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IRV ARONS
With the first approval of a gene therapy for treating a genetic disorder
in the Western world, the future of gene therapy for treating ocular
disorders looks bright. Glybera (alipogene tiparvovec), developed by the
Dutch company UniQure, to treat a rare lipoprotein lipase deficiency
(LPLD), was approved by the European Medicines Agency last
November. 1
Glybera is the first gene therapy treatment approved in Europe, but the
fourth worldwide. We have seen two previous approvals in China in the
field of oncology, and one approval in Russia for peripheral arterial
disease. The most recent approval provides a good time to discuss the
status of gene therapy for ocular disorders.
I first learned about gene therapy in November 2010, when I was
introduced to a company called RetroSense and its research using gene
therapy for the treatment of retinitis pigmentosa and dry AMD. 2 Since
that first write-up, I have been closely following developments in this
exciting field.
So what is gene therapy? How does it work? What are the applications in
ophthalmology? Who is involved? What is the current status of the many
clinical trials now under way? What does the future hold? Here, Ill
provide answers.
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Wet AMD
Another major area of emphasis in gene therapy is treatment of wet
AMD. Although anti-VEGF drugs are currently successfully treating wet
AMD, the cost and time involved in monthly or semimonthly injections
can be troublesome. A one-time treatment the promise of gene
therapy (the forever fix8) is attractive.
Several companies are at the forefront of research into the use of gene
therapy for wet AMD. These include Genzyme; Avalanche
Biotechnologies, working with the Lions Eye Institute of Perth, Australia;
and Oxford BioMedica, in partnership with Sanofi.
In wet AMD, VEGF plays a critical role because blockade of VEGF is
sufficient to suppress the development of choroidal neovascularization. A
variety of antiangiogenic proteins oppose the actions of proangiogenic
factors, such as VEGF. Gene transfer to augment expression of these
endogenous inhibitors or related engineered proteins is a potential
alternative to suppress CNV and avoid frequent intraocular injections.
Considerable preclinical and emerging clinical data suggest this approach
may be feasible.
The secreted extracellular domain of VEGF receptor-1, sFlt-1, is a
naturally occurring protein antagonist of VEGF formed by alternative
splicing of the pre-mRNA for the full-length receptor. Intraocular
injection of Ad.sFlt-1 strongly suppressed retinal or subretinal
neovascularization in mice
Genzyme has developed a VEGF-binding protein that consists of domain
2 of Flt-1 linked to a human immunoglobulin G1 (IgG) heavy chain Fc
fragment (sFLT01). Intravitreous injection of AAV2.sFLT01 is being
evaluated in a phase 1/2 clinical trial of wet AMD.9
At least 17 patients have been treated to date with safety demonstrated,
but no visual improvement results have been reported, in keeping with
normal clinical trial protocol.
Stargardt Disease
The progressive vision loss associated with Stargardt disease usually
starts between the ages of 6 and 12 years plateaus shortly afterward,
with rapid reduction in visual acuity.
The gene identified in the treatment of Stargardt disease is ABCA4. This
gene produces a protein involved in energy transport to and from
photoreceptor cells in the retina. Mutations in the ABCA4 gene produce a
dysfunctional protein that cannot perform its transport function. As a
result, photoreceptor cells degenerate and vision loss occurs.
Stargardt is being studied by Oxford BioMedica and Sanofi. They have an
ongoing phase 1/2a clinical trial under way, in both the United States at
the Casey Eye Institute in Seattle and at the Centre Hospitalier
Nationale dOphthalmologie des Quinz-Vingts in Paris. To date, 12
patients have been treated in cohorts 1 and 2, with cohort 3 under way
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at dose level 2.
Safety has been demonstrated for up to 12 months, but as is normal
procedure in clinical trials, no vision improvement results have yet been
reported.
Usher Syndrome 1b
Usher syndrome is a rare inherited condition characterized by both
hearing impairment and progressive vision loss and is a leading cause of
deaf-blindness. The vision loss is due to retinitis pigmentosa. Balance
may also be affected. Symptoms vary from person to person and
progress at different rates.
Three forms of Usher syndrome have been identified. Patients with type
1 have severe hearing loss and experience problems with balance, along
with RP. Those newborns with type 2 have moderate to severe hearing
impairment and symptoms of RP typically start shortly after
adolescence. Visual problems progress less rapidly than in Usher type 1,
and hearing loss usually remains stable.
Children with type 3, a rarer type, are usually born with good or only
mild hearing impairment. Their hearing and vision loss is progressive,
starting around puberty. Balance may also be affected.
