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Song X, Liu J, Chen T, Zheng T, Wang X, Guo X. Gene therapy and gene editing strategies in inherited blood disorders. J Genet Genomics 2024:S1673-8527(24)00180-2. [PMID: 38986807 DOI: 10.1016/j.jgg.2024.07.004] [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: 04/30/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
Gene therapy has shown significant potential in treating various diseases, particularly inherited blood disorders such as hemophilia, sickle cell disease, and thalassemia. Advances in understanding the regulatory network of disease-associated genes have led to the identification of additional therapeutic targets for treatment, especially for β-hemoglobinopathies. Erythroid regulatory factor BCL11A offers the most promising therapeutic target for β-hemoglobinopathies and reduction of its expression using the commercialized gene therapy product Casgevy was approved for use in the UK and USA in 2023. Notably, the emergence of innovative gene editing technologies has further broadened the gene therapy landscape, presenting new possibilities for treatment. Intensive studies indicate that base editing and prime editing, built upon CRISPR technology, enable precise single-base modification in hematopoietic stem cells for addressing inherited blood disorders ex vivo and in vivo. In this review, we present an overview of the current landscape of gene therapies, focusing on clinical research and gene therapy products for inherited blood disorders, evaluation of potential gene targets, and the gene editing tools employed in current gene therapy practices, which provides an insight for the establishment of safer and more effective gene therapy methods for a wider range of diseases in the future.
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Affiliation(s)
- Xuemei Song
- Institute of Blood Diseases, Department of Hematology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine of University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China
| | - JinLei Liu
- Institute of Blood Diseases, Department of Hematology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine of University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China
| | - Tangcong Chen
- Institute of Blood Diseases, Department of Hematology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine of University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China
| | - Tingfeng Zheng
- Institute of Blood Diseases, Department of Hematology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine of University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China
| | - Xiaolong Wang
- Institute of Blood Diseases, Department of Hematology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine of University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China
| | - Xiang Guo
- Institute of Blood Diseases, Department of Hematology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Medicine of University of Electronic Science and Technology of China, Chengdu, Sichuan 610000, China.
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Barak M, Hu C, Matthews A, Fortenberry YM. Current and Future Therapeutics for Treating Patients with Sickle Cell Disease. Cells 2024; 13:848. [PMID: 38786070 PMCID: PMC11120250 DOI: 10.3390/cells13100848] [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: 03/22/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Sickle cell disease (SCD) is the most common genetic blood disorder in the United States, with over 100,000 people suffering from this debilitating disease. SCD is caused by abnormal hemoglobin (Hb) variants that interfere with normal red blood cell (RBC) function. Research on SCD has led to the development and approval of several new SCD therapies in recent years. The recent FDA-approved novel gene therapies are potentially curative, giving patients an additional option besides a hematopoietic bone marrow transplant. Despite the promise of existing therapies, questions remain regarding their long-term pharmacological effects on adults and children. These questions, along with the exorbitant cost of the new gene therapies, justify additional research into more effective therapeutic options. Continual research in this field focuses on not only developing cheaper, more effective cures/treatments but also investigating the physiological effects of the current therapies on SCD patients, particularly on the brain and kidneys. In this article, we undertake a comprehensive review of ongoing clinical trials with completion dates in 2024 or later. Our exploration provides insights into the landscape of current therapeutics and emerging novel therapies designed to combat and potentially eradicate SCD, including the latest FDA-approved gene therapies.
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Affiliation(s)
| | | | | | - Yolanda M. Fortenberry
- Biology Department, Case Western Reserve University, Cleveland, OH 44106, USA; (M.B.); (C.H.); (A.M.)
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Jacobberger JW, Woost PG. A pharmacodynamic assay to monitor treatment with the hypomethylating cytosine analogs, decitabine and azacitidine. Methods Cell Biol 2024; 186:131-150. [PMID: 38705597 DOI: 10.1016/bs.mcb.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Hypomethylating therapies using decitabine or azacitidine are actively investigated to treat acute myeloid leukemia, myelodysplastic syndromes, as maintenance therapy after allogenic stem cell transplant and hemoglobinopathies. The therapeutic mechanism is to de-repress genes that have been turned off through oncogenesis or development via methylation. The therapy can be non-cytotoxic at low dosage, sparing healthy stem cells and operating on committed precursors. Because the methods of determining maximum tolerated dose are not well suited to this paradigm, and because the mechanism of action, which is depletion of DNA methylase 1 (DNMT1), is complex and dependent on passing through a cell cycle, a pharmacodynamic assay that measures DNMT1 can inform clinical trials aimed at establishing and improving therapy. Herein, we provide an assay that measures DNMT1 relative levels in circulating T cells of peripheral blood.
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Affiliation(s)
| | - Philip G Woost
- Cleveland Cytometry Services Co., Novelty, OH, United States
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Lugthart S, Ginete C, Kuona P, Brito M, Inusa BPD. An update review of new therapies in sickle cell disease: the prospects for drug combinations. Expert Opin Pharmacother 2024; 25:157-170. [PMID: 38344818 DOI: 10.1080/14656566.2024.2317336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Sickle cell disease (SCD) is an inherited disorder characterised by polymerisation of deoxygenated haemoglobin S and microvascular obstruction. The cardinal feature is generalised pain referred to as vaso-occlusive crises (VOC), multi-organ damage and premature death. SCD is the most prevalent inherited life-threatening disorders in the world and over 85% of world's 400,000 annual births occur low-and-middle-income countries. Hydroxyurea remained the only approved disease modifying therapy (1998) until the FDA approved L-glutamine (2017), Crizanlizumab and Voxelotor (2019) and gene therapies (Exa-cel and Lovo-cel, 2023). AREAS COVERED Clinical trials performed in the last 10 years (November 2013 - November 2023) were selected for the review. They were divided according to the mechanisms of drug action. The following pubmed central search terms [sickle cell disease] or [sickle cell anaemia] Hydroxycarbamide/ Hydroxyurea, L-Glutamine, Voxelotor, Crizanlizumab, Mitapivat, Etavopivat, gene therapy, haematopoietic stem cell transplantation, and combination therapy. EXPERT OPINION We recommend future trials of combination therapies for specific complications such as VOCs, chronic pain and renal impairment as well as personalised medicine approach based on phenotype and patient characteristics. Following recent approval of gene therapy for SCD, the challenge is addressing the role of shared decision-making with families, global access and affordability.
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Affiliation(s)
- Sanne Lugthart
- Haematology department, University Hospitals of Bristol and Weston Foundation Trust, Bristol, UK
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Catarina Ginete
- Health and Technology Research Center, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
| | - Patience Kuona
- Child, Adolescent and Women's Health Department, University of Zimbabwe Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Miguel Brito
- Health and Technology Research Center, Escola Superior de Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa, Portugal
| | - Baba Psalm Duniya Inusa
- Paediatric Haematology, Evelina London, Guy's and St Thomas NHS Foundation Trust, London
- Women's and Children Academic health, Life Sciences and Medicine, King's College London, London
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Woost PG, William BM, Cooper BW, Ueda Oshima M, Otegbeye F, De Lima MJ, Wald D, Mahfouz RZ, Saunthararajah Y, Stefan T, Jacobberger JW. Flow cytometry of DNMT1 as a biomarker of hypomethylating therapies. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2024; 106:11-24. [PMID: 38345160 PMCID: PMC11000818 DOI: 10.1002/cyto.b.22158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024]
Abstract
The 5-azacytidine (AZA) and decitabine (DEC) are noncytotoxic, differentiation-inducing therapies approved for treatment of myelodysplastic syndrome, acute myeloid leukemias (AML), and under evaluation as maintenance therapy for AML postallogeneic hematopoietic stem cell transplant and to treat hemoglobinapathies. Malignant cell cytoreduction is thought to occur by S-phase specific depletion of the key epigenetic regulator, DNA methyltransferase 1 (DNMT1) that, in the case of cancers, thereby releases terminal-differentiation programs. DNMT1-targeting can also elevate expression of immune function genes (HLA-DR, MICA, MICB) to stimulate graft versus leukemia effects. In vivo, there is a large inter-individual variability in DEC and 5-AZA activity because of pharmacogenetic factors, and an assay to quantify the molecular pharmacodynamic effect of DNMT1-depletion is a logical step toward individualized or personalized therapy. We developed and analytically validated a flow cytometric assay for DNMT1 epitope levels in blood and bone marrow cell subpopulations defined by immunophenotype and cell cycle state. Wild type (WT) and DNMT1 knock out (DKO) HC116 cells were used to select and optimize a highly specific DNMT1 monoclonal antibody. Methodologic validation of the assay consisted of cytometry and matching immunoblots of HC116-WT and -DKO cells and peripheral blood mononuclear cells; flow cytometry of H116-WT treated with DEC, and patient samples before and after treatment with 5-AZA. Analysis of patient samples demonstrated assay reproducibility, variation in patient DNMT1 levels prior to treatment, and DNMT1 depletion posttherapy. A flow-cytometry assay has been developed that in the research setting of clinical trials can inform studies of DEC or 5-AZA treatment to achieve targeted molecular pharmacodynamic effects and better understand treatment-resistance/failure.
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Affiliation(s)
- Philip G Woost
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Basem M William
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Medicine, Division of Hematology, and Oncology and Stem Cell Transplant Program, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Brenda W Cooper
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Medicine, Division of Hematology, and Oncology and Stem Cell Transplant Program, Case Western Reserve University, Cleveland, Ohio, USA
| | - Masumi Ueda Oshima
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Medicine, Division of Hematology, and Oncology and Stem Cell Transplant Program, Case Western Reserve University, Cleveland, Ohio, USA
| | - Folashade Otegbeye
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Medicine, Division of Hematology, and Oncology and Stem Cell Transplant Program, Case Western Reserve University, Cleveland, Ohio, USA
| | - Marcos J De Lima
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Medicine, Division of Hematology, and Oncology and Stem Cell Transplant Program, Case Western Reserve University, Cleveland, Ohio, USA
| | - David Wald
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Reda Z Mahfouz
- Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yogen Saunthararajah
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
- Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tammy Stefan
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - James W Jacobberger
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
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Ibanez V, Vaitkus K, Ruiz MA, Lei Z, Maienschein-Cline M, Arbieva Z, Lavelle D. Effect of the LSD1 inhibitor RN-1 on γ-globin and global gene expression during erythroid differentiation in baboons (Papio anubis). PLoS One 2023; 18:e0289860. [PMID: 38134183 PMCID: PMC10745162 DOI: 10.1371/journal.pone.0289860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Elevated levels of Fetal Hemoglobin interfere with polymerization of sickle hemoglobin thereby reducing anemia, lessening the severity of symptoms, and increasing life span of patients with sickle cell disease. An affordable, small molecule drug that stimulates HbF expression in vivo would be ideally suited to treat the large numbers of SCD patients that exist worldwide. Our previous work showed that administration of the LSD1 (KDM1A) inhibitor RN-1 to normal baboons increased Fetal Hemoglobin (HbF) and was tolerated over a prolonged treatment period. HbF elevations were associated with changes in epigenetic modifications that included increased levels of H3K4 di-and tri-methyl lysine at the γ-globin promoter. While dramatic effects of the loss of LSD1 on hematopoietic differentiation have been observed in murine LSD1 gene deletion and silencing models, the effect of pharmacological inhibition of LSD1 in vivo on hematopoietic differentiation is unknown. The goal of these experiments was to investigate the in vivo mechanism of action of the LSD1 inhibitor RN-1 by determining its effect on γ-globin expression in highly purified subpopulations of bone marrow erythroid cells enriched for varying stages of erythroid differentiation isolated directly from baboons treated with RN-1 and also by investigating the effect of RN1 on the global transcriptome in a highly purified population of proerythroblasts. Our results show that RN-1 administered to baboons targets an early event during erythroid differentiation responsible for γ-globin repression and increases the expression of a limited number of genes including genes involved in erythroid differentiation such as GATA2, GFi-1B, and LYN.
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Affiliation(s)
- Vinzon Ibanez
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Kestis Vaitkus
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Maria Armila Ruiz
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Zhengdeng Lei
- Research Informatics Core, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Ambry Genetics, Aliso Viejo, California, United States of America
| | - Mark Maienschein-Cline
- Research Informatics Core, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Zarema Arbieva
- Genomics Research Core, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Donald Lavelle
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
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Jacob SA, Talati R, Kanter J. The evolving treatment landscape for children with sickle cell disease. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:797-808. [PMID: 37858508 DOI: 10.1016/s2352-4642(23)00201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 10/21/2023]
Abstract
Sickle cell disease is the most common inherited pathological haemoglobinopathy. Over the past 30 years, disease-related morbidity and mortality have improved in high-income countries due to advances in preventive care and treatments. Established disease-modifying therapies, such as hydroxyurea (hydrocarbamide), are continuing to have an important role in the treatment of sickle cell disease, and newer agents also show promise. In the past 5 years, the US Food and Drug Administration approved three additional sickle cell disease-modifying medications, and new gene therapies have been developed as an alternative curative treatment to haematopoietic stem-cell transplantation. In this Review, we discuss the current treatment landscape for paediatric sickle cell disease and emerging innovations in care. We also review the need for close, long-term management for children receiving newer therapies and the importance of ongoing investment in people with sickle cell disease in low-income and middle-income countries.
