Fighting Rare Diseases: The Model of the Telethon Research Institutes in Italy

The Telethon Institute of Genetics and Medicine (TIGEM)

In 1994, the Telethon Foundation founded the Telethon Institute of Genetics and Medicine (TIGEM), a multidisciplinary research institute devoted to the study of the genetic defects and the mechanisms of genetic diseases, and to the development of safe and effective therapies. Research at TIGEM is focused on three strategic programs: Cell Biology of Genetic Diseases, Systems Biology and Functional Genomics, and Molecular Therapy. TIGEM is equipped with state-of-the-art facilities and instrumentation for biological research, including core support in advanced microscopy, bioinformatics and systems biology, high-content screening (HCS), next generation sequencing, and viral vector production. TIGEM currently focuses on a variety of diseases, including neurodegenerative diseases, lysosomal storage disorders, membrane trafficking defects, disorders of liver metabolism, and eye diseases. TIGEM hosts' researchers from all over the world and trains graduate students in human genetics through a joint program with the Open University (UK) and in systems medicine in collaboration with the Federico II University of Naples.

The Cell Biology of Genetic Diseases program focuses on the identification of basic disease mechanisms. The ultimate goal is to provide improved management of genetic diseases through the deeper understanding of the underlying molecular and cellular mechanisms, and development of novel therapeutic tools. The program on Systems Biology and Functional Genomics is focused on the development and application of integrated experimental and computational tools in mammalian systems to study genetic diseases and either develop or monitor therapeutic approaches.

The Molecular Therapy program is focused on developing new strategies for therapy and prevention of genetic diseases and includes the most “translational” aspects of research performed at TIGEM. One of TIGEM's major research strategies is in vivo vector-mediated gene delivery. The general approach is to develop new vector systems and delivery methods, uncover the mechanisms involved in vector transduction, generate the proof-of-concept data in the appropriate animal models, and move the most promising approaches to the clinic. One of the main achievements of the program was the first clinical trials of gene therapy for a genetic form of blindness coordinated by Jean Bennett at the University of Pennsylvania and Children's Hospital of Philadelphia in collaboration with TIGEM researchers and the Department of Ophthalmology at the Second University Hospital in Naples. The first five patients enrolled in the trial were diagnosed and selected based on eligibility criteria established in this collaboration. TIGEM scientists are now working to extend this initial success to other blinding conditions such as Stargardt disease, the most common inherited macular degeneration, which requires expanding adeno-associated virus (AAV) limited cargo capacity to accommodate the large ABCA4 gene that is mutated in this condition. A different but similarly challenging approach is the suppression and replacement of genes involved in dominant forms of retinitis pigmentosa, which TIGEM investigators are addressing by delivering artificial zinc-finger transcriptional repressors. Inborn errors of metabolism are a major therapeutic target for TIGEM. Scientists at TIGEM are now coordinating a consortium supported by European Union funding to develop a clinical trial to test the safety and efficacy of intravenous administrations of AAV8 in patients with the lysosomal storage disorder mucopolysaccharidosis VI. In addition to gene therapy, TIGEM focuses on high-content screening technologies to drive drug discovery in genetic diseases. The goals of HCS at an academic environment are two-fold, a strong focus on drug discovery efforts, which brings TIGEM's expertise and know-how on biological assays and disease models, and, in addition, HCS is also an ideal tool for basic disease mechanism discovery where the function of all genes or a subset of genes can be studied in a quantitative manner. The HCS screening facility at TIGEM has already performed and established suitable assays for primary screens for a number of cell phenotypes and completed the validation of those assays using small selected libraries of compounds. Strategic alliances with industrial partnerships will allow running the high volume screens and performing the medicinal chemistry on active compounds.

