IL2RG protein, encoded by tL2RG complementary DNA. (https://commons.wikimedia.org/wiki/File:Protein_IL2RG_PDB_2b5i.png)
As reported in the 18 April issue of the New England Journal of Medicine, researchers at the St. Jude Children’s Research Hospital (Memphis, TN) and their colleagues have used gene therapy to restore immune function to eight infants with newly diagnosed X-linked severe combined immunodeficiency (SCID-X1).
SCID-X1 is sometimes called “bubble-boy disease”, because of the case of a boy born in 1971 with SCID-X1, who had to be isolated in a plastic bubble while awaiting a bone-marrow transplant.
SCID-X1 is a rare X-linked genetic disease caused by a mutation in the L2RG gene. This gene encodes the interleukin-2 receptor subunit gamma (IL-2RG), which is common to the receptor complexes for at least six different interleukin receptors, including IL-2 and IL-4. Individuals with SCID-X1 produce very few T and NK (natural killer) cells, and are thus severely immunodeficient. As a result, they are very susceptible to infections, and typically die before age 2 if not isolated or treated.
Although SCID-X1 is a rare disease, it is the most common form of severe combined immunodeficiency. It probably affects at least 1 in 50,000 to 100,000 newborns.
SCID-X1 can sometimes be cured by a bone-marrow transplant from a matched sibling donor. However, fewer than 20% of SCID-X1 patients have such an available donor.
A previous attempt to apply gene therapy to treatment of SCID-X1, in the early 2000s, utilized a Moloney murine leukemia virus (MoMuLV) gammaretrovirus as a vector. This resulted in a high level of leukemia induction, as discussed in a previous article on this blog. So this approach had to be abandoned. Instead, researchers have developed lentiviral vectors, which appear to have a lower risk of leukemogenesis than gammaretroviral vectors. We discussed the development and use of lentiviral vectors in our November 2015 book-length report, Gene Therapy: Moving Toward Commercialization, published by Cambridge Healthtech Institute.
The new experimental gene therapy for SCID-X1 utilized a lentiviral vector carrying IL2RG complementary DNA. This was used to transfect patient-derived bone-marrow stem cells. The transfected stem cells were infused back into eight infants with newly diagnosed SCID-X1after low-exposure, targeted busulfan conditioning. (“Conditioning”, for example via a myelosuppressive chemotherapy like busulfan given prior to stem-cell transplantation, is designed to make room for transplanted blood stem cells to grow.
The eight infants were studied for a median of 16.4 months, and experienced no unexpected side effects. In seven of the infants, the numbers of T cells and NK cells normalized by 3 to 4 months after infusion. The vector was present in T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors in these seven subjects. The eighth subject initially had an insufficient T-cell count. However, a boost of gene-corrected cells without busulfan conditioning resulted in T-cell normalization. Previous infections were cleared in all infants, and all continued to grow normally. The subjects also showed other signs of immune system normalization, including vaccine response in three of the infants.
The researchers concluded that the IL2RG-lentiviral vector gene therapy combined with low-exposure, targeted busulfan conditioning in infants with newly diagnosed SCID-X1 showed low-grade acute toxic effects, and resulted in engraftment of transduced cells, reconstitution of functional T cells and B cells, and normalization of NK-cell counts during a median follow-up of 16 months. Children treated with this gene therapy should therefore be protected against common ailments by their reconstituted immune systems. However, they will still need to be monitored long-term to determine if the treatment is durable and free of side effects over the long term.
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As the producers of this blog, and as consultants to the biotechnology and pharmaceutical industry, Haberman Associates would like to hear from you. If you are in a biotech or pharmaceutical company, and would like a 15-20-minute, no-obligation telephone discussion of issues raised by this or other blog articles, or of other issues that are important to your company, please contact us by phone or e-mail. We also welcome your comments on this or any other article on this blog.
Adeno-associated virus. Source: https://commons.wikimedia.org/wiki/File:Adeno-associated_virus_serotype_AAV2.jpg
In recent weeks, buyouts of gene therapy companies by Big Pharmas or Big Biotechs—as well as other major gene therapy deals—have been making the news. Specifically, on February 25, 2019, leading gene therapy company Spark Therapeutics (Philadelphia, PA) announced that it had entered into a merger agreement with Roche. Under this agreement, Roche will fully acquire Spark for $4.3 billion.
Roche will keep Spark as a independent entity, similar to Roche’s Genentech. This should enable the type of innovation that has been demonstrated by Spark since its founding in 2013.
