aav5 factor viii gene transfer in severe hemophilia a

There was no evidence of inhibitor formation to FIX-Padua. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A | NEJM Multiyear Follow-up of AAV5-hFVIII-SQ Gene Therapy for Hemophilia A Young mice administered adult doses of AAV5-hFVIII-SQ achieve In addition, he is a consultant to several biopharmaceutical companies and is an inventor on patents licensed to Freeline Therapeutics and BioMarin Pharmaceutical. SPK-8011 is a recombinant-AAV vector consisting of SPK200 (a bioengineered capsid derived from AAV3 [specifically, subtype LK03])18 with a liver-specific, truncated transthyretin enhancer and promoter, a synthetic intron sequence, and codon-optimized F8 complementary DNA encoding FVIII-SQ, a B-domaindeleted form of factor VIII (Fig. Of the 7 patients treated using 6e13 vg/kg, 6 achieved an FVIII level > 50% (Table 2), using a 1-stage clotting assay, at 1 year. Hemophilia Gene Therapy: Ready for Prime Time? Copyright 2023 by American Society of Hematology, Recent advances in hemophilia treatment and the rationale for gene therapy, Recent trials of gene transfer in hemophilia B, AAV vectors and gene therapy for hemophilia A, Obstacles to wider use of AAV vector technology, Alternative gene therapy approaches that show promise, https://doi.org/10.1182/hematology.2019000007, Transient except in 1 patient who had expression of 25% at last report, Codon-optimized FIX containing the Padua mutation, In phase 3 trial as AMT-061 using a FIX cDNA containing the Padua mutation, AAV6/zinc-fingermediated targeted integration into the albumin locus in hepatocytes. In this issue of Blood, Miesbach et al show that adeno-associated virus-5 (AAV5) liver-directed gene therapy in severe and moderate hemophilia B was clinically effective, with patients achieving stable factor IX (FIX) expression. All participant data were analyzed (Fig. As expected, a small amount of durable factor VIII expression conferred a marked clinical benefit in the 15 participants with sustained factor VIII expression who were followed for more than 52 weeks. Adenovirus-associated virus vector-mediated gene transfer in hemophilia B. George LA, Sullivan SK, Giermasz A, et al. Panel A shows the annualized rate of bleeding events before and after vector infusion. This is consistent with the fact that wild-type AAV infection in humans, although common, is not associated with oncogenesis. 1 INTRODUCTION. Thus, the therapeutic goal for gene therapy of hemophilia is modest in comparison with the majority of monogenetic disorders. 3,4 One strategy to overcome NAbs, which works well in animal models, is to switch AAV serotype20; however, this may not be applicable in humans because of the cross-reactivity of NAbs. Hum Mol Genet. Thus, the impact of scAAV vectors in animal models may have been overestimated.21, Another important aspect of the St. Jude/UCL study was the use of vector pseudotyped with AAV serotype 8 capsid. Factor VIII activity was determined with the use of a one-stage factor VIII assay. Attention is currently focused on the downstream purification process so that the purity of clinical-grade AAV preparation can be improved. ), Hemophilia A is an X-linked bleeding disorder caused by the deficiency or dysfunction of coagulation factor VIII. S2 in the Supplementary Appendix). Panel A shows the factor VIII activity relative to the annualized rate of spontaneous bleeding among Participants 1 through 18. An official website of the United States government. The hemophilias have always been considered good candidates for gene therapy, because all of their clinical manifestations are due to the lack of a single protein that circulates in minute amounts in the blood stream. The precise pathophysiological basis for transaminitis remains unclear, in part because it has not been possible to recapitulate this toxicity in animal models.27,37 Clinical data show that the increase in ALT postAAV gene therapy is dependent on vector dose and possibly the number of CpG motifs, as discussed previously, but is independent of AAV capsid, genome configuration, transgene promoter, and method of manufacture. Factor VIII activity was determined with the use of a one-stage factor VIII assay. Multiyear Follow-up of AAV5-hFVIII-SQ Gene Therapy for Hemophilia A. Valoctocogene Roxaparvovec Gene Therapy for Hemophilia A. Multiyear Factor VIII Expression after AAV Gene Transfer for Hemophilia A. Understand progress with gene therapy for hemophilia, Hemophilia A and B are X-linked recessive disorders