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Clark RD, Rabito F, Munyonho FT, Remcho TP, Kolls JK. Evaluation of anti-vector immune responses to adenovirus-mediated lung gene therapy and modulation by αCD20. Mol Ther Methods Clin Dev 2024; 32:101286. [PMID: 39070292 PMCID: PMC11283059 DOI: 10.1016/j.omtm.2024.101286] [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: 08/16/2023] [Accepted: 06/21/2024] [Indexed: 07/30/2024]
Abstract
Although the last decade has seen tremendous progress in drugs that treat cystic fibrosis (CF) due to mutations that lead to protein misfolding, there are approximately 8%-10% of subjects with mutations that result in no significant CFTR protein expression demonstrating the need for gene editing or gene replacement with inhaled mRNA or vector-based approaches. A limitation for vector-based approaches is the formation of neutralizing humoral responses. Given that αCD20 has been used to manage post-transplant lymphoproliferative disease in CF subjects with lung transplants, we studied the ability of αCD20 to module both T and B cell responses in the lung to one of the most immunogenic vectors, E1-deleted adenovirus serotype 5. We found that αCD20 significantly blocked luminal antibody responses and efficiently permitted re-dosing. αCD20 had more limited impact on the T cell compartment, but reduced tissue resident memory T cell responses in bronchoalveolar lavage fluid. Taken together, these pre-clinical studies suggest that αCD20 could be re-purposed for lung gene therapy protocols to permit re-dosing.
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Affiliation(s)
- Robert D.E. Clark
- Departments of Pediatrics & Medicine, Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Felix Rabito
- Departments of Pediatrics & Medicine, Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Ferris T. Munyonho
- Departments of Pediatrics & Medicine, Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - T. Parks Remcho
- Departments of Pediatrics & Medicine, Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Jay K. Kolls
- Departments of Pediatrics & Medicine, Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70112, USA
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2
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Ismail AM, Witt E, Bouwman T, Clark W, Yates B, Franco M, Fong S. The longitudinal kinetics of AAV5 vector integration profiles and evaluation of clonal expansion in mice. Mol Ther Methods Clin Dev 2024; 32:101294. [PMID: 39104575 PMCID: PMC11298592 DOI: 10.1016/j.omtm.2024.101294] [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: 03/28/2024] [Accepted: 06/24/2024] [Indexed: 08/07/2024]
Abstract
Adeno-associated virus (AAV)-based vectors are used clinically for gene transfer and persist as extrachromosomal episomes. A small fraction of vector genomes integrate into the host genome, but the theoretical risk of tumorigenesis depends on vector regulatory features. A mouse model was used to investigate integration profiles of an AAV serotype 5 (AAV5) vector produced using Sf and HEK293 cells that mimic key features of valoctocogene roxaparvovec (AAV5-hFVIII-SQ), a gene therapy for severe hemophilia A. The majority (95%) of vector genome reads were derived from episomes, and mean (± standard deviation) integration frequency was 2.70 ± 1.26 and 1.79 ± 0.86 integrations per 1,000 cells for Sf- and HEK293-produced vector. Longitudinal integration analysis suggested integrations occur primarily within 1 week, at low frequency, and their abundance was stable over time. Integration profiles were polyclonal and randomly distributed. No major differences in integration profiles were observed for either vector production platform, and no integrations were associated with clonal expansion. Integrations were enriched near transcription start sites of genes highly expressed in the liver (p = 1 × 10-4) and less enriched for genes of lower expression. We found no evidence of tumorigenesis or fibrosis caused by the vector integrations.
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Affiliation(s)
| | - Evan Witt
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
| | | | - Wyatt Clark
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
| | | | - Matteo Franco
- ProtaGene CGT GmbH, Heidelberg 69120, Germany
- ProtaGene Inc., Burlington, MA 01803, USA
| | - Sylvia Fong
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
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3
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Agarwal S, Sandza K, Obrochta Moss K, Vora M, Bowen A, Bunch B, Holcomb J, Robinson TM, Jayaram K, Russell CB, Zoog S, Vettermann C, Henshaw J. Blood biodistribution and vector shedding of valoctocogene roxaparvovec in people with severe hemophilia A. Blood Adv 2024; 8:4606-4615. [PMID: 39024543 DOI: 10.1182/bloodadvances.2024013150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 07/20/2024] Open
Abstract
ABSTRACT Following systemically administered adeno-associated virus gene therapy, vector particles are widely distributed, raising concerns about horizontal or germline vector transmission. Characterization of biodistribution and kinetics of vector DNA in body fluids can address these concerns and provide insights into vector behavior in accessible samples. We investigated biodistribution and vector shedding profile of valoctocogene roxaparvovec in men with severe hemophilia A enrolled in the phase 3 GENEr8-1 trial. Participants (n = 134) received a single 6 × 1013 vector genome (vg)/kg infusion and were assessed over 3 years. Vector DNA was measured using 4 different assays. Total vector DNA was evaluated in blood, saliva, stool, semen, and urine by quantitative polymerase chain reaction (qPCR). Encapsidated vector DNA was measured in plasma and semen with immunocapture-based qPCR. Contiguity of vgs and assembly of inverted terminal repeat fusions were measured in whole blood and peripheral blood mononuclear cells (PBMCs) using multicolor digital PCR. Median peak vector DNA levels observed 1 to 8 days after dosing were highest in blood, followed by saliva, semen, stool, and urine. Concentrations declined steadily. Encapsidated vector DNA cleared faster than total vector DNA, achieving clearance by ≤12 weeks in plasma and semen. Predominant vector genome forms transitioned from noncontiguous to full-length over time in whole blood and PBMCs, indicating formation of stable circularized episomes within nucleated cells. The replication-incompetent nature of valoctocogene roxaparvovec, coupled with steady clearance of total and encapsidated vector DNA from shedding matrices, indicates transmission risk is low. This trial was registered at www.ClinicalTrials.gov as #NCT03370913.
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Affiliation(s)
- Suresh Agarwal
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | - Krystal Sandza
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | | | - Monica Vora
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | - Alisa Bowen
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | - Brenna Bunch
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | | | - Tara M Robinson
- Late Clinical Development, BioMarin Pharmaceutical Inc, Novato, CA
| | - Kala Jayaram
- Pharmacovigilance, BioMarin Pharmaceutical Inc, Novato, CA
| | - Chris B Russell
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | - Stephen Zoog
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
| | | | - Joshua Henshaw
- Translational Sciences, BioMarin Pharmaceutical Inc, Novato, CA
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Liu F, Li R, Zhu Z, Yang Y, Lu F. Current developments of gene therapy in human diseases. MedComm (Beijing) 2024; 5:e645. [PMID: 39156766 PMCID: PMC11329757 DOI: 10.1002/mco2.645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 08/20/2024] Open
Abstract
Gene therapy has witnessed substantial advancements in recent years, becoming a constructive tactic for treating various human diseases. This review presents a comprehensive overview of these developments, with a focus on their diverse applications in different disease contexts. It explores the evolution of gene delivery systems, encompassing viral (like adeno-associated virus; AAV) and nonviral approaches, and evaluates their inherent strengths and limitations. Moreover, the review delves into the progress made in targeting specific tissues and cell types, spanning the eye, liver, muscles, and central nervous system, among others, using these gene technologies. This targeted approach is crucial in addressing a broad spectrum of genetic disorders, such as inherited lysosomal storage diseases, neurodegenerative disorders, and cardiovascular diseases. Recent clinical trials and successful outcomes in gene therapy, particularly those involving AAV and the clustered regularly interspaced short palindromic repeats (CRISPR)-CRISPR-associated proteins, are highlighted, illuminating the transformative potentials of this approach in disease treatment. The review summarizes the current status of gene therapy, its prospects, and its capacity to significantly ameliorate patient outcomes and quality of life. By offering comprehensive analysis, this review provides invaluable insights for researchers, clinicians, and stakeholders, enriching the ongoing discourse on the trajectory of disease treatment.
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Affiliation(s)
- Fanfei Liu
- Department of OphthalmologyWest China HospitalChengduSichuanChina
| | - Ruiting Li
- State Key Laboratory of BiotherapyWest China HospitalChengduSichuanChina
| | - Zilin Zhu
- College of Life SciencesSichuan UniversityChengduSichuanChina
| | - Yang Yang
- Department of OphthalmologyWest China HospitalChengduSichuanChina
- State Key Laboratory of BiotherapyWest China HospitalChengduSichuanChina
| | - Fang Lu
- Department of OphthalmologyWest China HospitalChengduSichuanChina
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Kachanov A, Kostyusheva A, Brezgin S, Karandashov I, Ponomareva N, Tikhonov A, Lukashev A, Pokrovsky V, Zamyatnin AA, Parodi A, Chulanov V, Kostyushev D. The menace of severe adverse events and deaths associated with viral gene therapy and its potential solution. Med Res Rev 2024; 44:2112-2193. [PMID: 38549260 DOI: 10.1002/med.22036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 08/09/2024]
Abstract
Over the past decade, in vivo gene replacement therapy has significantly advanced, resulting in market approval of numerous therapeutics predominantly relying on adeno-associated viral vectors (AAV). While viral vectors have undeniably addressed several critical healthcare challenges, their clinical application has unveiled a range of limitations and safety concerns. This review highlights the emerging challenges in the field of gene therapy. At first, we discuss both the role of biological barriers in viral gene therapy with a focus on AAVs, and review current landscape of in vivo human gene therapy. We delineate advantages and disadvantages of AAVs as gene delivery vehicles, mostly from the safety perspective (hepatotoxicity, cardiotoxicity, neurotoxicity, inflammatory responses etc.), and outline the mechanisms of adverse events in response to AAV. Contribution of every aspect of AAV vectors (genomic structure, capsid proteins) and host responses to injected AAV is considered and substantiated by basic, translational and clinical studies. The updated evaluation of recent AAV clinical trials and current medical experience clearly shows the risks of AAVs that sometimes overshadow the hopes for curing a hereditary disease. At last, a set of established and new molecular and nanotechnology tools and approaches are provided as potential solutions for mitigating or eliminating side effects. The increasing number of severe adverse reactions and, sadly deaths, demands decisive actions to resolve the issue of immune responses and extremely high doses of viral vectors used for gene therapy. In response to these challenges, various strategies are under development, including approaches aimed at augmenting characteristics of viral vectors and others focused on creating secure and efficacious non-viral vectors. This comprehensive review offers an overarching perspective on the present state of gene therapy utilizing both viral and non-viral vectors.
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Affiliation(s)
- Artyom Kachanov
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
| | - Anastasiya Kostyusheva
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
| | - Sergey Brezgin
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
- Division of Biotechnology, Scientific Center for Genetics and Life Sciences, Sirius University of Science and Technology, Sochi, Russia
| | - Ivan Karandashov
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
| | - Natalia Ponomareva
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
- Division of Biotechnology, Scientific Center for Genetics and Life Sciences, Sirius University of Science and Technology, Sochi, Russia
| | - Andrey Tikhonov
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
| | - Alexander Lukashev
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
| | - Vadim Pokrovsky
- Laboratory of Biochemical Fundamentals of Pharmacology and Cancer Models, Blokhin Cancer Research Center, Moscow, Russia
- Department of Biochemistry, People's Friendship University, Russia (RUDN University), Moscow, Russia
| | - Andrey A Zamyatnin
- Division of Biotechnology, Scientific Center for Genetics and Life Sciences, Sirius University of Science and Technology, Sochi, Russia
- Faculty of Bioengineering and Bioinformatics, Lomonosov Moscow State University, Moscow, Russia
- Belozersky Research, Institute of Physico-Chemical Biology, Lomonosov Moscow State University, Moscow, Russia
| | - Alessandro Parodi
- Division of Biotechnology, Scientific Center for Genetics and Life Sciences, Sirius University of Science and Technology, Sochi, Russia
| | - Vladimir Chulanov
- Division of Biotechnology, Scientific Center for Genetics and Life Sciences, Sirius University of Science and Technology, Sochi, Russia
- Faculty of Infectious Diseases, Sechenov University, Moscow, Russia
| | - Dmitry Kostyushev
- Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Sechenov University, Moscow, Russia
- Division of Biotechnology, Scientific Center for Genetics and Life Sciences, Sirius University of Science and Technology, Sochi, Russia
- Faculty of Bioengineering and Bioinformatics, Lomonosov Moscow State University, Moscow, Russia
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6
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Hwu WL. Gene therapy for ultrarare diseases: a geneticist's perspective. J Biomed Sci 2024; 31:79. [PMID: 39138523 PMCID: PMC11321167 DOI: 10.1186/s12929-024-01070-1] [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: 05/04/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Abstract
Gene therapy has made considerable strides in recent years. More than 4000 protein-coding genes have been implicated in more than 6000 genetic diseases; next-generation sequencing has dramatically revolutionized the diagnosis of genetic diseases. Most genetic diseases are considered very rare or ultrarare, defined here as having fewer than 1:100,000 cases, but only one of the 12 approved gene therapies (excluding RNA therapies) targets an ultrarare disease. This article explores three gene supplementation therapy approaches suitable for various rare genetic diseases: lentiviral vector-modified autologous CD34+ hematopoietic stem cell transplantation, systemic delivery of adeno-associated virus (AAV) vectors to the liver, and local AAV delivery to the cerebrospinal fluid and brain. Together with RNA therapies, we propose a potential business model for these gene therapies.
