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Indelicato E, Wanschitz J, Löscher W, Boesch S. Skeletal Muscle Involvement in Friedreich Ataxia. Int J Mol Sci 2024; 25:9915. [PMID: 39337401 PMCID: PMC11432698 DOI: 10.3390/ijms25189915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 09/06/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024] Open
Abstract
Friedreich Ataxia (FRDA) is an inherited neuromuscular disorder triggered by a deficit of the mitochondrial protein frataxin. At a cellular level, frataxin deficiency results in insufficient iron-sulfur cluster biosynthesis and impaired mitochondrial function and adenosine triphosphate production. The main clinical manifestation is a progressive balance and coordination disorder which depends on the involvement of peripheral and central sensory pathways as well as of the cerebellum. Besides the neurological involvement, FRDA affects also the striated muscles. The most prominent manifestation is a hypertrophic cardiomyopathy, which also represents the major determinant of premature mortality. Moreover, FRDA displays skeletal muscle involvement, which contributes to the weakness and marked fatigue evident throughout the course of the disease. Herein, we review skeletal muscle findings in FRDA generated by functional imaging, histology, as well as multiomics techniques in both disease models and in patients. Altogether, these findings corroborate a disease phenotype in skeletal muscle and support the notion of progressive mitochondrial damage as a driver of disease progression in FRDA. Furthermore, we highlight the relevance of skeletal muscle investigations in the development of biomarkers for early-phase trials and future therapeutic strategies in FRDA.
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Affiliation(s)
- Elisabetta Indelicato
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Julia Wanschitz
- Unit for Neuromuscular Disorders and Clinical Neurophysiology, Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Wolfgang Löscher
- Unit for Neuromuscular Disorders and Clinical Neurophysiology, Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Sylvia Boesch
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
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Beaudin M, Dupre N, Manto M. The importance of synthetic pharmacotherapy for recessive cerebellar ataxias. Expert Rev Neurother 2024; 24:897-912. [PMID: 38980086 DOI: 10.1080/14737175.2024.2376840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION The last decade has witnessed major breakthroughs in identifying novel genetic causes of hereditary ataxias, deepening our understanding of disease mechanisms, and developing therapies for these debilitating disorders. AREAS COVERED This article reviews the currently approved and most promising candidate pharmacotherapies in relation to the known disease mechanisms of the most prevalent autosomal recessive ataxias. Omaveloxolone is an Nrf2 activator that increases antioxidant defense and was recently approved for treatment of Friedreich ataxia. Its therapeutic effect is modest, and further research is needed to find synergistic treatments that would halt or reverse disease progression. Promising approaches include upregulation of frataxin expression by epigenetic mechanisms, direct protein replacement, and gene replacement therapy. For ataxia-telangiectasia, promising approaches include splice-switching antisense oligonucleotides and small molecules targeting oxidative stress, inflammation, and mitochondrial function. Rare recessive ataxias for which disease-modifying therapies exist are also reviewed, emphasizing recently approved therapies. Evidence supporting the use of riluzole and acetyl-leucine in recessive ataxias is discussed. EXPERT OPINION Advances in genetic therapies for other neurogenetic conditions have paved the way to implement feasible approaches with potential dramatic benefits. Particularly, as we develop effective treatments for these conditions, we may need to combine therapies, consider newborn testing for pre-symptomatic treatment, and optimize non-pharmacological approaches.
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Affiliation(s)
- Marie Beaudin
- Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Nicolas Dupre
- Neuroscience axis, CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Mario Manto
- Service des Neurosciences, Université de Mons, Mons, Belgique
- Unité des Ataxies Cérébelleuses, Service de Neurologie, CHU-Charleroi, Charleroi, Belgique
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3
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Perry CE, Halawani SM, Mukherjee S, Ngaba LV, Lieu M, Lee WD, Davis JG, Adzika GK, Bebenek AN, Bazianos DD, Chen B, Mercado-Ayon E, Flatley LP, Suryawanshi AP, Ho I, Rabinowitz JD, Serai SD, Biko DM, Tamaroff J, DeDio A, Wade K, Lin KY, Livingston DJ, McCormack SE, Lynch DR, Baur JA. NAD+ precursors prolong survival and improve cardiac phenotypes in a mouse model of Friedreich's Ataxia. JCI Insight 2024; 9:e177152. [PMID: 39171530 PMCID: PMC11343603 DOI: 10.1172/jci.insight.177152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 07/12/2024] [Indexed: 08/23/2024] Open
Abstract
Friedreich's ataxia (FRDA) is a progressive disorder caused by insufficient expression of frataxin, which plays a critical role in assembly of iron-sulfur centers in mitochondria. Individuals are cognitively normal but display a loss of motor coordination and cardiac abnormalities. Many ultimately develop heart failure. Administration of nicotinamide adenine dinucleotide-positive (NAD+) precursors has shown promise in human mitochondrial myopathy and rodent models of heart failure, including mice lacking frataxin in cardiomyocytes. We studied mice with systemic knockdown of frataxin (shFxn), which display motor deficits and early mortality with cardiac hypertrophy. Hearts in these mice do not "fail" per se but become hyperdynamic with small chamber sizes. Data from an ongoing natural history study indicate that hyperdynamic hearts are observed in young individuals with FRDA, suggesting that the mouse model could reflect early pathology. Administering nicotinamide mononucleotide or riboside to shFxn mice increases survival, modestly improves cardiac hypertrophy, and limits increases in ejection fraction. Mechanistically, most of the transcriptional and metabolic changes induced by frataxin knockdown are insensitive to NAD+ precursor administration, but glutathione levels are increased, suggesting improved antioxidant capacity. Overall, our findings indicate that NAD+ precursors are modestly cardioprotective in this model of FRDA and warrant further investigation.
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Affiliation(s)
- Caroline E. Perry
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah M. Halawani
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarmistha Mukherjee
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lucie V. Ngaba
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Melissa Lieu
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Won Dong Lee
- Department of Chemistry, Princeton University, Princeton, New Jersey, USA
| | - James G. Davis
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gabriel K. Adzika
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alyssa N. Bebenek
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel D. Bazianos
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Beishan Chen
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Mercado-Ayon
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Liam P. Flatley
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arjun P. Suryawanshi
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Isabelle Ho
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Suraj D. Serai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology and
| | - David M. Biko
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Radiology and
| | - Jaclyn Tamaroff
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anna DeDio
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kristin Wade
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kimberly Y. Lin
- Division of Pediatric Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Shana E. McCormack
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R. Lynch
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph A. Baur
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kissell J, Rochmann C, Minini P, Eichler F, Stephen CD, Lau H, Toro C, Johnston JM, Krupnick R, Hamed A, Cox GF. Clinical outcome assessments of disease burden and progression in late-onset GM2 gangliosidoses. Mol Genet Metab 2024; 142:108512. [PMID: 38870773 PMCID: PMC11317923 DOI: 10.1016/j.ymgme.2024.108512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/15/2024]
Abstract
The late-onset GM2 gangliosidoses, comprising late-onset Tay-Sachs and Sandhoff diseases, are rare, slowly progressive, neurogenetic disorders primarily characterized by neurogenic weakness, ataxia, and dysarthria. The aim of this longitudinal study was to characterize the natural history of late-onset GM2 gangliosidoses using a number of clinical outcome assessments to measure different aspects of disease burden and progression over time, including neurological, functional, and quality of life, to inform the design of future clinical interventional trials. Patients attending the United States National Tay-Sachs & Allied Diseases Family Conference between 2015 and 2019 underwent annual clinical outcome assessments. Currently, there are no clinical outcome assessments validated to assess late-onset GM2 gangliosidoses; therefore, instruments used or designed for diseases with similar features, or to address various aspects of the clinical presentations, were used. Clinical outcome assessments included the Friedreich's Ataxia Rating Scale, the 9-Hole Peg Test, and the Assessment of Intelligibility of Dysarthric Speech. Twenty-three patients participated in at least one meeting visit (late-onset Tay-Sachs, n = 19; late-onset Sandhoff, n = 4). Patients had high disease burden at baseline, and scores for the different clinical outcome assessments were generally lower than would be expected for the general population. Longitudinal analyses showed slow, but statistically significant, neurological progression as evidenced by worsening scores on the 9-Hole Peg Test (2.68%/year, 95% CI: 0.13-5.29; p = 0.04) and the Friedreich's Ataxia Rating Scale neurological examination (1.31 points/year, 95% CI: 0.26-2.35; p = 0.02). Time since diagnosis to study entry correlated with worsening scores on the 9-Hole Peg Test (r = 0.728; p < 0.001), Friedreich's Ataxia Rating Scale neurological examination (r = 0.727; p < 0.001), and Assessment of Intelligibility of Dysarthric Speech intelligibility (r = -0.654; p = 0.001). In summary, patients with late-onset GM2 gangliosidoses had high disease burden and slow disease progression. Several clinical outcome assessments suitable for clinical trials showed only small changes and standardized effect sizes (change/standard deviation of change) over 4 years. These longitudinal natural history study results illustrate the challenge of identifying responsive endpoints for clinical trials in rare, slowly progressive, neurogenerative disorders where arguably the treatment goal is to halt or decrease the rate of decline rather than improve clinical status. Furthermore, powering such a study would require a large sample size and/or a long study duration, neither of which is an attractive option for an ultra-rare disease with no available treatment. These findings support the development of potentially more sensitive late-onset GM2 gangliosidoses-specific rating instruments and/or surrogate endpoints for use in future clinical trials.
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Affiliation(s)
| | | | | | | | | | - Heather Lau
- New York University Medical Center, New York, NY, USA
| | - Camilo Toro
- National Institutes of Health, Bethesda, MD, USA
| | | | | | | | - Gerald F Cox
- NTSAD Association, Brookline, MA, USA; Gerald Cox Rare Care Consulting, LLC, Needham, MA, USA
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Lynch DR, Sharma S, Hearle P, Greeley N, Gunther K, Keita M, Strawser C, Hauser L, Park C, Schadt K, Lin KY. Characterization of clinical serum cardiac biomarker levels in individuals with Friedreich ataxia. J Neurol Sci 2024; 461:123053. [PMID: 38759249 DOI: 10.1016/j.jns.2024.123053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/18/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024]
Abstract
Friedreich ataxia is a progressive autosomal recessive neurodegenerative disorder characterized by ataxia, dyscoordination, and cardiomyopathy. A subset of patients with Friedreich ataxia have elevated levels of serum cardiac troponin I, but associations with disease outcomes and features of cardiomyopathy remain unclear. In this study, we characterized clinically obtained serum cardiac biomarker levels including troponin I, troponin T, and B-type natriuretic peptide in subjects with Friedreich ataxia and evaluated their association with markers of disease. While unprovoked troponin I levels were elevated in 36% of the cohort, cTnI levels associated with a cardiac event (provoked) were higher than unprovoked levels. In multivariate linear regression models, younger age predicted increased troponin I values, and in logistic regression models younger age, female sex, and marginally longer GAA repeat length predicted abnormal troponin I levels. In subjects with multiple assessments, mean unprovoked troponin I levels decreased slightly over time. The presence of abnormal troponin I values and their levels were predicted by echocardiographic measures of hypertrophy. In addition, troponin I levels predicted long-term markers of clinical cardiac dysfunction over time to a modest degree. Consequently, troponin I values provide a marker of hypertrophy but only a minimally predictive biomarker for later cardiac manifestations of disease such as systolic dysfunction or arrhythmia.
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Affiliation(s)
- David R Lynch
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States of America.
| | - Sonal Sharma
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Patrick Hearle
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Nathaniel Greeley
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Katherine Gunther
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Medina Keita
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Cassandra Strawser
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Lauren Hauser
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Courtney Park
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Kimberly Schadt
- Divisions of Neurology Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
| | - Kimberly Y Lin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States of America; Divisions of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America
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Koka M, Li H, Akther R, Perlman S, Wong D, Fogel BL, Lynch DR, Chandran V. Long non-coding RNA TUG1 is downregulated in Friedreich's ataxia. Brain Commun 2024; 6:fcae170. [PMID: 38846537 PMCID: PMC11154142 DOI: 10.1093/braincomms/fcae170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/25/2024] [Accepted: 05/14/2024] [Indexed: 06/09/2024] Open
Abstract
Friedreich's ataxia is a neurodegenerative disorder caused by reduced frataxin levels. It leads to motor and sensory impairments and has a median life expectancy of around 35 years. As the most common inherited form of ataxia, Friedreich's ataxia lacks reliable, non-invasive biomarkers, prolonging and inflating the cost of clinical trials. This study proposes TUG1, a long non-coding RNA, as a promising blood-based biomarker for Friedreich's ataxia, which is known to regulate various cellular processes. In a previous study using a frataxin knockdown mouse model, we observed several hallmark Friedreich's ataxia symptoms. Building on this, we hypothesized that a dual-source approach-comparing the data from peripheral blood samples from Friedreich's ataxia patients with tissue samples from affected areas in Friedreich's ataxia knockdown mice, tissues usually unattainable from patients-would effectively identify robust biomarkers. A comprehensive reanalysis was conducted on gene expression data from 183 age- and sex-matched peripheral blood samples of Friedreich's ataxia patients, carriers and controls and 192 tissue data sets from Friedreich's ataxia knockdown mice. Blood and tissue samples underwent RNA isolation and quantitative reverse transcription polymerase chain reaction, and frataxin knockdown was confirmed through enzyme-linked immunosorbent assays. Tug1 RNA interaction was explored via RNA pull-down assays. Validation was performed in serum samples on an independent set of 45 controls and 45 Friedreich's ataxia patients and in blood samples from 66 heterozygous carriers and 72 Friedreich's ataxia patients. Tug1 and Slc40a1 emerged as potential blood-based biomarkers, confirmed in the Friedreich's ataxia knockdown mouse model (one-way ANOVA, P ≤ 0.05). Tug1 was consistently downregulated after Fxn knockdown and correlated strongly with Fxn levels (R 2 = 0.71 during depletion, R 2 = 0.74 during rescue). Slc40a1 showed a similar but tissue-specific pattern. Further validation of Tug1's downstream targets strengthened its biomarker candidacy. In additional human samples, TUG1 levels were significantly downregulated in both whole blood and serum of Friedreich's ataxia patients compared with controls (Wilcoxon signed-rank test, P < 0.05). Regression analyses revealed a negative correlation between TUG1 fold-change and disease onset (P < 0.0037) and positive correlations with disease duration and functional disability stage score (P < 0.04). This suggests that elevated TUG1 levels correlate with earlier onset and more severe cases. This study identifies TUG1 as a potential blood-based biomarker for Friedreich's ataxia, showing consistent expression variance in human and mouse tissues related to disease severity and key Friedreich's ataxia pathways. It correlates with frataxin levels, indicating its promise as an early, non-invasive marker. TUG1 holds potential for Friedreich's ataxia monitoring and therapeutic development, meriting additional research.
