RESEARCH ARTICLE Long-Term Retrospective Analysis of Gene Therapy with Alipogene Tiparvovec and Its Effect on Lipoprotein Lipase Deficiency-Induced Pancreatitis Daniel Gaudet,1,* Erik S. Stroes,2 Julie Me´ thot,1 Diane Brisson,1 Karine Tremblay,1 Sophie J. Bernelot Moens,2 Giorgio Iotti,3 Irene Rastelletti,3 Diego Ardigo,3 Deyanira Corzo,4 Christian Meyer,4 Marc Andersen,4 Philippe Ruszniewski,5 Mark Deakin,6 and Marco J. Bruno7 1Ecogene-21 Clinical and Translational Research Center and Lipidology Unit, Community Genetic Medicine Centre, Department of Medicine, Universite´ de Montreal, Montreal, Canada; 2Academic Medical Center, Amsterdam, The Netherlands; 3Chiesi Farmaceutici, Parma, Italy; 4uniQure B.V., Amsterdam, The Netherlands; 5Beaujon Hospital, Denis Diderot University, Paris, France; 6University Hospital of North Midlands, Stoke-on-Trent, United Kingdom; 7Erasmus Medical Centre, Rotterdam, The Netherlands. Alipogene tiparvovec (Glybera) is a gene therapy product approved in Europe under the ‘‘exceptional cir- cumstances’’ pathway as a treatment for lipoprotein lipase deficiency (LPLD), a rare genetic disease re- sulting in chylomicronemia and a concomitantly increased risk of acute and recurrent pancreatitis, with potentially lethal outcome. This retrospective study analyzed the frequency and severity of pancreatitis in 19 patients with LPLD up to 6 years after a single treatment with alipogene tiparvovec. An independent adjudication board of three pancreas experts, blinded to patient identification and to pre- or post-gene therapy period, performed a retrospective review of data extracted from the patients’ medical records and categorized LPLD-related acute abdominal pain events requiring hospital visits and/or hospitalizations based on the adapted 2012 Atlanta diagnostic criteria for pancreatitis. Both entire disease time period data and data from an equal time period before and after gene therapy were analyzed. Events with available medical record information meeting the Atlanta diagnostic criteria were categorized as definite pancreatitis; events treated as pancreatitis but with variable levels of laboratory and imaging data were categorized as probable pancreatitis or acute abdominal pain events. A reduction of approximately 50% was observed in all three categories of the adjudicated post-gene therapy events. Notably, no severe pancreatitis and only one intensive care unit admission was observed in the post-alipogene tiparvovec period. However, important inter- and intraindividual variations in the pre- and post-gene therapy incidence of events were observed. There was no relationship between the posttreatment incidence of events and the number of LPL gene copies injected, the administration of immunosuppressive regimen or the percent triglyceride decrease achieved at 12 weeks (primary end point in the prospective clinical studies). Although a causal relationship cannot be established and despite the limited number of individuals evaluated, results from this long-term analysis suggest that alipogene tiparvovec was associated with a lower frequency and severity of pancre- atitis events, and a consequent overall reduction in health care resource use up to 6 years posttreatment. INTRODUCTION teins.3,4 In patients with LPLD, the LPL gene LIPOPROTEIN LIPASE DEFICIENCY (LPLD) is a debili- defect leads to impaired LPL function; the rate of tating genetic disease for which there is currently lipolysis of TG-rich particles is much lower than in no effective drug therapy available. The prevalence normal subjects, causing extreme accumulation of of LPLD is approximately 1–2 per million.1,2 In- chylomicron (CM) particles, clinically observed as dividuals with LPLD display marked chylomicro- chylomicronemia. nemia and severe hypertriglyceridemia.1 Major clinical signs of LPLD consist of plasma LPL is the key enzyme responsible for the hy- lactescence, lipemia retinalis, hepatosplenomegaly, drolysis of triglycerides (TGs) in TG-rich lipopro- and eruptive xanthomas.1,5 Feared complications *Correspondence: Dr. Daniel Gaudet, Ecogene-21 Clinical Research Center and Department of Medicine, Universite´ de Montre´al, Montreal, 225 St-Vallier Saguenay (Chicoutimi), Quebec, Canada G7H 7P2. E-mail: [email protected] HUMAN GENE THERAPY, VOLUME 28 NUMBER 00 DOI: 10.1089/hum.2015.158 1 ª 2016 by Mary Ann Liebert, Inc. j 2 GAUDET ET AL. include recurrent acute pancreatitis and possible duced by alipogene tiparvovec were sustained at development of pancreatic insufficiency and the 52-week assessment and were independent of insulin-dependent diabetes.6 If infection or necro- pretreatment TG values.23 tizing pancreatitis develops, the risk of a fatal To gain further insight into the long-term clini- outcome may reach 5–15% of