1
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Pierce GF, Fong S, Long BR, Kaczmarek R. Deciphering conundrums of adeno-associated virus liver-directed gene therapy: focus on hemophilia. J Thromb Haemost 2024; 22:1263-1289. [PMID: 38103734 DOI: 10.1016/j.jtha.2023.12.005] [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: 09/15/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Adeno-associated virus gene therapy has been the subject of intensive investigation for monogenic disease gene addition therapy for more than 25 years, yet few therapies have been approved by regulatory agencies. Most have not progressed beyond phase 1/2 due to toxicity, lack of efficacy, or both. The liver is a natural target for adeno-associated virus since most serotypes have a high degree of tropism for hepatocytes due to cell surface receptors for the virus and the unique liver sinusoidal geometry facilitating high volumes of blood contact with hepatocyte cell surfaces. Recessive monogenic diseases such as hemophilia represent promising targets since the defective proteins are often synthesized in the liver and secreted into the circulation, making them easy to measure, and many do not require precise regulation. Yet, despite initiation of many disease-specific clinical trials, therapeutic windows are often nonexistent, resulting in excess toxicity and insufficient efficacy. Iterative progress built on these attempts is best illustrated by hemophilia, with the first regulatory approvals for factor IX and factor VIII gene therapies eventually achieved 25 years after the first gene therapy studies in humans. Although successful gene transfer may result in the production of sufficient transgenic protein to modify the disease, many emerging questions on durability, predictability, reliability, and variability of response have not been answered. The underlying biology accounting for these heterogeneous responses and the interplay between host and virus is the subject of intense investigation and the subject of this review.
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Affiliation(s)
- Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada.
| | - Sylvia Fong
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Brian R Long
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, Wells Center for Pediatric Research, Indiana, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
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2
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Di Minno G, Spadarella G, Maldonato NM, De Lucia N, Castaman G, De Cristofaro R, Santoro C, Peyvandi F, Borrelli A, Lupi A, Follino M, Guerrino G, Morisco F, Di Minno M. Awareness of individual goals, preferences, and priorities of persons with severe congenital haemophilia A for a tailored shared decision-making approach to liver-directed gene therapy. A practical guideline. Blood Rev 2023; 62:101118. [PMID: 37544828 DOI: 10.1016/j.blre.2023.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/26/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
In clinical medicine, shared decision making (SDM) is a well-recognized strategy to enhance engagement of both patients and clinicians in medical decisions. The success of liver-directed gene therapy (GT) to transform severe congenital haemophilia A (HA) from an incurable to a curable disease has launched a shift beyond current standards of treatment. However, GT acceptance remains low in the community of HA persons. We argue for both persons with haemophilia (PWH) and specialists in HA care including clinicians, as needing SDM-oriented educational programs devoted to GT. Here, we provide an ad hoc outline to implement education to SDM and tailor clinician information on GT to individual PWHs. Based on routine key components of SDM: patient priorities; recommendations based on individual risk reduction; adverse effects; drug-drug interactions; alternatives to GT; and ongoing re-assessment of the objectives as risk factors (and individual priorities) change, this approach is finalized to exploit efficacious communication.
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Affiliation(s)
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Naples, Italy.
| | - Nelson Mauro Maldonato
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy
| | - Natascia De Lucia
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Section of Haemorrhagic and Thrombotic Diseases, Department of Medicine and Translational Surgery, Sacred Heart University, Rome, Italy..
| | - Cristina Santoro
- Ematologia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy.
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy.
| | - Anna Borrelli
- Direzione Sanitaria, AOU "Federico II" Napoli, Italy
| | - Angelo Lupi
- Federazione delle Associazioni Emofilici (FedEmo), Milan, Italy.
| | | | | | | | - Matteo Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Naples, Italy.
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3
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Rasul E, Hallock R, Hellmann M, Konduros J, Pembroke L, LeCleir G, Malacan J, von Mackensen S. Gene Therapy in Hemophilia: A Transformational Patient Experience. J Patient Exp 2023; 10:23743735231193573. [PMID: 37663068 PMCID: PMC10472832 DOI: 10.1177/23743735231193573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
Hemophilia is a bleeding disorder caused by a single absent/defective gene and characterized by a lack of functional clotting factors. People with hemophilia may experience joint damage, pain, and psychological impairments, all of which could contribute to reduced health-related quality of life (HRQoL). The current standard of care is clotting factor replacement, which is associated with regular infusions; therefore, alternative treatments such as gene therapy (GT) are in development. GT involves the delivery of a functional copy of the clotting factor 8/9 gene by a single infusion into the patient's cells, enabling them to produce their own clotting factor VIII/IX. The impact of treatment on patients' HRQoL can be assessed using hemophilia-specific patient-reported outcome (PRO) measures. Since these measures were designed before the advent of GT, there is a need for updated individualized PRO measures. Patient groups and regulatory authorities emphasize the need for increased patient engagement when considering clinical trial design. Here, we provide patients' perspective on undergoing GT and discuss how to capture the patient voice when measuring the therapy's transformative impact.
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Affiliation(s)
- Enayet Rasul
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Ryan Hallock
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Magnus Hellmann
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Jay Konduros
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | - Luke Pembroke
- Patient author. Have either haemophilia A or B and have undergone gene therapy treatment
| | | | | | - Sylvia von Mackensen
- Department of Medical Psychology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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4
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The ethics of gene therapy for hemophilia: a narrative review. J Thromb Haemost 2023; 21:413-420. [PMID: 36696181 DOI: 10.1016/j.jtha.2022.12.027] [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: 10/17/2022] [Revised: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/26/2023]
Abstract
Gene therapy is expected to become a promising treatment, and potentially even a cure, for hemophilia. After several years of research, the first gene therapy product has been granted conditional market authorization by the European Union in August 2022. The recent progress in the field also has implications on the ethical aspects of hemophilia gene therapy. Reviews conducted in the 2000s mainly identified questions on the ethics of conducting early-phase clinical trials. However, since then, the knowledge on safety and efficacy has improved, and the field has moved toward clinical application, a phase that has its own ethical aspects. Therefore, we conducted a narrative review to take stock of the ethical aspects of hemophilia gene therapy. Based on our analysis of the literature, we identified 3 ethical themes. The theme Living up to expectations describes the existing hopes for gene therapy and the unlikelihood of the currently approved product becoming a permanent cure. In the theme Psychosocial impacts, we discuss the fear that gene therapy will impact the identity of people with hemophilia and their need for psychosocial support. The theme Costs and access discusses the expected cost-effectiveness of gene therapy and its implications on accessibility worldwide. We conclude that it may be necessary to change the narratives surrounding gene therapy, from describing it as a cure to describing it as one of the many treatments that temporarily relieve symptoms and that there is a need to reevaluate the desirability of gene therapy for hemophilia, given the availability of other treatments.
