Article(id=1198624469112685379, tenantId=1146029695717560320, journalId=1189982191388893191, issueId=1198624466902287155, articleNumber=null, orderNo=null, doi=10.16438/j.0513-4870.2022-1099, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1665331200000, receivedDateStr=2022-10-10, revisedDate=1678550400000, revisedDateStr=2023-03-12, acceptedDate=null, acceptedDateStr=null, onlineDate=1763703942802, onlineDateStr=2025-11-21, pubDate=1681228800000, pubDateStr=2023-04-12, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763703942802, onlineIssueDateStr=2025-11-21, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763703942802, creator=13701087609, updateTime=1763703942802, updator=13701087609, issue=Issue{id=1198624466902287155, tenantId=1146029695717560320, journalId=1189982191388893191, year='2023', volume='58', issue='4', pageStart='1', pageEnd='1092', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1763703942275, creator=13701087609, updateTime=1763704125380, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198625234971619912, tenantId=1146029695717560320, journalId=1189982191388893191, issueId=1198624466902287155, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198625234971619913, tenantId=1146029695717560320, journalId=1189982191388893191, issueId=1198624466902287155, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=867, endPage=874, ext={EN=ArticleExt(id=1198624470203204434, articleId=1198624469112685379, tenantId=1146029695717560320, journalId=1189982191388893191, language=EN, title=Allergic reactions of COVID-19 vaccine based on mRNA-LNP and its pharmacokinetics in vivo, columnId=null, journalTitle=Acta Pharmaceutica Sinica, columnName=null, runingTitle=null, highlight=null, articleAbstract=

Vaccination has been proved to be the most effective strategy to prevent the Corona Virus Disease 2019 (COVID-19). The mRNA vaccine based on nano drug delivery system (NDDS) - lipid nanoparticles (LNP) has been widely used because of its high effectiveness and safety. Although there have been reports of severe allergic reactions caused by mRNA-LNP vaccines, the mechanism and components of anaphylaxis have not been completely clarified yet. This review focuses on two mRNA-LNP vaccines, BNT162b2 and mRNA-1273. After summarizing the structural characteristics, potential allergens, possible allergic reaction mechanism, and pharmacokinetics of mRNA and LNP in vivo, this article then reviews the evaluation methods for patients with allergic history, as well as the regulations of different countries and regions on people who should not be vaccinated, in order to promote more safe injection of vaccines. LNP has become a recognized highly customizable nucleic acid delivery vector, which not only shows its value in mRNA vaccines, but also has great potential in treating rare diseases, cancers and other broad fields in the future. At the moment when mRNA-LNP vaccines open a new era of nano medicine, it is expected to provide some inspiration for safety research in the process of research, development and evaluation of more nano delivery drugs, and promote more nano drugs successfully to market.

, correspAuthors=Bo ZHANG, authorNote=null, correspAuthorsNote=null, copyrightStatement=Copyright ©2023 Acta Pharmaceutica Sinica. All rights reserved., copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, authorCompany=null, fund=null, authors=null, authorsList=Chun-su LIANG, Wei ZUO, Li-ping DU, Bo ZHANG), CN=ArticleExt(id=1198624471532798879, articleId=1198624469112685379, tenantId=1146029695717560320, journalId=1189982191388893191, language=CN, title=mRNA-LNP新冠疫苗过敏反应及其体内药代动力学, columnId=1198624468278018876, journalTitle=药学学报, columnName=专题报道: 纳米药物药代动力学研究, runingTitle=null, highlight=null, articleAbstract=

接种新型冠状病毒感染(Corona Virus Disease 2019, COVID-19) 疫苗在阻止COVID-19中起到了关键作用。基于纳米药物递送系统(nano drug delivery system, NDDS)——脂质纳米粒(lipid nanoparticles, LNP) 的mRNA疫苗因其较高的有效性和安全性已实现了广泛应用。尽管已有基于mRNA-LNP的新冠疫苗严重过敏反应的报道, 但目前过敏反应发生的机制和成分尚未完全明确。本文关注BNT162b2和mRNA-1273两种已上市的mRNA-LNP新冠疫苗, 在讨论其结构特点、潜在的过敏原、过敏反应机制、mRNA和LNP的体内药代动力学之后, 还对有过敏史人群的评估方法, 以及各国家、地区对接种疫苗人群的范围进行综述, 以期在一定程度上促进疫苗的安全接种。LNP已成为一种公认的高度可定制的核酸递送载体, 不仅在mRNA疫苗中显示出价值, 在治疗罕见疾病和癌症等广阔领域更有着巨大的潜力。在mRNA-LNP疫苗开启纳米医学的新时代之际, 期望能为更多纳米递送药物研发及评价过程中安全性研究提供一些启发, 助力更多纳米药物成功实现临床转化。

, correspAuthors=张波, authorNote=null, correspAuthorsNote=
*张波, Tel: 86-10-69156527, E-mail:
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[EB/OL]. 2022 [2023-03-10]. http://www.nhc.gov.cn/cms-search/xxgk/getManuscriptXxgk.htm?id=c2febfd04fc5498f916b1be080905771., articleTitle=null, refAbstract=null), Reference(id=1198702053485806078, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, doi=10.1016/j.vaccine.2022.07.033, pmid=null, pmcid=null, year=2022, volume=40, issue=null, pageStart=5322, pageEnd=5332, url=null, language=null, rfNumber=[64], rfOrder=63, authorNames=null, journalName=Vaccine, refType=null, unstructuredReference=Chen H, Huang Z, Chang S, et al. Immunogenicity and safety of an inactivated SARS-CoV-2 vaccine (Sinopharm BIBP-CorV) coadministered with quadrivalent split-virion inactivated influenza vaccine and 23-valent pneumococcal polysaccharide vaccine in China: a multicentre, non-inferiority, open-label, randomised, controlled, phase 4 trial[J]. Vaccine, 2022, 40: 5322-5332., articleTitle=Immunogenicity and safety of an inactivated SARS-CoV-2 vaccine (Sinopharm BIBP-CorV) coadministered with quadrivalent split-virion inactivated influenza vaccine and 23-valent pneumococcal polysaccharide vaccine in China: a multicentre, non-inferiority, open-label, randomised, controlled, phase 4 trial, refAbstract=null)], funds=[Fund(id=1198702042811302499, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, awardId=2022-PUMCH-B-059, language=CN, fundingSource=中央高水平医院临床科研业务费(2022-PUMCH-B-059), fundOrder=null, country=null), Fund(id=1198702043050377850, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, awardId=2022-PUMCH-B-060, language=CN, fundingSource=中央高水平医院临床科研业务费(2022-PUMCH-B-060), fundOrder=null, country=null), Fund(id=1198702043218150027, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, awardId=2022-PUMCH-A-199, language=CN, fundingSource=中央高水平医院临床科研业务费(2022-PUMCH-A-199), fundOrder=null, country=null), Fund(id=1198702043343979160, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, awardId=2021-I2M-1-003, language=CN, fundingSource=中国医学科学院医学与健康科技创新工程项目(2021-I2M-1-003), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1198702036905721916, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, xref=null, ext=[AuthorCompanyExt(id=1198702036909916221, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, companyId=1198702036905721916, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China), AuthorCompanyExt(id=1198702036918304830, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, companyId=1198702036905721916, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=中国医学科学院, 北京协和医院药剂科, 北京 100730)])], figs=[ArticleFig(id=1198702041628508640, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, language=EN, label=null, caption=null, figureFileSmall=3crsL8huvpFoOO3ro+v7hg==, figureFileBig=3ryZvCipFARJQA9BxArAPg==, tableContent=null), ArticleFig(id=1198702041855001069, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, language=CN, label=Figure 1, caption= Structure of BNT162b2 by Pfizer/BioNTech<sup>[<a href="javascript:;" class="mag_content_a" onclick="piaofuRef(this,'b19')" rid="b19">19</a>]</sup> (A), structure of mRNA-1273 by Moderna<sup>[<a href="javascript:;" class="mag_content_a" onclick="piaofuRef(this,'b19')" rid="b19">19</a>]</sup> (B), and lipid nanoparticle structure<sup>[<a href="javascript:;" class="mag_content_a" onclick="piaofuRef(this,'b21')" rid="b21">21</a>]</sup> (C) , figureFileSmall=3crsL8huvpFoOO3ro+v7hg==, figureFileBig=3ryZvCipFARJQA9BxArAPg==, tableContent=null), ArticleFig(id=1198702042056327686, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, language=EN, label=null, caption=null, figureFileSmall=1bZSAWJLNzZbtA2yEDObUQ==, figureFileBig=7hJWupllliEro9+mdXYgTg==, tableContent=null), ArticleFig(id=1198702042194739732, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, language=CN, label=Figure 2, caption= The sequence of events leading from anti-PEG IgM induction to accelerated blood clearance of PEGylated liposomes<sup>[<a href="javascript:;" class="mag_content_a" onclick="piaofuRef(this,'b53')" rid="b53">53</a>, <a href="javascript:;" class="mag_content_a" onclick="piaofuRef(this,'b58')" rid="b58">58</a>]</sup> , figureFileSmall=1bZSAWJLNzZbtA2yEDObUQ==, figureFileBig=7hJWupllliEro9+mdXYgTg==, tableContent=null), ArticleFig(id=1198702042345734698, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
Description Pfizer-BioNTech BNT162h2 mRNA-LNP SARS-CoV-2 vaccine Moderna 1273 mRNA-LNP SARS-CoV-2 vaccine
Active component[20] mRNA encoding the viral spike (S) glycoprotein of SARS-CoV-2
Carrier or vector[20] PEGylated lipid nanoparticle
mRNA dose[22] 30 μg in 0.3 mL 100 μg in 0.5 mL
LNPs[22] 0.43 mg ALC-0315 (((4-hydroxybutyl) azanediyl)bis (hexane-6, 1-diyl)bis(2-hexyldecanoate)), 0.05 mg ALC-0159 (2-((polyethyleneglycol)-2000)-N,N-ditetradecylacetamide), 0.09 mg DSPC, 0.2 mg cholesterol, total lipids: 2.57 mg·mL-1, 0.77 mg per 0.3 mL dose SM-102 (proprietary ionizable lipid) (heptadecan-9-yl-8-((2-hydroxyethyl) (6-oxo-6-(undecyloxy)hexyl)amino)octanoate), PEG2000-DMG (1-monomethoxypolyethyleneglycol 2000-2, 3-dimyristylglycerol), DSPC, cholesterol, total lipids: 3.86 mg·mL-1, 1.93 mg per 0.5 mL dose
Molar lipid ratios (%) (ionizable cationic lipid ∶ PEGylated lipid ∶ DSPC ∶ cholesterol) 46.3∶1.5∶9.4∶42.7 50∶1.5∶10∶38.5
Molar N/P ratio[22] 6 5
