Patent Application
20230310654
The contents of the text file submitted electronically herewith are incorporated herein by reference in their entirety: A computer readable format copy of the Sequence Listing (filename: PRVL_014_01WO_SeqList.txt, date recorded: Aug. 10, 2021, file size ˜361,207 bytes).
Aberrant expression of proteins such as lysosomal acid β-glucocerebrosidase (Gcase) and α-Synuclein is involved in many central nervous system disorders. Gaucher disease is a rare inborn error of glycosphingolipid metabolism due to deficiency of Gcase. Patients suffer from non-CNS symptoms and findings including hepatosplenomegaly, bone marrow insufficiency leading to pancytopenia, lung disorders and fibrosis, and bone defects. In addition, a significant number of patients suffer from neurological manifestations, including defective saccadic eye movements and gaze, seizures, cognitive deficits, developmental delay, and movement disorders including Parkinson's disease.
Several therapeutics exist that address the peripheral disease and the principal clinical manifestations in hematopoietic bone marrow and viscera, including enzyme replacement therapies, chaperone-like small molecule drugs that bind to defective Gcase and improve stability, and substrate reduction therapy that block the production of substrates that accumulate in Gaucher disease, leading to symptoms and pathology. However, other aspects of Gaucher disease appear refractory to treatment.
In addition to Gaucher disease patients (who possess mutations in both chromosomal alleles of GBA1 gene), patients with mutations in only one allele of GBA1 are at highly increased risk of Parkinson's disease (PD). Elevated α-Synuclein levels also underlie synucleinopathies such as PD. The severity of PD symptoms—which include gait difficulty, a tremor at rest, rigidity, and often depression, sleep difficulties, and cognitive decline—correlate with the degree of enzyme activity reduction. Thus, Gaucher disease patients have the most severe course, whereas patients with a single mild mutation in GBA1 typically have a more benign course. Mutation carriers are also at high risk of other PD-related disorders, including Lewy Body Dementia, characterized by executive dysfunction, psychosis, and a PD-like movement disorder, and multi-system atrophy, with characteristic motor and cognitive impairments. No therapies exist that alter the inexorable course of these disorders and other synucleinopathies.
The disclosure relates to the field of gene therapy and methods of using same.
Provided herein is a method for treating a subject having or suspected of having Parkinson's disease with a glucocerebrosidase-1 (GBA1) mutation, the method comprising administering to the subject:
Further provided herein is a method for suppressing an immune response in a subject having or suspected of having Parkinson's disease with a glucocerebrosidase-1 (GBA1) mutation, the method comprising administering to the subject:
In some embodiments of the methods provided herein, the rAAV is administered to the subject at a dose ranging from about 5×1013 vector genomes (vg) to about 5×1014 vg. In some embodiments of the methods provided herein, the rAAV is administered to the subject at a dose of about 1.4×1014 vg or about 2.8×1014 vg.
Provided herein is a method for treating a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
Further provided herein is a method for suppressing an immune response in a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
In some embodiments of the methods provided herein, the rAAV is administered to the subject at a dose ranging from about 5×1010 vg/g brain to about 5×1011 vg/g brain. In some embodiments of the methods provided herein, the rAAV is administered to the subject at a dose of about 1.3×1011 vg/g brain.
In some embodiments of the methods provided herein, the rAAV is administered via an injection into the cisterna magna.
Provided herein is a method for treating a subject having or suspected of having Type 1 Gaucher disease, the method comprising administering to the subject:
Further provided herein is a method for suppressing an immune response in a subject having or suspected of having Type 1 Gaucher disease, the method comprising administering to the subject:
In some embodiments of the methods provided herein, the rAAV is administered to the subject at a dose ranging from about 5×1013 vg to about 5×1014 vg. In some embodiments of the methods provided herein, the rAAV is administered intravenously.
Further provided herein is a method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
Provided herein is a method for suppressing an immune response in a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
Provided herein is a method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
Further provided herein is a method for suppressing an immune response in a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
In some embodiments of the methods provided herein, the promoter is a chicken beta actin (CBA) promoter. In some embodiments of the methods provided herein, the rAAV vector further comprises a cytomegalovirus (CMV) enhancer. In some embodiments of the methods provided herein, the rAAV vector further comprises a Woodchuck Hepatitis Virus Posttranscriptional Regulatory Element (WPRE). In some embodiments of the methods provided herein, the rAAV vector further comprises a Bovine Growth Hormone polyA signal tail.
In some embodiments of the methods provided herein, the nucleic acid comprises two adeno-associated virus inverted terminal repeats (ITR) sequences flanking the expression construct. In some embodiments of the methods provided herein, each ITR sequence is an AAV2 ITR sequence. In some embodiments of the methods provided herein, the rAAV vector further comprises a TRY region between the 5′ ITR and the expression construct, wherein the TRY region comprises SEQ ID NO: 28.
Provided herein is a method for treating a subject having or suspected of having Parkinson's disease with a GBA1 mutation, the method comprising administering to the subject:
Further provided herein is a method for suppressing an immune response in a subject having or suspected of having Parkinson's disease with a GBA1 mutation, the method comprising administering to the subject:
Provided herein is a method for treating a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
Provided herein is a method for suppressing an immune response in a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
In some embodiments of the methods provided herein, the rAAV is administered via an injection into the cisterna magna.
In some embodiments of the methods provided herein, the rAAV is administered in a formulation comprising about 20 mM Tris, pH 8.0, about 1 mM MgCl2, about 200 mM NaCl, and about 0.001% w/v poloxamer 188.
In some embodiments of the methods provided herein, the methylprednisolone is administered intravenously at a dose of about 1000 mg either one day before or on the same day as administration of the rAAV.
In some embodiments of the methods provided herein, the prednisone is administered orally (A) at a dose of about 30 mg per day for 14 days beginning on the day after the administration of about 1000 mg of the methylprednisolone; and (B) tapered during the 7 days following the end of the 14-day period of (A).
In some embodiments of the methods provided herein, the rituximab is administered intravenously at a dose of about 1000 mg on any single day between 14 days before and 1 day before administration of the rAAV. In some embodiments of the methods provided herein, the methylprednisolone is administered before the rituximab is administered. In some embodiments of the methods provided herein, the methylprednisolone is administered at least about 30 minutes before the rituximab is administered.
In some embodiments of the methods provided herein, the methylprednisolone and the rituximab are both administered the day before administration of the rAAV; and wherein the methylprednisolone is administered at least about 30 minutes before the rituximab is administered.
In some embodiments of the methods provided herein, the rituximab is administered on any single day between 14 days before and 2 days before administration of the rAAV; and wherein methylprednisolone is administered intravenously at a dose of about 100 mg at least about 30 minutes before the rituximab is administered on the same day as the rituximab is administered.
In some embodiments of the methods provided herein, the sirolimus is administered orally (A) as a single dose of about 6 mg three days, two days or one day before administration of the rAAV; and (B) at a dose of about 2 mg per day to maintain serum trough levels of from about 4 ng/ml to about 9 ng/mL for about 90 days after administration of the rAAV; wherein the first dose of about 2 mg per day of the sirolimus is administered the day after the single dose of about 6 mg of the sirolimus.
In some embodiments of the methods provided herein, the sirolimus is administered orally (A) at two doses of about 1.0 mg/m2 each, wherein the two doses are administered 1 day or 2 days before administration of the rAAV, wherein the first dose is administered in the morning and the second dose is administered in the evening of the day on which the two doses are administered; and (B) at a dose of from about 0.6 mg/m2/day to about 1.0 mg/m2/day to maintain serum trough levels of from about 2 ng/mL to about 8 ng/mL for about 3 months after administration of the rAAV.
In some embodiments of the methods provided herein, the sirolimus administration is tapered during the 15 days to 30 days following the end of the 90-day period after administration of the rAAV.
In some embodiments of the methods provided herein, the method comprises:
In some embodiments of the methods provided herein, the method comprises:
In some embodiments of the methods provided herein, the immune response is an immune response to the rAAV. In some embodiments of the methods provided herein, the immune response is a T cell response. In some embodiments of the methods provided herein, the immune response is a B cell response. In some embodiments of the methods provided herein, the immune response is an antibody response. In some embodiments of the methods provided herein, the immune response is pleocytosis. In some embodiments of the methods provided herein, the pleocytosis is cerebrospinal fluid (CSF) pleocytosis. In some embodiments of the methods provided herein, the immune response is an abnormal level of CSF protein.
In some embodiments of the methods provided herein, an additional immunosuppressant that is not sirolimus, methylprednisolone, rituximab or prednisone is further administered to the subject.
In some embodiments of the methods provided herein, the synucleinopathy or parkinsonism is multiple system atrophy, Parkinson's disease, Parkinson's disease with GBA1 mutation, Lewy body disease, dementia with Lewy bodies, dementia with Lewy bodies with GBA1 mutation, progressive supranuclear palsy, or corticobasal syndrome.
Provided herein is a therapeutic combination of
Also provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
In some embodiments, a therapeutic combination comprises from about 5×1013 vg to about 5×1014 vg of the rAAV. In some embodiments, a therapeutic combination comprises about 1.4×1014 vg or about 2.8×1014 vg of the rAAV.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
Further provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
Further provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
Provided herein is a therapeutic combination of
The disclosure relates to gene therapies for diseases associated with aberrant lysosomal function such as Parkinson's disease (PD), Gaucher disease (GD) and synucleinopathies. In particular, the disclosure is related to an immunosuppression regimen administered in combination with a recombinant adeno-associated virus (rAAV). The rAAV may deliver a functional copy of the GBA1 gene encoding the protein Gcase. Additionally or alternatively, the rAAV may deliver a nucleic acid encoding an interfering nucleic acid that inhibits expression of α-Synuclein. An immunosuppression regimen is needed to reduce the risk of immune-related adverse events in a subject being treated with gene therapy.
The disclosure is based, in part, on compositions and methods for expression of combinations of certain gene products (e.g., gene products associated with central nervous system (CNS) disease) in a subject. A gene product can be a protein, a fragment (e.g., portion) of a protein, an interfering nucleic acid that inhibits a CNS disease-associated gene, etc. In some embodiments, a gene product is a protein or a protein fragment encoded by a CNS disease-associated gene. In some embodiments, a gene product is an interfering nucleic acid (e.g., shRNA, siRNA, miRNA, amiRNA, etc.) that inhibits a CNS disease-associated gene.
A CNS disease-associated gene refers to a gene encoding a gene product that is genetically, biochemically or functionally associated with a central nervous system (CNS) disease, such as Parkinson's disease (PD), Gaucher disease (GD) or a synucleinopathy. For example, individuals having mutations in the GBA1 gene (which encodes the protein Gcase), have been observed to be have an increased risk of developing PD compared to individuals that do not have a mutation in GBA1. In another example, PD is associated with accumulation of protein aggregates comprising α-Synuclein (α-Syn) protein; accordingly, SNCA (which encodes α-Syn) is a CNS disease-associated gene. In some embodiments, an expression cassette described herein encodes a wild-type or non-mutant form of a CNS disease-associated gene (or coding sequence thereof). Examples of CNS disease-associated genes are listed in Table 1.
Deficits in enzymes such as lysosomal acid β-glucocerebrosidase (e.g., the gene product of GBA1 gene; also referred to as GCase), as well as common variants in many genes implicated in lysosome function or trafficking of macromolecules to the lysosome (e.g., Lysosomal Membrane Protein 1 (LIMP), also referred to as SCARB2), have been associated with increased PD risk and/or increased risk of Gaucher disease (e.g., neuronopathic Gaucher disease, such as Type 2 Gaucher disease or Type 3 Gaucher disease). The disclosure is based, in part, on expression constructs (e.g., vectors) encoding Gcase (or a portion thereof), prosaposin (or a portion thereof), LIMP2 (or a portion thereof), or a combination of Gcase (or a portion thereof) and one or more additional gene products from genes (e.g., LIMP2, Prosaposin, and/or α-Synuclein (α-Syn)) associated with central nervous system (CNS) diseases, for example PD, Gaucher disease, etc. In some embodiments, combinations of gene products described herein act together (e.g., synergistically) to reduce one or more signs and symptoms of a CNS disease when expressed in a subject.
Accordingly, in some aspects, the disclosure provides an isolated nucleic acid comprising an expression construct encoding a Gcase (e.g., the gene product of GBA1 gene). In some embodiments, the isolated nucleic acid comprises a Gcase-encoding sequence that has been codon optimized (e.g., codon optimized for expression in mammalian cells, for example human cells). In some embodiments, the nucleic acid sequence encoding the Gcase encodes a protein comprising an amino acid sequence as set forth in SEQ ID NO: 14 (e.g., as set forth in NCBI Reference Sequence NP_000148.2). In some embodiments, the isolated nucleic acid comprises the sequence set forth in SEQ ID NO: 15. The codon optimized sequence set forth in SEQ ID NO: 15 eliminates a predicted donor splice site that begins at nucleotide 49 in the wild type GBA1 nucleotide sequence. In some embodiments the expression construct comprises adeno-associated virus (AAV) inverted terminal repeats (ITRs), for example AAV ITRs flanking the nucleic acid sequence encoding the Gcase.
In some aspects, the disclosure provides an isolated nucleic acid comprising an expression construct encoding Prosaposin (e.g., the gene product of PSAP gene). In some embodiments, the isolated nucleic acid comprises a prosaposin-encoding sequence that has been codon optimized (e.g., codon optimized for expression in mammalian cells, for example human cells). In some embodiments, the nucleic acid sequence encoding the prosaposin encodes a protein comprising an amino acid sequence as set forth in SEQ ID NO: 16 (e.g., as set forth in NCBI Reference Sequence NP_002769.1). In some embodiments, the isolated nucleic acid comprises the sequence set forth in SEQ ID NO: 17. In some embodiments the expression construct comprises adeno-associated virus (AAV) inverted terminal repeats (ITRs), for example AAV ITRs flanking the nucleic acid sequence encoding the prosaposin.
In some aspects, the disclosure provides an isolated nucleic acid comprising an expression construct encoding LIMP2/SCARB2 (e.g., the gene product of SCARB2 gene). In some embodiments, the isolated nucleic acid comprises a SCARB2-encoding sequence that has been codon optimized (e.g., codon optimized for expression in mammalian cells, for example human cells). In some embodiments, the nucleic acid sequence encoding the LIMP2/SCARB2 encodes a protein comprising an amino acid sequence as set forth in SEQ ID NO: 18 (e.g., as set forth in NCBI Reference Sequence NP_005497.1). In some embodiments, the isolated nucleic acid comprises the sequence set forth in SEQ ID NO: 29. In some embodiments the expression construct comprises adeno-associated virus (AAV) inverted terminal repeats (ITRs), for example AAV ITRs flanking the nucleic acid sequence encoding the SCARB2.
In some aspects, the disclosure provides an isolated nucleic acid comprising an expression construct encoding a first gene product and a second gene product, wherein each gene product independently is selected from the gene products, or portions thereof, set forth in Table 1.
In some embodiments, a first gene product or a second gene product is a Gcase protein, or a portion thereof. In some embodiments, a first gene product or a second gene product is LIMP2 or a portion thereof, or Prosaposin or a portion thereof. In some embodiments, the first gene product is a Gcase protein, and the second gene product is LIMP2 or a portion thereof, or Prosaposin or a portion thereof.
In some embodiments, an expression construct encodes (e.g., alone or in addition to another gene product) an interfering nucleic acid (e.g., shRNA, miRNA, dsRNA, etc.). In some embodiments, an interfering nucleic acid inhibits expression of α-Synuclein (α-Syn). In some embodiments, an interfering nucleic acid that targets α-Synuclein comprises a sequence set forth in any one of SEQ ID NOs: 20-25. In some embodiments, an interfering nucleic acid that targets α-Synuclein comprises a sequence set forth in SEQ ID NO: 20. In some embodiments, an interfering nucleic acid that targets α-Synuclein binds to (e.g., hybridizes with) a sequence set forth in any one of SEQ ID NO: 20-25. In some embodiments, an interfering nucleic acid that targets α-Synuclein binds to (e.g., hybridizes with) a sequence set forth in SEQ ID NO: 20.
In some embodiments, an expression construct further comprises one or more promoters. In some embodiments, a promoter is a chicken-beta actin (CBA) promoter, a CAG promoter, a CD68 promoter, or a JeT promoter. In some embodiments, a promoter is a RNA pol II promoter (e.g., or an RNA pol III promoter (e.g., U6, etc.).
In some embodiments, an expression construct further comprises an internal ribosomal entry site (IRES). In some embodiments, an IRES is located between a first gene product and a second gene product.
In some embodiments, an expression construct further comprises a self-cleaving peptide coding sequence. In some embodiments, a self-cleaving peptide is a T2A peptide.
In some embodiments, an expression construct comprises two adeno-associated virus (AAV) inverted terminal repeat (ITR) sequences. In some embodiments, ITR sequences flank a first gene product and a second gene product (e.g., are arranged as follows from 5′-end to 3′-end: ITR-first gene product-second gene product-ITR). In some embodiments, one of the ITR sequences of an isolated nucleic acid lacks a functional terminal resolution site (trs). For example, in some embodiments, one of the ITRs is a ΔITR.
The disclosure relates, in some aspects, to rAAV vectors comprising an ITR having a modified “D” region (e.g., a D sequence that is modified relative to wild-type AAV2 ITR, SEQ ID NO: 29). In some embodiments, the ITR having the modified D region is the 5′ ITR of the rAAV vector. In some embodiments, a modified “D” region comprises an “S” sequence, for example as set forth in SEQ ID NO: 26. In some embodiments, the ITR having the modified “D” region is the 3′ ITR of the rAAV vector. In some embodiments, a modified “D” region comprises a 3′ITR in which the “D” region is positioned at the 3′ end of the ITR (e.g., on the outside or terminal end of the ITR relative to the transgene insert of the vector). In some embodiments, a modified “D” region comprises a sequence as set forth in SEQ ID NO: 26 or 27.
In some embodiments, an isolated nucleic acid (e.g., an rAAV vector) comprises a TRY region. In some embodiments, a TRY region comprises the sequence set forth in SEQ ID NO: 28.
