Gene Therapy for DMD
Current status: Approved in the USA
Sarepta’s micro-dystrophin gene therapy (elevidys, delandistrogene moxeparvovec) is approved (via accelerated approval pathway) by the Food and Drug Administration (USA) for patients 4-5 years old without a deletion involving exon 8 or 9. Approval is only based on expression of micro-dystrophin. Functional effects still have to be confirmed.
To deliver a healthy gene to Duchenne muscles, to allow normal dystrophin production.
Challenge 1: delivery of the gene to muscle
We have a lot of muscle – about 30-40% of our body weight is muscle, and we have more than 750 different muscles, each consisting of billions and billions of cells. The healthy gene has to be delivered to a significant portion of the cell nuclei of all muscles.
Fortunately, there is an organism that is quite good at injecting genes into cells: the virus. Thus, the gene therapy field has developed viral vectors, where the viral genes are removed, so there is room for the new gene and the modified viruses cannot replicate themselves.
Challenge 2: finding the right viral vector
Most viruses like to infect dividing cells. Muscle tissue hardly divides and thus is a poor target. In addition, muscle fibers are enveloped by layers of connective tissue, which trap viral particles, so the virus cannot reach the muscle fiber to inject its dystrophin gene.
There is a virus that is relatively good at infecting muscle cells, the so called adeno-associated virus (AAV). This virus can infect human cells but is not pathogenic (it does not cause a disease, about 50% of people have been infected by an AAV in the past without realizing this). There are many different types of AAV (called serotypes). For Duchenne serotypes that go to skeletal muscle and heart are used.
Challenge 3: making the dystrophin gene code fit
Unfortunately, AAV is so small that the dystrophin genetic code does not fit (the entire gene is ~500 times to big, the genetic code ~4 times too big).
Scientists have attempted to create the smallest possible dystrophin, containing only the bare essential domains (micro-dystrophin). The genetic code of this micro-dystrophin is small enough to fit into the AAV vector. This micro-dystrophin contains only ~32% of the full-length dystrophin protein and is smaller than the dystrophins that are found in Becker patients. In the Duchenne mouse model (mdx mouse) treatment with microdystrophin containing AAV viruses resulted in an improved muscle quality and function.
Challenge 4: immune response
Since the body does not know the AAV-micro-dystrophin has good intentions, there will be an immune response to the viruses.
Suppress the immune response when delivering the AAV-microdystrophin particles. This is done with high doses of corticosteroids.
Many individuals have been infected with a subtype of AAV (serotype). These individuals have antibodies against AAV that would preclude them from receiving viral vectors of that specific subtype. Since huge amounts of viruses are used for AAV-microdystrophin gene therapy (about 400 times more than the number of erythrocytes in your body), the immune response would be very dangerous and potentially lethal. The percentage of individuals with AAV antibodies varies per region (e.g. 20-50% in the Western world but higher in Asia) and per serotype (e.g. more for AAV2 than for AAV74). Ways to avoid a response of the antibodies to the AAV particles are under investigation, e.g. one could filter out the antibodies (a process called plasmapheresis). For now, Duchenne patients with antibodies against AAV are excluded from clinical trials with AAV-micro-dystrophin or treatment with micro-dystrophin.
Components of a gene therapy viral vector
The gene therapy product consists of the viral vector (AAV) and the gene that is delivered. For Duchenne this is a micro-dystrophin gene with a volume switch (promotor), that makes sure the micro-dystrophin is only produced in muscle tissues.
There are currently trials ongoing with 5 variations of AAV-micro-dystrophin, which differ in the type of AAV used, the parts of dystrophin selected for the micro-dystrophin versions, and the gene switch used to ensure proper expression of the micro-dystrophin in skeletal muscle and heart.
Clinical development summary
So far >150 Duchenne patients have been treated with AAV micro-dystrophin. Detailed findings of each trial and results is given below per company. However, general findings are as follows:
- Micro-dystrophin is restored after treatment, in 5-80% of muscle fibers at levels of 1-74% of normal. Higher doses of virus result in higher levels of micro-dystrophin
- AAV gene therapy can result in severe side effects, such as extreme nausea and vomiting, liver damage, transient kidney failure and in two cases, death. These likelihood of these side effects appear to increase with higher amounts of virus used. The deaths occurred in older (>16 years) patients and appear to be due to an innate immune response to the virus.
