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Li Z, Sun J, Li Z, Chen Z, Liu G, Yao W, Cheng X, Li G, Zhen Y, Ai D, Zhou Y, Mao Q, Poon M, Wu R. Low-dose immune tolerance induction for severe hemophilia A inhibitor patients: Immunosuppressants are generally not necessary for inhibitor-titer below 200 BU/mL. Pediatr Investig 2024; 8:91-100. [PMID: 38910855 PMCID: PMC11193377 DOI: 10.1002/ped4.12429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/24/2024] [Indexed: 06/25/2024] Open
Abstract
Importance It remained unclear that the efficacy comparison between low-dose immune tolerance induction (LD-ITI) incorporating immunosuppressants (IS) when severe hemophilia A (SHA) patients had inhibitor-titer ≥200 Bethesda Units (BU)/mL (LD-ITI-IS200 regimen) and LD-ITI combining with IS when SHA patients had inhibitor-titer ≥40 BU/mL (LD-ITI-IS40 regimen). Objective To compare the efficacy of the LD-ITI-IS200 regimen with that of the LD-ITI-IS40 regimen for SHA patients with high-titer inhibitors. Methods A prospective cohort study on patients receiving LD-ITI-IS200 compared to those receiving LD-ITI-IS40 from January 2021 to December 2023. Both received LD-ITI [FVIII 50 IU/kg every other day]. IS (rituximab + prednisone) was added when peak inhibitor tier ≥200 BU/mL in the LD-ITI-IS200 regimen and ≥40 BU/mL in the LD-ITI-IS40 regimen. Success is defined as a negative inhibitor plus FVIII recovery ≥66% of the expected. Results We enrolled 30 patients on LD-ITI-IS200 and 64 patients on LD-ITI-IS40, with similar baseline clinical characteristics. A lower IS-use rate was discovered in the LD-ITI-IS200 regimen compared to the LD-ITI-IS40 regimen (30.0% vs. 62.5%). The two regimens (LD-ITI-IS200 vs. LD-ITI-IS40) had similar success rate (70.0% vs. 79.7%), median time to success (9.4 vs. 10.6 months), and annualized bleeding rate during ITI (3.7 vs. 2.8). The cost to success was lower for LD-ITI-IS200 than for LD-ITI-IS40 (2107 vs. 3256 US Dollar/kg). Among patients with peak inhibitor-titer 40-199 BU/mL, 10 non-IS-using (on LD-ITI-IS200 regimen) and 28 IS-using (on LD-ITI-IS40 regimen) had similar success rates (70.0% vs. 78.6%) and time to success (9.0 vs. 8.8 months). Interpretation In LD-ITI, IS are not necessary for inhibitor titer <200 BU/mL.
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Affiliation(s)
- Zhengping Li
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Jie Sun
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Zekun Li
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Zhenping Chen
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Guoqing Liu
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Xiaoling Cheng
- Department of PharmacyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Gang Li
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Di Ai
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yaohan Zhou
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Qianqian Mao
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Hematologic Disease LaboratoryHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Man‐Chiu Poon
- Departments of MedicinePediatrics and OncologyUniversity of Calgary Cumming School of MedicineCalgaryCanada
| | - Runhui Wu
- Hemophilia Comprehensive Care CenterHematology Department, Hematology CenterBeijing Key Laboratory of Pediatric Hematology‐OncologyKey Laboratory of Major Diseases in ChildrenNational Key Discipline of Pediatrics (Capital Medical University)Ministry of EducationBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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Arruda VR, Lillicrap D, Herzog RW. Immune complications and their management in inherited and acquired bleeding disorders. Blood 2022; 140:1075-1085. [PMID: 35793465 PMCID: PMC9461471 DOI: 10.1182/blood.2022016530] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/23/2022] [Indexed: 02/06/2023] Open
Abstract
Disorders of coagulation, resulting in serious risks for bleeding, may be caused by autoantibody formation or by mutations in genes encoding coagulation factors. In the latter case, antidrug antibodies (ADAs) may form against the clotting factor protein drugs used in replacement therapy, as is well documented in the treatment of the X-linked disease hemophilia. Such neutralizing antibodies against factors VIII or IX substantially complicate treatment. Autoantibody formation against factor VIII leads to acquired hemophilia. Although rare, antibody formation may occur in the treatment of other clotting factor deficiencies (eg, against von Willebrand factor [VWF]). The main strategies that have emerged to address these immune responses include (1) clinical immune tolerance induction (ITI) protocols; (2) immune suppression therapies (ISTs); and (3) the development of drugs that can improve hemostasis while bypassing the antibodies against coagulation factors altogether (some of these nonfactor therapies/NFTs are antibody-based, but they are distinct from traditional immunotherapy as they do not target the immune system). Choice of immune or alternative therapy and criteria for selection of a specific regimen for inherited and autoimmune bleeding disorders are explained. ITI serves as an important proof of principle that antigen-specific immune tolerance can be achieved in humans through repeated antigen administration, even in the absence of immune suppression. Finally, novel immunotherapy approaches that are still in the preclinical phase, such as cellular (for instance, regulatory T cell [Treg]) immunotherapies, gene therapy, and oral antigen administration, are discussed.
