Gene Therapy for Hemophilia A

Overseen By Parameswaran Hari, MD

Age: 18+

Sex: Male

Trial Phase: Phase 1

Sponsor: Parameswaran Hari

Must be taking: Factor VIII mimetics

Disqualifiers: Thrombophilic disorders, Active malignancy, HIV, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 1

5 Participants Needed

Trial Summary

What is the purpose of this trial?

This is a Phase I study. This research study is being conducted to find new ways to treat severe hemophilia A. This study is a gene therapy study. Gene therapy is an experimental way to introduce, into a person's cells, specific genetic material. A gene can be delivered/introduced into a cell using a carrier known as a "vector." In this study, a virus (lentivirus), the "vector", is used to introduce or deliver a gene that creates and stores a protein Factor VIII (FVIII) in your platelets. These platelets are made from stem cells (mother cells for your bone marrow) that are removed from your blood by a procedure called apheresis. This research study will take some of the patient's own stem cells, from the apheresis procedure, and genetically modify them using the vector in order to make them produce FVIII in platelets that arise from the stem cells. They will then give the genetically modified stem cells back to the patient so that they can possibly create platelets that produce and store Factor VIII on their own.

Will I have to stop taking my current medications?

The trial protocol does not specify if you need to stop taking your current medications. However, if you are on factor VIII for immune tolerance induction, you must stop it 30 days before joining the study.

What data supports the effectiveness of the treatment Auto CD34+PBSC, transduced with a lentiviral vector encoding the B domain deleted form of human coagulation factor VIII for Hemophilia A?

Research shows that using lentiviral vectors to deliver a modified version of factor VIII can lead to high levels of factor VIII expression, which is crucial for treating Hemophilia A. In studies, this approach has resulted in significant increases in factor VIII activity and sustained correction of bleeding symptoms in animal models. ^{1 2 3 4 5}

Is gene therapy for Hemophilia A using lentiviral vectors safe?

Preclinical studies in mice have shown that gene therapy using lentiviral vectors for Hemophilia A is generally safe, with no signs of toxicity observed. These studies demonstrated sustained production of the necessary blood clotting factor without harmful effects. ^{1 3 4 6 7}

How is the gene therapy treatment for Hemophilia A unique?

This gene therapy for Hemophilia A uses a lentiviral vector to deliver a modified version of the human coagulation factor VIII gene, which is designed to produce higher levels of the factor needed for blood clotting. Unlike traditional treatments that require regular infusions of factor VIII, this approach aims to provide a long-term solution by integrating the therapeutic gene into the patient's cells, potentially reducing the frequency of treatment. ^{1 2 3 4 8}

Research Team

Mary Eapen, MD, MS

Principal Investigator

Froedtert Hosptial and Medical College of Wisconsin

Eligibility Criteria

Adult males over 18 with severe hemophilia A and a history of FVIII inhibitors. They must have had multiple bleeding episodes, adequate bone marrow reserve, renal and liver function, and be willing to document their condition for 15 years. Excluded are those recently in other trials or with certain medical conditions.

Inclusion Criteria

I may be taking medication to help with blood clotting before joining the study.

I am a man over 18 with severe hemophilia A and have or had inhibitors.

I am willing to keep a diary of my bleeding episodes and treatments.

Exclusion Criteria

I do not have any active infections that would prevent me from receiving treatments that weaken my immune system.

My life expectancy is not majorly shortened by conditions other than hemophilia A.

I have an active cancer that is not a non-melanoma skin cancer or carcinoma in situ.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Conditioning

Participants undergo reduced intensity conditioning prior to stem cell infusion

1-2 weeks

Gene Therapy Infusion

Single infusion of autologous CD34+PBSC transduced with a lentiviral vector

1 day

1 visit (in-person)

Follow-up

Participants are monitored for safety and effectiveness after gene therapy infusion

3 months

Multiple visits (in-person)

Long-term Follow-up

Participants are monitored for long-term safety and effectiveness

Up to 4 years

Treatment Details

Interventions

• Auto CD34+PBSC, transduced with a lentiviral vector encoding the B domain deleted from of human coagulation factor VIII

Trial Overview This Phase I gene therapy trial is testing if genetically modified stem cells can produce platelets that create Factor VIII on their own in patients with severe hemophilia A. Patients' stem cells will be altered using a viral vector and then returned to them.

Participant Groups

Group I: Autologous CD34+PBSC transduced with a lentiviral vector Experimental Treatment 1 Intervention

Patients will receive a patient specific (autologous) cytokine mobilized CD34+Peripheral Blood Stem Cells (PBSC) transduced ex vivo with a lentiviral vector containing cDNA encoding the human B-domain deleted FVIII protein.

Who Is Running the Clinical Trial?

Parameswaran Hari

Lead Sponsor

Trials

2

Recruited

40+

Medical College of Wisconsin

Lead Sponsor

Trials

645

Recruited

1,180,000+

Findings from Research

The recombinant lentiviral vector pXZ208-BDDhFVIII was successfully created and showed effective integration into human liver (HLF), Chang-Liver, and mesenchymal stem cells (MSC), with infection rates of 74.52%, 27.24%, and 42.34%, respectively.

The expression of human coagulation factor VIII (FVIII) was confirmed, with HLF cells producing the highest activity at 54.1%, indicating the potential of this vector for gene therapy in hemophilia treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Establishment of a high expressing system of human coagulant factor VIII in vitro]. Cheng, H., Xu, KL., Sun, HY., et al.[2009]

The study demonstrated that canine bone marrow stromal cells (BMSCs) can effectively express and secrete human factor VIII (hFVIII) for potential gene therapy in hemophilia A, achieving secretion levels as high as 1000-4000 mU/10(6) cells/24 hr when using retroviral vectors.

