M.J. Welsh and A.E. Smith, RAC Application 
Ad2-ORF6/PGK-CFTR 
Item 5 - Clinical Protocol 
High resolution computerized tomography of the chest . 
Purpose: To assess patient's pulmonary disease. 
Methods: High resolution, thin section computerized tomography of the chest will be performed in the 
Department of Radiology at the University of Iowa Hospitals and Clinics. 
Biopsv of the nasal epithelium . 
Purpose : To assess nasal mucosa and submucosa for evidence of an inflammatory/immune response. 
Methods: After mild sedation, the nasal mucosa will be anesthetized by atomizing 0.5 ml of 5% cocaine. 
After endoscopic inspection, and identification of the site to be biopsied, the submucosa will be injected 
with 1% xylocaine, with 1/100,000 epinephrine. A small area of the mucosa of the inferior turbinate will 
be removed. After biopsy, the mucosa in the area of the inferior turbinate may be packed with cotton 
pledgets previously soaked in a mixture of 2 ml of 0.1% adrenaline and 8 ml of 1% tetracaine. The 
pledgets remained in place for 10-40 min. The biopsy will be performed on day 1, day 3, or day 7 after 
the last treatment. The first and fourth patient will be biopsied on day 1; the second and fifth patient will 
be biopsied on day 3; etc. 
Potential Alterations in the Timing of the Procedures and the Doses. 
The planned timing of the procedures and dose of Ad2-ORF6/PGK-CFTR are given above and in the 
flow chart The biopsy will be performed after the last administration of vector. These timings and doses 
may, however, be changed by the investigators, based on the data. For example, if we observe 
convincing evidence of an inflammatory response by inspection of the nasal epithelium, by assessment of 
the cytology of the swabs of nasal mucosa, or by a systemic response, we will not proceed further, but 
instead will immediately proceed to a biopsy of the nasal mucosa on both the treated and the sham side. 
In the case that we see inflammation on the treated side, we will also alter the dosing strategy. As an 
example, suppose that we observe an inflammatory response after the third administration (2xl0 9 IU). 
In the next patient, we would proceed with the first and second doses (2xl0 7 IU and 2xl0 8 IU), but then 
for the third dose we would repeat the dose of 2xl0 8 IU. If there were no adverse effects we would then 
proceed with dose escalation. 
Interpretation and Advantages. 
This portion of the study focuses on the safety of an adenovirus vector - one of the most pressing issues 
in the use of adenovirus vectors for the treatment of CF lung disease - and its design provides several 
advantages in evaluating safety. These include the following: 
a) Most importantly, because we use the nasal epithelium, we can obtain critical data about safety, yet 
we minimize any possible risk to the participants. 
b) The quality of the control (the opposite nasal mucosa ) is excellent In each individual patient the 
virus will be administered in a random manner to one of two nasal cavities and thereafter to the same 
cavity. All other systemic factors will be identical. 
c) We will be able to assess biochemical efficacy by measuring the voltage across the nasal epithelium. 
The results of these studies are critical to the design of future studies directed at delivering the gene to the 
pulmonary airways and treatment of the lung disease and to the design and development of future vectors 
(which may or may not be based on adenovirus) to treat CF. 
Potential Risks Associated with the Virus. 
The risks associated with somatic cell gene transfer using the Ad2-ORF6/PGK-CFTR gene construct in 
humans are unknown. However, we now have experience with administration of the related Ad2/CFTR- 
1 construct to humans (Appendix 7.8). The data suggest that there was no viral replication nor any 
adverse symptoms or findings that could be attributed to the recombinant virus. 
Inflammation and Immune Response. It is possible that inflammation locally at the site of application of 
the virus could occur as a result of an immune response to the recombinant virus. Local cytopathic effects 
on the respiratory nasal epithelium are also possible. Inflammation or cytopathic effects include local 
pain, bleeding or subsequent scarring; although serious effects appear very unlikely. The use of nasal 
mucosa, rather than bronchial mucosa, is a major safety feature that should allow us to assess safety 
without endangering the patient. 
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Recombinant DNA Research, Volume 18 
