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Geroscience and The Exposome Mass Spectrometry Supports Development of New Oligonucleotide Therapeutics

Developing Plasmid DNA Production Platforms to Support Novel Gene Therapies

How the Biopharmaceutical Industry is

Responding to Patient Demand for Injection Alternatives

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Contents 04 Foreword MARKET REPORT 06 Building a Better Healthcare Cluster DIRECTORS: Martin Wright Mark A. Barker BUSINESS DEVELOPMENT: Mark Sen mark@ibijournal.com EDITORIAL: Virginia Toteva virginia@pharmapubs.com DESIGN DIRECTOR: Jana Sukenikova www.fanahshapeless.com FINANCE DEPARTMENT: Martin Wright martin@ipimedia.com RESEARCH & CIRCULATION: Ana de Jesus ana@pharmapubs.com COVER IMAGE: iStockphoto © PUBLISHED BY: Pharma Publications 50 D, City Business Centre London, SE16 2XB Tel: +44 (0)20 7237 2036 Fax: +44 (0)01 480 247 5316 Email: info@ibijournal.com www.biopharmaceuticalmedia.com All rights reserved. No part of this publication may be reproduced, duplicated, stored in any retrieval system or transmitted in any form by any means without prior written permission of the Publishers. The next issue of IBI will be published in Summer 2020. ISSN No.International Biopharmaceutical Industry ISSN 1755-4578. The opinions and views expressed by the authors in this magazine are not necessarily those of the Editor or the Publisher. Please note that although care is taken in preparation of this publication, the Editor and the Publisher are not responsible for opinions, views and inaccuracies in the articles. Great care is taken with regards to artwork supplied, the Publisher cannot be held responsible for any loss or damage incurred. This publication is protected by copyright. 2020 PHARMA PUBLICATIONS / Volume 3 Issue 1 – Spring 2020

Science and technology have always been a powerful dynamic in regeneration, and the fourth industrial revolution has many parallels with the first in the way that it continues to shape our thinking about towns, cities and places. Neil Murray of Impact Data Metrics discusses why science and technology is more or less unchallenged at the vanguard of how economists think the country should approach the future, and how in the UK this means a vision of creating a highly-skilled, high-value economy, with life sciences to the fore. 8

Unique Challenges and Opportunities in Orphan Diseases

Looking back, the 1983 Orphan Drug Act was a pivotal moment for healthcare, not just in the US but worldwide too. Research on orphan diseases has since flourished, paving the way in 2017 for the first US-approved gene therapy launch, and to date, hundreds of gene therapies are in the pipeline. Jeremy Edwards of Raremark, a patient community online specialist in rare conditions, outlines the challenges and opportunities in the orphan space. RESEARCH / INNOVATION / DEVELOPMENT 10 Geroscience and The Exposome There has been an unprecedented shift in global demographics, as the human population becomes more aged. This is bringing with it a significant burden of age-related disease and a requirement to better understand and mitigate a dysregulated ageing process underpinning a wide range of non-communicable diseases. This review by Paul Shiels, Professor of Geroscience at the University of Glasgow et al. will explore these concepts in the context of emerging senotherapies and address the impact of potential confounding factors for their translation into clinical and general use. 16 Betting on the Bug, Part III: Leveraging the Microbiome to Generate New Models Interest in the microbiome continues to grow at a robust rate, underlying its potential to significantly benefit human health. In part 1 of this series, the role of the microbiome in impacting experimental reproducibility and translatability was examined. In part 2, Dr. Alexander Maue at Taconic Biosciences focuses on the microbiome’s ability to alter the effectiveness of therapeutics by transforming drugs into bioactive or inactive forms, and how the presence or absence of specific microbes is associated with clinical outcomes. 18 Mass Spectrometry Supports Development of New Oligonucleotide Therapeutics Oligonucleotides’ ability to inhibit genes or to function as aptamers to interact with protein targets are increasingly vital research tools in the biopharmaceutical industry. Oligonucleotides target RNA at the cellular level, where specific malfunctioning genes can be manipulated and/ or modulated. Anjali Alving of Bruker Scientific discusses

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Contents how this capability presents biopharma companies with opportunities to target diseases which have proven difficult to combat using classic small molecule approaches. CLINICAL RESEARCH 24 Congenital Hyperinsulinism Treatment Gaps and a Potential Solution Although rare diseases, by definition, affect fewer individuals than other diseases do, they tend to be particularly devastating: they are often debilitating or lethal. It is estimated that as many as 7000 rare diseases exist globally. While the number of individuals with a specific rare disease may be small, the total number of people with any rare disease is quite large. Dr. Roberts at Fibrogen, Inc. discusses new avenues of treatment for Congenital HI. 28 Increasing Patient Access to Advanced Therapies; the UK Perspective Over the past five years, we have seen remarkable growth and clinical results in an area of medicine known as advanced therapy medicinal products (ATMPs), which comprise gene therapies, somatic cell therapies, and tissue engineered products. These treatments offer the potential to address significant and growing unmet healthcare needs. Ian Hollingsworth of Cell and Gene Therapy Catapult explains how they offer the promise of treating and altering the course of diseases which cannot be addressed adequately by existing pharmaceuticals, offering a lifeline to some patients who have failed all other treatment options. 32 The New Drugs and Clinical Trial Rules of India: Regulatory Highlights

Biologics discusses how Cobra Biologics and CombiGene, a leading Nordic gene therapy company, are working for the development of plasmids and AAV-based gene therapy vectors, for their first treatment with the potential to dramatically improve the quality of life for a group of epilepsy patients for whom there is currently no effective treatment. REGULATORY/QUALITY COMPLIANCE 42 Driving the Commercialisation of Regenerative Medicine With more than 7000 distinct types of rare and genetic diseases and 400+ million individuals suffering from a rare disease, regenerative medicine holds the hope for a cure – transforming healthcare by revolutionising patient care from conventional treatment models to curative therapy models. Colin Coffua of EVERSANA discusses how the promise of regenerative medicine becomes a reality for the millions of patients who deserve it. 44 How the Biopharmaceutical Industry is Responding to Patient Demand for Injection Alternatives Biologics represent a powerful and innovative class of therapeutics in the fight against chronic disease and their sales are projected to reach $326 billion by 2022 – roughly 30% of global prescription drug sales. Biologics tend to be highly selective, effective, and have fewer side-effects than conventional drugs. However, their chemical structure makes them challenging to administer using oral delivery, so the accepted standard of care is needle-based delivery methods, particularly intravenous injection. Christophe Pierlot of Pall Biotech discusses how subcutaneous delivery will become a routine option for both novel and legacy drugs.

The New Drugs and Clinical Trial Rules (NDTC), 2019 were recently issued, emphasising the changes on the regulatory aspects relating to clinical trials. The final document was published by MOHFW, and covers the clinical trials, BA/BE, ethics committee and biomedical research. These rules also supplant part XA and schedule Y of the D&C Act. This study by Kamireddy Karuna at Jagadguru Sri Shivratreeshwara University et al. includes a major outlook on the changes that occurred in the regulatory aspects for conducting clinical trials in India. MANUFACTURING/TECHNOLOGY PLATFORMS 34 Go-to-market Challenges of CAR-T Therapies CAR-T therapies are set to revolutionise cancer treatment. With first curative therapies gaining market access across the globe, CAR-T therapies are subject to numerous commercial and non-commercial challenges. Christian Zuberer and Maximilian Feld of Homburg & Partner analyse how, despite positive clinical responses, the ability to overcome these challenges will determine the future of CAR-T therapies and show whether pharmaceutical companies can make true on the promise of initiating a new era of cancer care. 38 Developing Plasmid DNA Production Platforms to Support Novel Gene Therapies Epilepsy is a debilitating illness which impacts the life of millions of people across the world. Tony Hitchcock of Cobra 2 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Spring 2020 Volume 3 Issue 1

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Foreword Pharmaceutical biotechnology is a relatively new and growing field in which the principles of biotechnology are applied to the development of drugs. Most therapeutic drugs in the current market are bioformulations, such as antibodies, nucleic acid products and vaccines. Such bioformulations are developed through several stages that include: understanding the principles underlying health and disease; the fundamental molecular mechanisms governing the function of related biomolecules; synthesis and purification of the molecules; determining the product shelf life, stability, toxicity and immunogenicity; drug delivery systems; patenting; and clinical trials. The pharmaceutical companies that have marketed bioformulations use biotechnology principles such as recombinant DNA technology to design more effective protein-based drugs, such as erythropoietin and fast-acting insulin.Advances in other areas such as genomics, proteomics and high-throughput screening have paved the way for exploring new avenues of drug discovery. The future of pharmaceuticals belongs to protein-based therapeutics. Designing stable and effective therapeutic proteins requires knowledge of protein structure and the interactions that stabilise the structure necessary for function. Structure prediction methods can be used for those proteins for which no structure is available. Therapeutic proteins frequently contain post translational modifications – for example, glycosylation of erythropoietin. It is important to patent any biomolecule which might have pharmaceutical value. A patent prevents others from exploiting the innovation for up to 20 years. Naturally occurring products cannot be patented unless they involve substantial post-extraction development.

A biotech innovator – in partnership with the National Institute of Allergy and Infectious Diseases (NIAID), a part of the National Institutes of Health (NIH), and the Coalition for Epidemic Preparedness Innovations (CEPI) – has developed a vaccine using mRNA technology with hopes to begin human tests of their product in April. An innovative drug developer, sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), will soon launch two Phase III clinical trials of its investigational antiviral. A leading biopharmaceutical company is working with Health and Human Services’ Biomedical Advanced Research and Development Authority, better known as BARDA, to develop a vaccine using a platform it currently uses to make a licensed influenza vaccine. A cutting-edge biotech company – with support from CEPI – is developing a new coronavirus vaccine. CEPI is also working with other industry leaders to accelerate the development of vaccines. At least a dozen companies have begun or accelerated development of vaccines and antiviral therapies. Work previously done on medical countermeasures (MCMs) against other coronaviruses including SARS and MERS are being tested against COVID-19. Numerous antiviral drugs and biologics are being investigated and several have entered clinical trials to test for efficacy and safety against COVID-19. This issue of IBI has an array of exiting articles to keep you enticed throughout the summer months. My team and I look forward to sourcing out more informative article in the forthcoming issue.

In the current circumstances, one of the most pressing matter is the onset of the COVID-19 Pandemic. Here is a snapshot of what is being done around the world.

I wish you all a safe and fun filled summer. Virginia Toteva, Editorial Manager

IBI – Editorial Advisory Board •

Ashok K. Ghone, PhD, VP, Global Services MakroCare, USA

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Jim James DeSantihas, Chief Executive Officer, PharmaVigilant

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Bakhyt Sarymsakova – Head of Department of International Cooperation, National Research Center of MCH, Astana, Kazakhstan

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Lorna. M. Graham, BSc Hons, MSc, Director, Project Management, Worldwide Clinical Trials

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Catherine Lund, Vice Chairman, OnQ Consulting

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Mark Goldberg, Chief Operating Officer, PAREXEL International Corporation

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Cellia K. Habita, President & CEO, Arianne Corporation

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Maha Al-Farhan, Chair of the GCC Chapter of the ACRP

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Chris Tait, Life Science Account Manager, CHUBB Insurance Company of Europe

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Deborah A. Komlos, Senior Medical & Regulatory Writer, Clarivate Analytics

Rick Turner, Senior Scientific Director, Quintiles Cardiac Safety Services & Affiliate Clinical Associate Professor, University of Florida College of Pharmacy

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Elizabeth Moench, President and CEO of Bioclinica – Patient Recruitment & Retention

Robert Reekie, Snr. Executive Vice President Operations, Europe, Asia-Pacific at PharmaNet Development Group

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Francis Crawley, Executive Director of the Good Clinical Practice Alliance – Europe (GCPA) and a World Health Organization (WHO) Expert in ethics

Stanley Tam, General Manager, Eurofins MEDINET (Singapore, Shanghai)

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Stefan Astrom, Founder and CEO of Astrom Research International HB

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Steve Heath, Head of EMEA – Medidata Solutions, Inc

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T S Jaishankar, Managing Director, QUEST Life Sciences

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Hermann Schulz, MD, Founder, PresseKontext

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Jeffrey W. Sherman, Chief Medical Officer and Senior Vice President, IDM Pharma.

4 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Spring 2020 Volume 3 Issue 1

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Market Report

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Building a better healthcare cluster

Science and technology has always been a powerful dynamic in regeneration, and the fourth industrial revolution has many parallels with the first in the way that it continues to shape our thinking about towns, cities and places.

In an era of unprecedented turmoil caused by the UK’s decision to leave the EU, followed by the global COVID-19 pandemic, it’s striking that science and technology is more or less unchallenged at the vanguard of how economists think the country should approach the future. In the UK this means a vision of creating a highly skilled, high value economy, with life sciences to the fore. The sector is one of the areas where the UK excels, aided by its base of world-class, research-intensive universities. The UK government has recognised this as a priority. Life science was the first industry to get a sector deal under the 2017 Industrial Strategy, with a second following soon afterwards. These deals are partnerships between government and industry on sector-specific issues with a view to creating significant opportunities to boost productivity, employment, innovation and skills. The UK regions are a key element in this story, but outside of the Golden Triangle of Oxford, Cambridge and London, to date it is only the North West that has been able to achieve a cluster of major significance. It is built around research intensive universities in Manchester and Liverpool, together with a deep pool of cancer research expertise in Manchester, and infectious disease knowledge in Liverpool. Other regions are seeking to develop along the same lines and for any emerging cluster, the buzzword ‘ecosystem’ is widely used. It reflects the notion of a series of spin-outs and businesses scaling up trading with each other within a cluster. A key feature making a science and technology-based ecosystem function is there needs to be strong links between industry, funders, universities, government, and the third sector. Location matters and proximity to talent, in particular, is one of the major reasons why sector clusters work well, whatever the industry. All of the evidence demonstrates that you are far more likely to make a success if you are engaged with like-minded people in a reasonably close environment – a reality that’s sat behind very different clusters on America’s West Coast for example; software in Silicon Valley, bioscience in San Diego, and, for that matter, the film industry in Hollywood. In a US context, England would be regarded as one single cluster because of the geographic proximity of the population. But the UK is a complicated place and we operate in more narrowlydefined geographies than elsewhere in the world. 6 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

In areas both with and without devolution deals the story is much the same. The West Midlands Combined Authority, for example, has a strategy focused on developing its digital tech, med tech and life science research assets. In West Yorkshire, fintech leads the way, whilst Bristol-Bath has a broad innovationfocused cluster, which includes health technology. Whatever the perspective on the boundaries of clusters, the reality is that economic development of this model requires certain fundamentals to be in place. There are four principal issues. Clearly, people are critical as knowledge underpins successful clusters. Company numbers come down to ensuring a strong flow of prosperous spin-outs as well as the presence of established companies providing anchors for any given region. Finally, funding is the lifeblood of any cluster with the flow of both grant and equity funding being key to success. At IDM, we’ve looked at these fundamental principles with the goal of identifying insights that can inform activity around the UK. To bring these issues to life, we produced a scorecard which contrasts the growing cluster in the North West, with those in Oxford and Cambridge. We didn’t look at London because its very size tends to skew the data, making an objective assessment more difficult. Our simple ranking system awarded five points for being first in a category, three points for second, and one for third. Cambridge led the way in terms of access to talent, followed by Oxford and then the North West. We assessed several factors when making this assessment – including job vacancies, existing sector employment and cost of living. We looked at advertised job vacancies for scientific staff over a period from October 2017 to January 2019. Cambridge consistently had the highest number of job vacancies with the North West next, followed by Oxford. We also looked at the cost of living in these regions and the relatively low cost of living in the North West compared to the South and East of England gave it an advantage. Cambridge is comparatively expensive and an area that was already demand-constrained has been further skewed by the pharmaceutical major AstraZeneca moving several thousand people to its new R&D HQ there. However, the flipside is the contextual point that Oxford and Cambridge are attractive because they are mature clusters. By and large, employees will favour an established cluster – particularly within the perceived high-risk environment of Life Science businesses. Turning to capability, we investigated the research landscape. Charting the number of research publications within peer-reviewed life science journals for academic institutions, Oxford and Cambridge again scored very highly and the North West, less so. Digging further into these numbers, we conducted a network analysis to identify how well-connected academic institutions Spring 2020 Volume 3 Issue 1

Market Report were. Looking at a sample of more than 100,000 relevant publications, we discovered that 82% of research was carried out solely within North West institutions whereas Oxford and Cambridge recorded 76% and 74% respectively. All successful clusters attract network partners from outside the cluster and this cross-fertilisation of knowledge contributes to perpetuation of that success. Another key set of metrics involves company numbers and in particular spin-out creation and established, anchor businesses. The ability to create new businesses is essential for sustained cluster growth – these businesses will hopefully produce the mid-sized and large companies of the future. Reviewing the number of spin outs from higher education institutions over the last 15 years, Cambridge (2nd) and Oxford (1st) have the best track record within the UK. In the North West, the picture is dominated by Manchester and Leeds, although both are some way behind their southern competitors. The story is different, though, if you examine established companies. We looked at large companies that are engaged in life science activities and the North West scores well with significantly more than in Oxford or Cambridge, due predominantly to its strength in pharma manufacturing. Given the rankings outlined above around academic research activity and spin-out creation, there was a surprise when we assessed grant funding activity. We looked at research funding awarded since 2010 by the five main scientific funding councils who provide funding into the life sciences - Innovate UK; the Biotechnology and Biological Sciences Research Council; the Engineering and Physical Sciences Research Council; the Medical Research Council; and the Science and Technology Facilities Council. Here, the North West wins – £18.5 billion of grant funding has been invested into research from these five bodies since 2010. In comparison, the Oxford cluster attracted £18.2 billion and Cambridge £14.6 billion. So the North West has the most research funding but it’s far and away the worst at company creation. It’s not producing anything like the number of academic publications or creating as many companies as Cambridge or Oxford. Comparing the cost of spin-outs on a per capita grant basis, our analysis indicates that every spin-out created in Oxford is comes at only 66% of the cost of a North West spin out, whereas in Cambridge that number is as low as 43%. This begs the critical question as to why grant funding in the North West is not being translated into output? One reason may be related to the availability of equity finance. Looking at equity investments in terms of the number of deals and deal value, Cambridge scores highest by volume, Oxford second and the North West third. By deal value however, Oxford scores highest, with Cambridge second and the North West third. From detailed breakdowns of the funding, it is clear that Oxford and Cambridge are streets ahead of the rest of the UK (excluding London). Cambridge leads on early-stage venture capital – £343m raised in 2018, followed by Oxford with £188m whilst the North West secured only £19m. For late-stage VC investments, Oxford led the way with a colossal £635m – the highest UK figure, with Cambridge on £398m and London, for context, attracting £385m. The North West drew in £88m. www.biopharmaceuticalmedia.com

There’s no doubting the greater breadth and scale of the investable propositions that exist in Oxford and Cambridge. For a challenger region such as the North West, one of the many hurdles is that investors are creatures of habit and will tend to focus on the businesses and entrepreneurs operating in an established cluster. The data around angel investors is much the same. The North West generated £2.7m of investment in 2018 whilst both Oxford and Cambridge secured circa £18.5 million. So, perhaps not surprisingly, on our simple scoring system, the North West comes third behind the relative behemoths of Oxford and Cambridge across the four fundamentals of people, knowledge, businesses and funding. The North West is getting more than its share of research funding. In contrast to Oxford and Cambridge, what it’s not doing however, is generating the research outputs that it should be. Nor is it effective enough at creating the number of start-up companies that it should be, relative to what Oxford and Cambridge are doing. And, given the circular nature of some of these fundamentals, it is that translation activity that is key to establishing a successful cluster. For the cluster to thrive, you need a supply of young companies, founded on high-quality science from leading academics. With the right companies, early stage investment will flow more readily attracting the pool of talent necessary to support growth. That growth, in turn, feeds a virtuous circle of activity attracting support businesses and inward investment.

Neil Murray Neil Murray is the CEO of Impact Data Metrics, a data analytics platform company. He is also Chair of Governors of Liverpool Life Sciences UTC, and a board member of Bionow, the north of England industry group for life science. Dr Murray was the founding CEO of Redx Pharma plc as well as PharmEcosse Ltd, a clinical-stage development company which pursued novel therapies for the prevention of scarring. He is also a founding partner of Essential Science Ltd, a consulting practice which provided expert support to early-stage companies. Having gained a PhD in Synthetic Organic Chemistry from the University of Dundee in 1987, his career has included senior positions with high-profile companies in the pharmaceutical and life science industry, including Solutia Inc, Vernalis Ltd (formerly Vanguard Medica Ltd), Sigma-Aldrich Inc and Glaxo-Wellcome Research & Development.

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Unique Challenges and Opportunities in Orphan Diseases

The sharp rise in internet usage and its adoption around the world – as of January 2020, there are 4.3 billion people using the internet every day – has given us access to a wealth of revealing data, such as the search behaviour of patients and the conversations happening about rare disease on social channels. Pre-internet, patients and families affected by a rare disease were very isolated. Their trusted healthcare providers would try their best to explain their complex disease, often not having many resources or examples to draw from. And their wider community too would just scratch their heads at their disease and not know how best to support them. Now though, people affected by a rare disease can connect with others in a similar situation to them and smartphones have granted internet access to so many computercautious or economically deprived individuals. They can now share experiences, provide support for one another and keep each other updated on the latest news and developments – all from a quick Google or Facebook search. For analysts like us, we can learn so much just by looking at the words patients and caregivers use in Google searches and their social media posts. These online channels also give us a chance to build trust through education and invite patients and caregivers to consider clinical trials that might be suitable for them.

