Treatment of Cystic Fibrosis using Personalised Medicine

A TECHNICAL SEMINAR BY SANDEEP KINI 1RV09BT042

Topics covered in this seminar

Cystic Fibrosis The disease

Causes and symptoms

CFTR What is it? Efforts to control CF

Personalised Medicine The concept

CFTR potentiators Ivacaftor CFTR Modulators

Challenges associated with PM

Cystic Fibrosis
Cystic fibrosis (also known as CF or mucoviscidosis)

is an autosomal recessive genetic disorder that affects most critically the lungs, and also the pancreas, liver, and intestine. It is characterised by abnormal transport of chloride and sodium across an epithelium, leading to thick, viscous secretions. These thick secretions often cause scarring which lends its name to the disease. CF is mainly caused by a mutation in the gene responsible for coding for the CFTR protein

A small Video on what really happens during cystic fibrosis

Manifestations of Cystic Fibrosis

Main parts of the body affected

Lungs Scarring, Cyst formation,

Secondary diseases (Pneumonia, Bronchitis, Alveolar inflammation) Pancreas Endocrine region : Islets of langerhans damaged CFRD Reproductive system : Infertility, Amenorrhea in females, CFTR mutation may also lead to congenital absence of vas deferens in males. GI tract : Gastrointestinal Eosophageal Reflux Disease (GERD), Meconium Peritonitis

CFTR gene and protein

CFTR or Cystic Fibrosis Transmembrane Regulator is a

protein that is encoded by the CFTR gene. The cftr proteins functionality is to ease ion transport across the cellular membrane. The protein acts as a Cyclic Adenosine Mono Phospate (CAMP) anion channel that increases the conductance of anions (Cl- etc) It allows transport of cl-, thiocyanate ions and balances them with Sodium ions, this balance allows water to flow due to osmosis and leads to the normal consistency of Mucous on the concerned Mucosal tissue areas.

CFTR Gene
CFTR gene behaves as an autosomal recessive gene

according to Mendelian/Classical genetics.

CFTR gene
Mutations on the gene can be deletions, or

insertions. Some common mutations are; F508 (Class 2) G542X (Class 1) G551D (Class 3) N1303K W1282X

Classes of mutations

CFTR protein
CFTR is a glycoprotein with 1480 amino acids. The

protein consists of five domains. There are two transmembrane domains, each with six spans of alpha helices. These are each connected to a nucleotide binding domain (NBD) in the cytoplasm. The first NBD is connected to the second transmembrane domain by a regulatory "R" domain that is a unique feature of CFTR, not present in other ABC transporters. The ion channel only opens when its R-domain has been phosphorylated by ATP is bound at the NBDs.[

Management of CF
While there are no cures for cystic fibrosis there are

several treatment methods. The most common form of management has been through the use of antibiotics. Prescribing antibiotics however implies that the patient must continually and constantly use them throughout lifetime so as to not only decrease the infection but also ensure the infection does not increase in any way.

Management of CF
Several mechanical techniques are used to dislodge

sputum and encourage its expectoration. In the hospital setting, chest physiotherapy (CPT) is utilized. CF is a genetic disorder caused by the mutation of the CFTR gene, the most effective treatment would ideally be gene therapy or gene replacement therapy. Ideally, gene therapy places a normal copy of the CFTR gene into affected cells. Transferring the normal CFTR gene into the affected epithelium cells would result in the production of functional CFTR in all target cells, without adverse reactions or an inflammation response.

Management of CF
Multiple approaches have been tested for gene

transfer, such as liposomes and viral vectors in animal models and clinical trials. However, both methods were found to be relatively inefficient treatment options. The main reason is that very few cells take up the vector and express the gene, so the treatment has little effect.

PM The concept
Personalized medicine or PM is a medical model that

proposes the customization of healthcare - with medical decisions, practices, and/or products being tailored to the individual patient. The use of genetic information has played a major role in certain aspects of personalized medicine, and the term was even first coined in the context of genetics. Pharmacogenetics (also termed pharmacogenomics) is the field of study that examines the impact of genetic variation and drug responses by biomarker (medicine). This approach is aimed at tailoring drug therapy at a dosage that is most appropriate for an individual patient, with the potential benefits of increasing the efficacy and safety of medications

Drug development and demographic studies

PM and CF
CF as a disease area is well positioned to take

advantage of personalised medicine. It is a monogenic disorder (i.e. is the result of mutation(s) in a specific gene) and has a well-characterised pathophysiology with clear therapeutic targets. Furthermore, diagnosis of CF often utilises genetic testing, leading to a high rate of mutation identification in the CF population. Research into CFTR gene mutations continues to reveal correlations between various CFTR genotypes and disease severity

Ivacaftor Treatment in patients with G551DCFTR mutation

One of the most succesful trials in CF treatment has

been using Ivacaftor. Ivacaftor (VX-770; Vertex Pharmaceuticals, Cambridge, MA, USA, Trade name: Kalydeco)is a potentiator that specifically targets the G551D gating mutation by improving the probability that the mutant channel will open at the cell surface, i.e. increases the channel opening probability and, therefore, the flow of ions transported through the channel.

