A lone volunteer, who had Duchenne muscular dystrophy and was involved in a unique study of a gene-editing technique, has died, and those behind the trial are now trying to figure out what killed him, so they can share the outcomes with the scientific community.
Terry Horgan (27) died last month, according to Cure Rare Disease, a Connecticut-based non-profit founded by his brother, Rich, to try to save him from the fatal condition.
MedicalXpress reports that although little is known about how he died, his death occurred during one of the first studies to test a gene-editing treatment built for one person. It’s raising questions about the overall prospect of such therapies, which have buoyed hopes among many families facing rare and devastating diseases.
“This whole notion that we can do designer genetic therapies is, I would say, uncertain,” said Arthur Caplan, a medical ethicist at New York University who was not involved in the study. “We are out on the far edge of experimentation.”
The early-stage safety study was sponsored by the non-profit, led by Dr Brenda Wong at the University of Massachusetts Chan Medical School and approved by the US Food and Drug Administration (FDA). The hope was to use a gene-editing tool called CRISPR to treat Horgan’s particular form of Duchenne muscular dystrophy. The rare, genetic muscle-wasting disease is caused by a mutation in the gene needed to produce a protein called dystrophin. Most people with Duchenne die from lung or heart issues caused by it.
At this point, it’s unclear whether Horgan received the treatment and whether CRISPR, other aspects of the study or the disease itself contributed to his death. Deaths are not unheard of in clinical trials, which test experimental treatments and sometimes involve very sick people.
But trials involving CRISPR are relatively new. And Fyodor Urnov, a CRISPR expert at the Innovative Genomics Institute at the University of California, Berkeley, said any death during a gene-therapy trial is an opportunity for the field to have a reckoning.
“Step one is to grieve for the passing of a brave human soul who agreed to be basically a participant in an experiment on a human being,” Urnov said. “But then, to the extent that we can, we must learn as much as we can to carve out a path forward.”
Few answers yet
A statement from Cure Rare Disease said multiple teams across the country are scrutinising the details of the trial and its outcome, and the company intends to share findings with the scientific community.
“It will probably be three-four months to come up with a full conclusion,” said spokesman Scott Bauman. “At this stage, saying anything is pure speculation.”
The company, which is also working on 18 other therapeutics, said the teams’ work is essential not only to shed light on the study’s outcome but also “on the challenges of gene therapy broadly”.
“Meanwhile, we will continue to work with our researchers, collaborators and partners to develop therapies for the neuromuscular diseases in our pipeline.”
A crucial question is whether CRISPR played a part in Horgan’s death.
The chemical tool can be used to “edit” genes by making cuts or substitutions in DNA. The tool has transformed genetic research and sparked the development of dozens of experimental therapies. The inventors of the tool won a Nobel Prize in 2020.
In this case, scientists used a modified form of CRISPR to increase the activity of a gene. The CRISPR therapeutic is inserted directly into the body and delivered to cells with a virus.
But CRISPR is not perfect.
“We know that CRISPR can miss its target. We know that CRISPR can be partially effective. And we also know that there may be issues with … viral vectors that deliver the therapy into the body,” Caplan said. “Red flags are flying here. We’ve got to make sure they get addressed very, very quickly.”
Safety issues have arisen in gene therapy studies before. Late last year, Pfizer reported the death of a patient in its early-stage trial for a different Duchenne muscular dystrophy gene therapy.
And in a major earlier setback for the gene therapy field, 18-year-old Jesse Gelsinger died in 1999 during a study that involved placing healthy genes into his liver to combat a rare metabolic disease. Scientists later learned that his immune system overreacted to the virus used to deliver the therapy. Many recent studies, including the Cure Rare Disease trial, use a different virus that’s considered safer.
Another difference? The recent trial involved just one person – a type of trial about which Caplan is sceptical.
Horgan’s death, he said, “may make us think whether we really do like studies that are just on one person, and do we want to say: ‘No, ethically, you’ve got to at least have a trial where you line up five, 10, 20 people (and) you learn from the data’.”
A ‘medical pioneer’
On the company’s web site, Horgan was described as a “medical pioneer” who “will be remembered as a hero.
He was diagnosed with Duchenne at three, studied information science at Cornell University and went on to work at the school in the information science department.
“As I grew up and began to understand what it meant to have DMD, my fears about this grew as it began to manifest,” Horgan wrote. “There weren’t many, or any, trials available to me through the years”– until this one brought the prospect of a customised drug.
He was enrolled in the study on 31 August. The plan was to suppress his immune system to prep his body for a one-time, gene-editing therapy delivered by IV at UMass medical school, followed by monitoring in the hospital. The company explained that the therapy is designed to increase the level of an alternate form of the dystrophin protein using CRISPR, with the goal of stabilising or potentially reversing the progression of symptoms.
Urnov, scientific director for technology and translation at the Berkeley genomics institute, said no other trial targeted the disease using this kind of virus to deliver this particular payload with its modified form of CRISPR.
Some other gene therapy trials, likes those targeting the blood disorders sickle cell disease and beta thalassemia, involve removing stem cells from someone’s blood, using CRISPR in the lab, then putting the altered cells back into the person. The first time CRISPR was used to edit genes within the body was to address a blindness-causing mutation.
Given the “exceptional distinctness” of the Cure Rare Disease approach, Urnov said he doesn’t think Horgan’s death will have a major impact on things like using gene therapy to fix blood diseases. But he said pinpointing the exact cause will help inform scientists throughout the field.
MedicalXpress article – Death in US gene therapy study sparks search for answers (Open access)
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