Patent Application
20230279434
Applicant hereby incorporates by reference a CRF sequence listing having file name 10738_1002 Sequence Listing.xml (19.4 KB), created on Dec. 21, 2022. In the accompanying sequence listing:
The present disclosure relates to methods and compositions for the treatment of motor neuron degenerative disorders, and more particularly, for the treatment of amyotrophic lateral sclerosis (ALS). The methods and compositions disclosed herein employ adeno-associated virus (AAV) vectors to introduce genes into skeletal muscle that increase ciliary neurotrophic factor receptor (CNTF) and ligand expression and inhibit ALS progression.
Amyotrophic lateral sclerosis (ALS) is an adult-onset, neurodegenerative, invariably terminal disease with death typically occurring within 2-3 years of symptom onset, and an estimated annual cost of over a billion dollars in the United States alone. There is no current cure and just one FDA approved treatment, riluzole, which prolongs survival by only 3 months.
ALS patients do not develop overt symptoms until late in the underlying disease process. Even with tertiary care centers and recent advances, diagnosis still takes approximately one year following symptom onset, further delaying treatment for all but the rare genetically diagnosed cases. Therefore, any broadly useful ALS treatment must be effective when initiated very late in the underlying disease after the ALS patient has been diagnosed. While the mechanism(s) underlying ALS are still being determined, they undoubtedly involve a series of molecular and cellular events. Interventions effective against early steps in this process would not necessarily be expected to be effective against the later steps occurring when patients are finally diagnosed. Therefore, it is not surprising that interventions developed by treating ALS mice at earlier disease stages have a history of failure in clinical trials.
Work with human ALS cell culture and model mice containing mutant copper zinc superoxide dismutase 1 (SOD1) indicates that multiple cell types, including glia, are involved in the motor neuron (MN) degeneration responsible for ALS symptoms and death. Many cellular and molecular causes have been proposed, but if a common cause is responsible for all ALS, it has yet to be established.
Endogenous neuroprotective mechanisms reduce the effects of neural insults, including neurodegenerative diseases. Ciliary neurotrophic factor receptor alpha (CNTFRα), the essential ligand binding subunit of the CNTF receptor, is expressed by both MNs and muscle. Its expression is increased in muscle by denervating nerve injury and denervating neuromuscular diseases in humans, including ALS. Evidence suggests that CNTF receptor signaling is a broadly effective endogenous neuroprotective mechanism suppressing ALS. In addition to protecting MNs during development and following perinatal nerve lesion, enhancing CNTF receptor signaling with exogenous CNTF delays disease progression and protects MN axons in several distinct models of ALS, including SOD1 mutant, pmn, and Wobbler mice, in contrast to the many potential therapies developed solely with SOD1 mutant mice.
Only two CNTF-related ALS clinical trials have been conducted with enough subjects and trial length to determine therapeutic effect. In both cases, CNTF was systemically injected into ALS patients. The systemic CNTF injections produced systemic side effects, most notably weight loss, as in CNTF injected mice. Systemic CNTF injections activate non-CNTF receptors in the liver and non-neuromuscular CNTF receptors regulating weight and produce side effects in mice at doses at least 10-fold lower than those needed to decrease disease in ALS mice. Therefore, it is understandable that the clinical trials failed in that they used systemic CNTF doses selected to produce minimal side effects, which are presumably also well below the doses needed to affect ALS in humans. Clinical trials demonstrated that ALS cannot be treated with systemic CNTF injections because side effects limit the amount of CNTF that can be administered. Clearly, there is a continuing need for ALS treatments that avoid negative systemic side effects and are effective even when initiated late in the underlying disease process.
Provided herein are methods and compositions for the treatment of motor neuron degenerative disorders, particularly ALS, that do not depend on the cause of the disorder, but are instead based on the finding that enhancing an endogenous neuroprotective, anti-ALS mechanism can inhibit motor neuron degeneration and ALS resulting from a wide variety of cellular and molecular causes. Because the disclosed compositions and methods are not dependent on reversing the causes, they have the potential to treat ALS before the cause(s) are identified and to be broadly effective in the likely event that ALS results from multiple causes. The compositions and methods disclosed herein employ adeno-associated virus (AAV) gene delivery vectors to introduce ciliary neurotrophic factor receptor alpha (CNTFRα), cardiotrophin-like cytokine factor 1 (CLC), and/or cytokine receptor-like factor 1 (CLF) to skeletal muscle, thereby increasing endogenous neuroprotective mechanisms and inhibiting progression of ALS.
In one embodiment, a method for slowing the progression of amyotrophic lateral sclerosis (ALS) in an adult subject in need thereof is provided, the method comprising: inhibiting motor neuron degeneration by administering to the subject a modified adeno-associated virus (AAV) vector, the modified AAV vector comprising a recombinant AAV (rAAV)-based genome consisting essentially of an AAV backbone, a control element, and a transgene consisting essentially of a ciliary neurotrophic factor receptor alpha (CNTFRα) cDNA insert, wherein the modified AAV vector is engineered to direct enhanced skeletal muscle expression of CNTFRα.
These and other objects, features, embodiments, and advantages will become apparent to those of ordinary skill in the art from a reading of the following detailed description and the appended claims.
