51
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Benatar M, Wuu J, McHutchison C, Postuma RB, Boeve BF, Petersen R, Ross CA, Rosen H, Arias JJ, Fradette S, McDermott MP, Shefner J, Stanislaw C, Abrahams S, Cosentino S, Andersen PM, Finkel RS, Granit V, Grignon AL, Rohrer JD, McMillan CT, Grossman M, Al-Chalabi A, Turner MR. Preventing amyotrophic lateral sclerosis: insights from pre-symptomatic neurodegenerative diseases. Brain 2022; 145:27-44. [PMID: 34677606 PMCID: PMC8967095 DOI: 10.1093/brain/awab404] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/16/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
Significant progress has been made in understanding the pre-symptomatic phase of amyotrophic lateral sclerosis. While much is still unknown, advances in other neurodegenerative diseases offer valuable insights. Indeed, it is increasingly clear that the well-recognized clinical syndromes of Alzheimer's disease, Parkinson's disease, Huntington's disease, spinal muscular atrophy and frontotemporal dementia are also each preceded by a pre-symptomatic or prodromal period of varying duration, during which the underlying disease process unfolds, with associated compensatory changes and loss of inherent system redundancy. Key insights from these diseases highlight opportunities for discovery in amyotrophic lateral sclerosis. The development of biomarkers reflecting amyloid and tau has led to a shift in defining Alzheimer's disease based on inferred underlying histopathology. Parkinson's disease is unique among neurodegenerative diseases in the number and diversity of non-genetic biomarkers of pre-symptomatic disease, most notably REM sleep behaviour disorder. Huntington's disease benefits from an ability to predict the likely timing of clinically manifest disease based on age and CAG-repeat length alongside reliable neuroimaging markers of atrophy. Spinal muscular atrophy clinical trials have highlighted the transformational value of early therapeutic intervention, and studies in frontotemporal dementia illustrate the differential role of biomarkers based on genotype. Similar advances in amyotrophic lateral sclerosis would transform our understanding of key events in pathogenesis, thereby dramatically accelerating progress towards disease prevention. Deciphering the biology of pre-symptomatic amyotrophic lateral sclerosis relies on a clear conceptual framework for defining the earliest stages of disease. Clinically manifest amyotrophic lateral sclerosis may emerge abruptly, especially among those who harbour genetic mutations associated with rapidly progressive amyotrophic lateral sclerosis. However, the disease may also evolve more gradually, revealing a prodromal period of mild motor impairment preceding phenoconversion to clinically manifest disease. Similarly, cognitive and behavioural impairment, when present, may emerge gradually, evolving through a prodromal period of mild cognitive impairment or mild behavioural impairment before progression to amyotrophic lateral sclerosis. Biomarkers are critically important to studying pre-symptomatic amyotrophic lateral sclerosis and essential to efforts to intervene therapeutically before clinically manifest disease emerges. The use of non-genetic biomarkers, however, presents challenges related to counselling, informed consent, communication of results and limited protections afforded by existing legislation. Experiences from pre-symptomatic genetic testing and counselling, and the legal protections against discrimination based on genetic data, may serve as a guide. Building on what we have learned-more broadly from other pre-symptomatic neurodegenerative diseases and specifically from amyotrophic lateral sclerosis gene mutation carriers-we present a road map to early intervention, and perhaps even disease prevention, for all forms of amyotrophic lateral sclerosis.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Joanne Wuu
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Caroline McHutchison
- Human Cognitive Neuroscience, Department of Psychology, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | - Ronald B Postuma
- Department of Neurology, Montreal Neurological Institute, McGill University, Montreal, Canada
| | | | | | - Christopher A Ross
- Division of Neurobiology, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Howard Rosen
- Department of Neurology, University of California San Francisco, CA, USA
| | - Jalayne J Arias
- Department of Neurology, University of California San Francisco, CA, USA
| | | | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeremy Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Sharon Abrahams
- Human Cognitive Neuroscience, Department of Psychology, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | | | - Peter M Andersen
- Department of Clinical Science, Neurosciences, Umeå University, Sweden
| | - Richard S Finkel
- Department of Pediatric Medicine, Center for Experimental Neurotherapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Volkan Granit
- Department of Neurology, University of Miami, Miami, FL, USA
| | | | - Jonathan D Rohrer
- Department of Neurodegenerative Disease, Dementia Research Centre, UCL Institute of Neurology, Queen Square, London, UK
| | - Corey T McMillan
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Murray Grossman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Thimm A, Brakemeier S, Kizina K, Munoz Rosales J, Stolte B, Totzeck A, Deuschl C, Kleinschnitz C, Hagenacker T. Assessment of Health-Related Quality of Life in Adult Spinal Muscular Atrophy Under Nusinersen Treatment—A Pilot Study. Front Neurol 2022; 12:812063. [PMID: 35140677 PMCID: PMC8818760 DOI: 10.3389/fneur.2021.812063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/27/2021] [Indexed: 01/16/2023] Open
Abstract
5q-Spinal muscular atrophy (SMA) is a severely disabling inherited neuromuscular disease that progressively reduces the motor abilities of affected individuals. The approval of the antisense oligonucleotide nusinersen, which has been shown to improve motor function in adult SMA patients, changed the treatment landscape. However, little is known about its impact on patients' quality of life (QoL), and there is still a need for adequate patient-reported outcome measures. In this study, we used the short form of the Neuro-QoL (Quality of Life in Neurological Disorders) for upper/lower extremity function to prospectively assess the health-related QoL of 17 adult SMA patients prior to initiation of nusinersen treatment and 2, 6, 10, and 14 months afterwards. At baseline, Neuro-QoL scores strongly correlated with motor function scores (Hammersmith Functional Motor Scale Expanded, HFMSE; Revised Upper Limb Module, RULM), but QoL did not increase significantly during the 14-month treatment period despite significant motor improvement as measured by HFMSE. Our results underline the need for novel, disease-specific assessments of QoL in SMA.
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Affiliation(s)
- Andreas Thimm
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
- *Correspondence: Andreas Thimm
| | - Svenja Brakemeier
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Kathrin Kizina
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Juan Munoz Rosales
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Benjamin Stolte
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Andreas Totzeck
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
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53
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[Spinal muscular atrophy]. DER NERVENARZT 2022; 93:191-200. [PMID: 35037967 DOI: 10.1007/s00115-021-01256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by biallelic mutations in the SMN1 (survival motor neuron 1) gene on chromosome 5q13.2, which leads to a progressive degeneration of alpha motor neurons in the spinal cord and in motor nerve nuclei in the caudal brainstem. It is characterized by progressive proximally accentuated muscle weakness with loss of already acquired motor skills, areflexia and, depending on the phenotype, varying degrees of weakness of the respiratory and bulbar muscles, although the facial muscles and eye muscles are not affected. The previously purely symptom-oriented treatment has undergone a significant expansion since 2017 with the approval of three drugs (nusinersen, onasemnogene abeparvovec and risdiplam) that modify the course of the disease at the gene expression level and have led to a change in the natural disease course of SMA. The effect of these new forms of treatment can only be fully assessed in the coming years. New aspects and challenges in this context are discussed in this article.
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Miccio A, Antoniou P, Ciura S, Kabashi E. Novel genome-editing-based approaches to treat motor neuron diseases: Promises and challenges. Mol Ther 2022; 30:47-53. [PMID: 33823304 PMCID: PMC8753272 DOI: 10.1016/j.ymthe.2021.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/07/2023] Open
Abstract
Motor neuron diseases are untreatable with common pharmacological approaches. Spinal muscular atrophy (SMA) is caused by SMN1 gene mutations leading to lowered SMN expression. Symptoms are alleviated in infants with a higher copy number of the SMN2 gene, which, however, displays a splicing defect resulting in low SMN levels. Amyotrophic lateral sclerosis (ALS) is caused by a number of mutations, with C9orf72 repeat expansions the most common genetic cause and SOD1 gain-of-function mutations the first genetic cause identified for this disease. Genetic therapies based on oligonucleotides that enhance SMN2 splicing and SMN production or lower SOD1 expression have shown promise in initial clinical trials for individuals with SMA and ALS harboring SOD1 mutations, respectively. Gene addition/silencing approaches using adeno-associated viruses (AAVs) are also currently under clinical investigation in trials for SMA and ALS. Here we provide a brief overview of these efforts and their advantages and challenges. We also review genome editing approaches aimed at correcting the disease-causing mutations or modulating the expression of genetic modifiers, e.g., by repairing SOD1 mutations or the SMN2 splicing defect or deleting C9orf72 expanded repeats. These studies have shown promising results to approach therapeutic trials that should significantly lower the progression of these deadly disorders.
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Affiliation(s)
- Annarita Miccio
- Laboratory of Chromatin and Gene Regulation during Development, Imagine Institute, Université de Paris, INSERM UMR 1163, 75015, Paris, France,Corresponding author: Annarita Miccio, Laboratory of Chromatin and Gene Regulation during Development, Imagine Institute, Université de Paris, INSERM UMR 1163, 75015, Paris, France.
| | - Panagiotis Antoniou
- Laboratory of Chromatin and Gene Regulation during Development, Imagine Institute, Université de Paris, INSERM UMR 1163, 75015, Paris, France
| | - Sorana Ciura
- Laboratory of Translational Research for Neurological Disorders, Imagine Institute, Université de Paris, INSERM UMR 1163, 75015, Paris, France
| | - Edor Kabashi
- Laboratory of Translational Research for Neurological Disorders, Imagine Institute, Université de Paris, INSERM UMR 1163, 75015, Paris, France,Corresponding author: Edor Kabashi, Laboratory of Translational Research for Neurological Disorders, Imagine Institute, Université de Paris, INSERM UMR 1163, 75015, Paris, France.
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55
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Yeo CJJ, Simmons Z, De Vivo DC, Darras BT. Ethical Perspectives on Treatment Options with Spinal Muscular Atrophy Patients. Ann Neurol 2022; 91:305-316. [PMID: 34981567 PMCID: PMC9305104 DOI: 10.1002/ana.26299] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/31/2021] [Accepted: 12/31/2021] [Indexed: 11/08/2022]
Abstract
Since 2016, 3 innovative therapies for spinal muscular atrophy (SMA) have changed the face of the disease. Although these therapies often result in remarkable improvements in infants and children, benefits in adults are modest and treatment is not curative. Concerns have been raised about the enormous costs of these medications, the ultimate burden to taxpayers, and the costs to society of withholding treatments and sacrificing or disadvantaging some individuals. Physicians are best positioned to serve our patients by carefully considering the costs, benefits, implications for quality of life (QOL), and the interplay of these factors within the framework of core ethical principles that guide clinical care. ANN NEUROL 2022;91:305–316
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Affiliation(s)
- Crystal J. J. Yeo
- Boston Children’s Hospital, Harvard Medical School Boston MA USA
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen Scotland, UK
- LKC school of Medicine Imperial College London and NTU Singapore
- A*STAR Singapore
- Feinberg School of Medicine, Northwestern University Chicago USA
| | - Zachary Simmons
- Penn State Health Milton S. Hershey Medical Center Hershey PA USA
| | | | - Basil T. Darras
- Boston Children’s Hospital, Harvard Medical School Boston MA USA
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56
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Biomarkers of disease progression in adolescents and adults with 5q spinal muscular atrophy: a systematic review and meta-analysis. Neuromuscul Disord 2022; 32:185-194. [DOI: 10.1016/j.nmd.2021.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/07/2021] [Accepted: 12/29/2021] [Indexed: 12/14/2022]
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Waldrop MA, Connolly AM, Mendell JR. An evaluation of onasemnogene abeparvovec for spinal muscular atrophy (SMN1). Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.2003778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Megan A. Waldrop
- Center for Gene Therapy, Abigail Wexner Research Institute Nationwide Children’s Hospital, Columbus OH USA
- Departments of Pediatrics and Neurology, Wexner Medical Center, Ohio State University, Columbus OH USA
| | - Anne M. Connolly
- Center for Gene Therapy, Abigail Wexner Research Institute Nationwide Children’s Hospital, Columbus OH USA
- Departments of Pediatrics and Neurology, Wexner Medical Center, Ohio State University, Columbus OH USA
| | - Jerry R. Mendell
- Center for Gene Therapy, Abigail Wexner Research Institute Nationwide Children’s Hospital, Columbus OH USA
- Departments of Pediatrics and Neurology, Wexner Medical Center, Ohio State University, Columbus OH USA
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58
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Kariyawasam DST, D'Silva AM, Herbert K, Howells J, Carey K, Kandula T, Farrar MA, Lin CSY. Axonal excitability changes in children with spinal muscular atrophy treated with nusinersen. J Physiol 2021; 600:95-109. [PMID: 34783018 DOI: 10.1113/jp282249] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/05/2021] [Indexed: 11/08/2022] Open
Abstract
Spinal muscular atrophy (SMA) is associated with developmental disruption of motor axons in ventral roots of the spinal cord alongside motor axon degeneration. The pathogenesis of peripheral axonal change during development is pertinent to understand treatment response. Nerve excitability techniques, stimulating the median motor nerve at the wrist, were utilised to investigate axonal change during neurodevelopment in 24 children with SMA, compared with 71 age-matched controls. Longitudinal axonal response to nusinersen treatment in 18 children was also investigated. Significant differences in axonal development were noted in the youngest children with SMA, signified by reduced compound muscle action potential (CMAP) (P = 0.030), higher axonal threshold (P = 0.016), rheobase (minimal current amplitude of infinite duration, required to generate an action potential) (P = 0.012) and greater changes in depolarising and hyperpolarising threshold electrotonus. Subexcitability increased in all children with SMA, compared to controls. With treatment, nerve excitability changes were observed prominently in young children, with increases in CMAP, reduction in axonal threshold, fanning-in of threshold electrotonus, increase in resting current-threshold slope and reduction in subexcitability. Whilst motor axons continue to mature in SMA, developmental delays in passive and active membrane properties occur especially in early childhood. Concurrently, motor axons actively undergo degeneration. Nusinersen restores the developmental trajectory of motor axons reducing degeneration, especially in children with early treatment initiation. Our findings move the field forward in understanding the developmental aspect of childhood-onset motor neurone diseases and changes in axonal function associated with disease modification. KEY POINTS: Pathomechanisms in spinal muscular atrophy involve concurrent neurodevelopmental and neurodegenerative processes. The greatest delays in maturation of the passive and active properties of the peripheral motor axon are seen in early childhood. Nusinersen facilitates developmental recovery of the motor axon whilst also reducing neurodegeneration. Axonal dysfunction is reversed with SMN repletion particularly when intervention occurs early in development.