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5
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Croteau SE. Hemophilia A/B. Hematol Oncol Clin North Am 2022; 36:797-812. [DOI: 10.1016/j.hoc.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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6
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Kaczmarek R. Gene therapy - are we ready now? Haemophilia 2022; 28 Suppl 4:35-43. [PMID: 35521736 PMCID: PMC9325484 DOI: 10.1111/hae.14530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia therapy has evolved from rudimentary transfusion‐based approaches to an unprecedented level of innovation with glimmers of functional cure brought by gene therapy. After decades of misfires, gene therapy has normalized factor (F)VIII and factor (F)IX levels in some individuals in the long term. Several clinical programmes testing adeno‐associated viral (AAV) vector gene therapy are approaching completion with imminent regulatory approvals. Discussion Phase 3 studies along with multiyear follow‐up in earlier phase investigations raised questions about efficacy as well as short‐ and long‐term safety, prompting a reappraisal of AAV vector gene therapy. Liver toxicities, albeit mostly low‐grade, occur in the first year in at least some individuals in all haemophilia A and B trials and are poorly understood. Extreme variability and unpredictability of outcome, as well as a slow decline in factor expression (seemingly unique to FVIII gene therapy), are vexing because immune responses to AAV vectors preclude repeat dosing, which could increase suboptimal or restore declining expression, while overexpression may result in phenotoxicity. The long‐term safety will need lifelong monitoring because AAV vectors, contrary to conventional wisdom, integrate into chromosomes at the rate that calls for vigilance. Conclusions AAV transduction and transgene expression engage the host immune system, cellular DNA processing, transcription and translation machineries in ways that have been only cursorily studied in the clinic. Delineating those mechanisms will be key to finding mitigants and solutions to the remaining problems, and including individuals who cannot avail of gene therapy at this time.
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Affiliation(s)
- Radoslaw Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada.,Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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7
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Cantore A, Fraldi A, Meneghini V, Gritti A. In vivo Gene Therapy to the Liver and Nervous System: Promises and Challenges. Front Med (Lausanne) 2022; 8:774618. [PMID: 35118085 PMCID: PMC8803894 DOI: 10.3389/fmed.2021.774618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 12/16/2021] [Indexed: 12/02/2022] Open
Abstract
In vivo genetic engineering has recently shown remarkable potential as a novel effective treatment for an ever-growing number of diseases, as also witnessed by the recent marketing authorization of several in vivo gene therapy products. In vivo genetic engineering comprises both viral vector-mediated gene transfer and the more recently developed genome/epigenome editing strategies, as long as they are directly administered to patients. Here we first review the most advanced in vivo gene therapies that are commercially available or in clinical development. We then highlight the major challenges to be overcome to fully and broadly exploit in vivo gene therapies as novel medicines, discussing some of the approaches that are being taken to address them, with a focus on the nervous system and liver taken as paradigmatic examples.
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Affiliation(s)
- Alessio Cantore
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- *Correspondence: Alessio Cantore
| | - Alessandro Fraldi
- CEINGE Biotecnologie Avanzate, Naples, Italy
- Department of Translational Medicine, University of Naples “Federico II”, Naples, Italy
| | - Vasco Meneghini
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Angela Gritti
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
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8
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Mahlangu J. An update of the current pharmacotherapeutic armamentarium for hemophilia A. Expert Opin Pharmacother 2021; 23:129-138. [PMID: 34404300 DOI: 10.1080/14656566.2021.1961742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION For several decades, we have seen unprecedented advances in novel therapy development for hemophilia A. These advances address the unmet need of replacement therapy, and they include the development of recombinant products with improved pharmacokinetics, subcutaneously administered products, and those with better efficacy and safety profiles in hemophilia A management. AREAS COVERED In this update of hemophilia A treatment, the author summarizes data from completed standard half-life FVIII products, extended half-life FVIII products and FVIII mimetic studies. All products have an acceptable safety profile. The standard half-life products, EHL-FVIII products and emicizumab are efficacious in the prevention and treatment of bleeds and for EHL-FVIII in the perisurgical setting. EXPERT OPINION Advances in pharmacotherapy for hemophilia A have been characterized by changing care goals from supportive care to eliminating infections, preventing inhibitors, and more recently achieving zero bleeds in many patients. While gene therapy has the potential for functional cure in hemophilia A, it has many limitations which need to be addressed. Therefore, pharmacotherapy is likely to remain the mainstay in the management of hemophilia A and promises to get better with currently available therapies. Evolving factor and non-factor replacement therapies may also improve current unmet needs in hemophilia A management.
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Affiliation(s)
- Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Parktown, South Africa
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9
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Witkop M, Morgan G, O'Hara J, Recht M, Buckner TW, Nugent D, Curtis R, O'Mahony B, Skinner MW, Mulhern B, Cawson M, Ali TM, Sawyer EK, Li N. Patient preferences and priorities for haemophilia gene therapy in the US: A discrete choice experiment. Haemophilia 2021; 27:769-782. [PMID: 34310811 PMCID: PMC9290457 DOI: 10.1111/hae.14383] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/23/2021] [Accepted: 07/15/2021] [Indexed: 12/18/2022]
Abstract
Introduction Gene therapy has shown promise in clinical trials for patients with haemophilia, but patient preference studies have focused on factor replacement treatments. Aim We conducted a discrete choice experiment (DCE) to investigate the relative importance and differential preferences patients provide for gene therapy attributes. Methods We surveyed male adults with haemophilia in the United States recruited from patient panels including the National Hemophilia Foundation Community Voices in Research platform using an online survey over 4 months in 2020/21. Participants indicated preferences for gene therapy attributes including dosing frequency/durability, effect on annual bleeding, uncertainty related to side effects, impact on daily activities, impact on mental health, and post‐treatment requirements. The relative importance of each attribute was analysed overall and for subgroups based on haemophilia type and severity. Results A total of 183 males with haemophilia A (n = 120) or B (n = 63) were included. Half (47%) had severe haemophilia; most (75%) were White. Overall, participants gave effect on bleeding rate the greatest relative importance (31%), followed by dose frequency/durability (26%), uncertainty regarding safety issues (17%), and impact on daily activities (11%). Dose frequency/durability had the greatest importance for those with haemophilia B (35%). Conclusion People with haemophilia prioritised reduced bleeding and treatment burden; the former was more important in haemophilia A and the latter in haemophilia B, followed by safety and impact on daily life in this DCE of gene therapy attributes. These findings and differences can inform clinical and health policy decisions to improve health equity for people with haemophilia.
