Human Gene Therapy: Risk

Assessment and Regulatory

Requirements

And Overview of the NIH rDNA Guidelines

EMD 545b
Lecture #10
NIH Guidelines for Research
Involving rDNA Molecules
(April, 2002)
 NIH Guidelines - April 2002

• NIH - OBA (Office of Biotechnology

Activities)
• Outline scope of regulated rDNA work and
required containment levels (changes
approved by NIH-OBA)
• Applicability
– NIH Sponsored Institutions
– NIH Supported projects (US & Abroad)
 Responsibilities: Institution

• Ensure full conformity with Guidelines

• Establish an IBC
• Appoint a BSO (if necessary)
• Ensure adequate expertise for protocol
review (plant, animal, human gene transfer)
• Training (IBC/BSO/PI’s/Lab staff)
• Health Surveillance (BL3/Large scale)
 Responsibilities - IBC

• 5 members (2 from community)

• Expertise (rDNA, biosafety, containment,
legal)
• Annual report to NIH-OBA (roster/CV’s)
• Assess
– Containment level, facilities, procedures
– Develop emergency plans, report violations
 Responsibilities: Biosafety
Officer
• IBC Member
• Inspections
• Report problems to IBC
• Develop emergency plans
• Advise on lab security
 Responsibilities: Principal
Investigator
• Full compliance with Guidelines
• Can’t start/modify non-exempt work w/out
approval
• Report violations w/in 30 days
• Make initial determination of containment
• Instruct/train lab staff
• Supervise safety performance
Section III: Experiments covered
by the NIH Guidelines
• Require approval before initiation
– III-A: Transfer significant drug-resistant trait
(IBC/RAC review/NIH Director)
– III-B: Cloning toxins (IBC/NIH-OBA)
– III-C: Human gene transfer (IBC/IRB/FDA
NIH-OBA registration)
– III-D: Risk group 2-4 & restricted, defective
virus in cell culture, animals, plants, large scale
 Section III: Experiments
Covered by the Guidelines
• IBC Notice at time of initiation
– III-E-1: < 2/3 viral genome
– III-E-3 Production of transgenic rodents
– III-E-2: Whole plants
 Section III: Exempt Experiments

• III-F-1 through III-F-6

– not in organisms/viruses, PCR, known
exchangers, in/out of same host
• Appendix C-1 through C-VI
– < 50% viral genome, E.coli, B. subtilis,
S.cerevisiae, Purchase transfer of transgenic
rodents, extrachromosomal elements of gm+
organisms
 Appendices to NIH Guidelines

• Appendix B: Classification of Etiologic

Agents on the Basis of Hazard
• Appendix F: Containment for toxin
experiments
• Appendix G: Biosafety containment levels
(in vitro experiments)
• Appendix H: Shipment
 Appendices to NIH Guidelines

• Appendix K: Large Scale containment

• Appendix M: Human gene transfer
• Appendix P: Plants (biocontainment for
rDNA plant experiments)
• Appendix Q: Animal Biosafety
containment levels
 Human Gene Therapy

• Gene Therapy: Any clinical therapeutic

procedure in which genes are intentionally
introduced into human somatic cells

• Gene transfer: The deliberate transfer of

recombinant DNA, or DNA or RNA
derived from rDNA into human subjects.
NIH
 Notable Quotes

• “Gene therapy has clearly matured from the

point of Gee-Whiz to getting down to hard
work.
• “Putting genes into people is no longer a
worry. We know there are no ill effects.
Now we can think of genes as drugs, and
that is quite remarkable.”
• Dr. Ronald Crystal, Cornell Medical School
• USA Today, 6/10/99
 Notable Quotes

• “The conclusions from these trials are that

gene therapy has the potential for treating a
broad array of human diseases and that the
procedure appears to carry a very low risk
of adverse reactions.”
• Dr. W. French Anderson
• Nature, April 30, 1998
 September 17, 1999

• 1st reported death attributed to a HGT

Protocol: UPENN OTC Trial
– subject may have not been properly informed of
risk
– not a suitable candidate for the trial
• NIH OBA request for unreported adverse
and serious adverse events (11/99)
• 650 previously unreported AE and SAE
received by NIH, including unexplained
deaths
 Lack of Oversight

• Insufficient monitoring once HGT protocols

begin
• Beth Israel Hospital (Boston): 7 subjects: 3
unreported deaths and 1 SAE
• Tufts Univ. (Boston): 2 deaths, 1
unexplained, but PI claim unrelated to study
Fox Guarding the Hen House
Rationale for Delayed Reporting

• Reports to FDA (private), not to NIH

(public)
• PI decision: “SAE unrelated to study drug”
• Competition between companies
• Financial implications of negative news
(stock value)
• Financial conflict of interest (those with
shares in parent company)
 FDA Response