cases.7 Management cal efficacy of alipogene tiparvovec, retrospective of patients currently consists of severe restrictions medical record review studies (CT-AMT-011-03 of dietary fat intake to less than 20 g/day or less and CT-AMT-011-05) were conducted to assess the than 15% of caloric intake and the use of medium- frequency and severity of disease-related acute chain triglycerides (MCTs).1 Compliance with this abdominal pain events reported from subjects with strict dietary regimen is difficult and, even if it is LPLD who were previously treated during the clin- good, such measures are usually not sufficient to ical development program for alipogene tiparvovec. reduce chylomicronemia. At present, no available Detailed information about acute abdominal pain drug is able to effectively modulate the course of events requiring hospital visits and/or admissions the illness, so these patients remain at high risk of was collected from patients’ medical records. Ana- morbidity and mortality. Enzyme replacement lyses were carried out for the entire disease time therapy is not expected to be effective, due to the period (e.g., the period from first hospital event and short intravascular half-life of the LPL protein the entire post-gene therapy follow-up) and for an (approximately 15 min). The disease is, however, equal pre- and post-gene therapy time period. amenable to gene therapy because it is a monogenic disease.8 Adeno-associated virus (AAV) is a nonpatho- MATERIALS AND METHODS genic virus that has been safely administered to Patients humans in numerous clinical trials.9–11 After sin- Twenty-seven patients with LPLD have re- gle intramuscular administration of recombinant ceived alipogene tiparvovec or its predecessor AAV vector particles12 long-term transgene protein AMT-010 in three clinical studies. All clinical expression has been reported in preclinical stud- studies were approved by the relevant ethics ies.13–17 Given the established safety profile and committees or institutional review boards and persistent expression, an AAV vector was chosen in were performed in accordance with Good Clinical the clinical development of alipogene tiparvovec Practice guidelines and the Declaration of Hel- (Glybera) to deliver the therapeutic gene. The sinki. Signed informed consent forms were ob- LPLS447X variant, a gain-of-function allele associ- tained from all participants. Figure 1 describes ated with lower plasma TG levels, was selected the clinical development program.20,22 as the candidate for gene therapy of patients None of the patients who received the alipogene with LPLD.18,19 Alipogene tiparvovec includes the tiparvovec predecessor (8 of the 27 patients who human LPL gene variant LPLS447X carried by an participated in the first study, CT-AMT-010-01) AAV vector, AAV1, in solution for intramuscular were included in the CT-AMT-11-03 and CT-AMT- injection designed to target muscle cells.18,19 11-05 analyses because hospital medical records Intramuscular administration of alipogene ti- pertaining to the historical period before gene parvovec in 14 patients with LPLD (study CT- therapy were mostly not available, and the gene AMT-011-01) was well tolerated without emerging therapy product was manufactured differently.24 safety concerns up to 5 years of follow-up.20,21 Half The CT-AMT-010-01 study used AMT-010, which of the patients demonstrated a ‡40% reduction in comprised the same LPLS447X gene construct and total fasting plasma TG between 3 and 12 weeks AAV vector as alipogene tiparvovec.4 However, after gene therapy. Total fasting plasma TG AMT-010 was manufactured using a mammalian showed subsequent significant variability and cell production system, whereas alipogene tiparvo- tended to return to baseline values, although sus- vec is produced in an insect cell-based system using tained LPLS447X expression and changes in TG- baculovirus technology.4 Therefore, the analysis rich lipoprotein characteristics were noted, inde- reported here includes 19 patients with LPLD pendently of the effect of alipogene tiparvovec on treated with alipogene tiparvovec solely in two of total fasting plasma TG.20 A later trial with alipo- three prospective clinical studies. gene tiparvovec in five patients with LPLD (CT- A subgroup of 12 patients with LPLD with pre- AMT-011-02) showed that the postprandial chylo- treatment occurrence of severe or multiple definitive micron (ppCM) kinetics significantly improved af- or probable pancreatitis episodesisdescribedsepa- ter 14 weeks of treatment.22 Signs of ppCM rately, as they constitute the ‘‘on label’’ patient pop- improvement of TG-rich lipoprotein kinetics in- ulation for the approved indication and dose of GENE THERAPY WITH ALIPOGENE TIPARVOVEC FOR LPLD 3 Figure 1. Overview of the clinical