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Affiliation(s)
- Seethal A Jacob
- Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Ravi Talati
- Division of Pediatric Hematology, Oncology & Blood/Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Julie Kanter
- Lifespan Comprehensive Sickle Cell Center, University of Alabama, Birmingham, AL, USA.
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Säll C, Koncsos G, Klukovits A. In Vitro Interaction of Tetrahydrouridine with Key Human Nucleoside Transporters. J Pharm Sci 2023; 112:2676-2684. [PMID: 37364771 DOI: 10.1016/j.xphs.2023.06.012] [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: 03/03/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 06/28/2023]
Abstract
NDec is a novel combination of oral decitabine and tetrahydrouridine that is currently under clinical development for the treatment of sickle cell disease (SCD). Here, we investigate the potential for the tetrahydrouridine component of NDec to act as an inhibitor or substrate of key concentrative nucleoside transporters (CNT1-3) and equilibrative nucleoside transporters (ENT1-2). Nucleoside transporter inhibition and tetrahydrouridine accumulation assays were performed using Madin-Darby canine kidney strain II (MDCKII) cells overexpressing human CNT1, CNT2, CNT3, ENT1, and ENT2 transporters. Results showed that tetrahydrouridine did not influence CNT- or ENT-mediated uridine/adenosine accumulation in MDCKII cells at the concentrations tested (25 and 250 µM). Accumulation of tetrahydrouridine in MDCKII cells was initially shown to be mediated by CNT3 and ENT2. However, while time- and concentration-dependence experiments showed active accumulation of tetrahydrouridine in CNT3-expressing cells, allowing for estimation of Km (3,140 µM) and Vmax (1,600 pmol/mg protein/min), accumulation of tetrahydrouridine was not observed in ENT2-expressing cells. Potent CNT3 inhibitors are a class of drugs not generally prescribed to patients with SCD, except in certain specific circumstances. These data suggest that NDec can be administered safely with drugs that act as substrates and inhibitors of the nucleoside transporters included in this study.
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Affiliation(s)
| | - Gábor Koncsos
- SOLVO Biotechnology a Charles River Company, Budapest, Hungary
| | - Anna Klukovits
- SOLVO Biotechnology a Charles River Company, Budapest, Hungary
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Lau H, Woost PG, Friedrich U, Ong Clausen WH, Jacobberger JW, Saunthararajah Y. Pharmacokinetics and pharmacodynamics of an oral formulation of decitabine and tetrahydrouridine. Eur J Haematol 2023; 111:345-355. [PMID: 37417197 PMCID: PMC10524919 DOI: 10.1111/ejh.14009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is caused by an inherited structural abnormality of adult hemoglobin causing polymerization. Fetal hemoglobin interferes with polymerization but is epigenetically silenced by DNA methyltransferase 1 (DNMT1) in adult erythropoiesis. Decitabine depletes DNMT1 and increases fetal and total hemoglobin in SCD patients, but is rapidly catabolized by cytidine deaminase (CDA) in vivo. Tetrahydrouridine (THU) inhibits CDA, safeguarding decitabine. METHODS The pharmacokinetics and pharmacodynamics of three oral combination formulations of THU and decitabine, with different coatings producing different delays in decitabine release, were investigated in healthy participants. RESULTS Tetrahydrouridine and decitabine were rapidly absorbed into the systemic circulation after a single combination oral dose, with relative bioavailability of decitabine ≥74% in fasted males compared with separate oral administration of THU followed by decitabine 1 h later. THU and decitabine Cmax and area under the plasma concentration versus time curve were higher in females versus males, and fasted versus fed states. Despite sex and food effect on pharmacokinetics, the pharmacodynamic effect of DNMT1 downregulation was comparable in males and females and fasted and fed states. Treatments were well tolerated. CONCLUSION Combination oral formulations of THU with decitabine produced pharmacokinetics and pharmacodynamics suitable for oral DNMT1-targeted therapy.
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Affiliation(s)
| | - Philip G. Woost
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
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10
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Ibanez V, Vaitkus K, Zhang X, Ramasamy J, Rivers AE, Saunthararajah Y, Molokie R, Lavelle D. Combinatorial targeting of epigenome-modifying enzymes with decitabine and RN-1 synergistically increases HbF. Blood Adv 2023; 7:3891-3902. [PMID: 36884303 PMCID: PMC10405201 DOI: 10.1182/bloodadvances.2022009558] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023] Open
Abstract
Increased fetal hemoglobin (HbF) levels reduce the symptoms of sickle cell disease (SCD) and increase the lifespan of patients. Because curative strategies for bone marrow transplantation and gene therapy technologies remain unavailable to a large number of patients, the development of a safe and effective pharmacological therapy that increases HbF offers the greatest potential for disease intervention. Although hydroxyurea increases HbF, a substantial proportion of patients fail to demonstrate an adequate response. Pharmacological inhibitors of DNA methyltransferase (DNMT1) and lysine-specific demethylase 1A (LSD1), 2 epigenome-modifying enzymes associated with the multiprotein corepressor complex recruited to the repressed γ-globin gene, are powerful in vivo inducers of HbF. The hematological side effects of these inhibitors limit feasible clinical exposures. We evaluated whether administering these drugs in combination could reduce the dose and/or time of exposure to any single agent to minimize adverse effects, while achieving additive or synergistic increases in HbF. The DNMT1 inhibitor decitabine (0.5 mg/kg per day) and the LSD1 inhibitor RN-1 (0.25 mg/kg per day) administered in combination 2 days per week produced synergistic increases in F-cells, F-reticulocytes, and γ-globin messenger RNA in healthy baboons. Large increases in HbF and F-cells were observed in healthy, nonanemic, and anemic (phlebotomized) baboons. Combinatorial therapy targeting epigenome-modifying enzymes could thus be a useful strategy for producing larger increases in HbF to modify the clinical course of SCD.
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Affiliation(s)
- Vinzon Ibanez
- Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL
| | - Kestis Vaitkus
- Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL
| | - Xu Zhang
- Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jagadeesh Ramasamy
- Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Angela E. Rivers
- Department of Pediatrics, School of Medicine, University of California at San Francisco Benioff Children’s Hospital Oakland, Oakland, CA
| | - Yogen Saunthararajah
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Robert Molokie
- Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL
- Department of Pharmaceutical Science, University of Illinois at Chicago, Chicago, IL
| | - Donald Lavelle
- Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
- Research and Development, Jesse Brown VA Medical Center, Chicago, IL
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Piel FB, Rees DC, DeBaun MR, Nnodu O, Ranque B, Thompson AA, Ware RE, Abboud MR, Abraham A, Ambrose EE, Andemariam B, Colah R, Colombatti R, Conran N, Costa FF, Cronin RM, de Montalembert M, Elion J, Esrick E, Greenway AL, Idris IM, Issom DZ, Jain D, Jordan LC, Kaplan ZS, King AA, Lloyd-Puryear M, Oppong SA, Sharma A, Sung L, Tshilolo L, Wilkie DJ, Ohene-Frempong K. Defining global strategies to improve outcomes in sickle cell disease: a Lancet Haematology Commission. Lancet Haematol 2023; 10:e633-e686. [PMID: 37451304 DOI: 10.1016/s2352-3026(23)00096-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Frédéric B Piel
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - David C Rees
- Department of Paediatric Haematology, King's College London, King's College Hospital, London, UK
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence for Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Obiageli Nnodu
- Department of Haematology and Blood Transfusion, College of Health Sciences and Centre of Excellence for Sickle Cell Disease Research and Training, University of Abuja, Abuja, Nigeria
| | - Brigitte Ranque
- Department of Internal Medicine, Georges Pompidou European Hospital, Assistance Publique-Hopitaux de Paris Centre, University of Paris Cité, Paris, France
| | - Alexis A Thompson
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell E Ware
- Division of Hematology and Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, and Sickle Cell Program, American University of Beirut, Beirut, Lebanon
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Emmanuela E Ambrose
- Department of Paediatrics and Child Health, Bugando Medical Centre, Mwanza, Tanzania
| | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health, Connecticut, USA
| | - Roshan Colah
- Department of Haematogenetics, Indian Council of Medical Research National Institute of Immunohaematology, Mumbai, India
| | - Raffaella Colombatti
- Pediatric Oncology Hematology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Nicola Conran
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Fernando F Costa
- Department of Clinical Medicine, School of Medical Sciences, Center of Hematology and Hemotherapy (Hemocentro), University of Campinas-UNICAMP, Campinas, Brazil
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Mariane de Montalembert
- Department of Pediatrics, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris Centre, Paris, France
| | - Jacques Elion
- Paris Cité University and University of the Antilles, Inserm, BIGR, Paris, France
| | - Erica Esrick
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Anthea L Greenway
- Department Clinical Haematology, Royal Children's Hospital, Parkville and Department Haematology, Monash Health, Clayton, VIC, Australia
| | - Ibrahim M Idris
- Department of Hematology, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
| | - David-Zacharie Issom
- Department of Business Information Systems, School of Management, HES-SO University of Applied Sciences and Arts of Western Switzerland, Geneva, Switzerland
| | - Dipty Jain
- Department of Paediatrics, Government Medical College, Nagpur, India
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Zane S Kaplan
- Department of Clinical Haematology, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Allison A King
- Departments of Pediatrics and Internal Medicine, Divisions of Pediatric Hematology and Oncology and Hematology, Washington University School of Medicine, St Louis, MO, USA
| | - Michele Lloyd-Puryear
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Samuel A Oppong
- Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leon Tshilolo
- Institute of Biomedical Research/CEFA Monkole Hospital Centre and Official University of Mbuji-Mayi, Mbuji-Mayi, Democratic Republic of the Congo
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Kwaku Ohene-Frempong
- Division of Hematology, Children's Hospital of Philadelphia, Pennsylvania, USA; Sickle Cell Foundation of Ghana, Kumasi, Ghana
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12
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Gibson JS, Rees DC. Emerging drug targets for sickle cell disease: shedding light on new knowledge and advances at the molecular level. Expert Opin Ther Targets 2023; 27:133-149. [PMID: 36803179 DOI: 10.1080/14728222.2023.2179484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION In sickle cell disease (SCD), a single amino acid substitution at β6 of the hemoglobin (Hb) chain replaces glutamate with valine, forming HbS instead of the normal adult HbA. Loss of a negative charge, and the conformational change in deoxygenated HbS molecules, enables formation of HbS polymers. These not only distort red cell morphology but also have other profound effects so that this simple etiology belies a complex pathogenesis with multiple complications. Although SCD represents a common severe inherited disorder with life-long consequences, approved treatments remain inadequate. Hydroxyurea is currently the most effective, with a handful of newer treatments, but there remains a real need for novel, efficacious therapies. AREAS COVERED This review summarizes important early events in pathogenesis to highlight key targets for novel treatments. EXPERT OPINION A thorough understanding of early events in pathogenesis closely associated with the presence of HbS is the logical starting point for identification of new targets rather than concentrating on more downstream effects. We discuss ways of reducing HbS levels, reducing the impact of HbS polymers, and of membrane events perturbing cell function, and suggest using the unique permeability of sickle cells to target drugs specifically into those more severely compromised.
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Affiliation(s)
- John S Gibson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - David C Rees
- Department of Paediatric Haematology, King's College Hospital, London, UK
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13
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Feld J, Tremblay D, Navada SC, Silverman LR. Ascertaining QUAZARs: slow-motion and light-speed development of oral azacitidine and decitabine. Leuk Lymphoma 2023; 64:525-539. [PMID: 36370098 DOI: 10.1080/10428194.2022.2142051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are devastating diseases that frequently rely on the use of parenteral hypomethylating agents (HMAs), either as monotherapy or in combination, as first-line treatment for many patients. Two new oral HMAs, decitabine/cedazuridine (DC) for use in place of azacitidine or decitabine in MDS, and azacitidine (CC-486) for use as maintenance treatment in AML, were recently approved by the FDA. We will discuss the development of these oral HMAs, including the advantages/disadvantages in transitioning to oral HMAs and an in depth look at the pivotal phase III trials that led to their FDA approval - ASCERTAIN for DC and QUAZAR-AML-001 for CC-486. We also review how these agents have been and are being studied in other malignancies, and examine the future role that these exciting novel agents will play in both MDS and AML.