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Affiliation(s)
- Wuh-Liang Hwu
- Center for Precision Medicine, China Medical University Hospital, Taichung City, Taiwan.
- Department of Pediatrics and Medical Genetics, National Taiwan University Hospital, Taipei City, Taiwan.
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7
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Mancuso ME, McLaughlin P, Forsyth AL, Valentino LA. Joint health and pain in the changing hemophilia treatment landscape. Expert Rev Hematol 2024; 17:431-444. [PMID: 38981851 DOI: 10.1080/17474086.2024.2378936] [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: 03/05/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Hemophilia is an inherited bleeding disorder. Bleeding, and in particular joint hemorrhage results in chronic arthropathy and disability. Acute and chronic pain are frequent and limit activity and participation and result in decreased health-related quality of life. Remarkable progress has been made in the diagnosis and treatment of hemophilia but bleeding continues to prove recalcitrant to currently available treatments and joint disease remains problematic. Physiotherapy and pain management are mainstays of current multidisciplinary integrated care of people with hemophilia (PWH). The focus of this review is on preservation of joint health in the era of new and innovative therapies. AREAS COVERED A search of the PubMed Central was conducted on 1 February 2024 using the MeSH Major Topic terms identified as keywords for the manuscript. This review will highlight what is known and unknown about joint bleeding and arthropathy, including insights on pain as a related complication. EXPERT OPINION Recent advances in therapeutic interventions aimed at promoting healthy joints in PWH will be discussed, including both the pharmacological treatment landscape and related strategies to promote joint health.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Department of Cardiovascular Medicine, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
- Research Department of Haematology, University College London, London, UK
| | - Angela L Forsyth
- Physical Therapy Collaborative, Optum Infusion Pharmacy, Eden Praire, MN, USA
| | - Leonard A Valentino
- Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA
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8
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Dougherty JA, Dougherty KM. Valoctocogene Roxaparvovec and Etranacogene Dezaparavovec: Novel Gene Therapies for Hemophilia A and B. Ann Pharmacother 2024; 58:834-848. [PMID: 37978816 DOI: 10.1177/10600280231202247] [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] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To review efficacy and safety data of valoctocogene roxaparvovec (Roctavian) and etranacogene dezaparavovec (Hemgenix), novel gene therapies for the treatment of the life-threatening bleeding disorders hemophilia A and B, respectively. DATA SOURCES A PubMed/Google Scholar search from inception through August 11, 2023 was conducted using the following keywords: gene therapy, hemophilia A, hemophilia B, etranacogene dezaparavovec, valoctocogene roxaparvovec, and bleeding. STUDY SELECTION AND DATA EXTRACTION Data, including phase 1 to 3 clinical trials (non-comparator), were obtained from primary literature and package inserts. These reports evaluated clinical pharmacology, efficacy, safety, adverse events, warnings, and precautions. DATA SYNTHESIS Valoctocogene phase 3 study in males (n = 134): 87% had factor VIII (FVIII) levels that at least met criteria for mild hemophilia. Etranacogene phase 3 study in males (n = 54): within 3 weeks of infusion, mean factor IX (FIX) levels had reached 26.8 IU/dL. Both therapies provided clinically and statistically significant decreases in bleeding events and prophylactic factor infusions. Most common adverse event was elevations in liver function tests that were treated with glucocorticoids. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON WITH EXISTING DRUGS The endogenous production of clotting factors mimics physiological production while decreasing morbidity and mortality related to bleeding events similar to the effects of existing replacement strategies. Gene therapy was also shown to increase patient quality of life. CONCLUSION Valoctocogene and etranacogene provide another treatment for selected patients with hemophilia. Treatment for the patient with hemophilia (gene therapy vs replacement strategy) must be personalized as new clinical data are published being cognizant of drug affordability.
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Affiliation(s)
- John A Dougherty
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
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Greig JA, Martins KM, Breton C, Lamontagne RJ, Zhu Y, He Z, White J, Zhu JX, Chichester JA, Zheng Q, Zhang Z, Bell P, Wang L, Wilson JM. Integrated vector genomes may contribute to long-term expression in primate liver after AAV administration. Nat Biotechnol 2024; 42:1232-1242. [PMID: 37932420 PMCID: PMC11324525 DOI: 10.1038/s41587-023-01974-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/29/2023] [Indexed: 11/08/2023]
Abstract
The development of liver-based adeno-associated virus (AAV) gene therapies is facing concerns about limited efficiency and durability of transgene expression. We evaluated nonhuman primates following intravenous dosing of AAV8 and AAVrh10 vectors for over 2 years to better define the mechanism(s) of transduction that affect performance. High transduction of non-immunogenic transgenes was achieved, although expression declined over the first 90 days to reach a lower but stable steady state. More than 10% of hepatocytes contained single nuclear domains of vector DNA that persisted despite the loss of transgene expression. Greater reductions in vector DNA and RNA were observed with immunogenic transgenes. Genomic integration of vector sequences, including complex concatemeric structures, were detected in 1 out of 100 cells at broadly distributed loci that were not in proximity to genes associated with hepatocellular carcinoma. Our studies suggest that AAV-mediated transgene expression in primate hepatocytes occurs in two phases: high but short-lived expression from episomal genomes, followed by much lower but stable expression, likely from integrated vectors.
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Affiliation(s)
- Jenny A Greig
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly M Martins
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Camilo Breton
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - R Jason Lamontagne
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yanqing Zhu
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zhenning He
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John White
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jing-Xu Zhu
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica A Chichester
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Qi Zheng
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zhe Zhang
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Bell
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lili Wang
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James M Wilson
- Gene Therapy Program, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Dargaud Y, Levrero M, Bailly F, Lienhart A, Zoulim F. Liver health in hemophilia in the era of gene therapy. Thromb Res 2024; 240:109064. [PMID: 38878740 DOI: 10.1016/j.thromres.2024.109064] [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: 03/23/2024] [Revised: 05/25/2024] [Accepted: 06/12/2024] [Indexed: 07/07/2024]
Abstract
Gene therapy for hemophilia is a groundbreaking treatment approach with promising results and potential to reduce the burden of the disease. However, uncertainties remain, particularly regarding the liver side effects of AAV gene therapy, which are more common in hemophilia A. Unlike some other diseases, such as spinal muscular atrophy, where the target cell for gene therapy is different from the one affected by side effects, hemophilia gene therapy operates within the same cellular domain-the hepatocyte. This overlap is challenging and requires a targeted strategy to mitigate the risks associated with liver injury, which often requires temporary immunosuppressive therapy. A comprehensive approach is essential to increase the efficacy of gene therapy and reduce the likelihood of hepatocyte damage. Key components of this strategy include a thorough pre-gene therapy assessment of liver health, careful post-gene therapy liver monitoring, and prompt therapeutic intervention for loss of transgene expression and liver injury. Collaboration between hematologists and hepatologists is essential to ensure a well-coordinated management plan for patients undergoing hemophilia gene therapy. This review addresses the critical aspect of hepatic comorbidities in patients with hemophilia, emphasizing the need to identify and address these issues prior to initiating gene therapy. It examines the known mechanisms of liver damage and emphasizes the importance of liver monitoring after gene therapy. In addition, the review draws insights from experiences with other AAV-based gene therapies, providing valuable lessons that can guide hemophilia centers in effectively managing liver damage associated with hemophilia gene therapy.
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Affiliation(s)
- Yesim Dargaud
- French Reference Center for Hemophilia, Clinical Haemostasis Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France; Universite Claude Bernard Lyon 1 (UCLB), Lyon, France; The Lyon Hepatology Institute EVEREST, France.
| | - Massimo Levrero
- Universite Claude Bernard Lyon 1 (UCLB), Lyon, France; Department of Hepatology, Hopital Croix-Rousse, Hospices Civils de Lyon, INSERM, Lyon, France; INSERM Unit 1052, Lyon, France; The Lyon Hepatology Institute EVEREST, France
| | - François Bailly
- Department of Hepatology, Hopital Croix-Rousse, Hospices Civils de Lyon, INSERM, Lyon, France; INSERM Unit 1052, Lyon, France; The Lyon Hepatology Institute EVEREST, France
| | - Anne Lienhart
- French Reference Center for Hemophilia, Clinical Haemostasis Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Fabien Zoulim
- Universite Claude Bernard Lyon 1 (UCLB), Lyon, France; Department of Hepatology, Hopital Croix-Rousse, Hospices Civils de Lyon, INSERM, Lyon, France; INSERM Unit 1052, Lyon, France; The Lyon Hepatology Institute EVEREST, France
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11
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Tonetto E, Cucci A, Follenzi A, Bernardi F, Pinotti M, Balestra D. DNA base editing corrects common hemophilia A mutations and restores factor VIII expression in in vitro and ex vivo models. J Thromb Haemost 2024; 22:2171-2183. [PMID: 38718928 DOI: 10.1016/j.jtha.2024.04.020] [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: 01/22/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Replacement and nonreplacement therapies effectively control bleeding in hemophilia A (HA) but imply lifelong interventions. Authorized gene addition therapy could provide a cure but still poses questions on durability. FVIIIgene correction would definitively restore factor (F)VIII production, as shown in animal models through nuclease-mediated homologous recombination (HR). However, low efficiency and potential off-target double-strand break still limit HR translatability. OBJECTIVES To correct common model single point mutations leading to severe HA through the recently developed double-strand break/HR-independent base editing (BE) and prime editing (PE) approaches. METHODS Screening for efficacy of BE/PE systems in HEK293T cells transiently expressing FVIII variants and validation at DNA (sequencing) and protein (enzyme-linked immunosorbent assay; activated partial thromboplastin time) level in stable clones. Evaluation of rescue in engineered blood outgrowth endothelial cells by lentiviral-mediated delivery of BE. RESULTS Transient assays identified the best-performing BE/PE systems for each variant, with the highest rescue of FVIII expression (up to 25% of wild-type recombinant FVIII) for the p.R2166∗ and p.R2228Q mutations. In stable clones, we demonstrated that the mutation reversion on DNA (∼24%) was consistent with the rescue of FVIII secretion and activity of 20% to 30%. The lentiviral-mediated delivery of the selected BE systems was attempted in engineered blood outgrowth endothelial cells harboring the p.R2166∗ and p.R2228Q variants, which led to an appreciable and dose-dependent rescue of secreted functional FVIII. CONCLUSION Overall data provide the first proof-of-concept for effective BE/PE-mediated correction of HA-causing mutations, which encourage studies in mouse models to develop a personalized cure for large cohorts of patients through a single intervention.
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Affiliation(s)
- Elena Tonetto
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy
| | - Alessia Cucci
- Department of Health Sciences, School of Medicine, University of Piemonte Orientale, Novara, Italy
| | - Antonia Follenzi
- Department of Health Sciences, School of Medicine, University of Piemonte Orientale, Novara, Italy
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy
| | - Mirko Pinotti
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy.
| | - Dario Balestra
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy
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Chernyi N, Gavrilova D, Saruhanyan M, Oloruntimehin ES, Karabelsky A, Bezsonov E, Malogolovkin A. Recent Advances in Gene Therapy for Hemophilia: Projecting the Perspectives. Biomolecules 2024; 14:854. [PMID: 39062568 PMCID: PMC11274510 DOI: 10.3390/biom14070854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
One of the well-known X-linked genetic disorders is hemophilia, which could be hemophilia A as a result of a mutation in the F8 (factor VIII) gene or hemophilia B as a result of a mutation in the F9 (factor IX) gene, leading to insufficient levels of the proteins essential for blood coagulation cascade. In patients with severe hemophilia, factor VIII or factor IX activities in the blood plasma are considerably low, estimated to be less than 1%. This is responsible for spontaneous or post-traumatic bleeding episodes, or both, leading to disease complications and death. Current treatment of hemophilia relies on the prevention of bleeding, which consists of expensive lifelong replacement infusion therapy of blood plasma clotting factors, their recombinant versions, or therapy with recombinant monoclonal antibodies. Recently emerged gene therapy approaches may be a potential game changer that could reshape the therapeutic outcomes of hemophilia A or B using a one-off vector in vivo delivery and aim to achieve long-term endogenous expression of factor VIII or IX. This review examines both traditional approaches to the treatment of hemophilia and modern methods, primarily focusing on gene therapy, to update knowledge in this area. Recent technological advances and gene therapeutics in the pipeline are critically reviewed and summarized. We consider gene therapy to be the most promising method as it may overcome the problems associated with more traditional treatments, such as the need for constant and expensive infusions and the presence of an immune response to the antibody drugs used to treat hemophilia.