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Affiliation(s)
| | | | - Jamie O'Hara
- HCD Economics, Daresbury, UK.,Faculty of Health and Social Care, University of Chester, Chester, UK
| | - Michael Recht
- Oregon Health & Science University, Portland, Oregon, USA.,American Thrombosis & Hemostasis Network, Rochester, New York, USA
| | - Tyler W Buckner
- Hemophilia and Thrombosis Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Diane Nugent
- Department of Pediatrics and Division of Hematology at CHOC Children's Hospital, Center for Inherited Blood Disorders, Orange, California, USA
| | | | - Brian O'Mahony
- Irish Haemophilia Society, Dublin, UK.,Trinity College, Dublin, UK
| | - Mark W Skinner
- Institute for Policy Advancement, Ltd., Washington, District of Columbia, USA.,McMaster University, Hamilton, Ontario, Canada
| | - Brendan Mulhern
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Australia
| | | | | | | | - Nanxin Li
- uniQure Inc, Lexington, Massachusetts, USA
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10
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Famà R, Borroni E, Merlin S, Airoldi C, Pignani S, Cucci A, Corà D, Bruscaggin V, Scardellato S, Faletti S, Pelicci G, Pinotti M, Walker GE, Follenzi A. Deciphering the Ets-1/2-mediated transcriptional regulation of F8 gene identifies a minimal F8 promoter for hemophilia A gene therapy. Haematologica 2021; 106:1624-1635. [PMID: 32467137 PMCID: PMC8168518 DOI: 10.3324/haematol.2019.239202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Indexed: 11/09/2022] Open
Abstract
Amajor challenge in the development of a gene therapy for hemophilia A is the selection of cell type- or tissue-specific promoters to ensure factor VIII (FVIII) expression without eliciting an immune response. As liver sinusoidal endothelial cells are the major FVIII source, understanding the transcriptional F8 regulation in these cells would help to optimize the minimal F8 promoter (pF8) to efficiently drive FVIII expression. In silico analyses predicted several binding sites (BS) for the E26 transformation-specific (Ets) transcription factors Ets-1 and Ets-2 in the pF8. Reporter assays demonstrated a significant up-regulation of pF8 activity by Ets-1 or Ets- 1/Est-2 combination, while Ets-2 alone was ineffective. Moreover, Ets-1/Ets- 2-DNA binding domain mutants (DBD) abolished promoter activation only when the Ets-1 DBD was removed, suggesting that pF8 up-regulation may occur through Ets-1/Ets-2 interaction with Ets-1 bound to DNA. pF8 carrying Ets-BS deletions unveiled two Ets-BS essential for pF8 activity and response to Ets overexpression. Lentivirus-mediated delivery of green fluorescent protein (GFP) or FVIII cassettes driven by the shortened promoters, led to GFP expression mainly in endothelial cells in the liver and to longterm FVIII activity without inhibitor formation in HA mice. These data strongly support the potential application of these promoters in hemophilia A gene therapy.
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Affiliation(s)
- Rosella Famà
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Ester Borroni
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Simone Merlin
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Chiara Airoldi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Silvia Pignani
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Alessia Cucci
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Davide Corà
- Department of Translational Medicine, Center for Translational Research on Autoimmune and Allergic Disease (CAAD), University of Piemonte Orientale, Novara, Italy
| | | | - Sharon Scardellato
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Stefania Faletti
- Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuliana Pelicci
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Mirko Pinotti
- Department of Life Sciences and Biotechnology, Universita' di Ferrara, Italy
| | - Gillian E Walker
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Antonia Follenzi
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
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11
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Discussing investigational AAV gene therapy with hemophilia patients: A guide. Blood Rev 2021; 47:100759. [DOI: 10.1016/j.blre.2020.100759] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/28/2020] [Accepted: 09/02/2020] [Indexed: 01/19/2023]
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12
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Woollard L, Gorman R, Rosenfelt DJ. Improving patient informed consent for haemophilia gene therapy: the case for change. THERAPEUTIC ADVANCES IN RARE DISEASE 2021; 2:26330040211047244. [PMID: 37181114 PMCID: PMC10032461 DOI: 10.1177/26330040211047244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/31/2021] [Indexed: 05/16/2023]
Abstract
Adeno-associated virus-based gene therapy points to a coming transformation in the treatment of people living with haemophilia, promising sustained bleed control and potential improvement in quality of life. Nevertheless, the consequences of introducing new genetic material are not trivial. The perceived benefits should not minimise the challenges facing patients in understanding the long-term risks and providing a valid and meaningful informed consent, whether in a research or clinical setting. Informed consent is a fundamentally important doctrine in both medical ethics and health law, upholding an individual's right to define their personal goals and make their own autonomous choices. Patients should be enabled to recognise their clinical situation, understand the implications of treatment and integrate every facet of their life into their decision. This review describes informed consent processes for haemophilia gene therapy clinical trials, factors affecting patients' decision making and the availability of patient-centred decision support interventions, to ensure that patients' interests are being protected. Regulatory guidance has been published for physicians and manufacturers in haemophilia on informed consent, including for gene therapy, while best-practice recommendations for patient-physician discussions are available. In all settings, however, communicating and presenting highly technical and complex therapeutic information is challenging, especially where multiple barriers to scientific knowledge and health literacy exist. We propose several evidence-informed strategies to enhance the consent procedure, such as utilising validated literacy and knowledge assessment tools as well as participatory learning environments over an extended period, to ensure that patients are fully cognisant of the consent they give or deny. Further research is needed to define new, creative approaches for patient education and the upholding of ethical values in the informed consent process for gene therapy. The lessons learnt and approaches developed within haemophilia could set the gold standard for good practice in ensuring ethical preparedness amidst advances in genetic therapies. Plain language summary Improving the informed consent process for people living with haemophilia considering gene therapy. Gene therapy is the process of replacing faulty genes with healthy ones. In haemophilia, gene therapy involves introducing a working copy of the gene for the clotting factor that patients are missing. Following treatment, patients should begin producing their own clotting factor normally. However, people living with haemophilia (PwH) need to be fully informed regarding the potential benefits and risks of gene therapy and what this means for them, whether as part of a research study or routine medical care.Patients must be respected and supported to make decisions about their own health and wellbeing, recognising their legal and moral right to set personal goals and make treatment choices. For this to happen in practice, patients should be aware of their individual health needs, understand the effects of treatment and consider lifestyle preferences in relation to their decisions. This article attempts to describe how informed consent is obtained in haemophilia gene therapy clinical trials, what affects a patient's ability to make decisions and the availability of information and support to respect and protect the interests of PwH.Regulators responsible for approving medical products have published guidance on informed consent for physicians and pharmaceutical manufacturers in haemophilia, including for gene therapy. Recommendations have been made about the best ways for PwH to discuss gene therapy with their physicians. Yet, poor communication of complex topics, such as gene therapy, can be problematic, especially if patients lack the skills and confidence to understand and discuss the science, or for physicians with limited time in clinic.We propose strategies to improve the consent process, so patients can feel more able to make informed decisions about new treatments. Further research is needed to find new, creative approaches for educating patients and ensuring that the informed consent process for gene therapy in haemophilia is ethical.