Phase 2 trials of Ivacaftor

In a phase II clinical trial the safety and adverse

event profile of ivacaftor was assessed as a primary end-point. Secondary end-points included improvements in CFTR-mediated ion transport (measured by nasal potential difference and sweat chloride concentrations), pulmonary status (measured by forced expiratory volume in 1 s (FEV1)) and healthrelated quality of life (measured by the Cystic Fibrosis Questionnaire-revised (CFQ-R))

 The study was conducted in 10 CF patients who

Phase 2 results

were 18 yrs and who had at least one copy of the G551D mutation as well as an FEV1 40% . This double-blind, placebo-controlled study was conducted and the results were studied before proceeding into the phase 3 trials.

Phase 3 trials
Two 48-week randomised, double-blind, placebo-controlled

phase III trials were conducted in adolescents/adults At the end of the 48-week study period patients were offered the opportunity to rollover into an optional open-label study As the dose of 250 mg twice daily did not show a significant increase in the phase II study when compared with 150 mg twice daily, the latter dose was used for the phase III studies. Patient-reported respiratory symptoms were assessed using the respiratory domain of the CFQ-R, which has been specifically validated for use in CF. Responses are scored on a 100-point scale, with higher numbers indicating a lower effect of symptoms on the patient's quality of life and a change of four points considered to be a minimal clinically important difference. Findings showed an improvement in CFQ-R scores, indicating a reduction in respiratory symptoms

Ivacaftor trials : A conclusion

Clinical development of ivacaftor is an outstanding

example of how personalised medicine can revolutionise medicine. Following identification of ivacaftor using high throughput screening, early pre-clinical research validated this small molecule as a promising therapeutic option for CF patients with the G551D-CFTRmutation A significant change in sweat chloride levels mirrored improvements in lung function, as a proof-of-concept of the drug mechanism of action. There were no important safety concerns for >48 weeks administration. Initial analysis of an ongoing longer term open-label study suggests that the efficacy of ivacaftor will be maintained in the long-term

FDA Approves Ivacaftor!

Video shows interview of FDA chairperson

CFTR Modulators
CFTR modulators can be categorised into three main

classes of agents: potentiators, correctors and premature stop codon suppressors or read-through agents. Premature stop mutations, or nonsense mutations, account for between 5% and 10% of all CFTR mutations, with high regional variations. Class I CFTR nonsense mutations can be targeted using premature stop codon suppressors, more commonly referred to as read-through agents, which force readthrough of premature stop codons during translation of the CFTR protein.

 In about 10% of patients worldwide and more than 50%

of patients in Israel, cystic fibrosis results from nonsense mutations (premature stop codons) in the messenger RNA (mRNA) for the cystic fibrosis transmembrane conductance regulator (CFTR). PTC124 or Atlauren is an orally bioavailable small molecule that is designed to induce ribosomes to selectively read through premature stop codons during mRNA translation, to produce functional CFTR. This phase II prospective trial recruited adults with cystic fibrosis who had at least one nonsense mutation in the CFTR gene.

 Patients were assessed in two 28-day cycles. During the

first cycle, patients received PTC124 at 16 mg/kg per day in three doses every day for 14 days, followed by 14 days without treatment; in the second cycle, patients received 40 mg/kg of PTC124 in three doses every day for 14 days, followed by 14 days without treatment. The primary outcome had three components: change in CFTR-mediated total chloride transport; proportion of patients who responded to treatment; and normalisation of chloride transport, as assessed by transepithelial nasal potential difference (PD) at baseline, at the end of each 14-day treatment course, and after 14 days without treatment.

Conclusion of PTC24 Trials

Transepithelial nasal PD was evaluated in 23

patients in the first cycle and in 21 patients in the second cycle. Mean total chloride transport increased in the first treatment phase, with a change of 71 (SD 70) mV (p<00001), and in the second, with a change of 37 (SD 73) mV (p=0032). Two patients given PTC124 had constipation without intestinal obstruction, and four had mild dysuria. No drugrelated serious adverse events were recorded.

Conclusion
Cystic Fibrosis is a dreadful disease sometimes leading to fatal cases. One such approach is the Personalised Medicine approach. Unlike general

medicine approaches which are more of a reactive approach, personalised medicine has been described as a Hands on approach. To target CFTR mutations and thus CF itself using personalised medicine, the approach has to be very specific. Thus a particular compound can only be able to target one particular type of mutation. Promising candidates were subsequently evaluated in clinical trials. One such modulator, the CFTR potentiator ivacaftor, is a first-in-class agent to be approved as an oral therapy for CF patients with the G551DCFTR mutation and is a pertinent example of personalised medicine. The availability of more sensitive surrogate biomarkers of CF disease, such as intestinal current measurements, may serve to streamline the development of future CFTR modulators. In summary, the concept that personalised medicine can be used to target CF and other respiratory diseases is a paradigm-shifting discovery. This insight has influenced essentially all areas of medicine or physiology.

Future work
Stabilise clinical trials

Run further clinical trials

Increase efficacy of biomolecules Discover more biomolecules capable of targeting all

possible mutations Allow patients to lead a better quality of life.

References
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Thank You