- For a subset of patients an immune response to the micro-dystrophin occurred resulting in rhabdomyolysis (breakdown of muscle) and myocarditis (inflammation of the heart). This appears to be associated with deletions at the beginning of the gene (see ‘immune response to micro-dystrophin’ section below).
Clinical trials :
Sarepte/Roche (SRP-9001/delandistrogene moxeparvovec/Elevidys)
In a clinical trial in Colombus, Ohio (coordinated by Sarepta Therapeutics) AAV-microdystrophin is delivered intravenously in young Duchenne patients together with high doses of corticosteroids (200,000 billion viral particles per kg bodyweight). Four patients have been treated and results have been published. No serious side effects were observed, but vomiting shortly after infusion was observed in 2 patients. Analysis of muscle biopsies 90 days after treatment revealed that for each patient the majority of muscle fibers expressed the micro-dystrophin. The total levels were ~75% of dystrophin levels expressed in healthy muscles.
Five other clinical trials are ongoing with this gene therapy product (called SRP-9001, delandistrogene moxeparvovec or Elevidys). For 2, results have been published.
- A placebo controlled trial In this trial 20 patients received SRP-9001 and 21 received placebo (to receive SRP-9001 after 48 weeks). Treatment was well tolerated, with most patients experiencing mild or moderately severe side effects. Severe side effects were reported for 4 treated patients (a severe breakdown of skeletal muscle (rhabdomyolysis – see below ‘Immune response to micro-dystrophin) and increased transaminases (a sign of liver damage)) and 1 placebo patient (rhabdomyolysis). A biopsy taken 12 weeks after treatment revealed treated patients on average produced 20% of micro-dystrophin. The patients receiving SRP-9001 with a year delay (i.e. those starting as the placebo group) produced 40% of dystrophin. It was later discovered that this group received the intended dose, while those receiving SRP-9001 initially received a reduced dose, which likely explains why they produce lower amounts of micro-dystrophin.
No significant improvement in the North Star Ambulatory Assessment (NSAA) was observed for treated patients compared to placebo.
- An open label study with commercially produced delandistrogene moxeparvovec (ENDEAVOUR study).
This open label study is ongoing to confirm the commercially produced delangistrogene moxeparvovec. Results are published for 12 months analysis for the first 20 patients (4-8 years old). A biopsy taken after 12 weeks revealed 54% of micro-dystrophin. Function could only be compared to natural history studies. This suggests a slower disease progression. However, caution has to be taken with interpreting this, as the patients treated with delandistrogene moxeparvovec are temporarily treated with higher doses of corticosteroids, which can also slow down disease progression.
- Ongoing studies with delandistrogene moxeparvovec
- A placebo-controlled trial is ongoing to test safety and efficacy in ambulatory patients age 4-8 years (EMBARK). This is the ‘pivotal’ study that has to confirm that treatment with melandistrogene moxeparvovec slows down disease progression, as also outlined in the conditions from FDA when they approved the approach for 4-5 year olds.
- A Placebo-controlled phase 3 clinical trial is ongoing in ambulatory and non-ambulatory patients (ENVISION).
- For long term follow-up, all patients previously treated with delandistrogene moxeparvovec in a clinical trial setting are enrolled in an open label extension study. Here long term effects (beneficial and side effects) will be monitored.
In parallel, Pfizer is developing fordadistrogene movaparvovec (previously PF06939926). A clinical trial assessing 2 different AAV-microdystrophin doses (using 0.5 and 1.5 times the dose used in the Sarepta trials) is ongoing. Three severe adverse events were reported, 1 patient experienced nausea and vomiting and 2 an immune response to the viral particles. In one patient this immune response was so severe it resulted in kidney injury. The patient was also hospitalized and required dialysis. The patient recovered and the kidney function is now normal. Based on these events, the monitoring protocol has now been amended. Dystrophin staining analysis on a biopsy obtained 2 months after treatment revealed that ~38% of fibers expressed micro-dystrophin in patients treated with lowest dose and ~69% of fibers expressed micro-dystrophin for patients treated with the higher dose. Mass spectrometry analysis revealed dystrophin levels of ~24% and 30% for the low and high dose, respectively. Since no western blot analysis was done a direct comparison with the results from Solid and Sarepta is not possible.
A trial in ambulant and nonambulant patients was initiated in parallel. However, after the unfortunate death of a 16 year old patient, this trial is now on hold. Recently, Pfizer started a clinical trial with fordadistrogene movaparvovec in 2-3 year old patients.