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Affiliation(s)
- Laurence Woollard
- On The Pulse Consultancy, Ltd., 14 Church View,
Wixoe, Sudbury, CO10 8UH, UK
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13
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Rodríguez-Márquez E, Meumann N, Büning H. Adeno-associated virus (AAV) capsid engineering in liver-directed gene therapy. Expert Opin Biol Ther 2020; 21:749-766. [PMID: 33331201 DOI: 10.1080/14712598.2021.1865303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Gene therapy clinical trials with adeno-associated virus (AAV) vectors report impressive clinical efficacy data. Nevertheless, challenges have become apparent, such as the need for high vector doses and the induction of anti-AAV immune responses that cause the loss of vector-transduced hepatocytes. This fostered research focusing on development of next-generation AAV vectors capable of dealing with these hurdles.Areas Covered: While both the viral vector genome and the capsid are subjects to engineering, this review focuses on the latter. Specifically, we summarize the principles of capsid engineering strategies, and describe developments and applications of engineered capsid variants for liver-directed gene therapy.Expert Opinion: Capsid engineering is a promising strategy to significantly improve efficacy of the AAV vector system in clinical application. Reduction in vector dose will further improve vector safety, lower the risk of host immune responses and the cost of manufacturing. Capsid engineering is also expected to result in AAV vectors applicable to patients with preexisting immunity toward natural AAV serotypes.
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Affiliation(s)
- Esther Rodríguez-Márquez
- Universidad Autónoma De Madrid, Madrid, Spain.,Institute of Experimental Hematology, Hannover Medical School, Hannover, Germany.,REBIRTH Research Center for Translational Regenerative Medicine, Hannover Medical School, Hannover, Germany
| | - Nadja Meumann
- Institute of Experimental Hematology, Hannover Medical School, Hannover, Germany.,REBIRTH Research Center for Translational Regenerative Medicine, Hannover Medical School, Hannover, Germany
| | - Hildegard Büning
- Institute of Experimental Hematology, Hannover Medical School, Hannover, Germany.,REBIRTH Research Center for Translational Regenerative Medicine, Hannover Medical School, Hannover, Germany.,Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany.,German Center for Infection Research (DZIF, Partner Site Hannover-Braunschweig, Germany
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14
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Noone D, Coffin D, Pierce GF. Reimbursing the value of gene therapy care in an era of uncertainty. Haemophilia 2020; 27:12-18. [PMID: 33245824 DOI: 10.1111/hae.14218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/19/2020] [Accepted: 11/09/2020] [Indexed: 01/19/2023]
Abstract
Early-stage gene therapy (GT) clinical trials are demonstrating exciting results for persons with haemophilia (PWH), with the first products possibly licenced over the next few years for haemophilia A and B. These new treatments offer the possibility of a one-off approach to the treatment of haemophilia, with demonstrated increases in factor level expression and substantial reductions in both bleeds and factor utilization. However, clinical trial participants have demonstrated variable expression in factor levels, including decreases, over time, suggesting in some cases the effect may not last. The consequence of this uncertainty has led to challenging discussions on value and reimbursement. In most national healthcare systems, the relatively high cost of paying for GT on a one-off basis may be prohibitive, resulting in a lack of access and less post-marketing data generated, ultimately keeping these performance uncertainties high for payers. Economic models have demonstrated the cost-effectiveness of GT in haemophilia based on current clinical trial inputs, but it is in the certainty of these inputs and concomitant budget impacts where the lack of available data will be a concern for payers. To overcome the 'chicken and egg' discussion in relation to reimbursement and data, GT will necessitate new pricing and reimbursement models that share the risk between the manufacturer and the payer. New models have been described for other conditions. The aim of this paper is to propose illustrative concepts of haemophilia reimbursement models that may be further considered in the assessment of a less predictable therapeutic such as GT.
