Say no to drugs: Bioactive macromolecular therapeutics without conventional drugs.

The vast majority of nanomedicines (NM) investigated today consists of a macromolecular carrier and a drug payload (conjugated or encapsulated), with a purpose of preferential delivery of the drug to the desired site of action, either through passive accumulation, or by active targeting via ligand-receptor interaction. Several drug delivery systems (DDS) have already been approved for clinical use. However, recent reports are corroborating the notion that NM do not necessarily need to include a drug payload, but can exert biological effects through specific binding/blocking of important target proteins at the site of action. The seminal work of Kopeček et al. on N-(2-hydroxypropyl)methacrylamide (HPMA) copolymers containing biorecognition motifs (peptides or oligonucleotides) for crosslinking cell surface non-internalizing receptors of malignant cells and inducing their apoptosis, without containing any low molecular weight drug, led to the definition of a special group of NM, termed Drug-Free Macromolecular Therapeutics (DFMT). Systems utilizing this approach are typically designed to employ pendant targeting-ligands on the same macromolecule to facilitate multivalent interactions with receptors. The lack of conventional small molecule drugs reduces toxicity and adverse effects at off-target sites. In this review, we describe different types of DFMT that possess biological activity without attached low molecular weight drugs. We classified the relevant research into several groups by their mechanisms of action, and compare the advantages and disadvantages of these different approaches. We show that identification of target sites, specificity of attached targeting ligands, binding affinity and the synthesis of carriers of defined size and ligand spacing are crucial aspects of DFMT development. We further discuss how knowledge in the field of NM accumulated in the past few decades can help in the design of a successful DFMT to speed up the translation into clinical practice.