Perspectives

source, such as pancreatic enzymes from

A g u i d e t o d r u g d i s c o v e ry — o p i n i o n hog and pig pancreas5,6, and α‑1-proteinase
inhibitor from pooled human plasma7,8,

Protein therapeutics: a summary but most are now produced by recombinant

DNA technology and purified from a wide

and pharmacological classification

range of organisms. Production systems
for recombinant proteins include bacteria,
yeast, insect cells, mammalian cells, and
transgenic animals and plants9–13. The
Benjamin Leader, Quentin J. Baca and David E. Golan
system of choice can be dictated by the cost
Abstract | Once a rarely used subset of medical treatments, protein therapeutics of production or the modifications of the
have increased dramatically in number and frequency of use since the introduction protein (for example, glycosylation, phos-
phorylation or proteolytic cleavage) that are
of the first recombinant protein therapeutic — human insulin — 25 years ago.
required for biological activity. For example,
Protein therapeutics already have a significant role in almost every field of bacteria do not perform glycosylation
medicine, but this role is still only in its infancy. This article overviews some of the reactions, and each of the other biological
key characteristics of protein therapeutics, summarizes the more than 130 protein systems listed above produces a different
therapeutics used currently and suggests a new classification of these proteins type or pattern of glycosylation. Protein
glycosylation patterns can have a dramatic
according to their pharmacological action.
effect on the activity, half-life and immuno-
genicity of the recombinant protein in the
Proteins have the most dynamic and diverse and complex set of functions that cannot be body. For example, the half-life of native
role of any macromolecule in the body, mimicked by simple chemical compounds. erythropoietin, a growth factor important in
catalysing biochemical reactions, forming Second, because the action of proteins is erythrocyte production (see below), can be
receptors and channels in membranes, pro- highly specific, there is often less potential for lengthened by increasing the glycosylation
viding intracellular and extracellular protein therapeutics to interfere with normal of the protein. Darbepoetin-a is an erythro­
scaffolding support, and transporting biological processes and cause adverse effects. poietin analogue that is engineered to
molecules within a cell or from one organ to Third, because the body naturally produces contain two additional amino acids that are
another. It is currently estimated that there are many of the proteins that are used as thera- substrates for N‑linked glycosylation reac-
25,000–40,000 different genes in the human peutics, these agents are often well tolerated tions. When expressed in Chinese hamster
genome, and with alternative splicing of and are less likely to elicit immune responses. ovary cells, the analogue is synthesized with
genes and post-translational modification of Fourth, for diseases in which a gene is five rather than three N‑linked carbohydrate
proteins (for example, by cleavage, phosphory­ mutated or deleted, protein therapeutics chains; this modification causes the half-life
lation, acylation and glycosylation), the can provide effective replacement treatment of darbepoetin to be threefold longer than
number of functionally distinct proteins is without the need for gene therapy, which that of erythropoietin14.
likely to be much higher1–3. Viewed from the is not currently available for most genetic Perhaps the best example of trends in the
perspective of disease mechanisms, these esti- disorders. Fifth, the clinical development and production and use of protein therapeutics
mates pose an immense challenge to modern FDA approval time of protein therapeutics is provided by the history of insulin in the
medicine, as disease may result when any one may be faster than that of small-molecule treatment of diabetes mellitus type I (DM‑I)
of these proteins contains mutations or other drugs. A study published in 2003 showed and type II (DM-II). Untreated, DM‑I is
abnormalities, or is present in an abnormally that the average clinical development and a disease that leads to severe wasting and
high or low concentration. Viewed from the approval time was more than 1 year faster for death due to lack of the protein hormone
perspective of therapeutics, however, these 33 protein therapeutics approved between insulin, which signals cells to perform
estimates represent a tremendous opportunity 1980 and 2002 than for 294 small-molecule numerous functions related to glucose
in terms of harnessing protein therapeutics drugs approved during the same time period4. homeostasis and intermediary metabo-
to alleviate disease. At present, more than Last, because proteins are unique in form lism15. In 1922, insulin was first purified
130 different proteins or peptides are and function, companies are able to obtain from bovine and porcine pancreas and used
approved for clinical use by the US Food far-reaching patent protection for protein as a life-saving daily injection for patients
and Drug Administration (FDA), and many therapeutics. The last two advantages make with DM‑I16. At least three problems
more are in development. proteins attractive from a financial perspec- hindered the widespread use of this protein
Protein therapeutics have several tive compared with small-molecule drugs. therapy: first, the availability of animal pan-
advantages over small-molecule drugs. A relatively small number of protein creases for purification of insulin; second,
First, proteins often serve a highly specific therapeutics are purified from their native the cost of insulin purification from animal

nature reviews | drug discovery volume 7 | january 2008 | 21

© 2008 Nature Publishing Group
Perspectives

quantity. One striking example is found in

Box 1 | Functional classification of protein therapeutics
the protein-based therapy for Gaucher’s
Protein therapeutics in the tables in this article are organized by function and therapeutic disease, a chronic congenital disorder of
application. The numbers of therapeutics per group reflect the relative difficulty associated with lipid metabolism caused by a deficiency
drug development across the various classes of protein therapeutics. Every effort has been made to of the enzyme β-glucocerebrosidase (also
include in these tables all US Food and Drug Administration (FDA)-approved Group I and Group II known as glucosylceramidase) that is char-
protein-based therapies. Groups III and IV present selected examples that highlight the use of
acterized by an enlarged liver and spleen,
proteins in vaccines and diagnostic agents.
increased skin pigmentation and painful
Group I: protein therapeutics with enzymatic or regulatory activity bone lesions21,22. At first, β-glucocerebro-
• Ia: Replacing a protein that is deficient or abnormal (TABLES 1,2). sidase purified from human placenta was
• Ib: Augmenting an existing pathway (TABLES 3,4). used to treat this disease, but this requires
• Ic: Providing a novel function or activity (TABLE 5). purification of protein from 50,000 placentas
Endocrine and metabolic disorders with defined molecular aetiologies dominate Group Ia. As more per patient per year, which obviously places
diseases are linked to deficiencies of specific proteins, this class will continue to grow. Group Ib is a practical limit on the amount of purified
dominated by therapies that augment haematological and endocrine pathways and immune protein available. A recombinant form of
responses. The many interferon and growth factor therapies in Group Ib effectively treat disease β-glucocerebrosidase was subsequently
even when their precise pharmacological mechanism of action is unknown. Group Ic demonstrates developed and introduced, which is not
the rational use of naturally occurring proteins to modify the pathophysiology of human diseases.
only available in sufficient quantities to treat
The future growth of this class depends on understanding protein function in human physiology as
many more patients with the disease, but
well as protein function in other organisms.
also eliminates the risk of transmissible
Group II: protein therapeutics with special targeting activity (for example, viral or prion) diseases associ-
• IIa: Interfering with a molecule or organism (TABLES 6,7).
ated with purifying the protein from human
• IIb: Delivering other compounds or proteins (TABLE 8). placentas23–25. This also illustrates a third
Group IIa therapeutics use their special targeting activity to interfere with molecules or organisms benefit of recombinant proteins over non-
by binding specifically to them and blocking their function, targeting them for destruction, recombinant proteins — the reduction of
or stimulating a signalling pathway. This group has grown as monoclonal antibody technology has exposure to animal or human diseases.
matured and will probably expand further as signalling pathways and aetiologies of disease are more
A fourth advantage is that recombinant
clearly identified. Group IIb therapeutics deliver other compounds or proteins to a specific site.
This class has great potential to grow, as demonstrated by the breadth of the specifically targeted
technology allows the modification of a
Group IIa therapies. protein or the selection of a particular gene
variant to improve function or specificity.
Group III: protein vaccines
• IIIa: Protecting against a deleterious foreign agent.
Again, recombinant β-glucocerebrosidase
provides an interesting example. When this
• IIIb: Treating an autoimmune disease.
protein is made recombinantly, a change
• IIIc: Treating cancer. of amino-acid arginine‑495 to histidine
Although this is currently a small class of therapies, there is great potential for the production of allows the addition of mannose residues
recombinant vaccines that provide broad protection against infectious agents. Similarly, to the protein. The mannose is recognized
individualized vaccines against cancers are likely to be in great demand. Selected examples of the by endocytic carbohydrate receptors on
57 FDA-approved vaccines in TABLE 9 highlight the use of recombinant protein technology in
macrophages and many other cell types,
vaccine production. Many of the FDA-approved vaccines protect against multiple infectious
agents and include synthetic, recombinant and purified protein components. A complete list of
allowing the enzyme to enter these cells
FDA-approved vaccines may be found at: http://www.fda.gov/cber/vaccine/licvacc.htm. more efficiently and to cleave the intracellu-
lar lipid that has accumulated in pathological
Group IV: protein diagnostics
amounts, which results in an improved
Group IV protein diagnostics, for which selected examples are shown in TABLE 10, are a class that
powerfully affect clinical decision-making. These diagnostics use technology and therapeutics therapeutic outcome23. Last, recombinant
developed in other classes to answer clinical questions. This table presents primarily in vivo protein technology allows the production of proteins
diagnostics, but in vitro protein diagnostics are also critical to medical decision-making and are too that provide a novel function or activity,
numerous to address comprehensively here. as discussed below.
The 25 years since the approval of
recombinant insulin by the FDA have seen a
pancreas; and third, the immunological commercially available recombinant protein remarkable expansion in the number of thera­
reaction of some patients to animal insulin. therapeutic, and has been the major therapy peutic applications of proteins. More than
These problems were addressed by isolating for DM‑I (and a major therapy for DM‑II) 130 proteins (over 95 of which are produced
the human insulin gene and engineering ever since16–20. recombinantly) are currently approved for
Escherichia coli to express human insulin Recombinantly produced proteins can clinical use by the FDA, and many more
by using recombinant DNA technology. have several further benefits compared with are in development. An appreciation of the
By growing vast quantities of these bacteria, non-recombinant proteins. First, transcrip- many therapeutic uses of proteins may be
large-scale production of human insulin was tion and translation of an exact human gene facilitated by categorizing such therapies
achieved. The resulting insulin was abun- can lead to a higher specific activity of the according to their mechanism of action,
dant, inexpensive, of low immunogenicity protein and a decreased chance of immuno­ and, in this article, we summarize currently
and free from other animal pancreatic logical rejection. Second, recombinant pro- approved protein therapeutics by suggesting
substances. Recombinant insulin, approved teins are often produced more efficiently and a classification system that is based on their
by the US FDA in 1982, was the first inexpensively, and in potentially limitless pharmacological action (BOX 1). Examples

