Gene Transfer Therapy for Treating Children and Adults With Limb Girdle Muscular Dystrophy Type 2D (LGMD2D)

Gene Transfer Therapy for Treating Children and Adults With Limb Girdle Muscular Dystrophy Type 2D (LGMD2D)

Phase I Gene Transfer of rAAV1.tMCK.Human-alpha-sarcoglycan for Limb Girdle Muscular Dystrophy Type 2D (LGMD2D)

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Muscular Dystrophy Association

Limb girdle muscular dystrophy type 2D (LGMD2D) is a genetic disease that affects skeletal muscle. Insufficient levels of the protein alpha-sarcoglycan result in muscle weakness that worsens over time. The purpose of this study is to evaluate the safety and effectiveness of gene therapy in treating children and adults with LGMD2D.

The primary objective of this study is the assessment of the safety of intramuscular administration to alpha-sarcoglycan deficient subjects of recombinant adeno-associated virus serotype 1 (rAAV1)-human alpha-sarcoglycan gene (hαSG) vector under control of a skeletal muscle creatine kinase promoter. The secondary objective is to determine the dose of rAAV1.tMCK.hαSG vector required to achieve a detectable level of alpha-sarcoglycan in muscle of subjects with this disorder. A recombinant virus vector constructed from AAV1 has been altered to carry the human alpha-sarcoglycan gene expressed from a tMCK promoter. The construct has been shown to initiate the production of a functional alpha-sarcoglycan protein in laboratory animals. This construct can reverse the dystrophic phenotype in the alpha-sarcoglycan knock out mouse, a laboratory animal model for the clinical disorder. Intramuscular injection of rAAV1 restores muscle histology to normal and increases muscle strength to levels exceeding control knock out mice but not to the same degree as wild-type mice. The proposed human clinical trial is a phase I, double-blind randomized protocol with injection of rAAV1.tMCK.hαSG gene vector into muscle. Two cohorts of subjects with LGMD2D(alpha-sarcoglycan deficiency), each with proven mutations will undergo gene transfer. A minimum of three subjects will be enrolled into each cohort. The first cohort will receive a total of 1.5 ml volume of study agent in two to six separate injections into the selected muscle (extensor digitorum brevis) or other muscle if more appropriate considering the individual patient) with a dose of 3.25 X 10 to the 11 vg in 1.5 ml. The anatomical midline point of the muscle will be identified on the skin and 2 to 6 vector injections will be distributed in the direction of an X. The second cohort will receive the same dose delivered to muscle according to the same paradigm. In each cohort, only one extremity will receive vector with transgene while the opposite extremity will be injected with placebo. On the day of the vector infusion, 4 hours before gene transfer, patients will receive intravenous methylprednisolone 2.0 mg/kg (not to exceed 1 gm total), with repeat doses on two consecutive mornings. The methylprednisolone is specifically given to diminish the immediate inflammation from the needle injection, which is known to arouse an inflammatory reaction and could contribute to bringing antigen presenting cells to the site of vector delivery. We have previously demonstrated that this treatment enhances gene expression by at least 2-fold (Included as part of BB-IND-12936 for minidystrophin gene transfer). Safety endpoints to be assessed include inflammatory reaction to the vector, as evaluated by muscle biopsy, and changes in hematology, serum chemistry, urinalysis, immunologic responses to rAAV1 and alpha-sarcoglycan, and reported history and observations of symptoms. The patient will have 10 to 12 follow-up visits for the next 2 years after the initial infusion.

limb girdle muscular dystrophy type 2D, alpha-sarcoglycanopathy, LGMD, LGMD2D, gene therapy, gene transfer, muscular dystrophy, SGCA, sarcoglycan, limb girdle, adeno-associated virus, AAV, AAV1

The first cohort will receive a total of 1.5 ml volume of study agent in two to six separate injections into the selected muscle (extensor digitorum brevis) or other muscle if more appropriate upon considering the individual patient. The dose will be 3.25 X 10 to the 11 vg in 1.5 ml. The anatomical midline point of the muscle will be identified on the skin and two to six vector injections will be distributed in the direction of an X. In each cohort, only one extremity will receive vector with transgene while the opposite extremity will be injected with placebo.

The second cohort will receive the same dose of 3.25 X 10 to the 11 vg in 1.5 ml delivered to muscle according to the same paradigm. In each cohort, only one extremity will receive vector with transgene while the opposite extremity will be injected with placebo.

The first cohort of subjects with LGMD2D (alpha-sarcoglycan deficiency) and proven mutations will undergo gene transfer with a minimum of three subjects enrolled into this cohort and will receive a total of 1.5 ml volume of study agent in two to six separate injections into the selected muscle (extensor digitorum brevis) or other muscle if more appropriate upon considering the individual patient. The dose will be 3.25 X 10 to the 11 vg in 1.5 ml. In each cohort, only one extremity will receive vector with transgene while the opposite extremity will be injected with placebo.

The second cohort will receive the same dosis of 3.25 X 10 to the 11 vg in 1.5 ml delivered to muscle according to the same paradigm. In each cohort, only one extremity will receive vector with transgene while the opposite extremity will be injected with placebo.

Safety of AAV1.tMCK.human-alpha-sarcoglycan gene transfer via intramuscular injection to the EDB muscle

First cohort: Measured 45 days for two patients and at 90 days after gene transfer for one patient; Second cohort: Measured at 6 months after gene transfer for the three patients

Muscle strength of the gene transferred muscle via maximal volume isometric contraction testing (MVICT) if selected muscle is suitable for strenght testing

Measured 45 or 90 days after gene transfer in the first cohort, or 6 months post-gene transfer in second cohort depending on muscle biopsy date

Inclusion Criteria: Six LGMD2D subjects ages 5 and older based on the clinical degree of involvement (impaired muscle function/weakness, sufficient muscle preservation) Preservation of EDB muscle or another muscle if judged more favorable because of adequate muscle mass for gene transfer Males and females of any ethnic group Established mutations of an -SG gene on both alleles Ability to cooperate for testing Sexually active patients must be willing to practice a reliable method of contraception during the study Exclusion Criteria: Active viral infection (symptoms listed in section 9.0 of the protocol) LGMD2D subjects without weakness or functional loss Cardiomyopathy based on clinical exam and ECHO with ejection fraction less than 40% HIV infected Hepatitis A, B, or C infected Autoimmune diseases and immunosuppressive drugs (other than pulse methylprednisolone at time of gene transfer) Persistent leucopenia or leucocytosis (WBC less than or equal to 3.5 K/cu mm or at least 20.0 K/ cu mm) or neutrophils less than 1.5 K/ cu mm Concomitant illness or requirement for chronic drug treatment that in the opinion of the Principal Investigator creates unnecessary risks for gene transfer Pregnancy Abnormal laboratory values considered clinically significant Alcoholism (CAGE questionnaire), and laboratory tests such as GGT and MCV

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