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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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Cai K, Anderson J, Utiger E, Ferreira G. Viral clearance capability of monoclonal antibody purification. Biologicals 2024; 85:101751. [PMID: 38387156 DOI: 10.1016/j.biologicals.2024.101751] [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: 09/29/2023] [Accepted: 02/12/2024] [Indexed: 02/24/2024] Open
Abstract
Viral clearance steps are routinely included in monoclonal antibody purification processes to safeguard product from potential virus contamination. These steps are often experimentally studied using product-specific feeds and parameters for each project to demonstrate viral clearance capability. However, published evidence suggests that viral clearance capability of many of these steps are not significantly impacted by variations in feed material or process parameter within commonly used ranges. The current investigation confirms robust retrovirus inactivation by low pH treatment and parvovirus removal by second-generation virus filters, independent to individual antibody molecules. Our results also reveal robust retrovirus removal by flowthrough anion exchange chromatography, inside the limits of protein load and host cell protein content. The cumulative viral clearance capability from these steps leads to an excess clearance safety factor of 10,000-fold for endogenous retrovirus-like particles. These results further justify the use of prior knowledge-based modular viral clearance estimation as opposed to repetitive experimentation.
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Affiliation(s)
- Kang Cai
- Purification Process and Analytical Sciences, Biopharmaceutical Development, R&D, AstraZeneca, Gaithersburg, MD, 20878, USA.
| | - Jennifer Anderson
- Purification Process and Analytical Sciences, Biopharmaceutical Development, R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Etienne Utiger
- Purification Process and Analytical Sciences, Biopharmaceutical Development, R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Gisela Ferreira
- Purification Process and Analytical Sciences, Biopharmaceutical Development, R&D, AstraZeneca, Gaithersburg, MD, 20878, USA.
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Kaczmarek R. Gene therapy - are we ready now? Haemophilia 2022; 28 Suppl 4:35-43. [PMID: 35521736 PMCID: PMC9325484 DOI: 10.1111/hae.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia therapy has evolved from rudimentary transfusion‐based approaches to an unprecedented level of innovation with glimmers of functional cure brought by gene therapy. After decades of misfires, gene therapy has normalized factor (F)VIII and factor (F)IX levels in some individuals in the long term. Several clinical programmes testing adeno‐associated viral (AAV) vector gene therapy are approaching completion with imminent regulatory approvals. Discussion Phase 3 studies along with multiyear follow‐up in earlier phase investigations raised questions about efficacy as well as short‐ and long‐term safety, prompting a reappraisal of AAV vector gene therapy. Liver toxicities, albeit mostly low‐grade, occur in the first year in at least some individuals in all haemophilia A and B trials and are poorly understood. Extreme variability and unpredictability of outcome, as well as a slow decline in factor expression (seemingly unique to FVIII gene therapy), are vexing because immune responses to AAV vectors preclude repeat dosing, which could increase suboptimal or restore declining expression, while overexpression may result in phenotoxicity. The long‐term safety will need lifelong monitoring because AAV vectors, contrary to conventional wisdom, integrate into chromosomes at the rate that calls for vigilance. Conclusions AAV transduction and transgene expression engage the host immune system, cellular DNA processing, transcription and translation machineries in ways that have been only cursorily studied in the clinic. Delineating those mechanisms will be key to finding mitigants and solutions to the remaining problems, and including individuals who cannot avail of gene therapy at this time.
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Affiliation(s)
- Radoslaw Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Bai H, Xue X, Tian L, Liu XT, Li Q. Case Report: Identification of a de novo Missense Mutation in the F8 Gene, p.(Phe690Leu)/c.2070C > A, Causing Hemophilia A: A Case Report. Front Genet 2021; 11:589899. [PMID: 33747028 PMCID: PMC7973284 DOI: 10.3389/fgene.2020.589899] [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: 10/19/2020] [Accepted: 11/23/2020] [Indexed: 12/03/2022] Open
Abstract
Hemophilia A is an X-linked recessive bleeding disorder caused by various types of pathological defects in the factor VIII gene (F8/FVIII). Preimplantation genetic testing for monogenic disease (PGT-M) is a powerful tool to tackle the transmission of monogenic inherited disorders from generation to generation. In our case, a mutation in F8 had passed through female carriers in a hemophilia A family and resulted in two male patients with hemophilia A. To identify the etiological genetic variants of F8, next-generation sequencing (NGS) was used for chromosome copy number variation detection, Sanger sequencing to verify mutation sites, single nucleotide polymorphism (SNP) for site amplification, and sequencing to validate the genetic linkage. Finally, a novel missense mutation, p. (Phe690Leu)/c.2070C > A, occurring in exon 13 of F8, was screened out as a pathogenic mutation. Following this, an F8 normal euploid blastocyst was transferred. At the 18th week, the pregnant mother underwent amniocentesis, NGS, Sanger sequencing, and SNP typing that further confirmed that the fetus had a healthy genotype. After delivery, a neonatal blood sample was sent for FVIII concentration detection, and the result established that the FVIII protein was rescued to a nearly average level. We first identified a new type of pathogenic mutation in F8, which has not been previously reported, selected a genetically healthy progeny for an affected family, and provided valuable knowledge of the diagnosis and treatment of hemophilia A.
