Clinical Gene Transfer Studies for Hemophilia B

Hemophilia B, a deficiency of functional factor IX (FIX), has been extensively explored as a model for gene transfer. Two U.S. Food and Drug Administration-approved clinical studies for hemophilia B have been undertaken, both using adeno-associated viral vectors (AAV). AAV vectors have tropism for liver, muscle, central nervous system, and the respiratory tract; both skeletal muscle and liver have been used as target tissues in the hemophilia B studies. In both studies, proof of principle was first established in the hemophilia B dog model, with long-term expression of canine FIX at therapeutic levels achieved before clinical studies were initiated. In the AAV-FIX muscle trial, vector was introduced into skeletal muscle of the upper and lower extremities of eight human patients by direct intramuscular injection. Muscle biopsies taken 2 to 10 months postinjection demonstrated gene transfer and expression (by Southern blot and immunofluorescence, respectively) in all patients, but circulating FIX levels were generally not >1%, and escalation of dose to levels that proved therapeutic in animals was thwarted by feasibility issues regarding the number of injections required. Nevertheless, the study demonstrated that parenteral injection of AAV-FIX was safe at the doses tested, and could result in long-term expression of the transgene. Moreover, the general characteristics of transduction of human muscle were similar to those observed in other animal models. The safety and efficacy data established in the first trial formed the basis for a second trial in which AAV-FIX is administered systemically to target the liver. The liver study is currently ongoing, with six patients enrolled to date.