The details of one or more embodiments of the presently-disclosed subject matter are set forth in this document. Modifications to embodiments described in this document, and other embodiments, will be evident to those of ordinary skill in the art after a study of the information provided in this document.
The practice of the present invention will employ, unless otherwise indicated, conventional methods of virology, microbiology, molecular biology and recombinant DNA techniques within the skill of the art. Such techniques are explained fully in the literature. See, e.g., Sambrook et al. Molecular Cloning: A Laboratory Manual (Current Edition); DNA Cloning: A Practical Approach, Vol. I & II (D. Glover, ed.); Oligonucleotide Synthesis (N. Gait, ed., Current Edition); Nucleic Acid Hybridization (B. Hames & S. Higgins, eds., Current Edition); Transcription and Translation (B. Hames & S. Higgins, eds., Current Edition); CRC Handbook of Parvoviruses, vol. I & II (P. Tijssen, ed.); Fundamental Virology, 2nd Edition, vol. I & II (B. N. Fields and D. M. Knipe, eds.); Freshney Culture of Animal Cells, A Manual of Basic Technique (Wiley-Liss, Third Edition); and Ausubel et al. (1991) Current Protocols in Molecular Biology (Wiley Interscience, NY).
While the following terms are believed to be well understood by one of ordinary skill in the art, definitions are set forth to facilitate explanation of the presently-disclosed subject matter. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the presently-disclosed subject matter belongs.
Unless otherwise indicated, all numbers expressing quantities of ingredients, properties such as reaction conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term “about.” Accordingly, unless indicated to the contrary, the numerical parameters set forth in this specification and claims are approximations that can vary depending upon the desired properties sought to be obtained by the presently-disclosed subject matter.
As used herein, the term “about,” when referring to a value or to an amount of mass, weight, time, volume, concentration or percentage is meant to encompass variations of in some embodiments ±20%, in some embodiments ±10%, in some embodiments ±5%, in some embodiments ±1%, in some embodiments ±0.5%, and in some embodiments ±0.1% from the specified amount, as such variations are appropriate to perform the disclosed method.
It should be understood that every maximum numerical limitation given throughout this specification includes every lower numerical limitation, as if such lower numerical limitations were expressly written herein. Every minimum numerical limitation given throughout this specification will include every higher numerical limitation, as if such higher numerical limitations were expressly written herein. Every numerical range given throughout this specification will include every narrower numerical range that falls within such broader numerical range, as if such narrower numerical ranges were all expressly written herein.
As used in this specification and the appended claims, the singular forms “a,” “an” and “the” include plural references unless the content clearly dictates otherwise.
“Functionally equivalent,” as used herein, refers to a CNTFRa, CLC, or CLF polypeptide that retains some or all of the biological properties regarding inhibition of motor neuron degenerative disorders, such as ALS, but not necessarily to the same degree, as a native CNTFRa, CLC, or CLF molecule.
“Homology” refers to the percent similarity between two polynucleotide or two polypeptide moieties. Two polynucleotide, or two polypeptide sequences are “substantially homologous” to each other when the sequences exhibit at least about 50%, at least about 75%, at least about 80%-85%, at least about 90%, or at least about 95%-99% or more sequence similarity or sequence identity over a defined length of the molecules. As used herein, substantially homologous also refers to sequences showing complete identity to the specified polynucleotide or polypeptide sequence.
In general, “identity” refers to an exact nucleotide-to-nucleotide or amino acid-to-amino acid correspondence of two polynucleotides or polypeptide sequences, respectively. Percent identity can be determined by a direct comparison of the sequence information between two molecules by aligning the sequences, counting the exact number of matches between the two aligned sequences, dividing by the length of the shorter sequence, and multiplying the result by 100.
By “variant” is meant a biologically active derivative of the reference molecule, or a fragment of such a derivative, that retains desired activity, such as anti-ALS activity in the assays described herein. In general, the term “variant” refers to compounds having a native polypeptide sequence and structure with one or more amino acid additions, substitutions (generally conservative in nature) and/or deletions, relative to the native molecule, so long as the modifications do not destroy anti-ALS activity. Preferably, the variant has at least the same biological activity as the native molecule.
As used herein, the term “motor neuron degenerative disorder” refers to a degenerative disorder affecting a neuron with motor function. Motor neuron degenerative disorders include, but are not limited to, amyotrophic lateral sclerosis (ALS), primary lateral sclerosis (PLS), progressive muscular atrophy (PMA), progressive bulbar palsy (PBP), pseudobulbar palsy, peripheral neuropathy, spinal muscular atrophy, and Kennedy’s disease. Motor neuron degenerative disorders cause increasing disability and can be terminal in nature. In a particular embodiment, the motor neuron degenerative disorder treated by the compositions and methods disclosed herein is ALS.
