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Miesbach W, Mulders G, Breederveld D, Pinachyan K, Le Quellec S, Pabinger I. A 360-degree perspective on adeno-associated virus (AAV)-based gene therapy for haemophilia: Insights from the physician, the nurse and the patient. Orphanet J Rare Dis 2024; 19:193. [PMID: 38741157 DOI: 10.1186/s13023-024-03181-2] [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: 03/05/2024] [Accepted: 03/30/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Adeno-associated virus (AAV)-based gene therapy for haemophilia has advanced substantially in the last 13 years; recently, three products have received approvals from regulatory authorities. Although the impact on quality of life seems promising, some limitations remain, such as the presence of pre-existing anti-AAV neutralising antibodies and the occurrence of hepatotoxicity. This review follows the CSL Behring-sponsored symposium at the 27th Congress of the European Hematology Association (EHA) 2022 that examined the haemophilia gene therapy process from a 360-degree multidisciplinary perspective. Here, the faculty (haematologist, nurse and haemophilia patient) summarised their own viewpoints from the symposium, with the aim of highlighting the key considerations required to engage with gene therapy effectively, for both patients and providers, as well as the importance of multidisciplinary collaboration, including with industry. RESULTS When considering these new therapies, patients face a complex decision-making process, which includes whether gene therapy is right for them at their current stage of life. The authors agreed that collaboration and tailored education across the multidisciplinary team (including patients and their carers/families), starting early in the process and continuing throughout the long-term follow-up period, is key for the success of gene therapy. Additionally, patient expectations, which may surround eligibility, follow-up requirements and treatment outcomes, should be continually explored. During these ongoing discussions, transparent communication of the unknown factors, such as anticipated clotting factor levels, long-term factor expression and safety, and psychological changes, is critical. To ensure efficiency and comprehensiveness, clearly‑defined protocols should outline the whole process, which should include the recording and management of long-term effects. CONCLUSION In order to engage effectively, both patients and providers should be familiar with these key considerations prior to their involvement with the haemophilia gene therapy process. The future after the approval of haemophilia gene therapies remains to be seen and real-world evidence is eagerly awaited.
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Affiliation(s)
- Wolfgang Miesbach
- Coagulation and Haemophilia Centre, Medical Clinic 2, Goethe University Hospital, Frankfurt am Main, Germany
| | - Greta Mulders
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daan Breederveld
- Brendaan Occupational Health Consultancy, Amsterdam, The Netherlands
| | | | | | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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2
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Itzler R, Buckner TW, Leebeek FWG, Miller J, Recht M, Drelich D, Monahan PE, Pipe SW. Effect of etranacogene dezaparvovec on quality of life for severe and moderately severe haemophilia B participants: Results from the phase III HOPE-B trial 2 years after gene therapy. Haemophilia 2024; 30:709-719. [PMID: 38462823 DOI: 10.1111/hae.14977] [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: 01/31/2024] [Accepted: 02/18/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION For people with haemophilia B (PwHB), bleeding may occur despite prophylaxis, negatively affecting health-related quality of life (HRQoL). The pivotal phase 3 HOPE-B trial investigating the adeno-associated virus gene transfer product, etranacogene dezaparvovec (EDZ), demonstrated sustained factor IX (FIX) activity and bleed protection in PwHB with baseline FIX levels ≤2%. AIM Assess how EDZ affects HRQoL in HOPE-B trial participants. METHODS HRQoL was evaluated using generic and disease-specific patient reported outcomes (PROs) including the EQ-5D-5L and the Hem-A-QoL questionnaires. Mean domain and total scores were compared 6 months pre- and the first 2 years post-EDZ administration using repeated measures linear mixed models. The percentage of participants with minimal clinically important improvements in HRQoL was also evaluated. RESULTS Two years post-EDZ, there were nominally significant increases in the least squares (LS) mean score for the EQ-5D-5L Index Value (.04; p = .0129), reflecting better HRQoL. Nominally significant decreases in the LS mean scores, reflecting better HRQoL, were also found for the Hem-A-QoL total score (-6.0; p < .0001) and the Treatment (-13.94; p < .0001), Feelings (-9.01; p < .0001), Future (-6.45; p = .0004) and Work/School (-5.21; p = .0098) domains. The percentage of participants with ≥15-point improvement ranged from 45.83% (95% CI: 31.37%, 60.83%) for Treatment to 13.89% (95% CI: 4.67%, 29.50%) for Family Planning. Results were similar for Year 1. CONCLUSION In conclusion, gene therapy with EDZ improved HRQoL in the first and second years in several Hem-A-QoL domains, including Treatment, Feelings, Work/School and Future domains, whereas improvement in other aspects of HRQoL were not demonstrated.
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Affiliation(s)
| | - Tyler W Buckner
- Division of Hematology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Michael Recht
- National Bleeding Disorders Foundation, New York, New York, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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3
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Miesbach W, von Drygalski A, Smith C, Sivamurthy K, Pinachyan K, Bensen-Kennedy D, Drelich D, Kulkarni R. The current challenges faced by people with hemophilia B. Eur J Haematol 2024; 112:339-349. [PMID: 38082533 DOI: 10.1111/ejh.14135] [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: 03/10/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Hemophilia B (HB) is a rare, hereditary disease caused by a defect in the gene encoding factor IX (FIX) and leads to varying degrees of coagulation deficiency. The prevailing treatment for people with HB (PWHB) is FIX replacement product. The advent of recombinant coagulation products ushered in a new era of safety, efficacy, and improved availability compared with plasma-derived products. For people with severe HB, lifelong prophylaxis with a FIX replacement product is standard of care. Development of extended half-life FIX replacement products has allowed for advancements in the care of these PWHB. Nonetheless, lifelong need for periodic dosing and complex surveillance protocols pose substantive challenges in terms of access, adherence, and healthcare resource utilization. Further, some PWHB on prophylactic regimens continue to experience breakthrough bleeds and joint damage, and subpopulations of PWHB, including women, those with mild-to-moderate HB, and those with inhibitors to FIX, experience additional unique difficulties. This review summarizes the current challenges faced by PWHB, including the unique subpopulations; identifying the need for improved awareness, personalized care strategies, and new therapeutic options for severe HB, which may provide future solutions for some of the remaining unmet needs of PWHB.
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Affiliation(s)
| | | | | | | | | | | | | | - Roshni Kulkarni
- Michigan State University Center for Bleeding and Clotting Disorders, Lansing, Michigan, USA
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4
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Astermark J, Baghaei F, Strandberg K, Toplican PG, Birkedal MF, Grahn EE, Hansson C, Kampmann P, Lehtinen AE, Täckström K, Holme PA, Magnusson M. Infrastructural considerations of implementing gene therapy for hemophilia in the Nordic context. Ther Adv Hematol 2023; 14:20406207231202306. [PMID: 37859645 PMCID: PMC10583513 DOI: 10.1177/20406207231202306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/18/2023] [Indexed: 10/21/2023] Open
Abstract
Background Despite improvements in hemophilia care, challenges remain, including treatment burden and impaired quality of life. Gene therapy may overcome these. However, its introduction presents a challenge. Objectives To outline a function-based gene therapy working model describing critical milestones associated with gene therapy handling, administration, and follow-up to facilitate and implement an effective infrastructure for gene therapy introduction. Design Literature review and consensus discussion among Hemophilia Comprehensive Care centers (HCCCs) in the Nordic region. Methods Representatives from six HCCCs sought to pinpoint milestones and key stakeholders for site readiness at the pre-, peri-, and post-infusion stages, including authority and genetically modified organism (GMO) product requirements, awareness, medical eligibility, logistics and product handling for infusion, laboratory monitoring, and follow-up. Results A gene therapy transit map was developed with key stakeholders identified. The approach to prepare the vector will differ between the Nordic centers, but the contracted pharmacy unit will be a key stakeholder. Therefore, a pharmacy checklist for the implementation of gene therapy was developed. For the future, Advanced Therapy Medicinal Product centers will also be implemented. Patients' expectations, commitments, and concerns need to be addressed repeatedly and education of patients and the expanded health-care professionals team will be the key to successful and optimal clinical management. Eligibility testing according to the product's summary of product characteristics and frequent follow-up and monitoring post-infusion according to the World Federation of Hemophilia chart will be crucial. Conclusion The approach to deliver gene therapy in the Nordic region will differ partly between the hemophilia centers, but the defined road map with checklists for the implementation of this advanced therapy will be applicable to all. The map may also serve as a platform for the use of future GMO product options both within and outside the area of hemophilia.
