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Puetz J. Emergent data influences the risk/benefit assessment of hemophilia gene therapy using recombinant adeno-associated virus. Front Med (Lausanne) 2023; 10:1256919. [PMID: 38020165 PMCID: PMC10667906 DOI: 10.3389/fmed.2023.1256919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
After decades of investigation, gene therapy has received regulatory approval to treat hemophilia. However, since gene therapy investigations were initially conceived, other avenues of treatment have revolutionized the care of hemophilia. Emergent data is showing that gene therapy may not be as beneficial as hoped and more toxic than planned. At a minimum, a reassessment of risk/benefit estimate of gene therapy for hemophilia is needed.
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Affiliation(s)
- John Puetz
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Saint Louis University School of Medicine, St. Louis, MO, United States
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2
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Di Minno G, Spadarella G, Maldonato NM, De Lucia N, Castaman G, De Cristofaro R, Santoro C, Peyvandi F, Borrelli A, Lupi A, Follino M, Guerrino G, Morisco F, Di Minno M. Awareness of individual goals, preferences, and priorities of persons with severe congenital haemophilia A for a tailored shared decision-making approach to liver-directed gene therapy. A practical guideline. Blood Rev 2023; 62:101118. [PMID: 37544828 DOI: 10.1016/j.blre.2023.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/26/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
In clinical medicine, shared decision making (SDM) is a well-recognized strategy to enhance engagement of both patients and clinicians in medical decisions. The success of liver-directed gene therapy (GT) to transform severe congenital haemophilia A (HA) from an incurable to a curable disease has launched a shift beyond current standards of treatment. However, GT acceptance remains low in the community of HA persons. We argue for both persons with haemophilia (PWH) and specialists in HA care including clinicians, as needing SDM-oriented educational programs devoted to GT. Here, we provide an ad hoc outline to implement education to SDM and tailor clinician information on GT to individual PWHs. Based on routine key components of SDM: patient priorities; recommendations based on individual risk reduction; adverse effects; drug-drug interactions; alternatives to GT; and ongoing re-assessment of the objectives as risk factors (and individual priorities) change, this approach is finalized to exploit efficacious communication.
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Affiliation(s)
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Naples, Italy.
| | - Nelson Mauro Maldonato
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy
| | - Natascia De Lucia
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Section of Haemorrhagic and Thrombotic Diseases, Department of Medicine and Translational Surgery, Sacred Heart University, Rome, Italy..
| | - Cristina Santoro
- Ematologia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy.
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy.
| | - Anna Borrelli
- Direzione Sanitaria, AOU "Federico II" Napoli, Italy
| | - Angelo Lupi
- Federazione delle Associazioni Emofilici (FedEmo), Milan, Italy.
| | | | | | | | - Matteo Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Naples, Italy.
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3
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Astermark J, Baghaei F, Strandberg K, Toplican PG, Birkedal MF, Grahn EE, Hansson C, Kampmann P, Lehtinen AE, Täckström K, Holme PA, Magnusson M. Infrastructural considerations of implementing gene therapy for hemophilia in the Nordic context. Ther Adv Hematol 2023; 14:20406207231202306. [PMID: 37859645 PMCID: PMC10583513 DOI: 10.1177/20406207231202306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/18/2023] [Indexed: 10/21/2023] Open
Abstract
Background Despite improvements in hemophilia care, challenges remain, including treatment burden and impaired quality of life. Gene therapy may overcome these. However, its introduction presents a challenge. Objectives To outline a function-based gene therapy working model describing critical milestones associated with gene therapy handling, administration, and follow-up to facilitate and implement an effective infrastructure for gene therapy introduction. Design Literature review and consensus discussion among Hemophilia Comprehensive Care centers (HCCCs) in the Nordic region. Methods Representatives from six HCCCs sought to pinpoint milestones and key stakeholders for site readiness at the pre-, peri-, and post-infusion stages, including authority and genetically modified organism (GMO) product requirements, awareness, medical eligibility, logistics and product handling for infusion, laboratory monitoring, and follow-up. Results A gene therapy transit map was developed with key stakeholders identified. The approach to prepare the vector will differ between the Nordic centers, but the contracted pharmacy unit will be a key stakeholder. Therefore, a pharmacy checklist for the implementation of gene therapy was developed. For the future, Advanced Therapy Medicinal Product centers will also be implemented. Patients' expectations, commitments, and concerns need to be addressed repeatedly and education of patients and the expanded health-care professionals team will be the key to successful and optimal clinical management. Eligibility testing according to the product's summary of product characteristics and frequent follow-up and monitoring post-infusion according to the World Federation of Hemophilia chart will be crucial. Conclusion The approach to deliver gene therapy in the Nordic region will differ partly between the hemophilia centers, but the defined road map with checklists for the implementation of this advanced therapy will be applicable to all. The map may also serve as a platform for the use of future GMO product options both within and outside the area of hemophilia.
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Affiliation(s)
- Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Jan Waldenströms gata 14, Malmö, SE-205 02, Sweden
| | - Fariba Baghaei
- Department of Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Strandberg
- Division of Laboratory Medicine, Department of Clinical Chemistry and Pharmacology, Coagulation, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | | | - Maj Friberg Birkedal
- Department of Pediatric Hematology/Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Emma Engman Grahn
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | | | - Peter Kampmann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Anna-Elina Lehtinen
- Coagulation Disorders Unit, Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | | | - Pål Andre Holme
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria Magnusson
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Clinical Chemistry and Blood Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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4
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Ling Q, Herstine JA, Bradbury A, Gray SJ. AAV-based in vivo gene therapy for neurological disorders. Nat Rev Drug Discov 2023; 22:789-806. [PMID: 37658167 DOI: 10.1038/s41573-023-00766-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 09/03/2023]
Abstract
Recent advancements in gene supplementation therapy are expanding the options for the treatment of neurological disorders. Among the available delivery vehicles, adeno-associated virus (AAV) is often the favoured vector. However, the results have been variable, with some trials dramatically altering the course of disease whereas others have shown negligible efficacy or even unforeseen toxicity. Unlike traditional drug development with small molecules, therapeutic profiles of AAV gene therapies are dependent on both the AAV capsid and the therapeutic transgene. In this rapidly evolving field, numerous clinical trials of gene supplementation for neurological disorders are ongoing. Knowledge is growing about factors that impact the translation of preclinical studies to humans, including the administration route, timing of treatment, immune responses and limitations of available model systems. The field is also developing potential solutions to mitigate adverse effects, including AAV capsid engineering and designs to regulate transgene expression. At the same time, preclinical research is addressing new frontiers of gene supplementation for neurological disorders, with a focus on mitochondrial and neurodevelopmental disorders. In this Review, we describe the current state of AAV-mediated neurological gene supplementation therapy, including critical factors for optimizing the safety and efficacy of treatments, as well as unmet needs in this field.
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Affiliation(s)
- Qinglan Ling
- Department of Paediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jessica A Herstine
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Paediatrics, The Ohio State University, Columbus, OH, USA
| | - Allison Bradbury
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Paediatrics, The Ohio State University, Columbus, OH, USA
| | - Steven J Gray
- Department of Paediatrics, UT Southwestern Medical Center, Dallas, TX, USA.
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5
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Limjoco J, Thornburg CD. Development of a haemophilia A gene therapy shared decision-making tool for clinicians. Haemophilia 2023; 29:1184-1190. [PMID: 37401924 DOI: 10.1111/hae.14822] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/22/2023] [Accepted: 06/18/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION As gene therapies are incorporated into clinical practice, shared decision-making (SDM) is recommended for implementation. AIM To inform development of a clinician SDM tool for haemophilia A gene therapy. METHODS Clinicians at US Hemophilia Treatment Centers completed semi-structured interviews about their experience with SDM and provided feedback on a clinician SDM tool prototype. Interviews were transcribed verbatim for coding and thematic content analysis. RESULTS Ten participants enrolled, eight physicians and two haemophilia nurses. All participants care for adults with haemophilia (1-27 years of experience) and 7 have gene therapy trials open at their institution. Confidence in having a clinical discussion about gene therapy included none (N = 1), slight (N = 3), moderate (N = 5) and high (N = 1). All participants reported familiarity with SDM and agreed that the tool would be useful for their clinical practice. Key themes in participant feedback for the tool were (1) language and presentation; (2) content; and (3) implementation. Participants highlighted the importance of providing unbiased information and having companion tools with patient-centric language. CONCLUSION These data highlight the need for SDM tools for haemophilia A gene therapy. Key information to include in the tool are safety, efficacy, cost and detailed information on the gene therapy process. Data should be provided in an unbiased format and allow comparison to other treatments. The tool will be evaluated in clinical practice and refined as clinical trial data and real-world experience mature.
