Botulinum Toxin Type B

// 颜究方法 关键总结点 免疫原是许多生物药物(包括用于治疗应用的肉毒毒素)常见的临床障碍；重复使用可能导致产生中和抗体，从而可能影响治疗结果。 降低生物药物免疫原性和中和抗体发生率的常见策略包括设计更小的蛋白质和减少污染物或不必要的制剂成分。 对于用于治疗应用的肉毒神经毒素制剂，incobotulinumtoxinA是纯度最高的；临床前和临床数据表明，与其他制剂相比，其免疫原性降低。 慢性疾病患者的BoNT治疗通常是终身的；因此，在制定关于BoNT制剂的治疗决策时，应考虑免疫原性的可能性和减少中和抗体产生的风险。 肉毒神经毒素注射用于管理多种适应症和美容应用中的慢性疾病，包括缓解眼睑痉挛、颈肌张力障碍、各种类型的局灶性肌肉痉挛以及暂时改善动态面部皱纹。BoNT在慢性疾病中的治疗应用可能是终身的，并且鉴于BoNT的细菌来源，重复暴露可引发抗体形成，导致临床无反应。长期使用某些BoNT制剂治疗后出现免疫原性的报道日益增多，其结果因诊断、BoNT制剂、既往BoNT治疗、神经毒素复合物蛋白负荷、单次注射剂量、治疗持续时间和再次注射间隔长度等因素而异。 全球许多国家批准了多种BoNT用于临床；第一代BoNT制剂包含核心神经毒素加上辅助的梭菌复合蛋白，而第二代BoNT由于在纯化过程中去除了这些辅助梭菌蛋白，因此不含这些蛋白。这些BoNT制剂与中和抗体(结合BoNT并可能降低疗效或临床反应持续时间的抗体)的不同发生率相关。此外，FDA已发布关于评估治疗性蛋白质产品免疫原性的指导文件，并推荐采用“基于风险的方法来评估和减轻与治疗性蛋白质产品相关的免疫反应或不良免疫相关反应”。这些新兴的证据和当前的指南强调了在处理慢性疾病时，采用能够最小化免疫反应并最大化患者反应性的方案进行BoNT治疗的重要性。 在这篇综述中，我们描述了免疫原性作为生物疗法疗效的潜在临床障碍的基础科学及其对BoNT制剂演变的影响。我们总结了与不同BoNT制剂相关的免疫原性和临床无反应的现有非临床和临床证据，并讨论了第二代BoNT制剂(incobotulinumtoxinA)是否具有较低的免疫原性风险。最后，我们讨论了解决当前知识空白的研究领域，并提供了一个从免疫学角度考虑将免疫原性作为选择BoNT制剂的因素的视角。 1 颜究方法 免疫原性与生物药物的临床局限性 免疫原是任何分子(包括外源蛋白质或生物药物)引发宿主免疫反应的能力。任何生物药物，如重组治疗性蛋白质、基因治疗载体或疫苗，都有可能成为免疫系统的靶点，特别是在重复给药或高剂量给药时。例如，基于蛋白质的疫苗旨在触发适应性免疫并产生针对潜在病原体的特异性抗体以发挥其作用。然而，当抗药物抗体的产生或其他免疫过程导致生物药物的治疗效力丧失时，免疫原性是不受欢迎的，这可通过直接中和以及药代动力学改变而发生。 对生物药物的免疫原性反应 生物制剂的识别和免疫反应的诱导由一个免疫细胞网络介导，包括抗原呈递细胞、T细胞和B细胞(图1)。 树突状细胞是一种抗原呈递细胞，通过多种细胞表面受体(包括Toll样受体、Fc受体和C型凝集素家族成员)捕获外源蛋白质(如生物制剂)来吞噬它们。树突状细胞随后可以处理捕获的生物制剂，并通过主要组织相容性复合体将肽片段展示在细胞表面。肽-MHC复合物被呈递给T细胞并被其识别，T细胞反过来可以刺激B细胞产生抗原特异性抗体。 T细胞的活化还取决于共刺激分子(包括细胞因子)的存在和结合，这些分子在抗原呈递细胞通过表面受体(如TLR)刺激而被激活时产生。随后的B细胞活化和扩增可通过记忆B细胞或浆细胞导致长期且大量地产生抗体，这是适应性免疫的标志。 此外，针对生物制剂的抗体可以通过非T细胞依赖性途径产生，其中生物制剂的聚集体可以直接结合并刺激B细胞产生抗体。通过T细胞依赖性途径或非T细胞依赖性途径产生的部分抗体是中和抗体，可以抑制生物制剂的活性并使其治疗效果无效。 图1：对生物药物的免疫原性反应。树突状细胞吞噬结合到各种细胞表面受体的生物制剂。生物制剂被处理并通过主要组织相容性复合体作为肽片段呈现在细胞表面。肽-MHC复合物被呈递给T细胞并被其识别，T细胞刺激B细胞克隆性扩增并产生抗原特异性抗体。共刺激分子(如细胞因子)对于T细胞的完全活化是必需的。随后B细胞的扩增导致长期且大量地产生抗体。TCR，T细胞受体。 免疫原性可能受几个关键因素影响，包括分子量、结构复杂性、翻译后修饰和氨基酸序列特征。然而，较小的分子本身可能不具有免疫原性，但它们可以与较大的内源性蛋白质结合并被免疫系统识别，导致树突状细胞活化和适应性免疫反应。形成大聚集体的生物制剂也可能能够与B细胞相互作用并激活B细胞。此外，生物制剂配方的其他成分，如赋形剂(例如表面活性剂)和污染物(例如宿主细胞蛋白，包括细菌鞭毛蛋白)，可能因非预期的佐剂效应而刺激免疫系统并导致针对生物制剂的中和抗体增加。这种佐剂效应被认为是通过TLR5暴露于鞭毛蛋白后引发先天免疫反应。 在适应性免疫反应初始启动后，重复暴露于抗原可能导致更快和更强的反应。在生物药物治疗(包括BoNT治疗)的情况下，重复的临床暴露可能潜在地引发持续的免疫反应和中和抗体的形成，导致一系列临床无反应结果。临床耐药性的常见体征包括为获得效果而增加给药频率或剂量、完全无反应和部分无反应(图2)。 图2：免疫原性驱动临床无反应。重复临床暴露于生物药物可引发持续的免疫反应和中和抗体的形成，导致临床耐药性。临床耐药性的常见体征包括为获得效果而增加给药频率或剂量。随着时间的推移，这可能导致临床无反应。nAb，中和抗体。 生物药物免疫原性的临床挑战 生物药物已经彻底改变了医学各个领域许多疾病的治疗。然而，免疫原性是许多生物疗法使用相关的关键临床挑战。在多个治疗领域中观察到中和抗体和针对制剂污染物的抗体的形成，包括法布里病、类风湿性关节炎、胰岛素依赖型糖尿病和哮喘等(也见于炎症性肠病、银屑病和银屑病关节炎)。 免疫原是许多生物药物治疗中常见的临床障碍，并且它影响了多种疾病状态下生物治疗的演变。一些降低一般免疫原性和中和抗体发生率的常见策略包括设计更小的蛋白质和减少污染物或不必要的制剂成分。这些通用主题可以帮助理解BoNT治疗的免疫原性。 2 颜究方法 肉毒神经毒素生物治疗的免疫原性与演变 肉毒神经毒素的结构与功能 BoNTs是由梭菌属细菌产生的蛋白质，经口摄入后会引起神经麻痹综合征--肉毒中毒。有七种BoNT血清型(A-G型)，具有不同的毒性但结构相似。在所有血清型中，细菌复合物由一个约150kDa的核心神经毒素和一组相关的辅助蛋白组成(图3A,B)。这些辅助蛋白组装成一个超分子结构，支持双重功能：在经口摄入时保护核心神经毒素免受低pH条件的影响，并促进胃肠道吸收。 图3：A，超分子复合物；B，纯化核心神经毒素中A型肉毒神经毒素的分子结构。A，BoNT-A是由血凝素蛋白、一个非毒性非血凝素蛋白和核心神经毒素组成的超分子复合物，由梭菌产生的分子量高达约900kDa。此处显示的结构模型(代表约760kDa)是使用重组蛋白和冷冻电子显微镜确定的，并且是目前可获得三维结构信息的最大的组装体。B，纯化的BoNT-A制剂仅包含核心神经毒素(约150kDa)。BoNT-A，A型肉毒神经毒素。 在低pH条件下，核心神经毒素被一个非毒性非血凝素蛋白和一个血凝素蛋白复合物包围。约140kDa的NTNH蛋白在保护BoNT免受胃蛋白酶消化和低pH降解方面起着关键作用。然而，在小肠的中性pH环境下，NTNH蛋白的“pH传感器”残基诱导构象变化，释放核心神经毒素。HA蛋白(HA1、HA2和HA3)介导细胞表面结合和跨肠上皮易位。NTNH蛋白、核心神经毒素和HA复合物组装形成最终的超分子结构。 核心神经毒素本身由一个重链(100kDa)和一个轻链(50kDa)通过二硫键连接而成。 重链的作用是结合神经肌肉接头处的突触前胆碱能末梢，进入细胞并介导解离的轻链易位到细胞质。 轻链是一种锌金属蛋白酶，可切割特定的可溶性N-乙基马来酰亚胺敏感因子附着蛋白受体靶蛋白，阻止囊泡融合和随后的乙酰胆碱释放，导致弛缓性麻痹。 七种BoNT血清型通过切割SNARE复合物的不同组分来实现这一效果。 BoNT-A和BoNT-E切割突触体相关蛋白25；BoNT-B、BoNT-D、BoNT-F和BoNT-G切割突触小泡蛋白； BoNT-C同时切割SNAP-25和syntaxin。 阻断乙酰胆碱释放是治疗性BoNT制剂的作用机制，BoNT-A和BoNT-B是目前临床使用的肉毒毒素血清型。 