In some embodiments, an isolated nucleic acid described by the disclosure comprises or consists of the sequence set forth in any one of SEQ ID NOs: 1 to 13, 15, 17, 19, and 32-48. In some embodiments, an isolated nucleic acid described by the disclosure encodes a peptide comprising or consisting of the sequence set forth in any one of SEQ ID NOs: 14, 16, and 18.
In some aspects, the disclosure provides a vector comprising an isolated nucleic acid as described by the disclosure. In some embodiments, a vector is a plasmid, or a viral vector. In some embodiments, a viral vector is a recombinant AAV (rAAV) vector. In some embodiments, an rAAV vector is single-stranded (e.g., single-stranded DNA).
In some aspects, the disclosure provides a host cell comprising an isolated nucleic acid as described by the disclosure or a vector as described by the disclosure.
In some aspects, the disclosure provides a recombinant adeno-associated virus (rAAV) comprising a capsid protein and an isolated nucleic acid or a vector as described by the disclosure.
In some embodiments, a capsid protein is capable of crossing the blood-brain barrier, for example an AAV9 capsid protein or an AAVrh.10 capsid protein. In some embodiments, an rAAV transduces neuronal cells and non-neuronal cells of the central nervous system (CNS).
In some aspects, the disclosure provides a method for treating a subject having or suspected of having or suspected of having a central nervous system (CNS) disease, the method comprising administering to the subject a composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure. In some embodiments, the CNS disease is a neurodegenerative disease, such as a neurodegenerative disease listed in Table 4. In some embodiments, the CNS disease is a synucleinopathy, such as a synucleinopathy listed in Table 5. In some embodiments, the CNS disease is a tauopathy, such as a tauopathy listed in Table 6. In some embodiments, the CNS disease is a lysosomal storage disease, such as a lysosomal storage disease listed in Table 7. In some embodiments, the lysosomal storage disease is neuronopathic Gaucher disease, such as Type 1 Gaucher disease, Type 2 Gaucher disease or Type 3 Gaucher disease.
In some aspects, the disclosure provides a method for treating a subject having or suspected of having Parkinson's disease, the method comprising administering to the subject a composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure.
In some embodiments, the disclosure provides a method for treating a subject having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype. In some embodiments, the rAAV is administered to a subject having Type 2 Gaucher disease or Type 3 Gaucher disease at a dose of about 1.3×1011 vector genomes (vg)/g brain.
In some embodiments, the disclosure provides a method for treating a subject having Parkinson's disease with a glucocerebrosidase-1 (GBA1) mutation, the method comprising administering to the subject a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype. In some embodiments, the rAAV is administered to a subject having Parkinson's disease at a dose of about 1×1014 vector genomes (vg) or about 2×1014 vg.
In some embodiments, the rAAV is administered via a suboccipital injection into the cisterna magna.
In some embodiments, a composition comprises a nucleic acid (e.g., an rAAV genome, for example encapsidated by AAV capsid proteins) that encodes two or more gene products (e.g., CNS disease-associated gene products), for example 2, 3, 4, 5, or more gene products described in this application. In some embodiments, a composition comprises two or more (e.g., 2, 3, 4, 5, or more) different nucleic acids (e.g., two or more rAAV genomes, for example separately encapsidated by AAV capsid proteins), each encoding one or more different gene products. In some embodiments, two or more different compositions are administered to a subject, each composition comprising one or more nucleic acids encoding different gene products. In some embodiments, different gene products are operably linked to the same promoter type (e.g., the same promoter). In some embodiments, different gene products are operably linked to different promoters.
An isolated nucleic acid may be DNA or RNA. The disclosure provides, in some aspects, an isolated nucleic acid comprising an expression construct encoding a Gcase (e.g., the gene product of GBA1 gene) or a portion thereof. Gcase, also referred to as β-glucocerebrosidase or GBA, refers to a lysosomal protein that cleaves the beta-glucosidic linkage of the chemical glucocerebroside, an intermediate in glycolipid metabolism. Deficiency in Gcase, a key lysosomal enzyme required for the normal metabolism of glycolipids, leads to the accumulation of the Gcase glycolipid substrates glucosylceramide (GluCer) and glucosylsphingosine (GluSph). In humans, Gcase is encoded by the GBA1 gene, located on chromosome 1. In some embodiments, GBA1 encodes a peptide that is represented by NCBI Reference Sequence NCBI Reference Sequence NP_000148.2 (SEQ ID NO: 14). In some embodiments, the isolated nucleic acid comprises a Gcase-encoding sequence that has been codon optimized (e.g., codon optimized for expression in mammalian cells, for example human cells), such as the sequence set forth in SEQ ID NO: 15.
In some aspects, the disclosure provides an isolated nucleic acid comprising an expression construct encoding Prosaposin (e.g., the gene product of PSAP gene). Prosaposin is a precursor glycoprotein for sphingolipid activator proteins (saposins) A, B, C, and D, which facilitate the catabolism of glycosphingolipids with short oligosaccharide groups. In humans, the PSAP gene is located on chromosome 10. In some embodiments, PSAP encodes a peptide that is represented by NCBI Reference Sequence NP_002769.1 (e.g., SEQ ID NO: 16). In some embodiments, the isolated nucleic acid comprises a prosaposin-encoding sequence that has been codon optimized (e.g., codon optimized for expression in mammalian cells, for example human cells), such as the sequence set forth in SEQ ID NO: 17.
Aspects of the disclosure relate to an isolated nucleic acid comprising an expression construct encoding LIMP2/SCARB2 (e.g., the gene product of SCARB2 gene). SCARB2 refers to a membrane protein that regulates lysosomal and endosomal transport within a cell. In humans, SCARB2 gene is located on chromosome 4. In some embodiments, the SCARB2 gene encodes a peptide that is represented by NCBI Reference Sequence NP_005497.1 (SEQ ID NO: 18). In some embodiments, the isolated nucleic acid comprises the sequence set forth in SEQ ID NO: 19. In some embodiments the isolated nucleic acid comprises a SCARB2-encoding sequence that has been codon optimized.
In some aspects, the disclosure provides an isolated nucleic acid comprising an expression construct encoding a first gene product and a second gene product, wherein each gene product independently is selected from the gene products, or portions thereof, set forth in Table 1.
In some embodiments, an isolated nucleic acid or vector (e.g., rAAV vector) described by the disclosure comprises or consists of a sequence set forth in any one of SEQ ID NOs: 1-48. In some embodiments, an isolated nucleic acid or vector (e.g., rAAV vector) described by the disclosure comprises or consists of a sequence that is complementary (e.g., the complement of) a sequence set forth in any one of SEQ ID NOs: 1-48. In some embodiments, an isolated nucleic acid or vector (e.g., rAAV vector) described by the disclosure comprises or consists of a sequence that is a reverse complement of a sequence set forth in any one of SEQ ID NOs: 1-48. In some embodiments, an isolated nucleic acid or vector (e.g., rAAV vector) described by the disclosure comprises or consists of a portion of a sequence set forth in any one of SEQ ID NOs: 1-48. A portion may comprise at least 25%, 50%, 60%, 70%, 80%, 90%, 95%, or 99% of a sequence set forth in any one of SEQ ID NOs: 1-48. In some embodiments, a nucleic acid sequence described by the disclosure is a nucleic acid sense strand (e.g., 5′ to 3′ strand), or in the context of a viral sequences a plus (+) strand. In some embodiments, a nucleic acid sequence described by the disclosure is a nucleic acid antisense strand (e.g., 3′ to 5′ strand), or in the context of viral sequences a minus (−) strand.
In some embodiments, a gene product is encoded by a coding portion (e.g., a cDNA) of a naturally occurring gene. In some embodiments, a first gene product is a protein (or a fragment thereof) encoded by the GBA1 gene. In some embodiments, a gene product is a protein (or a fragment thereof) encoded by the SCARB2/LIMP2 gene and/or the PSAP gene. However, the skilled artisan recognizes that the order of expression of a first gene product (e.g., Gcase) and a second gene product (e.g., LIMP2) can generally be reversed (e.g., LIMP2 is the first gene product and Gcase is the second gene product). In some embodiments, a gene product is a fragment (e.g., portion) of a gene listed in Table 1. A protein fragment may comprise about 50%, about 60%, about 70%, about 80% about 90% or about 99% of a protein encoded by the genes listed in Table 1. In some embodiments, a protein fragment comprises between 50% and 99.9% (e.g., any value between 50% and 99.9%) of a protein encoded by a gene listed in Table 1.
In some embodiments, an expression construct is monocistronic (e.g., the expression construct encodes a single fusion protein comprising a first gene product and a second gene product). In some embodiments, an expression construct is polycistronic (e.g., the expression construct encodes two distinct gene products, for example two different proteins or protein fragments).
A polycistronic expression vector may comprise a one or more (e.g., 1, 2, 3, 4, 5, or more) promoters. Any suitable promoter can be used, for example, a constitutive promoter, an inducible promoter, an endogenous promoter, a tissue-specific promoter (e.g., a CNS-specific promoter), etc. In some embodiments, a promoter is a chicken beta-actin promoter (CBA promoter), a CAG promoter (for example as described by Alexopoulou et al. (2008) BMC Cell Biol. 9:2; doi: 10.1186/1471-2121-9-2), a CD68 promoter, or a JeT promoter (for example as described by Tornøe et al. (2002) Gene 297(1-2):21-32). In some embodiments, a promoter is operably-linked to a nucleic acid sequence encoding a first gene product, a second gene product, or a first gene product and a second gene product. In some embodiments, an expression cassette comprises one or more additional regulatory sequences, including but not limited to transcription factor binding sequences, intron splice sites, poly(A) addition sites, enhancer sequences, repressor binding sites, or any combination of the foregoing.
In some embodiments, a nucleic acid sequence encoding a first gene product and a nucleic acid sequence encoding a second gene product are separated by a nucleic acid sequence encoding an internal ribosomal entry site (IRES). Examples of IRES sites are described, for example, by Mokrejs et al. (2006) Nucleic Acids Res. 34(Database issue):D125-30. In some embodiments, a nucleic acid sequence encoding a first gene product and a nucleic acid sequence encoding a second gene product are separated by a nucleic acid sequence encoding a self-cleaving peptide. Examples of self-cleaving peptides include but are not limited to T2A, P2A, E2A, F2A, BmCPV 2A, and BmIFV 2A, and those described by Liu et al. (2017) Sci Rep. 7: 2193. In some embodiments, the self-cleaving peptide is a T2A peptide.
Pathologically, disorders such as PD and Gaucher disease are associated with accumulation of protein aggregates composed largely of α-Synuclein (α-Syn) protein. Accordingly, in some embodiments, isolated nucleic acids described herein comprise an inhibitory nucleic acid that reduces or prevents expression of α-Syn protein. A sequence encoding an inhibitory nucleic acid may be placed in an untranslated region (e.g., intron, 5′UTR, 3′UTR, etc.) of the expression vector.
In some embodiments, an inhibitory nucleic acid is positioned in an intron of an expression construct, for example in an intron upstream of the sequence encoding a first gene product. An inhibitory nucleic acid can be a double stranded RNA (dsRNA), siRNA, shRNA, micro RNA (miRNA), artificial miRNA (amiRNA), or an RNA aptamer. Generally, an inhibitory nucleic acid binds to (e.g., hybridizes with) between about 6 and about 30 (e.g., any integer between 6 and 30, inclusive) contiguous nucleotides of a target RNA (e.g., mRNA). In some embodiments, the inhibitory nucleic acid molecule is an miRNA or an amiRNA, for example an miRNA that targets SNCA (the gene encoding α-Syn protein). In some embodiments, the miRNA does not comprise any mismatches with the region of SNCA mRNA to which it hybridizes (e.g., the miRNA is “perfected”). In some embodiments, the inhibitory nucleic acid is an shRNA (e.g., an shRNA targeting SNCA). In some embodiments, an shRNA that targets SNCA is encoded by SEQ ID NO: 47. In some embodiments, an shRNA that targets SNCA is encoded by a sequence comprising SEQ ID NO: 20.
The skilled artisan recognizes that when referring to nucleic acid sequences comprising or encoding inhibitory nucleic acids (e.g., dsRNA, siRNA, shRNA, miRNA, amiRNA, etc.) any one or more thymidine (T) nucleotides or uridine (U) nucleotides in a sequence provided herein may be replaced with any other nucleotide suitable for base pairing (e.g., via a Watson-Crick base pair) with an adenosine nucleotide. For example, T may be replaced with U, and U may be replaced with T.
An isolated nucleic acid as described herein may exist on its own, or as part of a vector. Generally, a vector can be a plasmid, cosmid, phagemid, bacterial artificial chromosome (BAC), or a viral vector (e.g., adenoviral vector, adeno-associated virus (AAV) vector, retroviral vector, baculoviral vector, etc.). In some embodiments, the vector is a plasmid (e.g., a plasmid comprising an isolated nucleic acid as described herein). In some embodiments, the vector is a recombinant AAV (rAAV) vector. In some embodiments, an rAAV vector is single-stranded (e.g., single-stranded DNA). In some embodiments, a vector is a Baculovirus vector (e.g., an Autographa californica nuclear polyhedrosis (AcNPV) vector).
Typically an rAAV vector (e.g., rAAV genome) comprises a transgene (e.g., an expression construct comprising one or more of each of the following: promoter, intron, enhancer sequence, protein coding sequence, inhibitory RNA coding sequence, polyA tail sequence, etc.) flanked by two AAV inverted terminal repeat (ITR) sequences. In some embodiments the transgene of an rAAV vector comprises an isolated nucleic acid as described by the disclosure. In some embodiments, each of the two ITR sequences of an rAAV vector is a full-length ITR (e.g., approximately 145 bp in length, and containing functional Rep binding site (RBS) and terminal resolution site (trs)). In some embodiments, one of the ITRs of an rAAV vector is truncated (e.g., shortened or not full-length). In some embodiments, a truncated ITR lacks a functional terminal resolution site (trs) and is used for production of self-complementary AAV vectors (scAAV vectors). In some embodiments, a truncated ITR is a ΔITR, for example as described by McCarty et al. (2003) Gene Ther. 10(26):2112-8. In some embodiments, each of the two ITR sequences is an AAV2 ITR sequence.
Aspects of the disclosure relate to isolated nucleic acids (e.g., rAAV vectors) comprising an ITR having one or more modifications (e.g., nucleic acid additions, deletions, substitutions, etc.) relative to a wild-type AAV ITR, for example relative to wild-type AAV2 ITR (e.g., SEQ ID NO: 29). The structure of wild-type AAV2 ITR is shown in
The disclosure is based, in part, on the surprising discovery that rAAV vectors comprising a “D” region located on the “outside” of the ITR (e.g., proximal to the terminus of the ITR relative to the transgene insert or expression construct) are efficiently encapsidated by AAV capsid proteins than rAAV vectors having ITRs with unmodified (e.g., wild-type) ITRs. In some embodiments, rAAV vectors having a modified “D” sequence (e.g., a “D” sequence in the “outside” position) have reduced toxicity relative to rAAV vectors having wild-type ITR sequences.
In some embodiments, a modified “D” sequence comprises at least one nucleotide substitution relative to a wild-type “D” sequence (e.g., SEQ ID NO: 27). A modified “D” sequence may have at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more than 10 nucleotide substitutions relative to a wild-type “D” sequence (e.g., SEQ ID NO: 27). In some embodiments, a modified “D” sequence comprises at least 10, 11, 12, 13, 14, 15, 16, 17, 18, or 19 nucleic acid substitutions relative to a wild-type “D” sequence (e.g., SEQ ID NO: 27). In some embodiments, a modified “D” sequence is between about 10% and about 99% (e.g., 10%, 15%, 20%, 25%, 30%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 99%) identical to a wild-type “D” sequence (e.g., SEQ ID NO: 27). In some embodiments, a modified “D” sequence comprises the sequence set forth in SEQ ID NO: 26, also referred to as an “S” sequence as described in Wang et al. (1995) J Mol Biol 250(5):573-80.
An isolated nucleic acid or rAAV vector as described by the disclosure may further comprise a “TRY” sequence, for example as set forth in SEQ ID NO: 28 or as described in Francois et al., (2005) J. Virol. 79(17):11082-11094. In some embodiments, a TRY sequence is positioned between an ITR (e.g., a 5′ ITR) and an expression construct (e.g., a transgene-encoding insert) of an isolated nucleic acid or rAAV vector.
In some aspects, the disclosure relates to Baculovirus vectors comprising an isolated nucleic acid or rAAV vector as described by the disclosure. In some embodiments, the Baculovirus vector is an Autographa californica nuclear polyhedrosis (AcNPV) vector, for example as described by Urabe et al. (2002) Hum Gene Ther 13(16):1935-43 and Smith et al. (2009) Mol Ther 17(11):1888-1896.
In some aspects, the disclosure provides a host cell comprising an isolated nucleic acid or vector as described herein. A host cell can be a prokaryotic cell or a eukaryotic cell. For example, a host cell can be a mammalian cell, bacterial cell, yeast cell, insect cell, etc. In some embodiments, a host cell is a mammalian cell, for example a HEK293T cell. In some embodiments, a host cell is a bacterial cell, for example an E. coli cell.
rAAVs
In some aspects, the disclosure relates to recombinant AAVs (rAAVs) comprising a transgene that encodes a nucleic acid as described herein (e.g., an rAAV vector as described herein). The term “rAAVs” generally refers to viral particles comprising an rAAV vector encapsidated by one or more AAV capsid proteins. An rAAV described by the disclosure may comprise a capsid protein having a serotype selected from AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, and AAV10. In some embodiments, an rAAV comprises a capsid protein from a non-human host, for example a rhesus AAV capsid protein such as AAVrh.10, AAVrh.39, etc. In some embodiments, an rAAV described by the disclosure comprises a capsid protein that is a variant of a wild-type capsid protein, such as a capsid protein variant that includes at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more than 10 (e.g., 15, 20, 25, 50, 100, etc.) amino acid substitutions (e.g., mutations) relative to the wild-type AAV capsid protein from which it is derived. In some embodiments, an AAV capsid protein variant is an AAV1RX capsid protein, for example as described by Albright et al. Mol Ther. 2018 Feb. 7; 26(2):510-523. In some embodiments, a capsid protein variant is an AAV TM6 capsid protein, for example as described by Rosario et al. Mol Ther Methods Clin Dev. 2016; 3: 16026.
