Base Editing for Mutation Repair in Hematopoietic Stem & Progenitor Cells for X-Linked Chronic Granulomatous Disease

Chronic Granulomatous Disease (CGD) Clinical Trial

Official title:

Phase 1/2 Trial of Base Editing for Mutation Repair in Hematopoietic Stem & Progenitor Cells for X-linked Chronic Granulomatous Disease

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT06325709
• Other study ID #: 10001580
• Secondary ID: 001580-I
• Status: Recruiting
• Phase: Phase 1/Phase 2
• Start date: April 17, 2024
• Est. completion date: December 31, 2032

Study information

• Verified date: May 8, 2024
• Source: National Institutes of Health Clinical Center (CC)
• Contact: Suk S De Ravin, M.D.
• Phone: (301) 496-6772
• Email: sderavin[@]mail.nih.gov
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Background: Chronic granulomatous disease (CGD) is a rare immune disorder caused by a mutation in the CYBB gene. People with CGD have white blood cells that do not work properly. This places them at risk of developing infections that may be life-threatening. Stem cell transplant can cure CGD but transplanting stem cells donated by other people can have serious complications. In addition, not everyone has a matched donor. Another approach is a type of gene therapy that involves base-editing to correct the mutation in a person s own stem cells. Researchers want to know if the base-edited stem cells can improve the white cells' functioning and result in fewer CGD-related infections. Objective: To learn if base-edited stem cells will improve white blood cells' ability to fight against infections in people with CGD. Eligibility: Males aged 18 years and older with X-linked CGD. Design: This is a non-randomized study. Participants with the specific mutation under study will be screened during the initial phase. During the development phase, participants will undergo apheresis to collect stem cells for base-editing correction of the mutation. During the treatment phase, participants will receive the base-edited cells after chemotherapy with busulfan. Participants will remain in the hospital until their immunity recovers. Follow-up visits will continue for 15 years.

Description:

Study Description: Open-label, phase 1/2 trial to determine the safety, and efficacy of a single infusion of base-edited (BE) autologous hematopoietic stem and progenitor cells (HSPCs) for treatment of X-linked chronic granulomatous disease (X-CGD). Base editing is performed to repair CYBB missense gene mutations (eg, CYBB c.676C>T). The study hypotheses are that 1) base editing can efficiently repair gene mutations in HSPCs; and 2) BE HSPCs can engraft and differentiate into functional phagocytes with restored nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity. During the initial development phase each study participant will undergo apheresis for CD34+ HSPC collection for the development and validation of a mutation-specific BE system. During the treatment phase, participants will receive a one-time infusion of the BE autologous HSPC Investigational Medicinal Product (IMP) after busulfan (total 12 mg/kg) conditioning. Participants will have follow-up evaluations at months 3, 6, 12, 18, and 24, and yearly thereafter until 5 years after treatment. Key study assessments include adverse event (AE) assessment, blood laboratory evaluations of functional protein made from the target gene (CYBB, encodes for gp91^phox), and deoxyribonucleic acid (DNA) sequencing to identify rates of gene repair and off-target mutation. The final study follow-up under this protocol will be at 5 years, but long-term follow-up under a separate NIH protocol will continue annually to 15 years after treatment. Objectives: Primary Objectives: - To evaluate the safety of BE autologous CD34+ cells. - To evaluate the efficacy of BE autologous CD34+ cells. Secondary Objectives: -To evaluate: - Efficiency of base editing (percentages of target nucleotide conversion). - Engraftment capability of BE HSPCs. - Efficiency in restoring gp91^phox expression - Efficiency in restoring NADPH oxidase function. - Clinical efficacy. - Stability of gene correction. Exploratory Objectives: -To evaluate: - Specificity of base editing by assessing rates of off-target edits at top predicted sites. - Random off-target edits by whole genome sequencing (WGS). Endpoints: Primary Endpoints: - Safety of gene therapy using BE autologous HSPCs as measured by study agent-related AEs and serious AEs (SAEs) through 2 years after treatment. - Efficacy of gene therapy determined as percentages of subjects who have >= 10% oxidase-positive granulocytes at 12 months after infusion. Secondary Endpoints: - Determine frequency of converted target nucleotide alleles. - Assess the frequency of gene-modified alleles compared to infusion product in peripheral blood at 12 months. - Evaluate efficacy of restoring gp91^phox expression. - Evaluate efficacy of NADPH oxidase functional restoration as measured by the dihydrorhodamine (DHR) flow cytometry oxidase assay at 12 months after treatment (>=10% oxidase-positive neutrophils), or by quantitative measurement of reactive oxygen species (ROS) using the ferricytochrome C assay on peripheral blood granulocytes. - Evaluate clinical benefit by improvement of baseline clinical problems such as recurrent infections, growth failure, malnutrition, inflammatory bowel disease, or antibiotic usage. - Assess stability of gene correction by serial measurement of percent of nucleotide-converted alleles. Exploratory Endpoints: - Evaluate specificity by assessing for off-target edits at predicted sites with high-throughput sequencing of the 5 most common candidate off-target sites identified by a comprehensive in vitro screen, Circularization for High-throughput Analysis of Nuclease Genome-wide Effects by sequencing (CHANGE-seq), in peripheral blood cells. - Determine rate of random off-target edits WGS.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 10
• Est. completion date: December 31, 2032
• Est. primary completion date: December 31, 2032
• Accepts healthy volunteers: No
• Gender: Male
• Age group: 18 Years to 75 Years