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Affiliation(s)
- Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Jan Waldenströms gata 14, Malmö, SE-205 02, Sweden
| | - Fariba Baghaei
- Department of Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Strandberg
- Division of Laboratory Medicine, Department of Clinical Chemistry and Pharmacology, Coagulation, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | | | - Maj Friberg Birkedal
- Department of Pediatric Hematology/Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Emma Engman Grahn
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | | | - Peter Kampmann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Anna-Elina Lehtinen
- Coagulation Disorders Unit, Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | | | - Pål Andre Holme
- Department of Hematology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria Magnusson
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Clinical Chemistry and Blood Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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von Drygalski A, Gomez E, Giermasz A, Castaman G, Key NS, Lattimore SU, Leebeek FWG, Miesbach WA, Recht M, Gut R, Dolmetsch R, Monahan PE, Le Quellec S, Pipe SW. Stable and durable factor IX levels in patients with hemophilia B over 3 years after etranacogene dezaparvovec gene therapy. Blood Adv 2023; 7:5671-5679. [PMID: 36490302 PMCID: PMC10539871 DOI: 10.1182/bloodadvances.2022008886] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/10/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
Etranacogene dezaparvovec (AMT-061) is a recombinant adeno-associated virus serotype 5 (AAV5) vector containing a codon-optimized Padua variant human factor IX (FIX) transgene with a liver-specific promoter. Here, we report 3-year outcomes from a phase 2b, open-label, single-dose, single-arm, multicenter trial conducted among adults with severe or moderately severe hemophilia B (FIX ≤2%). All participants (n = 3) received a single intravenous dose (2 × 1013 gene copies per kg) and will be followed up for 5 years. The primary end point of FIX activity ≥5% at 6 weeks was met. Secondary end points included bleed frequency, FIX concentrate use, joint health, and adverse events (AEs). All participants required routine FIX prophylaxis and had neutralizing antibodies to AAV5 before etranacogene dezaparvovec treatment. After administration, FIX activity rose to a mean of 40.8% in year 1 and was sustained in year 3 at 36.9%. All participants discontinued FIX prophylaxis. Bleeding was completely eliminated in 2 out of 3 participants. One participant required on-demand FIX replacement therapy per protocol because of elective surgical procedures, for 2 reported bleeding episodes, and twice for a single self-administered infusion because of an unreported reason. One participant experienced 2 mild, self-limiting AEs shortly after dosing. During the 3-year study period, there were no clinically significant elevations in liver enzymes, no requirement for steroids, no FIX inhibitor development, and no late-emergent safety events in any participant. Etranacogene dezaparvovec was safe and effective in adults with hemophilia B over 3 years after administration. This trial was registered at www.clinicaltrials.gov as #NCT03489291.
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Affiliation(s)
- Annette von Drygalski
- Division of Hematology/Oncology, Department of Medicine, University of California San Diego, San Diego, CA
| | | | - Adam Giermasz
- Division of Hematology/Oncology, Department of Medicine, Hemophilia Treatment Center, University of California Davis, Sacramento, CA
| | - Giancarlo Castaman
- Center for Bleeding Disorders, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Nigel S. Key
- Division of Hematology and Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Frank W. G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wolfgang A. Miesbach
- Department of Hemostaseology and Hemophilia Center, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, NY
- Hemophilia Treatment Center, Yale University School of Medicine, New Haven, CT
| | | | | | | | | | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI
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6
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Rasul E, Hallock R, Hellmann M, Konduros J, Pembroke L, LeCleir G, Malacan J, von Mackensen S. Gene Therapy in Hemophilia: A Transformational Patient Experience. J Patient Exp 2023; 10:23743735231193573. [PMID: 37663068 PMCID: PMC10472832 DOI: 10.1177/23743735231193573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Hemophilia is a bleeding disorder caused by a single absent/defective gene and characterized by a lack of functional clotting factors. People with hemophilia may experience joint damage, pain, and psychological impairments, all of which could contribute to reduced health-related quality of life (HRQoL). The current standard of care is clotting factor replacement, which is associated with regular infusions; therefore, alternative treatments such as gene therapy (GT) are in development. GT involves the delivery of a functional copy of the clotting factor 8/9 gene by a single infusion into the patient's cells, enabling them to produce their own clotting factor VIII/IX. The impact of treatment on patients' HRQoL can be assessed using hemophilia-specific patient-reported outcome (PRO) measures. Since these measures were designed before the advent of GT, there is a need for updated individualized PRO measures. Patient groups and regulatory authorities emphasize the need for increased patient engagement when considering clinical trial design. Here, we provide patients' perspective on undergoing GT and discuss how to capture the patient voice when measuring the therapy's transformative impact.
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Affiliation(s)
- Enayet Rasul
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Ryan Hallock
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Magnus Hellmann
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Jay Konduros
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Luke Pembroke
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | | | | | - Sylvia von Mackensen
- Department of Medical Psychology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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7
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Castaman G, Coppens M, Pipe SW. Etranacogene dezaparvovec for the treatment of adult patients with severe and moderately severe hemophilia B. Expert Rev Hematol 2023; 16:919-932. [PMID: 37882214 DOI: 10.1080/17474086.2023.2276206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/24/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Etranacogene dezaparvovec is the first gene therapy approved for treatment of adults with severe and moderately severe hemophilia B. AREAS COVERED This review describes the results of the clinical trial program of AMT-060 and etranacogene dezaparvovec, outlining the pharmacokinetic, clinical efficacy and safety data. With the entry of etranacogene dezaparvovec into the market, this review summarizes the treatment landscape in hemophilia B and discusses the current unknowns in the field. EXPERT OPINION Gene therapy appears to be a feasible option for adults with severe and moderately severe hemophilia B. Etranacogene dezaparvovec enables most patients to reach stable factor IX (FIX) levels after a single intravenous infusion, eliminating the need for regular prophylaxis; thus, drastically reducing treatment burden and avoiding variable bleeding risk owing to fluctuating FIX activity levels. Efficacy of etranacogene dezaparvovec has been demonstrated even in the presence of preexisting neutralizing antibodies (up to a titer of 1:678), with a relative low risk of transaminitis and its associated potential loss of transgene expression. However, long-term data are required to ascertain the durability of FIX levels achieved and safety. The cost-effectiveness and adoption of innovative payment models for reimbursement are key in choosing gene therapy over existing treatments.
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Affiliation(s)
- Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Michiel Coppens
- Vascular Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
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8
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Fletcher S, Jenner K, Holland M, Khair K. Expectation and loss when gene therapy for haemophilia is not an option: An exigency sub-study. Haemophilia 2023; 29:776-783. [PMID: 36882329 DOI: 10.1111/hae.14774] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Qualitative studies have explored why people with haemophilia (PwH) might consider or forgo gene therapy, the impact it has had on those who have received it, and what support might be needed throughout the process. No studies have yet examined what withdrawal prior to transfection might mean for PwH and their families. AIMS To understand the experiences of PwH and their families of withdrawal from gene therapy and to understand what support mechanisms might be required. METHODS Qualitative interviews were conducted with people with severe haemophilia who consented to take part in a gene therapy study in the UK but either withdrew or were withdrawn before transfection. RESULTS Nine PwH and a family member were invited to this sub-study. Eight participants were recruited: six PwH (five haemophilia A and one haemophilia B) and two family members. Four participants were excluded from a study after consenting but before transfection, having failed to meet all the inclusion criteria; two withdrew after consenting but before transfection due to concerns including duration of factor expression and the time commitment involved in follow-up. The mean age of participants was 40.5 years (range 25-63 years). Two major themes emerged during the interviews: Expectation and loss. CONCLUSIONS PwH have many expectations about the difference gene therapy can make to their lives. Studies show that these expectations may not be fully realised. For those who have either withdrawn or been withdrawn from gene therapy, any expectations they had may now be unachievable. The nature of these expectations and the loss expressed by the participants indicate that support needs to be provided to help them and their families manage it.
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Affiliation(s)
- Simon Fletcher
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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9
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Mihaila RG. From a bispecific monoclonal antibody to gene therapy: A new era in the treatment of hemophilia A. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:1-8. [PMID: 36413008 DOI: 10.5507/bp.2022.046] [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: 08/19/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment of hemophilia A has progressed amazingly in recent years. Emicizumab, a bispecific-humanized monoclonal antibody, is able to improve coagulation by bridging activated factor IX and factor X. Emicizumab is administered subcutaneously and much less often compared to factor VIII products. It has low immunogenicity, does not require dose adjustment, and can be administered regardless of the presence of factor VIII inhibitors. Thrombin generation assays but not factor VIII activity are indicated to guide and monitor the treatment. Emicizumab has enabled the conversion of patients with severe forms into patients with milder forms of hemophilia A. It has reduced the number of bleeding episodes compared to both on-demand and prophylactic substitution therapy and has an excellent safety profile. Gene therapy can elevate factor VIII plasma levels for many years after a single treatment course, could offer long-term protection from bleeding episodes, and minimize or eliminate the need for substitutive treatment with factor VIII concentrates. Gene therapy can provoke an immune response, manifested by an increase in common liver enzymes, that require immunotherapy. Long term monitoring is necessary to identify possible adverse effects. Future objectives are: the development of an ideal viral vector, the possibility of its re-administration, the use of gene therapy in hemophiliac children, and determining whether it can be successfully used to induce immune tolerance to factor VIII ceteri paribus. The future will determine the place of each type of treatment and group of patients for which it is indicated.
