Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study.
<h4>Background</h4>Sickle cell disease (SCD), a congenital hemolytic anemia that exacts terrible global morbidity and mortality, is driven by polymerization of mutated sickle hemoglobin (HbS) in red blood cells (RBCs). Fetal hemoglobin (HbF) interferes with this polymerization, but HbF i...
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Public Library of Science (PLoS)
2017-09-01
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| author | Robert Molokie Donald Lavelle Michel Gowhari Michael Pacini Lani Krauz Johara Hassan Vinzon Ibanez Maria A Ruiz Kwok Peng Ng Philip Woost Tomas Radivoyevitch Daisy Pacelli Sherry Fada Matthew Rump Matthew Hsieh John F Tisdale James Jacobberger Mitch Phelps James Douglas Engel Santhosh Saraf Lewis L Hsu Victor Gordeuk Joseph DeSimone Yogen Saunthararajah |
| author_facet | Robert Molokie Donald Lavelle Michel Gowhari Michael Pacini Lani Krauz Johara Hassan Vinzon Ibanez Maria A Ruiz Kwok Peng Ng Philip Woost Tomas Radivoyevitch Daisy Pacelli Sherry Fada Matthew Rump Matthew Hsieh John F Tisdale James Jacobberger Mitch Phelps James Douglas Engel Santhosh Saraf Lewis L Hsu Victor Gordeuk Joseph DeSimone Yogen Saunthararajah |
| author_sort | Robert Molokie |
| collection | DOAJ |
| description | <h4>Background</h4>Sickle cell disease (SCD), a congenital hemolytic anemia that exacts terrible global morbidity and mortality, is driven by polymerization of mutated sickle hemoglobin (HbS) in red blood cells (RBCs). Fetal hemoglobin (HbF) interferes with this polymerization, but HbF is epigenetically silenced from infancy onward by DNA methyltransferase 1 (DNMT1).<h4>Methods and findings</h4>To pharmacologically re-induce HbF by DNMT1 inhibition, this first-in-human clinical trial (NCT01685515) combined 2 small molecules-decitabine to deplete DNMT1 and tetrahydrouridine (THU) to inhibit cytidine deaminase (CDA), the enzyme that otherwise rapidly deaminates/inactivates decitabine, severely limiting its half-life, tissue distribution, and oral bioavailability. Oral decitabine doses, administered after oral THU 10 mg/kg, were escalated from a very low starting level (0.01, 0.02, 0.04, 0.08, or 0.16 mg/kg) to identify minimal doses active in depleting DNMT1 without cytotoxicity. Patients were SCD adults at risk of early death despite standard-of-care, randomized 3:2 to THU-decitabine versus placebo in 5 cohorts of 5 patients treated 2X/week for 8 weeks, with 4 weeks of follow-up. The primary endpoint was ≥ grade 3 non-hematologic toxicity. This endpoint was not triggered, and adverse events (AEs) were not significantly different in THU-decitabine-versus placebo-treated patients. At the decitabine 0.16 mg/kg dose, plasma concentrations peaked at approximately 50 nM (Cmax) and remained elevated for several hours. This dose decreased DNMT1 protein in peripheral blood mononuclear cells by >75% and repetitive element CpG methylation by approximately 10%, and increased HbF by 4%-9% (P < 0.001), doubling fetal hemoglobin-enriched red blood cells (F-cells) up to approximately 80% of total RBCs. Total hemoglobin increased by 1.2-1.9 g/dL (P = 0.01) as reticulocytes simultaneously decreased; that is, better quality and efficiency of HbF-enriched erythropoiesis elevated hemoglobin using fewer reticulocytes. Also indicating better RBC quality, biomarkers of hemolysis, thrombophilia, and inflammation (LDH, bilirubin, D-dimer, C-reactive protein [CRP]) improved. As expected with non-cytotoxic DNMT1-depletion, platelets increased and neutrophils concurrently decreased, but not to an extent requiring treatment holds. As an early phase study, limitations include small patient numbers at each dose level and narrow capacity to evaluate clinical benefits.<h4>Conclusion</h4>Administration of oral THU-decitabine to patients with SCD was safe in this study and, by targeting DNMT1, upregulated HbF in RBCs. Further studies should investigate clinical benefits and potential harms not identified to date.<h4>Trial registration</h4>ClinicalTrials.gov, NCT01685515. |
| format | Article |
| id | doaj-art-c7733c856c0b41248e7cccfad4c6af2d |
| institution | DOAJ |
| issn | 1549-1277 1549-1676 |
| language | English |
| publishDate | 2017-09-01 |
| publisher | Public Library of Science (PLoS) |
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| series | PLoS Medicine |