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Affiliation(s)
- Jonathan Feld
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Douglas Tremblay
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shyamala C Navada
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lewis R Silverman
- Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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14
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Fontana L, Alahouzou Z, Miccio A, Antoniou P. Epigenetic Regulation of β-Globin Genes and the Potential to Treat Hemoglobinopathies through Epigenome Editing. Genes (Basel) 2023; 14:genes14030577. [PMID: 36980849 PMCID: PMC10048329 DOI: 10.3390/genes14030577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Beta-like globin gene expression is developmentally regulated during life by transcription factors, chromatin looping and epigenome modifications of the β-globin locus. Epigenome modifications, such as histone methylation/demethylation and acetylation/deacetylation and DNA methylation, are associated with up- or down-regulation of gene expression. The understanding of these mechanisms and their outcome in gene expression has paved the way to the development of new therapeutic strategies for treating various diseases, such as β-hemoglobinopathies. Histone deacetylase and DNA methyl-transferase inhibitors are currently being tested in clinical trials for hemoglobinopathies patients. However, these approaches are often uncertain, non-specific and their global effect poses serious safety concerns. Epigenome editing is a recently developed and promising tool that consists of a DNA recognition domain (zinc finger, transcription activator-like effector or dead clustered regularly interspaced short palindromic repeats Cas9) fused to the catalytic domain of a chromatin-modifying enzyme. It offers a more specific targeting of disease-related genes (e.g., the ability to reactivate the fetal γ-globin genes and improve the hemoglobinopathy phenotype) and it facilitates the development of scarless gene therapy approaches. Here, we summarize the mechanisms of epigenome regulation of the β-globin locus, and we discuss the application of epigenome editing for the treatment of hemoglobinopathies.
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Affiliation(s)
- Letizia Fontana
- Laboratory of Chromatin and Gene Regulation during Development, INSERM UMR 1163, Imagine Institute, Université Paris Cité, F-75015 Paris, France
| | - Zoe Alahouzou
- Laboratory of Chromatin and Gene Regulation during Development, INSERM UMR 1163, Imagine Institute, Université Paris Cité, F-75015 Paris, France
| | - Annarita Miccio
- Laboratory of Chromatin and Gene Regulation during Development, INSERM UMR 1163, Imagine Institute, Université Paris Cité, F-75015 Paris, France
- Correspondence: (A.M.); (P.A.)
| | - Panagiotis Antoniou
- Laboratory of Chromatin and Gene Regulation during Development, INSERM UMR 1163, Imagine Institute, Université Paris Cité, F-75015 Paris, France
- Genome Engineering, Discovery Sciences, BioPharmaceuticals R&D Unit, AstraZeneca, 431 50 Gothenburg, Sweden
- Correspondence: (A.M.); (P.A.)
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15
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Takase S, Hiroyama T, Shirai F, Maemoto Y, Nakata A, Arata M, Matsuoka S, Sonoda T, Niwa H, Sato S, Umehara T, Shirouzu M, Nishigaya Y, Sumiya T, Hashimoto N, Namie R, Usui M, Ohishi T, Ohba SI, Kawada M, Hayashi Y, Harada H, Yamaguchi T, Shinkai Y, Nakamura Y, Yoshida M, Ito A. A specific G9a inhibitor unveils BGLT3 lncRNA as a universal mediator of chemically induced fetal globin gene expression. Nat Commun 2023; 14:23. [PMID: 36635268 PMCID: PMC9837035 DOI: 10.1038/s41467-022-35404-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 12/01/2022] [Indexed: 01/14/2023] Open
Abstract
Sickle cell disease (SCD) is a heritable disorder caused by β-globin gene mutations. Induction of fetal γ-globin is an established therapeutic strategy. Recently, epigenetic modulators, including G9a inhibitors, have been proposed as therapeutic agents. However, the molecular mechanisms whereby these small molecules reactivate γ-globin remain unclear. Here we report the development of a highly selective and non-genotoxic G9a inhibitor, RK-701. RK-701 treatment induces fetal globin expression both in human erythroid cells and in mice. Using RK-701, we find that BGLT3 long non-coding RNA plays an essential role in γ-globin induction. RK-701 selectively upregulates BGLT3 by inhibiting the recruitment of two major γ-globin repressors in complex with G9a onto the BGLT3 gene locus through CHD4, a component of the NuRD complex. Remarkably, BGLT3 is indispensable for γ-globin induction by not only RK-701 but also hydroxyurea and other inducers. The universal role of BGLT3 in γ-globin induction suggests its importance in SCD treatment.
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Affiliation(s)
- Shohei Takase
- Laboratory of Cell Signaling, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, 192-0392, Japan
| | - Takashi Hiroyama
- Cell Engineering Division, RIKEN BioResource Research Center, Tsukuba, Ibaraki, 305-0074, Japan
| | - Fumiyuki Shirai
- Drug Discovery Chemistry Platform Unit, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan
| | - Yuki Maemoto
- Laboratory of Cell Signaling, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, 192-0392, Japan
| | - Akiko Nakata
- Drug Discovery Seed Compounds Exploratory Unit, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan
| | - Mayumi Arata
- Chemical Genomics Research Group, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan
| | - Seiji Matsuoka
- Drug Discovery Seed Compounds Exploratory Unit, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan
| | - Takeshi Sonoda
- Drug Discovery Seed Compounds Exploratory Unit, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan
| | - Hideaki Niwa
- Drug Discovery Structural Biology Platform Unit, RIKEN Center for Biosystems Dynamics Research, Yokohama, Kanagawa, 230-0045, Japan
| | - Shin Sato
- Drug Discovery Structural Biology Platform Unit, RIKEN Center for Biosystems Dynamics Research, Yokohama, Kanagawa, 230-0045, Japan
| | - Takashi Umehara
- Drug Discovery Structural Biology Platform Unit, RIKEN Center for Biosystems Dynamics Research, Yokohama, Kanagawa, 230-0045, Japan
| | - Mikako Shirouzu
- Drug Discovery Structural Biology Platform Unit, RIKEN Center for Biosystems Dynamics Research, Yokohama, Kanagawa, 230-0045, Japan
| | - Yosuke Nishigaya
- Watarase Research Center, Discovery Research Headquarters, Kyorin Pharmaceutical Co. Ltd., Shimotsuga-gun, Tochigi, 329-0114, Japan
| | - Tatsunobu Sumiya
- Watarase Research Center, Discovery Research Headquarters, Kyorin Pharmaceutical Co. Ltd., Shimotsuga-gun, Tochigi, 329-0114, Japan
| | - Noriaki Hashimoto
- Watarase Research Center, Discovery Research Headquarters, Kyorin Pharmaceutical Co. Ltd., Shimotsuga-gun, Tochigi, 329-0114, Japan
| | - Ryosuke Namie
- Watarase Research Center, Discovery Research Headquarters, Kyorin Pharmaceutical Co. Ltd., Shimotsuga-gun, Tochigi, 329-0114, Japan
| | - Masaya Usui
- Support Unit for Bio-Material Analysis, Research Resources Division, RIKEN Center for Brain Science, Wako, Saitama, 351-0198, Japan
| | - Tomokazu Ohishi
- Institute of Microbial Chemistry (BIKAKEN), Numazu, Microbial Chemistry Research Foundation, Numazu, Shizuoka, 410-0301, Japan
| | - Shun-Ichi Ohba
- Institute of Microbial Chemistry (BIKAKEN), Numazu, Microbial Chemistry Research Foundation, Numazu, Shizuoka, 410-0301, Japan
| | - Manabu Kawada
- Institute of Microbial Chemistry (BIKAKEN), Numazu, Microbial Chemistry Research Foundation, Numazu, Shizuoka, 410-0301, Japan
| | - Yoshihiro Hayashi
- Laboratory of Oncology, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, 192-0392, Japan
| | - Hironori Harada
- Laboratory of Oncology, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, 192-0392, Japan
| | - Tokio Yamaguchi
- RIKEN Program for Drug Discovery and Medical Technology Platforms, Yokohama, Kanagawa, 230-0045, Japan
| | - Yoichi Shinkai
- Cellular Memory Laboratory, Cluster for Pioneering Research, Wako, Saitama, 351-0198, Japan
| | - Yukio Nakamura
- Cell Engineering Division, RIKEN BioResource Research Center, Tsukuba, Ibaraki, 305-0074, Japan
| | - Minoru Yoshida
- Drug Discovery Seed Compounds Exploratory Unit, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan. .,Chemical Genomics Research Group, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan. .,Department of Biotechnology, the University of Tokyo, Bunkyo-ku, Tokyo, 113-8657, Japan.
| | - Akihiro Ito
- Laboratory of Cell Signaling, School of Life Sciences, Tokyo University of Pharmacy and Life Sciences, Hachioji, Tokyo, 192-0392, Japan. .,Chemical Genomics Research Group, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan.
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16
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Pavan AR, Lopes JR, Dos Santos JL. The state of the art of fetal hemoglobin-inducing agents. Expert Opin Drug Discov 2022; 17:1279-1293. [PMID: 36302760 DOI: 10.1080/17460441.2022.2141708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Sickle cell anemia (SCA) is a hematological genetic disorder caused by a mutation in the gene of the β-globin. Pharmacological treatments will continue to be an important approach, including the strategy to induce fetal hemoglobin (HbF). AREAS COVERED Here, we analyzed the articles described in the literature regarding the drug discovery of HbF inducers. The main approaches for such strategy will be discussed, highlighting those most promising. EXPERT OPINION The comprehension of the mechanisms involved in the β-globin regulation is the main key to design new drugs to induce HbF. Among the strategies, gamma-globin regulation by epigenetic enzymes seems to be a promising approach to be pursued, although the comprehension of the selectivity role for those new drugs is crucial to reduce adverse effects. The low druggability of transcription factors and their vital role in embryonic human development are critical points that should be taken in account for drug design. The guanylate cyclase and the NO/cGMP signaling pathway seem to be promising not only for HbF induction, but also for the protective effects in the cardiovascular system. The association of drugs acting through different mechanisms to induce HbF seems to be promising for the discovery of new drugs.
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Affiliation(s)
- Aline Renata Pavan
- São Paulo State University (UNESP), Institute of Chemistry, Araraquara, Brazil
| | - Juliana Romano Lopes
- School of Pharmaceutical Sciences, São Paulo State University (UNESP), Drugs and Medicine Department, Araraquara, Brazil
| | - Jean Leandro Dos Santos
- São Paulo State University (UNESP), Institute of Chemistry, Araraquara, Brazil.,School of Pharmaceutical Sciences, São Paulo State University (UNESP), Drugs and Medicine Department, Araraquara, Brazil
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17
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Costa E, Cappellini MD, Rivella S, Chilin A, Alessi E, Riccaboni M, Leufkens HGM, Luzzatto L. Emergent treatments for β-thalassemia and orphan drug legislations. Drug Discov Today 2022; 27:103342. [PMID: 36058507 DOI: 10.1016/j.drudis.2022.103342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 07/19/2022] [Accepted: 08/29/2022] [Indexed: 01/19/2023]
Abstract
In many countries, β-thalassemia (β-THAL) is not uncommon; however, it qualifies as a rare disease in the US and in European Union (EU), where thalassemia drugs are eligible for Orphan Drug Designation (ODD). In this paper, we evaluate all 28 ODDs for β-THAL granted since 2001 in the US and the EU: of these, ten have since been discontinued, twelve are pending, and six have become licensed drugs available for clinical use. The prime mover for these advances has been the increasing depth of understanding of the pathophysiology of β-THAL; at the same time, and even though only one-fifth of β-THAL ODDs have become licensed drugs, the ODD legislation has clearly contributed substantially to the development of improved treatments for β-THAL.
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Affiliation(s)
- Enrico Costa
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation at Utrecht University, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Science, Utrecht, the Netherlands.
| | | | - Stefano Rivella
- Department of Pediatrics, Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA; Cell and Molecular Biology Affinity Group (CAMB), University of Pennsylvania, Philadelphia, PA, USA; Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Penn Center for Musculoskeletal Disorders, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Institute for Regenerative Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Adriana Chilin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy.
| | | | | | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Science, Utrecht, the Netherlands.
| | - Lucio Luzzatto
- Department of Haematology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
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18
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Brogi S, Tabanelli R, Calderone V. Combinatorial approaches for novel cardiovascular drug discovery: a review of the literature. Expert Opin Drug Discov 2022; 17:1111-1129. [PMID: 35853260 DOI: 10.1080/17460441.2022.2104247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION In this article, authors report an inclusive discussion about the combinatorial approach for the treatment of cardiovascular diseases (CVDs) and for counteracting the cardiovascular risk factors. The mentioned strategy was demonstrated to be useful for improving the efficacy of pharmacological treatments and in CVDs showed superior efficacy with respect to the classical monotherapeutic approach. AREAS COVERED According to this topic, authors analyzed the combinatorial treatments that are available on the market, highlighting clinical studies that demonstrated the efficacy of combinatorial drug strategies to cure CVDs and related risk factors. Furthermore, the review gives an outlook on the future perspective of this therapeutic option, highlighting novel drug targets and disease models that could help the future cardiovascular drug discovery. EXPERT OPINION The use of specifically designed and increasingly rational and effective drug combination therapies can therefore be considered the evolution of polypharmacy in cardiometabolic and CVDs. This approach can allow to intervene on multiple etiopathogenetic mechanisms of the disease or to act simultaneously on different pathologies/risk factors, using the combinations most suitable from a pharmacodynamic, pharmacokinetic, and toxicological perspective, thus finding the most appropriate therapeutic option.