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Affiliation(s)
- Nikita Chernyi
- Laboratory of Molecular Virology, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia
| | - Darina Gavrilova
- Department of Biology and General Genetics, First Moscow State Medical University (Sechenov University), Moscow 105043, Russia
| | - Mane Saruhanyan
- Laboratory of Molecular Virology, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia
| | - Ezekiel S. Oloruntimehin
- Laboratory of Molecular Virology, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia
| | - Alexander Karabelsky
- Center for Translational Medicine, Sirius University of Science and Technology, Sochi 354530, Russia
| | - Evgeny Bezsonov
- Laboratory of Molecular Virology, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia
- Department of Biology and General Genetics, First Moscow State Medical University (Sechenov University), Moscow 105043, Russia
| | - Alexander Malogolovkin
- Laboratory of Molecular Virology, First Moscow State Medical University (Sechenov University), Moscow 119435, Russia
- Center for Translational Medicine, Sirius University of Science and Technology, Sochi 354530, Russia
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13
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Symington E, Rangarajan S, Lester W, Madan B, Pierce GF, Raheja P, Millar C, Osmond D, Li M, Robinson TM. Valoctocogene roxaparvovec gene therapy provides durable haemostatic control for up to 7 years for haemophilia A. Haemophilia 2024. [PMID: 38975624 DOI: 10.1111/hae.15071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/15/2024] [Accepted: 06/09/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION Valoctocogene roxaparvovec is an adeno-associated virus vector serotype 5 (AAV5)-mediated gene therapy approved for severe haemophilia A (HA). AIM To report the safety and efficacy of valoctocogene roxaparvovec 7 years after dosing in a phase 1/2 clinical study (NCT02576795). METHODS Males ≥18 years with severe HA (factor VIII [FVIII] ≤1 international unit [IU]/dL) who were previously receiving exogenous FVIII and had no history of FVIII inhibitors or anti-AAV5 antibodies received valoctocogene roxaparvovec treatment and were followed for 7 (6 × 1013 vg/kg; n = 7) and 6 (4 × 1013 vg/kg; n = 6) years. RESULTS In the last year, one participant in each cohort reported treatment-related adverse events (AEs): grade 1 (G1) hepatomegaly (6 × 1013), and G1 splenomegaly and G1 hepatic steatosis (4 × 1013). During all follow-up, mean annualized treated bleeds and exogenous FVIII infusion rates were ≥88% lower than baseline values. At years 7 and 6, mean (median) FVIII activity (chromogenic assay) was 16.2 (10.3) and 6.7 (7.2) IU/dL in the 6 × 1013 (n = 5) and 4 × 1013 (n = 4) cohorts, respectively, corresponding to mild haemophilia. Regression analyses of the last year estimated rate of change in FVIII activity was -0.001 and -0.07 IU/dL/week for the 6 × 1013 and 4 × 1013 cohorts, respectively. Two participants (6 × 1013) resumed prophylaxis in year 7: one after a non-treatment-related G4 serious AE of spontaneous internal carotid artery bleed, and the other to manage bleeds and FVIII activity. CONCLUSIONS The safety and efficacy of valoctocogene roxaparvovec remain generally consistent with previous reports, with good haemostatic control for most participants. Two participants returned to prophylaxis.
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Affiliation(s)
- Emily Symington
- Haemophilia Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Will Lester
- Institute of Cardiovascular Sciences, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bella Madan
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Priyanka Raheja
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Carolyn Millar
- Department of Immunology and Inflammation, Imperial College Healthcare NHS Trust and Centre for Haematology, Imperial College London, London, UK
| | - Dane Osmond
- Clinical sciences, BioMarin Pharmaceutical Inc, Novato, California, USA
| | - Mingjin Li
- Clinical sciences, BioMarin Pharmaceutical Inc, Novato, California, USA
| | - Tara M Robinson
- Clinical sciences, BioMarin Pharmaceutical Inc, Novato, California, USA
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14
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Shih FH, Chang HH, Wang YC. Utilizing adeno-associated virus as a vector in treating genetic disorders or human cancers. IUBMB Life 2024. [PMID: 38970351 DOI: 10.1002/iub.2896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 06/17/2024] [Indexed: 07/08/2024]
Abstract
Clinical data from over two decades, involving more than 3000 treated patients, demonstrate that adeno-associated virus (AAV) gene therapy is a safe, effective, and well-tolerated therapeutic method. Clinical trials using AAV-mediated gene delivery to accessible tissues have led to successful treatments for numerous monogenic disorders and advancements in tissue engineering. Although the US Food and Drug Administration (FDA) has approved AAV for clinical use, systemic administration remains a significant challenge. In this review, we delve into AAV biology, focusing on current manufacturing technologies and transgene engineering strategies. We examine the use of AAVs in ongoing clinical trials for ocular, neurological, and hematological disorders, as well as cancers. By discussing recent advancements and current challenges in the field, we aim to provide valuable insights for researchers and clinicians navigating the evolving landscape of AAV-based gene therapy.
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Affiliation(s)
- Fu-Hsuan Shih
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Hsiung-Hao Chang
- Department of Pharmacology, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Yi-Ching Wang
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
- Department of Pharmacology, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
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15
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Wong D, Martinez J, Quijada P. Exploring the Function of Epicardial Cells Beyond the Surface. Circ Res 2024; 135:353-371. [PMID: 38963865 PMCID: PMC11225799 DOI: 10.1161/circresaha.124.321567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
The epicardium, previously viewed as a passive outer layer around the heart, is now recognized as an essential component in development, regeneration, and repair. In this review, we explore the cellular and molecular makeup of the epicardium, highlighting its roles in heart regeneration and repair in zebrafish and salamanders, as well as its activation in young and adult postnatal mammals. We also examine the latest technologies used to study the function of epicardial cells for therapeutic interventions. Analysis of highly regenerative animal models shows that the epicardium is essential in regulating cardiomyocyte proliferation, transient fibrosis, and neovascularization. However, despite the epicardium's unique cellular programs to resolve cardiac damage, it remains unclear how to replicate these processes in nonregenerative mammalian organisms. During myocardial infarction, epicardial cells secrete signaling factors that modulate fibrotic, vascular, and inflammatory remodeling, which differentially enhance or inhibit cardiac repair. Recent transcriptomic studies have validated the cellular and molecular heterogeneity of the epicardium across various species and developmental stages, shedding further light on its function under pathological conditions. These studies have also provided insights into the function of regulatory epicardial-derived signaling molecules in various diseases, which could lead to new therapies and advances in reparative cardiovascular medicine. Moreover, insights gained from investigating epicardial cell function have initiated the development of novel techniques, including using human pluripotent stem cells and cardiac organoids to model reparative processes within the cardiovascular system. This growing understanding of epicardial function holds the potential for developing innovative therapeutic strategies aimed at addressing developmental heart disorders, enhancing regenerative therapies, and mitigating cardiovascular disease progression.
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Affiliation(s)
- David Wong
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90029
- Molecular, Cellular and Integrative Physiology Graduate Program, University of California, Los Angeles, CA 90029
| | - Julie Martinez
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90029
- Molecular, Cellular and Integrative Physiology Graduate Program, University of California, Los Angeles, CA 90029
| | - Pearl Quijada
- Department of Integrative Biology and Physiology, University of California, Los Angeles, CA 90029
- Eli and Edythe Broad Stem Research Center, University of California, Los Angeles, CA 90029
- Molecular Biology Institute, University of California, Los Angeles, CA 90029
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16
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Liang SQ, Navia AW, Ramseier M, Zhou X, Martinez M, Lee C, Zhou C, Wu J, Xie J, Su Q, Wang D, Flotte TR, Anderson DG, Tarantal AF, Shalek AK, Gao G, Xue W. AAV5 Delivery of CRISPR/Cas9 Mediates Genome Editing in the Lungs of Young Rhesus Monkeys. Hum Gene Ther 2024. [PMID: 38767512 DOI: 10.1089/hum.2024.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Genome editing has the potential to treat genetic diseases in a variety of tissues, including the lung. We have previously developed and validated a dual adeno-associated virus (AAV) CRISPR platform that supports effective editing in the airways of mice. To validate this delivery vehicle in a large animal model, we have shown that intratracheal instillation of CRISPR/Cas9 in AAV5 can edit a housekeeping gene or a disease-related gene in the lungs of young rhesus monkeys. We observed up to 8% editing of angiotensin-converting enzyme 2 (ACE2) in lung lobes after single-dose administration. Single-nuclear RNA sequencing revealed that AAV5 transduces multiple cell types in the caudal lung lobes, including alveolar cells, macrophages, fibroblasts, endothelial cells, and B cells. These results demonstrate that AAV5 is efficient in the delivery of CRISPR/Cas9 in the lung lobes of young rhesus monkeys.
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Affiliation(s)
- Shun-Qing Liang
- RNA Therapeutics Institute, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Andrew W Navia
- Institute for Medical Engineering and Science, Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Michelle Ramseier
- Institute for Medical Engineering and Science, Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Xuntao Zhou
- RNA Therapeutics Institute, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Michele Martinez
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, California, USA
| | - Charles Lee
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, California, USA
| | - Chen Zhou
- Horae Gene Therapy Center and Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Joae Wu
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jun Xie
- Horae Gene Therapy Center and Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Viral Vector Core, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Qin Su
- Horae Gene Therapy Center and Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Viral Vector Core, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Dan Wang
- Horae Gene Therapy Center and Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Terence R Flotte
- Horae Gene Therapy Center and Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Daniel G Anderson
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Harvard and MIT Division of Health Science and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, California, USA
| | - Alex K Shalek
- Institute for Medical Engineering and Science, Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Guangping Gao
- Horae Gene Therapy Center and Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Viral Vector Core, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Wen Xue
- RNA Therapeutics Institute, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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17
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Long BR, Robinson TM, Day JRS, Yu H, Lau K, Imtiaz U, Patton KS, de Hart G, Henshaw J, Agarwal S, Vettermann C, Zoog SJ, Gupta S. Clinical immunogenicity outcomes from GENEr8-1, a phase 3 study of valoctocogene roxaparvovec, an AAV5-vectored gene therapy for hemophilia A. Mol Ther 2024; 32:2052-2063. [PMID: 38796703 PMCID: PMC11286804 DOI: 10.1016/j.ymthe.2024.05.033] [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: 02/22/2024] [Revised: 05/10/2024] [Accepted: 05/23/2024] [Indexed: 05/28/2024] Open
Abstract
Gene transfer therapies utilizing adeno-associated virus (AAV) vectors involve a complex drug design with multiple components that may impact immunogenicity. Valoctocogene roxaparvovec is an AAV serotype 5 (AAV5)-vectored gene therapy for the treatment of hemophilia A that encodes a B-domain-deleted human factor VIII (FVIII) protein controlled by a hepatocyte-selective promoter. Following previous results from the first-in-human phase 1/2 clinical trial, we assessed AAV5-capsid- and transgene-derived FVIII-specific immune responses with 2 years of follow-up data from GENEr8-1, a phase 3, single-arm, open-label study in 134 adult men with severe hemophilia A. No FVIII inhibitors were detected following administration of valoctocogene roxaparvovec. Immune responses were predominantly directed toward the AAV5 capsid, with all participants developing durable anti-AAV5 antibodies. Cellular immune responses specific for the AAV5 capsid were detected in most participants by interferon-γ enzyme-linked immunosorbent spot assay 2 weeks following dose administration and declined or reverted to negative over the first 52 weeks. These responses were weakly correlated with alanine aminotransferase elevations and showed no association with changes in FVIII activity. FVIII-specific cellular immune responses were less frequent and more sporadic compared with those specific for AAV5 and showed no association with safety or efficacy parameters.