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Affiliation(s)
- Mert Koka
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Hui Li
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Rumana Akther
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Susan Perlman
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Darice Wong
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Clinical Neurogenomics Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Brent L Fogel
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Clinical Neurogenomics Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - David R Lynch
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Vijayendran Chandran
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
- Department of Neuroscience, College of Medicine, University of Florida, and McKnight Brain Institute, Gainesville, FL 32610, USA
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Shen MM, Rummey C, Lynch DR. Phenotypic variation of FXN compound heterozygotes in a Friedreich ataxia cohort. Ann Clin Transl Neurol 2024; 11:1110-1121. [PMID: 38396238 PMCID: PMC11093247 DOI: 10.1002/acn3.52027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/24/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE Most individuals with Friedreich ataxia (FRDA) have homozygous GAA triplet repeat expansions in the FXN gene, correlating with a typical phenotype of ataxia and cardiomyopathy. A minority are compound heterozygotes carrying a GAA expansion on one allele and a mutation on the other. The study aim was to examine phenotypic variation among compound heterozygotes. METHODS Data on FXN mutations were obtained from the Friedreich Ataxia Clinical Outcome Measures Study (FA-COMS). We compared clinical features in a single-site FA-COMS cohort of 51 compound heterozygous and 358 homozygous patients, including quantitative measures of cardiac, neurologic, and visual disease progression. RESULTS Non-GAA repeat mutations were associated with reduced cardiac disease, and patients with minimal/no function mutations otherwise had a typical FRDA phenotype but with significantly more severe progression. The partial function mutation group was characterized by relative sparing of bulbar and upper limb function, as well as particularly low cardiac involvement. Other clinical features in this group, including optic atrophy and diabetes mellitus, varied widely depending on the specific type of partial function mutation. INTERPRETATION These data support that the typical FRDA phenotype is driven by frataxin deficiency, especially severe in compound heterozygotes with minimal/no function mutations, whereas the heterogeneous presentations of those with partial function mutations may indicate other contributing factors to FRDA pathogenesis.
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Affiliation(s)
- Megan M. Shen
- Division of NeurologyThe Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Perelman School of Medicine, University of Pennsylvania.PhiladelphiaPennsylvaniaUSA
| | | | - David R. Lynch
- Division of NeurologyThe Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Perelman School of Medicine, University of Pennsylvania.PhiladelphiaPennsylvaniaUSA
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Cilenti NA, Tamaroff JG, Capiola CJ, Faig W, McBride MG, Paridon SM, O'Malley S, Edelson JB, Lynch DR, McCormack SE, Lin KY. Cardiopulmonary exercise testing on adaptive equipment in children and adults with Friedreich ataxia. Muscle Nerve 2024; 69:613-619. [PMID: 38515223 PMCID: PMC11013735 DOI: 10.1002/mus.28085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION/AIMS Traditional exercise is often difficult for individuals with Friedreich ataxia (FRDA), and evidence is limited regarding how to measure exercise performance in this population. We evaluated the feasibility, reliability, and natural history of adaptive cardiopulmonary exercise test (CPET) performance in children and adults with FRDA. METHODS Participants underwent CPET on either an arm cycle ergometer (ACE) or recumbent leg cycle ergometer (RLCE) at up to four visits (baseline, 2 weeks, 4 weeks, and 1 year). Maximum work, oxygen consumption (peak VO2), oxygen (O2) pulse, and anaerobic threshold (AT) were measured in those who reached maximal volition. Test-retest reliability was assessed with intraclass coefficients, and longitudinal change was assessed using regression analysis. RESULTS In our cohort (N = 23), median age was 18 years (interquartile range [IQR], 14-23), median age of FRDA onset was 8 years (IQR 6-13), median Friedreich Ataxia Rating Scale score was 58 (IQR 54-62), and GAA repeat length on the shorter FXN allele (GAA1) was 766 (IQR, 650-900). Twenty-one (91%) completed a maximal CPET (n = 8, ACE and n = 13, RLCE). Age, sex, and GAA1 repeat length were each associated with peak VO2. Preliminary estimates demonstrated reasonable agreement between visits 2 and 3 for peak work by both ACE and RLCE, and for peak VO2, O2 pulse, and AT by RLCE. We did not detect significant performance changes over 1 year. DISCUSSION Adaptive CPET is feasible in FRDA, a relevant clinical trial outcome for interventions that impact exercise performance and will increase access to participation as well as generalizability of findings.
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Affiliation(s)
- Nicolette A. Cilenti
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jaclyn G. Tamaroff
- Division of Pediatric Endocrinology and Diabetes, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J. Capiola
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Walter Faig
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael G. McBride
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephen M. Paridon
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan B. Edelson
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R. Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shana E. McCormack
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly Y. Lin
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gunther K, Lynch DR. Pharmacotherapeutic strategies for Friedreich Ataxia: a review of the available data. Expert Opin Pharmacother 2024; 25:529-539. [PMID: 38622054 DOI: 10.1080/14656566.2024.2343782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/12/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Friedreich ataxia (FRDA) is a rare autosomal recessive disease, marked by loss of coordination as well as impaired neurological, endocrine, orthopedic, and cardiac function. There are many symptomatic medications for FRDA, and many clinical trials have been performed, but only one FDA-approved medication exists. AREAS COVERED The relative absence of the frataxin protein (FXN) in FRDA causes mitochondrial dysfunction, resulting in clinical manifestations. Currently, the only approved treatment for FRDA is an Nrf2 activator called omaveloxolone (Skyclarys). Patients with FRDA also rely on various symptomatic medications for treatment. Because there is only one approved medication for FRDA, clinical trials continue to advance in FRDA. Although some trials have not met their endpoints, many current and upcoming clinical trials provide exciting possibilities for the treatment of FRDA. EXPERT OPINION The approval of omaveloxolone provides a major advance in FRDA therapeutics. Although well tolerated, it is not curative. Reversal of deficient frataxin levels with gene therapy, protein replacement, or epigenetic approaches provides the most likely prospect for enduring, disease-modifying therapy in the future.
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Affiliation(s)
- Katherine Gunther
- Friedreich Ataxia Program, Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David R Lynch
- Friedreich Ataxia Program, Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Indelicato E, Reetz K, Maier S, Nachbauer W, Amprosi M, Giunti P, Mariotti C, Durr A, de Rivera Garrido FJR, Klopstock T, Schöls L, Klockgether T, Bürk K, Pandolfo M, Didszun C, Grobe-Einsler M, Nanetti L, Nenning L, Kiechl S, Dichtl W, Ulmer H, Schulz JB, Boesch S. Predictors of Survival in Friedreich's Ataxia: A Prospective Cohort Study. Mov Disord 2024; 39:510-518. [PMID: 38140802 DOI: 10.1002/mds.29687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/24/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Friedreich's ataxia (FA) is a rare multisystemic disorder which can cause premature death. OBJECTIVES To investigate predictors of survival in FA. METHODS Within a prospective registry established by the European Friedreich's Ataxia Consortium for Translational Studies (EFACTS; ClinicalTrials.gov identifier NCT02069509) we enrolled genetically confirmed FA patients at 11 tertiary centers and followed them in yearly intervals. We investigated overall survival applying the Kaplan-Meier method, life tables, and log-rank test. We explored prognostic factors applying Cox proportional hazards regression and subsequently built a risk score which was assessed for discrimination and calibration performance. RESULTS Between September 2010 and March 2017, we enrolled 631 FA patients. Median age at inclusion was 31 (range, 6-76) years. Until December 2022, 44 patients died and 119 terminated the study for other reasons. The 10-year cumulative survival rate was 87%. In a multivariable analysis, the disability stage (hazard ratio [HR] 1.51, 95% CI 1.08-2.12, P = 0.02), history of arrhythmic disorder (HR 2.93, 95% CI 1.34-6.39, P = 0.007), and diabetes mellitus (HR 2.31, 95% CI 1.05-5.10, P = 0.04) were independent predictors of survival. GAA repeat lengths did not improve the survival model. A risk score built on the previously described factors plus the presence of left ventricular systolic dysfunction at echocardiography enabled identification of four trajectories to prognosticate up to 10-year survival (log-rank test P < 0.001). CONCLUSIONS Arrhythmias, progressive neurological disability, and diabetes mellitus influence the overall survival in FA. We built a survival prognostic score which identifies patients meriting closer surveillance and who may benefit from early invasive cardiac monitoring and therapy. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Elisabetta Indelicato
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Kathrin Reetz
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Sarah Maier
- Institute of Medical Statistics and Informatics, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Nachbauer
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Matthias Amprosi
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Paola Giunti
- Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Caterina Mariotti
- Unit of Genetics of Neurodegenerative and Metabolic Diseases, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alexandra Durr
- Institut du Cerveau et de la Moelle Epinière, INSERM U1127, CNRS UMR 7225, Sorbonne Universités, UPMC Université Paris VI UMR S1127, Paris, France
- APHP, Genetics Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Francisco J R de Rivera Garrido
- Reference Unit of Hereditary Ataxias and Paraplegias, Department of Neurology, IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | - Thomas Klopstock
- Department of Neurology with Friedrich-Baur-Institute, University of Munich, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Ludger Schöls
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Thomas Klockgether
- Department of Neurology, University Hospital of Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Katrin Bürk
- Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Massimo Pandolfo
- Laboratory of Experimental Neurology, Université Libre de Bruxelles, Brussels, Belgium
- Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
| | - Claire Didszun
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Marcus Grobe-Einsler
- Department of Neurology, University Hospital of Bonn, Bonn, Germany
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Lorenzo Nanetti
- Unit of Genetics of Neurodegenerative and Metabolic Diseases, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Lukas Nenning
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
- VASCage, Centre on Clinical Stroke Research, Innsbruck, Austria
| | - Wolfgang Dichtl
- Department of Internal Medicine III (Cardiology and Angiology), Medical University Innsbruck, Innsbruck, Austria
| | - Hanno Ulmer
- Institute of Medical Statistics and Informatics, Medical University Innsbruck, Innsbruck, Austria
| | - Jörg B Schulz
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute of Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Sylvia Boesch
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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Lynch DR, Perlman S, Schadt K. Omaveloxolone for the treatment of Friedreich ataxia: clinical trial results and practical considerations. Expert Rev Neurother 2024; 24:251-258. [PMID: 38269532 DOI: 10.1080/14737175.2024.2310617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/23/2024] [Indexed: 01/26/2024]
Abstract
INTRODUCTION Omavaloxolone, an NRF2 activator, recently became the first drug approved specifically for the treatment of Friedreich ataxia (FRDA). This landmark achievement provides a background for a review of the detailed data leading to the approval. AREAS COVERED The authors review the data from the 4 major articles on FRDA in the context of the authors' considerable (>1000 patients) experience in treating individuals with FRDA. The data is presented in the context not only of its scientific meaning but also in the practical context of therapy in FRDA. EXPERT OPINION Omaveloxolone provides a significant advance in the treatment of FRDA that is likely to be beneficial in a majority of the FRDA population. The data suggesting a benefit is consistent, and adverse issues are relatively modest. The major remaining questions are the subgroups that are most responsive and how long the beneficial effects will remain significant in FRDA patients.
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Affiliation(s)
- David R Lynch
- Friedrech Ataxia Program, Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan Perlman
- Department of Neurology, David Geffen UCLA School of Medicine, Los Angeles, CA, USA
| | - Kim Schadt
- Friedreich Ataxia Program, Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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12
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Smith FM, Kosman DJ. Loss of filamentous actin, tight junction protein expression, and paracellular barrier integrity in frataxin-deficient human brain microvascular endothelial cells-implications for blood-brain barrier physiology in Friedreich's ataxia. Front Mol Biosci 2024; 10:1299201. [PMID: 38274097 PMCID: PMC10808331 DOI: 10.3389/fmolb.2023.1299201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction: Friedreich's Ataxia (FRDA) is the most prevalent inherited ataxia. FRDA results from loss of Frataxin (FXN), an essential mitochondrial iron trafficking protein. FRDA starts with an early burst of neurodegeneration of the dorsal root ganglion and cerebellar dentate nuclei, followed by progressive brain iron accumulation in the latter. End stage disease includes cardiac fibrosis that contributes to hypertrophic cardiomyopathy. The microvasculature plays an essential barrier role in both brain and heart homeostasis, thus an investigation of this tissue system in FRDA is essential to the delineation of the cellular dysfunction in this genetic disorder. Previous reports have identified cytoskeletal alterations in non-barrier forming FRDA cell models, but physiological consequences are limited. Methods: We investigated brain microvascular endothelial cell integrity in FRDA in a model of the blood-brain barrier (BBB). We have knocked down FXN in immortalized human brain microvascular endothelial cells (hBMVEC), which compose the microcapillaries of the BBB, by using shRNA. We confirmed known cellular pathophysiologies of FXN-knockdown including decreased energy metabolism, markers of oxidative stress, and increased cell size. Results: We investigated cytoskeletal architecture, identifying decreased filamentous actin and Occludin and Claudin-5 tight junction protein expression in shFXN hBMVECs. This was consistent with decreased transendothelial electrical resistance (TEER) and increased paracellular tracer flux during early barrier formation. shFXN hBMVEC start with only 67% barrier integrity of the controls, and flux a paracellular tracer at 800% of physiological levels. Discussion: We identified that insufficient FXN levels in the hBMVEC BBB model causes changes in cytoskeletal architecture and tight junction protein abundance, co-incident with increased barrier permeability. Changes in the integrity of the BBB may be related to patient brain iron accumulation, neuroinflammation, neurodegeneration, and stroke. Furthermore, our findings implicate other barrier cells, e.g., the cardiac microvasculature, loci of disease pathology in FRDA.
