Gene Therapy for Hemophilia A and B: Patient Selection and Follow-up, Requirements for a Cure

1999 ◽  
Vol 82 (08) ◽  
pp. 572-575 ◽  
Author(s):  
Jeanne Lusher
Keyword(s):  
Gene Therapy ◽  
Factor Viii ◽  
Hepatitis A ◽  
Hemophilia A ◽  
The United States ◽  
Factor Ix ◽  
Clotting Factor ◽  
R Factor ◽  
New Variant ◽  
Clotting Factor Concentrates

IntroductionThe treatment of hemophilia A and B has improved considerably in recent years. The availability of hepatitis A and B vaccines, safer clotting factor concentrates (particularly recombinant factor VIII and recombinant factor IX concentrates), and synthetic agents, such as desmopressin,1 has resulted in earlier, more aggressive treatment and prophylactic regimens aimed at preventing chronic, debilitating joint disease.2-8There have been no new cases of human immunodeficiency virus (HIV) disease attributable to clotting factor in North America since 1987, and documented instances of hepatitis transmission by clotting factor concentrates have been rare in the 1990s. Concerns remain that certain nonenveloped viruses, such as human parvovirus B19 and hepatitis A virus, can still be transmitted by some plasma-derived clotting factor concentrates,9and questions linger as to whether the agents causing Creutzfeld-Jacob disease (CJD) and new variant CJD might also be transmitted. Overall, however, the products available to treat hemophilia today are safer than ever before.An increasing number of persons with hemophilia are receiving exclusively recombinant (r) products, and manufacturers are now producing new, second-generation r-factor VIII products that are stabilized with sugars, rather than albumin, or are smaller, truncated molecules.10 Scientists are now designing specific changes into the factor VIII genes in an attempt to derive unique and improved forms of r-factor VIII.11 The next logical areas of focus are to bring to fruition the promise of an “unlimited supply” of r-factor VIII and r-factor IX products, to meet the needs of persons with hemophilia, not only in developed countries, but throughout the world, and to be able to cure hemophilia through gene therapy.As gene therapy trials begin in humans with hemophilia, the scientists involved, the United States Food and Drug Administration (FDA), and perhaps most importantly, members of the hemophilia community must decide which categories of affected individuals should be entered in these trials, particularly the earliest, Phase I trials. Who is most likely to benefit if gene therapy proves to be both effective and safe? Who should be the first patients to be enrolled in each new trial? Who is at greatest risk if something unexpected happens? What would be considered a good outcome? Clearly, some of these questions are more difficult to answer than others.

Animal Testing of Retroviral-Mediated Gene Therapy for Factor VIII Deficiency

1999 ◽  
Vol 82 (08) ◽  
pp. 555-561 ◽  
Author(s):  
Douglas Jolly ◽  
Judith Greengard
Keyword(s):  
Gene Therapy ◽  
Factor Viii ◽  
Hemophilia A ◽  
Joint Damage ◽  
Coagulation Factor ◽  
The United States ◽  
Severe Hemophilia ◽  
Factor Viii Gene ◽  
Bleeding Episodes

IntroductionHemophilia A results from the plasma deficiency of factor VIII, a gene carried on the X chromosome. Bleeding results from a lack of coagulation factor VIII, a large and complex protein that circulates in complex with its carrier, von Willebrand factor (vWF).1 Severe hemophilia A (<1% of normal circulating levels) is associated with a high degree of mortality, due to spontaneous and trauma-induced, life-threatening and crippling bleeding episodes.2 Current treatment in the United States consists of infusion of plasma-derived or recombinant factor VIII in response to bleeding episodes.3 Such treatment fails to prevent cumulative joint damage, a major cause of hemophilia-associated morbidity.4 Availability of prophylactic treatment, which would reduce the number and severity of bleeding episodes and, consequently, would limit such joint damage, is limited by cost and the problems associated with repeated venous access. Other problems are associated with frequent replacement treatment, including the dangers of transmission of blood-borne infections derived from plasma used as a source of factor VIII or tissue culture or formulation components. These dangers are reduced, but not eliminated, by current manufacturing techniques. Furthermore, approximately 1 in 5 patients with severe hemophilia treated with recombinant or plasma-derived factor VIII develop inhibitory humoral immune responses. In some cases, new inhibitors have developed, apparently in response to unnatural modifications introduced during manufacture or purification.5 Gene therapy could circumvent most of these difficulties. In theory, a single injection of a vector encoding the factor VIII gene could provide constant plasma levels of factor in the long term. However, long-term expression after gene transfer of a systemically expressed protein in higher mammals has seldom been described. In some cases, a vector that appeared promising in a rodent model has not worked well in larger animals, for example, due to a massive immune response not seen in the rodent.6 An excellent review of early efforts at factor VIII gene therapy appeared in an earlier volume of this series.7 A summary of results from various in vivo experiments is shown in Table 1. This chapter will focus on results pertaining to studies using vectors based on murine retroviruses, including our own work.