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© 2008 Nature Publishing Group
 Perspectives

Table 1 | Protein therapeutics replacing a protein that is deficient or abnormal (Group Ia)*
Therapeutic Trade name Function Examples of clinical use
Endocrine disorders (hormone deficiencies)
‡
Insulin16–20 Humulin, Novolin Regulates blood glucose, shifts potassium into cells Diabetes mellitus, diabetic
ketoacidosis, hyperkalaemia
‡
Insulin human Exubera Insulin formulated for inhalation with faster onset Diabetes mellitus
inhalation146–149 of action
‡
Insulin aspart150; Novolog (aspart), Insulin analogues with faster onset of action and Diabetes mellitus
insulin glulisine151; Apidra (glulisine), shorter duration of action
Insulin lispro150 Humalog (lispro)
‡
Isophane insulin150 NPH Insulin protamine crystalline formulation with slower Diabetes mellitus
onset of action and longer duration of action
‡
Insulin detemir152; Levemir (detemir), Insulin analogues with slower onset of action and Diabetes mellitus
Insulin glargine150 Lantus (glargine) longer duration of action
‡
Insulin zinc Lente, Ultralente Insulin zinc hexameric complex with slower onset Diabetes mellitus
extended150 of action and longer duration of action
Pramlintide Symlin Mechanism unknown; recombinant synthetic peptide Diabetes mellitus, in combination
acetate153 analogue of human amylin (a naturally occurring with insulin
neuroendocrine hormone regulating post-prandial
glucose control)
‡
Growth Genotropin, Humatrope, Anabolic and anticatabolic effector Growth failure due to GH deficiency
hormone (GH), Norditropin, NorIVitropin, or chronic renal insufficiency,
somatotropin133–137 Nutropin, Omnitrope, Prader-Willi syndrome, Turner
Protropin, Siazen, syndrome, AIDS wasting or cachexia
Serostim, Valtropin with antiviral therapy
‡
Mecasermin154 Increlex Recombinant insulin-like growth factor 1 (IGF1) induces Growth failure in children with GH
mitogenesis, chondrocyte growth and organ growth, gene deletion or severe primary IGF1
which combine to restore appropriate statural growth deficiency
‡
Mecasermin IPlex Similar to mecasermin; IGF1 bound to IGF binding Growth failure in children with GH
rinfabate155 protein 3 (IGFBP3) is thought to keep the hormone gene deletion or severe primary IGF1
inactive until it reaches its target tissues, thereby deficiency
decreasing hypoglycaemia-like side effects
Haemostasis and thrombosis
Factor VIII27,28,118 Bioclate, Helixate, Coagulation factor Haemophilia A
Kogenate, Recombinate,
ReFacto
Factor IX29,30,141,142 Benefix Coagulation factor Haemophilia B
§
Antithrombin III Thrombate III Purified human AT-III from pooled plasma inactivates Hereditary AT-III deficiency in
(AT-III)143,144 thrombin by forming a covalent bond between the connection with surgical or
catalytic serine residue of thrombin and an arginine obstetrical procedures or for
reactive site on AT-III; AT-III replacement therapy thromboembolism
prevents inappropriate blood-clot formation
§
Protein C Ceprotin After activation by the thrombin–thrombomodulin Treatment and prevention of venous
concentrate145 complex, protein C inhibits coagulation factors Va thrombosis and purpura fulminans
and VIIIa in patients with severe hereditary
protein C deficiency
*Continued in TABLE 2. Protein therapeutics derive their specificity and function from their structure. Molecules ranging from large and complex enzymes to short peptide
sequences have specific biological activity due to their amino-acid-based secondary and tertiary structure. For example, somatostatin is active as either a 14 or 28 amino-acid
peptide, and its even shorter synthetic analogues share a characteristic hairpin-loop structure that defines their specificity and biological activity. Some very short peptide
therapeutics are better thought of as small-molecule drugs, as they lack secondary and tertiary structures that define their biological activity. For this reason, therapeutics such as
glatiramer acetate (a four amino-acid peptide consisting of acetate with l‑Glu, l‑Ala, l‑Tyr and l‑Lys) are not addressed in this article. Protein therapeutics are recombinant unless
otherwise stated. ‡Also classed in Group Ib. §Non-recombinant.

of protein therapeutics in each category and
clinical conditions in which they are used
are discussed in the text, and a listing of
FDA-approved protein therapies and their
functions and clinical uses is presented
in TABLES 1–8. Examples of protein-based
vaccines and diagnostics that highlight the
growing importance of proteins in medicine
are provided in TABLES 9,10.
Group I: enzymes and regulatory proteins
Protein therapeutics in this group function
by a classic paradigm in which a specific
endogenous protein is deficient, and the
deficit is then remedied by treatment with
exogenous protein. Protein therapeutics
that we have classified in Group Ia are used
to replace a particular activity in cases of
protein deficiency or abnormal protein
production. These proteins are used in a
range of conditions, from providing lactase
in patients lacking this gastrointestinal
enzyme26 to replacing vital blood-clotting
factors such as factor VIII27,28 and factor
IX29,30 in haemophiliacs. A classic example,
as mentioned above, is the use of insulin
for the treatment of diabetes. Another
important example is in the treatment of

nature reviews | drug discovery volume 7 | january 2008 | 23

© 2008 Nature Publishing Group
Perspectives
cystic fibrosis, a common lethal genetic
disorder. In this disease, defects in the
chloride channel encoded by the CFTR gene
lead to abnormally thick secretions, which
can (among other effects) block pancreatic
enzymes from travelling down the pancreatic
duct into the duodenum31. This prevents
food from being properly digested and
results in malnutrition. Patients with cystic
fibrosis are often treated with a combination
of pancreatic enzymes isolated from pigs —
including lipases, amylases and proteases
— that allow the digestion of lipids,
sugars and proteins. Patients who have had
their pancreas removed or who suffer from
chronic pancreatitis can also benefit from
this therapy5,6. Other striking examples
include various diseases caused by metabolic
enzyme deficiencies, such as Gaucher’s
disease as mentioned above, mucopoly-
saccharidosis, Fabry disease and others.
Additional protein therapies that replace a
particular activity are listed in TABLES 1,2.
It may sometimes be desirable to enhance
the magnitude or timing of a particular nor-
mal protein activity, and protein therapeutics
that we have classified in Group Ib are
administered to achieve this. Such protein
therapeutics have been successful in treating
haematopoietic defects; the most prominent
example is recombinant erythropoietin,
a protein hormone secreted by the kidney
that stimulates erythrocyte production in
the bone marrow31. In patients with chemo-
therapy-induced anaemia or myelodysplastic
syndrome, recombinant erythropoietin is
used to increase erythrocyte production
and thereby ameliorate the anaemia. In
patients with renal failure, whose levels of
endogenous erythropoietin are below nor-
mal, recombinant protein is administered to
correct this deficiency32–36. Another example
is provided by the treatment of neutropaenic
patients with granulocyte- or granulocyte-
monocyte colony stimulating factor (G-CSF
or GM‑CSF, respectively)36,37, which stimu-
late an increase in the number of neutrophils
produced by the bone marrow to allow these
patients to better combat microbial infec-
tions. Similarly, thrombocytopaenic patients
can be treated with interleukin 11 (IL11)38,
which increases platelet production and
thereby prevents bleeding complications.
In vitro fertilization (IVF) is another
area in which Group Ib proteins are applied.
Increased levels of follicle-stimulating hor-
mone (FSH) are normally produced by the
anterior pituitary gland just before ovulation.
These high levels of FSH can be enhanced by
treatment with recombinant FSH, leading to
maturation of an increased number of follicles
24 | january 2008 | volume 7 www.nature.com/reviews/drugdisc
and to an increased number of oocytes
available for IVF39,40. Similarly, recombinant
human chorionic gonadotropin (HCG)41 is
used in assisted reproductive technology to
promote follicle rupture, a process that must
occur before the oocytes can be transported
into the fallopian tubes for fertilization.
Group Ib proteins can also have life-saving
effects on thrombosis and haemostasis.
Alteplase (recombinant tissue plasminogen
activator (tPA; also known as PLAT)), is used
to treat life-threatening blood clots in condi-
tions such as coronary artery occlusion, acute
ischaemic stroke and pulmonary embo-
lism42–46. Endogenous tPA is secreted by the
endothelial cells that line blood vessels. The
secreted tPA normally cleaves plasminogen
to plasmin, which then degrades fibrin and
thereby lyses fibrin-based clots15. Although
endogenous tPA may be present at normal
or even increased levels near the site of a
blood clot, administration of relatively large
amounts of exogenous tPA may be required
to disrupt these clots. Reteplase, a genetically
modified form of recombinant tPA, is used
to treat acute myocardial infarction47,48, and
enecteplase, another genetically engineered
derivative of tPA, has greater specificity
than tPA for binding to plasminogen and
therefore causes a more efficacious lysis of
fibrin in blood clots49,50. Supraphysiological
levels of coagulation factor VIIa may catalyse
thrombosis and thereby stop life-threatening
bleeding in patients with haemophilia A or
B51,52. Also, recent studies have suggested
that recombinant activated protein C53,54 can
improve immunoregulation and prevent
excessive clotting reactions in patients with
severe, life-threatening sepsis and organ
dysfunction. Many other Group Ib protein
therapeutics are also used for immunoregula-
tion — chronic hepatitis B and C, Kaposi’s
sarcoma, melanoma, and some types of
leukaemia and lymphoma have been treated
with various forms of interferon, as noted
in TABLE 3. Other disease states treated
with Group Ib proteins are summarized in
TABLES 3,4.
Occasionally, the activity of a particular
protein is desirable even though the body
does not normally express that activity.
Protein therapeutics that we have classified in
Group Ic contain examples of this paradigm,
including foreign proteins with novel func-
tions and endogenous proteins that act at
a novel time or place in the body. Papain,
for example, is a protease purified from the
Carica papaya fruit. This protein is used thera­
peutically to degrade proteinaceous debris
in wounds55. Collagenase, obtained from
fermentation by Clostridium histolyticum,
© 2008 Nature Publishing Group
can be used to digest collagen in the necrotic
base of wounds56,57. The protease-mediated
debridement or removal of necrotic tissue
is useful in the treatment of burns, pressure
ulcers, post-operative wounds, carbuncles
and other types of wounds. Recombinant
human deoxyribonuclease I (DNASE1) also
has an interesting novel use. Normally found
inside human cells, this recombinant enzyme
can be used to degrade the DNA left over
from dying neutrophils in the respiratory
tract of patients with cystic fibrosis58. Such
DNA could otherwise form mucus plugs
that obstruct the respiratory tract and lead
to pulmonary fibrosis, bronchiectasis and
recurrent pneumonias. Thus, recombinant
protein technology has allowed the thera-
peutic application of a normally intracellular
enzyme in a novel extracellular environment.
There are many other successful examples
of this approach to protein therapy. For
instance, certain forms of acute lymphoblastic
leukaemia are unable to synthesize asparagine
and therefore require the availability of this
amino acid to survive. l‑Asparaginase, puri-
fied from E. coli, can be used to lower serum
levels of asparagine in such patients and
thereby inhibit cancer cell growth59,60. Studies
of the medical leech, Hirudo medicinalis,
revealed that its salivary gland produces hiru-
din, a potent thrombin inhibitor. The gene for
this protein was then identified, cloned and
used recombinantly to provide a new protein
therapy, lepirudin, which prevents clot forma-
tion in patients with heparin-induced throm-
bocytopaenia61,62. Other organisms can also
be used to produce proteins that are capable
of breaking up clots that have already formed;
for example, streptokinase is a plasminogen
activating protein produced by group C
β-haemolytic streptococci63–66. Many more
therapeutic proteins that provide a novel
function or activity are presented in TABLE 5.
Group II: targeted proteins
The exquisite binding specificity of mono-
clonal antibodies and immunoadhesins67
can be exploited in numerous ways using
recombinant DNA technology. Many protein
therapeutics that we have classified in Group
IIa use the antigen recognition sites of
immunoglobulin (Ig) molecules or the recep-
tor-binding domains of native protein ligands
to guide the immune system to destroy
specifically targeted molecules or cells. Other
monoclonal antibodies and immunoadhesins
neutralize molecules by simple physical
occupation of a functionally important
region of the molecule. Immunoadhesins
combine the receptor-binding domains of
protein ligands with the Fc region of an Ig.
 Perspectives

