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11 PEGylation ofTherapeutic Proteins andPeptides
327
heterogeneity often observed with lysine chemistry is considerably reduced, even though total selectivity is not seen. Because amino groups in proteins have a compa­rable propensity to PEG amines and may thus form cross-linked aggregates, reduc­tive alkylation involving PEG-amine is challenging. In these circumstances, PEG-hydrazides are more advantageous. The amino groups in proteins are mostly protonated in an acidic environment (approximate pH 5). Still, because PEG­hydrazide is a weaker base than primary amines (pKa, about 3), the reaction is selec­tive for the synthesis of PEG-hydrazone (Wang etal. 2018). Using an N-terminal serine or threonine, which may be oxidized by periodate into a glyoxylic derivative, is another strategy for site-specic conjugation (Gaertner and Offord 1996).
11.3.2.2 Cysteine Conjugation
Because agents that preferentially react with cysteines have been created and because there are far fewer free cysteine residues on the surface of proteins than there are lysine residues, PEGylation targeting free cysteine in proteins is the pri­mary method for site-specic modication (Gaertner and Offord 1996). Genetic engineering can insert one or more free cysteines into native proteins that do not contain any. This method can enable site-specic PEGylation in protein regions, minimizing biological activity loss but reducing immunogenicity (Byrne et al.
2021). This tactic has several drawbacks, however. For instance, the possibility of
improper disulde generation and protein dimerization increases when free cyste­ines are inserted by genetic engineering (Gunnoo and Madder 2016).
Various PEG derivatives, each with unique benets and drawbacks, have been produced using cysteine residues. Starting with PEG-vinyl sulfone (PEG-VS) at mildly basic circumstances (pH7–8), PEG-VS slowly reacts with thiols to create a robust thioether bond with the protein. The reaction will occur more rapidly if the pH is raised. While stable in aqueous systems, PEG-VS may interact with lysine residues at high pH levels (Morpurgo etal. 1996).
Unlike PEG-VS, the PEG-maleimide (PEG-MAL) is unstable in water and can initiate ring-opening reactions or the addition of water molecules to the double bond. The thioether bond between the PEG-MAL and proteins is stable, although hydrolysis can slowly cleave one of the amide links. However, it is more active in thiols even in slightly acidic pH6–7 (Fontaine etal. 2015). Through nucleophilic substitution, PEG-iodoacetamide (PEG-IA) progressively interacts with free thiols to form a persistent thioether bond. To prevent the production of free iodine, which might react with other amino acids, the reaction should be carried out in a dark container with a small molar excess of PEG-IA [74]. Lastly, to create a disulde bond with the protein, ortho-pyridyl disulde-PEG (PEG-OPSS) can be used to interact with sulfhydryl groups in both acidic and basic environments (pH3–10). These disulde links are stable, except when transformed to thiols in a reducing environment (Kunstelj etal. 2013).
11.3.2.3 Serine, Threonine, andTryptophan Conjugation
A periodate oxidation reaction can produce glyoxylic groups by targeting the N-terminal positions of serines and threonines. The susceptibility of 1, 2- amino alcohols towards periodate oxidation affects this process (Kolate etal. 2014). The N-terminal serine
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residue was previously subjected to a site-specic PEGylation procedure, which involved oxime ligation of aminooxy and hydrazide PEG derivatives and sodium per­oxide for oxidation. Interleukin-8 (IL-8), granulocyte colony- stimulating factor (G-CSF), and IL-1r preserved their biological activity after PEGylation.
Strong reaction conditions, which frequently cause protein denaturation in conjugation protocols, or decreased reaction yields are the main problems. Much focus has recently been placed on the bioorthogonal alteration of the side chains of aromatic amino acids. Tyrosine, in particular, is a desirable target for protein modication due to its relative rarity (as opposed to certain other sensi­tive endogenous amino acids like lysine) and capacity for alteration without changing charge. The alkylation reaction of tyrosine residues catalyzed by pal­ladium is one technique for modifying proteins. This process modies PPDs in an aqueous medium at room temperature using electrophilic intermediates such as π-allyl produced via allylic acetate and carbamate predecessors (Tilley and Francis 2006).
