Navigating Market Authorization: The Path Holoclar Took to Become the First Stem Cell Product Approved in the European Union.

Gene therapy, cell therapy, and tissue engineering have the potential to revolutionize the treatment of disease and injury. Attaining marketing authorization for such advanced therapy medicinal products (ATMPs) requires a rigorous scientific evaluation by the European Medicines Agency-authorization is only granted if the product can fulfil stringent requirements for quality, safety, and efficacy. However, many ATMPs are being provided to patients under alternative means, such as "hospital exemption" schemes. Holoclar (ex vivo expanded autologous human corneal epithelial cells containing stem cells), a novel treatment for eye burns, is one of the few ATMPs to have been granted marketing authorization and is the first containing stem cells. This review highlights the differences in standards between an authorized and unauthorized medicinal product, and specifically discusses how the manufacture of Holoclar had to be updated to achieve authorization. The result is that patients will have access to a therapy that is manufactured to high commercial standards, and is supported by robust clinical safety and efficacy data. Stem Cells Translational Medicine 2018;7:146-154.

In vitro effects of fluoroquinolone and aminoglycoside antibiotics on human keratocytes.

PURPOSE: The purpose of this study was to assess the cytotoxic effects of the fluoquinolone ofloxacin and the aminoglycoside netilmicin on stromal human keratocytes in vitro. METHODS: Cultured human keratocytes were exposed to various concentrations of ofloxacin or netilmicin (0.16-5.0 mg/mL). Both cell proliferation (MTT assay) and cell morphology (phase-contrast microscopy) were evaluated after 1, 4, 12, and 24 hours of incubation. Measurement of annexin V binding performed in association with the dye exclusion test using propidium iodide (PI) was also performed by FACS analysis after 4 hours of exposure. RESULTS: Both antimicrobials induced dose- and time-dependent morphologic changes in keratocytes, yet the effects of netilmicin were minimal. After 24 hours of exposure, both drugs induced a dose-dependent inhibition of cell proliferation; however, ofloxacin demonstrated significantly more toxic effects than netilmicin (t test for ED50 values, P < 0.0001). Statistical differences between 2 antibiotics start at concentrations above 1.25 mg/mL (ANOVA with post-hoc test, P < 0.01). Expression of the apoptotic marker annexin V was unaffected by antibiotic exposure, whereas the uptake of the necrotic marker PI was increased by ofloxacin (5 mg/mL) but not by netilmicin (ofloxacin versus netilmicin, ANOVA, P < 0.05). CONCLUSIONS: Relative effects of aminoglycosides and fluoroquinolones on stromal keratocytes appear to be different: netilmicin was shown to be significantly less toxic than ofloxacin. This finding is particularly relevant in deciding the optimal antibiotic to be applied in clinical situations in which the epithelium is absent or compromised, as after photorefractive keratectomy, alkali burns, or ulcerative keratitis.

Long term treatment with sodium hyaluronate-containing artificial tears reduces ocular surface damage in patients with dry eye.

BACKGROUND/AIMS: Several studies have reported that sodium hyaluronate is able to improve both symptoms and signs in patients with dry eye but none have demonstrated an improvement of conjunctival epithelial cell abnormalities of the ocular surface. The aim of this study was to explore the effect of sodium hyaluronate-containing eye drops on the ocular surface of patients with dry eye during long term treatment. METHODS: A randomised double blind study was undertaken in 86 patients with medium to severe dry eye (that is, rose bengal and/or fluorescein test score of at least 3, tear film break up time <10 seconds, or Schirmer's test <5.5 mm). Patients were treated with either preservative-free sodium hyaluronate or saline for 3 months at a dose of one drop 4-8 times a day. Bulbar impression cytology, slit lamp examinations, and subjective symptoms were evaluated after 1, 2, and 3 months. Impression cytology was considered the primary efficacy parameter of the study. RESULTS: The efficacy analysis was performed on a total of 44 patients who were able to fully adhere to the protocol. After 3 months of treatment sodium hyaluronate improved impression cytology score (p = 0.024 v baseline). At the same time also the difference with respect to placebo was statistically significant (p = 0.036). Study medication was well tolerated and no treatment related adverse events occurred during the study. CONCLUSIONS: Sodium hyaluronate may effectively improve ocular surface damage associated with dry eye syndrome.

Naproxen ophthalmic solution to manage inflammation after phacoemulsification.