Meanwhile, Biogen is buying gene therapy company Nightstar Therapeutics (London, UK) for $800 million in order to gain access to its suite of gene therapies for rare retinal diseases. According to “Endpoints News”, the Biogen/Nightstar deal is the result of a bidding war for Nighrstar by Biogen and three other (unnamed) companies.
And Johnson & Johnson has signed a deal with MeiraGTX (London and New York) for rights to its experimental gene therapies for rare retinal diseases. The two companies also will collaborate on improving gene therapy manufacturing. J&J paid Meira $100 million in cash upfront, and Meira could get up to $340 million in additional downstream payments plus royalties on sales if its products reach the market. J&J will be paying for clinical development of the therapies.
Our previous discussions of Spark and Nightstar
We discussed Spark and Nightstar and their gene therapy programs in our 2015 book-length report, Gene Therapy: Moving Toward Commercialization. We also updated our discussion of Spark’s lead ophthalmological gene therapy product Luxturna (voretigene neparvovec-rzyl) (formerly known as SPK-RPE65), in our December 21, 2017 article on this blog.
As we discussed in these publications, Spark’s Luxturna is a one-time gene therapy designed to treat patients with an inherited retinal disease (IRD) caused by mutations in both copies of the RPE65 (retinal pigment epithelium-specific 65 kDa protein) gene. It consists of a version of the human RPE65 gene delivered via an adeno-associated virus 2 (AAV2) viral vector, and is administered via subretinal injection. Luxturna is the first FDA-approved gene therapy for a genetic disease, the first FDA-approved pharmacologic treatment for an IRD, and the first AAV-vector gene therapy approved in the USA.
Nightstar is clinical stage company whose initial focus is treatment of the IRD choroideremia (CHM). CHM is an X-linked genetic disease caused by mutations in the X-CHM gene. These mutations interfere with the production of Rab escort protein-1 (REP1). REP1 is involved in intracellular protein trafficking, and the elimination of waste products from retinal cells.
Nightstar’s lead product is NSR-REP1 (formerly known as AAV2-REP1). This gene therapy consists of an AAV2 vector containing recombinant human complementary DNA, (cDNA), that is designed to produce REP1 inside the eye. NSR-REP1 is currently in a Phase 3 registrational clinical trial, known as the STAR trial. It is thus the most clinically advanced candidate for choroideremia in the world.
In addition to discussing gene therapies under development (including the above-mentioned Spark and Nightstar programs, as well as many others), our 2015 gene therapy report also discusses development and use of gene therapy vectors, especially AAV. It thus continues to be a valuable reference for understanding the gene therapy field.
MeiraGTX
MeiraGTX focuses on AAV-based gene therapies. Its five programs in clinical development include three ophthalmological therapies, as well as gene therapies for a salivary gland condition, and for Parkinson’s disease. The company’s most advanced programs are in Phase 1/2 clinical development, and include treatments for achromatopsia and X-linked retinitis pigmentosa.
Spark is also developing gene therapies for hemophilia
As discussed in a February 23, 2019 “Endpoints News” article on the Roche/Spark merger, Roche’s interest in Spark is not only because of its leadership position in ophthalmological gene therapies, but also because of its broad product portfolio. Notably, among Spark’s product candidates is SPK-8011, one of the leading clinical-stage gene therapies for hemophilia A. SPK-8011 is a novel AAV vector containing a codon-optimized human factor VIII gene under the control of a liver-specific promoter. As the result of promising Phase 2 data, SPK-8011 is now in a lead-in study (NCT03876301) for phase 3 clinical trials. Also in a lead-in study for Phase 3 trials (sponsored by Spark’s partner for this therapy, Pfizer) is Spark’s hemophilia B candidate, fidanacogene elaparvovec (SPK-9001).
The hemophilia gene therapy field is highly competitive. Other companies with clinical-stage hemophilia gene therapies include BioMarin, uniQure, and Sangamo/Pfizer.
Roche’s acquisition of Spark’s SPK-8001 may enable Roche/Genentech to strengthen its leading competitive position in the hemophilia A market. Roche received FDA approval for its blockbuster prophylactic Hemlibra for hemophilia A without factor VIII inhibitors in October 2018.
Pfizer enters the gene-therapy buyout arena
In late-breaking (March 20, 2019) news, Pfizer has taken an exclusive option to acquire Vivet Therapeutics (Paris, France).
Vivet focuses on the development of gene therapies for inherited liver diseases with high unmet medical need. Under the new agreement, Pfizer has acquired 15% of Vivet’s equity, and an exclusive option to acquire all outstanding shares. Initially, the two companies will collaborate on the development of Vivet’s VTX-801, a preclinical-stage gene therapy for Wilson disease.
