Angelo Vertti, 18 de setembro de 2022

A total of 33 treatment-related adverse events occurred in 8 participants; 17 events were vector-related, including 1 serious adverse event, and 16 were glucocorticoid-related. In our trial, nonsustained, drug-related elevations in alanine aminotransferase levels that met toxicity criteria (>2.5 to 3.6 times the upper limit of the normal range) occurred in 22% of the participants who had a cellular immune response against SPK200. The full-length AAV5-hFVIII-SQ is >4.9 kb, which is over the optimal packaging limit of AAV5. Interindividual variability in transgene mRNA and protein - PubMed Clipboard, Search History, and several other advanced features are temporarily unavailable. Roctavian (ValRox, Valoctocogene Roxaparvovec) - Rare Disease Advisor Among four participants, there were seven nonsustained elevations in alanine aminotransferase levels that met protocol-specified toxicity criteria: six elevations were grade 1 (>2.5 to 2.9 times the upper limit of the normal range), and one elevation was grade 2 (Fig. N Engl J Med. Simioni P, Cagnin S, Sartorello F, et al. 2021 Nov 18;385(21):1961-1973. doi: 10.1056/NEJMoa2104205. However, deep-sequencing studies show that integration of the AAV genome can occur in the liver.38,39 Indeed, a recent publication has found wild-type AAV2 genome fragments integrated in the proximity of known proto-oncogenes in a small percentage of human hepatocellular carcinoma specimens40; however, the pathogenic role of AAV2 in this setting is not certain. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. All participant data were analyzed (Fig. Nathwani AC, Tuddenham EGD, Rangarajan S, et al. Hemophilia A is a genetic disease caused by a deficiency of clotting factor VIII. 2017 Nov;28(11):1013-1023. doi: 10.1089/hum.2017.116. 2022 Mar 17;386(11):1013-1025. doi: 10.1056/NEJMoa2113708. ), and Spark Therapeutics (P.E.M., A.M., K.J., R.N., M.C., K.K., F.M., T.C., K.Z.R., X.M.A., K.A.H. Bilirubin, alkaline phosphatase, and -glutamyl-transpeptidase levels remained in the normal range. In a separate phase 1/2 clinical trial (GO-8; NCT03001830), the FVIII construct used in the BioMarin study was modified to include a 17-amino-acid peptide comprising 6 N-linked glycosylation motifs from the human FVIII B-domain (AAV-HLP-hFVIII-V3) that are highly conserved through evolution.34 In murine studies, AAVHLP-hFVIII-V3 mediated expression of FVIII at threefold higher levels compared with AAVHLP-hFVIII-SQ, encoding the conventional B domaindeleted FVIII. Our phase 12 trial data showed that SPK-8011 imparted multiyear durable factor VIII expression that significantly reduced bleeding. Consistent with findings in other trials of therapy for hemophilia A,7,22 factor VIII activity that was determined with the use of a one-stage factor VIII assay was 1.5 times as high as that determined with the use of a chromogenic factor VIII assay (Fig. . AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. Endogenous factor VIII activity greater than 10% of the normal value is associated with a low risk of spontaneous joint bleeding.3,4 Either recurrent intravenous infusion of exogenous factor or sub-cutaneous administration of a factor VIIImimetic bispecific monoclonal antibody, emicizumab, is currently used to confer a moderate or mild hemophilia phenotype in patients with hemophilia A.3,5,6, Multiple ongoing clinical trials of gene therapy for hemophilia A involve the use of recombinant adeno-associated viral (AAV) vectors to target hepatocyte factor VIII expression with the goal of a one-time disease-altering therapy. Mean FIX activity at 36 weeks postgene transfer in the 3 patients enrolled to date was 45%, with no reports of transaminitis.30 Therefore, these results are on par with SPK-9001. 2023 May 19;24(10):9023. doi: 10.3390/ijms24109023. Because of the prolonged use of immune modulation in the participants who received prophylactic glucocorticoids, Participant 18 received glucocorticoids when evidence of an immune response to the vector was noted and expression was maintained. , , Considerations for shared decision management in previously untreated patients with hemophilia A or B. RNAi-mediated rheostat for dynamic control of AAV-delivered transgenes. 2021 Nov 18;385(21):1961-1973. doi: 10.1056/NEJMoa2104205. 3,4 Cessation of corticosteroids was not associated with an increase in ALT levels or a decrease in FIX activity. Thereafter, the participants received a single, intravenous infusion of SPK-8011 on an outpatient basis. The recent progress of gene therapy for HA with viral and nonviral delivery vectors, including piggyBac, lentiviral and adeno-associated viral vectors, are discussed, as well as new raising issues involving liver toxicity, pre-existing neutralizing antibodies of viral approach, and the selection of the target cell type for nonViral delivery. The median safety observation period was 36.6 months (range, 5.5 to 50.3). The development of a new generation of lentiviral vectors designed for efficient delivery of the transgene to the liver following systemic delivery of vectors carrying FVIII and FIX shows great promise and supports the further evaluation of this approach in the clinic.49. 