PURPOSE: To explore the efficacy and safety of 2 concentrations (0.1% and 0.2%) of sodium naproxen ophthalmic solution in controlling ocular inflammation in patients having phacoemulsification and intraocular lens implantation. SETTING: Service d'Ophtalmologie La Pitie' and Centre Ophtalmologique, Paris, and Clinique Sourdille, Nantes, France; Department of Ophthalmology, University of Lausanne, Switzerland. METHODS: One hundred one patients were randomly treated with naproxen 0.1%, naproxen 0.2%, or diclofenac 0.1% 3 times a day for 30 days starting the day before surgery. Postsurgical ocular inflammation was measured after 1, 10, and 30 days using the Kowa FC-1000 laser flare-cell meter and a conventional slitlamp biomicroscope. Safety parameters were evaluated at the same visits. RESULTS: Naproxen 0.2% ophthalmic solution and diclofenac 0.01% were comparable in controlling postsurgical inflammation. The naproxen was well tolerated. No serious adverse events occurred during the study. CONCLUSIONS: These preliminary results suggest that naproxen ophthalmic solution may be effectively and safely used to control inflammation after uneventful phacoemulsification. Because of the limited number of patients, larger studies are needed to confirm these results.

Efficacy and safety of desonide phosphate for the treatment of allergic conjunctivitis.

PURPOSE: To study the safety and efficacy of the topical corticosteroid, desonide 0.25% ophthalmic solution, for inhibition of the clinical allergic reaction induced by conjunctival provocation (CPT) and for the treatment of seasonal allergic conjunctivitis (SAC). METHODS: For the CPT study, 12 allergic but inactive patients were exposed in both eyes to increasing doses of a specific allergen until a positive bilateral, symmetrical early- and late-phase reaction was obtained. After 2 weeks the last positive dose was readministrated and their positive response confirmed. After an additional 2 weeks, CPT was performed 30 minutes after topical administration of desonide in one eye and placebo in the contralateral eye (Group A) or after topical desonide or placebo four times a day for 2 days (Group B). Clinical signs and symptoms were recorded after 15, 30, and 60 minutes, and after 6 hours. Regarding the seasonal study, 96 patients with active SAC were treated bilaterally with either desonide or fluorometholone for 3 weeks, and allergic signs and symptoms evaluated at regular intervals. The safety of the drugs was assessed by identification of any side effects or adverse events of any kind. RESULTS: For the CPT study: individual itching and redness, and the sum score for signs and symptoms were all statistically (p < 0.05) and clinically (greater than 1 change between treated eyes) significantly lower in desonide versus placebo eyes. Both early- and late-phase reactions were reduced by desonide pretreatment. Seasonal study: desonide and fluorometholone were both highly effective in reducing itching, tearing, and conjunctival hyperemia over time (p < 0.0001). Both drugs appeared safe, with no statistically significant changes in IOP observed with either treatment. CONCLUSIONS: Desonide has a significant therapeutic effect on both the induced conjunctival early- and late-allergic reaction and in active SAC. It was also safe, with no side effects such as increases in intraocular pressure observed by physician or patient.

Treatment of acute bacterial conjunctivitis with topical netilmicin.

PURPOSE: This study compares the clinical and microbiologic value of topical netilmicin with that of gentamicin in the treatment of acute bacterial conjunctivitis. METHODS: A double-blind, randomized, prospective, controlled study was performed in 209 patients. One to two drop(s) of either antibiotic was applied to the affected eye(s) four times a day for up to 10 days. Patients were examined at the time of diagnosis and after 3, 5, and 10 days. Clinical efficacy was measured as the cumulative sum score (CSS) of the key signs and symptoms of acute bacterial ocular infection. Sensitivity/resistance was evaluated using the disk diffusion method. RESULTS: Drug efficacy assessment was restricted only to patients with positive baseline culture results (n = 121). Of the isolated organisms, 96.9% were sensitive to netilmicin, whereas only 75.0% were sensitive to gentamicin (p = 0.00001). Netilmicin provided a broad-spectrum coverage comparable with that of ciprofloxacin, ofloxacin, and norfloxacin. Netilmicin also was more effective than gentamicin in eradicating infections (p = 0.001 at day 5 and p = 0.037 at day 10) and in ameliorating the CSS (p = 0.037 at day 3, p = 0.001 at both day 5 and day 10). Only minor adverse events occurred in patients treated with either netilmicin or gentamicin. CONCLUSIONS: This study demonstrates that netilmicin is a safe and effective antibiotic that can be used as first-line therapy for the treatment of acute bacterial conjunctivitis.

Effect of ofloxacin and netilmicin on human corneal and conjunctival cells in vitro.