Wilson disease is a rare and potentially life-threatening liver disorder involving impaired copper transport, resulting in severe copper poisoning. The Wilson’s disease mutation disables the excretion pathway for copper via the bile. This results in excess copper accumulation in the liver and other organs, including the central nervous system. Untreated, Wilson disease results in severe copper toxicity, which can be fatal. It can only be cured by liver transplantation. Existing therapies for Wilson disease are of low efficacy and/or result in significant side effects.
VTX-801, like other therapies discussed in this article, is an AAV-based gene therapy. It is Vivet’s first gene therapy, and the most advanced in development.
Under the terms of the agreement, Pfizer paid approximately €45 million (US$51 million) upon signing and may pay up to €560 million (US$635.8 million) in milestone payments. Pfizer also has an option to acquire 100% of Vivet, based on the results of a Phase 1/2 clinical trial for VTX-801. Pfizer senior executive Monika Vnuk, M.D., Vice President, Worldwide Business Development, is also joining Vivet’s Board of Directors.
Vivet’s earlier-stage preclinical liver-directed gene therapies include a program for progressive familial intrahepatic cholestasis (PFIC) for bile excretion defects and in citrullinemia for defects in the urea cycle.
The Pfizer/Vivet agreement is yet another example of the recent Large Pharma/Biotech enthusiasm for buying up small gene-therapy companies.
Concerns about cost and patient selection for “one and done” gene therapies
As we discussed in our December 21, 2017 article on this blog, Luxturna, as the first FDA-approved gene therapy for an inherited disease, is expected to be a one-time (“one and done”) therapy for its targeted condition. It is expensive, priced at $850,000 ($425,000 per eye affected by an RPE65 gene mutation). This made Luxturna the highest priced therapy in the U.S. to date. Other “one and done” gene therapies are also expected to be expensive. Pricing and related issues with “one and done” gene therapies thus affect the prospects for gene therapy companies and for larger companies that are planning to acquire or partner with them.
In our December 21, 2017 article, we discussed payer programs designed to enable patient access to treatment with Luxturna. These include an outcomes-based rebate plan with a long-term durability measure, and a proposal under which payments for Luxturna would be made over time. Such programs are designed to reduce risk and financial burden for payers and treatment centers. As we discussed, pricing and payer programs that become established for Luxturna may have a wide impact on the entire gene therapy field.
A March 5, 2019 article on gene therapy by Jeremy Schafer, PharmD, MBA of Precision for Value was published in Clinical Leader. This article focused on designing gene therapy clinical trials to meet the concerns of payers and health systems.
At the recent annual meeting of the Academy of Managed Care Pharmacy, the results of a survey that included the perceptions of gene therapy among health plans and health system stakeholders were presented. Among these respondents, 35% stated that their primary concern with gene therapy was “selecting appropriate patients.” Another 30% named “the potential need for retreatment” as their main concern. The major concern of 5% of respondents was that patients treated with gene therapy would still need conventional treatment for their condition. A total of 88 percent of respondents felt that information on appropriate patient selection as well as durability of response would be extremely valuable. Another 60 percent would like to have an economic model on the long-term value of the gene therapy.
Dr. Schafer’s article discussed how clinical trial design might help address these concerns. For example, gene therapy clinical trials might include a long-term follow-up plan to capture data on an ongoing basis. This might help address the question as to whether a gene therapy is truly “one and done”. Ongoing data from these trials might be shared in peer-reviewed publications. The long-term data might be used in economic models by health plans.
In terms of identifying appropriate patients for gene therapies, clinical trial design might include clearly-defined inclusion and exclusion criteria, based on good scientific rationales. Preplanned subgroup analyses might show which groups respond well or not so well to a gene therapy. Clinical trials could also be designed to determine whether and to what extent gene-therapy patients will still need ongoing therapy with conventional drugs.
All these issues in structuring payer programs and in clinical trials designed to meet the concerns of payers and health plans (and of partner and acquiring companies) may enable the development and acceptance of gene therapies as this field moves beyond the release of the first few products.
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As the producers of this blog, and as consultants to the biotechnology and pharmaceutical industry, Haberman Associates would like to hear from you. If you are in a biotech or pharmaceutical company, and would like a 15-20-minute, no-obligation telephone discussion of issues raised by this or other blog articles, or of other issues that are important to your company, please contact us by phone or e-mail. We also welcome your comments on this or any other article on this blog.