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Affiliation(s)
- Didu S T Kariyawasam
- Department of Neurology, Randwick, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Arlene M D'Silva
- School of Women's and Children's Health, University of New South Wales Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Karen Herbert
- Department of Physiotherapy, Randwick, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - James Howells
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kate Carey
- School of Women's and Children's Health, University of New South Wales Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tejaswi Kandula
- Department of Neurology, Randwick, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Michelle A Farrar
- Department of Neurology, Randwick, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Cindy Shin-Yi Lin
- Translational Research Collective, Faculty of Medicine and Health, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
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Edinoff AN, Nguyen LH, Odisho AS, Maxey BS, Pruitt JW, Girma B, Cornett EM, Kaye AM, Kaye AD. The Antisense Oligonucleotide Nusinersen for Treatment of Spinal Muscular Atrophy. Orthop Rev (Pavia) 2021; 13:24934. [PMID: 34745470 DOI: 10.52965/001c.24934] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/17/2021] [Indexed: 01/25/2023] Open
Abstract
Spinal muscular atrophy (SMA) is a rare, autosomal recessive neuromuscular degenerative disease characterized by loss of spinal cord motor neurons leading to progressive muscle wasting. The most common pathology results from a homozygous disruption in the survival motor neuron 1 (SMN1) gene on chromosome 5q13 via deletion, conversion, or mutation. SMN2 is a near duplicate of SMN1 that can produce full-length SMN mRNA transcripts, but its overall production capability of these mRNA transcripts is lower than that seen in SMN1. This leads to lower levels of functional SMN protein within motor neurons. The FDA approved nusinersen in December 2016 to treat SMA associated with SMN1 gene mutation. It is administered directly to the central nervous system by intrathecal injection. An antisense oligonucleotide (ASO) drug, nusinersen, provides an upcoming and promising treatment option for SMA and represents a novel pharmacological approach with a mechanism of action relevant for other neurodegenerative disorders. Nusinersen begins with four initial loading doses that are followed by three maintenance doses per year. Three major studies (CHERISH, ENDEAR, and NURTURE) have shown to improve motor function in early and late-onset individuals and reduce the chances of ventilator requirements in pre-symptomatic infants. Studies investigating the timing of drug delivery in mouse models of SMA report the best outcomes when drugs are delivered early before any significant motor function is lost. Nusinersen is a novel therapeutic approach with consistent results in all three studies and is proof of the novel concept for treating SMA and other neurodegenerative disorders in the future.
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Affiliation(s)
| | - Long H Nguyen
- Louisiana State University Health Science Center Shreveport
| | - Amira S Odisho
- Louisiana State University Health Science Center Shreveport
| | | | - John W Pruitt
- Louisiana State University Health Science Center Shreveport
| | - Brook Girma
- Louisiana State University Health Science Center Shreveport
| | | | - Adam M Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Louisiana State University Health Science Center Shreveport
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Rich KA, Fox A, Yalvac M, Heintzman S, Tellez M, Bartlett A, Severyn S, Linsenmayer M, Kelly K, Reynolds J, Sterling GB, Weaver T, Rajneesh K, Pino MG, Arnold WD, Elsheikh B, Kolb SJ. Neurofilament Levels in CSF and Serum in an Adult SMA Cohort Treated with Nusinersen. J Neuromuscul Dis 2021; 9:111-119. [PMID: 34776417 DOI: 10.3233/jnd-210735] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To retrospectively evaluate the utility of serum and cerebrospinal fluid (CSF) levels of neurofilament light chain (NfL) and phosphorylated neurofilament heavy chain (pNfH) as biomarkers for spinal muscular atrophy (SMA) progression and response to nusinersen treatment. METHODS NfL and pNfH levels were quantified using single molecular array (SIMOA) in CSF of 33 adult SMA patients (SMN copy number 3-5) before and in response to nusinersen treatment. In 11 of the patients, blood serum samples were also collected. CSF NfL and pNfH from patients were compared to CSF Nfs from age-matched controls without neurological disease (n = 6). For patients, pearson correlation coefficients (r) were calculated to investigate associations between Nf levels and other functional outcome measures. RESULTS Nf levels were similar between SMA and control adults and showed no change in response to nusinersen treatment in CSF or serum. Cross-sectional analyses showed an increase in CSF NfL and pNfH with age in patients (NfL p = 0.0013; pNfH p = 0.0035) and an increase in CSF NfL in controls (p = 0.002). In non-ambulatory patients, baseline serum pNfH showed a negative correlation with multiple strength and functional assessment metrics including Revised Upper Limb Module (r = -0.822, p = 0.04), upper extremity strength (r = -0.828, p = 0.042), lower extremity strength (r = -0.860, p = 0.028), and total strength (r = -0.870, p = 0.024). CONCLUSIONS Nf levels did not change in response to nusinersen in adults with SMA and were not different from controls. In patients and controls, we detected an age-related increase in baseline CSF NfL and pNfH levels. Though some associations were identified, our results suggest Nf levels are not preditive or prognostic biomarkers in this population.
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Affiliation(s)
- Kelly A Rich
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Ashley Fox
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Mehmet Yalvac
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Sarah Heintzman
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Marco Tellez
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Amy Bartlett
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Steven Severyn
- Department of Anesthesiology, The Ohio StateUniversity Wexner Medical Center, Columbus, OH, USA
| | - Mathew Linsenmayer
- Assistive Technology Department, The Ohio StateUniversity Wexner Medical Center, Columbus, OH, USA
| | - Kristina Kelly
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Jerry Reynolds
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Gary Brent Sterling
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Tristan Weaver
- Department of Anesthesiology, The Ohio StateUniversity Wexner Medical Center, Columbus, OH, USA
| | - Kiran Rajneesh
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Megan G Pino
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - W David Arnold
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Bakri Elsheikh
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA
| | - Stephen J Kolb
- Department of Neurology, The Ohio State UniversityWexner Medical Center, Columbus, OH, USA.,Department of Biological Chemistry &Pharmacology, The Ohio State University, Columbus, OH, USA
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61
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Kotulska K, Fattal-Valevski A, Haberlova J. Recombinant Adeno-Associated Virus Serotype 9 Gene Therapy in Spinal Muscular Atrophy. Front Neurol 2021; 12:726468. [PMID: 34721262 PMCID: PMC8548432 DOI: 10.3389/fneur.2021.726468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/17/2021] [Indexed: 11/14/2022] Open
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease caused by deletion or mutation of the SMN1 gene. It is characterized by a progressive loss of motor neurons resulting in muscle weakness. The disease affects 1 in 11,000 live births and before the era of treatment SMA was a leading genetic cause of mortality in infants. Recently, disease modifying therapies have been introduced in clinical practice. They include intrathecal and oral antisense oligonucleotides binding to pre-mRNA of SMN2 gene and increasing the translation of fully functional SMN protein as well as SMN1 gene replacement therapy. Onasemnogene abeparvovec uses the adeno-associated virus 9 (AAV9) vector to deliver the SMN1 gene. Phase 1 and phase 3 clinical trials showed that a single administration of onasemnogene abeparvovec resulted in improvement of motor functions in the majority of infants with SMA. Currently, phase 3 trials in SMA1 and SMA2 patients, as well as presymptomatic infants diagnosed with SMA, are ongoing. The drug was approved for medical use in the US in 2019, and in Japan and the European Union in 2020. Thus, first real-world data on efficacy and safety of onasemnogene abeparvovec in SMA patients are available.
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Affiliation(s)
- Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Aviva Fattal-Valevski
- Pediatric Neurology Institute, "Dana-Dwek" Children Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Jana Haberlova
- Neuromuscular Center, Department of Pediatric Neurology, Faculty Hospital Motol, 2nd School of Medicine Charles University, Prague, Czechia
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Kray KM, McGovern VL, Chugh D, Arnold WD, Burghes AHM. Dual SMN inducing therapies can rescue survival and motor unit function in symptomatic ∆7SMA mice. Neurobiol Dis 2021; 159:105488. [PMID: 34425216 PMCID: PMC8502210 DOI: 10.1016/j.nbd.2021.105488] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/06/2021] [Accepted: 08/16/2021] [Indexed: 11/24/2022] Open
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive disease characterized by survival motor neuron (SMN) protein deficiency which results in motor neuron loss and muscle atrophy. SMA is caused by a mutation or deletion of the survival motor neuron 1 (SMN1) gene and retention of the nearly identical SMN2 gene. SMN2 contains a C to T change in exon 7 that results in exon 7 exclusion from 90% of transcripts. SMN protein lacking exon 7 is unstable and rapidly degraded. The remaining full-length transcripts from SMN2 are insufficient for normal motor neuron function leading to the development of SMA. Three different therapeutic approaches that increase full-length SMN (FL-SMN) protein production are approved for treatment of SMA patients. Studies in both animal models and humans have demonstrated increasing SMN levels prior to onset of symptoms provides the greatest therapeutic benefit. Treatment of SMA, after some motor neuron loss has occurred, is also effective but to a lesser degree. The SMN∆7 mouse model is a well characterized model of severe or type 1 SMA, dying at 14 days of age. Here we treated three groups of ∆7SMA mice starting before, roughly during, and after symptom onset to determine if combining two mechanistically distinct SMN inducing therapies could improve the therapeutic outcome both before and after motor neuron loss. We found, compared with individual therapies, that morpholino antisense oligonucleotide (ASO) directed against ISS-N1 combined with the small molecule compound RG7800 significantly increased FL-SMN transcript and protein production resulting in improved survival and weight of ∆7SMA mice. Moreover, when give late symptomatically, motor unit function was completely rescued with no loss in function at 100 days of age in the dual treatment group. We have therefore shown that this dual therapeutic approach successfully increases SMN protein and rescues motor function in symptomatic ∆7SMA mice.
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Affiliation(s)
- Kaitlyn M Kray
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 1060 Carmack Road, Columbus, OH 43210, USA.
| | - Vicki L McGovern
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 1060 Carmack Road, Columbus, OH 43210, USA.
| | - Deepti Chugh
- Department of Neurology, Neuromuscular Division, The Ohio State University Wexner Medical Center, 395 W. 12(th) Ave, Columbus, OH 43210, USA
| | - W David Arnold
- Department of Neurology, Neuromuscular Division, The Ohio State University Wexner Medical Center, 395 W. 12(th) Ave, Columbus, OH 43210, USA.
| | - Arthur H M Burghes
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 1060 Carmack Road, Columbus, OH 43210, USA; Department of Neurology, Neuromuscular Division, The Ohio State University Wexner Medical Center, 395 W. 12(th) Ave, Columbus, OH 43210, USA.
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63
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Alves CR, Petrillo M, Spellman R, Garner R, Zhang R, Kiefer M, Simeone S, Sohn J, Eichelberger EJ, Rodrigues E, Arruda EA, Townsend EL, Farwell W, Swoboda KJ. Implications of circulating neurofilaments for spinal muscular atrophy treatment early in life: A case series. Mol Ther Methods Clin Dev 2021; 23:524-538. [PMID: 34853799 PMCID: PMC8605296 DOI: 10.1016/j.omtm.2021.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/06/2021] [Accepted: 10/26/2021] [Indexed: 12/17/2022]
Abstract
This longitudinal cohort study aimed to determine whether circulating neurofilaments (NFs) can monitor response to molecular therapies in newborns with spinal muscular atrophy (SMA; NCT02831296). We applied a mixed-effect model to examine differences in serum NF levels among healthy control infants (n = 13), untreated SMA infants (n = 68), and SMA infants who received the genetic therapies nusinersen and/or onasemnogene abeparvovec (n = 22). Increased NF levels were inversely associated with SMN2 copy number. SMA infants treated with either nusinersen or onasemnogene abeparvovec achieved important motor milestones not observed in the untreated cohort. NF levels declined more rapidly in the nusinersen cohort as compared with the untreated cohort. Unexpectedly, those receiving onasemnogene abeparvovec monotherapy showed a significant rise in NF levels regardless of SMN2 copy number. In contrast, symptomatic SMA infants who received nusinersen, followed by onasemnogene abeparvovec within a short interval after, did not show an elevation in NF levels. While NF cannot be used as the single marker to predict outcomes, the elevated NF levels observed with onasemnogene abeparvovec and its absence in infants treated first with nusinersen may indicate a protective effect of co-therapy during a critical period of vulnerability to acute denervation.