Other strategies for tyrosine-targeted posttranslational modications using ani­line derivatives were also developed, which allows the tyrosine’s phenol group to react as a nucleophile. The diazonium coupling procedure has been discovered, in which the phenol of tyrosine residues in proteins is coupled to a diazonium salt made from aniline derivatives. Tyrosine residues have been targeted by diazonium in the polymer coupling of medically necessary proteins and peptides (Jones etal.
2012). Another method is the Mannich-type reaction, which allows for highly
selective tyrosine residue alteration at the ortho position on the phenol group. At a pH range of 5.5–6.5, Mannich-type reactions occur under gentle circumstances with millimolar reagent concentration. Both techniques use aniline derivatives to target tyrosine in milder, biocompatible, and metal-free environments (Szijj etal. 2020).
Peptides with N-terminal tryptophan residues can be changed using the Pictet– Spengler procedure with an aldehyde in a solution of glacial acetic acid. The cre­ation of a stable C-C bond occurs in just one step as a result of this reaction, which involves the oxidation of the N-terminal amino group to imine and the cyclic con­densation of an aldehyde and the α-amine as well as the indole functionality of a tryptophan residue (Turecek etal. 2016). For example, researchers created folic acid (FA) and monoclonal antibody (mAb) conjugates utilizing a tryptophan (Trp)­selective process, which produced relatively consistent results when compared to other approaches. The mAb-FA conjugates signicantly killed cancer cells express­ing the folate receptor, proving that the conjugates still carried out the Fc region’s primary purpose (Tagawa etal. 2020).
11.3.2.4 Enzymatic Tools forSelective PEGylation
Enzymes have special selective, specic, and catalytic properties. They have not been used to their full potential in chemistry up to this point, but enormous strides could be made with this method soon (Sato 2002). Regarding the application of enzymes for selective PEGylation, one method, namely transglutaminase, has pro­duced signicant outcomes and sparked several PEGylation investigations. Recently,
11 PEGylation ofTherapeutic Proteins andPeptides
329
PEG chains were covalently linked at the glutamine (Gln) protein residue’s carbox­amide group using the transglutaminase (TGase) enzyme (Mero etal. 2009). TGases are an enzyme type that can catalyze an acyl transfer between two proteins using the glutamyl group of glutamine as the acyl donor and a primary amine as the acyl acceptor, typically the ε-amino of lysine. It is important to emphasize that glutamine cannot be altered chemically without tagging other residues or impairing the struc­ture of the protein. Because TGase has stringent constraints for the amino acid sequence and substrate exibility, this enzymatic conjugation is selective (Fontana etal. 2008). Thus, just one or two of the many glutamines in a protein typically meet the requirements for TGase catalysis.
A new method known as glycopegylation for site-directed PEGylation that attaches PEG to O-glycans using glycosyltransferases is proposed. Proteins pro­duced in Escherichia coli without glycosylation undergo enzymatic GalNAc gly­cosylation at specied serine and threonine residues. Then, sialic acid conjugated with PEG is transferred enzymatically to the GalNAc residues. The method was used with three therapeutic polypeptides that are currently used in clinical settings: granulocyte colony-stimulating factor (G-CSF), interferon-alpha2b (IFN-alpha2b), and granulocyte/macrophage colony-stimulating factor (GM-CSF) (Defrees etal.
2006). Because between 80–90% of eukaryotic PPDs are acetylated at the
N-termini, the specic modication of the α-amine employing subtiligase is a powerful method in proteomics to enrich novel N-termini originating from proteo­lytic recognition and fragmentation. This benet might be utilized for the novel application of selectively attaching PEG-modied peptides and proteins to increase conjugation effectiveness (Weeks and Wells 2020). Butelase 1, a productive aspar­agine and aspartate-specic cysteine-ligase, was discovered in the medicinal plant Clitoria ternatea. Butelase 1 was only recently identied, yet it has already been used for various things, including protein engineering and modication (Nguyen etal. 2015). Other enzymes, such as tubulin tyrosine ligase, N-myristoyl transfer­ase, biotin ligase, and lipoid acid ligase, have also been used for protein bioconjugation.
11.4 Critical Parameters toConsider forProtein PEGylation

