global seroprevalence of pre -existing immunity against ......charlotte maxeke johannesburg academic...
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Global seroprevalence of pre-existing immunity against various AAV serotypes in the hemophilia A population
Gregory Hayes1, Tatiana Andreeva2, Keith Gregg1, Robert Klamroth3, Brandon Hardesty4, Jorja Warren5, Patricia Slev5, Takashi Suzuki6, Natalie Stieltjes7, Flora Peyvandi8, Midori Shima9, Jean-Francois Schved10, Segolene Claeyssens11, Alex Trinh1, Brigitte Pan-Petesch12, Sabine-Marie Castet13, Savita Rangarajan14,
Syed Kazmi14, Doris Quon15, Ismail Haroon Mitha16, Andrew D. Leavitt17, Johannes Oldenburg18,Margareth Castro Ozelo19, Johnny Mahlangu20, Wing Yen Wong1
1BioMarin Pharmaceutical Inc, Novato, USA; 2 City Outpatient Clinic #37, St. Petersburg, Russia;3 Vivantes Hospital in Friedrichshain, Center for Hemophilia and Hemostasis, Berlin, Germany;4Indiana Hemophilia and Thrombosis Center, Indianapolis, USA; 5ARUP Laboratories, Salt Lake City USA; 6Ogikubo Hospital, Tokyo, Japan; 7Cochin Hospital Hemophilia Treatment Center, Paris, France;8Maggiore Polyclinic Hospital General Medicine Hemostasis and Thrombosis, Milan, Italy9Nara Medical University Hospital, Nara, Japan; 10Montpellier University Hospital, Montpellier, France;11Purpan Hospital, Regional Hemophilia Center, Toulouse, France; 12Morvan Hospital, Brest, France;13Pellegrin Hospital, Bordeaux Cedex, France; 14Southampton General Hospital, Southampton, UK;15Los Angeles Orthopedic Hospital, Hemophilia Treatment Center, Los Angeles, USA; 16Worthwhile Clinical Trials, Lakeview Hospital, Benoni, South Africa; 17UCSF Medical Center, San Francisco, USA; 18University Hospital Bonn, Bonn, Germany; 19Campinas University Clinical Hospital, Campina, Brazil20Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
PRESENTING AUTHOR DISCLOSURE
• Gregory Hayes is an employee of BioMarin Pharmaceutical Inc.
VALOCTOCOGENE ROXAPARVOVEC (BMN 270) – CLINICAL PROGRAM
Phase 1/2 Dose Escalation Study Enrollment completed• 15 participants (AAV5-), 4 dose cohorts; UK 201
AAV5+ Phase 1/2 Titer Escalation Study FPI May 2018• 10 participants; 2 titer cohorts (≤500, >500); UK. 203
Global AAV Seroprevalence Study FPI Aug 2017• 820 participants; US, UK, France, Russia, Germany, Italy, Japan, S. Africa, Brazil 901
Non-Interventional Study FPI Feb 2018• N= ~145 AAV5-/HIV- participants, participate for ≥ 6 months, given priority to enroll into GENEr8-1 or GENEr8-2• AAV5+ participants can participate in 902; however, will not be eligible for GENEr8-1 or GENEr8-2• 14 Countries
902
Phase 3 Study with 6×1013 vg/kg dose FPI Dec 2017• N = ~130 participants• 13 Countries
GENEr8-1
Phase 3 Study with 4×1013 vg/kg dose FPI May 2018• N = ~40 participants• 13 Countries
GENEr8-235
110
Advanced Gene Therapy Program for which a Companion Diagnostic (CDx) is being co-developed to select hemophilia A patients without pre-existing antibodies to AAV5 (partnered with ARUP Laboratories)
MULTIPLE METHODS FOR MEASURING PRE-EXISTING AAV IMMUNITYCell-based Transduction Inhibition (TI) Assay
AAV-luciferase
Patient Plasma
HEK293T HEK293T
• Measures ability of plasma to block transduction of a cell line by AAV• Differing amounts of capsid needed for different serotypes can make
TI titer comparisons across capsids more difficult
Anti-AAV Total Antibody (TAb) Assay
AAVx-Ru
AAVx
• Electrochemiluminescent assay (ECLA) on the MSD platform• Ease of qualifying divergent capsid serotype assays in identical format
Passive Immunity Transfer In Vivo
• Immuno-compromised mice are reconstituted with donor plasma or IVIg prior to dosing with AAV
• Ability to detect low neutralizing titers• Often has high variability across animals (low n due
to plasma volumes required)1. Falese L. et al Gene Ther. 2017; 24: 768-7782. Sun L. et al. J Immunol Methods, 2013; 387:114-120
MOST PATIENTS EXHIBIT CONCORDANCE BETWEEN AAV5 TAb & TI
AAV5
TAb
Tite
r
AAV5 Transduction Inhibition (TI) Titer
TAb+ TI+(25%)
TAb- TI+(9%)
TAb+ TI-(4%)
TAb- TI-(62%)
• Majority of hemophilia A patients are negative or positive in both TAb and TI assays (n=253)
• 62% TAb & TI negative • 25% TAb & TI positive
• Patients with detectable titers in only one assay generally exhibit low titer values
• Can efficacy be achieved in TAb+ or TI+ individuals?
AAV5 TOTAL ANTIBODY (TAb) ASSAY PREDICTS BMN 270 EFFICACY
Group (n) Purpose TI Titer TAb Titer
1 (3) Control Negative Negative
2 (4) Non-TAb TI 2 - <5 Negative
3 (3) Non-TAb TI 5 - 10 Negative
4 (5) TAb+ >10 Positive
• Non-human primates exhibit similar levels of pre-existing immunity as humans
• Animals screened with TAb and TI assays, assigned to groups below, and dosed with 6e13 vg/kg valoctocogene roxaparvovec (BMN 270)
TAb- TAb- TAb- TAb+TI- TI+ (2-5) TI+ (5-10) TI>10
72%
Hum
an F
VIII
(ng/
mL)
Group Mean FVIII Protein – Day 29
TI titers in TAb-negative subjects were not associated with reduced transduction or efficacy TAb assay chosen for screening of patients in Ph3 clinical studies and intended as a
companion diagnostic for the program.