Out of the 44% of drugs approved by the FDA last year, the most notable one was Trikafta, a triple combination therapy for patients with cystic fibrosis. Data by Evaluate Pharma shows that Trikafta is the most valuable R&D orphan product, with an estimated NPV of $24bn. Trikafta is for patients with the most common form of the CF gene mutation – around 90% of CF patients. Research we conducted last year with Raremark’s CF community showed a healthy interest and awareness for triple combination therapies and mid to low adherence for current treatments.

A new wave of online patient platforms has emerged in the past decade, built to connect patients to pharmaceutical research. Our platform, Raremark, is one of them. It’s the world’s largest patient experience network in rare disease. The platform provides easy-to-understand information at various stages of a patient’s or caregiver’s journey by combining behavioural science, machine learning and carefully planned nudge techniques to give members a personalised, self-paced learning experience.

Other notable orphan drugs approved were for sickle cell disease patients: Adakveo to help prevent vasoocclusive crisis (the most common complication in sickle cell disease), and Oxbryta to help prevent the risk of stroke in SCD patients.

Platforms like ours then act as an ethical interface between patients and researchers. Once an interest is expressed, we pre-screen trial candidates and refer potentially eligible patients to the closest study site.

Opportunities Provided by Orphan Drug Trial Recruitment When it comes to orphan drug trials, the cost of running them is usually lower than trials for non-orphan drugs, mainly down to a lower number of participants. The return on investment for orphan drug sales is also very attractive when compared to non-orphan drugs. A challenge many sponsors encounter when planning an orphan drug trial is patient recruitment and retention. Finding and engaging people affected by a rare condition can be a struggle, especially if your trial is focused on a very specific subset of a rare disease. Patients are usually geographically diffuse, leading many trial sites recruiting just one or two patients per trial. Finding the hard-to-reach and then keeping each and every patient engaged with the trial is paramount.

Opportunities Provided by Trial Patient Engagement We speak to hundreds of patients every year about clinical trials; about anything including encouraging them to participate, educating them about trials and finding out what they think about them.

We see this challenge as an opportunity to evolve the ways in which participants for trials are recruited. 8 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Having a rare disease can have a huge impact on the lives of a patient and their family. For example, some patients need to make frequent visits to hospital based on the nature of their disease, and the idea of making multiple visits to clinical trial sites on top of their visits to hospital could be too much. Our sickle cell community reported visiting the ER about five times a year on average, with some visiting their primary healthcare provider over 300 times in a 12-month period – and so a clever trial design might incorporate home visits where possible, and video check-ins into their trial design. Spring 2020 Volume 3 Issue 1

Market Report From our experience, it’s always best to underline what’s expected of trial participants in the first conversation. People with a rare disease are often highly motivated to take part in clinical research but may overlook the most obvious requirements; particularly the number and frequency of visits to the study site – and the logistics involved in getting there. Keeping communication lines open before, during and after a trial is a great way to retain trial participants. Patients should feel comfortable asking questions and voicing concerns. And researchers should use every opportunity to keep patients informed and valued. Some ways researchers do this include: Replying to patient emails and callbacks promptly – there’s nothing worse than spending lots of time looking for patients only to lose them because of a missed call. Catering for work schedules patients have, and planning calls and screening appointments accordingly – remember patients have lives too. And addressing any anxieties patients and caregivers have about coming off treatments, taking the trial drug and the tests and procedures involved in the trial. Real-world Evidence: An Emerging Frontier Industry interest in real-world evidence and real-world data collection has been growing. A 2019 survey by Deloitte shows the importance executive leadership teams placed on RWE more than doubled, compared to the previous year. For rare disease, where patients by definition are hard to find, RWE is crucial. Sonal Bhatia, Pfizer’s vice president, North America medical lead, rare disease made a great point in her interview with Pharmaphorum: “There may be misconceptions in the medical literature about what affects patients at different stages of the disease. This could lead to assumed clinical facts about that disease that may be wrong.” Take treatment adherence as an example – from speaking to our rare disease communities, we learnt about patient thoughts and attitudes towards their current treatments. A recent study we conducted with our cystic fibrosis community showed us that not all patients asked were taking their medication as prescribed, with some missing doses anywhere from once a month to as often as once a day. The reasons they gave included lack of appetite in the morning (they need to be taken with food) and not being able to keep the medicine down. Sometimes patients don’t like the way a drug is administered, for example having to inject themselves regularly, or dealing with the side-effects of the medicine on a daily basis. These patient experiences bring into question the viability of certain treatments – yes, medically they address the complications associated with a rare disease, but if they don’t take into account the patient experience of taking the treatment regularly and the disruption and distress this may cause a patient and caregiver, then can the treatment be effective? There are lots of opportunities to be gained from orphan disease research. Taking a patient-centric approach when studying orphan disease can be the best way to grow our understanding and can be a springboard for further research – especially when we take into account the real-world, lived experiences of patients. www.biopharmaceuticalmedia.com

REFERENCES 1.

3. 4.

Evaluate Pharma 2020 Orphan Drug Report https://www.evaluate. com/thought-leadership/pharma/evaluatepharma-orphan-drugreport-2020 FDA 2019 drug approvals https://www.fda.gov/drugs/new-drugsfda-cders-new-molecular-entities-and-new-therapeutic-biologicalproducts/new-drug-therapy-approvals-2019 Internet usage trends https://wearesocial.com/global-digital-report2019 2019 Raremark report: Patient perspectives on current and future therapies for cystic fibrosis https://raremark.com/research/patientperspectives-on-current-and-future-therapies-for-cystic-fibrosis

Jeremy Edwards For nearly 25 years, Jeremy has been focused on aiding the biopharmaceutical and health sciences industry in the development of key compounds and new therapies. He has been instrumental in introducing small, European-based eClinical organizations to the US Market, creating new verticals, growing operations, and increasing revenue. His diverse background includes executive leadership positions across the clinical development continuum; from full-service CROs, to highly specialized imaging modalities, to niche patient-focused service providers. By stretching the way we think about study conduct, both pre and post-approval, and driven by innovative technologies, Jeremy focuses on helping people succeed by addressing unmet needs, in an unconventional, innovative way.

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Research / Innovation / Development

PEER REVIEWED

Geroscience and The Exposome

There has been an unprecedented shift in global demographics, as the human population becomes more aged. This is bringing with it a significant burden of age-related disease and a requirement to better understand and mitigate a dysregulated ageing process underpinning a wide range of non-communicable diseases. Interventions to treat age-related physiological decline are no longer the stuff of science fiction, and a range of senotherapies are in development and trialling, following exciting pre-clinical and proof-of-concept studies. While these studies are in their infancy, it is pertinent to consider how differing environmental and life-course exposures may impact on their efficacy; in particular the foodome, the microbiota and pyschosocial factors. This review will explore these concepts in the context of emerging senotherapies and address the impact of potential confounding factors for their translation into clinical and general use.

Introduction The bio-pharmaceutical industry has had a longstanding interest in diseases of ageing, but efforts to improve healthspan (i.e. years of healthy living) have not matched global improvements in lifespan. Consequently, a global cohort of multi-morbid old has emerged and their numbers have increased at an alarming rate. Presently, geroscience, which champions research on ageing and disease, has provided new avenues for translational interventions designed to mitigate the effects of age-related diseases and compress the period of morbidity in the final decades of life. No doubt, such an approach will have major effects on both health economics and quality of life. There has been a modern bio-pharmaceutical ‘gold rush’ into this arena, based on solid basic research and pre-clinical data. This editorial, however, will try to address potential confounding factors that need to be considered when translating pre-clinical findings to human studies. Additionally, it will suggest synergistic approaches for pharmacological treatments to improve healthspan, based on life-course exposures and lifestyle, to enhance their efficacy. This requires a basic understanding of the concept of ageing and the factors which drive it. 1. What is Ageing? Ageing is a process occurring over the entire life-course. It can be defined as a segmental loss of physiological function and physical capability over time. It displays substantial inter-individual variation in its manifestation and there is, as yet, no ‘Gold Standard’ for normative ageing. Increasing chronological age brings with it physiological frailty, loss of resilience and an increased likelihood of morbidity and mortality1,2. As the global population is becoming increasingly more aged, understanding the process of ageing is thus an urgent and growing concern. Despite advances in medicine 10 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

and clinical science having enabled more people to live longer lives, improvement in lifespan has not been matched by an improvement in healthspan. As such, there has been a slow response to adapt to a tidal wave of non-communicable ‘burden of lifestyle’ diseases in the global aged population. This ‘diseasome of ageing’1,3 includes cancer, chronic kidney disease, type-2 diabetes, arteriosclerosis, Alzheimer’s disease, non-alcoholic steatohepatitis and osteoporosis. The associated cost to healthcare systems alone is estimated to be $47 trillion in the period 2010–20304, with the economic burden expected to increase disproportionately in low- and middleincome countries. There is thus an urgent need for a better understanding of ageing processes and the development of appropriate and cost-effective interventions, at both an individual and societal level. 2. How Might We Mitigate the Effects of Ageing? At a cellular level, the ageing process is regulated by distinct biochemical pathways which are common across taxa and characterised by a set of distinct ‘hallmark’ features, comprising telomere erosion, cellular senescence, mitochondrial dysfunction, genomic instability, epigenetic dysregulation, loss of proteostasis, dysregulated nutrient sensing, stem cell exhaustion and altered intercellular communication5. Mammals may have additional features driving ageing, including phosphate toxicity, diminished expression of Nrf2, low-level chronic inflammation (i.e. inflammageing), altered microbiotal diversity and diminution of interferon-mediated responses to retrosponson instability or infection6,7. It is notable, in the light of the current coronavirusdisease 2019 (COVID-19) pandemic, that interferon-driven physiological responses to the virus (and thus biological ageing), may play a key role in clinical outcomes. Added to the above features, social, psychological, lifestyle and nutritional risk factors influence the trajectory of age-related health, as part of variation in the life-course exposome. The exposome encapsulates the totality of an individual’s environmental exposure over their life-course8,9. It modulates normative ageing processes through a range of independent, cumulative and synergistic interactions with the genome/epigenome that mediate an individual’s trajectory of ageing10,11 (Figure 1). Within the framework of an exposome, the 'diseasome of ageing' reflects allostatic (over)load as a burden of lifestyle and consequently, age-related diseases share common underpinning features of a dysregulated ageing process. This suggests that the ‘diseasome of ageing’ is amenable to intervention through targeting the ageing process per se, thus pre-empting development of a range of age-related morbidities that are currently treated clinically as individual disease modalities11. 3. Geroscience and Senotherapies Geroscience seeks to understand and target interventions to mitigate the effects of an advancing ageing process and the resultant ‘diseasome of ageing’. It is a rapidly growing area of Spring 2020 Volume 3 Issue 1

Research / Innovation / Development caveat. Senotherapies include agents that tackle ageing at a more systemic level than senolytics, and include those designed to target inflammageing (e.g. senomorphics)18 and senostatics that suppress senescence-associated bystander effects19,20. While senolytics induce apoptosis of senescent cells, senomorphics and senostatics do not induce apoptosis, but suppress pathways associated with ageing (e.g. IkB kinase (IKK) and nuclear factor (NF)-kB signalling) and modulate the pro-inflammatory secretome of senescent cells. However, the distinction between senolytics and senomorphics is not always clear. Some compounds (e.g. fisetin) exhibit both senolytic and senomorphic activities in vitro, depending on the target tissue19,20.

Figure 1: Interaction between the exposome and the genome. The exposome comprises external and internal factors interacting with an individual across their life-course. Independent, cumulative and synergistic interactions between exposome factors and the genome are mediated via the epigenetic landscape. This mediation is critical to regulation of age-related health and healthspan.

research and innovation, with particular advances under the subfields of senolytics and senotherapeutics. Interventions to mitigate the effects of ageing have initially developed along the lines of a traditional pharmacological model, which aims to treat ageing like a disease. This is of both medical and social merit and should be viewed as a moral obligation in the face of an ageing global population. Using the hallmarks of ageing as primary targets for intervention, there are a range of therapies in development and trialling. Pre-clinical models have demonstrated outstanding success for a range of senolytic drugs that remove senescent cells from the body12–14. Senescent cells are in a state of growth arrest but remain metabolically active. They are not physiologically contributory, and have a pro-inflammatory senescence associated secretory phenotype (SASP) that poisons the surrounding tissue and facilitates diminution of local physiological function. They are resistant to apoptosis and accumulate in the body over time and at sites of pathology within the ‘diseasome of ageing’. Selectively enabling apoptosis for these cells results in a gain of physiological function, improvement in healthspan and an increase in lifespan in mice13. A range of senolytic agents (i.e. drugs able to selectively remove senescent cells) has now been identified, including dasatinib, piperlongumine, the (poly) phenolics fisetin and quercetin, navitoclax (ABT-263), ABT-7378, A133185211 and A1155463. Human proof-of-concept clinical trialling is ongoing for a range of indications within the diseasome of ageing, with promising early results reported for diabetic kidney disease15–17 and osteoarthritis-related articular cartilage degeneration18. Such trialling is essential for the long-term translational use of these compounds, but remains complex. It is obvious, given the heterogeneity in human ageing that endpoints for such trials cannot appropriately address lifespan, nor overall healthspan, and therefore must look to improve age-related physiological or physical capability within the context of a multi-morbid milieu. Similarly, other strategies under the broader umbrella term of senotherapies must adhere to this www.biopharmaceuticalmedia.com

All such therapies will need to be applied in an appropriate context, either singly or in combination. Critically, their efficacity will require establishment of when and where they are administered in the life-course. For those compounds with dietary sources, exposure, in terms of dose and duration, needs to be carefully evaluated, taking into consideration the mode of administration, bioavailability and toxicity. It has yet to be ascertained how senolytics, or other senotherapies, will fare in the context of hyperphosphataemic toxicity or in a multi-morbid milieu, typical in those with poor health in old age. The design and use of senotherapies also presents a further challenge, as the factors targeted by these therapies (e.g. (NF)-kB, p38, GABA4, mTOR), often have key roles in the regulation of the immune response, stress responses and development, hence any off-target effects need minimised and any effects subject to antagonistic pleiotropic addressed. Recent demonstrations of the power of combinatorial senotherapeutics have been intriguing. For example, reversal of age, based on a partial reset of an epigenetic clock, has been both tantalising and notable, despite this being performed in an underpowered primary study with nine human participants, as part of the TRIMM trial looking at thymic involution and immunosenescence21. How such epigenomic changes are reflected in wider physiological and physical capability will require robust evaluation within the framework of established clinical trial procedures. It thus remains to be determined if any of these approaches will reverse the effects or allostatic overload, or how they will interplay with elements of the exposome, such as the foodome and microbiome22,23. 4. Mitigating the Effect of the Exposome in Ageing The foodome acts as a key factor affecting an individual’s age-related health and is a stronger risk factor for mortality than tobacco smoking, with 22% of global deaths associated with diet23. A link between nutrition and age-related health has already been well established within the scientific literature, with caloric and/or dietary restriction shown to improve healthspan across taxa. Some natural senolytic agents, in particular polyphenols, such as fisetin, quercetin, curcumin, resveratrol and piperlongumine, are geroprotective/ senomorphic. All have effects on modulation of inflammatory pathways and the epigenetic landscape of ageing24–26. Additionally, both zinc and vitamin E have been implicated as naturally occurring agents within the foodome that are potentially geroprotective agents27,28. In man, such effects may be mediated, at least in part, by the activity of the microbiota. In keeping with this, a recent study on turquoise killifish has INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 11

Research / Innovation / Development demonstrated that transfer of microbiota from a young individual to an aged host has the potential to extend the host’s lifespan29. In humans, the greatest diversity in the microbiota occurs in the gut, but this shows substantial inter-individual variation and the composition of the normative gut microbiota for humans has been difficult to define30,31. However, many diseases have been associated with perturbations in the composition of the gut microbiota (often termed “dysbiosis” (Figure 2))32. The composition of the gut microbiota changes with age and is largely influenced by exposome factors, particularly the diet33.

Figure 2: Gut microbial imbalance results in dysbiosis associated with disease and ageing. In healthy adults, there is a conserved gut microbiota composition dominated by firmicutes and bacteroidetes and low levels of protobacteria and actinobacteria. There is a gradual change in the composition of these four phyla in the gut microbiota with ageing and/or disease, resulting in dysbiosis.

Multiple cross-sectional studies have observed broad loss of diversity and compositional stability in the gut microbiota with increasing age34–36. Moreover, taxa associated with aspects of good health have been identified at disproportionately elevated levels in the ‘oldest’ old37,38. As long-term longitudinal studies are not practicable in humans, it remains difficult to attribute the drivers of the composition of a centenarian’s gut microbiota and the relative contributory effects of individual exposome variables over their life-course. Some insight may, however, be gained from the naked mole-rat (NMR). These animals exhibit no decrease in mortality rate, or deterioration of physiological functions throughout their lifespan. A strong correlation between the chronological age and temporal accumulation of DNA methylation at specific loci has recently been demonstrated in the NMR39. NMRs display resistance to environmental oxidative stress, which is thought to depend in part on their microbiota, which is rich in soil sulphate bacteria and salutogenic taxa with a high production capacity for short chain fatty acids. Similarities with the NMR microbiota have been found in human populations such as the Hadza hunter-gatherers, whose microbiota is being considered as a model for normative ageing23. Yet, while the gut microbiome shifts following dietary interventions, it also returns to its baseline profile following intervention cessation, querying the sustainability of time-defined interventions40. Sex differences, both with respect to ageing and to the microbiota remain to be adequately addressed, with notable difference in the response to dietary bioactives attributed to the microbiome41–43, with marked difference in gut catabolism of plant (poly)phenolics in groups contrasting in terms of biological age, ethnicity and health status44–47. Sex differences in mammalian rates of ageing, longevity and mortality are particularly notable, with females exhibiting over 18% longer lifespans than conspecific males, across 101 species48. These differences might be attributable to 12 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

the interaction between sex-specific physiological traits, such as hormonal profile (e.g. higher production of androgen in males), and environmental conditions, which overall might make males less resilient48. Both ageing and dysbiosis of the gut microbiota share chronic, low-grade inflammation as a common hallmark49. An accumulation of senescent cells during ageing contributes to an inflammatory burden. However, epidemiological studies have revealed that cellular ageing only accounts for a small proportion of the observed inflammation50,51. One novel hypothesis that links the epigenetic landscape of ageing to diet, inflammation and the microbiome, involves the generation of trimethylamine N-oxide (TMAO). This is derived from the microbial metabolite tri-methyl amine (TMA) via digestion of animal protein-rich foods, including red meat, fish and eggs52. In the liver, TMA is converted to TMAO. Elevated levels of TMAO have been associated with mortality within the diseasome of ageing, including CKD, cardiovascular disease (CVD) and neurodegenerative conditions53–55. TMAO also promotes brainageingand cognitive impairment in mice56. An intuitive link between the foodome and microbiota also centres on the dietary intake of fruit and vegetables. Diets low in fruit and vegetable intake have been associated with poor healthspan and accelerated ageing in those of low socioeconomic position50,57–59. Indeed, this exposome variable even explains many of the beneficial effects attributed to a Mediterranean diet60. However, at a mechanistic level, benefit is partly derived from (poly)phenolic acids in fruit and vegetables converted to alkyl catechols/phenolic acids by gut microbes. These are Nrf2 agonists and therefore critical to any derived cellular protection against oxidative damage, as Nrf2 mediates expression of >350 cytoprotective genes11. The microbes required for these salutogenic effects are often not supported by a typical Western diet (low in dietary fibre)61. Notably, several (poly)phenolics and their derivatives are senolytic, such as fisetin, quercetin and piperlongumine. Other plant bioactives, including sulforaphane, are directly senotherapeutic11. One additional adverse effect needs mention, which is translocation of gut microbiota and/or microbial endotoxins into the circulation via age-related gut leakage. This may contribute any inflammatory burden, through impairment of the epigenetic regulation of Nrf2-mediated cellular defences and thus predispose to morbidity62. 5. Senotherapeutic Strategies to Mitigate Adverse Influences in the Exposome Modification of the environmental exposome may enable a number of simple senotherapeutic strategies. Firstly, design of more salutogenic urban environments (i.e. healthimproving as opposed to pathogenic), which have been shown to reduce psychosocial stressors and thus improve healthspan, especially in women63. Additionally, centenarians and semi-supercentenarians, present with a salutogenic gut microbiota profile associated with xenobiotic biodegradation, decreased in carbohydrate metabolism and less inflammatory burden61,63. Secondly, modification of the foodome, and, directly or indirectly, the gut microbiota important for maintenance of the epigenome and cell defences via nutrition. This is synergistic with salutogenic environmental change, as there is a loss of diversity in the microbiota of urban dwellers associated with Spring 2020 Volume 3 Issue 1

Research / Innovation / Development an increase in prevalence of diseases of ageing64. Additionally, this approach will provide enhanced Nrf2 agonism and thus improved healthspan. Thirdly, via mitigation of foodome effects on inflammation and phosphataemia. Red meat consumption, in particular, contributes directly to both hyperphosphataemia and TMAO generation6,65,66. Mammals exhibit a striking correlation between lifespan and nutritionally-acquired serum phosphate levels67. Indeed, in the klotho mouse, living only 12 weeks, a normative lifespan can be restored via knock-out of the sodium-phosphate transporter. However, putting these animals on a high-phosphate diet returned their lifespan to <12 weeks68. The mechanistic basis for such observations is via the generation and action of calciprotein particles (CPPs). These are nanocrystalline entities made from calcium phosphate and Fetuin A, a circulating inhibitor of vascular calcification. It was recently shown that a high level of CPPs is a surrogate marker for coronary atherosclerosis69. In excess, they are endocytosed and cause mitochondrial dysfunction (a hallmark of ageing). Strategies to remove CPPs from the circulation are already being evaluated clinically for the management of late stage CKD70. A small change in dietary habits to address the challenge of hyperphosphataemia might have a disproportionately positive effect on healthspan. Reduced red meat intake, which aligned with dietary targets for health and sustainability, would be expected to reduce both hyperphosphataemia and inflammation. Indeed, obligate carnivores, such as felids, display an inflammatory burden and disproportionately higher incidence of mortality linked to renal dysfunction and cancer71. A similar elevated incidence of renal dysfunction and colon cancer has been observed in human populations associated with frequency of red meat consumption72,73. Mitigating any TMAO driven age-related inflammatory burden can be tackled similarly. Notably, switching weekly red meat in the diet for a plant-based protein, has been reported to reduce overall mortality due to cancer and CVD in the Rotterdam study74. Improved gut barrier function can be achieved naturally via the foodome, or via a synthetic agent targeting intestinal alkaline phosphatase (iALP) that helps maintain intestinal homeostasis75,76. A similar approach has been demonstrated with great success using urolithin A, a microbial metabolite

derived from nutritionally-acquired (poly)phenolics which displays anti-inflammatory, anti-oxidative, and geroprotective activity. Both UroA and a synthetic analogue UAS03 significantly enhanced gut barrier function and reduced inflammation via Nrf2 agonism in a pre-clinical demonstration of efficacy77. Conclusions Interventions built upon a solid scientific evidence base, to mitigate the loss of physical capability with age, are showing great promise. A range of senotherapies developed along traditional pharmacological lines are now in early clinical trialling following exciting pre-clinical and proof-of-principle studies. What is evident, however, is that how we age, both physiologically and at a molecular and cellular level, is dramatically influenced by our exposome. Notably, our gut microbiota in this context, is acting like a surrogate organ, mediating epigenetic responses to the foodome and the broader landscape of ageing. Consequently, senotherapies and the nutritional exposome may emerge as a synergistic strategy to treat the dysregulated ageing process, underpinning the development of the diseasome of ageing. This will enable the development, or progression, of a range of age-related morbidities to be pre-empted more easily, with the positive sequel of compressing any period morbidity, thus increasing healthspan so that it matches lifespan more closely. REFERENCES 1.

