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Risse J, Krzemien M, Schnalke J, Heinemann T. Towards ethical drug pricing: the European Orphan Genomic Therapies Fund. Gene Ther 2024:10.1038/s41434-024-00452-2. [PMID: 38658672 DOI: 10.1038/s41434-024-00452-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024]
Abstract
An increasing number of novel genomic therapies are expected to become available for patients with rare or ultra-rare diseases. However, the primary obstacle to equal patient access to these orphan genomic therapies are currently very high prices charged by manufacturers in the context of limited healthcare budgets. Taking into account ethical pricing theories, the paper proposes the implementation of a pricing infrastructure covering all European member states, which has the potential to promote distributive justice while maintaining the attractiveness of genomic therapy development.
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Affiliation(s)
- Johanna Risse
- Institute for Medical Humanities, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany
| | - Merlin Krzemien
- Institute for Medical Humanities, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany
| | - Jan Schnalke
- Institute for Medical Humanities, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany
| | - Thomas Heinemann
- Institute for Medical Humanities, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
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Kostadinov K, Marinova Y, Dimitrov K, Hristova-Atanasova E, Iskrov G, Stefanov R. Navigating Gene Therapy Access: The Case of Bulgaria in the Context of the EU Regulatory Landscape. Healthcare (Basel) 2024; 12:458. [PMID: 38391833 PMCID: PMC10888421 DOI: 10.3390/healthcare12040458] [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: 12/13/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Gene therapies (GTs) have recently emerged as revolutionary personalized therapeutic options. Despite their promising potential, challenges such as uncertainty regarding long-term health benefits and safety, along with extreme price tags, pose significant obstacles to patient access. Within the EU, the European Medicines Agency plays a pivotal role with regards to GT market authorization. However, national authorities are responsible for pricing and reimbursement, which results in fragment patient access within the EU. This study aimed to provide an overview of the complex landscape of post-market authorization accessibility for GT products in Bulgaria, comparing it with neighboring EU countries. We applied a mixed-methods approach, including desk research, public data requests, and list price comparisons. As of 1 April 2023, 14 GTs had a valid market authorization at the EU level. In Bulgaria, Kymriah® was the only GT included in the Positive Drug List (PDL), with an official list price of EUR 335,636.94. Similar results were found in Romania, whereas five GTs were included in Greece's PDL. Additionally, Zolgensma® was found accessible in Bulgaria through an alternative individual access scheme at an estimated price of EUR 1,945,000.00. In conclusion, this study emphasized targeted policy interventions to address health inequalities and to ensure timely access to GTs within the EU.
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Affiliation(s)
- Kostadin Kostadinov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
| | - Yuliyana Marinova
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
| | - Kostadin Dimitrov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
- Institute for Rare Diseases, 4023 Plovdiv, Bulgaria
| | - Eleonora Hristova-Atanasova
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
| | - Georgi Iskrov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
- Institute for Rare Diseases, 4023 Plovdiv, Bulgaria
| | - Rumen Stefanov
- Department of Social Medicine and Public Health, Faculty of Public Health, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria
- Institute for Rare Diseases, 4023 Plovdiv, Bulgaria
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Matsuyama K, Kurihara C, Crawley FP, Kerpel-Fronius S. Utilization of genetic information for medicines development and equitable benefit sharing. Front Genet 2023; 14:1085864. [PMID: 37388927 PMCID: PMC10300349 DOI: 10.3389/fgene.2023.1085864] [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: 10/31/2022] [Accepted: 05/03/2023] [Indexed: 07/01/2023] Open
Abstract
Advances in genomic research have significantly enhanced modern drug development. However, equitable benefit sharing of the results of scientific advancement has not always been achieved. This paper shows how molecular biology has modified medicines development while also leaving open significant challenges for benefit sharing. Presented here is a conceptual modeling describing the processes in genetic-related medicines development and how these are related to specific ethical considerations. The focus is on three important areas: 1) population genetics and the need for discrimination prevention; 2) pharmacogenomics and the need for inclusive governance; and 3) global health to be achieved in open science frameworks. Benefit sharing is taken as the ethical value that underlies all these aspects. The implementation of benefit sharing requires a value shift in which the outcomes of health science are not viewed simply as trade commodities but also as a "global public good". This approach should lead to genetic science to contribute to promoting the fundamental human right to health to all members of the global community.