resulting from mutations in the gene for blood clotting factor VIII (FVIII) and factor IX (FIX), respectively. The factor VIII pharmacodynamic profiles reflected cellular turnover in the blood and molecular events leading to episomal DNA stabilization for persistent expression, findings that are consistent with previous observations in two model systems. Although the increase in anti-AAV immunoglobulin G does not have direct clinical consequences, its persistence at high titers precludes subsequent successful gene transfer with a vector of the same serotype, in the event that transgene expression should fall below therapeutic levels. The hemophilias are ideally suited for gene therapy because a small increment in . [6] Multiple ongoing clinical trials of gene therapy for Hemophilia A involve different serotypes of recombinant adeno-associated viral vectors targeting hepatocytes. clinical trials utilizing AAV5 for hemophilia A have noted that patients with pre-existing anti-AAV5 antibodies had sustained levels of FVIII expression comparable to patients without neutralizing factors which indicates that AAV5 could be used even in . eCollection 2023 Jun 13. Furthermore, the observed annualized bleeding rate of 0 events in 60 to 100% of 16 participants with sustained factor VIII expression is similar to the results with emicizumab prophylaxis in severe hemophilia A.6 Collectively, these data suggest that multiyear, durable factor VIII expression of greater than 10% as determined by a one-stage factor VIII assay may be a threshold for minimally targeted therapeutic efficacy after gene transfer and may confer a phenotype analogous to emicizumab prophylaxis. Standard of care for people with severe haemophilia A is prophylactic administration of exogenous factor VIII (FVIII) or emicizumab to reduce frequency of bleeding. 1, 2 However, some people with severe haemophilia A on prophylaxis still experience bleeding. sharing sensitive information, make sure youre on a federal Consistent with the presence of a glucocorticoid response element in the promoter, factor VIII expression increased in all the participants while they were receiving glucocorticoids. We tested UK people with hemophilia B for immunity against AAV6. Mol Ther. Two of the 18 participants, both of whom were in the cohort that received 2 1012 vg per kilogram, lost expression after a cellular immune response against SPK200 detailed below and in the Supplementary Results section in the Supplementary Appendix. Overexpression of factor VIII after AAV delivery is transiently associated with cellular stress in hemophilia A mice, Factor VIII exhibits chaperone-dependent and glucose-regulated reversible amyloid formation in the endoplasmic reticulum. The first author wrote the first draft of the manuscript with subsequent input from the other authors and without editorial assistance. Thereafter, the participants received a single, intravenous infusion of SPK-8011 on an outpatient basis. Integrating vectors, based on lentivirus to propagate integration of the FIX or FVIII transgene into target cells, is also under evaluation in hematopoietic stem cells or blood outgrowth endothelial cells following ex vivo manipulations. Gene therapy offers the potential for a cure for patients with hemophilia by establishing continuous endogenous expression of factor VIII or factor IX (FIX) following transfer of a functional gene to replace the hemophilic patient's own defective gene. Young mice administered adult doses of AAV5-hFVIII-SQ achieve 2023 Apr 8;14(1):1970. doi: 10.1038/s41467-023-37774-5. The complete loss of factor VIII expression in two participants in the highest-dose cohort showed that the AAV capsid immune response was not universally sensitive to glucocorticoids; this observation was noted in another trial of AAV gene transfer.17 Although the use of prophylactic glucocorticoids prevented loss of expression, attempts to wean participants from these agents were complicated by the recurrence of laboratory findings that were consistent with a cellular immune response. cDNA, complementary DNA; IM, intramuscular. Hemophilia B gene therapy with a high-specific-activity factor IX variant, BAX 335 hemophilia B gene therapy clinical trial results: potential impact of CpG sequences on gene expression, Selection and evaluation of clinically relevant AAV variants in a xenograft liver model, CpG reduced factor VIII variants, compositions and methods and uses for treatment of hemostasis disorders. The planned phase 3 trial utilizing this vector is sponsored by Pfizer (New York, NY). 