BoNT制剂的免疫原性与演变：非临床数据 与其他生物药物一样，BoNT核心神经毒素和相关的辅助蛋白都有可能具有免疫原性。解毒的BoNT提取物和无催化活性的BoNT蛋白多年来一直被用于开发抗肉毒中毒疫苗。接种这些疫苗会导致产生能够中和BoNT毒性作用的抗体。例如，靶向核心神经毒素并成功抑制其神经元结合、摄取或催化活性的抗体可能具有中和作用。 辅助蛋白的免疫原性 BoNT制剂中的辅助蛋白具有非治疗性作用，并且会迅速在中性pH条件下与核心神经毒素解离。因此，总的梭菌蛋白负荷(包括辅助蛋白和核心神经毒素)和组成可能决定每种BoNT制剂的相对免疫原性。 有证据表明，辅助梭菌蛋白，特别是HA-1，可作为免疫反应的佐剂，并且这种免疫系统的激活可以促进针对BoNT核心神经毒素的治疗相关中和抗体的产生。在小鼠中，单独注射BoNT复合物的核心神经毒素具有低免疫原性。相反，当同时注射HA蛋白(尤其是HA-1和HA-3b)时，抗体产生显著增加。此外，用完整的灭活BoNT复合物免疫兔子，与单独用核心神经毒素诱导的抗体相比，会产生具有更强中和效果的抗体。这些数据支持辅助蛋白的佐剂效应，因为注射是在BoNT复合物会解离的中性pH缓冲液中进行的。 此外，辅助蛋白可能诱导其他免疫介导的效应。体外试验表明，在BoNT辅助蛋白存在下，神经元细胞会增加炎症细胞因子(如IL-6和TNF-α)的产生。辅助蛋白还结合多种非神经元细胞类型，包括成纤维细胞、淋巴母细胞和骨骼肌细胞。相比之下，核心神经毒素不与非神经元细胞类型结合，也不诱导细胞因子释放。 根据现有的临床前数据，希望使用含有尽可能少梭菌蛋白的BoNT制剂，因为这可能避免刺激宿主免疫反应导致中和抗体形成和临床无反应。三种BoNT-A产品已获得FDA批准用于治疗用途：onabotulinumtoxinA(Botox)、abobotulinumtoxinA(Dysport)和incobotulinumtoxinA(Xeomin)；第四种BoNT-A产品daxibotulinumtoxinA(Daxxify)目前正在针对非治疗性适应症接受监管审查。这些产品在辅助蛋白数量和赋形剂(例如白蛋白；表1)方面有所不同。PrabotulinumtoxinA是一种BoNT-A产品，仅被研究和批准用于治疗眉间纹，未纳入我们关于治疗应用的讨论。此外，一种BoNT-B制剂rimabotulinumtoxinB(Myobloc)已获FDA批准，含有核心神经毒素和辅助蛋白。这些BoNT制剂的不同蛋白负荷、赋形剂和其他特性可能影响其免疫原性潜力。 表1.当前第一代和第二代BoNT-A制剂的特性 BoNT，肉毒神经毒素；FDA，美国食品药品监督管理局；HSA，人血清白蛋白；MU，小鼠单位；NA，不适用；NaCl，氯化钠。 a第一代BoNT-A制剂含有核心神经毒素和辅助肉毒蛋白；仅展示了获批或正在研究用于治疗应用的制剂。 b第二代BoNT-A制剂仅含有治疗性神经毒素，不含辅助蛋白或其他细菌物质(如鞭毛蛋白)。 c目前正在接受FDA审查；制剂的完整细节尚未公布。 d制剂是多种分子量的混合物，其中300和500kDa最常见。 e无活性神经毒素的数值是近似值。 含有辅助蛋白的BoNT-A制剂 OnabotulinumtoxinA是首个于1989年获得FDA批准的BoNT-A制剂。最初的制剂含有很大比例的无活性核心神经毒素加上梭菌蛋白，高达17%的患者产生了抗BoNT抗体。1997年，生产了一种含有减少量无活性神经毒素的、免疫原性较低的制剂(图4A)。目前，onaBoNT-A含有0.73ng核心神经毒素蛋白(活性蛋白和无活性/变性类毒素的混合物)和约4.3ng的额外辅助蛋白(图4，表1)。 图4：BoNT-A制剂中的总梭菌蛋白和活性核心神经毒素。A，onaBoNT-A、aboBoNT-A和incoBoNT-A制剂中总梭菌蛋白含量随时间的变化。B，onaBoNT-A、aboBoNT-A和incoBoNT-A制剂中的总BoNT-A核心神经毒素，分为变性/无活性毒素和活性神经毒素组分。aboBoNT-A，abobotulinumtoxinA；BoNT-A，A型肉毒神经毒素；incoBoNT-A，incobotulinumtoxinA；NA，不适用；onaBoNT-A，onabotulinumtoxinA。 体内证据表明，针对onaBoNT-A注射会产生抗BoNT抗体，并且更频繁的给药与更高的抗体水平相关。此外，在间隔2至8周接受9次onaBoNT-A或incoBoNT-A注射的兔子中，在20%的onaBoNT-A治疗的动物中检测到中和抗体。相比之下，在使用仅含核心神经毒素的incoBoNT-A制剂治疗的动物中未检测到中和抗体，这表明onaBoNT-A中的辅助蛋白和高核心神经毒素浓度具有佐剂效应。 另一种第一代BoNT-A制剂abobotulinumtoxinA含有的梭菌蛋白总量少于当前的onaBoNT-A制剂；然而，辅助蛋白约占总梭菌蛋白含量的30%(表1；图4)。aboBoNT-A制剂还含有非BoNT梭菌鞭毛残余物(鞭毛蛋白)，已显示其可激活TLR5，启动先天免疫反应。鉴于其免疫刺激特性，鞭毛蛋白已被用作疫苗佐剂，并可能增加aboBoNT-A的免疫原性。 不含辅助蛋白的BoNT-A制剂 第二代BoNT-A制剂(incoBoNT-A和daxiBoNT-A)仅含有治疗性神经毒素，不含辅助蛋白或其他细菌物质(如鞭毛蛋白)(表1，图4)。incoBoNT-A中缺乏辅助蛋白对疗效没有影响。daxiBoNT-A的配方不寻常，因为它不含人血清白蛋白，而是含有一种专利的、源自HIV的5kDa稳定肽和聚山梨酯20。这些赋形剂(特别是这种未在FDA批准的任何其他药物制剂中使用过的新型HIV衍生肽)的佐剂效应尚不清楚。 BoNT治疗期间的免疫原性和临床无反应：临床数据 BoNT治疗可引起适应性免疫反应，重复注射会随时间导致中和抗体的形成。这是临床相关的，因为中和抗体的形成与继发性无反应(治疗耐药性)密切相关。BoNT治疗期间存在多个与治疗参数、患者特征和BoNT制剂选择相关的免疫原性临床风险因素。 BoNT制剂：免疫原性数据 所有BoNT制剂都可能产生中和抗体；然而，中和抗体的产生率和临床耐药性的发生似乎至少部分取决于BoNT制剂，并与制剂中的蛋白质含量相关。发生率因适应症而异，在支持FDA批准临床使用BoNT制剂的关键试验中，使用rimaBoNT-B、onaBoNT-A、aboBoNT-A或incoBoNT-A治疗的患者产生了中和抗体(这些incoBoNT-A患者均曾接受过onaBoNT-A或aboBoNT-A的预先治疗；表2)。 同样重要的是要注意，BoNT制造商用于检测中和抗体存在的测定方法的相对灵敏度存在差异，这可能使直接比较变得复杂。支持FDA批准onaBoNT-A、aboBoNT-A和rimaBoNT-B的关键研究使用小鼠保护试验；相反，大多数关于incoBoNT-A的研究使用小鼠半膈肌试验，其灵敏度至少比MPA高五倍，但尽管如此，仍显示出最低的中和抗体形成率(表2)。此外，产品标签中报告的中和抗体发生率基于短期临床试验(约2年)的数据，考虑到重复使用BoNT可能产生的累积效应，这些数据可能无法反映真实世界的数据。 表2.当前BoNT制剂中中和抗体产生率和临床无反应的发生率 BoNT-A，A型肉毒神经毒素；BoNT-B，B型肉毒神经毒素；nAb，中和抗体。 用于检测第一代onabotulinumtoxinA和abobotulinumtoxinA制剂中和抗体的抗体测定方法，其敏感性低于用于第二代incobotulinumtoxinA的测定方法。 然而，在长期随访分析的真实世界研究中观察到了类似的趋势，显示接受incoBoNT-A治疗的患者中中和抗体存在的减少。一项回顾性荟萃分析表明，在接受onaBoNT-A(约1.5%)或aboBoNT-A(约1.7%)治疗的患者中，跨适应症的中和抗体发生率高于接受incoBoNT-A(0.5%)治疗的患者。虽然总体发生率较低，但在被确定为表现出继发性无反应的患者中，中和抗体的产生率相当高。在此类患者中，在接受onaBoNT-A治疗的患者中报告了32.5%的中和抗体阳性率，在接受aboBoNT-A治疗的患者中报告了56.7%。重要的是，没有接受incoBoNT-A治疗的患者表现出继发性无反应。 