1
|
Muenzer J, Burton BK, Amartino HM, Harmatz PR, Gutiérrez-Solana LG, Ruiz-Garcia M, Wu Y, Merberg D, Alexanderian D, Jones SA. Neurodevelopmental status and adaptive behavior of pediatric patients with mucopolysaccharidosis II: a longitudinal observational study. Orphanet J Rare Dis 2023; 18:357. [PMID: 37974184 PMCID: PMC10652632 DOI: 10.1186/s13023-023-02805-3] [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: 04/14/2023] [Accepted: 07/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Mucopolysaccharidosis (MPS) II is a rare, X-linked lysosomal storage disease. Approximately two-thirds of patients have central nervous system involvement with some demonstrating progressive cognitive impairment (neuronopathic disease). The natural history of cognitive and adaptive function in patients with MPS II is not well-defined. This 2-year, prospective, observational study evaluated the neurodevelopmental trajectories of boys with MPS II aged ≥ 2 years and < 18 years. RESULTS Overall, 55 patients were enrolled. At baseline, mean (standard deviation [SD]) age was 5.60 (3.32) years; all patients were receiving intravenous idursulfase. Cognitive and adaptive function were assessed using the Differential Ability Scales, Second Edition (DAS-II) General Conceptual Ability (GCA) and the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) Adaptive Behavior Composite (ABC) scores, respectively. Baseline mean (SD) DAS-II GCA and VABS-II ABC scores were 78.4 (19.11) and 83.7 (14.22), respectively, indicating low cognitive function and moderately low adaptive behavior. Over 24 months, modest deteriorations in mean (SD) scores were observed for DAS-II GCA (-3.8 [12.7]) and VABS-II ABC (-2.0 [8.07]). Changes in DAS-II GCA scores varied considerably, and data suggested the existence of four potential patient subgroups: (1) patients with marked early impairment and rapid subsequent decline, (2) patients with marked early impairment then stabilization, (3) patients with mild early impairment then stabilization, and (4) patients without impairment who remained stable. Subgroup analyses revealed numerically greater DAS-II GCA score reductions from baseline in patients aged < 7 years at baseline (vs. those aged ≥ 7 years) and in patients with DAS-II GCA scores ≤ 70 at baseline (vs. those with scores > 70); between-group differences were nonsignificant. No clear subgroups or patterns were identified for individual changes in VABS-II ABC scores. In total, 49 patients (89.1%) reported ≥ 1 adverse event (AE) and nine patients (16.4%) reported serious AEs. CONCLUSIONS Some patients with MPS II had rapid declines in cognitive ability, whereas others remained relatively stable after an initial decline. These insights provide a basis for more detailed analyses of different patient subgroups, which may enhance the definition and understanding of factors that influence cognitive and adaptive function in MPS II. TRIAL REGISTRATION ClinicalTrials.gov, NCT01822184. Registered retrospectively: April 2, 2013.
Collapse
Affiliation(s)
- Joseph Muenzer
- University of North Carolina at Chapel Hill, 101 Manning Drive CB# 7487, Medical School Wing E Room 117, Chapel Hill, NC, 27599-7487, USA.
| | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | | | - Paul R Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Yuna Wu
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | - David Merberg
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - David Alexanderian
- Takeda Development Center Americas, Inc., Lexington, MA, USA
- Merck, Boston, MA, USA
| | - Simon A Jones
- St Mary's Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
| |
Collapse
|
2
|
Zhao P, Zhang N, An Z. Engineering antibody and protein therapeutics to cross the blood-brain barrier. Antib Ther 2022; 5:311-331. [PMID: 36540309 PMCID: PMC9759110 DOI: 10.1093/abt/tbac028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/10/2022] [Accepted: 11/01/2022] [Indexed: 08/17/2023] Open
Abstract
Diseases in the central nervous system (CNS) are often difficult to treat. Antibody- and protein-based therapeutics hold huge promises in CNS disease treatment. However, proteins are restricted from entering the CNS by the blood-brain barrier (BBB). To achieve enhanced BBB crossing, antibody-based carriers have been developed by utilizing the endogenous macromolecule transportation pathway, known as receptor-mediated transcytosis. In this report, we first provided an overall review on key CNS diseases and the most promising antibody- or protein-based therapeutics approved or in clinical trials. We then reviewed the platforms that are being explored to increase the macromolecule brain entry to combat CNS diseases. Finally, we have analyzed the lessons learned from past experiences and have provided a perspective on the future engineering of novel delivery vehicles for antibody- and protein-based therapies for CNS diseases.