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Affiliation(s)
- Declan Noone
- European Haemophilia Consortium, Brussels, Belgium
| | - Donna Coffin
- World Federation of Haemophilia, Montréal, Quebec, Canada
| | - Glenn F Pierce
- World Federation of Haemophilia, Montréal, Quebec, Canada
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15
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Konkle B, Pierce G, Coffin D, Naccache M, Clark RC, George L, Iorio A, O’Mahony B, Pipe S, Skinner M, Watson C, Peyvandi F, Mahlangu J. Core data set on safety, efficacy, and durability of hemophilia gene therapy for a global registry: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:3074-3077. [PMID: 33463024 PMCID: PMC7756325 DOI: 10.1111/jth.15023] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/03/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gene therapy for people with hemophilia (PWH) will soon become available outside current clinical trials. The World Federation of Hemophilia (WFH), in collaboration with International Society of Thrombosis and Hemostasis Scientific and Standardization Committee (ISTH SSC), the European Haemophilia Consortium (EHC), the US National Hemophilia Foundation (NHF), the American Thrombosis and Hemostasis Network (ATHN), industry gene therapy development partners and Regulatory liaisons have developed the Gene Therapy Registry (GTR), designed to collect long-term data on all PWH who receive hemophilia gene therapy. OBJECTIVE The objectives of the GTR are to record the long-term safety and efficacy data post gene therapy infusion and to assess the changes in quality of life and burden of disease post-gene-therapy infusion. METHODS The GTR is a prospective, observational, and longitudinal registry developed under the guidance of a multi-stakeholder GTR Steering Committee (GTR SC), composed of health care professionals, patient advocates, industry representatives, and regulatory agency liaisons. All PWH who receive gene therapy by clinical trial or commercial product will be invited to enrol in the registry through their hemophilia treatment centers (HTCs). The registry aims to recruit 100% of eligible post gene therapy PWH globally. Through an iterative process, and following the guidance of the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA), the GTR SC has developed a core set of data to be collected on all patients post gene therapy. RESULTS The core data set includes demographic information, vector infusion details, safety, efficacy, quality of life and burden of disease. CONCLUSIONS The GTR is a global effort to ensure that long term safety and efficacy outcomes are recorded and analysed and rare adverse events, in a small patient population, are identified. Many unknowns on the long-term safety and efficacy of gene therapy for hemophilia may also be addressed.
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Affiliation(s)
- Barbara Konkle
- Bloodworks Northwest, Research InstituteUniversity of WashingtonSeattleWAUSA
| | | | | | | | | | - Lindsey George
- The Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Alfonso Iorio
- Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonONCanada
| | | | - Steven Pipe
- PediatricsUniversity of MichiganAnn ArborMIUSA
| | - Mark Skinner
- Institute for Policy Advancement LtdWashingtonDCUSA
| | | | - Flora Peyvandi
- Internal MedicineFaculty of Medicine and SurgeryUniversity of MilanMilanItaly
| | - Johnny Mahlangu
- Faculty of Health Sciences and NHLSUniversity of the WitwatersrandJohannesburgSouth Africa
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16
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Pierce GF, Kaczmarek R, Noone D, O’Mahony B, Page D, Skinner MW. Gene therapy to cure haemophilia: Is robust scientific inquiry the missing factor? Haemophilia 2020; 26:931-933. [DOI: 10.1111/hae.14131] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Declan Noone
- European Haemophilia Consortium Brussels Belgium
| | | | - David Page
- Canadian Haemophilia Society Montreal Canada
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17
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Arruda VR, Doshi BS. Gene Therapy for Hemophilia: Facts and Quandaries in the 21st Century. Mediterr J Hematol Infect Dis 2020; 12:e2020069. [PMID: 32952980 PMCID: PMC7485465 DOI: 10.4084/mjhid.2020.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/19/2020] [Indexed: 01/19/2023] Open
Abstract
Therapy for hemophilia has evolved in the last 40 years from plasma-based concentrates to recombinant proteins and, more recently, to non-factor therapeutics. Along this same timeline, research in adeno-associated viral (AAV) based gene therapy vectors has provided the framework for early phase clinical trials initially for hemophilia B (HB) and now for hemophilia A. Successive lessons learned from early HB trials have paved the way for current advanced phase trials. Nevertheless, questions linger regarding 1) the optimal balance of vector dose to transgene expression, 2) amount and durability of transgene expression required, and 3) long-term safety. Some trials have demonstrated unique findings not seen previously regarding transient elevation of liver enzymes, immunogenicity of the vector capsid, and loss of transgene expression. This review will provide an update on the clinical AAV gene therapy trials in hemophilia and address the questions above. A thoughtful and rationally approached expansion of gene therapy to the clinics would certainly be a welcome addition to the arsenal of options for hemophilia therapy. Further, the global impact of gene therapy could be vastly improved by expanding eligibility to different patient populations and to developing nations. With the advances made to date, it is possible to envision a shift from the early goal of simply increasing life expectancy to a significant improvement in quality of life by reduction in spontaneous bleeding episodes and disease complications.
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Affiliation(s)
- Valder R. Arruda
- Divsion of Hematology, Children’s Hospital of Philadelphia, Philadelphia PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia PA USA
| | - Bhavya S. Doshi
- Divsion of Hematology, Children’s Hospital of Philadelphia, Philadelphia PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA USA
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18
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Konkle BA, Coffin D, Pierce GF, Clark C, George L, Iorio A, Mahlangu J, Naccache M, O’Mahony B, Peyvandi F, Pipe S, Quartel A, Sawyer EK, Skinner MW, Tortella B, Watson C, Winburn I. World Federation of Hemophilia Gene Therapy Registry. Haemophilia 2020; 26:563-564. [PMID: 32462720 PMCID: PMC8944922 DOI: 10.1111/hae.14015] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Barbara A. Konkle
- Bloodworks NW, Washington Center for Bleeding Disorders, Seattle, WA, USA
| | - Donna Coffin
- World Federation of Hemophilia, Montreal, QC, Canada
| | | | - Cary Clark
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
| | - Lindsey George
- The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Univerisity of Pennsylvania, Philadelphia, PA, USA
| | | | - Johnny Mahlangu
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
- Haemophilia Comprehensive Care Centre, University of the Witwatersrand, NHLS and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | | | - Brian O’Mahony
- Irish Haemophilia Society, Dublin, Ireland
- European Hemophilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
- IRCCS Maggiore Hospital Milan and University of Milan, Milan, Italy
| | - Steve Pipe
- University of Michigan, Pediatrics, Ann Arbor, MI, USA
- National Hemophilia Foundation, New York, NY, USA
| | | | | | | | | | - Crystal Watson
- American Thrombosis and Hemostssasis Network, Chicago, IL, USA
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19
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Pipe SW. Delivering on the promise of gene therapy for haemophilia. Haemophilia 2020; 27 Suppl 3:114-121. [PMID: 32490590 DOI: 10.1111/hae.14027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
The promise of gene therapy is a single treatment ('one and done') that leads to steady-state expression of endogenous factor VIII or factor IX sufficient to achieve a functional cure (free of recurrent haemophilic bleeding) if not normalized haemostasis. The elimination of the need for continued prophylaxis, or factor replacement following trauma or prior to surgery would lead to annual cost savings. Such optimized health and well-being would be reaching a level of health equity that was unimaginable several decades ago. 'Before anything else, preparation is the key to success'-Alexander Graham Bell. This quote from the famous inventor, scientist and engineer highlights that, although we currently stand on the threshold of this achievement, delivering on this promise will require broad-based multistakeholder preparation (scientists, manufacturers, federal regulators, health technology assessors, persons with haemophilia, national advocacy groups and multidisciplinary healthcare teams) with a focused emphasis on education, approval of safe and effective therapies, removal of barriers to access and excellence in clinical delivery.