One of the genes being studied for Usher Syndrome is MY07A, the basis
of UshStat in clinical trials by Oxford BioMedica and Sanofi. Their phase
1/2a clinical trial has treated the first cohort of three patients and has
received approval to proceed to cohort 2 at dose level 2. This trial is also
being conducted at the two locations noted above for Stargardt Casey
Eye and the Centre Hospitalier Nationale. Again, per protocol, no results
have yet been released.
In all, as shown in Table 3 (online), more than 80 patients have
received ocular gene therapy treatment, and the initial results that have
been reported (mostly for LCA) have shown some improvements in
vision, along with the safety of the treatment.
REMAINING QUESTIONS
To date, gene therapy in ophthalmology looks promising, in the sense
that some vision capacity has been restored, but several questions
remain. Will gene therapy deliver the holy grail of the forever fix or
something less? And with the first Western approval of a gene therapy
treatment (Glybera for LPLD), will ophthalmic therapies be next?
The question of cost also persists. One treatment of Glybera granted,
to treat a very rare disease with a worldwide population of only several
hundred may cost as much as $1.6 million.10 Nobody expects that
any of the proposed ophthalmic treatments will cost that much, as most
of the relevant disorders to be treated have populations several orders
of magnitude larger than the very rare disease treated by Glybera,
although certainly some rarer ocular disorders affect only a few hundred
to a few thousand individuals worldwide.
CONCLUSION
In 2012, officials with the Office of Cellular, Tissue and Gene Therapies
(OCTGT), Center for Biologics Evaluation and Research of the FDA,
stated , The recent history of gene therapy has been a mixture of
promise and disappointment Despite the setbacks of the past, the
OCTGT shares the enthusiasm of the field and is confident that ongoing
clinical investigations will lead to commercially available gene therapy
products that are safe and effective and advance the public health.11
RP
REFERENCES
1. Arons I. Gene therapy in ophthalmology update 15: First gene
therapy treatment. Irv Arons J. 2012 Nov 6. Available at:
http://tinyurl.com/GeneTherapy15. Accessed March 1, 2013.
2. Arons I. The use of gene therapy in treating retinitis pigmentosa and
dry AMD. Irv Arons J. 2012 Nov 6. Available at: http://tinyurl.com
/GeneTherapy-RP-AMD. Accessed March 1, 2013.
3. Abelson MB, Tzekov RT, Howe A. Gene therapy turns foes into
friends. Rev Ophthalmol. 2009 Aug 13. Available at:
http://www.revophth.com/content/d/therapeutic_topics/i/1213/c/22855.
Accessed March 1, 2013.
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Platform
Product/Partner Application
Applied Genetic
Technologies
Corp. (AGTC)
AAV
AAV2-sFLT01 Genzyme
AAV2-RPE65 OHSU
- Univ of
Florida
- OHSU
- Univ of Br.
Col
- UPenn
- Univ of
Florida
Status
wet AMD
Phase I/II
NCT01024998
Lebers
Congenital
Amaurosis
(LCA)
Phase I/II
NCT00749957
X-linked
Retinoschisis
Pre-Clinical
Achromatopsia
Pre-Clinical
Glaucoma
Avalanche
Biotechnologies
Inc.
AAV
Wet AMD
Phase I/II
NCT01494805
Ceregene
AAV
CERE-140
AAV-NT4
retinitis
pigmentosa
(RP)
Pre-Clinical
AMD
Childrens Hosp,
Philadelphia
AAV2
AAV2-hRPE65v2
- Univ of Iowa
Lebers
Congenital
Amaurosis
(LCA)
Phase I
NCT00516477
NCT01208389
(2nd eye)
Phase III
NCT00999609
Choroideremia
Copernicus
Therapeutics
EOS Neuroscience
AAV
Pre-Clinical
nanoparticle
delivery of genes
- Oklahoma
Health Services
Major retinal
diseases
rds (gene) RP
Pre-Clinical
Eos 013 -
retinitis
pigmentosa
(RP)
(optogenetic)
Pre-Clinical
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AMD (wet or
dry?)
Genable
Technologies
AAV
GT038
autosomal
dominant
retinitis
pigmentosa
(adRP)
Pre-Clinical
Genesolve Vision
Diagnostics
CVD Cure
L-Opsin
Color
Blindness
Pre-Clinical
GenVec
AAV
AdPEDF
wet AMD
Phase I*
*GenVec has
abandoned
this research
program
Hadassah Medical
AAV2
AAV2-hRPE65
LCA
Phase I
NCT00821340
Hemera
Biosciences
AAV2
HMR59
GA and Dry
AMD
Pre-clinical
Oxford Biomedica
LentiVector
RetinoStat Sanofi-Aventis
- Wilmer Eye
(Johns Hopkins
Univ)
- OHSU
wet AMD
Phase I
NCT01301443
diabetic
retinopathy
(DR)
IND prep.