In some embodiments, rAAVs described by the disclosure readily spread through the CNS, particularly when introduced into the CSF space or directly into the brain parenchyma. Accordingly, in some embodiments, rAAVs described by the disclosure comprise a capsid protein that is capable of crossing the blood-brain barrier (BBB). For example, in some embodiments, an rAAV comprises a capsid protein having an AAV9 or AAVrh.10 serotype. Production of rAAVs is described, for example, by Samulski et al. (1989) J Virol. 63(9):3822-8 and Wright (2009) Hum Gene Ther. 20(7): 698-706. In some embodiments, an rAAV comprises a capsid protein that specifically or preferentially targets myeloid cells, for example microglial cells.
In some embodiments, the disclosure provides an rAAV referred to as “PR001”. This rAAV expresses the codon-optimized coding sequence of human GBA1 (SEQ ID NO:15). In some embodiments, the disclosure provides an rAAV referred to as “PR001A”. PR001A (AAV9.CBA.GBA1.A) is a rAAV that delivers a functional human GBA1 gene, leading to increased expression of functional human Gcase. The PR001A vector insert comprises the chicken β-actin (CBA) promoter element, comprising 4 parts: the cytomegalovirus (CMV) enhancer, CBA promoter, exon 1, and intron (int) to constitutively express the codon-optimized coding sequence of human GBA1 (SEQ ID NO:15). The 3′ region also contains a woodchuck hepatitis virus post-transcriptional regulatory element (WPRE) followed by a bovine growth hormone polyadenylation signal tail. Three well described transcriptional regulatory activation sites are included at the 5′ end of the promoter region: TATA, RBS, and YY1 (see, e.g., Francois et al., (2005) J. Virol. 79(17):11082-11094). The flanking inverted terminal repeats (ITRs) allow for the correct packaging of the intervening sequences. Two variants of the 5′ ITR sequence (
In some embodiments, the disclosure provides an rAAV referred to as “PR004”. This rAAV expresses the codon-optimized coding sequence of human GBA1 (SEQ ID NO:15) and an inhibitory nucleic acid coding sequence that targets reduces α-Synuclein and comprises the nucleotide sequence of SEQ ID NO: 20. In some embodiments, the disclosure provides an rAAV referred to as “PR004X”. In some embodiments, the disclosure provides an rAAV referred to as “PR004Y”. Each of PR004X and PR004Y is a rAAV that (i) delivers a functional human GBA1 gene, leading to increased expression of functional human Gcase, and (ii) encodes a shRNA that reduces α-Synuclein levels via RNA interference. The PR004 vector insert comprises the chicken β-actin (CBA) promoter element, comprising 4 parts: the cytomegalovirus (CMV) enhancer, CBA promoter, exon 1, and intron (int) to constitutively express the codon-optimized coding sequence of human GBA1 (SEQ ID NO:15) and an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20. The 3′ region also contains a woodchuck hepatitis virus post-transcriptional regulatory element (WPRE) followed by a bovine growth hormone polyadenylation signal tail. Three well described transcriptional regulatory activation sites are included at the 5′ end of the promoter region: TATA, RBS, and YY1 (see, e.g., Francois et al., (2005) J. Virol. 79(17):11082-11094). The flanking inverted terminal repeats (ITRs) allow for the correct packaging of the intervening sequences. The backbone contains the gene to confer resistance to kanamycin as well as a stuffer sequence to prevent reverse packaging. A schematic depicting a plasmid encoding the rAAV PR004X vector is shown in
In some embodiments, the disclosure provides an rAAV referred to as “PR014”. This rAAV expresses an inhibitory nucleic acid coding sequence that targets reduces α-Synuclein and comprises the nucleotide sequence of SEQ ID NO: 20. In some embodiments, the disclosure provides an rAAV referred to as “PR014X”. PR014X is a rAAV that encodes a shRNA that reduces α-Synuclein levels via RNA interference. The PR014X vector insert comprises the chicken β-actin (CBA) promoter element, comprising 4 parts: the cytomegalovirus (CMV) enhancer, CBA promoter, exon 1, and intron (int) to constitutively express an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20. The 3′ region also contains a woodchuck hepatitis virus post-transcriptional regulatory element (WPRE) followed by a bovine growth hormone polyadenylation signal tail. Three well described transcriptional regulatory activation sites are included at the 5′ end of the promoter region: TATA, RBS, and YY1 (see, e.g., Francois et al., (2005) J. Virol. 79(17):11082-11094). The flanking inverted terminal repeats (ITRs) allow for the correct packaging of the intervening sequences. The backbone contains the gene to confer resistance to kanamycin as well as a stuffer sequence to prevent reverse packaging. A schematic depicting a plasmid encoding the rAAV vector is shown in
In some embodiments, an rAAV as described by the disclosure (e.g., comprising a recombinant rAAV genome encapsidated by AAV capsid proteins to form an rAAV capsid particle) is produced in a Baculovirus vector expression system (BEVS). Production of rAAVs using BEVS are described, for example by Urabe et al. (2002) Hum Gene Ther 13(16):1935-43, Smith et al. (2009) Mol Ther 17(11):1888-1896, U.S. Pat. Nos. 8,945,918, 9,879,282, and International PCT Publication WO 2017/184879. However, an rAAV can be produced using any suitable method (e.g., using recombinant rep and cap genes). In some embodiments, an rAAV as disclosed herein is produced in HEK293 (human embryonic kidney) cells.
In some aspects, the disclosure provides pharmaceutical compositions comprising an isolated nucleic acid or rAAV as described herein and a pharmaceutically acceptable carrier. As used herein, the term “pharmaceutically acceptable” refers to a material, such as a carrier or diluent, which does not abrogate the biological activity or properties of the compound, and is relatively non-toxic, e.g., the material may be administered to an individual without causing undesirable biological effects or interacting in a deleterious manner with any of the components of the composition in which it is contained.
As used herein, the term “pharmaceutically acceptable carrier” means a pharmaceutically acceptable material, composition or carrier, such as a liquid or solid filler, stabilizer, dispersing agent, suspending agent, diluent, excipient, thickening agent, solvent or encapsulating material, involved in carrying or transporting a compound useful within the invention within or to the patient such that it may perform its intended function. Additional ingredients that may be included in the pharmaceutical compositions used in the practice of the invention are known in the art and described, for example in Remington's Pharmaceutical Sciences (Genaro, Ed., Mack Publishing Co., 1985, Easton, PA), which is incorporated herein by reference.
Compositions (e.g., pharmaceutical compositions) provided herein can be administered by any route, including enteral (e.g., oral), parenteral, intravenous, intramuscular, intra-arterial, intramedullary, intrathecal, subcutaneous, intraventricular, transdermal, interdermal, rectal, intravaginal, intraperitoneal, topical (as by powders, ointments, creams, and/or drops), mucosal, nasal, bucal, sublingual; by intratracheal instillation, bronchial instillation, and/or inhalation; and/or as an oral spray, nasal spray, and/or aerosol. Specifically contemplated routes are oral administration, intravenous administration (e.g., systemic intravenous injection), regional administration via blood and/or lymph supply, and/or direct administration to an affected site. In general, the most appropriate route of administration will depend upon a variety of factors including the nature of the agent (e.g., its stability in the environment of the gastrointestinal tract), and/or the condition of the subject (e.g., whether the subject is able to tolerate oral administration). In certain embodiments, the compound or pharmaceutical composition described herein is suitable for topical administration to the eye of a subject.
In some embodiments, the disclosure provides a PR001 (e.g., PR001A) finished drug product comprising the PR001 rAAV described above presented in aqueous solution. In some embodiments, the final formulation buffer comprises about 20 mM Tris [pH 8.0], about 1 mM MgCl2, about 200 mM NaCl, and about 0.001% [w/v] poloxamer 188. In some embodiments, the finished drug product and the final formulation buffer are suitable for intra-cisterna magna (ICM) injection or intravenous administration.
The disclosure encompasses a therapeutic combination of (A) a rAAV comprising: (a) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert encoding a Gcase protein, wherein the transgene insert comprises the nucleotide sequence of SEQ ID NO: 15; and (b) an AAV9 capsid protein; and (B) sirolimus, for use in a method of treating Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease or Parkinson's disease with a GBA1 mutation in a subject.
The disclosure encompasses a therapeutic combination of (A) a rAAV comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising: (a) a Gcase protein coding sequence comprising the nucleotide sequence of SEQ ID NO: 15; and (b) an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an AAV9 capsid protein; and (B) sirolimus, for use in a method of treating a synucleinopathy or parkinsonism in a subject.
The disclosure encompasses a therapeutic combination of: (A) a rAAV comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an AAV9 capsid protein; and (B) sirolimus, for use in a method of treating a synucleinopathy or parkinsonism in a subject.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert encoding a Gcase protein, wherein the transgene insert comprises the nucleotide sequence of SEQ ID NO: 15; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more immunosuppressants for use in a method of treating Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease or Parkinson's disease with a GBA1 mutation in a subject. Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert encoding a Gcase protein, wherein the transgene insert comprises the nucleotide sequence of SEQ ID NO: 15; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more of the following: (A) sirolimus; (B) methylprednisolone; (C) rituximab; and (D) prednisone for use in a method of treating Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease or Parkinson's disease with a GBA1 mutation in a subject.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert encoding a Gcase protein, wherein the transgene insert comprises the nucleotide sequence of SEQ ID NO: 15; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more of the following: (A) sirolimus; (B) methylprednisolone; (C) rituximab; and (D) prednisone for use in a method of suppressing an immune response in a subject having or suspected of having Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease or Parkinson's disease with a GBA1 mutation.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising: (a) a Gcase protein coding sequence comprising the nucleotide sequence of SEQ ID NO: 15; and (b) an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more immunosuppressants for use in a method of treating a synucleinopathy or parkinsonism in a subject. Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising: (a) a Gcase protein coding sequence comprising the nucleotide sequence of SEQ ID NO: 15; and (b) an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more of the following: (A) sirolimus; (B) methylprednisolone; (C) rituximab; and (D) prednisone for use in a method of treating a synucleinopathy or parkinsonism in a subject.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising: (a) a Gcase protein coding sequence comprising the nucleotide sequence of SEQ ID NO: 15; and (b) an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more of the following: (A) sirolimus; (B) methylprednisolone; (C) rituximab; and (D) prednisone for use in a method of suppressing an immune response in a subject having or suspected of having a synucleinopathy or parkinsonism.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more immunosuppressants for use in a method of treating a synucleinopathy or parkinsonism in a subject. Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more of the following: (A) sirolimus; (B) methylprednisolone; (C) rituximab; and (D) prednisone for use in a method of treating a synucleinopathy or parkinsonism in a subject.
Provided herein is a therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising: (i) a rAAV vector comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a transgene insert comprising an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20; and (ii) an adeno-associated virus (AAV) 9 capsid protein; and one or more of the following: (A) sirolimus; (B) methylprednisolone; (C) rituximab; and (D) prednisone for use in a method of suppressing an immune response in a subject having or suspected of having a synucleinopathy or parkinsonism.
In some embodiments, the therapeutic combination comprises from about 5×1013 vg to about 5×1014 vg of the rAAV. In some embodiments, the therapeutic combination comprises about 1.4×1014 vg or about 2.8×1014 vg of the rAAV.
In some embodiments, the therapeutic combination comprises an additional immunosuppressant that is not sirolimus, methylprednisolone, rituximab or prednisone.
Aspects of the disclosure relate to delivery of compositions (e.g., isolated nucleic acids, rAAVs, etc.) engineered to express CNS disease-associated gene products to a cell or cells (e.g., a cell or cells of a subject).
As described further in the Examples section, aspects of the disclosure relate to compositions expressing gene products that inhibit or prevent glial scarring (e.g., gliosis). Accordingly, in some aspects, the disclosure provides a method for inhibiting glial scarring in a subject, the method comprising administering to the subject a composition (e.g., an isolated nucleic acid or rAAV) as described herein.
In some embodiments, the subject has or is suspected of having a central nervous system (CNS) disease. In some embodiments, the subject has Gaucher disease (GD). In some embodiments, the subject has neuronopathic GD (nGD) (e.g., Type 2 GD or Type 3 GD). In some embodiments, the subject has Type 1 GD. In some embodiments, a subject having GD does not have PD or PD symptoms. In some embodiments, the subject has parkinsonism. In some embodiments, a subject has Parkinson's disease (PD). In some embodiments, the subject has an atypical Parkinsonian disorder. In some embodiments, an atypical Parkinsonian disorder is dementia with Lewy bodies, progressive supranuclear palsy, multiple system atrophy or corticobasal syndrome.
The disclosure is based, in part, on compositions for expression of one or more CNS disease-associated gene products in a subject to treat CNS-associated diseases. The one or more CNS disease-associated gene products may be encoded by one or more isolated nucleic acids or rAAV vectors. In some embodiments, a subject is administered a single vector (e.g., isolated nucleic acid, rAAV, etc.) encoding one or more (1, 2, 3, 4, 5, or more) gene products. In some embodiments, a subject is administered a plurality (e.g., 2, 3, 4, 5, or more) vectors (e.g., isolated nucleic acids, rAAVs, etc.), where each vector encodes a different CNS disease-associated gene product. In some embodiments, the composition expresses GBA or a portion thereof. In some embodiments, the composition expresses an interfering RNA that targets alpha-Synuclein. In some embodiments, the composition expresses GBA or a portion thereof and an interfering RNA that targets alpha-Synuclein.
A CNS-associated disease may be a neurodegenerative disease, synucleinopathy, tauopathy, or a lysosomal storage disease. Examples of neurodegenerative diseases and their associated genes are listed in Table 4.
A “synucleinopathy” refers to a disease or disorder characterized by the accumulation of alpha-Synuclein (the gene product of SNCA) in a subject (e.g., relative to a healthy subject, for example a subject not having a synucleinopathy). Examples of synucleinopathies and their associated genes are listed in Table 5.
A “tauopathy” refers to a disease or disorder characterized by accumulation of abnormal Tau protein in a subject (e.g., relative to a healthy subject not having a tauopathy). Examples of tauopathies and their associated genes are listed in Table 6.
A “lysosomal storage disease” refers to a disease characterized by abnormal build-up of toxic cellular products in lysosomes of a subject. Examples of lysosomal storage diseases and their associated genes are listed in Table 7.
As used herein “treat” or “treating” refers to (a) preventing or delaying onset of a CNS disease; (b) reducing severity of a CNS disease; (c) reducing or preventing development of symptoms characteristic of a CNS disease; (d) and/or preventing worsening of symptoms characteristic of a CNS disease. Symptoms of CNS disease may include, for example, motor dysfunction (e.g., shaking, rigidity, slowness of movement, difficulty with walking, paralysis), cognitive dysfunction (e.g., dementia, depression, anxiety, psychosis), difficulty with memory, and emotional and behavioral dysfunction.
The disclosure is based, in part, on compositions for expression of one or more PD-associated gene products in a subject that act together (e.g., synergistically) to treat Parkinson's disease.
Accordingly, in some aspects, the disclosure provides a method for treating a subject having or suspected of having Parkinson's disease, the method comprising administering to the subject a composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure.
The disclosure is based, in part, on compositions for expression of one or more CNS disease-associated gene products in a subject to treat Gaucher disease (GD). The diagnosis of GD is established by the presence of biallelic pathogenic mutations in GBA1 or a finding of less than 15% of normal GCase activity in peripheral blood leukocytes. GBA1 mutations causing more profound enzyme deficiencies are associated with earlier onset of disease, faster progression of symptoms, and a higher likelihood to develop neurological symptoms (Svennerholm et al., Clin Genet. 1986; 30(2):131-5; Cox, Biologics. 2010; 4:299-313). GD has traditionally been subdivided into three broader phenotypes distinguished by the presence of neurologic manifestations (neuronopathic [Type 2 GD and Type 3 GD; nGD] or non-neuronopathic [Type 1 GD]).
Within nGD, the distinctions between Type 2 GD and Type 3 GD may represent a phenotypic continuum of an acute to chronic presentation of CNS and visceral symptoms. Infants with Type 2 GD, known as the acute neuronopathic form, classically present with early bulbar signs (such as squint and/or swallowing difficulty), opisthotonus or spasticity, supranuclear gaze palsy, and failure to achieve motor, behavior, and cognitive milestones. Most children die by age 2. (Goker-Alpan et al., J Pediatr. 2003; 143(2):273-6; Roshan and Sidransky, Diseases. 2017; 5(1):pii:E10). In Type 3 GD, the hallmark clinical sign is a slow horizontal supranuclear gaze palsy, with other neurologic manifestations ranging from cognitive impairment to ataxia to seizures to death in childhood or early adolescence (Goker-Alpan et al., J Pediatr. 2003; 143(2):273-6; Tylki-Szymańska et al., J Inherit Metab Dis. 2010; 33(4):339-46).
Accordingly, in some aspects, the disclosure provides a method for treating a subject having or suspected of having neuronopathic Gaucher disease, the method comprising administering to the subject a composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure.
In some aspects, the disclosure provides a method for treating a subject having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype. In some embodiments, the disclosure provides a method for treating a neurological symptom of a subject having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype. In some embodiments, a neurological symptom of Type 2 Gaucher disease or Type 3 Gaucher disease is supranuclear gaze palsy, hypotonia, seizures, spasticity, hypokinesia, motor or behavioral developmental delay or impairment, cognitive delay or impairment, ataxia, intention tremor, or rigidity.
In some embodiments, patients having certain forms of Gaucher disease exhibit symptoms of peripheral neuropathy, for example as described in Biegstraaten et al. (2010) Brain 133(10):2909-2919. In some embodiments, the disclosure provides a method for treating peripheral neuropathy in a subject having Gaucher disease (e.g., Type 1 Gaucher disease), the method comprising administering to the subject: (A) a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype; and (B) sirolimus. In some embodiments, the disclosure provides a method for treating Type 1 Gaucher disease in a subject, the method comprising administering to the subject: (A) a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype; and (B) sirolimus. In some embodiments, the rAAV is administered to the subject intravenously for treating Type 1 Gaucher disease.