2A) and a 96.4% reduction (95% CI, 95.7 to 97.1) in the annualized number of factor VIII infusions (median, 57.5 infusions [range, 24 to 245] per year before vector administration vs. 0.6 [range, 0 to 28.6] after administration) (Fig. It is demonstrated that increasing time with a FVIII below 1IUdL1 is associated with increased total bleeds and hemarthroses, and has important implications for the management of patients with severe hemophilia. Mol Ther. Methods: The dose under evaluation in AMT-061 is 2e13 vg/kg, the highest used in the AMT-060 Phase 1/2 trial. Valoctocogene roxaparvovec (AAV5-hFVIII-SQ) gene transfer provided reduced bleeding for adult clinical trial participants with severe hemophilia A. Factor VIII activity levels remained at 3 IU or less per deciliter in the recipients of the low or intermediate dose. Hematology Am Soc Hematol Educ Program 2019; 2019 (1): 18. Although the reason for this late decline in FVIII activity remains unclear, potential explanations include loss of the episomally retained oversized FVIII AAV transgene from the transduced hepatocytes and silencing of the FVIII transgene. Potential for cellular stress response to hepatic factor VIII expression from AAV vector, Engineering adeno-associated viral vectors to evade innate immune and inflammatory responses, Protein-engineered coagulation factors for hemophilia gene therapy. Participant 5 was lost to follow-up 32.6 months after administration of vector. Standard of care for people with severe haemophilia A is prophylactic administration of exogenous factor VIII (FVIII) or emicizumab to reduce frequency of bleeding. This has engendered interest in targeting approaches.46 One such approach, GeneRide, entails the use of AAV vectors to deliver a promoterless FIX gene flanked by a guide DNA arm that is several hundred base pairs long and matches a specific locus (eg, albumin locus). RNAi for the Treatment of People with Hemophilia: Current Evidence and Patient Selection. 2023 Apr 17;14:20406207231165857. doi: 10.1177/20406207231165857. eCollection 2023 Jun 13. Early treatment is needed for people with severe hemophilia A, but gene therapies have only been tested clinically in adults. Advances in gene therapy for hemophilia: basis, current status, and future perspectives. However, pediatric outcomes are unknown. Safety end points included adverse events and the changes from baseline in findings on physical examination and laboratory values. MeSH Results: Updated follow-up of the Alta study, a phase 1/2, open-label, adaptive, dose-ranging study to assess the safety and tolerability of SB-525 gene therapy. Characteristics of the Participants at Baseline and after Gene Transfer.*. ), Philadelphia, the Department of Medicine, Division of Hematology and Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey (M.E.E. The gray vertical line indicates an annualized rate of spontaneous bleeding of 1 event. and transmitted securely. Lange AM, Altynova ES, Nguyen GN, Sabatino DE. Efficacy end points included factor VIII activity determined by a central laboratory on the basis of a steady-state one-stage factor VIII assay and the number of factor VIII infusions and bleeding events after vector administration. Left untreated, this capsid immune response results in complete loss of transgene expression. Gene therapy for hemophilia cannot be given to patients with anti-AAV capsid-neutralizing antibodies, and cellular immunity with CD8 + T cells should be controlled for sustained expression, and long-term therapeutic effects should be closely observed because of the failure of the AAV vector genome to replicate during cell division. PDF Supplementary Appendix - The New England Journal of Medicine den Uijl IEM, Fischer K, Van Der Bom JG, Grobbee DE, Rosendaal FR, Plug I. Thirtyone percent of people with hemophilia B had neutralizing factors against AAV6. S1 in the Supplementary Appendix, available at NEJM.org).19 SPK-8011 was manufactured with transient triple transfection of human embryonic kidney cells (HEK293 cells), and titers were determined by means of quantitative polymerase chain reaction (Supplementary Methods section in the Supplementary Appendix). Engineered adeno-associated virus 3 vector with reduced reactivity to AAV5-Factor VIII Gene Transfer in Severe Hemophilia A | NEJM Hum Gene Ther. The safety and efficacy of AAV8 serotype pseudotyped HLP-hFVIII-V3, manufactured in mammalian HEK-293 