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Affiliation(s)
- Frances M. Smith
- Jacobs School of Medicine and Biomedical Sciences, Department of Biochemistry, The State University of New York at Buffalo, Buffalo, NY, United States
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13
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Lynch DR, Goldsberry A, Rummey C, Farmer J, Boesch S, Delatycki MB, Giunti P, Hoyle JC, Mariotti C, Mathews KD, Nachbauer W, Perlman S, Subramony S, Wilmot G, Zesiewicz T, Weissfeld L, Meyer C. Propensity matched comparison of omaveloxolone treatment to Friedreich ataxia natural history data. Ann Clin Transl Neurol 2024; 11:4-16. [PMID: 37691319 PMCID: PMC10791025 DOI: 10.1002/acn3.51897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/22/2023] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVE The natural history of Friedreich ataxia is being investigated in a multi-center longitudinal study designated the Friedreich ataxia Clinical Outcome Measures Study (FACOMS). To understand the utility of this study in analysis of clinical trials, we performed a propensity-matched comparison of data from the open-label MOXIe extension (omaveloxolone) to that from FACOMS. METHODS MOXIe extension patients were matched to FACOMS patients using logistic regression to estimate propensity scores based on multiple covariates: sex, baseline age, age of onset, baseline modified Friedreich Ataxia Rating scale (mFARS) score, and baseline gait score. The change from baseline in mFARS at Year 3 for the MOXIe extension patients compared to the matched FACOMS patients was analyzed as the primary efficacy endpoint using mixed model repeated measures analysis. RESULTS Data from the MOXIe extension show that omaveloxolone provided persistent benefit over 3 years when compared to an untreated, matched cohort from FACOMS. At each year, in all analysis populations, patients in the MOXIe extension experienced a smaller change from baseline in mFARS score than matched FACOMS patients. In the primary pooled population (136 patients in each group) by Year 3, patients in the FACOMS matched set progressed 6.6 points whereas patients treated with omaveloxolone in MOXIe extension progressed 3 points (difference = -3.6; nominal p value = 0.0001). INTERPRETATION These results suggest a meaningful slowing of Friedreich ataxia progression with omaveloxolone, and consequently detail how propensity-matched analysis may contribute to understanding of effects of therapeutic agents. This demonstrates the direct value of natural history studies in clinical trial evaluations.
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Affiliation(s)
- David R. Lynch
- Departments of Pediatrics and NeurologyThe Children's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | | | - Jennifer Farmer
- Friedreich Ataxia Research AllianceDowningtownPennsylvaniaUSA
| | - Sylvia Boesch
- Department of NeurologyMedical University InnsbruckInnsbruckAustria
| | - Martin B. Delatycki
- Victorian Clinical Genetics ServicesMurdoch Children's Research InstituteParkvilleVictoriaAustralia
| | - Paola Giunti
- University College London HospitalBloomsburyLondonUK
| | - J. Chad Hoyle
- Department of NeurologyOhio State University College of MedicineColumbusOhioUSA
| | | | - Katherine D. Mathews
- Department of PediatricsUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | | | - Susan Perlman
- Department of NeurologyUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - S.H. Subramony
- Department of Neurology, McKnight Brain InstituteUniversity of Florida Health SystemGainesvilleFloridaUSA
| | - George Wilmot
- Department of NeurologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Theresa Zesiewicz
- Department of NeurologyUniversity of South Florida Ataxia Research CenterTampaFloridaUSA
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14
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Porcu L, Fichera M, Nanetti L, Rulli E, Giunti P, Parkinson MH, Durr A, Ewenczyk C, Boesch S, Nachbauer W, Indelicato E, Klopstock T, Stendel C, Rodríguez de Rivera FJ, Schöls L, Fleszar Z, Giordano I, Didszun C, Castaldo A, Rai M, Klockgether T, Pandolfo M, Schulz JB, Reetz K, Mariotti C. Longitudinal changes of SARA scale in Friedreich ataxia: Strong influence of baseline score and age at onset. Ann Clin Transl Neurol 2023; 10:2000-2012. [PMID: 37641437 PMCID: PMC10647003 DOI: 10.1002/acn3.51886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The Scale for Assessment and Rating of Ataxia (SARA) is widely used in different types of ataxias and has been chosen as the primary outcome measure in the European natural history study for Friedreich ataxia (FA). METHODS To assess distribution and longitudinal changes of SARA scores and its single items, we analyzed SARA scores of 502 patients with typical-onset FA (<25 years) participating in the 4-year prospective European FA Consortium for Translational Studies (EFACTS). Pattern of disease progression was determined using linear mixed-effects regression models. The chosen statistical model was re-fitted in order to estimate parameters and predict disease progression. Median time-to-change and rate of score progression were estimated using the Kaplan-Meier method and weighted linear regression models, respectively. RESULTS SARA score at study enrollment and age at onset were the major predictive factors of total score progression during the 4-year follow-up. To a less extent, age at evaluation also influenced the speed of SARA progression, while disease duration did not improve the prediction of the statistical model. Temporal dynamics of total SARA and items showed a great variability in the speed of score increase during disease progression. Gait item had the highest annual progression rate, with median time for one-point score increase of 1 to 2 years. INTERPRETATION Analyses of statistical properties of SARA suggest a variable sensitivity of the scale at different disease stages, and provide important information for population selection and result interpretation in future clinical trials.
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Affiliation(s)
- Luca Porcu
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUK
| | - Mario Fichera
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
| | - Lorenzo Nanetti
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
| | - Eliana Rulli
- Laboratory of Methodology for Clinical Research, Oncology DepartmentIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Paola Giunti
- Department of Clinical and Movement NeurosciencesAtaxia Centre, UCL‐Queen Square Institute of NeurologyLondonWC1N 3BGUK
| | - Michael H. Parkinson
- Department of Clinical and Movement NeurosciencesAtaxia Centre, UCL‐Queen Square Institute of NeurologyLondonWC1N 3BGUK
| | - Alexandra Durr
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP‐HP, INSERM, CNRSUniversity Hospital Pitié‐SalpêtrièreParis75646France
| | - Claire Ewenczyk
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP‐HP, INSERM, CNRSUniversity Hospital Pitié‐SalpêtrièreParis75646France
| | - Sylvia Boesch
- Department of NeurologyMedical University InnsbruckInnsbruck6020Austria
| | | | | | - Thomas Klopstock
- Department of NeurologyFriedrich Baur Institute, University Hospital, LMUMunich80336Germany
- German Center for Neurodegenerative Diseases (DZNE)Munich81377Germany
- Munich Cluster for Systems Neurology (SyNergy)Munich81377Germany
| | - Claudia Stendel
- Department of NeurologyFriedrich Baur Institute, University Hospital, LMUMunich80336Germany
- German Center for Neurodegenerative Diseases (DZNE)Munich81377Germany
| | | | - Ludger Schöls
- Department of Neurology and Hertie‐Institute for Clinical Brain ResearchUniversity of TübingenTübingen72076Germany
- German Center for Neurodegenerative Diseases (DZNE)Tübingen72076Germany
| | - Zofia Fleszar
- Department of Neurology and Hertie‐Institute for Clinical Brain ResearchUniversity of TübingenTübingen72076Germany
| | - Ilaria Giordano
- Department of NeurologyUniversity Hospital of BonnBonn53127Germany
| | - Claire Didszun
- Department of NeurologyRWTH Aachen UniversityAachen52074Germany
| | - Anna Castaldo
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
| | - Myriam Rai
- Laboratory of Experimental NeurologyUniversité Libre de BruxellesBrussels1070Belgium
| | - Thomas Klockgether
- Department of NeurologyUniversity Hospital of BonnBonn53127Germany
- German Center for Neurodegenerative Diseases (DZNE)Bonn53127Germany
| | - Massimo Pandolfo
- Laboratory of Experimental NeurologyUniversité Libre de BruxellesBrussels1070Belgium
- Department of Neurology and NeurosurgeryMcGill UniversityMontrealQCH3A 0G4Canada
| | - Jörg B. Schulz
- Department of NeurologyRWTH Aachen UniversityAachen52074Germany
- JARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen UniversityAachen52056Germany
| | - Kathrin Reetz
- Department of NeurologyRWTH Aachen UniversityAachen52074Germany
- JARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen UniversityAachen52056Germany
| | - Caterina Mariotti
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
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15
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Rodden LN, McIntyre K, Keita M, Wells M, Park C, Profeta V, Waldman A, Rummey C, Balcer LJ, Lynch DR. Retinal hypoplasia and degeneration result in vision loss in Friedreich ataxia. Ann Clin Transl Neurol 2023; 10:1397-1406. [PMID: 37334854 PMCID: PMC10424660 DOI: 10.1002/acn3.51830] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/16/2023] [Accepted: 05/26/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Friedreich ataxia (FRDA) is an inherited condition caused by a GAA triplet repeat (GAA-TR) expansion in the FXN gene. Clinical features of FRDA include ataxia, cardiomyopathy, and in some, vision loss. In this study, we characterize features of vision loss in a large cohort of adults and children with FRDA. METHODS Using optical coherence tomography (OCT), we measured peripapillary retinal nerve fiber layer (RNFL) thickness in 198 people with FRDA, and 77 controls. Sloan letter charts were used to determine visual acuity. RNFL thickness and visual acuity were compared to measures of disease severity obtained from the Friedreich Ataxia Clinical Outcomes Measures Study (FACOMS). RESULTS The majority of patients, including children, had pathologically thin RNFLs (mean = 73 ± 13 μm in FRDA; 98 ± 9 μm in controls) and low-contrast vision deficits early in the disease course. Variability in RNFL thickness in FRDA (range: 36 to 107 μm) was best predicted by disease burden (GAA-TR length X disease duration). Significant deficits in high-contrast visual acuity were apparent in patients with an RNFL thickness of ≤68 μm. RNFL thickness decreased at a rate of -1.2 ± 1.4 μm/year and reached 68 μm at a disease burden of approximately 12,000 GAA years, equivalent to disease duration of 17 years for participants with 700 GAAs. INTERPRETATION These data suggest that both hypoplasia and subsequent degeneration of the RNFL may be responsible for the optic nerve dysfunction in FRDA and support the development of a vision-directed treatment for selected patients early in the disease to prevent RNFL loss from reaching the critical threshold.
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Affiliation(s)
- Layne N. Rodden
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Kellie McIntyre
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Medina Keita
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Mckenzie Wells
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Courtney Park
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Victoria Profeta
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Amy Waldman
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | - Laura J. Balcer
- Departments of Neurology, Population Health and OphthalmologyNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - David R. Lynch
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Boesch S, Indelicato E. Experimental drugs for Friedrich's ataxia: progress and setbacks in clinical trials. Expert Opin Investig Drugs 2023; 32:967-969. [PMID: 37886821 DOI: 10.1080/13543784.2023.2276758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/25/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Sylvia Boesch
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elisabetta Indelicato
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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17
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Rodden LN, Rummey C, Kessler S, Wilson RB, Lynch DR. A Novel Metric for Predicting Severity of Disease Features in Friedreich's Ataxia. Mov Disord 2023. [PMID: 36928898 DOI: 10.1002/mds.29370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/25/2023] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Friedreich's ataxia (FRDA), most commonly caused by a GAA triplet repeat (GAA-TR) expansion in intron 1 of the FXN gene, is characterized by deficiency of frataxin protein and clinical features such as progressive ataxia, dysarthria, impaired proprioception and vibration, abolished deep tendon reflexes, Babinski sign, and vision loss in association with non-neurological features such as skeletal anomalies, hearing loss, cardiomyopathy, and diabetes. Pathogenic GAA-TRs range in size from 60 to 1500 triplets and negatively correlate with age of onset. Clinical severity is predicted by a combination of GAA-TR length and disease duration (DD) via multivariable regressions, which cannot typically be used for the small sample sizes in most studies on this rare disease. OBJECTIVE We aimed to develop a single metric, which we call "disease burden" (DB), that encompasses both GAA-TR length and DD for predicting disease features of FRDA in small sample sizes. METHODS Linear regression and multivariable regression analysis was used to determine correlation coefficients between different disease features of FRDA. RESULTS Using large datasets for validation, we found that DB predicts measures of neurological dysfunction in FRDA better than GAA-TR length or DD. Analogous results were found using small datasets. CONCLUSIONS FRDA DB is a novel metric of disease severity that has utility in small datasets to demonstrate correlations that would not otherwise be evident with either GAA-TR or DD alone. This is important for discovering new biomarkers, as well as improving the prediction of severity of disease features in FRDA. © 2023 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Layne N Rodden
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sudha Kessler
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert B Wilson
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R Lynch
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Lynch DR, Mathews KD, Perlman S, Zesiewicz T, Subramony S, Omidvar O, Vogel AP, Krtolica A, Litterman N, van der Ploeg L, Heerinckx F, Milner P, Midei M. Double blind trial of a deuterated form of linoleic acid (RT001) in Friedreich ataxia. J Neurol 2023; 270:1615-1623. [PMID: 36462055 DOI: 10.1007/s00415-022-11501-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES Friedreich ataxia is (FRDA) an autosomal recessive neurodegenerative disorder associated with intrinsic oxidative damage, suggesting that decreasing lipid peroxidation (LPO) might ameliorate disease progression. The present study tested the ability of RT001, a deuterated form of linoleic acid (D2-LA), to alter disease severity in patients with FRDA in a double-blind placebo-controlled trial. METHODS Sixty-five subjects were recruited across six sites and received either placebo or active drug for an 11-month study. Subjects were evaluated at 0, 4, 9, and 11 months, with the primary outcome measure being maximum oxygen consumption (MVO2) during cardiopulmonary exercise testing (CPET). A key secondary outcome measure was a composite statistical test using results from the timed 1-min walk (T1MW), peak workload, and MVO2. RESULTS Forty-five subjects completed the protocol. RT001 was well tolerated, with no serious adverse events related to drug. Plasma and red blood cell (RBC) membrane levels of D2-LA and its primary metabolite deuterated arachidonic acid (D2-AA) achieved steady-state concentrations by 4 months. No significant changes in MVO2 were observed for RT001 compared to placebo. Similarly, no differences between the groups were found in secondary or exploratory outcome measures. Post hoc evaluations also suggested minimal effects of RT001 at the dosages used in this study. INTERPRETATIONS The results of this study provide no evidence for a significant benefit of RT001 at the dosages tested in this Friedreich ataxia patient population.