11.4.1 Binding Affinity

PEGylation may have a range of effects on a protein’s binding afnity, from an increase to a decrease to having no effect at all. For instance, PEGylated Trypsin and Amino Oxidase exhibit higher activity when used with low-molecular-weight sub­strates. These ndings were attributed to either a positive change in the three­dimensional structure or an improved afnity for the substrates due to the altered microenvironment the amphiphilic PEG produced (Monfardini etal. 1995). Pegaptanib is an aptamer that targets vascular endothelial growth factor (VEGF). This protein causes pathological neovascularization of the eye and increased vascular permeabil­ity, contributing to a particular type of macular degeneration. The rst anti-VEGF
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aptamer used to bind the protein displayed the typical aptamer drawback of a limited half-life caused by nuclease degradation and a fast kidney clearance rate. Conjugation to a 40kDa branching PEG increased the plasma half-life and lengthened tissue reten­tion while reducing binding afnity by a factor of four. PEGylation allows delayed vitreous humor diffusion, increasing effectiveness and lowering systemic exposure (Ng etal. 2006). A humanized antitumor necrosis factor (TNF) monoclonal antibody marketed as certolizumab pegol is a PEGylated Fab fragment that binds to and neu­tralizes membrane-bound or soluble membrane TNFa. In this instance, the conjuga­tion with a branching PEG allows for the retention of recognition ability, a long blood circulation period, and perhaps even a decrease in immunogenicity.
Furthermore, because the Fab segment is targeted for site-specic PEGylation at a location distant from the antigen-binding site, the compound retains biologic activity while exhibiting the same afnity for TNF as the original antibody. PEG2 maleimide with a molecular weight of 40kDa serves as the reagent for the conjuga­tion, which takes place at a single, free thiol cysteine residue. In April 2008, the FDA authorized certolizumab pegol to treat people with moderate to severe Crohn’s disease (Schreiber 2011). G120K, in which a lysine was put in place of glycine, was the rst growth hormone mutant to be investigated as an antagonist. G120K, like the growth hormone itself, had a relatively short half-life but binds the growth hormone receptor with great afnity while blocking signal transmission. Its plasma circula­tion time was increased by performing a randomized conjugation with PEG 5kDa. This conjugation resulted in a protein with a low afnity for the receptor and a half­life of roughly 100hours. Further mutations were added to lessen the number of possible PEG binding sites to address this (Fishburn 2008).

11.4.2 Altered Biological Activity

PEGylation can occasionally change the biological features of the protein; for exam­ple, PEGylated cholesterol oxidase and esterase swap specicity from total choles­terol to HDL cholesterol (Sugiuchi etal. 1995). This concept has been exploited in developing a commercial kit for HDL cholesterol assay. After being PEGylated, IL-15 competes with other ligands for receptor binding (Pettit et al. 1997). Peglgrastim’s self-regulating pharmacokinetics illustrates how PEGylation changes biological characteristics (Finck etal. 2020). Similarly, the PEGylation of growth hormone altered the activity from agonist to antagonist (Yowell and Blackwell 2002).

11.4.3 Physicochemical Modifications

PEGylation causes numerous physicochemical changes in biomolecules. Since PEG comprises ethylene oxide subunits that absorb three water molecules, the hydrodynamic volume has increased (Bailon and Won 2009). Furthermore, aggre­gation may result from charge alteration (such as acylation), which is more apparent
11 PEGylation ofTherapeutic Proteins andPeptides
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when assessed after incubating at higher temperatures. Less aggregation occurs when the charge on the alpha-amino group is preserved after PEGylation. PEGylation may also conceal charges and glycosylation capabilities, reducing the ability of RES and hepatocytes to phagocytose PEG-induced epitope shielding on proteins may lessen immunogenicity and proteolytic breakdown (Baumann etal. 2014).

11.4.4 PEG Size

The only polymer used for several years was 5 kDa in size and was also end-capped by the methoxyl group and terminated by the hydroxyl group. Despite it becoming evident that the size of the polymer has a signicant impact on assessing the biologi­cal behavior of PEG conjugates, this has not been the case for many years. This decision was made since the polymer is simple to activate, and conjugation may be carried out not simply by professional polymer scientists but also in biological labo­ratories (Plesner etal. 2011).
Also, it was understood that the mass of attached PEG was crucial in determining how long it remained in the blood. One large PEG chain, or several tiny PEG chains, can be added to the protein to achieve the necessary mass. Due to the strong poly­dispersity and considerable amount of diol contaminants in the samples, conjuga­tion was troublesome for a very long time creating heterogeneity in the nished product (Wang etal. 2020a). Commercializing a puried, low polydisperse, acti­vated, extremely high-weight polymer (30–40kDa) that was far more ideal for medical applications helped solve this issue later in the 1990s. Pharmaceutical PEG should range in polydispersity from 1.01 for a 5 kDa product to 1.1 for a 50kDa product, considering that the value is 1.00 for a monodisperse product.

