Gene therapies which utilise modified viruses or plasmid DNA (pDNA), to re-introduce functional copies of defective or mutated genes, are being investigated for the treatment of a wide range of lung diseases including cystic fibrosis (CF), cancer and alpha-1 anti-trypsin deficiency (Gill et al., 2004).
The relative accessibility of the pulmonary epithelium makes aerosol delivery of gene therapy formulations an attractive possibility, allowing non-invasive application to target cells within the lung whilst minimising the risks associated with systemic delivery.
Following identification of the gene responsible for CF in 1989 (Riordan et al., 1989) the disease has served as a paradigm for gene therapy in general and aerosol gene therapy in particular. To date there have been ~30 Phase I/II gene therapy clinical trials for CF including 8 trials incorporating aerosol delivery (of gene transfer agents) to the lungs of CF patients as a key component of the study (Griesenbach et al., 2009).
Typical clinical nebuliser generating an aerosol
Although the field of gene therapy proceeds at pace, transfer of technological developments to aerosol gene therapy has been limited by the additional constraints placed upon formulations for nebulisation and the associated costs of developing and testing aerosol formulations in relevant animal model systems.
To date, only 3 gene transfer agents, recombinant adenovirus (Ad) (Perricone et al., 2001), adeno-associated virus (AAV)(Moss et al., 2007) and pDNA complexed to the cationic lipid Genzyme Lipid 67A (GL67A) (Alton et al., 1999) have been aerosolized to the lungs of patients and whilst a huge variety of gene transfer agents are now available, few have proven suitable for aerosolisation.
A recent study by the Consortium identified shear related degradation of pDNA during nebulisation as the primary limitation in the progression of novel non-viral gene therapy formulations towards the clinic. Only 10% of tested formulations demonstrating efficacy following jet nebulisation.
Consequently, potential aerosol gene therapy applications are currently limited both by the choice of suitable vectors and available delivery devices. Evidence from in-vivo studies and human clinical trials has indicated that lung gene transfer mediated commitment by aerosolisable vectors remains inefficient and gene expression is transient in nature (Rochat et al., 2002).
As a result, it is likely that repeated administration of gene therapy formulations will be required to observe clinical benefit.
A Next Generation Cascade Impactor (NGI). Used for measuring the droplet sizes in aerosol formulations.
Considerable advances have been made to achieve gene delivery via aerosol. More effective nebulisation devices are available to deliver gene therapy formulations efficiently and without destructive effects. Optimisation of gene transfer agents to generate persistent high-level gene expression in the lung will also be of significant benefit.