Buffer[22] 0.01 mg phosphate (potassium dihydrogen phosphate, 0.07 mg disodium hydrogen phosphate dihydrate) Tris (tromethamine) (0.31 mg tromethamine, 1.18 mg tromethamine hydrochloride)
Other excipients[22] 0.01 mg potassium chloride, 0.36 mg sodium chloride, 6 mg sucrose, water for injection 0.043 mg acetic acid, 0.12 mg sodium acetate, 43.5 mg sucrose, water for injection
), ArticleFig(id=1198702042505118269, tenantId=1146029695717560320, journalId=1189982191388893191, articleId=1198624469112685379, language=CN, label=Table 1, caption=

Composition of Pfizer-BioNTech and Moderna SARS-CoV-2 mRNA vaccines. DSPC: 1, 2-Distearoyl-sn-glycero-3-phosphocholine; LNPs: Lipid nanoparticles

, figureFileSmall=null, figureFileBig=null, tableContent=
Description Pfizer-BioNTech BNT162h2 mRNA-LNP SARS-CoV-2 vaccine Moderna 1273 mRNA-LNP SARS-CoV-2 vaccine
Active component[20] mRNA encoding the viral spike (S) glycoprotein of SARS-CoV-2
Carrier or vector[20] PEGylated lipid nanoparticle
mRNA dose[22] 30 μg in 0.3 mL 100 μg in 0.5 mL
LNPs[22] 0.43 mg ALC-0315 (((4-hydroxybutyl) azanediyl)bis (hexane-6, 1-diyl)bis(2-hexyldecanoate)), 0.05 mg ALC-0159 (2-((polyethyleneglycol)-2000)-N,N-ditetradecylacetamide), 0.09 mg DSPC, 0.2 mg cholesterol, total lipids: 2.57 mg·mL-1, 0.77 mg per 0.3 mL dose SM-102 (proprietary ionizable lipid) (heptadecan-9-yl-8-((2-hydroxyethyl) (6-oxo-6-(undecyloxy)hexyl)amino)octanoate), PEG2000-DMG (1-monomethoxypolyethyleneglycol 2000-2, 3-dimyristylglycerol), DSPC, cholesterol, total lipids: 3.86 mg·mL-1, 1.93 mg per 0.5 mL dose
Molar lipid ratios (%) (ionizable cationic lipid ∶ PEGylated lipid ∶ DSPC ∶ cholesterol) 46.3∶1.5∶9.4∶42.7 50∶1.5∶10∶38.5
Molar N/P ratio[22] 6 5
Buffer[22] 0.01 mg phosphate (potassium dihydrogen phosphate, 0.07 mg disodium hydrogen phosphate dihydrate) Tris (tromethamine) (0.31 mg tromethamine, 1.18 mg tromethamine hydrochloride)
Other excipients[22] 0.01 mg potassium chloride, 0.36 mg sodium chloride, 6 mg sucrose, water for injection 0.043 mg acetic acid, 0.12 mg sodium acetate, 43.5 mg sucrose, water for injection
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mRNA-LNP新冠疫苗过敏反应及其体内药代动力学
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梁春苏 , 左玮 , 都丽萍 , 张波 *
药学学报 | 专题报道: 纳米药物药代动力学研究 2023,58(4): 867-874
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药学学报 | 专题报道: 纳米药物药代动力学研究 2023, 58(4): 867-874
mRNA-LNP新冠疫苗过敏反应及其体内药代动力学
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梁春苏, 左玮, 都丽萍, 张波*
作者信息
  • 中国医学科学院, 北京协和医院药剂科, 北京 100730

通讯作者:

*张波, Tel: 86-10-69156527, E-mail:
Allergic reactions of COVID-19 vaccine based on mRNA-LNP and its pharmacokinetics in vivo
Chun-su LIANG, Wei ZUO, Li-ping DU, Bo ZHANG*
Affiliations
  • Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
出版时间: 2023-04-12 doi: 10.16438/j.0513-4870.2022-1099
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接种新型冠状病毒感染(Corona Virus Disease 2019, COVID-19) 疫苗在阻止COVID-19中起到了关键作用。基于纳米药物递送系统(nano drug delivery system, NDDS)——脂质纳米粒(lipid nanoparticles, LNP) 的mRNA疫苗因其较高的有效性和安全性已实现了广泛应用。尽管已有基于mRNA-LNP的新冠疫苗严重过敏反应的报道, 但目前过敏反应发生的机制和成分尚未完全明确。本文关注BNT162b2和mRNA-1273两种已上市的mRNA-LNP新冠疫苗, 在讨论其结构特点、潜在的过敏原、过敏反应机制、mRNA和LNP的体内药代动力学之后, 还对有过敏史人群的评估方法, 以及各国家、地区对接种疫苗人群的范围进行综述, 以期在一定程度上促进疫苗的安全接种。LNP已成为一种公认的高度可定制的核酸递送载体, 不仅在mRNA疫苗中显示出价值, 在治疗罕见疾病和癌症等广阔领域更有着巨大的潜力。在mRNA-LNP疫苗开启纳米医学的新时代之际, 期望能为更多纳米递送药物研发及评价过程中安全性研究提供一些启发, 助力更多纳米药物成功实现临床转化。

新冠疫苗  /  过敏反应  /  脂质纳米颗粒  /  信使核糖核酸  /  药代动力学

Vaccination has been proved to be the most effective strategy to prevent the Corona Virus Disease 2019 (COVID-19). The mRNA vaccine based on nano drug delivery system (NDDS) - lipid nanoparticles (LNP) has been widely used because of its high effectiveness and safety. Although there have been reports of severe allergic reactions caused by mRNA-LNP vaccines, the mechanism and components of anaphylaxis have not been completely clarified yet. This review focuses on two mRNA-LNP vaccines, BNT162b2 and mRNA-1273. After summarizing the structural characteristics, potential allergens, possible allergic reaction mechanism, and pharmacokinetics of mRNA and LNP in vivo, this article then reviews the evaluation methods for patients with allergic history, as well as the regulations of different countries and regions on people who should not be vaccinated, in order to promote more safe injection of vaccines. LNP has become a recognized highly customizable nucleic acid delivery vector, which not only shows its value in mRNA vaccines, but also has great potential in treating rare diseases, cancers and other broad fields in the future. At the moment when mRNA-LNP vaccines open a new era of nano medicine, it is expected to provide some inspiration for safety research in the process of research, development and evaluation of more nano delivery drugs, and promote more nano drugs successfully to market.