The purpose of this study was to compare the cytotoxic effects of the fluoroquinolone ofloxacin with that of the aminoglycoside netilmicin. Human corneal epithelial cells (HCE-T) and human conjunctival epithelial cells (Wong-Kilbourne derivative of Chang conjunctiva) were exposed to antibiotics (0.08-5.0 mg/mL) for 4 or 24 hours. Cell proliferation and viability were assessed with the MTT assay, neutral red uptake, and bromo deoxy uridine incorporation. In both cell lines, ofloxacin inhibited cell proliferation and viability. These effects were time and dose dependent. Concentrations of ofloxacin ranging from 0.4 to 2.4 mg/mL (0.04% to 0.24%) produced a 50% inhibition of proliferation and viability. In contrast, netilmicin induced no toxic effect. The differences between ofloxacin and netilmicin were highly statistically significant (p < 0.001). This finding is particularly relevant in deciding the optimal antibiotic to be applied in clinical situations in which the epithelium is compromised.

Updating the evidence on patent foramen ovale closure versus medical therapy in patients with cryptogenic stroke: a systematic review and comprehensive meta-analysis of 2,303 patients from three randomised trials and 2,231 patients from 11 observational studies.

AIMS: We aimed at updating the evidence coming from randomised and observational studies of patent foramen ovale (PFO) closure compared to medical therapy in patients with cryptogenic stroke (CS). METHODS AND RESULTS: Comparative studies of PFO closure versus medical therapy published or presented through March 2013 were identified. Data from 2,303 patients in three randomised clinical trials (RCTs) and from 2,231 patients in 11 observational studies were included. In RCTs, the stroke hazard ratio (HR) for PFO closure versus medical therapy was 0.62 (95% confidence interval [CI]: 0.34-1.11; p=0.10 in the random effects model) with no significant heterogeneity or systematic bias. There was no significant difference in transient ischaemic attacks (TIA) (HR 0.77, 95% CI: 0.46-1.32; p=0.34) and no study-related deaths occurred. Pooling trials of the AMPLATZER PFO occluder device resulted in a significant reduction of stroke (HR 0.44, 95% CI: 0.20-0.95; p=0.04). Procedural success, new onset atrial fibrillation and cardiac thrombus were observed more frequently with the STARFlex compared with the AMPLATZER device. In observational studies, with high potential for baseline confounders, PFO closure was found to reduce the risk of recurrent stroke significantly (HR 0.23, 95% CI: 0.11-0.49; p<0.01 in the random effects model), with no significant effect on TIAs. CONCLUSIONS: In RCTs, unlike observational studies, PFO closure compared with medical therapy failed to achieve a statistically significant reduction in recurrent stroke. However, pooling RCTs of the AMPLATZER PFO occluder device yielded a statistically significant reduction in stroke over medical treatment that may warrant further investigation.

Positive airway pressure in patients with coronary artery disease and obstructive sleep apnea syndrome.

AIMS: We designed a prospective nonrandomized study aiming at assessing the impact of continuous positive airway pressure (CPAP) after a new diagnosis of obstructive sleep apnea syndrome (OSAS) in patients with coronary artery disease (CAD). METHODS: Consecutive patients referred to coronary angiography underwent an overnight sleep study during their hospital stay. Among those with angiographically confirmed CAD and a new diagnosis of moderate or severe OSAS, we compared the 3-year major adverse cardiac or cerebrovascular event (MACCE)-free survival stratified by CPAP at discharge. RESULTS: Of 496 patients undergoing an overnight sleep study, 129 had angiographically confirmed CAD and presented with moderate or severe OSAS. The incidence of 3-year MACCE was significantly lower in the CPAP-treated group (n = 17) than in the untreated group (n = 112; 12 vs. 44%, P = 0.02). After adjusting for differences in baseline characteristics, CPAP was significantly associated with a decreased risk of MACCE [adjusted hazard ratio 0.18, 95% confidence interval (CI) 0.04-0.78, P = 0.02]. Among men, CPAP was associated with a significant 3-year risk reduction in MACCE (adjusted hazard ratio 0.12, 95% CI 0.02-0.87, P = 0.04), whereas no significant benefit of CPAP was seen in women (adjusted hazard ratio 2.1, 95% CI 0.10-41.6, P = 0.63). The statistical interaction between CPAP and sex trended to be significant (adjusted P for interaction = 0.10). CONCLUSION: In patients with OSAS and CAD, the initiation of CPAP is associated with a significant reduction in MACCE compared with patients left untreated.