KEYWORDS

Hemophilia B - factor IX - adeno-associated virus - gene therapy

REFERENCES

• 1 Evans J P, Brinkhous K M, Brayer G D, Reisner H M, High K A. Canine hemophilia B resulting from a point mutation with unusual consequences.  Proc Natl Acad Sci USA. 1989;  86 10095-10099
• 2 Mauser A E, Whitney K M, Lothrop Jr C D. A deletion mutation causes hemophilia B in Lhasa apso dogs.  Blood. 1996;  88 3451-3455
• 3 Couto L B. Preclinical gene therapy studies for hemophilia using adeno-associated virus (AAV) vectors.  Semin Throm Hemost. 2004;  30 161-172
• 4 Herzog R, Hagstrom N, Kung S et al.. Stable gene transfer and expression of human FIX following intramuscular injection of recombinant AAV.  Proc Natl Acad Sci USA. 1997;  94 5804-5809
• 5 Herzog R, Yang E, Couto L et al.. Long-term correction of canine hemophilia B by gene transfer of blood coagulation factor IX mediated by adeno-associated viral vector.  Nat Med. 1999;  5 56-63
• 6 Snyder R O, Miao C H, Patijn G A et al.. Persistent and therapeutic concentrations of human factor IX in mice after hepatic gene transfer of recombinant AAV vectors.  Nat Genet. 1997;  16 270-276
• 7 Snyder R O, Miao C, Meuse L et al.. Correction of hemophilia B in canine and murine models using recombinant adeno-associated viral vectors.  Nat Med. 1999;  5 64-70
• 8 Balagué C, Zhou J, Dai Y et al.. Sustained high-level expression of full-length human factor VIII and restoration of clotting activity in hemophilic mice using a minimal adenovirus vector.  Blood. 2000;  95 820-828
• 9 Gallo-Penn A M, Shirley P S, Andrews J L et al.. Systemic delivery of an adenoviral vector encoding canine factor VIII results in short-term phenotypic correction, inhibitor development, and biphasic liver toxicity in hemophilia A dogs.  Blood. 2001;  97 107-113
• 10 Monahan P E, Samulski R J, Tazelaar J et al.. Direct intramuscular injection with recombinant AAV vectors results in sustained expression in a dog model of hemophilia.  Gene Ther. 1998;  5 40-49
• 11 Mount J D, Herzog R W, Tillson D M et al.. Sustained phenotype correction of hemophilia B dogs with a factor IX null mutation by liver-directed gene therapy.  Blood. 2002;  99 2670-2676
• 12 Wagner J A, Reynolds T, Moran M L et al.. Efficient and persistent gene transfer of AAV-CFTR in maxillary sinus.  Lancet. 1998;  351 1702-1703
• 13 Wagner J A, Moran M L, Messner A H et al.. A phase I/II study of tgAAV-CF for the treatment of chronic sinusitis in patients with cystic fibrosis.  Hum Gene Ther. 1998;  9 889-909
• 14 Department of Health and Human Services .National Institutes of Health Recombinant DNA Advisory Committee. Minutes of Meeting, March 11-12 1999 Bethesda, MD: NIH; Available at: http://www4.od.nih.gov/oba/rac/minutes/3-99RAC.htm. Accessed March 18, 2004
• 15 Arruda V R, Hagstrom J N, Deitch J et al.. Posttranslational modifications of recombinant myotube-synthesized human factor IX.  Blood. 2001;  97 130-138
• 16 Pollak E S, High K A. Hemophilia B factor IX deficiency. In: Sciver CR, Beaudet AL, Valle D, Sly WS The Metabolic and Molecular Bases of Inherited Diseases, 8th Ed. New York; McGraw-Hill 2001: 4393-4418
• 17 Lofqvist T, Nilsson I M, Berntorp E, Pettersson H. Haemophilia prophylaxis in young patients-a long term follow up.  J Intern Med. 1997;  241 395-400
• 18 Kay M A, Manno C S, Ragni M V et al.. Evidence for gene transfer and expression of factor IX in haemophilia B patients treated with an AAV vector.  Nat Genet. 2000;  24 257-261
• 19 Manno C S, Chew A J, Hutchison S et al.. AAV-mediated factor IX gene transfer to skeletal muscle in patients with severe hemophilia B.  Blood. 2003;  101 2963-2972
• 20 Dimichele D. Inhibitors: resolving diagnostic and therapeutic dilemmas.  Haemophilia. 2002;  8 280-287
• 21 Donsante A, Vogler C, Muzyczka N et al.. Observed incidence of tumorigenesis in long-term rodent studies of rAAV vectors.  Gene Ther. 2001;  8 1291-1298
• 22 Summerford C, Samulski R J. Membrane-associated heparan sulfate proteoglycan is a receptor for adeno-associated virus type 2 virions.  J Virol. 1998;  72 1438-1445
• 23 Qing K, Mah C, Hansen J et al.. Human fibroblast growth factor receptor 1 is a co-receptor for infection by adeno-associated virus 2.  Nat Med. 1999;  5 71-77
• 24 Herzog R W, Fields P A, Arruda V R et al.. Influence of vector dose on factor IX-specific T and B cell responses in muscle-directed gene therapy.  Hum Gene Ther. 2002;  13 1281-1291
• 25 Arruda V R, Schuettrumpf J, Herzog R W et al.. Safety and efficacy of factor IX gene transfer to skeletal muscle in murine and canine hemophilia B models by adeno-associated viral vector serotype 1.  Blood. 2004;  103 85-92
• 26 Chao H, Liu Y, Rabinowitz J et al.. Several log increase in therapeutic transgene delivery by distinct adeno-associated viral serotype vectors.  Mol Ther. 2000;  2 619-623
• 27 Arruda V R, Stedman H, Nichols T C et al.. Sustained correction of hemophilia B phenotype following intravascular delivery of AAV vector to skeletal muscle.  Mol Ther. 2002;  5 S157
• 28 Orkin S H, Motulsky A G. Report and recommendations of the panel to assess the NIH investment in research on gene therapy. Bethesda, MD: National Institutes of Health; 1995 Available at: http//www.nih.gov/od/orda/panelrep.htm. Accessed March 18, 2004
• 29 Raper S E, Yudkoff M, Chirmule N et al.. A pilot study of in vivo liver-directed gene transfer with an adenoviral vector in partial ornithine transcarbamylase deficiency.  Hum Gene Ther. 2002;  13 163-175