Table 2 | Protein therapeutics replacing a protein that is deficient or abnormal (Group Ia)*
Therapeutic Trade name Function Examples of clinical use
Metabolic enzyme deficiencies
β-Gluco- Cerezyme Hydrolyzes glucocerebroside to glucose and ceramide Gaucher’s disease
cerebrosidase21,22,24
‡
β-Gluco- Ceredase (purified from Hydrolyzes glucocerebroside to glucose and ceramide Gaucher’s disease
cerebrosidase23,25,156 pooled human placenta)
Alglucosidase-α157 Myozyme Degrades glycogen by catalyzing the hydrolysis of Pompe disease (glycogen storage
α-1,4 and α-1,6 glycosidic linkages of lysosomal glycogen disease type II)
Laronidase158–160 Aldurazyme Digests endogenous glycosaminoglycans (GAGs) Hurler and Hurler-Scheie forms of
(α-l-iduronidase) within lysosomes, and thereby prevents an mucopolysaccharidosis I
accumulation of GAGs that can cause cellular, tissue,
and organ dysfunction
Idursulphase161 Elaprase Cleaves the terminal 2-O-sulphate moieties from Mucopolysaccharidosis II (Hunter
(Iduronate-2- the GAGs dermatan sulphate and heparan sulphate, syndrome)
sulphatase) thereby allowing their digestion and preventing
GAG accumulation
Galsulphase162 Naglazyme Cleaves the terminal sulphate from the GAG dermatan Mucopolysaccharidosis VI
sulphate, thereby allowing its digestion and preventing
GAG accumulation
Agalsidase-β163,164 Fabrazyme Enzyme that hydrolyzes globotriaosylceramide (GL3) Fabry disease; prevents accumulation
(human and other glycosphingolipids, reducing deposition of of lipids that could lead to renal and
α-galactosidase A) these lipids in capillary endothelium of the kidney and cardiovascular complications
certain other cell types
Pulmonary and gastrointestinal-tract disorders
‡
α-1-Proteinase Aralast, Prolastin Inhibits elastase-mediated destruction of pulmonary Congenital α-1-antitrypsin deficiency
inhibitor8,165 tissue; purified from pooled human plasma
Lactase26
‡
Lactaid Digests lactose; purified from fungus Aspergillus oryzae Gas, bloating, cramps and diarrhoea
due to inability to digest lactose
‡
Pancreatic enzymes Arco-Lase, Cotazym, Digests food (protein, fat and carbohydrate); purified Cystic fibrosis, chronic pancreatitis,
(lipase, amylase, Creon, Donnazyme, from hogs and pigs pancreatic insufficiency, post-Billroth
protease)5,6 Pancrease, Viokase, II gastric bypass surgery, pancreatic
Zymase duct obstruction, steatorrhoea, poor
digestion, gas, bloating
Immunodeficiencies
‡
Adenosine Adagen Metabolizes adenosine, prevents accumulation of Severe combined immunodeficiency
deaminase166 adenosine; purified from cows disease due to adenosine deaminase
(pegademase deficiency
bovine, PEG-ADA)
‡
Pooled Octagam Intravenous immunoglobulin preparation Primary immunodeficiencies
immunoglobulins167
Other
Human albumin168
‡
Albumarc, Albumin, Increases circulating plasma osmolarity, thereby Decreased production of albumin
Albuminar, AlbuRx, restoring and maintaining circulating blood volume (hypoproteinaemia), increased loss
Albutein, Flexbumin, of albumin (nephrotic syndrome),
Buminate, Plasbumin hypovolaemia, hyperbilirubinaemia
*Continued from TABLE 1. Protein therapeutics are recombinant unless otherwise stated. ‡Non-recombinant.

The Fc region can target a soluble molecule
for destruction because cells of the immune
system can recognize the Fc region, endo­
cytose the attached molecule and break down
the molecule chemically and enzymatically.
When bound to specifically recognized
molecules on the surface of a cell, the Fc
region can target the cell for destruction by
the immune system. Cell killing can be
mediated by macrophages, by other immune
cells or by complement fixation.
Several Group IIa protein therapeutics
have been approved for the treatment of
inflammatory diseases, such as the immuno­
adhesin etanercept, which is a fusion
between two human proteins: tumour necro-
sis factor (TNF) receptor and the Fc region of
the human antibody protein IgG1. The TNF
receptor portion of the molecule binds excess
TNF in the plasma, while the Fc portion of
the molecule targets the TNF for destruction.
By combining these two functions, the drug
neutralizes the deleterious effects of TNF
(a cytokine that stimulates increased activity
of the immune system) and thereby provides
an effective therapy for inflammatory
arthritis and psoriasis68–70. Another Group
IIa protein that targets TNF is infliximab.
This recombinantly produced monoclonal
antibody binds to TNFα, and is used to
neutralize the action of TNFα in inflamma-
tory conditions such as rheumatoid arthritis
and inflammatory bowel disease71–73.