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Affiliation(s)
- Christiano R.R. Alves
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marco Petrillo
- Biogen, Cambridge, MA, USA
- Takeda Pharmaceuticals, Lexington, MA, USA
| | - Rebecca Spellman
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Reid Garner
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ren Zhang
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Kiefer
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA
| | - Sarah Simeone
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Eric J. Eichelberger
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Emma Rodrigues
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A. Arruda
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Elise L. Townsend
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, MA, USA
| | | | - Kathryn J. Swoboda
- Department of Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Corresponding author: Kathryn J. Swoboda, MD, Massachusetts General Hospital, Center for Genomic Medicine, 185 Cambridge Street, Boston, MA 02114, USA.
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Theil D, Valdez R, Darribat K, Doelemeyer A, Sivasankaran R, Hartmann A. Orally administered branaplam does not impact neurogenesis in juvenile mice, rats, and dogs. Biol Open 2021; 10:272197. [PMID: 34528068 PMCID: PMC8565466 DOI: 10.1242/bio.058551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 09/08/2021] [Indexed: 12/05/2022] Open
Abstract
Branaplam is a therapeutic agent currently in clinical development for the treatment of infants with type 1 spinal muscular atrophy (SMA). Since preclinical studies showed that branaplam had cell-cycle arrest effects, we sought to determine whether branaplam may affect postnatal cerebellar development and brain neurogenesis. Here, we describe a novel approach for developmental neurotoxicity testing (DNT) of a central nervous system (CNS) active drug. The effects of orally administered branaplam were evaluated in the SMA neonatal mouse model (SMNΔ7), and in juvenile Wistar Hannover rats and Beagle dogs. Histopathological examination and complementary immunohistochemical studies focused on areas of neurogenesis in the cerebellum (mice, rats, and dogs), and the subventricular zone of the striatum and dentate gyrus (rats and dogs) using antibodies directed against Ki67, phosphorylated histone H3, cleaved caspase-3, and glial fibrillary acidic protein. Additionally, image-analysis based quantification of calbindin-D28k and Ki67 was performed in rats and dogs. The patterns of cell proliferation and apoptosis, and neural migration and innervation in the cerebellum and other brain regions of active adult neurogenesis did not differ between branaplam- and control-treated animals. Quantitative image analysis did not reveal any changes in calbindin-D28k and Ki67 expression in rats and dogs. The data show that orally administered branaplam has no impact on neurogenesis in juvenile animals. Application of selected immunohistochemical stainings in combination with quantitative image analysis on a few critical areas of postnatal CNS development offer a reliable approach to assess DNT of CNS-active drug candidates in juvenile animal toxicity studies. Summary: Branaplam exhibits effects on the cell cycle but does not impair neuronal proliferation in juvenile or young adult animals, as demonstrated by immunohistochemistry and automated digital imaging.
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Affiliation(s)
- Diethilde Theil
- Translation medicine/preclinical safety, Novartis Institutes for Biomedical Research, Basel 4058, Switzerland
| | - Reginald Valdez
- Neuroscience/rare diseases, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Katy Darribat
- Translation medicine/preclinical safety, Novartis Institutes for Biomedical Research, Basel 4058, Switzerland
| | - Arno Doelemeyer
- Translation medicine/preclinical safety, Novartis Institutes for Biomedical Research, Basel 4058, Switzerland
| | - Rajeev Sivasankaran
- Neuroscience/rare diseases, Novartis Institutes for Biomedical Research, Cambridge, MA 02139, USA
| | - Andreas Hartmann
- Translation medicine/preclinical safety, Novartis Institutes for Biomedical Research, Basel 4058, Switzerland
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Thomsen G, Burghes AHM, Hsieh C, Do J, Chu BTT, Perry S, Barkho B, Kaufmann P, Sproule DM, Feltner DE, Chung WK, McGovern VL, Hevner RF, Conces M, Pierson CR, Scoto M, Muntoni F, Mendell JR, Foust KD. Biodistribution of onasemnogene abeparvovec DNA, mRNA and SMN protein in human tissue. Nat Med 2021; 27:1701-1711. [PMID: 34608334 DOI: 10.1038/s41591-021-01483-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
Spinal muscular atrophy type 1 (SMA1) is a debilitating neurodegenerative disease resulting from survival motor neuron 1 gene (SMN1) deletion/mutation. Onasemnogene abeparvovec (formerly AVXS-101) is a gene therapy that restores SMN production via one-time systemic administration. The present study demonstrates widespread biodistribution of vector genomes and transgenes throughout the central nervous system (CNS) and peripheral organs, after intravenous administration of an AAV9-mediated gene therapy. Two symptomatic infants with SMA1 enrolled in phase III studies received onasemnogene abeparvovec. Both patients died of respiratory complications unrelated to onasemnogene abeparvovec. One patient had improved motor function and the other died shortly after administration before appreciable clinical benefit could be observed. In both patients, onasemnogene abeparvovec DNA and messenger RNA distribution were widespread among peripheral organs and in the CNS. The greatest concentration of vector genomes was detected in the liver, with an increase over that detected in CNS tissues of 300-1,000-fold. SMN protein, which was low in an untreated SMA1 control, was clearly detectable in motor neurons, brain, skeletal muscle and multiple peripheral organs in treated patients. These data support the fact that onasemnogene abeparvovec has effective distribution, transduction and expression throughout the CNS after intravenous administration and restores SMN expression in humans.
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Affiliation(s)
| | - Arthur H M Burghes
- Department of Neurology, The Ohio State University, Columbus, OH, USA. .,Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH, USA.
| | | | - Janet Do
- Novartis Gene Therapies, Bannockburn, IL, USA
| | | | | | | | | | | | | | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY, USA
| | - Vicki L McGovern
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH, USA
| | - Robert F Hevner
- Department of Pathology, University of California, San Diego, CA, USA
| | - Miriam Conces
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Christopher R Pierson
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Mariacristina Scoto
- National Institute for Health Research, Great Ormond Street Institute of Child Health Biomedical Research Centre, University College London, London, UK.,Great Ormond Street Hospital Trust, London, UK
| | - Francesco Muntoni
- National Institute for Health Research, Great Ormond Street Institute of Child Health Biomedical Research Centre, University College London, London, UK.,Great Ormond Street Hospital Trust, London, UK
| | - Jerry R Mendell
- Department of Neurology, The Ohio State University, Columbus, OH, USA.,Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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66
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Arnold WD, Severyn S, Zhao S, Kline D, Linsenmayer M, Kelly K, Tellez M, Bartlett A, Heintzman S, Reynolds J, Sterling G, Weaver T, Rajneesh K, Burghes AHM, Kolb SJ, Elsheikh B. Persistent neuromuscular junction transmission defects in adults with spinal muscular atrophy treated with nusinersen. BMJ Neurol Open 2021; 3:e000164. [PMID: 34466806 PMCID: PMC8362737 DOI: 10.1136/bmjno-2021-000164] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022] Open
Abstract
Objective Spinal muscular atrophy (SMA) is a motor neuron disease caused by low levels of survival motor neuron (SMN) protein. Prior work in models and patients has demonstrated electrophysiological and morphological defects at the neuromuscular junction (NMJ). Therapeutic development has resulted in clinically available therapies to increase SMN protein levels in patients and improve muscle function. Here we aimed to investigate the effect of SMN restoration (via nusinersen) on NMJ transmission in adults with SMA. Methods Participants undergoing nusinersen treatment underwent 3 Hz repetitive nerve stimulation (RNS) of the spinal accessory nerve to assess compound muscle action potential amplitude decrement. Maximum voluntary isometric contraction (MVICT), Revised Upper Limb Module (RULM), and 6 min walk test (6MWT) were assessed for correlations with decrement. Results Data from 13 ambulatory (7 men/6 women, mean age 40±11 years) and 11 non-ambulatory (3 men/8 women, mean age 38±12 years) participants were analysed. Cross-sectional analyses of RNS decrement were similar at 14 months of nusinersen (−14.2%±11.5%, n=17) vs baseline (−11.9%±8.3%, n=15) (unpaired t-test, p=0.5202). Longitudinal comparison of decrement in eight participants showed no change at 14 months (−13.9%±6.7%) vs baseline (−16.9%±13.4%) (paired t-test, p=0.5863). Decrement showed strong correlations with measures of MVICT, RULM and 6MWT but not age or disease duration. Conclusion Adults with SMA had significant NMJ transmission defects that were not corrected with 14 months of nusinersen treatment. NMJ defects were negatively associated with physical function, and thus may represent a promising target for additive or combinatorial treatments.
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Affiliation(s)
- W David Arnold
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven Severyn
- Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Songzhu Zhao
- Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - David Kline
- Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Matthew Linsenmayer
- Assistive Technology Department, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kristina Kelly
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marco Tellez
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Amy Bartlett
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sarah Heintzman
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jerry Reynolds
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Gary Sterling
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tristan Weaver
- Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kiran Rajneesh
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Arthur H M Burghes
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, Ohio, USA
| | - Stephen J Kolb
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, Ohio, USA
| | - Bakri Elsheikh
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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67
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Klotz J, Tesi Rocha C, Dunaway Young S, Duong T, Buu M, Sampson J, Day JW. Advances in the Therapy of Spinal Muscular Atrophy. J Pediatr 2021; 236:13-20.e1. [PMID: 34197889 DOI: 10.1016/j.jpeds.2021.06.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Jenna Klotz
- Stanford University School of Medicine, Palo Alto, CA.
| | | | | | - Tina Duong
- Stanford University School of Medicine, Palo Alto, CA
| | - MyMy Buu
- Stanford University School of Medicine, Palo Alto, CA
| | | | - John W Day
- Stanford University School of Medicine, Palo Alto, CA
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68
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McGovern VL, Kray KM, Arnold WD, Duque SI, Iyer CC, Massoni-Laporte A, Workman E, Patel A, Battle DJ, Burghes AHM. Intragenic complementation of amino and carboxy terminal SMN missense mutations can rescue Smn null mice. Hum Mol Genet 2021; 29:3493-3503. [PMID: 33084884 DOI: 10.1093/hmg/ddaa235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/18/2020] [Accepted: 10/15/2020] [Indexed: 01/15/2023] Open
Abstract
Spinal muscular atrophy is caused by reduced levels of SMN resulting from the loss of SMN1 and reliance on SMN2 for the production of SMN. Loss of SMN entirely is embryonic lethal in mammals. There are several SMN missense mutations found in humans. These alleles do not show partial function in the absence of wild-type SMN and cannot rescue a null Smn allele in mice. However, these human SMN missense allele transgenes can rescue a null Smn allele when SMN2 is present. We find that the N- and C-terminal regions constitute two independent domains of SMN that can be separated genetically and undergo intragenic complementation. These SMN protein heteromers restore snRNP assembly of Sm proteins onto snRNA and completely rescue both survival of Smn null mice and motor neuron electrophysiology demonstrating that the essential functional unit of SMN is the oligomer.