cells, have been assessed in 3 adult men with severe hemophilia A with a short follow-up period of 13 to 47 weeks; FVIII levels of 69% were achieved in 1 of the patients treated at a dose of 2e12 vg/kg. Molecular analysis of AAV5-hFVIII-SQ vector-genome-processing 2020 Jan 2;382(1):29-40. doi: 10.1056/NEJMoa1908490. The limited packaging capacity of AAV vectors (4680 nucleotides) and the poor expression profile of FVIII have hindered the use of these vectors for gene therapy of hemophilia A. *, Four participants had adverse events related to glucocorticoids (Table 2). AAV5-factor VIII gene transfer in severe hemophilia A. N Engl J Med 2017;377:2519-30. Copyright 2023 by American Society of Hematology, Recent advances in hemophilia treatment and the rationale for gene therapy, Recent trials of gene transfer in hemophilia B, AAV vectors and gene therapy for hemophilia A, Obstacles to wider use of AAV vector technology, Alternative gene therapy approaches that show promise, https://doi.org/10.1182/hematology.2019000007, Transient except in 1 patient who had expression of 25% at last report, Codon-optimized FIX containing the Padua mutation, In phase 3 trial as AMT-061 using a FIX cDNA containing the Padua mutation, AAV6/zinc-fingermediated targeted integration into the albumin locus in hepatocytes. Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. For instance, the decrease in expression in the 4e13-vg/kg dose cohort was modest. All but 1 participant had baseline hemophilic arthropathy (mean [SD] number of arthropathic joints, 2.81.7; range, 0 to 6.0). AAV5-factor VIII gene transfer in severe hemophilia A. Completed recruitment to low (6e11 vg/kg) and intermediate (2e12 vg/kg) dose levels. Emicizumab prophylaxis in patients who have hemophilia A without inhibitors, AAV5-factor VIII gene transfer in severe hemophilia A. Pasi KJ, Rangarajan S, Mitchell N, et al. J. Med. Confocal microscopy analysis of native, full length and B-domain deleted coagulation factor VIII trafficking in mammalian cells, Enhanced biosynthesis of coagulation factor VIII through diminished engagement of the unfolded protein response. Integrating vectors, based on lentivirus to propagate integration of the FIX or FVIII transgene into target cells, is also under evaluation in hematopoietic stem cells or blood outgrowth endothelial cells following ex vivo manipulations. 1, 2 However, some people with severe haemophilia A on prophylaxis still experience bleeding. Five participants did not receive glucocorticoids. Epub 2017 Apr 11. FVIII expression = 7-30%. Our trial provided data on multiyear, stable factor VIII expression after hepatocyte-directed AAV gene transfer. 1 INTRODUCTION. Here, Zhang, Yates, and colleagues found dosing neonatal mice with the same absolute number of valoctocogene roxaparvovec (AAV5-hFVIII-SQ) vector genomes as adult mice resulted in appreciable transgene expression into adulthood. Attention is currently focused on the downstream purification process so that the purity of clinical-grade AAV preparation can be improved. Overexpression of factor VIII after AAV delivery is transiently associated with cellular stress in hemophilia A mice, Factor VIII exhibits chaperone-dependent and glucose-regulated reversible amyloid formation in the endoplasmic reticulum. Valoctocogene roxaparvovec (BMN 270) is an AAV type 5 (AAV5)-mediated gene therapy developed for the treatment of HA, and it encodes a codon-optimized, B-domain-deleted human FVIII protein (hFVIII-SQ) under control of a hybrid liver-specific promoter. Hemophilia Gene Therapy: Ready for Prime Time? Several obstacles still remain, but the field is evolving at a rapid pace, raising the prospects of eventual licensure of gene therapy for the hemophilias. Four dose cohorts were enrolled; the lowest-dose cohort received a dose of 5 1011 vector genomes (vg) per kilogram of body weight, and the highest-dose cohort received 2 1012 vg per kilogram. Would you like email updates of new search results? In response to the loss of factor VIII expression in two participants, the protocol was amended, and the subsequent five participants (Participants 13 through 17) received prophylactic glucocorticoids that were initiated early (2 to 4 weeks after vector administration); transgene expression was maintained in all these participants. Hemophilia A gene therapy trial using AAV. Patients with hemophilia A rely on exogenous factor VIII to prevent bleeding in joints, soft tissue, and the central nervous system. The participants were followed for 52 weeks after vector administration, and all the participants subsequently were enrolled in a 4-year long-term follow-up trial. In the gene therapy trial that followed (SPK-9001), sustained mean FIX activity of 36% was observed in the 10 subjects following a single administration of vector at a dose