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Perspectives
Table 3 | Protein therapeutics augmenting an existing pathway (Group Ib)*
Therapeutic
Haematopoiesis
Erythropoietin,
Epoetin-α32–36,169,170
Darbepoetin-α14
Filgrastim36, 37
(granulocyte colony stimulating
factor; G-CSF)
Pegfilgrastim171 (Peg-G-CSF)
Sargramostim36, 37 (granulocyte-
macrophage colony stimulating
factor; GM-CSF)
Oprelvekin38
(interleukin11; IL11)
Fertility
Human follicle-stimulating
hormone (FSH)39,40
Human chorionic gonadotropin
(HCG)41
Lutropin-α172
Immunoregulation
Type I alpha-interferon,
interferon alfacon 1, consensus
interferon173–178
Interferon-α2a (IFNα2a)179–183
PegInterferon-α2a184–186
Interferon-α2b (IFNα2b)187–189
PegInterferon-α2b190
Interferon-αn3 (IFNαn3)191,192
‡ Alferon N
Interferon-β1a (rIFN-β)178,193–196
Interferon-β1b (rIFN-β)197–199
Interferon-γ1b (IFNγ)200–204
Aldesleukin205–208
(interleukin 2 (IL2), epidermal
thymocyte activating factor;
ETAF)
*Continued in TABLE 4. Protein therapeutics are recombinant unless otherwise stated. ‡Non-recombinant.
26 | january 2008 | volume 7 www.nature.com/reviews/drugdisc
Trade name Function Examples of clinical use
Epogen, Stimulates erythropoiesis Anaemia of chronic disease, myleodysplasia,
Procrit anaemia due to renal failure or chemotherapy,
preoperative preparation
Aranesp Modified erythropoietin with longer half-life; Treatment of anaemia in patients with chronic
stimulates red blood cell production in the renal insufficiency and chronic renal failure
bone marrow (+/- dialysis)
Neupogen Stimulates neutrophil proliferation, Neutropaenia in AIDS or post-chemotherapy
differentiation and migration or bone-marrow transplantation, severe
chronic neutropaenia
Neulasta Stimulates neutrophil proliferation, Neutropaenia in AIDS or post-chemotherapy
differentiation and migration or bone marrow transplantation, severe
chronic neutropaenia
Leukine Stimulates proliferation and differentiation Leukopaenia, myeloid reconstitution
of neutrophils, eosinophils and monocytes post-bone-marrow transplantation,
HIV/AIDS
Neumega Stimulates megakaryocytopoiesis and Prevention of severe thrombocytopaenia,
thrombopoiesis especially after myelosuppressive
chemotherapy
Gonal-F, Augments ovulation Assisted reproduction
Follistim
Ovidrel Stimulates ovarian follicle rupture and ovulation Assisted reproduction
Luveris Recombinant human luteinizing hormone; Infertility with luteinizing hormone
increases estradiol secretion, thereby deficiency
supporting follicle-stimulating
hormone-induced follicular development
Infergen Mechanism unknown; immunoregulator Chronic hepatitis C infection
Roferon-A Mechanism unknown; immunoregulator Hairy cell leukaemia, chronic myelogenous
leukaemia, Kaposi’s sarcoma, chronic
hepatitis C infection
Pegasys Recombinant interferon-α2a conjugated to Adults with chronic hepatitis C who have
polyethylene glycol (PEG) to increase half-life compensated liver disease and who have not
been previously treated with IFNα; used alone
or in combination with ribavirin
Intron A Mechanism unknown; immunoregulator Hepatitis B, melanoma, Kaposi’s sarcoma,
follicular lymphoma, hairy-cell leukaemia,
condylomata acuminata, hepatitis C
Peg-Intron Recombinant interferon-α2b conjugated to Adults with chronic hepatitis C who have
polyethylene glycol (PEG) to increase half-life compensated liver disease and who have not
been treated previously with IFNα
Mechanism unknown; nonrecombinant human Condylomata acuminata (genital warts
IFNα-n3 purified from pooled human leukocytes caused by human papillomavirus)
Avonex, Mechanism unknown; antiviral and Multiple sclerosis
Rebif immunoregulator
Betaseron Mechanism unknown; antiviral and Multiple sclerosis
immunoregulator
Actimmune Increases inflammatory and antimicrobial Chronic granulomatous disease, severe
response osteopetrosis
Proleukin Stimulates T and B cells, natural killer cells, Metastatic renal cell cancer, melanoma
and lymphokine-activated killer cells
© 2008 Nature Publishing Group
 Perspectives

Table 4 | Protein therapeutics augmenting an existing pathway (Group Ib)*

Therapeutic Trade name Function Examples of clinical use
Haemostasis and thrombosis
Alteplase42–46 Activase Promotes fibrinolysis by binding fibrin and converting Pulmonary embolism, myocardial
(tissue plasminogen plasminogen to plasmin infarction, acute ischaemic stroke, 
activator; tPA) occlusion of central venous access
devices 
Reteplase Retavase Contains the non-glycosylated kringle 2 and protease Management of acute myocardial
(deletion mutein of tPA)47,48 domains of human tPA; functions similarly to tPA infarction, improvement of ventricular
function
‡
Tenecteplase49,50 TNKase tPA with greater specificity for plasminogen Acute myocardial infarction
conversion; has amino-acid substitutions of Thr103 to
Asp, Asp117 to Gln, and Ala for amino-acids 296–299
§
Urokinase209,210 Abbokinase Nonrecombinant plasminogen activator derived from Pulmonary embolism
human neonatal kidney cells
Factor VIIa51,52 NovoSeven Pro-thrombotic (activated factor VII; initiates the Haemorrhage in patients with
coagulation cascade) haemophilia A or B and inhibitors to
factor VIII or factor IX
Drotrecogin-α53,54 Xigris Antithrombotic (inhibits coagulation factors Va and Severe sepsis with a high risk of death
(activated protein C) VIIIa), anti-inflammatory
Endocrine disorders
Salmon calcitonin211,212 Fortical, Mechanism unknown; inhibits osteoclast function Postmenopausal osteoporosis
||
Miacalcin
Teriparatide213–216 Forteo Markedly enhances bone formation; administered as Severe osteoporosis
(human parathyroid a once-daily injection
hormone residues 1–34)
‡||
Exenatide217 Byetta Incretin mimetic with actions similar to glucagon- Type 2 diabetes resistant to treatment
like peptide 1 (GLP1); increases glucose-dependent with metformin and a sulphonylurea
insulin secretion, suppresses glucagon secretion,
slows gastric emptying, decreases appetite (first
identified in saliva of the Gila monster Heloderma
suspectum)
Growth regulation
Octreotide218,219
||
Sandostatin Potent somatostatin analogue; inhibits growth Acromegaly, symptomatic relief of
hormone, glucagon and insulin VIP-secreting adenoma and metastatic
carcinoid tumours
Dibotermin-α220,221 Infuse Mechanism unknown Spinal fusion surgery, bone injury
(recombinant human bone repair
morphogenic protein 2;
rhBMP2)
Recombinant human bone Osteogenic Mechanism unknown Tibial fracture nonunion, lumbar
morphogenic protein 7 protein 1 spinal fusion
(rhBMP7)222
Histrelin acetate223,224
||
Supprelin LA, Synthetic analogue of human GnRH; acts as a potent Precocious puberty
(gonadotropin releasing Vantas inhibitor of gonadotropin secretion when administered
hormone; GnRH) continuously by causing a reversible downregulation of
GnRH receptors in the pituitary and desensitizing the
pituitary gonadotropes
Palifermin225 Kepivance Recombinant analogue of KGF; stimulates Severe oral mucositis in patients
(keratinocyte growth factor; keratinocyte growth in skin, mouth, stomach and undergoing chemotherapy
KGF) colon
Becaplermin226–228 Regranex Promotes wound healing by enhancing granulation Debridement adjunct for diabetic
(platelet-derived growth tissue formation and fibroblast proliferation and ulcers
factor; PDGF) differentiation
Other
§
Trypsin229 Granulex Proteolysis Decubitus ulcer, varicose ulcer,
debridement of eschar, dehiscent
wound, sunburn
Nesiritide230, 231 Natrecor Recombinant B-type natriuretic peptide Acute decompensated congestive
heart failure
*Continued from TABLE 3. Protein therapeutics are recombinant unless otherwise stated. ‡Also classed in Group Ic. §Non-recombinant. ||Synthetic.

nature reviews | drug discovery volume 7 | january 2008 | 27

© 2008 Nature Publishing Group
Perspectives

Some Group IIa proteins are used to treat
infectious diseases. Patients at high-risk for
severe respiratory syncytial virus (RSV)
infection, one of the leading causes of hospital
admissions for paediatric respiratory
illness, are given a recombinant monoclonal
antibody, palivizumab, which binds to
the RSV F protein and thereby directs the
immune-mediated clearance of the virus
from the body74,75. Enfuvirtide is an example
of a Group II protein therapeutic that is not a
monoclonal antibody or an immunoadhesin.
By binding to gp120/gp41 — the HIV
envelope protein responsible for fusion of the
virus with host cells — this 36-amino-acid
peptide prevents the conformational change
in gp41 that is required for viral fusion, and
thereby inhibits viral entry into the cell76–78.

Table 5 | Protein therapeutics providing a novel function or activity (Group Ic)

Therapeutic Trade name Function Examples of clinical use
Enzymatic degradation of macromolecules
*Botulinum toxin Botox Cleaves SNAP25 at neuromuscular junctions to Many types of dystonia, particularly cervical;
type A232,233 disrupt SNARE complex and prevent acetylcholine cosmetic uses
release, causing flaccid paralysis
*Botulinum toxin Myoblock Cleaves synaptobrevin at neuromuscular junctions to Many types of dystonia, particularly cervical;
type B233,234 disrupt SNARE complex and prevent acetylcholine cosmetic uses
release, causing flaccid paralysis
*Collagenase56,57 Collagenase, Collagenase obtained from fermentation by Debridement of chronic dermal ulcers and
Santyl Clostridium histolyticum; digests collagen in necrotic severely burned areas
base of wounds
Human deoxy- Pulmozyme Degrades DNA in purulent pulmonary secretions Cystic fibrosis; decreases respiratory tract
ribonuclease I, infections in selected patients with FVC
dornase-α58 greater than 40% of predicted
*Hyaluronidase Amphadase Catalyses the hydrolysis of hyaluronic acid to Used as an adjuvant to increase the absorption
(bovine, ovine)235 (bovine), Hydase increase tissue permeability and allow faster drug and dispersion of injected drugs, particularly
(bovine), Vitrase absorption anaesthetics in ophthalmic surgery and certain
(ovine) imaging agents
Hyaluronidase Hylenex Catalyses the hydrolysis of hyaluronic acid to Used as an adjuvant to increase the absorption
(recombinant increase tissue permeability and allow faster and dispersion of injected drugs, particularly
human)236 drug absorption anaesthetics in ophthalmic surgery and certain
imaging agents
*Papain55 Accuzyme, Protease from the Carica papaya fruit Debridement of necrotic tissue or liquefication
Panafil of slough in acute and chronic lesions, such as
pressure ulcers, varicose and diabetic ulcers,
burns, postoperative wounds, pilonidal cyst
wounds, carbuncles, and other wounds
Enzymatic degradation of small-molecule metabolites
*l-Asparaginase60 ELSPAR Provides exogenous asparaginase activity, Acute lymphocytic leukaemia, which requires
removing available asparagine from serum; exogenous asparagine for proliferation
purified from Escherichia coli
*Peg-asparaginase59 Oncaspar Provides exogenous asparaginase activity, removing Acute lymphocytic leukaemia, which requires
available asparagine from serum; purified from E. coli exogenous asparagine for proliferation
Rasburicase237 Elitek Catalyzes enzymatic oxidation of uric acid into an Paediatric patients with leukaemia, lymphoma,
inactive, soluble metabolite (allantoin); originally and solid tumours who are undergoing
isolated from Aspergillus flavus anticancer therapy that may cause tumour lysis
syndrome
Haemostasis and thrombosis
Lepirudin61,62 Refludan Recombinant hirudin, a thrombin inhibitor from the Heparin-induced thrombocytopaenia
salivary gland of the medicinal leech Hirudo medicinalis
Bivalirudin238,239
‡
Angiomax Synthetic hirudin analogue; specifically binds both Reduce blood-clotting risk in coronary
the catalytic site and the anion-binding exosite of angioplasty and heparin-induced
circulating and clot-bound thrombin thrombocytopaenia
*Streptokinase63–65,240 Streptase Converts plasminogen to plasmin; produced by Acute evolving transmural myocardial
group C b-haemolytic streptococci infarction, pulmonary embolism, deep vein
thrombosis, arterial thrombosis or
embolism, occlusion of arteriovenous
cannula
*Anistreplase241,242 Eminase Converts plasminogen to plasmin; p-anisoyl group Thrombolysis in patients with unstable angina
(anisoylated protects the catalytic centre of the plasminogen-
plasminogen streptokinase complex and prevents premature
streptokinase activator deactivation, thereby providing longer duration of
complex; APSAC) action than streptokinase
Protein therapeutics are recombinant unless otherwise stated. *Non-recombinant. ‡Synthetic. FVC, forced vital capacity; SNAP25, synaptosomal-associated protein, 25 kDa;
SNARE, soluble N-ethylmaleimide-sensitive factor attachment protein receptor.