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Affiliation(s)
- David R Lynch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA. .,Departments of Pediatrics and Neurology, The Children's Hospital of Philadelphia, 502F Abramson Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Katherine D Mathews
- Departments of Pediatrics and Neurology, University of Iowa Carver College of Medicine, Iowa City, USA
| | - Susan Perlman
- University of California Los Angeles, Los Angeles, USA
| | - Theresa Zesiewicz
- USF Ataxia Research Center, University of South Florida, James A. Haley Veteran's Hospital, Tampa, FL, USA
| | - Sub Subramony
- Norman Fixel Center for Neurological Disorders, University of Florida College of Medicine, Gainesville, USA
| | - Omid Omidvar
- University of California Los Angeles, Los Angeles, USA
| | - Adam P Vogel
- University of Melbourne, Parkville, Australia.,Redenlab Inc, Melbourne, Australia
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19
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Rojsajjakul T, Wu L, Grady CB, Hwang WT, Mesaros C, Lynch DR, Blair IA. Liquid Chromatography-Mass Spectrometry Analysis of Frataxin Proteoforms in Whole Blood as Biomarkers of the Genetic Disease Friedreich's Ataxia. Anal Chem 2023; 95:4251-4260. [PMID: 36800320 PMCID: PMC9979142 DOI: 10.1021/acs.analchem.3c00091] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Friedreich's ataxia (FRDA) is caused primarily by expanded GAA repeats in intron 1 of both alleles of the FXN gene, which causes transcriptional silencing and reduced expression of frataxin mRNA and protein. FRDA is characterized by slowly progressive ataxia and cardiomyopathy. Symptoms generally appear during adolescence, and patients slowly progress to wheelchair dependency usually in the late teens or early twenties with death on average in the 4th decade. There are two known mature proteoforms of frataxin. Mitochondrial frataxin (frataxin-M) is a 130-amino acid protein with a molecular weight of 14,268 Da, and there is an alternatively spliced N-terminally acetylated 135-amino acid form (frataxin-E) with a molecular weight of 14,953 Da found in erythrocytes. There is reduced expression of frataxin in the heart and brain, but frataxin is not secreted into the systemic circulation, so it cannot be analyzed in serum or plasma. Blood is a readily accessible biofluid that contains numerous different cell types that express frataxin. We have found that pig blood can serve as an excellent surrogate matrix to validate an assay for frataxin proteoforms because pig frataxin is lost during the immunoprecipitation step used to isolate human frataxin. Frataxin-M is expressed in blood cells that contain mitochondria, whereas extra-mitochondrial frataxin-E is found in erythrocytes. This means that the analysis of frataxin in whole blood provides information on the concentration of both proteoforms without having to isolate the individual cell types. In the current study, we observed that the distributions of frataxin levels for a sample of 25 healthy controls and 50 FRDA patients were completely separated from each other, suggesting 100% specificity and 100% sensitivity for distinguishing healthy controls from FRDA cases, a very unusual finding for a biomarker assay. Additionally, frataxin levels were significantly correlated with the GAA repeat length and age of onset with higher correlations for extra-mitochondrial frataxin-E than those for mitochondrial frataxin-M. These findings auger well for using frataxin levels measured by the validated stable isotope dilution ultrahigh-performance liquid chromatography-multiple reaction monitoring/mass spectrometry assay to monitor therapeutic interventions and the natural history of FRDA. Our study also illustrates the utility of using whole blood for protein disease biomarker discovery and validation.
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Affiliation(s)
- Teerapat Rojsajjakul
- Penn/CHOP
Friedreich’s Ataxia Center of Excellence, Philadelphia, Pennsylvania 19104, United States,Center
of Excellence in Environmental Toxicology, Department of Systems Pharmacology
and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Linfeng Wu
- Agilent
Technologies Inc., 5301
Stevens Creek Blvd., Santa Clara, California 95051, United States
| | - Connor B. Grady
- Center
for Clinical Epidemiology and Biostatistics, Department of Biostatistics,
Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States
| | - Wei-Ting Hwang
- Center
for Clinical Epidemiology and Biostatistics, Department of Biostatistics,
Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States
| | - Clementina Mesaros
- Penn/CHOP
Friedreich’s Ataxia Center of Excellence, Philadelphia, Pennsylvania 19104, United States,Center
of Excellence in Environmental Toxicology, Department of Systems Pharmacology
and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - David R. Lynch
- Penn/CHOP
Friedreich’s Ataxia Center of Excellence, Philadelphia, Pennsylvania 19104, United States,Departments
of Pediatrics and Neurology, Children’s
Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Ian A. Blair
- Penn/CHOP
Friedreich’s Ataxia Center of Excellence, Philadelphia, Pennsylvania 19104, United States,Center
of Excellence in Environmental Toxicology, Department of Systems Pharmacology
and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States,. Phone: +1-610-529-0610. Fax: +1-215-573-9889
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20
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Smith FM, Kosman DJ. Frataxin-deficient human brain microvascular endothelial cells lose polymerized actin and are paracellularly permeable -implications for blood-brain barrier integrity in Friedreich's Ataxia. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.09.527936. [PMID: 36798283 PMCID: PMC9934603 DOI: 10.1101/2023.02.09.527936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Background Friedreich's Ataxia (FRDA) is the most prevalent inherited ataxia; the disease results from loss of Frataxin, an essential mitochondrial iron trafficking protein. FRDA presents as neurodegeneration of the dorsal root ganglion and cerebellar dentate nuclei, followed by brain iron accumulation in the latter. End stage disease includes cardiac fibrosis that contributes to hypertrophic cardiomyopathy. The microvasculature plays an essential barrier role in both the brain and heart, thus an investigation of this tissue system in FRDA is essential to the delineation of the cellular dysfunction in this genetic disorder. Here, we investigate brain microvascular endothelial cell integrity in FRDA in a model of the blood-brain barrier (BBB). Methods We used lentiviral mediated shRNA delivery to generate a novel FRDA model in immortalized human brain microvascular endothelial cells (hBMVEC) that compose the microcapillaries of the BBB. We verified known cellular pathophysiologies of FXN knockdown including increased oxidative stress, loss of energy metabolism, and increased cell size. Furthermore, we investigated cytoskeletal architecture including the abundance and organization of filamentous actin, and barrier physiology via transendothelial electrical resistance and fluorescent tracer flux. Results shFXN hBMVEC display the known FRDA cell morbidity including increased oxidative stress, decreased energy metabolism, and an increase in cell size. We demonstrate that shFXN hBMVEC have less overall filamentous actin, and that filamentous actin is lost at the cell membrane and cortical actin ring. Consistent with loss of cytoskeletal structure and anchorage, we found decreased barrier strength and increased paracellular tracer flux in the shFXN hBMVEC transwell model. Conclusion We identified that insufficient FXN levels in the hBMVEC BBB model causes changes in cytoskeletal architecture and increased barrier permeability, cell pathologies that may be related to patient brain iron accumulation, neuroinflammation, neurodegeneration, and stroke. Our findings implicate other barrier cells, e.g., the cardiac microvasculature, likely contributory also to disease pathology in FRDA.
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Affiliation(s)
- Frances M Smith
- Department of Biochemistry, Jacobs School of Medicine and Biomedical Sciences, The University of New York at Buffalo
| | - Daniel J Kosman
- Department of Biochemistry, Jacobs School of Medicine and Biomedical Sciences, The University of New York at Buffalo
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21
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Shen MM, Rodden LN, McIntyre K, Arias A, Profeta V, Schadt K, Lynch DR. SARS-CoV-2 in patients with Friedreich ataxia. J Neurol 2023; 270:610-613. [PMID: 36219242 PMCID: PMC9552162 DOI: 10.1007/s00415-022-11419-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Megan M Shen
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Layne N Rodden
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA
| | - Kellie McIntyre
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA
| | - Adriana Arias
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA
| | - Victoria Profeta
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA
| | - Kimberly Schadt
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA
| | - David R Lynch
- Division of Neurology, The Children's Hospital of Philadelphia, 502 Abramson, Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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22
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Lynch DR, Chin MP, Boesch S, Delatycki MB, Giunti P, Goldsberry A, Hoyle JC, Mariotti C, Mathews KD, Nachbauer W, O'Grady M, Perlman S, Subramony SH, Wilmot G, Zesiewicz T, Meyer CJ. Efficacy of Omaveloxolone in Friedreich's Ataxia: Delayed-Start Analysis of the MOXIe Extension. Mov Disord 2023; 38:313-320. [PMID: 36444905 DOI: 10.1002/mds.29286] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/29/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND MOXIe was a two-part study evaluating the safety and efficacy of omaveloxolone in patients with Friedreich's ataxia, a rare, progressive neurological disease with no proven therapy. MOXIe part 2, a randomized double-blind placebo-controlled trial, showed omaveloxolone significantly improved modified Friedreich's Ataxia Rating Scale (mFARS) scores relative to placebo. Patients who completed part 1 or 2 were eligible to receive omaveloxolone in an open-label extension study. OBJECTIVE The delayed-start study compared mFARS scores at the end of MOXIe part 2 with those at 72 weeks in the open-label extension period (up to 144 weeks) for patients initially randomized to omaveloxolone versus those initially randomized to placebo. METHODS We performed a noninferiority test to compare the difference between treatment groups (placebo to omaveloxolone versus omaveloxolone to omaveloxolone) using a single mixed model repeated measures (MMRM) model. In addition, slopes of the change in mFARS scores were compared between both groups in the open-label extension. RESULTS The noninferiority testing demonstrated that the difference in mFARS between omaveloxolone and placebo observed at the end of placebo-controlled MOXIe part 2 (-2.17 ± 1.09 points) was preserved after 72 weeks in the extension (-2.91 ± 1.44 points). In addition, patients previously randomized to omaveloxolone in MOXIe part 2 continued to show no worsening in mFARS relative to their extension baseline through 144 weeks. CONCLUSIONS These results support the positive results of MOXIe part 2 and indicate a persistent benefit of omaveloxolone treatment on disease course in Friedreich's ataxia. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- David R Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Sylvia Boesch
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Martin B Delatycki
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Paola Giunti
- University College London Hospital, London, United Kingdom
| | | | - J Chad Hoyle
- Department of Neurology, Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | - Katherine D Mathews
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Wolfgang Nachbauer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Susan Perlman
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - S H Subramony
- Department of Neurology, McKnight Brain Institute, University of Florida Health System, Gainesville, Florida, USA
| | - George Wilmot
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Theresa Zesiewicz
- Department of Neurology, University of South Florida Ataxia Research Center, Tampa, Florida, USA
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23
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Profeta V, McIntyre K, Wells M, Park C, Lynch DR. Omaveloxolone: an activator of Nrf2 for the treatment of Friedreich ataxia. Expert Opin Investig Drugs 2023; 32:5-16. [PMID: 36708320 DOI: 10.1080/13543784.2023.2173063] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Friedreich ataxia (FRDA) is a rare autosomal recessive degenerative disorder characterized by ataxia, dysarthria, diabetes, cardiomyopathy, scoliosis, and occasionally vision loss in late-stage disease. The discovery of the abnormal gene in FRDA and its product frataxin has provided insight into the pathophysiology and mechanisms of treatment. AREAS COVERED Although the neurologic phenotype of FRDA is well defined, there are currently no established pharmacological treatments. Omaveloxolone, a nuclear factor erythroid 2-related factor 2 (Nrf2) activator, is currently under review by the Food and Drug Administration (FDA) and has the potential to be the first approved treatment for FRDA. In the present report, we have reviewed the basic and clinical literature on Nrf2 deficiency in FRDA, and evidence for the benefit of omaveloxolone. EXPERT OPINION The present perspective suggests that omaveloxolone is a rational and efficacious therapy that is possibly disease modifying in treatment of FRDA.
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Affiliation(s)
- Victoria Profeta
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kellie McIntyre
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - McKenzie Wells
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Courtney Park
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David R Lynch
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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24
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Pandolfo M, Reetz K, Darling A, Rodriguez de Rivera FJ, Henry PG, Joers J, Lenglet C, Adanyeguh I, Deelchand D, Mochel F, Pousset F, Pascual S, Van den Eede D, Martin-Ugarte I, Vilà-Brau A, Mantilla A, Pascual M, Martinell M, Meya U, Durr A. Efficacy and Safety of Leriglitazone in Patients With Friedreich Ataxia. Neurol Genet 2022; 8:e200034. [DOI: 10.1212/nxg.0000000000200034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022]
Abstract
Background and ObjectivesFriedreich ataxia (FRDA) is an autosomal recessive ataxia with no approved treatments. Leriglitazone is a selective peroxisome proliferator–activated receptor γ agonist that crosses the blood-brain barrier and, in preclinical models, improved mitochondrial function and energy production. We assessed effects of leriglitazone in patients with FRDA in a proof-of-concept study.MethodsIn this double-blind, randomized controlled trial, eligible participants (age 12–60 years) had genetically confirmed FRDA, a Scale for the Assessment and Rating of Ataxia (SARA) total score <25, and a SARA item 1 score of 2–6, inclusive. Key exclusion criteria were age at FRDA onset ≥25 years and history of cardiac dysfunction. Participants were randomly assigned (2:1) to receive a daily, oral, individualized dose of leriglitazone or placebo for 48 weeks. The primary endpoint was the change from baseline to week 48 in spinal cord area (C2-C3) (measured by MRI). Secondary endpoints included the change from baseline to week 48 in iron accumulation in the dentate nucleus (quantitative susceptibility mapping) and totalN-acetylaspartate to myo-inositol (tNAA/mIns) ratio.ResultsOverall, 39 patients were enrolled (mean age 24 years; 43.6% women; mean time since symptom onset 10.5 years): 26 patients received leriglitazone (20 completed) and 13 received placebo (12 completed). There was no difference between groups in spinal cord area from baseline to week 48 (least-squares [LS] mean change [standard error (SE)]: leriglitazone, −0.39 [0.55] mm2; placebo, 0.08 [0.72] mm2;p= 0.61). Iron accumulation in the dentate nucleus was greater with placebo (LS mean change [SE]: leriglitazone, 0.10 [1.33] ppb; placebo, 4.86 [1.84] ppb;p= 0.05), and a numerical difference was seen in tNAA/mIns ratio (LS mean change [SE]: leriglitazone, 0.03 [0.02]; placebo, −0.02 [0.03];p= 0.25). The most frequent adverse event was peripheral edema (leriglitazone 73.1%, placebo 0%).DiscussionThe primary endpoint of change in spinal cord area was not met. Secondary endpoints provide evidence supporting proof of concept for leriglitazone mode of action and, with acceptable safety data, support larger studies in patients with FRDA.Trial Registration InformationClinicalTrials.gov:NCT03917225; EudraCT: 2018-004405-64; submitted April 17, 2019; first patient enrolled April 2, 2019.clinicaltrials.gov/ct2/show/NCT03917225?term=NCT03917225&draw=2&rank=1.Classification of EvidenceThis study provides Class I evidence that individualized dosing of leriglitazone, compared with placebo, is not associated with changes in spinal cord area in patients with FRDA.