Arming NK cells with enhanced antitumor activity. Source: Oberoi P, Wels WS – Oncoimmunology (2013)
I attended and participated in an interactive breakout discussion session entitled “Targeting Solid Tumors with NK Cells” at the Cambridge Healthtech Institute conference “Discovery on Target” on Wednesday, September 26, 2018.
The session moderator was Dan Kaufman, MD, Ph.D., Professor and Director of the Cell Therapy Program, University of California, San Diego. Also among the attendees at the session were several conference speakers.
There is an article in the 14 September issue Science by science writer Mitch Leslie that is relevant to this topic. It focuses on the development of engineered natural killer (NK) cells and macrophages for use in treating various malignancies, especially solid tumors. Several of us referred to that article in our discussion.
A major reason for the interest in developing engineered NK cell therapies for solid tumors is that at least so far treatment with CAR-T cell therapies (chimeric antigen receptor T-cell therapies) has not worked in solid tumors. Solid tumors inhibit entry of CAR-T cells, and suppress those CAR-T cells that are able to enter the tumor. They can also downregulate expression of antigens targeted by the CAR-T cells. We discussed these issues with CAR-T treatment of solid tumors in our 2017 report, Cancer Immunotherapy: Building on Initial Successes to Improve Clinical Outcomes.
Earlier this year Dan Kaufman and his colleagues published a xenograft model study of CAR-NK treatment of human ovarian tumors. They used human NK cells derived from iPSCs (induced pluripotent stem cells), and modified them with a CAR construct containing an NK-derived transmembrane domain. These CAR-NK cells significantly inhibited tumor growth and prolonged survival compared with unmodified NK cells. They also demonstrated in vivo activity similar to that of CAR-T-expressing T cells, but with less toxicity (e.g., excess cytokine release).
So far, nearly all human clinical trials of engineered NK cells (other than in China) are in various types of leukemias and lymphomas, such as a study led by Katy Rezvani of the University of Texas MD Anderson Cancer Center in Houston. In this trial, patients with B cell lymphoma will receive stem cell transplants and chemotherapy before CAR NK cells. Thus, the NK-CAR cells will have fewer cancer cells to deal with than without this pretreatment, and researchers hope that the NK-CAR cells will be able to eliminate the remaining cancer cells.
With respect to engineered NK cell trials in solid tumors, researchers in Germany are testing NK cells with a CAR construct that targets ErbB2 against human glioblastoma. This is the first clinical trial of engineered NK cells against a solid tumor outside of China.
Which solid tumors might be the best targets for engineered NK cells?
Most of the discussion in the breakout session focused on which solid tumors might be the best targets for engineered NK cells. The first “candidate” was acute myeloid leukemia (AML), which is not a solid tumor at all. It is, however, an NK target.
The next candidate was melanoma. Melanoma exhibits low levels of Class I MHC, and thus constitutes an NK target via the “missing self” model of NK recognition. Renal cell cancer (RCC) was also suggested as a candidate. (For example, see this study, which involves enabling NK cells to more efficiently home to RCC.)
Glioblastoma is being targeted by engineered NK researchers (e.g., the German group) because “there is nothing else” in the way of treatment.
Another candidate is viral-induced cancers (See this review for examples of such cancers, including, for example, hepatocellular carcinoma, Burkitt’s lymphoma, and cervical cancer.) NK cells become activated during viral infections and may have the capacity to restrain virus-induced cancers.
Some session participants specifically cited hepatocellular carcinoma (a viral-induced cancer) as a candidate, using local delivery.
Another candidate was the sarcomas, especially synovial sarcoma. Sarcomas may possess NKD2 ligands, which are targets for NKD2 receptors on NK cells.
Session participants stressed that debulking of solid tumors (surgical removal of as much of a tumor as possible) should be done before engineered NK treatment. (This is analogous to the preliminary reduction of most of the cancer cells via conventional methods prior to NK-CAR treatment in the Rezvani B cell lymphoma clinical trial.) Participants also believed that it was important to select a good antigen target for NK-CAR studies.
Combination treatments involving engineered NKs and alternative NK-based therapies
Potential combination treatments involving engineered NKs were also discussed in the session. These included, for example, combining NK-CARs with checkpoint inhibitor antibodies that target PD-1 (e.g., pembrolizumab or nivolumab) or CTLA4 (e.g., ipilimumab).
An alternative NK-based therapy might involve the use of “NK cell engagers”. These are bispecific antibodies that engage NK cells to kill tumor cells. For example, Innate Pharma has been developing bispecific NK cell engagers that bind with one arm to NKp46 (an activating receptor expressed on all NK cells) and with the other arm to an antigen at the surface of tumor cells.
