to provide treatment-free remissions. At ASH 2021, new data for the investigational use of IMBRUVICA® in combination with venetoclax as an all-oral, fixed-duration therapy for the treatment of frontline CLL/small lymphocytic lymphoma (SLL) will be presented. Oral presentations of this combination will feature MRD outcomes from the Phase 3 GLOW study (Abstract #70). It will also feature long-term data regarding disease-free survival from the Phase 2 CAPTIVATE study MRD cohort (Abstract #68), evaluating IMBRUVICA® plus venetoclax as a time-limited first-line treatment for patients with CLL/SLL that include a broad range of age and fitness groups. Poster presentations of real-world data will reinforce the efficacy of IMBRUVICA® in patients with CLL/SLL treated in routine practice (Abstract #4112). Advancing and delivering new insights around antithrombotic care Blood clots, or venous thromboembolism (VTE), represent the second leading cause of death in people with cancer.1 Janssen is committed to delivering new data to further validate and inform the use of XARELTO® (rivaroxaban) in patients at risk for cancer-associated thrombosis, helping evolve the standard of care for patients at risk for VTE. During ASH, Janssen will present data from CALLISTO, a comprehensive program of research on cancer-associated thrombosis (CAT), which included three randomized trials of XARELTO® versus low molecular weight heparin (LMWH) for the treatment of venous thrombosis in patients with solid and hematological cancers (SELECT-D, CASTA-DIVA and CONKO-11). The results of this pooled analysis (Abstract #1068) suggest XARELTO® may be an alternative treatment option for the prevention of VTE recurrence in cancer patients with VTE. Janssen will also present data that further advances understanding and provides new insights in the antithrombotic space, including OSCAR-US, evaluating patient characteristics and temporal changes in anticoagulation treatment patterns in patients diagnosed with cancer-associated thrombosis (Abstract #2132) and RIVA-DM, an analysis of thromboembolism, bleeding, and vascular death among older and younger nonvalvular atrial fibrillation patients with type 2 diabetes receiving XARELTO® or warfarin (Abstract #3234). Advancing science for patients with wAIHA Janssen continues to advance clinical trials exploring nipocalimab, an FcRn antagonist, in warm Autoimmune Hemolytic Anemia (wAIHA), an autoimmune disease characterized by the premature destruction of healthy red blood cells. A Trial in Progress (TiP) poster presentation of the ENERGY study (Abstract #1999) will highlight the rationale and study design for an adaptive, Phase 2/3 multicenter, randomized, double-blind, placebo-controlled study in patients with wAIHA whose aim is to evaluate the efficacy, safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of nipocalimab compared with placebo. In real-world evidence, a poster presentation (Abstract #2000) will highlight the use of predictive analytics of a known clinically profiled patient cohort to support the identification of patients with wAIHA. The above two abstracts were previously accepted and presented at the European Hematology Association (EHA) 2021 Annual Congress. A complete list of Janssen-sponsored abstracts is available at Janssen.com/ASH2021. About Cilta-cel Cilta-cel is a BCMA-directed, genetically modified autologous T-cell immunotherapy, which involves reprogramming a patient's own T cells with a transgene encoding a chimeric antigen receptor (CAR) that identifies and eliminates cells that express BCMA. BCMA is primarily expressed on the surface of malignant multiple myeloma B-lineage cells, as well as late-stage B cells and plasma cells. The cilta-cel CAR protein features two BCMA-targeting single domain antibodies designed to confer high avidity against human BCMA. Upon binding to BCMA-expressing cells, the CAR promotes T-cell activation, expansion, and elimination of target cells. In December 2017, Janssen Biotech, Inc. entered into an exclusive worldwide license and collaboration agreement with Legend Biotech USA, Inc. to develop and commercialize cilta-cel. In addition to U.S. Breakthrough Therapy Designation (BTD) granted in December 2019, by the U.S. FDA, Janssen also received Orphan Drug Designation for cilta-cel, in February 2019. In December 2020, Janssen announced initiation of a rolling submission of its BLA to the U.S. FDA for cilta-cel, which was accepted under Priority Review in May 2021. In November 2021, Janssen announced the extension of the PDUFA date. Cilta-cel received a PRIority MEdicines (PRIME) designation from the European Commission in April 2019, and the Orphan Drug Designation for cilta-cel from the European Commission in February 2020. A Breakthrough Therapy Designation for cilta-cel was granted in August 2020, for China. In April 2021, Janssen announced its submission of a Marketing Authorisation to the European Medicines Agency seeking approval of cilta-cel for the treatment of patients with relapsed and/or refractory multiple myeloma. About Teclistamab Teclistamab is an off-the-shelf, T-cell redirecting, bispecific antibody targeting both BCMA and CD3, a primary component of the T-cell receptor. CD3 is involved in activating T cells, and BCMA is expressed at high levels on multiple myeloma cells. Teclistamab redirects