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GENE THERAPY FOR HAEMOPHILIA B

PRANALI PATIL
MSc.1
PAPER II
SEM-1
TEACHER IN-CHARGE :Ms. RAZIA ENGINEER
Index
 INTRODUCTION
 GENE THERAPY
 AAV8
 AAV5
 SPK-9001
 CONCLUSION
 REFERENCES
Introduction

 Haemophilia is an X-linked recessive bleeding disorder -


defect in the gene encoding coagulation factor IX (FIX)
 characterized by lifelong spontaneous haemorrhages into
joints, soft tissues, and muscles
 Clinically, patients are classified as severe, moderate or mild
 Current treatment -frequent intravenous injections of FIX
protein concentrate
 Administered on demand or prophylactically
 However, treatment is cumbersome, extraordinarily
expensive
Gene therapy

 Somatic gene therapy for the haemophilia B offers the potential


for cure through continuous endogenous production of FIX after
a single dose administration of vector
 Haemophilia B is an ideal target
 Mediated by adenovirus- associated virus (AAV)
 Serotype AAV2 was used most extensively in early studies
 However, showed only transient expression of FIX
 Clinical trials on humans were carried out by using different AAV
vectors
AAV8
 Liver targeted
 Differed from earlier studies in following aspects:
(a) utilized a codon-optimized FIX (FIXco) expression cassette
packaged as complementary dimers within a single virion.
These self-complementary AAV vectors mediate transgene
expression at substantially higher levels than a single-
stranded AAV vectors
(b) packaged into an AAV8 capsid, administered by peripheral
vein infusion. (scAAV2/8-LP1-hFIXco).
 10 men with haemophilia B
undergoing prophylaxis- divided in
one the three groups according to
dose level:
 low (2×1011 vector genomes [vg] /kg),
 intermediate (6×1011) vg/kg),
 and high (2×1012vg/kg)
 Stable FIX levels achieved - 1 to 6% of
the normal value
 FIX levels of the patients was roughly
dose – dependent - high dose having
a peak at 8-12% of normal levels
 Prophylaxis with FIX stopped
 Amount of factor IX concentrate -
of 2613 IU/kg in the year before
vector infusion to 206 IU/kg after
a vector infusion
 Annual number of bleeding
episodes decreased from a
median of 15.5 bleeding
episodes a year before vector
infusion to 1.5 bleeding episodes
in the year after vector infusion
i.e. approximately 90%
reduction.
 Transient increase in alanine aminotransferase (ALT)
 A decrease in the levels of factor IX by 50-70%
 Prednisolone therapy
 No increase in neutralizing antibodies
AAV5
 AMT-060 is a novel gene transfer product that consists of an adeno-
associated virus-5 (AAV5) vector incorporating a small gene
cassette containing codon-optimized wild – type human FIX gene
under the control of liver specific promoter (LP1)
 10 patients in two groups as a single 250ml peripheral intravenous
infusion for 30 minutes
 Group 1 -low dose of 5×1012gc/kg
 Group 2 – high dose of 2×1013gc/kg
 In group 1, the residual endogenous
FIX activity increased from <1IU/ dL
to a mean of 4.4 IU/dL
 In group 2, the values reached to a
mean of 6.9IU/ dL
 FIX levels remained stable for the
duration
 Three participants experienced mild
asymptomatic elevations in ALT
levels
 Humoral immune response to AAV5
 FIX prophylaxis stopped
 Total annualized reduction of
exogenous FIX use -79% overall.
 The reduction in spontaneous
bleeds was lower in group 1 (53%)
as compared to group2 (70%).
SPK-9001
 Risk of an immune response against AAV-transduced hepatocytes was
dependent on the vector dose
 Need of use the lowest dose - AAV vector expressing a high-specific-
activity factor IX variant
 Factor IX–R338L is a naturally occurring gain-of-function mutation-
specific activity 8 to 12 times as high as that of nonmutant factor IX
 SPK-9001, consists of a bioengineered capsid (AAV-Spark100) and an
expression cassette containing the apolipoprotein E gene hepatic-
control region (APOE), a liver-specific human α1-antitrypsin (hAAT)
promoter, and a codon-optimized F9–Padua minigene.
 10 participants with haemophilia B received an infusion of SPK-
9001 intravenously at a dose of 5×1011 vg/kg of the body
weight over a period of 1 hour
 Vector-derived factor IX coagulant activity was 33.7±18.5% of
the normal value
 Increase in the ALT levels- prednisone course
 the annual bleeding rate
decreased after vector
administration from 11.1 to 0.4
events per year
 Consumption of the factor –
2908 IU/kg to 49.3 IU/kg
 100 % reduction in the use of
exogenous factor IX
Vector FIX activity ALT levels FIX activity Efficacy Bleed rates
after rise in and
ALT levels consumption
of exogenous
FIX

AAV8 INCREASED INCREASED DECREASED _ REDUCED


IN HIGH
DOSE GROUP

AAV5 INCREASED INCREASED STABLE _ REDUCED


IN HIGH
DOSE GROUP

SPK-090 INCREASED INCREASED STABLE INCREASED REDUCED


IN HIGH
DOSE GROUP
Conclusion
 Somatic gene therapy for the haemophilia B offers the potential for
cure through continuous endogenous production of FIX after a single
dose administration of vector
 AMT-060 was well tolerated and effective in all participants including
those with low-titer antibodies.
 A single peripheral-vein infusion of scAAV2/8-LP1-hFIXco vector-
mediated gene transfer in Hemophilia B vector consistently led to
long-term expression of the FIX transgene at therapeutic levels,
without acute or long-lasting toxicity in patients with severe
hemophilia B.
 The use of a high-specific-activity transgene, factor IX–R338L, and
codon-optimized expression cassette permitted the safe use of a low
dose of vector (5×1011 vg per kilogram) and yielded high levels of
sustained vector-derived factor IX coagulant activity and a low
incidence of a capsid-directed immune response.
 Immune-mediated, AAV-capsid– induced elevations in aminotransferase
levels remained a concern, but it was found that this process may be
controlled by a short course of glucocorticoids, without loss of transgene
expression. In all the cases, the annualized bleeding rates and the
consumption of exogenous FIX decreased showing the success of the
gene therapy.
 The different outcomes of gene transfer in the participants in this study
and in the previous trial of AAV2 hemophilia B gene therapy suggest that
in addition to AAV vector dose, other factors such as individual variations
in antigen processing and presentation, as well as exposure to wild-type
AAV, seem to influence the type and magnitude of the immunological
response to AAV-vector particles. It is very important to identify these
immune modifying factors, as well as to determine the frequency of
clinically significant elevations in aminotransferase levels after gene
transfer.