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et al. Chronic inflammation in the etiology of disease across the life span. Nat Med. 2019;25(12):1822-32. Beydoun MA, Fanelli-Kuczmarski MT, Allen A, Beydoun HA, Popkin BM, Evans MK et al. Monetary Value of Diet Is Associated with Dietary Quality and Nutrient Adequacy among Urban Adults, Differentially by Sex, Race and Poverty Status. Plos One. 2015;10(11):21. Bonaccio M, Di Castelnuovo A, Pounis G, Costanzo S, Persichillo M, Cerletti C et al. High adherence to the Mediterranean diet is associated with cardiovascular protection in higher but not in lower socioeconomic groups: prospective findings from the Moli-sani study. Int J Epidemiol. 2017;46(5):1478-87. Senger DR, Li D, Jaminet SC, Cao S. Activation of the Nrf2 Cell Defense Pathway by Ancient Foods: Disease Prevention by Important Molecules and Microbes Lost from the Modern Western Diet. PLoS One. 2016;11(2):e0148042. Shiels PG, McGuinness D, Eriksson M, Kooman JP, Stenvinkel P. The role of epigenetics in renal ageing. Nat Rev Nephrol. 2017;13(8):471-82. Ellaway A, Dundas R, Oien J, Shiels PG. Perceived neighbourhood problems over time and associations with adiposity. Int J Environ Res Public Health 2018 28;15. Lederbogen F, Kirsch P, Haddad L, Streit F, Tost H, Schuch P et al. City living and urban upbringing affect neural social stress processing in humans. Nature. 2011;474(7352):498-501. Lew QJ, Jafar TH, Koh HW, Jin A, Chow KY, Yuan JM et al. Red Meat Intake and Risk of ESRD. J Am Soc Nephrol. 2017;28(1):304-12. Goraya N, Wesson DE. Is Dietary Red Meat Kidney Toxic? J Am Soc Nephrol. 2017;28(1):5-7. Kuro-o M. A potential link between phosphate and aging--lessons from Klotho-deficient mice. Mech Ageing Dev. 2010;131(4):270-5. Ohnishi M, Razzaque MS. Dietary and genetic evidence for phosphate toxicity accelerating mammalian aging. FASEB J. 2010;24(9):3562-71.

Paul Shiels Paul Shiels is Professor of Gerosicence at the University of Glasgow, He has over 30 years research experience on the biology of ageing, established in both academia and the commercial sector. He is author of over 150 peer reviewed publications and a number of Patents in this sector. He has given over 100 invited lectures around the world to academia and industry. His research has involved determining socio-economic, psychological, lifestyle and biological factors that are required for healthy ageing. His current research portfolio comprises investigation and application of novel senotherapies and how the microbiome impacts on age related health. He is currently funded by 4D Pharma and Constant Pharma.

Peter Stenvinkel Peter Stenvinkel serves as a full professor and senior lecturer at Dept. of Renal Medicine Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden. He has published about 540 original publications and reviews and >30 book chapters on various aspects of inflammation, wasting, vascular calcification and metabolism in chronic kidney disease. He is interested in bio-inspired medicine and epigenetics. His Hirsch index is 85 according to PubMed and 107 according to Google Schoolar. He has given more than 400 invited lectures at various international meetings and congresses in about 30 different countries.

www.biopharmaceuticalmedia.com

69. Nakazato J, Hoshide S, Wake M, Miura Y, Kuro OM, Kario K. Association of calciprotein particles measured by a new method with coronary artery plaque in patients with coronary artery disease: A cross-sectional study. Journal of Cardiology. 2019;74(5):428-35. 70. Nakamura K, Nagata Y, Hiroyoshi T, Isoyama N, Fujikawa K, Miura Y et al. The effect of lanthanum carbonate on calciprotein particles in hemodialysis patients. Clin Exp Nephrol. 2019. 71. Junginger J, Hansmann F, Herder V, Lehmbecker A, Peters M, Beyerbach M et al. Pathology in Captive Wild Felids at German Zoological Gardens. PLoS One. 2015;10(6):e0130573. 72. Maxwell F, McGlynn LM, Muir HC, Talwar D, Benzeval M, Robertson T et al. Telomere attrition and decreased fetuin-A levels indicate accelerated biological aging and are implicated in the pathogenesis of colorectal cancer. Clin Cancer Res. 2011;17(17):5573-81. 73. McClelland R, Christensen K, Mohammed S, McGuinness D, Cooney J, Bakshi A et al. Accelerated ageing and renal dysfunction links lower socioeconomic status and dietary phosphate intake. Aging (Albany NY). 2016;8(5):1135-49. 74. Chen Z, Glisic M, Song M, Aliahmad HA, Zhang X, Moumdjian AC et al. Dietary protein intake and all-cause and cause-specific mortality: results from the Rotterdam Study and a meta-analysis of prospective cohort studies. Eur J Epidemiol. 2020. 75. Lalles JP. Intestinal alkaline phosphatase: multiple biological roles in maintenance of intestinal homeostasis and modulation by diet. Nutr Rev. 2010;68(6):323-32. 76. Kuhn F, Adiliaghdam F, Cavallaro PM, Hamarneh SR, Tsurumi A, Hoda RS et al. Intestinal alkaline phosphatase targets the gut barrier to prevent aging. JCI Insight. 2020;5(6). 77. Singh R, Chandrashekharappa S, Bodduluri SR, Baby BV, Hegde B, Kotla NG et al. Enhancement of the gut barrier integrity by a microbial metabolite through the Nrf2 pathway. Nat Commun. 2019;10(1):89.

Denise Mafra Denise Mafra is a full Professor at the Faculty of Nutrition and Postgraduate Courses in Medical Sciences, Federal Fluminense University Niterói-Rio de Janeiro, –Brazil. She has an extensive portfolio of over 100 publications on nutrition research with special reference to renal disease and associated co-morbidities. Her current interests are in Food as Medicine and the microbiome.

Emilie Combet Emilie Combet is a senior lecturer in nutrition at the University of Glasgow. Her research focuses on foods, nutrition and the life cycle, with special interest on stress (metabolic, oxidative) in relation to ageing and obesity, and the “farm to fork to society” nexus and its implications for all stakeholders (community, industry and clinical settings). Her work has contributed toward establishing innovative solutions to explore the contribution of diet on lifelong health, including near-market research (reformulated meals, use of novel ingredients) to answer challenges to the nutritional status.

Holly Kerr, Anita Gattei Holly Kerr and Anita Gattei are students in the Shiels group currently researching on senotherpies and the nutritional exposome.

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 15

Research / Innovation / Development

Betting on the Bug, Part III: Leveraging the Microbiome to Generate New Models Interest in the microbiome continues to grow at a robust rate, underlying its potential to significantly benefit human health. In part 1 of this series, the role of the microbiome in impacting experimental reproducibility and translatability was examined, and it was demonstrated that the microbiome can affect all researchers (not only microbiome-focused investigators). Part 2 focused on the microbiome’s ability to alter the effectiveness of therapeutics by transforming drugs into bioactive or inactive forms, and how the presence or absence of specific microbes is associated with clinical outcomes. As the research field’s understanding of the microbiome’s role increases, so does the opportunity to leverage the microbiome, leading to the creation of novel models that increase reproducibility, are more predictable, and aid in advancing drug discovery and development. The final installation of this series will focus on several of these models and approaches that utilise defined microbiome profiles.

Generation of Custom Microbiome Models Many studies have demonstrated that it is possible to transfer phenotypes via microbiota transplantation in mice, reinforcing rodent models as an important research tool that may aid in determining causality. Germ-free animals (devoid of any detectable microorganisms, including bacteria, fungi, parasites and viruses, with the exception of endogenous viral elements) remain the ideal “blank slate” to evaluate the properties of transplanted microbial communities. Germ-free mice have altered metabolism and thus special nutritional requirements, altered intestinal motility and structure, and a less developed mucosal immune system in the gut1. The abnormalities of germ-free mice expand beyond the gastrointestinal tract, as altered behavioural profiles and altered brain physiology and structure have also been reported2. The realisation that microorganisms, and bacteria in particular, are essential for normal development of the host constitutes the one major disadvantage of germ-free mice in biomedical research. Many, but not all, of these abnormal traits can be normalised by microbiota transplantation later in life. One method to circumvent the effect of an early-life germ-free period is to breed germ-free mice transplanted with the microorganism(s) of interest and use their offspring for experiments, with these subsequent generations having the microbiota transmitted in a natural way from birth3. With gnotobiotic husbandry, this approach allows for custom microbiome profiles to be created in mice and maintained to limit unwanted microbiome changes that may impact reproducibility. Microbiome Profiles to Evaluate Therapeutics Although microbiome research remains at robust levels of 16 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

growth in academic research settings, the microbiome drug industry is still in early stages of development. However, two main approaches in microbiome-based drugs have risen up: “bugs as drugs” (live microbiota-based therapeutics), and small molecules derived from the microbiome or used to target the microbiome itself. As the gut microbiome is quite diverse, it can be challenging to ascertain or assign observed effects to specific community members or a drug candidate. By tailoring the microbiome, investigators can utilise germ-free models associated with a minimal bacterial community. A minimal community would be helpful in evaluating potential therapies in a disease model dependent on having microbiota present, such as spontaneous colitis in an interleukin-10 deficient mouse. The following are two examples of these defined compositions that can help researchers answer their questions. Altered Schaelder Flora (ASF) is a model community of eight anaerobic bacteria that are essential for proper gastrointestinal and immune functions. This microbial profile consists of ASF 356: Clostridium sp., ASF 360: Lactobacillus intestinalis, ASF 361: Lactobacillus murinus, ASF 457: Mucispirillum schaedleri, ASF 492: Eubacterium plexicaudatum, ASF 500: Pseudoflavonifactor sp., ASF 502: Clostridium sp., and ASF 519: Parabacteriodes goldsteinii4. The establishment of the ASF community of microbes in mice promotes the development and maturation of the immune system, as well as contributes to improved colonisation resistance. When compared to germ-free mice, mice with ASF microbiomes are better suited for combating pathogenic infections and maintaining normal gastrointestinal health5. Oligo-Mouse-Microbiota (Oligo-MM12) is a community of 12 strains representing members of the major bacterial phyla in the murine gut that was developed utilising genome-guided design6. Oligo-MM12 was shown to be stable over consecutive mouse generations and provided a level of colonisation resistance against Salmonella enterica serovar Typhimurium. Additional strains were added to complement the functional profile of the 12-member consortium. Creating Translational Models In many instances, preclinical models do not accurately predict what will occur in humans. Thus, there always exists a need for animal models that are more human-predictive. To address this need, researchers at the National Institute of Digestive Diseases and Kidney Diseases (NIDDK), part of the United States National Institutes of Health (NIH), created a model they termed ‘wilding mice’7. The researchers live-caught wild mice from a Maryland location to be used as surrogate mothers in a rederivation. These wild surrogate dams were implanted with C57BL/6N embryos to yield wildling mice or C57BL/6N mice harbouring the natural microbiota of wild mice. The researchers posited that these mice would be more reflective Spring 2020 Volume 3 Issue 1

Research / Innovation / Development

of the human state due to the diversity of their microbiota, and also have a microbiota profile that closely resembles that of a wild mouse in multiple anatomic sites.

microbiome discovery research and advancing preclinical studies. REFERENCES

To evaluate the translational research potential of the wildling mice, the researchers chose to replicate a rodentbased study that had failed upon transitioning to clinical trials in humans. One trial they identified was the evaluation of the CD28 superagonist TGN14128. In preclinical rodent testing, TGN1412 was found to preferentially activate and expand regulatory T cells with therapeutic effects. However, after entering the clinic the opposite was found. Soon after administration of TGN1412, all six human volunteers experienced severe adverse symptoms relating to a cytokine storm with multi-organ failure. This was later attributed to the unintended activation of inflammatory effector T cells and the release of pro-inflammatory cytokines9.

1. 2.

4. 5.

When TGN1412 was tested in conventional laboratory mice and wildling mice, the NIDDK researchers observed the same activation and expansion of regulatory T cells that occurred in the original preclinical characterisations7. However, when the CD28 superagonist was tested in wildling mice, they did not observe a regulatory T cell response but instead observed higher levels of pro-inflammatory cytokines than their conventional laboratory mouse counterparts, which was indicative of what was seen in volunteers from the failed clinical trial. Thus, the researchers had created a model that possessed a higher level of predictability by altering the microbiome profile of a laboratory mouse. Summary Understanding the microbiome and its impact on the body represents the next transformative step in improving human health. The microbiome has links to nearly every therapeutic area and its ability to impact experimental reproducibility, the course of disease, or therapeutic interventions is emerging as a critical factor for drug developers to consider. The research mouse will continue to have a key role in driving www.biopharmaceuticalmedia.com

Al-Asmakh, M. & Zadjali, F. Use of Germ-Free Animal Models in MicrobiotaRelated Research. J. Microbiol. Biotechnol 25, 1583–1588 (2015). Luczynski, P. et al. Growing up in a Bubble: Using Germ-Free Animals to Assess the Influence of the Gut Microbiota on Brain and Behavior. Int. J. Neuropsychopharmacol. 19, pyw020 (2016). Lundberg, R., Bahl, M. I., Licht, T. R., Toft, M. F. & Hansen, A. K. Microbiota composition of simultaneously colonized mice housed under either a gnotobiotic isolator or individually ventilated cage regime. Sci. Rep. (2017). doi:10.1038/srep42245 Brand, M. W. et al. The altered schaedler flora: Continued applications of a defined murine microbial community. ILAR J. 56, 169–178 (2015). Gomes-Neto, J. C. et al. A real-time PCR assay for accurate quantification of the individual members of the Altered Schaedler Flora microbiota in gnotobiotic mice. J. Microbiol. Methods 135, 52–62 (2017). Brugiroux, S. et al. Genome-guided design of a defined mouse microbiota that confers colonization resistance against Salmonella enterica serovar Typhimurium. Nat. Microbiol. (2016). doi:10.1038/ nmicrobiol.2016.215 Rosshart, S. P. et al. Laboratory mice born to wild mice have natural microbiota and model human immune responses. Science (80-. ). (2019). doi:10.1126/science.aaw4361 Hünig, T. The rise and fall of the CD28 superagonist TGN1412 and its return as TAB08: a personal account. FEBS J. (2016). doi:10.1111/ febs.13754 Hünig, T. The storm has cleared: Lessons from the CD28 superagonist TGN1412 trial. Nature Reviews Immunology (2012). doi:10.1038/nri3192

Alexander C. Maue Dr. Alexander Maue is Director of Microbiome Research Services at Taconic Biosciences. Previously he was Head of the Campylobacter Immunology Laboratory at the Naval Medical Research Center. Trained as an immunologist, his research focus was on enteric diseases and the development of vaccines and therapies to prevent illness.

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 17

Research / Innovation / Development

Mass Spectrometry Supports Development of New Oligonucleotide Therapeutics Oligonucleotides’ ability to inhibit genes or to function as aptamers to interact with protein targets are increasingly vital research tools in the biopharmaceutical industry. Oligonucleotides (polymeric sequences of RNA and DNA) target RNA at the cellular level, where specific malfunctioning genes can be manipulated and/ or modulated1. This capability presents biopharma companies with opportunities to target diseases which have proven difficult to combat using classical small molecule approaches. Robust, accurate analytical characterisation of oligonucleotides is necessary in order to confirm their identity and to determine purity and quality. Mass spectrometry (MS) techniques used to address the challenges facing oligonucleotide drug development are discussed as well as improvements to high-throughput oligonucleotide analysis.

Regulatory Guidance The demand for oligonucleotides for clinical and research use, including gene therapies, is expected to grow by 20.6% per year to reach US$3,697 million by 20262. Regulatory guidance, however, remains a challenge. Synthesis of a 25-base oligonucleotide requires more than 100 sequential chemical reactions resulting in inevitable impurities – even with highly efficient reactions3. Determining molecular weight, confirming the nucleotide sequence, and location of modifications of an oligonucleotide are essential attributes to monitor product quality. Variance in oligonucleotide structure (i.e. whether they are singleor double-stranded), molecular weight, molecular size, and number of negative charges all affect the molecular interaction with targeted tissue. They are considered neither small nor large molecules, and regulatory agencies disagree on how to classify them.

downregulate gene expression. Additionally, potential degradation when oligonucleotides are introduced into biological systems complicates drug development. Other potential issues include poor uptake through cell membranes, unfavourable bio-distribution and pharmacokinetic properties, and sub-optimal binding affinity for complementary sequences6. Researchers are addressing these challenges by applying tailored solutions based on the molecule’s characteristics, including chemical modification of the oligonucleotide itself; implementation of lipid or polymeric nanocarriers; and linking oligonucleotides to receptor targeting agents such as carbohydrates, peptides, or aptamers. Analytical Approaches Because oligonucleotide analysis is an essential part of drug development, registration and QC, biopharma companies must establish methods that can separate and/or identify impurities. The most common of these methods include liquid chromatography-mass spectrometry (LC-MS), high-performance liquid chromatography (HPLC), nuclear magnetic resonance (NMR), Fourier transform infrared spectroscopy (FTIR), and polyacrylamide gel electrophoresis (PAGE). Significant progress in ionisation techniques, instrumentation and software have now established MS as an excellent tool with high sensitivity, high mass accuracy, and the ability to provide structural information. MS can be applied across the biopharmaceutical pipeline – from oligonucleotide development to QC. Advantages of Mass Spectrometry High-resolution MS enable the determination of oligonucleotide mass and in some cases sequence. This method is based on obtaining negative ion spectra of the oligonucleotide, followed by interpretation of the spectra using deconvolution software algorithms where the multiply-charged species are reconstructed into a singly-charged form. The accuracy of these

The US FDA considers oligonucleotides as small molecules and provides no official FDA guidance for quality control (QC) expectations. However, the agency has issued some guidance on oligonucleotide analysis with respect to identity, purity, quality, and strength in the chemistry, manufacturing, and controls (CMC) regulatory process4. In contrast, the European Medicine Agency (EMA) uses a centralised procedure required for drug products manufactured using biotechnology processes5. Oligonucleotide Delivery Challenges In addition to regulatory ambiguities, diverse modes of action can complicate oligonucleotide delivery in vivo. First, the oligonucleotide must be transported to the tissue of therapeutic interest with minimised exposure to other tissues. Second, it must be delivered to the correct intracellular compartment in order to function and penetrate the targeted cells to 18 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Biopharma compass results of an oligonucleotide analysis done with ESI. Various views highlight the modifications, chromatogram, average and deconvoluted spectra. Spring 2020 Volume 3 Issue 1

Research / Innovation / Development high-resolution ESI-QTOF and MALDI-TOF data. Coupled with flexible data analysis software, mass spectrometry continues to be an essential tool to support the development of new oligonucleotide therapeutics.

