Progress in Predicting the Immune Response to an RNAi Therapeutics

When in 2010 Tekmira decided to prematurely terminate its first clinical RNAi Therapeutics candidate, TKM-ApoB, due to unexpected immune stimulation in a phase I, it was disappointing in a number of ways.  Not only did it destroy TKM-ApoB right there, it also cast doubts on how predictive our preclinical immune stimulation tests really were and whether as a result, other candidates may suffer similar fates.  Apparently, using rodents or even non-human primates for that purpose had not been all that useful either. It is also said that the event served as a red flag to some regulators which wanted the technology being developed more slowly.

Tekmira, however, soon claimed to have discovered the reason why their PBMC-based assay did not pick up on the immunostimulatory potential of TKM-ApoB and reported that they had have found a more predictive test tube assay instead.  Apparently, using heparin during the preparation of PBMCs (sample enriched for certain immune cells from blood) was the culprit and a whole blood-based assay (including things like red cells and albumin) would reflect much more reliably the situation in people.

A nice paper by Coch et al. from the Hartmann group in Bonn, Germany, now provides comprehensive insight into possible causes for false positives and false negatives when using in vitro immune stimulation assays.

Role of serum proteins  

It is known that phosphorothioate oligonucleotides, a particularly widely used chemistry in the antisense field, rapidly bind to proteins in serum.  Given its abundance and sticky nature itself, albumin is thought to be an important target of such oligos.  The group thus found that their binding in whole blood sequestered them from the immune cells such that the immune response was significantly lessened.  By contrast, in the PBMC-based assay, these phosphorothioates stimulated a robust immune response.

This insight is obviously particularly important if the interest was in developing oligonucleotides that are immunostimulatory on purpose, especially for cancer and viral applications (false positive in PBMC).  Whether the finding that in whole blood assay phosphorothioate oligos may not exhibit immune stimulation can be used to conclude that they will be safe is another question as the blood-based assays may not be informative on what is going on in the tissues.   

Role of anticoagulants

Closer to the TKM-ApoB story, another important insight was that the nature of the anticoagulant can have a big impact on the outcome of the assay.  When drawing blood, and especially when employing a whole blood assay, it is important to use an anticoagulant as otherwise standing blood would start to clot. 

EDTA and heparin are standard reagents for this purpose.  EDTA has been recognized that it can distort immune stimulation assays and thus is not used.  The surprise (well not that surprising in hindsight) is that heparin, due to its negative charge, could displace oligos such as RNAi triggers from their delivery vehicles, including liposomal nanoparticles (LNPs).  It is often the delivery agents that bring the oligonucleotides to the immune receptors.  Moreover, nanoparticle formulations such as LNPs can facilitate multivalent interactions as they hold together and present a number of oligonucleotides simultaneously.  This in turn can potentiate the immune signaling.

Accordingly, what probably caused the immunostimulation of TKM-ApoB to be missed is that heparin at some point displaced the ApoB siRNA from the liposomes thus destroying the potentiator effect of SNALPs.  Importantly, replacing heparin with hirudin (think leeches) did not suffer from the same limitation.  Therefore, human whole blood assays with hirudin as the anticoagulants appear to be the simplest and most reliable preclinical innate immune stimulation assay for Oligonucleotide Therapeutics development.

Growing the database

Of course, these insights are only a first, albeit critical step.  The next step is to understand what degree of immune stimulation in the test tube relates to a likely adverse event in the clinic.  For this, it is necessary to go back and forth between the test tube and clinical observations and correlate the clinical phenotype (cytokine production, fever/chill symptoms) with the test tube response. Complicating matters, different persons have individual innate immunostimulatory sensitivities, and depending on the state of the immune system (e.g. existing infection) there will also be intra-patient variability.

   

On a more positive note, not all delivery/RNAi trigger formats are equally prone to stimulating the immune system with LNPs probably being one of the more challenged formats with regard to innate immune stimulation.  Even so, the clinical track record with SNALPs after TKM-ApoB (lowered doses of steroids with ALN-TTR02, no steroids apparently used in the TKM-EBOLA trial) suggests that the new assays are having a positive impact already.

Journal Club: Unraveling the Substrate Specificity of RIG-I and what it Means for RNAi Therapeutics

A paper by the Hartmann group in Bonn, Germany, takes the mystery out of the structural features of RNAs that activate the cytosolic viral innate immune sensor RIG-I and offers simple design rules for either avoiding, or in some cases intentionally inducing such activities with RNAi triggers. It is good news for essentially all types of synthetic siRNAi as practiced today, but requires re-evaluation of some (but not all!) DNA-directed RNAi approaches, and those approaches that depend on the preparation of RNAi triggers by in vitro transcription rather than by synthetic means.