scholarly journals Antibodies reactive with human T cell leukemia viruses in the serum of hemophiliacs receiving factor VIII concentrate

Blood ◽  
1985 ◽  
Vol 65 (2) ◽  
pp. 492-495 ◽  
Author(s):  
JJ Goedert ◽  
MG Sarngadharan ◽  
ME Eyster ◽  
SH Weiss ◽  
AJ Bodner ◽  
...  
Keyword(s):  
T Cell ◽  
Factor Viii ◽  
Factor Ix ◽  
Clotting Factor ◽  
T Cell Leukemia ◽  
Cell Leukemia ◽  
Seronegative Patient ◽  
Human T Cell ◽  
Clotting Factor Concentrates ◽  
Leukemia Viruses

Abstract The third member of the family of T cell leukemia viruses (HTLV III) has been proposed as the primary etiologic agent of the acquired immunodeficiency syndrome (AIDS). A high risk of AIDS has been reported among patients with hemophilia, particularly those with factor VIII deficiency who receive commercial clotting factor concentrates. In a prevalence survey conducted between September 1982 and April 1984, initial serum samples from 74% of hemophiliacs who had ever been treated with commercial factor VIII concentrate, 90% of those frequently treated with factor VIII concentrate, and 50% of those treated with both factor VIII and factor IX concentrates had antibodies reactive against antigens of HTLV III, compared with none of the hemophiliacs treated only with factor IX concentrate or volunteer donor plasma or cryoprecipitate. Two of the seropositive patients have developed AIDS-related illnesses, and a third patient died of bacterial pneumonia. One initially seronegative patient developed antibodies against HTLV III during the study and is currently well. The predominant antibody specificities appear directed against p24 and p41, the presumed core and envelope antigens of HTLV III, suggesting that factor VIII concentrate may transmit the p24 and p41 antigens of HTLV III. However, the presence of infectious retroviruses in clotting factor concentrates and the effectiveness of screening and viral neutralization procedures remain to be determined.

scholarly journals Antibodies reactive with human T cell leukemia viruses in the serum of hemophiliacs receiving factor VIII concentrate

Blood ◽  
1985 ◽  
Vol 65 (2) ◽  
pp. 492-495
Author(s):  
JJ Goedert ◽  
MG Sarngadharan ◽  
ME Eyster ◽  
SH Weiss ◽  
AJ Bodner ◽  
...  
Keyword(s):  
T Cell ◽  
Factor Viii ◽  
Factor Ix ◽  
Clotting Factor ◽  
T Cell Leukemia ◽  
Cell Leukemia ◽  
Seronegative Patient ◽  
Human T Cell ◽  
Clotting Factor Concentrates ◽  
Leukemia Viruses

The third member of the family of T cell leukemia viruses (HTLV III) has been proposed as the primary etiologic agent of the acquired immunodeficiency syndrome (AIDS). A high risk of AIDS has been reported among patients with hemophilia, particularly those with factor VIII deficiency who receive commercial clotting factor concentrates. In a prevalence survey conducted between September 1982 and April 1984, initial serum samples from 74% of hemophiliacs who had ever been treated with commercial factor VIII concentrate, 90% of those frequently treated with factor VIII concentrate, and 50% of those treated with both factor VIII and factor IX concentrates had antibodies reactive against antigens of HTLV III, compared with none of the hemophiliacs treated only with factor IX concentrate or volunteer donor plasma or cryoprecipitate. Two of the seropositive patients have developed AIDS-related illnesses, and a third patient died of bacterial pneumonia. One initially seronegative patient developed antibodies against HTLV III during the study and is currently well. The predominant antibody specificities appear directed against p24 and p41, the presumed core and envelope antigens of HTLV III, suggesting that factor VIII concentrate may transmit the p24 and p41 antigens of HTLV III. However, the presence of infectious retroviruses in clotting factor concentrates and the effectiveness of screening and viral neutralization procedures remain to be determined.

scholarly journals Expression of the blood-clotting factor-VIII cDNA is repressed by a transcriptional silencer located in its coding region