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Affiliation(s)
- Jacqueline Limjoco
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California, USA
| | - Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California, USA
- Department of Pediatrics, University of California San Diego Health Sciences, La Jolla, California, USA
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6
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Valentino LA, Kaczmarek R, Pierce GF, Noone D, O'Mahony B, Page D, Rotellini D, Skinner MW. Hemophilia gene therapy: first, do no harm. J Thromb Haemost 2023; 21:2354-2361. [PMID: 37353081 DOI: 10.1016/j.jtha.2023.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023]
Abstract
The introduction of adeno-associated virus-mediated, liver-directed gene therapy into the hemophilia treatment landscape brings not only great promise but also considerable uncertainty to a community that has a history punctuated by the devastating effects of HIV and hepatitis C virus. These infections were introduced into people with hemophilia through the innovation of factor concentrates in the 1970s and 1980s. Concentrates, heralded as a major advance in treatment at the time, brought devastation and death to the community already challenged by the complications of bleeding into joints, vital organs, and the brain. Over the past 5 decades, considerable advances in hemophilia treatment have improved the survival, quality of life, and participation of people with hemophilia, although challenges remain and health equity with their unaffected peers has not yet been achieved. The decision to take a gene therapy product is one in which an informed, holistic, and shared decision-making approach must be employed. Bias on the part of health care professionals and people with hemophilia must be addressed and minimized. Here, we review data leading to the regulatory authorization of valoctocogene roxaparvovec, an adeno-associated virus 5 gene therapy, in Europe to treat hemophilia A and etranacogene dezaparvovec-drlb in the United States and Europe to treat hemophilia B. We also provide an overview of the decision-making process and recommend steps that should be taken by the hemophilia community to ensure the safety of and optimal outcomes for people with hemophilia who choose to receive a gene therapy product.
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Affiliation(s)
- Leonard A Valentino
- Rush University, Chicago, Illinois, USA; National Hemophilia Foundation, New York, New York, USA.
| | - Radoslaw Kaczmarek
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
| | - Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada
| | - Declan Noone
- European Haemophilia Consortium, Brussels, Belgium; Irish Haemophilia Society, Dublin, Ireland
| | - Brian O'Mahony
- Irish Haemophilia Society, Dublin, Ireland; Trinity College, Dublin, Ireland
| | - David Page
- Canadian Hemophilia Society, Montreal, Quebec, Canada
| | | | - Mark W Skinner
- Institute for Policy Advancement, Washington, DC, USA; McMaster University, Hamilton, Ontario, Canada
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7
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Labella B, Cotti Piccinelli S, Risi B, Caria F, Damioli S, Bertella E, Poli L, Padovani A, Filosto M. A Comprehensive Update on Late-Onset Pompe Disease. Biomolecules 2023; 13:1279. [PMID: 37759679 PMCID: PMC10526932 DOI: 10.3390/biom13091279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Pompe disease (PD) is an autosomal recessive disorder caused by mutations in the GAA gene that lead to a deficiency in the acid alpha-glucosidase enzyme. Two clinical presentations are usually considered, named infantile-onset Pompe disease (IOPD) and late-onset Pompe disease (LOPD), which differ in age of onset, organ involvement, and severity of disease. Assessment of acid alpha-glucosidase activity on a dried blood spot is the first-line screening test, which needs to be confirmed by genetic analysis in case of suspected deficiency. LOPD is a multi-system disease, thus requiring a multidisciplinary approach for efficacious management. Enzyme replacement therapy (ERT), which was introduced over 15 years ago, changes the natural progression of the disease. However, it has limitations, including a reduction in efficacy over time and heterogeneous therapeutic responses among patients. Novel therapeutic approaches, such as gene therapy, are currently under study. We provide a comprehensive review of diagnostic advances in LOPD and a critical discussion about the advantages and limitations of current and future treatments.
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Affiliation(s)
- Beatrice Labella
- Department of Clinical and Experimental Sciences, University of Brescia, 25100 Brescia, Italy; (B.L.); (S.C.P.); (A.P.)
- Unit of Neurology, ASST Spedali Civili, 25100 Brescia, Italy;
| | - Stefano Cotti Piccinelli
- Department of Clinical and Experimental Sciences, University of Brescia, 25100 Brescia, Italy; (B.L.); (S.C.P.); (A.P.)
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25064 Brescia, Italy; (B.R.); (F.C.); (S.D.); (E.B.)
| | - Barbara Risi
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25064 Brescia, Italy; (B.R.); (F.C.); (S.D.); (E.B.)
| | - Filomena Caria
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25064 Brescia, Italy; (B.R.); (F.C.); (S.D.); (E.B.)
| | - Simona Damioli
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25064 Brescia, Italy; (B.R.); (F.C.); (S.D.); (E.B.)
| | - Enrica Bertella
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25064 Brescia, Italy; (B.R.); (F.C.); (S.D.); (E.B.)
| | - Loris Poli
- Unit of Neurology, ASST Spedali Civili, 25100 Brescia, Italy;
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, University of Brescia, 25100 Brescia, Italy; (B.L.); (S.C.P.); (A.P.)
- Unit of Neurology, ASST Spedali Civili, 25100 Brescia, Italy;
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia, 25100 Brescia, Italy; (B.L.); (S.C.P.); (A.P.)
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, 25064 Brescia, Italy; (B.R.); (F.C.); (S.D.); (E.B.)
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8
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Byams VR, Baker JR, Bailey C, Connell NT, Creary MS, Curtis RG, Dinno A, Guelcher CJ, Kim M, Kulkarni R, Lattimore S, Norris KL, Ramirez L, Skinner MW, Symington S, Tobase P, Vázquez E, Warren BB, Wheat E, Buckner TW. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities in health services; diversity, equity, and inclusion; and implementation science. Expert Rev Hematol 2023; 16:87-106. [PMID: 36920863 PMCID: PMC11075128 DOI: 10.1080/17474086.2023.2183836] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/20/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND The National Hemophilia Foundation (NHF) conducted extensive all-stakeholder inherited bleeding disorder (BD) community consultations to inform a blueprint for future research. Sustaining and expanding the specialized and comprehensive Hemophilia Treatment Center care model, to better serve all people with inherited BDs (PWIBD), and increasing equitable access to optimal health emerged as top priorities. RESEARCH DESIGN AND METHODS NHF, with the American Thrombosis and Hemostasis Network (ATHN), convened multidisciplinary expert working groups (WG) to distill priority research initiatives from consultation findings. WG5 was charged with prioritizing health services research (HSR); diversity, equity, and inclusion (DEI); and implementation science (IS) research initiatives to advance community-identified priorities. RESULTS WG5 identified multiple priority research themes and initiatives essential to capitalizing on this potential. Formative studies using qualitative and mixed methods approaches should be conducted to characterize issues and meaningfully investigate interventions. Investment in HSR, DEI and IS education, training, and workforce development are vital. CONCLUSIONS An enormous amount of work is required in the areas of HSR, DEI, and IS, which have received inadequate attention in inherited BDs. This research has great potential to evolve the experiences of PWIBD, deliver transformational community-based care, and advance health equity.
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Affiliation(s)
- Vanessa R. Byams
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Judith R. Baker
- Center for Inherited Blood Disorders, Western States Regional Hemophilia Network, Orange, California, USA
| | - Cindy Bailey
- Los Angeles Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Nathan T. Connell
- Boston Hemophilia Center, Division of Hematology, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa S. Creary
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Randall G. Curtis
- Hematology Utilization Group Study (HUGS), University of Southern California, Los Angeles, California, USA
- Hemophilia Foundation of Southern California, Pasadena, California, USA
| | - Alexis Dinno
- The Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Christine J. Guelcher
- Hemostasis and Thrombosis Program, Children’s National Hospital, Washington, DC, USA
| | - Michelle Kim
- The Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Roshni Kulkarni
- MSU Center of Bleeding and Clotting Disorders, Department Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA
| | - Susan Lattimore
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
- Mountain States Regional Hemophilia Network, Portland, Oregon, USA
| | | | - Lucy Ramirez
- Rush Hemophilia and Thrombophilia Treatment Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Mark W. Skinner
- Institute for Policy Advancement, Washington, DC, USA
- Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Patricia Tobase
- University of California San Francisco Hemophilia Treatment Center, University of California San Francisco, San Francisco, California, USA
| | | | - Beth B. Warren
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Hemophilia and Thrombosis Center, Division of Hematology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Emily Wheat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Hemophilia and Thrombosis Center, Division of Hematology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tyler W. Buckner
- Hemophilia and Thrombosis Center, Division of Hematology, University of Colorado School of Medicine, Aurora, Colorado, USA
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9
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Di Minno G, Castaman G, De Cristofaro R, Brunetti-Pierri N, Pastore L, Castaldo G, Trama U, Di Minno M. Progress, and prospects in the therapeutic armamentarium of persons with congenital hemophilia. Defining the place for liver-directed gene therapy. Blood Rev 2023; 58:101011. [PMID: 36031462 DOI: 10.1016/j.blre.2022.101011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
In persons with congenital severe hemophilia A (HA) living in high-income countries, twice weekly intravenous infusions of extended half-life (EHL) factor VIII (FVIII) products, or weekly/biweekly/monthly subcutaneous injections of emicizumab are the gold standard home treatments to grant days without hurdles and limitations. Once weekly/twice monthly infusions of EHL Factor IX (FIX) products achieve the same target in severe hemophilia B (HB). Gene therapy, which is likely to be licensed for clinical use within 1-2 years, embodies a shift beyond these standards. At an individual patient level, a single functional gene transfer leads to a > 10-yr almost full correction of the hemostatic defect in HB and to a sustained (3-6-yrs) expression of FVIII sufficient to discontinue exogenous clotting factor administrations. At the doses employed, the limited liver toxicity of systemically infused recombinant adeno-associated virus (rAAV) vectors is documented by long-term (12-15 yrs) follow-ups, and pre-existing high-titer neutralizing antibodies to the AAV5 vector are no longer an exclusion criterion for effective transgene expression with this vector. A safe durable treatment that converts a challenging illness to a phenotypically curable disease, allows persons to feel virtually free from the fears and the obligations of hemophilia for years/decades. Along with patient organizations and health care professionals, communicating to government authorities and reimbursement agencies the liberating potential of this substantial innovation, and disseminating across the Centers updated information on benefits and risks of this strategy, will align expectations of different stakeholders and establish the notion of a potentially lifelong cure of hemophilia.