COVID-19 vaccine  /  allergic reaction  /  lipid nano particle  /  mRNA  /  pharmacokinetics
梁春苏, 左玮, 都丽萍, 张波. mRNA-LNP新冠疫苗过敏反应及其体内药代动力学. 药学学报, 2023 , 58 (4) : 867 -874 . DOI: 10.16438/j.0513-4870.2022-1099
Chun-su LIANG, Wei ZUO, Li-ping DU, Bo ZHANG. Allergic reactions of COVID-19 vaccine based on mRNA-LNP and its pharmacokinetics in vivo[J]. Acta Pharmaceutica Sinica, 2023 , 58 (4) : 867 -874 . DOI: 10.16438/j.0513-4870.2022-1099
截至2023年1月, 世界卫生组织已报告超过6.5亿例COVID-19确诊病例, 其中有660余万例死亡病例[1]。根据美国儿科学会和美国疾病控制与预防中心的数据统计显示COVID-19的总体住院死亡率约为15%~20%, 在需要ICU监护的人群中甚至高达40%, 80至89岁人群的院内病死率更是高于60%[2]。可见高危人群的死亡率相当高, 而接种疫苗无疑是防止新冠疫情扩散蔓延最有效的策略之一。截至2022年7月, 全球共接种了120多亿剂次疫苗[3]。截至2022年4月, 世界卫生组织(WHO) 已认可了10个安全性和有效性符合标准的新冠疫苗, 最早获得WHO可供紧急使用批准的是Pfizer/BioNTech的mRNA疫苗BNT162b2, 其他陆续还批准了阿斯利康公司的腺病毒载体疫苗AZD1222、强生公司的重组蛋白疫苗Ad26.COV2.S、Moderna公司的mRNA疫苗mRNA-1273、韩国SK Bio公司和印度血清研究所的腺病毒载体疫苗Covishield、国药集团的灭活疫苗SARS-CoV-2、北京科兴的灭活疫苗、Bharat公司的灭活疫苗COVAXIN、Novavax的重组蛋白疫苗Covovax以及康希诺公司的腺病毒载体新冠疫苗Ad5-nCoV等[4]
核酸疫苗利用宿主细胞产生编码的蛋白抗原, 通过产生中和抗体和细胞毒性T淋巴细胞来激活免疫系统。与传统的灭活疫苗、重组蛋白亚单位疫苗相比, 其优点有: 可同时刺激细胞免疫和体液免疫, 易于设计, 可快速适应不断变化的病原体菌株, 以及可定制多抗原疫苗等[5]。与DNA疫苗相比, mRNA疫苗有着独特的优势。mRNA不需要穿过核膜, 更容易递送, 且递送目标位置是细胞质, 由于胞质mRNA与基因组没有相互作用, 使得mRNA疫苗兼具了高有效性和高安全性[6, 7]。毋庸置疑的是, 两种mRNA-LNP疫苗的快速开发及上市走通了纳米药物输送系统(NDDS)的临床转化之路, 有学者甚至认为COVID-19带来的mRNA-LNP疫苗大范围使用可能是截至目前纳米医学最辉煌的时刻[8]。毕竟, mRNA疫苗是由NDDS递送的, 如果没有纳米粒子LNP, mRNA疫苗和DNA疫苗的效果将是微乎其微的[9]
但是自2020年12月开始使用mRNA疫苗接种后不久, 就出现了一些过敏反应的报告。根据美国疾病控制与预防中心和美国食品药品监督管理局通过疫苗不良反应报告系统统计, 1 893 360例首次接种Pfizer/BioNTech疫苗的人群中, 有175例严重过敏反应[10], 而在2020年12月21日至2021年1月10日期间接种第一剂Moderna疫苗的4 041 396名受试者中, 有10例出现过敏反应[11]。此处指的疫苗过敏反应是指严重的急性发作, 通常在接种疫苗后通常在几分钟到几小时内发生, 发生率很低。可能出现的格林-巴利综合征、血小板减少症以及自身免疫性疾病的加重或发作等[12-14]。关于mRNA疫苗中导致过敏的组分, 传统的容易引起过敏的疫苗过敏原如天然胶乳(在注射器柱塞和瓶塞中)、卵清蛋白、明胶和乳蛋白等[15]在2种mRNA-LNP疫苗中均不存在, 且除了微量截短和修饰的杂质外, 合成的mRNA也最不可能引发过敏反应, 因此考虑LNP和其他赋形剂是最可疑的过敏原[15-17]
本文主要聚焦两种基于mRNA-LNP的COVID-19疫苗BNT162b2和mRNA-1273, 对二者的结构、潜在的过敏原、可能的过敏反应机制、过敏反应、mRNA和LNP的体内药代动力学进行了综述, 并对不应接种疫苗的人群和有过敏史人群的评估方法进行了总结, 旨在提升对COVID-19疫苗过敏的理解, 帮助科学评估疫苗过敏的原因, 快速准确地实现过敏人群的鉴定, 最终实现更加安全的疫苗使用和全面管理。更重要的是, NDDS在各种类型的药物中应用越来越广泛[18], 而基于纳米技术的mRNA-LNP疫苗的批准无疑是克服临床转化纳米药物艰巨挑战的重要一步, 它的意义不仅在于新冠疫苗的诞生, 而且在于奠定了纳米药物实现临床转化的基础, 而本综述也期望能够在一定程度上促进更多纳米药物的成功开发。