ALS is characterized by stages progressing in severity. In early stage ALS disease, muscles may be weak and soft or stiff, tight, and spastic. Muscle cramping and twitching occurs, as does loss of muscle bulk. Symptoms may be limited to a single body region or mild symptoms may affect more than one region. The subject suffering from ALS may experience fatigue, poor balance, slurred words, weak grip, tripping, or other minor symptoms. Middle stage ALS is characterized by more widespread symptoms, muscle paralysis, or muscle weakening. Cramping and twitching may also be present. Unused muscles may cause contractures, whereby joints may become rigid, painful, and deformed. Weakness in swallowing muscles may cause choking and difficulties eating. Weakened breathing muscles can lead to respiratory insufficiency, particularly when lying prone. Subjects may also experience inappropriate laughing or crying (pseudobulbar affect). In late stage ALS, most voluntary muscles are paralyzed. Respiratory muscles are severely compromised. Mobility is limited and assistance is required for personal care. Poor respiration may cause fatigue, confusion, headaches, and pneumonia. Speech, eating, and drinking may not be possible. In certain embodiments, the modified AAV gene delivery vectors packaging rAAV genomes comprising cDNA inserts described herein are useful in treating a subject suffering from ALS. In a specific embodiment, the modified AAV vectors are useful in treating subjects suffering from early, middle, or late stage ALS. In a very specific embodiment, the modified AAV vectors are useful in treating late stage ALS disease.
Studies have shown that a subset of patients with ALS possess mutations in certain genes. One such mutation occurs in the TDP-43 (TARDBP) gene, which suggests that gain of toxic function or loss of function in TDP-43 is an underlying cause of ALS. Pesiridis, et al., Mutations in TDP-43 link glycine-rich domain functions to amyotrophic lateral sclerosis, Human Mol. Genet. 18(R2): R156-R162 (2009). In certain embodiments, the methods and compositions disclosed herein are useful for treating ALS characterized by one or both of at least one TDP-43 mutation and abnormal TDP-43 distribution in a subject.
As used herein, the term “subject” refers to any mammalian subject, including humans.
An “effective amount” is an amount sufficient to effect beneficial or desired results. An effective amount can be administered in one or more administrations, applications or dosages. The effective amount of modified AAV vectors for use in the compositions and methods herein will vary with the motor neuron degenerative disorder being treated, the age and physical condition of the subject to be treated, the severity of the condition, the duration of the treatment, the nature of concurrent therapy, the particular modified AAV vector being employed, the particular pharmaceutically-acceptable carriers utilized, and like factors within the knowledge and expertise of the attending physician.
The present disclosure is based on the discovery that increased CNTF receptor alpha expression in denervated muscle inhibits ALS. CNTFRα is attached to the extracellular surface of the plasma membrane by a glycosyl-phosphatidylinositol (GPI) linkage and is released following nerve lesion in soluble, functional form that may enhance CNTF receptor activity in MNs. As described herein, CNTFRα RNA expression is increased in the skeletal muscle of a wide variety of ALS model mice (as in human ALS) and selective in vivo genetic disruption shows that in each case this muscle CNTFRα expression can inhibit the disease. Together, these unexpected findings indicate that the increased muscle CNTFRα expression in human ALS is an endogenous neuroprotective, anti-ALS response and that enhancing this response slows disease progression and/or reverses, at least temporarily, motor symptoms associated with ALS.
As discussed herein, SOD1G93A ALS mice were injected intramuscularly with a muscle tropic AAV-CNTFRa vector to increase muscle CNTFRα expression. Treatment delayed end stage paralysis and slowed disease progression, even though only a local injection was administered. Most importantly, treatment was effective when initiated later in the disease than other proposed treatments known in the art. Given the clinical reality that ALS treatments must be effective when started very late in the underlying disease, the presently disclosed methods and compositions represent a promising ALS therapeutic approach.
Targeted increase in muscle CNTFRα expression via gene therapy is less likely to produce the side effects seen with systemic CNTF injection. First, unlike CNTF, CNTFRα does not contribute to non-CNTF receptor signaling. Second, unlike CNTF injections, increasing CNTFRα expression should enhance CNTF receptor signaling only where and when endogenous CNTF receptor ligands are active because, without the ligands, increased receptor expression does not increase signaling. Third, CNTF knockout studies indicate that endogenous CNTF is not active in weight regulation, the primary side effect of exogenous CNTF administration. Fourth, unlike CNTF injections, targeted increases in muscle CNTFRα expression should enhance a natural, endogenous, ALS-induced response (i.e., the increase in muscle CNTFRα RNA). As described herein, targeting of muscle CNTFRα led to no side effects and reduced ALS associated weight loss, the opposite of the CNTF related side effect observed with systemic administration. The compositions and methods disclosed herein target muscle CNTFRα with high level, continuous changes in gene expression.
Adeno-associated virus (AAV) is a small, nonenveloped icosahedral virus that infects humans and other primates, but causes only weak immune response and is not considered pathogenic. At present, multiple AAV serotypes (AAV1-AAV13) have been sequenced and studies have identified other AAV genomes. AAVs differ in tropism for target tissues, including cardiac and skeletal muscle, liver and lung tissue, and cells in the CNS. Differing tropisms can be exploited for use in gene therapy, enabling the directed treatment of specific tissues. Drouin, et al., Adeno-associated virus structural biology as a tool in vector development, Future. Virol. 8(12): 1183-99 (2013). AAV vectors modified to be muscle-tropic are particularly useful in gene therapy treatments for motor neuron degenerative disorders. By an “AAV vector” is meant a vector derived from an adeno-associated virus serotype.