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Affiliation(s)
- Steven W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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20
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Konkle BA, Recht M, Hilger A, Marks P. The critical need for postmarketing surveillance in gene therapy for haemophilia. Haemophilia 2020; 27 Suppl 3:126-131. [PMID: 32495492 DOI: 10.1111/hae.13972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/26/2020] [Accepted: 03/02/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The goal of gene therapy for haemophilia is to alter the clinical phenotype to a milder form or even cure, by increasing endogenous coagulation factor levels through transfer of a functional gene encoding the respective deficient coagulation factor and subsequent transgene expression. Over the past decade, there has been tremendous progress in gene therapy, particularly in use of liver-directed adeno-associated viral vectors, such that several programmes for both haemophilia A and B are in phase 3 trials. With regulatory approval of the first gene therapy product expected as early as mid-2020, there is an urgent need for a mechanism to collect long-term data on safety and variability and durability of efficacy. There will be elements required by regulators for postmarketing surveillance and additional data needed to enhance our understanding of gene therapy outcomes and their impact on the lives of people with haemophilia. AIM The aim of this manuscript was to describe efforts underway by the American Thrombosis and Hemostasis Network and the World Federation of Hemophilia to collect long-term harmonized data and considerations of the European and US regulatory agencies, which will inform ongoing data collection. METHODS The status of data collection around gene therapy in haemophilia and important outcome measures were obtained by literature review. Each author described elements relevant to the activities of their organization. CONCLUSION Support of all stakeholders in gene therapy, providers, patients, industry and regulators, augers successful capture of uniform long-term safety and efficacy data to ensure optimal treatment of people with haemophilia.
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Affiliation(s)
- Barbara A Konkle
- Bloodworks Northwest and The University of Washington, Seattle, WA, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, NY, USA.,Oregon Health and Science University, Portland, OR, USA
| | - Anneliese Hilger
- Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Peter Marks
- U.S. Food and Drug Administration, Silver Spring, MD, USA
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21
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Pierce GF. Uncertainty in an era of transformative therapy for haemophilia: Addressing the unknowns. Haemophilia 2020; 27 Suppl 3:103-113. [PMID: 32484283 DOI: 10.1111/hae.14023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/24/2020] [Indexed: 12/12/2022]
Abstract
Haemophilia is at the dawn of a new era in therapeutic management, one that can generate greater protection from bleeding and a functional cure in some individuals. Prior advances in protein engineering and monoclonal antibody technology have facilitated therapeutic options to maintain decreased risk of bleeding and less burdensome treatment. The use of gene transfer, first proposed in 1971 for monogenic diseases, is emerging as an effective long-term treatment for a variety of diseases. Transfer of functional factor VIII (FVIII) and factor IX (FIX) genes has witnessed a series of advances and setbacks since the first non-clinical experiments in animals were initiated nearly 30 years ago. More recently, multiyear therapeutic levels of FVIII and FIX activity have been achieved in human clinical trials, translated into meaningful clinical benefit and a functional cure. While clinical progress has been definitive, many questions remain unanswered as prelicensure phase 3 clinical trials are underway. These unanswered questions translate into a state of uncertainty about the known unknowns and unknown unknowns intrinsic to any new therapeutic platform. Accepting this modality as a means to functionally cure haemophilia also means accepting the uncertainty regarding the biology of viral vector-mediated gene transfer, which remains inadequately understood. Gene therapy is a far more complex biological 'drug' than small molecule and protein drugs, where manufacturing processes and the drugs themselves are now well characterized. Extent of community acceptance of uncertainty and acknowledgement of the need for an uncompromising drive for answers to the unknowns will characterize the introduction of this first generation of gene therapy for haemophilia to the wider patient population in both resource-rich and resource-poor countries.
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22
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Pierce GF, Pasi KJ, Coffin D, Kaczmarek R, Lillicrap D, Mahlangu J, Rottellini D, Sannié T, Srivastava A, VandenDriessche T, Weill A. Towards a global multidisciplinary consensus framework on haemophilia gene therapy: Report of the 2nd World Federation of Haemophilia Gene Therapy Round Table. Haemophilia 2020; 26:443-449. [PMID: 32202382 DOI: 10.1111/hae.13971] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/19/2020] [Accepted: 03/02/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION With approval of gene therapy for haemophilia likely in the near future, policy frameworks are needed to guide the path forward for this disruptive and novel therapeutic advance. AIM The WFH has initiated a series of multi-stakeholder Gene Therapy Round Tables (GTRT) to better understand where guidance is needed and develop initial consensus statements to inform policy. METHODS The first day of the 2nd GTRT was devoted to didactic presentations on models of access to gene therapy, payment and health technology assessment considerations, regulatory issues and the generation of evidence on safety and durable efficacy of gene therapy products. On the second day, participants were tasked with developing and voting on consensus statements that reflected the information presented and multi-stakeholder views expressed during discussions in the 1st and 2nd WFH GTRTs. The statements covered global access to gene therapy for all people with haemophilia (PWH), collection of long-term safety and efficacy data, ensuring gene therapy is available for all subgroups of PWH including those who have been largely excluded from clinical trials and characterizing acceptable and ideal factor expression levels for gene therapy products. RESULTS The first 3 statements achieved consensus (at least 80% agreement) by this group of experts. The statement on identifying an ideal and an acceptable factor level expression elicited a lively discussion but failed to achieve consensus by this group. CONCLUSIONS This issue of ideal and acceptable factor level expression and other unresolved issues will be brought to the 3rd WFH GTRT in 2020.