CD3-positive T cells to BCMA-expressing myeloma cells to induce killing of tumor cells. Results from Phase 1 studies demonstrated deep and durable response in heavily pretreated patients with multiple myeloma.2 Teclistamab is currently being evaluated in several studies both as monotherapy (NCT04557098) and is also being explored in combination studies (NCT04586426, NCT04108195, NCT04722146, NCT05083169). In 2020, the European Commission and the U.S. Food and Drug Administration each granted teclistamab Orphan Drug Designation for the treatment of multiple myeloma. In January 2021 and June 2021, teclistamab was granted PRIME designation by the European Commission and BTD by the U.S. FDA, respectively. PRIME offers enhanced interaction and early dialogue to optimize drug development plans and speed up evaluation of cutting-edge, scientific advances that target a high unmet medical need.3 The U.S. FDA grants Breakthrough Therapy Designation to expedite the development and regulatory review of an investigational medicine that is intended to treat a serious or life-threatening condition and is based on preliminary clinical evidence that demonstrates the drug may have substantial improvement on at least one clinically significant endpoint over available therapy.4 About Talquetamab Talquetamab is a first-in-class, investigational T-cell redirecting bispecific antibody targeting both GPRC5D, a novel multiple myeloma target, and CD3, a primary component of the T-cell receptor and is involved in activating T cells, and GPRC5D is highly expressed on multiple myeloma cells. Results from the Phase 1 MonumenTAL-1 study demonstrated durable responses that deepen over time in heavily pre-treated patients with multiple myeloma.5 Talquetamab is currently being evaluated in a Phase 1/2 clinical study for the treatment of relapsed or refractory multiple myeloma (NCT03399799) and is also being explored in combination studies (NCT04586426). In January 2021, talquetamab was granted PRIME designation by the European Commission. About DARZALEX FASPRO® and DARZALEX® DARZALEX FASPRO® received U.S. FDA approval in May 2020 and is approved for six indications in multiple myeloma (MM), two of which are for frontline treatment in newly diagnosed patients who are transplant ineligible.6 DARZALEX FASPRO® is the only subcutaneous CD38-directed antibody globally approved to treat patients with MM. DARZALEX FASPRO® is co-formulated with recombinant human hyaluronidase PH20 (rHuPH20), Halozyme's ENHANZE® drug delivery technology. In January 2021, DARZALEX FASPRO® became the first FDA-approved therapy for light chain amyloidosis. In August 2012, Janssen Biotech, Inc. entered into an exclusive global license and development agreement with Genmab A/S to develop, manufacture, and commercialize DARZALEX®.7 DARZALEX® has been approved in eight indications, three of which are in the frontline setting, including for newly diagnosed patients who are transplant eligible as well as those who are ineligible.8 DARZALEX® (daratumumab) is indicated for the treatment of adult patients with multiple myeloma: In combination with lenalidomide and dexamethasone in newly diagnosed patients who are ineligible for autologous stem cell transplant and in patients with relapsed or refractory multiple myeloma who have received at least one prior therapy In combination with bortezomib, melphalan, and prednisone in newly diagnosed patients who are ineligible for autologous stem cell transplant In combination with bortezomib, thalidomide, and dexamethasone in newly diagnosed patients who are eligible for autologous stem cell transplant In combination with bortezomib and dexamethasone in patients who have received at least one prior therapy In combination with carfilzomib and dexamethasone in patients with relapsed or refractory multiple myeloma who have received one to three prior lines of therapy In combination with pomalidomide and dexamethasone in patients who have received at least two prior therapies including lenalidomide and a proteasome inhibitor As monotherapy in patients who have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent DARZALEX FASPRO® (daratumumab and hyaluronidase-fihj) is indicated for the treatment of adult patients with multiple myeloma: In combination with bortezomib, melphalan, and prednisone in newly diagnosed patients who are ineligible for autologous stem cell transplant In combination with lenalidomide and dexamethasone in newly diagnosed patients who are ineligible for autologous stem cell transplant and in patients with relapsed or refractory multiple myeloma who have received at least one prior therapy In combination with bortezomib, thalidomide, and dexamethasone in newly diagnosed patients who are eligible for autologous stem cell transplant In combination with pomalidomide and dexamethasone in patients who have received at least one prior line of therapy including lenalidomide and a proteasome inhibitor In combination with bortezomib and dexamethasone in patients who have received at least one prior therapy As monotherapy in patients who have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent For more information, visit . About IMBRUVICA® IMBRUVICA® (ibrutinib) is a once-daily oral medication that is jointly developed and commercialized by Janssen Biotech, Inc. and Pharmacyclics LLC, an AbbVie