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Affiliation(s)
- Giovanni Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Center for Hemorrhagic and Thrombotic Diseases, Foundation University Hospital A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy; Dept of Translational Medicine, School of Medicine, Università degli Studi di Napoli "Federico II", Italy.
| | - Lucio Pastore
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Ugo Trama
- Coordination of the Regional Health System, General Directorate for Health Protection, Naples, Italy.
| | - Matteo Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
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10
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Hermans C, Gruel Y, Frenzel L, Krumb E. How to translate and implement the current science of gene therapy into haemophilia care? Ther Adv Hematol 2023; 14:20406207221145627. [PMID: 36654740 PMCID: PMC9841832 DOI: 10.1177/20406207221145627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 11/28/2022] [Indexed: 01/15/2023] Open
Abstract
Gene-based therapy opens an entirely new paradigm in managing people with haemophilia (PWH), offering them the possibility of a functional cure by enabling continuous expression of factor VIII (FVIII) or factor IX (FIX) after transfer of a functional gene designed to replace the PWH's own defective gene. In recent years, significant advances in gene therapy have been made, resulting in clotting factor activity attaining near-normal levels, as reflected by 'zero bleeding rates' in previously severely inflicted patients following a single administration of adeno-associated viral (AAV) vectors. While this new approach represents a major advancement, there are still several issues that must be resolved before applying this technology in clinical practice. First, awareness, communication, and education about the therapeutic potential and modalities of gene therapy must be further strengthened. To this end, objective, unbiased, transparent, and regularly updated information must be shared, in an appropriate way and understandable language with the support of patients' organizations. Second, healthcare providers should adopt a patient-centred approach, as the 'one size fits all' approach is inappropriate when considering gene therapy. Instead, a holistic patient view taking into account their physical and mental dimensions, along with unexpressed expectations and preferences, is mandatory. Third, the consent procedure must be improved, ensuring that patients' interests are maximally protected. Finally, gene therapy is likely to be first delivered in a few centres, with the highest expertise and experience in this domain. Thus, patients should be managed based on a hub-and-spoke model, taking into account that the key to gene therapy's success lies in an optimal communication and collaboration both within and between haemophilia centres sharing their experiences in the frame of international registries. This review describes recent progress and explains outstanding hurdles that must be tackled to ease the implementation of this paradigm-changing new therapy.
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Affiliation(s)
| | - Yves Gruel
- Centre Régional de Traitement de l’Hémophilie, Hôpital Trousseau, CHRU de Tours, Tours, France
| | - Laurent Frenzel
- Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutical Implications, Labex GR-Ex, Imagine Institute, Inserm, Paris Descartes – Sorbonne Paris Cité University, Paris, France,Hematology unit care, Hemophilia Center, Necker Hospital, Paris, France
| | - Evelien Krumb
- Haemostasis and Thrombosis Unit, Division of Adult Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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11
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Limjoco J, Thornburg CD. Gene Therapy for Hemophilia A: A Mixed Methods Study of Patient Preferences and Shared Decision-Making. Patient Prefer Adherence 2023; 17:1093-1105. [PMID: 37102127 PMCID: PMC10123005 DOI: 10.2147/ppa.s406894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023] Open
Abstract
Purpose As gene therapies for hemophilia are incorporated into clinical practice, shared decision-making (SDM) is recommended for implementation. SDM tools may facilitate informed decision-making for gene therapy and other novel therapies. Objective To inform the development of SDM tools for hemophilia gene therapy. Patients and Methods Men with severe hemophilia were recruited from the National Hemophilia Foundation (NHF) Community Voices in Research (CVR). Semi-structured interviews were completed, and the interviews were transcribed verbatim for quantitative and qualitative analysis. Results Twenty-five men with severe hemophilia A participated. All participants reported treatment with prophylaxis, nine (36%) on continuous prophylaxis with clotting factor, one (4%) on intermittent prophylaxis with clotting factor, and 15 (60%) on continuous prophylaxis with emicizumab. Ten (40%) indicated that they are excited about gene therapy, 12 (48%) indicated that they are hopeful about gene therapy, one (4%) indicated that they are worried or scared about gene therapy, and one (4%) indicated that they do not have strong feelings about gene therapy. Participants reported engaging Hemophilia Treatment Center, family, and the hemophilia community in their decision-making process. The most reported information needs are efficacy, safety, cost/insurance, mechanism of action, and follow-up. In addition, key information themes that emerged were patient testimonials, hard data and statistics, and comparison to other products. Twenty-two (88%) indicated that a SDM tool would be useful when discussing gene therapy with their hemophilia team. Two indicated that they do their own research, and the tool would not add anything. One needed more information to provide an answer. Conclusion These data highlight the utility of a SDM tool for hemophilia gene therapy and key information needs. Data including comparison to other treatments should be provided along with patient testimonials in a transparent format. Patients will engage the Hemophilia Treatment Center, family, and community members in the decision-making process.
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Affiliation(s)
- Jacqueline Limjoco
- Hemophilia and Thrombosis Treatment Center, Rady Children’s Hospital San Diego, San Diego, CA, USA
| | - Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children’s Hospital San Diego, San Diego, CA, USA
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, CA, USA
- Correspondence: Courtney D Thornburg, Rady Children’s Hospital San Diego, 3020 Children’s Way, MC 5035, San Diego, CA, 92123, USA, Tel +1 858-966-5811, Fax +1 858-966-8035, Email
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12
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Pipe SW, Arruda VR, Lange C, Kitchen S, Eichler H, Wadsworth S. Characteristics of BAY 2599023 in the Current Treatment Landscape of Hemophilia A Gene Therapy. Curr Gene Ther 2023; 23:81-95. [PMID: 36111754 DOI: 10.2174/1566523222666220914105729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/22/2022]
Abstract
Hemophilia A, a single gene disorder leading to deficient Factor VIII (FVIII), is a suitable candidate for gene therapy. The aspiration is for single administration of a genetic therapy that would allow the production of endogenous FVIII sufficient to restore hemostasis and other biological processes. This would potentially result in reliable protection from bleeding and its associated physical and emotional impacts. Gene therapy offers the possibility of a clinically relevant improvement in disease phenotype and transformational improvement in quality of life, including an opportunity to engage in physical activities more confidently. Gene therapy products for hemophilia A in advanced clinical development use adeno-associated viral (AAV) vectors and a codon-optimized B-domain deleted FVIII transgene. However, the different AAV-based gene therapies have distinct design features, such as choice of vector capsid, enhancer and promoter regions, FVIII transgene sequence and manufacturing processes. These, in turn, impact patient eligibility, safety and efficacy. Ideally, gene therapy technology for hemophilia A should offer bleed protection, durable FVIII expression, broad eligibility and limited response variability between patients, and long-term safety. However, several limitations and challenges must be overcome. Here, we introduce the characteristics of the BAY 2599023 (AAVhu37.hFVIIIco, DTX 201) gene therapy product, including the low prevalence in the general population of anti-AAV-hu37 antibodies, as well as other gene therapy AAV products and approaches. We will examine how these can potentially meet the challenges of gene therapy, with the ultimate aim of improving the lives of patients with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Valder R Arruda
- Division of Hematology, Department of Pediatrics, Center for Cell and Molecular Therapeutics at Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephen Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield Teaching Hospitals, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
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13
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Astermark J, Blatný J, Königs C, Hermans C, Jiménez-Yuste V, Hart DP. Considerations for shared decision management in previously untreated patients with hemophilia A or B. Ther Adv Hematol 2023; 14:20406207231165857. [PMID: 37113810 PMCID: PMC10126613 DOI: 10.1177/20406207231165857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/04/2023] [Indexed: 04/29/2023] Open
Abstract