The growing number of proofs-of-concepts generated at the preclinical level led TIGEM investigators to establish collaborations with University Hospital Clinical Centers (Department of Translational Medicine, Federico II University of Naples and Department of Ophthalmology, Second University of Naples) and industries to facilitate their clinical translation. “Translatability” requires diverse expertise from basic science, clinical knowledge, drug development, and business development. A successful translation of a basic scientific discovery requires partnerships between non-profit organizations and pharmaceutical companies due to the complexity of expertise required and the high costs of translational studies and clinical trials. Following this model TIGEM has established crucial industrial alliances aimed at helping bridge the gap to bring scientific discoveries to the clinic. One very important alliance was established in 2012 with Shire PLC. This is a long-term, multi-indication research collaboration in rare diseases to facilitate research on 13 undisclosed rare disease indications. The collaboration brings together Shire's established capabilities in developing and distributing effective, life-altering therapies for patients with rare diseases and TIGEM's world-renowned research expertise in gene therapy and other novel therapeutics. Under the terms of the agreement, Shire provides funding over 5 years for several research projects that collectively address a number of different lysosomal storage disorders and neurodegenerative diseases. The research developed in this collaboration has the potential to add multiple, novel therapeutic candidates into an early clinical stage pipeline. Successful projects that arise from this research will be incorporated into Shire's development pipeline and benefit from additional Shire investment and resources. Through the combination of TIGEM's scientific expertise in discovering and translating novel therapeutic concepts and Shire's nonclinical, clinical, and manufacturing capabilities, the goal of the alliance is to bring much needed therapies for rare diseases to patients around the world.

The San Raffaele Telethon Institute for Gene Therapy (TIGET)

The San Raffaele Telethon Institute for Gene Therapy (TIGET) was created in 1995 as a joint venture between the Telethon Foundation and the San Raffaele Scientific Institute in Milan, with the mission to perform cutting edge research on gene transfer and cell and gene therapy, and to promote its translation into therapeutic advances for genetic diseases. The San Raffaele Scientific Institute comprises one of the largest hospitals in Italy and represents a center of excellence for research and clinical application in the field of molecular medicine. The Institute also performs higher education and training in biomedical research and medicine in collaboration with the Vita-Salute San Raffaele University. Research at TIGET spans from basic to preclinical to early phase clinical studies and is mainly geared to: (i) identify the genetic bases, investigate the pathophysiological processes, and develop novel cell and gene therapies for several types of inherited diseases, including primary immunodeficiencies and autoimmune disorders, thalassemia, hemophilia, inherited leukodystrophies, and other lysosomal storage and neurodegenerative diseases; (ii) develop new gene transfer and editing technologies for more efficient and safe genetic correction of diseases ex vivo and in vivo; (iii) characterize the biological properties of hematopoietic and neural stem and progenitor cells and establish procedures for their ex vivo manipulation and transplantation; iv) investigate cell types mediating innate and adaptive immunity and modulate immune response to gene and cell products to improve efficacy and stability of the therapies; and (v) exploit the know-how developed above to design new gene therapy strategies for more common and acquired diseases, including diabetes and cancer.

The new gene and cell therapy strategies being developed are then tested in preclinical disease models in preparation for clinical trials. In order to fulfill the regulations and guidelines for the conduct of the preclinical testing required for clinical trial applications, a GLP (good laboratory practice) compliant test facility has been recently established within TIGET. This represents to our knowledge one of the first GLP-certified facilities able to perform gene and cell therapy studies hosted within an academic Institution.

Furthermore, TIGET is well-equipped to assess the efficacy and safety of the novel therapeutic strategies in patients within early phase clinical trials. This clinical activity is conducted within the TIGET Clinical Research Unit, which is devoted to the diagnosis, treatment, and follow-up of patients with primary immunodeficiencies, hematologic, and metabolic disorders, including those enrolled in gene therapy trials. Patients' treatment is performed in close collaboration with the other clinical units of the San Raffaele Hospital, including the Pediatric Immunohematology Unit and the Hematology and Bone Marrow Transplantation Unit. The cell and gene therapy products for clinical use are supplied by the GMP (good manufacturing practice) facility of MolMed S.p.A, a medical biotechnology company certified for the production and release of advanced therapy medicinal products and located within the San Raffaele biomedical science park.