含有辅助蛋白的BoNT-A制剂 在接受onaBoNT-A或aboBoNT-A治疗后，在颈肌张力障碍、痉挛状态和其他适应症的患者中报告了中和抗体的发生。在一项针对面肌痉挛、眼睑痉挛、颈肌张力障碍、其他肌张力障碍和痉挛状态患者的横断面研究中，使用onaBoNT-A(7%)和aboBoNT-A(6%)均报告了中和抗体，但使用incoBoNT-A则没有。 这些发现与最近一项针对长期BoNT治疗(跨适应症)的回顾性队列研究一致，该研究显示在接受onaBoNT-A(4%)或aboBoNT-A(16%)治疗的患者中出现中和抗体诱导的治疗失败，但在接受incoBoNT-A治疗的患者中则没有。此外，来自BoNT-A用于美容适应症的案例研究证据表明，随着时间的推移，使用onaBoNT-A和aboBoNT-A都会产生中和抗体和继发性无反应。通常，中和抗体产生和继发性无反应的发生率在美容适应症中较低，这可能反映了较低的剂量和最少的长期数据。 不含辅助蛋白的BoNT-A制剂 使用不含辅助蛋白的BoNT制剂，抗体产生和临床无反应的可能性降低。根据灵敏的MHDA测定，没有未接触过毒素的患者在接受incoBoNT-A治疗后产生中和抗体。此外，医学文献中尚无关于初始接受incoBoNT-A治疗时未接触过毒素的患者出现临床无反应的报道。 在最近一项研究两个患者队列的研究中，那些仅接受incoBoNT-A治疗的患者没有显示出任何继发性治疗失败的迹象，而那些先前接受过其他BoNT制剂治疗的患者则更可能出现此类迹象。这项研究还表明，在与其他BoNT制剂治疗发生继发性治疗失败后，转换为incoBoNT-A有助于患者开始恢复对治疗的反应；仅在两名先前接受过aboBoNT-A治疗的患者中检测到中和抗体。此外，来自跨美容适应症的关键临床研究的汇总数据分析报告称，没有因产生中和抗体而导致治疗反应缺乏的情况。 在关键临床试验中超过2600名接受incoBoNT-A治疗的患者中，跨所有批准适应症，仅有9名成人(5名基线中和抗体状态未知，4名为阴性)和4名儿童(基线中和抗体状态未知)产生了中和抗体(这些患者均预先接受过onaBoNT-A或aboBoNT-A治疗)，并且没有人因中和抗体而出现继发性治疗失败。令人鼓舞的是，在临床试验期间，没有接受incoBoNT-A治疗的儿童产生耐药性，因为这些患者可能需要从幼年开始终身接受BoNT治疗，并且可能面临更大的免疫反应风险。 治疗参数 多个治疗参数影响BoNT的免疫原性。最重要的是，在潜在的终身治疗过程中，中和抗体的发生率随慢性BoNT使用(累积剂量、重复注射和总治疗持续时间)而增加。其他参数，如蛋白负荷、单次注射剂量和再次注射间隔长度，也已被证明与BoNT免疫原性临床相关。 患者特征 在临床实践中，中和抗体的产生率在某些情况下可能更高；几项研究表明，颈肌张力障碍患者的长期治疗后的发生率约为15-20%，而肢体痉挛状态患者约为1-6%。这些差异的原因尚不完全清楚，但可能与潜在的病理生理学差异和剂量/给药要求有关。需要更频繁给药或更高剂量的疾病似乎与更大的免疫原性风险相关。 控制免疫反应的遗传差异表明，患者表现出不同速度和程度的免疫反应以及中和抗体产生模式。此外，并非所有中和抗体都相同--靶标结合位点和结合亲和力的差异导致针对BoNT产生的抗体在其中和能力上有所不同。因此，中和抗体的出现与治疗耐药性之间没有绝对的相关性，并且似乎没有一个特定的中和抗体滴度阈值，超过该阈值就会发生临床耐药性。然而，对此类阈值的研究是有限的。通常，继发性治疗失败可能是在几个治疗周期后，在观察到初始阳性反应之后出现的。 3 颜究方法 免疫学家的视角：免疫原性应成为选择BoNT治疗的关键因素 对于患有终身疾病(如颈肌张力障碍)的患者，以及在一生中因多种不同适应症(包括美容和治疗)接受多次BoNT-A治疗的患者，BoNT的使用可能随时间产生累积的免疫原性效应。FDA和欧洲药品管理局均建议评估和减轻与治疗性蛋白质产品相关的不良免疫反应，并鼓励降低风险。因此，在疗效和安全性相当的情况下，应优先考虑使用潜在地引起免疫原性可能性较低的BoNT制剂作为一线治疗。 虽然它们不可互换，但比较onaBoNT-A和incoBoNT-A的临床研究数据表明，在多种适应症中以相似剂量使用时，具有相似的疗效和安全性。因此，使用具有较低免疫原性潜力的第二代BoNT-A制剂(incoBoNT-A)开始治疗，可能会降低中和抗体产生和未来治疗失败的风险。对于已开始使用免疫原性较高的BoNT制剂(onaBoNT-A或aboBoNT-A)治疗的患者，转换为免疫原性较低的制剂可能是一个合适的选择，因为产生中和抗体的过程可能在临床症状出现耐药性之前就早已开始。主动、系统地识别临床耐药性迹象(例如剂量增加和注射间隔缩短)尤为重要。在这种情况下，更换为免疫原性较低的制剂尤其有必要，并且理想情况下应尽早进行，以有效恢复最佳的临床反应。 从免疫学角度来看，转换为BoNT-B制剂是不可取的，因为BoNT-B比BoNT-A具有更高的免疫原性(表2)。此外，从BoNT-A转换为BoNT-B的患者对BoNT-B的反应会随时间降低，并且可能在几个治疗周期内产生耐药性。总体而言，在无法进行商业化中和抗体检测的情况下，关于不同BoNT制剂在免疫原性潜力及临床反应性随时间变化方面差异的现有证据，应用于指导治疗决策。 数据空白与未知 尽管有证据表明辅助梭菌蛋白可作为免疫反应的佐剂，并且有体内数据将第一代BoNT-A制剂与中和抗体的形成联系起来，但关于BoNT制剂免疫原性仍有未解问题。需要进一步研究阐明单独的核心神经毒素和辅助蛋白对免疫系统的不同影响，包括特定细胞因子、TLRs及其他先天免疫或模式识别标志物的作用。 目前很大程度上尚不清楚无活性的变性毒素(例如用于BoNT疫苗的那种，也存在于onaBoNT-A和aboBoNT-A中)是否对中和抗体的产生有任何影响，尽管从治疗效果的角度来看，这显然是值得关注的。然而，初步证据强烈表明，在缺乏辅助蛋白的制剂(incoBoNT-A)中，中和抗体减少，需要更多大规模研究来证实这种相关性。 最大的数据空白可能是缺乏针对儿科患者的长期数据，这些患者通常接受终身治疗，并且由于免疫系统的反复刺激，可能面临更高的慢性炎症和其他潜在并发症的风险。一些数据表明，在接受onaBoNT-A或aboBoNT-A治疗痉挛状态的儿科患者中，免疫反应的可能性随治疗次数增加而增加。然而，识别儿科患者临床耐药性的迹象很复杂，因为他们仍在成长，其潜在疾病状态的轨迹可能与成人患者不同；因此，随时间推移使用更高剂量的BoNT或临床效果提前减弱，可能在儿童中并不具有同样的信息价值。 4 颜究方法 研究结论 免疫原是许多生物药物使用中常见的临床障碍。重复暴露于生物疗法(包括BoNT)可能引发持续的免疫反应，导致中和抗体的形成，进而可能导致一系列临床结局(例如，疗效降低和/或治疗失败)。在某些情况下，通过设计更小的蛋白质和减少污染物或不必要的制剂成分，已经实现了针对生物疗法的一般免疫原性和中和抗体形成的缓解。具体而言，BoNT制剂中的辅助梭菌蛋白，特别是HA-1，可能作为免疫反应的佐剂。此外，BoNT-A制剂的蛋白含量影响中和抗体的形成--较高的蛋白含量与中和抗体诱导增加相关。 与onaBoNT-A和aboBoNT-A相比，第二代BoNT制剂incoBoNT-A仅含有治疗性神经毒素(150kDa)，缺乏辅助蛋白或其他潜在佐剂(例如鞭毛蛋白)。此外，incoBoNT-A在多种适应症中显示出强大的临床疗效和安全性，以及低免疫原性。鉴于BoNT治疗通常是终身的，在制定关于BoNT制剂的治疗决策时，应考虑免疫原性的可能性和减少中和抗体产生的风险。 参考文献 Carr W, Jain N, Sublett JW. Immunogenicity of botulinum toxin formulations: potential therapeutic implications. Adv Ther (2021) 38:5046–5064. 声明：本文仅作为学术分享，诊疗请以正规医疗机构的专业医务人员意见为准。