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Another area in which Group IIa anti-
bodies have been successful is oncology.
For example, rituximab is a human/mouse
chimeric monoclonal antibody that binds to
CD20, a transmembrane protein expressed on
>90% of B‑cell non-Hodgkin’s lymphomas,
and targets the cells for destruction by the
body’s immune system79–81. Although rituxi-
mab is most often used in combination with
anthracycline-based chemotherapy, it is one
of the few monoclonal antibody anticancer
therapies that is approved as a monotherapy.
Cetuximab is a monoclonal antibody that is
used to treat colorectal cancer and head and
neck cancer; this monoclonal antibody binds
epidermal growth factor receptor (EGFR) and
impairs cancer cell growth and proliferation82.
Other recently developed Group IIa protein
therapeutics are listed in TABLES 6,7, and
many more protein therapeutics utilizing the
exquisite specificity of monoclonal antibodies
are in development, especially for cancer and
inflammatory diseases.
Many important processes are modulated
by cell-surface receptors that are activated
upon binding of their cognate ligands15.
By binding to such receptors, targeted pro-
tein therapeutics may activate cell signalling
pathways and profoundly affect cell func-
tion. Outcomes may range from cell death
(through the induction of apoptosis), to
downregulation of cell division to increased
cell proliferation. Although it has been diffi­
cult to prove that a particular target-binding
protein mediates an in vivo effect through the
modulation of a particular signalling path-
way, in vitro evidence suggests that this type
of modulation is involved in the mechanism
of action of certain therapeutic proteins.
For example, the treatment of certain breast
cancers, in which the malignant cells express
the HER2/Neu (also known as ERBB2) cell
surface receptor, is enhanced by the addition
of trastuzumab (an anti-HER2/Neu mono-
clonal antibody) to the therapeutic regimen83.
Although trastuzumab contains an Fc region
that facilitates antibody-dependent cellular
cytotoxicity mediated by natural killer cells, it
seems unlikely that this is trastuzumab’s only
mechanism of action. Other monoclonal
antibodies, with similar Fc regions and abili-
ties to target breast cancer cells, have failed to
show efficacy in vivo. Trastuzumab, however,
has been shown in vitro to induce intracellu­
lar signalling events that control the growth
of breast cancer cells. It is therefore likely
that a combination of mechanisms accounts
for the therapeutic activity of trastuzumab,
including inhibition of the phosphatidyl­
inositol 3-kinase (PI3K) pathway, inhibition
of angiogenesis and inhibition of HER2
nature reviews | drug discovery volume 7 | january 2008 | 29
receptor cleavage84,85. The complex action of
trastuzumab highlights the fact that, while
modulation of cell physiology through
simple receptor binding may play a role in
the activity of some targeted therapies, the
relative contribution of receptor binding to
the overall efficacy of the therapeutic may be
difficult to dissect.
One of the great challenges in drug ther-
apy is the selective delivery of small-molecule
drugs and proteins to the intended therapeu-
tic target. The body normally uses proteins to
achieve specialized transport and delivery of
molecules. An active area of current research
is focused on understanding the principles of
protein-based, targeted delivery of molecules,
so that these principles can be applied to
modern pharmacotherapy. This strategy is
exploited by protein therapeutics that we
have classified in Group IIb (TABLE 8), such
as gemtuzumab ozogamicin, which links the
binding region of a monoclonal antibody
directed against CD33 with calicheamicin,
a small-molecule chemotherapeutic agent.
By using this therapy, the toxic compound is
selectively delivered to CD33-positive acute
myeloid leukaemia cells, resulting in the
selective killing of these cells86,87. Similarly,
refractory CD20-positive non-Hodgkin’s
lymphoma cells can be destroyed selectively
by ibritumomab tiuxetan, a monoclonal
antibody that is directed against CD20
and linked to a radioactive yttrium isotope
(Y‑90)88. Another example is provided by
denileukin diftitox, which uses a monoclonal
antibody that is directed against the CD25
component of the IL2 receptor to deliver
cytocidal diphtheria toxin to T-cell lym-
phoma cells that express this receptor89,90.
In addition to these current examples,
interesting developments are in progress that
illustrate where the field might be heading.
For example, herpes simplex virus produces
a protein, VP22, which enters human cells.
VP22 has been used in vitro to deliver pro-
teins or other compounds to the nucleus. In
one application, VP22 was used to target the
tumour suppressor protein p53 to cultured
osteosarcoma cells that lacked the p53 gene
(and hence the protein)91. Reintroduction of
p53 led to apoptosis of the cells. It is thought
that a novel and effective therapy for certain
forms of cancer could use protein-based
targeting of the p53 gene. Another area of
research involves the delivery of proteins
and other macromolecules to the CNS,
which is challenging owing to the highly
selective blood–brain barrier (BBB). Animal
experiments have demonstrated, however,
that fusion proteins combining a therapeutic
protein with a protein that naturally has
© 2008 Nature Publishing Group
Perspectives
specific access through the BBB can allow
successful delivery of the therapeutic protein
to the CNS. For example, a fragment of the
tetanus toxin protein that naturally crosses
the BBB has been shown in animal experi-
ments to deliver the enzyme superoxide
dismutase (SOD) to the CNS92. This type of
therapeutic could potentially be used to treat
neurological disorders such as amyotrophic
lateral sclerosis, in which CNS levels of SOD
are reported to be low. Exciting prospects
also exist for the treatment of other disorders
of the CNS in which levels of a particular
protein are abnormal.
Group III: protein vaccines
As recombinant DNA technology was being
developed, great strides were also being
made in understanding the molecular mech-
anisms that allow the immune system to
protect the body against infectious diseases
and cancer. Armed with this new under-
standing, proteins that we have classified in
Group III have been successfully applied as
prophylactic or therapeutic vaccines. TABLE 9
provides selected examples.
For humans to develop effective immunity
against foreign organisms or cancer cells,
immune cells such as helper T cells must be
activated. Immune-cell activation is mediated
by antigen-presenting cells, which display
on their surface specific oligopeptides that
are derived from proteins found in foreign
organisms or cancer cells. Vaccination against
certain organisms such as polio or measles
has most often been achieved by injecting
heat-killed or attenuated forms of these path-
ogens. Unfortunately, these methods have
involved a certain amount of unavoidable risk
of infection or adverse reaction. By specifi-
cally injecting the appropriate immunogenic
(but non-pathogenic) protein components
of a microorganism, vaccines can hopefully
be created that provide immunity in an indi-
vidual without exposing the individual to the
risks of infection or toxic reaction.
Proteins that we have classified in Group
IIIa are used to generate protection against
infectious diseases or toxins. One successful
example is the hepatitis B vaccine93,94. This
vaccine was created by producing recom-
binant hepatitis B surface antigen (HBsAg)
protein, a non-infectious protein of the
hepatitis B virus. When immunocompetent
humans are challenged and rechallenged
with this protein, significant immunity
results in the large majority of individuals.
Similarly, the non-infectious lipoprotein on
the outer surface of Borrelia burgdorferi has
been engineered into a vaccine for Lyme
disease (OspA)95,96. A recently approved
Perspectives

vaccine against human papillomavirus
(HPV) combines the major capsid proteins
from four HPV strains that commonly
cause genital warts (strains 6 and 11) and
cervical cancer (strains 16 and 18)97.
In addition to generating protection
against foreign invaders, recombinant
proteins can induce protection against an
overactive immune system that attacks
its own body or ‘self ’. One theory is that
administration of large amounts of this self-
protein causes the body’s immune system to
develop tolerance to that protein by elimi-
nating or deactivating cells that react against
the self-protein. Proteins that we have