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25
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Hohenfeld C, Terstiege U, Dogan I, Giunti P, Parkinson MH, Mariotti C, Nanetti L, Fichera M, Durr A, Ewenczyk C, Boesch S, Nachbauer W, Klopstock T, Stendel C, Rodríguez de Rivera Garrido FJ, Schöls L, Hayer SN, Klockgether T, Giordano I, Didszun C, Rai M, Pandolfo M, Rauhut H, Schulz JB, Reetz K. Prediction of the disease course in Friedreich ataxia. Sci Rep 2022; 12:19173. [PMID: 36357508 PMCID: PMC9649725 DOI: 10.1038/s41598-022-23666-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
We explored whether disease severity of Friedreich ataxia can be predicted using data from clinical examinations. From the database of the European Friedreich Ataxia Consortium for Translational Studies (EFACTS) data from up to five examinations of 602 patients with genetically confirmed FRDA was included. Clinical instruments and important symptoms of FRDA were identified as targets for prediction, while variables such as genetics, age of disease onset and first symptom of the disease were used as predictors. We used modelling techniques including generalised linear models, support-vector-machines and decision trees. The scale for rating and assessment of ataxia (SARA) and the activities of daily living (ADL) could be predicted with predictive errors quantified by root-mean-squared-errors (RMSE) of 6.49 and 5.83, respectively. Also, we were able to achieve reasonable performance for loss of ambulation (ROC-AUC score of 0.83). However, predictions for the SCA functional assessment (SCAFI) and presence of cardiological symptoms were difficult. In conclusion, we demonstrate that some clinical features of FRDA can be predicted with reasonable error; being a first step towards future clinical applications of predictive modelling. In contrast, targets where predictions were difficult raise the question whether there are yet unknown variables driving the clinical phenotype of FRDA.
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Affiliation(s)
- Christian Hohenfeld
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
| | - Ulrich Terstiege
- grid.1957.a0000 0001 0728 696XChair for Mathematics of Information Processing, RWTH Aachen University, 52062 Aachen, Germany
| | - Imis Dogan
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
| | - Paola Giunti
- grid.83440.3b0000000121901201Department of Clinical and Movement Neurosciences, Ataxia Centre, UCL-Queen Square Institute of Neurology, London, WC1N 3BG UK
| | - Michael H. Parkinson
- grid.83440.3b0000000121901201Department of Clinical and Movement Neurosciences, Ataxia Centre, UCL-Queen Square Institute of Neurology, London, WC1N 3BG UK
| | - Caterina Mariotti
- grid.417894.70000 0001 0707 5492Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Lorenzo Nanetti
- grid.417894.70000 0001 0707 5492Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Mario Fichera
- grid.417894.70000 0001 0707 5492Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy ,grid.7563.70000 0001 2174 1754PhD Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Alexandra Durr
- grid.411439.a0000 0001 2150 9058Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP-HP, INSERM, CNRS, University Hospital Pitié-Salpêtrière, 75646 Paris, France
| | - Claire Ewenczyk
- grid.411439.a0000 0001 2150 9058Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP-HP, INSERM, CNRS, University Hospital Pitié-Salpêtrière, 75646 Paris, France
| | - Sylvia Boesch
- grid.5361.10000 0000 8853 2677Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Wolfgang Nachbauer
- grid.5361.10000 0000 8853 2677Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Thomas Klopstock
- grid.5252.00000 0004 1936 973XDepartment of Neurology, Friedrich Baur Institute, University Hospital, LMU, 80336 Munich, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 81377 Munich, Germany ,grid.452617.3Munich Cluster for Systems Neurology (SyNergy), 81377 Munich, Germany
| | - Claudia Stendel
- grid.5252.00000 0004 1936 973XDepartment of Neurology, Friedrich Baur Institute, University Hospital, LMU, 80336 Munich, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 81377 Munich, Germany
| | | | - Ludger Schöls
- grid.10392.390000 0001 2190 1447Department of Neurology and Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076 Tübingen, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 72076 Tübingen, Germany
| | - Stefanie N. Hayer
- grid.10392.390000 0001 2190 1447Department of Neurology and Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076 Tübingen, Germany
| | - Thomas Klockgether
- grid.15090.3d0000 0000 8786 803XDepartment of Neurology, University Hospital of Bonn, 53127 Bonn, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
| | - Ilaria Giordano
- grid.15090.3d0000 0000 8786 803XDepartment of Neurology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Claire Didszun
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany
| | - Myriam Rai
- grid.4989.c0000 0001 2348 0746Laboratory of Experimental Neurology, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Massimo Pandolfo
- grid.4989.c0000 0001 2348 0746Laboratory of Experimental Neurology, Université Libre de Bruxelles, 1070 Brussels, Belgium ,grid.14709.3b0000 0004 1936 8649Department of Neurology and Neurosurgery, McGill University, Montreal, QC H3A 0G4 Canada
| | - Holger Rauhut
- grid.1957.a0000 0001 0728 696XChair for Mathematics of Information Processing, RWTH Aachen University, 52062 Aachen, Germany
| | - Jörg B. Schulz
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
| | - Kathrin Reetz
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
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26
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Li Y, Li J, Wang J, Zhang S, Giles K, Prakash TP, Rigo F, Napierala JS, Napierala M. Premature transcription termination at the expanded GAA repeats and aberrant alternative polyadenylation contributes to the Frataxin transcriptional deficit in Friedreich's ataxia. Hum Mol Genet 2022; 31:3539-3557. [PMID: 35708503 PMCID: PMC9558844 DOI: 10.1093/hmg/ddac134] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/12/2022] [Accepted: 06/05/2022] [Indexed: 11/18/2022] Open
Abstract
Frataxin deficiency in Friedreich's ataxia results from transcriptional downregulation of the FXN gene caused by expansion of the intronic trinucleotide guanine-adenine-adenine (GAA) repeats. We used multiple transcriptomic approaches to determine the molecular mechanism of transcription inhibition caused by long GAAs. We uncovered that transcription of FXN in patient cells is prematurely terminated upstream of the expanded repeats leading to the formation of a novel, truncated and stable RNA. This FXN early terminated transcript (FXN-ett) undergoes alternative, non-productive splicing and does not contribute to the synthesis of functional frataxin. The level the FXN-ett RNA directly correlates with the length of the longer of the two expanded GAA tracts. Targeting GAAs with antisense oligonucleotides or excision of the repeats eliminates the transcription impediment, diminishes expression of the aberrant FXN-ett, while increasing levels of FXN mRNA and frataxin. Non-productive transcription may represent a common phenomenon and attractive therapeutic target in diseases caused by repeat-mediated transcription aberrations.
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Affiliation(s)
- Yanjie Li
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
| | - Jixue Li
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
| | - Jun Wang
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
| | - Siyuan Zhang
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
| | - Keith Giles
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
| | - Thazha P Prakash
- Ionis Pharmaceuticals Inc., 2855 Gazelle Court, Carlsbad, CA 92010, USA
| | - Frank Rigo
- Ionis Pharmaceuticals Inc., 2855 Gazelle Court, Carlsbad, CA 92010, USA
| | - Jill S Napierala
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Marek Napierala
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, 1825 University Blvd., Birmingham, AL 35294, USA
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
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Rummey C, Corben LA, Delatycki M, Wilmot G, Subramony SH, Corti M, Bushara K, Duquette A, Gomez C, Hoyle JC, Roxburgh R, Seeberger L, Yoon G, Mathews K, Zesiewicz T, Perlman S, Lynch DR. Natural History of Friedreich Ataxia: Heterogeneity of Neurologic Progression and Consequences for Clinical Trial Design. Neurology 2022; 99:e1499-e1510. [PMID: 35817567 PMCID: PMC9576299 DOI: 10.1212/wnl.0000000000200913] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The understanding of the natural history of Friedreich ataxia (FRDA) has improved considerably recently, but patterns of neurologic deterioration are not fully clarified, compromising the assessment of the clinical relevance of effects and guidance for study design. The goal of this study was to acknowledge the broad genetic diversity of the population, especially for younger individuals, and to provide analyses stratified by age to guide population selection in future studies. METHODS Based on a large natural history study, the FRDA Clinical Outcome Measures study that at the current data cut enrolled 1,115 participants, followed up for 5,287 yearly visits, we present results from the modified FRDA Rating Scale and its subscores. The secondary outcomes included the patient-reported activities of daily living scale, the timed 25-foot walk, and the 9-hole peg test. Long-term progression was modeled using slope analyses within early-onset, typical-onset, intermediate-onset, and late-onset FRDA. To reflect recruitment in clinical trials, short-term changes were analyzed within age-based subpopulations. All analyses were stratified by ambulation status. RESULTS Long-term progression models stratified by disease severity indicated highly differential disease progression, especially at earlier ages at onset. In the ambulatory phase, decline was driven by axial items assessed by the Upright Stability subscore of the mFARS. The analyses of short-term changes showed slower progression with increasing population age due to decreasing genetic severity. Future clinical studies could reduce population diversity, interpatient variability, and the risk of imbalanced treatment groups by selecting the study population based on the functional capacity (e.g., ambulatory status) and by strict age-based stratification. DISCUSSION The understanding of the diversity within FRDA populations and their patterns of functional decline provides an essential foundation for future clinical trial design including patient selection and facilitates the interpretation of the clinical relevance of progression detected in FRDA.
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Affiliation(s)
- Christian Rummey
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Louise A Corben
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Martin Delatycki
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - George Wilmot
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Sub H Subramony
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Manuela Corti
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Khalaf Bushara
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Antoine Duquette
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Christopher Gomez
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - J Chad Hoyle
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Richard Roxburgh
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Lauren Seeberger
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Grace Yoon
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Katherine Mathews
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Theresa Zesiewicz
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - Susan Perlman
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA
| | - David R Lynch
- From the Clinical Data Science GmbH (C.R.), Basel, Switzerland; Bruce Lefroy Centre for Genetic Health Research (L.A.C., M.D.), Murdoch Children's Research Institute, Parkville, Victoria; Department of Paediatrics (L.A.C., M.D.), University of Melbourne. Parkville, Victoria, Australia; Emory University (G.W.), Atlanta, GA; Department of Neurology (S.H.S., M.C.), McKnight Brain Institute, Gainesville, FL; University of Minnesota (K.B.), Minneapolis; Service de Neurologie (A.D.), Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Montréal (CHUM) and CRCHUM, Quebec, Canada; University of Chicago (C.G.), IL; Ohio State University (J.C.H.), Columbus; University of Auckland (R.R.), New Zealand; University of Colorado (L.S.), Denver; Divisions of Neurology and Clinical and Metabolic Genetics (G.Y.), Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; University of Iowa (K.M.), Iowa City, Carver College of Medicine, Iowa City, IA; University of South Florida (T.Z.), Tampa; University of California Los Angeles (S.P.); and Division of Neurology (D.R.L.), Children's Hospital of Philadelphia, PA.
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Joers JM, Adanyeguh IM, Deelchand DK, Hutter DH, Eberly LE, Iltis I, Bushara KO, Lenglet C, Henry PG. Spinal cord magnetic resonance imaging and spectroscopy detect early-stage alterations and disease progression in Friedreich ataxia. Brain Commun 2022; 4:fcac246. [PMID: 36300142 PMCID: PMC9581897 DOI: 10.1093/braincomms/fcac246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/04/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023] Open
Abstract
Friedreich ataxia is the most common hereditary ataxia. Atrophy of the spinal cord is one of the hallmarks of the disease. MRI and magnetic resonance spectroscopy are powerful and non-invasive tools to investigate pathological changes in the spinal cord. A handful of studies have reported cross-sectional alterations in Friedreich ataxia using MRI and diffusion MRI. However, to our knowledge no longitudinal MRI, diffusion MRI or MRS results have been reported in the spinal cord. Here, we investigated early-stage cross-sectional alterations and longitudinal changes in the cervical spinal cord in Friedreich ataxia, using a multimodal magnetic resonance protocol comprising morphometric (anatomical MRI), microstructural (diffusion MRI), and neurochemical (1H-MRS) assessments.We enrolled 28 early-stage individuals with Friedreich ataxia and 20 age- and gender-matched controls (cross-sectional study). Disease duration at baseline was 5.5 ± 4.0 years and Friedreich Ataxia Rating Scale total neurological score at baseline was 42.7 ± 13.6. Twenty-one Friedreich ataxia participants returned for 1-year follow-up, and 19 of those for 2-year follow-up (cohort study). Each visit consisted in clinical assessments and magnetic resonance scans. Controls were scanned at baseline only. At baseline, individuals with Friedreich ataxia had significantly lower spinal cord cross-sectional area (-31%, P = 8 × 10-17), higher eccentricity (+10%, P = 5 × 10-7), lower total N-acetyl-aspartate (tNAA) (-36%, P = 6 × 10-9) and higher myo-inositol (mIns) (+37%, P = 2 × 10-6) corresponding to a lower ratio tNAA/mIns (-52%, P = 2 × 10-13), lower fractional anisotropy (-24%, P = 10-9), as well as higher radial diffusivity (+56%, P = 2 × 10-9), mean diffusivity (+35%, P = 10-8) and axial diffusivity (+17%, P = 4 × 10-5) relative to controls. Longitudinally, spinal cord cross-sectional area decreased by 2.4% per year relative to baseline (P = 4 × 10-4), the ratio tNAA/mIns decreased by 5.8% per year (P = 0.03), and fractional anisotropy showed a trend to decrease (-3.2% per year, P = 0.08). Spinal cord cross-sectional area correlated strongly with clinical measures, with the strongest correlation coefficients found between cross-sectional area and Scale for the Assessment and Rating of Ataxia (R = -0.55, P = 7 × 10-6) and between cross-sectional area and Friedreich ataxia Rating Scale total neurological score (R = -0.60, P = 4 × 10-7). Less strong but still significant correlations were found for fractional anisotropy and tNAA/mIns. We report here the first quantitative longitudinal magnetic resonance results in the spinal cord in Friedreich ataxia. The largest longitudinal effect size was found for spinal cord cross-sectional area, followed by tNAA/mIns and fractional anisotropy. Our results provide direct evidence that abnormalities in the spinal cord result not solely from hypoplasia, but also from neurodegeneration, and show that disease progression can be monitored non-invasively in the spinal cord.
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Affiliation(s)
- James M Joers
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Isaac M Adanyeguh
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Dinesh K Deelchand
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Diane H Hutter
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Lynn E Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Isabelle Iltis
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Khalaf O Bushara
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Christophe Lenglet
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Pierre-Gilles Henry
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
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Keita M, McIntyre K, Rodden LN, Schadt K, Lynch DR. Friedreich ataxia: clinical features and new developments. Neurodegener Dis Manag 2022; 12:267-283. [PMID: 35766110 PMCID: PMC9517959 DOI: 10.2217/nmt-2022-0011] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Friedreich's ataxia (FRDA), a neurodegenerative disease characterized by ataxia and other neurological features, affects 1 in 50,000-100,000 individuals in the USA. However, FRDA also includes cardiac, orthopedic and endocrine dysfunction, giving rise to many secondary disease characteristics. The multifaceted approach for clinical care has necessitated the development of disease-specific clinical care guidelines. New developments in FRDA include the advancement of clinical drug trials targeting the NRF2 pathway and frataxin restoration. Additionally, a novel understanding of gene silencing in FRDA, reflecting a variegated silencing pattern, will have applications to current and future therapeutic interventions. Finally, new perspectives on the neuroanatomy of FRDA and its developmental features will refine the time course and anatomical targeting of novel approaches.