company. IMBRUVICA® blocks the Bruton's tyrosine kinase (BTK) protein, which is needed by normal and abnormal B cells, including specific cancer cells, to multiply and spread. By blocking BTK, IMBRUVICA®may help move abnormal B cells out of their nourishing environments in the lymph nodes, bone marrow, and other organs.9,10,11 IMBRUVICA® is approved in more than 100 countries and has been used to treat more than 250,000 patients worldwide. There are more than 50 company-sponsored clinical trials, including 18 Phase 3 studies, over 11 years evaluating the efficacy and safety of IMBRUVICA®.12,13,14 IMBRUVICA® was first approved by the U.S. Food and Drug Administration (FDA) in November 2013, and today is indicated for adult patients in six disease areas, including five hematologic cancers. These include adults with CLL/small lymphocytic lymphoma (SLL) with or without 17p deletion (del17p) and adults with Waldenström's macroglobulinemia (WM), as well as adult patients with previously treated mantle cell lymphoma (MCL)*, adult patients with previously treated marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy* – and adult patients with previously treated chronic graft-versus-host disease (cGVHD) after failure of one or more lines of systemic therapy.13 *Accelerated approval was granted for relapsed/refractory (R/R) MCL and R/R MZL based on overall response rate. Continued approval for R/R MCL and R/R MZL may be contingent upon verification and description of clinical benefit in confirmatory trials. Since 2019, the National Comprehensive Cancer Network® (NCCN®), recommends ibrutinib (IMBRUVICA®) as a preferred regimen for the initial treatment of CLL/SLL and has Category 1 treatment status for treatment-naïve patients without deletion 17p. In 2020, the NCCN Guidelines were updated to recommend IMBRUVICA®, with or without rituximab, as a preferred regimen for the treatment of R/R MCL, and as a Category 1 preferred regimen for both untreated and previously treated WM patients. For more information, visit . About Nipocalimab Nipocalimab is a high affinity, fully human, aglycosylated, effectorless anti-FcRn IgG1 monoclonal antibody being studied for autoantibody-driven conditions including myasthenia gravis, hemolytic diseases of the fetus and newborn (HDFN), and warm autoimmune hemolytic anemia.15 Nipocalimab targets FcRn, which plays a central role in prolonging the half–life of IgG autoantibodies.16 Antagonism of this receptor reduces overall IgG autoantibody levels without widespread immune suppression. In 2019, nipocalimab received Fast Track Designation for wAIHA.17 In 2020, Johnson & Johnson acquired Momenta Pharmaceuticals, Inc., including full global rights to nipocalimab. DARZALEX® and DARZALEX FASPRO® IMPORTANT SAFETY INFORMATION DARZALEX® AND DARZALEX FASPRO®: CONTRAINDICATIONS DARZALEX® and DARZALEX FASPRO® are contraindicated in patients with a history of severe hypersensitivity to daratumumab, hyaluronidase (for DARZALEX FASPRO®), or any of the components of the formulations. DARZALEX®: Infusion-Related Reactions DARZALEX® can cause severe and/or serious infusion-related reactions including anaphylactic reactions. These reactions can be life-threatening, and fatal outcomes have been reported. In clinical trials (monotherapy and combination: N=2066), infusion-related reactions occurred in 37% of patients with the Week 1 (16 mg/kg) infusion, 2% with the Week 2 infusion, and cumulatively 6% with subsequent infusions. Less than 1% of patients had a Grade 3/4 infusion-related reaction at Week 2 or subsequent infusions. The median time to onset was 1.5 hours (range: 0 to 73 hours). Nearly all reactions occurred during infusion or within 4 hours of completing DARZALEX®. Severe reactions have occurred, including bronchospasm, hypoxia, dyspnea, hypertension, tachycardia, headache, laryngeal edema, and pulmonary edema. Signs and symptoms may include respiratory symptoms, such as nasal congestion, cough, throat irritation, as well as chills, vomiting, and nausea. Less common symptoms were wheezing, allergic rhinitis, pyrexia, chest discomfort, pruritus, and hypotension. When DARZALEX® dosing was interrupted in the setting of ASCT (CASSIOPEIA) for a median of 3.75 months (range: 2.4 to 6.9 months), upon re-initiation of DARZALEX®, the incidence of infusion-related reactions was 11% for the first infusion following ASCT. Infusion-related reactions occurring at re-initiation of DARZALEX® following ASCT were consistent in terms of symptoms and severity (Grade 3 or 4: <1%) with those reported in previous studies at Week 2 or subsequent infusions. In EQUULEUS, patients receiving combination treatment (n=97) were administered the first 16 mg/kg dose at Week 1 split over two days, ie, 8 mg/kg on Day 1 and Day 2, respectively. The incidence of any grade infusion-related reactions was 42%, with 36% of patients experiencing infusion-related reactions on Day 1 of Week 1, 4% on Day 2 of Week 1, and 8% with subsequent infusions. Pre-medicate patients with antihistamines, antipyretics, and corticosteroids. Frequently monitor patients during the entire infusion. Interrupt DARZALEX® infusion for reactions of any severity and institute medical management as needed. Permanently discontinue DARZALEX® therapy if an anaphylactic reaction or life-threatening (Grade 4) reaction occurs and institute appropriate