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Affiliation(s)
- Simone Brogi
- Department of Pharmacy, University of Pisa, Pisa, Italy
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19
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Treadwell MJ, Du L, Bhasin N, Marsh AM, Wun T, Bender MA, Wong TE, Crook N, Chung JH, Norman S, Camilo N, Cavazos J, Nugent D. Barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families: Report from a U.S. regional collaborative. Front Genet 2022; 13:921432. [PMID: 36092883 PMCID: PMC9461276 DOI: 10.3389/fgene.2022.921432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder that affects about 100,000 people in the U.S., primarily Blacks/African-Americans. A multitude of complications negatively impacts quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD, but is underutilized. Negative and uninformed perceptions of hydroxyurea and barriers to its use hinder adherence and promotion of the medication. As the largest real-world study to date that assessed hydroxyurea use for children and adults with SCD, we gathered and analyzed perspectives of providers, individuals with SCD, and families. Participants provided information about socio-demographics, hospital and emergency admissions for pain, number of severe pain episodes interfering with daily activities, medication adherence, and barriers to hydroxyurea. Providers reported on indications for hydroxyurea, reasons not prescribed, and current laboratory values. We found that hydroxyurea use was reported in over half of eligible patients from this large geographic region in the U.S., representing a range of sickle cell specialty clinical settings and practices. Provider and patient/caregiver reports about hydroxyurea use were consistent with one another; adults 26 years and older were least likely to be on hydroxyurea; and the likelihood of being on hydroxyurea decreased with one or more barriers. Using the intentional and unintentional medication nonadherence framework, we found that, even for patients on hydroxyurea, challenges to taking the medicine at the right time and forgetting were crucial unintentional barriers to adherence. Intentional barriers such as worry about side effects and “tried and it did not work” were important barriers for young adults and adults. For providers, diagnoses other than HgbSS or HgbS-β0 thalassemia were associated with lower odds of prescribing, consistent with evidence-based guidelines. Our results support strengthening provider understanding and confidence in implementing existing SCD guidelines, and the importance of shared decision making. Our findings can assist providers in understanding choices and decisions of families; guide individualized clinical discussions regarding hydroxyurea therapy; and help with developing tailored interventions to address barriers. Addressing barriers to hydroxyurea use can inform strategies to minimize similar barriers in the use of emerging and combination therapies for SCD.
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Affiliation(s)
- Marsha J. Treadwell
- Division of Hematology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
- *Correspondence: Marsha J. Treadwell,
| | - Lisa Du
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Neha Bhasin
- Division of Hematology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Anne M. Marsh
- Division of Hematology/Oncology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Theodore Wun
- Division of Hematology and Oncology, Department of Internal Medicine, University of California, Davis, Davis, CA, United States
| | - M. A. Bender
- Odessa Brown Children’s Clinic, Seattle Children’s Hospital, Seattle, WA, United States
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health and Sciences University, Portland, OR, United States
| | - Nicole Crook
- Center for Inherited Blood Disorders, Orange, CA, United States
| | - Jong H. Chung
- Hematology-Oncology, Department of Pediatrics, University of California, Davis, Davis, CA, United States
| | - Shannon Norman
- Alaska Bleeding Disorders Clinic, Anchorage, AK, United States
| | - Nicolas Camilo
- St. Luke’s Children’s Cancer Institute, Boise, ID, United States
| | - Judith Cavazos
- UCSF Benioff Children’s Hospital Oakland, Oakland, CA, United States
| | - Diane Nugent
- Center for Inherited Blood Disorders, Orange, CA, United States
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20
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Bou-Fakhredin R, De Franceschi L, Motta I, Cappellini MD, Taher AT. Pharmacological Induction of Fetal Hemoglobin in β-Thalassemia and Sickle Cell Disease: An Updated Perspective. Pharmaceuticals (Basel) 2022; 15:ph15060753. [PMID: 35745672 PMCID: PMC9227505 DOI: 10.3390/ph15060753] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 12/04/2022] Open
Abstract
A significant amount of attention has recently been devoted to the mechanisms involved in hemoglobin (Hb) switching, as it has previously been established that the induction of fetal hemoglobin (HbF) production in significant amounts can reduce the severity of the clinical course in diseases such as β-thalassemia and sickle cell disease (SCD). While the induction of HbF using lentiviral and genome-editing strategies has been made possible, they present limitations. Meanwhile, progress in the use of pharmacologic agents for HbF induction and the identification of novel HbF-inducing strategies has been made possible as a result of a better understanding of γ-globin regulation. In this review, we will provide an update on all current pharmacological inducer agents of HbF in β-thalassemia and SCD in addition to the ongoing research into other novel, and potentially therapeutic, HbF-inducing agents.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
| | - Lucia De Franceschi
- Department of Medicine, University of Verona and Azienda Ospedaliera Universitaria Verona, 37128 Verona, Italy;
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (R.B.-F.); (I.M.)
- UOC General Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence: (M.D.C.); (A.T.T.)
| | - Ali T. Taher
- Department of Internal Medicine, Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
- Correspondence: (M.D.C.); (A.T.T.)
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21
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Czuppa M, Dhingra A, Zhou Q, Schludi C, König L, Scharf E, Farny D, Dalmia A, Täger J, Castillo-Lizardo M, Katona E, Mori K, Aumer T, Schelter F, Müller M, Carell T, Kalliokoski T, Messinger J, Rizzu P, Heutink P, Edbauer D. Drug screen in iPSC-Neurons identifies nucleoside analogs as inhibitors of (G 4C 2) n expression in C9orf72 ALS/FTD. Cell Rep 2022; 39:110913. [PMID: 35675776 DOI: 10.1016/j.celrep.2022.110913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 12/22/2021] [Accepted: 05/12/2022] [Indexed: 11/03/2022] Open
Abstract
An intronic (G4C2)n expansion in C9orf72 causes amyotrophic lateral sclerosis and frontotemporal dementia primarily through gain-of-function mechanisms: the accumulation of sense and antisense repeat RNA foci and dipeptide repeat (DPR) proteins (poly-GA/GP/GR/PA/PR) translated from repeat RNA. To therapeutically block this pathway, we screen a library of 1,430 approved drugs and known bioactive compounds in patient-derived induced pluripotent stem cell-derived neurons (iPSC-Neurons) for inhibitors of DPR expression. The clinically used guanosine/cytidine analogs decitabine, entecavir, and nelarabine reduce poly-GA/GP expression, with decitabine being the most potent. Hit compounds nearly abolish sense and antisense RNA foci and reduce expression of the repeat-containing nascent C9orf72 RNA transcript and its mature mRNA with minimal effects on global gene expression, suggesting that they specifically act on repeat transcription. Importantly, decitabine treatment reduces (G4C2)n foci and DPRs in C9orf72 BAC transgenic mice. Our findings suggest that nucleoside analogs are a promising compound class for therapeutic development in C9orf72 repeat-expansion-associated disorders.
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Affiliation(s)
- Mareike Czuppa
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Ashutosh Dhingra
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany.
| | - Qihui Zhou
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Carina Schludi
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Laura König
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Elisabeth Scharf
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Daniel Farny
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Anupriya Dalmia
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Joachim Täger
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | | | - Eszter Katona
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Kohji Mori
- Psychiatry, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tina Aumer
- Ludwig-Maximilians-University Munich, Faculty of Chemistry and Pharmacy, Munich, Germany
| | - Florian Schelter
- Ludwig-Maximilians-University Munich, Faculty of Chemistry and Pharmacy, Munich, Germany
| | - Markus Müller
- Ludwig-Maximilians-University Munich, Faculty of Chemistry and Pharmacy, Munich, Germany
| | - Thomas Carell
- Ludwig-Maximilians-University Munich, Faculty of Chemistry and Pharmacy, Munich, Germany
| | | | - Josef Messinger
- Orion Corporation Orion Pharma, Medicine Design, Espoo, Finland
| | - Patrizia Rizzu
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Peter Heutink
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Dieter Edbauer
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany; Ludwig-Maximilians-University Munich, Graduate School of Systemic Neurosciences (GSN), Munich, Germany.
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Lopez NH, Li B, Palani C, Siddaramappa U, Takezaki M, Xu H, Zhi W, Pace BS. Salubrinal induces fetal hemoglobin expression via the stress-signaling pathway in human sickle erythroid progenitors and sickle cell disease mice. PLoS One 2022; 17:e0261799. [PMID: 35639781 PMCID: PMC9154101 DOI: 10.1371/journal.pone.0261799] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited blood disorder caused by a mutation in the HBB gene leading to hemoglobin S production and polymerization under hypoxia conditions leading to vaso-occlusion, chronic hemolysis, and progressive organ damage. This disease affects ~100,000 people in the United States and millions worldwide. An effective therapy for SCD is fetal hemoglobin (HbF) induction by pharmacologic agents such as hydroxyurea, the only Food and Drug Administration-approved drug for this purpose. Therefore, the goal of our study was to determine whether salubrinal (SAL), a selective protein phosphatase 1 inhibitor, induces HbF expression through the stress-signaling pathway by activation of p-eIF2α and ATF4 trans-activation in the γ-globin gene promoter. Sickle erythroid progenitors treated with 24μM SAL increased F-cells levels 1.4-fold (p = 0.021) and produced an 80% decrease in reactive oxygen species. Western blot analysis showed SAL enhanced HbF protein by 1.6-fold (p = 0.0441), along with dose-dependent increases of p-eIF2α and ATF4 levels. Subsequent treatment of SCD mice by a single intraperitoneal injection of SAL (5mg/kg) produced peak plasma concentrations at 6 hours. Chronic treatments of SCD mice with SAL mediated a 2.3-fold increase in F-cells (p = 0.0013) and decreased sickle erythrocytes supporting in vivo HbF induction.
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Affiliation(s)
- Nicole H. Lopez
- Department of Biochemistry and Cancer Biology, Augusta University, Augusta, GA, United States of America
| | - Biaoru Li
- Department of Pediatrics, Augusta University, Augusta, GA, United States of America
| | - Chithra Palani
- Department of Pediatrics, Augusta University, Augusta, GA, United States of America
| | - Umapathy Siddaramappa
- Department of Medicine, Division of Hematology/Oncology Augusta University, Augusta GA, United States of America
| | - Mayuko Takezaki
- Department of Pediatrics, Augusta University, Augusta, GA, United States of America
| | - Hongyan Xu
- Department of Biostatistics and Epidemiology, Augusta University, Augusta, GA, United States of America
| | - Wenbo Zhi
- Center for Biotechnology & Genomic Medicine, Augusta University, Augusta, GA, United States of America
| | - Betty S. Pace
- Department of Biochemistry and Cancer Biology, Augusta University, Augusta, GA, United States of America
- Department of Pediatrics, Augusta University, Augusta, GA, United States of America
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23
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Starlard-Davenport A, Gu Q, Pace BS. Targeting Genetic Modifiers of HBG Gene Expression in Sickle Cell Disease: The miRNA Option. Mol Diagn Ther 2022; 26:497-509. [PMID: 35553407 PMCID: PMC9098152 DOI: 10.1007/s40291-022-00589-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 12/14/2022]
Abstract
Sickle cell disease (SCD) is one of the most common inherited hemoglobinopathy disorders that affects millions of people worldwide. Reactivation of HBG (HBG1, HBG2) gene expression and induction of fetal hemoglobin (HbF) is an important therapeutic strategy for ameliorating the clinical symptoms and severity of SCD. Hydroxyurea is the only US FDA-approved drug with proven efficacy to induce HbF in SCD patients, yet serious complications have been associated with its use. Over the last three decades, numerous additional pharmacological agents that reactivate HBG transcription in vitro have been investigated, but few have proceeded to FDA approval, with the exception of arginine butyrate and decitabine; however, neither drug met the requirements for routine clinical use due to difficulties with oral delivery and inability to achieve therapeutic levels. Thus, novel approaches that produce sufficient efficacy, specificity, and sustainable HbF induction with low adverse effects are desirable. More recently, microRNAs (miRNAs) have gained attention for their diagnostic and therapeutic potential to treat various diseases ranging from cancer to Alzheimer’s disease via targeting oncogenes and their gene products. Thus, it is plausible that miRNAs that target HBG regulatory genes may be useful for inducing HbF as a treatment for SCD. Our laboratory and others have documented the association of miRNAs with HBG activation or suppression via silencing transcriptional repressors and activators, respectively, of HBG expression. Herein, we review progress made in understanding molecular mechanisms of miRNA-mediated HBG regulation and discuss the extent to which molecular targets of HBG might be suitable prospects for development of SCD clinical therapy. Lastly, we discuss challenges with the application of miRNA delivery in vivo and provide potential strategies for overcoming barriers in the future.