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Iglesias-López C, Agustí A, Vallano A, Obach M. Financing and Reimbursement of Approved Advanced Therapies in Several European Countries. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:841-853. [PMID: 36646280 DOI: 10.1016/j.jval.2022.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 12/01/2022] [Accepted: 12/27/2022] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The uncertainty in the cost-benefit of advanced therapy medicinal products (ATMPs) is a current challenge for their reimbursement in health systems. This study aimed to provide a comparative analysis of the National Health Authorities (NHAs) reimbursement recommendations issued in different European countries. METHODS The NHA reimbursement recommendations for the approved ATMPs were compared among 8 European Union (EU) Countries (EU8: Ireland, England/Wales, Scotland, The Netherlands, France, Germany, Spain, and Italy). The search was carried out until December 31, 2021. RESULTS A total of 19 approved ATMPs and 76 appraisal reports were analyzed. The majority of the ATMPs were reimbursed, although with uncertainty in added therapeutic value. No relationship between the type of the European Medicines Agency approval and reimbursement was found. Managed entry agreements, such as payment by results, were necessary to ensure market access. The main issue during the evaluation was to base the cost-effectiveness analyses on assumptions because of the limited long-term data. The estimated incremental cost-effectiveness ratio among countries reveals high variability. Overall, the median time to NHA recommendation for the EU8 is in the range of 9 to 17 months. CONCLUSIONS Transparent, harmonized, and systematic assessments across the EU NHAs in terms of cost-effectiveness, added therapeutic value, and grade of innovativeness are needed. This could lead to a more aligned access, increasing the EU market attractiveness and raising public fairness in terms of patient access and pricing.
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Affiliation(s)
- Carolina Iglesias-López
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antònia Agustí
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain; Clinical Pharmacology Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antoni Vallano
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain; Medicines Department, Catalan Healthcare Service, Barcelona, Spain.
| | - Mercè Obach
- Healthcare Planning Department, Catalan Healthcare Service, Barcelona, Spain
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Wagner M, Goetghebeur MM, Ganache I, Demers-Payette O, Auclair Y, Olivier C, Arbour S, de Guise M. HTA challenges for appraising rare disease interventions viewed through the lens of an institutional multidimensional value framework. Expert Rev Pharmacoecon Outcomes Res 2023; 23:143-152. [PMID: 36542763 DOI: 10.1080/14737167.2023.2161513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Evaluating rare disease interventions poses challenges for HTA agencies, including uncertainties and ethical issues and tensions. INESSS has recently adopted a Statement of Principles and Ethical Foundations which proposes a multidimensional approach to value appraisal as well as five principles to frame the evaluation process. AREAS COVERED Our aim was to identify and analyze HTA challenges for appraising interventions for rare diseases, using the Statement's approach to value appraisal as an analytical framework, and outline how the Statement's principles can help address these challenges. Challenges, covering a diversity of aspects, were identified by leveraging institutional experience in diverse domains of expertise and consolidated through narrative literature review. Challenges were categorized by value dimension (clinical, populational, economic, organizational, and sociocultural), which allowed to pinpoint how each challenge affects the ability to appraise the value of an intervention. Key ethical tensions across dimensions were also identified. Specific approaches to addressing these challenges - related to knowledge mobilization and integration, deliberation, and recommendation-making - were outlined on the basis of the principles promulgated in the Statement. EXPERT OPINION A multidimensional approach can be fruitful for analyzing challenges for appraising the value of rare disease interventions and help guide approaches to tackle them.