Gundo Diedrich, Ph.D. of MacroGenics was a speaker at the conference. He gave a presentation on “Development of DART and TRIDENT Molecules to Target Costimulatory and Checkpoint Receptors for Immuno-Oncology Applications”. DART and TRIDENT refer to MacroGenics’ bispecific and tri-specific antibody platforms for use in immuno-oncology. He also led a breakout discussion on “Considerations in Selecting Bispecific Antibody Formats for Immunotherapies”.
Sources of human NK cells for immunotherapy
We also briefly discussed the issue of sources of human NK cells for immunotherapy, such as cord blood. The Science article by Mitch Leslie discusses this in greater detail. Among the other potential sources are NK cells derived from human iPSCs, such as used in Dr. Kaufman’s study discussed earlier.
The Merck-Dragonfly Therapeutics alliance, October 1, 2018
A few days after the close of the “Discovery on Target” conference, Merck (a cancer immunotherapy leader via its PD-1 inhibitor pembrolizumab) entered into an alliance with Dragonfly, worth a potential $695 million per program. Dragonfly specializes in NK cell engagers The willingness of Merck to enter an alliance with Dragonfly suggests that NK cell-based treatments may become important in cancer immunotherapies.
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As the producers of this blog, and as consultants to the biotechnology and pharmaceutical industry, Haberman Associates would like to hear from you. If you are in a biotech or pharmaceutical company, and would like a 15-20-minute, no-obligation telephone discussion of issues raised by this or other blog articles, or of other issues that are important to your company, please contact us by phone or e-mail. We also welcome your comments on this or any other article on this blog.
Checkpoint inhibitor therapies (NIH)
On October 1, 2018, the The Nobel Assembly at the Karolinska Institute announced that it had awarded the 2018 Nobel Prize in Physiology or Medicine jointly to James P. Allison and Tasuku Honjo for their discovery of cancer immunotherapy via immune checkpoint inhibition.
As is usual, these Nobel Prize awards were made decades after the original discoveries. This is despite the growing importance of immunotherapy in cancer treatment, including the prospect for long-term survival of an increasing number of patients.
As we discussed in our January 9, 2014 article on this blog, the development of checkpoint inhibitors was made possible by a line of academic research on T cells that was begun in the 1980s by James P Allison, Ph.D., one of the 2018 Nobel laureates. Dr. Allison’s research focused on targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) on activated T cells in tumors.
Even after Dr. Allison’s research demonstrated in 1996 that an antibody that targeted CTLA-4 had anti-tumor activity in mice, no pharmaceutical company would agree to work on this system. However, the monoclonal antibody (mAb) specialist company Medarex licensed the antibody in 1999. Bristol-Myers Squibb (BMS) acquired Medarex in 2009, and the anti-CTLA-4 mAb ipilimumab (BMS’ Yervoy) was approved in 2011 for treatment of metastatic melanoma. It was the first checkpoint inhibitor to be approved by the FDA.
Meanwhile, Dr. Honjo discovered the T-cell protein PD-1 in 1992. PD-1 (programmed cell death protein 1) acts as a brake on the immune system via a different mechanism. PD-1 became a target for other checkpoint inhibitors, notably nivolumab (BMS’ Opdivo—originally developed by Medarex and Ono Pharmaceutical) and pembrolizumab (Merck’s Keytruda). The FDA approved nivolumab for treatment of metastatic melanoma in 2014, and it approved pembrolizumab for the same indication, also in 2014.
Since 2014, clinical studies—and regulatory approvals—of checkpoint inhibitor therapies have been expanded to other types of cancer (e.g., lung and renal cancers, lymphomas). They now also include mAb agents that target yet another checkpoint protein, PD-L1. (programmed death-ligand 1). Moreover, clinical studies of combination therapies of inhibitors of both PD-1 and CTLA-4 in patients with metastatic melanoma showed that the combination therapy is more effective than treatment with either agent alone.
Clinical studies on immune checkpoint therapy have since developed rapidly. Researchers have applied this type of therapy to a wide range of types of cancer, and have also developed additional checkpoint inhibitor drugs. A major reason for the intense interest in checkpoint inhibitor therapy is the potential of these drugs to produce long-term survival. However, only a minority of patients show such dramatic responses. Researchers have therefore been attempting to develop biomarkers and diagnostic tests to identify factors that promote long-term survival in patients. They have also been working to develop potentially more-effective therapies by combining checkpoint inhibitors with other agents. Such attempts to build on prior achievements in immuno-oncology to improve outcomes for more patients are often referred to as “immuno-oncology 2.0.” Agents that are intended to improve the results of treatment with agents like checkpoint inhibitors may also be referred to as “second-wave” or “third-wave” immuno-oncology agents.