Canada is the first country to approve a new botulinum neurotoxin serotype for aesthetic use Boey® is the first and only rapid-onset and short-duration botulinum neurotoxin serotype E approved for the temporary improvement in the appearance of glabellar lines Boey® offers a differentiated treatment option for many people who are curious about facial injectables Results may be seen as early as eight hours after treatment and typically wear off within approximately two to three weeks BOTOX Cosmetic® (onabotulinumtoxinA) is the only neurotoxin clinically tested for use following treatment with Boey® IRVINE, Calif., June 23, 2026 /PRNewswire/ -- Today, Allergan Aesthetics, an AbbVie company (NYSE: ABBV), announced Health Canada has approved Boey® (trenibotulinumtoxinE) for the temporary improvement in the appearance of moderate to severe lines between the eyebrows (glabellar lines) in adult patients. Boey® is the first and only rapid-onset and short-duration botulinum neurotoxin serotype E approved for the temporary improvement in the appearance of glabellar lines. "Health Canada's approval of Boey® marks an important scientific and regulatory milestone in advancing toxin science. As the world's first approval of a botulinum neurotoxin based on serotype E in aesthetics, Boey® represents a meaningful advancement in aesthetic medicine — a fast-acting neurotoxin with a differentiated profile that expands the treatment options for clinicians and patients," said Roopal Thakkar, M.D., executive vice president, research and development, chief scientific officer, AbbVie. A new Allergan Aesthetics survey found that 80% of people are open to learning about new treatments to get the results they want and 79% wish they could temporarily preview the outcome of an aesthetic treatment. 1 Despite growing interest in facial injectables, many patients are hesitant to take the next step due to uncertainty around treatment outcomes and committing to long-lasting results. Boey® was developed for these patients, offering a new way to experience neurotoxin treatment. "Boey® represents an important new advancement for patients and healthcare professionals, addressing a key need in aesthetic neurotoxins. With its truly differentiated profile, Boey® is redefining aesthetics and expanding what's possible by giving practitioners another option to tailor treatment to individual needs and goals, specifically, the ability to try a toxin without the long-term commitment," said Nicole Mowad-Nassar, senior vice president, AbbVie and president, global Allergan Aesthetics. "Allergan Aesthetics is proud to bring this innovation to Canada first and to continue advancing options that help shape the future of aesthetic medicine." Developed by the makers of BOTOX Cosmetic®, Boey® offers a new option for suitable patients considering facial injectables. BOTOX Cosmetic® is the only neurotoxin clinically tested for use following treatment with Boey®. Allergan Aesthetics plans to begin training healthcare professionals on the appropriate use of Boey® and is preparing for a commercial launch in the upcoming months as trenibotulinumtoxinE is under review for approval in multiple other countries. Allergan Aesthetics develops, manufactures and markets a portfolio of leading aesthetics brands and products. Allergan Aesthetics is well positioned to lead the future of injectable aesthetics, with dedicated research and development focused on driving innovation to meet the evolving needs of patients and healthcare professionals worldwide. -ENDS- About the Boey® clinical studies The approval of Boey® is supported by data from two randomised, multi-centre, double-blind, placebo-controlled