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Affiliation(s)
- Athena Starlard-Davenport
- College of Medicine, Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
| | - Qingqing Gu
- College of Medicine, Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.,Department of Cardiology, Affiliated Hospital of Nantong University, Jiangsu, 226001, China
| | - Betty S Pace
- Department of Pediatrics, Division of Hematology/Oncology, Augusta University, Augusta, GA, USA.,Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA, USA
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Abstract
INTRODUCTION Sickle cell disease and β thalassemia are the principal β hemoglobinopathies. The complex pathophysiology of sickle cell disease is initiated by sickle hemoglobin polymerization. In β thalassemia, insufficient β-globin synthesis results in excessive free α globin, ineffective erythropoiesis and severe anemia. Fetal hemoglobin (HbF) prevents sickle hemoglobin polymerization; in β thalassemia HbF compensates for the deficit of normal hemoglobin. When HbF constitutes about a third of total cell hemoglobin, the complications of sickle cell disease are nearly totally prevented. Similarly, sufficient HbF in β thalassemia diminishes or prevents ineffective erythropoiesis and hemolysis. AREAS COVERED This article examines the pathophysiology of β hemoglobinopathies, the physiology of HbF, intracellular distribution and the regulation of HbF expression. Inducing high levels of HbF by targeting its regulatory pathways pharmacologically or with cell-based therapeutics provides major clinical benefit and perhaps a "cure." EXPERT OPINION Erythrocytes must contain about 10 pg of HbF to "cure" sickle cell disease. If HbF is the only hemoglobin present, much higher levels are needed to "cure" β thalassemia. These levels of HbF can be obtained by different iterations of gene therapy. Small molecule drugs that can achieve even modest pancellular HbF concentrations are a major unmet need.
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Affiliation(s)
- Martin H Steinberg
- Professor of Medicine, Pediatrics, Pathology and Laboratory Medicine, Boston University School of Medicine.,Department of Medicine, Division of Hematology/Oncology, Center of Excellence for Sickle Cell Disease, Boston University School of Medicine, 72 East Concord St., Boston, MA, 02118, USA.,Department of Medicine, Boston University School of Medicine, 72 E. Concord St. Boston, MA 02118. ., Tel
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25
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Down-regulation of the transcriptional repressor ZNF802 (JAZF1) reactivates fetal hemoglobin in β 0-thalassemia/HbE. Sci Rep 2022; 12:4952. [PMID: 35322124 PMCID: PMC8943019 DOI: 10.1038/s41598-022-08920-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/08/2022] [Indexed: 12/13/2022] Open
Abstract
Reactivating of fetal hemoglobin (HbF; α2γ2) can ameliorate the severity of β-thalassemia disease by compensating for adult hemoglobin deficiency in patients. Previously, microarray analysis revealed that zinc finger protein (ZNF)802 (also known as Juxta-posed with another zinc finger gene-1 (JAZF1)) was upregulated in human erythroblasts derived from adult peripheral blood compared with fetal liver-derived cells, implying a potential role as a HbF repressor. However, deficiency in ZNF802 induced by lentiviral shRNA in β0-thalassemia/hemoglobinE erythroblasts had no effect on erythroblast proliferation and differentiation. Remarkably, the induction of HBG expression was observed at the transcriptional and translational levels resulting in an increase of HbF to 35.0 ± 3.5%. Interestingly, the embryonic globin transcripts were also upregulated but the translation of embryonic globin was not detected. These results suggest ZNF802 might be a transcriptional repressor of the γ-globin gene in adult erythroid cells.
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26
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Dela-Pena JC, King MA, Brown J, Nachar VR. Incorporation of novel therapies for the management of sickle cell disease: A pharmacist's perspective. J Oncol Pharm Pract 2022; 28:646-663. [DOI: 10.1177/10781552211072468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with sickle cell disease (SCD) experience significant disease-related morbidity including multiorgan damage, chronic anemia, and debilitating pain crises. While hydroxyurea has been the primary disease modifying modality in SCD, novel therapies with unique mechanism of action have recently been approved. This review article examines the evidence surrounding the available SCD therapies to guide pharmacists on potential treatment selection and management strategies for patients with SCD. A systematic search of online databases was performed to identify literature on the management of SCD. While the newly approved novel agents have demonstrated clinical benefit it remains unclear how these agents fit into the treatment paradigm. Pharmacists should be aware of the data supporting the use of these novel agents to optimize use on a patient-specific basis.
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Affiliation(s)
| | | | - Julia Brown
- C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
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Säll C, Fogt Hjorth C. In vitro drug-drug interactions of decitabine and tetrahydrouridine involving drug transporters and drug metabolising enzymes. Xenobiotica 2021; 52:1-15. [PMID: 34913834 DOI: 10.1080/00498254.2021.2018628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
1. NDec is a novel, oral, fixed-dose formulation of decitabine and tetrahydrouridine that is currently being developed for the treatment of patients with sickle cell disease. Here, we examine the potential for both components of NDec to interact with key drug metabolising enzymes (tetrahydrouridine only) and drug transporters (decitabine and tetrahydrouridine).2. This study assessed the inhibition and induction of cytochrome P450 (CYP) enzymes by tetrahydrouridine, as well as the involvement of specific drug metabolising enzymes in tetrahydrouridine metabolism. Inhibition of efflux and uptake transporters by both decitabine and tetrahydrouridine was also studied.3. Tetrahydrouridine did not inhibit or induce relevant CYP enzymes at concentrations ranging from 0.1 to 100 μM. Metabolism of tetrahydrouridine did not occur in the presence of the human drug metabolising enzymes tested. Tetrahydrouridine showed weak inhibition towards the MATE2-K transporter (∼30% inhibition at 5 and 50 μM), which was not deemed clinically relevant. Tetrahydrouridine did not inhibit any of the remaining uptake or efflux transporters. Decitabine (0.5 and 5 μM) did not inhibit any of the evaluated uptake or efflux drug transporters.4. Data presented confirm that tetrahydrouridine and decitabine are unlikely to be involved in metabolism- or transporter-based drug-drug interactions.
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28
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Mussolino C, Strouboulis J. Recent Approaches for Manipulating Globin Gene Expression in Treating Hemoglobinopathies. Front Genome Ed 2021; 3:618111. [PMID: 34713248 PMCID: PMC8525358 DOI: 10.3389/fgeed.2021.618111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Tissue oxygenation throughout life depends on the activity of hemoglobin (Hb) one of the hemeproteins that binds oxygen in the lungs and secures its delivery throughout the body. Hb is composed of four monomers encoded by eight different genes the expression of which is tightly regulated during development, resulting in the formation of distinct hemoglobin tetramers in each developmental stage. Mutations that alter hemoglobin structure or its regulated expression result in a large group of diseases typically referred to as hemoglobinopathies that are amongst the most common genetic defects worldwide. Unprecedented efforts in the last decades have partially unraveled the complex mechanisms that control globin gene expression throughout development. In addition, genome wide association studies have revealed protective genetic traits capable of ameliorating the clinical manifestations of severe hemoglobinopathies. This knowledge has fueled the exploration of innovative therapeutic approaches aimed at modifying the genome or the epigenome of the affected cells to either restore hemoglobin function or to mimic the effect of protective traits. Here we describe the key steps that control the switch in gene expression that concerns the different globin genes during development and highlight the latest efforts in altering globin regulation for therapeutic purposes.
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Affiliation(s)
- Claudio Mussolino
- Institute for Transfusion Medicine and Gene Therapy, Medical Center-University of Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - John Strouboulis
- Laboratory of Molecular Erythropoiesis, Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
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Zavras PD, Shastri A, Goldfinger M, Verma AK, Saunthararajah Y. Clinical Trials Assessing Hypomethylating Agents Combined with Other Therapies: Causes for Failure and Potential Solutions. Clin Cancer Res 2021; 27:6653-6661. [PMID: 34551907 DOI: 10.1158/1078-0432.ccr-21-2139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/19/2021] [Accepted: 09/17/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Azacitidine and decitabine are hypomethylating agents (HMA), that is, both inhibit and deplete DNA methyltransferase 1 (DNMT1). HMAs are standard single-agent therapies for myelodysplastic syndromes and acute myelogenous leukemias. Several attempts to improve outcomes by combining HMAs with investigational agents, excepting with the BCL2-inhibitor venetoclax, have failed in randomized clinical trial (RCT) evaluations. We extract lessons from decades of clinical trials to thereby inform future work. EXPERIMENTAL DESIGN Serial single-agent clinical trials were analyzed for mechanism and pathway properties of HMAs underpinning their success, and for rules for dose and schedule selection. RCTs were studied for principles, dos and don'ts for productive combination therapy. RESULTS Single-agent HMA trial results encourage dose and schedule selection to increase S-phase-dependent DNMT1 targeting, and discourage doses that cause indiscriminate antimetabolite effects/cytotoxicity, because these attrit myelopoiesis reserves needed for clinical response. Treatment-related myelosuppression should prompt dose/frequency reductions of less active investigational agents rather than more active HMA. Administering cytostatic agents concurrently with HMA can antagonize S-phase-dependent DNMT1 targeting. Supportive care that enables on-time administration of S-phase (exposure-time)-dependent HMA could be useful. Agents that manipulate pyrimidine metabolism to increase HMA pro-drug processing into DNMT1-depleting nucleotide, and/or inhibit other epigenetic enzymes implicated in oncogenic silencing of lineage differentiation, could be productive, but doses and schedules should adhere to therapeutic index/molecular-targeted principles already learned. CONCLUSIONS More than 40 years of clinical trial history indicates mechanism, pathway, and therapeutic index properties of HMAs that underpin their almost exclusive success and teaches lessons for selection and design of combinations aiming to build on this treatment foundation.
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Affiliation(s)
- Phaedon D Zavras
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Aditi Shastri
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Mendel Goldfinger
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Amit K Verma
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - Yogen Saunthararajah
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
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30
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Parker WB, Thottassery JV. 5-Aza-4'-thio-2'-deoxycytidine, a new orally bioavailable non-toxic "best-in-class" DNMT1 depleting agent in clinical development. J Pharmacol Exp Ther 2021; 379:211-222. [PMID: 34503994 DOI: 10.1124/jpet.121.000758] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022] Open
Abstract
DNA methyltransferase 1 (DNMT1) is an enzyme that functions as a maintenance methyltransferase during DNA replication, and depletion of this enzyme from cells is considered to be a rational goal in DNA methylation dependent disorders. Two DNMT1 depleting agents aza-dCyd (5-aza-2'-deoxycytidine, decitabine) and aza-Cyd (5-aza-cytidine, azacitidine) are currently used for the treatment of myelodysplastic syndromes and acute myeloid leukemia, and have also been investigated for non-oncology indications such as sickle cell disease. However, these agents have several off-target activities leading to significant toxicities that limit dosing and duration of treatment. Development of more selective inhibitors of DNMT1 could therefore afford treatment for long durations at effective doses. We have discovered that 5-aza-4'-thio-2'-deoxycytidine (aza-T-dCyd) is as effective as aza-dCyd in depleting DNMT1 in mouse tumor models, but with markedly low toxicity. In this review we describe the preclinical studies that led to the development of aza-T-dCyd as a superior DNMT1 depleting agent with respect to aza-dCyd, and will describe its pharmacology, metabolism, and mechanism of action. In an effort to understand why aza-T-dCyd is a more selective DNMT1 depleting agent than aza-dCyd, we will also compare and contrast the activities of these two agents. Significance Statement Aza-T-dCyd is a potent DNMT1 depleting agent. Although similar in structure to decitabine (aza-dCyd) its metabolism and mechanism of action is different than that of aza-dCyd, resulting in less off target activity and less toxicity. The larger therapeutic index of aza-T-dCyd (DNMT1 depletion vs toxicity) in mice suggests that it would be a better clinical candidate to selectively deplete DNMT1 from target cells and determine whether or not depletion of DNMT1 is an effective target for various diseases.