StarGen Sanofi-Aventis
- OHSU
- Institute de
la Vision
(France)
UshStat Sanofi-Aventis
-OHSU
- Institute de
la Vision
(France)
ReGenX
Biosciences
NAV/AAV
Phase I/IIa
NCT01367444
Stargardts
RP/Usher
Syndrome
Type 1b
EncorStat Sanofi-Aventis
Corneal graft
rejection
Phase I/IIa
prep.
chronic
glaucoma
IND prep
rAAV8 -
X-Linked
retinitis
pigmentosa
(RP)
Lebers
Congenital
Amaurosis
(LCA)
RetroSense
Targeted Genetics
AAV
AAV
RST-001 (Chop2)
(also known as
ChR2)
RPE65 -
(Now, AmpliPhi
Biosciences
Corporation)
Univ. College,
London/Moorfields
Eye Hospital
AAV
Phase I/IIa.
NCT01505062
AAV2-RPE65
Pre-Clinical
Pre-Clinical
retinitis
pigmentosa
(RP)
(optogenetic)
Pre-Clinical
dry AMD
Pre-Clinical
Lebers
Congenital
Amaurosis
(LCA)
Phase II*
Lebers
Congenital
Amaurosis
PhaseI/II
NCT00643747
*According to
my sources,
Targeted
Genetics made
the vector for
the
Moorfields/UCL
LCA trial and
have no
interest in
ocular
applications
going forward.
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(LCA)
Wellstat
Ophthalmics, Inc.
(Formerly Advanced
Vision Therapies,
Inc.)
AAV
AVT 101 -
dry AMD
wet AMD
diabetic
retinopathy
(DR)
retinitis
pigmentosa
(RP)
Univ of Southern
Calif.
Mx-dnG1
corneal
scarring
Phase I/II
Univ of Wisconsin
SCH-412499
glaucoma
Phase I
Usher
Syndrome
Type 1b
Pre-Clinical
Univ of Michigan,
UPenn, Univ of
Florida NEI
X-linked
retinitis
pigmentosa
(RP)
Pre-Clinical
Choroideremia
Phase I/II
NCT01461213
Lebers
Congenital
Amaurosis
(LCA)
Phase I
NCT00481546
Imperial College
London, Oxford
Univ, Moorfields
AAV
rAAV2.REP1
-OHSU
-Nationwide
Childrens Hosp.
UPenn
UPenn
Univ of Florida
rAAV2-CBSB-hR
PE65
-NEI
-NEI
Pre-clinical
Univ of Nantes
rAAV-2/4.hRPE65
Phase I/II
NCT01496040
Institute de la
Vision (Paris)
Friedrich Miescher
Instit (Basel)
AAV
AAV
Univ of Florida
AAV8
retinitis
pigmentosa
(RP)
(optogenetics)
Pre-Clinical
MERTK (gene)
-Univ Calif San
Diego
- Univ Florida
(produced the
vector - not
involved in
patient trials)
MERTK-related
autosomal
recessive RP
Phase I
NCT01482195
MFRP (gene)
arRP
Pre-Clinical
Company/Institution Status
Lebers
Applied Genetic
Congenital
Technologies
Amaurosis (LCA)
Childrens Hosp. Phil.