Electrospray ionisation spectrum of a 65 – mer oligonucleotide showing the molecular ion and modifications.

measurements is typically better than 5ppm and, as such, the mass can help establish the empirical formula of the molecule, which is used to postulate or confirm structure7. Mass spectrometry with electrospray ionisation (ESI) and matrix-assisted laser desorption/ionisation (MALDI) are used to obtain accurate molecular weight, sequence confirmation, and characterise impurities in both high- and low-throughput modes. Mass analysers used for LC-MS can be divided into two main groups: beam type analysers that continually scan ions (e.g., time-of-flight [TOF] and quadrupole) and trap-based analysers that capture ions of interest for a specific time to acquire mass spectrum. A quadrupole mass analyser acts as a variable mass filter that separates ionised species using only electrical fields generated by a direct current and superimposed radio-frequency potential. Ions are then introduced in a path parallel to a quadrupole rod. Only ions of a particular mass and charge can pass through, with all non-confirming ions filtered out. Most quadrupole TOF (QTOF) MS systems have tandem capabilities, so precursor ions separated by mass-to-charge ratio in the first stage (MS1) can be selected, then separated and detected in the second stage (MS2) as fragments (product ions) in the QTOF. Precursor ions are selected in the quadrupole and sent to the collision cell for fragmentation. The generated product ions are then detected by TOF MS. MALDI-TOF offers high sensitivity for oligonucleotides and is relatively easy to use. MALDI-TOF is also amenable to high throughput since the sample/matrix mixture is spotted on a metal plate and then analysed in the instrument, with data typically acquired in a fraction of a second. It is also reasonably tolerant of salts, buffers, and other additives. The resolution offered by MALDI TOF linear mode is optimal for to measure oligonucleotides with 50 bases or less. Alternatively, ESI technology delivers high mass accuracy, resolution, and sensitivity over a wide range of lengths (3–120 bases), but has a reduced throughput compared to MALDI-TOF. In ESI-MS, the sample is introduced via a syringe pump or by an HPLC system, and data acquisition takes place in several minutes, depending on sample complexity. ESI requires closer attention to sample desalting in order to maximize the data quality. MS techniques such as ESI-QTOF and MALDI-TOF can be used for ultra-high-resolution analysis of oligonucleotides to achieve sensitive detection with enhanced speed and data quality. Current data analysis software such as Bruker Daltonics’ BioPharma Compass works with both www.biopharmaceuticalmedia.com

Biopharma Compass software results view of oligonucleotide screening by MALDI. The results are seen in a traffic-light reporting based on multi-attribute criteria set by the user.

REFERENCES 1.

2. 3.

6. 7. 8.

B2B Labs, “Oligonucleotides: Opportunities, Pipeline and Challenges”, accessed Dec. 12, 2016. https://www.pharmamanufacturing.com/ articles/2016/oligonucleotides-opportunities-pipeline-and-challenges/ Zion Market Research, “Oligonucleotide Synthesis Market Expected to Reach USD 3,697 Million By 2026, Globally”, Press Release, January 2019. Integrated DNA Technologies, “Technical Report: Mass Spectrometry Analysis of Oligonucleotide Syntheses”, 2017. https://sfvideo.blob. core.windows.net/sitefinity/docs/default-source/technical-report/ mass-spec-of-oligos.pdf?sfvrsn=ca483407_6 FDA, “CMC Regulatory Considerations for Oligonucleotide Drug Products: FDA Perspective”, pqri.gov, 2017. http://pqri.org/wp-content/ uploads/2017/02/3-SapruPQRI-FDA-Conference-Oligo-2017Presentation.pdf B2B Labs, Oligonucleotides: Opportunities, Pipeline and Challenges, June 2016. https://www.pharmamanufacturing.com/articles/2016/ oligonucleotides-opportunities-pipeline-and-challenges/ X. Shen, D. R Corey, Nucleic Acids Research, 46(4), 2018. R. Houghton, “Oligonucleotides: The Next Big Challenge for Analytical Science”, Chromatography Today, March 2011. C. Stein and D. Castanotto, Molecular Therapy, 25 (5), 2017.

Anjali Alving An analytical scientist by training, Anjali Alving has been working at Bruker Scientific for more than 9 years. She has broad experience with bioanalytical mass spectrometry focusing mainly on Bruker’s ESI UHR QTOFs and Ion trap instruments. In her current capacity as a senior scientist in the Pharma/BioPharmagroup her work centers on performing analyses of samples utilizing QTOF and Ion mobility mass spectrometry based workflows for oligonucleotide analysis, characterization of intact proteins, peptide mapping, HCP analysis, glycan and polymer analysis. She has also authored technical documents to highlight new and innovative application results using Bruker’s ESI MS systems.

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 19

Application Study

Using LIMS to Transform Drug Development and Manufacturing Workflows

Modern laboratory information management systems (LIMS) play a key role in streamlining and optimising the laboratory operations and processes of drug manufacturers. Thermo Fisher Pharma Services, the largest provider of drug development and manufacturing services, recently implemented LIMS to improve efficiency and quality as a part of its multi-phase programme. Based on the successful outcomes of the initial single-site deployment, this article describes the need for integrated LIMS in the pharma industry, benefits of bringing informatics into drug development and manufacturing workflows, and key considerations for a smooth transition from traditional data systems.

The Need for Informatics in Pharma To meet compliance requirements and make important decisions in the drug development pipeline, all the data generated by developers and manufacturers needs to be accurate, precise, valid and archivable for future access. Biotech and pharma companies typically invest significant time and money on upgrading technologies and improving scientific workflows, while the systems to manage data often remain outdated. As a result, documenting and maintaining details about experimental methods can become a tedious, time-consuming task for scientists. To ensure data integrity and regulatory compliance, laboratory personnel need to document the lot number of a reagent each time it is used, maintain records of calibration dates and record every use of a controlled substance. With every manual step in the process, there is an increased risk of compromising data quality due to human error and fatigue. By automating these processes, teams are much more productive and scientists have the opportunity to focus on their science rather than spending time on data drudgery. Large-scale pharmaceutical operations that span across the entire spectrum of the pharma pipeline from development through to manufacturing need efficient systems that connect between departments to enable seamless, error-free and reliable data sharing. It is not uncommon for teams to develop their own systems based on their specific needs and data workflows. The resulting data silos can interfere with collaboration and standardisation, further introducing data discrepancies. When information management systems used by individual departments within an organisation are not connected, it is time-consuming to share, review or retrieve data. There is a pressing need for pharma companies to adopt information management systems that eliminate the laborious methods of handling data, reduce data silos and, ultimately, make processes more efficient. For contract development and 20 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

manufacturing organisations, it is even more critical that they leverage digital systems to optimise processes and provide sponsors with the information they need. Transforming Pharmaceutical Workflows with LIMS Setting up LIMS in a high-throughput pharmaceutical facility can considerably enhance productivity, eliminate manual processes, sustain compliance, and facilitate easy collaboration across departments and sites. Thermo Fisher Pharma Services made the decision to deploy Thermo Scientific SampleManager LIMS software to manage their 25-site deployment. The recent acquisition of a new site in Cork, Ireland made this site the logical choice for a first deployment. They were able to significantly transform data and lab processes during the successful implementation of LIMS at the company’s new location. Utilise Systems that Support Compliance As regulations become more stringent, pharma companies need a platform to automate and capture the day-to-day processes accurately. The expansive pharmaceutical and manufacturing operations at Thermo Fisher Pharma Services sites warrant regular audits from international regulatory bodies. With over 600 ongoing projects and a broad range of capabilities, the facilities need to remain fully compliant with various regulations and safety standards. Implementing LIMS enables compliance with Good Manufacturing Practices (GMP), 21 CFR Part 11 recommendations and the latest data integrity guidelines. For example, the system will prevent operators from executing a workflow or using an instrument without the proper training records or if the instrument is out of calibration, thereby ensuring compliance. By entering data only once and sharing across validated integrations between LIMS, chromatography data systems (CDS) and enterprise resource planning systems (ERP), there are immense compliance benefits and a significantly reduced review effort. Store and Manage Data in One Central Location Pharmaceutical facilities typically incorporate LIMS into their current workflows to obtain a ‘single system of truth’ for data. Storing all the data output and reports in one centralised repository makes it easier to compile information from different instruments and laboratories. Implementing an organisation-wide LIMS ensures all raw data and associated metadata across the company remain documented, traceable and retrievable for the future. The use of informatics makes it possible to convert data generated from different instruments into a vendor-neutral format, making it available for sponsors in the future and enabling compliance with regulatory requirements. Using LIMS, managers can also monitor ongoing processes by visualising data. For instance, relevant numbers can be extracted from connected systems, such as ERP, and displayed pictorially to Autumn 2019 Volume 2 Issue 3

Application Study

provide a real-time snapshot. To keep an eye on critical points in a process or visually map a dynamic experiment, data dashboards can be personalised for the end user in different display formats, such as tables, graphs and charts. Improve Reproducibility by Managing Workflows In addition to storing data, LIMS allows individual teams within an organisation to define and execute procedural workflows to drive compliance and reproducibility. The different steps involved in ensuring repeatable execution of processes on LIMS include: (i) detailed step-by-step instructions for each method, (ii) in-process checks to confirm user authorisation and instrument availability, (iii) verification of the process, and (iv) flagging out-of-spec steps for review. By integrating LIMS with other key systems like a CDS, data is automatically available in the LIMS for review and approval. This eliminates the data integrity issues caused by manual data entry. Automate Laboratory Resource Management Laboratory personnel need to keep records of reagents and other consumables, and associate them with the samples and instrument runs for complete traceability. Rather than manually document and manage the stocks, the LIMS software can be configured to autodecrement from stock levels each time a method is run, and notify personnel when laboratory inventory is low and it is time for reordering. Communicate and Collaborate Across Departments A company-wide information management system offers seamless integration between departments and across www.biopharmaceuticalmedia.com

multiple sites. At Thermo Fisher Pharma Services, LIMS is currently being employed to facilitate data transfer between different departments, such as manufacturing and clinical trials. Additionally, as the company’s international presence comes from multiple site acquisitions, having a global, integrated LIMS platform will make it more efficient and effective to manage information across all sites. Data connectivity across departments and company locations provides a big-picture overview of data sources, location-independent access to information and the ability to make faster decisions to advance projects. LIMS can also automate report generation for multiple end users in different locations. The ability to build connections across data sources is inherently valuable to the business. Maintaining a reliable and comprehensive database can help teams make informed data-driven decisions by examining data trends and gaining insights from patterns. Eliminate Data Drudgery and be More Productive In a regulated environment, every detail needs to be documented. These repetitive and labour-intensive administrative tasks benefit from automation. One of the outcomes at the Cork site was the autogeneration of certificates of analysis that were previously being generated and validated manually. Automating these processes not only saves time, it can also free up mental energy that scientists can channel elsewhere. Implementing LIMS across different laboratory workflows and departments relieves scientists of mundane, repetitive INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 21

Application Study and time-consuming tasks. It also enforces a process that automatically stores data, generates reports, reduces errors and upholds quality, significantly improving the overall productivity and efficiency of the whole system. Harmonising processes and adopting best practices further enables continual improvement for the organisation. At Thermo Fisher Pharma Services, one of the core objectives in bringing informatics into their operations was to enable scientists to record a piece of information only once. Saving minutes, hours and days in this manufacturing process can ultimately bring drugs to the market faster. Challenges in Building an Informatics Platform Bringing new data management systems into an industrious pharmaceutical facility can often be mistaken as disruption. As team members strive to meet deadlines and uphold high quality output, launching an informatics platform with minimal interference to the daily operation poses some challenges: Change Management: Traditional systems have been ingrained into the team’s functioning for years. In introducing or changing LIMS, it is important to actively involve teams so that each person understands the value in upgrading the system. Without a robust change management plan in place, end users of LIMS may not fully appreciate the benefits of automation or worse, may resist the change. Connectivity: There needs to be a smooth transition between legacy systems and the new informatics platform so that no information is lost during the process. The multi-site nature of

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Thermo Fisher Pharma Services meant ensuring that previous data, protocols, reports and other essential information stored across different laboratories were carefully populated into the new LIMS. Validation: As pharma facilities are regularly audited, great efforts are made by every team to ensure the highest production quality, safety and compliance. Introducing LIMS into these already established workflows will require validation of the new processes to meet cGMP requirements. The Key to LIMS Success: A Multi-disciplinary Approach Thermo Fisher Pharma Services will be launching SampleManager LIMS software at 24 other sites, following the successful deployment at Cork. The key to incorporating data management systems into a fully functional facility involves a highly collaborative approach that combines business, IT and scientific teams. Bringing together multi-disciplinary expertise provides the opportunity for the informatics platform to serve the overall goals of the company. Gathering valuable feedback from laboratory scientists who will use these new systems daily ensures they are set up in the most user-friendly and effective way possible, while involving other key team members allows the implementation to equally meet IT and business requirements. A collaborative implementation of LIMS, where experts from various departments have a voice at the table, minimises resistance to change by the members of individual departments. These conversations also make room to prepare for imminent adjustments, encouraging teams to back up important information

Autumn 2019 Volume 2 Issue 3

Application Study

and contribute towards improving the process. Inclusion during the early stages also offers opportunities to configure the LIMS to best suit the team’s needs during the initial setup, while remaining compliant with the regulations. SampleManager LIMS software is adaptable to the ever-evolving business dynamics of a fast-paced pharmaceutical company. A flexible LIMS helps facilitate collaboration, and can be configured according to laboratory requirements to provide dashboards for scientists as well as management teams. By automating the laboratory process and enabling data to be reviewed on entry, laboratories are able to maintain best practices as well as manage by exception. The Versatility of LIMS Serves Every Team Involved: For scientists: LIMS offers automated workflows and reliable data generation, while saving time on laborious processes. For laboratory managers: Configurable workflows in LIMS enable the monitoring of processes in real time, making it easy to stay updated. The system offers secured access to data, tracks user information and instrument history for audits, and sustains regulatory compliance. For IT staff: Modern information management systems have been designed for easier integration with existing systems. Plus, the software offers programmable timeouts and password checks for added security. Meanwhile, cloud-based storage platforms also allow flexibility to expand in the future without the need for additional infrastructure. For management: Data visualisation tools in LIMS can be used to monitor and measure key performance indicators against set business metrics. Automating tedious tasks at various levels in www.biopharmaceuticalmedia.com

the pipeline boosts the overall productivity and efficiency of the entire organisation. A Standardised Process for Continued Success Launching LIMS software across different laboratories and sites offers pharmaceutical companies the opportunity to standardise processes across multiple locations. An integrated data management strategy that connects the development of active pharmaceutical ingredients with the manufacturing of finished products enables companies to speed up the drug development and manufacturing pipeline. By reducing overhead and maintenance costs through automation, fostering inter-departmental collaboration, and building a strong foundation for centralised data management, pharma companies can set themselves up for continued success. Deploying information management systems, such as LIMS, equips team members with the necessary tools to be more productive, enables laboratories to optimise their operations to become more efficient and, ultimately, streamlines processes across an organisation.

Kevin Smith Kevin Smith is the Senior Director Global Services and Support for the Digital Science business unit at Thermo Fisher Scientific and has been with the organization for 35 years. During that time, his career has focused on the development and deployment of enterprise laboratory informatics solutions for food and beverage, pharmaceutical and process industries. Kevin previously held positions at Ciba Geigy and BP, and holds a BS in Physics and Computing from The University of Canterbury in the UK.

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 23

Clinical Research

PEER REVIEWED

Congenital Hyperinsulinism Treatment Gaps and a Potential Solution Defining Rare Disease Although rare diseases, by definition, affect fewer individuals than other diseases do, they tend to be particularly devastating: they are often debilitating or lethal. If fewer than 200,000 people in the United States (about 1 in 1655 people) are affected by a given disease, it is designated as rare; similarly, the European Union defines a rare disease as one that affects fewer than 1 in 2000.1

It is estimated that as many as 7000 rare diseases exist globally. While the number of individuals with a specific rare disease may be small, the total number of people with any rare disease is actually quite large.1 A significant proportion of patients diagnosed with a rare disease have inherited it, but many others are due to other causes. For example, some infections and autoimmune diseases are considered to be rare diseases. Rare diseases may be diagnosed during childhood or later in adulthood. Due to the paucity of information available about diseases that affect so few, people living with rare diseases can face long paths to correct diagnoses, several barriers to disease management and few to no therapeutic options. Additionally, it is often the case that fewer research and therapeutic development efforts are invested in each individual rare disease because of their low demographic impact. In the US, federal efforts to counteract these trends were formalised through the Orphan Drug Act, which was created by Congress in 1983 in an effort to encourage drug developers to look into potential treatments for these rare or orphan diseases. The National Institutes of Health and one of its centres, the National Center for Advancing Translational Sciences, support research and the discovery and advancement of new potential treatments or cures for rare diseases. Efforts to bring these treatments to market are incentivised by the US Food and Drug Administration along with its Office of Orphan Products Development (OOPD).1 Since 1983, the OOPD has assisted the development and commercialisation of more than 400 drugs and biologic products for rare diseases,1 but many are still left with little or no effective therapeutic options. Congenital hyperinsulinism is just one example of a rare disease and patient population with a significant unmet need for improved treatments. Exploring Congenital Hyperinsulinism Congenital hyperinsulinism (HI) is an ultra-rare paediatric genetic disorder characterised by excessive and dysregulated production and secretion of the hormone insulin, which plays a key role in blood sugar regulation. The condition affects roughly 1 in 25,000 to 1 in 50,000 newborns, but it is more common in certain populations.2,3,4 24 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Although genetic mutations account for a significant number of cases, the specific underlying causes of roughly half of congenital HI cases remain unknown.2 So far, more than ten single-gene mutations that account for congenital HI have been identified.5 Patients with congenital HI experience frequent episodes of hypoglycaemia, or low blood sugar, due to the effect of excess insulin in the body. When food is consumed, insulin is secreted by the pancreas to support the uptake, utilisation, and storage of glucose by peripheral target tissues, and to maintain normal blood glucose levels. When fasting, insulin secretion decreased, resulting in the release of glucose from peripheral target tissues such as the liver, into the bloodstream, to keep blood glucose normal. During periods of prolonged fasting, decreases in insulin and other metabolic countermeasures allow protein and fat stores to be used as sources of fuel in the body. This tight regulation enables a person without congenital HI to have normal blood glucose levels and sustained nutrition to the brain during both mealtime and fasting.3 In patients with congenital HI, excess amounts of insulin are produced by the pancreas regardless of blood glucose concentration, which can lead to profound hypoglycaemia that compromises processes in numerous organs and systems and especially threatens the brain. Glucose is the major source of energy for the brain, and when the brain does not receive enough glucose, it relies on alternative fuel sources, called ketone bodies, for its metabolism. However, in congenital HI, ketone body production is also suppressed by elevated insulin.6 Thus, the brain is particularly vulnerable to HI-induced metabolic deprivation of its two fuel sources, which may lead to complications including developmental delays, learning disabilities, behavioural issues, seizures, coma or even death. As many as half of all congenital HI patients are believed to suffer from at least one of these outcomes.7 Albeit rare, congenital HI is the most common cause of persistent hypoglycaemia in children. Infants generally show symptoms in the first few days of life or during infancy, including poor feeding, seizures, unresponsiveness, irritability and increased sleepiness. In young children, symptoms of low blood sugar can be alarming and disruptive and include sweating, feelings of tiredness and shakiness and rapid heart rate.3 With early and aggressive intervention, brain damage can be prevented in patients with congenital HI, but diagnostic difficulties present a challenge and significant neurological consequences can occur if the condition is not recognised or if treatment is ineffective.3 Diagnosing Congenital HI The diagnosis of congenital HI is relatively challenging to make – it is difficult to identify symptoms as such because they are Spring 2020 Volume 3 Issue 1

Clinical Research non-specific and may often be confused with typical newborn behaviours. In patients with hypoglycaemia, a thorough and detailed history should be obtained and include the timing and relation of episodes to mealtimes or fasting, along with birth weight, gestational age and family history. Physical examination should include looking for findings that may point a clinician toward a specific diagnosis or syndromic condition that may be associated with hypoglycaemia. Whenever possible and before treatment, a “critical sample” of blood should be obtained at time of presentation of hypoglycaemia, to confirm hypoglycaemia and support the diagnostic evaluation. In the absence of this, a provocative fasting test is the most informative method for identifying the underlying cause of hypoglycaemia disorders.6 Knowing which infants and children to evaluate diagnostically for hypoglycaemia is an important first step. For neonates suspected to be at high risk of having a persistent hypoglycaemia disorder, evaluation is recommended when the infant is at least 48 hours of age.6 Delaying diagnostic evaluations until two to three days after birth is important because of the difficulty in distinguishing a suspected persistent hypoglycaemia disorder from what is called transitional neonatal glucose concentrations. For safety, a fasting test should be completed with frequent monitoring of vital signs, plasma glucose and other concentrations of key laboratory values. A fasting study identifies if a child is able to fast appropriately for his or her age and confirms if he or she is making too much insulin or missing other hormones. The constellation of persistent hypoglycaemia, increased consumption of glucose, insulin greater than the lower limit of detection, low plasma ketones, decreased free fatty acids and a response to glucagon when hypoglycaemic are strongly suggestive of hyperinsulinism.6 Genetic testing is another diagnostic approach that physicians and geneticists may consider, which can be useful in certain cases, particularly if the hypoglycaemia persists, the patient has a form of HI that is non-responsive to diazoxide, and the case is de novo in the absence of a known family and genetic history, but otherwise is not necessarily part of standard prenatal or neonatal care. Once a diagnosis is made, treatment is the next step, but there is no satisfactory treatment or cure for congenital HI to date. Treating Congenital HI On a day-to-day basis, management of congenital HI requires promptly addressing acute low blood sugar episodes as they arise, both for immediate safety and to prevent the long-term complications associated with frequent, repeated episodes of low blood sugar. Patients must often receive extra sugar to offset the immediate effects of excess insulin until longer-term interventions can be made. Children may need an infusion of a dextrose-containing solution into their vein to relieve severe hypoglycaemia, until other measures can be implemented. Some children require a feeding tube that infuses a sugar solution into the gut overnight or during other extended periods of fasting to prevent severe hypoglycaemia. However, these short-term solutions do not address the underlying pathology of congenital HI and they introduce immense burdens to parents or caregivers since they require frequent, close monitoring. www.biopharmaceuticalmedia.com