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Bull C, Mayrhofer G, Fenech M. Exposure to hypomethylating 5-aza-2'-deoxycytidine (decitabine) causes rapid, severe DNA damage, telomere elongation and mitotic dysfunction in human WIL2-NS cells. MUTATION RESEARCH-GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2021; 868-869:503385. [PMID: 34454691 DOI: 10.1016/j.mrgentox.2021.503385] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/31/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND 5-aza-2'-deoxycytidine (5azadC, decitabine) is a DNA hypomethylating agent used in the treatment of myelodysplastic syndromes. Due to cytotoxic side effects dose optimization is essential. The aim of this study was to define and quantify the effects of 5azadC on biomarkers of chromosomal stability, and telomere length, in human lymphoblastoid cell line, WIL2-NS, at clinically relevant dosages. METHODS Human WIL2-NS cells were maintained in complete medium containing 0, 0.2 or 1.0 μM 5azadC for four days, and analysed daily for telomere length (flow cytometry), chromosomal stability (cytokinesis-block micronucleus cytome (CBMN-cyt) assay), and global methylation (%5me-C). RESULTS DNA methylation decreased significantly in 1.0 μM 5azadC, relative to control (p < 0.0001). Exposure to 1.0 μM 5azadC resulted in 1.7-fold increase in telomere length (p < 0.0001), in parallel with rapid increase in biomarkers of DNA damage; (micronuclei (MN, 6-fold increase), nucleoplasmic bridges (NPB, a 12-fold increase), and nuclear buds (NBud, a 13-fold increase) (all p < 0.0001). Fused nuclei (FUS), indicative of mitotic dysfunction, showed a 5- and 13-fold increase in the 0.2 μM and 1.0 μM conditions, respectively (p = 0.001) after 4 days. CONCLUSIONS These data show that (i) clinically relevant concentrations of 5azadC are highly genotoxic; (ii) hypomethylation was associated with increased TL and DNA damage; and (iii) longer TL was associated with chromosomal instability. These findings suggest that lower doses of 5azdC may be effective as a hypomethylating agent, while potentially reducing DNA damage and risk for secondary disease.
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Affiliation(s)
- Caroline Bull
- CSIRO Health & Biosecurity, Gate 13 Kintore Avenue, Adelaide, South Australia, Australia; School of Molecular and Biomedical Sciences, University of Adelaide, North Terrace, Adelaide, South Australia, Australia.
| | - Graham Mayrhofer
- School of Molecular and Biomedical Sciences, University of Adelaide, North Terrace, Adelaide, South Australia, Australia
| | - Michael Fenech
- CSIRO Health & Biosecurity, Gate 13 Kintore Avenue, Adelaide, South Australia, Australia
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A natural DNMT1 mutation elevates the fetal hemoglobin level via epigenetic derepression of the γ-globin gene in β-thalassemia. Blood 2021; 137:1652-1657. [PMID: 33227819 DOI: 10.1182/blood.2020006425] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023] Open
Abstract
DNA methyltransferase 1 (DNMT1) is a major epigenetic regulator of the formation of large macromolecular complexes that repress human γ-globin expression by maintaining DNA methylation. However, very little is known about the association of DNMT1 variants with β-thalassemia phenotypes. We systematically investigated associations between variants in DNMT1 and phenotypes in 1142 β-thalassemia subjects and identified a novel missense mutation (c.2633G>A, S878F) in the DNMT1 bromo-adjacent homology-1 (BAH1) domain. We functionally characterized this mutation in CD34+ cells from patients and engineered HuDEP-2 mutant cells. Our results demonstrate that DNMT1 phosphorylation is abrogated by substituting serine with phenylalanine at position 878, resulting in lower stability and catalytic activity loss. S878F mutation also attenuated DNMT1 interactions with BCL11A, GATA1, and HDAC1/2, and reduced recruitment of DNMT1 to the γ-globin (HBG) promoters, leading to epigenetic derepression of γ-globin expression. By analyzing the F-cell pattern, we demonstrated that the effect of DNMT1 mutation on increased fetal hemoglobin (HbF) is heterocellular. Furthermore, introduction of S878F mutation into erythroid cells by clustered regularly interspaced short palindromic repeats (CRISPR)-CRISPR-associated protein 9 (Cas9) recapitulated γ-globin reactivation. Thus, the natural S878F DNMT1 mutation is a novel modulator of HbF synthesis and represents a potential new therapeutic target for β-hemoglobinopathies.
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34
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Starlard-Davenport A, Fitzgerald A, Pace BS. Exploring epigenetic and microRNA approaches for γ-globin gene regulation. Exp Biol Med (Maywood) 2021; 246:2347-2357. [PMID: 34292080 DOI: 10.1177/15353702211028195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Therapeutic interventions aimed at inducing fetal hemoglobin and reducing the concentration of sickle hemoglobin is an effective approach to ameliorating acute and chronic complications of sickle cell disease, exemplified by the long-term use of hydroxyurea. However, there remains an unmet need for the development of additional safe and effective drugs for single agent or combination therapy for individuals with β-hemoglobinopathies. Regulation of the γ-globin to β-globin switch is achieved by chromatin remodeling at the HBB locus on chromosome 11 and interactions of major DNA binding proteins, such as KLF1 and BCL11A in the proximal promoters of the globin genes. Experimental evidence also supports a role of epigenetic modifications including DNA methylation, histone acetylation/methylation, and microRNA expression in γ-globin gene silencing during development. In this review, we will critically evaluate the role of epigenetic mechanisms in γ-globin gene regulation and discuss data generated in tissue culture, pre-clinical animal models, and clinical trials to support drug development to date. The question remains whether modulation of epigenetic pathways will produce sufficient efficacy and specificity for fetal hemoglobin induction and to what extent targeting these pathways form the basis of prospects for clinical therapy.
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Affiliation(s)
- Athena Starlard-Davenport
- Department of Genetics, Genomics and Informatics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Ashley Fitzgerald
- Department of Genetics, Genomics and Informatics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Betty S Pace
- Department of Pediatrics, Division of Hematology/Oncology, Augusta University, Augusta, GA 30912, USA
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Gilmartin AG, Groy A, Gore ER, Atkins C, Long ER, Montoute MN, Wu Z, Halsey W, McNulty DE, Ennulat D, Rueda L, Pappalardi MB, Kruger RG, McCabe MT, Raoof A, Butlin R, Stowell A, Cockerill M, Waddell I, Ogilvie D, Luengo J, Jordan A, Benowitz AB. In vitro and in vivo induction of fetal hemoglobin with a reversible and selective DNMT1 inhibitor. Haematologica 2021; 106:1979-1987. [PMID: 32586904 PMCID: PMC8252945 DOI: 10.3324/haematol.2020.248658] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/18/2020] [Indexed: 12/20/2022] Open
Abstract
Pharmacological induction of fetal hemoglobin (HbF) expression is an effective therapeutic strategy for the management of beta-hemoglobinopathies such as sickle cell disease. DNA methyltransferase (DNMT) inhibitors 5-azacytidine (5-aza) and 5-aza-2'-deoxycytidine (decitabine) have been shown to induce fetal hemoglobin expression in both preclinical models and clinical studies, but are not currently approved for the management of hemoglobinopathies. We report here the discovery of a novel class of orally bioavailable DNMT1-selective inhibitors as exemplified by GSK3482364. This molecule potently inhibits the methyltransferase activity of DNMT1, but not DNMT family members DNMT3A or DNMT3B. In contrast with cytidine analog DNMT inhibitors, the DNMT1 inhibitory mechanism of GSK3482364 does not require DNA incorporation and is reversible. In cultured human erythroid progenitor cells (EPCs), GSK3482364 decreased overall DNA methylation resulting in de-repression of the gamma globin genes HBG1 and HBG2 and increased HbF expression. In a transgenic mouse model of sickle cell disease, orally administered GSK3482364 caused significant increases in both HbF levels and in the percentage HbF-expressing erythrocytes, with good overall tolerability. We conclude that in these preclinical models, selective, reversible inhibition of DNMT1 is sufficient for the induction of HbF, and is well-tolerated. We anticipate that GSK3482364 will be a useful tool molecule for the further study of selective DNMT1 inhibition both in vitro and in vivo.
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Affiliation(s)
| | - Arthur Groy
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | | | - Charity Atkins
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | - Edward R. Long
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | | | - Zining Wu
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | - Wendy Halsey
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | | | | | - Lourdes Rueda
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | | | - Ryan G. Kruger
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | | | - Ali Raoof
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
| | - Roger Butlin
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
| | - Alexandra Stowell
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
| | - Mark Cockerill
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
| | - Ian Waddell
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
| | - Donald Ogilvie
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
| | - Juan Luengo
- GlaxoSmithKline, Collegeville, Pennsylvania, PA, USA and
| | - Allan Jordan
- Drug Discovery Unit, Cancer Research UK Manchester Institute, University of Manchester, Alderley Park, Manchester, UK
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Tumburu L, Thein SL. Targeting ZNF410 as a potential β-hemoglobinopathy therapy. Nat Genet 2021; 53:589-590. [PMID: 33859418 DOI: 10.1038/s41588-021-00817-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Laxminath Tumburu
- National Heart, Lung and Blood Institute/NIH, Sickle Cell Branch, Bethesda, MD, USA
| | - Swee Lay Thein
- National Heart, Lung and Blood Institute/NIH, Sickle Cell Branch, Bethesda, MD, USA.
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37
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Salinas Cisneros G, Thein SL. Research in Sickle Cell Disease: From Bedside to Bench to Bedside. Hemasphere 2021; 5:e584. [PMID: 34095767 PMCID: PMC8171370 DOI: 10.1097/hs9.0000000000000584] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 01/25/2023] Open
Abstract
Sickle cell disease (SCD) is an exemplar of bidirectional translational research, starting with a remarkable astute observation of the abnormally shaped red blood cells that motivated decades of bench research that have now translated into new drugs and genetic therapies. Introduction of hydroxyurea (HU) therapy, the only SCD-modifying treatment for >30 years and now standard care, was initiated through another clinical observation by a pediatrician. While the clinical efficacy of HU is primarily due to its fetal hemoglobin (HbF) induction, the exact mechanism of how it increases HbF remains not fully understood. Unraveling of the molecular mechanism of how HU increases HbF has provided insights on the development of new HbF-reactivating agents in the pipeline. HU has other salutary effects, reduction of cellular adhesion to the vascular endothelium and inflammation, and dissecting these mechanisms has informed bench-both cellular and animal-research for development of the 3 recently approved agents: endari, voxelotor, and crizanlizumab; truly, a bidirectional bench to bedside translation. Decades of research to understand the mechanisms of fetal to adult hemoglobin have also culminated in promising anti-sickling genetic therapies and the first-in-human studies of reactivating an endogenous (γ-globin) gene HBG utilizing innovative genomic approaches.
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Affiliation(s)
- Gabriel Salinas Cisneros
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
- Division of Hematology and Oncology, Children’s National Medical Center, Washington, District of Columbia, USA
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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38
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Hasanali SL, Morera DS, Racine RR, Hennig M, Ghosh S, Lopez LE, Hupe MC, Escudero DO, Wang J, Zhu H, Sarcan S, Azih I, Zhou M, Jordan AR, Terris MK, Kuczyk MA, Merseburger AS, Lokeshwar VB. HYAL4-V1/Chondroitinase (Chase) Drives Gemcitabine Resistance and Predicts Chemotherapy Failure in Patients with Bladder Cancer. Clin Cancer Res 2021; 27:4410-4421. [PMID: 34031055 DOI: 10.1158/1078-0432.ccr-21-0422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/01/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Gemcitabine-based chemotherapy regimens are first-line for several advanced cancers. Because of better tolerability, gemcitabine + cisplatin is a preferred neoadjuvant, adjuvant, and/or palliative chemotherapy regimen for advanced bladder cancer. Nevertheless, predicting treatment failure and overcoming resistance remain unmet clinical needs. We discovered that splice variant (V1) of HYAL-4 is a first-in-class eukaryotic chondroitinase (Chase), and CD44 is its major substrate. V1 is upregulated in bladder cancer and drives a malignant phenotype. In this study, we investigated whether V1 drives chemotherapy resistance. EXPERIMENTAL DESIGN V1 expression was measured in muscle-invasive bladder cancer (MIBC) specimens by qRT-PCR and IHC. HYAL-4 wild-type (Wt) and V1 were stably expressed or silenced in normal urothelial and three bladder cancer cell lines. Transfectants were analyzed for chemoresistance and associated mechanism in preclinical models. RESULTS V1 levels in MIBC specimens of patients who developed metastasis, predicted response to gemcitabine + cisplatin adjuvant/salvage treatment and disease-specific mortality. V1-expressing bladder cells were resistant to gemcitabine but not to cisplatin. V1 expression neither affected gemcitabine influx nor the drug-efflux transporters. Instead, V1 increased gemcitabine metabolism and subsequent efflux of difluorodeoxyuridine, by upregulating cytidine deaminase (CDA) expression through increased CD44-JAK2/STAT3 signaling. CDA inhibitor tetrahydrouridine resensitized V1-expressing cells to gemcitabine. While gemcitabine (25-50 mg/kg) inhibited bladder cancer xenograft growth, V1-expressing tumors were resistant. Low-dose combination of gemcitabine and tetrahydrouridine abrogated the growth of V1 tumors with minimal toxicity. CONCLUSIONS V1/Chase drives gemcitabine resistance and potentially predicts gemcitabine + cisplatin failure. CDA inhibition resensitizes V1-expressing tumors to gemcitabine. Because several chemotherapy regimens include gemcitabine, our study could have broad significance.
