Haemoglobinopathies, including thalassaemia and sickle cell anaemia, are common genetic diseases with significant associated morbidity and mortality. The potentially curative modality, haematopoietic stem cell (HSC) transplant, is restricted to a minority with matched donors, and has potential immunological adverse sequelae. Autologous HSC‐based therapies, using a patient's own genetically modified HSCs as donor cells, eliminates the need for an allogeneic matched donor and the immunological adverse effects of allogeneic HSC transplants. Gene therapy for haemoglobinopathies can be categorised as: (1) gene addition, (2) gene disruption, (3) gene correction, or (4) gene modification resulting in pharmacological upregulation of foetal haemoglobin. Currently, additive gene therapies are in clinical trials, while promising therapies based on gene disruption, editing and modulation of gene regulation are currently under development. Many of these therapies use the latest innovations in gene editing, the designer nucleases, including zinc‐fingers, transcription activator‐like effector nucleases, and clustered regularly interspaced short palindromic repeats/Cas technologies.
Key Concepts
Haemoglobin exists as a heterotetramer of two α‐globin subfamily peptides and two β‐globin subfamily peptides; adult haemoglobin primarily composed of α
2
β
2.
Haemoglobinopathies are genetic diseases that affect either the function or level of globin peptides.
Haemoglobinopathies are the most prevalent genetic diseases with significant morbidity and mortality.
Of these, β‐globinopathies (sickle cell anaemia and β‐thalassaemia) are the most common monogenic diseases worldwide and manifest within 6–12 months of birth.
Severity of haemoglobinopathies can be ameliorated through the expression of the missing haemoglobin subunit beta (HBB), additional β‐like globins, or genes that upregulate alternative globins.
Additive gene therapy using lentivirus vectors has proven to be successful for both β‐thalassaemia and sickle cell anaemia clinically.
Gene editing strategies, using ZFNs, TALENs or CRISPR/Cas, can be used as a ‘fix and run’ approach and have the advantage over additive gene therapies by avoiding insertional genotoxicity and restoring innate regulatory mechanisms.
Erythroid‐specific modulation of
BCL11A
has been shown to increase expression of haemoglobin subunits gamma 1 (HBG1) and gamma 2 (HBG2), and may be a viable alternative treatment modality.