Individual combinations of danger signals synergistically increase FVIII product immunogenicity

INTRODUCTION: The most severe side effect in haemophilia A treatment is the development of antifactor VIII antibodies, also called inhibitors. Why inhibitors develop in a proportion of treated patients while others are unaffected still remains unanswered. The presence of immunological danger signals, associated with events such as infection or surgery, has been proposed to play a role. Previous studies demonstrated that the presence of the bacterial molecule lipopolysaccharide (LPS) can synergistically increase the activation of human DC and subsequent T cell activation by FVIII. AIM AND METHODS: In the present study, we investigated whether a combination of two danger signals can further increase immune cell activation by FVIII. For this, human in vitro differentiated DC that were treated with combinations of danger signals were co-cultured with autologous primary T cells, and T cell proliferation was analysed. RESULTS: Interestingly, by combining LPS with a second danger signal, lower LPS concentrations were sufficient to synergistically increase DC and subsequent T cell activation by FVIII. Of note, a combination of LPS and the double-stranded RNA, polyinosinic-polycytidylic acid (poly(I:C)), was most potent in increasing FVIII immunogenicity, followed by LPS + R848 (resiquimod). However, a combination of LPS and the bacterial lipopeptide Pam3CysSK4 did not induce increased immune cell activation by FVIII. CONCLUSION: Thus, individual combinations of danger signals can increase FVIII product immunogenicity. This should be considered in the treatment routine of haemophilia A patients.