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Affiliation(s)
- Sarrah L Hasanali
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Daley S Morera
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Ronny R Racine
- Department of Urology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Martin Hennig
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Santu Ghosh
- Department of Population Health Sciences, Augusta University, Augusta, Georgia
| | - Luis E Lopez
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Marie C Hupe
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Diogo O Escudero
- Molecular Cell and Developmental Biology Graduate Program, University of Miami-Miller School of Medicine, Miami, Florida
| | - Jiaojiao Wang
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Huabin Zhu
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Semih Sarcan
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ijeoma Azih
- Clinical Trials Office, Augusta University, Augusta, Georgia
| | - Michael Zhou
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Andre R Jordan
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia
| | - Martha K Terris
- Surgery, Division of Urology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Markus A Kuczyk
- Department of Urology and Urologic Oncology, Hannover Medical School, Hannover, Germany
| | - Axel S Merseburger
- Department of Urology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Vinata B Lokeshwar
- Departments of Biochemistry and Molecular Biology, Augusta University, Augusta, Georgia.
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Pavan AR, Dos Santos JL. Advances in Sickle Cell Disease Treatments. Curr Med Chem 2021; 28:2008-2032. [PMID: 32520675 DOI: 10.2174/0929867327666200610175400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/23/2020] [Accepted: 05/07/2020] [Indexed: 11/22/2022]
Abstract
Sickle Cell Disease (SCD) is an inherited disorder of red blood cells that is caused by a single mutation in the β -globin gene. The disease, which afflicts millions of patients worldwide mainly in low income countries, is characterized by high morbidity, mortality and low life expectancy. The new pharmacological and non-pharmacological strategies for SCD is urgent in order to promote treatments able to reduce patient's suffering and improve their quality of life. Since the FDA approval of HU in 1998, there have been few advances in discovering new drugs; however, in the last three years voxelotor, crizanlizumab, and glutamine have been approved as new therapeutic alternatives. In addition, new promising compounds have been described to treat the main SCD symptoms. Herein, focusing on drug discovery, we discuss new strategies to treat SCD that have been carried out in the last ten years to discover new, safe, and effective treatments. Moreover, non-pharmacological approaches, including red blood cell exchange, gene therapy and hematopoietic stem cell transplantation will be presented.
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Affiliation(s)
- Aline Renata Pavan
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, Sao Paulo State University (UNESP), Araraquara, Brazil
| | - Jean Leandro Dos Santos
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, Sao Paulo State University (UNESP), Araraquara, Brazil
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40
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Wessels MW, Cnossen MH, van Dijk TB, Gillemans N, Schmidt KLJ, van Lom K, Vinjamur DS, Coyne S, Kurita R, Nakamura Y, de Man SA, Pfundt R, Azmani Z, Brouwer RWW, Bauer DE, van den Hout MCGN, van IJcken WFJ, Philipsen S. Molecular analysis of the erythroid phenotype of a patient with BCL11A haploinsufficiency. Blood Adv 2021; 5:2339-2349. [PMID: 33938942 PMCID: PMC8114548 DOI: 10.1182/bloodadvances.2020003753] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/12/2021] [Indexed: 12/29/2022] Open
Abstract
The BCL11A gene encodes a transcriptional repressor with essential functions in multiple tissues during human development. Haploinsufficiency for BCL11A causes Dias-Logan syndrome (OMIM 617101), an intellectual developmental disorder with hereditary persistence of fetal hemoglobin (HPFH). Due to the severe phenotype, disease-causing variants in BCL11A occur de novo. We describe a patient with a de novo heterozygous variant, c.1453G>T, in the BCL11A gene, resulting in truncation of the BCL11A-XL protein (p.Glu485X). The truncated protein lacks the 3 C-terminal DNA-binding zinc fingers and the nuclear localization signal, rendering it inactive. The patient displayed high fetal hemoglobin (HbF) levels (12.1-18.7% of total hemoglobin), in contrast to the parents who had HbF levels of 0.3%. We used cultures of patient-derived erythroid progenitors to determine changes in gene expression and chromatin accessibility. In addition, we investigated DNA methylation of the promoters of the γ-globin genes HBG1 and HBG2. HUDEP1 and HUDEP2 cells were used as models for fetal and adult human erythropoiesis, respectively. Similar to HUDEP1 cells, the patient's cells displayed Assay for Transposase-Accessible Chromatin (ATAC) peaks at the HBG1/2 promoters and significant expression of HBG1/2 genes. In contrast, HBG1/2 promoter methylation and genome-wide gene expression profiling were consistent with normal adult erythropoiesis. We conclude that HPFH is the major erythroid phenotype of constitutive BCL11A haploinsufficiency. Given the essential functions of BCL11A in other hematopoietic lineages and the neuronal system, erythroid-specific targeting of the BCL11A gene has been proposed for reactivation of γ-globin expression in β-hemoglobinopathy patients. Our data strongly support this approach.
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Affiliation(s)
| | - Marjon H Cnossen
- Department of Pediatric Hematology
- Academic Center for Hemoglobinopathies and Rare Anemias
| | - Thamar B van Dijk
- Academic Center for Hemoglobinopathies and Rare Anemias
- Department of Cell Biology, and
| | - Nynke Gillemans
- Academic Center for Hemoglobinopathies and Rare Anemias
- Department of Cell Biology, and
| | - K L Juliëtte Schmidt
- Academic Center for Hemoglobinopathies and Rare Anemias
- Department of Cell Biology, and
| | - Kirsten van Lom
- Academic Center for Hemoglobinopathies and Rare Anemias
- Department of Hematology, Erasmus MC, Rotterdam, The Netherlands
| | - Divya S Vinjamur
- Division of Hematology/Oncology, Department of Pediatric Oncology, Boston Children's Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Stem Cell Institute, Boston, MA
- Broad Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Steven Coyne
- Division of Hematology/Oncology, Department of Pediatric Oncology, Boston Children's Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Stem Cell Institute, Boston, MA
- Broad Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ryo Kurita
- Department of Research and Development, Central Blood Institute, Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Yukio Nakamura
- Cell Engineering Division, RIKEN, BioResource Center, Tsukuba, Japan
| | - Stella A de Man
- Department of Pediatrics, Amphia Hospital, Breda, The Netherlands
| | - Rolph Pfundt
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - Zakia Azmani
- Department of Cell Biology, and
- Center for Biomics, Erasmus MC, Rotterdam, The Netherlands
| | - Rutger W W Brouwer
- Department of Cell Biology, and
- Center for Biomics, Erasmus MC, Rotterdam, The Netherlands
| | - Daniel E Bauer
- Division of Hematology/Oncology, Department of Pediatric Oncology, Boston Children's Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Stem Cell Institute, Boston, MA
- Broad Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Wilfred F J van IJcken
- Department of Cell Biology, and
- Center for Biomics, Erasmus MC, Rotterdam, The Netherlands
| | - Sjaak Philipsen
- Academic Center for Hemoglobinopathies and Rare Anemias
- Department of Cell Biology, and
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Schiffer M, Zhao J, Johnson A, Lee J, Bewersdorf JP, Zeidan AM. The development and clinical use of oral hypomethylating agents in acute myeloid leukemia and myelodysplastic syndromes: dawn of the total oral therapy era. Expert Rev Anticancer Ther 2021; 21:989-1002. [PMID: 33853476 DOI: 10.1080/14737140.2021.1918002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Intravenous and subcutaneous hypomethylating agents have held a key role in myelodysplastic syndrome, chronic myelomonocytic leukemia and acute myeloid leukemia treatment. Following the approval of the cedazuridine/decitabine combination, ASTX727, as well as development of an oral formulation of azacitidine, CC-486, in the USA in 2020, these agents could gradually replace their injectable counterparts. AREAS COVERED ASTX727 is approved for the treatment of adult patients with intermediate 1 or high-risk MDS as well as those with chronic myelomonocytic leukemia based on the findings from the ASTX727-01-B and ASCERTAIN trials. Oral azacitidine (CC-486) is approved for maintenance treatment of acute myeloid leukemia after induction chemotherapy for patients unfit for allogeneic hematopoietic cell transplant based on the findings from the QUAZAR AML-001 trial. EXPERT OPINION Oral hypomethylating agent formulations have the potential to offer a convenient alternative to injectable hypomethylating agent. However, their current FDA-approved indications are narrow and efficacy needs to be shown in clinical trials before considering use beyond the approved indications. Areas of special interest include: identification of predictive biomarkers for clinical benefit, post-transplant maintenance therapy, and potential combination therapies with other oral agents such as venetoclax, IDH and FLT3 inhibitors.
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Affiliation(s)
- Molly Schiffer
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jennifer Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Aubrey Johnson
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Jane Lee
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | | | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, and Yale Cancer Center, New Haven, CT, USA
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42
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Tukker AM, Royal CD, Bowman AB, McAllister KA. The Impact of Environmental Factors on Monogenic Mendelian Diseases. Toxicol Sci 2021; 181:3-12. [PMID: 33677604 PMCID: PMC8599782 DOI: 10.1093/toxsci/kfab022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Environmental factors and gene-environment interactions modify the variable expressivity, progression, severity, and onset of some classic (monogenic) Mendelian-inherited genetic diseases. Cystic fibrosis, Huntington disease, Parkinson's disease, and sickle cell disease are examples of well-known Mendelian disorders that are influenced by exogenous exposures. Environmental factors may act by direct or indirect mechanisms to modify disease severity, timing, and presentation, including through epigenomic influences, protein misfolding, miRNA alterations, transporter activity, and mitochondrial effects. Because pathological features of early-onset Mendelian diseases can mimic later onset complex diseases, we propose that studies of environmental exposure vulnerabilities using monogenic model systems of rare Mendelian diseases have high potential to provide insight into complex disease phenotypes arising from multi-genetic/multi-toxicant interactions. Mendelian disorders can be modeled by homologous mutations in animal model systems with strong recapitulation of human disease etiology and natural history, providing an important advantage for study of these diseases. Monogenic high penetrant mutations are ideal for toxicant challenge studies with a wide variety of environmental stressors, because background genetic variability may be less able to alter the relatively strong phenotype driving disease-causing mutations. These models promote mechanistic understandings of gene-environment interactions and biological pathways relevant to both Mendelian and related sporadic complex disease outcomes by creating a sensitized background for relevant environmental risk factors. Additionally, rare disease communities are motivated research participants, creating the potential of strong research allies among rare Mendelian disease advocacy groups and disease registries and providing a variety of translational opportunities that are under-utilized in genetic or environmental health science.
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Affiliation(s)
- Anke M Tukker
- School of Health Sciences, Purdue University, West Lafayette, Indiana 47907-2051
| | - Charmaine D Royal
- Departments of African and African American Studies, Biology, Global Health, and Family Medicine and Community Health and Center on Genomics, Race, Identity, Difference, Duke University, Durham, North Carolina 27708
| | - Aaron B Bowman
- School of Health Sciences, Purdue University, West Lafayette, Indiana 47907-2051
| | - Kimberly A McAllister
- Genes Environment and Health Branch, Division of Extramural Research and Training, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina 27709
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43
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Patel AA, Cahill K, Saygin C, Odenike O. Cedazuridine/decitabine: from preclinical to clinical development in myeloid malignancies. Blood Adv 2021; 5:2264-2271. [PMID: 33904891 PMCID: PMC8095139 DOI: 10.1182/bloodadvances.2020002929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/23/2021] [Indexed: 12/23/2022] Open
Abstract
Since the US Food and Drug Administration (FDA) approvals of parenteral decitabine and azacitidine, DNA methyltransferase inhibitors, otherwise referred to as DNA hypomethylating agents (HMAs), have been a mainstay in the treatment of higher-risk myelodysplastic syndromes. The development of oral HMAs has been an area of active interest; however, oral bioavailability has been quite poor due to rapid metabolism by cytidine deaminase (CDA). This led to the development of the novel CDA inhibitor cedazuridine, which was combined with an oral formulation of decitabine. Preclinical work demonstrated a pharmacokinetic and pharmacodynamic profile approximate to parenteral decitabine, leading to early-phase clinical trials of oral cedazuridine-decitabine (C-DEC) in myelodysplastic syndromes and chronic myelomonocytic leukemia (CMML). A combination of oral decitabine 35 mg with oral cedazuridine 100 mg was established as the recommended phase 2 dose. Phase 2 data confirmed bioequivalence of C-DEC when compared with parenteral decitabine, and a larger phase 3 trial has demonstrated similar results, leading to the FDA approval of C-DEC for use in intermediate/high-risk myelodysplastic syndrome (MDS) and CMML. This review will focus upon the current role of HMA therapy in MDS/CMML, preclinical and clinical development of C-DEC, and potential roles of oral HMA therapy in myeloid malignancies moving forward.