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Affiliation(s)
- Monika Wagner
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Mireille M Goetghebeur
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Management, Evaluation and Health Policy, Université de Montréal; 7101, avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Isabelle Ganache
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, 7101avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Olivier Demers-Payette
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Management, Evaluation and Health Policy, Université de Montréal; 7101, avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Yannick Auclair
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Catherine Olivier
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, 7101avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Sylvie Arbour
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Michèle de Guise
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Québec, Canada
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Wijekoon N, Gonawala L, Ratnayake P, Sirisena D, Gunasekara H, Dissanayake A, Senanayake S, Keshavaraj A, Hathout Y, Steinbusch HW, Mohan C, Dalal A, Hoffman E, D de Silva K. Gene therapy for selected neuromuscular and trinucleotide repeat disorders - An insight to subsume South Asia for multicenter clinical trials. IBRO Neurosci Rep 2023; 14:146-153. [PMID: 36819775 PMCID: PMC9931913 DOI: 10.1016/j.ibneur.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Background In this article, the authors discuss how they utilized the genetic mutation data in Sri Lankan Duchenne muscular dystrophy (DMD), Spinal muscular atrophy (SMA), Spinocerebellar ataxia (SCA) and Huntington's disease (HD) patients and compare the available literature from South Asian countries to identifying potential candidates for available gene therapy for DMD, SMA, SCA and HD patients. Methods Rare disease patients (n = 623) with the characteristic clinical findings suspected of HD, SCA, SMA and Muscular Dystrophy were genetically confirmed using Multiplex Ligation Dependent Probe Amplification (MLPA), and single plex PCR. A survey was conducted in the "Wiley database on Gene Therapy Trials Worldwide" to identify DMD, SMA, SCA, and HD gene therapy clinical trials performed worldwide up to April 2021. In order to identify candidates for gene therapy in other neighboring countries we compared our findings with available literature from India and Pakistan which has utilized the same molecular diagnostic protocol to our study. Results From the overall cohort of 623 rare disease patients with the characteristic clinical findings suspected of HD, SCA, SMA and Muscular Dystrophy, n = 343 (55%) [Muscular Dystrophy- 65%; (DMD-139, Becker Muscular Dystrophy -BMD-11), SCA type 1-3-53% (SCA1-61,SCA2- 23, SCA3- 39), HD- 52% (45) and SMA- 34% (22)] patients were positive for molecular diagnostics by MLPA and single plex PCR. A total of 147 patients in Sri Lanka amenable to available gene therapy; [DMD-83, SMA-15 and HD-49] were identified. A comparison of Sri Lankan finding with available literature from India and Pakistan identified a total of 1257 patients [DMD-1076, SMA- 57, and HD-124] from these three South Asian Countries as amenable for existing gene therapy trials. DMD, SMA, and HD gene therapy clinical trials (113 studies) performed worldwide up to April 2021 were concentrated mostly (99%) in High Income Countries (HIC) and Upper Middle-Income Countries (UMIC). However, studies on the potential use of anti-sense oligonucleotides (ASO) for treatment of SCAs have yet to reach clinical trials. Conclusion Most genetic therapies for neurodegenerative and neuromuscular disorders have been evaluated for efficacy primarily in Western populations. No multicenter gene therapy clinical trial sites for DMD, SMA and HD in the South Asian region, leading to lack of knowledge on the safety and efficacy of such personalized therapies in other populations, including South Asians. By fostering collaboration between researchers, clinicians, patient advocacy groups, government and industry in gene therapy initiatives for the inherited-diseases community in the developing world would link the Global North and Global South and breathe life into the motto "Together we can make a difference".
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Key Words
- BMD, Becker muscular dystrophy
- Bio Bank
- DMD, Duchenne muscular dystrophy
- Developing Countries
- Duchenne Muscular Dystrophy
- EMA, European Medical Agency
- EMQN, European Molecular Quality Genetics Network
- FDA, U. S. Food and Drug Administration
- HD, Huntington’s disease
- HIC, High Income Countries
- Huntington’s Disease
- Indian Sub-continent
- MLPA, Multiplex Ligation Dependent Probe Amplification
- Neurogenetic Disorders
- SCA, Spinocerebellar ataxia
- SMA, Spinal muscular atrophy
- Spinal Muscular Atrophy
- Spinocerebellar Ataxia
- UMIC, Upper Middle Income Countries
- WTO, World Trade Organization
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Affiliation(s)
- Nalaka Wijekoon
- Interdisciplinary Centre for Innovations in Biotechnology and Neuroscience, University of Sri Jayewardenepura, Nugegoda, Sri Lanka,School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, the Netherlands,EURON - European Graduate School of Neuroscience, the Netherlands
| | - Lakmal Gonawala