Collapse
Affiliation(s)
- Peng Zhao
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, 1825 Pressler Street, Houston, Texas, USA
| | - Ningyan Zhang
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, 1825 Pressler Street, Houston, Texas, USA
| | - Zhiqiang An
- Texas Therapeutics Institute, Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, 1825 Pressler Street, Houston, Texas, USA
| |
Collapse
|
3
|
Boado RJ. IgG Fusion Proteins for Brain Delivery of Biologics via Blood-Brain Barrier Receptor-Mediated Transport. Pharmaceutics 2022; 14:pharmaceutics14071476. [PMID: 35890374 PMCID: PMC9322584 DOI: 10.3390/pharmaceutics14071476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 01/01/2023] Open
Abstract
The treatment of neurological disorders with large-molecule biotherapeutics requires that the therapeutic drug be transported across the blood–brain barrier (BBB). However, recombinant biotherapeutics, such as neurotrophins, enzymes, decoy receptors, and monoclonal antibodies (MAb), do not cross the BBB. These biotherapeutics can be re-engineered as brain-penetrating bifunctional IgG fusion proteins. These recombinant proteins comprise two domains, the transport domain and the therapeutic domain, respectively. The transport domain is an MAb that acts as a molecular Trojan horse by targeting a BBB-specific endogenous receptor that induces receptor-mediated transcytosis into the brain, such as the human insulin receptor (HIR) or the transferrin receptor (TfR). The therapeutic domain of the IgG fusion protein exerts its pharmacological effect in the brain once across the BBB. A generation of bifunctional IgG fusion proteins has been engineered using genetically engineered MAbs directed to either the BBB HIR or TfR as the transport domain. These IgG fusion proteins were validated in animal models of lysosomal storage disorders; acute brain conditions, such as stroke; or chronic neurodegeneration, such as Parkinson’s disease and Alzheimer’s disease. Human phase I–III clinical trials were also completed for Hurler MPSI and Hunter MPSII using brain-penetrating IgG-iduronidase and -iduronate-2-sulfatase fusion protein, respectively.
Collapse
Affiliation(s)
- Ruben J Boado
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
| |
Collapse
|
4
|
Pardridge WM. Blood-brain barrier delivery for lysosomal storage disorders with IgG-lysosomal enzyme fusion proteins. Adv Drug Deliv Rev 2022; 184:114234. [PMID: 35307484 DOI: 10.1016/j.addr.2022.114234] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/25/2022] [Accepted: 03/14/2022] [Indexed: 12/12/2022]
Abstract
The majority of lysosomal storage diseases affect the brain. Treatment of the brain with intravenous enzyme replacement therapy is not successful, because the recombinant lysosomal enzymes do not cross the blood-brain barrier (BBB). Biologic drugs, including lysosomal enzymes, can be re-engineered for BBB delivery as IgG-enzyme fusion proteins. The IgG domain of the fusion protein is a monoclonal antibody directed against an endogenous receptor-mediated transporter at the BBB, such as the insulin receptor or the transferrin receptor. This receptor transports the IgG across the BBB, in parallel with the endogenous receptor ligand, and the IgG acts as a molecular Trojan horse to ferry into brain the lysosomal enzyme genetically fused to the IgG. The IgG-enzyme fusion protein is bi-functional and retains both high affinity binding for the BBB receptor, and high lysosomal enzyme activity. IgG-lysosomal enzymes are presently in clinical trials for treatment of the brain in Mucopolysaccharidosis.
Collapse
|
5
|
Eshraghi M, Ahmadi M, Afshar S, Lorzadeh S, Adlimoghaddam A, Rezvani Jalal N, West R, Dastghaib S, Igder S, Torshizi SRN, Mahmoodzadeh A, Mokarram P, Madrakian T, Albensi BC, Łos MJ, Ghavami S, Pecic S. Enhancing autophagy in Alzheimer's disease through drug repositioning. Pharmacol Ther 2022; 237:108171. [PMID: 35304223 DOI: 10.1016/j.pharmthera.2022.108171] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/18/2022] [Accepted: 03/08/2022] [Indexed: 02/07/2023]
Abstract
Alzheimer's disease (AD) is one of the biggest human health threats due to increases in aging of the global population. Unfortunately, drugs for treating AD have been largely ineffective. Interestingly, downregulation of macroautophagy (autophagy) plays an essential role in AD pathogenesis. Therefore, targeting autophagy has drawn considerable attention as a therapeutic approach for the treatment of AD. However, developing new therapeutics is time-consuming and requires huge investments. One of the strategies currently under consideration for many diseases is "drug repositioning" or "drug repurposing". In this comprehensive review, we have provided an overview of the impact of autophagy on AD pathophysiology, reviewed the therapeutics that upregulate autophagy and are currently used in the treatment of other diseases, including cancers, and evaluated their repurposing as a possible treatment option for AD. In addition, we discussed the potential of applying nano-drug delivery to neurodegenerative diseases, such as AD, to overcome the challenge of crossing the blood brain barrier and specifically target molecules/pathways of interest with minimal side effects.