One drug option is glucagon, prescribed for its opposition of insulin action. However, its use is not straightforward: glucagon formulations currently have a short half-life, so they can only correct hypoglycaemia for short periods of time. Long-term use of glucagon may diminish its efficacy and deplete stores of glucose in the liver, further compounding glucose dysregulation.8 Other drug therapies may also be prescribed in an effort to control symptoms. Currently available pharmaceutical options, however, are co-opted from other indications and were not specifically developed or approved by the US Food and Drug Administration (FDA) for use in congenital HI. Standard-of-care medications include drugs that block insulin production or the effects of insulin, such as diazoxide, octreotide or lanreotide. Unfortunately, not all patients respond well to these options and they may lose efficacy over time or cause especially unwanted side-effects. For diazoxide, which doesn’t work in the half or more of patients with severe KATP channel hyperinsulinemia, these include an FDA black box warning, the strongest warning that the FDA can apply, for pulmonary hypertension, a type of high blood pressure that affects the vessels in the lungs and the right side of the heart.9 Other more common side-effects include excessive hair growth all over the body, altered, coarsened facial features, and fluid retention which requires co-administration with diuretics and may adversely affect the heart and lungs.5 For the somatostatin analogs octreotide and lanreotide, side-effects include gastrointestinal symptoms and gallstones,10 the potential to interfere with the pituitary thyroid and growth axes, as well as potentially increased risk of dangerous tissue death in the bowel in the newborn period, called necrotising enterocolitis.11 Surgical removal of the pancreas is sometimes an option, but this approach is usually not curative, so much as it simply trades excess insulin production for the absence of insulin production altogether. Removing the pancreas is also a relatively invasive intervention and even after surgery, many children still experience low blood sugar, requiring frequent meals and medications to counteract their persistent symptoms. Accordingly, removing the entire pancreas may cause the near converse of HI: lifelong insulin-dependent type 1 diabetes, as well as insufficiency in pancreatic digestive enzymes. On the other hand, in cases of congenital HI in which only a certain area or focal lesion of the pancreas over-secretes insulin, removal of the lesion is often curative.5 Currently available treatments for congenital HI leave gaping deficits in quality of life and daily independence for patients. Patients, their families and their caregivers shoulder profound, lifelong burdens. In the absence of a safer, truly restorative therapy, patients remain at risk of feeding problems, developmental delays, learning disabilities, and lifelong brain damage. New Avenues of Treatment for Congenital HI Drug developers are evaluating a purpose-built antibody as a potential treatment for congenital HI patients. The antibody, named RZ358, is an intravenously administered human monoclonal antibody that binds specifically but reversibly to a site on insulin receptors. Its effect is dependent on both insulin levels and blood sugar levels in a reversible and dose-dependent manner, which should enable patients to achieve and maintain safe blood sugar levels. INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 25

Clinical Research rarediseases.org/rare-diseases/congenital-hyperinsulinism/ Congenital Hyperinsulinism (n.d.). Retrieved May 2020, from https:// congenitalhi.org/congenital-hyperinsulinism/ 5. Stanley, C. A. (2016). Perspective on the Genetics and Diagnosis of Congenital Hyperinsulinism Disorders. The Journal of Clinical Endocrinology & Metabolism, 101(3), 815-826. doi:10.1210/jc.20153651 6. Thornton, P. S., Stanley, C. A., Leon, D. D., Harris, D., Haymond, M. W., Hussain, K. & Wolfsdorf, J. I. (2015). Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children. The Journal of Pediatrics, 167(2), 238-245. doi:10.1016/j. jpeds.2015.03.057 7. Lord, K., Radcliffe, J., Gallagher, P. R., Adzick, N. S., Stanley, C. A., León, D. D. (2015). High Risk of Diabetes and Neurobehavioral Deficits in Individuals With Surgically Treated Hyperinsulinism. The Journal of Clinical Endocrinology; Metabolism, 100(11), 4133-4139. doi:10.1210/jc.2015-2539 8. Welters, A., Lerch, C., Kummer, S., Marquard, J., Salgin, B., Mayatepek, E. & Meissner, T. (2015, November 25). Long-term medical treatment in congenital hyperinsulinism: a descriptive analysis in a large cohort of patients from different clinical centers. 9. Center for Drug Evaluation and Research (2015). FDA Drug Safety Communication: FDA warns about a serious lung condition in infants and newborns treated with Proglycem (diazoxide). Retrieved May 2020, from https://www.fda.gov/drugs/drug-safety-and-availability/ fda-drug-safety-communication-fda-warns-about-serious-lungcondition-infants-and-newborns-treated 10. Hosokawa, Y., Kawakita, R., Yokoya, S., Ogata, T., Ozono, K., Arisaka, O. & Yorifuji, T. (2017, September 30). Efficacy and safety of octreotide for the treatment of congenital hyperinsulinism: A prospective, open-label clinical trial and an observational study in Japan using a nationwide registry. 11. McMahon, A. W., Wharton, G. T., Thornton, P. & Leon, D. D. (2016). Octreotide use and safety in infants with hyperinsulinism. Pharmacoepidemiology and Drug Safety, 26(1), 26-31. doi:10.1002/ pds.4144 4.

More specifically, RZ358 works by binding to an allosteric site on insulin receptors, which are present at high density in insulin’s target tissues like muscle, fat and liver tissue. As an allosteric modulator, RZ358 reduces the ability of insulin to bind and signal through its receptor. This results in an effective decrease in insulin activity, correcting the body’s misperception of a ‘fed’ state and thus increasing the blood levels of glucose and ketone bodies that the brain depends on. At the same time, RZ358 counteracts insulin only when and to the extent that insulin is elevated, still permitting insulin to continue to act at physiological levels. Importantly, because RZ358 acts at insulin-dependent target tissues downstream from the insulin over-producing beta cells, it may be more universally effective in addressing any of the underlying genetic defects that cause the disease. This combination of mechanistic features makes RZ358 ideally suited as a potential therapy for conditions associated with endogenous hyperinsulinemia, including congenital HI. Clinical Development RZ358 is currently being studied in clinical trials to determine if it is suitable as a treatment for patients with congenital HI. To date, RZ358 was safe and well-tolerated in healthy volunteers in a Phase I trial, as well as in adult and paediatric patients with congenital HI in a Phase IIa proof-of-concept trial. Additionally, there was a durable dose- and disease-dependent normalisation of blood sugar in patients with congenital HI who had hypoglycaemia at baseline. Consistent with the premise that RZ358 self-regulates and thus precludes ‘overshooting’ by inhibiting insulin excessively, RZ358 did not increase blood sugar levels in a subset of patients with normal baseline blood sugar levels. Consistent with its mechanism of action, RZ358 appears to attenuate insulin activity only when insulin is present in excess, i.e. it works only when it needs to. Further modelling and analysis of the data suggest that RZ358 will likely be effective at relatively infrequent dosing intervals of weekly to monthly. Currently, a multi-centre, open-label, Phase IIb study of longer treatment duration is in progress, with goals of evaluating safety, efficacy, and the most appropriate dosing regimen of RZ358 in patients with congenital HI. Additional data will be necessary to determine whether RZ358 may offer the targeted, restorative, and universal treatment option currently absent from the congenital HI treatment landscape. REFERENCES 1.

FAQs About Rare Diseases (2017, November 30). Retrieved May 2020, from https://rarediseases.info.nih.gov/diseases/pages/31/ faqs-about-rare-diseases Congenital hyperinsulinism – Genetics Home Reference - NIH (2020, April 28). Retrieved May 2020, from https://ghr.nlm.nih.gov/ condition/congenital-hyperinsulinism Congenital Hyperinsulinism (2020). Retrieved May 2020, from https://

26 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Brian Roberts Prior to joining Rezolute, Dr. Roberts directed clinical development at Fibrogen, Inc, where he helped successfully launch and execute the global Phase 3 program and pharmaceutical partnership for a novel oral therapy for anemia associated with kidney disease, concluding the largest Phase 3 program ever conducted in CKD anemia, and resulting in global NDA filings. During his tenure, Fibrogen achieved the largest biotech IPO in the previous 10 years. From 2007 until 2012 Dr. Roberts held clinical development positions of increasing responsibility at Metabolex, Inc., where he developed novel therapies for metabolic diseases such as diabetes, dyslipidemia, NASH, and gout. His program and clinical leadership from IND through clinical proof-of-concept helped secure a global licensing and co-development agreement with a major pharmaceutical partner for a novel diabetes therapy. He is an inventor or author on more than 20 patents and publications in the fields of Endocrinology and Metabolism. Dr. Roberts received his B.S. in biochemistry from the University of California, San Diego and his medical degree Magna Cum Laude from Georgetown University. He completed residency in Internal Medicine and fellowship in Endocrinology at Stanford University, where he also now serves as Adjunct Associate Professor in the Division of Endocrinology.

Spring 2020 Volume 3 Issue 1

Patient-focused drug delivery devices Drug Delivery Devices Innovative developments Customized solutions GMP customer IP manufacturing

www.nemera.net information@nemera.net Phone: +33 (0)4 74 94 06 54

www.biopharmaceuticalmedia.com

www.ipimediaworld.com

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 27

INTERNATIONAL PHARMACEUTICAL INDUSTRY 15

Clinical Research

Increasing Patient Access to Advanced Therapies; the UK Perspective Over the past five years, we have seen remarkable growth and clinical results in an area of medicine known as advanced therapy medicinal products (ATMPs), which comprise gene therapies, somatic cell therapies, and tissue engineered products. These treatments offer the potential to address significant and growing unmet healthcare needs. They offer the promise of treating and altering the course of diseases which cannot be addressed adequately by existing pharmaceuticals, offering a lifeline to some patients who have failed all other treatment options. The field of advanced therapies is relatively new, however advances in technology have driven this industry to grow at a significant rate both in the number of clinical trials being run, and companies developing products. At the time of writing, there are nearly 1000 companies worldwide, with over 230 companies headquartered within Europe1. Consequently, the number of clinical trials has grown at pace, a worldwide increase of 32% from 2014–2019, with over 2000 trials initiated in this period and 323 centred in Europe. There are also 129 multi-regional trials, most likely including at least one European country2. The expanding activity is reflected in the UK accounts with 127 ongoing trials; 12% of all global clinical trials in this field. Oncology has been the dominant therapeutic area for a number of years, blood cancers in particular; however, there are trials examining a broad variety of indications, with oncology now being just 39% of trials (Figure 1.)3.

transported to the site of manufacture and, following release, the product is shipped to the hospital for patient treatment. The orchestration of this complex supply chain requires hospitals to adapt their infrastructure and this will be increasingly so as more of these products become available. The UK is committed to providing patients with access to these novel treatments and was one of the first countries to approve the use of one type of ATMP in the healthcare system – Kymriah™ and Yescarta™ CAR-T therapies (chimeric antigen receptor T cell therapy) directed against the tumour antigen CD19. These two treatments were approved for use within the NHS in England through the Cancer Drugs Fund soon after receiving their EU marketing authorisation. Another confirmation of the UK Government’s support to the sector of advanced therapies was the investment in the Advanced Therapy Treatment Centre (ATTC) network programme; a network of centres designed to develop systems and processes to support the routine supply and delivery of advanced therapies by the NHS. The ATTC Network Programme is a world-first. Three Advanced Therapy Treatment Centres spanning the UK operate within the NHS framework, coordinated by the Cell and Gene Therapy Catapult, to address the unique and complex challenges of bringing pioneering ATMPs to patients (Figure 2). The three centres in the network are: • •

•

Innovate Manchester Advanced Therapy Centre Hub (iMATCH) Midlands-Wales Advanced Therapy Treatment Centre (MW-ATTC, comprising Birmingham, Bristol, Cardiff, Leicester, Nottingham and Swansea) Northern Alliance Advanced Therapies Treatment Centre (NA-ATTC, comprising Edinburgh, Glasgow, Leeds and Newcastle)

Figure 1: Distribution of UK ATMP clinical trials according to therapeutic area in 2019

Figure 2: The UK network of Advanced Therapy Treatment Centres

Whilst there are advantages for patients coming from these newer therapies, they pose many challenges to healthcare systems around the world. Currently, most of the cell therapy treatments in development are autologous, meaning the product is manufactured from the patient’s own cells. The cells are

The network, funded by the Industrial Challenge Strategy Fund, has the aim of building the skills and experience across the network as well as creating easily run and ready-to-use systems and solutions that can be rolled out more widely across the NHS in the United Kingdom.

28 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Spring 2020 Volume 3 Issue 1

Clinical Research The Cell and Gene Therapy Catapult has the core purpose of building a world-leading cell and gene therapy ecosystem in the UK as a key part of a global industry, and supporting the ATTC network is a significant activity in delivery of this ambition. Some of the key activities of the ATTC network are described below. Pharmacy Pharmacists are responsible for the supply of licensed medicinal products, ensuring that the ordering, storage, reconstitution and dispensing of ATMPs are in line with their product specifications. The national Pharmacy Working Group (PWG) is acting as an expert and informed body to support the activities of the three ATTCs in the optimisation of administration of ATMPs. The group consists of pharmacists from across the UK that specialise in the governance, clinical trials, prescribing, administration and monitoring of ATMPs, and is an excellent example of collaboration across the NHS. The aims of the group are to promote good practice, and identify and resolve pharmacy issues to maximise the effectiveness and development of services for hospitals to administer advanced therapies. The group is developing a series of guidelines and checklists in the handling of ATMPs to provide consistency in pharmacies across the country. Training A highly-skilled workforce is key to the successful adoption of ATMPs into mainstream clinical practice. Experienced professionals from within the ATTC network are creating a combination of educational resources that will equip the NHS with the knowledge they need to be able to carry out their roles effectively when treating patients with advanced therapies. The training will consist of a series of e-learning modules that will cover basic introductory training to ATMPs, through to a detailed knowledge of the products, their applications, their side-effects and their manufacture, supply, delivery and follow-up. This initiative is, overall, preparing the UK healthcare workforce for the introduction of novel treatments across the NHS, providing access to high-quality educational material. The result is that all staff will be able to fulfil their roles effectively and understand how they facilitate the treatment of patients with these therapies. Supply Chain The performance of the supply chain for these living therapies is key to the safe and effective treatment of patients. The ATTCs are working with supply chain specialists to track and trace both the patient’s starting material going from the hospital to the therapy manufacturing facility and the medicine returning from the site of manufacture back to the patient. We are also working with logistics operators and hospitals to be able to effectively coordinate the transportation of ATMPs. The electronic capture of the data and tracking of the cells throughout their journey is crucial to ensure the patients’ safety at point of delivery. Supporting the creation of teams that effectively collaborate to deliver these treatments is a key, as many of these treatments are time-critical and success relies on an integrated and transparent supply chain, keeping everyone fully informed so they may schedule their activities to deliver the best patient care. www.biopharmaceuticalmedia.com

Standardisation of Starting Material for Use in the Manufacture of ATMPs As demand for access to new ATMPs increases, driven by the growing number of clinical trials and/or by commissioned services, it is essential to identify and address potential bottlenecks in the supply chain. One such bottleneck that could arise, unique to ATMPs as a class of medicines, is the capacity within the healthcare system to ‘procure’ starting material from an increasing number of patients. Cell and tissue procurement is time-consuming and requires specialist staff and equipment. Furthermore, each ATMP has its own specific procurement requirements and the impact of limited space and limited safe cryopreservation technologies on large-scale storage will most likely be felt as the implementation of these treatments grows. The ATTC has a project, SAMPLE (Standard Approach to atMP tissue colLEction), examining the standardisation of the collection, preparation, labelling and transport of starting materials, e.g. apheresis, solid tumour material. The project brings together NHS, developers and equipment providers. Within the SAMPLE project, the ATTC network aims to reduce unnecessary complexity and variation in apheresis collection. The network is also examining critical quality attributes of apheresis cryopreservation protocols to produce an optimal ATMP starting material for ATMP developers. For surgical tissue, an aseptic fresh-frozen process suitable for ATMP manufacture is being developed. Expertise from developers, equipment suppliers, UK blood services, tissue banks, clinical teams and biobanks is being gathered to ensure quality and safety of tissue procurement in a robust, efficient and compliant manner. Patient Involvement and Engagement ATMPs are significantly different from conventional medicines and some of the key differences can impact both patients and their families. Notably for some advanced therapies, this can include ‘curative’ potential, possible side-effects, and use of the patient’s own tissues and cells. Ensuring patients understand both the benefits and risks associated with developing and delivering ATMPs is imperative. Knowledge Sharing In preparation for an increased number of ATMP products being adopted into clinical practice, sharing knowledge across the ATTC network has been identified as a key strategic activity. A crucial part of this project as a whole is to effectively create and share expertise across the network, as well as more widely across the UK. Linking in with hospitals that have not run ATMP trials and supporting their development of the infrastructure and implementation of the changes required allows the wider NHS to bring these medicines to patients. Using Technology to Record Patient-reported Outcomes for ATMP Patients Part of the assessment of the value of ATMPs by NICE (National Institute for Health and Care Excellence) in the UK is to assess the impact of these new therapies. There is a need to demonstrate that these products are effective over the long term. A single administration of an ATMP improves a patient’s health over a period of years; however, there is a need to provide a means of gaining an insight into the way patients perceive their health INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 29

Clinical Research Whilst the EMA and payers may approve the medicines for use in a national healthcare setting, this doesn’t immediately translate into easy patient access. By funding the Advanced Therapy Treatment Centres, the UK government has set itself apart from other countries to provide a coordinated approach nationally to adopting ATMPs in the most straightforward manner possible. Other activities, such as the formation of the AAC, see a collaboration of multiple stakeholders feed into the advancement of new innovations such as ATMPs into the clinic5. Reaffirmation that advanced therapies are a key element of the UK life science strategy is also welcome6.

and the impact that treatments have on their quality of life. This assessment needs to occur both at the point of receiving therapy and over long-term follow up once the patient has been discharged. It can be difficult to monitor patients once they have returned home and stop seeing medical teams on a regular basis. The PROmics™ (Patient-Reported Outcomes assessment to support accelerated access to advanced cell and gene therapies) project is developing a device to allow real-time identification of side-effects following therapy and how it has impacted on patients’ quality of life. This should facilitate clinical intervention and ensure patient safety in the adoption of advanced therapies within the NHS. Patients will be able to report how they feel on the treatment by using electronic devices. This data will also be used to assess the effectiveness of the treatment and be used as an evidence base for regulators and policy-makers to make informed decisions to support uptake in the NHS. Patients have been directly involved in development of the project and will provide direct input into the system development to ensure that it meets their needs. Industry Advisory Group It is important that the systems developed by the ATTCs meet the needs of the NHS, as well as those of industry. The ATTC Industry Advisory Group (IAG) was established to bring ATMP developers and supporting industry together to address key challenges they have in common and advise on the ATTC programme. The core focus of the group is to enable early traction of new advanced therapies by engagement with ATTCs and developing standards and best practices across the industry in the UK and internationally. Recently, the group has been joined by representatives from NHS England to ensure alignment for clinical adoption. Conclusions The approval of two CAR-T therapies and the press coverage these have received has shone a light on ATMPs and significantly raised their profile, both in the industry and the population as a whole. This raises the expectation that patients will be able to access these treatments easily. Currently, across the UK, some NHS hospitals are successfully delivering ATMPs to patients, but these are currently in small numbers for commissioned treatments or as part of clinical trials. There is an expectation of significant increase in patient numbers due to the anticipated number of trials and approvals of ATMPs. The Accelerated Access Collaborative (AAC) has undertaken a horizon scan of ATMP developments and conclude there are 30 ATMPs expected to undergo NICE assessment in the next three years4. 30 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

As the industry around advanced therapies grows and matures further, the UK is positioning itself to be well placed to support the adoption of these treatments into the clinic; through a well-prepared clinical research network, hospitals with the infrastructure to deliver them and a workforce that is educated and skilled in their delivery.

This project has been funded by the Industrial Strategy Challenge Fund, part of the government’s modern Industrial Strategy. The fund is delivered by UK Research and Innovation. REFERENCES 1.

3. 4. 5. 6.