Our 2017 report, Cancer Immunotherapy: Building on Initial Successes to Improve Clinical Outcomes (published by Insight Pharma Reports) focuses on immuno-oncology 2.0 strategies. This report, as well as several articles on this blog, provide updated discussions of approved and clinical stage agents in immuno-oncology (including checkpoint inhibitors and “second-wave” agents). These materials also discuss other classes of cancer immunotherapy agents, such as cancer vaccines and cellular immunotherapies.
Other early immuno-oncology researchers who did not receive the Nobel
As pointed out in the October 1 Nature News article about the Nobel Prize, there were other researchers who made seminal early discoveries in immuno-oncology who were not included in the Nobel Prize. (This usually happens.)
Gordon Freeman, an immunologist at the Dana-Farber Cancer Institute (Boston, MA), was named in the Nature News article as one of these researchers. Dr. Freeman, along with immunologists Arlene Sharpe (Harvard Medical School, Boston MA) and Lieping Chen (Yale University, New Haven, CT), studied checkpoint proteins, especially a protein that binds to PD-1 known as PD-L1. PD-L1 is the target for the approved checkpoint inhibitor mAb agents atezolizumab (Roche/ Genentech’s Tecentriq) and avelumab (Merck/Serono-Pfizer’s Bavencio). Although the CTLA-4 inhibitor ipilimumab was the first checkpoint inhibitor to be approved, it has so far been shown to work only in melanoma. However, PD-1 and PD-L1 inhibitors have been approved for the treatment of 13 different types of cancer so far. According to Dr. Freeman, his discoveries and those of his collaborators “were foundational” in the development of PD-1 and PD-L1 inhibitors.
Nevertheless, Dr. Freeman also said that Dr. Allison’s work with CTLA-4 was foundational for the development of the field of immuno-oncology, beginning when most researchers and pharmaceutical companies considered it to be scientifically premature. “Jim Allison has been a real advocate and champion of the idea of immunotherapy,” he said. “And CTLA-4 was a first success.”
All in all, Dr. Freeman says that it has been exciting to watch the immuno-oncology field develop. Not only has this development involved “an incredible amount of human creativity and energy,” but many cancer patients are doing better as the result of the entry of immuno-oncology drugs into the oncologist’s armamentarium.
Also as usual, Drs. Allison and Honjo received other prestigious awards prior to receiving the Nobel. In 2015, Dr. Allison received a Lasker prize for his work in cancer immunotherapy. (Lasker awards are commonly called the “American Nobels”). Dr. Honjo won the Kyoto Prize in basic sciences in 2016. This is a global prize awarded by the Inamori Foundation.
____________________________________________________________________________________________
As the producers of this blog, and as consultants to the biotechnology and pharmaceutical industry, Haberman Associates would like to hear from you. If you are in a biotech or pharmaceutical company, and would like a 15-20-minute, no-obligation telephone discussion of issues raised by this or other blog articles, or of other issues that are important to your company, please contact us by phone or e-mail. We also welcome your comments on this or any other article on this blog.
Lipid nanoparticle structure
On August 10, 2018, Alnylam Pharmaceuticals (Cambridge, MA) announced the first-ever FDA approval of an RNAi (RNA interference) drug. The drug is Alnylam’s patisiran, which is indicated for the treatment of polyneuropathy due to transthyretin-mediated amyloidosis (ATTR). ATTR is a rare inherited, debilitating, and often fatal disease caused by mutations in the transthyretin (TTR) gene. Patisiran is trade-named “Onpattro”. The FDA approved patisiran for the treatment of polyneuropathy in adults with hereditary transthyretin-mediated amyloidosis (hATTR) in adults.
On August 30, 2018 Alnylam announced that the European Commission (EC) has granted marketing authorization for patisiran for the treatment of hATTR in adults with stage 1 or stage 2 polyneuropathy.
Shortly after Alnylam’s initial announcement, Nature published a news article in its 16 August 2018 issue, entitled “Gene-silencing technology gets first drug approval after 20-year wait”, by senior reporter Heidi Ledford, Ph.D.