The research highlighted that the B domain-deleted hFVIII with the proteolytic site retained over 93% of normal biological activity, making it a more suitable candidate for therapeutic applications compared to the unprocessed form, which had less than 55% activity.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Bone marrow stromal cell-mediated gene therapy for hemophilia A: in vitro expression of human factor VIII with high biological activity requires the inclusion of the proteolytic site at amino acid 1648. Chiang, GG., Rubin, HL., Cherington, V., et al.[2012]

Lentiviral vectors (LV) can effectively integrate therapeutic genes into host genomes, showing promise for treating hereditary diseases like hemophilia A, as demonstrated by high levels of factor VIII (FVIII) expression in various cell types.

In a study involving C57BL/6 FVIII knockout mice, while the LV successfully produced FVIII, the therapeutic levels were low due to the development of neutralizing antibodies against FVIII, highlighting the need to address immune responses for effective gene therapy.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficient production of human FVIII in hemophilic mice using lentiviral vectors. Kootstra, NA., Matsumura, R., Verma, IM.[2022]

Shorter expression cassettes for factor VIII (FVIII), particularly those with a partial B domain deletion (N6), can significantly enhance FVIII secretion, achieving up to a 44-fold increase in expression compared to traditional constructs.

In hemophilic mice, gene therapy using these optimized FVIII constructs led to sustained expression of FVIII activity for over 250 days, indicating a promising approach for effective long-term treatment of hemophilia A.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Codon optimization of human factor VIII cDNAs leads to high-level expression. Ward, NJ., Buckley, SM., Waddington, SN., et al.[2022]

A lentiviral vector carrying the human coagulant factor VIII (FVIII) gene was successfully constructed and used to transfect 293T cells, achieving a transfection rate of 59.57%.

The transfected cells expressed FVIII with increasing activity levels of 12%, 43%, and 87% at 24, 48, and 72 hours post-infection, indicating the potential for this method in gene therapy for hemophilia A.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Expression of B domain-deleted human coagulant factor VIII gene in 293T cells mediated by lentiviral vector in vitro]. Cheng, H., Xu, KL., Sun, HY., et al.[2016]

A new lentiviral vector system was successfully developed to express human coagulation factor VIII (FVIII) in CHO cells, achieving a high concentration of FVIII antigen (1724.9 mU/ml) and activity (10.58% FVIII:C) after 72 hours.

The system demonstrated good biosafety, as no viral particles or gag gene were detected in the supernatant, indicating it does not produce offspring viruses.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Establishment of a high efficient human coagulation factor VIII eukaryotic expression system using lentiviral vector]. Song, XG., Cao, J., Zeng, LY., et al.[2013]

The investigational product CD68-ET3-LV CD34+ shows promising safety and efficacy in treating hemophilia A, as demonstrated by sustained production of coagulation factor VIII in murine models without toxicity.

The genetically modified autologous hematopoietic stem and progenitor cells (HSPCs) effectively produced factor VIII, supporting the potential of this gene therapy approach for patients with hemophilia A.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Preclinical Development of a Hematopoietic Stem and Progenitor Cell Bioengineered Factor VIII Lentiviral Vector Gene Therapy for Hemophilia A. Doering, CB., Denning, G., Shields, JE., et al.[2019]

A new hybrid human/porcine coagulation factor VIII (fVIII) transgene, which is 89% identical to human fVIII, shows up to 100-fold greater expression than traditional human fVIII when delivered via lentiviral vectors to hematopoietic stem cells, indicating a promising approach for gene therapy in hemophilia A.

Transplanting these genetically modified stem cells into hemophilia A mice resulted in long-term therapeutic levels of fVIII expression, even with less than 5% of the blood cells being genetically modified, suggesting effective and sustained treatment potential.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Directed engineering of a high-expression chimeric transgene as a strategy for gene therapy of hemophilia A. Doering, CB., Denning, G., Dooriss, K., et al.[2022]

References

1. China pubmed.ncbi.nlm.nih.gov

[Establishment of a high expressing system of human coagulant factor VIII in vitro]. [2009]

2. United States pubmed.ncbi.nlm.nih.gov

Bone marrow stromal cell-mediated gene therapy for hemophilia A: in vitro expression of human factor VIII with high biological activity requires the inclusion of the proteolytic site at amino acid 1648. [2012]

3. United States pubmed.ncbi.nlm.nih.gov

Efficient production of human FVIII in hemophilic mice using lentiviral vectors. [2022]

4. United States pubmed.ncbi.nlm.nih.gov

Codon optimization of human factor VIII cDNAs leads to high-level expression. [2022]

5. China pubmed.ncbi.nlm.nih.gov

[Expression of B domain-deleted human coagulant factor VIII gene in 293T cells mediated by lentiviral vector in vitro]. [2016]

6. China pubmed.ncbi.nlm.nih.gov

[Establishment of a high efficient human coagulation factor VIII eukaryotic expression system using lentiviral vector]. [2013]

7. United States pubmed.ncbi.nlm.nih.gov

Preclinical Development of a Hematopoietic Stem and Progenitor Cell Bioengineered Factor VIII Lentiviral Vector Gene Therapy for Hemophilia A. [2019]

8. United States pubmed.ncbi.nlm.nih.gov

Directed engineering of a high-expression chimeric transgene as a strategy for gene therapy of hemophilia A. [2022]