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Affiliation(s)
- Vicki L McGovern
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - Kaitlyn M Kray
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - W David Arnold
- Department of Neurology, The Ohio State University, Columbus, OH 43210, USA
| | - Sandra I Duque
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - Chitra C Iyer
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - Aurélie Massoni-Laporte
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - Eileen Workman
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - Aalapi Patel
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA
| | - Daniel J Battle
- Department of Biological Chemistry, The Ohio State University, Columbus, OH 43210, USA
| | - Arthur H M Burghes
- Department of Biological Chemistry and Pharmacology, The Ohio State University, Columbus, OH 43210, USA.,Department of Neurology, The Ohio State University, Columbus, OH 43210, USA.,Department of Molecular Genetics, The Ohio State University, Columbus, OH 43210, USA
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69
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Pino MG, Rich KA, Kolb SJ. Update on Biomarkers in Spinal Muscular Atrophy. Biomark Insights 2021; 16:11772719211035643. [PMID: 34421296 PMCID: PMC8371741 DOI: 10.1177/11772719211035643] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022] Open
Abstract
The availability of disease modifying therapies for spinal muscular atrophy (SMA) has created an urgent need to identify clinically meaningful biomarkers. Biomarkers present a means to measure and evaluate neurological disease across time. Changes in biomarkers provide insight into disease progression and may reveal biologic, physiologic, or pharmacologic phenomena occurring prior to clinical detection. Efforts to identify biomarkers for SMA, a genetic motor neuron disease characterized by motor neuron degeneration and weakness, have culminated in a number of putative molecular and physiologic markers that evaluate biological media (eg, blood and cerebrospinal fluid [CSF]) or nervous system function. Such biomarkers include SMN2 copy number, SMN mRNA and protein levels, neurofilament proteins (NFs), plasma protein analytes, creatine kinase (CK) and creatinine (Crn), and various electrophysiology and imaging measures. SMN2 copy number inversely correlates with disease severity and is the best predictor of clinical outcome in untreated individuals. SMN mRNA and protein are commonly measured in the blood or CSF of patients receiving SMA therapies, particularly those aimed at increasing SMN protein expression, and provide insight into current disease state. NFs have proven to be robust prognostic, disease progression, and pharmacodynamic markers for SMA infants undergoing treatment, but less so for adolescents and adults. Select plasma proteins are altered in SMA individuals and may track response to therapy. CK and Crn from blood correlate with motor function and disease severity status and are useful for predicting which individuals will respond to therapy. Electrophysiology measures comprise the most reliable means for monitoring motor function throughout disease course and are sensitive enough to detect neuromuscular changes before overt clinical manifestation, making them robust predictive and pharmacodynamic biomarkers. Finally, magnetic resonance imaging and muscle ultrasonography are non-invasive techniques for studying muscle structure and physiology and are useful diagnostic tools, but cannot reliably track disease progression. Importantly, biomarkers can provide information about the underlying mechanisms of disease as well as reveal subclinical disease progression, allowing for more appropriate timing and dosing of therapy for individuals with SMA. Recent therapeutic advancements in SMA have shown promising results, though there is still a great need to identify and understand the impact of biomarkers in modulating disease onset and progression.
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Affiliation(s)
- Megan G Pino
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Kelly A Rich
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Stephen J Kolb
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
- Department of Biological Chemistry and
Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH,
USA
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Romanelli Tavares VL, Monfardini F, Lourenço NCV, da Rocha KM, Weinmann K, Pavanello R, Zatz M. Newborn Screening for 5q Spinal Muscular Atrophy: Comparisons between Real-Time PCR Methodologies and Cost Estimations for Future Implementation Programs. Int J Neonatal Screen 2021; 7:ijns7030053. [PMID: 34449526 PMCID: PMC8396021 DOI: 10.3390/ijns7030053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/15/2021] [Accepted: 08/05/2021] [Indexed: 01/09/2023] Open
Abstract
Since the approval of modifying therapies for Spinal Muscular Atrophy (SMA), several protocols aiming to screen SMN1 homozygous deletion in a neonatal context have been published. However, no work has compared different methodologies along with detailed implementation costs for centers where the neonatal screening of SMA has not yet been implemented. Therefore, our work compared different qualitative real-time PCR approaches for SMA screening and the estimated costs of test implementation. Using Brazilian blood samples, the presence and absence (P/A) and melt curve protocols were analyzed. MLPA was used as a confirmatory test. The costs were calculated for the simplex and multiplex tests plus equipment. The test workflow was based on the present experience and literature report. The accuracy of the P/A protocol was 1 (95% CI 0.8677-1) using dried blood spots (DBS). The melt curve protocol also achieved 100% concordance. The consumable costs ranged from USD 1.68 to 4.42 and from USD 2.04 to 12.76 per reaction, for the simplex and multiplex tests, respectively. The equipment acquisition costs ranged from USD 44,817.07 to 467,253.10, with several factors influencing this value presented. Our work presents a framework for decision-making, with a project demonstration of the different assays that will be useful in dealing with the issues of cost and availability of reagents. Moreover, we present a literature review and discussion of important concerns regarding treatment policies. We take the first step towards a future SMA NBS pilot program where it is not yet a reality.
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Abstract
PURPOSE OF REVIEW This article provides an overview of the pathophysiology and clinical presentations of spinal muscular atrophy (SMA) and reviews therapeutic developments, including US Food and Drug Administration (FDA)-approved gene-targeted therapies and mainstays of supportive SMA care. RECENT FINDINGS Over the past decades, an understanding of the role of SMN protein in the development and maintenance of the motor unit and the intricate genetics underlying SMA has led to striking developments in therapeutics with three FDA-approved treatments for SMA, one targeting SMN1 gene replacement (onasemnogene abeparvovec-xioi) and two others enhancing SMN protein production from the SMN2 gene (nusinersen and risdiplam). These therapies are most effective in infants treated at younger ages, and improvement is most striking in babies treated as neonates. Despite improvements in motor function, patients (especially those treated at older ages) continue to experience significant weakness and require continued close monitoring of respiratory and orthopedic symptoms. SUMMARY Striking therapeutic advancements have changed the clinical course of SMA dramatically, although supportive care continues to play an important role in patient care.
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72
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Butchbach MER. Genomic Variability in the Survival Motor Neuron Genes ( SMN1 and SMN2): Implications for Spinal Muscular Atrophy Phenotype and Therapeutics Development. Int J Mol Sci 2021; 22:ijms22157896. [PMID: 34360669 PMCID: PMC8348669 DOI: 10.3390/ijms22157896] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 02/07/2023] Open
Abstract
Spinal muscular atrophy (SMA) is a leading genetic cause of infant death worldwide that is characterized by loss of spinal motor neurons leading to muscle weakness and atrophy. SMA results from the loss of survival motor neuron 1 (SMN1) gene but retention of its paralog SMN2. The copy numbers of SMN1 and SMN2 are variable within the human population with SMN2 copy number inversely correlating with SMA severity. Current therapeutic options for SMA focus on increasing SMN2 expression and alternative splicing so as to increase the amount of SMN protein. Recent work has demonstrated that not all SMN2, or SMN1, genes are equivalent and there is a high degree of genomic heterogeneity with respect to the SMN genes. Because SMA is now an actionable disease with SMN2 being the primary target, it is imperative to have a comprehensive understanding of this genomic heterogeneity with respect to hybrid SMN1–SMN2 genes generated by gene conversion events as well as partial deletions of the SMN genes. This review will describe this genetic heterogeneity in SMA and its impact on disease phenotype as well as therapeutic efficacy.
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Affiliation(s)
- Matthew E. R. Butchbach
- Center for Applied Clinical Genomics, Nemours Children’s Health Delaware, Wilmington, DE 19803, USA;
- Center for Pediatric Research, Nemours Children’s Health Delaware, Wilmington, DE 19803, USA
- Department of Biological Sciences, University of Delaware, Newark, DE 19716, USA
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Boulay C, Delmont E, Audic F, Chabrol B, Attarian S. Motor unit number index: A potential electrophysiological biomarker for pediatric spinal muscular atrophy. Muscle Nerve 2021; 64:445-453. [PMID: 34255873 DOI: 10.1002/mus.27372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIMS In adult spinal muscular atrophy (SMA), the motor unit number index (MUNIX) has been shown to be an useful electrophysiological biomarker. This study evaluated the feasibility and the clinical relevance of using the MUNIX technique for patients with pediatric SMA (Ped-SMA) and correlated MUNIX results with clinical scores. METHODS Fourteen patients with type II Ped-SMA (11 females; median age 11 y [interquartile range (IQR), 4.8-17 y]) and 14 controls (nine females; median age 10.75 y [IQR, 6.5-13.4 y]) were enrolled and matched by sex, age, height, weight, and body mass index. Clinical examination included manual muscle testing, dynamometry (grasp and pinch), and motor function measure (MFM). The MUNIX technique was evaluated in the abductor digiti minimi (ADM) and abductor pollicis brevis (APB) on two sides when possible. RESULTS In the patients with Ped-SMA, the MUNIX and compound muscle action potential (CMAP) amplitudes were significantly decreased and the motor size unit index (MUSIX) was significantly increased in the ADM and APB when compared to controls. The intraclass correlation coefficient was good for the intrarater variability of the CMAP amplitude, MUNIX, and MUSIX in the ADM (0.95, 0.83, and 0.89, respectively) and the APB (0.98, 0.96, and 0.94, respectively). The total CMAP amplitude correlated with the grasp and pinch scores (P < .05), and the MUNIX measurements correlated with the MFM scores. DISCUSSION The MUNIX technique, which accurately estimated lower motor neuron loss and the number of remaining functional motor units, was shown to be a useful electrophysiological biomarker for disease progression and a potential biomarker for treatment response.
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Affiliation(s)
- Christophe Boulay
- Neuropediatric Department, Children Timone University Hospital, Aix-Marseille University, Marseille, France.,Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Emilien Delmont
- Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, UMR 7286, Medicine Faculty, Marseille, France
| | - Frédérique Audic
- Neuropediatric Department, Children Timone University Hospital, Aix-Marseille University, Marseille, France.,Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Brigitte Chabrol
- Neuropediatric Department, Children Timone University Hospital, Aix-Marseille University, Marseille, France.,Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, Inserm UMR S 910, Medical Genetics and Functional Genomics, Marseille, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, Inserm UMR S 910, Medical Genetics and Functional Genomics, Marseille, France
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Kong L, Valdivia DO, Simon CM, Hassinan CW, Delestrée N, Ramos DM, Park JH, Pilato CM, Xu X, Crowder M, Grzyb CC, King ZA, Petrillo M, Swoboda KJ, Davis C, Lutz CM, Stephan AH, Zhao X, Weetall M, Naryshkin NA, Crawford TO, Mentis GZ, Sumner CJ. Impaired prenatal motor axon development necessitates early therapeutic intervention in severe SMA. Sci Transl Med 2021; 13:13/578/eabb6871. [PMID: 33504650 DOI: 10.1126/scitranslmed.abb6871] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 09/18/2020] [Indexed: 12/21/2022]
Abstract
Gene replacement and pre-mRNA splicing modifier therapies represent breakthrough gene targeting treatments for the neuromuscular disease spinal muscular atrophy (SMA), but mechanisms underlying variable efficacy of treatment are incompletely understood. Our examination of severe infantile onset human SMA tissues obtained at expedited autopsy revealed persistence of developmentally immature motor neuron axons, many of which are actively degenerating. We identified similar features in a mouse model of severe SMA, in which impaired radial growth and Schwann cell ensheathment of motor axons began during embryogenesis and resulted in reduced acquisition of myelinated axons that impeded motor axon function neonatally. Axons that failed to ensheath degenerated rapidly postnatally, specifically releasing neurofilament light chain protein into the blood. Genetic restoration of survival motor neuron protein (SMN) expression in mouse motor neurons, but not in Schwann cells or muscle, improved SMA motor axon development and maintenance. Treatment with small-molecule SMN2 splice modifiers beginning immediately after birth in mice increased radial growth of the already myelinated axons, but in utero treatment was required to restore axonal growth and associated maturation, prevent subsequent neonatal axon degeneration, and enhance motor axon function. Together, these data reveal a cellular basis for the fulminant neonatal worsening of patients with infantile onset SMA and identify a temporal window for more effective treatment. These findings suggest that minimizing treatment delay is critical to achieve optimal therapeutic efficacy.
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Affiliation(s)
- Lingling Kong
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - David O Valdivia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Christian M Simon
- Center for Motor Neuron Biology and Disease, Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
| | - Cera W Hassinan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Nicolas Delestrée
- Center for Motor Neuron Biology and Disease, Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA
| | - Daniel M Ramos
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jae Hong Park
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Celeste M Pilato
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Xixi Xu
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Melissa Crowder
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chloe C Grzyb
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Zachary A King
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | | | - Kathryn J Swoboda
- Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Crystal Davis
- Genetic Resource Science, The Jackson Laboratory, Bar Harbor, ME 04609, USA
| | - Cathleen M Lutz
- Genetic Resource Science, The Jackson Laboratory, Bar Harbor, ME 04609, USA
| | - Alexander H Stephan
- F. Hoffmann-La Roche Ltd., pRED, Pharma & Early Development, Roche Innovation Center Basel, Basel CH-4070, Switzerland
| | - Xin Zhao
- PTC Therapeutics, 100 Corporate Court, South Plainfield, NJ 07080, USA
| | - Marla Weetall
- PTC Therapeutics, 100 Corporate Court, South Plainfield, NJ 07080, USA
| | | | - Thomas O Crawford
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - George Z Mentis
- Center for Motor Neuron Biology and Disease, Department of Pathology and Cell Biology, Columbia University, New York, NY 10032, USA.,Department of Neurology, Columbia University, New York, NY 10032, USA
| | - Charlotte J Sumner
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA. .,Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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75
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Butterfield RJ. Spinal Muscular Atrophy Treatments, Newborn Screening, and the Creation of a Neurogenetics Urgency. Semin Pediatr Neurol 2021; 38:100899. [PMID: 34183144 PMCID: PMC8243405 DOI: 10.1016/j.spen.2021.100899] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
Spinal muscular atrophy (SMA) is a progressive neuromuscular disorder characterized by loss of motor neurons leading to muscle weakness and atrophy. The United States' Food and Drug Administration's (FDA) approval of nusinersen, onasemnogene abeparvovec, and risdiplam for SMA has challenged existing treatment paradigms with multiple treatment options, a new natural history of the disease, and an emerging understanding of the importance of early and pre-symptomatic treatment. The profound impact of early, pre-symptomatic treatment has led to the creation of a neurogenetics urgency for newly identified patients with SMA, a novel problem for neurologists more accustomed to a more methodical approach to diagnosis and care. Implementation of newborn screening programs has helped facilitate early diagnosis and treatment, but challenges remain in overcoming administrative and procedural hurdles that can lead to treatment delays. Herein I discuss 2 cases that highlight the importance of early treatment, as well as gaps in our understanding of the progression of SMA in pre-symptomatic infants.