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10
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Pipe SW, Arruda VR, Lange C, Kitchen S, Eichler H, Wadsworth S. Characteristics of BAY 2599023 in the Current Treatment Landscape of Hemophilia A Gene Therapy. Curr Gene Ther 2023; 23:81-95. [PMID: 36111754 DOI: 10.2174/1566523222666220914105729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/22/2022]
Abstract
Hemophilia A, a single gene disorder leading to deficient Factor VIII (FVIII), is a suitable candidate for gene therapy. The aspiration is for single administration of a genetic therapy that would allow the production of endogenous FVIII sufficient to restore hemostasis and other biological processes. This would potentially result in reliable protection from bleeding and its associated physical and emotional impacts. Gene therapy offers the possibility of a clinically relevant improvement in disease phenotype and transformational improvement in quality of life, including an opportunity to engage in physical activities more confidently. Gene therapy products for hemophilia A in advanced clinical development use adeno-associated viral (AAV) vectors and a codon-optimized B-domain deleted FVIII transgene. However, the different AAV-based gene therapies have distinct design features, such as choice of vector capsid, enhancer and promoter regions, FVIII transgene sequence and manufacturing processes. These, in turn, impact patient eligibility, safety and efficacy. Ideally, gene therapy technology for hemophilia A should offer bleed protection, durable FVIII expression, broad eligibility and limited response variability between patients, and long-term safety. However, several limitations and challenges must be overcome. Here, we introduce the characteristics of the BAY 2599023 (AAVhu37.hFVIIIco, DTX 201) gene therapy product, including the low prevalence in the general population of anti-AAV-hu37 antibodies, as well as other gene therapy AAV products and approaches. We will examine how these can potentially meet the challenges of gene therapy, with the ultimate aim of improving the lives of patients with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Valder R Arruda
- Division of Hematology, Department of Pediatrics, Center for Cell and Molecular Therapeutics at Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephen Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield Teaching Hospitals, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
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11
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Miesbach W, Klamroth R, Oldenburg J, Tiede A. Gene Therapy for Hemophilia-Opportunities and Risks. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:887-894. [PMID: 36468250 PMCID: PMC10011720 DOI: 10.3238/arztebl.m2022.0353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 06/29/2022] [Accepted: 10/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AAV (adeno-associated virus)-based gene therapy is a new treatment for hemophilia and has recently received approval for the treatment of severe hemophilia A. It does not suffer from the limitations of the current standard treatment (regular prophylactic intravenous injections of the missing clotting factor; subcutaneous injection of a bispecific antibody in hemophilia A) and can, it is hoped, raise the concentration of the missing clotting factor over the long term. AAV-based gene therapy can only be performed once, however, because of the generation of antibodies to AAV. METHODS This review is based on publications retrieved by a selective search in the MEDLINE/PubMed database employing the relevant key words, supplemented by expert opinions and the recommendations of the relevant medical societies. RESULTS Data from non-randomized phase 1 to phase 3 trials reveal an adequate expression of factors VIII and IX in patients with mostly severe hemophilia A or B. Even though they were no longer receiving prophylactic treatment, most patients experienced a considerable reduction, by 53% to 96%, in the number of bleedings compared to previous therapy. Persistently elevated factor levels have been described for up to six years in hemophilia A and up to eight years in hemophilia B. The most common side effect of gene therapy is an inflammatory response with elevated alanine aminotransferase levels (17% to 89%, depending on the study), which may be associated with a reduced clotting factor level and requires treatment with transient immunosuppression. CONCLUSION Gene therapy for hemophilia holds out the prospect of freedom from hemorrhage without the need for regular treatment with drugs. The various steps that need to be carried out in gene therapy should be coordinated in a graded and partly overlapping integrated care model (a so-called hub-and-spoke model). Electronic platforms should be used for data acquisition and transmission.
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Affiliation(s)
- Wolfgang Miesbach
- Department of Haemostaseology and Hemophilia Center, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt am Main; Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin; Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn; Department of Hematology, Hemostaseology, Oncology and Stem Cell Transplantation, Hannover Medical School
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12
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Co-administration of FVIII with IVIG reduces immune response to FVIII in hemophilia A mice. Sci Rep 2022; 12:20074. [PMID: 36418333 PMCID: PMC9684572 DOI: 10.1038/s41598-022-19392-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/03/2022] [Indexed: 11/24/2022] Open
Abstract
Hemophilia A is an X-linked recessive congenital bleeding disorder. Exogenous infusion of FVIII is the treatment of choice, and the development of immunoglobulins against FVIII (inhibitors) remains the major challenge in clinical management of the disease. Here, we investigated the effect of co-administration of FVIII with intravenous immunoglobulin (IVIG) on the development of inhibitors in previously untreated hemophilia A mice. A group of hemophilia A mice (C57BL/6FVIII-/-) received weekly injections of recombinant human FVIII (rFVIII) for twelve consecutive weeks while a second group received co-injections of rFVIII + IVIG. An in-house enzyme-linked immunosorbent assay (ELISA) was designed to detect antibodies to rFVIII. Every mouse in the first group developed antibodies to rFVIII. In contrast, mice treated with rFVIII + IVIG showed significantly lower antibody titers. Interestingly, when co-administration of IVIG was discontinued after 12 weeks in some mice (rFVIII continued), these mice experienced an increase in antibody titer. In contrast, mice that continued to receive rFVIII + IVIG retained significantly lower titers. In conclusion, prophylactic rFVIII co-administration with IVIG modulated the immune response to FVIII and resulted in decreased anti-FVIII antibody titer. These findings suggest that co-injection therapy with IVIG could potentially be effective in the management of hemophilia A patients at risk of inhibitor development.
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13
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Bolous NS, Bhatt N, Bhakta N, Neufeld EJ, Davidoff AM, Reiss UM. Gene Therapy and Hemophilia: Where Do We Go from Here? J Blood Med 2022; 13:559-580. [PMID: 36226233 PMCID: PMC9550170 DOI: 10.2147/jbm.s371438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
Gene therapy for hemophilia using adeno-associated virus (AAV) derived vectors can reduce or eliminate patients' disease-related complications and improve their quality of life. Broad implementation globally will lead to societal gains and foster health equity. Several vector products each for factor IX (FIX) or factor VIII (FVIII) deficiency are in advanced clinical development. Safety data are reassuring. Efficacy data for up to 8 and 5 years, respectively, vary considerably among vector types and among individuals, but indicate significant reduction in bleeds and factor use. Products will soon be approved for marketing. This review highlights the relevant considerations for implementation of hemophilia gene therapy, specifically across a broad range of socioeconomic backgrounds globally, based on recent publications and our own experience. We address the current efficacy and safety data and relevant aspects of vector immunology. We then discuss pertinent implementation steps including pre-implementation and readiness assessments, considerations on cost, cost-effectiveness and payment models, approaches to education and informed consent, and the operational needs as well as the need for monitoring of health outcomes and implementation outcomes. To prevent a lag or complete lack of establishing access to this life-changing therapy option for all patients with hemophilia worldwide, adaptable pathways supported by collaborative and international efforts of all stakeholders are needed.
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Affiliation(s)
- Nancy S Bolous
- Department of Global Pediatric Medicine – St. Jude Children’s Research Hospital, Memphis, TN, USA,Correspondence: Nancy S Bolous, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop 721, Memphis, TN, 38105, USA, Tel +1 901 595 1968, Fax +1 901 595 5319, Email
| | - Nidhi Bhatt
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ellis J Neufeld
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ulrike M Reiss
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
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14
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Mack HG, Britten-Jones AC, McGuinness MB, Chen FK, Grigg JR, Jamieson RV, Edwards TL, De Roach J, O'Hare F, Martin KR, Ayton LN. Survey of perspectives of people with inherited retinal diseases on ocular gene therapy in Australia. Gene Ther 2022; 30:336-346. [PMID: 36183012 PMCID: PMC10113139 DOI: 10.1038/s41434-022-00364-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 11/09/2022]
Abstract
Many gene therapies are in development for treating people with inherited retinal diseases (IRD). We hypothesized that potential recipients of gene therapy would have knowledge gaps regarding treatment. We aimed to assess knowledge, attitudes, and perceptions of genetic therapies among potential recipients with IRD, using a novel instrument we designed (Attitudes to Gene Therapy-Eye (AGT-Eye)) and their associations with demographic data, self-reported visual status, and tools assessing quality of life and attitudes toward clinical trials using a community-based cross-sectional survey of Australian adults with IRD. AGT-Eye, overall quality of life EQ-5D-5L, National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) and Patient Attitudes to Clinical Trials (PACT-22) instruments were administered. Six hundred and eighty-one people completed the study, 51.7% women of mean age 53.5 years (SD ± 15.8). Most participants (91.6%) indicated they would likely accept gene therapy if it was available to them or family members. However, only 28.3% agreed that they had good knowledge of gene therapy. Most obtained information about gene therapy from the internet (49.3%). Respondents with post-graduate degrees scored highest compared to other educational levels on methods (p < 0.001) and outcomes (p = 0.003) and were more likely to see economic value of treatment (p = 0.043). Knowledge gaps were present regarding methods and outcomes of gene therapy. This survey has shown high level of interest in the IRD community for gene therapies, and highlights areas for improved clinician and patient education.