• 30 Schnell M A, Zhang Y, Tazelaar J et al.. Activation of innate immunity of nonhuman primates following intraportal administration of adenoviral vectors.  Mol Ther. 2001;  3 708-722
• 31 Herzog R W, Mount J D, Arruda V R, High K A, Lothrop Jr C D. Muscle-directed gene transfer and transient immune suppression result in sustained partial correction of canine hemophilia B caused by a null mutation.  Mol Ther. 2001;  4 192-199
• 32 Pruchnic R, Cao B, Peterson Z Q et al.. The use of adeno-associated virus to circumvent the maturation-dependent viral transduction of muscle fibers.  Hum Gene Ther. 2000;  11 521-536
• 33 Johnson M A, Polgar J, Weightman D. Data on the distribution of fibre types in thirty-six human muscles. An autopsy study.  J Neurol Sci. 1973;  18 111-129
• 34 Mingozzi F, Liu Y-L, Dobrzynski E et al.. Induction of immune tolerance to coagulation factor IX antigen by in vivo hepatic gene transfer.  J Clin Invest. 2003;  111 1347-1356
• 35 Franchini M, Rossetti G, Tagliaferri A et al.. The natural history of chronic hepatitis C in a cohort of HIV-negative Italian patients with hereditary bleeding disorders.  Blood. 2001;  98 1836-1841
• 36 Meijer K, Haagsma E B, Kok T et al.. Natural history of hepatitis C in HIV-negative patients with congenital coagulation disorders.  J Hepatol. 1999;  31 400-406
• 37 Bedossa P, Poynard T. French METAVIR Cooperative Study Group. An algorithm for the grading of activity in chronic hepatitis C.  Hepatology. 1996;  24 289-293
• 38 French METAVIR Cooperative Study Group . Interobserver and intraobserver variation in liver biopsy interpretation in patients with chronic hepatitis C.  Hepatology. 1994;  20 15-20
• 39 Nathwani A C, Davidoff A M, Hanawa H et al.. Sustained high level expression of human factor IX (hFIX) after liver-targeted delivery of recombinant adeno-associated virus encoding the hFIX gene in rhesus macaques.  Blood. 2002;  100 1662-1669
• 40 Zhang Y, Chirmule N, Gao G-P et al.. Acute cytokine response to systemic adenoviral vectors in mice is mediated by dendritic cells and macrophages.  Mol Ther. 2001;  3 697-707
• 41 Miao C H, Snyder R O, Schowalter D B et al.. The kinetics of rAAV integration in the liver.  Nat Genet. 1998;  19 13-15
• 42 Editorial . Gene therapy and the germline.  Nat Med. 1999;  5 245
• 43 Farber D. Gene therapy: safer and virus-free?.  Science. 2001;  294 1638-1642
• 44 National Institutes of Health .Recombinant DNA Advisory Committee Minutes, June 18-19. 1998 Bethesda, MD: NIH; Available at: http://www4.od.nih.gov/oba/rac/minutes/6-98min.htm. Accessed March 18, 2004
• 45 FDA Biological Response Modifiers Advisory Committee .Issues Pertaining to Inadvertent Germline Transmission of Gene Transfer Vectors. Gaithersburg, MD: Food and Drug Administration, May 9-10; 2002 Available at: http://www.fda.gov/ohrms/dockets/ac/02/briefing/3855B2_01.doc. Accessed March 18, 2004
• 46 Frankel M, Chapman A. Human inheritable genetic modifications: assessing scientific, ethical, religious, and policy issues. Available at http://archives.aaas.org/publications.php?pubid=687.
• 47 King N M. Inadvertent germline effects in clinical research.  Hastings Cent Rep. 2003;  33 23-30
• 48 Ye X, Gao G P, Pabin C, Raper S E, Wilson J M. Evaluating the potential of germ line transmission after intravenous administration of recombinant adenovirus in the C3H mouse.  Hum Gene Ther. 1998;  9 2135-2142
• 49 Roehl H H, Leibbrandt M E, Greengard J S et al.. Analysis of testes and semen from rabbits treated by intravenous injection with a retroviral vector encoding the human factor VIII gene: no evidence of germ line transduction.  Hum Gene Ther. 2000;  11 2529-2540
• 50 Arruda V R, Fields P A, Milner R et al.. Lack of germline transmission of vector sequences following systemic administration of recombinant AAV-2 vector in males.  Mol Ther. 2001;  4 586-592
• 51 Couto L B, Parker A, Gordon J W. Direct exposure of mouse sperm to high concentrations of an adeno-associated virus gene therapy vector fails to lead to germ cell transduction.  Mol Ther. 2003;  7 S161(abst)
• 52 Department of Health and Human Services .National Institutes of Health Recombinant DNA Advisory Committee. Minutes of Meeting, March 7-8 2002 Bethesda, MD; NIH Available at: http://www4.od.nih.gov/oba/RAC/meeting.html. Accessed March 18, 2004
• 53 Department of Health and Human Services .National Institutes of Health Recombinant DNA Advisory Committee. Minutes of Meeting, December 6 2001 Bethesda, MD; NIH Available at: http://www4.od.nih.gov/oba/RAC/meeting.html. Accessed March 18, 2004
• 54 Balagué C, Kalla M, Zhang W W. Adeno-associated virus Rep78 protein and terminal repeats enhance integration of DNA sequences into the cellular genome.  J Virol. 1997;  71 3299-3306
• 55 Young S MJ, McCarty D M, Degtyareva N, Samulaki R J. Roles of adeno-associated virus Rep protein and human chromosome 19 in site-specific recombination.  J Virol. 2000;  74 3953-3966
• 56 Nakai H, Yant S R, Storm T A et al.. Extrachromosomal recombinant adeno-associated virus vector genomes are primarily responsible for stable liver transduction in vivo .  J Virol. 2001;  75 6969-6975
• 57 Miller D G, Rutledge E A, Russell D W. Chromosomal effects of adeno-associated virus vector integration.  Nat Genet. 2002;  30 147-148
• 58 Nakai H, Montini E, Fuess S et al.. AAV serotype 2 vectors preferentially integrate into active genes in mice.  Nat Genet. 2003;  34 297-302