As readers of my blog know, I am a strong supporter of a disciplined R&D model that focuses on: picking targets based on causal human biology (e.g., genetics); developing molecules that therapeutically recapitulate causal human biology; deploying pharmacodynamic biomarkers that also recapitulate causal human biology; and conducting small clinical proof-of-concept studies to quickly test therapeutic hypotheses (see Figure below).As such, I am constantly on the look-out for literature or news reports to support / refute this model.Each week, I cryptically tweet these reports, and occasionally – like this week – I have the time and energy to write-up the reports in a coherent framework.
Like many, I waited with bated breath for results of the anti-PCSK9 (evolocumab) FOURIER cardiovascular outcome study last week. There have been many interesting commentaries written on the findings.A few of my favorites are listed here (Matthew Herper), here (David Grainger), here (Derek Lowe), and here (Larry Husten), amongst others, with summaries provided at the end of this blog.Most of these articles focused on clinical risk reduction vs. what was predicted for cardiovascular outcome, as well as whether payers will cover the cost of the drugs.These are incredibly important topics, and I won’t comment on them further here, other than to say that the debate is now about who should get the drug and how much it should cost.
In this blog, I want to emphasize key points that pertain to human genetics and drug discovery.And make no mistake: the anti-PCSK9 story and FOURIER clinical trial outcome is a triumph for genetics and drug discovery. This message seems to be getting muddled, however, given the current cost of evolocumab and the observation that cardiovascular risk reduction was less than expected, based on predictions from a 2005 study published by Cholesterol Treatment Trialists (CTT) (see Lancet study here).…
There were so many good articles and news reports this week on genetics/genomics and drug discovery & development. A few examples include: article in Nature Communications on gene therapy via CRISPR/Cas9 for retinitis pigments (here); a partnership between Editas and Allergan (Matthew Herper story here); Nature Reviews Genetics article by Khera and Kathiresan on genetics of coronary heart disease (here); Genome Magazine article on the importance of pharmacogenetics across ethnic groups to prevent severe adverse events (here); and a victory for pre-prints in challenging the statistical robustness of a publication in Nature Genetics (here).
I decided to focus on a study that provides a mechanistic link between a genetic mutation and a therapeutic hypothesis in Parkinson’s disease. The reason I chose this article is that it highlights the challenges of going from a robust genetic association to a biology hypothesis, and ultimately how to gain confidence in a therapeutic hypothesis with pre-clinical models. As you will see at the end, a clinical trial is now underway to test the therapeutic hypothesis in humans.
Yesterday I participated in the National Academy workshop, “Enabling Precision Medicine: The Role of Genetics in Clinical Drug Development” (link here). There were a number of great talks from leaders across academics, industry and government (agenda here).
I was struck, however, by a consistent theme: most think that “precision medicine” will improve delivery of approved therapies or those that are currently being developed, whether or not the therapies were developed originally with precision medicine explicitly in mind. Many assume that the observation that ~90% medicines are effective in only 30% to 50% is the result of biological differences in people across populations (see recent Forbes blog here). This hypothesis is very appealing, as there are many unique features to each of us.
An alternative explanation is that most medicines developed without precision medicine from the beginning only work in ~30% patients because the medicines don’t target the biological pathways that make each of us unique.
I believe the most likely application is in the discovery and development of new therapies. That is, I believe that the greatest impact will come when precision medicine strategies are incorporated into the very beginning of drug discovery, and will only rarely have an impact on therapies that were not developed with precision medicine in mind from the start.…
A new sickle cell anemia gene therapy study published in the New England Journal of Medicine (see here, here) gives hope to patients and the concept of rapidly programmable therapeutics based on causal human biology. But how close are we really?
It takes approximately 5-7 years to advance from a therapeutic hypothesis to an early stage clinical trial, and an additional 4-7 years of late stage clinical studies to advance to regulatory approval. This is simply too long, too inefficient and too expensive.
But how can timelines be shortened?
In the current regulatory environment, it is difficult to compress late stage development timelines. This leaves the time between target selection (or “discovery”) and early clinical trials (ideally clinical proof-of-concept, or “PoC”) as an important time to gain efficiencies. Further, discovery to PoC is an important juncture for minimizing failure rates in late development and delivering value to patients in the real world (see here).
Here, I argue that rapidly programmable therapeutics based a molecular understanding of the causal disease process is key to compressing the discovery to PoC timeline.
Imagine a world where the molecular basis of disease is completely understood. For common diseases, germline genetics contributes approximately two-thirds of risk; for rare diseases, germline genetics contributes nearly 100% of risk.…