studies Phase 3 clinical trials evaluating the efficacy and safety of Boey® in adults with moderate to severe glabellar lines (M21-500 and M21-508) associated with corrugator and/or procerus muscle activity. The studies enrolled 947 patients treated with Boey® 700 U total dose or placebo. The primary efficacy measure was defined as the percentage of subjects achieving None or Mild and ≥ 2-Grade Improvement from baseline in glabellar line severity at maximum frown based on both investigator and subject assessments using the Facial Wrinkle Scale (FWS) at Day 7. Efficacy was assessed in the ITT population. The composite responder rates at Day 7 were 60.0% and 65.7% (M2-500: n=289/482; M21-508: n=149/227; p<0.0001). Secondary efficacy endpoints were measured by Facial Line Satisfaction Questionnaire (FLSQ), a validated scale developed by Allergan Aesthetics, and included satisfaction with achieving a natural look and overall satisfaction with treatment effect. The onset of effect for patients treated with Boey® appeared as early as 8 hours after injection in both pivotal studies. Glabellar lines returned to baseline severity in approximately 14-21 days after administration. The most frequently reported treatment-related adverse events were headache (3.4% in the Boey-treated group and 4.2% in the placebo-treated group), injection site pain (1.7% in the Boey-treated group and 2.9% in the placebo-treated group), and injection site erythema (0.6% in the Boey-treated group and 1.3% in the placebo-treated group).2 BOEY ® CANADA APPROVED USES AND IMPORTANT SAFETY INFORMATION Boey® is used in adults to temporarily improve the appearance of moderate to severe frown lines between the eyebrows (glabellar/frown lines). IMPORTANT SAFETY INFORMATION Boey ® may cause serious side effects, including: Distant spread of toxin effects. It is possible that the effect of botulinum toxin may affect areas of the body away from the injection site and cause symptoms of a serious condition called botulism. Trouble breathing and trouble swallowing can be life threatening. One unit (amount) of Boey® is NOT the same as one unit of other botulinum products. Boey® should only be given by a trained healthcare professional. They should have experience using Boey®. Follow the dose and schedule of injection recommended by your healthcare provider. Do not use Boey® if you are allergic to botulinum toxin or any of the other ingredients or you have a skin infection where you plan to get the injection To help avoid side effects and ensure proper use, talk to your healthcare professional before you take Boey®. Talk about any health conditions or problems you may have, including if you have allergies to any botulinum toxin product, had a side effect from any botulinum toxin product in the past, have had facial surgery or injured your face, are planning to have facial surgery soon, have any redness or swelling (inflammation) where you plan to get an injection, muscles where the injection will be given are weak, have drooping of one or both eyelids (ptosis), have any other change in the way your face normally looks, have certain diseases that affect your nervous system (such as amyotrophic lateral sclerosis or motor neuropathy) Other warnings you should know about include: Injection site reactions: Like with any injection procedure, injection site reactions may happen after receiving Boey®. Symptoms at the injection site(s) may include pain/discomfort, swelling/inflammation, redness, bruising, bleeding, itching, warmth, hardness