Eligibility

• INCLUSION CRITERIA:

->= 18 years of age.

• Confirmed CYBB c.676 C>T mutation.
• Male patients.
• Clinically stable and eligible to undergo apheresis and conditioning chemotherapy. ->=5 x 10^6 cryopreserved cells/kg body weight available for study agent manufacturing.
• History of at least one prior serious infection or inflammatory complication requiring hospitalization despite conventional therapy.
• Able and willing to use a highly effective method of contraception, AND partner has communicated her willingness through subject to do same, if engaging in potentially reproductive sex from the signing of the informed consent and for 6 months after IMP

infusion. Acceptable methods of contraception include the following:

• Hormonal contraception in continuously effective use by female partner.
• Male or female condom with spermicide as indicated.
• Diaphragm or cervical cap in consistent and effective pattern of use with a spermicide by female partner.
• Intrauterine device in-situ throughout above period by female partner. EXCLUSION CRITERIA: Individuals meeting any of the following criteria will be excluded from study

participation:

• Untreated, acute infection.
• Anti-platelet antibody screening with >1 anti-platelet antibody positive in the presence of an ongoing brain infection; OR >1 anti-platelet antibody positive and considered unsafe for study participation after consultation with hematology specialist.
• Known hypersensitivity to busulfan or any component of the product.
• Contraindications for administration of busulfan.
• Any current or pre-existing hematologic malignancy.
• Chronic infections that are considered unsafe for participation in the study by Infectious Disease Consultant.
• Cardiac abnormlaties and neurological abnormalities that are deemed unsafe to participate in the study.
• Childhood malignancy (occurring before 18 years of age) in the patient or a first degree relative, or previously diagnosed known genotype of the participant conferring a predisposition to cancer (no DNA or other testing for cancer predisposition genes will be performed as part of the screen for this protocol).
• Hematological parameters unsafe for apheresis or above Grade 2 Common Terminology Criteria for Adverse Events (CTCAE) criteria until improved.
• Hepatic dysfunction- alanine aminotransferase (ALT >3.0 - 5.0 x upper limit of normal [ULN]), aspartate aminotransferase (AST >3.0 - 5.0 x ULN), bilirubin (>1.5 - 3.0 x ULN).
• Renal dysfunction-serum creatinine >1.5 - 3.0 x ULN or creatinine clearance 59-30 mL/min/1.73 m^2.
• Coagulation dysfunction- Prothrombin INR or Partial thromboplastin time >2 x ULN (patients on controlled anticoagulation agents will not be excluded for therapeutic levels).
• Uncontrolled hypertension- Systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg.
• Abnormal blood chemistries- Hyperkalemia (K >5.5 - 6.0 mmol/L), Hypokalemia (<LLN - 3.0 mmol/L and requiring intervention); OR Hypercalcemia (corrected serum calcium >11.5 - 12.5 mg/dL), Hypocalcemia (corrected serum calcium <8.0 -7.0 mg/dL) These values exclude false abnormalities secondary to hemolysis.
• Cytogenetic abnormalities evidenced on bone marrow aspirate.
• Pulmonary dysfunction FEV1<25% predicted.
• Previous treatment with gene therapy or gene editing products.
• Any other condition that, in the opinion of the investigator, may unduly compromise the safety or compliance of the patient, or would make successful study completion highly unlikely.