emergency care. For patients with Grade 1, 2, or 3 reactions, reduce the infusion rate when re-starting the infusion. To reduce the risk of delayed infusion-related reactions, administer oral corticosteroids to all patients following DARZALEX® infusions. Patients with a history of chronic obstructive pulmonary disease may require additional post-infusion medications to manage respiratory complications. Consider prescribing short- and long-acting bronchodilators and inhaled corticosteroids for patients with chronic obstructive pulmonary disease. DARZALEX FASPRO®: Hypersensitivity and Other Administration Reactions Both systemic administration-related reactions, including severe or life-threatening reactions, and local injection-site reactions can occur with DARZALEX FASPRO®. Fatal reactions have been reported with daratumumab-containing products, including DARZALEX FASPRO®. Systemic Reactions In a pooled safety population of 832 patients with multiple myeloma (N=639) or light chain (AL) amyloidosis (N=193) who received DARZALEX FASPRO® as monotherapy or in combination, 9% of patients experienced a systemic administration-related reaction (Grade 2: 3.5%, Grade 3: 0.8%). Systemic administration-related reactions occurred in 8% of patients with the first injection, 0.4% with the second injection, and cumulatively 1% with subsequent injections. The median time to onset was 3.2 hours (range: 9 minutes to 3.5 days). Of the 129 systemic administration-related reactions that occurred in 74 patients, 110 (85%) occurred on the day of DARZALEX FASPRO® administration. Delayed systemic administration-related reactions have occurred in 1% of the patients. Severe reactions included hypoxia, dyspnea, hypertension, and tachycardia. Other signs and symptoms of systemic administration-related reactions may include respiratory symptoms, such as bronchospasm, nasal congestion, cough, throat irritation, allergic rhinitis, and wheezing, as well as anaphylactic reaction, pyrexia, chest pain, pruritus, chills, vomiting, nausea, and hypotension. Pre-medicate patients with histamine-1 receptor antagonist, acetaminophen, and corticosteroids. Monitor patients for systemic administration-related reactions, especially following the first and second injections. For anaphylactic reaction or life-threatening (Grade 4) administration-related reactions, immediately and permanently discontinue DARZALEX FASPRO®. Consider administering corticosteroids and other medications after the administration of DARZALEX FASPRO® depending on dosing regimen and medical history to minimize the risk of delayed (defined as occurring the day after administration) systemic administration-related reactions. Local Reactions In this pooled safety population, injection-site reactions occurred in 8% of patients, including Grade 2 reactions in 0.6%. The most frequent (>1%) injection-site reaction was injection-site erythema. These local reactions occurred a median of 5.5 minutes (range: 0 minutes to 6.5 days) after starting administration of DARZALEX FASPRO®. Monitor for local reactions and consider symptomatic management. DARZALEX® and DARZALEX FASPRO®: Neutropenia and Thrombocytopenia DARZALEX® and DARZALEX FASPRO® may increase neutropenia and thrombocytopenia induced by background therapy. Monitor complete blood cell counts periodically during treatment according to manufacturer's prescribing information for background therapies. Monitor patients with neutropenia for signs of infection. Consider withholding DARZALEX® or DARZALEX FASPRO® until recovery of neutrophils or for recovery of platelets. In lower body weight patients receiving DARZALEX FASPRO®, higher rates of Grade 3-4 neutropenia were observed. DARZALEX® and DARZALEX FASPRO®: Interference With Serological Testing Daratumumab binds to CD38 on red blood cells (RBCs) and results in a positive indirect antiglobulin test (indirect Coombs test). Daratumumab-mediated positive indirect antiglobulin test may persist for up to 6 months after the last daratumumab administration. Daratumumab bound to RBCs masks detection of antibodies to minor antigens in the patient's serum. The determination of a patient's ABO and Rh blood type are not impacted. Notify blood transfusion centers of this interference with serological testing and inform blood banks that a patient has received DARZALEX® and DARZALEX FASPRO®. Type and screen patients prior to starting DARZALEX® and DARZALEX FASPRO®. DARZALEX® and DARZALEX FASPRO®: Interference With Determination of Complete Response Daratumumab is a human immunoglobulin G (IgG) kappa monoclonal antibody that can be detected on both the serum protein electrophoresis (SPE) and immunofixation (IFE) assays used for the clinical monitoring of endogenous M-protein. This interference can impact the determination of complete response and of disease progression in some patients with IgG kappa myeloma protein. DARZALEX® and DARZALEX FASPRO®: Embryo-Fetal Toxicity Based on the mechanism of action, DARZALEX® and DARZALEX FASPRO® can cause fetal harm when administered to a pregnant woman. DARZALEX® and DARZALEX FASPRO® may cause depletion of fetal immune cells and decreased bone density. Advise pregnant women of the potential risk to a fetus. Advise females with reproductive potential to use effective contraception during treatment with DARZALEX® or DARZALEX FASPRO® and