Recent advances in therapeutics are now providing a wide range of options for adults and children living with hemophilia. Although therapeutic choices are also increasing for the youngest individuals with severe disease, challenges remain about early management decisions, as supporting data are currently limited. Parents and healthcare professionals are tasked with helping children achieve an inclusive quality of life and maintain good joint health into adulthood. Primary prophylaxis is the gold standard to optimize outcomes and is recommended to start before 2 years of age. A range of topics need to be discussed with parents to aid their understanding of the decisions they can make and how these will affect the management of their child/children. For those with a family history of hemophilia, prenatal considerations include the possibility of genetic counseling, prenatal investigations, and planning for delivery, together with monitoring of the mother and neonate, as well as diagnosis of the newborn and treatment of any birth-associated bleeding. Subsequent considerations, which are also applicable to families where infant bleeding has resulted in a new diagnosis of sporadic hemophilia, involve explaining bleed recognition and treatment options, practical aspects of initiating/continuing prophylaxis, dealing with bleeds, and ongoing aspects of treatment, including possible inhibitor development. Over time, optimizing treatment efficacy, in which individualizing therapy around activities can play a role, and long-term considerations, including retaining joint health and tolerance maintenance, become increasingly important. The evolving treatment landscape is creating a need for continually updated guidance. Multidisciplinary teams and peers from patient organizations can help provide relevant information. Easily accessible, multidisciplinary comprehensive care remains a foundation to care. Equipping parents early with the knowledge to facilitate truly informed decision-making will help achieve the best possible longer-term health equity and quality of life for the child and family living with hemophilia. Plain language summary Points to be taken into account to help families make decisions to best care for children born with hemophilia Medical advances are providing a range of treatment options for adults and children with hemophilia. There is, however, relatively limited information about managing newborns with the condition. Doctors and nurses can help parents to understand the choices for infants born with hemophilia. We describe the various points doctors and nurses should ideally discuss with families to enable informed decision-making. We focus on infants who require early treatment to prevent spontaneous or traumatic bleeding (prophylaxis), which is recommended to start before 2 years of age. Families with a history of hemophilia may benefit from discussions before pregnancy, including how an affected child would be treated to protect against bleeds. When mothers are pregnant, doctors can explain investigations that can provide information about their unborn child, plan for the birth, and monitor mother and baby to minimize bleed risks at delivery. Testing will confirm whether the baby is affected by hemophilia. Not all infants with hemophilia will be born to families with a history of the condition. Identification of hemophilia for the first time in a family (which is 'sporadic hemophilia') occurs in previously undiagnosed infants who have bleeds requiring medical advice and possibly hospital treatment. Before any mothers and babies with hemophilia are discharged from hospital, doctors and nurses will explain to parents how to recognize bleeding and available treatment options can be discussed. Over time, ongoing discussions will help parents to make informed treatment decisions:• When and how to start, then continue, prophylaxis.• How to deal with bleeds (reinforcing previous discussions about bleed recognition and treatment) and other ongoing aspects of treatment. ○ For instance, children may develop neutralizing antibodies (inhibitors) to treatment they are receiving, requiring a change to the planned approach.• Ensuring treatment remains effective as their child grows, considering the varied needs and activities of their child.
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Affiliation(s)
| | - Jan Blatný
- Department of Pediatric Hematology, University
Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Christoph Königs
- Clinical and Molecular Hemostasis, Department
of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt,
Germany
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of
Hematology, Cliniques Universitaires Saint-Luc, Université catholique de
Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hematology Department, Hospital Universitario
La Paz, Autónoma University, Madrid, Spain
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14
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Limjoco J, Calatroni A, Aristizabal P, Thornburg CD. Gene therapy preferences and informed decision-making: Results from a National Hemophilia Foundation Community Voices in research survey. Haemophilia 2023; 29:51-60. [PMID: 36469856 DOI: 10.1111/hae.14706] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION To inform education and treatment discussions, it is important to understand how persons with haemophilia prefer to learn about and discuss new therapies and to identify variables that influence decision-making. AIM The aim of this study was to evaluate preferences and variables which influence decision-making related to gene therapy and other novel haemophilia therapies. METHODS An online survey was sent to men with severe haemophilia enrolled in the National Hemophilia Foundation Community Voices in Research online platform for patient-powered research. RESULTS One hundred four men completed the survey including 33% Hispanics, 96 who had had not gene therapy and 71/96 (74%) who were on prophylaxis. Ninety-five percent were somewhat or very familiar with gene therapy. Men with haemophilia obtain information about new therapies from several sources, most commonly their haemophilia treatment team, patient advocacy groups and self-study. Participants identified safety and efficacy as well as other educational needs to inform decision-making. Of those without prior gene therapy, 73% indicated a high likelihood of considering gene therapy. Hispanic ethnicity and government-issued insurance were associated with a higher likelihood of considering gene therapy as a treatment option. CONCLUSION Haemophilia Treatment Centers and patient advocacy groups must be able to educate persons with haemophilia about aspects of novel therapies which are important to the individual, especially short- and long-term safety and efficacy. Further research is needed to determine how patient activation and health literacy influence decision-making and how to achieve equitable access and valid informed consent for novel therapies.
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Affiliation(s)
- Jacqueline Limjoco
- Hemophilia and Thrombosis Treatment Center, Rady Children's, Hospital San Diego, San Diego, California, USA
| | | | - Paula Aristizabal
- Hemophilia and Thrombosis Treatment Center, Rady Children's, Hospital San Diego, San Diego, California, USA.,Department of Pediatrics, University of California San Diego Health Sciences, La Jolla, California, USA.,Population Sciences, Disparities and Community Engagement, University of California San Diego Moores Cancer Center and University of California San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, California, USA
| | - Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's, Hospital San Diego, San Diego, California, USA.,Department of Pediatrics, University of California San Diego Health Sciences, La Jolla, California, USA
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15
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Kapelanski-Lamoureux A, Chen Z, Gao ZH, Deng R, Lazaris A, Lebeaupin C, Giles L, Malhotra J, Yong J, Zou C, de Jong YP, Metrakos P, Herzog RW, Kaufman RJ. Ectopic clotting factor VIII expression and misfolding in hepatocytes as a cause for hepatocellular carcinoma. Mol Ther 2022; 30:3542-3551. [PMID: 36242517 PMCID: PMC9734080 DOI: 10.1016/j.ymthe.2022.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
Abstract
Hemophilia A gene therapy targets hepatocytes to express B domain deleted (BDD) clotting factor VIII (FVIII) to permit viral encapsidation. Since BDD is prone to misfolding in the endoplasmic reticulum (ER) and ER protein misfolding in hepatocytes followed by high-fat diet (HFD) can cause hepatocellular carcinoma (HCC), we studied how FVIII misfolding impacts HCC development using hepatocyte DNA delivery to express three proteins from the same parental vector: (1) well-folded cytosolic dihydrofolate reductase (DHFR); (2) BDD-FVIII, which is prone to misfolding in the ER; and (3) N6-FVIII, which folds more efficiently than BDD-FVIII. One week after DNA delivery, when FVIII expression was undetectable, mice were fed HFD for 65 weeks. Remarkably, all mice that received BDD-FVIII vector developed liver tumors, whereas only 58% of mice that received N6 and no mice that received DHFR vector developed liver tumors, suggesting that the degree of protein misfolding in the ER increases predisposition to HCC in the context of an HFD and in the absence of viral transduction. Our findings raise concerns of ectopic BDD-FVIII expression in hepatocytes in the clinic, which poses risks independent of viral vector integration. Limited expression per hepatocyte and/or use of proteins that avoid misfolding may enhance safety.
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Affiliation(s)
- Audrey Kapelanski-Lamoureux
- Department of Anatomy and Cell Biology, McGill University, Cancer Research Program, Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Zhouji Chen
- Degenerative Diseases Program, Center for Genetic Disorders and Aging Research, SBP Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Zu-Hua Gao
- Department of Pathology and Oncology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada,Cancer Research Program, Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Ruishu Deng
- Degenerative Diseases Program, Center for Genetic Disorders and Aging Research, SBP Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Anthoula Lazaris
- Cancer Research Program, Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Cynthia Lebeaupin
- Degenerative Diseases Program, Center for Genetic Disorders and Aging Research, SBP Medical Discovery Institute, La Jolla, CA 92037, USA,Department of Pharmacology, University of California, San Diego, La Jolla, CA 92093, USA
| | - Lisa Giles
- Department of Biological Chemistry, University of Michigan Medical Center, Ann Arbor, MI 48109, USA
| | - Jyoti Malhotra
- Department of Biological Chemistry, University of Michigan Medical Center, Ann Arbor, MI 48109, USA
| | - Jing Yong
- Degenerative Diseases Program, Center for Genetic Disorders and Aging Research, SBP Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Chenhui Zou
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Ype P. de Jong
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Peter Metrakos
- Department of Surgery, McGill University; Cancer Research Program, Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Roland W. Herzog
- Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN 46202, USA
| | - Randal J. Kaufman
- Degenerative Diseases Program, Center for Genetic Disorders and Aging Research, SBP Medical Discovery Institute, La Jolla, CA 92037, USA,Department of Biological Chemistry, University of Michigan Medical Center, Ann Arbor, MI 48109, USA,Department of Pharmacology, University of California, San Diego, La Jolla, CA 92093, USA,Howard Hughes Medical Institute, University of Michigan Medical Center, Ann Arbor, MI 48109, USA,Corresponding author: Randal J. Kaufman, Degenerative Diseases Program, SBP Medical Discovery Institute, La Jolla, CA 92037, USA.
