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Monday, June 3, 2019

‘CRISPR baby mutation’ seen significantly increasing mortality

A genetic mutation that a Chinese scientist attempted to create in twin babies born last year, ostensibly to help them fend off HIV infection, is also associated with a 21% increase in mortality in later life, according to an analysis by University of California, Berkeley, scientists.
The researchers scanned more than 400,000 genomes and associated health records contained in a British database, UK Biobank, and found that people who had two mutated copies of the gene had a significantly higher death rate between ages 41 and 78 than those with one or no copies.
Previous studies have associated two mutated copies of the gene, CCR5, with a fourfold increase in the death rate after influenza infection, and the higher overall mortality rate may reflect this greater susceptibility to death from the flu. But the researchers say there could be any number of explanations, since the protein that CCR5 codes for, and which no longer works in those having the mutation in both copies of the gene, is involved in many body functions.
“Beyond the many ethical issues involved with the CRISPR babies, the fact is that, right now, with current knowledge, it is still very dangerous to try to introduce mutations without knowing the full effect of what those mutations do,” said Rasmus Nielsen, a UC Berkeley professor of integrative biology. “In this case, it is probably not a mutation that most people would want to have. You are actually, on average, worse off having it.”
“Because one gene could affect multiple traits, and because, depending on the environment, the effects of a mutation could be quite different, I think there can be many uncertainties and unknown effects in any germline editing,” said postdoctoral fellow Xinzhu “April” Wei.
Wei is first author and Nielsen is senior author of a paper describing the research that will appear online on Monday, June 3, in the journal Nature Medicine.
Mutation prevents HIV infection
The gene CCR5 codes for a protein that, among other things, sits on the surface of immune cells and helps some strains of HIV, including the most common ones, to enter and infect them. Jiankui He, the Chinese scientist who last November shocked the world by announcing he had experimented with CCR5 on at least two babies, said he wanted to introduce a mutation in the gene that would prevent this. Naturally-occurring mutations that disable the protein are rare in Asians, but a mutation found in about 11% of Northern Europeans protects them against HIV infection.
The genetic mutation, ∆32 (Delta 32), refers to a missing 32-base-pair segment in the CCR5 gene. This mutation interferes with the localization on the cell surface of the protein for which CCR5 codes, thwarting HIV binding and infection. He was unable to duplicate the natural mutation, but appears to have generated a similar deletion that would also inactivate the protein. One of the twin babies reportedly had one copy of CCR5 modified by CRISPR-Cas9 gene editing, while the other baby had both copies edited.
But inactivating a protein found in all humans and most animals is likely to have negative effects, Nielsen said, especially when done to both copies of the gene — a so-called homozygous mutation.
“Here is a functional protein that we know has an effect in the organism, and it is well-conserved among many different species, so it is likely that a mutation that destroys the protein is, on average, not good for you,” he said. “Otherwise, evolutionary mechanisms would have destroyed that protein a long time ago.”
After He’s experiment became public, Nielsen and Wei, who study current genetic variation to understand the origin of human, animal and plant traits, decided to investigate the effect of the CCR5-∆32 mutation using data from UK Biobank. The database houses genomic information on a half million U.K. citizens that is linked to their medical records. The genomic information is much like that acquired by Ancestry.com and 23andMe: details on nearly a million individual variations in the genetic sequence, so-called single nucleotide polymorphisms (SNPs).
Two independent measures indicated a higher mortality rate for those with two mutated genes. Fewer people than expected with two mutations enrolled in the database, indicating that they had died at a higher rate than the general population. And fewer than expected survived from ages 40 to 78.
“Both the proportions before enrollment and the survivorship after enrollment tell the same story, which is that you have lower survivability or higher mortality if you have two copies of the mutation,” Nielsen said. “There is simply a deficiency of individuals with two copies.”
Because the ∆32 mutation is relatively common in Northern Europeans, it must have been favored by natural selection at some point, Nielsen said, though probably not to protect against HIV, since the virus has circulated among humans only since the 1980s.
Wei said that some evidence links the mutation to increased survival after stroke and protection against smallpox and flaviviruses, a group that includes the dengue, Zika and West Nile viruses.
Despite these possible benefits, the potential unintended effects of creating genetic mutations, in both adult somatic cells and in embryonic, germline cells, argue for caution, the researchers said.
“I think there are a lot of things that are unknown at the current stage about genes’ functions,” Wei said. “The CRISPR technology is far too dangerous to use right now for germline editing.”
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This work was supported by the National Institutes of Health (R01GM116044).