for 3 months after the last dose. The combination of DARZALEX® or DARZALEX FASPRO® with lenalidomide, pomalidomide, or thalidomide is contraindicated in pregnant women because lenalidomide, pomalidomide, and thalidomide may cause birth defects and death of the unborn child. Refer to the lenalidomide, pomalidomide, or thalidomide prescribing information on use during pregnancy. DARZALEX®: ADVERSE REACTIONS The most frequently reported adverse reactions (incidence ≥20%) were: upper respiratory infection, neutropenia, infusion-related reactions, thrombocytopenia, diarrhea, constipation, anemia, peripheral sensory neuropathy, fatigue, peripheral edema, nausea, cough, pyrexia, dyspnea, and asthenia. The most common hematologic laboratory abnormalities (≥40%) with DARZALEX® are: neutropenia, lymphopenia, thrombocytopenia, leukopenia, and anemia. DARZALEX FASPRO®: ADVERSE REACTIONS In multiple myeloma, the most common adverse reaction (≥20%) with DARZALEX FASPRO® monotherapy is upper respiratory tract infection. The most common adverse reactions with combination therapy (≥20% for any combination) include fatigue, nausea, diarrhea, dyspnea, insomnia, pyrexia, cough, muscle spasms, back pain, vomiting, upper respiratory tract infection, peripheral sensory neuropathy, constipation, and pneumonia. The most common hematologic laboratory abnormalities (≥40%) with DARZALEX FASPRO® are decreased leukocytes, decreased lymphocytes, decreased neutrophils, decreased platelets, and decreased hemoglobin. IMBRUVICA® IMPORTANT SAFETY INFORMATION Warnings and Precautions Hemorrhage: Fatal bleeding events have occurred in patients who received IMBRUVICA®. Major hemorrhage (≥ Grade 3, serious, or any central nervous system events; e.g., intracranial hemorrhage [including subdural hematoma], gastrointestinal bleeding, hematuria, and post procedural hemorrhage) occurred in 4% of patients, with fatalities occurring in 0.4% of 2,838 patients who received IMBRUVICA® in 27 clinical trials. Bleeding events of any grade including bruising and petechiae occurred in 39%, and excluding bruising and petechiae occurred in 23% of patients who received IMBRUVICA®, respectively. The mechanism for the bleeding events is not well understood. Use of either anticoagulant or antiplatelet agents concomitantly with IMBRUVICA® increases the risk of major hemorrhage. Across clinical trials, 3.1% of 2,838 patients who received IMBRUVICA® without antiplatelet or anticoagulant therapy experienced major hemorrhage. The addition of antiplatelet therapy with or without anticoagulant therapy increased this percentage to 4.4%, and the addition of anticoagulant therapy with or without antiplatelet therapy increased this percentage to 6.1%. Consider the risks and benefits of anticoagulant or antiplatelet therapy when co-administered with IMBRUVICA®. Monitor for signs and symptoms of bleeding. Consider the benefit-risk of withholding IMBRUVICA® for at least 3 to 7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding. Infections: Fatal and non-fatal infections (including bacterial, viral, or fungal) have occurred with IMBRUVICA® therapy. Grade 3 or greater infections occurred in 21% of 1,476 patients who received IMBRUVICA® in clinical trials. Cases of progressive multifocal leukoencephalopathy (PML) and Pneumocystis jirovecii pneumonia (PJP) have occurred in patients treated with IMBRUVICA®. Consider prophylaxis according to standard of care in patients who are at increased risk for opportunistic infections. Monitor and evaluate patients for fever and infections and treat appropriately. Cytopenias: In 645 patients with B-cell malignancies who received IMBRUVICA® as a single agent, Grade 3 or 4 neutropenia occurred in 23% of patients, Grade 3 or 4 thrombocytopenia in 8% and Grade 3 or 4 anemia in 3%, based on laboratory measurements. Monitor complete blood counts monthly. Cardiac Arrhythmias and Cardiac Failure: Fatal and serious cardiac arrhythmias and cardiac failure have occurred with IMBRUVICA®. Grade 3 or greater ventricular tachyarrhythmias occurred in 0.2% of patients, Grade 3 or greater atrial fibrillation and atrial flutter occurred in 4%, and Grade 3 or greater cardiac failure occurred in 1% of 1,476 patients who received IMBRUVICA® in clinical trials. These events have occurred particularly in patients with cardiac risk factors, hypertension, acute infections, and a previous history of cardiac arrhythmias. At baseline and then periodically, monitor patients clinically for cardiac arrhythmias and cardiac failure. Obtain an ECG for patients who develop arrhythmic symptoms (e.g., palpitations, lightheadedness, syncope, chest pain) or new onset dyspnea. Manage cardiac arrhythmias and cardiac failure appropriately, and if it persists, consider the risks and benefits of IMBRUVICA® treatment and follow dose modification guidelines. Hypertension: Hypertension occurred in 19% of 1,476 patients who received IMBRUVICA® in clinical trials. Grade 3 or greater hypertension occurred in 8% of patients. Based on data from 1,124 of these patients, the median time to onset was 5.9 months (range, 0.03 to 24 months). Monitor blood pressure in patients treated with IMBRUVICA® and initiate or adjust anti-hypertensive medication throughout treatment with IMBRUVICA® as appropriate. Second Primary Malignancies: Other malignancies (10%), including non-skin carcinomas (4%), occurred among the 1,476 patients who received IMBRUVICA® in clinical trials. The most frequent second primary malignancy was non-melanoma skin cancer (6%). Tumor Lysis Syndrome: Tumor lysis syndrome has been infrequently reported with IMBRUVICA®. Assess the baseline risk (e.g., high tumor burden) and take appropriate precautions. Monitor patients closely and treat as appropriate. Embryo-Fetal Toxicity: Based on findings in animals, IMBRUVICA® can cause fetal harm when administered to a pregnant woman. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with IMBRUVICA® and for 1 month after the last dose. Advise males with female partners of reproductive potential to use effective contraception during the same time period. ADVERSE REACTIONS B-cell malignancies: The most common adverse reactions (≥30%) in patients with B-cell malignancies (MCL, CLL/SLL, WM and MZL) were thrombocytopenia (54.5%)*, diarrhea (43.8%), fatigue (39.1%), musculoskeletal pain (38.8%), neutropenia (38.6%)*, rash (35.8%), anemia (35.0%)*, and bruising (32.0%). The most common Grade ≥3 adverse reactions (≥5%) in patients with B-cell malignancies (MCL, CLL/SLL, WM and MZL) were neutropenia (20.7%)*, thrombocytopenia (13.6%)*, pneumonia (8.2%), and hypertension (8.0%). Approximately 9% (CLL/SLL), 14% (MCL), 14% (WM) and 10% (MZL) of patients had a dose reduction due to adverse reactions. Approximately 4-10% (CLL/SLL), 9% (MCL), and 7% (WM [5%] and MZL [13%]) of patients discontinued due to adverse reactions. cGVHD: The most common adverse reactions (≥20%) in patients with cGVHD were fatigue (57%), bruising (40%), diarrhea (36%), thrombocytopenia (33%)*, muscle spasms (29%), stomatitis (29%), nausea (26%), hemorrhage (26%), anemia (24%)*, and pneumonia (21%). The most common Grade 3 or higher adverse reactions (≥5%) reported in patients with cGVHD were pneumonia (14%), fatigue (12%), diarrhea (10%), neutropenia (10%)*, sepsis (10%), hypokalemia (7%), headache (5%), musculoskeletal pain (5%), and pyrexia (5%). Twenty-four percent of patients receiving IMBRUVICA® in the cGVHD trial discontinued treatment due to adverse reactions. Adverse reactions leading to dose reduction occurred in 26% of patients. *Treatment-emergent decreases (all grades) were based on laboratory measurements. DRUG INTERACTIONS CYP3A Inhibitors: Co-administration of IMBRUVICA® with strong or moderate CYP3A inhibitors may increase ibrutinib plasma concentrations. Dose modifications of IMBRUVICA® may be recommended when used concomitantly with posaconazole, voriconazole, and moderate CYP3A inhibitors. Avoid concomitant use of other strong CYP3A inhibitors. Interrupt IMBRUVICA® if strong inhibitors are used short-term (e.g., for ≤7 days). See dose modification guidelines in USPI sections 2.3 and 7.1. CYP3A Inducers: Avoid coadministration with strong CYP3A inducers. SPECIFIC POPULATIONS Hepatic Impairment (based on Child-Pugh criteria): Avoid use of IMBRUVICA® in patients with severe hepatic impairment. In patients with mild or moderate impairment, reduce recommended IMBRUVICA® dose and monitor more frequently for adverse reactions of IMBRUVICA®. Please see full Prescribing Information. INDICATIONS IMBRUVICA® (ibrutinib) is a kinase inhibitor indicated for the treatment of adult patients with: Mantle cell lymphoma (MCL) who have received at least one prior therapy. This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s). Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL). Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL) with 17p deletion. Waldenström's macroglobulinemia (WM). Marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy. This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s). Chronic graft versus host disease (cGVHD) after failure of one or more lines of systemic therapy. XARELTO® IMPORTANT SAFETY INFORMATION XARELTO® may cause serious side effects, including: Increased risk of blood clots if you stop taking XARELTO®. People with atrial fibrillation (an irregular heart beat) that is not caused by a heart valve problem (nonvalvular) are at an increased risk of forming a blood clot in the heart, which can travel to the brain, causing a stroke, or to other parts of the body. XARELTO® lowers your chance of having a stroke by helping to prevent clots from forming. If you stop taking XARELTO®, you may have increased risk of forming a clot in your blood. Do not stop taking XARELTO® without talking to the doctor who prescribes it for you. Stopping XARELTO® increases your risk of having a stroke. If you have to stop taking XARELTO®, your doctor may prescribe another blood thinner medicine to prevent a blood clot from forming. Increased risk of bleeding. XARELTO® can cause bleeding which can be serious, and may lead to death. This is because XARELTO® is a blood thinner medicine (anticoagulant) that lowers blood clotting. During treatment with XARELTO® you are likely to bruise more easily, and it may take longer for bleeding to stop. You may be at higher risk of bleeding if you take XARELTO® and have certain other medical problems. You may have a higher risk of bleeding if you take XARELTO® and take other medicines that increase your risk of bleeding, including: Aspirin or aspirin-containing products Long-term (chronic) use of non-steroidal anti-inflammatory drugs (NSAIDs) Warfarin sodium (Coumadin®, Jantoven®) Any medicine that contains heparin Clopidogrel (Plavix®) Selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) Other medicines to prevent or treat blood clots Tell your doctor if you take any of these medicines. Ask your doctor or pharmacist if you are not sure if your medicine is one listed above. Call your doctor or get medical help right away if you develop any of these signs or symptoms of bleeding: Unexpected bleeding or bleeding that lasts a long time, such as: Nosebleeds that happen often Unusual bleeding from gums Menstrual bleeding that is heavier than normal, or vaginal bleeding Bleeding that is severe or you cannot control Red, pink, or brown urine Bright red or black stools (looks like tar) Cough up blood or blood clots Vomit blood or your vomit looks like "coffee grounds" Headaches, feeling dizzy or weak Pain, swelling, or new drainage at wound sites Spinal or epidural blood clots (hematoma). People who take a blood thinner medicine (anticoagulant) like XARELTO®, and have medicine injected into their spinal and epidural area, or have a spinal puncture, have a risk of forming a blood clot that can cause long-term or permanent loss of the ability to move (paralysis). Your risk of developing a spinal or epidural blood clot is higher if: A thin tube called an epidural catheter is placed in your back to give you certain medicine You take NSAIDs or a medicine to prevent blood from clotting You have a history of difficult or repeated epidural or spinal punctures You have a history of problems with your spine or have had surgery on your spine If you take XARELTO® and receive spinal anesthesia or have a spinal puncture, your doctor should watch you closely for symptoms of spinal or epidural blood clots. Tell your doctor right away if you have: back pain tingling numbness muscle weakness (especially in your legs and feet) or loss of control of the bowels or bladder (incontinence) XARELTO® is not for use in people with artificial heart valves. XARELTO® is not for use in people with antiphospholipid syndrome (APS), especially with positive triple antibody testing. Do not take XARELTO® if you: Currently have certain types of abnormal bleeding. Talk to your doctor before taking XARELTO® if you currently have unusual bleeding. Are allergic to rivaroxaban or any of the ingredients of XARELTO®. Before taking XARELTO®, tell your doctor about all your medical conditions, including if you: Have ever had bleeding problems Have liver or kidney problems Have antiphospholipid syndrome (APS) Are pregnant or plan to become pregnant. It is not known if XARELTO® will harm your unborn baby. Tell your doctor right away if you become pregnant during treatment with XARELTO®. Taking XARELTO® while you are pregnant may increase the risk of bleeding in you or in your unborn baby. If you take XARELTO® during pregnancy, tell your doctor right away if you have any signs or symptoms of bleeding or blood loss. See "What is the most important information I should know about XARELTO®?" for signs and symptoms of bleeding. Are breastfeeding or plan to breastfeed. XARELTO® may pass into your breast milk. Talk to your doctor about the best way to feed your baby during treatment with XARELTO®. Tell all of your doctors and dentists that you are taking XARELTO®. They should talk to the doctor who prescribed XARELTO® for you before you have any surgery, medical or dental procedure. Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some of your other medicines may affect the way XARELTO® works, causing side effects. Certain medicines may increase your risk of bleeding. See "What is the most important information I should know about XARELTO®?" HOW SHOULD I TAKE XARELTO®? Take XARELTO® exactly as prescribed by your doctor. Do not change your dose or stop taking XARELTO® unless your doctor tells you to. Your doctor may change your dose if needed. Your doctor will decide how long you should take XARELTO®. XARELTO® may need to be stopped for one or more days before any surgery or medical or dental procedure. Your doctor will tell you when to stop taking XARELTO® and when to start taking XARELTO® again after your surgery or procedure. If you need to stop taking XARELTO® for any reason, talk to the doctor who prescribed XARELTO® to you to find out when you should stop taking it. Do not stop taking XARELTO® without first talking to the doctor who prescribes it to you. If you have difficulty swallowing XARELTO® tablets whole, talk to your doctor about other ways to take XARELTO®. Do not run out of XARELTO®. Refill your prescription of XARELTO® before you run out. When leaving the hospital following a hip or knee replacement, be sure that you will have XARELTO® available to avoid missing any doses. If you take too much XARELTO®, go to the nearest hospital emergency room or call your doctor right away. If you take XARELTO® for: Atrial Fibrillation that is not caused by a heart valve problem: Take XARELTO® 1 time a day with your evening meal. If you miss a dose of XARELTO®, take it as soon as you remember on the same day. Take your next dose at your regularly scheduled time. Blood clots in the veins of your legs or lungs: Take XARELTO® 1 or 2 times a day as prescribed by your doctor. For the 10-mg dose, XARELTO® may be taken with or without food. For the 15-mg and 20-mg doses, take XARELTO® with food at