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16
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Yamaguti-Hayakawa GG, Ozelo MC. Gene therapy for hemophilia: looking beyond factor expression. Exp Biol Med (Maywood) 2022; 247:2223-2232. [PMID: 36691324 PMCID: PMC9899988 DOI: 10.1177/15353702221147565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Hemophilia A (factor VIII [FVIII] deficiency) and hemophilia B (factor IX [FIX] deficiency) are the X-linked recessive bleeding disorders that clinically manifest with recurrent bleeding, predominantly into muscles and joints. In its severe presentation, when factor activity is less than 1% of normal, hemophilia presents with spontaneous musculoskeletal bleeds and may progress to debilitating chronic arthropathy. Management of hemophilia has changed profoundly in the past decades. From on-demand to prophylactic factor concentrate replacement, the treatment goal shifted from controlling bleeds to preventing bleeds and improving quality of life. In this new scenario, gene therapy has arisen as a paradigm-changing therapeutic option, a one-time treatment with the potential to achieve sustained coagulation FVIII or FIX expression even within the normal range. This review discusses the critical impact of adeno-associated virus (AAV) gene transfer in hemophilia care, including the recent clinical outcomes, changes in disease perceptions, and its treatment burden. We also discuss the challenging scenario of the AAV-directed immune response in the clinical setting and potential strategies to improve the long-lasting efficacy of hemophilia gene therapy efficacy.
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Affiliation(s)
- Gabriela G Yamaguti-Hayakawa
- Department of Internal Medicine,
School of Medical Sciences, University of Campinas, UNICAMP, Campinas
13083-878, Brazil,Hemocentro UNICAMP, University of
Campinas, Campinas 13083-878, Brazil
| | - Margareth C Ozelo
- Department of Internal Medicine,
School of Medical Sciences, University of Campinas, UNICAMP, Campinas
13083-878, Brazil,Hemocentro UNICAMP, University of
Campinas, Campinas 13083-878, Brazil,Margareth C Ozelo.
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17
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Bolous NS, Bhatt N, Bhakta N, Neufeld EJ, Davidoff AM, Reiss UM. Gene Therapy and Hemophilia: Where Do We Go from Here? J Blood Med 2022; 13:559-580. [PMID: 36226233 PMCID: PMC9550170 DOI: 10.2147/jbm.s371438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
Gene therapy for hemophilia using adeno-associated virus (AAV) derived vectors can reduce or eliminate patients' disease-related complications and improve their quality of life. Broad implementation globally will lead to societal gains and foster health equity. Several vector products each for factor IX (FIX) or factor VIII (FVIII) deficiency are in advanced clinical development. Safety data are reassuring. Efficacy data for up to 8 and 5 years, respectively, vary considerably among vector types and among individuals, but indicate significant reduction in bleeds and factor use. Products will soon be approved for marketing. This review highlights the relevant considerations for implementation of hemophilia gene therapy, specifically across a broad range of socioeconomic backgrounds globally, based on recent publications and our own experience. We address the current efficacy and safety data and relevant aspects of vector immunology. We then discuss pertinent implementation steps including pre-implementation and readiness assessments, considerations on cost, cost-effectiveness and payment models, approaches to education and informed consent, and the operational needs as well as the need for monitoring of health outcomes and implementation outcomes. To prevent a lag or complete lack of establishing access to this life-changing therapy option for all patients with hemophilia worldwide, adaptable pathways supported by collaborative and international efforts of all stakeholders are needed.
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Affiliation(s)
- Nancy S Bolous
- Department of Global Pediatric Medicine – St. Jude Children’s Research Hospital, Memphis, TN, USA,Correspondence: Nancy S Bolous, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop 721, Memphis, TN, 38105, USA, Tel +1 901 595 1968, Fax +1 901 595 5319, Email
| | - Nidhi Bhatt
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ellis J Neufeld
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ulrike M Reiss
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
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18
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Mulcrone PL, Herzog RW, Xiao W. Adding recombinant AAVs to the cancer therapeutics mix. Mol Ther Oncolytics 2022; 27:73-88. [PMID: 36321134 PMCID: PMC9588955 DOI: 10.1016/j.omto.2022.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Gene therapy is a powerful biological tool that is reshaping therapeutic landscapes for several diseases. Researchers are using both non-viral and viral-based gene therapy methods with success in the lab and the clinic. In the cancer biology field, gene therapies are expanding treatment options and the possibility of favorable outcomes for patients. While cellular immunotherapies and oncolytic virotherapies have paved the way in cancer treatments based on genetic engineering, recombinant adeno-associated virus (rAAV), a viral-based module, is also emerging as a potential cancer therapeutic through its malleability, specificity, and broad application to common as well as rare tumor types, tumor microenvironments, and metastatic disease. A wide range of AAV serotypes, promoters, and transgenes have been successful at reducing tumor growth and burden in preclinical studies, suggesting more groundbreaking advances using rAAVs in cancer are on the horizon.
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Affiliation(s)
- Patrick L. Mulcrone
- Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN 46202, USA,Department of Pediatrics, Indiana University, Indianapolis, IN 46202, USA
| | - Roland W. Herzog
- Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN 46202, USA
| | - Weidong Xiao
- Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN 46202, USA,Corresponding author Weidong Xiao, Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, IN 46202, USA.
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19
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Castaman G, Di Minno G, De Cristofaro R, Peyvandi F. The Arrival of Gene Therapy for Patients with Hemophilia A. Int J Mol Sci 2022; 23:10228. [PMID: 36142153 PMCID: PMC9499514 DOI: 10.3390/ijms231810228] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/01/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Historically, the standard of care for hemophilia A has been intravenous administration of exogenous factor VIII (FVIII), either as prophylaxis or episodically. The development of emicizumab, a humanized bispecific monoclonal antibody mimicking activated FVIII, was a subsequent advance in treatment. However, both exogenous FVIII and emicizumab require repeated and lifelong administration, negatively impacting patient quality of life. A recent breakthrough has been the development of gene therapy. This allows a single intravenous treatment that could result in long-term expression of FVIII, maintenance of steady-state plasma concentrations, and minimization (or possibly elimination) of bleeding episodes for the recipient's lifetime. Several gene therapies have been assessed in clinical trials, with positive outcomes. Valoctocogene roxaparvovec (an adeno-associated viral 5-based therapy encoding human B domain-deleted FVIII) is expected to be the first approved gene therapy in European countries, including Italy, in 2022. Some novel challenges exist including refining patient selection criteria, managing patient expectations, further elucidation of the durability and variability of transgene expression and long-term safety, and the development of standardized 'hub and spoke' centers to optimize and monitor this innovative treatment. Gene therapy represents a paradigm shift, and may become a new reference standard for treating patients with hemophilia A.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders, Department of Oncology, Careggi University Hospital, Largo Brambilla 3, 50134 Firenze, Italy
| | - Giovanni Di Minno
- Regional Reference Centre for Hemo-Coagulation Diseases, Federico II University, Via S. Pansini 5, 80131 Naples, Italy
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e Trombotiche, Dipartimento di Medicina e Chirurgia Traslazionale, Fondazione Policlinico Universitraio “A. Gemelli” IRCCS, Università Cattolica S. Cuore Roma, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Via Pace 9, 20122 Milan, Italy
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20
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Cho S, Perry AM, Cheng AM, Wang C, Rico JF. Advances in Hemophilia A Management. Adv Pediatr 2022; 69:133-147. [PMID: 35985706 DOI: 10.1016/j.yapd.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hemophilia A is an inherited insufficiency of Factor VIII (FVIII), one of the critical clotting factors. The gold standard for the management of moderate-to-severe hemophilia A is prophylaxis using regular replacement therapy with clotting factor concentrates. Compared with conventional treatment, extended half-life products reduce the burden of frequent factor replacement injections. Of note, up to 30% of patients with hemophilia A receiving prophylactic factor infusions develop "inhibitors," neutralizing anti-FVIII autoantibodies. Therapeutic options for patients with hemophilia A and inhibitors include the immune tolerance induction (ie, eradication of inhibitors) and the management of acute bleeds with bypassing agents and/or emicizumab. Emicizumab is a biphasic monoclonal antibody mimicking activated FVIII, approved for patients with hemophilia A with/without inhibitors. Gene therapy is an emerging therapy for hemophilia A, essentially curing patients with hemophilia A or transforming them to a milder phenotype by establishing continuous endogenous expression of FVIII after one-time treatment.
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Affiliation(s)
- Sukjoo Cho
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA
| | - Ashley M Perry
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA
| | - Anna M Cheng
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Carrie Wang
- University of South Florida Morsani College of Medicine, 560 Channelside Drive, Tampa, FL 33602, USA
| | - Juan Felipe Rico
- Division of Hematology/Oncology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, 5th Floor, Tampa, FL 33606, USA.