As discussed in the Nature article, patisiran is the first-ever FDA approved drug based on RNA interference (RNAi), a specific gene-silencing technology. Two researchers—Andrew Fire of Stanford University School of Medicine in California and Craig Mello of the University of Massachusetts Medical School in Worcester—shared the Nobel Prize in Physiology or Medicine in 2006 for their 1998 publication of their discovery of RNAi. However, it took 20 years from the original discovery of RNAi until the first RNAi drug was approved by the FDA. The main technological issue that needed to be overcome to turn RNAi into drugs was drug delivery.
Formulation of the RNAi agent patisiran in lipid nanoparticle carriers
We discussed patisiran (then also known as ALN-TTR02) in our January 24, 2014 article on this blog. Patisiran consists of a specific oligonucleotide molecule encapsulated in a lipid nanoparticle (LNP) carrier (formerly known as a SNALP—stable nucleic acid lipid particle). The oligonucleotide is designed to inhibit expression of the gene for TTR via RNA interference. The LNP (see the Figure above) is based on technology developed by Alnylam’s partner Arbutus Biopharma (formerly known as Tekmira). LNP-encapsulated oligonucleotides accumulate in the liver, which is the site of expression, synthesis, and secretion of TTR.
The carrier used in patisiran is a second-generation LNP that contains combinations of synthetic ionizable lipid-like molecules known as lipidoids. This strategy was developed by Alnylam in collaboration with Dr. Robert Langer’s laboratory at MIT. The second-generation LNP renders patisiran much more potent than the first generation version of Alnylam’s anti-TTR product, ALN-TTR01. In a Phase 1 clinical trial (referenced in our January 24, 2014 blog article), ALN-TTR02 gave mean reductions at doses from 0.15 to 0.3 milligrams per kilogram ranging from 82.3% to 86.8% at 7 days, with reductions of 56.6 to 67.1% at 28 days.
On September 20, 2017 Arbutus announced the success of a Phase 3 clinical trial of Alnylam’s second-generation LNP-encapsulated anti-TTR agent, patisiran.
We included a detailed discussion of the development of second-generation LNP-encapsulated RNAi products, especially ALN-TTR02/patisiran, in Chapter 4 of our book-length report, RNAi Therapeutics: Second-Generation Candidates Build Momentum, published by Cambridge Healthtech Institute’s Insight Pharma Reports in October 2010.
Phase 3 clinical trial of patisiran published in the New England Journal of Medicine
The New England Journal of Medicine (NEJM) published a Phase 3 trial (known as APOLLO) of patisiran in patients with hereditary transthyretin amyloidosis (hATTR) in its July 5, 2018 issue. According to Alnylam, the FDA approval of patisiran was based on the positive results of this trial. APOLLO was a randomized, double-blind, placebo-controlled, global Phase 3 study, and was the largest-ever study in hereditary ATTR amyloidosis patients with polyneuropathy.
The APOLLO study showed that patisiran treatment improved measures of polyneuropathy, quality of life, activities of daily living, ambulation, nutritional status and autonomic symptoms–as compared to the placebo group, in adult patients with hATTR amyloidosis with polyneuropathy. The most common adverse events in patisiran-treated patients were upper respiratory infections and infusion-related reactions. The risk of infusion-related reactions could be reduced via premedication prior to infusion.
RNAi as a premature technology, and the need to move it up the technology development curve
In our July 13, 2009 article on this blog, I mentioned the presentation that I gave earlier that year at a conference entitled “Executing on the Promise of RNAi” in Cambridge MA. My presentation was entitled, “The Therapeutic RNAi Market – Lessons from the Evolution of the Biologics Market”. In that presentation, I compared the field of monoclonal antibody (mAb) drugs to that of RNAi drugs. Despite the high level of investment in therapeutic RNAi over nearly 20 years, the formation of numerous biotech companies specializing in RNAi drug development, and the strong interest of Big Pharma in the field, there still was not one therapeutic RNAi product on the market until the August 2018 launch of patisiran. At the time of the 2009 conference—and beyond—researchers envisioned significant hurdles to the development of RNAi drugs, especially those involving systemic drug delivery. Many experts therefore believed that therapeutic RNAi was scientifically and/or technologically premature.
As of the past 15-20 years, mAbs have represented the most successful class of biologics. However, the therapeutic MAb field went through a long period of scientific prematurity, from 1975 through the mid-1990s. Several enabling technologies, developed from the mid-1980s to the mid-1990s, were necessary for the explosion of successful MAb drugs, from the mid-1990s to today. Similarly, many companies and academic laboratories have been hard at work developing enabling technologies to move the therapeutic RNAi field up the technology development curve.