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McMillan HJ, Kernohan KD, Yeh E, Amburgey K, Boyd J, Campbell C, Dowling JJ, Gonorazky H, Marcadier J, Tarnopolsky MA, Vajsar J, MacKenzie A, Chakraborty P. Newborn Screening for Spinal Muscular Atrophy: Ontario Testing and Follow-up Recommendations. Can J Neurol Sci 2021; 48:504-511. [PMID: 33059774 DOI: 10.1017/cjn.2020.229] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is characterized by the progressive loss of motor neurons causing muscle atrophy and weakness. Nusinersen, the first effective SMA therapy was approved by Health Canada in June 2017 and has been added to the provincial formulary of all but one Canadian province. Access to this effective therapy has triggered the inclusion of SMA in an increasing number of Newborn Screening (NBS) programs. However, the range of disease-modifying SMN2 gene copy numbers encountered in survival motor neuron 1 (SMN1)-null individuals means that neither screen-positive definition nor resulting treatment decisions can be determined by SMN1 genotype alone. We outline an approach to this challenge, one that specifically addresses the case of SMA newborns with four copies of SMN2. OBJECTIVES To develop a standardized post-referral evaluation pathway for babies with a positive SMA NBS screen result. METHODS An SMA NBS pilot trial in Ontario using first-tier MassARRAY and second-tier multi-ligand probe amplification (MLPA) was launched in January 2020. Prior to this, Ontario pediatric neuromuscular disease and NBS experts met to review the evidence regarding the diagnosis and treatment of children with SMA as it pertained to NBS. A post-referral evaluation algorithm was developed, outlining timelines for patient retrieval and management. CONCLUSIONS Ontario's pilot NBS program has created a standardized path to facilitate early diagnosis of SMA and initiation of treatment. The goal is to provide timely access to those SMA infants in need of therapy to optimize motor function and prolong survival.
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Affiliation(s)
- Hugh J McMillan
- Children's Hospital of Eastern Ontario Research Institute, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kristin D Kernohan
- Children's Hospital of Eastern Ontario Research Institute, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Newborn Screening Ontario, Ottawa, Ontario, Canada
| | - Ed Yeh
- Children's Hospital of Eastern Ontario Research Institute, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Newborn Screening Ontario, Ottawa, Ontario, Canada
| | - Kim Amburgey
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Boyd
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Craig Campbell
- Children's Hospital Western Ontario, Department of Pediatrics, Epidemiology and Clinical Neurological Sciences, Schulich School of Medicine, University of Western Ontario, London, Ontario, Canada
| | - James J Dowling
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Hernan Gonorazky
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark A Tarnopolsky
- McMaster Children's Hospital, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Jiri Vajsar
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Alex MacKenzie
- Children's Hospital of Eastern Ontario Research Institute, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Pranesh Chakraborty
- Children's Hospital of Eastern Ontario Research Institute, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Newborn Screening Ontario, Ottawa, Ontario, Canada
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77
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Kichula EA, Proud CM, Farrar MA, Kwon JM, Saito K, Desguerre I, McMillan HJ. Expert recommendations and clinical considerations in the use of onasemnogene abeparvovec gene therapy for spinal muscular atrophy. Muscle Nerve 2021; 64:413-427. [PMID: 34196026 PMCID: PMC8518380 DOI: 10.1002/mus.27363] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 12/21/2022]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive, neurodegenerative disease caused by biallelic mutations in the survival motor neuron 1 (SMN1) gene. SMA is characterized by motor neuron degeneration, resulting in progressive muscle atrophy and weakness. Before the emergence of disease-modifying therapies, children with the most severe form of SMA would never achieve the ability to sit independently. Only 8% survived beyond 20 months of age without permanent ventilator support. One such therapy, onasemnogene abeparvovec, an adeno-associated virus-based gene replacement therapy, delivers functional human SMN through a one-time intravenous infusion. In addition to substantially improving survival, onasemnogene abeparvovec was found to increase motor milestone attainment and reduce the need for respiratory or nutritional support in many patients. This expert opinion provides recommendations and practical considerations on the patient-centered decisions to use onasemnogene abeparvovec. Recommendations include the need for patient-centered multidisciplinary care and patient selection to identify those with underlying medical conditions or active infections to reduce risks. We also describe the importance of retesting patients with elevated anti-adeno-associated virus serotype 9 antibodies. Recommendations for prednisolone tapering and monitoring for potential adverse events, including hepatotoxicity and thrombotic microangiopathy, are described. The need for caregiver education on managing day-to-day care at time of treatment and patient- and family-centered discussions on realistic expectations are also recommended. We detail the importance of following standard-of-care guidance and long-term monitoring of all children with SMA who have received one or more disease-modifying therapy using registries. We also highlight the need for presymptomatic or early symptomatic treatment of this disorder.
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Affiliation(s)
| | - Crystal M Proud
- Children's Hospital of the King's Daughters, Norfolk, Virginia, USA
| | - Michelle A Farrar
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales Sydney and Sydney Children's Hospital Network, Sydney, New South Wales, Australia
| | - Jennifer M Kwon
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Kayoko Saito
- Institute of Medical Genetics, Tokyo Women's Medical University, Tokyo, Japan
| | - Isabelle Desguerre
- Necker-Enfants Malades Hospital, University of Paris, AP-HP, Paris, France
| | - Hugh J McMillan
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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78
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Finkel RS, Chiriboga CA, Vajsar J, Day JW, Montes J, De Vivo DC, Bishop KM, Foster R, Liu Y, Ramirez-Schrempp D, Schneider E, Bennett CF, Wong J, Farwell W. Treatment of infantile-onset spinal muscular atrophy with nusinersen: final report of a phase 2, open-label, multicentre, dose-escalation study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:491-500. [PMID: 34089650 DOI: 10.1016/s2352-4642(21)00100-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/15/2021] [Accepted: 03/24/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Nusinersen showed a favourable benefit-risk profile in participants with infantile-onset spinal muscular atrophy at the interim analysis of a phase 2 clinical study. We present the study's final analysis, assessing the efficacy and safety of nusinersen over 3 years. METHODS This phase 2, open-label, multicentre, dose-escalation study was done in three university hospital sites in the USA and one in Canada. Infants aged between 3 weeks and 6 months with two or three SMN2 gene copies and infantile-onset spinal muscular atrophy were eligible for inclusion. Eligible participants received multiple intrathecal loading doses of 6 mg equivalent nusinersen (cohort 1) or 12 mg dose equivalent (cohort 2), followed by maintenance doses of 12 mg equivalent nusinersen. The protocol amendment on Jan 25, 2016, changed the primary efficacy endpoint from safety and tolerability to reaching motor milestones, assessed using the Hammersmith Infant Neurological Examination section 2 (HINE-2) at the last study visit, in all participants who successfully completed the loading dose period and day 92 assessment. The statistical analysis plan was amended on Feb 10, 2016, to include additional analyses of the subgroup of participants with two SMN2 copies. Adverse events were assessed in all participants who received at least one dose of study treatment. The study is registered at ClinicalTrials.gov (NCT01839656). FINDINGS Between May 3, 2013, and July 9, 2014, 20 symptomatic participants with infantile-onset spinal muscular atrophy (12 boys and 8 girls; median age at diagnosis 78 days [range 0-154]) were enrolled. Median time on study was 36·2 months (IQR 20·6-41·3). The primary endpoint of an incremental improvement in HINE-2 developmental motor milestones was reached by 12 (63%) of 19 evaluable participants. In the 13 participants with two SMN2 copies treated with 12 mg nusinersen, the HINE-2 motor milestone total score increased steadily from a baseline mean of 1·46 (SD 0·52) to 11·86 (6·18) at day 1135, representing a clinically significant change of 10·43 (6·05). At study closure (Aug 21, 2017), 15 (75%) of 20 participants were alive. 101 serious adverse events were reported in 16 (80%) of 20 participants; all five deaths (one in cohort 1 and four in cohort 2) were likely to be related to spinal muscular atrophy disease progression. INTERPRETATION Our findings are consistent with other trials of nusinersen and show improved survival and attainment of motor milestones over 3 years in patients with infantile-onset spinal muscular atrophy, with a favourable safety profile. FUNDING Biogen and Ionis Pharmaceuticals.
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Affiliation(s)
- Richard S Finkel
- Nemours Children's Hospital, Orlando, FL, USA; St Jude Children's Research Hospital, Memphis, TN, USA.
| | | | - Jiri Vajsar
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - John W Day
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Kathie M Bishop
- Ionis Pharmaceuticals, Carlsbad, CA, USA; Locana, San Diego, CA, USA
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Lee BH, Waldrop MA, Connolly AM, Ciafaloni E. Time is muscle: A recommendation for early treatment for preterm infants with spinal muscular atrophy. Muscle Nerve 2021; 64:153-155. [PMID: 33959970 DOI: 10.1002/mus.27261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022]
Abstract
Implementation of newborn screening for spinal muscular atrophy (SMA) in 33 US states and increased genetic carrier screening have led to an increase in early, presymptomatic diagnosis of SMA. Early treatment is critically important and is recommended for presymptomatic infants with two to four copies of survival motor neuron 2. Currently, no specific treatment recommendations exist for preterm infants with SMA. The US Food and Drug Administration does not recommend using onasemnogene abeparvovec-xioi in preterm infants. Some insurance companies interpret "preterm" to be less than 40 weeks gestational age (GA) instead of the commonly accepted 37 weeks GA, which can be a barrier to treatment access. Given the risk of rapid decline in some infants, we recommend treatment of preterm infants when they reach 37 weeks GA, based on the definitions of term GA from the World Health Organization and Centers for Disease Control and Prevention, assuming all other treatment criteria are met.
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Affiliation(s)
- Bo Hoon Lee
- Child Neurology Division, Department of Neurology, University of Rochester, Rochester, New York, USA.,Neuromuscular Division, Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Megan A Waldrop
- Center for Gene Therapy, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.,Center for Gene Therapy, Department of Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Anne M Connolly
- Center for Gene Therapy, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.,Center for Gene Therapy, Department of Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Emma Ciafaloni
- Neuromuscular Division, Department of Neurology, University of Rochester, Rochester, New York, USA
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80
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Curry M, Cruz R, Belter L, Schroth M, Lenz M, Jarecki J. Awareness screening and referral patterns among pediatricians in the United States related to early clinical features of spinal muscular atrophy (SMA). BMC Pediatr 2021; 21:236. [PMID: 34001052 PMCID: PMC8127310 DOI: 10.1186/s12887-021-02692-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Spinal Muscular Atrophy (SMA), a leading genetic cause of death in infants, is an autosomal recessive neuromuscular disease characterized by progressive muscle weakness and atrophy. While early diagnosis of SMA is critical to modifying disease progression and improving outcomes, serious diagnostic delays persist. There is a need to improve SMA awareness, screening, and referral patterns. Methods Two online surveys, developed by Cure SMA for general pediatricians, were distributed by Medscape Education via email (September 2018, n = 300, December 2019, n = 600). The surveys asked about adherence to the American Academy of Pediatrics (AAP) developmental screening and surveillance guidelines, comfort with identification of early signs of neuromuscular disease (NMD), familiarity with SMA, and barriers to timely referral. Results In 2018, 70.3% of survey respondents indicated comfort in identifying early signs of NMD and 67.3% noted familiarity with SMA. 52.7% correctly indicated the need for genetic testing to make a definitive diagnosis of SMA, 74.0% meet or exceed developmental screening recommendations, and 52.0% said they would immediately refer to a specialist. In 2019, with a larger sample, 73.0% adhere to developmental screening guidelines, and awareness of the genetic testing requirement for SMA was significantly lower by 7.7% (p < 0.03). Specialist wait times emerged as a barrier to referral, with 64.2% of respondents citing wait times of 1–6 months. Conclusions Many pediatricians underutilize developmental screening tools and lack familiarity with diagnostic requirements for SMA. Continuing efforts to expand awareness and remove barriers to timely referral to SMA specialists, including reducing appointment wait times, are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02692-2.