| spelling | doaj-art-c7733c856c0b41248e7cccfad4c6af2d2025-08-20T03:11:25ZengPublic Library of Science (PLoS)PLoS Medicine1549-12771549-16762017-09-01149e100238210.1371/journal.pmed.1002382Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study.Robert MolokieDonald LavelleMichel GowhariMichael PaciniLani KrauzJohara HassanVinzon IbanezMaria A RuizKwok Peng NgPhilip WoostTomas RadivoyevitchDaisy PacelliSherry FadaMatthew RumpMatthew HsiehJohn F TisdaleJames JacobbergerMitch PhelpsJames Douglas EngelSanthosh SarafLewis L HsuVictor GordeukJoseph DeSimoneYogen Saunthararajah<h4>Background</h4>Sickle cell disease (SCD), a congenital hemolytic anemia that exacts terrible global morbidity and mortality, is driven by polymerization of mutated sickle hemoglobin (HbS) in red blood cells (RBCs). Fetal hemoglobin (HbF) interferes with this polymerization, but HbF is epigenetically silenced from infancy onward by DNA methyltransferase 1 (DNMT1).<h4>Methods and findings</h4>To pharmacologically re-induce HbF by DNMT1 inhibition, this first-in-human clinical trial (NCT01685515) combined 2 small molecules-decitabine to deplete DNMT1 and tetrahydrouridine (THU) to inhibit cytidine deaminase (CDA), the enzyme that otherwise rapidly deaminates/inactivates decitabine, severely limiting its half-life, tissue distribution, and oral bioavailability. Oral decitabine doses, administered after oral THU 10 mg/kg, were escalated from a very low starting level (0.01, 0.02, 0.04, 0.08, or 0.16 mg/kg) to identify minimal doses active in depleting DNMT1 without cytotoxicity. Patients were SCD adults at risk of early death despite standard-of-care, randomized 3:2 to THU-decitabine versus placebo in 5 cohorts of 5 patients treated 2X/week for 8 weeks, with 4 weeks of follow-up. The primary endpoint was ≥ grade 3 non-hematologic toxicity. This endpoint was not triggered, and adverse events (AEs) were not significantly different in THU-decitabine-versus placebo-treated patients. At the decitabine 0.16 mg/kg dose, plasma concentrations peaked at approximately 50 nM (Cmax) and remained elevated for several hours. This dose decreased DNMT1 protein in peripheral blood mononuclear cells by >75% and repetitive element CpG methylation by approximately 10%, and increased HbF by 4%-9% (P < 0.001), doubling fetal hemoglobin-enriched red blood cells (F-cells) up to approximately 80% of total RBCs. Total hemoglobin increased by 1.2-1.9 g/dL (P = 0.01) as reticulocytes simultaneously decreased; that is, better quality and efficiency of HbF-enriched erythropoiesis elevated hemoglobin using fewer reticulocytes. Also indicating better RBC quality, biomarkers of hemolysis, thrombophilia, and inflammation (LDH, bilirubin, D-dimer, C-reactive protein [CRP]) improved. As expected with non-cytotoxic DNMT1-depletion, platelets increased and neutrophils concurrently decreased, but not to an extent requiring treatment holds. As an early phase study, limitations include small patient numbers at each dose level and narrow capacity to evaluate clinical benefits.<h4>Conclusion</h4>Administration of oral THU-decitabine to patients with SCD was safe in this study and, by targeting DNMT1, upregulated HbF in RBCs. Further studies should investigate clinical benefits and potential harms not identified to date.<h4>Trial registration</h4>ClinicalTrials.gov, NCT01685515.https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002382&type=printable |
| spellingShingle | Robert Molokie Donald Lavelle Michel Gowhari Michael Pacini Lani Krauz Johara Hassan Vinzon Ibanez Maria A Ruiz Kwok Peng Ng Philip Woost Tomas Radivoyevitch Daisy Pacelli Sherry Fada Matthew Rump Matthew Hsieh John F Tisdale James Jacobberger Mitch Phelps James Douglas Engel Santhosh Saraf Lewis L Hsu Victor Gordeuk Joseph DeSimone Yogen Saunthararajah Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. PLoS Medicine |
| title | Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. |
| title_full | Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. |
| title_fullStr | Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. |
| title_full_unstemmed | Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. |
| title_short | Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. |
| title_sort | oral tetrahydrouridine and decitabine for non cytotoxic epigenetic gene regulation in sickle cell disease a randomized phase 1 study |
| url | https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002382&type=printable |
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