The AAV vectors disclosed herein are engineered to package a recombinant AAV-based genome (rAAV). rAAV genomes can be single stranded rAAV, which requires synthesis of a complementary DNA strand, or self-complementary rAAV (scrAAV), which packages two shorter DNA strands that are complementary to each other. By avoiding second-strand synthesis, scrAAV can express more quickly, although vector capacity is reduced. In certain embodiments, the AAV vectors disclosed herein comprise an rAAV genome comprising single stranded rAAV, self-complementary rAAV (scrAAV), and combinations thereof.
Ciliary neurotrophic factor receptor alpha (CNTFRα) is an essential ligand binding subunit of the CNTF receptor, which is composed of CNTFRa, a leukemia inhibitory factor receptor (β (LIFRβ), and glycoprotein (gp) 130. While LIFRβ and gp130 are found in other related receptors, CNTFRα is unique to CNTF receptors and is required for all known forms of CNTF receptor signaling. A number of CNTFRα polynucleotide and amino acid sequences are known. The degree of homology between rat, human, and mouse proteins is about 94%. Representative protein coding sequences of rat, human, and mouse CNTFRα are set forth herein as SEQ ID NOs: 2, 3, and 4, respectively. Additional CNTFRα sequences are known in the art. See, e.g., NCBI accession numbers AL160270, AL537375, BM714356, BT019824, BX364434, BC001492, BI829871, and BM714356 (human); BC046974, CX202454, AL831723, and BY715214 (mouse); S54212 (rat); JU332908 (rhesus monkey); and AF529215 (dog) (all accession numbers accessed Mar. 31, 2017, 12:00 a.m. EST); as well as other known mammalian CNTFRα sequences. Any of these sequences, as well as variants thereof, such as sequences substantially homologous and functionally equivalent to these sequences, will find use in the present methods. In a specific embodiment, the modified AAV vector comprises an rAAV genome comprising a CNTFRα cDNA insert, wherein the vector produces a protein selected from SEQ ID NOs: 2, 3, or 4, or a substantially homologous or functionally equivalent variant thereof.
Cardiotrophin-like cytokine factor 1 (CLC) is a member of the gp130 cytokine family and encodes cardiotrophin-like cytokine factor 1. CLC forms a heterodimer complex with cytokine receptor-like factor 1 (CLF). This dimer competes with ciliary neurotrophic factor (CNTF) for binding to the ciliary neurotrophic factor receptor (CNTFR) complex, and activates the Jak-STAT signaling cascade. CLC can be actively secreted from cells by forming a complex with soluble type I CLF or soluble CNTFR. CLC is a potent neurotrophic factor, B-cell stimulatory agent and neuroendocrine modulator of pituitary corticotroph function. A number of CLC polynucleotide and amino acid sequences are known. Representative protein coding sequences of human and mouse CLC are set forth herein as SEQ ID NOs: 5 and 6, respectively. Additional CLC sequences are known in the art. See, e.g., NCBI accession numbers AK298052, BC012939, DC393345, and BM846622 (human); AC109138, AI451696, AK137396, BB786146, BC104258, and CX202966 (mouse); and BC098643 (rat) (all accession numbers accessed Mar. 31, 2017, 12:00 a.m. EST); as well as other mammalian CLC sequences. Any of these sequences, as well as variants thereof, such as sequences substantially homologous and functionally equivalent to these sequences, will find use in the present methods. In a specific embodiment, the modified AAV vector comprises an rAAV genome comprising a CLC cDNA insert, wherein the vector produces a protein selected from SEQ ID NOs: 5 or 6, or a substantially homologous or functionally equivalent variant thereof.
Cytokine receptor-like factor 1 (CLF) encodes a member of the cytokine type I receptor family. The protein forms a secreted complex with cardiotrophin-like cytokine factor 1 (CLC) and acts on cells expressing ciliary neurotrophic factor receptors. The complex can promote survival of neuronal cells. A number of CLF polynucleotide and amino acid sequences are known. Representative protein coding sequences of human and mouse CLF are set forth herein as SEQ ID NOs: 7 and 8, respectively. Additional CLF sequences are known in the art. See, e.g., NCBI accession numbers AF073515 and AY358291 (human); AC157774 (mouse); CH474031 (rat); and BC076526 (zebrafish) (all accession numbers accessed Mar. 31, 2017, 12:00 a.m. EST); as well as other mammalian CLF sequences. Any of these sequences, as well as variants thereof, such as sequences substantially homologous and functionally equivalent to these sequences, will find use in the present methods. In a specific embodiment, the modified AAV vector comprises an rAAV genome comprising a CLF cDNA insert, wherein the vector produces a protein selected from SEQ ID NOs: 7 or 8, or a substantially homologous or functionally equivalent variant thereof.
Each rAAV genome is engineered to comprise at least one cDNA insert protein coding sequence. In one embodiment, the cDNA insert is selected from the group consisting of a ciliary neurotrophic factor receptor alpha (CNTFRα) cDNA insert, a cardiotrophin-like cytokine factor 1 (CLC) cDNA insert, and a cytokine receptor-like factor 1 (CLF) cDNA insert. In certain embodiments, the cDNA insert is a CNTFRα cDNA insert. In another embodiment, the cDNA insert is a CLC cDNA insert. In another embodiment, the cDNA insert is a CLF insert. While not desiring to be bound by theory, it is believed that the administration of AAV vectors packaging rAAV genomes comprising CLC, and/or CLF cDNA inserts to a subject suffering from a motor neuron degenerative disorder will enhance the therapeutic effects of the administration of AAV vectors packaging rAAV CNTFRα genomes by providing ligands for the increased receptor expression. Moreover, it is believed that the administration of AAV vectors packaging rAAV genomes comprising CLC and/or CLF cDNA inserts to a subject suffering from a motor neuron degenerative disorder will enhance the therapeutic effects of the increase in endogenous muscle CNTFRα.