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Affiliation(s)
- Brian R Long
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA.
| | | | | | - Hua Yu
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
| | - Kelly Lau
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
| | - Urooj Imtiaz
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
| | | | - Greg de Hart
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
| | | | | | | | | | - Soumi Gupta
- BioMarin Pharmaceutical Inc., Novato, CA 94949, USA
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18
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Chandran R, Tohit ERM, Stanslas J, Salim N, Mahmood TMT, Rajagopal M. Shifting Paradigms and Arising Concerns in Severe Hemophilia A Treatment. Semin Thromb Hemost 2024; 50:695-713. [PMID: 38224699 DOI: 10.1055/s-0043-1778103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The management of hemophilia A has undergone a remarkable revolution, in line with technological advancement. In the recent past, the primary concern associated with Factor VIII (FVIII) concentrates was the risk of infections, which is now almost resolved by advanced blood screening and viral inactivation methods. Improving patients' compliance with prophylaxis has become a key focus, as it can lead to improved health outcomes and reduced health care costs in the long term. Recent bioengineering research is directed toward prolonging the recombinant FVIII (rFVIII) coagulant activity and synthesising higher FVIII yields. As an outcome, B-domain deleted, polyethylene glycolated, single-chain, Fc-fused rFVIII, and rFVIIIFc-von Willebrand Factor-XTEN are available for patients. Moreover, emicizumab, a bispecific antibody, is commercially available, whereas fitusiran and tissue factor pathway inhibitor are in clinical trial stages as alternative strategies for patients with inhibitors. With these advancements, noninfectious complications, such as inhibitor development, allergic reactions, and thrombosis, are emerging concerns requiring careful management. In addition, the recent approval of gene therapy is a major milestone toward a permanent cure for hemophilia A. The vast array of treatment options at our disposal today empowers patients and providers alike, to tailor therapeutic regimens to the unique needs of each individual. Despite significant progress in modern treatment options, these highly effective therapies are markedly more expensive than conventional replacement therapy, limiting their access for patients in developing countries.
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Affiliation(s)
- Rubhan Chandran
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
| | - Eusni R Mohd Tohit
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Johnson Stanslas
- Department of Medicine, Pharmacotherapeutics Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Norazlinaliza Salim
- Centre of Foundation Studies for Agricultural Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- Integrated Chemical Biophysics Research, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Tuan M T Mahmood
- Faculty of Pharmacy, The National University of Malaysia (UKM), Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Mogana Rajagopal
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
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19
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Madan B, Ozelo MC, Raheja P, Symington E, Quon DV, Leavitt AD, Pipe SW, Lowe G, Kenet G, Reding MT, Mason J, Wang M, von Drygalski A, Klamroth R, Shapiro S, Chambost H, Dunn AL, Oldenburg J, Chou SC, Peyvandi F, Millar CM, Osmond D, Yu H, Dashiell-Aje E, Robinson TM, Mahlangu J. Three-year outcomes of valoctocogene roxaparvovec gene therapy for hemophilia A. J Thromb Haemost 2024; 22:1880-1893. [PMID: 38614387 DOI: 10.1016/j.jtha.2024.04.001] [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: 11/03/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Valoctocogene roxaparvovec transfers a human factor (F)VIII coding sequence into hepatocytes of people with severe hemophilia A to provide bleeding protection. OBJECTIVES To present 3-year efficacy and safety in the multicenter, open-label, single-arm, phase 3 GENEr8-1 trial. METHODS GENEr8-1 enrolled 134 adult males with severe hemophilia A who were receiving FVIII prophylaxis. Efficacy endpoints included annualized bleeding rate, annualized FVIII utilization, FVIII activity (chromogenic substrate assay; imputed as 1 IU/dL at baseline and 0 IU/dL after discontinuation), and the Haemophilia-Specific Quality of Life Questionnaire for Adults. Safety was assessed by adverse events (AEs). RESULTS At week 156, 131 of 134 participants remained in the study; overall, 17 of 134 resumed prophylaxis. Mean annualized bleeding rate for treated bleeds decreased from 4.8 (SD, 6.5) bleeds/y at baseline to 0.8 (SD, 2.3; P < .0001) bleeds/y after prophylaxis (prophylaxis cessation to last follow-up) and 0.97 (SD, 3.48) bleeds/y during year 3. Annualized FVIII utilization decreased 96.8% from baseline after prophylaxis and 94.2% during year 3. At week 156, mean and median FVIII activity were 18.4 (SD, 30.8) and 8.3 IU/dL, respectively. FVIII activity decrease was lower between years 2 and 3 than between years 1 and 2. At the end of year 3, clinically meaningful improvements in the Haemophilia-Specific Quality of Life Questionnaire for Adults Total Score were observed (mean change from baseline, 6.6; 95% CI, 4.24-8.87; P < .0001). Mild alanine aminotransferase elevations remained the most common AE during year 3 (23.7% of participants). A serious AE of B-cell acute lymphoblastic leukemia was considered unrelated to treatment. CONCLUSION Hemostatic efficacy was maintained, and safety remained unchanged from previous years.
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Affiliation(s)
- Bella Madan
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' National Health Service Trust, London, United Kingdom.
| | - Margareth C Ozelo
- Hemocentro University of Campinas, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Priyanka Raheja
- Haemophilia Centre, Royal London Hospital, Barts Health National Health Service Trust, London, United Kingdom
| | - Emily Symington
- Haemophilia Centre, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Doris V Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Andrew D Leavitt
- Hemophilia Treatment Center, University of California San Francisco, San Francisco, California, USA
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gillian Lowe
- West Midlands Adult Haemophilia Comprehensive Care Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Gili Kenet
- The National Hemophilia Center and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel HaShomer, Tel Aviv University, Tel Aviv, Israel
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jane Mason
- Queensland Haemophilia Centre, Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany; Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Susan Shapiro
- Blood Theme Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; Oxford National Institute for Health Research Biomedical Research Centre, Oxford, United Kingdom
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone & Aix Marseille University, Institut national de la santé et de la recherche médicale, Institut national de la recherche agronomique, Centre recherche en CardioVasculaire et Nutrition, Marseille, France
| | - Amy L Dunn
- The Division of Hematology, Oncology, and Blood and Marrow Transplantation at Nationwide Children's Hospital and Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine and Center for Rare Diseases, University Hospital Bonn, Bonn, Germany
| | - Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Carolyn M Millar
- Centre for Haematology, Imperial College London, London, United Kingdom; Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Dane Osmond
- BioMarin Pharmaceutical Inc, Novato, California, USA
| | - Hua Yu
- BioMarin Pharmaceutical Inc, Novato, California, USA
| | | | | | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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Benemei S, Boni L, Castaman G. Outcome measures in hemophilia: current and future perspectives. Expert Rev Hematol 2024; 17:329-340. [PMID: 38861342 DOI: 10.1080/17474086.2024.2365929] [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: 12/20/2023] [Accepted: 06/05/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Hemophilia can detrimentally affect patients' quality of life and likelihood of survival. In the evolving landscape of therapies, the therapeutic gain of each treatment must be understood to accurately position it in the therapeutic armamentarium. Accordingly, appropriate outcomes must be measured with appropriate tools. AREAS COVERED Our narrative review (PubMed search for 'hemophilia AND outcome' until June 2023), provides a compendium of outcome measures used in hemophilia clinical research. To define each outcome measure's relative value and applicability, several characteristics are critically discussed. EXPERT OPINION Bleeding assessment, first annual/annualized bleeding rate, remains central in evaluating the efficacy and safety of hemophilia treatments. As modern therapies improve clinical outcomes toward zero bleeding events, this endpoint may become less sensitive to detect differences between therapeutic approaches. Technological advancements necessitate the adaptation of outcome measures to address infrequent bleeding events, age-related comorbidities, and laboratory parameters with limited comparability after different treatments. Considerable effort has been dedicated to the development of tools that comprehensively assess coagulation, such as thrombin generation assays. Patient-reported outcome measures are gaining importance although limited by their subjectivity. A definitive set of research outcome measures remains elusive. Outcomes may need to be tailored to different therapeutic interventions.
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Affiliation(s)
| | - Luca Boni
- U.O. Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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21
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Muñoz-Melero M, Biswas M. Role of FoxP3 + Regulatory T Cells in Modulating Immune Responses to Adeno-Associated Virus Gene Therapy. Hum Gene Ther 2024; 35:439-450. [PMID: 38450566 PMCID: PMC11302314 DOI: 10.1089/hum.2023.227] [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: 12/27/2023] [Accepted: 03/04/2024] [Indexed: 03/08/2024] Open
Abstract
Adeno-associated virus (AAV) gene therapy is making rapid strides owing to its wide range of therapeutic applications. However, development of serious immune responses to the capsid antigen or the therapeutic transgene product hinders its full clinical impact. Immune suppressive (IS) drug treatments have been used in various clinical trials to prevent the deleterious effects of cytotoxic T cells to the viral vector or transgene, although there is no consensus on the best treatment regimen, dosage, or schedule. Regulatory T cells (Tregs) are crucial for maintaining tolerance against self or nonself antigens. Of importance, Tregs also play an important role in dampening immune responses to AAV gene therapy, including tolerance induction to the transgene product. Approaches to harness the tolerogenic effect of Tregs include the use of selective IS drugs that expand existing Tregs, and skew activated conventional T cells into antigen-specific peripherally induced Tregs. In addition, Tregs can be expanded ex vivo and delivered as cellular therapy. Furthermore, receptor engineering can be used to increase the potency and specificity of Tregs allowing for suppression at lower doses and reducing the risk of disrupting protective immunity. Because immune-mediated toxicities to AAV vectors are a concern in the clinic, strategies that can enhance or preserve Treg function should be considered to improve both the safety and efficacy of AAV gene therapy.
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Affiliation(s)
- Maite Muñoz-Melero
- Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, Indiana, USA
| | - Moanaro Biswas
- Herman B Wells Center for Pediatric Research, Indiana University, Indianapolis, Indiana, USA
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22
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Agarwal S, Hermans C, Miesbach W, Peyvandi F, Sidonio R, Osmond D, Newman V, Henshaw J, Pipe S. Transitioning from emicizumab prophylaxis to valoctocogene roxaparvovec gene therapy: A simulation study for individuals with severe haemophilia A. Haemophilia 2024; 30:905-913. [PMID: 38684460 DOI: 10.1111/hae.15025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Valoctocogene roxaparvovec, a gene therapy evaluated in the phase 3 GENEr8-1 trial, supports endogenous factor VIII (FVIII) production to prevent bleeding in people with severe haemophilia A. Individuals receiving emicizumab, an antibody mimicking the function of activated FVIII, were excluded from GENEr8-1 enrolment since emicizumab was an investigational therapy at the time of trial initiation. AIM Utilize pharmacokinetic simulations to provide guidance on best practices for maintaining haemostatic control while transitioning from emicizumab prophylaxis to valoctocogene roxaparvovec. METHODS To estimate bleeding risk at weekly intervals following valoctocogene roxaparvovec infusion, a published emicizumab pharmacokinetic model was used to simulate emicizumab concentrations and merged with FVIII activity time-course data for participants in GENEr8-1. The analysis investigated three approved emicizumab dosing regimens for two transition scenarios that varied whether the last dose of emicizumab was administered on the same day or 4 weeks after valoctocogene roxaparvovec infusion. RESULTS Simulations demonstrated administering the last emicizumab dose the day of valoctocogene roxaparvovec infusion and 4 weeks after offered similar levels of haemostatic control, and bleeding risk was similar for all emicizumab dosing regimens. An algorithm was developed to provide guidance for discontinuation of emicizumab. Theoretical cases based on GENEr8-1 participants are presented to illustrate how decisions may vary among individuals. CONCLUSION Pharmacokinetic simulations demonstrated no clinically meaningful difference in bleeding risk caused by decaying emicizumab levels and rising gene therapy-derived endogenous FVIII for all examined emicizumab doses and dosing regimens. Therefore, multiple approaches can safely transition individuals from emicizumab prophylaxis to valoctocogene roxaparvovec.
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Affiliation(s)
| | - Cedric Hermans
- Division of Adult Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Robert Sidonio
- Hemostasis and Thrombosis Program, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Dane Osmond
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | | | - Josh Henshaw
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | - Steven Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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23
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Male C, Ay C, Crevenna R, Eichinger S, Feistritzer C, Füller R, Haushofer A, Kurringer A, Neumeister P, Puchner S, Rettl J, Schindl T, Schuster G, Schwarz R, Sohm M, Streif W, Thom K, Wagner B, Wissmann E, Zwiauer K, Pabinger I. [Treatment of haemophilia in Austria]. Wien Klin Wochenschr 2024; 136:75-102. [PMID: 38743098 DOI: 10.1007/s00508-024-02370-0] [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] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
This guideline is intended to provide practical guidance for the diagnosis and treatment of haemophilia in Austria. Few randomized controlled interventional trials are available addressing the treatment of haemophilia, therefore recommendations are usually based on low level of evidence and represent expert consensus.This guideline is based on the WFH guideline, published in 2020, and adapted according to the national circumstances and experience.It includes recommendations and suggestions for diagnosis and follow-up visits and pharmacological therapies for treatment and prophylaxis. Further topics comprise special aspects in children and adults with severe haemophilia, outcome measurement, and management of trauma, special bleedings and interventions, including dental procedures, inhibitors, management of haemophilia carriers, and psychosocial aspects.