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Affiliation(s)
- Mary Curry
- Cure SMA, 925 Busse Road, Elk Grove Village, IL, 60007, USA.
| | - Rosángel Cruz
- Cure SMA, 925 Busse Road, Elk Grove Village, IL, 60007, USA
| | - Lisa Belter
- Cure SMA, 925 Busse Road, Elk Grove Village, IL, 60007, USA
| | - Mary Schroth
- Cure SMA, 925 Busse Road, Elk Grove Village, IL, 60007, USA
| | - Megan Lenz
- Cure SMA, 925 Busse Road, Elk Grove Village, IL, 60007, USA
| | - Jill Jarecki
- Cure SMA, 925 Busse Road, Elk Grove Village, IL, 60007, USA
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81
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Elsheikh B, Severyn S, Zhao S, Kline D, Linsenmayer M, Kelly K, Tellez M, Bartlett A, Heintzman S, Reynolds J, Sterling G, Weaver T, Rajneesh K, Kolb SJ, Arnold WD. Safety, Tolerability, and Effect of Nusinersen in Non-ambulatory Adults With Spinal Muscular Atrophy. Front Neurol 2021; 12:650532. [PMID: 33935949 PMCID: PMC8085528 DOI: 10.3389/fneur.2021.650532] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/19/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: Investigation of the safety, tolerability, and treatment effect of nusinersen treatment in non-ambulatory adults with spinal muscular atrophy (SMA). Methods: Non-ambulatory individuals, aged 18 years or older with genetically confirmed 5q SMA were enrolled. In participants with spinal fusion, fluoroscopy guided cervical C1–C2 lateral approach was used. Outcomes at 2, 6, 10, and 14 months post-treatment were compared with baseline assessment. Forced vital capacity (FVC) was the primary outcome, and RULM, HFMSE, the modified SMA-FRS, and ulnar nerve electrophysiology [compound muscle action potential (CMAP), single motor unit size, and motor unit number] were secondary. Adverse and serious adverse events and clinically significant vital sign or lab abnormalities were recorded. Results: Results from 12 women and 7 men (mean age: 39.7 ± 13.9, range: 21–64 years) were analyzed. No clinically significant changes of vital signs or laboratory parameters were observed. Five participants were hospitalized for pneumonia. Other adverse events included headache, back pain, cervical injection site pain, and upper respiratory and urinary tract infections. High baseline protein/creatinine ratio without significant change on treatment noted in 4 participants. FVC was feasible in all participants. HFMSE and RULM were not feasible in the majority of participants. FVC and functional outcomes were stable without improvement. CMAP and single motor unit potential sizes showed enlargement while motor unit numbers were stable. Conclusions: Nusinersen, including C1/C2 delivery, was safe overall and well-tolerated. Several outcome measures were limited by floor effect. Overall, treatment resulted in stability of motor outcomes, but motor unit and CMAP size were increased.
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Affiliation(s)
- Bakri Elsheikh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Steven Severyn
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Songzhu Zhao
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, OH, United States
| | - David Kline
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, OH, United States
| | - Matthew Linsenmayer
- Assistive Technology Department, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Kristina Kelly
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Marco Tellez
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Amy Bartlett
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Sarah Heintzman
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jerry Reynolds
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Gary Sterling
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Tristan Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Kiran Rajneesh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Stephen J Kolb
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - W David Arnold
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Mendonça RH, Machado LMS, Heise CO, Polido GJ, Matsui C, Silva AMS, Reed UC, Zanoteli E. Motor unit number index (MUNIX) in children and adults with 5q-spinal muscular atrophy: Variability and clinical correlations. Neuromuscul Disord 2021; 31:498-504. [PMID: 33824074 DOI: 10.1016/j.nmd.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/11/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
Spinal muscular atrophy (SMA) is a motor neuron disease associated with progressive muscle weakness and motor disability. The motor unit number index (MUNIX) is a biomarker used to assess loss of motor units in later-onset SMA patients. Twenty SMA patients (SMA types 3 and 4), aged between 7 and 41 years, were clinically evaluated through the Hammersmith Motor Functional Scale Expanded and the Spinal Muscular Atrophy-Functional Rating Scale. The patients underwent compound motor action potential (CMAP) and MUNIX studies of the right abductor pollicis brevis, abductor digiti minimi and tibialis anterior (TA) muscles. Age-matched healthy controls (n = 20) were enrolled to obtain normative CMAP and MUNIX values from the same muscles. Compared to healthy controls, SMA patients showed significant reductions in MUNIX values among all muscles studied, whereas CMAP showed reductions only in the weaker muscles (abductor digiti minimi and TA). MUNIX variability was significantly higher in the SMA group than in the control group. MUNIX variability in TA correlated with CMAP variability. Motor functional scores correlated with TA MUNIX. The MUNIX study is feasible in later-onset SMA patients, and TA MUNIX values correlate with disease severity in patients with mild motor impairment.
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Affiliation(s)
| | | | - Carlos Otto Heise
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Graziela Jorge Polido
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ciro Matsui
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Umbertina Conti Reed
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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83
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Otto LA, Froeling M, van Eijk RP, Asselman F, Wadman R, Cuppen I, Hendrikse J, van der Pol W. Quantification of disease progression in spinal muscular atrophy with muscle MRI-a pilot study. NMR IN BIOMEDICINE 2021; 34:e4473. [PMID: 33480130 PMCID: PMC7988555 DOI: 10.1002/nbm.4473] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/30/2020] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Quantitative MRI (qMRI) of muscles is a promising tool to measure disease progression or to assess therapeutic effects in neuromuscular diseases. Longitudinal imaging studies are needed to show sensitivity of qMRI in detecting disease progression in spinal muscular atrophy (SMA). In this pilot study we therefore studied one-year changes in quantitative MR parameters in relation to clinical scores. METHODS We repeated quantitative 3 T MR analysis of thigh muscles and clinical testing one year after baseline in 10 treatment-naïve patients with SMA, 5 with Type 2 (21.6 ± 7.0 years) and 5 with Type 3 (33.4 ± 11.9 years). MR protocol consisted of Dixon, T2 mapping and diffusion tensor imaging (DTI). The temporal relation of parameters was examined with a mixed model. RESULTS We detected a significant increase in fat fraction (baseline, 38.2% SE 0.6; follow-up, 39.5% SE 0.6; +1.3%, p = 0.001) in all muscles. Muscles with moderate to high fat infiltration at baseline show a larger increase over time (+1.6%, p < 0.001). We did not find any changes in DTI parameters except for low fat-infiltration muscles (m. adductor longus and m. biceps femoris (short head)). The T2 of muscles decreased from 28.2 ms to 28.0 ms (p = 0.07). Muscle strength and motor function scores were not significantly different between follow-up and baseline. CONCLUSION Longitudinal imaging data show slow disease progression in skeletal muscle of the thigh of (young-) adult patients with SMA despite stable strength and motor function scores. Quantitative muscle imaging demonstrates potential as a biomarker for disease activity and monitoring of therapy response.
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Affiliation(s)
- Louise A.M. Otto
- Department of Neurology, UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Martijn Froeling
- Department of RadiologyUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Ruben P.A. van Eijk
- Department of Neurology, UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Biostatistics & Research Support, Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Fay‐Lynn Asselman
- Department of Neurology, UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Renske Wadman
- Department of Neurology, UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Inge Cuppen
- Department of Neurology and Child Neurology, UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Jeroen Hendrikse
- Department of RadiologyUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - W‐Ludo van der Pol
- Department of Neurology, UMC Utrecht Brain CenterUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
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84
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Rudnicki SA, Andrews JA, Duong T, Cockroft BM, Malik FI, Meng L, Wei J, Wolff AA, Genge A, Johnson NE, Tesi-Rocha C, Connolly AM, Darras BT, Felice K, Finkel RS, Shieh PB, Mah JK, Statland J, Campbell C, Habib AA, Kuntz NL, Oskoui M, Day JW. Reldesemtiv in Patients with Spinal Muscular Atrophy: a Phase 2 Hypothesis-Generating Study. Neurotherapeutics 2021; 18:1127-1136. [PMID: 33624184 PMCID: PMC8423982 DOI: 10.1007/s13311-020-01004-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2020] [Indexed: 02/07/2023] Open
Abstract
This phase 2, double-blind, placebo-controlled, hypothesis-generating study evaluated the effects of oral reldesemtiv, a fast skeletal muscle troponin activator, in patients with spinal muscular atrophy (SMA). Patients ≥ 12 years of age with type II, III, or IV SMA were randomized into 2 sequential, ascending reldesemtiv dosing cohorts (cohort 1: 150 mg bid or placebo [2:1]; cohort 2: 450 mg bid or placebo [2:1]). The primary objective was to determine potential pharmacodynamic effects of reldesemtiv on 8 outcome measures in SMA, including 6-minute walk distance (6MWD) and maximum expiratory pressure (MEP). Changes from baseline to weeks 4 and 8 were determined. Pharmacokinetics and safety were also evaluated. Patients were randomized to reldesemtiv 150 mg, 450 mg, or placebo (24, 20, and 26, respectively). The change from baseline in 6MWD was greater for reldesemtiv 450 mg than for placebo at weeks 4 and 8 (least squares [LS] mean difference, 35.6 m [p = 0.0037] and 24.9 m [p = 0.058], respectively). Changes from baseline in MEP at week 8 on reldesemtiv 150 and 450 mg were significantly greater than those on placebo (LS mean differences, 11.7 [p = 0.038] and 13.2 cm H2O [p = 0.03], respectively). For 6MWD and MEP, significant changes from placebo were seen in the highest reldesemtiv peak plasma concentration quartile (Cmax > 3.29 μg/mL; LS mean differences, 43.3 m [p = 0.010] and 28.8 cm H2O [p = 0.0002], respectively). Both dose levels of reldesemtiv were well tolerated. Results suggest reldesemtiv may offer clinical benefit and support evaluation in larger SMA patient populations.
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Affiliation(s)
| | - Jinsy A Andrews
- Cytokinetics, Incorporated, South San Francisco, CA, USA
- Columbia University, New York, NY, USA
| | | | - Bettina M Cockroft
- Cytokinetics, Incorporated, South San Francisco, CA, USA
- Sangamo Therapeutics, Brisbane, CA, USA
| | - Fady I Malik
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | - Lisa Meng
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | - Jenny Wei
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | - Andrew A Wolff
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | - Angela Genge
- Montreal Neurological Institute, Montreal, QC, Canada
| | - Nicholas E Johnson
- Virginia Commonwealth University, Richmond, VA, USA
- University of Utah, Salt Lake City, UT, USA
| | | | - Anne M Connolly
- Nationwide Children's Hospital, Columbus, OH, USA
- Washington University, St Louis, MO, USA
| | - Basil T Darras
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Richard S Finkel
- Nemours Children's Hospital, Orlando, FL, USA
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Perry B Shieh
- University of California, Los Angeles, Los Angeles, CA, USA
| | - Jean K Mah
- University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | | | - Craig Campbell
- Department of Pediatrics, Epidemiology and Clinical Neurological Sciences, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
| | - Ali A Habib
- University of California, Irvine, Orange, CA, USA
| | - Nancy L Kuntz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Maryam Oskoui
- McGill University Health Centre Research Institute, Montreal, QC, Canada
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85
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Baranello G, Gorni K, Daigl M, Kotzeva A, Evans R, Hawkins N, Scott DA, Mahajan A, Muntoni F, Servais L. Prognostic Factors and Treatment-Effect Modifiers in Spinal Muscular Atrophy. Clin Pharmacol Ther 2021; 110:1435-1454. [PMID: 33792051 PMCID: PMC9292571 DOI: 10.1002/cpt.2247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/21/2021] [Indexed: 12/20/2022]
Abstract
Spinal muscular atrophy (SMA) is a rare, progressive neuromuscular disease characterized by loss of motor neurons and muscle atrophy. Untreated infants with type 1 SMA do not achieve major motor milestones, and death from respiratory failure typically occurs before 2 years of age. Individuals with types 2 and 3 SMA exhibit milder phenotypes and have better functional and survival outcomes. Herein, a systematic literature review was conducted to identify factors that influence the prognosis of types 1, 2, and 3 SMA. In untreated infants with type 1 SMA, absence of symptoms at birth, a later symptom onset, and a higher survival of motor neuron 2 (SMN2) copy number are all associated with increased survival. Disease duration, age at treatment initiation, and, to a lesser extent, baseline function were identified as potential treatment‐modifying factors for survival, emphasizing that early treatment with disease‐modifying therapies (DMT) is essential in type 1 SMA. In patients with types 2 and 3 SMA, factors considered prognostic of changes in motor function were SMN2 copy number, age, and ambulatory status. Individuals aged 6–15 years were particularly vulnerable to developing complications (scoliosis and progressive joint contractures) which negatively influence functional outcomes and may also affect the therapeutic response in patients. Age at the time of treatment initiation emerged as a treatment‐effect modifier on the outcome of DMTs. Factors identified in this review should be considered prior to designing or analyzing studies in an SMA population, conducting population matching, or summarizing results from different studies on the treatments for SMA.