Alliance for Regenerative Medicine Q3 2019 Quarterly Regenerative Medicine Sector Report; http://alliancerm.org/wp-content/ uploads/2019/11/ARM_Q3_2019_FINAL-1.pdf Alliance for regenerative medicine, Clinical trials in Europe 2019; https://alliancerm.org/wp-content/uploads/2019/10/Trends-inClinical-Trials-2019-Final_Digital.pdf Cell and Gene Therapy Catapult, UK clinical trials database 2019; https://ct.catapult.org.uk/resources/cell-and-gene-therapy-catapultuk-clinical-trials-database https://www.england.nhs.uk/aac/wp-content/uploads/ sites/50/2020/01/aac005-atmps.pdf https://www.england.nhs.uk/aac/what-we-do/what-innovations-dowe-support/ https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/857348/Life_sciences_ industrial_strategy_update.pdf

Ian Hollingsworth Ian is a programme manager at the Cell and Gene Therapy Catapult working exclusively on the Advanced Therapy Treatment Centre programme. He has 20 years’ experience in the pharmaceutical industry, originally as a medicinal chemist in drug discovery before moving into project management. Ian has worked across multiple drug discovery and development programmes within different companies in the pharmaceutical industry. Ian is now working to understand and reduce the bottlenecks of bringing transformative cell and gene therapies into the UK and the NHS. Email: ian.hollingsworth@ct.catapult.org.uk

Spring 2020 Volume 3 Issue 1

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www.biopharmaceuticalmedia.com Emerson® is a registered trademark of Emerson Electric Co., USA. DeltaV™ is a trademark of Emerson Electric Co., USA. Mettler Toledo® is a registered trademark of Mettler Toledo AG, Switzerland. Eppendorf AG. 31 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY Eppendorf ®, the Eppendorf logo, and BioFlo ® are registered trademarks of Eppendorf AG, Germany. All rights reserved, including graphics and images. Copyright © 2020 by Eppendorf AG.

Clinical Research

The New Drugs and Clinical Trial Rules of India: A Regulatory Highlights • • •

Abstract The New Drugs and Clinical Trial Rules (NDTC), 2019 were recently issued which emphases the changes on the regulatory aspects relating to clinical trials. The final document was published by MOHFW which covers the clinical trials, BA/BE, ethics committee as well as biomedical research, also these rules supplants the part XA and schedule Y of D&C Act. This study includes major outlook on the changes that occurred in the regulatory aspects for conducting clinical trials in India along with the of various application requirements to conduct Clinical Trials, Manufacture and Import of New Drugs in India as per the new rules, in addition to these rules a brief study on regulatory aspects for conduct of clinical trials during the current pandemic situation has be included which is COVID-19.

Orphan drug registration regulations. Increased application fees for various applications. Ethics committees.

Figure 1 – Classification

II. Discussion

Keywords: Clinical trials, New rule, COVID-19. I. Introduction The NDCT Rules have come into force from 19 March 2019, with the exception of Chapter IV, This came into force 180 days after its publication in the Gazette, that is to say 180 days after 19 March 2019, which is 15 September 2019, which has come into effect 180 days after publication in the Gazette, i.e. 180 days after March 19, 2019 which is from 15th September 2019. Applicability • • • • • • •

All new drugs Investigational new drugs for human use Clinical trials Bioequivalence studies Bioavailability studies Ethics Committees Biomedical research

Table 1 – Phases of clinical Trials

Application for conduct of clinical trials • •

•

Application is made in form CT-04 along with the required documents as specified in NDTC rules. Application made to central Licencing authority in CT-04 is Scrutinized, verified, reviewed and Registration is granted in CT-06 within a period of 90 working days. The applicant before starting the study, information is given Form CT-4A which is related to trial. Permission is granted in Form CT-06 which is valid for 2 years.

Contents

•

• • • •

Management of Clinical Trials during COVID-19 in India

Thirteen chapters. Hundred and seven rules. Eight schedules. Twenty-eight forms.

•

Major highlights • • • • • •

Revision in the definition of “New Drug”. Applicable regulations on biomedical and health research. Academic clinical trials. Pre-submission meeting. Post-trial access to subjects.

32 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

•

Any submissions or reporting related to the above changes in the conduct of clinical trials can be made to CDSCO by email at dci@nci.in and with a copy marked to the concerned division of CDSCO (HQ). Applications to manufacture or import drugs/vaccines for test, analysis and further use BA/BE or clinical trial may be processed within 7 days. Depending on the type of vaccine, nature of drug, plant from which it is extracted, data requirements like animal toxicity studies, clinical study and stability data can be deferred, Spring 2020 Volume 3 Issue 1

Clinical Research regulations relating to the conduct of clinical Trials and there rules will provide a greater transparency into the regulations in India. The major highlights include change in definition of clinical trials and providing the review timelines for each application. A brief study on the current pandemic situation and its relation to trials has shown that, CDSCO has recently published few guidelines relating to conduct of clinical trials with some waivers and slop providing expedited review and accelerated approval. The review timeline has been reduced to 7 days for the applications regarding testing, BA/BE of the current pandemic situation with is COVID-19. Figure 2 – Classification for conduct of clinical trials

REFERENCES 1.

G.S.R.227(E). New Drugs and Clinical Trials Rules, 2019. Ministry of Health and Family Welfare, India. March 2019. http://www.egazette. nic.in/WriteReadData/2019/200759.pdf. Gazette Notification- GSR available at https://cdsco.gov.in/opencms/ opencms/system/modules/CDSCO.WEB/elements/download_file_ division.jsp?num_id=NTc2OQ==

Kamireddy Karuna

Figure 3 – fee and validity of CT-04

•

• •

abbreviated or waived off. Expedited review and accelerated approval for any firm having drug/vaccine approved for COVID-19 in any other country. Any applications for clinical trials, import and manufacture gets Expedited review and accelerated approval. Any application for COVID-19 will be considered and processed as High priority by CDSCO.

Conclusion Part XA and Schedule Y of D&C Act are replaced by these new rules and cover various gaps that were previously existing in the

Kamireddy Karuna is perusing Masters in Regulatory Affairs, Department of Pharmaceutics, Jagadguru Sri Shivratreeshwara University, Sri Shivarathreeshwara Nagara, Mysore, Karnataka, India. – 570 015. Email: karunakamireddy9@gmail.com

Balamuralidhara V. Balamuralidhara V. is an Assistant Professor in Department of Pharmaceutics in JSS College of Pharmacy, Jagadguru Sri Shivratreeshwara University, Sri Shivarathreeshwara Nagara, Mysore, Karnataka, India. – 570 015. Email: baligowda@gmail.com

CT 04 Approval Pathway Applica�on on FORM CT-05 Applica�on along with required documents is received by Central Licencing Authority (CLA) Scru�niza�on, veriﬁca�on, review of submi�ed documents by CLA Informa�on provided is in compliance with the requirements 90 working days No Rejected

Yes Approved Registra�on is granted on CT-07

Reasons to be recorded in wri�ng and applicant is no�ﬁed

Applicant rec�fies the deficiencies and resubmits applica�on along with required fee within a period specified by CLA. 90 working days No Rejected

Yes Approved

Request to reconsider within 60 days

File an appeal within 45 working days

Gangadharappa H.V. Gangadharappa H. is an Assistant Professor in Department of Pharmaceutics in JSS College of Pharmacy, JSS Academy of Higher Education & Research, Sri Shivarathreeshwara Nagara, Mysore – 570 015, Karnataka, India. Email: hvgangadharappa@jssuni.edu.in

M.P. Venkatesh M.P. Venkatesh is an Assistant Professor in Department of Pharmaceutics in JSS College of Pharmacy, JSS Academy of Higher Education & Research, Sri Shivarathreeshwara Nagara, Mysore – 570 015, Karnataka, India Email: venkateshmpv@jssuni.edu.in

Hear from the central government within 60 working days

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INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 33

Manufacturing/Technology Platforms

PEER REVIEWED

Go-to-market Challenges of CAR-T Therapies cell therapy trials is investigating the potential of CAR-T treatments, which are regarded to be a revolution in cancer therapy7.

CAR-T therapies are set to revolutionise cancer treatment. With first curative therapies gaining market access across the globe, CAR-T therapies are subject to numerous commercial and non-commercial challenges. Despite positive clinical responses, the ability to overcome these challenges will determine the future of CAR-T therapies and show whether pharmaceutical companies can make true on the promise of initiating a new era of cancer care.

CAR-T Therapies at a Glance CAR-T therapy refers to chimeric antigen receptor (CAR)-T-cell therapy, an innovative and individualised cancer treatment method that combines the capabilities of cell, immune and gene therapy into one therapy concept. T-cells are ex-vivo genetically modified to express a chimeric antigen receptor on their surface that recognises and binds to a specific antigen on the surface of malignant cells. Once the receptor binds to an antigen, the T-cell is stimulated to attack and destroy the malignant cell. Due to the fact that CARs have the ability to combine both antigen-binding and T-cell-activating functions into a single receptor, they are defined as chimeric8,9.

Setting the Scene In 2019, the commercial pharmaceutical industry recorded global sales of ~1300bn USD, and is expected to grow at a CAGR of 6.8% until 2024. Even though the majority of sales is still generated with traditional single-compound medicines, biologics are the major growth driver of the pharmaceutical industry. Development of simple compound medicines has reached its T-cells leveraged for the manufacturing of CAR-T therapies limits and research in this area is almost at peak. Today, biologics are the most promising technology which, combined with may originate from the patient (autologous) or an external donorCHALLENGES (allogeneic). increased knowledge of medicinal chemistry and new methods “GO-TO-MARKET OF CAR-T THERAPIES” As all currently approved CAR-T therapies manufacturing process are autologous, the drug manufacturing process is integrated of production, enable companies to develop completely new CAR-T drugs and treatments1. In 2019, biologics accounted for ~21% into the patient treatment journey. Figure 2 illustrates the of global drug sales2 and represented 21 of 69 Drug License manufacturing process of a CAR-T therapy9. Application Approvals granted by the FDA3,4. 2. Leukapheresis: T4. Genetic modification of 6. Modified T-cells are cells removal from patient’s blood

Within the field of biologics, advanced therapies have emerged as the innovative spearhead focusing on novel curative treatments. They comprise cell and gene therapies, as well as tissue engineering, as shown in Figure 15. Curative cell therapies today are mostly oncology-focused treatments where genetically modified T-cells are transferred into a patient to target a specific protein and destroy the malignant cells. Gene therapies are treatments that focus on delivering therapeutic DNA into a patient´s cells to cure the underlying disease. Current methods comprise the editing of genetic material, the addition of genetic material and the targeted silencing of genes. Tissue engineering is the umbrella term for therapies which restore, maintain and/or improve damaged tissue or organs by combining scaffolds, cells 6 Overview of curative advanced therapies and biologically active molecules . “GO-TO-MARKET CHALLENGES OF CAR-T THERAPIES”

Advanced therapy types Cell Therapy

Curative advanced therapies

Gene Therapy

Tissue Engineering

Methods ▪ CAR-T Cell Therapy ▪ CAR-NKT Cell Therapy

▪ Gene adding (Viral vectors, etc.) ▪ Gene editing (CRIPRS-Cas 9, etc.) ▪ Gene silencing (Antisense, etc.)

▪ Nanofiber self-assembly ▪ Textile technologies ▪ …

# ongoing clinical trials

# approved curative drugs

Focus

~ 625 active clinical trials

Oncology

~ 362 active clinical trials

Rare diseases

~ 31 active clinical trials

Skin / cartilage replacement

(Phase I – 211, Phase II – 386, Phase III – 49)

(Phase I – 120, Phase II – 210, Phase III – 32)

(Phase I – 10, Phase II – 20, Phase III – 11)

Figure 1 – Overview of curative advanced therapies5,6,7

As illustrated in Figure 1, there are currently ~1000 registered clinical trials for advanced therapies, accounting for ~15% of all clinical trials conducted globally. The trial landscape is coined by gene therapies focussing on rare diseases across numerous indications and curative cell therapies focussing on oncology. The majority of the ~625 1

Source: Homburg & Partner | 5, 6, 7

34 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

1. Patient’s blood drawn for eligibility testing

T-cells to enable CAR formation

3. Isolation and activation of T-cells

re-transferred to patient

5. Reproduction of modified T-cells

Figure 2 – CAR-T manufacturing process8,9

Prerequisite to initiating the CAR-T manufacturing process is the referral of an identified patient to a specialised CAR-T centre. Only after passing a CAR-T treatment eligibility assessment is the patient approved to undergo leukapheresis. Leukapheresis is the separation and collection of the patient’s white blood cells and resembles the first step of CAR-T manufacturing8. Source: Homburg & Partner | 8, 9

The obtained sample of white blood cells is frozen and transported to a specialised manufacturing laboratory, where T-cells are isolated from the sample. Following the isolation is the activation of the cells using monoclonal antibodies. Once the T-cells are activated, they are genetically modified to express a specific CAR on their surface. This is achieved by utilising modified viral vectors to deliver a strand of therapeutic DNA into the cell. Modified CAR-T-cells are then duplicated to achieve a clinically significant number of cells and prepared as an infusion for the patient. The CAR-T therapy is transported back to the CAR-T center and administered to the patient10. Today, there are two CAR-T therapies that have received market approval. Both, KYMRIAH® (Novartis) and YESCARTA® (Gilead Sciences) are curative CAR-T therapies which target liquid tumours with the surface antigen CD1911. As targeting Spring 2020 Volume 3 Issue 1

Manufacturing/Technology Platforms these specific surface proteins has proven to be successful in the treatment of haematologic cancer, the majority of clinical trials (~95%) within the field of CAR-T therapies is focussed on liquid tumours for late-stage relapse and refractory patients7. So far, translating the mode of action of CAR-T therapies has not proven to be successful. Even though big pharma has been the first mover with regard to CAR-T market approval, innovation in this field is driven by small biotech firms12. Despite the curative potential and promising clinical responses, CAR-T therapies face numerous go-to-market challenges. These challenges can be divided into non-commercial and commercial challenges, and need to be overcome for CAR-T therapies to gain market traction and make true on the promise to revolutionise cancer treatment. In the following section, the main challenges of CAR-T therapies will be highlighted, and potential solutions on how to tackle these challenges carved out. Non-commercial Go-to-market Challenges of CAR-T Therapies Manufacturing An essential part of manufacturing CAR-T therapies is the ex vivo genetic modification of autologous T-cells. The process incorporates the manufacturing process of gene therapies into the manufacturing of cell therapies. Following the isolation, enrichment and activation of the T-cells, viral vectors are leveraged to insert therapeutic DNA into the T-cells to trigger the expression of the CAR on the cell surface. This complex multi-level process is not only cost-extensive and time-consuming, but also subject to a high failure rate and thus a low production efficiency8. The low efficiency of CAR-T manufacturing is amplified by the fact that autologous T-cells gained through leukapheresis are often not usable as they express lasting damage from previous chemotherapies. This again leads to a decreased efficiency in the expansion of the modified CAR-T-cells and thus the production of the therapy14. Furthermore, the complex process entails manufacturing of CAR-T therapies in highly specified laboratories. Availability of these laboratories is limited, leading to capacity shortage in production 10. This contrasts with the conventional industrial manufacturing of pharmaceutical products, which allows for high-output production and follows clear Good Manufacturing Practice (GMP) guidelines. As CAR-T therapies are manufactured on a patient-individual basis in a laboratory, it is challenging to implement dedicated quality assessments that ensure a continuous quality control along the manufacturing process10,13.

• •

Supply Chain The limitation to produce CAR-T therapies in highly specified laboratories entails a high degree of centralisation of the available manufacturing facilities13. Due to the centralisation and the fact that all currently approved CAR-T therapies are autologous, a patient’s blood sample is required for every batch of CAR-T therapy produced16. Transporting the blood sample from the CAR-T centre to the specified laboratory, and the genetically modified CAR-T therapy back to the hospital, requires a complex and sophisticated delivery system with a flawless cooling chain. The stakeholder within this delivery system – specified CAR-T centres, dedicated courier services and the manufacturing laboratories – need to be able to meet the requirements with regard to storage, packaging, shipping and sample tracking. All steps in the delivery system must be coordinated in a way that the time-to-treatment for the patient is optimised. This process is often referred to as patient scheduling5. Sample tracking is the essential part of the delivery system. The tracking system is bi-directional and requires an error-free tracking of the patients’ blood sample and the respective individualised CAR-T therapy. As current therapies are autologous, errors in the adequate tracking of a sample lead to the disposal of the therapy and a prolongation of the manufacturing process13. Another challenge related to the supply chain of CAR-T therapies is the availability and production of viral vectors. In addition to CAR-T therapies, gene therapies are also applying the same viral vectors. As there are only a few companies specialising in manufacturing viral vectors, they are not able to meet the continuously increasing global demand. This limited availability entails waiting times during CAR-T development and manufacturing16. Furthermore, viral vector production is very cost-extensive and time-consuming, as it is coined by low yields per viral batch (approximately one clinically useful viral particle out of 100,000 produced) due to a low transfection efficiency18. In order to overcome the supply chain challenges, pharmaceutical companies should consider whether to: •

• In order to overcome the manufacturing challenges, pharmaceutical companies should consider whether to: • •

•

Leverage innovation in gene therapy to improve viral vector efficiency and consider potential alternatives for genetic modification (i.e. CRISPR-Cas9) Foster early storage of “healthier” T-cells in hospitals for patients likely to receive CAR-T therapy to increase

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manufacturing efficiency and time Cooperate with academic institutions to leverage their laboratories and increase manufacturing facilities Define standard operation procedures (SOPs) for CAR-T manufacturing to allow for dedicated quality assessment along the manufacturing process steps.

•

Invest in laboratories / cooperate with academic laboratories to decentralise manufacturing facilities and decrease transportation time and effort Cooperate with digital companies / courier services specialising in tracking software and leverage cloud-computing for real-time tracking of patient samples Provide end-to-end software to improve overall patient scheduling and supply chain processes by leveraging digital health solutions Set-up in-house production facilities for viral vectors or enter exclusivity contracts with manufacturers to avoid supply bottlenecks and decrease costs INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 35

Manufacturing/Technology Platforms •

Foster innovation towards allogenic CAR-T therapies to develop patient-independent “off-the-shelf” treatments with simplified supply chain.

Commercial Go-to-market Challenges of CAR-T Therapies Administration The administration of a CAR-T therapy entails complex infrastructural, personnel and regulatory requirements. Since the patient is incorporated into the supply and manufacturing process, hospitals and physicians are also integrated. They need to be able to conduct leukapheresis, handle cryopreserved patient blood samples, collaborate with couriers and integrate the sample tracking into their pharmacy supply systems. Furthermore, physicians need to have CAR-T medical expertise and the hospital needs to have specific SOPs in place that allow for a CAR-T dedicated reporting and documentation of side-effects and patient responses. The hospital must be able to cooperate with the manufacturing team at the laboratory with regard to patient information about treatment history, therapy responses and current health status during conditioning therapy. This complexity results in the need for multi-stakeholder cooperation at a scale that the majority of hospitals is not able to deliver. Therefore, administration of CAR-T therapies is allocated to a limited number of dedicated CAR-T centres that can meet these requirements17. Like the manufacturing facilities, specialised CAR-T centres are also coined by a high degree of centralisation. This results in the fact that fragile late-stage cancer patients have to travel to these centres for their diagnosis, treatment preparation, treatment and follow-up monitoring, resulting in a high health risk for the patient. In addition, CAR-T centres face the challenge of patient referral by treating physicians in other hospitals17. Thus, the greatest challenge for pharmaceutical companies with regard to administration is transferring the eligible patients to the CAR-T centres and understanding the roles and responsibilities of the stakeholders involved in the patient referral process. In order to overcome the administration challenges, pharmaceutical companies should consider whether to: •

•

Support clinics with dedicated services and support knowledge and capability building to increase amount and capacity of approved CAR-T centres Develop a sophisticated patient-monitoring programme that can be conducted in non-CAR-T centres and the outpatient sector to decrease pressure on CAR-T centres Establish an international CAR-T patient register to improve identification of potential CAR-T therapy candidates Invest in laboratories / cooperate with academic laboratories to decrease transportation time and simplify communication with CAR-T centres.

Costs & Reimbursement Currently, CAR-T therapies entail high costs for the healthcare system. Due to the complex manufacturing, elaborate supply chain and the cost- and time-extensive R&D process, CAR-T therapies come along with a high price tag of >350,000 USD 36 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

per therapy22. This high price, based on the curative nature of the therapy and in contrast to conventional treatments, is concentrated into a single upfront payment. High one-time payments challenge the current budget planning of payers and hospitals, which is set up to spread therapy costs over a defined treatment period23. Furthermore, there is a lack of adequate data with regard to long-term efficiency, safety profile and the need for additional patient care of curative CAR-T therapies10. This results in the payer having the burden of carrying the financial risk of a therapy upfront, without assurance that the therapy will work efficiently in the long run. Currently, the pressure on the healthcare system exerted from the high-priced CAR-T therapies is manageable, as only small patient populations receive the treatment. With additional CAR-T therapies coming to market, the price pressure is set to increase, suggesting significant marketaccess challenges across countries in the future22. In order to overcome the cost and reimbursement challenges, pharmaceutical companies should consider whether to: •

Lead price negotiations with long-term cost-benefit assessments and innovative contracting solutions (i.e. annuity-based contracts, outcomes-based contracts) Understand the patient referral process to foster transfer of patients to CAR-T centres to increase market uptake and patient access of CAR-T therapies Choose a targeted patient population to be assigned to the right comparative therapy and avoid price cuts (in case of non-superior benefit assessment).