of 5e11 vg/kg. Considerations for shared decision management in previously untreated patients with hemophilia A or B. Seven participants (who had received 61013 vg per kilogram) had a median factor VIII expression of 20 IU per deciliter; the median number of annualized treated bleeding events was 0, and the median use of exogenous factor VIII was reduced from 138.5 infusions to 0 infusions per year. The first author wrote the first draft of the manuscript with subsequent input from the other authors and without editorial assistance. No major safety concerns were reported. Zolotukhin I, Markusic DM, Palaschak B, Hoffman BE, Srikanthan MA, Herzog RW. Unlike FVIII, emicizumab is active in plasma all of the time and is associated with microangiopathy and thrombosis, particularly when used in combination with activated prothrombin complex concentrates.8 Other novel approaches entail the lowering of endogenous anticoagulants, such as antithrombin or tissue factor pathway inhibitor, with antisense RNA technology (fitusiran)9 or a monoclonal antibody (eg, concizumab),10 respectively. Therefore, a small increase in plasma FIX antigen levels would lead to a substantial increase in plasma FIX clotting activity. AAV5-hFVIII-SQ differs from SPK-8011 in that it was manufactured with baculovirus transduction of Spodoptera frugiperda (Sf9) cells. There was no evidence of inhibitor formation to FIX-Padua. ), and the Department of Medicine, University of Pittsburgh, Pittsburgh (M.V.R.) Hemophilia provides an attractive target for gene therapy studies, due to the monogenic nature of these disorders and easily measurable endpoints (factor levels and bleed rates), and AAV based gene therapy is one of a number of novel approaches for treatment of hemophilia progressing through clinical trials. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Before Ozelo MC, Mahlangu J, Pasi KJ, Giermasz A, Leavitt AD, Laffan M, Symington E, Quon DV, Wang JD, Peerlinck K, Pipe SW, Madan B, Key NS, Pierce GF, O'Mahony B, Kaczmarek R, Henshaw J, Lawal A, Jayaram K, Huang M, Yang X, Wong WY, Kim B; GENEr8-1 Trial Group. The hemophilias are ideally suited for gene therapy because a small increment in . The safe achievement of sustained, stable, and predictable factor VIII levels in all participants, even in the presence of immune responses, remains an unrealized goal of gene therapy for hemophilia A. sharing sensitive information, make sure youre on a federal The first participant was enrolled on January 26, 2017, and the data cutoff date for the analysis was May 3, 2021. Careers. Haemophilia - Emerging treatments Safety is further enhanced by the dependence of AAV on coinfection with a helper virus (usually adenovirus or herpesvirus) for productive infection. HHS Vulnerability Disclosure, Help Molecular therapy : the journal of the American Society of Gene Therapy, View 4 excerpts, cites background and methods, Molecular therapy. Although successful gene transfer has been reported in patients with hemophilia B, the large size of the factor VIII coding region has precluded improved outcomes with gene therapy in patients with hemophilia A. Partial F8 gene duplication (factor VIII Padua) associated with high factor VIII levels and familial thrombophilia. The FVIII B-domain, which is not required for cofactor activity, was removed to reduce the size of the FVIII expression cassette. All the participants had factor VIII expression after vector administration. Ther Adv Hematol. Notably, 2 subjects treated at the high-dose level had no evidence of transaminitis and did not require treatment with steroids. Konkle BASK, Visweshwar N, Harrington TJ, et al. Progression of preexisting chronic arthropathy in one participant was the only serious adverse event. Additional objectives were to characterize expression pharmacokinetics and the immune response to SPK200 and expressed factor VIII-SQ protein. No neutralizing antibodies to factor VIII were detected. However, the Nathwani group developed an AAV-based gene-transfer approach that addresses the size constraints and inefficient FVIII expression. AAV5-factor viii gene transfer in severe hemophilia . In general, higher vector doses were required for therapeutic transgene expression when the vector preparations were made using the insect cellbaculovirus method. The protocol, available with the full text of this article at NEJM.org, was approved by the institutional review board at each investigative site. Disclaimer. Hemophilia B gene therapy with a high-specific-activity factor IX variant, BAX 335 hemophilia B gene therapy clinical trial results: potential impact of CpG sequences on gene expression, Selection and evaluation of clinically relevant AAV variants in a xenograft liver model, CpG reduced factor VIII variants, compositions and methods and uses for treatment of hemostasis disorders. 