• FDA request for detailed monitoring plans

from institutions and site visits
• Shutdowns
– Duke
– LA VA Hospitals
– Oklahoma State
– Univ. Colorado Health Sciences Center
– Others
 Additional Adverse Events

• Vector associated leukemia - France

– 2002- HGT Trials suspended after 2nd case of
leukemia caused by integration of “defective”
retroviral vector in host chromosome
 Cellular HGT

• Somatic cells
– non-reproductive
– genetic information not passed to next
generation
• Germ line cells
– sperm/egg cells
– currently not allowed
 Categories of HGT Research

• ex vivo
– cells removed from patient
– incubated with vector
– altered cells returned to patient
• in vivo
– direct injection into affected tissues
– systemic delivery
 HGT Protocols

• 1st U.S. trial 1990: ADA

• 400 trials in past 10 years (3,000+ patients)
worldwide

– 62% Cancer
– 13% single gene disorders
– 9% AIDS
 Delivery Vehicles for HGT

• Viruses
– murine retroviruses (46%)
– adenoviruses (22%)
– Other vectors
• adeno-associated virus, vaccinia virus, herpesvirus
• Cationic liposomes (non-viral delivery)
• naked plasmid DNA or RNA (gene guns)
 Murine Retroviruses

• Advantages
– stable infection
– long-term expression
– will infect dividing cells only
• Disadvantages
– insertional mutagenesis
– activate an oncogene/shut off tumor suppressor
– recombine with host retrovirus
 Murine Retroviruses
• Before 2002 adverse events:
• 10+ year experience
– no adverse events (800 patients)
– no malignancies
– no replication competent retroviruses

– FDA has dropped requirement for lifetime

monitoring of patients
 Adenoviruses
• Advantages
– capacity for large genetic insert
– high level of expression
– can also infect non-dividing cells
– does not integrate into host genome
• Disadvantages
– potential recombination with host adenovirus
– inflammation, immune response
 Adenoviruses

• Last decade
– minimal viral shedding from subjects
– standard precautions adequate (replace isolation
practices)
– consideration of using replication competent
vectors with adequate isolation and monitoring
of subjects
 Liposomal Vectors

• Positive charged lipid particle

– Advantages
• capacity for very large genetic insert
• safe
• ease of mass production
– Disadvantages
• low efficiency
• poor specificity
 Other Vectors

• Lentiviral vectors (HIV) can infect non-

dividing cells
• Vaccinia (HGT vaccines)
• Baculovirus (insect virus)
• Salmonella
• No bounds on imagination of investigators
 Oversight of HGT Research

• Food and Drug Administration (FDA)

– Sole authority of approval of HGT protocols
– Center for Biologics Evaluation & Research
(CBER)
• drugs/biological products intended for use in human
subjects
– Investigational New Drug application (IND)
• 21 CFR Part 312 Subpart B
 Oversight of HGT Research

• Objectives of the FDA

– ensure safety/rights of research subjects
– ensure scientific quality of clinical
investigations
– safeguard public health while promoting novel
therapies
 Oversight of HGT Research

• National Institutes of Health (NIH)

• applicable to entities that receive NIH funding
– DHHS Office of Human Research Protection
(OHRP)
• regulations that protect human subjects/control
research risks
– Office of Biotechnology Activities
• mandatory registration of HGT Protocols
• national repository
 Oversight of HGT Research
• NIH
– Recombinant DNA Activities Committee
(RAC)
• public notification/participation in discussion
• review 10% of submitted HGT protocols
• NIH Guidelines for Research Involving rDNA,
Appendix M
• Points to Consider for Human Gene Therapy
 Oversight of HGT Research

• History of NIH RAC Involvement

– 1990 - 1996: Approval authority
– 1996 - 2000: can recommend RAC review to
FDA
– October, 2000: RAC review prior to local
institutional approval to ensure public
notification and adequate risk assessment
 Local Oversight for HGT

• Institutional Review Board (IRB)

– Ensure compliance with FDA and NIH OHRP
requirements to protect human subjects.
Federally mandated for any work with humans.
– Informed Consent
• risk/benefit evaluation on behalf of subject
• conflict of interest (financial implications)
• ethical issues (false hope)
• review of adverse effects
 Local Oversight for HGT

• Institutional Biosafety Committee (IBC)

– NIH Requirement (funded locales)
– safety
– acute/chronic effects
– risk to patient, contacts
– exclusion criteria
– adverse effects (stopping rules)
 HGT Protocol Pathway
• PI submission to IRB, IBC and NIH OBA
• OBA/NIH RAC filter: public review?
• RAC comments to IBC, IRB, FDA, OHRP
• IBC/IRB approval
• PI application for FDA IND
• Final FDA approved protocol to NIH OBA,
IBC, IRB
• Adverse Effects reported
 HGT Risk Assessment