Some of the first wave of RNAi Therapeutics candidates that were rushed into the clinic were most likely based on pre-clinical efficacy results due to the induction of non-specific innate immunity. As an aside, it always ‘surprised’ me for example how companies with no track record in nucleic acid therapeutic development would suddenly claim to be the first ones to enter an RNAi Therapeutics candidate into the clinic. Innate immunity is based on the recognition of pathogen-associated molecular patterns, PAMPs, by cellular receptors that then initiate a powerful signaling cascade leading to the successful defense against viral and bacterial infections, often resulting in the death of the infected cell itself. Therefore, to avoid mis-interpretation of RNAi data and to ensure safety, the RNAi Therapeutics field needs to take into account the structural and sequence-specific signatures of nucleic acid triggers of innate immunity.

There are two classes of nucleic acid receptors relevant to this discussion. The first one are the toll-like receptors (TLRs) 3, 7, and 8 which recognize certain types of single- and double-stranded RNAs mainly in the endosomes. This is important when RNAi triggers are delivered from the outside, but not for DNA-directed RNAi. The second one is comprised of cytosolic PAMP receptors that both synthetic and DNA-directed RNAi triggers may encounter. While PKR was initially thought to be the main cytosolic receptor relevant to RNAi, it more and more emerges that the RNA helicase RIG-I is what the field needs to be mindful of, and is the subject of the present paper by Schlee and colleagues.

Before these findings, it had been thought that any RNA with a triphosphate chemical group at the 5’ end would induce RIG-I. Blunt-end double-strand RNAs of the size of siRNAs were also thought by some to have this capacity independent of a 5-triphosphate modification. The present findings, however, show that the confusion about the exact RIG-I substrate structural features arose from the origin of the RNAs used in those studies. Since 5’-triphosphate modifications are not routinely offered by synthetic RNA vendors, it has been convenient to use RNAs generated through in vitro transcription by recombinant, purified phage polymerases which leave a triphosphate group at the 5’ end. Unfortunately, these phage polymerases have the property of generating additional species of RNAs aside from the desired one. It turns out that double-stranded RNAs, still with a 5-triphospate group, are one of those and that these are the ones actually recognized by RIG-I. The authors were thus able to show that well-defined synthetic single-strand RNAs with a 5’-triphosphate alone were not sufficient to induce RIG-I.

For RNAi Therapeutics the findings mean that RIG-I should not be a concern for essentially all synthetic siRNA therapeutics, as almost all of them are administered in a 5-hydroxylated form which are then 5’-monophosphorylated. Both modifications would abolish RIG-I activation. This is also good news for blunt-end ‘Atu RNAi’-type siRNAs as practiced by Silence Therapeutics which may have been previously suspected to trigger RIG-I. It is true, however, that in the context of 5’-triphosphates, the more traditional double-stranded Tuschl-type siRNAs which contain 3’ overhangs further diminish RIG-I activity even in a 5’-triphosphate context.

The picture is somewhat more complex for DNA-directed RNAi Therapeutics approaches. Historically, perfect complementary hairpin RNAs driven by RNA polymerase III promoters (Pol III) have been used. As these hairpins are destined to be exported into the cytoplasm, the cellular location of RIG-I, the minimally or not at all modified 5’ ends of such shRNAs, i.e. 5’-triphosphates, run the risk of triggering RIG-I responses. However, a simple mismatch of the 5’-triphosphate nucleotide with the opposite strand should abrogate most RIG-I activity and some of the widely used Pol III expression cassettes fortuitously carry such mismatches which do not appear to affect gene silencing. For RNA Polymerase II-driven DNA-directed RNAi Therapeutics, RIG-I should not be a concern for the reason alone that Pol II transcripts exhibit a 5’ modification that does not induce RIG-I. And finally, for trans-kingdom RNAi Therapeutics where the bacteria expresses the RNAi trigger, one may want to design shRNAs that are similar to the Pol III strategies. It is also good news that not any 5’-triphosphate RNA induces RIG-I, since bacterial transcripts are quite rich in 5’-triphosphates.