2021 Nov 18;385(21):1961-1973. doi: 10.1056/NEJMoa2104205. Panel C shows the percentage of participants with no bleeding events after SPK-8011 administration. Results The median safety observation period was 36.6 months (range, 5.5 to 50.3). Gene therapy for hemophilia - American Society of Hematology The authors designed the trial. Although successful gene trans - fer has been reported in patients with hemophilia B, the large size of the factor VIII coding region has precluded improved outcomes with gene therapy in patients with hemophilia A. The primary objective of the trial was to evaluate the safety and preliminary efficacy of SPK-8011. AAV vectors typically use a B-domain-deleted FVIII transgene, such as human FVIII-SQ in valoctocogene roxaparvovec (AAV5-FVIII-SQ). Factor VIII gene transfer with a single intravenous infusion of valoctocogene roxaparvovec (AAV5-hFVIII-SQ) has demonstrated clinical benefits lasting 5 years to date in people with. *, Four participants had adverse events related to glucocorticoids (Table 2). Descriptive statistics were used to analyze data from all the enrolled participants. One way to reduce or avoid this complication would be to improve vector performance so that low doses of AAV vectors could be used to mediate plasma FIX activity levels at >5% of normal. Hemophilia provides an attractive target for gene therapy studies, due to the monogenic nature of these disorders and easily measurable endpoints (factor levels and bleed rates), and AAV based gene therapy is one of a number of novel approaches for treatment of hemophilia progressing through clinical trials. However, the Nathwani group developed an AAV-based gene-transfer approach that addresses the size constraints and inefficient FVIII expression. The participants had a 91.5% reduction (95% CI, 88.8 to 94.1) in the annualized bleeding rate (median rate, 8.5 events per year [range, 0 to 43.0] before vector administration vs. 0.3 events per year [range, 0 to 6.5] after vector administration). FOIA Astermark J, Blatn J, Knigs C, Hermans C, Jimnez-Yuste V, Hart DP. The protocol, available with the full text of this article at NEJM.org, was approved by the institutional review board at each investigative site. These vectors have the best safety profile among gene transfer vectors of viral origin, because wild-type AAV has not been associated with human disease. Stable FIX expression and durable reductions in bleeding and factor IX consumption for up to 4 years following AMT-060 gene therapy in adults with severe or moderate-severe hemophilia B, Packaging capacity of adeno-associated virus serotypes: impact of larger genomes on infectivity and postentry steps, The unfolded protein response: from stress pathway to homeostatic regulation, Antioxidants reduce endoplasmic reticulum stress and improve protein secretion. This review explores recent progress and the remaining limitations that need to be overcome for wider availability of this novel treatment of inherited bleeding disorders. 2019 Oct 1;28(R1):R95-R101. Gene therapy for hemophilia cannot be given to patients with anti-AAV capsid-neutralizing antibodies, and cellular immunity with CD8 + T cells should be controlled for sustained expression, and long-term therapeutic effects should be closely observed because of the failure of the AAV vector genome to replicate during cell division. There were concerns that the use of a variant transgene would increase the risk of FIX inhibitor development, but preclinical studies in a canine model of hemophilia B showed that FIX-R338L expression after gene transfer did not result in inhibitor formation and, furthermore, was able to induce tolerance.27, The first clinical study to evaluate the FIX-R338L transgene in hemophilia B patients (BAX 335 [NCT01687608]) showed that peak FIX activity at 30% to 58% could be achieved at the high-dose level (3e12 vg/kg); unfortunately, expression declined to basal levels in all but 1 patient, who continues to express at the 20% level. In addition, AAV5-hFVIII-SQ differs from SPK-8011 with respect to codon optimization of the expression cassette, AAV capsid serotype, vector dose (30 to 120 times as high with AAV5-hFVIII-SQ), and the promoter.7,8. Background Patients with hemophilia A rely on exogenous factor VIII to prevent bleeding in joints, soft tissue, and the central nervous system. DOI: 10.1056/NEJMoa1708483 Epub 2023 May 17. Because of the prolonged use of immune modulation in the participants who received prophylactic glucocorticoids, Participant 18 received glucocorticoids when evidence of an immune response to the vector was noted and expression was maintained. N Engl J Med. 1, 2 Recent achievements include the regulatory approval of 2 AAV-based therapeutics and an increasing number of clinical trials with encouraging results. 