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Reyes Ruiz A, Bhale AS, Venkataraman K, Dimitrov JD, Lacroix-Desmazes S. Binding Promiscuity of Therapeutic Factor VIII. Thromb Haemost 2024. [PMID: 38950594 DOI: 10.1055/a-2358-0853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
The binding promiscuity of proteins defines their ability to indiscriminately bind multiple unrelated molecules. Binding promiscuity is implicated, at least in part, in the off-target reactivity, nonspecific biodistribution, immunogenicity, and/or short half-life of potentially efficacious protein drugs, thus affecting their clinical use. In this review, we discuss the current evidence for the binding promiscuity of factor VIII (FVIII), a protein used for the treatment of hemophilia A, which displays poor pharmacokinetics, and elevated immunogenicity. We summarize the different canonical and noncanonical interactions that FVIII may establish in the circulation and that could be responsible for its therapeutic liabilities. We also provide information suggesting that the FVIII light chain, and especially its C1 and C2 domains, could play an important role in the binding promiscuity. We believe that the knowledge accumulated over years of FVIII usage could be exploited for the development of strategies to predict protein binding promiscuity and therefore anticipate drug efficacy and toxicity. This would open a mutational space to reduce the binding promiscuity of emerging protein drugs while conserving their therapeutic potency.
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Affiliation(s)
- Alejandra Reyes Ruiz
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Aishwarya S Bhale
- Centre for Bio-Separation Technology (CBST), Vellore Institute of Technology (VIT), Vellore, Tamil Nadu, India
| | - Krishnan Venkataraman
- Centre for Bio-Separation Technology (CBST), Vellore Institute of Technology (VIT), Vellore, Tamil Nadu, India
| | - Jordan D Dimitrov
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Sébastien Lacroix-Desmazes
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
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Morfini M, Agnelli Giacchiello J, Baldacci E, Carulli C, Castaman G, Giuffrida AC, Malcangi G, Rocino A, Siragusa S, Zanon E. Managing Relevant Clinical Conditions of Hemophilia A/B Patients. Hematol Rep 2023; 15:384-397. [PMID: 37367088 DOI: 10.3390/hematolrep15020039] [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: 02/09/2023] [Revised: 04/21/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023] Open
Abstract
The Medical Directors of nine Italian Hemophilia Centers reviewed and discussed the key issues concerning the replacement therapy of hemophilia patients during a one-day consensus conference held in Rome one year ago. Particular attention was paid to the replacement therapy needed for surgery using continuous infusion (CI) versus bolus injection (BI) of standard and extended half-life Factor VIII (FVIII) concentrates in severe hemophilia A patients. Among the side effects, the risk of development of neutralizing antibodies (inhibitors) and thromboembolic complications was addressed. The specific needs of mild hemophilia A patients were described, as well as the usage of bypassing agents to treat patients with high-responding inhibitors. Young hemophilia A patients may take significant advantages from primary prophylaxis three times or twice weekly, even with standard half-life (SHL) rFVIII concentrates. Patients affected by severe hemophilia B probably have a less severe clinical phenotype than severe hemophilia A patients, and in about 30% of cases may undergo weekly prophylaxis with an rFIX SHL concentrate. The prevalence of missense mutations in 55% of severe hemophilia B patients allows the synthesis of a partially changed FIX molecule that can play some hemostatic role at the level of endothelial cells or the subendothelial matrix. The flow back of infused rFIX from the extravascular to the plasma compartment allows a very long half-life of about 30 h in some hemophilia B patients. Once weekly, prophylaxis can assure a superior quality of life in a large severe or moderate hemophilia B population. According to the Italian registry of surgery, hemophilia B patients undergo joint replacement by arthroplasty less frequently than hemophilia A patients. Finally, the relationships between FVIII/IX genotypes and the pharmacokinetics of clotting factor concentrates have been investigated.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Haemophilia Centers (AICE), 21121 Milan, Italy
| | - Jacopo Agnelli Giacchiello
- Hemostasis and Thrombosis Center, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Erminia Baldacci
- Haematology, "Umberto I" Policlinico, Department of Translational and Precision Medicine, Sapienza University of Rome, 00118 Rome, Italy
| | - Christian Carulli
- Department of Orthopaedic Surgery, Orthopaedic Clinic, University of Florence, 50121 Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, 50121 Florence, Italy
| | | | - Giuseppe Malcangi
- UOSD Centro Emofilia e Trombosi, Azienda Ospedaliero Universitaria Policlinico di Bari, 70121 Bari, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, S.M. di Loreto Nuovo Hospital, 80121 Naples, Italy
| | - Sergio Siragusa