The AAV vectors disclosed herein comprise control elements capable of directing the in vivo transcription and translation of CNTFRa, CLC, or CLF. In certain embodiments, the control elements comprise a promoter. The term “promoter” is used herein to refer to a nucleotide region comprising a DNA regulatory sequence, wherein the regulatory sequence is derived from a gene which is capable of binding RNA polymerase and initiating transcription of a downstream (3′-direction) coding sequence. In one embodiment, the promoter is selected from a cytomegalovirus early enhancer element/chicken beta-actin (CAG) promoter and a muscle-specific promoter. In a specific embodiment, the muscle-specific promoter is a muscle specific creatine kinase (MCK) promoter. In a more specific embodiment, the MCK promoter comprises double muscle specific creatine kinase (dMCK) or triple muscle specific creatine kinase (tMCK) promoter. The skilled artisan will appreciate that other promoters are known in the art and suitable for use in controlling and directing the in vivo transcription and translation of CNTFRa, CLC, or CLF.
In a particular embodiment, combinations of modified AAV vectors are administered to a subject. For example, in one embodiment, a method for treating a subject suffering from a motor neuron disorder comprises administering (1) a modified AAV vector packaging an rAAV-based genome comprising a CNTFRα cDNA insert, together with (2) a modified AAV vector packaging an rAAV-based genome comprising a CLC cDNA insert. In another embodiment, the method comprises administering (1) a modified AAV vector packaging an rAAV-based genome comprising a CNTFRα cDNA insert, together with (2) a modified AAV vector packaging an rAAV-based genome comprising a CLF cDNA insert. In another embodiment, the method comprises administering (1) a modified AAV vector packaging an rAAV-based genome comprising a CNTFRα cDNA insert, together with (2) a modified AAV vector packaging an rAAV-based genome comprising a CLC cDNA insert, and (3) a modified AAV vector packaging an rAAV-based genome comprising a CLF cDNA insert. In another embodiment, the method comprises administering (1) a modified AAV vector packaging an rAAV-based genome comprising a CLC cDNA insert, together with (2) a modified AAV vector packaging an rAAV-based genome comprising a CLF cDNA insert.
Modified AAV vectors comprising distinct cDNA inserts can be co-administered or sequentially administered. When sequentially administered, the duration of time between administering a first AAV vector and administering a subsequent AAV vector may be from about 1 hour, 2 hours, 3 hours, 4 hours, 6 hours, 12 hours, 24 hours, one week, two weeks, three weeks, 4 weeks, one month, up to six months. In some embodiments, administration of one or more AAV vectors as described herein is initiated prior to, contemporaneous with, or even after onset of motor symptoms in the subject. In a specific embodiment, administration is initiated during late stage ALS disease and is effective to slow disease progression and/or at least temporarily partially reverse motor symptoms in the subject, including paralysis.
Administration of modified AAV vectors comprises systemic and non-systemic administration. In particular embodiments, non-systemic administration comprises intramuscular (IM) injection to one or more muscles selected from non-respiratory skeletal muscles, respiratory skeletal muscles, and combinations thereof. In certain embodiments, IM injections are administered unilaterally to a subject. In other embodiments, IM injections are administered bilaterally to the subject, for example, bilaterally to the gastrocnemius muscle on each side of the subject. When two or more AAV vectors packaging genomes comprising distinct cDNA inserts are administered, the two or more AAV vectors can be independently administered; for example, one AAV vector may be administered systemically, and a second AAV vector may be administered non-systemically. Similarly, the location (i.e., skeletal muscle) and manner (i.e., unilateral or bilateral) of injection for non-systemic administration may vary between distinct AAV vectors.
Pharmaceutical compositions will comprise sufficient genetic material to produce a therapeutically effective amount of the CNTFRa, CLC, and/or CLF of interest, i.e., an amount sufficient to reduce or ameliorate symptoms of the disease state in question or an amount sufficient to confer the desired benefit. The compositions will also contain a pharmaceutically acceptable excipient. Such excipients include any pharmaceutical agent that does not itself induce the production of antibodies harmful to the individual receiving the composition, and which may be administered without undue toxicity. Pharmaceutically acceptable excipients include, but are not limited to, sorbitol, any of the various TWEEN compounds, and liquids such as water, saline, glycerol and ethanol. Pharmaceutically acceptable salts can be included therein, for example, mineral acid salts such as hydrochlorides, hydrobromides, phosphates, sulfates, and the like; and the salts of organic acids such as acetates, propionates, malonates, benzoates, and the like. Additionally, auxiliary substances, such as wetting or emulsifying agents, pH buffering substances, and the like, may be present in such vehicles. A thorough discussion of pharmaceutically acceptable excipients is available in REMINGTON’S PHARMACEUTICAL SCIENCES (Mack Pub. Co., N.J. 1991).