• IBC Review Process

– NIH Guidelines, Appendix M
– Composition of IBC
• molecular biologists
• infectious disease experts
• immunologists, relevant expertise as needed
• biosafety/containment representation
• occupational health
• community representation
 HGT Risk Assessment

• Can your existing IBC efficiently review

the HGT protocol?
– @ Yale - HGT Subcommittee
• Melanoma Trial
– oncologists, hematologists, immunobiologists
• Canavan’s Disease
– pediatric neurologists
– neurosurgeons
– ethicists
 HGT Risk Assessment

• IBC HGT Review Team should also

include:
– IRB members
– hospital pharmacy
– infection control representatives
– clinical virologists
– legal
– ethicists
 HGT Risk Assessment

• IBC Questions to the PI:

– why is disease a good candidate for HGT?
– objective/quantitative disease measures
present?
– alternative therapies?
– what cells have been targeted for HGT?
– describe methods, reagents, full sequence of
inserted DNA, steps to derive construct
 HGT Risk Assessment
• IBC Questions for the PI:
– preparation of the vector in compliance with FDA
21 CFR Part 211 (Good Manufacturing Practices)?
– clean room facility requirements met?
– Trained personnel?
– Documented/validated SOP’s and equipment?
– QA/QC program in place?
– Sterility testing (RCV/adventitious agents)?
 HGT Risk Assessment

• IBC Questions for the PI:

– adequacy of pre-clinical studies (best animal or
cellular model)?
– observed toxicity/efficacy?
– chronic effects (time followed after treatment)?
– accuracy/efficiency of delivery system?
• affect target cells only (spread to reproductive cells)
• transient of stable infection
 HGT Risk Assessment

• IBC Questions to PI:

– determination that sequences have been
expressed?
– expected benefits or adverse effects
– length of follow-up for subjects
– post-mortem studies?
 HGT Risk Assessment

• IBC Questions for PI:

– can DNA spread from subject to contacts or
environment?
– required precautions to prevent dissemination?
– safety protocols for pharmacy, healthcare staff?
– adequacy of clinical facilities?
– informed consent/clear communication of risks
to subjects
 HGT Risk Assessment

• IRB Considerations:
– risk/benefit of protocol
– protect subjects from coercion/undue influence
– confidentiality/disclosure of information
– verification or informed consent process
– verify eligibility/withdrawal criteria
– ongoing monitoring of subjects
– annual renewal of protocol
 Adverse Effects

• Serious Adverse Effect (SAE)

– FDA
• report immediately if related to study drug
– NIH
• ANY SAE reportable immediately to all related
compliance groups
– Annual Data Report
• includes SAE’s and AE’s to related compliance
groups
 Approval of HGT Protocols

• IRB/IBC Coordination
– NIH OBA registration/FDA IND approved
• PI sign-off/acceptance of responsibilities
– contingencies outlined on approval letter
• oversight/monitoring
– informed consent/eligibility, adverse events,
stopping criteria
 HGT Report Card

• “The efficiency of gene transfer and

expression in human patients is, however,
still disappointingly low.”
• W. French Anderson, Nature, 1998
 HGT Report Card

• Not really therapy (treatment)

• Few clinically significant results
• Don’t sell false hope
– Human Gene Transfer RESEARCH
– SUBJECTS not patients
– may or may not gain information
 Success Stories

• US ADA 1990 (Anderson)

• French ADA 1999
• Cancer (marker gene) Deisseroth, 1993
• Herpes TK, brain tumor, 1993 (Blaise)
• SHH (activator), heart disease, hair growth
(Crystal)
 Conclusion

• HGT a promising field

• Human genome project will feed fire
• build on successes, share information
• Goal
– cost-effective approach
– improved delivery and expression of gene
– sustained expression of therapeutic gene
 Conclusion

• Responsibility of Regulators:
– ensure adequate process of review
– approve only sensible, valid projects
– ensure the ethical conduct of research
– protect human subjects, healthcare workers, and
public
 2007 Investigation of Serious
Adverse Event

• Death of patient enrolled in study involving

an AAV vector (Adeno-Associated Virus)
– Focus of NIH OBA Meeting
– AAV not a known human pathogen?
– Dose?
– AAV as cause of event indeterminable
 Institutional Approval of HGT
Protocols

• Review of location, personnel

• Infection control
• SAE notification
 Institutional Approval of HGT
Protocols

• Certificate of Analysis to institution from

sponsor or designated lab
• GMP Compliance statement from sponsor
• FDA approval letter on file
• Copy of final FDA authorized protocol
 Institutional Approval of HGT
Protocols

• Data Safety Management Board

• Periodic review of patient safety
information
• Report to IRB and IBC
• Annual Renewal of HGT Protocol
• Report changes in protocol
 Additional NIH Requirements

• < 20 days post initiation of HGT Protocol

– copy of final protocol
– NIH Grant # (if applicable)
– copy of IRB and IBC approvals
– written response to RAC recommendations
– date of initiation of trial