In some embodiments, the disclosure provides a method for treating a subject having Parkinson's disease (PD) with a glucocerebrosidase-1 (GBA1) mutation (e.g., a pathogenic GBA1 mutation), the method comprising administering to the subject a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype. In some embodiments, the disclosure provides a method for treating a symptom of a subject having PD with a GBA1 mutation, the method comprising administering to the subject a rAAV comprising a nucleic acid comprising an expression construct comprising a promoter operably linked to a sequence encoding a Gcase protein, wherein the sequence encoding a Gcase protein comprises SEQ ID NO:15; and wherein the rAAV comprises a capsid protein having an AAV9 serotype. In some embodiments, a motor symptom of PD is resting tremor, bradykinesia, rigidity, or gait difficulty. In some embodiments, a non-motor symptom of PD is cognitive impairment/dementia, depression, delusions/hallucinations, psychosis, sleep disturbances, constipation, urinary symptoms, pain, anosmia, difficulty swallowing, or hypotension. In some embodiments, the subject having PD has one GBA1 mutation. In some embodiments, the subject having PD has two GBA1 mutations.
In some embodiments, a rAAV encoding a Gcase protein for treating Type 1 Gaucher disease, Type 2 Gaucher disease or Type 3 Gaucher disease or Parkinson's disease with a GBA1 mutation is administered to a subject at a dose ranging from about 1×1012 vector genomes (vg) to about 1×1015 vg, or from about 1×1013 vg to about 5×1014 vg, or from about 5×1013 vg to about 5×1014 vg, or from about 3.4×1013 vg to about 1×1014 vg, or from about 1×1014 vg to about 5×1014 vg, or from about 1×1014 vg to about 3×1014 vg, or from about 1×1014 vg to about 2×1014 vg. The total dose assumes an adult brain mass of 1.3 kg (Hakim and Mathieson, Neurology, 1979; 29(9 Pt 1):1209-14). For pediatric subjects, the dose may be scaled accordingly. In some embodiments, the dose for pediatric subjects may be adjusted using estimates of brain weight by age, for example, based on a composite dataset that includes derived brain weights from 21 autopsy and neuroimaging publications (Vannucci and Vannucci, Am J Phys Anthropol. 2019; 168(2):247-61).
In some embodiments, a rAAV encoding a Gcase protein for treating Parkinson's disease with a GBA1 mutation is administered to a subject (e.g., a human adult subject) at a dose of about 1×1014 vg, about 2×1014 vg, about 3×1014 vg, about 4×1014 vg, or about 5×1014 vg. In some embodiments, a rAAV for treating Parkinson's disease with a GBA1 mutation is administered to a subject (e.g., a human adult subject) at a dose of about 1×1014 vg (about 7.7×1010 vg/g brain), about 2×1014 vg (about 1.5×1011 vg/g brain), or about 3×1014 vg (about 1.9×1011 vg/g brain). In some embodiments, a rAAV for treating Parkinson's disease with a GBA1 mutation is administered to a subject (e.g., a human adult subject) at a dose of about 1.4×1014 vg or about 2.8×1014 vg.
In some embodiments, a rAAV encoding a Gcase protein for treating Type 2 or Type 3 Gaucher disease is administered to a subject (e.g., a human pediatric subject) at a dose ranging from about 5×1010 vg/g brain to about 5×1011 vg/g brain. In some embodiments, a rAAV for treating Type 2 Gaucher disease or Type 3 Gaucher disease is administered to a subject (e.g., a human pediatric subject) at a dose of about 1.3×1011 vg/g brain (from about 5.9×1013 vg to about 1.7×1014 vg). In some embodiments, a rAAV for treating Type 2 Gaucher disease or Type 3 Gaucher disease is administered to a subject (e.g., a human pediatric subject) at a dose of about 1.9×1011 vg/g brain (from about 8.6×1013 vg to about 2.5×1014 vg). In some embodiments, a rAAV for treating Type 2 Gaucher disease or Type 3 Gaucher disease is administered to a subject (e.g., a human pediatric subject) at a dose of about 7.7×1010 vg/g brain (from about 3.4×1013 vg to about 1×1014 vg) or a dose of about 2.3×1011 vg/g brain (from about 1×1014 vg to about 3×1014 vg).
In some embodiments, a rAAV encoding a Gcase protein for treating Type 1, Type 2 or Type 3 Gaucher disease or Parkinson's disease with a GBA1 mutation is administered to a subject as a single dose, and the rAAV is not administered to the subject subsequently.
In some embodiments, a rAAV encoding a Gcase protein is administered via a single suboccipital injection into the cisterna magna. In some embodiments, the injection into the cisterna magna is performed under radiographic guidance.
In some embodiments, the disclosure provides a method for treating a subject having a synucleinopathy or parkinsonism, the method comprising administering to the subject: (A) a rAAV comprising a nucleic acid comprising an expression construct comprising a transgene comprising (a) a Gcase protein coding sequence comprising the nucleotide sequence of SEQ ID NO: 15; and (b) an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20 or SEQ ID NO: 47; wherein the rAAV comprises a capsid protein having an AAV9 serotype; and (B) sirolimus.
In some embodiments, the disclosure provides a method for treating a subject having multiple system atrophy, Parkinson's disease, Parkinson's disease with GBA1 mutation, Lewy body disease, dementia with Lewy bodies, dementia with Lewy bodies with GBA1 mutation, progressive supranuclear palsy, or corticobasal syndrome, the method comprising administering to the subject: (A) a rAAV comprising a nucleic acid comprising an expression construct comprising a transgene comprising (a) a Gcase protein coding sequence comprising the nucleotide sequence of SEQ ID NO: 15; and (b) an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20 or SEQ ID NO: 47; wherein the rAAV comprises a capsid protein having an AAV9 serotype; and (B) sirolimus.
In some embodiments, the disclosure provides a method for treating a subject having a synucleinopathy or parkinsonism, the method comprising administering to the subject: (A) a rAAV comprising a nucleic acid comprising an expression construct comprising a transgene comprising an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20 or SEQ ID NO: 47; wherein the rAAV comprises a capsid protein having an AAV9 serotype; and (B) sirolimus.
In some embodiments, the disclosure provides a method for treating a subject having multiple system atrophy, Parkinson's disease, Parkinson's disease with GBA1 mutation, Lewy body disease, dementia with Lewy bodies, dementia with Lewy bodies with GBA1 mutation, progressive supranuclear palsy, or corticobasal syndrome, the method comprising administering to the subject: (A) a rAAV comprising a nucleic acid comprising an expression construct comprising a transgene comprising an inhibitory nucleic acid coding sequence comprising the nucleotide sequence of SEQ ID NO: 20 or SEQ ID NO: 47; wherein the rAAV comprises a capsid protein having an AAV9 serotype; and (B) sirolimus.
A subject is typically a mammal, preferably a human. In some embodiments, a subject is between the ages of 1 month old and 10 years old (e.g., 1 month, 2 months, 3 months, 4, months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, 24 months, 3, years, 4 years, 5 years, 6 years, 7 years, 8 years, 9 years, 10 years, or any age therebetween). In some embodiments, a subject is between 2 years old and 20 years old. In some embodiments, a subject is between 30 years old and 100 years old. In some embodiments, a subject is older than 55 years old.
In some embodiments, a composition is administered directly to the CNS of the subject, for example by direct injection into the brain and/or spinal cord of the subject. Examples of CNS-direct administration modalities include but are not limited to intracerebral injection, intraventricular injection, intracisternal injection, intraparenchymal injection, intrathecal injection, and any combination of the foregoing. In some embodiments, a composition is administered to a subject by intra-cisterna magna (ICM) injection. In some embodiments, direct injection into the CNS of a subject results in transgene expression (e.g., expression of the first gene product, second gene product, and if applicable, third gene product) in the midbrain, striatum and/or cerebral cortex of the subject. In some embodiments, direct injection into the CNS results in transgene expression (e.g., expression of the first gene product, second gene product, and if applicable, third gene product) in the spinal cord and/or CSF of the subject.
In some embodiments, direct injection to the CNS of a subject comprises convection enhanced delivery (CED). Convection enhanced delivery is a therapeutic strategy that involves surgical exposure of the brain and placement of a small-diameter catheter directly into a target area of the brain, followed by infusion of a therapeutic agent (e.g., a composition or rAAV as described herein) directly to the brain of the subject. CED is described, for example by Debinski et al. (2009) Expert Rev Neurother. 9(10): 1519-27.
In some embodiments, a composition is administered peripherally to a subject, for example by peripheral injection. Examples of peripheral injection include subcutaneous injection, intravenous injection, intra-arterial injection, intraperitoneal injection, or any combination of the foregoing. In some embodiments, the peripheral injection is intra-arterial injection, for example injection into the carotid artery of a subject.
In some embodiments, a composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure is administered both peripherally and directly to the CNS of a subject. For example, in some embodiments, a subject is administered a composition by intra-arterial injection (e.g., injection into the carotid artery) and by intraparenchymal injection (e.g., intraparenchymal injection by CED). In some embodiments, the direct injection to the CNS and the peripheral injection are simultaneous (e.g., happen at the same time). In some embodiments, the direct injection occurs prior (e.g., between 1 minute and 1 week, or more before) to the peripheral injection. In some embodiments, the direct injection occurs after (e.g., between 1 minute and 1 week, or more after) the peripheral injection.
In some embodiments, a subject is administered an immunosuppressant prior to (e.g., between 1 month and 1 minute prior to) or at the same time as a composition as described herein. In some embodiments, the immunosuppressant is a corticosteroid (e.g., prednisone, budesonide, etc.), an mTOR inhibitor (e.g., sirolimus, everolimus, etc.), an antibody (e.g., adalimumab, etanercept, natalizumab, etc.), or methotrexate.
In some embodiments, a subject is administered a sirolimus oral loading dose of about 6 mg on Day −1 (window Day −3 to Day −1) (where day 0 is the administration of the rAAV). For example, a sirolimus dose may be administered at Day −3, Day −2, or Day −1. In some embodiments a pediatric subject (e.g., a human subject aged 0 months to 24 months) is administered a sirolimus oral loading dose of about 1.0 mg/m2 in the morning and evening (i.e., 2 doses) on Day −1 (window Day −2 to Day −1) (where day 0 is the administration of the rAAV). For example, two sirolimus doses of about 1.0 mg/m2 each may be administered to a pediatric subject at either Day −2 or Day −1. In some embodiments, a subsequent sirolimus maintenance dose of about 2 mg is administered and adjusted, as needed, to maintain serum trough levels of about 4 ng/mL (range from about 2 ng/mL to about 8 ng/mL) through Month 3. In some embodiments, for a pediatric subject, a subsequent sirolimus maintenance dose of from about 0.6 mg/m2/day to about 1.0 mg/m2/day is administered and adjusted, as needed, to maintain serum trough levels of about 4 ng/mL (range from about 2 ng/mL to about 8 ng/mL) through Month 3. In some embodiments, a subsequent sirolimus maintenance dose of 2 mg is administered and adjusted, as needed, to maintain serum trough levels of from about 4 ng/ml to about 9 ng/mL through Month 3. In some embodiments, sirolimus is tapered during the subsequent 15 days to 30 days (after the conclusion of Month 3). In some embodiments, trough levels are collected prior to administration of the sirolimus dose.
In some embodiments, a subject is administered a methylprednisolone intravenous loading dose of about 1 g on Day 0 (window Day −1 to Day 0) followed by administration of about 30 mg prednisone orally for 14 days starting the day after the rAAV administration. In some embodiments a pediatric subject (e.g., a human subject aged 0 months to 24 months) is administered a methylprednisolone intravenous loading dose of about 10 mg/kg on Day 0 prior to the administration of the rAAV, followed by administration of about 0.5 mg/kg prednisone or prednisolone orally for 14 days starting the day the administration of the rAAV. In some embodiments, prednisone or prednisolone is tapered during the subsequent 7 days to 8 days. In some embodiments, prednisone or prednisolone is administered orally at a dose of 0.5 mg/kg daily as concomitant medication from Day 1 for 14 days, then 0.25 mg/kg daily for 4 days, followed by a slow taper from 0.1 mg/kg to 0 mg/kg daily over 4 days. In some embodiments, the methylprednisolone and prednisone or prednisolone administration is combined with the sirolimus administration described above. In some embodiments, higher doses or a longer taper of prednisone or prednisolone may be used (e.g., in cases of elevated AST/ALT).
Further provided herein is a method for treating a subject having Parkinson's disease with a GBA1 mutation, the method comprising administering to the subject: (A) a rAAV comprising: (i) a rAAV vector comprising a nucleic acid comprising, in 5′ to 3′ order: (a) an AAV2 ITR; (b) a CMV enhancer; (c) a CBA promoter; (d) a transgene insert encoding a Gcase protein, wherein the transgene insert comprises the nucleotide sequence of SEQ ID NO: 15; (e) a WPRE; (f) a Bovine Growth Hormone polyA signal tail; and (g) an AAV2 ITR; and (ii) an AAV9 capsid protein; and (B) sirolimus; wherein the sirolimus is administered orally (A) at a dose of about 6 mg in the range of 1 day to 3 days before administration of the rAAV; and (B) at a dose of about 2 mg to maintain serum trough levels of from about 2 ng/mL to about 8 ng/mL for about 3 months after administration of the rAAV; and wherein the sirolimus administration is tapered during the 15 days to 30 days following the end of the 3-month period after administration of the rAAV.
Further provided herein is a method for treating a subject (e.g., a pediatric subject) having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject: (A) a rAAV comprising: (i) a rAAV vector comprising a nucleic acid comprising, in 5′ to 3′ order: (a) an AAV2 ITR; (b) a CMV enhancer; (c) a CBA promoter; (d) a transgene insert encoding a Gcase protein, wherein the transgene insert comprises the nucleotide sequence of SEQ ID NO: 15; (e) a WPRE; (f) a Bovine Growth Hormone polyA signal tail; and (g) an AAV2 ITR; and (ii) an AAV9 capsid protein; and (B) sirolimus; wherein the sirolimus is administered orally (A) at two doses of about 1.0 mg/m2 each, wherein the two doses are administered 1 day or 2 days before administration of the rAAV, wherein the first dose is administered in the morning and the second dose is administered in the evening of the day on which the two doses are administered; and (B) at a dose of from about 0.6 mg/m2/day to about 1.0 mg/m2/day to maintain serum trough levels of from about 2 ng/mL to about 8 ng/mL for about 3 months after administration of the rAAV; and wherein the sirolimus administration is tapered during the 15 days to 30 days following the end of the 3-month period after administration of the rAAV.
The disclosure provides a method for treating a subject having or suspected of having Parkinson's disease with GBA1 mutation, Type 1 Gaucher disease, Type 2 Gaucher disease or Type 3 Gaucher disease, that combines (1) administration of a rAAV delivering a functional copy of the GBA1 gene encoding wild type Gcase with (2) administration of an immunosuppressant regimen.
The disclosure also provides a method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, that combines (1) administration of a rAAV delivering a functional copy of the GBA1 gene encoding wild type Gcase and an inhibitory nucleic acid coding sequence targeting α-Synuclein with (2) administration of an immunosuppressant regimen.
The disclosure also provides a method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, that combines (1) administration of a rAAV delivering an inhibitory nucleic acid coding sequence targeting α-Synuclein with (2) administration of an immunosuppressant regimen.
In some embodiments, the immunosuppressant regimen comprises administration of one or more of the following: sirolimus; methylprednisolone; an anti-CD20 antibody; and prednisone. In some embodiments, the immunosuppressant regimen comprises administration of all of the following: sirolimus; methylprednisolone; an anti-CD20 antibody; and prednisone. In some embodiments, the immunosuppressant regimen consists of administration of all of the following: sirolimus; methylprednisolone; an anti-CD20 antibody; and prednisone. In some embodiments, an anti-CD20 antibody is rituximab.
In some embodiments, the immunosuppressant regimen suppresses AAV-related and/or transgene protein expression-related immune responses in a subject. In some embodiments, the immunosuppressant regimen reduces an AAV9 capsid immune response in a subject. In some embodiments, the immunosuppressant regimen reduces a CSF inflammatory response in a subject.
Provided herein is a method for treating a subject having or suspected of having Parkinson's disease with a glucocerebrosidase-1 (GBA1) mutation, the method comprising administering to the subject:
Also provided herein is a method for treating a subject having or suspected of having Parkinson's disease with a GBA1 mutation, the method comprising administering to the subject:
Provided herein is a method for treating a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
Further provided herein is a method for treating a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
Further provided herein is a method for treating a subject having or suspected of having Type 1 Gaucher disease, the method comprising administering to the subject:
Provided herein is a method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
Provided herein is a method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
In methods disclosed herein for suppressing an immune response in a subject, the immunosuppression is produced by the immunosuppressants (e.g., sirolimus, methylprednisolone, an anti-CD20 antibody and prednisone) and not by the gene therapy (e.g., rAAV).
In some embodiments, the methylprednisolone is administered intravenously at a dose of about 1000 mg one day before administration of the rAAV. In some embodiments, the methylprednisolone is administered intravenously at a dose of about 1000 mg on the same day as administration of the rAAV.
In some embodiments, the prednisone is administered orally (A) at a dose of about 30 mg per day for 14 days beginning on the day after the administration of about 1000 mg of the methylprednisolone; and (B) tapered during the 7 days following the end of the 14-day period of (A). In some embodiments, a longer prednisone taper is used over an additional 4 weeks in a subject presenting with ALT and/or AST>3×upper limit of normal (ULN) at the end of the initial 14-day taper.
In some embodiments, an anti-CD20 antibody (e.g., rituximab) is administered intravenously at a dose of about 1000 mg on any single day between 14 days before and 1 day before administration of the rAAV.