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Affiliation(s)
- Christoph Male
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Cihan Ay
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Richard Crevenna
- Universitätsklinik für Physikalische Medizin, Rehabilitation und Arbeitsmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Sabine Eichinger
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Clemens Feistritzer
- Abteilung für Innere Medizin V - Hämatologie und Onkologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Robert Füller
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | - Alexander Haushofer
- Institut für Medizinische und Chemische Labordiagnostik, Klinikum Wels-Grieskirchen, Wels-Grieskirchen, Österreich
| | - Andreas Kurringer
- Abteilung für Kinder- und Jugendheilkunde, Landeskrankenhaus Bregenz, Bregenz, Österreich
| | - Peter Neumeister
- Klinische Abteilung für Hämatologie, Medizinische Universität Graz, Graz, Österreich
| | - Stephan Puchner
- Klinische Abteilung für Orthopädie, Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Joachim Rettl
- Abteilung für Innere Medizin und Hämatologie und internistische Onkologie, Klinikum Klagenfurt, Klagenfurt, Österreich
| | - Thomas Schindl
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | | | - Rudolf Schwarz
- Abteilung für Kinder- und Jugendheilkunde, Landesklinikum Amstetten, Universität Wien, Wien, Österreich
| | - Michael Sohm
- Universitätsklinik für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
| | - Werner Streif
- Department Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Katharina Thom
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Barbara Wagner
- Universitätsklinik für Physikalische Medizin, Rehabilitation und Arbeitsmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Eva Wissmann
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Karl Zwiauer
- Universitätsklinik für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
| | - Ingrid Pabinger
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
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24
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Mackall CL, Bollard CM, Goodman N, Carr C, Gardner R, Rouce R, Sotillo E, Stoner R, Urnov FD, Wayne AS, Park J, Kohn DB. Enhancing pediatric access to cell and gene therapies. Nat Med 2024; 30:1836-1846. [PMID: 38886624 DOI: 10.1038/s41591-024-03035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/30/2024] [Indexed: 06/20/2024]
Abstract
Increasing numbers of cell and gene therapies (CGTs) are emerging to treat and cure pediatric diseases. However, small market sizes limit the potential return on investment within the traditional biopharmaceutical drug development model, leading to a market failure. In this Perspective, we discuss major factors contributing to this failure, including high manufacturing costs, regulatory challenges, and licensing practices that do not incorporate pediatric development milestones, as well as potential solutions. We propose the creation of a new entity, the Pediatric Advanced Medicines Biotech, to lead late-stage development and commercialize pediatric CGTs outside the traditional biopharmaceutical model in the United States-where organized efforts to solve this problem have been lacking. The Pediatric Advanced Medicines Biotech would partner with the academic ecosystem, manufacture products in academic good manufacturing practice facilities and work closely with regulatory bodies, to ferry CGTs across the drug development 'valley of death' and, ultimately, increase access to lifesaving treatments for children in need.
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Affiliation(s)
- Crystal L Mackall
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, Stem Cell Transplant and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Medicine, Division of Bone Marrow Transplant and Cell Therapy, Stanford University School of Medicine, Stanford, CA, USA.
| | - Catherine M Bollard
- Center for Cancer and Immunology Research and Department of Pediatrics, Children's National Hospital and The George Washington University, Washington, DC, USA
| | | | - Casey Carr
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Rayne Rouce
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX, USA
| | - Elena Sotillo
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Fyodor D Urnov
- Innovative Genomics Institute, University of California at Berkeley, Berkeley, CA, USA
| | - Alan S Wayne
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Julie Park
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Donald B Kohn
- Departments of Microbiology, Immunology & Molecular Genetics; Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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25
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Dyachkova Y, Dunger-Baldauf C, Barbier N, Devenport J, Franzén S, Kazeem G, Künzel T, Mancini P, Mordenti G, Richert K, Ridolfi A, Saure D. Do You Want to Stay Single? Considerations on Single-Arm Trials in Drug Development and the Postregulatory Space. Pharm Stat 2024. [PMID: 38923796 DOI: 10.1002/pst.2412] [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: 12/06/2023] [Revised: 04/03/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Single-arm trials (SATs), while not preferred, remain in use throughout the drug development cycle. They may be accepted by regulators in particular contexts (e.g., in oncology or rare diseases) when the potential effects of new treatments are very large and placebo treatment is unethical. However, in the postregulatory space, SATs are common, and perhaps even more poorly suited to address the questions of interest. In this manuscript, we review regulatory and HTA positions on SATs; challenges posed by SATs to address research questions beyond regulators, evolving statistical methods to provide context for SATs, case studies where SATs could and could not address questions of interest, and communication strategies to influence decision making and optimize study design to address evidence needs.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Daniel Saure
- Boehringer Ingelheim Europe GmbH, Ingelheim, Germany
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26
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Eldem I, Antunes-Heck L, Subramanian R, Lasky NM, Ashworth K, Di Paola J, Girard TJ. Deletion of tissue factor pathway inhibitor isoform beta or gamma, but not alpha, improves clotting in hemophilic mice. J Thromb Haemost 2024:S1538-7836(24)00363-5. [PMID: 38925489 DOI: 10.1016/j.jtha.2024.06.006] [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: 01/22/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Tissue factor pathway inhibitor (TFPI) regulates tissue factor-triggered coagulation. Humans and mice express transcripts encoding for multidistributed (endothelial, platelet, and plasma) 3-Kunitz domain TFPIα and endothelial membrane-anchored 2-Kunitz TFPIβ. Mice express a third transcript, γ, that encodes plasma lipoprotein-associated 2-Kunitz TFPI. In humans, proteolysis of α and/or β produces plasma lipoprotein-associated 2-Kunitz TFPI at lower levels. In clinical trials, monoclonal antibodies that target all TFPI isoforms extend coagulation and correct bleeding in hemophilic patients but with some thrombosis risks. OBJECTIVES To determine the impact of TFPI isoform-specific deletions on promoting clotting in hemophilic mice. METHODS Engineered TFPI isoform-specific, hemophilic (factor VIII-null) mice were evaluated for clotting. RESULTS Mice expressing any single TFPI isoform were healthy. Thrombin generation assays identified TFPIγ as the dominant anticoagulation isoform in mouse plasma. Hemostasis was assessed by serial bleeding times from a tail vein laceration. Repeatedly, after a clot forms, it was manually disrupted; the number of clots/disruptions occurring over a 15-minute period were reported. C57BL/6 and hemophilic mice clot on average 25.6 vs 5.4 times, respectively. On a hemophilia background, TFPIβ or TFPIγ-specific deletion improved clotting to 14.6 and 15.2 times, respectively (P < .0001). TFPIα-specific deletion was without impact, clotting 5.1 times. Heterozygous deletion of TFPIβ was effective, clotting 11.8 times (P < .0001). Heterozygous deletion of TFPIα or TFPIγ alone was ineffective, clotting 3.0 and 6.1 times, respectively, but heterozygous TFPIαγ deletion improved clotting to 11.2 times (P < .001). CONCLUSION In hemophilic mice, endothelial TFPIβ and plasma γ-derived 2-Kunitz TFPI individually contribute more to bleeding than total TFPIα.
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Affiliation(s)
- Irem Eldem
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lilian Antunes-Heck
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Renumathi Subramanian
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nina M Lasky
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Katrina Ashworth
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jorge Di Paola
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Thomas J Girard
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA.
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27
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Mansueto MF, Bigi S, Follino M, Lupi A, Coppola A. Patient Perspective on Disease Burden and Gene Therapy for Hemophilia A and B: The "Haemvolution for Patients" Italian Survey. Semin Thromb Hemost 2024. [PMID: 38889801 DOI: 10.1055/s-0044-1787664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Hemophilia is a rare X-linked congenital bleeding disorder due to a deficiency of factor VIII (hemophilia A [HA]) or factor IX (hemophilia B [HB]). Replacement and nonreplacement treatments are available but have limitations. Gene therapy (GT) provides an effective, long-term, single-dose treatment option, now approaching clinical practice. This study aimed to understand patient perspectives on GT for HA and HB in Italy using a qualitative questionnaire distributed through Italian patient associations, addressing patient views on daily life, treatments, unmet needs, quality of life (QoL), and GT for hemophilia. In total, 141 participants had HA, and 14 had HB (severe 78.6%). Daily life was most affected by pain and/or joint function limitations (57.5% of participants), high infusion frequency (42.5%), management of breakthrough bleeding episodes (40.3%), and anxiety/fear of severe or sudden bleeding (38.8%). Despite current treatments, about half of the participants experienced three or more annual bleeding episodes. Most participants knew of GT (87.2%) and expected improvements in QoL (60.5%), reduced frequency of current treatments (53.5%), and a permanent cure (49.1%); 46.4% were unaware of its once-off dosage and 46.4% were not concerned about the costs they anticipated to be associated with GT. Although several fears were reported, 25.0% of participants were willing to undergo GT with the support of a multidisciplinary team. This survey provided valuable insight into patient perspectives on hemophilia and GT in Italy. Overall, relevant proportions of patients still experience limitations affecting their daily life. Most were positive about GT and anticipated improvements in their clinical outcomes and QoL.
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Affiliation(s)
- Maria Francesca Mansueto
- Centro Emofila e Divisione di Ematologia, Azienda Ospedaliera Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | - Sarah Bigi
- Dipartimento di Scienze Linguistiche e Letterature Straniere, Università Cattolica del Sacro Cuore, Milan, Italy
| | | | - Angelo Lupi
- Federation of Haemophilia Associations (FedEmo), Rome, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, Department of General and Specialist Medicine, University Hospital of Parma, Parma, Italy
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28
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Tang Y, Ebadi M, Lei J, Feng Z, Fakhari S, Wu P, Smith MD, Limberis MP, Kolbeck R, Excoffon KJ, Yan Z, Engelhardt JF. Durable transgene expression and efficient re-administration after rAAV2.5T-mediated fCFTRΔR gene delivery to adult ferret lungs. Mol Ther Methods Clin Dev 2024; 32:101244. [PMID: 38638546 PMCID: PMC11024656 DOI: 10.1016/j.omtm.2024.101244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024]
Abstract
The dosing interval for effective recombinant adeno-associated virus (rAAV)-mediated gene therapy of cystic fibrosis lung disease remains unknown. Here, we assessed the durability of rAAV2.5T-fCFTRΔR-mediated transgene expression and neutralizing antibody (NAb) responses in lungs of adult wild-type ferrets. Within the first 3 months following rAAV2.5T-fCFTRΔR delivery to the lung, CFTRΔR transgene expression declined ∼5.6-fold and then remained stable to 5 months at ∼26% the level of endogenous CFTR. rAAV NAbs in the plasma and bronchoalveolar lavage fluid (BALF) peaked at 21 days, coinciding with peak ELISpot T cell responses to AAV capsid peptides, after which both responses declined and remained stable at 4-5 months post dosing. Administration of reporter vector rAAV2.5T-gLuc (gaussia luciferase) at 5 months following rAAV2.5T-fCFTRΔR dosing gave rise to similar levels of gLuc expression in the BALF as observed in age-matched reporter-only controls, demonstrating that residual BALF NAbs were functionally insignificant. Notably, the second vector administration led to a 2.6-fold greater ELISpot T cell response and ∼2.3-fold decline in fCFTRΔR mRNA and vector genomes derived from the initial rAAV2.5T-fCFTRΔR administration, suggesting selective destruction of transduced cells from the first vector dose. These findings provide insights into humoral and cellular immune response to rAAV that may be useful for optimizing gene therapy to the cystic fibrosis lung.
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Affiliation(s)
- Yinghua Tang
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Mehrnoosh Ebadi
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Junying Lei
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Zehua Feng
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Shahab Fakhari
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Peipei Wu
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | | | | | | | | | - Ziying Yan
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - John F. Engelhardt
- Department of Anatomy & Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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29
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Papapetropoulos A, Topouzis S, Alexander SPH, Cortese-Krott M, Kendall DA, Martemyanov KA, Mauro C, Nagercoil N, Panettieri RA, Patel HH, Schulz R, Stefanska B, Stephens GJ, Teixeira MM, Vergnolle N, Wang X, Ferdinandy P. Novel drugs approved by the EMA, the FDA, and the MHRA in 2023: A year in review. Br J Pharmacol 2024; 181:1553-1575. [PMID: 38519837 DOI: 10.1111/bph.16337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 03/25/2024] Open
Abstract
In 2023, seventy novel drugs received market authorization for the first time in either Europe (by the EMA and the MHRA) or in the United States (by the FDA). Confirming a steady recent trend, more than half of these drugs target rare diseases or intractable forms of cancer. Thirty drugs are categorized as "first-in-class" (FIC), illustrating the quality of research and innovation that drives new chemical entity discovery and development. We succinctly describe the mechanism of action of most of these FIC drugs and discuss the therapeutic areas covered, as well as the chemical category to which these drugs belong. The 2023 novel drug list also demonstrates an unabated emphasis on polypeptides (recombinant proteins and antibodies), Advanced Therapy Medicinal Products (gene and cell therapies) and RNA therapeutics, including the first-ever approval of a CRISPR-Cas9-based gene-editing cell therapy.
