# Dihydroartemisinin decreases pre-existing neutralizing antibodies against adeno-associated virus in challenged mice

## TL;DR

Dihydroartemisinin (DHA) safely reduces pre-existing antibodies against AAV, improving the potential for gene therapy in more patients.

## Contribution

DHA is shown as a safe alternative to traditional immunosuppressants for reducing anti-AAV antibodies in mice.

## Key findings

- DHA reduced anti-AAV neutralizing antibodies without affecting transgene expression or vector distribution.
- DHA decreased splenic B cells and plasma cells linked to antibody production.
- DHA did not cause liver toxicity or interfere with AAV infection in vitro.

## Abstract

The high prevalence of pre-existing neutralizing antibodies (NAbs) against adeno-associated virus (AAV) poses a major obstacle to in vivo gene therapy. Current immunosuppressive (IS) strategies, such as corticosteroids, are limited by toxicity and adverse effects. To explore safer alternatives, we evaluated dihydroartemisinin (DHA), a synthetic derivative of artemisinin inspired by traditional Chinese medicine (TCM), as a potential IS agent.

In vivo experiments were conducted by administering DHA at either 30 or 210 days post-injection (PI) of rAAVDJ vectors. Anti-AAV NAb levels, transgene expression, and vector genome biodistribution were assessed. Flow cytometry was used to quantify CD20+ B cells, germinal center B cells, and plasma cells in the spleen. Splenic gene expression profiling, liver histology, and serum biochemical analyses were performed to evaluate immunological and safety responses. In vitro, the impact of DHA and its serum metabolites on rAAV infection efficiency was tested in HEK293 cells.

DHA administration significantly reduced anti-AAV NAb levels without compromising transgene expression or vector genome distribution. DHA treatment resulted in a reduction of splenic CD20+ B cells, germinal center B cells, and plasma cells, alongside changes in splenic gene expression profiles. Liver histology and serum markers confirmed that DHA at 125 mg/kg/day did not induce hepatotoxicity. In vitro assays demonstrated that DHA and its blood metabolites did not interfere with rAAV infection of HEK293 cells across multiple serotypes.

These findings suggest that DHA is a safe and effective agent for modulating humoral immune responses to AAV vectors. Our results provide proof-of-concept evidence supporting the use of TCM-derived compounds to address immunological barriers in gene therapy.

We investigated whether DHA could reduce pre-existing AAV neutralizing antibodies by modulating the humoral immune response. DHA treatment led to a reduction in splenic GC B cells and plasma cells, which are key contributors to antibody production. This immunosuppressive effect was associated with decreased anti-AAV NAb levels, suggesting that DHA could expand the applicability of rAAV gene therapy to a wider patient population and potentially facilitate the re-administration of rAAV-based treatments.Diagram illustrating a scientific experiment with mice. The control mouse receives “i.g. PBS” injection and rAAV, while the experimental “DHA” mouse receives “i.g. DHA” injection and rAAV. Both mice have spleen arrows pointing to a germinal center with zones. GC B cells transition to plasma cells, then to NAbs, showing more activity in the control. Detection methods include flow cytometry for GC B and plasma cells, and in vitro assays for NAbs.

We investigated whether DHA could reduce pre-existing AAV neutralizing antibodies by modulating the humoral immune response. DHA treatment led to a reduction in splenic GC B cells and plasma cells, which are key contributors to antibody production. This immunosuppressive effect was associated with decreased anti-AAV NAb levels, suggesting that DHA could expand the applicability of rAAV gene therapy to a wider patient population and potentially facilitate the re-administration of rAAV-based treatments.