One particularly useful formulation comprises recombinant AAV vectors in combination with one or more dihydric or polyhydric alcohols, and, optionally, a detergent, such as a sorbitan ester. See, for example, International Publication No. WO 00/32233.
Pharmaceutical compositions described herein may be formulated for intramuscular administration or intravenous administration and may be administered according to any of the methods disclosed herein.
As is apparent to those skilled in the art in view of the teachings of this specification, an effective amount of viral vector which must be added can be empirically determined. Representative doses are detailed below. Administration can be effected in one dose, continuously or intermittently throughout the course of treatment. Methods of determining the most effective means and dosages of administration are well known to those of skill in the art and will vary with the viral vector, the composition of the therapy, the target cells, and the subject being treated. Single and multiple administrations can be carried out with the dose level and pattern being selected by the treating physician. In certain embodiments, increasing a dose level increases the therapeutic benefit of the composition.
It should be understood that distinct AAV vectors, each expressing one or more different transgenes, can also be delivered as described herein. Furthermore, it is also intended that the viral vectors delivered by the methods of the present invention be combined with other suitable compositions and therapies. Where the transgene is under the control of an inducible promoter, certain systemically delivered compounds such as muristerone, ponasteron, tetracyline or aufin may be administered in order to regulate expression of the transgene.
Modified AAV vectors may be delivered directly to muscle by injection with a needle, catheter, or related device, using techniques known in the art. For in vivo delivery, the AAV vectors will be formulated into pharmaceutical compositions and one or more dosages may be administered directly in the indicated manner. A therapeutically effective dose will include on the order of from about 108/kg to 1016/kg of the AAV vectors, optionally from about 1010/kg to 1014/kg, and optionally from about 1011/kg to 1013/kg of each modified AAV vector (or viral genomes, also termed “vg”), or any value within these ranges.
In one embodiment, a pharmaceutical composition for the treatment of a motor neuron degenerative disorder is provided, the composition comprising: one or more muscle-tropic modified AAV vectors, each of said AAV vectors packaging an rAAV genome, each of said rAAV genomes engineered to comprise: (i) a cDNA insert selected from the group consisting of a CNTFRα cDNA insert, a CLC cDNA insert, and a CLF cDNA insert; and (ii) a promoter; and a pharmaceutically acceptable excipient. In certain embodiments, the rAAV genome comprises single-stranded rAAV, self-complementary rAAV (scrAAV), or combinations thereof. As described above, in some embodiments the promoter is selected from the group consisting of a cytomegalovirus early enhancer element/chicken beta-actin (CAG) promoter and a muscle-specific promoter. In a specific embodiment, the promoter is a muscle specific promoter selected from the group consisting of muscle specific creatine kinase (MCK) promoter, double MCK (dMCK) promoter, and triple MCK (tMCK) promoter.
The following examples are given by way of illustration and are in no way intended to limit the scope of the present invention.
Mice were monitored for weight and inability to right themselves in 30 sec when placed on side, i.e., -universal index of end stage paralysis (loss of motor function) in ALS mouse models. These data, and age at max weight, age at 10% weight loss from max, and time from max weight to end stage (widely used indexes of disease onset, early disease and disease duration, respectively) were analyzed by 2-tailed log rank test.
The CNTF receptor contains CNTFRa, leukemia inhibitory factor receptor β and gp130. Only CNTFRα is unique to the CNTF receptor, absolutely required for all CNTF receptor signaling, and not involved in any other signaling. Therefore, disruption of CNTFRα in vivo is the best way to determine the endogenous roles played by CNTF receptor signaling. Neuromuscular CNTF receptors are restricted to MNs and muscle.
Human and animal data suggest that MN terminal loss is the initial critical step in MN degeneration leading to ALS symptoms. When the CNTFRα gene is selectively disrupted in adult MNs (confirmed by CNTFRα immunohistochemistry) by crossing floxed CNTFRα mice with “SLICK-A” mice and treating adults with tamoxifen to drive Creactivity and a YFP reporter in a subset of MNs (but not muscle), it has no effect on MN terminals (homozygous floxed mice had 97.9% as many reporter+ terminals as littermate controls; p>0.5, t=0.02, N=6 pair). Therefore, without insult, adult MN CNTFRα expression is not required to maintain terminals. However, when the “CreER” construct and a YFP reporter was used in an analogous experiment to disrupt the CNTFRα gene in both a subset of MNs, comparable to SLICK-A, and in muscle (both confirmed) the depleted mice contained only 28.9% as many reporter+ terminals as their littermate controls (p=0.005; t= 5.53; N=5 pair). Therefore, the additional loss of muscle CNTFRα expression led to terminal loss not seen with MN CNTFRα disruption alone, indicating that muscle CNTFRα expression can surprisingly maintain MN terminals under some circumstances (in MNs lacking CNTFRa).