American Pain Society Seeks OK to Call It Quits

The American Pain Society may soon vote itself out of existence, blaming soaring legal costs to fight litigation that alleges the organization, along with medical associations, acted as “front groups” for opioid drugmakers that gave them financial support.
“It is with heavy hearts that we write to inform you that it is the recommendation of the Board of Directors that [[the] American Pain Society (APS) cease its business operations,” said an email the board sent to the society’s membership Wednesday.
“APS has been named as a defendant in numerous spurious lawsuits and is subject to numerous subpoenas … (and) was unsuccessful in its attempts to resolve these lawsuits without the need for what will no doubt be lengthy and expensive litigation,” the May 22 message to members said.
With an 11 to 1 vote, the APS board voted to recommend that its members approve the filing of a Chapter 7 bankruptcy petition, under which the group would dissolve with an independent trustee disposing of its assets.
The email said at least 10% of its 1,173 eligible members must vote, with a majority of those approving the bankruptcy filing by 11:55 p.m. CDT Wednesday, May 29, for it to go through.
APS spokesman Chuck Weber said that if members vote for the board’s recommendation, the organization’s monthly Journal of Pain, numerous research grants, a young investors fund, and the group’s annual scientific meeting would disappear or be taken over by other organizations. The 2020 annual meeting had already been cancelled; the group’s president recently reported that membership had declined by nearly half since 2014, and meeting attendance had fallen off markedly as well.
In shock
“I’m in shock,” said Steven Stanos, DO, a past president of the American Academy of Pain Medicine, and medical director of pain services at Swedish Health System in Seattle, when told about the board email Wednesday. “This is a great association that’s done a lot of great work for patients and pain research.”
The AAPM and the American Geriatric Society are also named as co-defendants in at least one lawsuit that filed against numerous drug manufacturers and distributors by the Illinois Public Risk Fund, the state’s worker compensation pool.
APS officials would not speak on the record about the specific reasons why professional pain organizations are being named as defendants in these lawsuits that primarily target opioid manufacturers such as Purdue Pharma, Endo Pharmaceuticals, and Johnson & Johnson.
But Robert Twillman, PhD, executive director of the now defunct Academy of Integrative Pain Management, said that trade organizations such as the APS are being named because opioid company money supported them, including his own, for years. And some outsiders believe the trade groups “were a front for their [opioid manufacturers’] marketing activities.”
“People outside the organization — some of them — had that concern but those inside the organization who saw what we were actually doing with the money didn’t have that concern. We advocated for the appropriate access for patients in need, but we also advocated for access to acupuncture and massage therapy and chiropractic and all the other things we have as treatments,” he said.
Pharma money dried up
With national public attention now focused on opioid overprescribing and the now-vilified guidelines that contributed to it, those sources of funding have dried up — either because the trade organizations now refuse it or because drugmakers stopped doling it out. That, along with declining membership, is what happened to the AIPM in January.
“Medical organizations were supported to some degree by pharmaceutical funding,” Twillman said. “And in the pain space, unfortunately, the vast majority of that money comes from opioid manufacturers. So when they started being sued, and part of the allegation was that they were supporting organizations like ours as a front for their marketing activities, a logical thing for them to do was withdraw their support.” In the case of his group, the AIPM, about $1 million, nearly half of its budget, came from pharma, he said.
One official familiar with the APS board deliberations, who declined to be named for this story, said this:
“Organizations like APS and the AAPM and others are being named in these complaints because they’re being accused of writing recommendations and guidelines favorable to the use of opioids and some claim those guidelines were supported financially by the pharma companies.”
