The inclusion of genes that control cell fate (so-called suicide, or kill-switch, genes) into gene therapy vectors is based on a compelling rationale for the safe and selective elimination of aberrant transfected cells. Prodrug-activated systems were developed in the 1980s and 1990s and rely on the enzymatic conversion of non-active prodrugs to active metabolites that lead to cell death. Although considerable effort and ingenuity has gone into vector design for gene therapy, less attention has been directed at the efficacy or associated adverse effects of the prodrug systems employed. In this review, we discuss prodrug systems employed in clinical trials and consider their role in the field of gene therapy. We highlight potential drawbacks associated with the use of specific prodrugs, such as systemic toxicity of the activated compound, the paucity of data on biodistribution of prodrugs, bystander effects, and destruction of genetically modified cells, and how these can inform future advances in cell therapies.
Prodrug-activated gene therapyEarly gene therapy trials carried out for monogenic diseases, such as severe combined immune deficiency (SCID) and alpha 1-antitypsin deficiency, initially focused on replacing a single deficient or mutated gene with a normal copy. However, the safety concerns inherent in cellular therapy were highlighted when 4 of 10 patients treated with gene therapy for SCID developed acute T cell lymphoblastic leukemia as the result of insertional mutagenesis into the host genome. 4 One strategy to mitigate potential adverse effects (AEs) caused by genetically modified cells is to include a cell-fate control system, such as a suicide gene, in the transfer vector; thus, a second transgene accompanies the gene of interest and acts as a suicide switch that allows transduced cells to be destroyed when exposed to a particular signal. 1,5 Several mechanisms can be used to control cell fate in this way (Figure 1). Prodrug-activated gene therapy (PAGT) strategies aim to enable the selective, on-demand destruction of transduced cells. A suicide transgene that encodes an enzyme is introduced into a target cell, and the transduced cell then becomes able to convert