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Affiliation(s)
- Medina Keita
- Departments of Pediatrics & Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kellie McIntyre
- Departments of Pediatrics & Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Layne N Rodden
- Departments of Pediatrics & Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kim Schadt
- Departments of Pediatrics & Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David R Lynch
- Departments of Pediatrics & Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Park YW, Joers JM, Guo B, Hutter D, Bushara K, Adanyeguh IM, Eberly LE, Öz G, Lenglet C. Corrigendum: Assessment of cerebral and cerebellar white matter microstructure in spinocerebellar ataxias 1, 2, 3, and 6 using diffusion MRI. Front Neurol 2022; 13:1038298. [PMID: 36247785 PMCID: PMC9559733 DOI: 10.3389/fneur.2022.1038298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Young Woo Park
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
- *Correspondence: Young Woo Park
| | - James M. Joers
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Bin Guo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Diane Hutter
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Khalaf Bushara
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Isaac M. Adanyeguh
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Lynn E. Eberly
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Gülin Öz
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Christophe Lenglet
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
- Christophe Lenglet
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Rodden LN, Rummey C, Dong YN, Lagedrost S, Regner S, Brocht A, Bushara K, Delatycki MB, Gomez CM, Mathews K, Murray S, Perlman S, Ravina B, Subramony SH, Wilmot G, Zesiewicz T, Bolotta A, Domissy A, Jespersen C, Ji B, Soragni E, Gottesfeld JM, Lynch DR. A non-synonymous single nucleotide polymorphism in SIRT6 predicts neurological severity in Friedreich ataxia. Front Mol Biosci 2022; 9:933788. [PMID: 36133907 PMCID: PMC9483148 DOI: 10.3389/fmolb.2022.933788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: Friedreich ataxia (FRDA) is a recessive neurodegenerative disease characterized by progressive ataxia, dyscoordination, and loss of vision. The variable length of the pathogenic GAA triplet repeat expansion in the FXN gene in part explains the interindividual variability in the severity of disease. The GAA repeat expansion leads to epigenetic silencing of FXN; therefore, variability in properties of epigenetic effector proteins could also regulate the severity of FRDA. Methods: In an exploratory analysis, DNA from 88 individuals with FRDA was analyzed to determine if any of five non-synonymous SNPs in HDACs/SIRTs predicted FRDA disease severity. Results suggested the need for a full analysis at the rs352493 locus in SIRT6 (p.Asn46Ser). In a cohort of 569 subjects with FRDA, disease features were compared between subjects homozygous for the common thymine SIRT6 variant (TT) and those with the less common cytosine variant on one allele and thymine on the other (CT). The biochemical properties of both variants of SIRT6 were analyzed and compared. Results: Linear regression in the exploratory cohort suggested that an SNP (rs352493) in SIRT6 correlated with neurological severity in FRDA. The follow-up analysis in a larger cohort agreed with the initial result that the genotype of SIRT6 at the locus rs352493 predicted the severity of disease features of FRDA. Those in the CT SIRT6 group performed better on measures of neurological and visual function over time than those in the more common TT SIRT6 group. The Asn to Ser amino acid change resulting from the SNP in SIRT6 did not alter the expression or enzymatic activity of SIRT6 or frataxin, but iPSC-derived neurons from people with FRDA in the CT SIRT6 group showed whole transcriptome differences compared to those in the TT SIRT6 group. Conclusion: People with FRDA in the CT SIRT6 group have less severe neurological and visual dysfunction than those in the TT SIRT6 group. Biochemical analyses indicate that the benefit conferred by T to C SNP in SIRT6 does not come from altered expression or enzymatic activity of SIRT6 or frataxin but is associated with changes in the transcriptome.
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Affiliation(s)
- Layne N. Rodden
- Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Yi Na Dong
- Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarah Lagedrost
- Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sean Regner
- Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Alicia Brocht
- University of Rochester, Rochester, NY, United States
| | | | - Martin B. Delatycki
- Murdoch Children’s Research Institute, Victorian Clinical Genetics Services, Melbourne, VIC, Australia
| | | | - Katherine Mathews
- Departments of Pediatrics and Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Sarah Murray
- Department of Pathology, School of Medicine, University of California, San Diego, San Diego, CA, United States
| | - Susan Perlman
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - S. H. Subramony
- Department of Neurology, University of Florida, College of Medicine, Gainesville, FL, United States
| | - George Wilmot
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Theresa Zesiewicz
- Department of Neurology, University of South Florida, Tampa, FL, United States
| | | | - Alain Domissy
- The Scripps Research Institute, La Jolla, CA, United States
| | | | - Baohu Ji
- The Scripps Research Institute, La Jolla, CA, United States
| | | | | | - David R. Lynch
- Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: David R. Lynch,
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Payne RM. Cardiovascular Research in Friedreich Ataxia: Unmet Needs and Opportunities. JACC Basic Transl Sci 2022; 7:1267-1283. [PMID: 36644283 PMCID: PMC9831864 DOI: 10.1016/j.jacbts.2022.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 01/18/2023]
Abstract
Friedreich Ataxia (FRDA) is an autosomal recessive disease in which a mitochondrial protein, frataxin, is severely decreased in its expression. In addition to progressive ataxia, patients with FRDA often develop a cardiomyopathy that can be hypertrophic. This cardiomyopathy is unlike the sarcomeric hypertrophic cardiomyopathies in that the hypertrophy is associated with massive mitochondrial proliferation within the cardiomyocyte rather than contractile protein overexpression. This is associated with atrial arrhythmias, apoptosis, and fibrosis over time, and patients often develop heart failure leading to premature death. The differences between this mitochondrial cardiomyopathy and the more common contractile protein hypertrophic cardiomyopathies can be a source of misunderstanding in the management of these patients. Although imaging studies have revealed much about the structure and function of the heart in this disease, we still lack an understanding of many important clinical and fundamental molecular events that determine outcome of the heart in FRDA. This review will describe the current basic and clinical understanding of the FRDA heart, and most importantly, identify major gaps in our knowledge that represent new directions and opportunities for research.
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Affiliation(s)
- R. Mark Payne
- Address for correspondence: Dr R. Mark Payne, Division of Pediatric Cardiology, Wells Center for Pediatric Research, Indiana University School of Medicine, 1044 West Walnut, R4 302b, Indianapolis, Indiana 46202, USA.
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Rodden LN, Rummey C, Dong YN, Lynch DR. Clinical Evidence for Variegated Silencing in Patients With Friedreich Ataxia. Neurol Genet 2022; 8:e683. [PMID: 35620135 PMCID: PMC9128033 DOI: 10.1212/nxg.0000000000000683] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives Friedreich ataxia (FRDA) is a neurodegenerative disease caused by a GAA triplet repeat (GAA-TR) expansion in intron 1 of the FXN gene. Patients have 100-1,300 GAA triplets compared with less than 30 in healthy controls. The GAA-TR expansion leads to FXN silencing, and consequent frataxin protein deficiency results in progressive ataxia, scoliosis, cardiomyopathy, and diabetes. The overt heterogeneity in age at onset and disease severity is explained partly by the length of the GAA-TR, in which shorter repeats correlate with milder disease. Evidence of variegated silencing in FRDA suggests that patients with shorter repeats retain a significant proportion of cells with FXN genes that have escaped GAA-TR expansion-induced silencing, explaining the less severe frataxin deficiency in this subpopulation. In ex vivo experiments, the proportion of spared cells negatively correlates with GAA-TR length until it plateaus at 500 triplets, an indication that the maximal number of silenced cells has been reached. In this study, we assessed whether an analogous ceiling effect occurs in severity of clinical features of FRDA by analyzing clinical outcome data. Methods The FRDA Clinical Outcome Measures Study database was used for a cross-sectional analysis of 1,000 patients with FRDA. Frataxin levels were determined by lateral flow immunoassays. Results The length of the GAA-TR in our cohort predicted frataxin level (R2 = 0.38, p < 0.0001) and age at onset (R2 = 0.46, p < 0.0001) but only with GAA-TRs with ≤700 triplets. Age and disease duration predicted performance on clinical outcome measures, and such predictions in linear regression models statistically improved in the subcohort of patients with >700 GAA triplets. The prevalence of cardiomyopathy and scoliosis increased as GAA-TR length increased up to 700 GAA triplets where prevalence plateaued. Discussion Our data suggest that there is a ceiling effect on the clinical consequences of GAA-TR length in FRDA, as would be predicted by variegated silencing. Patients with GAA-TRs of >700 triplets represent a subgroup in which the severity of clinical manifestations based on GAA-TR length have reached maximal levels and therefore display limited clinical variability in disease progression.
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Affiliation(s)
- Layne N. Rodden
- From the Departments of Pediatrics and Neurology (L.N.R., Y.N.D., D.R.L.), Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania; and Clinical Data Science GmbH (C.R.), Basel, Switzerland
| | - Christian Rummey
- From the Departments of Pediatrics and Neurology (L.N.R., Y.N.D., D.R.L.), Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania; and Clinical Data Science GmbH (C.R.), Basel, Switzerland
| | - Yi Na Dong
- From the Departments of Pediatrics and Neurology (L.N.R., Y.N.D., D.R.L.), Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania; and Clinical Data Science GmbH (C.R.), Basel, Switzerland
| | - David R. Lynch
- From the Departments of Pediatrics and Neurology (L.N.R., Y.N.D., D.R.L.), Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania; and Clinical Data Science GmbH (C.R.), Basel, Switzerland
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Tamaroff J, DeDio A, Wade K, Wells M, Park C, Leavens K, Rummey C, Kelly A, Lynch DR, McCormack SE. Friedreich's Ataxia related Diabetes: Epidemiology and management practices. Diabetes Res Clin Pract 2022; 186:109828. [PMID: 35301072 PMCID: PMC9075677 DOI: 10.1016/j.diabres.2022.109828] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 01/21/2023]
Abstract
AIMS Friedreich's Ataxia (FRDA) is a progressive neuromuscular disorder typically caused by GAA triplet repeat expansions in both frataxin gene alleles. FRDA can be complicated by diabetes mellitus (DM). The objective of this study was to describe the prevalence of, risk factors for, and management practices of FRDA-related DM. METHODS FACOMS, a prospective, multi-site natural history study, includes 1,104 individuals. Extracted data included the presence of DM and other co-morbidities, genetic diagnosis, and markers of disease severity. We performed detailed medical record review and a survey for the subset of individuals with FRDA-related DM followed at one FACOMS site, Children's Hospital of Philadelphia. RESULTS FRDA-related DM was reported by 8.7% of individuals. Age, severe disease, and FRDA cardiac complications were positively associated with DM risk. FRDA-related DM was generally well-controlled, as reflected by HbA1c, though diabetic ketoacidosis did occur. Insulin is the mainstay of treatment (64-74% overall); in adults, metformin use was common and newer glucose-lowering agents were used rarely. CONCLUSIONS Clinical factors identify individuals at increased risk for FRDA-related DM. Future studies should test strategies for FRDA-related DM screening and management, in particular the potential role for novel glucose-lowering therapies in preventing or delaying FRDA-related cardiac disease.
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Affiliation(s)
- Jaclyn Tamaroff
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Anna DeDio
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kristin Wade
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - McKenzie Wells
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Courtney Park
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karla Leavens
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David R Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shana E McCormack
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Recessive cerebellar and afferent ataxias - clinical challenges and future directions. Nat Rev Neurol 2022; 18:257-272. [PMID: 35332317 DOI: 10.1038/s41582-022-00634-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 02/07/2023]
Abstract
Cerebellar and afferent ataxias present with a characteristic gait disorder that reflects cerebellar motor dysfunction and sensory loss. These disorders are a diagnostic challenge for clinicians because of the large number of acquired and inherited diseases that cause cerebellar and sensory neuron damage. Among such conditions that are recessively inherited, Friedreich ataxia and RFC1-associated cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) include the characteristic clinical, neuropathological and imaging features of ganglionopathies, a distinctive non-length-dependent type of sensory involvement. In this Review, we discuss the typical and atypical phenotypes of Friedreich ataxia and CANVAS, along with the features of other recessive ataxias that present with a ganglionopathy or polyneuropathy, with an emphasis on recently described clinical features, natural history and genotype-phenotype correlations. We review the main developments in understanding the complex pathology that affects the sensory neurons and cerebellum, which seem to be most vulnerable to disorders that affect mitochondrial function and DNA repair mechanisms. Finally, we discuss disease-modifying therapeutic advances in Friedreich ataxia, highlighting the most promising candidate molecules and lessons learned from previous clinical trials.
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Rufini A, Malisan F, Condò I, Testi R. Drug Repositioning in Friedreich Ataxia. Front Neurosci 2022; 16:814445. [PMID: 35221903 PMCID: PMC8863941 DOI: 10.3389/fnins.2022.814445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Friedreich ataxia is a rare neurodegenerative disorder caused by insufficient levels of the essential mitochondrial protein frataxin. It is a severely debilitating disease that significantly impacts the quality of life of affected patients and reduces their life expectancy, however, an adequate cure is not yet available for patients. Frataxin function, although not thoroughly elucidated, is associated with assembly of iron-sulfur cluster and iron metabolism, therefore insufficient frataxin levels lead to reduced activity of many mitochondrial enzymes involved in the electron transport chain, impaired mitochondrial metabolism, reduced ATP production and inefficient anti-oxidant response. As a consequence, neurons progressively die and patients progressively lose their ability to coordinate movement and perform daily activities. Therapeutic strategies aim at restoring sufficient frataxin levels or at correcting some of the downstream consequences of frataxin deficiency. However, the classical pathways of drug discovery are challenging, require a significant amount of resources and time to reach the final approval, and present a high failure rate. Drug repositioning represents a viable alternative to boost the identification of a therapy, particularly for rare diseases where resources are often limited. In this review we will describe recent efforts aimed at the identification of a therapy for Friedreich ataxia through drug repositioning, and discuss the limitation of such strategies.