But, he added, “any guidelines that were published were published on the basis of the evidence that was known at the time. Medical science changes, and something that was published in 2009 might not be as germane in 2019, given what’s known about these drugs 10 years later.”
Litigation purgatory
In a letter posted recently on the APS website, its president, William Maixner, DDS, PhD, noted the group has been named in several lawsuits against opioid manufacturers filed in Illinois and in California, now transferred to an Ohio Multi-District litigation court.
“Monetary damages are not the goal for the vast majority of these legal claims, and plaintiffs are currently NOT prosecuting claims against [the] APS, which means we’re in ‘litigation purgatory,'” Maixner wrote. “We are being kept on the sidelines while they fight other parties.”
However, the APS has had to respond to “several subpoenas or demands for information … [that] are draining resources — both time and money. It impacts our ability to secure adequate insurance coverage and diminishes our risk tolerance. Our communication and advocacy efforts have been thwarted because of our inability to speak freely,” he said.
What the APS may have genuinely contributed to harmful and fatal overprescribing is up for debate and judicial consideration. Some investigations, however, have concluded that the APS and like organizations share in the blame.
On May 22, in fact, the APS was specifically named in a report by U.S. Rep. Katherine Clark (D-Mass.) and U.S. Rep. Hal Rogers (R-Ky.), entitled “Corrupting Influence: Purdue & the WHO.”
“The American Pain Society and its global arm, the International Association for the Study of Pain (IASP), promote opioid use, especially for chronic, noncancer pain [and it] is an organization with longstanding ties to Purdue that were the subject of a Senate investigation in 2017,” the House members’ report said. “The investigation revealed that multiple organizations that claimed to be independent patient advocacy groups, including the American Pain Society, received significant payments from opioid manufacturers.” The report also charged that the APS was “affiliated with multiple prominent individuals with connections to the opioid industry.”
A past APS president, Dennis Turk, received “personal fees from opioid manufacturers,” the report said. Another past president and former APS board chairman, James Campbell, is “credited with first saying pain should be treated as ‘the fifth vital sign,’ which became a key component of opioid manufacturer-funded promotional materials encouraging higher prescribing rates.”
Another Congressional report, issued by the U.S. Senate Committee on Homeland Security & Governmental Affairs, “Fueling an Epidemic,” said that from 2012 through 2017, the American Pain Society received $962,724, with more than half of that from Purdue. It was one of 14 specialty groups that received nearly $9 million from five opioid manufacturers, including Janssen, Depomed, Insys, and Mylan.
A legal shotgun
Robert Wailes, MD, chairman of the California Medical Association’s board of trustees and a San Diego-area pain specialist, lamented the lawsuits, calling them “a shotgun approach to include as many defendants as possible.”
Practically speaking, he continued, they are merely after deep pockets of pharma, with no blame for most physicians or their organizations, and said the lawsuits are abusing the legal system.
“It is very, very costly to have attorneys represent you and be present long enough to get you dropped from any individual case. If you multiply this by scores of lawsuits in different venues the costs are really enormous.”
Wailes, who also is the AAPM’s representative to the American Medical Association, stressed that he was speaking only for himself rather than any organization he represents.
Others emphasized that if the APS does dissolve, it will be a shame.
“It would be a tremendous loss nationally for pain education and pain research,” said Rollin ‘Mac’ Gallagher, MD, editor of the journal Pain Medicine, the official journal of the AAPM, and the recently retired national director for pain management for the Department of Veterans Affairs. Gallagher blamed the opioid epidemic not on the APS or other specialty provider groups’ guideline advocacy, but rather that practitioners “were not trained to take care of pain appropriately.”
Added Beth Darnall, PhD, pain researcher associate professor of anesthesiology at Stanford University’s Pain Management Center, “It would be a tremendous loss for pain education and pain research. They’ve really been a go-to place for researchers, and clinicians.”