the same time each day. If you miss a dose: If you take the 15-mg dose of XARELTO® 2 times a day (a total of 30 mg of XARELTO® in 1 day): Take XARELTO® as soon as you remember on the same day. You may take 2 doses at the same time to make up for the missed dose. Take your next dose at your regularly scheduled time. If you take XARELTO® 1 time a day: Take XARELTO® as soon as you remember on the same day. Take your next dose at your regularly scheduled time. Hip or knee replacement surgery: Take XARELTO® 1 time a day with or without food. If you miss a dose of XARELTO®, take it as soon as you remember on the same day. Take your next dose at your regularly scheduled time. Blood clots in people hospitalized for an acute illness: Take XARELTO® 1 time a day, with or without food, while you are in the hospital and after you are discharged as prescribed by your doctor. If you miss a dose of XARELTO®, take it as soon as you remember on the same day. Take your next dose at your regularly scheduled time. Reducing the risk of serious heart problems, heart attack and stroke in coronary artery disease: Take XARELTO® 2.5 mg 2 times a day with or without food. If you miss a dose of XARELTO®, take your next dose at your regularly scheduled time. Take aspirin 75 to 100 mg once daily as instructed by your doctor. Reducing the risk of a sudden decrease in blood flow to the legs, major amputation, serious heart problems or stroke in people with peripheral artery disease, including those who have recently had a procedure to improve blood flow to the legs: Take XARELTO® 2.5 mg 2 times a day with or without food. If you miss a dose of XARELTO®, take your next dose at your regularly scheduled time. Take aspirin 75 to 100 mg once daily as instructed by your doctor. WHAT ARE THE POSSIBLE SIDE EFFECTS OF XARELTO®? XARELTO® may cause serious side effects: See "What is the most important information I should know about XARELTO®?" The most common side effect of XARELTO® was bleeding. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. You may also report side effects to Janssen Pharmaceuticals, Inc., at 1-800-JANSSEN (1-800-526-7736). Please read full Prescribing Information, including Boxed Warnings, and Medication Guide for XARELTO®. About the Janssen Pharmaceutical Companies of Johnson & Johnson At Janssen, we're creating a future where disease is a thing of the past. We're the Pharmaceutical Companies of Johnson & Johnson, working tirelessly to make that future a reality for patients everywhere by fighting sickness with science, improving access with ingenuity, and healing hopelessness with heart. We focus on areas of medicine where we can make the biggest difference: Cardiovascular & Metabolism, Immunology, Infectious Diseases & Vaccines, Neuroscience, Oncology, and Pulmonary Hypertension. Learn more at . Follow us at and . Janssen Research & Development, LLC and Janssen Biotech, Inc. are part of the Janssen Pharmaceutical Companies of Johnson & Johnson. Cautions Concerning Forward-Looking Statements This press release contains "forward-looking statements" as defined in the Private Securities Litigation Reform Act of 1995 regarding development of teclistamab, talquetamab, cilta-cel (BCMA CAR-T), DARZALEX® (daratumumab), DARZALEX FASRO® (daratumumab and hyaluronidase-fihj), IMBRUVICA® (ibrutinib), XARELTO® (rivaroxaban), and nipocalimab. The reader is cautioned not to rely on these forward-looking statements. These statements are based on current expectations of future events. If underlying assumptions prove inaccurate or known or unknown risks or uncertainties materialize, actual results could vary materially from the expectations and projections of Janssen Research & Development, LLC, Janssen Biotech, Inc., any of the other Janssen Pharmaceutical Companies and/or Johnson & Johnson. Risks and uncertainties include, but are not limited to: challenges and uncertainties inherent in product research and development, including the uncertainty of clinical success and of obtaining regulatory approvals; uncertainty of commercial success; manufacturing difficulties and delays; competition, including technological advances, new products and patents attained by competitors; challenges to patents; [product efficacy or safety concerns resulting in product recalls or regulatory action;] changes in behavior and spending patterns of purchasers of health care products and services; changes to applicable laws and regulations, including global health care reforms; and trends toward health care cost containment. A further list and descriptions of these risks, uncertainties and other factors can be found in Johnson & Johnson's Annual Report on Form 10-K for the fiscal year ended January 3, 2021, including in the sections captioned "Cautionary Note Regarding Forward-Looking Statements" and "Item 1A. Risk Factors," and in the company's most recently filed Quarterly Report on Form 10-Q, and the company's subsequent filings with the Securities and Exchange Commission. Copies of these filings are available online at , or on request from Johnson & Johnson. None of the Janssen Pharmaceutical Companies nor Johnson & Johnson undertakes to update any forward-looking statement as a result of new information or future events or developments. Investor Relations: Jennifer McIntyre (732) 524-3922 U.S. Medical Inquiries: +1 800-526-7736