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Affiliation(s)
- Andreas Papapetropoulos
- Laboratory of Pharmacology, Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
- Clinical, Experimental Surgery and Translational Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Stavros Topouzis
- Laboratory of Molecular Pharmacology Department of Pharmacy, University of Patras, Patras, Greece
| | | | - Miriam Cortese-Krott
- Myocardial Infarction Research Laboratory, Department of Cardiology, Pneumology, Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
- CARID, Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | | | | | - Claudio Mauro
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Hemal H Patel
- VA San Diego Healthcare System and University of California/San Diego, San Diego, CA, USA
| | | | | | | | | | - Nathalie Vergnolle
- IRSD, Université de Toulouse, INSERM, INRAE, ENVT, UPS, Toulouse, France
| | - Xin Wang
- University of Manchester, Manchester, UK
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
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30
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Oldenburg J, Chambost H, Liu H, Hawes C, You X, Yang X, Newman V, Robinson TM, Hatswell AJ, Hinds D, Santos S, Ozelo M. Comparative Effectiveness of Valoctocogene Roxaparvovec and Prophylactic Factor VIII Replacement in Severe Hemophilia A. Adv Ther 2024; 41:2267-2281. [PMID: 38616241 PMCID: PMC11133144 DOI: 10.1007/s12325-024-02834-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/05/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION A prospective, non-interventional study (270-902) followed 294 adults with severe hemophilia A (SHA) receiving prophylactic factor VIII (FVIII). From these participants, 112 rolled over into a single-arm, multicenter, phase 3 trial (GENEr8-1; NCT03370913) that evaluated efficacy and safety of valoctocogene roxaparvovec, a gene therapy that provides endogenous FVIII in individuals with SHA. Participants from 270-902 who did not roll over provide an opportunity for a contemporaneous external control. Therefore, the comparative effectiveness of valoctocogene roxaparvovec vs FVIII prophylaxis was evaluated using propensity scoring (PS). METHODS This post hoc analysis compared 112 participants from GENEr8-1 (treated cohort) to 73 participants in 270-902 who did not enroll in GENEr8-1 (control cohort). The primary analysis used standardized mortality ratio weighting to re-weight baseline characteristics of the control cohort to better match the treated cohort. Mean annualized bleeding rates (ABR) for treated and all bleeds were compared between cohorts along with the proportion of participants with zero bleeds (treated and all bleeds). Sensitivity and scenario analyses were also conducted. RESULTS PS adjustments reduced differences in baseline characteristics between cohorts. Mean treated (4.40 vs 0.85; P < 0.001) and all (5.01 vs 1.54; P < 0.001) ABR were significantly lower, and the proportions of participants with zero treated bleeds (82.1% vs 32.9%; P < 0.001) and all bleeds (58.0% vs 28.5%; P < 0.001) were significantly higher in GENEr8-1. CONCLUSIONS PS-adjusted analyses were consistent with prior intra-individual comparisons. Compared with participants receiving prophylactic FVIII, the participants receiving valoctocogene roxaparvovec experienced lower ABR, and a higher proportion had zero bleeds. TRAIL REGISTRATION ClinicalTrials.gov identifier, NCT03370913.
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Affiliation(s)
- Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine and Center for Rare Diseases, University Hospital Bonn, Bonn, Germany.
| | - Herve Chambost
- Department of Pediatric Hematology Oncology, AP-HM, Children Hospital La Timone & Aix Marseille University, INSERM, INRA, C2VN, Marseille, France
| | - Hai Liu
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | - Xiaojun You
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - Xinqun Yang
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | | | - Anthony J Hatswell
- DeltaHat Limited, Nottingham, UK
- Department of Statistical Science, University College London, London, UK
| | - David Hinds
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | - Margareth Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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Levien TL, Baker DE. Valoctocogene Roxaparvovec. Hosp Pharm 2024; 59:254-263. [PMID: 38764998 PMCID: PMC11097925 DOI: 10.1177/00185787231222506] [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: 05/21/2024]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.
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Fox TA, Booth C. Improving access to gene therapy for rare diseases. Dis Model Mech 2024; 17:dmm050623. [PMID: 38639083 PMCID: PMC11051979 DOI: 10.1242/dmm.050623] [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] [Indexed: 04/20/2024] Open
Abstract
Effective gene therapy approaches have been developed for many rare diseases, including inborn errors of immunity and metabolism, haemoglobinopathies and inherited blindness. Despite successful pre-clinical and clinical results, these gene therapies are not widely available, primarily for non-medical reasons. Lack of commercial interest in therapies for ultra-rare diseases, costs of development and complex manufacturing processes required for advanced therapy medicinal products (ATMPs) are some of the main problems that are restricting access. The complexities and costs of navigating the regulatory environments in different jurisdictions for treatments that affect small numbers of patients is a problem unique to ATMPS for rare and ultra-rare diseases. In this Perspective, we outline some of the challenges and potential solutions that, we hope, will improve access to gene therapy for rare diseases.
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Affiliation(s)
- Thomas A. Fox
- UCL Institute of Immunity and Transplantation, University College London, London, NW3 2PP, United Kingdom
| | - Claire Booth
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, UCL, London WC1N 1EH, UK
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Castaman G, Miesbach W. Gene Therapy for Hemophilia B: Achievements, Open Issues, and Perspectives. Semin Thromb Hemost 2024. [PMID: 38821066 DOI: 10.1055/s-0044-1787190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Hemophilia B is the first bleeding disorder for which gene therapy clinical programs began. Presently, adenovirus-associated vectors represent the best means to deliver the transgene, and their administration by intravenous route has been used in recent clinical trials. The natural occurring factor IX (FIX) Padua variant, which allows for a 5- to 8-fold higher activity of FIX, while maintaining a normal protein concentration, was subsequently used to enhance the level of transgene expression. All the recent trials using this variant showed good results, and accumulating data suggest that long-term expression durability could be maintained at a significant hemostatic level. However, the risk of loss of transgene expression associated to immune response with liver enzymes elevation remains a concern, especially as to the efficacy and duration of immunosuppressive treatment. Notwithstanding this limitation, the results of clinical trials suggest that gene therapy in hemophilia B has the potential to provide long-term benefits with sustained factor activity levels predicted to last several years in many patients.
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Affiliation(s)
- Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Wolfgang Miesbach
- Hemophilia Center of the Medical Clinic 2, University Hospital, Frankfurt/Main, Germany
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Milagros S, de Erenchun PRR, Guembe M, Carte B, Méndez M, Uribarri A, Aldabe R. The infectivity of AAV9 is influenced by the specific location and extent of chemically modified capsid residues. J Biol Eng 2024; 18:34. [PMID: 38745236 PMCID: PMC11092203 DOI: 10.1186/s13036-024-00430-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Several treatments for genetic diseases utilizing recombinant adeno-associated viruses (AAVs) have recently gained approval. However, the development of a greater number of therapeutic AAVs is constrained by certain limitations. While extensive efforts have concentrated on screening AAV genetic libraries, an alternative strategy involves modifying the AAV capsid by attaching various moieties. The capsid of AAV plays a pivotal role in transducing target cells and evading immune responses, making modifications a key avenue for engineering improved variants. RESULTS In our study, we replaced specific AAV9 capsid residues with an unnatural amino acid bearing a bioorthogonal group, identifying four positions with no adverse impact on production. Utilizing click chemistry, we attached varying proportions of Cy5.5 to these positions, allowing us to assess the impact of these modifications on AAV9 infectivity in cultured cells. Our findings reveal that both the position and degree of capsid modification significantly affect AAV transduction. While higher amounts of attached molecules lead to an increased number of AAV genomes within cells, this does not positively impact transgene expression. Conversely, a negative impact on transgene expression is observed when the AAV capsid is highly modified, with the degree of this effect associated with the modified residue. CONCLUSION Careful control of both the degree and specific position of capsid modifications is crucial for optimizing transduction efficiency and minimizing undesired effects on transgene expression. These results underscore the importance of precision in AAV capsid modification to achieve optimal transduction efficiency while mitigating potential drawbacks on transgene expression.
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Affiliation(s)
- Sergio Milagros
- DNA and RNA Medicine Division, CIMA Universidad de Navarra, 31008, Pamplona, Spain
| | | | - Maite Guembe
- DNA and RNA Medicine Division, CIMA Universidad de Navarra, 31008, Pamplona, Spain
| | - Beatriz Carte
- DNA and RNA Medicine Division, CIMA Universidad de Navarra, 31008, Pamplona, Spain
| | - Miriam Méndez
- DNA and RNA Medicine Division, CIMA Universidad de Navarra, 31008, Pamplona, Spain
| | - Ander Uribarri
- DNA and RNA Medicine Division, CIMA Universidad de Navarra, 31008, Pamplona, Spain
| | - Rafael Aldabe
- DNA and RNA Medicine Division, CIMA Universidad de Navarra, 31008, Pamplona, Spain.
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Doxzen KW, Adair JE, Fonseca Bazzo YM, Bukini D, Cornetta K, Dalal V, Guerino-Cunha RL, Hongeng S, Jotwani G, Kityo-Mutuluuza C, Lakshmanan K, Mahlangu J, Makani J, Mathews V, Ozelo MC, Rangarajan S, Scholefield J, Batista Silva Júnior J, McCune JM. The translational gap for gene therapies in low- and middle-income countries. Sci Transl Med 2024; 16:eadn1902. [PMID: 38718130 DOI: 10.1126/scitranslmed.adn1902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/18/2024] [Indexed: 06/26/2024]
Abstract
Gene therapies are designed to address the root cause of disease. As scientific understanding of disease prevention, diagnosis, and treatment improves in tandem with technological innovation, gene therapies have the potential to become safe and effective treatment options for a wide range of genetic and nongenetic diseases. However, as the medical scope of gene therapies expands, consideration must be given to those who will benefit and what proactive steps must be taken to widen development and access potential, particularly in regions carrying a high disease burden.
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Affiliation(s)
| | - Jennifer E Adair
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Departments of Medical Oncology and Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Yris Maria Fonseca Bazzo
- Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Brasília, Brasília, DF, Brazil
| | - Daima Bukini
- Sickle Cell Programme, Department of Haematology and Blood Transfusion, Muhimbili University of Health & Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
- SickleInAfrica Clinical Coordinating Center, Muhimbili University of Health & Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
| | | | - Varsha Dalal
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Renato Luiz Guerino-Cunha
- Centro Paulista de Oncologia, Grupo Oncoclínicas, São Paulo, SP, Brazil
- Instituto Oncoclínicas, Rio de Janeiro, RJ, Brazil
| | - Suradej Hongeng
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Geeta Jotwani
- Indian Council of Medical Research, New Delhi, India
| | | | - Krishnamurti Lakshmanan
- Department of Pediatric Hematology and Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Julie Makani
- Sickle Cell Programme, Department of Haematology and Blood Transfusion, Muhimbili University of Health & Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
- SickleInAfrica Clinical Coordinating Center, Muhimbili University of Health & Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Vikram Mathews
- Department of Haematology, Christian Medical College (CMC), Vellore, India
| | - Margareth C Ozelo
- INCT Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Savita Rangarajan
- Advanced Center for Oncology, Haematology & Rare Disorders (ACOHRD), K. J. Somaiya Medical College & Research Center, Somaiya Ayurvihar, Mumbai, Maharashtra, India
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Janine Scholefield
- Bioengineering and Integrated Genomics Group, Next Generation Health Cluster, Council for Scientific and Industrial Research, Pretoria, South Africa
- Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - João Batista Silva Júnior
- Brazilian Health Regulatory Agency-ANVISA, Brasília, DF, Brazil
- Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Brasília, Brasília, DF, Brazil
| | - Joseph M McCune
- HIV Frontiers, Global Health Accelerator, Bill & Melinda Gates Foundation, Seattle, WA, USA
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36
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Pabinger I, Ayash-Rashkovsky M, Escobar M, Konkle BA, Mingot-Castellano ME, Mullins ES, Negrier C, Pan L, Rajavel K, Yan B, Chapin J. Multicenter assessment and longitudinal study of the prevalence of antibodies and related adaptive immune responses to AAV in adult males with hemophilia. Gene Ther 2024; 31:273-284. [PMID: 38355967 PMCID: PMC11090810 DOI: 10.1038/s41434-024-00441-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 02/16/2024]
Abstract
Adeno-associated virus (AAV) based gene therapy has demonstrated effective disease control in hemophilia. However, pre-existing immunity from wild-type AAV exposure impacts gene therapy eligibility. The aim of this multicenter epidemiologic study was to determine the prevalence and persistence of preexisting immunity against AAV2, AAV5, and AAV8, in adult participants with hemophilia A or B. Blood samples were collected at baseline and annually for ≤3 years at trial sites in Austria, France, Germany, Italy, Spain, and the United States. At baseline, AAV8, AAV2, and AAV5 neutralizing antibodies (NAbs) were present in 46.9%, 53.1%, and 53.4% of participants, respectively; these values remained stable at Years 1 and 2. Co-prevalence of NAbs to at least two serotypes and all three serotypes was present at baseline for ~40% and 38.2% of participants, respectively. For each serotype, ~10% of participants who tested negative for NAbs at baseline were seropositive at Year 1. At baseline, 38.3% of participants had detectable cell mediated immunity by ELISpot, although no correlations were observed with the humoral response. In conclusion, participants with hemophilia may have significant preexisting immunity to AAV capsids. Insights from this study may assist in understanding capsid-based immunity trends in participants considering AAV vector-based gene therapy.
