Caroline Hroncich was associate editor for Pharmaceutical Technology, Pharmaceutical Technology Europe, and BioPharm International from 2015 to 2017.

Caroline Hroncich

	A group of scientists have developed a potential new approach to treat common blood disorders by using CRISPR-Cas9 gene-editing technology. In a new 

scientists led by a group of researchers from St. Jude Children’s Research Hospital, say they have identified a possible DNA target for genome editing that could be used to treat sickle cell disease and beta thalassemia.

, researchers performed CRISPR-Cas9 genome editing of human blood progenitors. According to the study, scientists edited human-blood progenitors in an attempt to mutate “a 13-nt sequence that is present in the promotors of the [hemoglobin subunit gamma 1] 

.” The edited progenitors produced red blood cells with higher levels of fetal hemoglobin, enough to stop the morphing of red blood cells that occur with sickle cell disease, thereby returning them to their natural state.

	The use of CRISPR-Cas9 provides a potentially viable option for 

 switching of hemoglobin subunits, which researchers indicate is effective for increasing the levels of fetal hemoglobin in patient’s red blood cells. For patients with sickle cell disease and beta thalassemia, the gamma subunits in fetal hemoglobin can more effectively transfer oxygen through the blood compared to the beta subunits in adult hemoglobin.

	“Several techniques have emerged in recent years that use gene editing to manipulate hematopoietic stem cells for the treatment of blood disorders. Some of them use artificial restriction enzymes like zinc finger nucleases, another method exploits structural changes that can be introduced into chromatin, and others, including our method, involve CRISPR gene editing,” study author Mitchell J. Weiss, MD, PhD, chair of the Hematology Department at St. Jude told 

“Each of these approaches is different and none have been tested in clinical trials in humans. Our approach uses CRISPR-Cas9 to disrupt the mutated genes and restore fetal hemoglobin levels in hematopoietic stem cells. It remains to be established which is the best and safest approach to gene editing for patients with sickle cell disease.”

	According to Weiss, some other methods that may prove effective for treating blood disorders include the correction of sickle cell-associated mutations by using 

” of chromatin, and a method that uses CRISPR-Cas9 to 

, which inhibits expression of fetal hemoglobin in adults. While many of these methods show promise as potential treatments for blood disorders, Weiss acknowledges that they have not yet been tested in clinical trials.

	“Our study is a proof-of-principle that our gene-editing approach can be successful in isolated blood-forming stem cells. Further work is needed to improve the gene editing process and to ensure that no off-target mutations arise with this approach,” Weiss continued. “More research is definitely needed before moving this work towards the clinic. What would be beneficial is a head-to-head comparison of the merits of each of the gene editing processes that have been proposed to date. It is likely to be some time before any of these approaches are tested in a clinical trial but the potential is clearly there.”

	The use of CRISPR-Cas9 technology has been a highly debated topic in the scientific community as 

 are set to begin. In July 2016, scientists at Sichuan University’s West China Hospital in Chengdu announced plans to begin the first human trial using CRISPR technology, 

 The scientists plan to begin the trial in patients with metastatic non-small cell lung cancer in August 2016. Researchers in the United States have also made strides toward bringing CRISPR-Cas9 to clinical trials. In June, a panel from the National Institutes of Health approved the first US clinical trial for CRISPR-Cas9 to test whether or not the technique is safe for use in humans. According to 

the small study will examine CRISPR-Cas9 in 18 patients with different types of cancer.

Articles

A new study reveals a potential new approach to treat sickle cell disease and beta thalassemia using CRISPR-Cas9 gene-editing technology.

Scientists Examine CRISPR as a Therapeutic Approach for Treating Blood Disorders

	FDA gave the okay to a generic version of Roche’s blockbuster Tamiflu (oseltamivir phosphate), the first generic version of the drug approved in the United States, FDA said in an August 3, 2016 statement. Tamiflu was developed by 

 and licensed to Roche in 1996. The drug was later approved by FDA in 1999.

	This generic version of Tamiflu is co-marketed by Natco, an Indian pharmaceutical company, and US-based Alvogen. In December 2015, Natco and Alvogen settled a patent infringement with Gilead Sciences, Genentech, and Roche, allowing them to market the capsules before the February 23, 2017 expiration of Tamiflu’s pediatric exclusivity period, Natco said in a 

	But Natco and Alvogen’s generic did not have a swift path to market. In 2011, Gilead sued Natco alleging that it’s Abbreviated New Drug Application (ANDA) infringed upon the company’s patent. A district court ruled in favor of Gilead, and Natco later appealed to a federal court. The appeals court 

 siding with Natco saying, “…the court contends that Gilead acted improperly by continuing to pursue claims in the application that issued as the ’375 patent. To support this conclusion, the court holds that in the case of competing patents, a patentee is stuck with the earliest expiration date irrespective of filing or issue dates.” Gilead later 

 to the US Supreme Court but the petition was denied.