2021 Nov 18; 385(21): 19611973. These results were unexpected given observations from clinical trials involving patients with hemophilia B that showed durable factor IX transgene-derived expression for 8 years after hepatocyte-directed AAV-mediated gene transfer and from studies in large-animal models of hemophilia A that showed durable factor VIII transgene-derived expression for 10 years.1012, One obstacle to efficacious AAV gene transfer is a cellular immune response against the AAV capsid, which was identified in trials of gene therapy for hemophilia B.13,14 This response is vector-dose dependent and classically manifested by an increase in the level of the liver enzyme alanine aminotransferase, a decrease in transgene expression, and identification of circulating capsid-specific T cells. The infusion of AAV5-hFVIII-SQ was associated with the sustained normalization of factor VIII activity level over a period of 1 year in six of seven participants who received a high dose,. . In 2011, the St. Jude/UCL phase 1/2 trial was the first to provide clear evidence of a stable dose-dependent increase in FIX levels in patients with severe hemophilia B following a single administration of adeno-associated viral (AAV) vectors. Considerations for shared decision management in previously untreated patients with hemophilia A or B. acts as an advisor for Freeline Therapeutics, BioMarin Pharmaceutical, and Generation Bio; is a founder of and has a sponsored research agreement with Freeline Therapeutics; and owns equity in Freeline Therapeutics. The critical impact of adeno-associated virus (AAV) gene transfer in hemophilia care is discussed, including the recent clinical outcomes, changes in disease perceptions, and its treatment burden. METHODS: We infused a single intravenous dose of a codon-optimized adeno-associated virus serotype 5 (AAV5) vector encoding a B-domain . Bethesda, MD 20894, Web Policies Transient transaminitis at 6-20 wk after gene transfer in 8 of 9 patients, Codon-optimized FVIII; B domain replaced with V3 peptide. official website and that any information you provide is encrypted 2017; 377: 2519-2530 . This method is cumbersome, but progress has been made on improving the productivity to supply phase 3/market-authorization hemophilia gene therapy trials.43 Another method being used by several biopharmaceutical companies, because of its scalability, is 1 based on baculovirus grown in SF9 insect cells.44 However, infectivity of AAV made using the baculovirus system is low, due in part to lower levels of VP1 incorporation into the AAV capsid. The analysis involving all 18 participants (median efficacy follow-up, 33.4 months; range, 3.7 to 47.6) showed a 91.5% reduction (95% confidence interval [CI], 88.8 to 94.1) in the annualized rate of bleeding events (median, 8.5 events per year [range, 0 to 43] before vector administration vs. 0.3 events per year [range, 0 to 6.5] after vector administration) (Fig. Before 2017 Dec 28;377 . Bookshelf Ex vivo factor VIII-modified proliferating human hepatocytes therapy for haemophilia A. Proof-of-concept study for liver-directed miQURE technology in a dyslipidemic mouse model. Mol Ther Nucleic Acids. The participants were followed for 52 weeks after vector administration, and all the participants subsequently were enrolled in a 4-year long-term follow-up trial. For instance, AAV5 serotype pseudotyped vectors (AMT-060; UniQure Therapeutics, Amsterdam, The Netherlands) made using the insect cellbaculovirus method, but containing the same FIX gene cassette as that used in the St. Jude/UCL trial, resulted in mean FIX activity levels of 6.9%, despite using a log higher vector dose of 2e13 vg/kg.25 Increased ALT levels were observed in 3 of 10 patients recruited to AMT-060, requiring treatment with corticosteroids. An increased incidence of hepatocellular carcinoma has been reported in the mucopolysaccharidoses type VII mouse model following perinatal gene transfer of AAV, potentially through integration and disruption of an imprinted region rich in microRNAs and small nucleolar RNAs on mouse chromosome 12.41 Subsequent studies in other murine models have failed to recapitulate this finding; collectively, the available data in mice, as well as larger