A trial coordinated by Solid Ventures was put on hold after the first patient experienced serious adverse events after infusion of the AAV-micro-dystrophin. The trial reinitiated in June 2018 and the biopsies of the 3 patients receiving the lowest dose (4 times lower than the Sarepta trial) have been analyzed as well as biopsies from 3 patients receiving a higher dose (same as Sarepta trial). This revealed low levels of dystrophin in up to 10% of fibers at levels of less than 5% of normal dystrophin for the lower dose and dystrophin in up to 50% of fibers in levels of ~10% for the higher dose. Adverse events were reported for the first patient treated with the higher dose, including a decline in platelet counts and markers suggesting liver damage. Things normalized after the dose of corticosteroids was increased. The trial was put on hold for a second time by FDA in November 2019, but this has been lifted in October 2020. Since then a 3 more patients have been treated without experiencing severe adverse events. In parallel Solid is working on a new AAV-micro-dystrophin product with a modified AAV capsid for improved delivery to muscle.
Solid is now preparing a new AAV-micro-dystrophin product (SGT-003) for clinical trial evaluation.
Genethon & RegenxBio
Genethon has received approval to initiate their clinical trial with AAV micro-dystrophin gene therapy in Europe in December 2020. Regenxbio has initiated clinical trial with their AAV micro-dystrophin gene therapy product.
Immune response to micro-dystrophin
It was noticed in each of the AAV micro-dystrophin trials that for some patients an immune response to the micro-dystrophin occurred. This resulted in inflammation of muscle and heart and breakdown of skeletal muscle (rhabdomyolysis). It turned out that these patients all carried deletions in the beginning of the dystrophin gene.
Duchenne patients do not produce dystrophin and the immune system recognizes and attacks foreign proteins. So in that sense, it is not strange that an immune response occurs. However, why does it only occur in the patients with a deletion at the start of the protein and not for all patients?
The phenomenon is still being studied but the current consensus on how patients with deletions at the start of the gene can have an anti-microdystrophin response while other do not, is as follows. Most patients have deletions and most of these deletions occur in the middle of the gene, which encodes the repeat domain. The micro-dystrophin has the two crucial domains of the protein: the actin-binding part and the part that binds to the extracellular matrix. For patients with a deletion in the middle of the gene, the micro-dystrophin components will not be foreign. Their cells will have produced the beginning of the protein (up till the deletion). This protein is not functional and not stable, but it is produced so the immune system ‘knows’ it. These patients will also know the second component of the micro-dystrophin binding to the extracellular matrix. In the brain different dystrophins are formed including a very short one that only contains the part that binds to the extracellular matrix. For patients with deletions before exon 62, this smaller dystrophin can be produced. As such, the micro-dystrophin as such is never seen, but the individual components have been encountered.
For patients with a deletion at the beginning of the gene, however, the first component will be foreign as they will not have produced this. Thus is it recognized by the immune system as foreign and attacked. Note that this recognition does not occur for all patients with deletions at the beginning of the gene but only a subset. It is not yet known why the immune system is triggered in some patients and not in others.
Furthermore, it is not known whether patients who cannot produce the last part of dystrophin will have an immune response to micro-dystrophin. These mutations are very rare.
Based on these developments companies have adapted their inclusion criteria. Pfizer now excludes patients of a deletion involving exon 9-13 or 29-30, Sarepta/Roche excludes patients with a deletion involving exon 1-17 or exon 45. Solid likely will exclude patients with deletions involving exon 8-13 and 42-45. For the approved Sarepta product (delandistrogene moxeparvovec), the FDA approval specifies that patients with a deletion involving exon 8 or 9 are excluded for treatment due to the risk of an anti-micro-dystrophin auto-immune response.
AAV does not integrate in the DNA. This is good from a safety perspective. However, because the microdystrophin is not fully functional, the muscles with microdystrophin will still be damaged. This means that over time the micro-dystrophin gene may be lost. Studies in dystrophic dogs suggest that most of the delivered gene is lost after 5 years. It is not known whether this is also the case in humans and if so how long the microdystrophin protein will persist. It is unlikely however that AAV-mediated microdystrophin delivery will be a ‘one time treatment’ for Duchenne.
Past clinical trial results if intramuscular injections
A first clinical trial where patients received local AAV-microdystrophin injections in the arm muscle was performed in the USA (Mendell, Xiao Xiao and Samulski). Results of this trial have been published. The authors report very poor expression of their microdystrophin version, and the anticipated immune response to AAV.