In some embodiments, the methylprednisolone is administered before the anti-CD20 antibody (e.g., rituximab) is administered. In some embodiments, the methylprednisolone is administered at least about 30 minutes before the anti-CD20 antibody (e.g., rituximab) is administered. In some embodiments, the methylprednisolone and the anti-CD20 antibody (e.g., rituximab) are both administered the day before administration of the rAAV; and the methylprednisolone is administered at least about 30 minutes before the anti-CD20 antibody (e.g., rituximab) is administered. In some embodiments, the anti-CD20 antibody (e.g., rituximab) is administered on any single day between 14 days before and 2 days before administration of the rAAV; and the methylprednisolone is administered intravenously at a dose of about 100 mg at least about 30 minutes before the anti-CD20 antibody (e.g., rituximab) is administered on the same day as the anti-CD20 antibody (e.g., rituximab) is administered.
In some embodiments, the sirolimus is administered orally (A) as a single dose of about 6 mg three days, two days or one day before administration of the rAAV; and (B) at a dose of about 2 mg per day to maintain serum trough levels of from about 4 ng/ml to about 9 ng/mL for about 90 days after administration of the rAAV; wherein the first dose of about 2 mg per day of the sirolimus is administered the day after the single dose of about 6 mg of the sirolimus. In some embodiments, the sirolimus administration is tapered during the 15 days to 30 days following the end of the 90-day period after administration of the rAAV.
Provided herein is a method for treating a subject having or suspected of having Parkinson's disease with GBA1 mutation, Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease, a synucleinopathy or parkinsonism, the method comprising:
Provided herein is a method for treating a subject having or suspected of having Parkinson's disease with GBA1 mutation, Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease, a synucleinopathy or parkinsonism, the method comprising:
Provided herein is a method for suppressing an immune response in a subject having or suspected of having Parkinson's disease with GBA1 mutation, Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease, a synucleinopathy or parkinsonism, the method comprising:
Provided herein is a method for suppressing an immune response in a subject having or suspected of having Parkinson's disease with GBA1 mutation, Type 1 Gaucher disease, Type 2 Gaucher disease, Type 3 Gaucher disease, a synucleinopathy or parkinsonism, the method comprising:
In some embodiments, the subject's immune response is an immune response to the rAAV. In some embodiments, the immune response is a T cell response. In some embodiments, the immune response is a B cell response. In some embodiments, the immune response is an antibody response. In some embodiments, the immune response is pleocytosis. In some embodiments, the pleocytosis is cerebrospinal fluid (CSF) pleocytosis. In some embodiments, the immune response is an abnormal level of CSF protein. In some embodiments, an abnormal level of CSF protein is greater than 70 mg/dL.
In some embodiments, prophylactic IV corticosteroid treatment (which targets both T-cells and B-cells) begins the day before treatment with the rAAV, and oral treatment continues for 14 days, followed by a taper over 7 days. Sirolimus treatment, which primarily targets T-cells, begins the day before treatment with the rAAV and will continue for 90 days followed by a taper. Rituximab, which primarily targets B-cells, is dosed once, preferably the day before treatment with the rAAV, and its activity is expected to persist for 6 months.
In some embodiments, a subject receives an immunosuppression regimen consisting of corticosteroids, rituximab, and sirolimus. A subject receives a loading dose of methylprednisolone 1000 mg IV pulse on Day −1 (allowed at Day −1 or Day 0). Prednisone at a dose of 30 mg/day is given orally as concomitant medication from the day after 1000 mg IV methylprednisolone pulse (Day 0 or Day 1) for 14 days and is then tapered over the ensuing 7 days. A subject receives a 1-time dose of 1000 mg rituximab IV on any single day between Day −14 and Day −1. In order to mitigate the risk and severity of infusion-related reaction (IRR) associated with rituximab, a subject receives IV methylprednisolone before receiving IV rituximab. For rituximab dose administration on Day −1, a subject receives a rituximab infusion at least 30 minutes after the 1000 mg IV methylprednisolone pulse described above. For rituximab dose administration between Day −14 and Day −2, a subject receives a 100 mg methylprednisolone IV infusion approximately 30 minutes before receiving the IV rituximab. A subject receives a sirolimus oral loading dose of 6 mg at Day −1 (window of Day −3 to Day −1). A subsequent sirolimus oral maintenance dose of 2 mg/day is provided as concomitant medication starting at Day 0 (or the day after the sirolimus loading dose, if the sirolimus loading dose is administered at Day −3 or Day −2) and adjusted as needed for 90 days to maintain serum trough levels of 6 ng/mL (range 4-9 ng/mL) for 90 days. Sirolimus is then tapered over the ensuing 15 to 30 days. Higher doses or a longer taper of corticosteroids and sirolimus may be used.
In some embodiments, a longer taper, or re-initiation of immunosuppressive treatment may be used (e.g., in cases of elevated AST or ALT, inflammatory changes in the CSF, or other suspected immune system reactions).
In some embodiments, an additional immunosuppressant that is not sirolimus, methylprednisolone, rituximab or prednisone is further administered to the subject.
In some embodiments, a method disclosed herein may comprise an increase in doses of the immunosuppressant agent, a prolonged tapering regimen, use of an additional agent, or re-initiation of treatment based on clinical signs or symptoms consistent with an immune response, for example:
The amount of composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure administered to a subject will vary depending on the administration method. For example, in some embodiments, a rAAV as described herein is administered to a subject at a titer between about 109 Genome copies (GC)/kg and about 1014 GC/kg (e.g., about 109 GC/kg, about 1010 GC/kg, about 1011 GC/kg, about 1012 GC/kg, about 1012 GC/kg, or about 1014 GC/kg). In some embodiments, a subject is administered a high titer (e.g., >1012 Genome Copies GC/kg of an rAAV) by injection to the CSF space, or by intraparenchymal injection. In some embodiments, a rAAV as described herein is administered to a subject at a dose ranging from about 1×1010 vector genomes (vg) to about 1×1017 vg by intravenous injection. In some embodiments, a rAAV as described herein is administered to a subject at a dose ranging from about 1×1010 vg to about 1×1016 vg by injection into the cisterna magna.
A composition (e.g., a composition comprising an isolated nucleic acid or a vector or a rAAV) as described by the disclosure can be administered to a subject once or multiple times (e.g., 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, or more) times. In some embodiments, a composition is administered to a subject continuously (e.g., chronically), for example via an infusion pump.
AAV vectors are generated using cells, such as HEK293 cells for triple-plasmid transfection. The ITR sequences flank an expression construct comprising a promoter/enhancer element for each transgene of interest, a 3′ polyA signal, and posttranslational signals such as the WPRE element. Multiple gene products can be expressed simultaneously such as GBA1 and LIMP2 and/or Prosaposin, by fusion of the protein sequences; or using a 2A peptide linker, such as T2A or P2A, which leads 2 peptide fragments with added amino acids due to prevention of the creation of a peptide bond; or using an IRES element; or by expression with 2 separate expression cassettes. The presence of a short intronic sequence that is efficiently spliced, upstream of the expressed gene, can improve expression levels. shRNAs and other regulatory RNAs can potentially be included within these sequences. Examples of plasmids comprising rAAV vectors described by the disclosure are shown in
Cells deficient in GBA1 are obtained, for example as fibroblasts from GD patients, monocytes, or hES cells, or patient-derived induced pluripotent stem cells (iPSCs). These cells accumulate substrates such as glucosylceramide and glucosylsphingosine (GluCer and GluSph). Treatment of wild-type or mutant cultured cell lines with Gcase inhibitors, such as CBE, is also be used to obtain GBA deficient cells.
Using such cell models, lysosomal defects are quantified in terms of accumulation of protein aggregates, such as of α-Synuclein with an antibody for this protein or phospho-αSyn, followed by imaging using fluorescent microscopy. Imaging for lysosomal abnormalities by ICC for protein markers such as LAMP1, LAMP2, LIMP1, LIMP2, or using dyes such as Lysotracker, or by uptake through the endocytic compartment of fluorescent dextran or other markers is also performed. Imaging for autophagy marker accumulation due to defective fusion with the lysosome, such as for LC3, can also be performed. Western blotting and/or ELISA is used to quantify abnormal accumulation of these markers. Also, the accumulation of glycolipid substrates and products of GBA1 is measured using standard approaches.
Therapeutic endpoints (e.g., reduction of PD-associated pathology) are measured in the context of expression of transduction of the AAV vectors, to confirm and quantify activity and function. Gcase can also be quantified using protein ELISA measures, or by standard Gcase activity assays.
An in vitro study to evaluate the ability of PR001A (AAV9.CBA.GBA1.A) (schematic of a plasmid encoding the vector provided in
In vitro studies were also conducted in HeLa cells, a human cell line, and in primary mouse hippocampal neurons. In HeLa cells treated with 2×106 vg/cell PR001A, an approximately 2-fold increase in GCase activity levels and a reduction in total α-Synuclein levels compared to excipient-treated control cells was observed (
Mouse hippocampal neurons transduced with 1.3×105 vg/cell or 1.3×106 vg/cell PR001A showed increased GCase activity levels and trended to decreased total α-Synuclein levels (
In summary, PR001A transduction in cell lines and primary neuron cultures resulted in increased GCase activity. In HeLa cells and mouse hippocampal neurons, PR001A transduction also resulted in decreased α-Synuclein levels, supporting the link between GCase activity and α-Synuclein levels (Mazzulli et al., Cell. 2011; 146(1):37-52).
This example describes in vivo assays of AAV vectors using mutant mice. In vivo studies of AAV vectors as above in mutant mice are performed using assays described, for example, by Liou et al. (2006) J. Biol. Chem. 281(7): 4242-4253, Sun et al. (2005) J. Lipid Res. 46:2102-2113, and Farfel-Becker et al. (2011) Dis. Model Mech. 4(6):746-752.
The intrathecal or intraventricular delivery of vehicle control and AAV vectors (e.g., at a dose of 2 ×1011 vg/mouse) are performed using concentrated AAV stocks, for example at an injection volume between 5-10 μL. Intraparenchymal delivery by convection enhanced delivery is performed.
Treatment is initiated either before onset of symptoms, or subsequent to onset. Endpoints measured are the accumulation of substrate in the CNS and CSF, accumulation of Gcase enzyme by ELISA and of enzyme activity, motor and cognitive endpoints, lysosomal dysfunction, and accumulation of α-Synuclein monomers, protofibrils or fibrils.
This example describes in vivo assays of AAV vectors using a chemically-induced mouse model of Gaucher disease (e.g., the CBE mouse model). In vivo studies of these AAV vectors are performed in a chemically-induced mouse model of Gaucher disease, for example as described by Vardi et al. (2016) J Pathol. 239(4):496-509.
Intrathecal or intraventricular delivery of vehicle control and AAV vectors (e.g., at a dose of 2 ×1011 vg/mouse) are performed using concentrated AAV stocks, for example with injection volume between 5-10 μL. Intraparenchymal delivery by convection enhanced delivery is performed. Peripheral delivery is achieved by tail vein injection.
Treatment is initiated either before onset of symptoms, or subsequent to onset. Endpoints measured are the accumulation of substrate in the CNS and CSF, accumulation of Gcase enzyme by ELISA and of enzyme activity, motor and cognitive endpoints, lysosomal dysfunction, and accumulation of α-Synuclein monomers, protofibrils or fibrils.
In some embodiments, patients having certain forms of Gaucher disease (e.g., GD1) have an increased risk of developing Parkinson's disease (PD) or Lewy body dementia (LBD). This Example describes clinical trials to assess the safety and efficacy of rAAVs as described by the disclosure, in patients having Gaucher disease, PD and/or LBD.
Clinical trials of such vectors for treatment of Gaucher disease, PD and/or LBD are performed using a study design similar to that described in Grabowski et al. (1995) Ann. Intern. Med. 122(1):33-39.
In some embodiments, patients having certain forms of Gaucher disease exhibit symptoms of peripheral neuropathy, for example as described in Biegstraaten et al. (2010) Brain 133(10):2909-2919.
This example describes in vivo assays of AAV vectors as described herein for treatment of peripheral neuropathy associated with Gaucher disease (e.g., Type 1 Gaucher disease). Briefly, Type 1 Gaucher disease patients identified as having signs or symptoms of peripheral neuropathy are administered a rAAV as described by the disclosure. In some embodiments, the peripheral neuropathic signs and symptoms of the subject are monitored, for example using methods described in Biegstraaten et al., after administration of the rAAV.
Levels of transduced gene products as described by the disclosure present in patients (e.g., in serum of a patient, in peripheral tissue (e.g., liver tissue, spleen tissue, etc.)) of a patient are assayed, for example by Western blot analysis, enzymatic functional assays, or imaging studies.
This example describes in vivo assays of rAAVs as described herein for treatment of CNS forms of Gaucher disease. Briefly, Gaucher disease patients identified as having a CNS form of Gaucher disease (e.g., Type 2 or Type 3 Gaucher disease) are administered a rAAV as described by the disclosure. Levels of transduced gene products as described by the disclosure present in the CNS of patients (e.g., in serum of the CNS of a patient, in cerebrospinal fluid (CSF) of a patient, or in CNS tissue of a patient) are assayed, for example by Western blot analysis, enzymatic functional assays, or imaging studies.
This example describes administration of a recombinant adeno-associated virus (rAAV) encoding GBA1 to a subject having Parkinson's disease characterized by a mutation in GBA1 gene.
The rAAV vector insert contains the CBA promoter element (CBA), consisting of four parts: the CMV enhancer (CMVe), CBA promoter (CBAp), Exon 1, and intron (int) to constitutively express the codon optimized coding sequence (CDS) of human GBA1 (maroon). The 3′ region also contains a Woodchuck hepatitis virus Posttranscriptional Regulatory Element (WPRE) posttranscriptional regulatory element followed by a bovine Growth Hormone polyA signal (bGH polyA) tail. The flanking ITRs allow for the correct packaging of the intervening sequences. Two variants of the 5′ ITR sequence (
GBA1-rAAV is administered to a subject as a single dose via a fluoroscopy guided sub-occipital injection into the cisterna magna (intracisternal magna; ICM). One embodiment of a dosing regimen study is as follows:
Initial studies were conducted in a chemical mouse model involving daily delivery of conduritol-β-epoxide (CBE), an inhibitor of GCase to assess the efficacy and safety of the PR001A rAAV vector (AAV9.CBA.GBA1.A) (schematic of a plasmid encoding the vector provided in
These mouse models exhibit phenotypes characteristic of nGD (neuronopathic Gaucher disease) and PD-GBA (having Parkinson's disease characterized by a mutation in GBA1 gene), including reduced GCase activity, accumulation of the glycolipid substrates of GCase, deficits in motor behavior, and neuropathological changes including astrogliosis and microgliosis, reflecting inflammation. Intracerebroventricular injection of PR001A suppressed all of these disease-associated phenotypes. Additionally, the 4 L/PS-NA mouse model displayed accumulation of α-Synuclein, and ICV administration of PR001A in the 4 L/PS-NA model reduced the accumulation of α-Synuclein.
Two slightly different versions of the 5′ inverted terminal repeat (ITR) in the AAV backbone were tested to assess manufacturability and transgene expression (
The nonclinical in vivo pharmacology (efficacy) studies are summarized in Table 14. A total of 10 studies were completed; the 4 principal studies are discussed in detail in subsequent sections.
In the CBE chemical mouse model, a pharmacological inhibition of GCase activity is achieved using a selective and irreversible covalent competitive inhibitor of GCase, leading to glycolipid (GluCer and GluSph) accumulation, neuropathological changes including astrogliosis and microgliosis, and motor behavior deficits (Manning-Bog et al., Neurotoxicology. 2009; 30(6):1127-32; Farfel-Becker et al., Dis Model Mech. 2011; 4(6):746-52; Rocha et al., Antioxid Redox Signal. 2015; 23 (6): 550-64).
CBE is a pharmacological inhibitor of GCase, and mice treated with CBE display phenotypes consistent with GCase loss-of-function. By varying CBE dosage and, thus, the degree of GCase inhibition in vivo, it is possible to recapitulate the varied degrees of enzyme deficiency seen in different GBA1-associated disorders, thereby modulating the severity of the resulting phenotype. For this reason, the CBE mouse model has significant technical advantages over genetic models of GCase deficiency, making it an attractive model for PD-GBA. The systemic reduction in GCase activity in the CBE model recapitulates the human disease as patients with PD-GBA present with a reduction in GCase activity throughout the CNS and peripheral organs. It is expected that this model will underestimate the effects of PR001A since CBE will inhibit both endogenous GCase activity as well as exogenous GCase activity resulting from PR001A treatment.
To establish the CBE model of GCase deficiency, juvenile mice were dosed with CBE, a specific inhibitor of GCase. Mice were given CBE by IP injection daily, starting at postnatal day 8 (P8). Three different CBE doses (25 mg/kg, 37.5 mg/kg, 50 mg/kg) or daily intraperitoneal (IP) vehicle (PBS) were tested to establish a model that exhibits a behavioral phenotype (
Mice surviving to the end of the study were sacrificed on the day after their last CBE dose (P27, “Day 1”) or after three days of CBE withdrawal (P29, “Day 3”). Lipid analysis was performed on the cortex of mice given 25 mg/kg CBE to evaluate the accumulation of GCase substrates in both the Day 1 and Day 3 cohorts. GluSph and GalSph levels (measured in aggregate in this example) were significantly accumulated in the CBE-treated mice compared to PBS-treated controls, consistent with GCase insufficiency (
In summary, a dose of 25 mg/kg CBE injected IP daily resulted in motor behavior deficits and accumulation of GCase substrates (aggregate of GluSph and GalSph levels), which is consistent with inhibition of GCase activity. Therefore, the 25 mg/kg dose was selected for subsequent studies since this recapitulated the core features of the human disease while permitting longer studies to evaluate persistence of vector.