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Affiliation(s)
- Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Miguel Escobar
- University of Texas Health Science Center, McGovern Medical School and Gulf States Hemophilia and Thrombophilia Center, Houston, TX, USA
| | - Barbara A Konkle
- BloodWorks Northwest, Seattle, WA, USA
- Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA
| | - María Eva Mingot-Castellano
- Hospital Regional Universitario de Málaga, Málaga, Spain
- Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Eric S Mullins
- Division of Hematology, Cincinnati Children's Hospital Medical Center and University of Cincinnati-College of Medicine, Cincinnati, OH, USA
| | - Claude Negrier
- UR4609 Hemostase & Thrombose, University Lyon 1, Lyon, France
| | - Luying Pan
- Takeda Development Center Americas Inc, Cambridge, MA, USA
| | | | - Brian Yan
- Takeda Development Center Americas Inc, Cambridge, MA, USA
| | - John Chapin
- Takeda Development Center Americas Inc, Cambridge, MA, USA.
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37
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Lee JH, Han JP. In vivo LNP-CRISPR Approaches for the Treatment of Hemophilia. Mol Diagn Ther 2024; 28:239-248. [PMID: 38538969 PMCID: PMC11068834 DOI: 10.1007/s40291-024-00705-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
Hemophilia is a genetic disorder that is caused by mutations in coagulation factor VIII (hemophilia A) or IX (hemophilia B) genes resulting in blood clotting disorders. Despite advances in therapies, such as recombinant proteins and products with extended half-lives, the treatment of hemophilia still faces two major limitations: the short duration of therapeutic effect and production of neutralizing antibodies against clotting factors (inhibitor). To overcome these limitations, new hemophilia treatment strategies have been established such as gene therapy, bispecific antibody, and rebalancing therapy. Although these strategies have shown promising results, it is difficult to achieve a permanent therapeutic effect. Advances in the clustered regularly interspaced short palindromic repeat (CRISPR) technology have allowed sustainable treatment by correcting mutated genes. Since genome editing generates irreversible changes in host genome, safety must be ensured by delivering target organs. Therefore, the delivery tool of the CRISPR system is crucial for safe, accurate, and efficient genome editing. Recently, non-viral vector lipid nanoparticles (LNPs) have emerged as safer tools for delivering CRISPR systems than other viral vectors. Several previous hemophilia pre-clinical studies using LNP-CRISPR showed that sufficient and sustainable therapeutic effects, which means that LNP-CRISPR-mediated genome-editing therapy can be a valid option for the treatment of hemophilia. In this paper, we summarize the latest advancements in the successful treatment of hemophilia and the potential of CRISPR-mediated genome-editing therapy using LNPs.
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Affiliation(s)
- Jeong Hyeon Lee
- Graduate School of International Agricultural Technology, Institute of Green BioScience and Technology, Seoul National University, 1447 Pyeongchang-ro, Daewha, Pyeongchang, 25354, Gangwon, Korea
| | - Jeong Pil Han
- Graduate School of International Agricultural Technology, Institute of Green BioScience and Technology, Seoul National University, 1447 Pyeongchang-ro, Daewha, Pyeongchang, 25354, Gangwon, Korea.
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Xicluna R, Avenel A, Vandamme C, Devaux M, Jaulin N, Couzinié C, Le Duff J, Charrier A, Guilbaud M, Adjali O, Gernoux G. Prevalence Study of Cellular Capsid-Specific Immune Responses to AAV2, 4, 5, 8, 9, and rh10 in Healthy Donors. Hum Gene Ther 2024; 35:355-364. [PMID: 38581431 DOI: 10.1089/hum.2023.225] [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] [Indexed: 04/08/2024] Open
Abstract
Recombinant adeno-associated virus (rAAV) vectors appear, more than ever, to be efficient viral vectors for in vivo gene transfer as illustrated by the approvals of 7 drugs across Europe and the United States. Nevertheless, preexisting immunity to AAV capsid in humans remains one of the major limits for a successful clinical translation. Whereas a preexisting humoral response to AAV capsid is well documented, the prevalence of preexisting capsid-specific T cell responses still needs to be studied and characterized. In this study, we investigated the prevalence of AAV-specific circulating T cells toward AAV2, 4, 5, 8, 9, and rh10 in a large cohort of healthy donors using the standard IFNγ ELISpot assay. We observed the highest prevalence of preexisting cellular immunity to AAV9 serotype followed by AAV8, AAV4, AAV2, AAVrh10, and AAV5 independently of the donors' serological status. An in-depth analysis of T cell responses toward the 2 most prevalent serotypes 8 and 9 shows that IFNγ secretion is mainly mediated by CD8 T cells for both serotypes. A polyfunctional analysis reveals different cytokine profiles between AAV8 and AAV9. Surprisingly, no IL-2 secretion was mediated by anti-AAV9 immune cells suggesting that these cells may rather be exhausted or terminally differentiated than cytotoxic T cells. Altogether, these results suggest that preexisting immunity to AAV may vary depending on the serotype and support the necessity of using multiparametric monitoring methods to better characterize anticapsid cellular immunity and foresee its impact in rAAV-mediated clinical trials.
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Affiliation(s)
- Rebecca Xicluna
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Allan Avenel
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Céline Vandamme
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Marie Devaux
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Nicolas Jaulin
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Célia Couzinié
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Johanne Le Duff
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Alicia Charrier
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Mickaël Guilbaud
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Oumeya Adjali
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
| | - Gwladys Gernoux
- Nantes Université, CHU de Nantes, INSERM, TaRGeT - Translational Research in Gene Therapy, UMR 1089, Nantes, France
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Hirniak S, Edginton AN, Iorio A, Alsabbagh MW, Hajducek DM, Wong WW. Health utilities in adults with hemophilia A: A retrospective cohort study. Haemophilia 2024; 30:733-742. [PMID: 38506967 DOI: 10.1111/hae.14979] [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: 08/01/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Haemophilia A negatively affects a patient's quality of life. There is a limited amount of health utility data (a measure of health-related quality of life) available for patients with haemophilia A. This information is crucial for cost-effectiveness analysis for haemophilia A treatment. OBJECTIVES The goal of this project is to elicit the health utilities and factors impacting utility values for haemophilia A patients in Canada. METHODS This is a population-based, cross-sectional, retrospective study of health utilities in patients with haemophilia A using Patient Report Outcomes Burdens and Experiences (PROBE) components from the Canadian Bleeding Disorders Registry (CBDR). A review of the mean utilities for three severity states, defined by clotting factor VIII level, was completed. A multiple linear regression analysis was completed to examine the determinants of health utilities including age, treatment type, chronic pain status, number of limited joints, and bleed rate. RESULTS The average utility values (and standard deviations) for patients with haemophilia A in Canada are .79(.17), .76(.20), and .77(.19) for patients with severe, moderate, and mild haemophilia. The regression showed chronic pain status and the number of additional comorbidities as major significant factors (p-value < .001) in haemophilia A utility. Haemophilia severity was shown to be a major factor with smaller p-value (p-value < .05). CONCLUSIONS Haemophilia A patients have lower utility than the general population. Chronic pain was shown to be a significant, major factor in health-related quality of life. Our study is essential for valuing health outcomes in haemophilia A-related cost-effectiveness analysis.
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Affiliation(s)
- Sam Hirniak
- School of Pharmacy, Faculty of Science, University of Waterloo, Kitchener, ON, Canada
| | - Andrea N Edginton
- School of Pharmacy, Faculty of Science, University of Waterloo, Kitchener, ON, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Mhd Wasem Alsabbagh
- School of Pharmacy, Faculty of Science, University of Waterloo, Kitchener, ON, Canada
| | - Dagmar M Hajducek
- School of Pharmacy, Faculty of Science, University of Waterloo, Kitchener, ON, Canada
| | - William Wl Wong
- School of Pharmacy, Faculty of Science, University of Waterloo, Kitchener, ON, Canada
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Pierce GF, Fong S, Long BR, Kaczmarek R. Deciphering conundrums of adeno-associated virus liver-directed gene therapy: focus on hemophilia. J Thromb Haemost 2024; 22:1263-1289. [PMID: 38103734 DOI: 10.1016/j.jtha.2023.12.005] [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: 09/15/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Adeno-associated virus gene therapy has been the subject of intensive investigation for monogenic disease gene addition therapy for more than 25 years, yet few therapies have been approved by regulatory agencies. Most have not progressed beyond phase 1/2 due to toxicity, lack of efficacy, or both. The liver is a natural target for adeno-associated virus since most serotypes have a high degree of tropism for hepatocytes due to cell surface receptors for the virus and the unique liver sinusoidal geometry facilitating high volumes of blood contact with hepatocyte cell surfaces. Recessive monogenic diseases such as hemophilia represent promising targets since the defective proteins are often synthesized in the liver and secreted into the circulation, making them easy to measure, and many do not require precise regulation. Yet, despite initiation of many disease-specific clinical trials, therapeutic windows are often nonexistent, resulting in excess toxicity and insufficient efficacy. Iterative progress built on these attempts is best illustrated by hemophilia, with the first regulatory approvals for factor IX and factor VIII gene therapies eventually achieved 25 years after the first gene therapy studies in humans. Although successful gene transfer may result in the production of sufficient transgenic protein to modify the disease, many emerging questions on durability, predictability, reliability, and variability of response have not been answered. The underlying biology accounting for these heterogeneous responses and the interplay between host and virus is the subject of intense investigation and the subject of this review.
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Affiliation(s)
- Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada.
| | - Sylvia Fong
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Brian R Long
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, Wells Center for Pediatric Research, Indiana, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
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Zangi AR, Amiri A, Pazooki P, Soltanmohammadi F, Hamishehkar H, Javadzadeh Y. Non-viral and viral delivery systems for hemophilia A therapy: recent development and prospects. Ann Hematol 2024; 103:1493-1511. [PMID: 37951852 DOI: 10.1007/s00277-023-05459-0] [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: 07/05/2023] [Accepted: 09/17/2023] [Indexed: 11/14/2023]
Abstract
Recent advancements have focused on enhancing factor VIII half-life and refining its delivery methods, despite the well-established knowledge that factor VIII deficiency is the main clotting protein lacking in hemophilia. Consequently, both viral and non-viral delivery systems play a crucial role in enhancing the quality of life for hemophilia patients. The utilization of viral vectors and the manipulation of non-viral vectors through targeted delivery are significant advancements in the field of cellular and molecular therapies for hemophilia. These developments contribute to the progression of treatment strategies and hold great promise for improving the overall well-being of individuals with hemophilia. This review study comprehensively explores the application of viral and non-viral vectors in cellular (specifically T cell) and molecular therapy approaches, such as RNA, monoclonal antibody (mAb), and CRISPR therapeutics, with the aim of addressing the challenges in hemophilia treatment. By examining these innovative strategies, the study aims to shed light on potential solutions to enhance the efficacy and outcomes of hemophilia therapy.
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Affiliation(s)
- Ali Rajabi Zangi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, 5166-15731, Iran
| | - Ala Amiri
- Department of Biotechnology, Faculty of Biological Sciences, Alzahra University, Tehran, Iran
| | - Pouya Pazooki
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Soltanmohammadi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, 5166-15731, Iran
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Science, Tabriz, 5166-15731, Iran
| | - Yousef Javadzadeh
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, 5166-15731, Iran.