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Affiliation(s)
| | - K John Pasi
- Royal London Haemophilia Centre, Barts and The London School of Medicine and Dentistry, London, UK
| | - Donna Coffin
- World Federation of Hemophilia, Montreal, QC, Canada
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
| | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Johnny Mahlangu
- Haemophilia Comprehensive Care Centre, NHLS and Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Alok Srivastava
- Department of Haematology, Christian Medical College Vellore, Vellore, India
| | - Thierry VandenDriessche
- Department of Gene Therapy & Regenerative Medicine, Vrije Universiteit Brussel (VUB), Brussels, Belgium.,Department of Cardiovascular Sciences, Center for Molecular & Vascular Biology, University of Leuven, Leuven, Belgium
| | - Alain Weill
- World Federation of Hemophilia, Montreal, QC, Canada
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23
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Shirley JL, Keeler GD, Sherman A, Zolotukhin I, Markusic DM, Hoffman BE, Morel LM, Wallet MA, Terhorst C, Herzog RW. Type I IFN Sensing by cDCs and CD4 + T Cell Help Are Both Requisite for Cross-Priming of AAV Capsid-Specific CD8 + T Cells. Mol Ther 2019; 28:758-770. [PMID: 31780366 DOI: 10.1016/j.ymthe.2019.11.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/23/2022] Open
Abstract
Adeno-associated virus (AAV) vectors are widely used in clinical gene therapy to correct genetic disease by in vivo gene transfer. Although the vectors are useful, in part because of their limited immunogenicity, immune responses directed at vector components have complicated applications in humans. These include, for instance, innate immune sensing of vector components by plasmacytoid dendritic cells (pDCs), which sense the vector DNA genome via Toll-like receptor 9. Adaptive immune responses employ antigen presentation by conventional dendritic cells (cDCs), which leads to cross-priming of capsid-specific CD8+ T cells. In this study, we sought to determine the mechanisms that promote licensing of cDCs, which is requisite for CD8+ T cell activation. Blockage of type 1 interferon (T1 IFN) signaling by monoclonal antibody therapy prevented cross-priming. Furthermore, experiments in cell-type-restricted knockout mice showed a specific requirement for the receptor for T1 IFN (IFNaR) in cDCs. In contrast, natural killer (NK) cells are not needed, indicating a direct rather than indirect effect of T1 IFN on cDCs. In addition, co-stimulation by CD4+ T cells via CD40-CD40L was required for cross-priming, and blockage of co-stimulation but not of T1 IFN additionally reduced antibody formation against capsid. These mechanistic insights inform the development of targeted immune interventions.
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Affiliation(s)
- Jamie L Shirley
- Department Pediatrics, University of Florida, Gainesville, FL, USA
| | | | | | - Irene Zolotukhin
- Department Pediatrics, University of Florida, Gainesville, FL, USA
| | - David M Markusic
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brad E Hoffman
- Department Pediatrics, University of Florida, Gainesville, FL, USA
| | - Laurence M Morel
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Mark A Wallet
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Cox Terhorst
- Division of Immunology, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Roland W Herzog
- Department Pediatrics, University of Florida, Gainesville, FL, USA; Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
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24
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Gollomp KL, Doshi BS, Arruda VR. Gene therapy for hemophilia: Progress to date and challenges moving forward. Transfus Apher Sci 2019; 58:602-612. [DOI: 10.1016/j.transci.2019.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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25
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Zou Y, Li D, Shen M, Shi X. Polyethylenimine-Based Nanogels for Biomedical Applications. Macromol Biosci 2019; 19:e1900272. [PMID: 31531955 DOI: 10.1002/mabi.201900272] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/04/2019] [Indexed: 12/25/2022]
Abstract
Nanogels (NGs) are 3-dimensional (3D) networks composed of hydrophilic or amphiphilic polymer chains, allowing for effective and homogeneous encapsulation of drugs, genes, or imaging agents for biomedical applications. Polyethylenimine (PEI), possessing abundant positively charged amine groups, is an ideal platform for the development of NGs. A variety of effective PEI-based NGs have been designed and much effort has been devoted to study the relationship between the structure and function of the NGs. In particular, PEI-based NGs can be prepared either using PEI as the major NG component or using PEI as a crosslinker. This review reports the recent progresses in the design of PEI-based NGs for gene and drug delivery and for bioimaging applications with a target focus to tackle the diagnosis and therapy of cancer.
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Affiliation(s)
- Yu Zou
- Department of Interventional and Vascular Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9000-390, Funchal, Portugal
| | - Du Li
- College of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai, 201620, P. R. China
| | - Mingwu Shen
- College of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai, 201620, P. R. China
| | - Xiangyang Shi
- Department of Interventional and Vascular Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.,CQM-Centro de Química da Madeira, Universidade da Madeira, Campus da Penteada, 9000-390, Funchal, Portugal.,College of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai, 201620, P. R. China
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26
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Liras A, Romeu L. Dental management of patients with haemophilia in the era of recombinant treatments: increased efficacy and decreased clinical risk. BMJ Case Rep 2019; 12:12/4/e227974. [PMID: 30962210 PMCID: PMC6453434 DOI: 10.1136/bcr-2018-227974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is a hereditary X-linked recessive disorder caused by a deficiency of either clotting factor VIII (haemophilia A) or IX (haemophilia B). Conventional treatment is currently based on the use of either plasma derived or recombinant coagulation factors. This paper reports on the case of a patient with severe haemophilia who presented with mesial decay and interproximal tartar build-up, for which extraction and scaling to remove tartar deposits were indicated. Following extraction, the usual haemostasis techniques were applied, and postoperative prophylactic antihaemophilic treatment was indicated for 2 or 3 days. The patient presented with moderate bleeding for a few minutes immediately after the procedure. Administration of factor VIII before surgery as well as the patient’s favourable pharmacokinetic response allowed for an optimal result. This treatment has afforded patients with haemophilia a better quality of life, and safe and efficient access to invasive surgical procedures.