Based on the study described above, the 25 mg/kg CBE dose was selected since it produced behavioral deficits without impacting survival. For all nonclinical mouse studies, intracerebroventricular (ICV) injection was chosen as the route of administration (ROA). As intra-cisterna magna (ICM) injection (the intended clinical ROA) is technically difficult in mice, ICV injection was deemed the most suitable alternative approach to recapitulate the ICM delivery of the therapeutic agent into the cerebrospinal fluid (CSF). To achieve widespread GBA1 distribution throughout the brain and transgene expression during CBE treatment, 4 μL vehicle (dPBS+0.001% Pluronic F68, “dPBS”) or 8.8×109 vg (5.9×1010 vg/g brain, based on a brain weight of 150 mg) PR001B was delivered via ICV injection at P3 and daily IP injection of PBS or 25 mg/kg CBE treatment was initiated at P8 (
The CBE-treated mice showed decreased body weight evolution that was attenuated with PR001B treatment (
At the completion of the in-life study, half of the mice were sacrificed the day after the last CBE dose (P36, “Day 1”) or after three days of CBE withdrawal (P38, “Day 3”) for biochemical analysis (
Lipid levels were negatively correlated with both GCase activity and performance on the Rotarod across treatment groups. The increased GCase activity after rAAV administration was associated with substrate reduction and enhanced motor function (
As shown in
In summary, at a dose of 8.8×109 vg (5.9×1010 vg/g brain) injected ICV, PR001B was distributed in the brain and peripheral tissues, and enzymatically active GCase was expressed in the brain. PR001B improved the biochemical (i.e., glycolipid levels) deficits and performance on rotarod. Because CBE withdrawal was not necessary in order to see the effects of PR001B, mice were sacrificed 1 day following the last CBE dose in all future studies.
A schematic showing an illustrative dose-ranging study design is provided in
A larger study in the CBE model further explored efficacious doses of PR001 rAAV in the CBE model. Using the 25 mg/kg CBE dose model, excipient or PR001 rAAV was delivered via ICV at P3, and daily IP PBS or CBE treatment initiated at P8. Given the similarity between the groups with and without CBE withdrawal observed in the previous studies, all mice were sacrificed one day after the final CBE dose (P38-40). The effect of three different rAAV doses was assessed, resulting in the following five groups, with 10 mice (5M/5F) per group:
The CBE-treated animals gained weight at a lower rate than control animals, a typical observation in this animal model. At the highest dose, PR001A corrected the CBE treatment-related failure to gain weight. Additionally, this dose resulted in a statistically significant improvement on the rotarod and tapered beam tasks, compared to the CBE-treated group that did not receive PR001A (
At the completion of the in-life study, mice were sacrificed for biodistribution and biochemical analysis (
Reactive astrogliosis and microglial activation are prominent inflammatory aspects of the CNS pathology described in neuronopathic GD and PD-GBA patients (Wong et al 2004; Ginns et al 2014). In this study, CBE-treated mice displayed glial scarring, a manifestation of reactive astrogliosis, in the cerebral cortex, consistent with prior studies showing CNS activation in the context of CBE (Sun et al 2011). PR001A treatment led to a statistically significant, dose-dependent reduction of the glial scarring phenotype (
Immunohistochemistry was performed for GCase and ionizing calcium-binding adaptor molecule 1 (Iba1; a marker of microgliosis) expression in the cortex (
In summary, the results of Study PRV-2018-005 show that ICV administration of PR001A at 3 dose levels led to broad vector genome biodistribution, increase in GCase activity, improvement on motor behavioral endpoints, and reduction in glycolipid accumulation. Two different measures of neuroinflammation (microgliosis and astrogliosis) showed a dose dependent, statistically significant decrease in mice treated with PR001A. The CBE model inherently underestimates the potency of PR001A since CBE also inhibits enzyme activity due to PR001A treatment. Taken together, these results indicate that ICV administration of PR001A at 2.0×1010 vg (1.3×1011 vg/g brain) was effective in the CBE mouse model. A trend towards efficacy was observed at lower doses of PR001A in a subset of endpoints.
This study assessed the persistence of PR001A vector copy number biodistribution and the durability of PR001A-mediated expression of GCase in the CBE mouse model. A single dose of excipient or PR001A was delivered via ICV at P3, and daily IP PBS or CBE treatment was initiated at P8 and continued until P183 through P185 (
A single ICV dose of PR001A in CBE-treated mice led to the presence of vector genome copies 6 months after dosing (
This study was intended to evaluate additional doses of PR001A to determine the minimum effective dose and examine higher doses for tolerability. However, due to an unexpected dosing deviation, this study replicated the doses from PRV-2018-005. Following a similar design as PRV-2018-005 (
Unlike previous studies, CBE treatment did not lead to a significant change in body weight. Although CBE treatment resulted in significantly poorer performance on the rotarod and tapered beam, treatment with PR001A did not significantly alter this performance (
Of the tissues examined, brain, spinal cord, liver, heart, and lungs were positive for PR001A at all dose levels. The kidney was also positive at the middle and highest doses, while the spleen was only positive at the highest dose. Gonads were also examined but were not positive at any dose level (
Consistent with the other studies in this model, CBE-treated mice exhibited accumulation of GluSph and GluCer in the brain, which was reduced by administering PR001A (
This study confirmed the findings from PRV-2018-005, showing that PR001A treatment results in broad biodistribution and a robust elevation of GCase activity that significantly reduces the glycolipid substrate accumulation caused by CBE treatment. This study did not replicate the behavioral phenotypes observed in PRV-2018-005; however, these phenotypes are known to be variable and less reliable in mice.
Given the study deviation in PRV-2018-008, an additional study was performed in the CBE model to expand on previous dose-ranging studies. The ICV dosing of PR001A and IP injection of PBS or CBE followed the same protocol as PRV-2018-005. However, this study included a lower PR001A dose to examine the minimum effective dose and a higher dose to examine tolerability.
In this study, CBE treatment did not lead to a failure to gain weight over time; however, a statistically significant decrease in motor performance was observed in CBE+excipient animals in both the rotarod and tapered beam. Treatment with PR001A at 5.2×1010 vg significantly improved motor performance to nearly the same level as PBS+excipient animals. An improvement was also observed in animals treated with 1.7×1010 vg PR001A, though this did not reach significance (
The cerebral cortex of animals treated with PROM was positive for vector genomes at all doses, and treatment with 5.2×1010 vg PR001A led to a significant increase in GCase activity. Treatment with 1.7×1010 vg PR001A restored activity to near wildtype levels (
Consistent with the other studies in this model, CBE-treated mice exhibited an accumulation of GluSph and GluCer in the brain, which was significantly reduced by administering PROM at either 1.7×1010 vg or 5.2×1010 vg (
This study confirmed and expanded on the findings from the previous studies in the CBE model. Although this study did not completely replicate the behavioral phenotypes observed in PRV-2018-005, nonsignificant improvements were seen in both rotarod and tapered beam with 1.7×1010 vg PROM, and treatment with 5.2×1010 vg PROM significantly improved performance in both tasks. Additionally, treatment at either dose decreased glycolipid substrate accumulation, confirming the results from the other CBE studies.
Results from CBE model studies show that PROM can be effectively delivered to the CNS and also peripheral tissues by ICV injection. Within the CNS, ICV delivery of PROM resulted in a consistent increase in GCase activity, a reduction of the glycolipid substrates GluCer and GluSph, a reduction of glial scarring, and improvement in some motor deficits. These effects, where assessed, persisted at 6 months post treatment.
4 L/PS-NA mice are an established genetic model of GD and PD-GBA (Sun et al., J Lipid Res. 2005; 46(10):2102-13; Mazzulli et al., Cell. 2011; 146(1):37-52; Xu et al., Mol Genet Metab. 2011; 102(4):436-47). These mice are homozygous for the V394L mutation in GBA1 and additionally harbor mutations in PSAP, which encodes saposin C, an activator of GCase; the presence of a mutant GCase enzyme and the low levels of the GCase activator saposin C together lead to a severe reduction in GCase activity, accumulation of glycolipid substrates, as well as motor behavior deficits. These mice exhibit motor strength, coordination, and balance deficits, as evidenced by their performance in the beam walk, rotarod, and wire hang assays. Typically the lifespan of these mice is less than 22 weeks. The “control” mice in this study are homozygous for the V394L mutation in Gba1, but wild-type for the endogenous prosaposin gene, and thus harbor a more modest reduction in GCase activity. Note that because treatment with PR001A does not have an effect on saposin C, results obtained in the 4 L/PS-NA mice likely underestimate the predicted effect in humans. Two studies were conducted with PR001A in these mice.
In Study PRV-2018-006, PR001A or excipient was delivered ICV to 3 to 4 week old 4 L/PS-NA mice, and animals were sacrificed 15 weeks post-PR001A administration. A dose of 3 μL of undiluted vector (1.5×1010 vg total; 3.7×1010 vg/g brain) was administered (
Progressive motor deficits were observed in the 4 L/PS-NA mice, and treatment with PR001A resulted in a nonsignificant improvement on beam walk 5 and 9 weeks after treatment. At 15 weeks post treatment, there was no statistically significant difference among the groups. Biodistribution of PR001A vector genomes in the 4 L/PS-NA mice was quantified approximately 15 weeks after dosing. All tissues examined, including cerebral cortex, spinal cord, liver, kidney, heart, lung, spleen, and gonads, were positive for vector genomes. (
There was a statistically significant accumulation of GluSph and GluCer in the brain lysates from 4 L/PS-NA mice relative to lysates from control animals. In the 4 L/PS-NA mice, treatment with PR001A led to a statistically significant reduction in GluSph accumulation and a trend (P=0.16) towards a reduction in GluCer (
Prior studies have demonstrated increased accumulation of α-Synuclein protein in the cortex of the 4 L/PS-NA mouse model, consistent with the proposed role of GCase in α-Synuclein pathology (Sun et al., J Lipid Res. 2005; 46(10):2102-13; Mazzulli et al., Cell. 2011; 146(1):37-52; Xu et al., Mol Genet Metab. 2011; 102(4):436-47). Cerebral cortical levels of soluble and insoluble α-Synuclein were examined biochemically. In 4 L/PS-NA mice treated with excipient, there was a nonsignificant increase in insoluble α-Synuclein and the ratio of insoluble to soluble α-Synuclein in the cerebral cortex; treatment with ICV PR001A reversed these effects (P=0.19, P=0.87, respectively) (
Motor performance by the beam walk test was assessed 4 weeks post-rAAV delivery. The group of mutant mice that received PR001A rAAV showed a trend towards fewer total slips and fewer slips per speed when compared to mutant mice treated with excipient, restoring motor function to near wild-type levels (
The second study with 4 L/PS-NA mice explored a range of PR001A doses using a design similar to the one used in Study PRV-2018-006 (
On the beam walk test, 4 L/PS-NA mice performed significantly worse than control mice. 4 L/PS-NA mice treated with 2.9×1011 vg, 9.3×1010 vg, or 2.9×1010 vg PR001A showed significant improvement when compared to 4 L/PS-NA mice treated with excipient at Week 18 (
All PR001A treatment groups were positive for vector genomes in the cortex. Effective GCase activity, evaluated using a fluorometric assay, was measured in the cortex and was found to be significantly increased in mice treated with 2.9×1011 vg PR001A (
Cerebral cortical and hippocampal levels of soluble and insoluble α-Synuclein were examined biochemically. There was no difference in these levels between 4 L/PS-NA mice and control animals; published reports in the literature have shown variable α-Synuclein phenotypes.
There was a statistically significant accumulation of GluSph and GluCer in the cerebellum of 4 L/PS-NA mice treated with excipient. Treatment with PR001A led to a dose-dependent trend to reduced levels of GluSph and a statistically significant dose-dependent reduction in GluCer (
Although the 4 L/PS-NA mice displayed variability with respect to the measured phenotypes across 2 studies, the overall data were consistent with the CBE model findings and published data: GCase deficiency was associated with an increased level of glycolipid substrates and motor behavioral deficits. Treatment with ICV PR001A strongly attenuated these phenotypes. In Study PRV-2018-006, insoluble α-Synuclein levels in the cerebral cortex were nonsignificantly increased in the 4 L/PS-NA relative to control mice, as reported in published studies (Sun et al., J Lipid Res. 2005; 46(10):2102-13; Mazzulli et al., Cell. 2011; 146(1):37-52; Xu et al., Mol Genet Metab. 2011; 102(4):436-47). Treatment with ICV PR001A reversed such accumulation, consistent with in vitro analyses disclosed herein. Taken together, these studies support the clinical development of PR001A.
Study PRV-2018-019 and PRV-2019-001: PR001A in α-Synuclein Transgenic Mice Treated with CBE
To further examine the effect of PR001A on α-Synuclein pathology, 2 studies were performed in dbl-PAC-Tg(SNCAA53T); Snca−/− mice, which are homozygous for a human PD-associated α-Synuclein A53T mutant transgene on a Snca knockout background (Snca encodes the murine α-Synuclein protein). These mice are reported to display gastrointestinal phenotypes and subtle motor abnormalities between 6 to 12 months of age but not widespread α-Synuclein pathology in the brain (Kuo et al., Hum Mol Genet. 2010; 19(9):1633-50). Previous studies in human α-Synuclein A53T transgenic mouse models have reported that the treatment of such mice with CBE leads to elevated α-Synuclein levels (Rockenstein et al., Hum Mol Genet. 2016; 25(13):2645-60; Papadopoulos et al., Hum Mol Genet. 2018; 27(10):1696-1710). Due to these published findings, and to validate the effects of GCase deficiency in this model, we treated these mice with CBE. At 9 to 10 weeks of age, mice were treated with 10 μL of excipient or 2.9×1011 vg (7.4×1011 vg/g brain, based on a brain weight of 400 mg) PR001A via ICV injection. Two weeks post-ICV treatment, IP PBS or 100 mg/kg CBE was given daily for 1 week.
The presence of vector genomes and GCase activity was assessed in the cerebral cortex. For PRV-2018-019, increased cortical glycolipid substrates with CBE treatment were confirmed, and assessed α-Synuclein levels from hippocampal lysates using an automated capillary Simple Western™ immunoblot system on a Jess instrument. Multiple α-Synuclein immunoreactive bands were observed, consistent with the presence of monomers and high molecular weight (HMW) species. A statistically significant reduction in the ratio of BMW α-Synuclein species to monomeric α-Synuclein levels was observed with PR001A treatment of CBE-dosed α-Synuclein transgenic mice (
The studies above show that a single ICV injection of PR001A effectively delivers GBA1 to the CNS and peripheral tissues of mice. In two animal models of PD-GBA and nGD, PR001A elevated GCase activity in the CNS. Increased GCase activity reduced the accumulation of glycolipid substrates in the brain; these glycolipid substrates are proposed as a biomarker outcome measure for the intended clinical trial. Importantly, these benefits persist for at least 6 months after a single treatment with PR001A. The CBE model presents with reactive astrogliosis as well as microgliosis, which are typical histopathological findings in patients with PD-GBA, nGD, and animal models of these disorders (Hamby and Sofroniew, Neurotherapeutics. 2010; 7(4):494-506; Farfel-Becker et al., Dis. Model Mech. 2011; 4(6):746-752; Farfel-Becker et al., Hum Mol Genet. 2011; 20(7):1375-86; Booth et al., Trends Neurosci. 2017; 40(6):358-70; McMahon et al., Mol Genet Metab. 2018; 123(2):S93). PR001A is able to prevent or reverse the CBE-induced reactive gliosis and microgliosis. Both models display motor deficits, and treatment with PR001A improves some of these deficits in both models. Alongside these two models, an additional mouse model was used to investigate α-Synuclein pathology. While α-Synuclein phenotypes are variable in mouse models, PR001A was able to suppress or reverse the phenotypes when they were observed; additional in vitro studies support the effectiveness of PR001A in reducing α-Synuclein levels. Together, these studies support the efficacy of PR001A in models of PD-GBA and nGD.
Safety and toxicology studies conducted with PR001A in mouse models are summarized in Table 15. Two of the mouse model efficacy studies (PRV-2018-005 and PRV-2018-006) also included select safety endpoints such as histopathology to evaluate the safety of PR001A in a disease model.
Histopathological analysis was performed by hematoxylin and eosin (H&E) staining of the brain, thoracic spinal cord, heart, liver, spleen, lung, and kidney; results were evaluated by a board-certified veterinary pathologist. In the mice treated with CBE, findings in the CNS included glial scars and neuronal necrosis in the cerebral cortex, brain stem, and thoracic spinal cord. Intracerebroventricular PR001A at doses up to 1.3×1011 vg/g was well tolerated in these mice, and this highest dose resulted in a notable reduction in the incidence of these CNS findings; low and mid dose PR001A had a dose-dependent reduction in the number of animals with glial scars in the cerebral cortex, with equivocal effects on the other CNS findings such as neuronal necrosis. No adverse effects of either CBE or PR001A were observed in peripheral tissues. In summary, there were no adverse histopathology findings or evidence of toxicity due to treatment with PR001A in studies with the CBE mouse model.
A pilot study was performed to assess in vitro activity of rAAV vectors encoding Prosaposin (PSAP) and SCARB2, alone or in combination with GBA1 and/or one or more inhibitory RNAs. One construct encoding PSAP and progranulin (PGRN) was also tested. Vectors tested include those shown in Table 3. “Opt” refers to a nucleic acid sequence codon optimized for expression in mammalian cells (e.g., human cells).
The effect of placement of ITR “D” sequence on cell transduction of rAAV vectors was investigated. HEK 293 cells were transduced with Gcase-encoding rAAVs having 1) wild-type ITRs (e.g., “D” sequences proximal to the transgene insert and distal to the terminus of the ITR) or 2) ITRs with the “D” sequence located on the “outside” of the vector (e.g., “D” sequence located proximal to the terminus of the ITR and distal to the transgene insert), as shown in
Fifty (50) mice were administered GBA1-encoding rAAVs via a 4 μl intracerebroventricular (ICV) injection on post-natal day 3. All mice received daily intraperitoneal (IP) injections of conduritol B-epoxide (CBE) or PBS, depending on treatment group, from post-natal day 8 to the end of the study. Animals were euthanized 24 hours after their last IP dose. After euthanasia, target tissues were harvested, drop fixed in chilled 4% paraformaldehyde and stored at 4° C., then sent for histopathological processing and evaluation.
Tissues from the forty-two (42) animals euthanized at 38-40 days were trimmed, processed, and embedded in paraffin blocks. They were then sectioned at ˜5 μm, stained with hematoxylin and eosin (H&E) and affixed to slides for evaluation.