- Interdisciplinary Centre for Innovations in Biotechnology and Neuroscience, University of Sri Jayewardenepura, Nugegoda, Sri Lanka,School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, the Netherlands,EURON - European Graduate School of Neuroscience, the Netherlands
| | | | | | | | | | | | | | - Yetrib Hathout
- Pharmaceutical Sciences Department, School of Pharmacy and Pharmaceutical Sciences, Binghamton University, New York, USA
| | - Harry W.M. Steinbusch
- School for Mental Health and Neuroscience, Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, the Netherlands,EURON - European Graduate School of Neuroscience, the Netherlands,Dept. of Brain & Cognitive Sciences, Daegu Gyeungbuk Institute of Science and Technology (DGIST), Daegu, Republic of Korea
| | - Chandra Mohan
- Department of Bioengineering, University of Houston, Houston, TX, USA
| | - Ashwin Dalal
- Diagnostics Division, Center for DNA Fingerprinting and Diagnostics, India
| | - Eric Hoffman
- Pharmaceutical Sciences Department, School of Pharmacy and Pharmaceutical Sciences, Binghamton University, New York, USA
| | - K.Ranil D de Silva
- Interdisciplinary Centre for Innovations in Biotechnology and Neuroscience, University of Sri Jayewardenepura, Nugegoda, Sri Lanka,EURON - European Graduate School of Neuroscience, the Netherlands,Institute for Combinatorial Advanced Research and Education (KDU-CARE), General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka,Corresponding author at: Institute for Combinatorial Advanced Research and Education (KDU-CARE), General Sir John Kotelawala Defence University, Ratmalana, Sri Lanka.
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Skweres-Kuchta M, Czerska I, Szaruga E. Literature Review on Health Emigration in Rare Diseases-A Machine Learning Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2483. [PMID: 36767849 PMCID: PMC9915846 DOI: 10.3390/ijerph20032483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/15/2023] [Accepted: 01/28/2023] [Indexed: 06/18/2023]
Abstract
The article deals with one of the effects of health inequalities and gaps in access to treatments for rare diseases, namely health-driven emigration. The purpose of the paper is to systematize knowledge about the phenomenon of health emigration observed among families affected by rare diseases, for which reimbursed treatment is available, but only in selected countries. The topic proved to be niche; the issue of "health emigration in rare diseases" is an area for exploration. Therefore, the further analysis used text mining and machine learning methods based on a database selected based on keywords related to this issue. The results made it possible to systematize the guesses made by researchers in management and economic fields, to identify the most common keywords and thematic clusters around the perspective of the patient, drug manufacturer and treatment reimbursement decision-maker, and the perspective integrating all the others. Since the topic of health emigration was not directly addressed in the selected sources, the authors attempted to define the related concepts and discussed the importance of this phenomenon in managing the support system in rare diseases. Thus, they indicated directions for further research in this area.
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Affiliation(s)
- Małgorzata Skweres-Kuchta
- Department of Organization and Management, Institute of Management, University of Szczecin, Cukrowa 8 Street, 71-004 Szczecin, Poland
| | - Iwona Czerska
- Department of Marketing Research, Faculty of Management, Wroclaw University of Economics and Business, 118/120 Komandorska Str, 53-345 Wroclaw, Poland
| | - Elżbieta Szaruga
- Department of Transport Management, Institute of Management, University of Szczecin, Cukrowa 8 Street, 71-004 Szczecin, Poland
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Leon-Astudillo C, Byrne BJ, Salloum RG. Addressing the implementation gap in advanced therapeutics for spinal muscular atrophy in the era of newborn screening programs. Front Neurol 2022; 13:1064194. [PMID: 36578307 PMCID: PMC9790909 DOI: 10.3389/fneur.2022.1064194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a rare genetic disease that results in progressive neuromuscular weakness. Without therapy, the most common form of the disease, type 1, typically results in death or chronic respiratory failure in the first 2 years of life. Thanks to the recent introduction of newborn screening programs and the discovery of three disease-modifying therapies in the last decade, the outcomes of children with SMA have dramatically improved. Patients are able to achieve many, if not all, of the typical neuromotor milestones, such as sitting, standing and walking, as well as safe oral intake. As the natural history of treated patients is continuously evolving, children with SMA continue to require complex and multidisciplinary care, posing implementation and sustainability challenges. Accordingly, there is a significant need for the application and evaluation of implementation science to address the steps involved in the diagnosis and treatment of patients with SMA, ensuring that all pertinent stakeholders and systems are working effectively to deliver timely and appropriate care. In this manuscript, we discuss the current challenges and gaps in the care for children with SMA, as well as how implementation science can advance this field. In addition, we provide an adapted implementation science framework that includes the main domains and subdomains involved in the care of patients with SMA.