11.4.5 PEG Structure

PEGs can be created in linear, branching, Y-shaped geometries, or multi-arm. It was discovered that the shape of the connected protein is just as crucial to its biological function as its weight or the binding chemistry (Veronese etal. 1997). The “Y”-shaped branched PEG substantially enhances the PEG shielding function on a protein surface, making it more successful at defending the conjugated protein against proteolytic enzymes and antibodies. The increased steric hindrance hinders the PEG from reaching the enzyme’s active site or other less accessible locations vital to biological activity. Enzyme active sites are frequently hidden in clefts inaccessible to bulky molecules. By utilizing hindered branched PEGs, this property can be used to prevent the active site from being modied during the PEGylation procedure. Compared to linear PEGs, branching PEGs have limited access to buried sites due to their structure, which helps preserve the enzymatic function. Also, the “umbrella-like” design of branching PEGs shields the proteins from deterioration to a larger extent and provides a higher level of surface protection per point of attachment (Veronese etal. 1997).
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11.5 Purification ofPEGylated Proteins
PEGylated proteins must be puried to extract the end product from complex mix­tures. It is necessary to separate the specic PEG–protein conjugate from unreacted proteins, proteins that have been over-PEGylated, unreacted PEG reagent, and addi­tional reagents that will eventually be incorporated into the PEGylation mixture. Typically, one seeks to take advantage of variances in physicochemical features while constructing a bioseparation method. Variability in charge, hydrodynamic radii, hydrophobicity, and, in some circumstances, afnity is used for the separation of the target PEG-protein. The complexity of the PEGylation mixture often deter­mines how effectively the purication procedure produces the necessary homogene­ity of the product (Veronese etal. 1997).
Column chromatography, particularly size exclusion chromatography (SEC) and ion-exchange chromatography (IEC), is used to purify most PEGylated proteins. The small amount of sample that can be loaded and the low mobile-phase ow velocity are constraints on SEC, a technique focused on the solute difference in size. As a result, it is typically utilized for analytical separations. IEC is centered around charge differences, with uncharged PEG being able to protect the protein’s intrinsic charge to a greater extent as PEGylation levels rise (Yoshimoto and Yamamoto
2012). Unfortunately, the separation speed is slowed down by the diffusion limita-
tion of column-based IEC based on porous particle chromatography. PEGylated proteins typically have a binding capability on IEC media that is weaker than native proteins. Both charge shielding and an increase in hydrodynamic radius, which reduces diffusivity, have been used to explain this phenomenon. While this makes it simple to separate native proteins and PEGylated proteins practically, it is challeng­ing to fractionate multiple PEGylated forms.
A puried protein sample that has been PEGylated poses two different categories of purifying difculties. In the rst, PEG-proteins are separated from other reaction products, such as but not exclusively unreacted PEGs and proteins. The second involves sub-fractionating PEG-proteins according to positional isomerism and the amount of PEGylation in both. Making such separations may seem simple, but several PEG polymer-related issues might make it more difcult (Fee and Van Alstine 2006).