	Tamiflu raked in 410 million Swiss Francs (approximately $421.09 million) in the first half of 2016, Roche said in a 

 According to the report, Tamiflu sales declined 18% due to a weak influenza season, but it is still the company’s top selling infectious disease product. According to FDA, Tamiflu is used to treat influenza A and B in patients two weeks of age and older who have had flu symptoms for no more than 48 hours. The drug can also be used to prevent flu in children one year of age and older.

FDA approved Natco and Alvogen’s generic Tamiflu to treat and prevent influenza.

FDA Approves First Generic Version of Tamiflu

	On July 26, 2016 FDA granted Breakthrough Therapy Designation to Genmab and Janssen’s multiple myeloma monoclonal antibody (mAb) treatment Darzalex (daratumumab) in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone, for patients that have received at least one prior therapy. Darzalex was originally 

 and was the first mAb approved to treat multiple myeloma.

 show that daratumumab in combination bortezomib and dexamethasone reduced disease progression by 61% in patients with multiple myeloma. During Phase III CASTOR trials, the three-drug combination increased overall response rate from 63% to 83%. In an American Society of Clinical Oncology 

, researchers reviewing the CASTOR study noted that the combination of daratumumab, bortezomib, and dexamethasone should be considered the new standard of care for patients with relapsed refractory multiple myeloma.

	While daratumumab has shown to improve treatment for patients with multiple myeloma, some scientists think daratumumab, which works by binding to the CD38 molecule, could have implications for patients requiring blood transfusions. In a 

Michael F. Murphy, MD, of the John Radcliffe Hospital, and colleagues raised concerns about the drug’s interference with blood compatibility testing for patients requiring transfusion.

 (AABB), anti-CD38 treatments like daratumumab can cause positive reactions in indirect antiglobulin tests, antibody detection tests, antibody identification panels, and antihuman globulin crossmatches. This often leads to delays in issuing red blood cell units to patients, the AABB says. Murphy and colleagues commented that during Phase I and II trials, daratumumab in patient’s plasma caused false positive antibody screens. After further examination, researchers were able to discover effective methods to circumvent this interference. However, Murphy continues, many of these methods are not readily available to hospitals completing compatibility testing.

The mAb, in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone, was granted a Breakthrough Therapy Designation from FDA for the treatment of multiple myeloma.

Darzalex Secures Breakthrough Therapy Designation

	A federal judge has officially denied AstraZeneca’s bid for seven more years of patent exclusivity by way of orphan drug legislation for its blockbuster drug Crestor (rosuvastatin). According to July 19, 2016 decision, the court refused to issue a restraining order that would prevent generic versions of Crestor for coming to market, 

	In late May, Crestor received an Orphan Drug designation for the treatment of patients with homozygous familial hypercholesterolemia (HoFH), providing the blockbuster drug exclusivity for this indication until 2023. Crestor, which is also approved to treat non-pediatric patients with high cholesterol, lost its patent protection for this indication in July 2016. 

, AstraZeneca asked the court to prevent generic versions of the drug from coming to the market. According to 

US District Judge Randolph Moss, ruled that the company “was not likely to win a lawsuit claiming it should get seven more years of exclusive rights to the drug thanks to its recent approval to treat a rare pediatric illness.”

	AstraZeneca also submitted a Citizen Petition to FDA, requesting the agency include data from its HoFH trial on the Crestor label and to refrain from approving Abbreviated New Drug Applications (ANDAs) referencing Crestor and its 

, FDA denied the company’s petition noting, "orphan drug exclusivity is limited in scope and protects against approval only of the same drug for the same indication. It does not preclude approval of the same drug for which orphan drug exclusivity was granted for a different, non-protected indication."

	FDA also says it will allow for an omission on generic labels if the indication is protected by patent exclusivity. The agency wrote in a 

, “Congress explicitly acknowledged that ‘the bill permits an ANDA to be approved for less than all of the indications for which the listed drug has been approved.'” This means, labels for generic versions of Crestor can be approved without the indication for HoFH.

	Other pharmaceutical companies have already announced plans to release generics versions of rosuvastatin. 

 the first generic version of the drug in late April, before the AstraZeneca received the Orphan Drug designation for the HoFH indication. Indian pharma company Aurobindo 

 on July 20, that it has received approval from FDA for a generic version of Crestor. 

 have also released generic versions of the drug.

