News in focus

Is CRISPR safe? Genome editing

gets its first FDA scrutiny
Advisers to the US regulatory agency will
examine the safety profile of a CRISPR-
based treatment for sickle-cell disease.

A therapy based on the CRISPR–Cas9

genome-editing system could become the
first of its kind to gain approval from the US
Food and Drug Administration (FDA). But the
treatment — designed to alleviate a painful
blood condition — must first face intense
scrutiny by the agency and its advisers.
On 31 October, external advisers to the
FDA discussed a DNA-altering therapy for
sickle-cell disease, a genetic condition
that causes red blood cells to become
misshapen, which can lead to debilitating
pain. Among the subjects discussed was

safety data submitted by the treatment’s
developers, Vertex Pharmaceuticals
in Boston, Massachusetts, and CRISPR
Therapeutics in Zug, Switzerland.
“The key to this is safety,” says Mark
Walters, a paediatrician at the UCSF Benioff
Children’s Hospital Oakland at the University
of California, San Francisco. Walters has
served on a steering committee that has
advised the companies on the clinical
development of the treatment, called
exagamglogene autotemcel (exa-cel).
“That’s the question that could really affect
decision-making, and the safety information
is still quite limited.”
Nature looks at what’s known about the
safety of exa-cel and experimental genome-
editing therapies that are hot on its heels.
How exa-cel works
Sickle-cell disease is caused by abnormal
forms of haemoglobin, the protein in red
blood cells that transports oxygen. Altered
haemoglobin makes blood cells misshapen
and sticky, causing them to clump together.
These clumps can sometimes clog blood
vessels. Clogged vessels deprive tissues
of oxygen, potentially causing long-lasting
damage and episodes of searing pain that
are called vaso-occlusive crises.
Exa-cel aims to trigger production of a
form of haemoglobin that is normally made
only in developing fetuses. Production of this
fetal haemoglobin is typically shut off soon
after birth by a gene called BCL11A. Exa-cel
disables BCL11A, allowing fetal-haemoglobin
production to resume. This provides some
haemoglobin that is not misshapen, and
Genome editing (artist’s illustration) might be used to treat sickle-cell disease.
dampens the effects of the abnormal form.
Vertex and CRISPR Therapeutics reported
that, at nine months after treatment, 31 of 32
participants in their clinical trial had not had a
single vaso-occlusive crisis. Before treatment,
they’d had an average of about four each year.
To apply exa-cel, clinicians first collect
blood-producing stem cells from a person
with sickle-cell disease. The cells are then
treated with the genome editor, which
includes the Cas9 enzyme for cutting DNA,
and a molecule that guides the enzyme to a
target stretch of DNA in the BCL11A gene.
Once at that region, the Cas9 enzyme cuts
both strands of DNA. The cell’s natural
DNA-­repair mechanisms then stitch the
strands back together. But those mechanisms
can make mistakes, which means that they
often introduce errors into the sequence of
DNA. These errors can disable BCL11A and
release the brakes on fetal-haemoglobin
production.
Edits that miss the mark
But Cas9 sometimes slices DNA at regions
in the genome that are similar to its target
sequence. The cell’s repairs to that ‘off-target’
DNA can introduce unwanted mutations.
A mutation in a critical gene could cause
cancer or other disorders. So although the risk
might be small, says Samira Kiani, a synthetic
MELETIOS VERRAS/GETTY
biologist at the University of Pittsburgh School
of Medicine in Pennsylvania, this scenario is
an important consideration for CRISPR–Cas9
therapies. In briefing documents released
on 27 October, FDA examiners flagged two
potential shortcomings in assays that Vertex
and CRISPR Therapeutics used to determine
exa-cel’s risk of causing off-target changes. In
one assay, researchers searched a database
of genomes to find regions that are similar
to exa-cel’s CRISPR–Cas9 target site and that
therefore might be cleaved mistakenly by the
Cas9 enzyme. The scientists then gauged the
risk of changes at these sites.
Most of the sites did not raise concerns, says
Walters. But sickle-cell disease predominantly
affects people of African descent, and FDA
examiners are concerned that the genomes
that the company searched do not capture the
genetic diversity in this population. So there
could be genetic sequences in this group that
might be targeted by Cas9 but were missed in
the analysis.
And exa-cel has been tested in only
40 people — too few to assess the risk of
off-target changes, says Akshay Sharma, a
bone-marrow-transplant specialist at St Jude
Children’s Research Hospital in Memphis,
Tennessee. “We’re going to deal with so much
more genetic diversity, which we haven’t
accounted for in these trials,” Sharma says.