11.6 PK Profiling

The two most crucial elements that affect the concentration of PEG-modied thera­peutics in blood circulation are molecular weight and injection site. The elimination rates from the injection point are intraperitoneal (IP)>subcutaneously (SC)>intra­muscularly (IM) [109]. The drug delivered as IM injection forms a reservoir at the injection site and progressively diffuses into the bloodstream; to a smaller degree, the same is true for the drug administered SC.As PEG’s molecular mass increases, the elimination rate for SC and IM reduces. The pharmacokinetic characteristic of the PEG adducts is signicantly inuenced by the mode of delivery (Veronese and Mero 2008).
11 PEGylation ofTherapeutic Proteins andPeptides
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A two-compartment model of biodistribution suggests that the relatively small PEG translocates readily between circulation to extravascular cells and back again through diffusion. In contrast, large PEG translocates much more poorly (Hamidi etal. 2006). On the other hand, relatively high-weight PEG circulates in the blood for a prolonged period while urine clearance is lowered. Regardless of molecular weight, PEG accumulates in tissues and organs (such as muscle, skin, bone, and, to a greater extent, the liver). PEG uptake increases by the Küpffer cells when the weight reaches 50kDa. Small and linear PEG are distributed all over the body with a high distribution volume, whereas branched PEG is distributed to a lesser extent, mainly in the liver and spleen (Witt etal. 2001).
The primary motivation for protein modication, especially PEGylation, is regulating protein PK properties, focusing on the elimination and half-life exten­sion. Rodents, usually rats that are big enough to provide the time course sam­pling necessary for PK prole determination, are typically used for the initial screening of PK properties. A universal analytical approach for identifying the conjugate in complicated biological materials is required to accurately and satis­factorily quantify the concentration of the PEG protein conjugate over time in blood sera. Thus, the preferred technique continues to be the protein-specic ELISA, which is typically sold commercially and has antibodies targeted to the conjugated protein (Kozma etal. 2020). Since these ELISAs can only detect the protein portion, they are less sensitive to PEGylated proteins than their counter­parts that are not PEGylated. This reduced sensitivity is one of their fundamental limitations.
Reduced sensitivity results from PEGs’ tendency to conceal crucial amino acid positions for receptor binding, which reduces the strength of the interaction between the receptor and the target antibody. The afnity for the antibodies is typically reduced by large PEGs and multi-PEGs connected to protein, which causes a less steep dose–response curve. It is crucial to utilize the same pure PEG-conjugate for the standard plot to prevent errors in the concentration of PEG–protein conjugates that are determined. Thus, the standard curve obtained from puried PEG-conjugate should be used to compute the nal quantities of PEG-conjugates in blood serum. Instead, the un-PEGylated protein should not be utilized as a comparison .
11.7 Passive andActive Targeting
The targeting mechanisms of polymeric therapeutic PPDs might be passive or active. This property is mainly exploited in the treatment of cancer. Passive target­ing is demonstrated by the EPR-induced accumulation of PEG-modied drugs inside permeable tumors. EPR’s passive targeting is enhanced by active targeting, which also increases selectivity. By receptor-mediated endocytosis, targeting moi­eties attached to the polymer backbone can further distinguish between healthy and malignant cells.
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The effectiveness of passive targeted drug delivery techniques mostly depends on the concentration gradient between intracellular and extracellular areas. With leaky vasculature and inadequate lymphatic drainage, PEG conjugates take advan­tage of the increased permeation and retention (EPR) phenomenon demonstrated by tumors and accumulate in the pathophysiological microenvironment of tumor arter­ies (Greish 2007). This size-dependent effect cannot be explored with low­molecular- weight proteins that rapidly extravasate and cause systemic toxicity. PEGylation enhances solubility, molecular mass, size, and serum stability. PEGylation is regarded as one of the most remarkable techniques for the passive targeted delivery of anticancer treatments for all these reasons.
The idea behind active drug targeting is to couple drug molecules to targeting agents (antibodies, ligands, etc.) to specically engage with the structures on the cell surface and deliver an anticancer agent where needed. The targeting and linker molecules on the prodrug govern how it will behave within the body. Also, based on the linker molecules, the drug can enter the tumor cell in one of two ways: either receptor-mediated endocytosis, which involves internalizing the entire prodrug for later destruction by the endosomal/lysosomal route, or receptor-independent inter­nalization, which occurs following extracellular dissociation of the prodrug (Filpula and Zhao 2008). Figure 11.4 represents the mechanism of internalization of the PEGylated PPDs.
Fig. 11.4 The mechanism of internalization of PEGylated PPDs
11 PEGylation ofTherapeutic Proteins andPeptides
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11.8 Analytical Methods forCharacterization
Analysis techniques for PEG protein adducts and PEG reagents are needed at differ­ent phases of the development process to create a safe and effective PEGylated ther­apy. To successfully develop PEGylated therapies, properly characterizing PEG reagents, which serve as a critical raw material, is imperative. PEG reagent quality can vary signicantly depending on molecular weights, polydispersity, impurity presence, and activation degree. NMR is often employed to determine the functional groups both qualitatively and quantitatively, and it is the release method chosen by all manu­facturers to determine the terminal activity of activated PEGs. A derivatization pro­cess is required to achieve UV absorbance because most PEG reagents are UV transparent and non-uorescent. Reversed-phase (RP)-HPLC, for instance, can be used to test methoxy-PEG aldehyde after it has been derivatized with 4-aminobenzoic acid (Zhang et al. 2014b). The variation in molecular mass of PEG chains can be determined using reverse phase chromatography and Size Exclusion Chromatography in conjunction with corona detection mode, enabling impurity detection in the nal PEG reagent. The molecular weight of PEG, which affects the protein’s nal half-life and directly impacts the bioavailability of PEGylated medicines, is another aspect of PEG that needs to be carefully managed (Wang etal. 2020b). The same technique is employed to identify polydispersity and the major peak fraction in PEG.
The complete characterization of the PEG-protein conjugates during the PEGylated therapeutics production process is a very challenging job. Beginning with the evaluation of PEGylated reaction mixtures, it continues with the analysis of each fraction throughout purication and ends with thorough nal product characteriza­tion. The characterization of PEGylated PPDs is affected by the reality that the asso­ciated PEG signicantly modies the protein’s properties. As was already mentioned, the most noticeable effects of PEGylation are a higher hydrodynamic volume and larger molecular size. Many techniques, including SEC, electrophoretic techniques, light scattering, and mass spectrometry, can be used to measure the molecular weight of proteins and PEG-protein conjugates (Caserman etal. 2009). Peptide mapping and MS are utilized to identify and quantify PEGylation sites via analyzing PEGylated and unPEGylated counterparts as well as to characterize impurities that are not always resolved and detected using simpler techniques (Kemptner etal. 2010).