The above data indicating that muscle CNTFRα expression helps maintain MN terminals also support that it can inhibit ALS, consistent with the increased muscle CNTFRα expression in denervating human disease, including ALS. Mlclf-Cre was then used to selectively deplete muscle CNTFRα expression in the most commonly used ALS model, “high copy number” SOD1G93A mice (Jax. Lab. stock #004435). This led to earlier end stage paralysis (
Of the potential ALS treatments developed with SOD1 mutant mice and taken to human trials only riluzole had any clinical benefit. Riluzole modestly slowed both human and mouse disease progression. All other treatments failed to slow mouse or human disease progression, while only delaying mouse disease onset, prompting the conclusion by leaders in the field that recognizing that success at human trial will require slowing of disease progression, the SOD1-mutant mice have perfectly predicted the success of riluzole and the failure of efficacy of each other drug attempted in human trial. Therefore, despite the examples of failed ALS treatments developed with SOD1-mutant mice, the assay is completely valid when used correctly to measure changes in disease progression.
Moreover, it is not enough that treatments slow disease progression. Late ALS symptom onset and subsequent, long delays in clinical diagnosis before treatment initiation dictate that any broadly useful ALS treatment must be effective when initiated very late in the underlying disease.
Safety and long term expression profiles of AAV have made it the vector of choice for human gene therapy. AAV1 is a preferred AAV capsid for intramuscular (IM) injection. AAV1.1 is a Samulski lab, AAV1-derived capsid engineered to direct enhanced skeletal muscle expression. AAV1.1 was used to package an AAV2-based vector (
The onset (
Of the many reports of SOD1G93A ALS mouse treatments, no other treatment to date has decreased SOD1G93A disease when initiated as late as the AAVl.l-CNTFRa treatment, with most treatments initiated much earlier. As expected, there are several reports of earlier treatment producing large therapeutic effects that diminish or disappear when treatment is started later (but still earlier than the instant experimental results). Given the clinical reality that ALS treatments need to be effective when started very late in the underlying disease, the AAV1.1-CNTFRa treatment is arguably the most promising ALS therapeutic proposed to date.
Unlike the weight loss side effect seen with systemic CNTF administration, the AAVl.l-CNTFRa surprisingly had the opposite effect, delaying weight loss in SOD1G93A mice (
Blind scoring of the SOD1G93A mice indicated that two mice (both AAV1.1-CNTFRα injected) temporarily “recovered,” with a dramatic decrease in paralysis (large decrease in righting time relative to previous measurements) for several days nearing end stage. Having lost 38.4±3.0% of their max weight, these two mice and one other AAV1.1-CNTFRα mouse gained a surprising and unexpected 23.6±2.2% of their total weight over the same 3-5 day “recovery” period before again declining. This is a unique and unprecedented outcome in the 30+ control SOD1G93A mice observed. These promising data support the conclusion that enhancing muscle CNTFRα expression, even very late in the disease, may delay decline as well as temporarily reverse the disease effects.
Mlclf-Cre and floxed CNTFRα mice were used to specifically reduce muscle CNTFRα in SOD1G37R mice, a widely used ALS model with a different human ALS-inducing mutation and lower mutant SOD1 levels, more like human ALS.
Muscle specific CNTFRα knockdown with mlclf-Cre (
CNTFRα knockdown specifically and greatly accelerated progression through the final disease phase (
Muscle CNTFRα was then knocked down starting in adulthood with HSA-MCM, which drives muscle specific, tamoxifen inducible Cre, with no pre-tamoxifen leakage.
Transactivating Response Region DNA binding protein 43 (TDP-43) mutations underlie 1-5% of familial ALS. TDP-43+ aggregates are found in all sporadic ALS, suggesting that TND-43 pathology underlies most ALS disease. Unlike other available TDP-43 mouse models that display unworkable phenotype variability and/or degenerate before adulthood, a line with a human ALS-causing TDP-43Q331K mutation, displays an adult-onset progressive motor deficit as needed for adult-onset disruption studies.
As shown in
This data with HSA-MCM clearly indicate that adult onset muscle specific CNTFRα knockdown greatly accelerates TDP-43Q331K disease since all three knockdown mice displayed the hindlimb clasp motor deficit long before any of the 7 controls. The data suggest an overall difference >150 days (
The data suggest that CNTFRα is induced to play the anti-ALS roles revealed by the presently disclosed knockdown data. The smaller CNTFRα knockdown effect throughout SOD1G93A disease compared to the larger effect specific to final stage SOD1G37R disease (
This demonstration of in vivo anti-ALS activity in multiple SOD1 models and a mammalian TDP-43 model is surprising. It suggests the muscle CNTFRα increase in human ALS and all ALS models is a broadly effective endogenous anti-ALS response and that further increasing this expression therapeutically enhances anti-ALS response.
When CLC and CNTFRα are heterologously expressed together in vitro, a soluble CLC/ CNTFRα complex is released, which can activate CNTF receptors and promote survival of cultured embryonic motor neurons (MNs). In situ hybridization indicates in vivo embryonic muscle cells express this combination of CLC and CNTFRa, indicating CLC/CNTFRa released from these cells protects MNs from development associated death in vivo. In agreement, knockout of either CLC or CNTFRα (but not CNTF) leads to embryonic MN loss. Together, the data indicate that the anti-ALS effects of endogenous muscle CNTFRα similarly involve muscle CLC/CNTFRa release protecting adult ALS MNs, either by acting on MN CNTF receptors or eliciting the release of neuroprotective muscle factors by acting on muscle CNTF receptors.