Amgen: 1st Data on Investigational KRASG12C Inhibitor AMG 510 At ASCO

Amgen (NASDAQ: AMGN) today announced the first clinical results from a Phase 1 study evaluating investigational AMG 510, the first KRASG12C inhibitor to reach the clinical stage. In the trial, there were no dose-limiting toxicities at tested dose levels. AMG 510 showed anti-tumor activity when administered as a monotherapy in patients with locally-advanced or metastatic KRASG12C mutant solid tumors. These data are being presented during an oral session at the 55th Annual Meeting of the American Society of Clinical Oncology (ASCO) in Chicago.
“KRAS has been a target of active exploration in cancer research since it was identified as one of the first oncogenes more than 30 years ago, but it remained undruggable due to a lack of traditional small molecule binding pockets on the protein. AMG 510 seeks to crack the KRAS code by exploiting a previously hidden groove on the protein surface,” said David M. Reese, M.D., executive vice president of Research and Development at Amgen. “By irreversibly binding to cysteine 12 on the mutated KRAS protein, AMG 510 is designed to lock it into an inactive state. With high selectivity for KRASG12C, we believe investigational AMG 510 has high potential as both a monotherapy and in combination with other targeted and immune therapies.”
The Phase 1, first-in-human, open-label multicenter study enrolled 35 patients with various tumor types (14 non-small cell lung cancer [NSCLC], 19 colorectal cancer [CRC] and two other). Eligible patients were heavily pretreated with at least two or more prior lines of treatment, consistent with their tumor type and stage of disease. The primary endpoint is safety, and key secondary endpoints include pharmacokinetics, objective response rate (assessed every six weeks), duration of response and progression-free survival. Patients were enrolled in four dose cohorts – 180 mg, 360 mg, 720 mg and 960 mg, taken orally once a day.
Five out of 10 evaluable patients with NSCLC experienced a partial response (PR), and another four had stable disease (SD), for a disease control rate (DCR) of 90 percent (9/10).1 All five patients with response to therapy had a treatment duration of 7.3-27.4 weeks at data cutoff and remain active on treatment. One patient with PR improved further to a complete response of the target lesions at week 18, post data cutoff.
In addition, 13 of 18 evaluable patients with CRC achieved SD, with the majority of CRC patients treated at the first two dose levels. Twenty-six patients remain on study and nine have discontinued.
Treatment-related adverse events (AEs) were primarily grade 1 events (approximately 68 percent). Two grade 3 treatment-related AEs were reported (anemia and diarrhea). No grade 4 treatment-related AEs and no serious treatment-related AEs were reported. Enrollment into dose expansion is underway.
“While there’s been significant progress in treating solid tumor cancers overall with targeted therapies, patients with the KRASG12C mutation have not benefited from these advances,” said Marwan G. Fakih, M.D., clinical study investigator and co-director of the Gastrointestinal Cancer Program, City of Hope, Duarte, Calif. “In this early Phase 1 trial, investigational AMG 510 showed encouraging anti-tumor activity. We look forward to further investigating AMG 510 with the goal of closing the treatment gap for patients with this type of mutation.”
Amgen Webcast Investor Meeting
Amgen will host a webcast investor meeting at ASCO 2019 on Monday, June 3 at 6:30 p.m. CTDavid M. Reese, M.D., executive vice president of Research and Development at Amgen, along with members of Amgen’s clinical development team and clinical investigators, will participate at the investor meeting to discuss Amgen’s oncology program and data presented at ASCO 2019. Live audio of the conference call will be broadcast over the internet simultaneously and will be available to members of the news media, investors and the general public.
The webcast, as with other selected presentations regarding developments in Amgen’s business given at certain investor and medical conferences, can be accessed on Amgen’s website, www.amgen.com, under Investors. Information regarding presentation times, webcast availability and webcast links are noted on Amgen’s Investor Relations Events Calendar. The webcast will be archived and available for replay for at least 90 days after the event.