In summary, the paper by Schlee and colleagues indicates that innate immune activation by siRNAs in the cytosol is no show-stopper by any means. By contrast, since 5-triphosphates do not necessarily abolish the RNAi activity of double-stranded RNAs, bi-functional immunostimulatory siRNAs can be designed such as for antiviral and cancer applications- as demonstrated late last year by the same group in a collaboration with Alnylam. Of course, 5’-triphosphate dsRNAs may also be used independently of RNAi for the same reasons.

RNAi Therapeutics and Innate Immunity- Keeping the Field Honest

As part of the RNAi Therapeutics review series in Human Gene Therapy earlier this year, former Protiva scientists Adam Judge and Ian MacLachlan (both now with Tekmira following the Protiva-Tekmira reunion) made some rather bold statements with regards to the interpretations of a number of pre-clinical RNAi Therapeutics validation papers (‘Overcoming the innate immune response to small interfering RNA’). As part of the same reviews series, in the risk section of “The Business of RNAi Therapeutics”, I also cautioned that some of the first RNAi Therapeutics candidates may show clinical efficacy, but not necessarily for all the right reasons.

The reason for this should not come as a surprise to anybody in the oligonucleotide therapeutics field: long known from the experience with antisense and other oligonucleotide therapeutics classes, oligonucleotides such as siRNAs have the potential to induce innate immune responses which can have antiviral and anti-angiogenic activity independent of their gene knockdown capacity. In fact, there are significant efforts to harness this biological property for therapy in its own right, particularly the TLR responses. Furthermore, the potential for inducing innate immune responses by synthetic and DNA-directed RNAi has been well documented since 2003 and many of the pathways involved elucidated. Nevertheless, one should not ignore the fact that while RNAi Therapeutics may actually be able to take advantage of such activity as part of synergistically acting immunostimulatory RNAi Therapeutics, the risk is that the oligo-dependent immune responses are quite complex and therefore often difficult to predict and in the worst case may cause serious adverse events.

Since many of the early RNAi Therapeutics validation papers involved antiviral and anticancer applications, it was therefore reasonable to suspect that some of the studies misinterpreted therapeutic effects as the result of RNAi gene knockdown when, in fact, innate immune responses accounted for the majority of the activity. In support, the Tekmira researchers now report that almost all of the unmodified siRNAs reported in a sample of such papers were immunostimulatory whereas a single siRNA that, somewhat disturbingly so, was used as the control siRNA in many of the studies proved to be the exception having no such detectable activity. I should add, however, that the assay conditions were rather stringent (types of cells used and high siRNA concentrations) and just because an siRNA may induce immune responses under these conditions does not prove that these were actually responsible for the treatment effect seen in each of the cited studies. Also, if TLR therapeutics history is any guide, oligonucleotides that elicit immune responses in small animal models, do not necessarily do so in primates.

Given its potential as a whole new class of therapeutics, the scientific and clinical bar for RNAi Therapeutics is set particularly high and reports like the effect of TLR3 stimulation by siRNAs on preclinical models for wet AMD and the present paper by Tekmira tend to get quite a bit of press. While they remind us of the complexities involved in establishing a functional new drug discovery platform, they should also be regarded as promoting that process. In fact, the handful of bona fide RNAi Therapeutics groups, pure-plays and Big Pharma subsidiaries alike, are already taking oligo-induced innate immune responses very seriously and have taken advantage of the rapid progress in the field by applying best practices for identifying and correcting these responses (modification, siRNA structure) in developing the latest crop of RNAi Therapeutics candidates.

The acquisition of former TLR therapeutics company Coley Pharmaceuticals by Pfizer for example may be interpreted as Pfizer investing in solving siRNA-induced innate immune responses as one of the main challenges for RNAi Therapeutics they had identified. Similarly, Sirna Therapeutics and Protiva in their prominent 2005 Nature Biotech paper on RNAi delivery in a mouse model of hepatitis B recognized the potential of unmodified siRNAs to elicit non-specific viral suppression and solved the issue by appropriately modifying the siRNAs. Around the same time, Alnylam somewhat quietly generated IP related to double-strand RNA immune stimulation that it then exclusively licensed to Tekmira. Clearly, the main players in the field have not chosen to ignore the issue, but have invested considerable efforts with tangible results.

But what about the current RNAi Therapeutics clinical candidates that have already entered the clinic? There are one phase III (Opko Health) and two phase II (Sirna/Merck-Allergan and Quark-Pfizer) siRNA candidates for the treatment of wet AMD that obviously have naturally come under increased scrutiny. As far as I am aware, all three of these are ‘unformulated’, intravitreally injected siRNAs with one of them, Opko’s, being an unmodified siRNA. While it is not clear how well the mouse TLR3 studies translate into humans, they certainly raise the concern that non-specific responses might be responsible for any thus far clinically observed therapeutic effects, particularly since in the recent Nature study gene knockdown by this route was very limited at best (cholesterol-conjugated siRNAs, however, administered by the same route were shown to mediate functional gene silencing in the same study).