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21
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Kavaklı K, Antmen B, Okan V, Şahin F, Aytaç S, Balkan C, Berber E, Kaya Z, Küpesiz A, Zülfikar B. Gene therapy in haemophilia: literature review and regional perspectives for Turkey. Ther Adv Hematol 2022; 13:20406207221104591. [PMID: 35898436 PMCID: PMC9310332 DOI: 10.1177/20406207221104591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is an X-linked lifelong congenital bleeding disorder that is caused by insufficient levels of factor VIII (FVIII; haemophilia A) or factor IX (FIX; haemophilia B) and characterized by spontaneous and trauma-related bleeding episodes. The cornerstone of the treatment, factor replacement, constitutes several difficulties, including frequent injections due to the short half-life of recombinant factors, intravenous administration and the risk of inhibitor development. While extended half-life factors and subcutaneous novel molecules enhanced the quality of life, initial successes with gene therapy offer a significant hope for cure. Although adeno-associated viral (AAV)-based gene therapy is one of the most emerging approaches for treatment of haemophilia, there are still challenges in vector immunogenicity, potency and efficacy, genotoxicity and persistence. As the approval for the first gene therapy product is coming closer, eligibility criteria for patient selection, multidisciplinary approach for optimal delivery and follow-up and development of new pricing policies and reimbursement models should be concerned. Therefore, this review addresses the unmet needs of current haemophilia treatment and explains the rationale and principles of gene therapy. Limitations and challenges are discussed from a global and national perspective and recommendations are provided to adopt the gene therapies faster and more sufficient for the haemophilia patients in developing countries like Turkey.
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Affiliation(s)
- Kaan Kavaklı
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100 İzmir, Turkey
| | - Bülent Antmen
- Division of Hematology, Department of Pediatrics, Acıbadem Adana Hospital, Adana, Turkey
| | - Vahap Okan
- Division of Hematology, Department of Internal Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Fahri Şahin
- Division of Hematology, Department of Internal Diseases, Ege Adult Hemophilia and Thrombosis Center, Ege University Faculty of Medicine, İzmir, Turkey
| | - Selin Aytaç
- Division of Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Can Balkan
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ergül Berber
- Department of Molecular Biology and Genetics, İstanbul Arel University, İstanbul, Turkey
| | - Zühre Kaya
- Division of Hematology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Alphan Küpesiz
- Division of Hematology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Bülent Zülfikar
- Division of Hematology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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22
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Croteau SE. Hemophilia A/B. Hematol Oncol Clin North Am 2022; 36:797-812. [DOI: 10.1016/j.hoc.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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23
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Reiss UM, Mahlangu J, Ohmori T, Ozelo MC, Srivastava A, Zhang L. Haemophilia gene therapy-Update on new country initiatives. Haemophilia 2022; 28 Suppl 4:61-67. [PMID: 35521726 DOI: 10.1111/hae.14512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Gene therapy is emerging as a potential cure for haemophilia. Gene therapy is a one-time treatment that can elevate factor levels for many years and minimize or eliminate the need for clotting factor concentrate (CFC) replacement therapy. However, there is a paucity of reports on gene therapy efforts in countries outside of North America or Europe, especially in low-and-middle-income countries (LMIC). All indications are that gene therapy will be one of standard care treatments for haemophilia in the future. Still, it may not be accessible to many countries due to various barriers and challenges. At the same time, each country may formulate solutions that may be used globally. AIM To summarize the approaches taken to establish haemophilia gene therapy in Japan, China, India, South Africa, and Brazil, and to describe the US-initiated multi-LMIC haemophilia gene therapy development program to include Peru, Vietnam, Thailand, Nepal, and Sri Lanka. METHODS A review of related published information or as accessible by each country's author. RESULTS Different starting conditions, differing input and level of support from the multitude of stakeholders, and strong leadership have led to various approaches for facilitating research and developing needed infrastructure and regulatory and financing models. Gene therapy programs are at various stages of development and include both adeno-associated viral and lentiviral vectors. CONCLUSION Global partnerships and collaboration, exchange of knowledge and experience, and alignment of processes across borders will promote further progress towards global access to gene therapy for haemophilia.
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Affiliation(s)
- Ulrike M Reiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Johnny Mahlangu
- Haemophilia Comprehensive Care Center, National Health Laboratory Service and University of the Witwatersrand, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Tsukasa Ohmori
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Margareth C Ozelo
- Department of Internal Medicine, School of Medical Sciences, Haemophilia Treatment Center 'Cláudio Luiz Pizzigatti Corrêa', Hemocentro UNICAMP, University of Campinas, UNICAMP, Campinas, Brazil
| | - Alok Srivastava
- Centre for Stem Cell Research, Unit of inStem, Bengaluru, and Department of Hematology, Christian Medical College, Vellore, India
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin Key Laboratory of Blood Disease Gene Therapy, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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24
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Kaczmarek R. Gene therapy - are we ready now? Haemophilia 2022; 28 Suppl 4:35-43. [PMID: 35521736 PMCID: PMC9325484 DOI: 10.1111/hae.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia therapy has evolved from rudimentary transfusion‐based approaches to an unprecedented level of innovation with glimmers of functional cure brought by gene therapy. After decades of misfires, gene therapy has normalized factor (F)VIII and factor (F)IX levels in some individuals in the long term. Several clinical programmes testing adeno‐associated viral (AAV) vector gene therapy are approaching completion with imminent regulatory approvals. Discussion Phase 3 studies along with multiyear follow‐up in earlier phase investigations raised questions about efficacy as well as short‐ and long‐term safety, prompting a reappraisal of AAV vector gene therapy. Liver toxicities, albeit mostly low‐grade, occur in the first year in at least some individuals in all haemophilia A and B trials and are poorly understood. Extreme variability and unpredictability of outcome, as well as a slow decline in factor expression (seemingly unique to FVIII gene therapy), are vexing because immune responses to AAV vectors preclude repeat dosing, which could increase suboptimal or restore declining expression, while overexpression may result in phenotoxicity. The long‐term safety will need lifelong monitoring because AAV vectors, contrary to conventional wisdom, integrate into chromosomes at the rate that calls for vigilance. Conclusions AAV transduction and transgene expression engage the host immune system, cellular DNA processing, transcription and translation machineries in ways that have been only cursorily studied in the clinic. Delineating those mechanisms will be key to finding mitigants and solutions to the remaining problems, and including individuals who cannot avail of gene therapy at this time.
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Affiliation(s)
- Radoslaw Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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25
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Transcutaneous ultrasound mediated gene delivery into canine livers achieves therapeutic levels of FVIII expression. Blood Adv 2022; 6:3557-3568. [PMID: 35427415 PMCID: PMC9631573 DOI: 10.1182/bloodadvances.2021006016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 04/03/2022] [Indexed: 11/24/2022] Open
Abstract
Nonviral UMGD can achieve therapeutic levels of FVIII gene expression in a large animal model. UMGD targeting liver is safe without evidence of any lasting damage.
A safe, effective, and inclusive gene therapy will significantly benefit a large population of patients with hemophilia. We used a minimally invasive transcutaneous ultrasound-mediated gene delivery (UMGD) strategy combined with microbubbles (MBs) to enhance gene transfer into 4 canine livers. A mixture of high-expressing, liver-specific human factor VIII (hFVIII) plasmid and MBs was injected into the hepatic vein via balloon catheter under fluoroscopy guidance with simultaneous transcutaneous UMGD treatment targeting a specific liver lobe. Therapeutic levels of hFVIII expression were achieved in all 4 dogs, and hFVIII levels were maintained at a detectable level in 3 dogs throughout the 60-day experimental period. Plasmid copy numbers correlated with hFVIII antigen levels, and plasmid-derived messenger RNA (mRNA) was detected in treated livers. Liver transaminase levels and histology analysis indicated minimal liver damage and a rapid recovery after treatment. These results indicate that liver-targeted transcutaneous UMGD is promising as a clinically feasible therapy for hemophilia A and other diseases.
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26
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Hermans C. Haemophilia gene therapy: experiences and lessons from treated patients. Orphanet J Rare Dis 2022; 17:154. [PMID: 35379279 PMCID: PMC8981926 DOI: 10.1186/s13023-022-02313-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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27
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Muhuri M, Levy DI, Schulz M, McCarty D, Gao G. Durability of transgene expression after rAAV gene therapy. Mol Ther 2022; 30:1364-1380. [PMID: 35283274 PMCID: PMC9077371 DOI: 10.1016/j.ymthe.2022.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/09/2022] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
Recombinant adeno-associated virus (rAAV) gene therapy has the potential to transform the lives of patients with certain genetic disorders by increasing or restoring function to affected tissues. Following the initial establishment of transgene expression, it is unknown how long the therapeutic effect will last, although animal and emerging human data show that expression can be maintained for more than 10 years. The durability of therapeutic response is key to long-term treatment success, especially since immune responses to rAAV vectors may prevent re-dosing with the same therapy. This review explores the non-immunological and immunological processes that may limit or improve durability and the strategies that can be used to increase the duration of the therapeutic effect.