- Department PROMISE, University of Palermo, 90121 Palermo, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35121 Padua, Italy
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3
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Lunghi B, Morfini M, Martinelli N, Branchini A, Linari S, Castaman G, Bernardi F. Modulation of factor VIII pharmacokinetics by genetic components in factor VIII receptors. Haemophilia 2023; 29:479-487. [PMID: 36533781 DOI: 10.1111/hae.14722] [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: 08/11/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Gene variation in receptors for circulating factor VIII (FVIII) is candidate to explain the large inter-patient variability of infused FVIII pharmacokinetics (PK) in haemophilia A (HA). AIM To compare in an Italian HA cohort (n = 26) the influence on FVIII PK of genetic components in four von Willebrand factor (VWF)/FVIII receptors. METHODS Genotypes of low-density lipoprotein receptor (LDLR), asialoglycoprotein receptor minor subunit (ASGR2), family 4 member M (CLEC4M), stabilin2 (STAB2) and ABO blood-group, and VWF:Ag levels were included as independent variables in linear regression analyses of two-compartment model (TCM) - standard half-life (SHL) FVIII PK parameters. RESULTS In the initial FVIII distribution phase, the STAB2 rs4981022 AA, ASGR2 rs2289645 TT and LDLR rs688 TT genotypes may contribute to increase Cmax , and prolong or shorten AlphaHL. In the elimination phase, a shorter BetaHL was associated with the CLEC4M rs868875 GG (beta-coefficient .366, p = .025) and ASGR2 rs2289645 TC (beta-coefficient .456, p = .006) genotypes, which also showed shorter mean residence time (MRT) than TT genotypes (p = .021). The alpha and beta phase effects were independent of ABO and VWF:Ag levels at baseline. The association of the LDLR rs2228671 genotypes with clearance was independent of ABO (beta-coefficient -.363, p = .035) but not of other receptors or VWF:Ag, which may point out multiple and competing interactions. CONCLUSIONS With the limitation of the small number of HA patients, these observations highlight multiple genetic components acting in distinct phases of FVIII PK and contributing to explain FVIII PK variability. This analysis provides candidates for genotype-based, individual tailoring of FVIII substitutive treatment.
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Affiliation(s)
- Barbara Lunghi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Massimo Morfini
- Italian Association of Hemophilia Centers (AICE), Naples, Italy
| | | | - Alessio Branchini
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Silvia Linari
- Center for Bleeding Disorders, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Giancarlo Castaman
- Center for Bleeding Disorders, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
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Elsheikh E, Lavin M, Heck LA, Larkin N, Mullaney B, Doherty D, Kennedy M, Keenan C, Guest T, O'Mahony B, Fazavana J, Fallon PG, Preston RJS, Gormley J, Ryan K, O'Connell NM, Singleton E, Byrne M, McGowan M, Roche S, Doyle M, Crowley MP, O'Shea SI, Reipert BM, Johnsen JM, Pipe SW, Di Paola J, Turecek PL, O'Donnell JS. Heterogeneity in the half-life of factor VIII concentrate in patients with hemophilia A is due to variability in the clearance of endogenous von Willebrand factor. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:1123-1134. [PMID: 36775768 DOI: 10.1016/j.jtha.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Previous studies have reported marked interindividual variation in factor VIII (FVIII) clearance in patients with hemophilia (PWH) and proposed a number of factors that influence this heterogeneity. OBJECTIVES To investigate the importance of the clearance rates of endogenous von Willebrand factor (VWF) compared with those of other FVIII half-life modifiers in adult PWH. METHODS The half-life of recombinant FVIII was determined in a cohort of 61 adult PWH. A range of reported modifiers of FVIII clearance was assessed (including plasma VWF:antigen and VWF propeptide levels; VWF-FVIII binding capacity; ABO blood group; and nonneutralizing anti-FVIII antibodies). The FVIII-binding region of the VWF gene was sequenced. Finally, the effects of variation in FVIII half-life on clinical phenotype were investigated. RESULTS We demonstrated that heterogeneity in the clearance of endogenous plasma VWF is a key determinant of variable FVIII half-life in PWH. Both ABO blood group and age significantly impact FVIII clearance. The effect of ABO blood group on FVIII half-life in PWH is modulated entirely through its effect on the clearance rates of endogenous VWF. In contrast, the age-related effect on FVIII clearance is, at least in part, VWF independent. In contrast to previous studies, no major effects of variation in VWF-FVIII binding affinity on FVIII clearance were observed. Although high-titer immunoglobulin G antibodies (≥1:80) were observed in 26% of PWH, these did not impact FVIII half-life. Importantly, the annual FVIII usage (IU/kg/y) was significantly (p = .0035) increased in patients with an FVIII half-life of <12 hours. CONCLUSION Our data demonstrate that heterogeneity in the half-life of FVIII concentrates in patients with hemophilia A is primarily attributable to variability in the clearance of endogenous VWF.