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Affiliation(s)
- Alessandra Rufini
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
- Fratagene Therapeutics, Rome, Italy
- Saint Camillus International University of Health and Medical Sciences, Rome, Italy
- *Correspondence: Alessandra Rufini,
| | - Florence Malisan
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
| | - Ivano Condò
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
| | - Roberto Testi
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
- Fratagene Therapeutics, Rome, Italy
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Thomas-Black G, Dumitrascu A, Garcia-Moreno H, Vallortigara J, Greenfield J, Hunt B, Walther S, Wells M, Lynch DR, Montgomery H, Giunti P. The attitude of patients with progressive ataxias towards clinical trials. Orphanet J Rare Dis 2022; 17:1. [PMID: 34983593 PMCID: PMC8729009 DOI: 10.1186/s13023-021-02091-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/17/2021] [Indexed: 12/17/2022] Open
Abstract
Background The development of new therapies may rely on the conduct of human experimentation as well as later clinical trials of therapeutic interventions. Ethical considerations seek to protect the patient from risk but few have sought to ascertain the attitude to such risk of patients with progressive debilitating or terminal conditions, for which no mitigating or curative therapies exist. Such understanding is also important if recruitment is to be maximized. We therefore sought to define the motivations for and barriers to trial participation amongst patients with progressive ataxias, as well as their condition-specific trial preferences. Methods We conducted an online survey consisting of 29 questions covering four key domains (demographics, personal motivation, drug therapy and study design) relating to the design of clinical trials. Two major ataxia charities, Ataxia UK and the Friedreich’s Ataxia Research Alliance (FARA) sent the survey to their members. Responses were analysed by disease and by ambulatory status. Results Of 342 respondents, 204 reported a diagnosis of Friedreich’s ataxia (FRDA), 55 inherited cerebellar ataxia (CA) and 70 idiopathic CA. The most important symptoms to be addressed by a trial were considered to be balance problems and ambulation, although these were superseded by speech problems in wheelchair users. Common motivations for participation were potential benefits to self and others. Reasons for non-participation included concerns about side effects, and the burden and cost of travel. Financial reimbursement for expenses was reported to be likely to increase trial engagement, Phase two trials were the most popular to participate in, and the use of a placebo arm was seen as a disincentive. Across all disease subgroups, drug repurposing trials proved popular and just under 70% of participants would be prepared to undergo intrathecal drug administration. Conclusions Knowledge of motivations for and barriers to trial participation as well as the acceptability of investigations, time commitments and routes of drug administration should inform better, more patient focused trial design. This in turn may improve recruitment and retention of participants to future trials. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02091-x.
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Affiliation(s)
- Gilbert Thomas-Black
- Department of Clinical and Movement Neurosciences, The Ataxia Centre, UCL Queen Square Institute of Neurology, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation NHS Trust, London, UK
| | - Andrada Dumitrascu
- Department of Clinical and Movement Neurosciences, The Ataxia Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Hector Garcia-Moreno
- Department of Clinical and Movement Neurosciences, The Ataxia Centre, UCL Queen Square Institute of Neurology, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation NHS Trust, London, UK
| | - Julie Vallortigara
- Department of Clinical and Movement Neurosciences, The Ataxia Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | | | - Barry Hunt
- Ataxia UK, 12 Broadbent Close, N6 5JW, London, UK
| | - Susan Walther
- Friedreich'S Ataxia Research Alliance, 533 W Uwchlan Ave, Downingtown, PA, 19335, USA
| | - Mackenzie Wells
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - David R Lynch
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Hugh Montgomery
- Institute of Sport Exercise and Health, University College London, London, UK
| | - Paola Giunti
- Department of Clinical and Movement Neurosciences, The Ataxia Centre, UCL Queen Square Institute of Neurology, University College London, London, UK. .,National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation NHS Trust, London, UK.
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Perlman S. Emerging Therapies in Friedreich's Ataxia: A Review. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Friedreich's ataxia (FRDA) is an inherited, neurodegenerative disease that typically presents in childhood and results in progressive gait and limb ataxia, with the extraneural features of hypertrophic cardiomyopathy, diabetes and scoliosis. The genetic defect results in a deficiency of frataxin protein, which is important for mitochondrial function, especially in the brain and heart. Drug development has approached FRDA through pathways addressing oxidative stress, mitochondrial dysfunction, frataxin protein deficiency and DNA transcriptional deficiency, paving the way for the first disease-modifying drugs for FRDA.
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Seminotti B, Grings M, Tucci P, Leipnitz G, Saso L. Nuclear Factor Erythroid-2-Related Factor 2 Signaling in the Neuropathophysiology of Inherited Metabolic Disorders. Front Cell Neurosci 2021; 15:785057. [PMID: 34955754 PMCID: PMC8693715 DOI: 10.3389/fncel.2021.785057] [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: 09/28/2021] [Accepted: 11/05/2021] [Indexed: 01/14/2023] Open
Abstract
Inherited metabolic disorders (IMDs) are rare genetic conditions that affect multiple organs, predominantly the central nervous system. Since treatment for a large number of IMDs is limited, there is an urgent need to find novel therapeutical targets. Nuclear factor erythroid-2-related factor 2 (Nrf2) is a transcription factor that has a key role in controlling the intracellular redox environment by regulating the expression of antioxidant enzymes and several important genes related to redox homeostasis. Considering that oxidative stress along with antioxidant system alterations is a mechanism involved in the neuropathophysiology of many IMDs, this review focuses on the current knowledge about Nrf2 signaling dysregulation observed in this group of disorders characterized by neurological dysfunction. We review here Nrf2 signaling alterations observed in X-linked adrenoleukodystrophy, glutaric acidemia type I, hyperhomocysteinemia, and Friedreich’s ataxia. Additionally, beneficial effects of different Nrf2 activators are shown, identifying a promising target for treatment of patients with these disorders. We expect that this article stimulates research into the investigation of Nrf2 pathway involvement in IMDs and the use of potential pharmacological modulators of this transcription factor to counteract oxidative stress and exert neuroprotection.
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Affiliation(s)
- Bianca Seminotti
- Postgraduate Program in Biological Sciences: Biochemistry, Department of Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Mateus Grings
- Postgraduate Program in Biological Sciences: Biochemistry, Department of Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Paolo Tucci
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Guilhian Leipnitz
- Postgraduate Program in Biological Sciences: Biochemistry, Department of Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Department of Biochemistry, Institute of Basic Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Postgraduate Program in Biological Sciences: Physiology, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luciano Saso
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Rome, Italy
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Patel M, McCormick A, Tamaroff J, Dunn J, Mitchell JA, Lin KY, Farmer J, Rummey C, Perlman SL, Delatycki MB, Wilmot GR, Mathews KD, Yoon G, Hoyle J, Corti M, Subramony SH, Zesiewicz T, Lynch D, McCormack SE. Body Mass Index and Height in the Friedreich Ataxia Clinical Outcome Measures Study. NEUROLOGY-GENETICS 2021; 7:e638. [PMID: 34786480 PMCID: PMC8589265 DOI: 10.1212/nxg.0000000000000638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/31/2021] [Indexed: 01/11/2023]
Abstract
Background and Objectives Body mass index (BMI) and height are important indices of health. We tested the association between these outcomes and clinical characteristics in Friedreich ataxia (FRDA), a progressive neuromuscular disorder. Methods Participants (N = 961) were enrolled in a prospective natural history study (Friedreich Ataxia Clinical Outcome Measure Study). Age- and sex-specific BMI and height Z-scores were calculated using CDC 2000 references for participants younger than 18 years. For adults aged 18 years or older, height Z-scores were also calculated, and absolute BMI was reported. Univariate and multivariate linear regression analyses tested the associations between exposures, covariates, and BMI or height measured at the baseline visit. In children, the superimposition by translation and rotation analysis method was used to compare linear growth trajectories between FRDA and a healthy reference cohort, the Bone Mineral Density in Childhood Study (n = 1,535 used for analysis). Results Median age at the baseline was 20 years (IQR, 13–33 years); 49% (n = 475) were women. A substantial proportion of children (17%) were underweight (BMI-Z < fifth percentile), and female sex was associated with lower BMI-Z (β = −0.34, p < 0.05). In adults, older age was associated with higher BMI (β = 0.09, p < 0.05). Regarding height, in children, older age (β −0.06, p < 0.05) and worse modified Friedreich Ataxia Rating Scale (mFARS) scores (β = −1.05 for fourth quartile vs first quartile, p < 0.01) were associated with shorter stature. In girls, the magnitude of the pubertal growth spurt was less, and in boys, the pubertal growth spurt occurred later (p < 0.001 for both) than in a healthy reference cohort. In adults, in unadjusted analyses, both earlier age of FRDA symptom onset (=0.09, p < 0.05) and longer guanine-adenine-adenine repeat length (shorter of the 2 GAA repeats, β = −0.12, p < 0.01) were associated with shorter stature. Both adults and children with higher mFARS scores and/or who were nonambulatory were less likely to have height and weight measurements recorded at clinical visits. Discussion FRDA affects both weight gain and linear growth. These insights will inform assessments of affected individuals in both research and clinical settings.
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Affiliation(s)
- Maya Patel
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Ashley McCormick
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Jaclyn Tamaroff
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Julia Dunn
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Jonathan A Mitchell
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Kimberly Y Lin
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Jennifer Farmer
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Christian Rummey
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Susan L Perlman
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Martin B Delatycki
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - George R Wilmot
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Katherine D Mathews
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Grace Yoon
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Joseph Hoyle
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Manuela Corti
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - S H Subramony
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Theresa Zesiewicz
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - David Lynch
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
| | - Shana E McCormack
- Division of Neurology (M.P., A.M.C., J.F., D.L.), Children's Hospital of Philadelphia; Department of Neurology (M.P., A.M.C., D.L.), Perelman School of Medicine at the University of Pennsylvania; Division of Endocrinology and Diabetes (J.T., J.D., S.E.M.), Children's Hospital of Philadelphia; Department of Pediatrics (J.A.M, K.Y.L., S.E.M.), Perelman School of Medicine at the University of Pennsylvania; Division of Gastroenterology (J.A.M.), Hepatology and Nutrition, Children's Hospital of Philadelphia; Division of Cardiology (K.Y.L), Children's Hospital of Philadelphia; Friedreich's Ataxia Research Alliance (J.F.); Clinical Data Science GmbH (C.R.), Basel, Switzerland; Department of Neurology (S.L.P), University of California Los Angeles; Murdoch Children's Research Institute (M.B.D.), Victoria, Australia; Department of Neurology (G.R.W), Emory University School of Medicine, Atlanta, Georgia; Department of Pediatrics (K.D.M.), University of Iowa Carver College of Medicine, Iowa; Divisions of Neurology (G.Y.) and Clinical and Metabolic Genetics, Department of Paediatrics, the Hospital for Sick Children, University of Toronto, Ontario, Canada; Department of Neurology (J.H.), Ohio State University College of Medicine, Columbus, Ohio; Department of Neurology (M.C., S.H.S.), University of Florida, College of Medicine, Gainesville, Florida; Department of Neurology (T.Z.), University of South Florida, Tampa, Florida
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Krishna R, Pathirana PN, Horne MK, Szmulewicz DJ, Corben LA. Objective Assessment of Progression and Disease Characterization of Friedreich Ataxia via an Instrumented Drinking Cup: Preliminary Results. IEEE Trans Neural Syst Rehabil Eng 2021; 29:2365-2377. [PMID: 34727035 DOI: 10.1109/tnsre.2021.3124869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The monitoring of disease progression in certain neurodegenerative conditions can significantly be quantified with the help of objective assessments. The severity assessment of diseases like Friedreich ataxia (FRDA) are usually based on different subjective measures. The ability of a participant with FRDA to perform standard neurological tests is the most common way of assessing disease progression. In this feasibility study, an Ataxia Instrumented Measurement-Cup (AIM-C) is proposed to quantify the disease progression of 10 participants (mean age 39 years, onset of disease 16.3 years) in longitudinal timepoints. The device consists of a sensing system with the provision of extracting both kinetic and kinematic information while engaging in an activity closely associated with activities of daily living (ADL). A common functional task of simulated drinking was used to capture features that possesses disease progression information as well as certain other features which intrinsically correlate with commonly used clinical scales such as the modified Friedreich Ataxia Rating Scale (mFARS), the Functional Staging of Ataxia score and the ADL scale. Frequency and time-frequency domain features allowed the longitudinal assessment of participants with FRDA. Furthermore, both kinetic and kinematic measures captured clinically relevant features and correlated 85% with clinical assessments.
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Abstract
INTRODUCTION Friedreich ataxia (FRDA) is an autosomal recessive disorder caused by deficiency of frataxin, an essential mitochondrial protein involved in iron sulfur cluster biogenesis, oxidative phosphorylation and other processes. FRDA most notably affects the heart, sensory neurons, spinal cord, cerebellum, and other brain regions, and manifests clinically as ataxia, sensory loss, dysarthria, spasticity, and hypertrophic cardiomyopathy. Therapeutic approaches in FRDA have consisted of two different approaches: (1) augmenting or restoring frataxin production and (2) modulating a variety of downstream processes related to mitochondrial dysfunction, including reactive oxygen species production, ferroptosis, or Nrf2 activation. AREAS COVERED In this review, we summarize data from major phase II clinical trials in FRDA published between 2015 and 2020, which includes A0001/EPI743, Omaveloxolone, RT001, and Actimmune. EXPERT OPINION A growing number of drug candidates are being tested in phase II clinical trials for FRDA; however, most have not met their primary endpoints, and none have received FDA approval. In this review, we aim to summarize completed phase II clinical trials in FRDA, outlining critical lessons that have been learned and that should be incorporated into future trial design to ultimately optimize drug development in FRDA.
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Harding IH, Lynch DR, Koeppen AH, Pandolfo M. Central Nervous System Therapeutic Targets in Friedreich Ataxia. Hum Gene Ther 2021; 31:1226-1236. [PMID: 33238751 PMCID: PMC7757690 DOI: 10.1089/hum.2020.264] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Friedreich ataxia (FRDA) is an autosomal recessive inherited multisystem disease, characterized by marked differences in the vulnerability of neuronal systems. In general, the proprioceptive system appears to be affected early, while later in the disease, the dentate nucleus of the cerebellum and, to some degree, the corticospinal tracts degenerate. In the current era of expanding therapeutic discovery in FRDA, including progress toward novel gene therapies, a deeper and more specific consideration of potential treatment targets in the nervous system is necessary. In this work, we have re-examined the neuropathology of FRDA, recognizing new issues superimposed on classical findings, and dissected the peripheral nervous system (PNS) and central nervous system (CNS) aspects of the disease and the affected cell types. Understanding the temporal course of neuropathological changes is needed to identify areas of modifiable disease progression and the CNS and PNS locations that can be targeted at different time points. As most major targets of long-term therapy are in the CNS, this review uses multiple tools for evaluation of the importance of specific CNS locations as targets. In addition to clinical observations, the conceptualizations in this study include physiological, pathological, and imaging approaches, and animal models. We believe that this review, through analysis of a more complete set of data derived from multiple techniques, provides a comprehensive summary of therapeutic targets in FRDA.