As catalogued in our blog, large pharmaceutical companies that had partnered with RNAi specialty biotechs and/or were pursuing their own internal RNAi drug development, dropped our of RNAi—one by one. These included Roche, Pfizer, Merck and Novartis. This was all due to the technological prematurity of the therapeutic RNAi field, especially the issue of drug delivery.
However, as of 2018, the suite of enabling technologies behind the second-generation LNP that has been incorporated into patisiran made the successful development and approval of this drug possible. The development of these technologies and delivery platforms at Alnylam and its partners—including laboratory, preclinical and clinical studies—took place over nearly a decade prior to the approval of patisiran.
As discussed in our book-length report, Alnylam and other RNAi specialty companies have been developing suites of liver-targeting therapeutics. For example, Alnylam is developing liver-targeting RNAi therapeutics for such conditions as acute hepatic porphyrias, hemophilia, and hypercholesterolemia. These clinical-stage RNAi therapeutics utilize Alnylam’s recently-developed liver-targeting Enhanced Stabilization Chemistry (ESC)-N-acetylgalactosamine (GalNAc) delivery platform rather than the RNP delivery vehicle.
However, according to Alnylam cofounder Thomas Tuschl, Ph.D. (Rockefeller University and the Howard Hughes Medical Institute, New York, NY), as quoted in the August 2018 Nature News article, Alnylam and other RNAi specialty companies are also working on RNAi-based therapies that are designed to target organs other than the liver. For example, Quark Pharmaceuticals (Fremont, CA) is testing RNAi therapies that target the kidneys and the eye. Alnylam is developing therapies that target the central nervous system (CNS), and Arrowhead Pharmaceuticals (Pasadena, CA) is developing an inhalable RNAi therapeutic for cystic fibrosis.
Rare-disease drug development and RNAi
Recently, there has been a controversy about development of drugs for rare diseases. This has been played out between an article by Milton Packer MD (Distinguished Scholar in Cardiovascular Science, Baylor University Medical Center) on Medpage Today and one by John LaMattina, Ph.D. (Senior Partner, PureTech Health; former President of R&D, Pfizer) in Forbes.
Rare diseases (as defined by NIH) are diseases that affect fewer than 200,000 individuals. There are an estimated 7,000 rare diseases. Some of the more common of these diseases are well known: e.g., muscular dystrophy, cystic fibrosis and multiple sclerosis. Many forms of cancer can also be considered rare diseases. Although each of these diseases is “rare”, the aggregate number of rare-disease patients in the U.S. is—according to the NIH—25 million. Thus “rare-disease patients” are not rare at all.
Dr. Packer argues that:
- the pharmaceutical industry is obsessed with rare-disease drugs;
- the FDA is less stringent about the types of data that it requires for approval for a new rare-disease drug;
- pharmaceutical companies have found that they can charge exorbitant prices for rare-disease drugs;
- if a company decides to develop a new rare-disease drug, the development costs will be low compared to drugs for more common diseases, the return on investment can be enormous, and the developer will have marketing exclusivity for many years.
Dr. LaMattina counters that the first two of these statements are not true. Moreover, even though rare-disease drugs command a high price, they still may lower the cost of treatment. If a rare disease costs the healthcare system $200,000/patient/year, and a new drug for this disease both ameliorates the disease and reduces other costs for treating these patients, a price of $100,000/patient/year can be a bargain – as well as help the patient. Payers thus often accept the high prices of rare-disease drugs.
With respect to market exclusivity, all drugs—whether for rare diseases or not—get the same length of patent exclusivity. There can also be tremendous competition in rare disease R&D leading to the potential for multiple drugs (and types of drugs) to treat specific rare diseases. This competition can also drive down prices.
An important issue that was not discussed in this exchange is that rare-disease research makes possible development of totally new types of therapies that may eventually be used for more common diseases. The development of patisiran—the first ever approved RNAi therapeutic—for the rare disease ATTR is a prime example. Gene therapy also represents an entirely new suite of technologies that have been first applied to rare diseases. See, for example, the recent approval of Spark’s Luxturna (voretigene neparvovec-rzyl) for the treatment of a rare inherited retinal disease. Several CAR-T (chimeric antigen receptor-T cell) therapies have been recently developed and approved for treatment of several types of rare hematologic cancers. Other CAR-T therapies are being developed for cancers that still do not have good treatment options. Meanwhile, the first clinical trial of a treatment based on the gene-editing technology known as CRISPR-Cas9 for the rare diseases beta thalassemia and sickle cell disease has recently launched.
Thus the rare disease field has been and will continue to be a fertile area for the development and application of novel therapies. Some of these therapies may eventually be applied to more common diseases. In particular, this includes RNAi-based therapies.
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