Pfizer/BioNTech的BNT162b2疫苗和Moderna的mRNA-1273疫苗结构示意图分别见图 1AB[19]所示。两种mRNA疫苗都是采用相同的基于编码SARS-CoV-2病毒的刺突糖蛋白技术[20]。LNP是一种具有脂质核心的囊泡(图 1C[21])。mRNA疫苗选择将mRNA包裹在LNP纳米颗粒中主要有两个目的: ①实现mRNA包封。裸mRNA本身不稳定, LNP可以保护mRNA免受细胞外核糖核酸酶的影响; ②促进mRNA转运。给药后在生理pH下颗粒表面为中性, 而一旦细胞转变为更酸性的环境则颗粒表面带正电, 能够促进细胞内mRNA转运[22]。LNP还经历了聚乙二醇(polyethylene glycol, PEG) 化的处理过程, 该过程是将PEG化学附着到LNP表面, 以提高其效率并输送到靶细胞, 并可延长循环半衰期, 提高转染效率和生物利用度[23], 进而影响LNP的半衰期和细胞摄取。与其他纳米载体一样, PEG为LNP提供了一个外部聚合物层, 通过阻止血清蛋白和单核吞噬细胞系统的吸附, 从而延长体内循环时间[24]。此外, PEG还可以防止血液中的纳米颗粒聚集, 以及可以使LNP表面功能化, 而功能化的PEG化脂质能促使LNP与配体或生物大分子生物结合[24]。PEG除了有利于LNP的稳定和生物结合, 其解吸对细胞转染也至关重要, LNP中PEG的脱落可通过血清蛋白(如载脂蛋白和白蛋白) 进行调节, 这些蛋白是LNP受体介导内吞作用的关键效应物[24]
Pfizer/BioNTech的mRNA-LNP新冠疫苗BNT162b2已披露的赋形剂有蔗糖、氯化钠、氯化钾、磷酸氢二钠、磷酸二氢钾和注射用水[25]。在Moderna的mRNA-1273中, 赋形剂则为氨丁三胺、氨丁三醇、乙酸、乙酸钠和蔗糖[26]。尽管大部分赋形剂不属于过敏原, 但有报道认为氨丁三醇可能导致皮肤点刺试验(skin prick test, SPT) 阳性, 引发接触性皮炎[27]。它还曾引发接受钆类造影剂的人群IgE介导的氨丁三醇过敏[28]。并且, 在美国疾病控制与预防中心关于mRNA-1273不良反应的报告中, 也曾观察到10名对疫苗有过敏反应的人群中有2名曾对钆、碘或静脉注射造影剂过敏[11]。因此, 仍有必要对氨丁三胺/氨丁三醇在mRNA-1273疫苗中是否引起全身过敏反应进行进一步研究。由于某些磷脂与过敏(如花粉过敏等) 有关, 赋形剂1, 2-二硬脂酰-sn-甘油-3-磷脂胆碱(DSPC) 是BNT162b2和mRNA-1273疫苗LNP中的磷脂, 迄今为止尚未发现明确由DSPC引起的过敏反应, 但已被指出是可能导致过敏反应的成分[29]
Pfizer/BioNTech疫苗中的LNP由四种成分组成(表 1[20, 22]), Moderna疫苗中的可电离脂质成分尚未披露, 很可能是十七烷-9-基8-((2-羟乙基)(6-氧代-6-(十一烷氧基)己基)氨基)辛酸盐, 根据先前报道的静脉输注PEG纳米药物的一些受试者的过敏反应, 推测ALC-0159 (一种PEG化脂质) 也可能在触发过敏反应中发挥作用[16]
两种mRNA疫苗均含PEG2000包裹mRNA分子的LNP结构。2021年, Sellaturay等[30]首次证明对PEG过敏能引起对Pfizer/BioNTech疫苗的过敏反应。PEG广泛应用于医疗、制药、化妆品、工业和食品产品, 是很多产品的常见成分, 包括伤口敷料, PEG化药物和水凝胶以及片剂, 润滑剂和牙线等[31]。然而, 自1990年以来, 对PEG产生轻微至危及生命的超敏反应(hypersensitivity reactions, HSR) 的报道越来越多。尽管赋形剂早已被怀疑是导致mRNA-LNP疫苗过敏的原因之一, 但由于成分名称标准化程度低、相关研究不足等多方面的原因, 对PEG及其潜在过敏原的认识仍然发展较慢[31]。PEG的致敏阈值取决于其分子量和浓度, PEG的分子量通常介于200至35 000 kDa之间, 低分子量(< 400 kDa) 的PEG通常以透明的黏性液体形式存在, 而高分子量(> 1 000 kDa) 的PEG通常以不透明的固体和粉末形式存在, 分子量超过100 000 kDa的产品被称为聚环氧乙烷或聚氧化乙烯[32]。低分子量的PEG可引起迟发性超敏反应, 即反复接触可引起接触性皮炎或皮疹[33]。由于有研究发现一些人群只对某些分子量的PEG过敏, 而对其他分子量的PEG不过敏, 因此, Cabanillas等[20]建议将引起反应的指标药物中所含PEG产物的分子量作为诊断流程的一部分, 并可以尝试探索PEG的致敏阈值。