As is the case with Alnylam’s lead candidate ALN-RSV01 for the treatment of RSV infection which has raised similar concerns, it will be important to be forthcoming in the interactions with the regulatory agencies such that safe trials can be designed based on our best understanding of the mechanisms of action of the different siRNAs. While I haven’t read the documents, it certainly wouldn’t be the first time if such non-specific effects were noted as potentially contributing to treatment. In the future, it would not surprise me at all to see openly declared immunostimulatory siRNA drug candidates enter the clinic. If, however, these issues are not addressed upfront, and should adverse events occur as a result, this could easily backfire and future trials rendered much more onerous- something that should be in nobody’s interest. As for the prospects of the individual drug candidates in question, even if non-specific effects contributed to the therapeutic efficacy of these candidates, as long as they are safe and well tolerated they may very well be viable drugs.

Finally, it is curious as to what exactly motivated Tekmira to re-test an entire battery of published siRNAs for their potential of inducing non-specific effects. It is possible that Tekmira has evaluated siRNA therapeutics for a number of the same applications like flu and wet AMD and were frustrated to see publications come out that according to their experience should have been artefacts (scientists tend to measure themselves by the number of publications and their impact factors and don’t like to see their own published work de-valued this way). Another part of the answer may also have been to keep the field honest at this early stage of RNAi Therapeutics drug development before long-term damage is caused: “However, surprisingly few of the reported studies have adequately tested, or controlled, for the potential effects of siRNA-mediated immune stimulation, making the many published claims of therapeutic efficacy a collective liability for the RNAi field that remains to be addressed.” By setting a rigorous new standard, Tekmira also signals their expertise not only in RNAi delivery, but also in siRNA chemistry and safety (like Coley, Tekmira has a long-standing interest in the use of immunostimulatory oligonucleotides for therapy). Supporting their claim, Tekmira/Protiva’s publications on abrogating TLR7/8 responses and SNALP RNAi delivery have proven to be extremely reproducible in many different laboratories.

The road to RNAi Therapeutics reality won’t be smooth. As much as it is important to tackle the scientific hurdles head-on, investors and the press should also make an effort to discriminate between ‘good’ and ‘bad’ science.

RNAi Therapeutics and the Indiscriminate Press

I was taken aback by the crude reporting on the back of a recent Nature paper about the potential immunostimulatory potential of siRNAs which may be responsible for any apparent efficacy seen with RNAi drug candidates currently in clinical development.

Needless to mention, the potential of nucleic acids in general, and double-stranded RNAs in particular, to elicit innate immune responses has long been known. In fact, the very discovery of siRNAs as triggers of gene-specific silencers in vertebrate cells was partly based on the hypothesis that such dsRNAs should not trigger an interferon response. That early RNAi Therapeutics programs, may not have sufficiently taken into account all the potential innate immune surveillance mechanisms present in the body, as at the time the field was still on a steep learning curve, should also not be too surprising, and I have pointed out before the risks of rushing RNAi Therapeutics into the clinic . But since two of RNAi’s most advanced, first generation candidates are nearing the crossing line, one probably understands why the press and critics of RNAi Therapeutics caught onto the findings the way they did.

A deceptively balanced New York Times article left us with the impression that the Nature paper marks a serious setback for the development of RNAi Therapeutics, instead of emphasizing that while RNAi is a relatively easily accessible tool in the laboratory, the study shows that the success of RNAi Therapeutics depends on companies and collaborations with the means and commitment of establishing a safe and efficacious RNAi drug development paradigm. I would also predict that a number of current clinical RNAi candidates will only poorly knock down their actual target in vivo and may elicit additional responses, although this does not exclude that as long as they are safe and show therapeutic efficacy they may still be considered approvable.

Scientists did their part in confusing the public to the extent that the outsider may be forgiven if he/she started to doubt the very existence of RNAi:

“The discovery is "paradigm shifting," said Dr. Charis Eng, chairwoman of the Genomic Medicine Institute at the Cleveland Clinic who works with siRNAs in cancer research. "Up until now, we all believed it's absolutely specific for gene X, so it prevents gene X from doing its job," she said.”
“Paradigm shifting?” “Absolutely”? Or how about the following passage:

"RNA interference does, of course, exist," said Ambati, a University Research Professor and the Dr. E. Vernon Smith & Eloise C. Smith Endowed Chair in Macular Degeneration Research. "It is just that siRNA functions differently than commonly believed -- not via RNA interference."