1. Panel A shows the annualized rate of bleeding events before and after vector infusion. Federal government websites often end in .gov or .mil. Two of the 18 participants, both of whom were in the cohort that received 2 1012 vg per kilogram, lost expression after a cellular immune response against SPK200 detailed below and in the Supplementary Results section in the Supplementary Appendix. Specifically, for the difference between matched pairs (i.e., an individual participants mean factor VIII activity when not receiving glucocorticoids during the period from 26 to 52 weeks vs. that participants mean factor VIII activity after 52 weeks), the confidence interval was 2.4 to 0.6 (Fig. 2021 Nov 18;385 . Methods: AAV5-hFVIII-SQ is currently under clinical investigation as a treatment for severe hemophilia A. 2023 May;56(5):e13467. Despite this widening therapeutic choice for the treatment of the hemophilia, gene therapy has great appeal because it offers the potential for a cure through endogenous production of FVIII or FIX following transfer of a normal copy of the respective gene. Building on these early studies, a novel approach for hemophilia B gene therapy (St. Jude Childrens Research Hospital [St. Jude]/University Collegel London [UCL]; NCT00979238) that addressed some of the limitations of previous trials was developed. For instance, AAV5 serotype pseudotyped vectors (AMT-060; UniQure Therapeutics, Amsterdam, The Netherlands) made using the insect cellbaculovirus method, but containing the same FIX gene cassette as that used in the St. Jude/UCL trial, resulted in mean FIX activity levels of 6.9%, despite using a log higher vector dose of 2e13 vg/kg.25 Increased ALT levels were observed in 3 of 10 patients recruited to AMT-060, requiring treatment with corticosteroids. Multiyear factor VIII expression after AAV gene transfer for hemophilia A. N Engl J Med. Indeed, longer follow-up of patients in the BMN 270-201 study shows a decline in FVIII activity of 50% between years 1 and 2 postgene transfer, with a slower decline between years 2 and 3. Hematology. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. N. Engl. official website and that any information you provide is encrypted Of the 34 men with hemophilia A who underwent screening, 18 men (18 to 52 years of age) were enrolled, received vector, and were followed for safety for a median of 36.6 months (range, 5.5 to 50.3) after administration of SPK-8011. Spontaneous hemorrhage classically occurs frequently in severe hemophilia (factor VIII activity, <1% of the normal value), infrequently in moderate hemophilia (1 to <5% of the normal value), and rarely in mild hemophilia (5 to <40% of the normal value). ); the Department of Cell and Molecular Therapies, Royal Prince Alfred Hospital, and the Gene and Stem Cell Therapy Program, Centenary Institute, Faculty of Medicine and Health, University of Sydney both in Camperdown, NSW, Australia (J.E.J.R. Mol Ther Nucleic Acids. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. The first study to use AAV vectors in hemophilia patients used ones based on AAV serotype 2, the first serotype to be isolated and fully characterized (Table 1).16,17 Intramuscular injections of AAV vector encoding the FIX gene in this study were not associated with serious adverse events, but efficacy was not observed in any of the 7 subjects recruited, despite immunohistochemical evidence of FIX expression at the site of injection. Continued progression toward flexible scalable production and purification methodologies is ongoing to support the commercialization of AAV biotherapeutics. S. et al. In the remaining 16 participants, factor VIII expression was maintained; 12 of these participants were followed for more than 2 years, and a one-stage factor VIII assay showed no apparent decrease in factor VIII activity over time (mean [SD] factor VIII activity, 12.96.9% of the normal value at 26 to 52 weeks when the participants were not receiving glucocorticoids vs. 12.07.1% of the normal value at >52 weeks after vector administration; 95% confidence interval [CI], 2.4 to 0.6 for the difference between matched pairs). Elevation of ALT was observed in 2 of 3 patients between weeks 4 and 6 after gene transfer, requiring treatment with corticosteroids.34 No participant has developed a FVIII inhibitor. In contrast with hemophilia B gene therapy approaches, an oversized transgene is used in most of the hemophilia A studies, which may influence durability. N Engl J Med. The https:// ensures that you are connecting to the Thus, the impact of scAAV vectors in animal models may have been overestimated.21, Another important aspect of the St. Jude/UCL study was the use of vector pseudotyped with AAV serotype 8 capsid.

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