There were no histopathologic findings or evidence of toxicity due to treatment with the rAAVs. In the mice treated with conduritol B-epoxide (CBE), there were findings in the central nervous system (CNS) that included glial scars and neuronal necrosis in the cerebral cortex, and neuronal necrosis in the brain stem and thoracic spinal cord. High dose rAAV treatment resulted in a notable reduction in the incidence of these CNS findings, while the low and mid dose virus had a dose dependent reduction in the incidence of glial scars in the cerebral cortex, with equivocal effects on the other CNS findings (
Immunohistochemistry was performed to assess GCase and Iba1 expression in the cortex (
The safety of PR001A (AAV9.CBA.GBA1.A), comprising the codon-optimized coding sequence of human GBA1 (SEQ ID NO:15), was evaluated in vivo in non-human primates (NHPs). Additional details of the PR001A components are provided above. The brain of the NHP is most similar to that of humans, and the anatomical features of the NHP spinal cord and CSF volume and flow permits an ICM (intra-cisterna magna) injection. Because of the anatomical similarities to humans, it was expected that NHP studies would provide reliable biodistribution data supporting clinical dosing of PR001A.
Safety and biodistribution of PR001A were evaluated in three toxicology studies in cynomolgus macaques (Table 8): two non-GLP (Good Laboratory Practice) studies (PRV-2018-015 and PRV-2019-005) and a larger 21CFR58 GLP-compliant study (PRV-2018-016).
A pilot non-GLP study (PRV-2018-015) was conducted in NHPs to confirm that the final PR001A product is delivered to the NHP brain following ICM administration. The GLP toxicology and biodistribution study in NHPs (PRV-2018-016) assessed the safety and biodistribution of PR001A.
The doses tested in NHPs include the maximum feasible dose as determined by the volume administered and test product titer. In addition, a lower dose was also evaluated in the GLP study. The time points of the GLP study were selected to evaluate safety after treatment but before peak expression (Day 7), the start of peak expression (Day 30), and long-term expression post peak (Day 183).
A non-GLP pilot tolerance and biodistribution study of PR001A was conducted in male cynomolgus monkeys. The goal of this study was to verify biodistribution of PR001A to various brain areas and major peripheral organs following ICM delivery. The time point for sacrifice was selected because it was predicted to allow for a meaningful measure of potential early toxicity to inform the planned GLP NHP toxicology study, most notably with early in-life observations as measured by a functional observational battery (FOB). Studies of intrathecal AAV delivery have demonstrated that transgene expression peaks 2 to 3 weeks after injection (Hinderer et al., Mol Ther. 2014; 22(12):2018-27; Hinderer et al., Mol Ther Methods Clin Dev. 2014; 1:14051; Hinderer et al., Mol Ther. 2015; 23(8)1298-307; Hinderer et al., Mol Genet Metab. 2016; 119(1-2):124-30). Day 18 evaluations, therefore, should detect immediate toxicity due to the injection procedure or an innate inflammatory response to the test article, as well as provide information regarding transgene biodistribution and expression at a time point corresponding to early peak expression. The study design included an arm with rapamycin treatment (0.3 mg/kg oral, Day −3 to Day 18) in combination with PR001A to determine if immunosuppression would be beneficial in mitigating potential toxicity. To increase transgene expression in the brain, one arm in the study included intraparenchymal (IPa) administration of PR001A directly into the midbrain targeting bilateral substantia nigra pars compacta in combination with ICM delivery. The ICM dose volume was 0.5 mL, the maximum volume there was experience with administering, and the IPa dose was 10 μL bilateral, translating to doses of 1.47×1013 vg for ICM alone and 1.53×1013 vg for treatment with both ICM and IPa. With an estimated brain weight of 74 g, this translates to an ICM dose of 2.0×1011 vg/g brain and a dose of 2.1×1011 vg/g brain for the group receiving ICM administration in combination with IPa. A tabulated summary of this study's design is provided in Table 9.
The H&E analysis was performed by two independent board-certified veterinary pathologists, and both concluded there were no PR001A-related toxicity findings. Spinal cord changes observed were likely the result of trauma at the time of ICM injection and were not considered related to PR001A. All histopathology findings in non-nervous system tissue were considered spontaneous or incidental changes commonly seen in control monkeys. Overall, there were no definitive adverse PR001A effects in the brain or spinal cord.
The reviewing pathologist noted nonspecific changes (predominantly variable infiltrates of mononuclear cells) in the meninges, brain or spinal cord parenchyma, and/or at the injection site (in these tissues) were likely associated with the test article, but the pathologist did not consider these changes to be adverse. At the severities noted, similar infiltrates might reasonably be expected to be observed in any monkey with an experimental procedure that disrupts the meninges and/or the blood brain barrier. Additionally, some infiltrates (notably those within the choroid plexus and occasionally in the parenchyma) are commonly observed in control monkeys (Butt et al., Toxicol Pathol. 2015; 43:513-8). All other histopathologic findings observed were considered incidental and/or were of similar incidence and severity in excipient and PR001A-treated animals and, therefore, were considered unrelated to administration of PR001A. A second independent, board-certified veterinary pathologist reviewing the same tissue samples noted that all findings were indistinguishable from incidental findings or trauma incurred during the injection procedure as findings were nonspecific and across all groups, including the control group receiving only excipient. In addition, a different board-certified veterinary pathologist reviewed the non-GLP tissues and concluded there were no PR001A-related effects.
Overall, there were no changes in FOB scores, body weight gain, or food consumption during the course of the study irrespective of group and across time points. Microglia morphology in the midbrain did not appear to differ across treatment groups (as determined with Iba1 staining). Expression and morphology of tyrosine hydroxylase positive neurons of the midbrain did not appear to differ across treatment groups. By Day 18, AAV9-nAb titers were increased in all PR001A-treated animals, while the excipient-treated control animals showed only modest changes compared to baseline. One of the monkeys in the group receiving oral rapamycin had a lower AAV9 nAb titer (1:64) at Day 18 compared to the other animals receiving PR001A treatment (>1:256); the difference in titers did not appear to affect biodistribution, but the sample size is too low to be conclusive.
Biodistribution was evaluated in all test samples collected using quantitative polymerase chain reaction (qPCR); tissues were considered positive with at least 100 vg/μg DNA (these criteria were also used to assess positive tissues in the mouse efficacy studies). All tissues tested were positive in all groups that were treated with PR001A, indicating widespread distribution throughout the CNS and periphery. In addition, animals that received ICM administration of PR001A in combination with bilateral IPa administration into the midbrain had increased localized expression. Treatment with rapamycin did not appear to have any effect on safety or biodistribution (select representative regions shown in
Taken together, the results of non-GLP NHP Study PRV-2018-015 indicated no safety or toxicity concerns with any of the in-life or postmortem assessments. All animals survived until their scheduled necropsy date, and postmortem pathology analysis indicated no adverse toxicity concerns. The study also showed uniform biodistribution of PR001A in the brain.
Study Design
The purpose of this GLP study was to evaluate the toxicity and biodistribution of PR001A when administered once via ICM injection in cynomolgus monkeys with a 7-, 30-, or 183-day post-administration observation period. The study was designed to evaluate 2 dose levels: the highest dose is the maximum feasible dose achievable with 1.2 mL volume (the highest volume there was experience with administering) of undiluted test product, and a lower dose ½ log unit lower than the high dose. The doses equated to a low dose of 4.6×1012 vg and a high dose of 1.7×1013 vg; with a brain weight estimate of 74 g in a cynomolgus monkey, this translates to approximately 6.2×1010 vg/g brain and 2.3×1011 vg/g brain. The study also included a control arm in which animals receive 1.2 mL of excipient only (20 mM Tris pH 8.0, 200 mM NaCl, 1 mM MgCl2, and 0.001% [w/v] poloxamer 188). This study utilized both male and female cynomolgus macaques. The Day 7 group included 1 male at the highest dose and was designed as a sentinel for early toxicity; the remaining 2 time points (Day 30 and Day 183) included 2 males and 1 female at each dose. In addition to samples from multiple brain regions, peripheral tissue samples were collected for qPCR analysis. All samples that were positive with qPCR were analyzed for transgene expression. A tabulated summary of this study's design is provided in Table 10.
aOrgans (when present) will be weighed or noted as missing:
bCollected in modified Davidson's fixative and stored in 10% neutral buffered formalin
a20 mM Tris pH 8.0, 200 mM NaCl, 1 mM MgCl2, and 0.001% (w/v) poloxamer 188.
Cynomolgus NHPs were assessed by multiple in-life observations and measurements, including mortality/morbidity (daily), clinical observations (daily), body weight (baseline and weekly thereafter), visual inspection of food consumption (daily), neurological observations (baseline and during Weeks 2 and 26), indirect ophthalmoscopy (baseline and during Weeks 2 and 26), and electrocardiographic measurement (baseline and during Weeks 2 and 26).
Analysis of nAb to the AAV9 capsid was performed at baseline and at sacrifice on Days 7, 30, or 183. Clinical pathology consisting of hematology, coagulation, clinical chemistry, and urinalysis was performed twice at baseline (blood tests; once for urinalysis) and once during Weeks 1 and 13 of the dosing phase.
Animals were euthanized, and tissues harvested on Days 7, 30, or 183. The tissues were collected from all animals, weighed (if applicable), and divided into replicates. One replicate was preserved in 10% neutral-buffered formalin (except when special fixatives are required for optimum fixation) for histopathological evaluation (all animals). Additional replicates were collected for qPCR and transgene expression analysis.
Safety and Toxicity
All animals survived to the scheduled necropsy date with no unexpected deaths. There were no concerns or issues with the in-life assessments for any of the groups; gross macroscopic examination at necropsy showed no PR001A-related abnormalities in any of the cohorts.
No PR001A-related organ weight differences or macroscopic or microscopic findings were present in any of the groups at the interim sacrifices on Day 7 or 30 or at the terminal sacrifice on Day 183. Hemorrhage, characterized by focal areas of perivascular hemorrhage mainly in region of the brain stem, was present across all groups including controls, and, therefore, was considered procedure-related (CSF collection prior to necropsy) and not related to PR001A. All other microscopic findings, including minimal mononuclear infiltrates in the brain or spinal cord, were considered spontaneous and/or incidental because they occurred at a low incidence, were randomly distributed across groups (including concurrent controls), and/or their severity was as expected for monkeys of this age; therefore, they were considered not related to PR001A.
No PR001A-related findings were observed in clinical pathology test results; increased fibrinogen was noted in the animal exhibiting the highest anti-AAV9 titer consistent with an immune response against the vector. Positive titers for anti-AAV9 antibodies were observed by Day 7 in all animals administered PR001A. No PR001A-related clinical observations, body weight changes, ophthalmic observations, or physical or neurological examination findings were noted. No PR001A-related differences in mean PR interval, QRS duration, QT interval, corrected QT (QTc) interval, or heart rate were observed in males only or combined sexes administered either dose of PR001A. No PR001A-related arrhythmias or abnormal waveforms were observed.
Dose levels of 0, 6.2×1010, or 2.3×1011 vg/g brain PR001A were well tolerated when administered via single injection at the cisterna magna to male and female monkeys. No in-life, clinical pathology, or anatomic pathology observations were observed that were considered related to the gene product in PR001A.
Biodistribution and Immune Response
Biodistribution analysis of vector genome copies was performed using a qPCR-based assay (vector presence); expression of the transgene (GBA1) was measured in samples that were positive for vector genome presence. At Days 30 and 183, all tissues examined (including CNS and peripheral) were positive by qPCR analysis following treatment with the high dose (2.3×1011 vg/g brain) (select representative regions from Day 183 shown in
To confirm that human GCase was produced in the treated NHPs, protein levels were evaluated on a Simple Western™ immunoblot system on a Jess instrument. Results from cortex, hippocampus, and midbrain samples obtained from NHPs dosed with PR001A indicated elevated levels of GCase expression when analyzed in aggregate compared to the samples from normal NHPs that only received excipient; both low dose and high dose groups were combined for statistical comparison to the control group (
In conclusion, the biodistribution findings indicate that ICM administration of PR001A in NHPs results in robust and broad transduction of the human GBA1 transgene in the brain and peripheral organs. In summary of the NHP biodistribution data, ICM administration of PR001A results in broad biodistribution throughout the brain comparable to levels shown to be efficacious in the mouse models; this transduction leads to the elevation of GCase protein levels in the brain.
Study Design
A non-GLP study was conducted in 12 male cynomolgus macaques to evaluate toxicity and biodistribution of PR001A when administered once via ICM injection with a 30- and 90-day post-administration observation period. The study was designed to evaluate a single dose level: 5.2×1013 vg, or 7.0×1011 vg/g brain assuming an average brain weight of 74 g in cynomolgus macaques. The dose administered is the maximum feasible dose achievable with 1.2 mL volume (the highest volume there was experience with administering) of undiluted PR001A product. The study included a control arm in which animals receive 1.2 mL of excipient only (20 mM Tris pH 8.0, 200 mM NaCl, and 1 mM MgCl2+0.001% [w/v] Pluronic F68). Samples from multiple brain regions and peripheral organs were collected for qPCR analysis to measure biodistribution, and clinical pathology measurements and histopathology were performed to evaluate safety. A tabulated summary of this study's design is provided in Table 11.
As part of this study, tissues were fixed in 10% formalin, embedded in paraffin, and processed to produce H&E-stained slides. Digital slides were prepared and examined by an independent board-certified veterinary pathologist. At both 30 and 90 days post treatment, there were no findings attributed to treatment with PR001A as findings in the PR001A-treated animals were either consistent with those commonly observed in cynomolgus macaque monkeys (Chamanza et al., Toxicol Pathol. 2010; 38(4):642-57), and/or were observed in both vehicle control animals and animals treated with PR001A, and, therefore, were considered incidental.
There was no effect of PR001A, administered to the cisterna magna, on weight gain or food consumption as there was no statistical difference between the treatment and control groups during the course of the study. In addition, there was no change in FOB scores irrespective of group and across timepoints, indicating no issues or concerns during the in-life phase of the study. Plasma levels of nAb against AAV9 were measured using an in vitro assay. Samples were prepared from animals in the study at baseline (pre-ICM administration) and at time of sacrifice (either Day 30 or 90). Treatment with PR001A resulted in increases in AAV9 nAb titers between baseline and time of necropsy at both Days 30 and 90, while vehicle-treated animals' titers overall remained stable or decreased.
Biodistribution and Expression of PR001A
Biodistribution of the PR001A transgene was evaluated in all test samples collected using qPCR; tissues were considered positive with at least 50 vg/μg DNA, the lower limit of quantitation for the assay. All tissues tested were positive in all groups that were treated with PR001A, indicating widespread distribution throughout the CNS and periphery. Data from select representative regions from both the Day 30 and Day 90 cohorts are shown in
Taken together, the results of non-GLP NHP Study PRV-2019-005 indicate no safety or toxicity concerns with any of the in-life or post-mortem assessments. All animals survived until their scheduled necropsy date, and post-mortem pathology analysis indicated no adverse toxicity concerns.
Safety and toxicology studies conducted with PR001A in NHPs are summarized in Table 16.
Parkinson's Disease with GBA1 Mutation
Human subjects will be enrolled in an open-label ascending dose trial of the PR001A rAAV. The subject inclusion criteria comprise: single or biallelic GBA1 mutations, moderate to severe Parkinson's disease, and has stable use of background Parkinson's disease medications prior to investigational product dosing. The subjects will be divided into two groups: (1) PR001 Low Dose (1.4×1014 vg) (N=6); and (2) PR001 High Dose (2.8×1014 vg) (N=6). Each subject will receive the investigational product as a single ICM (intra-cisterna magna) injection. The trial will include a 3-month biomarker readout, a 12-month clinical readout and a 5-year safety and clinical follow-up. The trial will analyze: (1) safety and tolerability; (2) key biomarkers, including: Gcase, GluCer, and GluSph (CSF and blood); (3) additional biomarkers, including: α-Synuclein, NfL (neurofilament light), DAT (Dopamine transporter) SPECT (single photon emission computed tomography); and MRI (magnetic resonance imaging); and (4) Efficacy: MDS-UPDRS (Movement Disorders Society Unified Parkinson's disease Rating Scale); cognition; and ADLs (Activities of Daily Living).
Human subjects (n=15) will be enrolled in an open-label trial of the PR001A rAAV. The subject inclusion criteria comprise: infants 0-24 months old; biallelic GBA1 mutations; neurological signs and symptoms consistent with Type 2 Gaucher disease; and stable standard of care background medications. Each subject will receive the investigational product as a single ICM (intra-cisterna magna) injection. The trial will include a 3-month biomarker readout, a 12-month clinical readout and a 5-year safety and clinical follow-up. The trial will analyze: (1) safety and tolerability; (2) key biomarkers, including: Gcase, GluCer, and GluSph (CSF and blood); (3) time to clinical event (e.g., tracheostomy, PEG (percutaneous endoscopic gastrostomy) placement, death); and (4) Efficacy: behavior, cognition, gross motor, function, QoL (quality of life).
A PR001 intravenous dose ranging study was carried out in the D409V Hom mouse model. Homozygous Gba1D409V/D409V (D409V Hom) mice (The Jackson Laboratory, Bar Harbor, ME) display Gaucher disease-related phenotypes including decreased GCase activity (see, e.g., Sardi et al., Proc Natl Acad Sci USA. 2011; 108(29):12101-6). The study design is provided in
†Wild type animals purchased from The Jackson Laboratory (Bar Harbor, ME), not littermates.
Intravenous administration of PR001 decreased inflammation in the liver (
A PR001 intravenous dose ranging study was also carried out in the 4 L/PS-NA mouse model. The study design is provided in
4 L/PS-NA mice showed glycolipid accumulation in the liver which was reduced by PR001 treatment (
HeLa cells were transduced with PR004 or PR014 at several multiplicities of infection (MOI). Both PR004 and PR014 decreased α-Synuclein protein levels in a dose-dependent manner (
PR004 efficacy was assessed in neuronal cultures from Parkinson's disease patient-derived induced pluripotent stem cells (iPSCs). Induced pluripotent stem cells derived from a Parkinson's disease patient with a SNCA triplication were differentiated into neurons (
No off-target effects of the PR004 rAAV vector were observed. Off-target effects of shRNA targeting SNCA from the PR004 vector were assessed in HEK293 cells by qRT-PCR. The expression of the 15 genes most similar in sequence to the target region of SNCA was evaluated (
PR004 efficacy was assessed in the AAV2-SNCA-A53T AAV mouse model of Parkinson's disease (
A 22-month old human infant with Type 2 Gaucher disease was treated with PR001 at a dose of 1.3×1014 vg (1.1×1011 vg/g brain) administered via an intra-cisterna magna injection. The subject's Gcase enzyme activity in the cerebrospinal fluid (CSF) increased from undetectable at baseline to normal level at Month 4 post-administration of PR001 (see Table 17).