Clinical Trial
Phase I/II
NCT00749957
Phase I
NCT00516477
NCT01208389
NCT00999609
Phase I
Phase III
Hadassah Medical
Phase I
ReGeneX Biosciences
Pre-Clinical
Univ. College
London/Moorfields
Phase I/II
Pre-Clinical
Univ. of Nantes
Phase I/II
NCT00821340
NCT00643747
NCT00481546
NCT01496040
NCT01267422
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Neuropathy
Wet AMD
Genzyme
Phase I/II
NCT01024998
Avalanche
Biotechnologies/Lions
Eye (Perth)
Phase I/II
NCT01494805
Phase I
NCT01301443
Oxford
Biomedica/Sanofi
Dry
Hemera Biosciences
AMD/Geographic
Atrophy (GA)
RetroSense
Pre-Clinical
Achromatopsia
Applied Genetic
Technologies
Pre-Clinical
Choroideremia
Childrens Hospital
Philadelphia
Pre-Clinical
Imperial College
London/Oxford
Univ./Moorfields
Phase I/II
Color Blindness
Gensolve Vision
Diagnostics
Pre-Clinical
Diabetic
Retinopathy
Oxford Biomedica
IND-Prep
Stargardts
Oxford
Biomedica/Sanofi
Corneal Graft
Rejection
Oxford
Biomedica/Sanofi
Phase I/IIa
Prep
Chronic
Glaucoma
Oxford
IND-Prep
Biomedica/Mayo Clinic
Univ. Of Wisconsin
Pre-Clinical
NCT01461213
Phase I
X-linked
Retinoschisis
Pre-Clinical
Pre-Clinical
RetroSense
Pre-Clinical
Institute de la
Vision(Paris)/Friedrich
Mieshcer Institute
(Basel)
Pre-Clinical
Applied Genetic
Technologies
Pre-Clinical
ReGeneX
Pre-Clinical
Univ of
Michigan/UPenn/Univ of Pre-Clinical
Florida/NEI
Autosomal
Dominent RP
(adRP)
MERTK-related
autosomal
recessive RP
Genable Technologies
Pre-Clinical
Copernicus
Therapeutics
Pre-Clinical
Phase I
Univ. of Florida
Pre-Clinical
NCT01482195
Clinical Trial
Sponsor
Clinical Sites
Status
Number
Patients
to be
Treated
Number
Treated to
Date
Lebers
Congenital
Amaurosis
(LCA)
NCT00749957
Applied Genetic
Technologies
Casey Eye
(OHSU) - R*
Phase
I/II
12
NCT00516477
Childrens Hosp.
Phil
Childrens Hosp
(Phil) (Active,
not recruiting)
Phase
I
12
12
12
4+ (have
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NCT01208389
Childrens Hosp
(Phil) (Followup
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Phase
I
had second
eye treated)
nd
for 2 eye of
above) - R
NCT00999609
Childrens
Hosp (Phil) NYR*
Univ of Iowa
- NYR
Phase
III
24
NCT00821340
Hadassah Medical
Hadassah Med
-R
Phase
I
10
NCT00643747
Univ College
London
Moorfields Eye
Hosp - R
Phase
I/II
12
12+ (Phase
II has
started)
NCT00481546
UPenn/NEI
Shands
Childrens Hosp
(UFla) - R
Scheie Eye
Inst. (UPenn) R
Phase
I
15
NCT01496040
Univ of Nantes
Nantes
University
Hospital - R
Phase
I/II
Leber
Hereditory
Optic
Neuropathy
(LHON)
NCT01267422
Huazhong Univ
(China)
Tongji
Hospital, - R
Tongji
Medical
College, - R
Huazhong
University - R
Phase
I
Wet AMD
NCT01024998
Genzyme
Retinal
Consultants of
AZ - R
Johns
Hopkins
University - R
Ophthalmic
Consultants of
Boston - R
UMass
Medical School
-R
Phase
I
34
NCT01494805
Lions Eye
Institute
(Perth)/Avalanche
Biotechnologies
Lions Eye
Institute
(Perth) - R
Phase
I/II
48
NCT01301443
Oxford
BioMedica/Sanofi
Johns
Hopkins
University - R
Casey Eye
Institute
(OHSU)- NYR
Phase
I
18
9 (Cohort 3
completed)
Confirmatory
Dose Level
Study
Underway
Choroideremia
NCT01461213
University of
Oxford
Moorfields
Eye Hospital R
St Marys
Hospital,
Manchester
Univ - R
Oxford
Radcliffe
Hospitals - R
Eye Unit,
Southampton
University
Hospitals - R
Phase
I/II
12
61
Stargardts
Disease
NCT01367444
Oxford
BioMedica/Sanofi
Casey Eye
Institute
(OHSU)- R
Centre
Hospitalier
Nationale
dOphthalmolog
ie des QuinzeVingts (Paris) R
Phase
I/IIa
28
8 (In Cohorts
1&2, 4
treated for
severe
disease and
4 for less
severe)
3 (Observed
for 8 mo.)
4 (Cohort 3
underway at
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dose level 2)
MERTKrelated
autosomal
recessive RP
NCT01482195
King Khaled
Eye Specialist
Hospital - R
Phase
I
31
Usher
Syndrome
(1b)
NCT01505062
Oxford
BioMedica/Sanofi
Casey Eye
Institute -R
Centre
Hospitalier
Nationale
dOphthalmolog
ie des
Quinze-Vingts
(Paris) - NYR
Phase
I/IIa
18
3 (Cohort 1
Completed)
Cohort 2
Approved to
Proceed at
Dose Level 2
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24
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