MEI Updates on Monotherapy, Combo Follicular Lymphoma Phase 1b at ASCO

MEI Pharma, Inc.,  (NASDAQ: MEIP), a late-stage pharmaceutical company focused on advancing potential new therapies for cancer, today announced that updated data presented at ASCO 2019 from a Phase 1bstudy of investigational ME-401, a selective oral inhibitor of PI3K delta, demonstrate an 80% overall response rate in patients with relapsed or refractory (r/r) follicular lymphoma (FL) (n= 50). Additionally, the data demonstrate:
  • Comparable overall response rates, ranging from 75% to 83%, across patient groups receiving ME-401 as a monotherapy or in combination with rituximab, and in patient groups dosed with ME-401 once daily on a continuous schedule (CS) or on an intermittent schedule (IS) of once daily for the first 7 days of a 28-day cycle after 2 months of continuous dosing.
  • A lower rate of delayed, grade 3 adverse events (e.g. 8.7% diarrhea/colitis for IS dosing) observed in patients in the IS group.
  • Durable responses in both CS and IS groups with no median yet reached.
The ME-401 ASCO 2019 poster can be accessed on the MEI Pharma website.
MEI has initiated a global Phase 2 study to evaluate the efficacy, safety, and tolerability of ME-401 as a single agent in patients with follicular lymphoma after failure of at least two prior systemic therapies including chemotherapy and an anti-CD20 antibody. The Phase 2 study, now labeled the TIDAL study ‘(Trials of PI3K DeltA in Non-Hodgkin’s Lymphoma), is intended to support an accelerated approval marketing application with the U.S. Food and Drug Administration.

FDA project to aid those seeking access to unapproved cancer therapies

Today, the U.S. Food and Drug Administration Oncology Center of Excellence announced a new pilot program to assist oncology health care professionals in requesting access to unapproved therapies for patients with cancer. A new call center called Project Facilitate will be a single point of contact where FDA oncology staff will help physicians treating patients with cancer through the process to submit an Expanded Access request for an individual patient, including follow-up of patient outcomes.

“For decades, the FDA has been deeply committed to helping facilitate access to investigational medical products for patients with serious or immediately life-threatening diseases, while also protecting patients and helping them to be able to make informed decisions with their physicians. The first option for patients who have exhausted available treatments is to enroll in a clinical trial, but when that is not an option, we support Expanded Access and are exploring ways to make it easier for patients, their families and health care professionals to understand the process and how to access investigational therapies,” said Acting FDA Commissioner Ned Sharpless, M.D. “The FDA has been working diligently to improve the Expanded Access framework, including development of an updated and more streamlined application form, but despite recent improvements, we understand that for many patients or health care professionals, especially those not familiar with the Expanded Access program, the process may appear confusing or burdensome. Today’s launch of Project Facilitate is part of our continued commitment to Expanded Access and we hope that this pilot program will simplify the process for oncologists, and ultimately benefit patients.”
The FDA recently issued guidances encouraging companies to broaden their eligibility criteria to allow more patients with cancer to participate in clinical trials. But in those cases where patients do not fit the trial requirements or live too far from a trial site, health care professionals can request permission from the FDA to treat a patient with an investigational medical product through Expanded Access.
Expanded Access is a pathway for a patient with an immediately life-threatening or serious disease or condition to gain access to an investigational medical product (drug, biologic or medical device) for treatment outside of clinical trials when there are no comparable or satisfactory alternative therapy options available. Because investigational medical products have not yet been approved or cleared by the FDA and have therefore not been found safe and effective for their specific use, part of the FDA’s role in granting Expanded Access requests is helping weigh whether the potential benefit of the investigational treatment justifies the potential risks. To make a request, the patient’s physician will contact the pharmaceutical company to ask for its agreement that it will provide the medical product. The company has the right to approve or disapprove the physician’s request. The FDA authorizes the vast majority of these requests. This process can be perceived as complex to navigate, particularly for oncologists who don’t have experience working with clinical trials or these types of requests.
“Ultimately, a patient cannot submit an application for an investigational medical product; only a qualified physician is able to officially make the request. The new Project Facilitate call center aims to help in making these requests as streamlined and efficient as possible for physicians who would like to request access to investigational therapies for their patients with cancer,” said Richard Pazdur, M.D., director of the FDA’s Oncology Center of Excellence and acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research. “Through this pilot program, experienced FDA oncology staff will be available to support physicians and other healthcare professionals with their questions, assist in filling out the appropriate paperwork and acting as a facilitator for the process.”
The new pilot call center will enhance the FDA’s efforts to gather data on the Expanded Access program to help improve the process for physicians and patients. Prior to the pilot program launch, Expanded Access requests for patients with cancer arrived at multiple places within the FDA and were forwarded separately to FDA oncology or hematology divisions. The pilot program includes a central office for oncology requests so that the FDA can follow up on individual requests and gather data, such as how many patients received the investigational medical products and if not, why the requests were denied. The FDA can use this data to determine how the process is benefiting patients and health care professionals. In addition, the data could assist in encouraging sponsors to open clinical trials to study drugs for additional indications.
The FDA’s Oncology Center of Excellence, in conjunction with the Reagan-Udall Foundation for the FDA, held a public workshop on May 16, 2019, to obtain input regarding gaps in patient and health care professionals’ knowledge of the current system for Expanded Access requests and to gain feedback on the Project Facilitate pilot program. The Reagan-Udall Foundation for the FDA, an independent 501(c)(3) not-for-profit organization created by Congress for the purpose of advancing regulatory science to support the FDA’s mission, recently updated its Expanded Access Navigator web resource designed to educate patients and health care professionals about the FDA Expanded Access process. The Navigator offers information provided by companies about their Expanded Access policies and now includes Expanded Access programs listed in ClinicalTrials.gov.
The Project Facilitate phone number is 240-402-0004 and the email address is OncProjectFacilitate@fda.hhs.gov. Health care professionals may call during regular business hours, 9 a.m. to 5 p.m., Eastern Standard Time, Monday through Friday. Patients and families with questions can call 301-796-3400 or email druginfo@fda.hhs.gov.
For more information:

Micro-cap device maker G Medical Innovations sets $15M US offering

G Medical Innovations Holdings, which provides app-connected medical devices for monitoring vital signs, announced terms for its US IPO on Monday. The company is currently listed on the ASX under the symbol GMV.
The London, United Kingdom-based company plans to raise $15 million by offering 1.43 million ADSs at a price of $10.50, where it would command a fully diluted market value of $81 million.
G Medical Innovations Holdings was founded in 2014 and booked $3 million in sales for the 12 months ended December 31, 2018. It plans to list on the Nasdaq under the symbol GMVD. H.C. Wainwright is the sole bookrunner on the deal. It is expected to price in June.

Bristol: 1st Results for Opdivo + Yervoy in Liver Cancer at ASCO

Opdivo plus Yervoy yielded objective response rate of 31% and median duration of response of 17.5 months
Data demonstrate potential of Immuno-Oncology combination in fourth most common cause of cancer death worldwide
Bristol-Myers Squibb Company (BMY) today announced first results from the Opdivo (nivolumab) plus Yervoy (ipilimumab) cohort of the Phase 1/2 CheckMate -040 study, evaluating the Immuno-Oncology combination in patients with advanced hepatocellular carcinoma (HCC) previously treated with sorafenib. With a minimum follow-up of 28 months, the blinded independent central review (BICR) objective response rate (ORR) was 31% per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1). At the time of data cutoff, the median duration of response (DoR) was 17.5 months (95% CI: 11.1, N/A). These data (Abstract #4012) will be featured at the American Society of Clinical Oncology (ASCO) Annual Meeting 2019 in Chicago in a poster display on Monday, June 3 from 8-11 AM CDT, and in a poster discussion from 3-4:30 PM CDT.
The study randomized patients into three arms evaluating three different dosing schedules of the Opdivo plus Yervoy combination: Opdivo 1 mg/kg and Yervoy 3 mg/kg every three weeks (Q3W) for four cycles, followed by Opdivo 240 mg every two weeks (Q2W) (Arm A); Opdivo 3 mg/kg and Yervoy 1 mg/kg Q3W for four cycles, followed by Opdivo 240 mg Q2W (Arm B); or Opdivo 3 mg/kg Q2W and Yervoy 1 mg/kg every six weeks (Q6W) (Arm C).
Meaningful responses were observed across treatment arms. Patients in Arm A experienced the longest median overall survival (OS) of the cohort at 22.8 months (95% CI: 9.4, N/A) and a 30-month OS rate of 44% (95% CI: 29.5, 57). Opdivo and Yervoy demonstrated a disease control rate (DCR) of 54%, 43% and 49% per BICR using RECIST v1.1 across treatment arms A, B and C, respectively. Across the cohort, 5% of patients experienced a complete response and 26% experienced a partial response. Patient responses were achieved regardless of baseline tumor PD-L1 status. Opdivo plus Yervoy showed an acceptable safety profile and the addition of Yervoy yielded no new safety signals in any treatment arm.