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Affiliation(s)
- Heather G Mack
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia. .,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia.
| | - Alexis Ceecee Britten-Jones
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia.,Department of Optometry and Vision Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Myra B McGuinness
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Fred K Chen
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Centre for Ophthalmology and Visual Sciences (incorporating Lions Eye Institute), The University of Western Australia, Perth, WA, Australia.,Royal Perth Hospital and Perth Children's Hospital, Perth, WA, Australia
| | - John R Grigg
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Eye Genetics Research Unit, Sydney Children's Hospitals Network, Save Sight Institute, Children's Medical Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Robyn V Jamieson
- Eye Genetics Research Unit, Sydney Children's Hospitals Network, Save Sight Institute, Children's Medical Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Thomas L Edwards
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - John De Roach
- Centre for Ophthalmology and Visual Sciences (incorporating Lions Eye Institute), The University of Western Australia, Perth, WA, Australia.,The Australian Inherited Retinal Disease Registry and DNA Bank, Perth, WA, Australia
| | - Fleur O'Hare
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia.,Department of Optometry and Vision Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Keith R Martin
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - Lauren N Ayton
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, VIC, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia.,Department of Optometry and Vision Sciences, University of Melbourne, Melbourne, VIC, Australia
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15
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Kavaklı K, Antmen B, Okan V, Şahin F, Aytaç S, Balkan C, Berber E, Kaya Z, Küpesiz A, Zülfikar B. Gene therapy in haemophilia: literature review and regional perspectives for Turkey. Ther Adv Hematol 2022; 13:20406207221104591. [PMID: 35898436 PMCID: PMC9310332 DOI: 10.1177/20406207221104591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is an X-linked lifelong congenital bleeding disorder that is caused by insufficient levels of factor VIII (FVIII; haemophilia A) or factor IX (FIX; haemophilia B) and characterized by spontaneous and trauma-related bleeding episodes. The cornerstone of the treatment, factor replacement, constitutes several difficulties, including frequent injections due to the short half-life of recombinant factors, intravenous administration and the risk of inhibitor development. While extended half-life factors and subcutaneous novel molecules enhanced the quality of life, initial successes with gene therapy offer a significant hope for cure. Although adeno-associated viral (AAV)-based gene therapy is one of the most emerging approaches for treatment of haemophilia, there are still challenges in vector immunogenicity, potency and efficacy, genotoxicity and persistence. As the approval for the first gene therapy product is coming closer, eligibility criteria for patient selection, multidisciplinary approach for optimal delivery and follow-up and development of new pricing policies and reimbursement models should be concerned. Therefore, this review addresses the unmet needs of current haemophilia treatment and explains the rationale and principles of gene therapy. Limitations and challenges are discussed from a global and national perspective and recommendations are provided to adopt the gene therapies faster and more sufficient for the haemophilia patients in developing countries like Turkey.
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Affiliation(s)
- Kaan Kavaklı
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100 İzmir, Turkey
| | - Bülent Antmen
- Division of Hematology, Department of Pediatrics, Acıbadem Adana Hospital, Adana, Turkey
| | - Vahap Okan
- Division of Hematology, Department of Internal Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Fahri Şahin
- Division of Hematology, Department of Internal Diseases, Ege Adult Hemophilia and Thrombosis Center, Ege University Faculty of Medicine, İzmir, Turkey
| | - Selin Aytaç
- Division of Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Can Balkan
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ergül Berber
- Department of Molecular Biology and Genetics, İstanbul Arel University, İstanbul, Turkey
| | - Zühre Kaya
- Division of Hematology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Alphan Küpesiz
- Division of Hematology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Bülent Zülfikar
- Division of Hematology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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16
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Miesbach W, Baghaei F, Boban A, Chowdary P, Coppens M, Hart DP, Jimenez-Yuste V, Klamroth R, Makris M, Noone D, Peyvandi F. Gene therapy of hemophilia: Hub centres should be haemophilia centres: A joint publication of EAHAD and EHC. Haemophilia 2022; 28:e86-e88. [PMID: 35263819 DOI: 10.1111/hae.14546] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Fariba Baghaei
- Coagulation Centre, Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital and Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ana Boban
- Haemophilia Centre, Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michiel Coppens
- Department of Vascular Medicine, Hemophilia Treatment Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine & Dentistry, QMUL, London, UK
| | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | - Robert Klamroth
- Department for Internal Medicine and Vascular Medicine, Haemophilia Treatment Center, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Declan Noone
- European Haemopilia Consortium, 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
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17
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Arjomandnejad M, Kopec AL, Keeler AM. CAR-T Regulatory (CAR-Treg) Cells: Engineering and Applications. Biomedicines 2022; 10:287. [PMID: 35203496 PMCID: PMC8869296 DOI: 10.3390/biomedicines10020287] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 01/27/2023] Open
Abstract
Regulatory T cells are critical for maintaining immune tolerance. Recent studies have confirmed their therapeutic suppressive potential to modulate immune responses in organ transplant and autoimmune diseases. However, the unknown and nonspecific antigen recognition of polyclonal Tregs has impaired their therapeutic potency in initial clinical findings. To address this limitation, antigen specificity can be conferred to Tregs by engineering the expression of transgenic T-cell receptor (TCR) or chimeric antigen receptor (CAR). In contrast to TCR Tregs, CAR Tregs are major histocompatibility complex (MHC) independent and less dependent on interleukin-2 (IL-2). Furthermore, CAR Tregs maintain Treg phenotype and function, home to the target tissue and show enhanced suppressive efficacy compared to polyclonal Tregs. Additional development of engineered CAR Tregs is needed to increase Tregs' suppressive function and stability, prevent CAR Treg exhaustion, and assess their safety profile. Further understanding of Tregs therapeutic potential will be necessary before moving to broader clinical applications. Here, we summarize recent studies utilizing CAR Tregs in modulating immune responses in autoimmune diseases, transplantation, and gene therapy and future clinical applications.
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Affiliation(s)
- Motahareh Arjomandnejad
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (M.A.); (A.L.K.)
| | - Acadia L. Kopec
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (M.A.); (A.L.K.)
| | - Allison M. Keeler
- Horae Gene Therapy Center, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA; (M.A.); (A.L.K.)
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
- NeuroNexus Institute, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
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18
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Wang M, Negrier C, Driessler F, Goodman C, Skinner MW. The Hemophilia Gene Therapy Patient Journey: Questions and Answers for Shared Decision-Making. Patient Prefer Adherence 2022; 16:1439-1447. [PMID: 35707346 PMCID: PMC9191577 DOI: 10.2147/ppa.s355627] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/13/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The anticipated emergence of hemophilia gene therapy will present people with hemophilia (PWH) and treating clinicians with increasingly complex treatment options. It will be critical that PWH and their families be empowered to participate fully in decision-making through transparent communication and the development of targeted educational resources. METHODS The Council of Hemophilia Community (CHC) convened across a series of roundtable meetings to define the patient journey for hemophilia gene therapy, and to develop a question-and-answer style resource to guide discussion between healthcare professionals (HCPs) and their patients. Patient groups were also consulted during the development of this tool. RESULTS The CHC defined 5 key stages in the hemophilia gene therapy patient journey: pre-gene therapy (information-seeking and decision-making), treatment initiation, short- and long-term post-gene therapy follow-up. PWH will have different questions and concerns at each stage of their journey, which should be discussed with their HCP to aid decision-making. The resulting patient journey infographic and Q&A resource (see Supplementary Materials) has been developed for HCPs and PWH to provide a novel and practical roadmap of key issues and considerations throughout all stages. CONCLUSION These resources support a collaborative, patient-centric, shared decision-making approach to inform treatment decision discussions between HCPs and PWH. The value of such discussions will be influenced by the language adopted; health literacy is a particularly important consideration, and these discussions should be accessible and tailored to PWH. HCPs and PWH can benefit from awareness of the common questions and uncertainties as they progress together along the patient journey. While the contents of this article are specific to hemophilia gene therapy, the concepts developed here could be adapted to aid patients in other disease states.