11.9 FDA-Approved PEGylated Products

PEGylated medications treat conditions like cancer, chronic renal disease, hepatitis, hemophilia, and gastrointestinal issues. FDA approved the sale of ADAGEN, a PEGylated protein Enzon Pharmaceuticals produced in March 1990. Several PEGylated PPDs have followed in ADAGEN’s footsteps since its release, and many more are currently through clinical trials or other phases of research. Neulasta and Cimzia, two of the FDA-approved medications, reached $3.221 billion and $1.953 billion in sales in 2019. It is important to note that all medications approved by the FDA involve methoxypolyethylene glycol. Table 11.1 represents the marketed PEGylated PPDs.
336
Reference
(2020)
Year of
approval
Average MW of
PEGs
N. Akojwar et al.
etal. (2021)
4 × 10kDa 2021 Maniatis etal. (2022)
40kDa 2021 Shah etal. (2022)
20kDa 2020 Yang etal. (2021)
20kDa 2019 (Cornes etal. 2020)
20kDa 2018 Webster etal. (2020)
20kDa 2018 Selby etal. (2021)
G-CSF Febrile neutropenia 3.4kDa 2022 Schwartzberg etal.
Company PEGylated entity Indications
Trade Name
Table 11.1 Marketed PEGylated products
Rolvedon Spectrum
G-CSF Neutropenia 20kDa 2022 Humphreys etal. (2022)
Pharmaceuticals
Stimufend Fresenius Kabi G-CSF Neutropenia 20kDa 2022 Panda etal. (2023)
Fylnetra Amneal pharmaceuticals
LLC
deciency
BESREMi PharmaEssentia Corp Interferon Polycythemia vera 40kDa 2021 Okikiolu etal. (2023)
Skytrofa Ascendis Human growth hormone Growth hormone
hemoglobinuria (PNH)
with chemotherapy
Hemophilia A 40kDa 2019 Ezban etal. (2020)
antihemophilic factor
Empaveli Apellis Pentadecapeptide Paroxysmal nocturnal
Nyvepria Pzer Inc. G-CSF Neutropenia associated
Esperoct Novo Nordisk Recombinant
Ziextenzo Sandoz G-CSF Infection during
chemotherapy
chemotherapy
Phenylketonuria ~ 9 X 20kDa 2018 Patrawala etal. (2020)
Recombinant
Udenyca Coherus biosciences G-CSF Infection during
Palynziq BioMarin
ADA-SCID 80kDa 2018 Carbonaro- Sarracino
phenylalanine ammonia
lyase
Pharmaceutical
Revcovi Leadiant bioscience Recombinant adenosine
chemotherapy
deaminase
Fulphila Mylan GmbH G-CSF Infection during
Asparlas Servier pharma L-asparaginase Leukemia 31–39 × 5kDa 2018 Bender etal. (2021)