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Affiliation(s)
- Haiyan Bai
- Assisted Reproductive Center, Women's & Children's Hospital of Northwest, Xi'an, China
| | - Xia Xue
- Assisted Reproductive Center, Women's & Children's Hospital of Northwest, Xi'an, China
| | - Li Tian
- Assisted Reproductive Center, Women's & Children's Hospital of Northwest, Xi'an, China
| | - Xi Tong Liu
- Assisted Reproductive Center, Women's & Children's Hospital of Northwest, Xi'an, China
| | - Qian Li
- Assisted Reproductive Center, Women's & Children's Hospital of Northwest, Xi'an, China
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Reddy OL, Savani BN, Stroncek DF, Panch SR. Advances in gene therapy for hematologic disease and considerations for transfusion medicine. Semin Hematol 2020; 57:83-91. [PMID: 32892847 DOI: 10.1053/j.seminhematol.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 12/26/2022]
Abstract
As the list of regulatory agency-approved gene therapies grows, these products are now in the therapeutic spotlight with the potential to cure or dramatically alleviate several benign and malignant hematologic diseases. The mechanisms for gene manipulation are diverse, and include the use of a variety of cell sources and both viral vector- and nuclease-based targeted approaches. Gene editing has also reached the realm of blood component therapy and testing, where cultured products are being developed to improve transfusion support for individuals with rare blood types. In this review, we summarize the milestones in the development of gene therapies for hematologic diseases, mechanisms for gene manipulation, and implications for transfusion medicine and blood centers as these therapies continue to advance and grow.
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Affiliation(s)
- Opal L Reddy
- Center for Cellular Engineering, National institutes of Health, Clinical Center, Bethesda, Maryland
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Stroncek
- Center for Cellular Engineering, National institutes of Health, Clinical Center, Bethesda, Maryland
| | - Sandhya R Panch
- Center for Cellular Engineering, National institutes of Health, Clinical Center, Bethesda, Maryland.
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Jun Z, Ming-Ming L, Qian-Qing Z, Yun-Hong W, Chong-Yang Z, Xin L. Functional identification of factor VIII B domain regions in hepatocyte cells. Biochem Biophys Res Commun 2020; 526:633-640. [PMID: 32248973 DOI: 10.1016/j.bbrc.2020.03.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/23/2020] [Indexed: 11/15/2022]
Abstract
Factor VIII (FVIII) functions as a cofactor within the intrinsic pathway of blood coagulation in process of FX activation by FIXa, for which deficiency results in the bleeding disorder hemophilia A. The gene of FVIII contains 26 exons that code for a 19 amino acid signal peptide and a 2332 amino acid polypeptide with a domain structure designated A1-A2-B-A3-C1-C2, of which the A domains are homologous with each other, as are the C domains. It has been well-documented that both the domains are the necessary elements for FVIII activities. The B domain is highly glycosylated and has a variable sequence, even among FVIIIs from different species. The B domain plays versatile roles in FVIII lifespan except for coagulation activity, but the functional characteristics of its specific regions remain still obscure. A series of recombinant FVIIIs (rFVIIIs) with B domain truncated were constructed and transiently expressed in hepatocyte cells. Media and cell lysates were collected after 72 h for the analyses of FVIII biosynthesis, secretion, activity and stability in ex vivo plasma relative to the full length wild-type FVIII. Unexpectedly, various regions in B domain exhibited different contribution to these functionalities. The discovery might facilitate the bioengineered rFVIIIs and gene therapeutics.
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Affiliation(s)
- Zhang Jun
- Institute of Molecular Medicine and Oncology, Chongqing Medical University, Chongqing, 400016, China.
| | - Lin Ming-Ming
- Institute of Molecular Medicine and Oncology, Chongqing Medical University, Chongqing, 400016, China
| | - Zhang Qian-Qing
- Institute of Molecular Medicine and Oncology, Chongqing Medical University, Chongqing, 400016, China
| | - Wang Yun-Hong
- Institute of Molecular Medicine and Oncology, Chongqing Medical University, Chongqing, 400016, China
| | - Zhu Chong-Yang
- Institute of Molecular Medicine and Oncology, Chongqing Medical University, Chongqing, 400016, China
| | - Li Xin
- Institute of Molecular Medicine and Oncology, Chongqing Medical University, Chongqing, 400016, China
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