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Affiliation(s)
- Michael Wang
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Claude Negrier
- National Reference Center for Haemophilia, Louis Pradel Cardiology Hospital, University of Lyon, Lyon, France
| | - Frank Driessler
- Bayer, Basel, Switzerland
- Correspondence: Frank Driessler, Bayer AG, Peter Merian Straße 84, Basel, CH-4052, Switzerland, Tel +41 79 422 32 18, Email
| | | | - Mark W Skinner
- Institute for Policy Advancement Ltd, Washington, DC, USA
- McMaster University, Hamilton, ON, Canada
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19
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Kuijlaars IAR, Teela L, van Vulpen LFD, Timmer MA, Coppens M, Gouw SC, Peters M, Kruip MJHA, Cnossen MH, Muis JJ, van Hoorn ES, Haverman L, Fischer K. Generic PROMIS item banks in adults with hemophilia for patient-reported outcome assessment: Feasibility, measurement properties, and relevance. Res Pract Thromb Haemost 2021; 5:e12621. [PMID: 34849449 PMCID: PMC8606028 DOI: 10.1002/rth2.12621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/02/2021] [Accepted: 10/13/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Legacy hemophilia-specific questionnaires are considered too long, show floor-/ceiling effects, and/or include irrelevant questions. Patient Reported Outcomes Measurement Information System (PROMIS) item banks, including Computer Adaptive Tests (CATs) and short forms, were designed for more efficient outcome assessment. OBJECTIVES Evaluate the feasibility, measurement properties, and relevance of seven PROMIS CATs and two short forms in patients with hemophilia. PATIENTS/METHODS In this cross-sectional study, Dutch adults with hemophilia completed nine PROMIS item banks electronically. Feasibility was assessed by number of items and floor/ceiling effects. Reliability was determined as the proportion of reliable scores (standard error ≤3.2). Construct validity was assessed by comparison with legacy instruments and expected differences between subgroups. Relevance of item banks was determined by proportions of limited scores. RESULTS Overall, 142 of 373 invited patients (mean age, 47 [range, 18-79], 49% severe hemophilia, 46% receiving prophylaxis) responded. Per CAT item bank, mean number of items answered varied from 5 (range, 3-12) to 9 (range, 5-12), with floor effects in pain interference (26% lowest scores) and depression (18% lowest scores). Construct validity and reliability were good for physical function, pain interference, satisfaction with social roles and activities, and fatigue. The CAT physical function showed the most limited scores (38%). The self-efficacy short forms showed ceiling effects (22%-28%) and no relation with the legacy instruments. CONCLUSIONS The PROMIS CATs physical function, pain interference, satisfaction with social roles and activities, and fatigue are feasible, reliable, and valid alternatives to legacy instruments for patients with hemophilia, with few items and low floor-/ceiling effects.
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Affiliation(s)
- Isolde A. R. Kuijlaars
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Lorynn Teela
- Amsterdam University Medical CentersEmma Children’s HospitalChild and Adolescent Psychiatry & Psychosocial CareAmsterdam Reproduction and DevelopmentAmsterdam Public HealthUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lize F. D. van Vulpen
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Merel A. Timmer
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Michiel Coppens
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Samantha C. Gouw
- Emma Children’s HospitalAmsterdam University Medical CentersPediatric HematologyUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Marjolein Peters
- Emma Children’s HospitalAmsterdam University Medical CentersPediatric HematologyUniversity of AmsterdamAmsterdamThe Netherlands
| | - Marieke J. H. A. Kruip
- Erasmus MCDepartment of HematologyErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Marjon H. Cnossen
- Erasmus MCDepartment of Pediatric HematologySophia Children’s HospitalErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Jelmer J. Muis
- Amsterdam University Medical CentersEmma Children’s HospitalChild and Adolescent Psychiatry & Psychosocial CareAmsterdam Reproduction and DevelopmentAmsterdam Public HealthUniversity of AmsterdamAmsterdamThe Netherlands
- Emma Children’s HospitalAmsterdam University Medical CentersPediatric HematologyUniversity of AmsterdamAmsterdamThe Netherlands
| | - Evelien S. van Hoorn
- Erasmus MCDepartment of Public HealthErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Lotte Haverman
- Amsterdam University Medical CentersEmma Children’s HospitalChild and Adolescent Psychiatry & Psychosocial CareAmsterdam Reproduction and DevelopmentAmsterdam Public HealthUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kathelijn Fischer
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
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20
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Miesbach W, Barcenilla SG, Golan G, Lobet S. Implications of haemophilia gene therapy for the changing role of the multidisciplinary team. Haemophilia 2021; 28:e12-e14. [PMID: 34668286 PMCID: PMC9298429 DOI: 10.1111/hae.14440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/27/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - Sara Garcia Barcenilla
- Grupo 14 de Coagulopatías y alteraciones de la hemostasia, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Universidad Autónoma de Madrid), Madrid, Spain
| | - Gaby Golan
- Israel National Haemophilia Centre, Tel Aviv Medical School, Tel Aviv, Sheba Hospital, Israel
| | - Sébastien Lobet
- Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium.,Université catholique de Louvain, Secteur des Sciences de la Santé, Neuromusculoskeletal Lab (NMSK), Institut de Recherche Expérimentale et Clinique, Brussels, Belgium.,Secteur de kinésithérapie, Cliniques universitaires Saint-Luc, Brussels, Belgium
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21
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Miesbach W, Chowdary P, Coppens M, Hart DP, Jimenez-Yuste V, Klamroth R, Makris M, Noone D, Peyvandi F. Delivery of AAV-based gene therapy through haemophilia centres-A need for re-evaluation of infrastructure and comprehensive care: A Joint publication of EAHAD and EHC. Haemophilia 2021; 27:967-973. [PMID: 34553460 DOI: 10.1111/hae.14420] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Adeno-associated virus (AAV)-based gene therapy for haemophilia presents a challenge to the existing structure of haemophilia centres and requires a rethink of current collaboration and information exchange with the aim of ensuring a system that is fit-for-purpose for advanced therapies to maximise benefits and minimise risks. In Europe, a certification process based on the number of patients and facilities is offered to the haemophilia centres by European Haemophilia Network (EUHANET). AIM AND METHODS This joint European Association for Haemophilia and Allied Disorders (EAHAD) and European Haemophilia Consortium (EHC) publication describes criteria for centres participating in gene therapy care that require a reassessment of the infrastructure of comprehensive care and provides an outlook on how these criteria can be implemented in the future work of haemophilia centres. RESULTS The core definition of a haemophilia treatment centre remains, but additional roles could be implemented. A modifiable 'hub-and-spoke' model addresses all aspects associated with gene therapy, including preparation and administration of the gene therapy product, determination of coagulation and immunological parameters, joint score and function, and liver health. This will also include the strategy on how to follow-up patients for a long-term safety and efficacy surveillance. CONCLUSION We propose a modifiable, networked 'hub and spoke' model with a long term safety and efficacy surveillance system. This approach will be progressively developed with the goal of making haemophilia centres better qualified to deliver gene therapy and to make gene therapy accessible to all persons with haemophilia, irrespective of their country or centre of origin.
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Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michiel Coppens
- Department of Vascular Medicine, Haemophilia Treatment Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | - Robert Klamroth
- Department for Internal Medicine and Vascular Medicine, Haemophilia Treatment Centre, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Michael Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Declan Noone
- European Haemophilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and Fondazione Luigi Villa, Milan, Italy.,Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
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22
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Lisowski L, Staber JM, Wright JF, Valentino LA. The intersection of vector biology, gene therapy, and hemophilia. Res Pract Thromb Haemost 2021; 5:e12586. [PMID: 34485808 PMCID: PMC8410952 DOI: 10.1002/rth2.12586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/01/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022] Open
Abstract
Gene therapy is at the forefront of the drive to bring the potential of cure to patients with genetic diseases. Multiple mechanisms of effective and efficient gene therapy delivery (eg, lentiviral, adeno-associated) for transgene expression as well as gene editing have been explored to improve vector and construct attributes and achieve therapeutic success. Recent clinical research has focused on recombinant adeno-associated viral (rAAV) vectors as a preferred method owing to their naturally occurring vector biology characteristics, such as serotypes with specific tissue tropisms, facilitated in vivo delivery, and stable physicochemical properties. For those living with hereditary diseases like hemophilia, this potential curative approach is balanced against the need to provide safe, predictable, effective, and durable factor expression. While in vivo studies of rAAV gene therapy have demonstrated amelioration of the bleeding phenotype in adults, long-term safety and effectiveness remain to be established. This review discusses vector biology in the context of rAAV-based liver-directed gene therapy for hemophilia and provides an overview of the types of viral vectors and vector components that are under investigation, as well as an assessment of the challenges associated with gene therapy delivery and durability of expression.