Table 6 | Protein therapeutics that interfere with a molecule or organism (Group IIa)*
Therapeutic Trade name Function Examples of clinical use
Cancer
Bevacizumab243–246 Avastin Humanized mAb that binds all isoforms of VEGFA  Colorectal cancer, non-small-cell lung cancer
Cetuximab140 Erbitux Humanized mAb that binds EGFR  Colorectal cancer, head and neck cancer
Panitumumab 247
Vectibix Human mAb that binds EGFR Metastatic colorectal cancer
Alemtuzumab248 Campath Humanized mAb directed against CD52 antigen on B-cell chronic lymphocytic leukaemia in patients
T and B cells who have been treated with alkylating agents and
who have failed fludabarine therapy
Rituximab79–81, 249–251 Rituxan Chimeric (human/mouse) mAb that binds CD20, Relapsed or refractory low-grade or follicular
a transmembrane protein found on over 90% of B-cell CD20+ B-cell NHL, primary low-grade or follicular
non-Hodgkin’s lymphomas (NHL); synergistic effect with CD20+ B-cell NHL in combination with CVP
some small-molecule chemotherapeutic agents has chemotherapy; diffuse large B-cell CD20+ NHL in
been demonstrated in lymphoma cell lines combination with CHOP or other anthracyline-
based chemotherapy; rheumatoid arthritis in
combination with methotrexate
Trastuzumab84 Herceptin Humanized mAb that binds HER2/Neu cell surface Breast cancer
receptor and controls cancer cell growth
Immunoregulation
Abatacept252 Orencia Fusion protein between extracellular domain of Rheumatoid arthritis (especially when refractory
human CTLA4 and the modified Fc portion of human to TNFa inhibition)
immunoglobulin G1; selective co-stimulation modulator;
inhibits T-cell activation by binding to CD80 and CD86,
thereby blocking interaction with CD28 and inhibiting
autoimmune T-cell activation
Anakinra253–255 Antril, Recombinant interleukin 1 (IL1) receptor antagonist Moderate to severe active rheumatoid arthritis
Kineret in adults who have failed one or more disease-
modifying antirheumatic drug
Adalimumab256,257 Humira Human mAb that binds specifically to TNFα and blocks its Rheumatoid arthritis, Crohn’s disease, ankylosing
interaction with p55 and p75 cell surface TNF receptors, spondylitis, psoriatic arthritis
resulting in decreased levels of inflammation markers
including CRP, ESR, and IL6
Etanercept68–70 Enbrel Dimeric fusion protein between recombinant soluble TNF Rheumatoid arthritis, polyarticular-course
receptor and Fc portion of human immunoglobulin G1 juvenile rheumatoid arthritis, psoriatic arthritis,
ankylosing spondylitis, plaque psoriasis
Infliximab71–73 Remicade Chimeric mAb that binds and neutralizes TNFα, preventing Rheumatoid arthritis, Crohn’s disease, ankylosing
induction of pro-inflammatory cytokines, changes in spondylitis, psoriatic arthritis, plaque psoriasis
endothelial permeability, activation of eosinophils and
neutrophils, induction of acute phase reactants, and
enzyme elaboration by synoviocytes and/or chondrocytes
Alefacept258,259 Amevive Dimeric fusion protein that binds CD2 on the surface Adults with moderate to severe chronic plaque
of lymphocytes and inhibits interaction with LFA3; this psoriasis who are candidates for systemic therapy
association is important for the activation of T lymphocytes or phototherapy
in psoriasis
Efalizumab260,261 Raptiva Humanized mAb directed against CD11a Adults with chronic moderate to severe plaque
psoriasis who are candidates for systemic therapy
or phototherapy
Natalizumab262 Tysabri Mechanism unknown; humanized mAb that binds to the Relapsing multiple sclerosis
α4-subunit of α4β1 and α4β7 integrins, blocking their
interactions with VCAM1 and MadCAM1, respectively
Eculizumab263,264 Soliris Humanized mAb that binds complement protein C5 Paroxysmal nocturnal haemoglobinuria
and inhibits its cleavage to C5a and C5b, preventing the
formation of the terminal complement complex C5b–9
*Continued in TABLE 7. Protein therapeutics are all recombinant. CHOP, cyclophosphamide, hydroxydaunorubicin, oncovin (vincristine), prednisone/prednisolone;
CTLA4, cytotoxicT-lymphocyte-associated antigen 4; CVP, cyclophosphamide, vincristine, prednisone; EGFR, epidermal growth factor receptor; LFA3, leukocyte function-
associated antigen 3; mAb, monoclonal antibody; MadCAM1, mucosal addressin cell adhesion molecule 1; TNF, tumour necrosis factor; VCAM1, vascular cell adhesion
molecule-1; VEGFA, vascular endothelial growth factor A.

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 Perspectives

classified in Group IIIb are used to treat
patients with disorders that arise from
this type of autoimmune phenomenon.
Immunological acceptance of a fetus during
pregnancy represents a special situation
with respect to vaccine use. Occasionally, a
pregnant woman can reject a fetus after she
has been immunized against certain anti-
gens carried by a fetus from a previous preg-
nancy. Administration of an anti-Rhesus D
antigen Ig prevents the sensitization of an
Rh-negative mother at the time of delivery of
an Rh-positive neonate. Because the woman
fails to develop antibodies directed against
the fetal Rh antigens, immune reactions

Table 7 | Protein therapeutics that interfere with a molecule or organism (Group IIa)*
Therapeutic Trade name Function Examples of clinical use
Transplantation
‡
Antithymocyte Thymoglobulin Selective depletion of T cells; exact mechanism Acute kidney transplant rejection, aplastic anaemia
globulin unknown
(rabbit)265–267
Basiliximab268 Simulect Chimeric (human/mouse) IgG1 that blocks Prophylaxis against allograft rejection in renal transplant
cellular immune response in graft rejection by patients receiving an immunosuppressive regimen
binding the alpha chain of CD25 (IL2 receptor) including cyclosporine and corticosteroids
and thereby inhibiting the IL2-mediated
activation of lymphocytes
Daclizumab269 Zenapax Humanized IgG1 mAb that blocks cellular Prophylaxis against acute allograft rejection in patients
immune response in graft rejection by binding receiving renal transplants
the alpha chain of CD25 (IL2 receptor) and
thereby inhibiting the IL2-mediated activation
of lymphocytes
Muromonab- Orthoclone, Murine mAb that binds CD3 and blocks T-cell Acute renal allograft rejection or steroid-resistant cardiac
CD3270–272 OKT3 function or hepatic allograft rejection
Pulmonary disorders
Omalizumab273–275 Xolair Humanized mAb that inhibits IgE binding to Adults and adolescents (at least 12 years old) with
the high-affinity IgE receptor on mast cells and moderate to severe persistent asthma who have a positive
basophils, decreasing activation of these cells skin test or in vitro reactivity to a perennial aeroallergen
and release of inflammatory mediators and whose symptoms are inadequately controlled with
inhaled corticosteroids
Palivizumab74,75 Synagis Humanized IgG1 mAb that binds the A Prevention of respiratory syncytial virus infection in
antigenic site of the F protein of respiratory high-risk paediatric patients
syncytial virus
Infectious diseases§
Enfuvirtide76–78 Fuzeon 36 amino-acid peptide that inhibits HIV entry Adults and children (at least 6 years old) with advanced
into host cells by binding to the HIV envelope HIV infection
protein gp120/gp41
Haemostasis and thrombosis
Abciximab276–278 ReoPro Fab fragment of chimeric (human/mouse) Adjunct to aspirin and heparin for prevention of cardiac
mAb 7E3 that inhibits platelet aggregation by ischaemia in patients undergoing percutaneous coronary
binding to the glycoprotein IIb/IIIa integrin intervention or patients about to undergo percutaneous
receptor coronary intervention with unstable angina not
responding to medical therapy
Endocrine disorders
Pegvisomant279,280 Somavert Recombinant human growth hormone Acromegaly
conjugated to PEG; blocks the growth hormone
receptor
Other||
‡
Crotalidae Crofab Mixture of Fab fragments of IgG that bind Crotalidae envenomation (Western diamondback,
polyvalent and neutralize venom toxins of ten Eastern diamondback and Mojave rattlesnakes,
immune Fab clinically important North American Crotalidae and water moccasins)
(ovine)281,282 snakes
‡
Digoxin immune Digifab Monovalent Fab immunoglobulin fragment Digoxin toxicity
serum Fab obtained from sheep immunized with a digoxin
(ovine)283,284 derivative
Ranibizumab285 Lucentis Humanized mAb fragment that binds isoforms Neovascular age-related macular degeneration
of vascular endothelial growth factor A (VEGFA)
*Continued from TABLE 6. Protein therapeutics are recombinant unless otherwise stated. ‡Non-recombinant. §Purified immune globulins can also be used to mitigate the acute
affects of exposure to an infectious agent. Human immune globulins targeting botulism, cytomegalovirus, hepatitis B, rabies, tetanus, and vaccinia have been approved by the
FDA. ||Two additional antivenins have been approved by the FDA: Antivenin immune globulin (equine) — Latrodectus mactans (black widow spider); Antivenin immune globulin
(equine) — Micrurus fulvius (North American coral snake). Fab, fragment antigen-binding; IgE/G/G1, immunoglobulin E/G/G1; IL2, interleukin 2; mAb, monoclonal antibody;
PEG, polyethylene glycol.