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Bala NS, Thornburg CD. Gene Therapy in Hemophilia A: Achievements, Challenges, and Perspectives. Semin Thromb Hemost 2024. [PMID: 38588706 DOI: 10.1055/s-0044-1785483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Strides in advancements of care of persons with hemophilia include development of long-acting factor replacement therapies, novel substitution and hemostatic rebalancing agents, and most recently approved gene therapy. Several decades of preclinical and clinical trials have led to development of adeno-associated viral (AAV) vector-mediated gene transfer for endogenous production of factor VIII (FVIII) in hemophilia A (HA). Only one gene therapy product for HA (valoctocogene roxaparvovec) has been approved by regulatory authorities. Results of valoctocogene roxaparvovec trial show significant improvement in bleeding rates and use of factor replacement therapy; however, sustainability and duration of response show variability with overall decline in FVIII expression over time. Further challenges include untoward adverse effects involving liver toxicity requiring immunosuppression and development of neutralizing antibodies to AAV vector rendering future doses ineffective. Real-life applicability of gene therapy for HA will require appropriate patient screening, infrastructure setup, long-term monitoring including data collection of patient-reported outcomes and innovative payment schemes. This review article highlights the success and development of HA gene therapy trials, challenges including adverse outcomes and variability of response, and perspectives on approach to gene therapy including shared decision-making and need for future strategies to overcome the several unmet needs.
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Affiliation(s)
- Natasha S Bala
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
| | - Courtney D Thornburg
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
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Wang JH, Gessler DJ, Zhan W, Gallagher TL, Gao G. Adeno-associated virus as a delivery vector for gene therapy of human diseases. Signal Transduct Target Ther 2024; 9:78. [PMID: 38565561 PMCID: PMC10987683 DOI: 10.1038/s41392-024-01780-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 04/04/2024] Open
Abstract
Adeno-associated virus (AAV) has emerged as a pivotal delivery tool in clinical gene therapy owing to its minimal pathogenicity and ability to establish long-term gene expression in different tissues. Recombinant AAV (rAAV) has been engineered for enhanced specificity and developed as a tool for treating various diseases. However, as rAAV is being more widely used as a therapy, the increased demand has created challenges for the existing manufacturing methods. Seven rAAV-based gene therapy products have received regulatory approval, but there continue to be concerns about safely using high-dose viral therapies in humans, including immune responses and adverse effects such as genotoxicity, hepatotoxicity, thrombotic microangiopathy, and neurotoxicity. In this review, we explore AAV biology with an emphasis on current vector engineering strategies and manufacturing technologies. We discuss how rAAVs are being employed in ongoing clinical trials for ocular, neurological, metabolic, hematological, neuromuscular, and cardiovascular diseases as well as cancers. We outline immune responses triggered by rAAV, address associated side effects, and discuss strategies to mitigate these reactions. We hope that discussing recent advancements and current challenges in the field will be a helpful guide for researchers and clinicians navigating the ever-evolving landscape of rAAV-based gene therapy.
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Affiliation(s)
- Jiang-Hui Wang
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia
- Ophthalmology, Department of Surgery, University of Melbourne, East Melbourne, VIC, 3002, Australia
| | - Dominic J Gessler
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Wei Zhan
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
| | - Thomas L Gallagher
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA
| | - Guangping Gao
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA.
- Department of Microbiology and Physiological Systems, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA.
- Li Weibo Institute for Rare Diseases Research, University of Massachusetts Chan Medical School, Worcester, MA, 01605, USA.
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Abdulla Alzahrani H, Warsi A, Mullah-Ali A, Alotaibi G, Abu-Riash M, Alshahrani M, Siddiqui M, Owaidah T, Hashmi S. Consensus-Based Expert Recommendations on the Management of Hemophilia A in the Gulf Region. Acta Haematol 2024:1-14. [PMID: 38565097 DOI: 10.1159/000538400] [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: 12/13/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Hemophilia A presents a significant health challenge in the Gulf region, where it has an especially high prevalence. There are several unmet needs associated with the management of hemophilia A in the region. The aim of this manuscript was to contextualize unmet management needs, provide recommendations to optimize care, and specify requirements for the establishment of gene therapy centers in the region. SUMMARY An expert panel was assembled comprising ten clinical hematologists from Kuwait, Oman, Saudi Arabia, and the UAE. The Delphi methodology was used to obtain a consensus on statements relating to several aspects of hemophilia A. A consensus was reached for all statements by means of an online, anonymized voting system. The consensus statements pertain to screening and diagnosis, treatment approaches, and requirements for the implementation of gene therapy. KEY MESSAGES There are significant challenges that hinder the optimal management of hemophilia A in the Gulf region. The consensus statements presented provide specific recommendations to improve diagnostic and treatment approaches, promote multidisciplinary care, and optimize regional data generation and reporting. These statements also delineate the requirements for the establishment of gene therapy centers for hemophilia A in the region.
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Affiliation(s)
- Hazzaa Abdulla Alzahrani
- Consultant Hematology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ashraf Warsi
- Department of Oncology, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ali Mullah-Ali
- Consultant Pediatric Hematology, National Bank of Kuwait Specialized Hospital for Children, Shuwaikh Industrial, Kuwait
| | - Ghazi Alotaibi
- Department of Medicine (Oncology Center), King Saud University, Riyadh, Saudi Arabia
| | - Mahmoud Abu-Riash
- Senior Clinical Specialist Hematology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammad Alshahrani
- Consultant Pediatric Hematology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mustaqeem Siddiqui
- Consultant Hematology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Tarek Owaidah
- Consultant Hemato-Pathology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Shahrukh Hashmi
- Consultant Hematology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Thornburg CD. The benefits of gene therapy in people with haemophilia. J Viral Hepat 2024; 31 Suppl 1:4-8. [PMID: 38606945 DOI: 10.1111/jvh.13882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/06/2023] [Indexed: 04/13/2024]
Abstract
Haemophilia is an inherited bleeding disorder which causes significant morbidity and mortality, especially in the severe form. Prophylaxis with factor replacement has high efficacy in reducing bleeding but is limited by the need for frequent intravenous infusion and fluctuations in haemostasis between doses. Additional prophylaxis therapies are being developed which may overcome some of the current treatment barriers. Gene therapy (GT) is being developed to provide a functional cure such that there is sustained factor expression and minimal to no need for additional haemostatic therapy. There are now two approved gene therapies for haemophilia which may be transformative for many individuals. Benefits of GT should go beyond increasing factor activity and reducing bleeding as persons with haemophilia aim to achieve a 'haemophilia-free mind' and health equity with optimal health and well-being.
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Affiliation(s)
- Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California, USA
- Department of Pediatrics, Division of Hematology/Oncology, UC San Diego School of Medicine, La Jolla, California, USA
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Kim J, Eygeris Y, Ryals RC, Jozić A, Sahay G. Strategies for non-viral vectors targeting organs beyond the liver. NATURE NANOTECHNOLOGY 2024; 19:428-447. [PMID: 38151642 DOI: 10.1038/s41565-023-01563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/01/2023] [Indexed: 12/29/2023]
Abstract
In recent years, nanoparticles have evolved to a clinical modality to deliver diverse nucleic acids. Rising interest in nanomedicines comes from proven safety and efficacy profiles established by continuous efforts to optimize physicochemical properties and endosomal escape. However, despite their transformative impact on the pharmaceutical industry, the clinical use of non-viral nucleic acid delivery is limited to hepatic diseases and vaccines due to liver accumulation. Overcoming liver tropism of nanoparticles is vital to meet clinical needs in other organs. Understanding the anatomical structure and physiological features of various organs would help to identify potential strategies for fine-tuning nanoparticle characteristics. In this Review, we discuss the source of liver tropism of non-viral vectors, present a brief overview of biological structure, processes and barriers in select organs, highlight approaches available to reach non-liver targets, and discuss techniques to accelerate the discovery of non-hepatic therapies.
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Affiliation(s)
- Jeonghwan Kim
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Portland, OR, USA
- College of Pharmacy, Yeungnam University, Gyeongsan, South Korea
| | - Yulia Eygeris
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Portland, OR, USA
| | - Renee C Ryals
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - Antony Jozić
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Portland, OR, USA
| | - Gaurav Sahay
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Portland, OR, USA.
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA.
- Department of Biomedical Engineering, Robertson Life Sciences Building, Oregon Health and Science University, Portland, OR, USA.
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Ozelo MC. Breaking ground in haemophilia B gene therapy: insights from the HOPE-B trial and beyond. Lancet Haematol 2024; 11:e243-e244. [PMID: 38437858 DOI: 10.1016/s2352-3026(24)00046-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Margareth C Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP 13083-878, Brazil.
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48
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Riedl MA, Bordone L, Revenko A, Newman KB, Cohn DM. Clinical Progress in Hepatic Targeting for Novel Prophylactic Therapies in Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:911-918. [PMID: 38142864 DOI: 10.1016/j.jaip.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/09/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
Hereditary angioedema (HAE) is typically caused by a deficiency of the protease inhibitor C1 inhibitor (C1INH). The absence of C1INH activity on plasma kallikrein and factor XIIa leads to overproduction of the vasoactive peptide bradykinin, with resulting angioedema. As the primary site of C1INH and prekallikrein production, the liver is recognized as an important therapeutic target in HAE, leading to the development of hepatic-focused treatment strategies such as GalNAc-conjugated antisense technology and gene modification. This report reviews currently available data on hepatic-focused interventions for HAE that have advanced into human trials. Donidalorsen is an investigational GalNAc3-conjugated antisense oligonucleotide that binds to prekallikrein mRNA in the liver and reduces the expression of prekallikrein. Phase 2 data with subcutaneous donidalorsen demonstrated a significant reduction in HAE attack rate compared with placebo. Phase 3 trials are underway. ADX-324 is a GalNAc3-conjugated short-interfering RNA being investigated in HAE. BMN 331 is an investigational AAV5-based gene therapy vector that expresses wild-type human C1INH and is targeted to hepatocytes. A single intravenous dose of BMN 331 is intended to replace the defective SERPING1 gene and enable patients to produce functional C1INH. A first-in-human phase 1/2 study is ongoing with BMN 331. NTLA-2002 is an investigational in vivo clustered regularly interspaced short palindromic repeats/Cas9-based therapy designed to knock out the prekallikrein-coding KLKB1 gene in hepatocytes; a phase 1/2 study is ongoing. Findings from these and other ongoing studies are highly anticipated with the expectation of expanding the array of treatment options in HAE.
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Affiliation(s)
- Marc A Riedl
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif.
| | | | | | | | - Danny M Cohn
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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49
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Maina A, Foster GR. Hepatitis after gene therapy, what are the possible causes? J Viral Hepat 2024; 31 Suppl 1:14-20. [PMID: 38606951 DOI: 10.1111/jvh.13919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/06/2023] [Accepted: 01/03/2024] [Indexed: 04/13/2024]
Abstract
Hepatitis is a common adverse event following gene therapy for haemophilia, often associated with a loss of transgene expression. Investigating the potential causes and implications of this is crucial for the overall success of treatment. Gene therapy trials using adeno-associated virus (AAV) vectors have demonstrated promising results marked by increases in factor FVIII and FIX levels and reductions in episodes of bleeding. However, hepatocellular injury characterised by elevations in alanine aminotransferases (ALT) has been noted. This liver injury is typically transient and asymptomatic, posing challenges in determining its clinical significance. Proposed causes encompass immune-mediated responses, notably T cell cytotoxicity in response to the AAV vector, direct liver injury from the viral capsid or transcribed protein via the unfolded protein response and pre-existing liver conditions. Liver biopsy data conducted years post-gene therapy infusion has shown sinusoidal infiltration without significant inflammation. The overall safety profile of gene therapy remains favourable with no evidence drug-induced liver injury (DILI) based on Hy's Law criteria. Essential pre-therapy monitoring and identifying patients at high risk of liver injury should involve liver function tests and non-invasive fibroscans, while novel blood-based biomarkers are under exploration. Further research is required to comprehend the mechanisms underlying transaminitis, loss of transgene expression and long-term effects on the liver, providing insights for optimising gene therapy for haemophilia.
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Tuddenham EGD, Foster GR. The complex, confusing and poorly understood immune responses to AAV-mediated gene transfer in haemophilia-Is more or less immunosuppression required? J Viral Hepat 2024; 31 Suppl 1:21-25. [PMID: 38606938 DOI: 10.1111/jvh.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/13/2024]
Abstract
Attempts to achieve a functional cure or amelioration of the severe X linked bleeding disorders haemophilia A (factor VIII deficiency) and haemophilia B (factor IX deficiency) using AAV-based vectors have been frustrated by immune responses that limit efficacy and durability. The immune responses include adaptive and innate pathways as well as cytokine mediated inflammation, especially of the target organ cells-hepatocytes. Immune suppression has only been partly effective in clinical trials at ameliorating the immune response and the lack of good animal models has delayed progress in identifying mechanisms and developing more effective approaches to controlling these effects of AAV gene transfer. Here we discuss the arguments for and against more potent immunosuppression to improve factor expression after AAV-mediated gene therapy.
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