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 News
explainer
The FDA’s examiners also worry that the
companies’ assays in live cells for off-target
effects did not include enough cells sampled
from people with sickle-cell disease.
Cancer concern
For Walters, there is a bigger concern than
off-target edits: two participants in a clinical
trial of another gene-altering therapy for
sickle-cell disease later developed blood
cancers (S. Goyal et al. N. Engl. J. Med. 386,
138–147; 2022). In that trial, conducted by
bluebird bio in Somerville, Massachusetts, a
virus shuttled copies of a non-sickled form of
haemoglobin into blood stem cells.
Subsequent investigations showed that
the cancers were not caused by the virus.
This finding has fuelled speculation that
similar cases could crop up among those
receiving other therapies, such as exa-cel,
that involve modifying blood stem cells from
people with sickle-cell disease and then
reinfusing them.
Some studies have shown that people
with sickle-cell disease might be more prone
to malignant blood cancers (A. Brunson et al.
Blood 130, 1597–1599; 2017). If precancerous
cells were among those that were removed,
altered and reinfused, the treatment might
have given them a boost that allowed them
to take over the population and become
cancerous. “This is a principal, long-term,
potential complication that we’re going to
have to sort out,” says Walters.
Vertex and CRISPR Therapeutics have
proposed to follow participants for 15 years
after treatment, to look for long-term
impacts. In the meantime, it is important that
physicians inform their patients of the risks,
says Tosin Ola, founder of the advocacy
group Sickle Cell Warriors in San Marcos,
California. “These are things that I know
because I’m a nurse and I do advocacy,” she
says. “But a typical mom who is worried for
her kid who has sickle cell, she won’t know it.
She’ll just sign up.”
Sharma shares those concerns but, like
Ola, acknowledges that the development of
treatments such as exa-cel should continue,
despite the unknowns. “There are patients
right now who are still suffering, and they
need some sort of therapy,” says Sharma.
“We’ve got to find something for them.”
By Heidi Ledford
Wolbachia-infected mosquitoes are released in Brazil.
DENGUE RATES DROP
AFTER RELEASE OF
MODIFIED MOSQUITOES
Deployment of Wolbachia-infected insects yields
‘encouraging’ results in three Colombian cities.
By Mariana Lenharo
T
hree cities in Colombia saw a dra-
matic fall in the incidence of dengue
in the years after the introduction of
mosquitoes carrying Wolbachia, a
bacterium that prevents the insect
from transmitting viruses. In neighbourhoods
where the Wolbachia mosquitoes became well
established, dengue incidence dropped by
94–97%.
The Aedes aegypti mosquitoes were released
by the World Mosquito Program (WMP), a
non-profit organization that has been con-
ducting similar experiments in Australia,
Brazil, Indonesia and Vietnam, among other
countries. In Colombia, the modified mos-
quitoes were released in one of the country’s
most populous regions. “That’s the largest
continuous releases of Wolbachia [mosqui-
toes] globally so far, in terms of the population
covered and the area,” says Katie Anders, an
epidemiologist at the WMP and Monash Uni-
versity in Melbourne, Australia.
Anders presented the results on 22 October
at the annual meeting of the American Society
of Tropical Medicine and Hygiene in Chicago,
Illinois.
When infected with Wolbachia, the
THE WORLD MOSQUITO PROGRAM
mosquitoes are much less likely to transmit
diseases such as dengue and Zika, because
the bacteria compete with these viruses. The
insects also pass the bacteria on to their off-
spring. Researchers hope that the modified
mosquitoes will interbreed with the wild pop-
ulation wherever they are released, and that
the number of mosquitoes with Wolbachia will
eventually surpass that of mosquitoes without
the bacteria.
The WMP first deployed modified mos-
quitoes in the Aburrá Valley in Colombia in
2015 and gradually expanded the releases
until late 2020. Eventually, the cities of
Bello, Medellín and Itagüí, with a combined
area of 135 square kilometres and home to
3.3 million people, were completely cov-
ered. WMP researchers consider an area to
be “fully treated” when more than 60% of the
local mosquitoes carry Wolbachia. This goal
was achieved in Bello and Itagüí. In Medellín,
about half of the city’s territory remained
below that level.
When the scientists compared the incidence
of dengue in fully treated areas with that in the
same regions in the ten years before the inter-
vention, they found that it had dropped by 95%
in Bello and Medellín and by 97% in Itagüí. Since
the project started, there hasn’t been a large
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