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Affiliation(s)
| | - Luis Romeu
- Universidad Complutense de Madrid, Madrid, Spain
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27
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Konkle BA, Skinner M, Iorio A. Hemophilia trials in the twenty-first century: Defining patient important outcomes. Res Pract Thromb Haemost 2019; 3:184-192. [PMID: 31011702 PMCID: PMC6462740 DOI: 10.1002/rth2.12195] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 02/01/2019] [Indexed: 01/19/2023] Open
Abstract
Treatment for hemophilia has advanced dramatically over the past 5 decades. Success of prophylactic therapy in preventing bleeding and decreasing associated complications has established a new standard of care. However, with the advent of gene therapy and treatments that effectively mimic sustained coagulation factor replacement, outcome measures that worked well for assessing factor replacement therapies in past clinical trials need to be reassessed. In addition, while therapies have advanced, so has the science of outcome assessment, including recognition of the importance of patient important and patient reported outcomes. This manuscript reviews strengths and limitations of outcome measures used in hemophilia from both a provider and patient perspective.
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Affiliation(s)
- Barbara A. Konkle
- Bloodworks NorthwestSeattleWashington
- Department of MedicineUniversity of WashingtonSeattleWashington
| | - Mark Skinner
- Institute for Policy Advancement, Ltd.WashingtonDistrict of Columbia
- Department of Health Resource Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
| | - Alfonso Iorio
- Department of Health Resource Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
- Department of MedicineMcMaster UniversityHamiltonCanada
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28
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Pierce GF, Coffin D. The 1st WFH Gene Therapy Round Table: Understanding the landscape and challenges of gene therapy for haemophilia around the world. Haemophilia 2019; 25:189-194. [PMID: 30604914 DOI: 10.1111/hae.13673] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 01/19/2023]
Abstract
In this first in a series of round table meetings, the 1st World Federation of Hemophilia Gene Therapy Round Table was convened to initiate a global dialogue on the expected challenges and opportunities that a disruptive therapy, such as gene therapy, will bring to the haemophilia community. Perspectives from key stakeholder groups, including healthcare professionals, regulators, payors, people with hemophilia and pharmaceutical industry representatives, were sought in the identification of the key issues we expect to face. Didactic presentations and open discussion covered the clinical development of gene therapy in haemophilia; regulatory perspectives of gene therapy; making informed decisions; accessibility, affordability and pricing of gene therapy; and ethical issues of gene therapy clinical trials. These were followed by small group work. This manuscript outlines the key issues identified and the path forward.
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Affiliation(s)
- Glenn F Pierce
- World Federation of Hemophilia, Montreal, Québec, Canada
| | - Donna Coffin
- World Federation of Hemophilia, Montreal, Québec, Canada
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29
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Evolution of Hemophilia Care in India. Indian J Hematol Blood Transfus 2018; 35:716-721. [PMID: 31741626 DOI: 10.1007/s12288-018-1059-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023] Open
Abstract
Haemophilia is a high cost low volume disease. Being a relatively uncommon condition governments of the day are not very interested in developing comprehensive care for such a condition. Patient's society where such kind of patients come together under one umbrella and fight for their rights and proper management of the condition has important role to play in developing and helping to deliver high standards care in such a condition. Haemophilia Federation of India, a patient's organization played a stellar role in developing haemophilia care in this country and continues to do so today, present article explains how this organization engaged itself through local, national and international interaction in evolving haemophilia care in this country. The present description can act as a template for developing similar architecture of care for rare but difficult and costly to treat disorders'.
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Update on clinical gene therapy for hemophilia. Blood 2018; 133:407-414. [PMID: 30559260 DOI: 10.1182/blood-2018-07-820720] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/21/2018] [Indexed: 12/21/2022] Open
Abstract
In contrast to other diverse therapies for the X-linked bleeding disorder hemophilia that are currently in clinical development, gene therapy holds the promise of a lasting cure with a single drug administration. Near-to-complete correction of hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency) have now been achieved in patients by hepatic in vivo gene transfer. Adeno-associated viral vectors with different viral capsids that have been engineered to express high-level, and in some cases hyperactive, coagulation factors were employed. Patient data support that sustained endogenous production of clotting factor as a result of gene therapy eliminates the need for infusion of coagulation factors (or alternative drugs that promote coagulation), and may therefore ultimately also reduce treatment costs. However, mild liver toxicities have been observed in some patients receiving high vector doses. In some but not all instances, the toxicities correlated with a T-cell response directed against the viral capsid, prompting use of immune suppression. In addition, not all patients can be treated because of preexisting immunity to viral capsids. Nonetheless, studies in animal models of hemophilia suggest that the approach can also be used for immune tolerance induction to prevent or eliminate inhibitory antibodies against coagulation factors. These can form in traditional protein replacement therapy and represent a major complication of treatment. The current review provides a summary and update on advances in clinical gene therapies for hemophilia and its continued development.
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Thornburg CD. How I approach: Previously untreated patients with severe congenital hemophilia A. Pediatr Blood Cancer 2018; 65:e27466. [PMID: 30251355 DOI: 10.1002/pbc.27466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 01/19/2023]
Abstract
Previously untreated patients with severe hemophilia A are a vulnerable population at risk for severe bleeding which is currently managed with exogenous clotting factor replacement. The primary burden of current treatment is high-titer inhibitor development. Evolving data on current treatment products as well as emerging therapeutics may inform treatment decisions to prevent bleeding and inhibitor formation. Considerations for diagnosis, education, and shared decision-making related to product choice and treatment regimen are discussed.
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Affiliation(s)
- Courtney D Thornburg
- Rady Children's Hospital San Diego, San Diego, California.,UC San Diego, La Jolla, California
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Factors affecting the quality, safety and marketing approval of clotting factor concentrates for haemophilia. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:525-534. [PMID: 30201084 DOI: 10.2450/2018.0150-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/22/2018] [Indexed: 12/27/2022]
Abstract
Selecting therapeutic products for the treatment of haemophilia follows the process of obtaining market approval of products submitted to the scrutiny of a regulatory agency. In well-resourced countries, key decisions on whether a product is sufficiently safe and of high quality are made by highly expert and well-resourced agencies, such as the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). In countries lacking such agencies, well-informed decisions can still be made through an appreciation of the key issues affecting the quality, safety and efficacy of haemophilia products. A number of well-established principles may then be applied in order to make a choice. In this review, reflecting principles outlined by the World Federation of Hemophilia, we outline the key features in determining the acceptability of therapeutic products for haemophilia in order to ensure an optimal choice in all the environments providing haemophilia care.
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