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Affiliation(s)
- Giovanni Baranello
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Developmental Neurology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Istituto Neurologico Carlo Besta, Milan, Italy
| | | | | | | | | | | | | | | | - Francesco Muntoni
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,National Institute for Health Research Biomedical Research Centre, University College of London Great Ormond Street Institute of Child Health, Great Ormond Street Hospital National Health Service Trust, London, UK
| | - Laurent Servais
- Division of Child Neurology Reference Center for Neuromuscular Disease, Department of Pediatrics, Centre Hospitalier Régional de Références des Maladies Neuromusculaires, University Hospital Liège & University of La Citadelle, Liège, Belgium.,Department of Paediatrics, Muscular Dystrophy UK Oxford Neuromuscular Centre, University of Oxford, Oxford, UK
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86
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Savini G, Asteggiano C, Paoletti M, Parravicini S, Pezzotti E, Solazzo F, Muzic SI, Santini F, Deligianni X, Gardani A, Germani G, Farina LM, Bergsland N, Gandini Wheeler-Kingshott CAM, Berardinelli A, Bastianello S, Pichiecchio A. Pilot Study on Quantitative Cervical Cord and Muscular MRI in Spinal Muscular Atrophy: Promising Biomarkers of Disease Evolution and Treatment? Front Neurol 2021; 12:613834. [PMID: 33854470 PMCID: PMC8039452 DOI: 10.3389/fneur.2021.613834] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction: Nusinersen is a recent promising therapy approved for the treatment of spinal muscular atrophy (SMA), a rare disease characterized by the degeneration of alpha motor neurons (αMN) in the spinal cord (SC) leading to progressive muscle atrophy and dysfunction. Muscle and cervical SC quantitative magnetic resonance imaging (qMRI) has never been used to monitor drug treatment in SMA. The aim of this pilot study is to investigate whether qMRI can provide useful biomarkers for monitoring treatment efficacy in SMA. Methods: Three adult SMA 3a patients under treatment with nusinersen underwent longitudinal clinical and qMRI examinations every 4 months from baseline to 21-month follow-up. The qMRI protocol aimed to quantify thigh muscle fat fraction (FF) and water-T2 (w-T2) and to characterize SC volumes and microstructure. Eleven healthy controls underwent the same SC protocol (single time point). We evaluated clinical and imaging outcomes of SMA patients longitudinally and compared SC data between groups transversally. Results: Patient motor function was stable, with only Patient 2 showing moderate improvements. Average muscle FF was already high at baseline (50%) and progressed over time (57%). w-T2 was also slightly higher than previously published data at baseline and slightly decreased over time. Cross-sectional area of the whole SC, gray matter (GM), and ventral horns (VHs) of Patients 1 and 3 were reduced compared to controls and remained stable over time, while GM and VHs areas of Patient 2 slightly increased. We found altered diffusion and magnetization transfer parameters in SC structures of SMA patients compared to controls, thus suggesting changes in tissue microstructure and myelin content. Conclusion: In this pilot study, we found a progression of FF in thigh muscles of SMA 3a patients during nusinersen therapy and a concurrent slight reduction of w-T2 over time. The SC qMRI analysis confirmed previous imaging and histopathological studies suggesting degeneration of αMN of the VHs, resulting in GM atrophy and demyelination. Our longitudinal data suggest that qMRI could represent a feasible technique for capturing microstructural changes induced by SMA in vivo and a candidate methodology for monitoring the effects of treatment, once replicated on a larger cohort.
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Affiliation(s)
- Giovanni Savini
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy
| | - Carlo Asteggiano
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Matteo Paoletti
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy
| | - Stefano Parravicini
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Elena Pezzotti
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Francesca Solazzo
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy
| | - Shaun I Muzic
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Francesco Santini
- Department of Radiology, Division of Radiological Physics, University Hospital Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Xeni Deligianni
- Department of Radiology, Division of Radiological Physics, University Hospital Basel, Basel, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Alice Gardani
- Child Neuropsychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Giancarlo Germani
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy
| | - Lisa M Farina
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States.,IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Claudia A M Gandini Wheeler-Kingshott
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,NMR Research Unit, Queen Square MS Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, University College London, Russell Square, London, United Kingdom.,Brain Connectivity Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Stefano Bastianello
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Anna Pichiecchio
- Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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87
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Lusakowska A, Jedrzejowska M, Kaminska A, Janiszewska K, Grochowski P, Zimowski J, Sierdzinski J, Kostera-Pruszczyk A. Observation of the natural course of type 3 spinal muscular atrophy: data from the polish registry of spinal muscular atrophy. Orphanet J Rare Dis 2021; 16:150. [PMID: 33761963 PMCID: PMC7992780 DOI: 10.1186/s13023-021-01771-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/09/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is one of the most frequent and severe genetic diseases leading to premature death or severe motor disability. New therapies have been developed in recent years that change the natural history of the disease. The aim of this study is to describe patients included in the Polish Registry of SMA, with a focus on the course of type 3 SMA (SMA3) before the availability of disease-modifying treatments. RESULTS 790 patients with SMA were included in the registry (173 with type 1 [SMA1], 218 with type 2 [SMA2], 393 with SMA3, and six with type 4 SMA [SMA4]), most (52%) of whom were adults. Data on SMN2 gene copy number were available for 672 (85%) patients. The mean age of onset was 5 months for SMA1, 11.5 months for SMA2, and 4.5 years for SMA3. In patients with SMA3, the first symptoms occurred earlier in those with three copies of SMN2 than in those with four copies of SMN2 (3.2 years vs. 6.7 years). The age of onset of SMA3 was younger in girls than in boys (3.1 years vs. 5.7 years), with no new cases observed in women older than 16 years. Male patients outnumbered female patients, especially among patients with SMA3b (49 female vs. 85 male patients) and among patients with SMA3 with four copies of SMN2 (30 female vs. 69 male patients). 44% of patients with SMA3 were still able to walk; in those who were not still able to walk, the mean age of immobilization was 14.0 years. Patients with SMA3a (age of onset < 3 years) and three copies of SMN2 had significantly worse prognosis for remaining ambulant than patients with SMA3b (age of onset ≥ 3 years) and four copies of SMN2. CONCLUSIONS The Registry of SMA is an effective tool for assessing the disease course in the real world setting. SMN2 copy number is an important prognostic factor for the age of onset and ambulation in SMA3. Sex and age of disease onset also strongly affect the course of SMA. Data supplied by this study can aid treatment decisions.
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Affiliation(s)
- Anna Lusakowska
- Department of Neurology, European Reference Network EURO-NMD, Medical University of Warsaw, Warsaw, Poland
| | - Maria Jedrzejowska
- Rare Diseases Research Platform, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
| | - Anna Kaminska
- Department of Neurology, European Reference Network EURO-NMD, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Janiszewska
- Department of Neurology, European Reference Network EURO-NMD, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Grochowski
- Student Research Group of Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Zimowski
- Department of Genetics, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Janusz Sierdzinski
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Kostera-Pruszczyk
- Department of Neurology, European Reference Network EURO-NMD, Medical University of Warsaw, Warsaw, Poland.
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88
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Yeo CJJ, Simeone SD, Townsend EL, Zhang RZ, Swoboda KJ. Prospective Cohort Study of Nusinersen Treatment in Adults with Spinal Muscular Atrophy. J Neuromuscul Dis 2021; 7:257-268. [PMID: 32333595 DOI: 10.3233/jnd-190453] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The impact of nusinersen therapy on outcomes in adults with Spinal Muscular Atrophy (SMA) remains uncertain. OBJECTIVE To demonstrate whether nusinersen therapy, at currently prescribed doses, can stabilize or improve motor function in adults with SMA using existing outcome measures. METHODS A single-center prospective cohort study of 6 adults with SMA type 3, with inclusion/exclusion criteria intended to optimize the ability to demonstrate change using established outcome measures. Primary outcomes were the Hammersmith Functional Motor Scale-Expanded (HFMSE) and the Revised Upper Limb Measure (RULM). Secondary outcomes were the PedsQL Fatigue scale, the SMA Functional Rating Scale (SMAFRS), and the 6-minute and 10-meter walk tests (6 MWT and 10 MWT). Estimates of change in HFMSE and RULM mean scores across visits were calculated using a linear mixed effects model. Change from baseline was used for other outcome measures. RESULTS HFMSE and RULM scores over 12 months were stable or improved in all participants, with a mean increase of 2 points in each. Other measures showed high intra-individual variability. Adverse events related to the primary diagnosis, including injury and infection, significantly impacted the ability to reliably perform walk tests in the four ambulatory participants. CONCLUSIONS HFMSE and RULM show potential as responsive outcome measures of motor function in ambulatory and non-ambulatory adults with SMA type 3. A time-dependent accrual of benefit of nusinersen on motor function was apparent in this cohort. More sensitive alternative measures of quality of life, fatigue, exercise tolerance, stability and ADLs are clearly needed for adults with SMA.
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Affiliation(s)
- Crystal Jing Jing Yeo
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Institute of Molecular and Cell Biology, Experimental Drug Development Center and National Neuroscience Institute, Singapore
| | - Sarah D Simeone
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Elise L Townsend
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Ren Zhe Zhang
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn J Swoboda
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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89
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Kariyawasam DS, D'Silva AM, Vetsch J, Wakefield CE, Wiley V, Farrar MA. " We needed this": perspectives of parents and healthcare professionals involved in a pilot newborn screening program for spinal muscular atrophy. EClinicalMedicine 2021; 33:100742. [PMID: 33842861 PMCID: PMC8020144 DOI: 10.1016/j.eclinm.2021.100742] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/17/2021] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Newborn screening (NBS) for spinal muscular atrophy (SMA) is a recognised model through which health outcomes can be improved. However, perspectives of parents and healthcare professionals (HCPs) involved in such programs are largely unknown. METHODS A pilot program for SMA ran from August 2018-July 2020. Using a mixed-methods convergent methodology, we used a self-administered questionnaire to understand parents' perceptions and psychological impact of the program from diagnosis to treatment. We thematically analysed successes/challenges encountered by HCPs and recommendations for service improvement from both participant groups. FINDINGS 202,388 infants were screened for SMA and the perceptions of 44 parents and HCPs affected by a positive result in eighteen newborns was ascertained. Parents (n=29, 100%) were satisfied with NBS for SMA. Although screen-positive result was distressing for all parents, quality of life improved over time [CarerQoL-7D baseline median score 4 (SD=1.4) vs six-month median score 8 (SD=1.3), p<0.001)]. Challenges for HCPs included managing the time-critical nature of the pathway whilst remaining cognisant of limitations associated with the predictive screening test. INTERPRETATION Interpretation: NBS for SMA fulfils criteria for population-wide screening. Net benefits are acknowledged by stakeholders to optimise lifelong outcomes. Harms including psychological distress associated with a screen-positive result may be managed by targeted psychosocial support, information provision and a personalised model of care together strengthening healthcare systems. FUNDING The NSW Pilot NBS study was funded by Luminesce Alliance. Dr Kariyawasam received funding from the RTP Scholarship, University of New South Wales and The Freedman Family Foundation Scholarship, Sydney Children's Hospital Foundation.
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Affiliation(s)
- Didu S.T. Kariyawasam
- Department of Neurology, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales Medicine, UNSW Sydney, New South Wales, Australia
| | - Arlene M. D'Silva
- School of Women's and Children's Health, University of New South Wales Medicine, UNSW Sydney, New South Wales, Australia
| | - Janine Vetsch
- School of Women's and Children's Health, University of New South Wales Medicine, UNSW Sydney, New South Wales, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
| | - Claire E. Wakefield
- School of Women's and Children's Health, University of New South Wales Medicine, UNSW Sydney, New South Wales, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
| | - Veronica Wiley
- NSW Newborn Screening Program, Children's Hospital Westmead, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Michelle A. Farrar
- Department of Neurology, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales Medicine, UNSW Sydney, New South Wales, Australia
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90
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Mofatteh M. Neurodegeneration and axonal mRNA transportation. AMERICAN JOURNAL OF NEURODEGENERATIVE DISEASE 2021; 10:1-12. [PMID: 33815964 PMCID: PMC8012751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
The prevalence of neurodegenerative diseases is accelerating in rapidly aging global population. Novel and effective diagnostic and therapeutic methods are required to tackle the global issue of neurodegeneration in the future. A better understanding of the potential molecular mechanism causing neurodegeneration can shed light on dysfunctional processes in diseased neurons, which can pave the way to design and synthesize novel targets for early diagnosis during the asymptomatic phase of the disease. Abnormal protein aggregation is a hallmark of neurodegenerative diseases which can hamper transportation of cargoes into axons. Recent evidence suggests that disruption of local protein synthesis has been observed in neurodegenerative diseases. Because of their highly asymmetric structure, highly polarized neurons require trafficking of cargoes from the cell body to different subcellular regions to meet the extensive demands of cellular physiology. Localization of mRNAs and subsequent local translation to corresponding proteins in axons is a mechanism which allows neurons to rapidly respond to external stimuli as well as establishing neuronal networks by synthesizing proteins on demand. Axonal protein synthesis is required for axon guidance, synapse formation and plasticity, axon maintenance and regeneration in response to injury. Different types of excitatory and inhibitory neurons in the central and peripheral nervous systems have been shown to localize mRNA. Rising evidence suggests that the repertoire of localizing mRNA in axons can change during aging, indicating a connection between axonal mRNA trafficking and aging diseases such as neurodegeneration. Here, I briefly review the latest findings on the importance of mRNA localization and local translation in neurons and the consequences of their disruption in neurodegenerative diseases. In addition, I discuss recent evidence that dysregulation of mRNA localization and local protein translation can contribute to the formation of neurodegenerative diseases such as Alzheimer's disease, Amyotrophic Lateral Sclerosis, and Spinal Muscular Atrophy. In addition, I discuss recent findings on mRNAs localizing to mitochondria in neurodegeneration.