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Affiliation(s)
- Carmen Leon-Astudillo
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States,*Correspondence: Carmen Leon-Astudillo
| | - Barry J. Byrne
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
| | - Ramzi G. Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL, United States
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Making Sure That Orphan Incentives Tip the Right Way in Europe. Healthcare (Basel) 2022; 10:healthcare10091600. [PMID: 36141212 PMCID: PMC9498781 DOI: 10.3390/healthcare10091600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 12/03/2022] Open
Abstract
The delicate balance of funding research and development of treatments for rare disease is only imperfectly achieved in Europe, and even the current provisional equilibrium is under a new threat from well-intentioned policy changes now in prospect that could—in addition to the intrinsic complexities of research—reduce the incentives on which commercial activity in this area is dependent. The European Union review of its pharmaceutical legislation, for which proposals are scheduled to appear before the end of 2022, envisages adjusting the decade-old incentives to meet objectives that are more precisely targeted. However, researchers, physicians, patients and industry have expressed concerns that ill-considered modifications could have unintended consequences in disrupting the current balance and could reduce rather than increase the flow of innovative treatments for rare diseases.
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Maestro S, Weber ND, Zabaleta N, Aldabe R, Gonzalez-Aseguinolaza G. Novel vectors and approaches for gene therapy in liver diseases. JHEP Rep 2021; 3:100300. [PMID: 34159305 PMCID: PMC8203845 DOI: 10.1016/j.jhepr.2021.100300] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 12/13/2022] Open
Abstract
Gene therapy is becoming an increasingly valuable tool to treat many genetic diseases with no or limited treatment options. This is the case for hundreds of monogenic metabolic disorders of hepatic origin, for which liver transplantation remains the only cure. Furthermore, the liver contains 10-15% of the body's total blood volume, making it ideal for use as a factory to secrete proteins into the circulation. In recent decades, an expanding toolbox has become available for liver-directed gene delivery. Although viral vectors have long been the preferred approach to target hepatocytes, an increasing number of non-viral vectors are emerging as highly efficient vehicles for the delivery of genetic material. Herein, we review advances in gene delivery vectors targeting the liver and more specifically hepatocytes, covering strategies based on gene addition and gene editing, as well as the exciting results obtained with the use of RNA as a therapeutic molecule. Moreover, we will briefly summarise some of the limitations of current liver-directed gene therapy approaches and potential ways of overcoming them.
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Key Words
- AAT, α1-antitrypsin
- AAV, adeno-associated virus
- AHP, acute hepatic porphyrias
- AIP, acute intermittent porphyria
- ALAS1, aminolevulic synthase 1
- APCs, antigen-presenting cells
- ASGCT, American Society of Gene and Cell Therapy
- ASGPR, asialoglycoprotein receptor
- ASOs, antisense oligonucleotides
- Ad, adenovirus
- CBS, cystathionine β-synthase
- CN, Crigel-Najjar
- CRISPR, clustered regularly interspaced short palindromic repeats
- CRISPR/Cas9, CRISPR associated protein 9
- DSBs, double-strand breaks
- ERT, enzyme replacement therapy
- FH, familial hypercholesterolemia
- FSP27, fat-specific protein 27
- GO, glycolate oxidase
- GSD1a, glycogen storage disorder 1a
- GT, gene therapy
- GUSB, β-glucuronidase
- GalNAc, N-acetyl-D-galactosamine
- HDAd, helper-dependent adenovirus
- HDR, homology-directed repair
- HT, hereditary tyrosinemia
- HemA/B, haemophilia A/B
- IDS, iduronate 2-sulfatase
- IDUA, α-L-iduronidase
- IMLD, inherited metabolic liver diseases
- ITR, inverted terminal repetition
- LDH, lactate dehydrogenase
- LDLR, low-density lipoprotein receptor
- LNP, Lipid nanoparticles
- LTR, long terminal repeat
- LV, lentivirus
- MMA, methylmalonic acidemia
- MPR, metabolic pathway reprograming
- MPS type I, MPSI
- MPS type VII, MPSVII
- MPS, mucopolysaccharidosis
- NASH, non-alcoholic steatohepatitis
- NHEJ, non-homologous end joining
- NHPs, non-human primates