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Affiliation(s)
- Valder R Arruda
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics at The Children's Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada; and
| | - Roland W Herzog
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Pipe SW, Gonen-Yaacovi G, Segurado OG. Hemophilia A Gene Therapy: Current and Next-Generation Approaches. Expert Opin Biol Ther 2021; 22:1099-1115. [PMID: 34781798 DOI: 10.1080/14712598.2022.2002842] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION : Hemophilia comprises a group of X-linked hemorrhagic disorders that result from a deficiency of coagulation factors. The disorder affects mainly males and leads to chronic pain, joint deformity, reduced mobility, and increased mortality. Current therapies require frequent administration of replacement clotting factors, but the emergence of alloantibodies (inhibitors) diminishes their efficacy. New therapies are being developed to produce the deficient clotting factors and prevent the emergence of inhibitors. AREAS COVERED : This article provides an update on the characteristics and disease pathophysiology of hemophilia A, as well as current treatments, with a special focus on ongoing clinical trials related to gene replacement therapies. EXPERT OPINION : Gene replacement therapies provide safe, durable, and stable transgene expression while avoiding the challenges of clotting factor replacement therapies in patients with hemophilia. Improving the specificity of the viral construct and decreasing the therapeutic dose are critical toward minimizing cellular stress, induction of the unfolded protein response, and the resulting loss of protein production in liver cells. Next-generation gene therapies incorporating chimeric DNA sequences in the transgene can increase clotting factor synthesis and secretion, and advance the efficacy, safety, and durability of gene replacement therapy for hemophilia A as well as other blood clotting disorders.
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Scott DW. Driving CARs to BARs: The Winding Road to Specific Regulatory T Cells for Tolerance. Front Immunol 2021; 12:742719. [PMID: 34552599 PMCID: PMC8450509 DOI: 10.3389/fimmu.2021.742719] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/16/2021] [Indexed: 02/05/2023] Open
Abstract
Chimeric antigen receptor (CAR) transduced T cells have significantly improved cancer immunotherapy. Similarly, engineering regulatory T cells (Treg) with specific receptors to endow specificity and increase efficacy of Tregs holds great promise for therapy of a variety of adverse immune responses. In this review, we focus on our approaches using retroviral transduction of specific T-cell receptors, single chain variable fragments (scFv) or antigen in models of monogenic diseases, autoimmunity and allergy. The advantages of each of these for different targets diseases are discussed as well as their potential for clinical translation.
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Affiliation(s)
- David W Scott
- Department of Medicine (MED), Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Cadé M, Muñoz-Garcia J, Babuty A, Fouassier M, Heymann MF, Monahan PE, Heymann D. FVIII at the crossroad of coagulation, bone and immune biology: Emerging evidence of biological activities beyond hemostasis. Drug Discov Today 2021; 27:102-116. [PMID: 34311113 DOI: 10.1016/j.drudis.2021.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022]
Abstract
Hemophilia A is an X-linked hereditary disorder that results from deficient coagulation factor VIII (FVIII) activity, leading to spontaneous bleeding episodes, particularly in joints and muscles. FVIII deficiency has been associated with altered bone remodeling, dysregulated macrophage polarization, and inflammatory processes that are associated with the neoformation of abnormal blood vessels. Treatment based on FVIII replacement can lead to the development of inhibitors that render FVIII concentrate infusion ineffective. In this context, hemophilia has entered a new therapeutic era with the development of new drugs, such as emicizumab, that seek to restore the hemostatic balance by bypassing pathologically acquired antibodies. We discuss the potential extrahemostatic functions of FVIII that may be crucial for defining future therapies in hemophilia.
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Affiliation(s)
- Marie Cadé
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Javier Muñoz-Garcia
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Antoine Babuty
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France; Department of Haemostasis, CHU de Nantes, France
| | | | - Marie-Francoise Heymann
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Paul E Monahan
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Dominique Heymann
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France; University of Sheffield, Department of Oncology and Metabolism, Sheffield, UK.
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Trezise S, Nutt SL. The gene regulatory network controlling plasma cell function. Immunol Rev 2021; 303:23-34. [PMID: 34109653 DOI: 10.1111/imr.12988] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 12/16/2022]
Abstract
Antibodies are an essential element of the immune response to infection, and in long-term protection upon re-exposure to the same micro-organism. Antibodies are produced by plasmablasts and plasma cells, the terminally differentiated cells of the B lymphocyte lineage. These relatively rare populations, collectively termed antibody secreting cells (ASCs), have developed highly specialized transcriptional and metabolic pathways to facilitate their extraordinarily high rates of antibody synthesis and secretion. In this review, we discuss the gene regulatory network that controls ASC identity and function, with a particular focus on the processes that influence the transcription, translation, folding, modification and secretion of antibodies. We will address how ASCs have adapted their transcriptional, metabolic and protein homeostasis pathways to sustain such high rates of antibody production, and the roles that the major ASC regulators, the transcription factors, Irf4, Blimp-1 and Xbp1, play in co-ordinating these processes.
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Affiliation(s)
- Stephanie Trezise
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Stephen L Nutt
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
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