Moreover, like muscle CNTFRα RNA, muscle CLC RNA: 1) increased starting early in SOD1G93A disease (238±31% of controls; p=0.0059; n=8), 2) increased in TDP-43Q331K mice at 1 year (undetectable in controls and ~2 fold above detection threshold in TDP-43Q331K mice; n=5) while unaffected at 3 months, and 3) selectively increased 6.9±1.5 fold; n=3 in final paralytic stage SOD1G37R mice. Therefore, while not desiring to be bound by theory, the data indicate that the endogenous anti-ALS mechanism may involve simultaneous CLC and CNTFRα increases, leading to increased MN protective CLC/CNTFRa release, such that the AAV1.1-CNTFRα therapeutic effect observed derives from a further increase in muscle CLC/CNTFRa release that should, at high enough AAV1.1-CNTFRα dose, be ultimately limited by available endogenous muscle CLC. Accordingly, an AAV-induced increase in muscle CLC enhances the efficacy of AAV1.1-CNTFRα. Moreover, by selectively targeting the cell type endogenously expressing CLC and CNTFRα (i.e., muscle), it is possible to exploit the endogenous mechanisms regulating release and avoid/reduce side effects.
CNTF receptors are also activated by a complex of CLC and CLF. CLF is also expressed in muscle and, like CLC and CNTFRa, muscle CLF expression is increased in ALS mice. Therefore, a combined increase in both muscle CNTFRα RNA and muscle CLF RNA enhances CNTF receptor activity and thereby produces a similar ALS therapeutic effect to that seen with increasing muscle CNTFRα.
CNTF receptors are also activated by a complex of CLC and CLF. CLF is also expressed in muscle and, like CLC and CNTFRα, muscle CLF expression is increased in ALS mice. Therefore, a combined increase in both muscle CLC RNA and muscle CLF RNA enhances CNTF receptor activity and thereby produces a similar ALS therapeutic effect to that seen with increasing muscle CNTFRα.
Increasing expression of all three of these critical CNTF receptor signaling genes (CNTFRa, CLC, and CLF) in muscle is also therapeutic in treating ALS.
Motor neuron degeneration underlies progression of ALS. However, the data demonstrate that treating ALS by increasing muscle CNTFRα maintains motor neuron axons.
AAV1.1-CNTFRα or vehicle (PBS) was injected unilaterally into lateral gastrocnemius and soleus muscles of randomly assigned SOD1G93A littermates at 120-130 days of age (late in disease progression, 81-88% of median control end stage age; well after substantial MN terminal loss, which starts at ~50 days of age). Injections included 3×1010vg of AAV1.1-CNTFRα prep frozen and thawed only once between generation and use (n=3). Analysis of triceps brachii forelimb muscle motor neuron (MN) terminals indicated more innervated endplates in AAV1.1-CNTFRa treated mice.
Panels A-C of
Compared to the control, AAV1.1-CNTFRa injected mice had a 40.2% increase in fully innervated endplates per triceps brachii muscle (p=0.006; unpaired t-test; AAV1.1-CNTFRα injected =2726±96; control= 1944±190; n=5 pair;
These results indicate that enhancing muscle CNTFRα expression, even late in disease progression, may delay motor neuron degeneration and temporarily reverse the effects of motor neuron degeneration.
The data further indicate that AAV1.1-CNTFRα in combination with AAV1.1-CLC slows disease progression by slowing end stage paralysis.
AAV1.1-CLC (3×1010vg) or vehicle (PBS) was injected bilaterally into the gastrocnemius and soleus muscles of randomly assigned SOD1G93A littermates at 120 days of age, after onset of ALS symptoms. As shown in
AAV1.1-CNTFRα and AAV1.1-CLC treatment inhibits ALS progression in SOD1G93A mice. Combined treatment or vehicle was injected bilaterally into the gastrocnemius and soleus muscles of randomly assigned female SOD1G93A littermates at 120 days of age, after onset of ALS symptoms.. As shown in
All documents cited are incorporated herein by reference; the citation of any document is not to be construed as an admission that it is prior art with respect to the present invention.
While particular embodiments of the present invention have been illustrated and described, it would be obvious to one skilled in the art that various other changes and modifications can be made without departing from the spirit and scope of the invention. It is therefore intended to cover in the appended claims all such changes and modifications that are within the scope of this invention.
This application is a Continuation-in-Part of U.S. Pat. Application No. 16/088,570, filed Sep. 26, 2018, which is a National Stage Entry of International Patent Application No. PCT/US2017/025315, filed Mar. 31, 2017, which claims the benefit of U.S. Provisional Application No. 62/315,988, filed Mar. 31, 2016, U.S. Provisional Application No. 62/433,985, filed Dec. 14, 2016, and U.S. Provisional Application No. 62/433,987, filed Dec. 14, 2016, each of which is incorporated by reference in its entirety.
This invention was made with government support under R01 NS066051 and R01 NS052700 awarded by National Institutes of Health. The government has certain rights in the invention.
| Number | Date | Country | |
|---|---|---|---|
| 62433985 | Dec 2016 | US | |
| 62433987 | Dec 2016 | US | |
| 62315988 | Mar 2016 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 16088570 | Sep 2018 | US |
| Child | 18069650 | US |