免疫介导的不良反应(immune-mediated adverse effects, IMAE) 属于I型速发型超敏反应(immediate-type hypersensitivity, ITH), 通常在几分钟内发生。轻度至重度过敏症状的分子机制可能因病例而异。这种类型的反应被称为假变态反应、类过敏反应或补体激活相关假变态反应(complement activation-related pseudoallergy, CARPA) 等[34]。mRNA-LNP疫苗潜在的具体过敏机制可能包括以下几种[22]
有三种补体激活途径: 经典途径、甘露糖和替代性抗体(IgM或某些IgG) 途径、甘露糖结合凝集素和C3b结合触发途径[34]
许多人类细胞类型可产生补体蛋白, 统称为细胞内补体或局部补体, 它们不同于血浆中存在的补体, 它们位于细胞内并可通过细胞内蛋白酶切割。在对抗原的先天和适应性反应过程中产生的促炎细胞因子, 可能触发细胞内补体激活[35]。除此之外, 过敏毒素(anaphylatoxins) 可能在增强类过敏反应中也起作用[16]。补体级联反应会导致很多小多肽如C3a、C4a和C5a等的产生, 这些也被称为过敏毒素, 属于炎症介质, 可以激活各种骨髓细胞, 包括肥大细胞和嗜碱性粒细胞[36]
肥大细胞是髓系来源的粒细胞, 位于连接组织中, 含有组胺、肝素、蛋白酶和细胞因子的颗粒。抗原特异性IgE分子能触发肥大细胞脱颗粒[22]
细胞因子是免疫刺激的生物标志物, 是免疫原性产生的重要前提。与补体系统类似, 激活先天免疫细胞能够提高疫苗疗效。然而, 过度激活可能导致细胞因子风暴和细胞因子介导的宿主组织损伤[37]
CARPA和HSR可能与血小板释放生物活性分子(如ATP、血栓素和趋化因子) 和脂质因子(例如血小板活化因子, platelet-activating factor, PAF) 有关。尽管PAF半衰期很短, 但它是炎症的中心, 能使血管周围肥大细胞脱颗粒, 从而导致炎症反应和组织损伤, 导致血栓素和血清素的释放[38]
氧化应激与某些药物(如磺胺类) 的HSR有关, 是纳米颗粒介导毒性的常见原因[39]。活性氧自由基可以作为危险信号, 引发免疫细胞产生免疫反应[40]
这是一种以B细胞免疫球蛋白生产不足、补体系统过度活动为特征的疾病。CVID患者可能容易发生mRNA-LNP疫苗引发的补体介导的毒性[41]
已知人HLA类型与许多疾病有关, 使一些特定人群更容易对某些类型的药物产生HSR[42]
mRNA-LNP疫苗注射后体内mRNA的药代动力学研究已有一些动物实验结果, 主要集中在mRNA-LNP疫苗注射后mRNA体内吸收、组织分布、蛋白表达等方面。
Bahl等[43]探究了肌肉注射和皮内注射两种给药途径的mRNA疫苗在小鼠中的药代动力学, 结果表明, 肌肉注射给药后, 注射部位肌肉的浓度最大, t1/2约为18.8 h。浓度第二高的是近端淋巴结, tmax为8 h, t1/2为25.4 h, 相对较长。这表明了mRNA是通过淋巴系统从注射部位分布到全身循环。其他组织中浓度较高的主要是脾脏和肝脏。在剩余的组织和血浆中, mRNA的水平低于以上组织100到1 000倍。皮内注射给药后, 注射部位皮肤内的浓度最高, 估计t1/2为23.4 h, 表明mRNA可能通过近端引流淋巴结消散至体循环, 与肌肉注射一致。在远端组织中, 脾脏的浓度最高。而在心脏、肾脏、肝脏和肺中只发现微量的mRNA。总的来说, 无论是注射皮内注射还是肌肉注射, 都能够观察到局部沉积效应, 随后排入局部淋巴结并随后在淋巴系统中循环。Bevers等[44]的研究表明, 在非人类灵长类中主要分布在脾脏。通过评估LNP在雌性和雄性食蟹猴体内的mRNA分布发现, mRNA主要存在于脾脏, 其次是肝脏、骨髓、引流淋巴结和肺, 且与给药剂量无关。另一项针对mRNA纳米疫苗的动物实验结果表明, 小鼠皮下注射后24 h, 肝脏、肺、淋巴结和对侧淋巴结中表现出较强的积累[45]。有研究者认为, 局部浸润至给药部位和引流淋巴结是通过LNP/mRNA诱导中性粒细胞、单核细胞和树突状细胞来实现的。而这些细胞有效地内化LNP, 主要是与单核细胞和树突状细胞说翻译的mRNA和上调关键的共刺激受体(CD80和CD86) 有关[46]。Maruggi等[47]的一项针对自扩增mRNA的SARS-CoV-2候选疫苗在临床前模型中的研究通过定量逆转录聚合酶链反应(qRT-PCR) 分析接种大鼠组织中mRNA的分布, 第2天在肌肉、淋巴结和脾脏中检测到相对较高水平的mRNA, 到第60天在淋巴结、脾脏和肌肉中仍然可以检测到。此外, Maier等[48]的研究表明, 连接LNP后的脂质在大鼠体内耐受性相当高, 相当于有效剂量水平的100至1 000倍, 显示出显著的治疗指数。由于mRNA疗法的迅速兴起导致监管标准有些滞后, RNA治疗药物的体内组织分布研究的监管指南仍在逐步完善的过程中[49]
关于mRNA在体内的表达情况, Bahl等[43]通过在小鼠中肌肉注射和皮内注射配方荧光素酶mRNA, 发现表达呈剂量依赖性。给药后6 h在远端组织中观察到峰值。肌肉注射和皮内注射的最大表达量和最大表达时间, 没有显著差异, 两种途径的表达时间进程也相似, 只是表达的分布略有变化。所有剂量水平均观察到给药部位以外的表达, 肌肉注射给药后更为明显。Pardi等[50]研究表明小鼠肌肉注射后1~4天内在肝脏中可检测到产生的蛋白。