Huh? siRNA functions, but not via RNAi? I don’t think he referred to the microRNA pathway here, and, to be generous, it may have just been an awkward attempt to explain his findings to a lay person, but wouldn’t it be the responsibility of the reporter, interested in educating the public about an emerging biotechnology, to avoid such ambiguous and factually wrong statements by confirming with Dr. Ambati the scientific correctness of his statements?

Or how about the following headline from RNAi News (which btw I otherwise think does a fantastic job on reporting on RNAi developments- though not for free, of course):

“Study Shows All siRNAs Have Anti-Angiogenic Property Associated with Immune Response”

Sounds pretty dire and does not leave much to be hoped for.

Having criticized the press for careless reporting, it would be, however, equally wrong to brush the whole RNAi-immunostimulation issue aside as being made up by the press and shorts. That would be making it too easy. In an excellent and unusually candid review article on the potential innate immune response to siRNAs, Ian MacLachlan (CSO of Protiva, soon to be Tekmira) predicted to the T the Nature results and made the somewhat unsettling observation that when his group investigated siRNAs from a number of the early preclinical RNAi studies for AMD, cancer, and infection, they found a disturbing bias in the inherently immunostimulatory potential of “active” vs “control” siRNAs. Fortunately science does not stand still and it is encouraging to see that it has become common practice for RNAi Therapeutics studies to look at the potential non-specific immune responses.

A few words on the scientific and IP implications of the interplay between RNAi and innate immunity. At least in the case of synthetic dsRNA-triggered RNAi, it appears that, a priori, being appropriately modified, short and overhung is safest. In the cytoplasm, long dsRNAs may trigger interferon responses and blunt ends may be recognized by sensors of foreign RNA. TLR7 is encountered by dsRNAs (but also ssRNAs) delivered via endosomal uptake, and as the Protiva group has so elegantly shown this may be abrogated by simple 2’-O-methyl modifications. TLR3 was reported in the Nature study to be activated by siRNAs on the cell surface and thus would be invisible to siRNAs delivered within “fat globules” according to Merck’s RNA Therapeutics VP Alan Sachs referring to liposomal delivery technology. SiRNAs, however, would have to be over 20 nucleotides long to facilitate TLR3 dimerization necessary for signaling. It is therefore likely that dimerization would be particularly susceptible to modifications at the ends of the dsRNA, which should also be compatible with silencing activity. I’m sure that as I speak, the systematic analysis of TLR3 activation by siRNAs and the effect of modifications is ongoing, if not already largely completed by some groups.

One has to also keep in mind that the Nature findings were made in mice and the rules of innate immunity are notoriously difficult to translate into primates. Based on my own over-the-weekend literature research, it appears to me that TLR3 activation in humans may well occur in the endosome, and based on structural studies, 21 base-pair dsRNAs should hardly trigger TLR3 responses in human cells. In agreement with this, Dharmacon scientists have shown before that 27mer Dicer-substrates, but not classical Tuschl siRNAs trigger most likely a TLR3-related immune response. That does not mean that modifications to Dicer substrates should not be able to abrogate TLR3 activation, but shows that by choosing non-standard, less studied designs, often as a means to circumvent IP, new obstacles may emerge for which there will be relatively little support by the general research community.

Finally, since tonight is the night to challenge some of the little scientific inaccuracies propagated in the press and companies in the space, I would like to take a look at the press release issued by Silence Therapeutics that publications such as the TLR3 in Nature “SUPPORT SILENCE THERAPEUTICS COMBINED DEVELOPMENT APPROACH”. While it is true that in the two studies by Silence Therapeutics that were cited in the press release, immune responses were not found to be triggered by the siRNAs used therein, referring to Alan Sachs’ “fat globule” comment to support the rationale behind Silence’s lipoplex technology is somewhat misleading since according to the formulation method and drawings in the papers, siRNAs should be externally associated with the liposomes and therefore in theory be exposed to cell surface TLR3, and are not internally captured as is the case with the liposome technology used by Merck and others. Another little fact not mentioned in the press release is that the absence of cytokines was determined for 19mer dsRNAs and are therefore different from Silence’s claimed, and notably larger 23mer “AtuRNAi” molecules.