THERAPEUTIC DIGEST RARE DISEASES PROGRESS AND CHALLENGES AHEAD IN COLLABORATION WITH DECEMBER 2020 Rare changes everything. Every day can be delayed, postponed, or canceled when you or a loved one has a rare disease. At the Center for Rare Diseases, we never forget that rare alters entire lives. We’re committed to changing that. To find out more, visit us at rarechangeseverything.com. Pharma VOICE.com RARE DISEASES Table of Contents Rare Diseases: Progress and Challenges Ahead ............................................................. 5 Defining Rare Diseases ..................................................................................................... 6 Small Molecules ................................................................................................................ 6 Progress ............................................................................................................................... 7 Clinical Success and Approvals ............................................................................................. 8 Strengths and Limitations ...................................................................................................... 9 Antibody Therapies ........................................................................................................ 10 Progress ............................................................................................................................. 10 Clinical Success and Approvals ........................................................................................... 11 Strengths and Limitations .................................................................................................... 12 Protein Replacement Therapies ..................................................................................... 13 Progress ............................................................................................................................. 14 Clinical Success and Approvals ........................................................................................... 14 Strengths and Limitations .................................................................................................... 15 Oligonucleotide Therapies ............................................................................................. 16 Progress ............................................................................................................................. 16 Clinical Success and Approvals ........................................................................................... 17 Strengths and Limitations .................................................................................................... 18 Gene and Cell Therapy .................................................................................................. 18 Progress ............................................................................................................................. 19 Clinical Success and Approvals ........................................................................................... 21 Strengths and Limitations .................................................................................................... 22 Table: Characteristics of Therapeutic Modalities ........................................................ 23 Pie Charts: Approvals by Therapeutic Modality .......................................................... 24 Table: glossary of Terms ............................................................................................. 24 Conclusion ................................................................................................................... 26 Notes ................................................................................................................................ 27 Resources ......................................................................................................................... 34 Editorial content provided by ThinkGen (www.think-gen.com) Written by Kristina Erfe Pines DECEMBER 2020 3 DIGITAL THERAPEUTICS Q&A with PRA’s Juliane Mills How are rare disease clinical trials different from Juliane Mills traditional clinical trials? Director, PRA Center for Rare Diseases Every patient is a precious resource in clinical research. PRA Health Sciences When conducting a clinical trial in a rare disease, there are by definition only a few eligible patients who can participate in a clinical trial. If someone drops out, there may not be anyone else to invite. The way we engage with patients needs to be reflective of the value of their participation. This means doing all we can to make it easy to volunteer such as with plain-language patients are partners in the journey. Patients should communication, reimbursement for time and travel, be empowered to do their own reading, talk to other and carefully planning visit procedures. people who have the same symptoms, and share their Rare disease trials are also different due to the ideas about treatment with their doctor. It’s never a statistical challenges when researching a low number one-way street. of patients. Just as every patient is precious, every data point is critically important. Because there are fewer patients, there are less data overall, and we may 90% of all rare disorders do not have an FDA- not have the statistical power in rare disease trials to approved treatment. How can the R&D process discriminate noise from a true signal. To reduce ‘noise’ address the smaller patient populations inherent in the data set, the methods used to collect data need with orphan or rare disease trials? to be standardized. We need to make sure every trial Registries are often set up by R&D companies, but site in a study is consistently using the same staff more and more we see advocacy groups setting them and the same methods to assess each patient. Every up and encouraged to do so by regulatory authorities. person involved, from the doctors administering the When advocacy groups set up registries on their own, assessment to the study coordinators and site staff, they can democratize ownership of all this data, which must follow the same procedures. puts ownership in the hands of patients. By building registries populated with shareable observational data, we can establish consensus in rare disease research Many families search for a diagnosis for years. and form a better singular view into these patient Historically, it’s been incredibly difficult to obtain populations. an accurate diagnosis. Some studies have estimated that up to 40% of rare disease patients As we share what we know about rare diseases, we are misdiagnosed at least once. What can be done find that some rare diseases operate in the same to change how rare diseases are diagnosed? biological pathway but may manifest with very different symptoms. Even though these patients have the When patients are misdiagnosed or bounced around same disease pathway, different types of doctors may from doctor to doctor, it can certainly upend the doctor- treat them depending on where the symptoms occur. patient relationship. Sometimes a diagnosis of a rare Advocacy groups have been bringing together doctors disease is a process of ruling out other diseases, which from all different specialties as well as academic means a lot of tests, painful procedures, and time. The researchers to build consensus on biomarkers, disease lack of answers can completely erode a patient’s faith in terminology, and treatments. n the medical system. Honesty on both sides of the patient-doctor relationship is a great way to move forward. Doctors need to be ____________________________________________________ willing to hear and listen to what patients are telling By partnering with patients in your rare disease them. Conversely, patients need to understand that research, you can develop more meaningful endpoints. doctors may not have all the answers. Doctors and Learn how in our latest white paper. 1220-TherapeuticDigest-PRA-120320.indd 1 12/10/20 11:44 AM Pharma VOICE.com RARE DISEASES Rare Diseases Progress and Challenges Ahead Rare diseases, also known as orphan disease, are a group of disorders that affects a small percentage of the population. Commonly presenting in early life, rare disease can also be seen in adulthood with a chronic phase. These diseases are frequently progressive, disabling, and life threatening. Approximately 30% of children suffering will die at 5 years of age1. Although rare diseases affect small numbers of patients by definition, they are estimated to collectively affect ~350 million patients globally2, more than double the number of patients affected by AIDS and cancer combined. While there have been substantial efforts to promote the development of therapies for rare diseases in the past few decades, supported by regulatory and economic incentives3, most of the estimated ~7,000 rare diseases still lack specific treatments. Moreover, recent analysis indicates that the number of rare diseases could be substantially higher than 7,000. The vast majority of rare diseases are characterized by Mendelian inheritance, and the recent evolution and broader application of sequencing technologies have revealed the causes of novel rare diseases and have identified new mutations responsible for previously defined disorders4. In addition, emerging applications of advanced analytics such as facial recognition have the potential to improve the screening and diagnosis of some disorders5. Nevertheless,