mRNA-LNP制剂的安全性与LNP体内药代动力学有关。脂质成分可能在全身或局部给药后激活宿主免疫反应, PEG化脂质可以通过刺激复合系统来诱导超敏反应[51]。PEG在LNP周围提供了一个空间屏障, 即水合区, 它的亲水性减少了调理蛋白在LNP表面的吸附, 从而减少了肝脏和脾脏中单核吞噬细胞系统(mononuclearphagocyte system, MPS) 对颗粒的吸收, 进而延长了其血液循环时间。而PEG聚合物可能触发抗PEG抗体的产生, 导致后续给药中出现加速血液清除(accelerated blood clearance, ABC) 现象[52], 也就是反复给药导致的蓄积作用启动了MPS对PEG稳定的“隐形”脂质体的识别。有了ABC现象, 在首次注射后的一定时间间隔内再次给药时, LNP会迅速从循环中清除。ABC现象是体内药代中非常值得关注的问题, 因为它不仅会降低反复给药后包封药物或PEG修饰蛋白的治疗效果[53], 还可能会改变PEG化纳米颗粒中包裹的药物的生物利用度和生物分布从而导致不良反应[54], 其中就包括mRNA-LNP疫苗的过敏反应。注射次数会影响LNP的体内药代动力学行为, 有报道表明预先注射PEG化脂质体可以改变反复注射PEG化脂质体的循环时间[55, 56]。Abu Lila等[53]的研究表明时间间隔、第三次注射、PEG表面密度、链长、尺寸和表面电荷、脂质剂量、给药方式、物种、包封药物、纳米载体结构和成分等都会对ABC现象产生影响。用于mRNA传递的LNP制剂很少使用超过1.5 mol%的PEG2000[52]。Ishida等[57]发现, 在第一次注射脂质体前进行脾切除的大鼠中, ABC现象完全消失, 在这些大鼠中, 血清IgM浓度以及与PEG化脂质结合的IgM量显著降低。表明脾切除术可减弱ABC现象, 证实脾脏在ABC现象的诱导阶段起着关键作用(图 2[53, 58])。Abu Lila等[53]研究表明, 脾脏在诱导ABC现象过程中起着关键作用的原因很可能是脾脏中产生PEG特异性的IgM。Kozma等[58]研究表明, 抗PEG抗体能够触发CARPA经典途径启动, 进而导致过敏反应, 至少在PEG化脂质的情况下是如此。而Stavnsbjerg等[59]已报道, 患者体内预先存在的抗PEG的IgG在给药后会引起严重过敏反应, 且过敏反应的严重程度与抗PEG的IgG水平相关。由此推测, PEG很可能是通过影响脾脏中产生的PEG特异性抗体(IgM和IgG) 浓度, 进而影响mRNA-LNP疫苗过敏反应的强弱。未来无抗原性的PEG替代品有可能会成为研究热点, 而现阶段, 检测患者体内的抗PEG抗体可能有助于严重过敏反应的风险控制。
总的来说, mRNA-LNP疫苗的体内药代动力学过程尚不十分明确, 纳米药代动力学还需要更深入更广泛的研究。了解纳米药物在局部和全身的药代动力学, 可以进一步明确下游免疫反应的结合过程, 建立配方设计、人群个体、治疗结果之间的联系, 进而促进有效性和安全性的进一步优化, 同时也为更多纳米药物的快速研发提供数据支持。
Sellaturay等[32]总结了5例严重PEG过敏人群的病例, 其中1例导致心脏骤停, 而在确诊PEG过敏前, 5名人群都被误诊为对药物过敏。因此, 如何实现PEG过敏人群的快速准确鉴别是目前我们面临的重要挑战。Sellaturay等[32]还提出了一种排查PEG过敏的算法, 旨在最大限度地减少全身过敏反应的风险。Rutkowski等[33]提出了新冠疫苗接种中心的创新过敏支持模型, 该模型允许大多数严重过敏人群接种, 能够降低被拒绝接种的风险, 最大限度地为过敏反应高风险的人群提供保护。为了实现安全接种、及时接种、经济接种的最终目标, Rutkowski等[33]还提出了一种实用算法, 用于调查对当前批准的冠状病毒疫苗中的赋形剂有过敏史的人群以及对第一剂疫苗有过敏反应的人群[33]。随着过敏检测数据的逐步积累, 这些算法可能会被进一步简化, 更适于推广。
各个国家及地区的学会和组织对于不应接种疫苗的人群的划分不尽相同。欧洲过敏及临床免疫学会(EAACI) 认为, 除有任何对COVID-19疫苗的过敏反应史的人群外, 其他人群无接种禁忌[60]。英国免疫接种绿皮书建议, 不应将该疫苗接种给先前对同一剂量的COVID-19疫苗和/或COVID-19疫苗的任何成分有过全身过敏反应(包括速发型过敏反应) 的人。任何有其他过敏(如食物过敏) 的人都可以接种疫苗[61]。WHO对公众接种疫苗的建议(2022年4月13日更新) 不应该接种疫苗的三种类型为: 对COVID-19疫苗的任何成分有严重过敏反应/过敏性休克史的人群; 在预约接种疫苗的当天体温超过38.5 ℃的人群, 需等到康复后再接种疫苗; 目前已确诊或怀疑感染了COVID-19的人群, 需等到规定的隔离期结束且已没有急性症状后再接种疫苗[62]。2021年3月29日, 中国疾病预防控制中心发布了《新冠病毒疫苗接种技术指南(第一版)》[63], 其接种禁忌中提到的不能接种的人群过敏种类有: ①对疫苗的活性成分、任何一种非活性成分、生产工艺中使用的物质过敏者, 或以前接种同类疫苗时出现过敏者; ②既往发生过疫苗严重过敏反应者(如急性过敏反应、血管神经性水肿、呼吸困难等)。尽管并没有具体到PEG等赋形剂, 但第一条可以解释为对PEG等赋形剂过敏者不能接种。