animal models, suggest that AAV has a relatively low risk of tumorigenesis.42 Nevertheless, safety considerations remain paramount and will require careful long-term monitoring of patients, likely beyond the 5 years of follow-up mandated by the U.S. Food and Drug Administration. Background: Prophylaxis was discontinued in the 16 participants who had sustained factor VIII expression. Patients with hemophilia A rely on exogenous factor VIII to prevent bleeding in joints, soft tissue, and the central nervous system. Bookshelf The safe achievement of sustained, stable, and predictable factor VIII levels in all participants, even in the presence of immune responses, remains an unrealized goal of gene therapy for hemophilia A. Ex vivo factor VIII-modified proliferating human hepatocytes therapy for haemophilia A. Proof-of-concept study for liver-directed miQURE technology in a dyslipidemic mouse model. The AAV genome is maintained in an episomal format, raising the potential for loss of transgene expression with division of the transduced cell. More than half of patients with hemophilia A or B have factor levels < 1% of normal.1 These individuals have a severe bleeding phenotype consisting of frequent spontaneous musculoskeletal and soft tissue bleeding. To date, none of these advances have impacted the standard of care for 80% of the worlds hemophilia patients who live in parts of the world with economies in transition or development.11 These patients have little or no access to factor concentrates and have a reduced life expectancy, with very few surviving beyond their teenage years. Simioni P, Cagnin S, Sartorello F, et al. Inclusion in an NLM database does not imply endorsement of, or agreement with, Directed Evolution of AAV Serotype 5 for Increased Hepatocyte Patients with hemophilia A rely on exogenous factor VIII to prevent bleeding in joints, soft tissue, and the central nervous system. ); the Department of Pediatrics, Harvard Medical School, and the Division of Hematology and Oncology, Boston Childrens Hospital both in Boston (S.E.C. American Society of Hematology. Achievement of Normal Circulating Factor VIII Activity Following Bmn 270 AAV5-FVIII Gene Transfer: Interim, Long-Term Efficacy and Safety Results from a Phase 1/2 Study in Patients with Severe Hemophilia a - ScienceDirect Volume 130, Supplement 1, 8 December 2017, Page 603 801. The gray vertical line indicates an annualized rate of spontaneous bleeding of 1 event. Activated protein C has a regulatory role in factor VIII function. The hemophilia phenotype correlates with measured plasma factor VIII activity. Seroprevalence to adenoassociated virus type 6 in people with The recent progress of gene therapy for HA with viral and nonviral delivery vectors, including piggyBac, lentiviral and adeno-associated viral vectors, are discussed, as well as new raising issues involving liver toxicity, pre-existing neutralizing antibodies of viral approach, and the selection of the target cell type for nonViral delivery. Engineered adeno-associated virus 3 vector with reduced reactivity to Factor VIII activity levels remained at 3 IU or less per deciliter in the recipients of the low or intermediate dose. All the participants had vector shedding that was below the quantification limit in saliva, serum, urine, and semen by 3 weeks after vector infusion and in PBMCs by 12 weeks after vector infusion (Fig. Careers. Adeno-associated virus (AAV)-based gene therapies can restore endogenous factor VIII (FVIII) expression in hemophilia A (HA). Transgenic FIX activity levels have remained stable in all 10 subjects over an 8-year follow-up, associated with a significant reduction in the annual FIX concentrate usage and frequency of spontaneous bleeding.24 Importantly, the quality of life of these individuals has improved dramatically because they are now able to undertake activities that previously provoked bleeds without suffering from bleeding episodes. N Engl J Med. The enrolled participants met all screening criteria outlined in the Supplementary Appendix. 2021 Nov 18;385 . This site needs JavaScript to work properly. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A - Semantic Scholar K. J. et al. Partial F8 gene duplication (factor VIII Padua) associated with high factor VIII levels and familial thrombophilia. Valoctocogene roxaparvovec (AAV5-hFVIII-SQ) gene transfer provided reduced bleeding for adult clinical trial participants with severe hemophilia A. Conclusions: Gene therapy with AAV5-hFVIII-SQ vector in participants with hemophilia A resulted in sustained, clinically relevant benefit, as measured by a substantial reduction in annualized rates of bleeding events and complete cessation of prophylactic factor VIII use in all participants who had received 410 13 vg per kilogram or 610 13 vg . 