Crestor accounted for more than 20% of AstraZeneca’s sales in 2015, which topped off at approximately $23.6 billion. A spokesperson for the company told 

that overall, they are “disappointed” with the decision.

Generic versions of AstraZeneca’s blockbuster Crestor will hit the US market after a federal judge refused to issue a restraining order blocking the approval of rosuvastatin ANDAs.

Generic Versions of Crestor Hit US Market Post Court Decision

	During a July 19, 2016 Dermatologic and Ophthalmic Drugs Advisory Committee, FDA panelists voted unanimously 

 of approving AstraZeneca and Valeant’s psoriasis drug brodalumab, but not without some stipulations. While the committee support the drug’s approval, 14 of the 18 members thought additional risk management options should be implemented, according to an analyst report from Evercore ISI.

	During clinical trials, the IL-17 receptor targeting monoclonal antibody (mAb) displayed a potential link to suicidal ideation and behavior (SIB). 

 indicates of 5041 patients receiving the drug during trials, there were 11 individual suicide behavior and ideation events, four completed suicides, and three deaths from unknown causes from Oct. 2010 through Feb. 2014. Throughout all brodalumab programs, a total of six completed suicides were reported.

	After reviewing these results, FDA requested Amgen, the drugs sponsor at the time, further evaluate the risk, the FDA report says. Amgen later announced it would no longer be co-developing the drug, and said it had plans to terminate clinical trials. In Nov. 2016, AstraZeneca submitted a biologics license application (BLA) for the treatment, and then transferred its commercialization rights to Valeant.

	According to the Evercore ISI, several FDA panelists recommended additional data be reviewed to determine if there is in fact a link between SIB and brodalumab. Some committee members recommended a label warning, while others indicated there may be a need for a black box warning. Still, others noted the benefits of brodalumab may outweigh the risks.

	In clinical trials brodalumab cleared skin plaques 

 than Johnson & Johnson’s Stelara (ustekinumab). Brodalumab is currently approved for use in the European Union and Japan, and will likely be approved in the US. If approved, the drug may be a 

 for Eli Lilly’s psoriasis treatment Taltz (ixekizumab) and Novartis’ Cosentyx (secukinumab).

The committee voted unanimously in favor of approving the drug, but the majority supported implementing additional risk management.

FDA Votes in Favor of Brodalumab, But Cautions of Risks

	A group of researchers from the the University of Nottingham, Uppsala University, and GE Healthcare have developed a novel method for scale-up of human stem cells, according to a 

. This new research, published on July 13, 2016, could potentially provide a viable method for large-scale production of stem cells.

	The study authors use inter-alpha inhibitors (IαI), a human serum-derived protein, to promote attachment and long-term growth in embryonic and human pluripotent stem cells (hPS) by adding it to the medium at seeding. Researchers present a “completely defined xeno-free medium that supports long-term propagation of hPS cells on uncoated tissue culture plastic…[consisting] of the Essential 8 (E8) formulation supplemented with IαI.” The use of IαI gives hPS the ability to survive in the absence of Rho-associated kinase inhibitor, researchers say.

	“This new method removes the need for a pre-treated surface, and shows better survival in harsh conditions,” Sara Pijuan Galitó, PhD, study author and postdoctoral researcher at Uppsala University, told 

 “Therefore it will have great implications for future large-scale and automated expansion of human pluripotent stem cells.”

	However, it is important to note scale-up on a very large scale does lead to high instances of cell senescence, an issue scientists looking to scale-up stem-cell production will have to address. “In bioreactor-based large-scale expansion, due to larger volumes and required stirring for nutrient and oxygen exchange, higher cell death and lower proliferation has been reported. This is due harsher conditions in culture, and both cell death programs and senescence have been reported,” Galitó told 

	Researchers also note the methods currently available for scale-up of stem cells are either too costly or lack reproducibility. Some researchers suggest 

 for large scale production. According to Galitó although scale-out of cell development facilitates tighter quality controls, scale-up is more efficient and cost-effective.

	“Bioreactor-based expansion has traditionally been preferred for its cost-effectiveness and large volume. Of course, in stem cell production cell quality is a key issue, and scale-out would facilitate tighter cell quality controls,” says Galitó. “Early clinical trials point to millions or even billions of cells required per patient and per treatment to achieve a beneficial effect. Therefore, I would say that it will result more cost and time- efficient to scale-up rather than scale-out the current, very small-scale methods validated for clinical-grade cell production.”

This new method uses inter-alpha inhibitors to promote attachment and long-term growth in stem cells.