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Affiliation(s)
- Einas Elsheikh
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Lilian Antunes Heck
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Niamh Larkin
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Brendan Mullaney
- Haemostasis Molecular Diagnostics Laboratory, National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Megan Kennedy
- Discipline of Physiotherapy, Trinity Centre for Health sciences, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Catriona Keenan
- Haemostasis Molecular Diagnostics Laboratory, National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Thomas Guest
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Judicael Fazavana
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Padraic G Fallon
- Inflammation and Immunity Research Group, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Roger J S Preston
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Gormley
- Discipline of Physiotherapy, Trinity Centre for Health sciences, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Kevin Ryan
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | | | - Evelyn Singleton
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mary Byrne
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mark McGowan
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Sheila Roche
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mairead Doyle
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Susan I O'Shea
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | | | - Jill M Johnsen
- Bloodworks Northwest Research Institute, Seattle, Washington, USA; Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge Di Paola
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Peter L Turecek
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland.
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Swystun LL, Lillicrap D. Current Understanding of Inherited Modifiers of FVIII Pharmacokinetic Variation. Pharmgenomics Pers Med 2023; 16:239-252. [PMID: 36998673 PMCID: PMC10046206 DOI: 10.2147/pgpm.s383221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/06/2023] [Indexed: 04/01/2023] Open
Abstract
The inherited bleeding disorder hemophilia A involves the quantitative deficiency of the coagulation cofactor factor VIII (FVIII). Prophylactic treatment of severe hemophilia A patients with FVIII concentrates aims to reduce the frequency of spontaneous joint bleeding and requires personalized tailoring of dosing regimens to account for the substantial inter-individual variability of FVIII pharmacokinetics. The strong reproducibility of FVIII pharmacokinetic (PK) metrics between repeat analyses in the same individual suggests this trait is genetically regulated. While the influence of plasma von Willebrand factor antigen (VWF:Ag) levels, ABO blood group, and patient age on FVIII PK is well established, estimates suggest these factors account for less than 35% of the overall variability in FVIII PK. More recent studies have identified genetic determinants that modify FVIII clearance or half-life including VWF gene variants that impair VWF-FVIII binding resulting in the accelerated clearance of VWF-free FVIII. Additionally, variants in receptors that regulate the clearance of FVIII or the VWF-FVIII complex have been associated with FVIII PK. The characterization of genetic modifiers of FVIII PK will provide mechanistic insight into a subject of clinical significance and support the development of personalized treatment plans for patients with hemophilia A.
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Affiliation(s)
- Laura L Swystun
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, ON, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, ON, Canada
- Correspondence: David Lillicrap, Richardson Laboratory, Queen’s University, 88 Stuart Street, Kingston, Ontario, K7L 3N6, Canada, Tel +1 613 548-1304, Fax +1 613 548-1356, Email
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Correlation Analysis of DNA Methylation in the von Willebrand Factor Promoter Region and the Risk of Unexplained Recurrent Hemophilia: Systematic Review and Meta-Analysis. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3977289. [PMID: 35711531 PMCID: PMC9187466 DOI: 10.1155/2022/3977289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/09/2022] [Indexed: 01/19/2023]
Abstract
This study systematically reviewed the effect of DNA methylation in the promoter region of the coagulation factor vWF gene on the risk of unexplained recurrent hemophilia. PubMed, Medline, Web of Science, and other computers were used to search the database, and the statistical randomized controlled trials of coagulation factor vWF in the risk analysis of unknown recurrent hemophilia were collected. The Cochrane systematic evaluation method was used to evaluate the quality of the included kinds of literature, and Revman5 software was used to sort out and analyze the kinds of literature. Meta-analysis showed that there was a statistical difference between the experimental group and the control group in case fatality rate (OR = 1.76, 95% CI (1.29, 2.39), P=0.0003, I2 = 0%, Z = 3.58), adverse events (OR = 2.38, 95% CI (1.65, 3.45), P < 0.00001, I2 = 0%, Z = 4.60), incidence of joint hemorrhage (OR = 2.52, 95% CI (1.62, 3.91), P < 0.00001, I2 = 0%, Z = 4.12), incidence of subcutaneous stasis (OR = 1.76, 95% CI (1.26, 2.45), P=0.0009, I2 = 5%, Z = 3.33), and hematoma volume (OR = 1.78, 95% CI (1.32, 2.40), P=0.0001, I2 = 23%, Z = 3.80). DNA methylation in the promoter region of the coagulation factor vWF gene was significantly associated with the risk of unexplained recurrent hemophilia. Whether demethylation can improve the bleeding index of patients with recurrent hemophilia remains to be further explored.