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Affiliation(s)
- Manish Muhuri
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA, USA; Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | | | - Guangping Gao
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA, USA; Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA; Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, MA, USA.
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28
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Mulcrone PL, Zhang J, Pride PM, Lam AK, Frabutt DA, Ball-Kell SM, Xiao W. Genomic Designs of rAAVs Contribute to Pathological Changes in the Livers and Spleens of Mice. ADVANCES IN CELL AND GENE THERAPY 2022; 2022:6807904. [PMID: 36507314 PMCID: PMC9730939 DOI: 10.1155/2022/6807904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Recombinant AAV (rAAV) gene therapy is being investigated as an effective therapy for several diseases including hemophilia B. Reports of liver tumor development in certain mouse models due to AAV treatment and genomic integration of the rAAV vector has raised concerns about the long-term safety and efficacy of this gene therapy. To investigate whether rAAV treatment causes cancer, we utilized two mouse models, inbred C57BL/6 and hemophilia B Balb/C mice (HemB), to test if injecting a high dose of various rAAV8 vectors containing or lacking hFIX transgene, a Poly-A sequence, or the CB or TTR promoter triggered liver fibrosis and/or cancer development over the course of the 6.5-month study. We observed no liver tumors in either mouse cohort regardless of rAAV treatment through ultrasound imaging, gross anatomical assessment at sacrifice, and histology. We did, however, detect differences in collagen deposition in C57BL/6 livers and HemB spleens of rAAV-injected mice. Pathology reports of the HemB mice revealed many pathological phenomena, including fibrosis and inflammation in the livers and spleens across different AAV-injected HemB mice. Mice from both cohorts injected with the TTR-hFIX vector demonstrated minimal adverse events. While not tumorigenic, high dose of rAAVs, especially those with incomplete genomes, can influence liver and spleen health negatively that could be problematic for cementing AAVs as a broad therapeutic option in the clinic.
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Affiliation(s)
- Patrick L. Mulcrone
- Herman B Wells Center for Pediatric Research, Indiana University, USA
- Department of Pediatrics, Indiana University, USA
| | - Junping Zhang
- Herman B Wells Center for Pediatric Research, Indiana University, USA
- Department of Pediatrics, Indiana University, USA
| | - P. Melanie Pride
- Herman B Wells Center for Pediatric Research, Indiana University, USA
| | - Anh K. Lam
- Herman B Wells Center for Pediatric Research, Indiana University, USA
- Department of Pediatrics, Indiana University, USA
| | - Dylan A. Frabutt
- Herman B Wells Center for Pediatric Research, Indiana University, USA
- Department of Microbiology & Immunology, Indiana University, Indianapolis, IN, USA
| | | | - Weidong Xiao
- Herman B Wells Center for Pediatric Research, Indiana University, USA
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29
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Zhao M, Sun YD, Yin M, Zhao JJ, Li SA, Li G, Zhang F, Xu J, Meng FY, Zhang B, Sun XY, Zhang JP, Cheng T, Zhang XB. Modulation of Immune Reaction in Hydrodynamic Gene Therapy for Hemophilia A. Hum Gene Ther 2021; 33:404-420. [PMID: 34555961 DOI: 10.1089/hum.2021.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hemophilia A (HA) is a monogenic disease characterized by plasma clotting factor 8 (F8) deficiency due to F8 mutation. We have been attempting to cure HA permanently using a CRISPR-Cas9 gene-editing strategy. Here, we induced targeted integration of BDDF8 (B-domain-deleted F8) gene into the albumin locus of HA mice by hydrodynamic tail vein injection of editing plasmid vectors. One week after treatment, a high F8 activity ranging from 70% to 280% of normal serum levels was observed in all treated HA mice but dropped to background levels 3-5 weeks later. We found that the humoral immune reaction targeting F8 is the predominant cause of the decreased F8 activity. We hypothesized that hydrodynamic injection-induced liver damage triggered the release of large quantities of inflammatory cytokines. However, co-injection of plasmids expressing a dozen immunomodulatory factors failed to curtail the immune reaction and stabilize F8 activity. The spCas9 plasmid carrying a miR-142-3p target sequence alleviated the cellular immune response but was unable to deliver therapeutic efficacy. Strikingly, immunosuppressant cyclo-phosphamide virtually abolished the immune response, leading to a year-long stable F8 level. Our findings should have important implications in developing therapies in mouse models using the hydrodynamic gene delivery approach, highlighting the ne-cessity of modulating the innate immune response triggered by liver damage.
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Affiliation(s)
- Mei Zhao
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Yi-Dan Sun
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Mengdi Yin
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Juan-Juan Zhao
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China.,Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Si-Ang Li
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Guohua Li
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Feng Zhang
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Jing Xu
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Fei-Ying Meng
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Beldon Zhang
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Xin-Yu Sun
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Jian-Ping Zhang
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Tao Cheng
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
| | - Xiao-Bing Zhang
- Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, 70585, Tianjin, Tianjin, China;
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30
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Rodríguez-Merchán EC, De Pablo-Moreno JA, Liras A. Gene Therapy in Hemophilia: Recent Advances. Int J Mol Sci 2021; 22:ijms22147647. [PMID: 34299267 PMCID: PMC8306493 DOI: 10.3390/ijms22147647] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023] Open
Abstract
Hemophilia is a monogenic mutational disease affecting coagulation factor VIII or factor IX genes. The palliative treatment of choice is based on the use of safe and effective recombinant clotting factors. Advanced therapies will be curative, ensuring stable and durable concentrations of the defective circulating factor. Results have so far been encouraging in terms of levels and times of expression using mainly adeno-associated vectors. However, these therapies are associated with immunogenicity and hepatotoxicity. Optimizing the vector serotypes and the transgene (variants) will boost clotting efficacy, thus increasing the viability of these protocols. It is essential that both physicians and patients be informed about the potential benefits and risks of the new therapies, and a register of gene therapy patients be kept with information of the efficacy and long-term adverse events associated with the treatments administered. In the context of hemophilia, gene therapy may result in (particularly indirect) cost savings and in a more equitable allocation of treatments. In the case of hemophilia A, further research is needed into how to effectively package the large factor VIII gene into the vector; and in the case of hemophilia B, the priority should be to optimize both the vector serotype, reducing its immunogenicity and hepatotoxicity, and the transgene, boosting its clotting efficacy so as to minimize the amount of vector administered and decrease the incidence of adverse events without compromising the efficacy of the protein expressed.
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Affiliation(s)
- E. Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research–IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain;
| | - Juan Andres De Pablo-Moreno
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, 28040 Madrid, Spain;
| | - Antonio Liras
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, 28040 Madrid, Spain;
- Correspondence:
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31
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Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
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Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
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32
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Zimta AA, Hotea I, Brinza M, Blag C, Iluta S, Constantinescu C, Bashimov A, Marchis-Hund EA, Coudsy A, Muller-Mohnssen L, Dirzu N, Gulei D, Dima D, Serban M, Coriu D, Tomuleasa C. The Possible Non-Mutational Causes of FVIII Deficiency: Non-Coding RNAs and Acquired Hemophilia A. Front Med (Lausanne) 2021; 8:654197. [PMID: 33968959 PMCID: PMC8099106 DOI: 10.3389/fmed.2021.654197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/11/2021] [Indexed: 12/28/2022] Open
Abstract
Hemophilia type A (HA) is the most common type of blood coagulation disorder. While the vast majority of cases are inherited and caused by mutations in the F8 gene, recent data raises new questions regarding the non-heritability of this disease, as well as how other molecular mechanisms might lead to the development of HA or increase the severity of the disease. Some data suggest that miRNAs may affect the severity of HA, but for some patients, miRNA-based interference might cause HA, in the absence of an F8 mutation. A mechanism in HA installation that is also worth investigating and which could be identified in the future is the epigenetic silencing of the F8 gene that might be only temporarily. Acquired HA is increasingly reported and as more cases are identified, the description of the disease might become challenging, as cases without FVIII autoantibodies might be identified.
