text: Consistently producing ligand-targeted liposomes through traditional methods is difficult. The process can be tedious, challenging to control and result in a poorly defined system. Using the ‘post-insertion’ technique that involves micelles formed from PEG-linked ligands incubated with pre-formed, drug-loaded, non-targeted liposomes and they combine to form LTLs can limit the associated manufacturing challenges.
  	When using certain ligands, such as antibodies, the risk for an immunological reaction poses a risk. Liposome design including size, charge, morphology, composition, surface characteristics, and dose size can all influence the immune response to administered LTLs. The ligands used can elicit an immune response when introduced into the body. For example, when peptide ligands such as CDX are used for brain-targeted delivery systems, they are immunogenic and trigger an immune response. Complement Activation-Related Pseudo-allergies (CARPA) is a hypersensitivity syndrome that can be triggered when LTLs activate the innate immune system and the complement system. CARPA can cause many side effects including anaphylaxis, cardiopulmonary distress, and facial swelling. These side effects have the potential to be severe, which generates concern when administering LTLs to patients with health problems, especially cardiovascular issues. This reaction can be reduced by slowing infusion rates or incorporating the use of allergy medicines like antihistamines into the treatment regimen.
  	Due to the immune response, LTLs can experience the accelerated blood clearance (ABC) phenomenon. This phenomenon is more common in repeated dosage usage of LTLs, such as multi-dose PEGylated formulas, because of immunological memory. The pharmokinetics and clearance rates of the second dose have been shown to be significantly reduced while accumulation in the spleen and liver increases. This poses challenges for clinical applications of LTLs that require multiple doses to be effective.
  Ligand-targeted liposomes need specific conditions to remain intact for use. Controlling environmental factors such as temperature and pH is necessary to maintain the integrity of the molecules. This can be helpful for temperature-sensitive or pH-dependent drug release conditions but is harmful if the pH changes at an inopportune time.  This technology can also be used in combination with enzymes such as in Gal-Dox, which releases active doxorubicin in combination with β-Galactosidase.  Making sure the compound does not encounter the enzyme too early is also important for effective usage.
  There is a possibility that LTLs lead to immunosuppression. LTLs are cleared through the RES which is part of the innate immune system. Macrophage saturation to remove the liposomes could impact the ability of the phagocytic cells to function properly to conduct immune functions. Significant immune suppression has not been observed in clinical cases for therapeutic doses of LTLs containing non-cytotoxic drugs.