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Affiliation(s)
- Ian H Harding
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia.,Monash Biomedical Imaging, Monash University, Melbourne, Australia
| | - David R Lynch
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arnulf H Koeppen
- Research, Neurology, and Pathology Services, Veterans Affairs Medical Center and Departments of Neurology and Pathology, Albany Medical College, Albany, New York, USA
| | - Massimo Pandolfo
- Laboratory of Experimental Neurology, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Mueller A, Paterson E, McIntosh A, Praestgaard J, Bylo M, Hoefling H, Wells M, Lynch DR, Rummey C, Krishnan ML, Schultz M, Malanga CJ. Digital endpoints for self-administered home-based functional assessment in pediatric Friedreich's ataxia. Ann Clin Transl Neurol 2021; 8:1845-1856. [PMID: 34355532 PMCID: PMC8419399 DOI: 10.1002/acn3.51438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/18/2023] Open
Abstract
Background Friedreich’s ataxia is an inherited, progressive, neurodegenerative disease that typically begins in childhood. Disease severity is commonly assessed with rating scales, such as the modified Friedreich’s Ataxia Rating Scale, which are usually administered in the clinic by a neurology specialist. Objective This study evaluated the utility of home‐based, self‐administered digital endpoints in children with Friedreich’s ataxia and unaffected controls and their relationship to standard clinical rating scales. Methods In a cross‐sectional study with 25 participants (13 with Friedreich’s ataxia and 12 unaffected controls, aged 6–15 years), home‐based digital endpoints that reflect activities of daily living were recorded over 1 week. Domains analyzed were hand motor function with a digitized drawing, automated analysis of speech with a recorded oral diadochokinesis test, and gait and balance with wearable sensors. Results Hand‐drawing and speech tests were easy to conduct and generated high‐quality data. The sensor‐based gait and balance tests suffered from technical limitations in this study setup. Several parameters discriminated between groups or correlated strongly with modified Friedreich’s Ataxia Rating Scale total score and activities of daily living total score in the Friedreich’s ataxia group. Hand‐drawing parameters also strongly correlated with standard 9‐hole peg test scores. Interpretation Deploying digital endpoints in home settings is feasible in this population, results in meaningful and robust data collection, and may allow for frequent sampling over longer periods of time to track disease progression. Care must be taken when training participants, and investigators should consider the complexity of the tasks and equipment used.
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Affiliation(s)
- Arne Mueller
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Elaine Paterson
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | | | | | - Mary Bylo
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - Holger Hoefling
- NIBR Informatics, Novartis Institute of Biomedical Research, Basel, Switzerland
| | - McKenzie Wells
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - David R Lynch
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Michelle L Krishnan
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Meredith Schultz
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - C J Malanga
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
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Correlation of Visual Quality of Life With Clinical and Visual Status in Friedreich Ataxia. J Neuroophthalmol 2021; 40:213-217. [PMID: 31977662 DOI: 10.1097/wno.0000000000000878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The primary objective was to determine the association of patient-reported vision-specific quality of life to disease status and visual function in patients with Friedreich's ataxia (FRDA). METHODS Patients with FRDA were assessed with the 25-Item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) along with measures of disease status (ataxia stage) and visual function (low- and high-contrast letter acuity scores). The relations of NEI-VFQ-25 scores to those for disease status and visual function were examined. RESULTS Scores for the NEI-VFQ-25 were lower in patients with FRDA (n = 99) compared with published disease-free controls, particularly reduced in a subgroup of FRDA patients with features of early onset, older age, and abnormal visual function. CONCLUSIONS The NEI-VFQ-25 captures the subjective component of visual function in patients with FRDA.
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Lynch DR, Schadt K, Kichula E, McCormack S, Lin KY. Friedreich Ataxia: Multidisciplinary Clinical Care. J Multidiscip Healthc 2021; 14:1645-1658. [PMID: 34234452 PMCID: PMC8253929 DOI: 10.2147/jmdh.s292945] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/04/2021] [Indexed: 12/17/2022] Open
Abstract
Friedreich ataxia (FRDA) is a multisystem disorder affecting 1 in 50,000-100,000 person in the United States. Traditionally viewed as a neurodegenerative disease, FRDA patients also develop cardiomyopathy, scoliosis, diabetes and other manifestation. Although it usually presents in childhood, it continues throughout life, thus requiring expertise from both pediatric and adult subspecialist in order to provide optimal management. The phenotype of FRDA is unique, giving rise to specific loss of neuronal pathways, a unique form of cardiomyopathy with early hypertrophy and later fibrosis, and diabetes incorporating components of both type I and type II disease. Vision loss, hearing loss, urinary dysfunction and depression also occur in FRDA. Many agents are reaching Phase III trials; if successful, these will provide a variety of new treatments for FRDA that will require many specialists who are not familiar with FRDA to provide clinical therapy. This review provides a summary of the diverse manifestation of FRDA, existing symptomatic therapies, and approaches for integrative care for future therapy in FRDA.
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Affiliation(s)
- David R Lynch
- Division of Neurology, Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia and the Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Kim Schadt
- Division of Neurology, Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia and the Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Elizabeth Kichula
- Division of Neurology, Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia and the Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Shana McCormack
- Division of Endocrinology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, Philadelphia, PA, 19104, USA
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Krishna R, Pathirana PN, Horne MK, Corben LA, Szmulewicz DJ. Quantitative Assessment of Friedreich Ataxia via Self-Drinking Activity. IEEE J Biomed Health Inform 2021; 25:1985-1996. [PMID: 33764881 DOI: 10.1109/jbhi.2021.3069007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Effective monitoring of the progression of neurodegenerative conditions can be significantly improved by objective assessments. Clinical assessments of conditions such as Friedreich's Ataxia (FA), currently rely on subjective measures commonly practiced in clinics as well as the ability of the affected individual to perform conventional tests of the neurological examination. In this study, we propose an ataxia measuring device, in the form of a pressure canister capable of sensing certain kinetic and kinematic parameters of interest to quantify the impairment levels of participants particularly when engaged in an activity that is closely associated with daily living. In particular, the functional task of simulated drinking was utilised to capture characteristic features of disability manifestation in terms of diagnosis (separation of individuals with FA and controls) and severity assessment of individuals diagnosed with the debilitating condition of FA. Time and frequency domain analysis of these biomarkers enabled the classification of individuals with FA and control subjects to reach an accuracy of 98% and a correlation level reaching 96% with the clinical scores.
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Rummey C, Flynn JM, Corben LA, Delatycki MB, Wilmot G, Subramony SH, Bushara K, Duquette A, Gomez CM, Hoyle JC, Roxburgh R, Seeberger L, Yoon G, Mathews KD, Zesiewicz T, Perlman S, Lynch DR. Scoliosis in Friedreich's ataxia: longitudinal characterization in a large heterogeneous cohort. Ann Clin Transl Neurol 2021; 8:1239-1250. [PMID: 33949801 PMCID: PMC8164850 DOI: 10.1002/acn3.51352] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/22/2021] [Accepted: 03/15/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The objective of this study was to characterize the incidence and progression of scoliosis in the natural history of Friedreich's ataxia (FRDA) and document the factors leading to the requirement for corrective surgery. METHODS Data on the prevalence of scoliosis and scoliosis surgery from up to 17 years of follow-up collected during a large natural history study in FRDA (1116 patients at 4928 visits) were summarized descriptively and subjected to time to event analyses. RESULTS Well over 90% of early or typical FRDA patients (as determined by age of onset) developed intermediate to severe scoliosis, while patients with a later onset (>14 years) had no or much lower prevalence of scoliosis. Diagnosis of scoliosis occurs during the onset of ataxia and in rare cases even prior to that. Major progression follows throughout the growth phase and puberty, leading to the need for surgical intervention in more than 50% of individuals in the most severe subgroup. The youngest patients appear to delay surgery until the end of the growth period, leading to further progression before surgical intervention. Age of onset of FRDA before or after reaching 15 years sharply separated severe and relatively mild incidence and progression of scoliosis. INTERPRETATION Scoliosis is an important comorbidity of FRDA. Our comprehensive documentation of scoliosis progression in this natural history study provides a baseline for comparison as novel treatments become available.
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Affiliation(s)
| | - John M Flynn
- Division of Orthopedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Louise A Corben
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Martin B Delatycki
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | | | - Sub H Subramony
- Department of Neurology, McKnight Brain Institute, Gainesville, Florida, USA
| | | | - Antoine Duquette
- Department of Neurosciences, University of Montreal Hospital Research Center, Montreal, Quebec, Canada
| | | | | | | | | | - Grace Yoon
- Divisions of Neurology and Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Susan Perlman
- University of California Los Angeles, Los Angeles, California, USA
| | - David R Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Selvadurai LP, Georgiou-Karistianis N, Shishegar R, Sheridan C, Egan GF, Delatycki MB, Harding IH, Corben LA. Longitudinal structural brain changes in Friedreich ataxia depend on disease severity: the IMAGE-FRDA study. J Neurol 2021; 268:4178-4189. [PMID: 33860369 DOI: 10.1007/s00415-021-10512-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Friedreich ataxia is an inherited neurodegenerative disease, with cerebral and cerebellar pathology evident. Despite an increased understanding of its neuropathology, disease progression in this disease remains poorly understood. This study aimed to characterise longitudinal change in brain structure using a multi-modal approach across cerebral and cerebellar grey and white matter. METHODS T1-weighted, diffusion-tensor, and magnetisation transfer magnetic resonance images were obtained from 28 individuals with Friedreich ataxia and 29 age- and gender-matched controls at two time-points, 2 years apart. Region-of-interest and exploratory between-group comparisons assessed changes in brain macrostructure (cerebellar lobule volume, cerebral cortical thickness/gyrification, brain white matter volume) and microstructure (white matter fractional anisotropy, mean/axial/radial diffusivity, magnetisation transfer ratio). Rates of change were correlated against change in neurological severity, Time 1 severity, and onset age. RESULTS Individuals with Friedreich ataxia had a greater rate of white matter volume loss than controls in the superior cerebellar peduncles and right peri-thalamic/posterior cerebral regions, and greater reduction in left primary motor cortex gyrification. Greater cerebellar/brainstem white matter volume loss and right dorsal premotor gyrification loss was observed amongst individuals with less severe neurological symptoms at Time 1. Conversely, cerebral atrophy and changes in axial diffusivity were observed in individuals with more severe Time 1 symptoms. Progression in radial diffusivity was more pronounced amongst individuals with earlier disease onset. Greater right ventral premotor gyrification loss correlated with greater neurological progression. CONCLUSION Heterogeneity in Friedreich ataxia progression is observed at the neurobiological level, with evidence of earlier cerebellar and later cerebral degeneration.
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Affiliation(s)
- Louisa P Selvadurai
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton Campus, Clayton, VIC, 3800, Australia
| | - Nellie Georgiou-Karistianis
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton Campus, Clayton, VIC, 3800, Australia.
| | - Rosita Shishegar
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton Campus, Clayton, VIC, 3800, Australia.,The Australian E-Health Research Centre, CSIRO, Melbourne, Australia
| | - Cathlin Sheridan
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton Campus, Clayton, VIC, 3800, Australia
| | - Gary F Egan
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton Campus, Clayton, VIC, 3800, Australia.,Monash Biomedical Imaging, Monash University, Clayton, Australia
| | - Martin B Delatycki
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia.,Victorian Clinical Genetics Services, Parkville, Australia
| | - Ian H Harding
- Monash Biomedical Imaging, Monash University, Clayton, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Louise A Corben
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton Campus, Clayton, VIC, 3800, Australia.,Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Australia
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50
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Tai G, Corben LA, Woodcock IR, Yiu EM, Delatycki MB. Determining the Validity of Conducting Rating Scales in Friedreich Ataxia through Video. Mov Disord Clin Pract 2021; 8:688-693. [PMID: 34307740 DOI: 10.1002/mdc3.13204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background The Friedreich Ataxia Rating Scale (FARS) and the Scale for the Assessment and Rating of Ataxia (SARA) are commonly used neurological rating scales in Friedreich ataxia (FRDA). The modified Friedreich Ataxia Rating Scale (mFARS) has been accepted as an appropriate outcome measure for clinical trials in FRDA. Objectives The COVID-19 pandemic has resulted in limited face-to-face interactions with individuals involved in natural history studies and clinical trials. The aim of this study was to determine the validity of conducting the mFARS and SARA through video. Methods Individuals who had the mFARS administered face-to-face in the previous 6 months were invited to participate. Participants were sent instructions and asked to have a carer present to assist. The mFARS and SARA were then administered by video. Differences between face-to-face and video scores and the reliability between scores obtained face-to-face and by video were examined. Results The mFARS and SARA were conducted by video with 19 individuals. Excellent test-retest reliability was seen in the mFARS lower limb coordination (ICC = 0.96, 95% CI 0.90-0.98) and upright stability sections (ICC = 0.97, 95% CI 0.93-0.99), total mFARS (ICC = 0.97, 95% CI 0.92-0.99) and SARA scores (ICC = 0.98, 95% CI 0.95-0.99). Conclusions Excellent test-retest reliability was demonstrated in the majority of the mFARS sections, and in the total mFARS and SARA scores, suggesting that video is a valid method of conducting these scales. This method enables inclusion of participants who are unable to travel to study sites. A larger cohort will be required to further validate the use of video mFARS and SARA for future studies.
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Affiliation(s)
- Geneieve Tai
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia
| | - Louise A Corben
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Parkville Victoria Australia.,School of Psychological Sciences Monash University Clayton Victoria Australia
| | - Ian R Woodcock
- Department of Paediatrics University of Melbourne Parkville Victoria Australia.,Department of Neurology Royal Children's Hospital Parkville Victoria Australia.,Division of Neuroscience Murdoch Children's Research Institute Parkville Victoria Australia
| | - Eppie M Yiu
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Parkville Victoria Australia.,Department of Neurology Royal Children's Hospital Parkville Victoria Australia.,Division of Neuroscience Murdoch Children's Research Institute Parkville Victoria Australia
| | - Martin B Delatycki
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Parkville Victoria Australia.,School of Psychological Sciences Monash University Clayton Victoria Australia.,Victorian Clinical Genetics Service Parkville Victoria Australia
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