TIGET has pioneered the gene therapy of a severe form of primary immunodeficiency (ADA-SCID), developing a hematopoietic stem cell (HSC)–based gene therapy employing gamma-retroviral vectors. With more than 13 years follow-up of the first treated patients, this seminal work has provided an as yet unique evidence of substantial clinical benefit without adverse effects in the field of gene therapy. The successful result obtained with ADA-SCID provided a rationale for extending the HSC-based gene therapy approach to other diseases. Meanwhile, the Institute also made essential contributions to the development of a powerful new gene transfer platform, based on lentiviral vectors, which improves the efficiency and, likely, the safety of gene transfer. Since 2010, TIGET has been conducting two first-in-human trials of lentiviral vector-mediated HSC-based gene therapy for metachromatic leukodystrophy and Wiskott-Aldrich syndrome. Several patients have already been safely treated in each trial and continue to show stable and remarkably high levels of hematopoietic reconstitution with gene corrected cells and evidence of major therapeutic benefit. Two new clinical trials of lentiviral vector-mediated HSC-based gene therapy are expected to start in the near future at TIGET for the treatment of beta-thalassemia and mucopolysaccharidosis type I.

In 2010, TIGET entered a strategic alliance with GlaxoSmithKline (GSK) for the clinical development of HSC-based gene therapy for some rare diseases. According to the agreement, GSK committed to develop ADA-SCID gene therapy toward registration and marketing. In addition, TIGET has remained responsible for preclinical development and early clinical testing of new therapies based on lentiviral vectors, on which GSK has license option rights once clinical proof-of-concept is achieved. At the end of 2013, GSK exercised its rights of option on HSC-based gene therapy for metachromatic leukodystrophy and Wiskott-Aldrich syndrome. The partnership with GSK provides TIGET with the skills and resources required to address the regulatory hurdles and manufacturing needs encountered along the path from early testing to registration of the new therapies as advanced therapy medical products. This alliance was one of the first to be signed between a major pharmaceutical company and an academic center with the aim to develop gene therapy. It helped to revitalize and bring new confidence and resources to the whole field and paved the way to many more such deals in the following years.

In parallel, TIGET scientists are continuing to invest in ameliorating vector design by limiting the impact on cellular transcription and exploiting microRNA regulation to stringently control transgene expression. Improvements are validated by sensitive in vivo models to score genotoxicity, as well as high-throughput vector integration site analyses to monitor clonal behavior of vector-transduced cells in experimental models and in clinical trial patients. Moreover, HSC biology is investigated to identify novel regulators of cell growth and quiescence, such as microRNAs, that help design better strategies for ex vivo expansion, genetic modification, and transplantation. An active area of research is also the development of new gene targeting approaches based on artificial endonucleases, such as zinc finger nucleases, TALENs, and CRISPR/Cas9 RNA-guided nucleases, bringing the possibility of targeted integration, genome, and epigenome editing and in situ correction of mutations within the reach of gene therapy.

TIGET has also been pursuing in vivo gene transfer strategies targeting the liver or the central nervous system. By designing a lentiviral platform stringently targeted to hepatocytes by transcriptional and microRNA-regulated control, TIGET scientists were able to overcome the immunological barrier to in vivo gene transfer, establish long-term expression of the transgene, and induce active tolerance to its product. This strategy enabled stable sustained correction of hemophilia B in small and large animal models and provided the ground for a recently established collaboration with the biopharmaceutical company Biogen toward the development of in vivo gene therapy for both hemophilia A and B.

Overall, TIGET represents a multidisciplinary research environment, which provides a unique blend of scientific expertise in the development of innovative ex vivo and in vivo gene therapy strategies, access to GLP compliant studies in preclinical models, as well as competence in conducting early phase clinical trials. This provides a fertile ground for alliances with industrial partners, which represent an invaluable means to reaching the ultimate goal of effectively developing and delivering therapies to patients.