A subject with Parkinson's disease with GBA1 mutation was treated with PR001 at a dose of 1.4×1014 vg administered via an intra-cisterna magna injection. The subject had GBA1 mutations in both chromosomal copies. The subject's Gcase enzyme activity in the CSF increased from undetectable at baseline to normal level at Month 3 post-administration of PR001 (see Table 18).
PR001A is an investigational gene therapy that utilizes an AAV9 viral vector to deliver DNA encoding wildtype GBA1, the gene encoding Gcase, to a patient's cells (see
Immunosuppressant Administration
Corticosteroid Administration: Patients will receive a loading dose of methylprednisolone (MPS) 1000 mg IV pulse on Day −1 (allowed at Day −1 or Day 0 depending on site set-up). See section below for possible 100 mg IV methylprednisolone administration between Day −14 to Day −2 prior to rituximab (RTX) administration. Prednisone at a dose of 30 mg/day will be given orally as concomitant medication from the day after 1000 mg IV methylprednisolone pulse (Day 0 or Day 1) for 14 days and will be then tapered over the ensuing 7 days. Higher doses or a longer taper of corticosteroids may be used at the health care provider's discretion.
Rituximab Administration: Patients will receive a 1-time dose of 1000 mg rituximab IV on any single day between Day −14 and Day −1. In order to mitigate the risk and severity of infusion-related reaction (IRR) associated with rituximab, patients will receive IV methylprednisolone before receiving IV rituximab. For rituximab dose administration on Day −1, patients will receive their rituximab infusion at least 30 minutes after the 1000 mg IV methylprednisolone pulse described above. For rituximab dose administration between Day −14 and Day −2, patients will receive a 100 mg methylprednisolone IV infusion approximately 30 minutes before receiving their IV rituximab.
Acetaminophen and/or diphenhydramine may be provided in addition for IRR prophylaxis per local practice and/or the health care provider's discretion.
Sirolimus Administration: Patients will receive a sirolimus oral loading dose of 6 mg at Day −1 (window of Day −3 to Day −1). A subsequent sirolimus oral maintenance dose of 2 mg/day will be provided as concomitant medication starting at Day 0 (or the day after the sirolimus loading dose, if the sirolimus loading dose is administered at Day −3 or Day −2) and adjusted as needed to maintain serum trough levels of 6 ng/mL (range 4-9 ng/mL) for 90 days. Sirolimus will then be tapered over the ensuing 15 to 30 days. Sirolimus trough levels will be collected prior to administration of the sirolimus dose for each visit. Higher doses or a longer taper of sirolimus may be used at the health care provider's discretion.
Immunosuppression Monitoring Criteria: In addition to monitoring sirolimus trough levels, each patient's clinical status, lab findings, and potential adverse events will be evaluated.
Consideration should also be given to the need to increase doses of the immunosuppressant agent, prolong the tapering regimen, add an additional agent, or reinitiate treatment based on clinical signs or symptoms consistent with an immune response, including:
The health care provider should consider implementing a longer prednisone taper over an additional 4 weeks in patients presenting with ALT and/or AST>3×ULN at the end of the initial 14-day taper. In case of AST/ALT elevations refractory to prednisone treatment, the health care provider should seek expert advice from a hepatologist. In case of CSF inflammatory changes requiring rescue immunosuppression, an unscheduled lumbar puncture should be performed between 1 and 2 months after immunosuppression reinitiation/dose increase/introduction of additional immunosuppression agent.
Pre-Cisternal Puncture Procedures
Patients will undergo standard of care medical evaluations in preparation for cisternal puncture, including anesthesiologist consultation. The proceduralist and anesthesiologist will review screening clinical laboratory analyses (including documented negative pregnancy test), brain and cervical spine (if requested by the proceduralist) MM and MRA, and local ECG results. Medical history and currently prescribed and over-the-counter medications will be reviewed with regards to any recent changes. At the anesthesiologist's discretion, additional clinical assessments may be performed (specific to concomitant medical conditions).
Intracisternal Injection
On Day 0, PR001A will be administered as a single dose via suboccipital injection into the cisterna magna by a proceduralist. Prior to injection, a volume of intracisternal fluid equivalent to the PR001A dosing volume will be removed. The procedure will be performed under general anesthesia or deep sedation and using imaging guidance. Patients will remain under observation for 24 hours (overnight inpatient stay) after PR001A administration.
This application incorporates by reference the contents of the following documents in their entirety: U.S. Application Publication No. 2020/0338148; International PCT Application Publication No. WO 2019/070894; International PCT Application Publication No. WO 2019/070891; U.S. Provisional Application Ser. No. 62/567,311, filed Oct. 3, 2017, entitled “GENE THERAPIES FOR LYSOSOMAL DISORDERS”; 62/567,319, filed Oct. 3, 2017, entitled “GENE THERAPIES FOR LYSOSOMAL DISORDERS”; 62/567,301, filed Oct. 3, 2018, entitled “GENE THERAPIES FOR LYSOSOMAL DISORDERS”; 62/567,310, filed Oct. 3, 2017, entitled “GENE THERAPIES FOR LYSOSOMAL DISORDERS”; 62/567,303, filed Oct. 3, 2017, entitled “GENE THERAPIES FOR LYSOSOMAL DISORDERS”; and 62/567,305, filed Oct. 3, 2017, entitled “GENE THERAPIES FOR LYSOSOMAL DISORDERS”.
Having thus described several aspects of at least one embodiment of this invention, it is to be appreciated that various alterations, modifications, and improvements will readily occur to those skilled in the art. Such alterations, modifications, and improvements are intended to be part of this disclosure, and are intended to be within the spirit and scope of the invention. Accordingly, the foregoing description and drawings are by way of example only.
While several embodiments of the present invention have been described and illustrated herein, those of ordinary skill in the art will readily envision a variety of other means and/or structures for performing the functions and/or obtaining the results and/or one or more of the advantages described herein, and each of such variations and/or modifications is deemed to be within the scope of the present invention. More generally, those skilled in the art will readily appreciate that all parameters, dimensions, materials, and configurations described herein are meant to be exemplary and that the actual parameters, dimensions, materials, and/or configurations will depend upon the specific application or applications for which the teachings of the present invention is/are used. Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein. It is, therefore, to be understood that the foregoing embodiments are presented by way of example only and that, within the scope of the appended claims and equivalents thereto, the invention may be practiced otherwise than as specifically described and claimed. The present invention is directed to each individual feature, system, article, material, and/or method described herein. In addition, any combination of two or more such features, systems, articles, materials, and/or methods, if such features, systems, articles, materials, and/or methods are not mutually inconsistent, is included within the scope of the present invention.
The indefinite articles “a” and “an,” as used herein in the specification and in the claims, unless clearly indicated to the contrary, should be understood to mean “at least one.”
The phrase “and/or,” as used herein in the specification and in the claims, should be understood to mean “either or both” of the elements so conjoined, i.e., elements that are conjunctively present in some cases and disjunctively present in other cases. Other elements may optionally be present other than the elements specifically identified by the “and/or” clause, whether related or unrelated to those elements specifically identified unless clearly indicated to the contrary. Thus, as a non-limiting example, a reference to “A and/or B,” when used in conjunction with open-ended language such as “comprising” can refer, in one embodiment, to A without B (optionally including elements other than B); in another embodiment, to B without A (optionally including elements other than A); in yet another embodiment, to both A and B (optionally including other elements); etc.
As used herein in the specification and in the claims, “or” should be understood to have the same meaning as “and/or” as defined above. For example, when separating items in a list, “or” or “and/or” shall be interpreted as being inclusive, i.e., the inclusion of at least one, but also including more than one, of a number or list of elements, and, optionally, additional unlisted items. Only terms clearly indicated to the contrary, such as “only one of” or “exactly one of,” or, when used in the claims, “consisting of,” will refer to the inclusion of exactly one element of a number or list of elements. In general, the term “or” as used herein shall only be interpreted as indicating exclusive alternatives (i.e. “one or the other but not both”) when preceded by terms of exclusivity, such as “either,” “one of” “only one of” or “exactly one of.”
As used herein in the specification and in the claims, the phrase “at least one,” in reference to a list of one or more elements, should be understood to mean at least one element selected from any one or more of the elements in the list of elements, but not necessarily including at least one of each and every element specifically listed within the list of elements and not excluding any combinations of elements in the list of elements. This definition also allows that elements may optionally be present other than the elements specifically identified within the list of elements to which the phrase “at least one” refers, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, “at least one of A and B” (or, equivalently, “at least one of A or B,” or, equivalently “at least one of A and/or B”) can refer, in one embodiment, to at least one, optionally including more than one, A, with no B present (and optionally including elements other than B); in another embodiment, to at least one, optionally including more than one, B, with no A present (and optionally including elements other than A); in yet another embodiment, to at least one, optionally including more than one, A, and at least one, optionally including more than one, B (and optionally including other elements); etc.
Use of ordinal terms such as “first,” “second,” “third,” etc., in the claims to modify a claim element does not by itself connote any priority, precedence, or order of one claim element over another or the temporal order in which acts of a method are performed, but are used merely as labels to distinguish one claim element having a certain name from another element having a same name (but for use of the ordinal term) to distinguish the claim elements.
It should also be understood that, unless clearly indicated to the contrary, in any methods claimed herein that include more than one step or act, the order of the steps or acts of the method is not necessarily limited to the order in which the steps or acts of the method are recited.
Each of the U.S. patents, U.S. patent application publications, U.S. patent applications, foreign patents, foreign patent applications and non-patent publications referred to in this application is incorporated herein by reference, in its entirety.
In some embodiments, an expression cassette encoding one or more gene products (e.g., a first, second and/or third gene product) comprises or consists of (or encodes a peptide having) a sequence set forth in any one of SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, or 48. In some embodiments, an expression cassette encoding one or more gene products comprises or consists of a sequence that is complementary (e.g., the complement of) a sequence set forth in any one of SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, or 48. In some embodiments, an expression cassette encoding one or more gene products comprises or consists of a sequence that is a reverse complement of a sequence set forth in any one of SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, or 48. In some embodiments, a gene product is encoded by a portion (e.g., fragment) of any one of SEQ ID NOs: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, or 48. In some embodiments, a nucleic acid sequence is a nucleic acid sense strand (e.g., 5′ to 3′ strand), or in the context of a viral sequences a plus (+) strand. In some embodiments, a nucleic acid sequence is a nucleic acid antisense strand (e.g., 3′ to 5′ strand), or in the context of viral sequences a minus (−) strand.
Notwithstanding the appended claims, the disclosure sets forth the following numbered embodiments:
1. A method for treating a subject having or suspected of having Parkinson's disease with a glucocerebrosidase-1 (GBA1) mutation, the method comprising administering to the subject:
2. A method for suppressing an immune response in a subject having or suspected of having Parkinson's disease with a glucocerebrosidase-1 (GBA1) mutation, the method comprising administering to the subject:
3. The method of embodiment 1 or 2, wherein the rAAV is administered to the subject at a dose ranging from about 5×1013 vector genomes (vg) to about 5×1014 vg.
4. The method of embodiment 1 or 2, wherein the rAAV is administered to the subject at a dose of about 1.4×1014 vg or about 2.8×1014 vg.
5. A method for treating a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
6. A method for suppressing an immune response in a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
7. The method of embodiment 5 or 6, wherein the rAAV is administered to the subject at a dose ranging from about 5×1010 vg/g brain to about 5×1011 vg/g brain.
8. The method of embodiment 5 or 6, wherein the rAAV is administered to the subject at a dose of about 1.3×1011 vg/g brain.
9. The method of any one of embodiments 1-8, wherein the rAAV is administered via an injection into the cisterna magna.
10. A method for treating a subject having or suspected of having Type 1 Gaucher disease, the method comprising administering to the subject:
11. A method for suppressing an immune response in a subject having or suspected of having Type 1 Gaucher disease, the method comprising administering to the subject:
12. The method of embodiment 10 or 11, wherein the rAAV is administered to the subject at a dose ranging from about 5×1013 vg to about 5×1014 vg.
13. The method of any one of embodiments 10-12, wherein the rAAV is administered intravenously.
14. A method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
15. A method for suppressing an immune response in a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
16. A method for treating a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
17. A method for suppressing an immune response in a subject having or suspected of having a synucleinopathy or parkinsonism, the method comprising administering to the subject:
18. The method of any one of embodiments 14-17, wherein the synucleinopathy or parkinsonism is multiple system atrophy, Parkinson's disease, Parkinson's disease with GBA1 mutation, Lewy body disease, dementia with Lewy bodies, dementia with Lewy bodies with GBA1 mutation, progressive supranuclear palsy, or corticobasal syndrome.
19. The method of any one of embodiments 1-18, wherein the promoter is a chicken beta actin (CBA) promoter.
20. The method of any one of embodiments 1-19, wherein the rAAV vector further comprises a cytomegalovirus (CMV) enhancer.
21. The method of any one of embodiments 1-20, wherein the rAAV vector further comprises a Woodchuck Hepatitis Virus Posttranscriptional Regulatory Element (WPRE).
22. The method of any one of embodiments 1-21, wherein the rAAV vector further comprises a Bovine Growth Hormone polyA signal tail.
23. The method of any one of embodiments 1-22, wherein the nucleic acid comprises two adeno-associated virus inverted terminal repeats (ITR) sequences flanking the expression construct.
24. The method of embodiment 23, wherein each ITR sequence is an AAV2 ITR sequence.
25. The method of embodiment 23 or 24, wherein the rAAV vector further comprises a TRY region between the 5′ ITR and the expression construct, wherein the TRY region comprises SEQ ID NO: 28.
26. A method for treating a subject having or suspected of having Parkinson's disease with a GBA1 mutation, the method comprising administering to the subject:
27. A method for suppressing an immune response in a subject having or suspected of having Parkinson's disease with a GBA1 mutation, the method comprising administering to the subject:
28. A method for treating a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
29. A method for suppressing an immune response in a subject having or suspected of having Type 2 Gaucher disease or Type 3 Gaucher disease, the method comprising administering to the subject:
30. The method of any one of embodiments 26-29, wherein the rAAV is administered via an injection into the cisterna magna.
31. The method of any one of embodiments 1-30, wherein the rAAV is administered in a formulation comprising about 20 mM Tris, pH 8.0, about 1 mM MgCl2, about 200 mM NaCl, and about 0.001% w/v poloxamer 188.
32. The method of any one of embodiments 1-31, wherein the methylprednisolone is administered intravenously at a dose of about 1000 mg either one day before or on the same day as administration of the rAAV.
33. The method of any one of embodiments 1-32, wherein the prednisone is administered orally
34. The method of any one of embodiments 1-33, wherein the rituximab is administered intravenously at a dose of about 1000 mg on any single day between 14 days before and 1 day before administration of the rAAV.
35. The method of embodiment 34, wherein the methylprednisolone is administered before the rituximab is administered.
36. The method of embodiment 35, wherein the methylprednisolone is administered at least about 30 minutes before the rituximab is administered.
37. The method of embodiment 34, wherein the methylprednisolone and the rituximab are both administered the day before administration of the rAAV; and wherein the methylprednisolone is administered at least about 30 minutes before the rituximab is administered.
38. The method of embodiment 34, wherein the rituximab is administered on any single day between 14 days before and 2 days before administration of the rAAV; and wherein methylprednisolone is administered intravenously at a dose of about 100 mg at least about 30 minutes before the rituximab is administered on the same day as the rituximab is administered
39. The method of any one of embodiments 1-38, wherein the sirolimus is administered orally
40. The method of any one of embodiments 5-13, 28 and 29, wherein the sirolimus is administered orally
41. The method of embodiment 39 or 40, wherein the sirolimus administration is tapered during the 15 days to 30 days following the end of the 90-day period after administration of the rAAV.
42. The method of any one of embodiments 1-39 and 41, the method comprising:
43. The method of any one of embodiments 1-39 and 41, the method comprising:
44. The method of any one of embodiments 2, 6, 11, 15, 17, 27 and 29, wherein the immune response is an immune response to the rAAV.
45. The method of any one of embodiments 2, 6, 11, 15, 17, 27, 29 and 44, wherein the immune response is a T cell response.
46. The method of any one of embodiments 2, 6, 11, 15, 17, 27, 29 and 44, wherein the immune response is a B cell response.
47. The method of any one of embodiments 2, 6, 11, 15, 17, 27, 29 and 44, wherein the immune response is an antibody response.
48. The method of any one of embodiments 2, 6, 11, 15, 17, 27, 29 and 44, wherein the immune response is pleocytosis.
49. The method of embodiment 48, wherein the pleocytosis is cerebrospinal fluid (CSF) pleocytosis.
50. The method of any one of embodiments 2, 6, 11, 15, 17, 27, 29 and 44, wherein the immune response is an abnormal level of CSF protein.
51. The method of any one of embodiments 1-50, wherein an additional immunosuppressant that is not sirolimus, methylprednisolone, rituximab or prednisone is further administered to the subject.
52. A therapeutic combination of
53. A therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
54. The therapeutic combination for use of embodiment 52 or 53, wherein the combination comprises from about 5×1013 vg to about 5×1014 vg of the rAAV.
55. The therapeutic combination for use of embodiment 52 or 53, wherein the combination comprises about 1.4×1014 vg or about 2.8×1014 vg of the rAAV.
56. A therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
57. A therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
58. A therapeutic combination of a recombinant adeno-associated virus (rAAV) comprising:
59. A therapeutic combination of
aPR001B is a version of PR001A with an altered D domain; PR001A and PR001B are otherwise identical.
aPost-PR001A treatment
This application claims the benefit of U.S. Provisional Patent Application No. 63/063,851, filed on Aug. 10, 2020, the disclosure of which is hereby incorporated by reference in its entirety.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US2021/045447 | 8/10/2021 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 63063851 | Aug 2020 | US |