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Affiliation(s)
- Alina-Andreea Zimta
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Ionut Hotea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Melen Brinza
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania.,Department of Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Blag
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Emergency Clinical Children's Hospital, Cluj Napoca, Romania
| | - Sabina Iluta
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Catalin Constantinescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Intensive Care Unit, Clinical Hospital for Infectious Diseases, Cluj Napoca, Romania
| | - Atamyrat Bashimov
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Elisabeth-Antonia Marchis-Hund
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Alexandra Coudsy
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Laetitia Muller-Mohnssen
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Noemi Dirzu
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Diana Gulei
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Delia Dima
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Margit Serban
- Louis Turcanu Emergency Children's Hospital, Timisoara, Romania.,European Hemophilia Treatment Center, Timisoara, Romania.,Department of Pediatrics, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Coriu
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania.,Department of Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ciprian Tomuleasa
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
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33
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Krumb E, Lambert C, Hermans C. Patient selection for hemophilia gene therapy: Real-life data from a single center. Res Pract Thromb Haemost 2021; 5:390-394. [PMID: 33870024 PMCID: PMC8035793 DOI: 10.1002/rth2.12494] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 02/07/2021] [Indexed: 02/06/2023] Open
Abstract
Background While the number of individuals with hemophilia who are expected to be or have already been included in gene therapy trials has been regularly reported, the number of unscreened or excluded individuals, in addition to the reasons for exclusion, is mostly not reported. Methods We conducted an eligibility assessment of all people with severe hemophilia for gene therapy trials in one large Belgian hemophilia treatment center based on patient selection criteria of gene therapy trials and patients’ profiling. Results Among 87 adult patients with severe hemophilia A and B, 11 aged ≥65 years and two women were excluded from analysis. Six patients were excluded because of inhibitor development. One patient exhibited active hepatitis C infection, one had insufficient exposure to factor VIII, and five had uncontrolled comorbidities, while two were enrolled in other trials and two abused alcohol. Overall, 43 patients were not screened owing to psychosocial factors. Among 14 patients accepting gene therapy, six had adeno‐associated virus type 5 neutralizing antibodies and one had liver fibrosis. The number of patients who would accept gene therapy in the absence of strict clinical trial requirements was estimated at 36 (41.4%), irrespective of any exclusion criteria. Conclusion The majority of individuals with severe hemophilia could not be enrolled in gene therapy trials, almost half of them because of partly modifiable psychosocial reasons (49.4%). The proportion of candidates should substantially increase in the future, as eligibility criteria are likely to change and as more data on long‐term efficacy and safety of gene therapy will become available.
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Affiliation(s)
- Evelien Krumb
- Hemostasis and Thrombosis Unit Division of Hematology Cliniques Universitaires Saint-Luc Université Catholique de Louvain (UCLouvain) Brussels Belgium
| | - Catherine Lambert
- Hemostasis and Thrombosis Unit Division of Hematology Cliniques Universitaires Saint-Luc Université Catholique de Louvain (UCLouvain) Brussels Belgium
| | - Cedric Hermans
- Hemostasis and Thrombosis Unit Division of Hematology Cliniques Universitaires Saint-Luc Université Catholique de Louvain (UCLouvain) Brussels Belgium
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Croteau SE, Wang M, Wheeler AP. 2021 clinical trials update: Innovations in hemophilia therapy. Am J Hematol 2021; 96:128-144. [PMID: 33064330 DOI: 10.1002/ajh.26018] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/19/2023]
Abstract
Therapies engineered to prolong clotting factor protein circulation time, manipulate the balance of pro-coagulant and anti-coagulant proteins, or introduce new genetic material to enable endogenous factor protein production dominate the clinical trial landscape of hemophilia. The availability of clotting factor concentrates and the establishment of primary prophylaxis have dramatically improved health outcomes for hemophilia patients. But, the burden of hemostatic therapy remains significant, and many barriers to consistent longitudinal use of prophylaxis exist. Several types of emerging therapeutics including engineered factor concentrates, substitutive therapies, rebalancing therapies, and gene transfer/editing all aim to reduce the challenges of current hemophilia treatment. Emerging treatment options may reduce treatment frequency or need for intravenous administration. They may also introduce new challenges in laboratory assessment of hemostasis. These novel therapies must not introduce significant new health risks and continue to support similar or improved outcomes. The potential ramifications of rebalancing the coagulation cascade, particularly in a stress or inflammatory state, or introduction of new genetic material are not trivial. The focus of this review is to provide an overview of active and recently completed clinical trials as well as emerging preclinical data investigating new therapeutic possibilities for hemophilia patients and potentially other rare bleeding disorders.
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Affiliation(s)
| | - Michael Wang
- University of Colorado Hemophilia and Thrombosis Center Aurora Colorado
| | - Allison P. Wheeler
- Department of Pathology, Microbiology & Immunology Vanderbilt University Medical Center Nashville Tennessee
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Woollard L, Gorman R, Rosenfelt DJ. Improving patient informed consent for haemophilia gene therapy: the case for change. THERAPEUTIC ADVANCES IN RARE DISEASE 2021; 2:26330040211047244. [PMID: 37181114 PMCID: PMC10032461 DOI: 10.1177/26330040211047244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/31/2021] [Indexed: 05/16/2023]
Abstract
Adeno-associated virus-based gene therapy points to a coming transformation in the treatment of people living with haemophilia, promising sustained bleed control and potential improvement in quality of life. Nevertheless, the consequences of introducing new genetic material are not trivial. The perceived benefits should not minimise the challenges facing patients in understanding the long-term risks and providing a valid and meaningful informed consent, whether in a research or clinical setting. Informed consent is a fundamentally important doctrine in both medical ethics and health law, upholding an individual's right to define their personal goals and make their own autonomous choices. Patients should be enabled to recognise their clinical situation, understand the implications of treatment and integrate every facet of their life into their decision. This review describes informed consent processes for haemophilia gene therapy clinical trials, factors affecting patients' decision making and the availability of patient-centred decision support interventions, to ensure that patients' interests are being protected. Regulatory guidance has been published for physicians and manufacturers in haemophilia on informed consent, including for gene therapy, while best-practice recommendations for patient-physician discussions are available. In all settings, however, communicating and presenting highly technical and complex therapeutic information is challenging, especially where multiple barriers to scientific knowledge and health literacy exist. We propose several evidence-informed strategies to enhance the consent procedure, such as utilising validated literacy and knowledge assessment tools as well as participatory learning environments over an extended period, to ensure that patients are fully cognisant of the consent they give or deny. Further research is needed to define new, creative approaches for patient education and the upholding of ethical values in the informed consent process for gene therapy. The lessons learnt and approaches developed within haemophilia could set the gold standard for good practice in ensuring ethical preparedness amidst advances in genetic therapies. Plain language summary Improving the informed consent process for people living with haemophilia considering gene therapy. Gene therapy is the process of replacing faulty genes with healthy ones. In haemophilia, gene therapy involves introducing a working copy of the gene for the clotting factor that patients are missing. Following treatment, patients should begin producing their own clotting factor normally. However, people living with haemophilia (PwH) need to be fully informed regarding the potential benefits and risks of gene therapy and what this means for them, whether as part of a research study or routine medical care.Patients must be respected and supported to make decisions about their own health and wellbeing, recognising their legal and moral right to set personal goals and make treatment choices. For this to happen in practice, patients should be aware of their individual health needs, understand the effects of treatment and consider lifestyle preferences in relation to their decisions. This article attempts to describe how informed consent is obtained in haemophilia gene therapy clinical trials, what affects a patient's ability to make decisions and the availability of information and support to respect and protect the interests of PwH.Regulators responsible for approving medical products have published guidance on informed consent for physicians and pharmaceutical manufacturers in haemophilia, including for gene therapy. Recommendations have been made about the best ways for PwH to discuss gene therapy with their physicians. Yet, poor communication of complex topics, such as gene therapy, can be problematic, especially if patients lack the skills and confidence to understand and discuss the science, or for physicians with limited time in clinic.We propose strategies to improve the consent process, so patients can feel more able to make informed decisions about new treatments. Further research is needed to find new, creative approaches for educating patients and ensuring that the informed consent process for gene therapy in haemophilia is ethical.
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Affiliation(s)
- Laurence Woollard
- On The Pulse Consultancy, Ltd., 14 Church View,
Wixoe, Sudbury, CO10 8UH, UK
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Thornburg CD. Etranacogene dezaparvovec for hemophilia B gene therapy. THERAPEUTIC ADVANCES IN RARE DISEASE 2021; 2:26330040211058896. [PMID: 37181105 PMCID: PMC10032433 DOI: 10.1177/26330040211058896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/21/2021] [Indexed: 05/16/2023]
Abstract
The treatment landscape for hemophilia has been rapidly changing with introduction of novel therapies. Gene therapy for hemophilia is a promising therapeutic option for sustained endogenous factor production to mitigate the need for prophylactic treatment to prevent spontaneous and traumatic bleeding. Etranacogene dezaparvovec is an investigational factor IX (FIX) gene transfer product that utilizes the adeno-associated virus (AAV) 5 vector with a liver-specific promoter and a hyperactive FIX transgene. Here, the development of etranacogene dezaparvovec and available efficacy and safety data from clinical trials are reviewed. Overall, etranacogene dezaparvovec provides sustained FIX expression for more than 2 years and allows for a bleed and infusion-free life in the majority of patients. Safety, efficacy, and quality-of-life data will inform shared decision-making for patients who are considering gene therapy. Long-term follow-up regarding duration of expression and safety are crucial.
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Affiliation(s)
- Courtney D. Thornburg
- Division of Hematology/Oncology, Rady Children’s
Hospital San Diego, 3020 Children’s Way, MC 5035, San Diego, CA 92123, USA.
Department of Pediatrics, UC San Diego School of Medicine, La Jolla, CA,
USA
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