at the site where the needle entered your skin Muscle weakness in areas next to or near the injection sites such as eyelid drooping and double vision (seeing two objects when there is only one). Driving and using machines: If you have drooping eyelids or problems with your vision after using Boey®, do not drive or use machinery until those symptoms go away. After you get Boey®, talk to your healthcare professional if you have the following: Allergic reaction: An allergic reaction is a reaction your body has to a medicine. This can cause symptoms such as hives, rash, or fever. Contact your healthcare professional right away if you have any of the symptoms listed as they can be signs of a severe allergic reaction: trouble breathing, swallowing, or speaking, swelling, including swelling of the face or throat, wheezing (a whistling sound while breathing), feeling dizzy or light-headed, shortness of breath Distant spread of toxin effect: Sometimes, the effects of botulinum toxin may spread from the injection area to other parts of the body. Contact your healthcare provider right away if you have any of the symptoms listed: muscle weakness, trouble swallowing, unwanted food or liquid going into the airways Reduced blinking or experience dryness in one or both eyes. Tell your healthcare professional about all the medicines you take, including any drugs, vitamins, minerals, natural supplements or alternative medicines. The following may interact with Boey®: a different medicine that has botulinum toxin, muscle relaxants (medicines that reduce muscle tension), antibiotics (medicines used to treat infections) , anticholinergics (medicines that reduce muscle strength). Ask your healthcare provider for advice before you take any new medicines. Boey® can have side effects, although not everybody gets them, including drooping eyelid (uncommon), drooping eyebrow (uncommon), or raising of the outer eyebrow (rare). These are not all the possible side effects you may have when taking Boey®. If you experience any side effects not listed here, tell your healthcare professional. Please consult the Boey® product monograph for more information. BOTOX® COSMETIC US APPROVED USES AND IMPORTANT SAFETY INFORMATION BOTOX® Cosmetic is a prescription medicine that is injected into muscles and used to temporarily improve the look of moderate to severe forehead lines, crow's feet lines, frown lines between the eyebrows, and vertical bands connecting the jaw and neck (platysma bands) in adults. IMPORTANT SAFETY INFORMATION BOTOX® Cosmetic may cause serious side effects that can be life threatening. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX® Cosmetic: Problems swallowing, speaking, or breathing, due to weakening of associated muscles, which can be severe and result in loss of life. You are at the highest risk if these problems are preexisting before injection. Swallowing problems may last for several months. Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms, including loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, and trouble swallowing. BOTOX® Cosmetic dosing units are not the same as, or comparable to, any other botulinum toxin product. There has not been a confirmed serious case of spread of toxin effect when BOTOX® Cosmetic has been used at the recommended dose to treat frown lines, crow's feet lines, forehead lines, and/or platysma bands. BOTOX® Cosmetic may cause loss of strength or general muscle weakness, vision problems, or dizziness within hours to weeks of receiving