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Affiliation(s)
- Mohammad Mofatteh
- Lincoln College, University of OxfordOxford, UK
- Sir William Dunn School of Pathology, Medical Sciences Division, University of OxfordOxford, UK
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91
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Keinath MC, Prior DE, Prior TW. Spinal Muscular Atrophy: Mutations, Testing, and Clinical Relevance. APPLICATION OF CLINICAL GENETICS 2021; 14:11-25. [PMID: 33531827 PMCID: PMC7846873 DOI: 10.2147/tacg.s239603] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/15/2021] [Indexed: 12/12/2022]
Abstract
Spinal muscular atrophy (SMA) is a heritable neuromuscular disorder that causes degeneration of the alpha motor neurons from anterior horn cells in the spinal cord, which causes severe progressive hypotonia and muscular weakness. With a carrier frequency of 1 in 40–50 and an estimated incidence of 1 in 10,000 live births, SMA is the second most common autosomal recessive disorder. Affected individuals with SMA have a homozygous loss of function of the survival motor neuron gene SMN1 on 5q13 but keep the modifying SMN2 gene. The most common mutation causing SMA is a homozygous deletion of the SMN1 exon 7, which can be readily detected and used as a sensitive diagnostic test. Because SMN2 produces a reduced number of full-length transcripts, the number of SMN2 copies can modify the clinical phenotype and as such, becomes an essential predictive factor. Population-based SMA carrier screening identifies carrier couples that may pass on this genetic disorder to their offspring and allows the carriers to make informed reproductive choices or prepare for immediate treatment for an affected child. Three treatments have recently been approved by the Food and Drug Administration (FDA). Nusinersen increases the expression levels of the SMN protein using an antisense oligonucleotide to alter splicing of the SMN2 transcript. Onasemnogene abeparvovec is a gene therapy that utilizes an adeno-associated virus serotype 9 vector to increase low functional SMN protein levels. Risdiplam is a small molecule that alters SMN2 splicing in order to increase functional SMN protein. Newborn screening for SMA has been shown to be successful in allowing infants to be treated before the loss of motor neurons and has resulted in improved clinical outcomes. Several of the recommendations and guidelines in the review are based on studies performed in the United States.
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Affiliation(s)
- Melissa C Keinath
- Pathology, University Hospitals Center for Human Genetics, Cleveland, OH, USA
| | - Devin E Prior
- Neurology, Mount Auburn Hospital, Cambridge, MA, USA
| | - Thomas W Prior
- Pathology, University Hospitals Center for Human Genetics, Cleveland, OH, USA
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92
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Volpe JJ. Infantile spinal muscular atrophy - the potential for cure of a fatal disease. J Neonatal Perinatal Med 2021; 14:153-157. [PMID: 33459670 PMCID: PMC8075397 DOI: 10.3233/npm-200680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- J J Volpe
- Department of Neurology, Harvard Medical School, Boston, MA, USA.,Department of Pediatric Newborn Medicine, Harvard Medical School, Boston, MA, USA
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93
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Rios R, Jablonka-Shariff A, Broberg C, Snyder-Warwick AK. Macrophage roles in peripheral nervous system injury and pathology: Allies in neuromuscular junction recovery. Mol Cell Neurosci 2021; 111:103590. [PMID: 33422671 DOI: 10.1016/j.mcn.2021.103590] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/15/2020] [Accepted: 01/01/2021] [Indexed: 12/11/2022] Open
Abstract
Peripheral nerve injuries remain challenging to treat despite extensive research on reparative processes at the injury site. Recent studies have emphasized the importance of immune cells, particularly macrophages, in recovery from nerve injury. Macrophage plasticity enables numerous functions at the injury site. At early time points, macrophages perform inflammatory functions, but at later time points, they adopt pro-regenerative phenotypes to support nerve regeneration. Research has largely been limited, however, to the injury site. The neuromuscular junction (NMJ), the synapse between the nerve terminal and end target muscle, has received comparatively less attention, despite the importance of NMJ reinnervation for motor recovery. Macrophages are present at the NMJ following nerve injury. Moreover, in denervating diseases, such as amyotrophic lateral sclerosis (ALS), macrophages may also play beneficial roles at the NMJ. Evidence of positive macrophages roles at the injury site after peripheral nerve injury and at the NMJ in denervating pathologies suggest that macrophages may promote NMJ reinnervation. In this review, we discuss the intersection of nerve injury and immunity, with a focus on macrophages.
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Affiliation(s)
- Rachel Rios
- Washington University School of Medicine, St. Louis, MO, United States of America
| | - Albina Jablonka-Shariff
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Curtis Broberg
- Washington University School of Medicine, St. Louis, MO, United States of America
| | - Alison K Snyder-Warwick
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States of America.
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94
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Spinal muscular atrophy: Broad disease spectrum and sex-specific phenotypes. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166063. [PMID: 33412266 DOI: 10.1016/j.bbadis.2020.166063] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
Spinal muscular atrophy (SMA) is one of the major genetic disorders associated with infant mortality. More than 90% of cases of SMA result from deletions of or mutations in the Survival Motor Neuron 1 (SMN1) gene. SMN2, a nearly identical copy of SMN1, does not compensate for the loss of SMN1 due to predominant skipping of exon 7. The spectrum of SMA is broad, ranging from prenatal death to infant mortality to survival into adulthood. All tissues, including brain, spinal cord, bone, skeletal muscle, heart, lung, liver, pancreas, gastrointestinal tract, kidney, spleen, ovary and testis, are directly and/or indirectly affected in SMA. Accumulating evidence on impaired mitochondrial biogenesis and defects in X chromosome-linked modifying factors, coupled with the sexual dimorphic nature of many tissues, point to sex-specific vulnerabilities in SMA. Here we review the role of sex in the pathogenesis of SMA.
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95
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Pierzchlewicz K, Kępa I, Podogrodzki J, Kotulska K. Spinal Muscular Atrophy: The Use of Functional Motor Scales in the Era of Disease-Modifying Treatment. Child Neurol Open 2021; 8:2329048X211008725. [PMID: 33997096 PMCID: PMC8107939 DOI: 10.1177/2329048x211008725] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a genetic condition characterized by progressive motoneuron loss. Infants affected by SMA type 1 do not gain developmental milestones and acutely decline, requiring ventilatory support. Several scales are used to assess motor disability and its progression in SMA. Recently, 3 disease-modifying therapies have been approved for SMA patients: nusinersen, an intrathecal antisense oligonucleotide enhancing SMN protein production by the SMN2 gene, risdiplam, also influencing the SMN2 gene to stimulate SMN production but administered orally, and onasemnogene abeparvovec-xioi, an SMN1 gene replacement therapy. Thus, the functional scales should now be applicable for patients improving their motor function over time to assess treatment efficacy. In this paper, we compare different functional scales used in SMA patients. Their usefulness in different SMA types, age groups, and feasibility in daily clinical practice is described below. Some changes in motor function assessments in SMA are also suggested.
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Affiliation(s)
- Katarzyna Pierzchlewicz
- Department of Neurology and Epileptology, Children’s Memorial Health
Institute, Warsaw, Poland
| | - Izabela Kępa
- Department of Neurology and Epileptology, Children’s Memorial Health
Institute, Warsaw, Poland
| | - Jacek Podogrodzki
- Department of Neurology and Epileptology, Children’s Memorial Health
Institute, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children’s Memorial Health
Institute, Warsaw, Poland
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96
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Clinical features of spinal muscular atrophy (SMA) type 3 (Kugelberg-Welander disease). Arch Pediatr 2020; 27:7S23-7S28. [DOI: 10.1016/s0929-693x(20)30273-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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97
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Singh RN, Ottesen EW, Singh NN. The First Orally Deliverable Small Molecule for the Treatment of Spinal Muscular Atrophy. Neurosci Insights 2020; 15:2633105520973985. [PMID: 33283185 PMCID: PMC7691903 DOI: 10.1177/2633105520973985] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
Spinal muscular atrophy (SMA) is 1 of the leading causes of infant mortality. SMA
is mostly caused by low levels of Survival Motor Neuron (SMN) protein due to
deletion of or mutation in the SMN1 gene. Its nearly identical
copy, SMN2, fails to compensate for the loss of
SMN1 due to predominant skipping of exon 7. Correction of
SMN2 exon 7 splicing by an antisense oligonucleotide (ASO),
nusinersen (Spinraza™), that targets the intronic splicing silencer N1 (ISS-N1)
became the first approved therapy for SMA. Restoration of SMN levels using gene
therapy was the next. Very recently, an orally deliverable small molecule,
risdiplam (Evrysdi™), became the third approved therapy for SMA. Here we discuss
how these therapies are positioned to meet the needs of the broad phenotypic
spectrum of SMA patients.
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Affiliation(s)
- Ravindra N Singh
- Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
| | - Eric W Ottesen
- Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
| | - Natalia N Singh
- Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
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98
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Characterization of Reference Materials for Spinal Muscular Atrophy Genetic Testing: A Genetic Testing Reference Materials Coordination Program Collaborative Project. J Mol Diagn 2020; 23:103-110. [PMID: 33197628 DOI: 10.1016/j.jmoldx.2020.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/14/2020] [Accepted: 10/14/2020] [Indexed: 01/21/2023] Open
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive disorder predominately caused by bi-allelic loss of the SMN1 gene. Increased copies of SMN2, a low functioning nearly identical paralog, are associated with a less severe phenotype. SMA was recently recommended for inclusion in newborn screening. Clinical laboratories must accurately measure SMN1 and SMN2 copy number to identify SMA patients and carriers, and to identify individuals likely to benefit from therapeutic interventions. Having publicly available and appropriately characterized reference materials with various combinations of SMN1 and SMN2 copy number variants is critical to assure accurate SMA clinical testing. To address this need, the CDC-based Genetic Testing Reference Materials Coordination Program, in collaboration with members of the genetic testing community and the Coriell Institute for Medical Research, has characterized 15 SMA reference materials derived from publicly available cell lines. DNA samples were distributed to four volunteer testing laboratories for genotyping using three different methods. The characterized samples had zero to four copies of SMN1 and zero to five copies SMN2. The samples also contained clinically important allele combinations (eg, zero copies SMN1, three copies SMN2), and several had markers indicative of an SMA carrier. These and other reference materials characterized by the Genetic Testing Reference Materials Coordination Program are available from the Coriell Institute and are proposed to support the quality of clinical laboratory testing.
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99
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Kariyawasam D, D'Silva A, Howells J, Herbert K, Geelan-Small P, Lin CSY, Farrar MA. Motor unit changes in children with symptomatic spinal muscular atrophy treated with nusinersen. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-324254. [PMID: 33106369 PMCID: PMC7803907 DOI: 10.1136/jnnp-2020-324254] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To elucidate the motor unit response to intrathecal nusinersen in children with symptomatic spinal muscular atrophy (SMA) using a novel motor unit number estimation technique. METHODS MScanFit MUNE studies were sequentially undertaken from the abductor pollicis brevis muscle after stimulation of the median nerve in a prospective cohort of symptomatic children with SMA, undergoing intrathecal treatment with nusinersen at a single neuromuscular centre from June 2017 to August 2019. Electrophysiological measures included compound muscle action potential (CMAP), motor unit number estimation (MUNE), motor unit number contributing to 50%-100% of CMAP (N50) and measures of collateral reinnervation including largest single motor unit potential (LSMUP) and amplitude of the smallest unit contributing to N50 (A50). RESULTS Twenty children (median age 99 months, range 4-193) were followed for a median of 13.8 (4-33.5) months. Therapeutic intervention was an independent and significant contributor to an increase in CMAP (p = 0.005), MUNE (p = 0.001) and N50 (p = 0.04). The magnitude of this electrophysiological response was increased in children with shorter disease durations (p<0.05). Electrophysiological changes delineated children who were functionally stable from those who attained clinically significant gains in motor function. INTERPRETATION Nusinersen therapy facilitated functional innervation in SMA through recovery of smaller motor units. Delineation of biomechanisms of therapeutic response may be the first step in identifying potential novel targets for disease modification in this and other motor neuropathies. MScanFit MUNE techniques may have a broader role in establishing biomarkers of therapeutic response in similar adult-onset diseases.
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Affiliation(s)
- Didu Kariyawasam
- Neurology, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Arlene D'Silva
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - James Howells
- Central Clinical School, Faculty of Medicine and Health, Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Karen Herbert
- Physiotherapy, Syndey Children's Hospital, Randwick, Sydney, New South Wales, Australia
| | - Peter Geelan-Small
- Mark Wainwright Analytical Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Cindy Shin-Yi Lin
- Central Clinical School, Faculty of Medicine and Health, Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Michelle Anne Farrar
- Neurology, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
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100
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Sumner CJ, Sumner AJ. Motor unit gains in treated spinal muscular atrophy patients. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-325022. [PMID: 33106365 DOI: 10.1136/jnnp-2020-325022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Charlotte J Sumner
- Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Austin J Sumner
- Department of Neurology, Louisiana State University, New Orleans, Louisiana, USA
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