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Affiliation(s)
- Leszek Lisowski
- Translational Vectorology Research UnitFaculty of Medicine and HealthChildren's Medical Research InstituteThe University of SydneyWestmeadAustralia
- Laboratory of Molecular Oncology and Innovative TherapiesMilitary Institute of MedicineWarsawPoland
| | - Janice M. Staber
- Stead Family Department of PediatricsUniversity of IowaIowa CityIAUSA
- Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - J. Fraser Wright
- Department of PediatricsDivision of Hematology, OncologyStem Cell Transplantation and Regenerative MedicineCenter for Definitive and Curative MedicineStanford University School of MedicineStanfordCAUSA
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Rodríguez-Merchán EC, De Pablo-Moreno JA, Liras A. Gene Therapy in Hemophilia: Recent Advances. Int J Mol Sci 2021; 22:ijms22147647. [PMID: 34299267 PMCID: PMC8306493 DOI: 10.3390/ijms22147647] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023] Open
Abstract
Hemophilia is a monogenic mutational disease affecting coagulation factor VIII or factor IX genes. The palliative treatment of choice is based on the use of safe and effective recombinant clotting factors. Advanced therapies will be curative, ensuring stable and durable concentrations of the defective circulating factor. Results have so far been encouraging in terms of levels and times of expression using mainly adeno-associated vectors. However, these therapies are associated with immunogenicity and hepatotoxicity. Optimizing the vector serotypes and the transgene (variants) will boost clotting efficacy, thus increasing the viability of these protocols. It is essential that both physicians and patients be informed about the potential benefits and risks of the new therapies, and a register of gene therapy patients be kept with information of the efficacy and long-term adverse events associated with the treatments administered. In the context of hemophilia, gene therapy may result in (particularly indirect) cost savings and in a more equitable allocation of treatments. In the case of hemophilia A, further research is needed into how to effectively package the large factor VIII gene into the vector; and in the case of hemophilia B, the priority should be to optimize both the vector serotype, reducing its immunogenicity and hepatotoxicity, and the transgene, boosting its clotting efficacy so as to minimize the amount of vector administered and decrease the incidence of adverse events without compromising the efficacy of the protein expressed.
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Affiliation(s)
- E. Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research–IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain;
| | - Juan Andres De Pablo-Moreno
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, 28040 Madrid, Spain;
| | - Antonio Liras
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, 28040 Madrid, Spain;
- Correspondence:
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24
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Fletcher S, Jenner K, Holland M, Chaplin S, Khair K. An exploration of why men with severe haemophilia might not want gene therapy: The exigency study. Haemophilia 2021; 27:760-768. [PMID: 34265145 DOI: 10.1111/hae.14378] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/15/2021] [Accepted: 07/05/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION For many people with haemophilia (PwH) gene therapy offers a potential functional cure. However, some have stated that they do not wish to have gene therapy either now or in the future. AIM This sub-study, part of the larger Exigency programme, assesses the attitudes, views and understanding of those who do not wish to undergo gene therapy. METHODS Participants were approached via social media and word of mouth referral and invited to participate in a focus group or individual interview to discuss their views. Interviews were recorded, transcribed verbatim and analysed thematically. RESULTS Ten adult men with severe haemophilia (eight haemophilia A and two haemophilia B), mean age 34.3 years, participated in a 1-h focus group (n = 9) or interview (n = 1). All were on prophylaxis. None reported significant treatment burden, and all had annual bleeding rates of less than five in the previous 12 months. Four major themes emerged: self-identity and its loss, lack of long-term safety and efficacy data, ongoing concerns about past viral infection, and lack of current treatment burden. CONCLUSION There are many concerns about gene therapy, including eligibility, effectiveness and safety, which may result in individuals declining it as a therapy. These concerns may recede as more data are published. This study reveals a psychological dynamic around self-identity and belonging for PwH. The nature of this dynamic is poorly understood and needs exploration to facilitate support for those making decisions about gene therapy.
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Affiliation(s)
- Simon Fletcher
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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25
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Hart DP, Branchford BR, Hendry S, Ledniczky R, Sidonio RF, Négrier C, Kim M, Rice M, Minshall M, Arcé C, Prince S, Kelleher M, Lee S. Optimizing language for effective communication of gene therapy concepts with hemophilia patients: a qualitative study. Orphanet J Rare Dis 2021; 16:189. [PMID: 33910590 PMCID: PMC8082836 DOI: 10.1186/s13023-020-01555-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/23/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND For communities of people living with hemophilia and other genetic conditions, gene therapy could represent a paradigm shift in treatment strategies. As investigational therapeutic modalities such as gene therapy become more widely used and discussed, there is a critical need for all stakeholders to communicate using a lexicon that is intelligible, accurate, consistent, and representative of novel treatments. In doing so, expectations can be more carefully managed and potential risks, benefits, and limitations better understood. In recognition of this need, a first-ever study of gene therapy lexicon was conducted using established methods of market research and linguistic analysis. METHODS Ninety-four participants representing hematologists, nurses, caregivers, and people with hemophilia A, in six countries (US, UK, Spain, Germany, France, Italy) took part in a series of in-depth interviews, face-to-face focus groups, an advisory board meeting, and online group interviews to develop, refine, and test verbal, written, and pictorial language concepts through a three-phase iterative process. Sessions were conducted in local languages using detailed discussion guides. Feedback from participants was captured using real-time instant-response dial testing to measure moment-by-moment emotional responses to language stimuli. Semiquantitative analysis of the responses informed selection of preferred language concepts for final testing, and qualitative discussion explored preference rationale. Participants also completed polling and forced rank and choice written exercises. RESULTS Study feedback showed that the hemophilia community has preferences around consistent lexicon to describe hemophilia and its management. Expert linguistic analysis of feedback from the three phases enabled agreement of a consensus lexicon of vocabulary and an optimized summary narrative for talking about gene therapy amongst people affected by hemophilia A. Preferences were largely consistent across audiences and countries, although some country-specific recommendations were made. A representative summary phrase was agreed: "Gene therapy is being studied in clinical trials with the aim to allow the body to produce factor VIII protein on its own". CONCLUSIONS The use of preferred language across different stakeholders increases understanding and comfort during discussions of novel and complex therapeutic modalities such as gene therapy. Consistent use of community-informed lexicon minimizes miscommunication and facilitates informed decision-making regarding potential future treatment opportunities.
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Affiliation(s)
- Daniel P Hart
- Royal London Haemophilia Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, E1 1BB, UK.
| | - Brian R Branchford
- Hemophilia and Thrombosis Center, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah Hendry
- Maslansky + Partners, 200 Varick Street, Suite 601, New York, NY, 10014, USA
| | - Robert Ledniczky
- Maslansky + Partners, 200 Varick Street, Suite 601, New York, NY, 10014, USA
| | | | - Claude Négrier
- Hemophilia and Thrombosis Center, Hôpital Cardiologique, Université Lyon 1, Lyon, France
| | - Michelle Kim
- Hemophilia Foundation of Southern California, Pasadena, CA, USA
| | | | | | - Claire Arcé
- Association française des hémophiles, Paris, France
| | | | | | - Sharon Lee
- BioMarin Pharmaceutical Inc., Novato, CA, USA
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Miesbach W, Pasi KJ, Pipe SW, Hermans C, O'Mahony B, Guelcher C, Steiner B, Skinner MW. Evolution of haemophilia integrated care in the era of gene therapy: Treatment centre's readiness in United States and EU. Haemophilia 2021; 27:511-514. [PMID: 33892516 DOI: 10.1111/hae.14309] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/15/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Affiliation(s)
| | - K John Pasi
- Royal London Haemophilia Centre, Barts & the London School of Medicine & Dentistry, London, UK
| | - Steven W Pipe
- University of Michigan, Ann Arbor, Michigan, USA.,National Hemophilia Foundation, New York, New York, USA
| | - Cedric Hermans
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain, Brussels, Belgium
| | - Brian O'Mahony
- Trinity College, Dublin, Ireland.,Irish Haemophilia Society, Dublin, Ireland
| | | | - Bruno Steiner
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Mark W Skinner
- Institute for Policy Advancement Ltd, Washington, District of Columbia, USA.,McMaster University, Hamilton, Ontario, Canada
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27
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Krumb E, Lambert C, Hermans C. Patient selection for hemophilia gene therapy: Real-life data from a single center. Res Pract Thromb Haemost 2021; 5:390-394. [PMID: 33870024 PMCID: PMC8035793 DOI: 10.1002/rth2.12494] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 02/07/2021] [Indexed: 02/06/2023] Open
Abstract
Background While the number of individuals with hemophilia who are expected to be or have already been included in gene therapy trials has been regularly reported, the number of unscreened or excluded individuals, in addition to the reasons for exclusion, is mostly not reported. Methods We conducted an eligibility assessment of all people with severe hemophilia for gene therapy trials in one large Belgian hemophilia treatment center based on patient selection criteria of gene therapy trials and patients’ profiling. Results Among 87 adult patients with severe hemophilia A and B, 11 aged ≥65 years and two women were excluded from analysis. Six patients were excluded because of inhibitor development. One patient exhibited active hepatitis C infection, one had insufficient exposure to factor VIII, and five had uncontrolled comorbidities, while two were enrolled in other trials and two abused alcohol. Overall, 43 patients were not screened owing to psychosocial factors. Among 14 patients accepting gene therapy, six had adeno‐associated virus type 5 neutralizing antibodies and one had liver fibrosis. The number of patients who would accept gene therapy in the absence of strict clinical trial requirements was estimated at 36 (41.4%), irrespective of any exclusion criteria. Conclusion The majority of individuals with severe hemophilia could not be enrolled in gene therapy trials, almost half of them because of partly modifiable psychosocial reasons (49.4%). The proportion of candidates should substantially increase in the future, as eligibility criteria are likely to change and as more data on long‐term efficacy and safety of gene therapy will become available.