BOTOX® Cosmetic. If this happens, do not drive a car, operate machinery, or do other dangerous activities. Serious and/or immediate allergic reactions have been reported, including itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint. Get medical help right away if you are wheezing or have asthma symptoms, or if you become dizzy or faint. Do not receive BOTOX® Cosmetic if you are allergic to any of the ingredients in BOTOX® Cosmetic (see Medication Guide for ingredients); had an allergic reaction to any other botulinum toxin product such as Myobloc (rimabotulinumtoxinB), Dysport (abobotulinumtoxinA), Xeomin (incobotulinumtoxinA), Jeuveau (prabotulinumtoxinA-xvfs), Daxxify (daxibotulinumtoxinA-lanm), or Letybo (letibotulinumtoxinA-wlbg); or have a skin infection at the planned injection site. This list may not include all available botulinum toxin products. Tell your doctor about all your muscle or nerve conditions, such as ALS or Lou Gehrig's disease, myasthenia gravis, or Lambert-Eaton syndrome, as you may be at increased risk of serious side effects, including difficulty swallowing and difficulty breathing, from standard doses of BOTOX® Cosmetic. Tell your doctor about all your medical conditions , including surgery or plans to have surgery on your face, trouble raising your eyebrows, drooping eyelids, any other abnormal facial change, are pregnant or plan to become pregnant (it is not known if BOTOX® Cosmetic can harm your unborn baby), or are breastfeeding or plan to (it is not known if BOTOX® Cosmetic passes into breast milk). Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Using BOTOX® Cosmetic with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your doctor that you have received BOTOX® Cosmetic in the past. Tell your doctor if you have received any other botulinum toxin product in the last 4 months; have received injections of botulinum toxin such as Myobloc, Dysport, Xeomin, Jeuveau, Daxxify, or Letybo in the past (tell your doctor exactly which product you received); have recently received an antibiotic by injection; take muscle relaxants; take an allergy or cold medicine; take a sleep medicine; or take aspirin-like products or blood thinners. Other side effects of BOTOX® Cosmetic include dry mouth; discomfort or pain at the injection site; tiredness; headache; neck pain; and eye problems, including double vision, blurred vision, decreased eyesight, drooping eyelids and eyebrows, swelling of eyelids, and dry eyes. For more information, refer to the Medication Guide or talk with your doctor. To report a side effect, please call Allergan Aesthetics at 1-800-678-1605. Please see BOTOX® Cosmetic full US Product Information , including Boxed Warning and Medication Guide . © 2026 AbbVie. All rights reserved. All trademarks are the property of their respective owners. About Boey® Boey® is a facial injectable neurotoxin serotype E indicated in adult patients for the temporary improvement in the appearance of of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity. It blocks neuromuscular transmission as the neurotoxin cleaves SNAP-25. It has a rapid uptake and translocation into neuronal cells, with a short half-life of the type E light chain, giving it a rapid onset of action and a short duration of effect when treating glabellar lines.2 About Glabellar lines Glabellar lines are the vertical lines that appear between the eyebrows and are commonly referred to as "frown lines". These lines develop over time due to repeated muscle contractions from facial