目前, 我国科学家已进行了新冠灭活疫苗与四价流感疫苗、23价肺炎多糖疫苗的同时接种免疫原性与安全性评价, 联合免疫可以增加易感人群免疫机会, 提高接种效率, 有助于疾病的控制, 但多种疫苗同时接种的过敏反应仍有待于进一步研究[64]。mRNA-LNP疫苗作为近几年新上市的纳米药物和生物制品, 可能引起严重的、可能致命的不良反应, 这是一个亟待解决的公共卫生问题, 向疫苗研发、卫生健康、疾病控制、药物监管等机构都提出了新的挑战。由于LNP过敏患者正在逐渐增多, 而医生及药师对此知之甚少。所有医院急诊科的医护人员都应了解LNP过敏鉴别及防治方法, 谨慎管理可能过敏的患者并防止死亡病例的出现。全科医生和药师还应在给LNP过敏患者开处方或药品调剂前, 检查药物是否含有LNP。电子病历系统也应该及时更新, 以便于准确记录LNP过敏患者及其避免使用的药物等信息。
本文通过对BNT162b2和mRNA-1273两种mRNA-LNP疫苗的结构特点、可能的过敏机制和过敏原进行综述, 旨在促进纳米药物过敏反应的进一步研究, 以更好地了解其免疫发病机制和病理生理, 不仅对当前COVID-19疫苗广泛接种的安全性至关重要, 而且对其他基于核酸的病毒、癌症、罕见病等的早期疫苗开发具有重要意义。更重要的是, 基于NDDS的mRNA-LNP疫苗的批准为开发更复杂的给药系统奠定了基础, 例如主动靶向系统和联合药物输送系统。除了PEG修饰纳米粒子表面以帮助避免聚集和免疫清除外, 纳米粒子的表面区域还可以与疾病特异性受体的靶蛋白进行功能化结合。mRNA-LNP疫苗的大量生产、销售和管理无疑已经启动了人类历史上最大规模的纳米医学研究, 目前, mRNA-LNP疫苗大规模第4阶段临床试验已经开始, 正在逐渐实现从“纳米医学的未知风险”向“纳米医学如何实现临床解决方案”的范式转变[9], 纳米医学和纳米药学未来的发展和应用值得期待。
作者贡献: 梁春苏主要负责撰写文章, 左玮、都丽萍、张波为文章逻辑及内容的修改提出意见。
利益冲突: 所有作者均声明不存在利益冲突。
  • 中央高水平医院临床科研业务费(2022-PUMCH-B-059)
  • 中央高水平医院临床科研业务费(2022-PUMCH-B-060)
  • 中央高水平医院临床科研业务费(2022-PUMCH-A-199)
  • 中国医学科学院医学与健康科技创新工程项目(2021-I2M-1-003)
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2023年第58卷第4期
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doi: 10.16438/j.0513-4870.2022-1099
  • 接收时间:2022-10-10
  • 首发时间:2025-11-21
  • 出版时间:2023-04-12
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  • 收稿日期:2022-10-10
  • 修回日期:2023-03-12
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中央高水平医院临床科研业务费(2022-PUMCH-B-059)
中央高水平医院临床科研业务费(2022-PUMCH-B-060)
中央高水平医院临床科研业务费(2022-PUMCH-A-199)
中国医学科学院医学与健康科技创新工程项目(2021-I2M-1-003)
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    中国医学科学院, 北京协和医院药剂科, 北京 100730

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2种不同金属材料的力学参数

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total species (%)

Genus
种数
Number of
species
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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