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Affiliation(s)
- Evelien Krumb
- Hemostasis and Thrombosis Unit Division of Hematology Cliniques Universitaires Saint-Luc Université Catholique de Louvain (UCLouvain) Brussels Belgium
| | - Catherine Lambert
- Hemostasis and Thrombosis Unit Division of Hematology Cliniques Universitaires Saint-Luc Université Catholique de Louvain (UCLouvain) Brussels Belgium
| | - Cedric Hermans
- Hemostasis and Thrombosis Unit Division of Hematology Cliniques Universitaires Saint-Luc Université Catholique de Louvain (UCLouvain) Brussels Belgium
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van Overbeeke E, Hauber B, Michelsen S, Goldman M, Simoens S, Huys I. Patient Preferences to Assess Value IN Gene Therapies: Protocol Development for the PAVING Study in Hemophilia. Front Med (Lausanne) 2021; 8:595797. [PMID: 33768101 PMCID: PMC7985056 DOI: 10.3389/fmed.2021.595797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/15/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction: Gene therapies are innovative therapies that are increasingly being developed. However, health technology assessment (HTA) and payer decision making on these therapies is impeded by uncertainties, especially regarding long-term outcomes. Through measuring patient preferences regarding gene therapies, the importance of unique elements that go beyond health gain can be quantified and inform value assessments. We designed a study, namely the Patient preferences to Assess Value IN Gene therapies (PAVING) study, that can inform HTA and payers by investigating trade-offs that adult Belgian hemophilia A and B patients are willing to make when asked to choose between a standard of care and gene therapy. Methods and Analysis: An eight-step approach was taken to establish the protocol for this study: (1) stated preference method selection, (2) initial attributes identification, (3) stakeholder (HTA and payer) needs identification, (4) patient relevant attributes and information needs identification, (5) level identification and choice task construction, (6) educational tool design, (7) survey integration, and (8) piloting and pretesting. In the end, a threshold technique survey was designed using the attributes “Annual bleeding rate,” “Chance to stop prophylaxis,” “Time that side effects have been studied,” and “Quality of Life.” Ethics and Dissemination: The Medical Ethics Committee of UZ KU Leuven/Research approved the study. Results from the study will be presented to stakeholders and patients at conferences and in peer-reviewed journals. We hope that results from the PAVING study can inform decision makers on the acceptability of uncertainties and the value of gene therapies to patients.
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Affiliation(s)
- Eline van Overbeeke
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Brett Hauber
- Health Preference Assessment, RTI Health Solutions, Durham, NC, United States
| | - Sissel Michelsen
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium.,Healthcare Management Centre, Vlerick Business School, Ghent, Belgium
| | - Michel Goldman
- Institute for Interdisciplinary Innovation in Healthcare, Université Libre de Bruxelles, Brussels, Belgium
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
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Kuijlaars IAR, van Emst M, van der Net J, Timmer MA, Fischer K. Assessing the test-retest reliability and smallest detectable change of the Haemophilia Activities List. Haemophilia 2020; 27:108-112. [PMID: 33314438 PMCID: PMC7898911 DOI: 10.1111/hae.14226] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 12/20/2022]
Abstract
Introduction The Haemophilia Activities List (HAL) is a preferred instrument to measure self‐reported limitations in activities in persons with haemophilia (PWH). Information on reliability and interpretability of HAL scores is lacking. Aim To examine the test‐retest reliability and smallest detectable change (SDC) of the HAL in adult PWH. Methods Fifty adult (≥18 years) persons with mild to severe haemophilia completed the HAL (42 items, 7 domains, optimum 100) at baseline (T0) and 3‐4 weeks later (T1). The intraclass correlation coefficient (ICC) and SDC were calculated for sum and component scores. Results Fifty persons with haemophilia were included (median age 49 years; 92% haemophilia A; 70% severe haemophilia). The median (interquartile ranges) HAL sum score was 77 (62 to 99) at T0 and 81 (64 to 98) at T1. Reliability was good with ICCs for sum and component scores >0.9. The SDC for the sum score was 10.2, for the upper extremity component score 9.2, for the basic lower extremity component score 16.7 and for the complex lower extremity component score 13.4. Conclusion The HAL has a good reliability for the sum and component scores. Score changes of the normalized sum HAL score greater than the SDC 10.2 indicate that the change was not a result of measurement error.
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Affiliation(s)
- Isolde A R Kuijlaars
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Madelon van Emst
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Janjaap van der Net
- Center for Child Development, Exercise and Physical Literacy, Children's Hospital of the University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Merel A Timmer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Woollard L, Gorman R, Rosenfelt DJ. Addressing patient education priorities in the era of gene therapy for haemophilia: Towards evidence-informed shared decision-making. Haemophilia 2020; 27:e302-e304. [PMID: 33245825 DOI: 10.1111/hae.14214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/19/2020] [Accepted: 11/08/2020] [Indexed: 02/05/2023]
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van Overbeeke E, Michelsen S, Hauber B, Peerlinck K, Hermans C, Lambert C, Goldman M, Simoens S, Huys I. Patient perspectives regarding gene therapy in haemophilia: Interviews from the PAVING study. Haemophilia 2020; 27:129-136. [PMID: 33161616 PMCID: PMC7894464 DOI: 10.1111/hae.14190] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 01/19/2023]
Abstract
Introduction Exploring patient perceptions regarding gene therapies may provide insights about their acceptability to patients. Objective To investigate opinions of people with haemophilia (PWH) regarding gene therapies. Moreover, this study aimed to identify patient‐relevant attributes (treatment features) that influence PWH’s treatment choices. Methods Semi‐structured individual interviews were conducted with Belgian PWH, types A and B. A predefined interview guide included information sections and open, attribute ranking and case questions. Qualitative data were organized using NVivo 12 and analysed following framework analysis. Sum totals of scores obtained in the ranking exercise were calculated per attribute. Results In total, 20 PWH participated in the interviews. Most participants demonstrated a positive attitude towards gene therapy and were very willing (40%; n = 8) or willing (35%; n = 7) to receive this treatment. The following five attributes were identified as most important to PWH in making their choice: annual bleeding rate, factor level, uncertainty of long‐term risks, impact on daily life, and probability that prophylaxis can be stopped. While participants were concerned about the uncertainty regarding long‐term safety, most participants were less concerned about uncertainty regarding long‐term efficacy. Conclusions This qualitative study showed that most PWH have a positive attitude towards gene therapy and that besides efficacy, safety and the related uncertainties, also impact on daily life is important to patients. The identified patient‐relevant attributes may be used by regulators, health technology assessment bodies and payers in their evaluation of gene therapies for haemophilia. Moreover, they may inform clinical trial design, pay‐for‐performance schemes and real‐world evidence studies.
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Affiliation(s)
- Eline van Overbeeke
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Sissel Michelsen
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Brett Hauber
- Health Preference Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
| | | | - Cedric Hermans
- Haemophilia Clinic, St-Luc University Hospital, Brussels, Belgium
| | | | - Michel Goldman
- Institute for Interdisciplinary Innovation in healthcare, Université libre de Bruxelles, Brussels, Belgium
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
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Etranacogene dezaparvovec (AMT-061 phase 2b): normal/near normal FIX activity and bleed cessation in hemophilia B. Blood Adv 2020; 3:3241-3247. [PMID: 31698454 DOI: 10.1182/bloodadvances.2019000811] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 09/16/2019] [Indexed: 12/23/2022] Open
Abstract
Etranacogene dezaparvovec (AMT-061) is a recombinant AAV5 vector including a gene cassette containing the factor IX (FIX) Padua variant under the control of a liver-specific promoter. A phase 2b study was conducted to confirm that a single dose of 2 × 1013 genome copies per kilogram of etranacogene dezaparvovec will result in FIX activity ≥5% 6 weeks after dosing. Secondary end points included FIX activity at other time points, bleed frequency, FIX replacement, and safety. Etranacogene dezaparvovec was administered as a single IV infusion to 3 adults with severe to moderately severe hemophilia B. Before treatment, participants had low levels of preexisting neutralizing antibodies to AAV5. This article reports a planned 26-week interim assessment. At week 6, mean FIX activity was 31% (23.9%-37.8%), increasing to 47% (33.2%-57.0%) at 26 weeks, with 2 subjects exhibiting sustained activity >40%. Consistent with the FIX activity, etranacogene dezaparvovec was associated with a complete bleed cessation with no need for FIX replacement therapy up to 26 weeks. Etranacogene dezaparvovec was generally well tolerated. No clinically significant elevations in levels of liver enzymes or inflammatory markers were observed, and no use of corticosteroids related to treatment was required. In individuals with severe to moderately severe hemophilia B, etranacogene dezaparvovec resulted in clinically relevant increases in FIX activity, cessation of bleeds, and abrogation of the need for FIX replacement, despite the presence of preexisting anti-AAV5 neutralizing antibodies detected by using a highly sensitive luciferase assay. Consistency of results in the 3 participants supported an expanded evaluation of the safety/efficacy of etranacogene dezaparvovec in the HOPE-B (Health Outcomes With Padua Gene; Evaluation in Hemophilia-B) phase 3 trial. The current trial was registered at www.clinicaltrials.gov as #NCT03489291.