2A). AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. Adenoassociated viruses (AAVs) are used as vectors for gene therapy to treat haemophilia. eCollection 2023 Jun 13. This led to the hypothesis that an excess of unmethylated CpG motifs, which are common in bacterial, but not mammalian, DNA, triggered a Toll-like receptor 9 response, leading to loss of transduced hepatocytes with an associated transaminitis that is not responsive to corticosteroids.28. Finally, on average, AAV5-hFVIII-SQ was associated with factor VIII activity that was 10 times as high at 1 year after vector administration as that of SPK-8011.8,9 This outcome was not unexpected given that vector doses of AAV5-hFVIIISQ were orders of magnitude higher than those of SPK-8011. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. N. Engl. The .gov means its official. Factor VIII gene transfer with a single intravenous infusion of valoctocogene roxaparvovec (AAV5-hFVIII-SQ) has demonstrated clinical benefits lasting 5 years to date in people with severe hemophilia A. Molecular mechanisms underlying sustained AAV5-hFVIII-SQ-derived FVIII expression have not been studied in humans. 3, 4 However, these successes also highlight a number of unanswered . Across all the dose cohorts, the initial peak factor VIII expression occurred 6 to 12 weeks after vector administration (Fig. For personal use only. Lange AM, Altynova ES, Nguyen GN, Sabatino DE. One proposed explanation is that factor VIII expression induces an unfolded protein response that, unmitigated, can produce apoptosis and loss of expression25; this has been observed in factor VIII mammalian cell culture and with supratherapeutic, but not low, levels of factor VIII expression after liver-directed gene transfer with AAV vectors in mice.2631. The cellular immune response was assessed by monitoring factor VIII activity, the alanine aminotransferase level, and the participants response to SPK200-derived peptides as determined by an interferon- enzyme-linked immune absorbent spot (ELISpot) assay of peripheral-blood mononuclear cells (PBMCs).16 Vector shedding was also assessed. This vector (AAV5hFVIII-SQ) was tested in 9 men with severe hemophilia A over a dose range of 6e12 to 6e13 vg/kg in the context of a phase 1/2 dose escalation trial (BMN 270-201).33 FVIII expression was <3% in the low- and intermediate-dose cohorts. The infusion of AAV5-hFVIII-SQ was associated with the sustained normalization of factor VIII activity level over a period of 1 year in six of seven participants who received a high dose, with stabilization of hemostasis and a profound reduction in factor VIII use in all seven participants. government site. Thus far, the risk for liver toxicity accompanied by a loss or reduction in transgene expression appears to be the most worrying toxicity associated with liver-targeted delivery of AAV, as described before. Konkle BASK, Visweshwar N, Harrington TJ, et al. A Bayesian negative binomial regression analysis with noninformative priors was used to analyze the relationship between the annualized rate of spontaneous bleeding after vector administration and the proportion of time participants had factor VIII activity that was greater than 10% of the normal value. Participants 5 and 12 lost transgene expression. official website and that any information you provide is encrypted Vagus nerve stimulation primes platelets and reduces bleeding in Bleeding in all target joints (major joints with 3 bleeding events within 6 months) in this cohort resolved (2 bleeding events within 12 months). 3 Standard of care for severe HAregular prophylaxis with exogenous FVIIIdoes not prevent breakthrough bleeding. Some participants received glucocorticoids within 52 weeks after vector administration either to prevent or to treat a presumed AAV capsid immune response. Multiyear factor VIII expression after AAV gene transfer for hemophilia A. N Engl J Med. This decline in transgenic protein coincided with a transient tenfold increase in liver transaminases (serum alanine aminotransferase [ALT] > aspartate transaminase [AST]), which spontaneously returned to baseline values over the subsequent weeks, consistent with a self-limiting process. 2023 May;56(5):e13467.
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