•

Strategic Recommendations Set to disrupt and revolutionise conventional cancer therapy, CAR-T therapies – and in turn the developing pharmaceutical companies – are facing numerous challenges, as broadly illustrated. At the same time, defining the right strategy and choosing the most relevant measurements for a successful go-to-market is a challenge itself. Figure 3 outlines four key recommendations for pharmaceutical companies to gain a competitive edge over their industry peers and to overcome go-to-market challenges of CAR-T therapies. Be the innovative leader in R&D

1. Drive CAR-T development towards off-the-shelf allogenic therapies 2. Invest in early R&D on solid tumors

Create best practices in CAR-T manufacturing

Gain a competitive edge in CAR-T race

1. Replace viral vector technique with innovative gene editing methods 2. Drive operational excellence in manufacturing with clear operating procedures (SOPs)

Manage commercial CAR-T ecosystem

1. Support to connect laboratories, physicians, clinics to establish CAR-T ecosystem 2. Identify and build-up labs for de-bottlenecking manufacturing capacity

Manage access and referral

1. Offer broad “bouquet” of contracting options to payers (annuity vs. one-time) 2. Understand drivers and barriers in patient referral process to CAR-T centers

Figure 3 – Key recommendations for pharmaceutical companies Spring 2020 Volume 3 Issue 1

Manufacturing/Technology Platforms Success with CAR-T therapies will be defined by companies willing to take risks, strive for innovative leadership and set industry standards. This, combined with a strategy focussing on building networks and establishing clearly defined innovative contracting options to secure therapy access and reimbursement, will be the foundation to become an industry leader in CAR-T cancer treatment, despite the present challenges. REFERENCES 1.

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Visiongain ‘Global Biologics Market, Industry and R&D: Forecasts 2015-2025 – Challenges and Opportunities from Rising Drug Demand and Biosimilar Competition’. https://www.visiongain. com/report_license.aspx? rid=1485 visited on 22 Mar. 2020. HKExnews. Size of the global chemical drugs and biologics pharmaceutical market from 2014 to 2023 (in billion U.S. dollars) [Graph] (2019). Statista. https://www.statista.com/ statistics/1085563/revenue-chemical-drugs-and-biologicsglobal-pharmaceuticals/ visited on 23 Mar. 2020. Food and Drug Admistration (FDA). New Drug Therapy Approvals 2019 (2019). https://www.fda.gov/media/134493/download, visited on 19 Mar. 2020. Food and Drug Admistration (FDA). 2019 Biological License Application Approvals (2019). https://www.fda.gov/ vaccines-blood-biologics/development-approval-processcber/2019-biological-license-application-approvals, visited on 19 Mar. 2020. Abou-El-Enein, M., Elsanhoury, A. & Reinke, P. Overcoming challenges facing advanced therapies in the EU market. Cell Stem Cell, 19(3), 293-297 (2016). European Medicines Agency. Advanced therapy medicinal products: Overview (n.d.) https://www.ema.europa.eu/en/ human-regulatory/overview/advanced-therapy-medicinalproducts-overviewTbd, visited on 23 Mar. 2020. U.S. National Library of Medicine, ClinicalTrials.gov https:// clinicaltrials.gov visited on 23 Mar. 2020. June, C. H., O’Connor, R. S., Kawalekar, O. U., Ghassemi, S. & Milone, M. C. CAR T cell immunotherapy for human cancer. Science, 359, 1361-1365 (2018). Levine, B. L., Miskin, J., Wonnacott, K. & Keir, C. Global manufacturing of CAR T cell therapy. Molecular Therapy-Methods & Clinical Development, 4, 92-101 (2017). Jørgensen, J., Hanna, E. & Kefalas, P. Outcomes-based reimbursement for gene therapies in practice: the experience of recently launched CAR-T cell therapies in major European countries. Journal of Market Access & Health Policy, 8(1), 1715536 (2020). Philippidis, A. Top 10 Companies Leveraging Gene Editing in 2019. Genetic Engineering & Biotechnology News, 39(10), 16–17 (2019). Papathanasiou, M. M., Stamatis, C., Lakelin, M., Farid, S., TitchenerHooker, N. & Shah, N. Autologous CAR T-cell therapies supply chain: challenges and opportunities? Cancer Gene Therapy, 1-11 (2020). Rafiq, S., Hackett, C. S. & Brentjens, R. J. Engineering strategies to overcome the current roadblocks in CAR T cell therapy.Nature Reviews Clinical Oncology, 17, 147-167 (2020). Li, C., Mei, H. & Hu, Y. Applications and explorations of CRISPR/ Cas9 in CAR T-cell therapy. Briefings in Functional Genomics, 1-8 (2020). Eyles, J. E., Vessillier, S., Jones, A., Stacey, G., Schneider, C. K. & Price, J. Cell therapy products: focus on issues with manufacturing and quality control of chimeric antigen receptor T-cell therapies. Journal of Chemical Technology & Biotechnology, 94(4), 1008-1016 (2019). Greinix, H. T., Attarbaschi, A., Girschikofsky, M., Greil, R., Holter, W., Neumeister, P., Peters, C., Petzer, A., Rudzki, J., Schlenke, P., Schmitt, C. A., Schwinger, W., Wolf, D., Worel, N. & Jaeger, U.

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Ensuring center quality, proper patient selection and fair access to chimeric antigen receptor T-cell therapy: position statement of the Austrian CAR-T Cell Network. memo-Magazine of European Medical Oncology, 1-5 (2020). Capacity Analysis for Viral Vector Manufacturing: Is There Enough? https://bioprocessintl.com/manufacturing/emergingtherapeutics-manufacturing/capacity-analysis-for-viral-vectormanufacturing-is-there-enough/ visited on 24 Mar. 2020. Tarnowski, J., Krishna, D., Jespers, L., Ketkar, A., Haddock, R., Imrie, J. & Kili, S. Delivering advanced therapies: the big pharma approach. Gene therapy, 24(9), 593-598 (2017). Callréus, T., El-Galaly, T. C., Jerkeman, M., de Nully Brown, P. & Andersen, M. Monitoring CAR-T-Cell Therapies Using the Nordic Healthcare Databases. Pharmaceutical Medicine, 33(2), 83-88 (2019). Ghosh, A. & Gheorghe, D. CAR T-Cell Therapies: Current Limitations & Future Opportunities (2019). https://www. cellandgene.com/doc/car-t-cell-therapies-current-limitationsfuture-opportunities-0001, visited on 25 Mar. 2020. Patel, N., Farid, S. S. & Morris, S. How should we evaluate the cost-effectiveness of CAR T-cell therapies? Health Policy and Technology (2020). Kefalas, P., Ali, O., Jørgensen, J., Merryfield, N., Richardson, T., Meads, A., Mungapen, L. & Durdy, M. Establishing the cost of implementing a performance-based, managed entry agreement for a hypothetical CAR T-cell therapy. Journal of market access & health policy, 6(1), 1511679 (2018). Santomasso, B., Bachier, C., Westin, J., Rezvani, K. & Shpall, E. J. The other side of CAR T-cell therapy: cytokine release syndrome, neurologic toxicity, and financial burden. American Society of Clinical Oncology Educational Book, 39, 433-444 (2019).

Christian Zuberer Christian is a Partner in the Mannheim office of Homburg & Partner. He is responsible for the (bio-) pharmaceutical competence centre. His focus is on healthcare, (bio-) pharmaceuticals and biosimilars / generics, with particular expertise in market access & pricing, strategy, marketing & sales (digital, multichannel) and transformation & organisation. His therapeutic focus is on (immune) oncology, haematology and rare diseases. Christian studied Business Administration (Master of Science) with a focus on Strategy and Finance at HHL Leipzig Graduate School of Management. Email: christian.zuberer@homburg-partner.com

Maximilian Feld Maximilian is a Consultant in the Düsseldorf office of Homburg & Partner. He is part of the (bio-) pharmaceutical competence centre and his focus is on healthcare, (bio-) pharmaceuticals and biosimilars / generics with expertise in market access & pricing, strategy, marketing & sales (digital, multichannel). His therapeutic focus is on (immune) oncology, haematology and rare diseases. Maximilian studied International Business (Master of Letters) with focus on Strategy & Innovation at the University of St Andrews. Email: maximilian.feld@homburg-partner.com

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 37

Manufacturing/Technology Platforms

Developing Plasmid DNA Production Platforms to Support Novel Gene Therapies Epilepsy is a debilitating illness which impacts the life of millions of people across the world, and so Cobra Biologics was delighted to be selected by CombiGene, a leading Nordic gene therapy company, working for the development of plasmids and AAV based gene therapy vectors for their first treatment with the potential to dramatically improve the quality of life for a group of epilepsy patients for whom there is currently no effective treatment.

CombiGene’s AAV1 vectors, like the majority of AAV vectors, are produced through transient transfection routes, using three plasmids, coding for the therapeutic gene, the vector capsid proteins of the selected AAV serotype and the helper plasmid required for the replication of the AAV vectors in the absence of the adenovirus. This requires three plasmids to be produced ahead of the production of the clinical vector that CombiGene will be putting into the clinic. To achieve this requires the production of plasmid at multi-gram levels, using large-scale production procedures (see Figure 1 below).

Figure 1: Overview of AAV production processes

Over the last five years, we have seen gene therapy starting to fulfil its potential promised over 25 years ago with several licensed products, and over 30 in late-stage clinical development. A key element in truly unlocking this promise will be establishing the required manufacturing processes and supply chains, of which plasmid DNA is a key element. Also, the establishment of manufacturing platforms will be critical to the success of gene therapies. Background The manufacturing of plasmid DNA for clinical use was first proposed over 30 years ago. The initial applications were as a route for non-viral gene therapy avoiding the use of viral vectors and as a potential route of vaccination; by using plasmids coding for the potential antigens from target pathogens, specifically HIV and TB, where significant funding was given, not least by the Bill and Melinda Gates Foundation. These potential applications led to significant research, both industrial and academic, with investment into the development of large-scale plasmid DNA production platforms. Unfortunately, in both therapeutic use and in vaccine trials, the lack of clinical success led to a fall back in research and investment in manufacturing capabilities. 38 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

However, in recent years there has been a marked increase in demand for plasmid DNA production, primarily based on the use of plasmid DNA for the construction of viral vectors in gene therapy applications, especially AAV and lentiviral vectors. Additionally, plasmid is still used in its own right as a therapy and for vaccine uses, including against Covid19, and as starting material for a range of other therapeutic applications such as the production of mRNA for vaccine and therapeutic applications (see Figure 2 below).

Figure 2: Plasmid DNA – “Starting Material” – Multiple Products

Plasmid DNA Production Processes When looking in more detail at the viral vector market, whilst a few drug developers have in-house manufacturing plasmid production capabilities, the majority of drug developers are outsourcing plasmid manufacture from contract manufacturing organisations (CMOs). Also, they are sourcing from multiple suppliers and each CMO will be using their own manufacturing process and analytical testing procedures. The regulatory authorities are accepting this approach. In theory, this makes plasmid DNA a commodity, where the quality or quality attributes are not linked to a specific manufacturing process but can be determined by testing and characterisation. The consequence of this is that vector developers are no longer locked into a single supplier for plasmid and are making their selection based on the quality of the service provision. Whilst most plasmid manufacturers have their “own” production process, most are based on very similar technical approaches developed over 15–20 years, which have been enhanced with the introduction of more up-to-date chromatography approaches (see Figure 3 below).

Figure 3a: Outline of plasmid DNA Manufacturing Process Spring 2020 Volume 3 Issue 1

Manufacturing/Technology Platforms

Figure 3b: Plasmid Purification Process Challenges

Plasmid production cell lines used within processes are usually established E. Coli K12 strains such as DH1, DH5α or DH10B, in combination with a high copy number plasmid backbone. Some companies do perform some element of clone selection in order to maximise productivity and ensure plasmid integrity. Most fermentation processes are relatively simple fed batch systems and may include temperature induction to switch on plasmid production, the aim really being to maximise plasmid copy number and plasmid production without excessive cell mass. As the plasmid is accumulated intracellularly, cells lysis during the fermentation should be kept to a minimum to reduce losses. The harvesting of cells is achieved through centrifugation or membrane harvest procedures. Again, cell lysis needs to be kept to a minimum and this requirement should be considered when selecting the harvest procedures. Where plasmid production processes differ most significantly from conventional microbial processes is the cell lysis process to recover plasmid from cells. The alkaline lysis process was developed in the late 70s by Birmboim and Doly for laboratory-scale recovery of plasmid DNA, and involves the lysis of cells and denaturation of cellular material including chromosomal DNA with an alkali detergent (usually sodium hydroxide and SDS), followed by the precipitation of cellular debris including chromosomal DNA using a strong acetate solution, leaving a solution containing mainly RNA and plasmid DNA with low levels of chromosomal DNA. The process is challenging to scale due to the large volume of solutions required and the rheological changes that take place during the lysis process. To date, there is no available commercial equipment specifically designed around this operation and DNA producers have designed their own approaches based on mixing vessels and in-line mixers to address this challenge, which remains a major barrier in developing large-scale manufacturing processes. The lysis operation is followed by clarification steps to remove the precipitated cell debris which forms large flocs and is present at a level of 10%v/v. Then a combination of concentration and precipitation steps is used to remove bulk RNA and to reduce process volumes with buffer exchange steps ahead of the chromatographic operations. The plasmid is usually then purified through a combination of hydrophobic and ion exchange chromatography. The key purification challenges are to firstly separate out key host-related impurities (RNA, chromosomal DNA and endotoxin) and then to reduce levels of open circle DNA. In terms of formulation, plasmid is often stored as a frozen liquid, but some lyophilisation formulations have also been developed. www.biopharmaceuticalmedia.com

A key requirement for plasmid production platforms is that of robustness, and that they can be applied to a wide range of plasmids with limited levels of process development or optimisation. In reality, due to the sizes, ranges and sequences, there is inevitably variation in productivity levels. Also, plasmids that exhibit high levels of instability require some levels of process development and in some cases a redesign to achieve required levels of productivity, especially for some of the viral plasmids which can contain inverted terminal repeats (ITRs) resulting in potential plasmid instability. Another key element is analytics; establishment of platform analytics is a key part of a production platform both in terms of release and in-process testing and there is a need that methodologies should be applicable to as wide a range of plasmids as possible. A New Set of Challenges Plasmid production facilities also face different challenges to those encountered for protein production facilities. Other than the need for alternative technologies for cell harvesting and cell breakage, the cleaning validation requirements for fixed equipment are also very different. This largely relates to a combination of the difficulty in removing plasmids from equipment, the use of highly sensitive PCR-based procedures able to detect individual plasmid molecules, and the lack of guidelines on acceptable levels of product crossover. This is critical, as facilities are often required to produce multiple plasmids with rapid product changeover. Consequently, there has been an increasing trend towards the use of single-use equipment for both upstream and downstream operations to avoid issues of cross-contamination and the need to establish validated cleaning procedures. Additionally, production scales are currently quite low compared to protein systems, with most production scales being <500L with a limited number of facilities at 1000L, producing batch sizes up to 200g. Such manufacturing scales may be able to meet demands for some gene therapy vectors, however they may not be enough for therapies treating large population numbers if transient production routes are retained. From a regulatory perspective, production of plasmids to produce viral vectors (and as a starting material for other products) has several key differences compared to vaccine development or as therapeutic vectors. The first is that, when plasmids are used in the production of viral vectors classified as either a drug substance or drug product, there has been some uncertainty with regard to what regulatory standards should be applied. There now seems to be a consensus that the plasmid should be regarded as a critical starting material. GMP guidelines for such materials with regard to the manufacturing and quality standards are less clear, especially for early-stage clinical materials. When viewed from the perspective of development companies looking to produce vector for first-in-man studies, the production of GMP-grade plasmid DNA is expensive and time-consuming. In response to this need, many plasmid suppliers have developed “high quality plasmid DNA” production platforms which, whilst not performed under GMP conditions or having GMP oversight, offer a high level of traceability with regard to the material used in the manufacturing. Because of both the reduced level of INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 39

Manufacturing/Technology Platforms regulatory oversight and the need to access GMP facilities, the production of these materials can be accelerated. Whilst some vector development companies have taken the decision to solely use GMP-grade plasmid, others have been prepared to use plasmids made in this manner. For products entering later-phase development and commercial supply, there is a recognition that plasmids need to be made to full GMP. Consequently, plasmid designs need to be future-proofed on the basis they are likely to be used in GMP manufacturing operations. Supplying Plasmid DNA to the Viral Vector Market The viral vector market creates many opportunities for plasmid DNA manufacturers, but equally it places many demands on suppliers, some of which are unique to this market. One key element is that there is a requirement to produce multiple plasmids with variable productivity levels, in differing amounts within the same facility, rather than singular products, to support each vector going into clinical trials and for in-market supply. The second point, as aforementioned, is that plasmids are increasingly seen as a commodity, and end users are sourcing material from multiple suppliers. Therefore, to compete in the market suppliers must look to be able to meet end users’ requirements for quality, time, cost and supply timelines. A key element in meeting these demands is to exploit the potential for standardisation in the production of plasmids and viral vectors. For example, only the therapeutic plasmid is unique to a specific therapy; helper plasmids can be standardised and used for the production of a wide range of vectors, and the RepCap plasmids coding for the vector capsids can be used for multiple therapies using the same vector serotype. The implication of this is that the production of some of the plasmids does not need to be linked to a specific therapy and can be produced ahead in bulk, potentially offering significant cost and time savings. Some vector development companies and suppliers are developing these options. Additionally, in terms of manufacturing technologies given the increased demand for plasmid, it is likely that plasmid suppliers and process equipment and consumables such as chromatography resins suppliers, are likely to increase investments in developing improved processes and process tools. Such improvement in fermentation productivities and streamlined downstream processes including cell lysis and chromatography are aimed at reducing costs as well as yield improvements. Recent developments in biopharmaceutical technologies have included the use of modular chromatography approaches such as membrane and monolith systems and the adoption of continuous manufacturing processes. These approaches allow for processes to be readily adapted to varying production batch sizes and may be applicable to plasmid production. These innovations create the opportunities not only for the streamlining of production processes, but also cost reductions and increasing facility throughput. Additionally, areas such as establishing production processes within closed processes, allowing for the downgrading of process environments and potentially parallel processing in the same facility may also be a route to reduced operational overheads, and increase process flexibility. 40 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

In Summary Recent years have seen a dramatic increase in interest in the production of plasmid DNA, almost entirely driven by the demand for viral vectors. The needs of this market are unique and different from those of traditional bio-therapeutics. However, they are creating significant opportunity and need for investment, not only in increased manufacturing capacity but also for the investment and adoption of innovative manufacturing technologies to meet future demands and to allow an increased number of therapies such as those being developed by CombiGene to come to the markets to give patients access to these innovative therapies.

Tony Hitchcock Tony Hitchcock , Technical Director, Cobra Biologics, has over 25 years experience in the biotechnology field, Over 20 years experience in the production of complex biologic for clinical trials in the EU and US. Tony has worked in areas of process development and manufacturing and has wide experience of engineering and process systems. Over the last 10 years Tony has worked in the CMO field and has worked on the development of over 30 products for clinical trials including plasmid DNA, viral and bacteriophage products and recombinant proteins from microbial, mammalian and insect cell sources.

Spring 2020 Volume 3 Issue 1

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INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 41

Regulatory/Quality Compliance

Driving the Commercialisation of Regenerative Medicine With more than 7000 distinct types of rare and genetic diseases and 400+ million individuals suffering from a rare disease, regenerative medicine holds the hope for a cure – transforming healthcare by revolutionising patient care from conventional treatment models to curative therapy models.

Regenerative medicine, defined by the National Institutes of Health, includes cell and gene therapy, biomaterials, and tissue engineering. With the advancement of new technologies coupled with the creation of new companies offering a wide range of innovative products and treatments, regenerative medicine has become one of the fastest-growing fields of research and the promise of commercial success for all patients. So, it’s not surprising, with the potential to treat incurable diseases and conditions (for example: cancers, blood disorders, diabetes), that in their Q3 2019 Data Report, The Alliance for Regenerative Medicine shared that there are more than 1000 ongoing global clinical trials. This growth is expected to continue over the next 10+ years with the launch of new therapies developed for specific diseases. With this growth, we must be mindful of the impact the time invested in developing these novel therapies has on their commercial success. Commercial effectiveness must be commenced promptly and efficiently to allow for recovering the investment made during development processes. Still, alignment of clinical development and commercialisation strategies, demanding more expertise and business modelling, insurance coverage and reimbursement strategies are critical factors to promote the clinical translation of regenerative medicine technologies. With a fragmented market focused on the clinical and scientific development and technical side of the industry, there is an immediate need for an innovative, end-to end commercial solution to support these emerging therapies. As the regenerative medicine landscape continues to mature, biopharmaceutical companies will need to make a number of strategic choices to drive success, given commercial challenges that include: fast depletion of addressable populations, complex market access dynamics, and challenging gene therapy franchise sustainability. “The continuous progress in regenerative medicine will change the future of healthcare. Manufacturers will need commercial strategies ready for this new healthcare paradigm, well in advance of product launch.” These therapies will change the future of healthcare and manufacturers will need commercial strategies ready for this new paradigm. The question for consideration is how do we successfully commercialise regenerative medicine therapies to ensure all the key stakeholders’ needs are properly addressed? With only a handful of approved therapies in the marketplace, we can build a regenerative medicine ecosystem that delivers more value to patients faster, by: Understanding the value of 42 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

regenerative therapies for patients, physicians, caregivers, healthcare systems and society; providing market insights, gene therapy market strategy, managed markets and HCP agency services, patient engagement and communication, and patient identification and commercial recruitment for complex therapies; sharing the risk of uncertainty to prove the lifelong value of therapies; providing health economics and outcome research tools and services; generating data for value that is meaningful to payers and government stakeholders; making treatments affordable; providing global pricing and market research tools specific to gene therapies; and innovative contracting models and pay for performance expertise helping patients realise the value of therapies; providing patient support programmes and reimbursement services, treatment coordination, cold chain logistics and alternative payment models addressing pricing and reimbursement for regenerative therapies; providing real-time market research, government and payer pricing consulting and management; generating data that is meaningful for all payer and government stakeholders. The path forward in leading the product lifecycle for regenerative medicine – from clinical trial recruitment through commercialisation – includes the process and infrastructure needed to accelerate effective launch planning to in-market success. Key to this dynamic are strategic alliances that provide commercial solutions directed at educating and supporting patients, providers, payers, and pharmaceutical companies. EVERSANA’s partnership with CRYOPORT, the global leader in providing temperature-controlled logistics solutions for life sciences commodities, provides unmatched clinical and commercial solutions. Our global solutions platform delivers everything from pricing and market access strategies to cold-chain channel management, patient services and speciality pharmacy. With the strength of our strategic alliances, EVERSANA has taken the lead in building an integrated ecosystem providing the most cost-effective and dynamic clinical and commercial solutions supporting regenerative medicine. Let us make the promise of regenerative medicine a reality for the millions of patients who deserve it.