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Affiliation(s)
- Anand A Patel
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Kirk Cahill
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Caner Saygin
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Olatoyosi Odenike
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine, Chicago, IL
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44
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Abstract
Fetal hemoglobin (HbF) can blunt the pathophysiology, temper the clinical course, and offer prospects for curative therapy of sickle cell disease. This review focuses on (1) HbF quantitative trait loci and the geography of β-globin gene haplotypes, especially those found in the Middle East; (2) how HbF might differentially impact the pathophysiology and many subphenotypes of sickle cell disease; (3) clinical implications of person-to-person variation in the distribution of HbF among HbF-containing erythrocytes; and (4) reactivation of HbF gene expression using both pharmacologic and cell-based therapeutic approaches. A confluence of detailed understanding of the molecular basis of HbF gene expression, coupled with the ability to precisely target by genomic editing most areas of the genome, is producing important preliminary therapeutic results that could provide new options for cell-based therapeutics with curative intent.
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45
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Gu X, Tohme R, Tomlinson B, Sakre N, Hasipek M, Durkin L, Schuerger C, Grabowski D, Zidan AM, Radivoyevitch T, Hong C, Carraway H, Hamilton B, Sobecks R, Patel B, Jha BK, Hsi ED, Maciejewski J, Saunthararajah Y. Decitabine- and 5-azacytidine resistance emerges from adaptive responses of the pyrimidine metabolism network. Leukemia 2021; 35:1023-1036. [PMID: 32770088 PMCID: PMC7867667 DOI: 10.1038/s41375-020-1003-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023]
Abstract
Mechanisms-of-resistance to decitabine and 5-azacytidine, mainstay treatments for myeloid malignancies, require investigation and countermeasures. Both are nucleoside analog pro-drugs processed by pyrimidine metabolism into a deoxynucleotide analog that depletes the key epigenetic regulator DNA methyltranseferase 1 (DNMT1). Here, upon serial analyses of DNMT1 levels in patients' bone marrows on-therapy, we found DNMT1 was not depleted at relapse. Showing why, bone marrows at relapse exhibited shifts in expression of key pyrimidine metabolism enzymes in directions adverse to pro-drug activation. Further investigation revealed the origin of these shifts. Pyrimidine metabolism is a network that senses and regulates deoxynucleotide amounts. Deoxynucleotide amounts were disturbed by single exposures to decitabine or 5-azacytidine, via off-target depletion of thymidylate synthase and ribonucleotide reductase respectively. Compensating pyrimidine metabolism shifts peaked 72-96 h later. Continuous pro-drug exposures stabilized these adaptive metabolic responses to thereby prevent DNMT1-depletion and permit exponential leukemia out-growth as soon as day 40. The consistency of the acute metabolic responses enabled exploitation: simple treatment modifications in xenotransplant models of chemorefractory leukemia extended noncytotoxic DNMT1-depletion and leukemia control by several months. In sum, resistance to decitabine and 5-azacytidine originates from adaptive responses of the pyrimidine metabolism network; these responses can be anticipated and thus exploited.
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Affiliation(s)
- Xiaorong Gu
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rita Tohme
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Tomlinson
- Department of Hematology and Oncology, University Hospitals, Cleveland, OH, USA
| | - Nneha Sakre
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Metis Hasipek
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa Durkin
- Department of Clinical Pathology, Tomsich Pathology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Caroline Schuerger
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dale Grabowski
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Asmaa M Zidan
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tomas Radivoyevitch
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Changjin Hong
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Hetty Carraway
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Betty Hamilton
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ronald Sobecks
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bhumika Patel
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Babal K Jha
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric D Hsi
- Department of Clinical Pathology, Tomsich Pathology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jaroslaw Maciejewski
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yogen Saunthararajah
- Department of Translational Hematology & Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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Targeting aberrant DNA hypermethylation as a driver of ATL leukemogenesis by using the new oral demethylating agent OR-2100. Blood 2021; 136:871-884. [PMID: 32391874 DOI: 10.1182/blood.2019003084] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/10/2020] [Indexed: 12/15/2022] Open
Abstract
Adult T-cell leukemia-lymphoma (ATL) is an aggressive hematological malignancy of CD4+ T cells transformed by human T-cell lymphotropic virus-1 (HTLV-1). Most HTLV-1-infected individuals are asymptomatic, and only 3% to 5% of carriers develop ATL. Here, we describe the contribution of aberrant DNA methylation to ATL leukemogenesis. HTLV-1-infected T-cells and their uninfected counterparts were separately isolated based on CADM1 and CD7 expression status, and differentially methylated positions (DMPs) specific to HTLV-infected T cells were identified through genome-wide DNA methylation profiling. Accumulation of DNA methylation at hypermethylated DMPs correlated strongly with ATL development and progression. In addition, we identified 22 genes downregulated because of promoter hypermethylation in HTLV-1-infected T cells, including THEMIS, LAIR1, and RNF130, which negatively regulate T-cell receptor (TCR) signaling. Phosphorylation of ZAP-70, a transducer of TCR signaling, was dysregulated in HTLV-1-infected cell lines but was normalized by reexpression of THEMIS. Therefore, we hypothesized that DNA hypermethylation contributes to growth advantages in HTLV-1-infected cells during ATL leukemogenesis. To test this idea, we investigated the anti-ATL activities of OR-1200 and OR-2100 (OR21), novel decitabine (DAC) prodrugs with enhanced oral bioavailability. Both DAC and OR21 inhibited cell growth, accompanied by global DNA hypomethylation, in xenograft tumors established by implantation of HTLV-1-infected cells. OR21 was less hematotoxic than DAC, whereas tumor growth inhibition was almost identical between the 2 compounds, making it suitable for long-term treatment of ATL patient-derived xenograft mice. Our results demonstrate that regional DNA hypermethylation is functionally important for ATL leukemogenesis and an effective therapeutic target.
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Pace BS, Starlard-Davenport A, Kutlar A. Sickle cell disease: progress towards combination drug therapy. Br J Haematol 2021; 194:240-251. [PMID: 33471938 DOI: 10.1111/bjh.17312] [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: 09/15/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 12/23/2022]
Abstract
Dr. John Herrick described the first clinical case of sickle cell anaemia (SCA) in the United States in 1910. Subsequently, four decades later, Ingram and colleagues characterized the A to T substitution in DNA producing the GAG to GTG codon and replacement of glutamic acid with valine in the sixth position of the βS -globin chain. The establishment of Comprehensive Sickle Cell Centers in the United States in the 1970s was an important milestone in the development of treatment strategies and describing the natural history of sickle cell disease (SCD) comprised of genotypes including homozygous haemoglobin SS (HbSS), HbSβ0 thalassaemia, HbSC and HbSβ+ thalassaemia, among others. Early drug studies demonstrating effective treatments of HbSS and HbSβ0 thalassaemia, stimulated clinical trials to develop disease-specific therapies to induce fetal haemoglobin due to its ability to block HbS polymerization. Subsequently, hydroxycarbamide proved efficacious in adults with SCA and was Food and Drug Administration (FDA)-approved in 1998. After two decades of hydroxycarbamide use for SCD, there continues to be limited clinical acceptance of this chemotherapy drug, providing the impetus for investigators and pharmaceutical companies to develop non-chemotherapy agents. Investigative efforts to determine the role of events downstream of deoxy-HbS polymerization, such as endothelial cell activation, cellular adhesion, chronic inflammation, intravascular haemolysis and nitric oxide scavenging, have expanded drug targets which reverse the pathophysiology of SCD. After two decades of slow progress in the field, since 2018 three new drugs were FDA-approved for SCA, but research efforts to develop treatments continue. Currently over 30 treatment intervention trials are in progress to investigate a wide range of agents acting by complementary mechanisms, providing the rationale for ushering in the age of effective and safe combination drug therapy for SCD. Parallel efforts to develop curative therapies using haematopoietic stem cell transplant and gene therapy provide individuals with SCD multiple treatment options. We will discuss progress made towards drug development and potential combination drug therapy for SCD with the standard of care hydroxycarbamide.
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Affiliation(s)
- Betty S Pace
- Department of Pediatrics, Augusta University, Augusta, GA, USA.,Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA, USA
| | - Athena Starlard-Davenport
- Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Abdullah Kutlar
- Department of Medicine, Center for Blood Disorders, Augusta University, Augusta, GA, USA
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When basic science reaches into rational therapeutic design: from historical to novel leads for the treatment of β-globinopathies. Curr Opin Hematol 2021; 27:141-148. [PMID: 32167946 DOI: 10.1097/moh.0000000000000577] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW β-hemoglobinopathies, such as β-Thalassemias (β-Thal) and sickle cell disease (SCD) are among the most common inherited genetic disorders in humans worldwide. These disorders are characterized by a quantitative (β-Thal) or qualitative (SCD) defects in adult hemoglobin production, leading to anemia, ineffective erythropoiesis and severe secondary complications. Reactivation of the fetal globin genes (γ-globin), making-up fetal hemoglobin (HbF), which are normally silenced in adults, represents a major strategy to ameliorate anemia and disease severity. RECENT FINDINGS Following the identification of the first 'switching factors' for the reactivation of fetal globin gene expression more than 10 years ago, a multitude of novel leads have recently been uncovered. SUMMARY Recent findings provided invaluable functional insights into the genetic and molecular networks controlling globin genes expression, revealing that complex repression systems evolved in erythroid cells to maintain HbF silencing in adults. This review summarizes these unique and exciting discoveries of the regulatory factors controlling the globin switch. New insights and novel leads for therapeutic strategies based on the pharmacological induction of HbF are discussed. This represents a major breakthrough for rational drug design in the treatment of β-Thal and SCD.
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Ultimate Precision: Targeting Cancer But Not Normal Self-Replication. Lung Cancer 2021. [DOI: 10.1007/978-3-030-74028-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Hill B, Jagadeesh D, Pohlman B, Dean R, Parameswaran N, Chen J, Radivoyevitch T, Morrison A, Fada S, Dever M, Robinson S, Lindner D, Smith M, Saunthararajah Y. A pilot clinical trial of oral tetrahydrouridine/decitabine for noncytotoxic epigenetic therapy of chemoresistant lymphoid malignancies. Semin Hematol 2021; 58:35-44. [PMID: 33509441 PMCID: PMC7847482 DOI: 10.1053/j.seminhematol.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/29/2020] [Indexed: 11/11/2022]
Abstract
One mechanism by which lymphoid malignancies resist standard apoptosis-intending (cytotoxic) treatments is genetic attenuation of the p53/p16-CDKN2A apoptosis axis. Depletion of the epigenetic protein DNA methyltransferase 1 (DNMT1) using the deoxycytidine analog decitabine is a validated approach to cytoreduce malignancy independent of p53/p16. In vivo decitabine activity, however, is restricted by rapid catabolism by cytidine deaminase (CDA). We, therefore, combined decitabine with the CDA-inhibitor tetrahydrouridine and conducted a pilot clinical trial in patients with relapsed lymphoid malignancies: the doses of tetrahydrouridine/decitabine used (∼10/0.2 mg/kg orally (PO) 2×/week) were selected for the molecular pharmacodynamic objective of non-cytotoxic, S-phase dependent, DNMT1-depletion, guided by previous Phase 1 studies. Patients with relapsed/refractory B- or T-cell malignancies (n = 7) were treated for up to 18 weeks. Neutropenia without concurrent thrombocytopenia is an expected toxicity of DNMT1-depletion and occurred in all patients (Grade 3/4). Subjective and objective clinical improvements occurred in 4 of 7 patients, but these responses were lost upon treatment interruptions and reductions to manage neutropenia. We thus performed parallel experiments in a preclinical in vivo model of lymphoma to identify regimen refinements that might sustain DNMT1-targeting in malignant cells but limit neutropenia. We found that timed-alternation of decitabine with the related molecule 5-azacytidine, and combination with inhibitors of CDA and de novo pyrimidine synthesis could leverage feedback responses of pyrimidine metabolism to substantially increase lymphoma cytoreduction but with less neutropenia. In sum, regimen innovations beyond incorporation of a CDA-inhibitor are needed to sustain decitabine DNMT1-targeting and efficacy against chemo-resistant lymphoid malignancy. Such potential solutions were explored in preclinical in vivo studies.
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Affiliation(s)
- Brian Hill
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | - Deepa Jagadeesh
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Brad Pohlman
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Robert Dean
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Neetha Parameswaran
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Joel Chen
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Ashley Morrison
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sherry Fada
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Meredith Dever
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Shelley Robinson
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel Lindner
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Mitchell Smith
- Department of Hematology and Oncology, George Washington University, DC
| | - Yogen Saunthararajah
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
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