Blood ◽  
1995 ◽  
Vol 85 (9) ◽  
pp. 2447-2454 ◽  
Author(s):  
RC Hoeben ◽  
FJ Fallaux ◽  
SJ Cramer ◽  
DJ van den Wollenberg ◽  
H van Ormondt ◽  
...  
Keyword(s):  
Gene Therapy ◽  
Factor Viii ◽  
Hemophilia A ◽  
Recombinant Dna ◽  
Transcription Unit ◽  
Current Treatment ◽  
Clotting Factor ◽  
Large Animal ◽  
Coding Region ◽  
Large Animal Models

Hemophilia A is caused by a deficiency of factor-VIII procoagulant (fVIII) activity. The current treatment by frequent infusions of plasma-derived fVIII concentrates is very effective but has the risk of transmittance of blood-borne viruses (human immunodeficiency virus [HIV], hepatitis viruses). Use of recombinant DNA-derived fVIII as well as gene therapy could make hemophilia treatment independent of blood-derived products. So far, the problematic production of the fVIII protein and the low titers of the fVIII retrovirus stocks have prevented preclinical trials of gene therapy for hemophilia A in large-animal models. We have initiated a study of the mechanisms that oppose efficient fVIII synthesis. We have established that fVIII cDNA contains sequences that dominantly inhibit its own expression from retroviral as well as from plasmid vectors. The inhibition is not caused by instability of the fVIII mRNA (t1/2, > or = 6 hours) but rather to repression at the level of transcription. A 305-bp fragment is identified that is involved in but not sufficient for repression. This fragment does not overlap the region recently identified by Lynch et al (Hum Gene Ther 4:259, 1993) as a dominant inhibitor of RNA accumulation. The repression is mediated by a cellular factor (or factors) and is independent of the orientation of the element in the transcription unit, giving the repressor element the hallmarks of a transcriptional silencer.

Prophylactic Infusion Regimens in the Management of Hemophilia

1999 ◽  
Vol 82 (08) ◽  
pp. 525-530 ◽  
Author(s):  
Rolf Ljung
Keyword(s):  
Factor Viii ◽  
Prophylactic Treatment ◽  
Hemophilia A ◽  
The United States ◽  
Factor Ix ◽  
Advisory Council ◽  
World Health ◽  
World Federation ◽  
Severe Hemophilia ◽  
The World

IntroductionThe goal of prophylactic treatment of hemophilia is to convert the severe form of the disorder into a milder form by administration of factors VIII or IX. The rationale behind this is that chronic arthropathy, the hallmark of hemophilia after repeated bleedings, is less frequent and less severe in moderate hemophilia (i.e., factor VIII or factor IX concentrations of 1% to 4% of normal) than in severe hemophilia (i.e., factor VIII/factor IX concentrations lower than 1% of normal).1 Keep in mind, however, that prophylactic treatment also provides protection from all other forms of hemorrhage that may occur spontaneously or as a result of trivial trauma in the untreated hemophilic child. Today, prophylactic treatment is available to only a few hemophilia patients in the world, although it is recommended by the World Health Organization (WHO) and the World Federation of Haemophilia (WFH): “Since the main goal is to prevent joint bleeding and its sequelae, prophylaxis should be considered optimal management for persons with severe hemophilia A or B (i.e., with basal factor VIII and/or factor IX levels <1% of normal). Treatment should be started at the age of 1-2 years and be continued indefinitely. Where prophylaxis is not feasible or appropriate, on-demand therapy should be given.”2 In the United States, the Medical and Scientific Advisory Council of the National Hemophilia Foundation has recommended that “prophylaxis should be considered the optimal therapy for children with severe hemophilia A or B.”3 The aim of this chapter is to discuss prophylactic infusion regimens in the management of hemophilia.

scholarly journals Ultrasound Combined with Microbubbles Mediated Factor VIII Plasmid Gene Therapy in Hemophilia a Mice

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2039-2039
Author(s):  
Shuxian Song ◽  
James Harrang ◽  
Bryn Smith ◽  
Carol H. Miao
Keyword(s):  
Gene Expression ◽  
Gene Therapy ◽  
Gene Transfer ◽  
Factor Viii ◽  
Hemophilia A ◽  
Liver Perfusion ◽  
Transfer Efficiency ◽  
Clotting Factor ◽  
Gene Transfer Efficiency ◽  
Fviii Activity