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Perspectives

Table 8 | Protein therapeutics that deliver other compounds or proteins (Group IIb) thyroid stimulating hormone (TSH) is an
important component of the surveillance
Therapeutic Trade name Function Examples of clinical use methods used to detect residual thyroid
Denileukin Ontak Directs the cytocidal Persistent or recurrent cancer cells. Before the advent of recombinant
diftitox89,90 action of diphtheria toxin cutaneous T-cell lymphoma TSH, patients with a history of thyroid cancer
to cells expressing the IL2 whose malignant cells express
were required to stop taking replacement
receptor the CD25 component of the
IL2 receptor thyroid hormone in order to develop a
hypothyroid state to which the anterior pitui-
*Ibritumomab Zevalin A mAb portion that Relapsed or refractory
tiuxetan88 recognizes CD20+ B cells low-grade, follicular, or tary would respond by releasing endogenous
and induces apoptosis transformed B-cell non- TSH. TSH-stimulated cancer cells could then
while the chelation site Hodgkin’s lymphoma (NHL), be detected by radioactive iodine uptake.
allows either imaging (In- including rituximab-refractory Unfortunately, this method required patients
111) or cellular damage by follicular NHL
beta emission (Y-90)
to experience the adverse consequences of
hypothyroidism. Use of recombinant instead
Gemtuzumab Mylotarg Humanized anti-CD33 Relapsed CD33+ acute myeloid of endogenous TSH not only allowed patients
ozogamicin86,87 IgG4k mAb conjugated leukaemia in patients who are
to calicheamicin, more than 60 years old and are to remain on replacement thyroid hormone
a small-molecule not candidates for cytotoxic but also resulted in the improved detection of
chemotherapeutic agent chemotherapy residual thyroid cancer cells105,106.
*Tositumomab Bexxar, Tositumomab is a mAb CD20+ follicular NHL, with Imaging agents are a broad group of
and 131I- Bexxar I-131 that binds CD20 surface and without transformation, protein diagnostics that can be used to help
tositumomab286,287 antigen and stimulates in patients whose disease identify the presence or localization of a
apoptosis. Tositumomab is refractory to rituximab pathological condition. For example, apcitide
coupled to radioactive and has relapsed following
iodine-131 binds CD20 chemotherapy; tositumomab is a technetium-labelled synthetic peptide
surface antigen and and then131I-tositumomab that binds glycoprotein IIb/IIIa receptors on
delivers cytotoxic are used sequentially in the activated platelets and is used to image acute
radiation treatment regimen venous thrombosis107. Caromab pendetide is
Protein therapeutics are all recombinant. *Also classed in Group IIa. IL2, interleukin 2; mAb, monoclonal antibody. an indium‑111-labelled anti-PSA (prostate-
specific antigen) antibody that can be used to
detect prostate cancer108. Protein-based
and pregnancy loss do not occur in subse- diagnostics (both in vivo and in vitro) are imaging agents are often used to detect
quent pregnancies, even when the new fetus mentioned here because they are invaluable otherwise hidden disease so it can be treated
carries the Rh antigens98. in the decision-making process that precedes early when treatment is most likely to
Proteins that we have classified in Group the treatment and management of many dis- succeed. Imaging agents are currently used
IIIc could be used as therapeutic anticancer eases. TABLE 10 provides selected examples. to detect cancer, image myocardial injury or
vaccines. Although there are currently no A classic example of an in vivo diagnostic identify sites of occult infection; these agents
FDA-approved recombinant anticancer is the purified protein derivative (PPD) are presented in more detail in Table 10.
vaccines, there are promising clinical trials test, which determines whether an indi- There are numerous in vitro protein
that use patient-specific cancer vaccines. For vidual has been exposed to antigens from diagnostics and two are presented here as
example, a vaccine for B‑cell non-Hodgkin’s Mycobacterium tuberculosis. In this example, examples of a much larger class. Natural
lymphoma uses transgenic tobacco plants a non-infectious protein component of the and recombinant HIV antigens are essential
(Nicotiana benthamiana)99. Each patient organism is injected under the skin of an components of common screening (enzyme
with this type of lymphoma has a malignant immunocompetent individual100–102. An immunoassay) and confirmatory (western
proliferation of an antibody-producing B‑cell active immune reaction is interpreted as blot) tests for HIV infection. In these tests,
that displays a unique antibody on its surface. evidence that the patient has been previously the antigens serve as ‘bait’ for specific anti-
By subcloning the idiotype region of this infected by M. tuberculosis or exposed to the bodies to HIV gag, pol and env gene prod-
tumour-specific antibody and expressing the antigens of this organism. ucts that have been elicited in the course of
region recombinantly in tobacco plants, a Several stimulatory protein hormones infection109–111. Oral versions of HIV tests
tumour-specific antigen is produced that can are used to diagnose endocrine disorders. have also become available. Hepatitis C
be used to vaccinate a patient. This process Growth hormone releasing hormone infection is diagnosed by using recombinant
requires only 6–8 weeks from biopsy of the (GHRH) stimulates somatotroph cells of the hepatitis C antigens to detect antibodies
lymphoma to a ready-to-use, patient-specific anterior pituitary gland to secrete growth directed against this virus in the serum of
vaccine. As the genomes of infectious organ- hormone. Used as a diagnostic, GHRH can potentially infected patients112,113.
isms and the nature of autoimmune diseases help to determine whether pituitary growth
and cancer are more fully elucidated, more hormone secretion is defective in patients Challenges for protein therapeutics
recombinant proteins will undoubtedly be with clinical signs of growth hormone There are now many examples in which
developed for use as vaccines. deficiency103,104. Similarly, the recombinant proteins have been used successfully thera-
human protein secretin is used to stimulate peutically. Nonetheless, potential protein
Group IV: protein diagnostics pancreatic secretions and gastrin release, and therapies that have failed far outnumber the
Proteins that we have classified in Group thereby aid in the diagnosis of pancreatic exo- successes so far, in part owing to a number of
IV are not used to treat disease, but purified crine dysfunction or gastrinoma. In patients challenges that are faced in the development
and recombinant proteins used for medical with a history of thyroid cancer, recombinant and use of protein therapeutics.

32 | january 2008 | volume 7 www.nature.com/reviews/drugdisc

© 2008 Nature Publishing Group

First, protein solubility, route of admin-
istration, distribution and stability are all
factors that can hinder the successful appli-
cation of a protein therapy114,115. Proteins
are large molecules with both hydrophilic
and hydrophobic properties that can make
entry into cells and other compartments
of the body difficult, and the half-life of
a therapeutic protein can be drastically
affected by proteases, protein-modifying
chemicals or other clearance mechanisms.
One example of how such challenges are
being addressed is through the produc-
tion of PEGylated versions of therapeutic
proteins. For example, PEG-interferon is a
modified form of interferon in which the
polymer polyethylene glycol (PEG) is added
to prolong the absorption, decrease the renal
clearance, retard the enzymatic degradation,
increase the elimination half-life and reduce
the immunogenicity of interferon15.
A second important challenge is that
the body may mount an immune response
against the therapeutic protein116. In some
cases, this immune response can neutralize
the protein and can even cause a harmful
reaction in the patient. For example, immune
responses can be generated against Group
Ia therapeutic proteins used to replace a
factor that has been missing since birth, as
illustrated by the development of antifactor
VIII antibodies (inhibitors) in patients with
severe haemophilia A who are treated with
recombinant human factor VIII117,118. More
commonly, however, immune responses are
generated against proteins of non-human
origin. Until quite recently, the widespread
clinical application of monoclonal antibodies
had been limited by the rapid induction
of immune responses against this class of
therapeutic proteins. The need for antibody
therapeutics that evade immune surveillance
and response has been a driving force in the
maturation of antibody production technol-
ogy. Recombinant technology and other
advances have allowed the development
of various antibody products that are less
likely to provoke an immune response than
unmodified murine antibodies. In human-
ized antibodies, portions of the antibody that
are not critical for antigen-binding specificity
are replaced with human Ig sequences that
confer stability and biological activity on the
protein but do not provoke an anti-antibody
response; and fully human antibodies can be
produced using transgenic animals or phage
display technologies67,119.
The field of cancer therapeutics illus-
trates the pace of advances in monoclonal
antibody development. In the 1980s, most
of the monoclonal cancer therapeutics
nature reviews | drug discovery volume 7 | january 2008 | 33
Perspectives
Table 9 | Protein vaccines (Group III)*
Therapeutic Trade name Function Examples of clinical use
Protecting against a deleterious foreign agent (IIIa)
Hepatitis B surface Engerix, Non-infectious protein Hepatitis B vaccination
antigen (HBsAg)93,94 Recombivax HB on surface of hepatitis
B virus
HPV vaccine97 Gardasil Quadrivalent HPV Prevention of HPV infection
recombinant vaccine
(strains 6, 11, 16, 18);
contains major capsid
proteins from four
HPV strains
OspA95,96 LYMErix Non-infectious Lyme disease vaccination
lipoprotein on outer
surface of Borrelia
burgdorferi
Treating an autoimmune disease (IIIb)
Anti-Rhesus (Rh) Rhophylac Neutralizes Rh Routine antepartum and
immunoglobulin G98 antigens that could postpartum prevention
otherwise elicit anti- of Rh(D) immunization in
Rh antibodies in an Rh(D)-negative women;
Rh-negative individual Rh prophylaxis in case of
obstetric complications or
invasive procedures during
pregnancy; suppression
of Rh immunization in
Rh(D)-negative individuals
transfused with
Rh(D)-positive red blood cells
Treating cancer (IIIc)
– – – Currently in clinical trials
*Selected vaccines highlight the use of recombinant protein technology in vaccine production. Vaccines for the
following agents or diseases are currently approved by the FDA: anthrax, acellular pertussis, BCG (for childhood
TB protection), diphtheria, hepatitis A and B, human papillomavirus (HPV) types 6,11,16,18, influenza types A, B,
and H5N1, Japanese encephalitis, Lyme disease, measles, meningococcus, mumps, plague, pneumococcus, polio,
rabies, rotavirus, rubella, smallpox, tetanus, typhoid, varicella-zoster, and yellow fever (see http://www.fda.gov/
cber/vaccine/licvacc.htm).
were murine, although there were a few The Fc portion extends the half-life of
examples of chimeric antibodies and iso- AMG 531 in the circulation, and the lack
lated instances of humanized and human of sequence homology to thrombopoietin
antibodies in clinical development. During will ideally prevent the development of cross­
the 1990s, humanized and fully human reactive anti-thrombopoietin antibodies — a
antibodies became the most common types serious adverse effect seen with a PEGylated
of antibodies introduced into clinical trials. version of thrombopoietin122,123.
Since 2000, there has been a further increase A third issue is that for a protein to be
in the proportion of antibodies that are fully physiologically active, post-translational
human, with the proportion of murine and modifications such as glycosylation,
chimeric antibodies being introduced into phosphorylation and proteolytic cleavage
clinical trials decreasing accordingly120. are often required124. These requirements
More heavily engineered protein therapies may dictate the use of specific cell types
that are based on human antibodies have also that are capable of expressing and modify-
been developed over the past 10–15 years. ing the protein appropriately. In addition,
One example is the ‘minibody’ AMG 531, recombinant proteins must be synthesized in
which is currently in clinical trials for the a genetically engineered cell type for large-
treatment of immune thrombocytopaenic scale production. The host system must
purpura. This construct consists of an Fc produce not only biologically active protein
region of a human antibody with two copies but also a sufficient quantity of this protein
of a peptide sequence linked to each of its to meet clinical demand124. Also, the system
IgG1 heavy chains. The peptide sequence must allow purification and storage of the
was selected to stimulate the thrombopoietin protein in a therapeutically active form
receptor, yet the sequence has no similarity to for extended periods of time. The protein’s
its endogenous analogue thrombopoietin121. stability, folding, and tendency to aggregate
© 2008 Nature Publishing Group
Perspectives

may be different in large-scale production
and storage systems than in those used to
produce the protein for animal testing and
clinical trials125,126. Some have proposed
engineering host systems that co-express a
chaperone or foldase with the therapeutic
protein of interest, but these approaches
have had limited success.
Potential solutions could include the
development of systems in which entire
cascades of genes involved in protein folding
are induced together with the therapeutic
protein; the impetus for this work is the
observation that plasma cells, which are
natural protein production facilities, use such
gene cascades to produce large quantities of
monoclonal antibody127. Although bacteria
and yeast are generally considered easy to
culture, certain mammalian cell types can be
more difficult and more costly to culture128.
Other methods of production — such as
genetically engineered animals and plants
— could provide a production advantage.
Transgenic cows, goats and sheep have been