expressions such as frowning, concentrating or squinting. About Allergan Aesthetics At Allergan Aesthetics, an AbbVie company, we develop, manufacture, and market a portfolio of leading aesthetics brands and products. Our aesthetics portfolio includes facial injectables, body contouring, plastics, skin care, and more. Our goal is to consistently provide our customers with innovation, education, exceptional service, and a commitment to excellence, all with a personal touch. For more information, visit About AbbVie AbbVie's mission is to discover and deliver innovative medicines and solutions that solve serious health issues today and address the medical challenges of tomorrow. We strive to have a remarkable impact on people's lives across several key therapeutic areas including immunology, neuroscience and oncology – and products and services in our Allergan Aesthetics portfolio. For more information about AbbVie, please visit us at . Follow @abbvie on LinkedIn, Facebook, Instagram, X and YouTube. Forward-Looking Statements Some statements in this news release are, or may be considered, forward-looking statements for purposes of the Private Securities Litigation Reform Act of 1995. The words "believe," "expect," "anticipate," "project" and similar expressions and uses of future or conditional verbs, generally identify forward-looking statements. AbbVie cautions that these forward-looking statements are subject to risks and uncertainties that may cause actual results to differ materially from those expressed or implied in the forward-looking statements. Such risks and uncertainties include, but are not limited to, challenges to intellectual property, competition from other products, difficulties inherent in the research and development process, adverse litigation or government action, changes to laws and regulations applicable to our industry, the impact of global macroeconomic factors, such as economic downturns or uncertainty, international conflict, trade disputes and tariffs, and other uncertainties and risks associated with global business operations. Additional information about the economic, competitive, governmental, technological and other factors that may affect AbbVie's operations is set forth in Item 1A, "Risk Factors," of AbbVie's 2025 Annual Report on Form 10-K, which has been filed with the Securities and Exchange Commission, as updated by its Quarterly Reports on Form 10-Q and in other documents that AbbVie subsequently files with the Securities and Exchange Commission that update, supplement or supersede such information. AbbVie undertakes no obligation, and specifically declines, to release publicly any revisions to forward-looking statements as a result of subsequent events or developments, except as required by law. FOOTNOTES * A global survey (28th November 2025 – 15th December 2025) of N=12,286 adults aged 18+ who have paid for at least 2 beauty or aesthetics related services in the past year (Brazil n=1318, Canada n=1304, China n=1318, France n=1302, Germany n=1301, KSA n=1311, Thailand n=1321, USA n=1802, UK n=1309).1 References Allergan Aesthetics Holistic Beauty Global Research. REF-148616. January 2026 Boey® Product Monograph. AbbVie 2026. -ENDS- Contacts: Allergan Aesthetics Media: Michael Salzillo +1 (908) 269-1688 [email protected] AbbVie Investors: Liz Shea +1 (847) 935-2211 [email protected] © 2026 AbbVie. All rights reserved. All trademarks are the property of their respective owners. SOURCE AbbVie 21% more press release views with Request a Demo