Colin Coffua Colin Coffua is Senior Vice President, Global Strategic Accounts at EVERSANA. Colin is an experienced Sales and Marketing Leader with a demonstrated history of working in the pharmaceutical and clinical development industries. Colin has strong professional skilled in Medical Devices, Business Development, Oncology, CRO Management, Marketing Strategy, Cell and Gene Therapy, and Cold Chain Logistics sectors.

Spring 2020 Volume 3 Issue 1

Volume 9 Issue 1 - Spring - 2017

Volume 9 Issue 1

Peer Reviewed

International Pharmaceutical Industry

Supporting the industry through communication

IPI – International Pharmaceutical Industry

INSIGHT / KNOWLEDGE / FORESIGHT

MALDI Mass Spectrometry in Drug Discovery Gaining A Deeper Understanding

Three Ways to Mitigate the Risk of

Late-Stage Failure in CNS Drug Development

Data

The Foundation of Clinical Trials www.ipimediaworld.com

Temperature Management Keep Your Cool

www.ipimediaworld.com

SUPER PUBLICATIONS FOR SUPER PHARMACEUTICALS

IPI

Peer Reviewed, IPI looks into the best practice in outsourcing management for the Pharmaceutical and Bio Pharmaceutical industry.

www.ipimediaworld.com

JCS

Peer Reviewed, JCS provides you with the best practice guidelines for conducting global Clinical Trials. JCS is the specialist journal providing you with relevant articles which will help you to navigate emerging markets.

www.jforcs.com

Volume 4 Issue 1 Volume 4 - Issue 1 Supporting the Development of Veterinary Drugs, Veterinary Devices & Animal Feed

PEER REVIEWED

Applying Game Theory to One Health Modelling Veterinary Healthcare Delivery International Animal Health Journal - Supporting the Development of Veterinary Drugs, Veterinary Devices & Animal Feed

Mastitis due to Mycoplasma bovis Insights Pet Obesity Prevention is Better than Cure Leadership Skills of Extraordinarily Successful Executives

www.animalhealthmedia.com

Official Supporting Associations -

Sponsor Companies -

www.animalhealthmedia.com 11_IAHJ_February2017.indd 1

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IAHJ

Peer Reviewed, IAHJ looks into the entire outsourcing management of the Veterinary Drug, Veterinary Devices & Animal Food Development Industry.

www.animalhealthmedia.com www.biopharmaceuticalmedia.com

IBI

Peer reviewed, IBI provides the biopharmaceutical industry with practical advice on managing bioprocessing and technology, upstream and downstream processing, manufacturing, regulations, formulation, scale-up/technology transfer, drug delivery, analytical testing and more.

www.biopharmaceuticalmedia.com INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 43

Regulatory/Quality Compliance

How the Biopharmaceutical Industry is Responding to Patient Demand for Injection Alternatives Biologics represent a powerful and innovative class of therapeutics in the fight against chronic disease and their sales are projected to reach $326 billion by 2022 – roughly 30% of global prescription drug sales.1 Biologics tend to be highly selective, effective and have fewer side-effects than conventional drugs. However, their chemical structure makes them challenging to administer using oral delivery, so the accepted standard of care is needle-based delivery methods, particularly intravenous injection.

Although biologics have many advantages, they are primarily administered via intravenous injections, which can be a negative experience for patients.Intravenous injections are uncomfortable, invasive and time-consuming, and come with the risk of complications such as thrombosis or infection at the injection site. For patients whose treatment requires frequent administrations, they mean regular visits to a hospital or clinic, considerable disruption to daily life and the risk of failing to adhere to medications. These routine visits also burden an institution’s valuable and often already strained resources. Estimates suggest that drug administration can be almost 50 per cent of patient-incurred treatment costs.2 Finding an Alternative Finding an alternative to intravenous injections will help improve the lives of patients and reduce hospital visits. Subcutaneous injections are one alternative solution and industry has been collaborating with drug manufacturers to develop new processing technologies to help make this a more viable option. For patients, this holds real potential. Therapies can be administered quickly and safely without needing to visit a healthcare facility. They are delivered using a short needle that injects the drug into the tissue between the skin and muscle.3 Medication administered this way is usually absorbed more slowly than if injected into a vein and can be convenient for administering treatments that must be absorbed into the bloodstream slowly and steadily and in smaller dosing volumes (up to 2ml). Self-administration means patients can take their medication when it is convenient, which has the potential to improve compliance rates. Subcutaneous administration can also reduce costs as well as save time for both patients and medical staff, because therapies that do need to be administered by a physician take minutes compared to the hours required for intravenous infusion (IV).4 For these reasons, subcutaneous injection has been shown to be effective, safe, well-tolerated and generally preferred by patients and healthcare providers alike. Administration requires innovative delivery technologies, like pen injectors used to deliver insulin, for the treatment of a range of diseases, from arthritis to multiple sclerosis (MS) 44 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

and cancer, that employ subcutaneous injections. There are additional therapies that could benefit from the technology, including cholesterol suppressants and asthma treatments and at least 30% of drugs currently going through clinical trials are expected to be administered subcutaneously once commercialised.5 In a marketplace as competitive as biologics, if you have two equally efficient drugs, convenience of delivery may be a key differentiating factor. Challenges of Subcutaneous Delivery While there are real possibilities offered by a shift to subcutaneous, delivering a drug in this manner comes with numerous challenges. A key consideration is the limited volume, usually 1 to 2mL, tolerated during subcutaneous injection.6,7 Although inconvenient, IV infusions administered over long time periods are capable of delivering large volumes (>10mL) with ease. This limitation typically requires a drug intended for subcutaneous delivery to be formulated differently; usually at a high concentration giving it a correspondingly high viscosity, which can cause further complications for storage and dispensing into the drug container. Commonly cited issues at the point of administration include prolonged injection time and high force requirements to eject the highly viscous formulation. Currently, subcutaneous injections are most often stored as a solid, but the eventual goal will be liquid storage which would be ready to use. Developing a high-concentration medicine for subcutaneous delivery requires new concentration technology to minimise damage to the sensitive drugs. During the concentration phase of product development, subcutaneous drugs require additional cycles which can negatively impact product recovery. Additionally, the formulation step requires 10 to 100 times longer mixing times and filtration is subject to larger surfaces. This results in a slower process and longer completion times, which can ultimately lead to higher product loss. For monoclonal antibodies (mAbs), treatment costs can be as high as $800K per year for patients. The financial implication of any product yield losses can therefore be enormous. An unforeseen challenge is also arising at the final drug product filling stage, where filling lines may experience needle clogging when aliquoting the drug into delivery containers. While filter clogging is a known phenomenon, manufacturers may experience unexpected needle clogging at the needle tip. Drugs intended for subcutaneous delivery are harder to prepare during the final production stages, from concentration to filling, and manufacturers may encounter quality, filtration, storage and dispensing challenges. These technical challenges slow drug time to market and result in lost product, time and money. Industry is focused on finding solutions. Spring 2020 Volume 3 Issue 1

Regulatory/Quality Compliance

Overcoming the Challenges One solution to overcome the challenges with subcutaneous delivery involves designing new concentration techniques. A way to significantly increase yields at the final concentration step is to simplify its operation from a long and detrimental recirculation step to a short and gentle flow-through step. Single-pass concentration entails a further benefit to allow for continuous processing, which entails further cost-saving benefits.8 Another area of opportunity relates to the diversity of membranes for use in filtration, some of which are particularly well suited for viscous streams to pass through a compact device (a compact device will minimise product loss). Finally, solutions also exist to overcome the difficulties encountered at final filling, notably needle clogging. A hydrophobic needle has been designed and developed whereby interactions with the drug and needle surface are minimized, which significantly reduces the needle clogging propensity. What the Future Holds Biologics are at the forefront of scientific discovery and offer patients with chronic disease hope for managing their www.biopharmaceuticalmedia.com

illnesses more effectively, affordably and conveniently. These cutting-edge therapies require a delivery method as innovative as the therapies themselves, and the benefits to patients and healthcare systems as a whole should not be understated. Industry is working hard to find solutions to the challenges, and progress is being made. The question is no longer whether the technology will make subcutaneous delivery a reality, but how quickly this will become a routine option for both novel and legacy drugs.

Christophe Pierlot Christophe Pierlot is Global Product Manager Single Use Technologies within Pall Biotech, where he has the global responsibility for product portfolio management of the Allegro filling needles, ARTeSYN fluid control portfolio and a broader marketing support function for formulation and filling activities. Christophe joined Pall Biotech 7.5 years ago just after he obtained his masters degree in bioprocess engineering. During those years he covered multiple roles including technical sales engineer, product specialist, and the current role in which he also supported extractables and particulates characterisation initiatives.

INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 45

News GT Biopharma Announces Completion of $5.6 Million Bridge Financing

GT Biopharma is conducting its FDA Phase I/II Clinical Trial for GTB-3550 at the Masonic Cancer Center, University of Minnesota under the direction of Dr. Erica Warlick. GTB-3550 is a tri-specific recombinant fusion protein conjugate composed of the variable regions of the heavy and light chains of anti-CD16 and anti-CD33 antibodies and a modified form of IL-15. The NK cell stimulating cytokine human IL-15 portion of the molecule provides a self-sustaining signal that activates NK cells and enhances their cytotoxic activity. Acute myeloid leukemia (AML) is a heterogeneous hematologic stem cell malignancy in adults with incidence rate of 3% to 5% per 100,000 people. The median age at the time of diagnosis is 65 to 69 years. Source: Biospace

Tomohiro Fujita wants to help Japan reach its potential in biotechnology

Tomohiro Fujita is the proverbial person with a finger in every pie. Active in business, research, and academia, he is described by a peer as “the hub of development for Japan’s biotech industry.” Under the umbrella of his company, Chitose Group, the Japanese entrepreneur and scientist is involved in everything from producing edible algae to manufacturing biopharmaceuticals. Fujita argues that Japan can be a strong player in biotechif the country focuses on its core capabilities. Those strengths have given rise to a handful of food and biopharmaceutical giants – like Ajinomoto, the inventor of monosodium glutamate, and Kyowa Kirin, an antibiotics pioneer – that have roots in traditional Japanese food practices such as the fermentation of soybeans to make miso. But overall, Japan has failed to harness the power of such firms to foster a vibrant biotech sector. Source: C&en

AiViva Biopharma Announces Positive Data from Phase 1/2a Clinical Trial of AIV001 for Dermal Scarring and Wound Healing

AiViva Biopharma Inc., a clinical-stage biotechnology company developing innovative therapies to address major unmet medical needs, today announced completion of its first Phase 1/2a study evaluating AIV001 in dermal scarring. A total of 16 subjects who were scheduled to undergo abdominoplasty were enrolled and completed in one of the four double-blind dose escalation or open label cohorts. Incisional wounds on the abdomen received a focal intradermal treatment of AIV001 or

vehicle on Days 1 and 21, or not treated as a control, and the wound healing was monitored for 49 days post-wounding. Our results showed that AIV001 was well tolerated by intradermal treatment as compared to the vehicle. No serious local or systemic side effects were observed in the subjects at any of the doses administered. Transient local skin reactions were observed at high doses and resolved by the end of the study. Source: GlobeNewswire

Amgen prevails in high-stakes drug case against Novartis

Amgen said Wednesday that a federal appeals court upheld two patents protecting its blockbuster inflammatory disease drug Enbrel, marking the latest legal setback for rival Sandoz, a Novartis company that develops copycat medicines.For years, Sandoz has tried to bring a biosimilar version of Enbrel to market. Its version, known as Erelzi, was one of the earliest biosimilars to gain approval in the U.S., securing clearance in 2016 to treat the same diseases as Enbrel, including rheumatoid arthritis, psoriatic arthritis and plaque psoriasis. Despite that approval, Sandoz hasn't been able to break through the thicket of patents protecting Amgen's drug. The companies have been in a years-long legal feud that started to go in Amgen's favor last summer. Source: Biopharmadive

CanSino Vaccine Produces Immune Response

A July 20, 2020 article inThe Lancetreported that the results of a trial for CanSino Biologics’ COVID-19 vaccine showed the non-replicating adenovirus type-5 (Ad5)-vectored vaccine was safe and induced “significant immune responses in the majority of recipients after a single immunization.” The randomized, double-blind, placebo-controlled, Phase II trial of the vaccine was conducted in Wuhan, China for more than 500 healthy adults aged 18 years or older. Participants received injections of 1×1011viral particles per mL, 5×1010viral particles per mL, or a placebo. The vaccine induced neutralizing antibodies in 59% of the 1 × 1011dose group participants and 47% of the 5×1010dose group participants. Source: Biopharm International

Global antimicrobial resistance fund to support development of innovative antibiotics

The Global AMR Action Fund aims to tackle antimicrobial resistance (AMR) by bringing two to four novel antibiotics to patients by 2030.The fund has so far raised $1 billion in new funding to support the clinical research of innovative new antibiotics to address the most resistant bacteria and life-threatening infections. More than 20 biopharmaceutical companies are involved in the fund, which is an initiative of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA).“Unlike COVID-19, AMR is a predictable and preventable crisis. Source: European Pharmaceutical Review

Coronavirus vaccine developers make case to Congress they can win public's trust

At a congressional hearing Tuesday, lawmakers pressed 46 INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY

Spring 2020 Volume 3 Issue 1

News officials from five drugmakers developing vaccines for the new coronavirus – Moderna, AstraZeneca, Johnson & Johnson, Pfizer and Merck & Co. – on their push to make a shot available in record time.Legislators questioned the companies on whether they will profit from their vaccines, how they'll be distributed and what can be done to give a skeptical American public confidence that drugmakers aren't compromising safety and effectiveness for speed. AstraZeneca and J&J have promised not to profit from vaccine sales during the pandemic, while the others would not commit Tuesday to selling at cost. Source: Biopharmadive

Speeding Up Development of Biosimilars With Improved Analytical Tools

Biotherapeutics have grown to be an indispensable tool in medicine today. Advances in the development of biologics have offered lifesaving treatments to patients with deadly diseases and quality of life improvements by managing chronic diseases. It sounds too good to be true, so what is the downside? Biologics are often associated with high costs and limited patient access. This is where the market opportunities open for biosimilars. To date, there are 26 biosimilars approved by the Food and Drug Administration and 53 approved by the European Medicines Agency, with thousands in development. Biosimilars can offer competition in the market to create pricing pressure and expand patient access to innovative medicines. Source:Analyte Guru

Intuitive Surgical beats expectations in Q2 despite COVID-19

Robotic-assisted surgery-focusedIntuitive Surgical Inc.revealed its second-quarter results late July 21, with worldwide Da Vinci procedures falling about 19% vs. the same period of 2019. Driven by this decline, second quarter 2020 instruments and accessories (I&A) revenue fell by 20% to $461 million, vs. $579 million in the second quarter of 2019.And while COVID-19 was the main culprit with this decline, analysts still saw hope as the company exceeded their expectations. As Wells Fargo’s Larry Biegelsen noted, the company saw revenue of $852 million, which was down 22.5% year-over-year.Still that figure “exceeded our estimate by $347 [million] and consensus estimate by $181 [million] driven by intra-quarter recovery in procedure volumes, higher net system placements, and lower impact from the customer financial relief program.” Source: Bioworld

Biocon’s repurposed psoriasis drug gets Indian approval for COVID-19

Bangalore-based Biocon Ltd. has received the Indian drug regulator's approval for restricted emergency use of its psoriasis biologic, itolizumab, to treat patients with severe cases of COVID-19 in need of ventilator support.Itolizumab, an immunomodulatory drug developed jointly by Biocon and the Centre of Molecular Immunology, Havana, has been used in India since 2013 to treat acute psoriasis, and has a seven-year track record of safety, Biocon’s executive chairperson, Kiran Mazumdar Shaw, said. Shaw described itolizumab as the "first-in-its-class novel biologic therapy for treating moderate to severe acute respiratory distress syndrome [ARDS] caused by COVID-19.” Source: Bioworld www.biopharmaceuticalmedia.com

Catalent Invests Millions to Create European Clinical Manufacturing Center of Excellence

Catalent has unveiled plans to invest US $30 million (EUR 27 million) to create a European center of excellence for clinical biologics formulation development and drug product fill/finish services at its facility in Limoges, France.According to a July 21, 2020 press release, the project has gained support from the Prefecture of Haute-Vienne, the Metropolitan Area of Limoges, the Limoges Haute-Vienne Chamber of Commerce and Industry, and the Regional Council of Nouvelle Aquitaine through a grant worth EUR 1.3 million (US $1.5 million). The investment will see the Limoges site be fully modernized so that large molecule programs can be handled, in addition to extra capacity for small molecule dosage form development. Source: Biopharm International

US to pay nearly $2 billion for supply of Pfizer, BioNTech coronavirus vaccine

The U.S. government plans topay nearly $2 billionto secure a supply of 100 million doses of an experimental coronavirus vaccine being developed by Pfizer and German drug developer BioNTech, the largest order yet in the Trump Administration's aggressive push to make a shot available to Americans by early next year.Pfizer and BioNTech's candidate is among the most advanced now in human testing. Results from two early studies in theU.S.andGermanyshowed the vaccine was generally safe and could elicit potentially protective immune responses.Per the agreement announced Wednesday, the U.S. government could also acquire an additional 500 million doses, although it's unclear what those would cost. Source: Biopharmadive

AstraZeneca and IQVIA Partner on Potential COVID-19 Vaccine

AstraZeneca and IQVIA, a Durham, NC-based advanced analytics and technology solutions provider, announced they are teaming up to develop a potential new vaccine for COVID-19 as part of the US government’s Operation Warp Speed project.The project will focus on providing a faster route to clinical studies for AstraZeneca’s potential COVID-19 vaccine, AZD1222, according to a July 14, 2020 press release. The initiative will also include a subject study which will utilize IQVIA’s virtual trial solutions. Source: Biopharm International

Oral bacteriotherapy improved outcomes in COVID-19 patients

A 70-patient clinical trial evaluating a bacterial biologic drug candidate plus standard of care in hospitalised COVID-19 patients reveal the addition of ‘bacteriotherapy’ reduced the need for mechanical ventilation and Intensive Care Unit (ICU) admission. The study conducted in Italy was based on a hypothesis of investigators at Policlinico Umberto I, “Sapienza” University of Rome. They suggested that a bacterial formulation with a specific biochemical and immunological profile could trigger the production of antiviral molecules and potentially mitigate COVID-19 severity via modulation of the gut-lung axis. Source: European Pharmaceutical Review INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 47

Ad Index

Page 5 Biopharma Group

Page 31 Eppendorf AG

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GenXPro GmbH

Page 27 Nemera

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Pharma Publications Ltd

IBC Pharmalex GmbH

IFC

R.G.C.C. Group

BC SGS SA

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Page 20–23

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Thermo Fisher Scientific

I hope this journal guides you progressively, through the maze of activities and changes taking place in the biopharmaceutical industry

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Spring 2020 Volume 3 Issue 1

STRATEGY & CONSULTING | REGULATORY AFFAIRS | PHARMACOVIGILANCE | QUALITY | MEDICAL AFFAIRS

TOGETHER BEYOND COVID-19

PharmaLex is a leading provider of specialized services for the pharma, biotech and medical device industries We guide you from early strategic planning activities and non-clinical requirements through clinical development, regulatory submission processes and post-approval / maintenance post-launch activities. Our experts use technology-enabled solutions to support you through the entire product lifecycle. We deliver exceptional results — going above and beyond the standard to deliver tailor-made solutions worldwide.

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contact@pharmalex.com INTERNATIONAL BIOPHARMACEUTICAL INDUSTRY 49

QUALITY

LIFE SCIENCES LIFE INSPIRED, QUALITY DRIVEN

RELIABILITY

SGS Life Sciences' integrated network of laboratories offers extensive experience in novel vaccines, providing biosafety, biologics characterization and bioanalytical testing solutions to support the fight against COVID-19.

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