Table 10 | Protein diagnostics (Group IV)

Diagnostic
In vivo infectious disease diagnostics
Recombinant purified protein
derivative (DPPD)100–102
Hormones
*Glucagon288,289
‡
Growth hormone releasing
hormone (GHRH)103,104
Secretin290,291
§
Thyroid stimulating hormone
(TSH), thyrotropin105,106
Imaging agents, cancer
Capromab pendetide108
Indium-111-octreotide292
§
Satumomab pendetide293
Arcitumomab294,295
Nofetumomab296
Imaging agents, other
Apcitide107
§
Imciromab pentetate297
Technetium fanolesomab298
Examples of in vitro diagnostics
HIV antigens109–111
Hepatitis C antigens112,113
Protein diagnostics are recombinant unless otherwise stated. *Also classed in Group Ib. ‡Also classed in Group Ia. §Synthetic. CEA, carcinoembryonic antigen; mAb, monoclonal
antibody; PSA, prostate-specific antigen.
Trade name Function Examples of clinical use
DPPD Noninfectious protein from Mycobacterium Diagnosis of tuberculosis exposure
tuberculosis
GlucaGen Pancreatic hormone that increases blood Diagnostic aid to slow gastrointestinal
glucose by stimulating the liver to convert motility in radiographic studies; reversal
glycogen to glucose of hypoglycaemia
Geref Recombinant fragment of GHRH that Diagnosis of defective growth-hormone
stimulates growth hormone release by secretion
somatotroph cells of the pituitary gland
ChiRhoStim (human Stimulation of pancreatic secretions and Aid in the diagnosis of pancreatic exocrine
peptide), SecreFlo gastrin dysfunction or gastrinoma; facilitates
(porcine peptide) identification of the ampulla of Vater
and accessory papilla during endoscopic
retrograde cholangiopancreatography
Thyrogen Stimulates thyroid epithelial cells or well- Adjunctive diagnostic for serum
differentiated thyroid cancer tissue to thyroglobulin testing in the follow-up of
take up iodine and produce and secrete patients with well-differentiated thyroid
thyroglobulin, triiodothyronine and thyroxine cancer
ProstaScint Imaging agent; indium-111-labelled anti-PSA Prostate cancer detection
antibody; recognizes intracellular PSA
OctreoScan Imaging agent; indium-111-labelled Neuroendocrine tumour and lymphoma
octreotide detection
OncoScint Imaging agent; indium-111-labelled mAb Colon and ovarian cancer detection
specific for tumour-associated glycoprotein
(TAG-72)
CEA-scan Imaging agent; technetium-labelled anti- Colon and breast cancer detection
CEA antibody
Verluma Imaging agent; technetium-labelled antibody Small-cell lung cancer detection and
specific for small-cell lung cancer staging
Acutect Imaging agent; technetium-labelled Imaging of acute venous thrombosis
synthetic peptide; binds GPIIb/IIIa receptors
on activated platelets
Myoscint Imaging agent; indium-111-labelled antibody Detects presence and location of
specific for human cardiac myosin myocardial injury in patients with
suspected myocardial infarction
NeutroSpec Imaging agent; technetium-labelled anti- Diagnostic agent (used in patients
CD15 antibody; binds neutrophils that with equivocal signs and symptoms
infiltrate sites of infection of appendicitis)
Enzyme immunoassay, Detects human antibodies to HIV (enzyme Diagnosis of HIV infection
OraQuick, Uni-Gold immunoassay, western blot)
Recombinant immuno- Detects human antibodies to hepatitis C virus Diagnosis of hepatitis C exposure
blot assay (RIBA)

34 | january 2008 | volume 7 www.nature.com/reviews/drugdisc

© 2008 Nature Publishing Group

engineered to secrete protein in their milk,
and transgenic chickens that lay eggs filled
with recombinant protein are anticipated
in the future129. Transgenic plants can inex-
pensively produce vast quantities of protein
without waste or bioreactors130, and potatoes
can be engineered to express recombinant
proteins and thereby make edible vaccines9.
Finally, by using fluid-shaking bioreactors,
microlitre-sized culture systems might be
able to predict the success of large-scale
culture systems and thereby provide substan-
tial cost savings by focusing investment on
systems that are more likely to succeed131.
A fourth important challenge is the costs
involved in developing protein therapies.
For example, switching to recombinant
methodology from laborious purification
of placentally derived protein has allowed
the production of sufficient β-glucocerebro-
sidase to treat Gaucher’s disease in many
patients. Even so, the cost of the
recombinant protein can be greater than
US$ 100,000 per patient per year132.
The example of Gaucher’s disease also
illustrates aspects of a fifth issue associated
with protein therapeutics: ethics (although
these ethical issues are not exclusive to
protein therapeutics). For example, the
possibility of efficacious but expensive protein
therapeutics for small but severely ill patient
populations, such as patients with Gaucher’s
disease, can present a dilemma with respect to
allocation of financial resources of health-care
systems132. In addition, the definition of ill-
ness or disease could be challenged by protein
therapeutics that can ‘improve upon’ condi-
tions previously viewed as variants of normal.
For example, the definition of short stature
may begin to change with the possibility of
using growth hormone to increase the height
of a child133–137.
Conclusion and future directions
Medicine is approaching a new era in which
approaches to manage disease are being made
at the level of the genetic and protein infor-
mation that underlies all biology, and protein
therapeutics are playing an increasingly
important role. Already, recombinant human
proteins make up the majority of FDA-
approved biotechnology medicines, which
include monoclonal antibodies, natural inter-
ferons, vaccines, hormones, modified natural
enzymes and various cell therapies. The
future potential for such therapies is huge,
given the thousands of proteins produced by
the human body and the many thousands of
proteins produced by other organisms.
Furthermore, recombinant proteins not
only provide alternative (or the only)
nature reviews | drug discovery volume 7 | january 2008 | 35
treatments for particular diseases, but can
also be used in combination with small-
molecule drugs to provide additive or syner-
gistic benefit. Treatment of EGFR-positive
colon cancer is illustrative of this point:
combination therapy with the small-molecule
drug irinotecan, which prevents DNA
repair by inhibiting DNA topoisomerase,
and the recombinant monoclonal antibody
cetuximab, which binds to and inhibits the
extracellular domain of the EGFR, results in
increased survival in patients with colorectal
cancer. The therapeutic synergy between
irinotecan and cetuximab may be due to the
fact that both drugs inhibit the same EGFR
signalling pathway, with one drug (cetuxi-
mab) inhibiting the initiation of the pathway
and the other drug (irinotecan) inhibiting a
target downstream in the pathway82,138–140.
The early success of recombinant
insulin production in the 1970s created an
atmosphere of enthusiasm and hope, which
was unfortunately followed by an era of
disappointment when the vaccine attempts,
non-humanized monoclonal antibodies and
cancer trials in the 1980s were largely unsuc-
cessful. Despite these setbacks, significant
progress has been made recently. As well as
the major successes with protein therapeu-
tics described in this article, new production
methods are changing the scale, cost and
even route of administration of recombinant
protein therapeutics. With the large number
of protein therapeutics both in current clini-
cal use and in clinical trials for a range of
disorders, one can confidently predict that
protein therapeutics will have an expanding
role in medicine for years to come.
Benjamin Leader is at the Department of Emergency
Medicine, Brown Medical School, 593 Eddy Street,
Providence, Rhode Island 02093, USA.
Quentin J. Baca and David E. Golan are at the
Department of Biological Chemistry and Molecular
Pharmacology, 250 Longwood Avenue, Harvard
Medical School, Boston, Massachusetts 02115, USA,
and Hematology Division, Brigham and Women’s
Hospital, 75 Francis Street, Boston, Massachusetts
02115.
Correspondence to D.E.G.
e-mail: dgolan@hms.harvard.edu
doi:10.1038/nrd2399  Gastroenterology 87, 1072–1082 (1984).
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Acknowledgements
We thank A. H. Tashjian Jr for many helpful discussions and
expert review of the manuscript. D.E.G. is supported by NIH
grants R37HL032854 and U54HL070819. Q.J.B. is supp­
orted by NIH grant T32GM07753. Portions of this article
have been published in abbreviated form (Golan, D. E. et al.
Principles of Pharmacology: The Pathophysiologic Basis of
Drug Therapy (Lippincott Williams & Wilkins, 2004); Golan,
D.E. et al. Principles of Pharmacology: The Pathophysiologic
Basis of Drug Therapy, 2nd edn (Lippincott Williams &
Wilkins, 2007)), and are adapted with permission.
DATABASES
OMIM:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM
Amyotrophic lateral sclerosis | cervical cancer | colorectal
cancer | cystic fibrosis | diabetes mellitus type I | diabetes
mellitus type II | Fabry disease | haemophilia A | haemophilia B |
hepatitis B | hepatitis C | inflammatory bowel disease | Kaposi’s
sarcoma | prostate cancer | psoriasis | rheumatoid arthritis
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