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33
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Pipe SW. Delivering on the promise of gene therapy for haemophilia. Haemophilia 2020; 27 Suppl 3:114-121. [PMID: 32490590 DOI: 10.1111/hae.14027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
The promise of gene therapy is a single treatment ('one and done') that leads to steady-state expression of endogenous factor VIII or factor IX sufficient to achieve a functional cure (free of recurrent haemophilic bleeding) if not normalized haemostasis. The elimination of the need for continued prophylaxis, or factor replacement following trauma or prior to surgery would lead to annual cost savings. Such optimized health and well-being would be reaching a level of health equity that was unimaginable several decades ago. 'Before anything else, preparation is the key to success'-Alexander Graham Bell. This quote from the famous inventor, scientist and engineer highlights that, although we currently stand on the threshold of this achievement, delivering on this promise will require broad-based multistakeholder preparation (scientists, manufacturers, federal regulators, health technology assessors, persons with haemophilia, national advocacy groups and multidisciplinary healthcare teams) with a focused emphasis on education, approval of safe and effective therapies, removal of barriers to access and excellence in clinical delivery.
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Affiliation(s)
- Steven W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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34
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Butterfield JSS, Hege KM, Herzog RW, Kaczmarek R. A Molecular Revolution in the Treatment of Hemophilia. Mol Ther 2020; 28:997-1015. [PMID: 31843450 PMCID: PMC7132613 DOI: 10.1016/j.ymthe.2019.11.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
For decades, the monogenetic bleeding disorders hemophilia A and B (coagulation factor VIII and IX deficiency) have been treated with systemic protein replacement therapy. Now, diverse molecular medicines, ranging from antibody to gene to RNA therapy, are transforming treatment. Traditional replacement therapy requires twice to thrice weekly intravenous infusions of factor. While extended half-life products may reduce the frequency of injections, patients continue to face a lifelong burden of the therapy, suboptimal protection from bleeding and joint damage, and potential development of neutralizing anti-drug antibodies (inhibitors) that require less efficacious bypassing agents and further reduce quality of life. Novel non-replacement and gene therapies aim to address these remaining issues. A recently approved factor VIII-mimetic antibody accomplishes hemostatic correction in patients both with and without inhibitors. Antibodies against tissue factor pathway inhibitor (TFPI) and antithrombin-specific small interfering RNA (siRNA) target natural anticoagulant pathways to rebalance hemostasis. Adeno-associated virus (AAV) gene therapy provides lasting clotting factor replacement and can also be used to induce immune tolerance. Multiple gene-editing techniques are under clinical or preclinical investigation. Here, we provide a comprehensive overview of these approaches, explain how they differ from standard therapies, and predict how the hemophilia treatment landscape will be reshaped.
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Affiliation(s)
| | - Kerry M Hege
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, USA; Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA.
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland.
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35
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Chen CY, Tran DM, Cavedon A, Cai X, Rajendran R, Lyle MJ, Martini PGV, Miao CH. Treatment of Hemophilia A Using Factor VIII Messenger RNA Lipid Nanoparticles. MOLECULAR THERAPY. NUCLEIC ACIDS 2020; 20:534-544. [PMID: 32330871 PMCID: PMC7178004 DOI: 10.1016/j.omtn.2020.03.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022]
Abstract
Hemophilia A (HemA) patients are currently treated with costly and inconvenient replacement therapy of short-lived factor VIII (FVIII) protein. Development of lipid nanoparticle (LNP)-encapsulated mRNA encoding FVIII can change this paradigm. LNP technology constitutes a biocompatible and scalable system to efficiently package and deliver mRNA to the target site. Mice intravenously infused with the luciferase mRNA LNPs showed luminescence signals predominantly in the liver 4 h after injection. Repeated injections of LNPs did not induce elevation of liver transaminases. We next injected LNPs carrying mRNAs encoding different variants of human FVIII (F8 LNPs) into HemA mice. A single injection of B domain-deleted F8 LNPs using different dosing regimens achieved a wide range of therapeutic activities rapidly, which can be beneficial for various usages in hemophilia treatment. The expression slowly declined yet remained above therapeutic levels up to 5–7 days post-injection. Furthermore, routine repeated injections of F8 LNPs in immunodeficient mice produced consistent expression of FVIII over time. In conclusion, F8 LNP treatment produced rapid and prolonged duration of FVIII expression that could be applied to prophylactic treatment and potentially various other treatment options. Our study showed potential for a safe and effective platform of new mRNA therapies for HemA.
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Affiliation(s)
- Chun-Yu Chen
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | - Xiaohe Cai
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Meghan J Lyle
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Carol H Miao
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
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Miesbach W, Klamroth R. The Patient Experience of Gene Therapy for Hemophilia: Qualitative Interviews with Trial Patients. Patient Prefer Adherence 2020; 14:767-770. [PMID: 32368018 PMCID: PMC7184858 DOI: 10.2147/ppa.s239810] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 03/12/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The phase ½ hemophilia B clinical trial (AMT-060) demonstrated stable endogenous FIX levels after 3.5 years (mean FIX activity between 5.1% and 7.5%) with continued reductions in annualized bleeds to near zero with the higher dose, and a 78-96% reduction by year in exogenous FIX use. OBJECTIVE The views of all the three participants from Germany participating in the AMT-060 study have been investigated about their experiences with conventional and gene therapy and the effects of the forms of therapy on everyday life. PATIENTS/METHODS The patients (aged 33-35 years) performed regular prophylactic replacement with factor IX concentrate prior to the gene therapy, reported 0-7 bleeds in the year prior to the treatment, with Hemophilia Joint Health Scores of 0-8. Following topics have been investigated "dealing with illness", "participation in studies", "perception of conventional therapy", "perception of gene therapy", "significance of participation in gene therapy studies", "therapy of haemophilia after the end of the study". RESULTS All three participants have started to become more active and do more sports. However, they expressed anxiety about not knowing how long the effect would last and they felt that psychological support would be needed if the factor IX level fell back in the future. No patient expressed concern about any long-term potential negative consequences of gene therapy. CONCLUSION Gene therapy has the potential to change the life of patients with haemophilia not only by the reduction of bleeding events but also by the increase of active and sportive activities.
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Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Frankfurt, Germany
- Correspondence: Wolfgang Miesbach Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Frankfurt, GermanyTel +49 69 6301-5051 Email
| | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Klinikum im Friedrichshain, BerlinD - 10249, Germany
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Miesbach W, O'Mahony B, Key NS, Makris M. How to discuss gene therapy for haemophilia? A patient and physician perspective. Haemophilia 2019; 25:545-557. [PMID: 31115117 PMCID: PMC6852207 DOI: 10.1111/hae.13769] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 01/19/2023]
Abstract
Gene therapy has the potential to revolutionise treatment for patients with haemophilia and is close to entering clinical practice. While factor concentrates have improved outcomes, individuals still face a lifetime of injections, pain, progressive joint damage, the potential for inhibitor development and impaired quality of life. Recently published studies in adeno‐associated viral (AAV) vector‐mediated gene therapy have demonstrated improvement in endogenous factor levels over sustained periods, significant reduction in annualised bleed rates, lower exogenous factor usage and thus far a positive safety profile. In making the shared decision to proceed with gene therapy for haemophilia, physicians should make it clear that research is ongoing and that there are remaining evidence gaps, such as long‐term safety profiles and duration of treatment effect. The eligibility criteria for gene therapy trials mean that key patient groups may be excluded, eg children/adolescents, those with liver or kidney dysfunction and those with a prior history of factor inhibitors or pre‐existing neutralising AAV antibodies. Gene therapy offers a life‐changing opportunity for patients to reduce their bleeding risk while also reducing or abrogating the need for exogenous factor administration. Given the expanding evidence base, both physicians and patients will need sources of clear and reliable information to be able to discuss and judge the risks and benefits of treatment.
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Affiliation(s)
- Wolfgang Miesbach
- Department of Haemostaseology and Haemophilia Centre, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Brian O'Mahony
- Chief Executive, Irish Haemophilia Society, Dublin, Ireland.,Trinity College, Dublin, Ireland
| | - Nigel S Key
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Mike Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK.,Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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