- Non-viral vectors
- OLT, orthotopic liver transplantation
- OTC, ornithine transcarbamylase
- PA, propionic acidemia
- PB, piggyBac
- PCSK9, proprotein convertase subtilisin/kexin type 9
- PEG, polyethylene glycol
- PEI, polyethyleneimine
- PFIC3, progressive familial cholestasis type 3
- PH1, Primary hyperoxaluria type 1
- PKU, phenylketonuria
- RV, retrovirus
- S/MAR, scaffold matrix attachment regions
- SB, Sleeping Beauty
- SRT, substrate reduction therapy
- STK25, serine/threonine protein kinase 25
- TALEN, transcription activator-like effector nucleases
- TTR, transthyretin
- UCD, urea cycle disorders
- VLDLR, very-low-density lipoprotein receptor
- WD, Wilson’s disease
- ZFN, zinc finger nucleases
- apoB/E, apolipoprotein B/E
- dCas9, dead Cas9
- efficacy
- gene addition
- gene editing
- gene silencing
- hepatocytes
- immune response
- lncRNA, long non-coding RNA
- miRNAs, microRNAs
- siRNA, small-interfering RNA
- toxicity
- viral vectors
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Affiliation(s)
- Sheila Maestro
- Gene Therapy Area, Foundation for Applied Medical Research, University of Navarra, IdisNA, Pamplona, Spain
| | | | - Nerea Zabaleta
- Grousbeck Gene Therapy Center, Schepens Eye Research Institute, Mass Eye and Ear, Boston, MA, USA
| | - Rafael Aldabe
- Gene Therapy Area, Foundation for Applied Medical Research, University of Navarra, IdisNA, Pamplona, Spain
- Corresponding authors. Address: CIMA, Universidad de Navarra. Av. Pio XII 55 31008 Pamplona. Spain
| | - Gloria Gonzalez-Aseguinolaza
- Gene Therapy Area, Foundation for Applied Medical Research, University of Navarra, IdisNA, Pamplona, Spain
- Vivet Therapeutics, Pamplona, Spain
- Corresponding authors. Address: CIMA, Universidad de Navarra. Av. Pio XII 55 31008 Pamplona. Spain
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Brock DC, Demarest S, Benke TA. Clinical Trial Design for Disease-Modifying Therapies for Genetic Epilepsies. Neurotherapeutics 2021; 18:1445-1457. [PMID: 34595733 PMCID: PMC8609073 DOI: 10.1007/s13311-021-01123-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 02/04/2023] Open
Abstract
Although trials with anti-seizure medications (ASMs) have not shown clear anti-epileptogenic or disease-modifying activity in humans to date, rapid advancements in genomic technology and emerging gene-mediated and gene replacement options offer hope for the successful development of disease-modifying therapies (DMTs) for genetic epilepsies. In fact, more than 26 potential DMTs are in various stages of preclinical and/or clinical development for genetic syndromes associated with epilepsy. The scope of disease-modification includes but is not limited to effects on the underlying pathophysiology, the condition's natural history, epilepsy severity, developmental achievement, function, behavior, sleep, and quality of life. While conventional regulatory clinical trials for epilepsy therapeutics have historically focused on seizure reduction, similarly designed trials may prove ill-equipped to identify these broader disease-modifying benefits. As we look forward to this pipeline of DMTs, focused consideration should be given to the challenges they pose to conventional clinical trial designs for epilepsy therapeutics. Just as DMTs promise to fundamentally alter how we approach the care of patients with genetic epilepsy syndromes, DMTs likewise challenge how we traditionally construct and measure the success of clinical trials. In the following, we briefly review the historical and preclinical frameworks for DMT development for genetic epilepsies and explore the many novel challenges posed for such trials, including the choice of suitable outcome measures, trial structure, timing and duration of treatment, feasible follow-up period, varying safety profile, and ethical concerns.
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Affiliation(s)
- Dylan C Brock
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
- Children's Hospital Colorado, Aurora, CO, 80045, USA.
| | - Scott Demarest
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA
- Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Tim A Benke
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA
- Departments of Neurology, Pharmacology, and Otolaryngology, University of Colorado School of Medicine, CO, 80045, Aurora, USA
- Children's Hospital Colorado, Aurora, CO, 80045, USA
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