TAb+ was associated with 72% decrease in hFVIII
1. Long B. et al Mol Therapy Methods & Clin Dev. 2019; 13: 440-452
BIOMARIN GLOBAL AAV SEROPREVALENCE STUDY DESIGN Objective: to provide epidemiological data characterizing pre-existing AAV immunity
among hemophilia A patients • Determine the prevalence of AAV5 capsid antibodies & regional differences that may impact efficacy• Compare seroprevalence and antibody titers against multiple AAV serotypes
• Identical AAV TAb formats specific for AAV2, 5, 6, 8, rh10 with comparable limits of detection (<20ng/mL) were validated at central laboratory
• Determination of titer stability (longitudinal sample analysis)
Study design:• Up to 100 patients enrolled per country in (≤75 adults, ≤25 12-17yo)• Countries: UK, USA, Russia, France, Germany, Japan, Italy, South Africa, Brazil
• Currently enrolled n=453 adults across 17 sites• Approximately 20% of patients returned at months 3 and 6 for follow-up testing
RATES OF AAV5 SEROPREVALENCE VARIES ACROSS COUNTRIES
% A
AV5
TAb
Posi
tive
France Germany Italy Japan Russia
Variability observed in the percentage of hemophilia A patients with pre-existing antibodies to AAV5
Differences represent valid geographic variance of this endemic virus based upon comparisons to healthy controls• e.g. healthy Russia controls = 43% AAV5+
Global weighted average = 31.0% AAV5+(hemophilia A global population-weighted mean)
USAUK
20
40
60
80
40.0 24.7 21.329.9 46.740.030.6
(Pairwise comparison * p-value <0.05)
**
*
*
AAV5 HAS THE LOWEST PREVALENCE ACROSS SEROTYPES TESTED
AAV
Antib
ody
Tite
r
AAV5 AAV2 AAV6 AAV8 AAVrh10
% Positive: 33 54 46 44 44 AAV5 exhibits lowest rate of seroprevalence compared to other serotypes tested
AAV5 exhibits lowest range of antibody titers compared to other serotypes tested
***
(Pairwise comparison to AAV5*** p-value <0.0001, ** p-value =0.0002)
*** *** **
AAV5 TAb RESULT & TITERS REMAIN CONSISTENT OVER 6 MONTHS TIME
Patient samples were collected at Day 0 (enrollment) and at 3 and/or 6 months
94% of patients did not seroconvert over 6 months of follow up time (n=47)
Only 3 patients converted from negative to positive (or vice versa) and all had titers near or below the MRD
Confidence in the MSD-platform based TAb approach to determine pre-existing immunity
• Minimum required dilution = 20 (MRD)
AAV5
Ant
ibod
y Ti
ter
Day 0 Month 3 Month 6
MRD
AAV-(n=23)
AAV+(n=21)
RATES OF AAV+ SEROPREVALENCE INCREASE WITH AGE % of TAb+ hemophilia A patients increases with age for all serotypes tested Probability of becoming AAV5+ is lowest among the serotypes examined
% A
AV T
Ab P
ositi
ve
Age Range
Prob
abili
ty o
f AAV
TAb
+Age
Logistic Regression of Seroprevalence with Age
AAV5
AAV2AAVrh10AAV8AAV6
SUMMARY There are multiple methods of measuring pre-existing AAV immunity which may impact
efficacy Total antibody assay appears to be more discriminating than TI in pre-clinical studies A central lab was used to measure antibodies against 5 different AAV serotypes using an identical
assay format with comparable sensitivities
AAV5 exhibits the lowest seroprevalence among serotypes tested across countries Regional variability in AAV5 seroprevalence across countries % TAb+ of hemophilia A patients and titer range is lowest for AAV5 compared to other serotypes AAV5 TAb results (+/-) and titers remain consistent over 6 months of time Rates of seroprevalence for each capsid increase with age but remain lowest for AAV5
A companion diagnostic is being developed to enable standardized assessment and controlled investigation of the clinical relevance or pre-existing AAV5 antibodies for BMN 270
THANK YOUTo all study participants, advisors, teams and principal investigators
Nara Medical University HospitalNara, Japan
City Outpatient Clinic #37St. Petersburg, Russia
Vivantes Hospital, Center for Hemophilia and Hemostasis Berlin, Germany
Montpellier University HospitalMontpellier, France
Indiana Hemophilia and Thrombosis Treatment CenterIndianapolis, United States
Purpan Hospital, Regional Hemophilia CenterToulouse, FranceMorvan Hospital
Brest, FranceOgikubo Hospital
Tokyo, JapanCochin Hospital, Hemophilia Treatment Center
Paris, FrancePellegrin Hospital
Bordeaux Cedex, FranceMaggiore Polyclinic Hospital
Milan, Italy
Southampton General HospitalSouthampton, UK
Thank you to the BioMarin team
Los Angeles Orthopedic HospitalLos Angeles, USA
Worthwhile Clinical Trials, Lakeview HospitalBenoni, South Africa
University Hospital Bonn, Bonn, Germany
UCSF Medical CenterSan Francisco, United States
Charlotte Maxeke Johannesburg Academic HospitaJohannesburg, South Africa
Campinas University Clinical HospitalCampinas, Brazil
ARUP LaboratoriesSalt Lake City, USA