Related Conditions & MeSH terms

• Chronic Granulomatous Disease (CGD)
• Granuloma
• Granulomatous Disease, Chronic
• X-Linked Chronic Granulomatous Disease

Intervention

Biological:
• Base-edited hematopoietic stem and progenitor cells
Investigational/Study Agent: Base-edited autologous CD34 plus hematopoietic stem and progenitor cell product. The product is administered intravenously as a single infusion. This product is under an IND.

Drug:
• Busulfan
Transplant Conditioning Agent: An alkylating chemotherapy drug to enhance engraftment of the study agent (base-edited stem cells). Conditioning will be given intravenously over 3 days with an approximate total dose of 12mg/kg. Drug levels obtained will be obtained to achieve the targeted total busulfan AUC of 65,000 ng/mL x hr.
• Palifermin
Mucositis Prophylaxis Agent: Intravenous infusion of keratinocyte growth factor (Palifermin) at 60 mcg/kg/day before (Days -7 to Day -5 administration of busulfan and (Days 1 to 3) post-busulfan administration to prevent oral mucositis.
• Filgrastim
Stem Cell Mobilizing Agent: Subcutaneous administration for 6 consecutive days. It is necessary to mobilize stem cells for collection.
• Plerixafor
Stem Cell Mobilizing Agent: Subcutaneous administration for 2 consecutive days to improve stem cell collection.

Locations

Country	Name	City	State
United States	National Institutes of Health Clinical Center	Bethesda	Maryland

Sponsors (1)

Lead Sponsor	Collaborator
National Institute of Allergy and Infectious Diseases (NIAID)

Country where clinical trial is conducted

United States, 

References & Publications (2)

Komor AC, Badran AH, Liu DR. Editing the Genome Without Double-Stranded DNA Breaks. ACS Chem Biol. 2018 Feb 16;13(2):383-388. doi: 10.1021/acschembio.7b00710. Epub 2017 Oct 9. — View Citation

Kuhns DB, Alvord WG, Heller T, Feld JJ, Pike KM, Marciano BE, Uzel G, DeRavin SS, Priel DA, Soule BP, Zarember KA, Malech HL, Holland SM, Gallin JI. Residual NADPH oxidase and survival in chronic granulomatous disease. N Engl J Med. 2010 Dec 30;363(27):2600-10. doi: 10.1056/NEJMoa1007097. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	To evaluate the safety of base-edited autologous CD34+ cells	Safety of gene therapy using base-edited autologous hematopoietic stem and progenitor cells as measured by study agent related adverse events and serious adverse events	Initiated from the time of the infusion of base-edited cells through 2 years post-infusion
Primary	To evaluate the efficacy of base-edited autologous CD34+ cells	Efficacy of gene therapy as determined by percentages ofparticipants who have >= 10 percent oxidase-positive granulocytes	Assessed 12 months post-infusion of base-edited cells
Secondary	Evaluate the efficiency of base-editing.	Measure the percentages of gp91-expressing cells	Assessed 12-24 months post-infusion of base-edited cells
Secondary	Evaluate the engraftment capability of base-edited hematopoietic stem progenitor cells.	Measure the percentages of edited myeloid cells	Assessed 12-24 months post-infusion of base-edited cells
Secondary	Evaluate the efficiency in restoring gp91phox expression.	Measure the frequency of gp91phox+ cells and the amount of gp91phox protein	Assessed 12-24 months post-infusion of base-edited cells
Secondary	Evaluate efficacy in restoring NADPH oxidase function.	Measure the frequency of DHR+ cells	Assessed 12-24 months post-infusion of base-edited cells
Secondary	Evaluate clinical efficacy	Assess the frequency of infections and progression of co-morbidities of CGD	Assessed through study completion
Secondary	Evaluate the stability of gene correction	Compare frequencies of corrected alleles before infusion and at study completion	Assessed through study completion

External Links

•   NIH Clinical Center Detailed Web Page