Abstract Hemophilia A is a genetic bleeding disorder resulted from a deficiency of blood clotting factor VIII. In order to develop the efficient approach to gene therapy for hemophilia A, we previously explored reporter gene transfer mediated by ultrasound (US) combined with microbubbles (MBs). It was demonstrated that US/MB can significantly enhance gene transfer efficiency and serve as an efficient non-viral physical delivery strategy. In this study, we further delivered a therapeutic FVIII plasmid into the livers of hemophilia A (HA) mice. In consideration of FVIII synthesis from multiple tissues/cell lines, we first explored the distribution of gene expression using a pGL4.13 [luc2/SV40] luciferase plasmid driven by a ubiquitous promoter. One day following gene transfer, hepatocytes and endothelia cells were isolated from treated lobes by liver perfusion and centrifuge method. Evaluation of luciferase levels in two cell populations indicated that luciferase predominantly expressed in hepatocytes (5.35´104 RLU/107 cells vs. 1.46´103 RLU/107 cells in endothelia cells). Furthermore, gene transfer of pGFP (driven by a ubiquitous CMV promoter) mediated by US/MB also showed fluorescence distribution mostly in hepatocytes. These results indicate that hepatocyte is the predominant site of gene expression following US/MB mediated gene transfer into the liver. Based on these results, a hepatocyte-specific human FVIII plasmid (pBS-HCRHP-hFVIII/N6A) was used for US/MB mediated gene transfer in HA mice. In the short-term experiment, FVIII activity levels of treated HA mice ranged from 4-40% of normal FVIII activity. To follow FVIII expression for longer term, HA mice were pretreated with IL-2/IL-2 mAb (JES6-1) complexes on day −5, −4, and −3 to prevent immune response. In addition, the mice were infused with normal mouse plasma and human FVIII protein prior to gene transfer to maintain hemostasis. Subsequently, FVIII plasmids and 5 Vol% NUVOX MBs were injected into the mouse liver under simultaneous US exposure (1.1MHz transducer H158A driven by a pulse generator and high-power radio frequency amplifier capable of generating up to 1000W). Blood and liver samples were collected at serial time points after treatment to determine FVIII activity in plasma and liver damage. Following gene transfer, 10-30% of FVIII activity was achieved on day 4 and persisted in the average level of 20% by day 28. In a separate long-term follow-up experiment (n=3), 2 of 3 mice still maintained 10-30% activity after 120 days. Both transaminase levels (alanine aminotransferase and aspartate aminotransferase) and histological examination showed that the procedure of plasmid/MBs portal-vein injection and pulse-train acoustic exposure produced transiently localized liver damages however the damages were repaired and the liver recovered rapidly. Phenotypic correction of HA mice was further examined by tail clip assay. Blood loss of US/MB treated mice was significantly reduced compared with naive HA mice. Furthermore, a novel plasmid encoding a B domain-deleted FVIII variant containing mutations of 10 amino acids in the A1 domain (BDDFVIII-X10, a kind gift from Weidong Xiao) was constructed. Preliminary results from ongoing study showed that the gene transfer efficiency could be further improved with better plasmid and more efficient immune modulation. Together all the results indicate that US/MB mediated gene transfer is highly promising for efficient and safe gene therapy of hemophilia A. Disclosures No relevant conflicts of interest to declare.

Immunologic aberrations, HIV seropositivity and seroconversion rates in patients with hemophilia B

Blood ◽  
1987 ◽  
Vol 70 (1) ◽  
pp. 276-281
Author(s):  
DB Brettler ◽  
F Brewster ◽  
PH Levine ◽  
A Forsberg ◽  
S Baker ◽  
...  
Keyword(s):  
Factor Viii ◽  
Male Volunteer ◽  
Hemophilia A ◽  
High Titer ◽  
Factor Ix ◽  
Hemophilia B ◽  
Clotting Factor ◽  
Immunodeficiency Virus ◽  
And Function ◽  
Factor Concentrate

Because there have been reports that factor IX concentrate is less immunosuppressive and therefore factor IX users have less immunologic aberrations, we have studied a group of 22 patients with hemophilia B and six patients with factor VIII deficiency and high titer inhibitors with respect to lymphocyte numbers and function, human immunodeficiency virus (HIV) serology, and factor usage. This group was compared to 111 patients with hemophilia A and a group of 28 healthy male volunteer controls. When the study began in 1983, the majority of patients with hemophilia B and with higher titer factor VIII inhibitors were seronegative, 77% and 83% respectively, as compared to only 30% of patients with hemophilia A. At that time the factor IX users also had milder immune aberrations than the hemophilia A group. However, with time and increasing clotting factor concentrate usage, seroconversion and more striking abnormalities in immune function have occurred in the hemophilia B group. In a subgroup of 16 patients with hemophilia B studied twice, the incidence of seropositivity increased from 31% in 1983 to 69% in 1985. We thus conclude that factor IX concentrate in itself is not less immunosuppressive than factor VIII concentrate. Seroconversion in factor IX concentrate users appears to be lagging behind seroconversion in factor VIII concentrate users, perhaps secondary to the lower cumulative dosage of concentrate that patients with hemophilia B utilize.

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