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Combination of CLEC4M rs868875 G-Carriership and ABO O Genotypes May Predict Faster Decay of FVIII Infused in Hemophilia A Patients. J Clin Med 2022; 11:jcm11030733. [PMID: 35160186 PMCID: PMC8837058 DOI: 10.3390/jcm11030733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/21/2022] [Accepted: 01/27/2022] [Indexed: 11/26/2022] Open
Abstract
The C-type lectin CLEC4M binds and internalizes factor VIII (FVIII). Common CLEC4M variants have been associated with FVIII pharmacokinetic (PK) profiles in hemophilia A (HA) patients. The two-compartment PK analysis of plasma-derived (pd-) and full length recombinant FVIII concentrates was conducted in twenty-six patients (FVIII:C ≤ 2 IU/dL). F8, ABO blood-groups, and the CLEC4M rs868875A/G polymorphism were genotyped. CLEC4M genotype groups differed for the elimination rate constant K 1-0 (p < 0.001), half-life (K 1-0 HL), and the Beta rate constant. Patients treated with pd-FVIII also differed in the Alpha phase. In linear regression models, the contribution of the CLEC4M genotypes to FVIII PK parameters remained significant after correction for ABO, age, and VWF antigen levels at PK. Combined CLEC4M rs868875A/G and ABO genotypes displayed significant interaction (K 1-0, p = 0.014). Compared to other combined genotypes, the G-carriers/O genotypes showed half-reduced K 1-0 HL (p = 0.008), and faster FVIII clearance (mean 7.1 ± 2.2 mL/h/kg SE) than in the G-carriers/non-O (mean 2.4 ± 0.3 mL/h/kg SE), (p = 0.038). Comparison in HA patients recruited in several countries suggests that CLEC4M genotypes coherently influence infused FVIII half-life and clearance. Our analysis supports substantially faster FVIII decay associated with the rs868875 G-carrier/ABO O genotypes, which has potential implications for genetically tailored substitutive HA treatment.
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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: 20] [Impact Index Per Article: 6.7] [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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Lunghi B, Morfini M, Martinelli N, Balestra D, Linari S, Frusconi S, Branchini A, Cervellera CF, Marchetti G, Castaman G, Bernardi F. The Asialoglycoprotein Receptor Minor Subunit Gene Contributes to Pharmacokinetics of Factor VIII Concentrates in Hemophilia A. Thromb Haemost 2021; 122:715-725. [PMID: 34407556 DOI: 10.1055/a-1591-7869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The asialoglycoprotein receptor (ASGPR) binds with high affinity factor VIII (FVIII) through its N-linked oligosaccharides. However, its contribution to the wide inter-individual variation of infused FVIII pharmacokinetics (PK) in hemophilia A (HA) is unknown. OBJECTIVE To investigate the variability in FVIII PK outcomes in relation to genetic variation in the ASGR2, encoding the ASGPR2 subunit. METHODS Thirty-two HA patients with FVIII:C ≤2 IU/dL underwent 66 single-dose FVIII PK studies. PK parameters were evaluated in relation to ASGR2 5' untranslated region (5'UTR) polymorphisms, which were investigated by recombinant and white blood cell reverse transcription-polymerase chain reaction approaches. RESULTS The 5'UTR polymorphisms determine a frequent and conserved haplotype (HT1) in a regulatory region. The HT1 homozygotes may differ in the amounts of alternatively spliced mRNA transcripts and thus ASGPR2 isoforms. Compared with the other ASGR2 genotypes, the c.-95TT homozygotes (n = 9), showed threefold longer Alpha HL (3.60 hours, 95% confidence interval: 1.44-5.76, p = 0.006), and the c.-95TC heterozygotes (n = 17) showed 25% shorter mean residence time (MRT; 18.5 hours, 15.0-22.0, p = 0.038) and 32% shorter Beta HL (13.5 hours, 10.9-16.0, p = 0.016). These differences were confirmed in patients (n = 27) undergoing PK studies (n = 54) with full-length FVIII only. In different linear regression models, the contribution of the ASGR2 genotypes remained significant after adjustment by ABO genotypes and von Willebrand factor (VWF) antigen levels, and explained 14% (MRT), 15 to 18% (Beta HL), and 22% (Alpha HL) of parameter variability. CONCLUSIONS Infused FVIII distribution was modulated by frequent ASGR2 genotypes, independently from and together with ABO and VWF antigen levels, which has potential implications for genetically tailored substitutive treatment in HA.
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Affiliation(s)
- Barbara Lunghi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Massimo Morfini
- Italian Association Hemophilia Centers (AICE), Naples, Italy
| | | | - Dario Balestra
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - Silvia Linari
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
| | - Sabrina Frusconi
- Genetic Diagnostics Unit, Laboratory Department, Careggi University Hospital, Florence, Italy
| | - Alessio Branchini
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | | | - Giovanna Marchetti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
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Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
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Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
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