Collapse
Affiliation(s)
- Mehdi Eshraghi
- Department of Human Anatomy and Cell Science, University of Manitoba College of Medicine, Winnipeg, MB R3E 0V9, Canada
| | - Mazaher Ahmadi
- Faculty of Chemistry, Bu-Ali Sina University, Hamedan, Iran; Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeid Afshar
- Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shahrokh Lorzadeh
- Department of Human Anatomy and Cell Science, University of Manitoba College of Medicine, Winnipeg, MB R3E 0V9, Canada
| | - Aida Adlimoghaddam
- Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; St. Boniface Hospital Albrechtsen Research Centre, Division of Neurodegenerative Disorders, Winnipeg, MB R2H2A6, Canada
| | | | - Ryan West
- Department of Chemistry and Biochemistry, California State University, Fullerton, United States of America
| | - Sanaz Dastghaib
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz Iran
| | - Somayeh Igder
- Department of Clinical Biochemistry, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Amir Mahmoodzadeh
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah 6734667149, Iran
| | - Pooneh Mokarram
- Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Tayyebeh Madrakian
- Faculty of Chemistry, Bu-Ali Sina University, Hamedan, Iran; Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Benedict C Albensi
- St. Boniface Hospital Albrechtsen Research Centre, Division of Neurodegenerative Disorders, Winnipeg, MB R2H2A6, Canada; Nova Southeastern Univ. College of Pharmacy, Davie, FL, United States of America; University of Manitoba, College of Medicine, Winnipeg, MB R3E 0V9, Canada
| | - Marek J Łos
- Biotechnology Center, Silesian University of Technology, 44-100 Gliwice, Poland
| | - Saeid Ghavami
- Department of Human Anatomy and Cell Science, University of Manitoba College of Medicine, Winnipeg, MB R3E 0V9, Canada; Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Research Institutes of Oncology and Hematology, Cancer Care Manitoba-University of Manitoba, Winnipeg, MB R3E 0V9, Canada; Biology of Breathing Theme, Children Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB R3E 0V9, Canada; Faculty of Medicine in Zabrze, University of Technology in Katowice, Academia of Silesia, 41-800 Zabrze, Poland
| | - Stevan Pecic
- Department of Chemistry and Biochemistry, California State University, Fullerton, United States of America.
| |
Collapse
|
6
|
Ullman JC, Arguello A, Getz JA, Bhalla A, Mahon CS, Wang J, Giese T, Bedard C, Kim DJ, Blumenfeld JR, Liang N, Ravi R, Nugent AA, Davis SS, Ha C, Duque J, Tran HL, Wells RC, Lianoglou S, Daryani VM, Kwan W, Solanoy H, Nguyen H, Earr T, Dugas JC, Tuck MD, Harvey JL, Reyzer ML, Caprioli RM, Hall S, Poda S, Sanchez PE, Dennis MS, Gunasekaran K, Srivastava A, Sandmann T, Henne KR, Thorne RG, Di Paolo G, Astarita G, Diaz D, Silverman AP, Watts RJ, Sweeney ZK, Kariolis MS, Henry AG. Brain delivery and activity of a lysosomal enzyme using a blood-brain barrier transport vehicle in mice. Sci Transl Med 2021; 12:12/545/eaay1163. [PMID: 32461331 DOI: 10.1126/scitranslmed.aay1163] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 02/10/2020] [Accepted: 04/02/2020] [Indexed: 12/20/2022]
Abstract
Most lysosomal storage diseases (LSDs) involve progressive central nervous system (CNS) impairment, resulting from deficiency of a lysosomal enzyme. Treatment of neuronopathic LSDs remains a considerable challenge, as approved intravenously administered enzyme therapies are ineffective in modifying CNS disease because they do not effectively cross the blood-brain barrier (BBB). We describe a therapeutic platform for increasing the brain exposure of enzyme replacement therapies. The enzyme transport vehicle (ETV) is a lysosomal enzyme fused to an Fc domain that has been engineered to bind to the transferrin receptor, which facilitates receptor-mediated transcytosis across the BBB. We demonstrate that ETV fusions containing iduronate 2-sulfatase (ETV:IDS), the lysosomal enzyme deficient in mucopolysaccharidosis type II, exhibited high intrinsic activity and degraded accumulated substrates in both IDS-deficient cell and in vivo models. ETV substantially improved brain delivery of IDS in a preclinical model of disease, enabling enhanced cellular distribution to neurons, astrocytes, and microglia throughout the brain. Improved brain exposure for ETV:IDS translated to a reduction in accumulated substrates in these CNS cell types and peripheral tissues and resulted in a complete correction of downstream disease-relevant pathologies in the brain, including secondary accumulation of lysosomal lipids, perturbed gene expression, neuroinflammation, and neuroaxonal damage. These data highlight the therapeutic potential of the ETV platform for LSDs and provide preclinical proof of concept for TV-enabled therapeutics to treat CNS diseases more broadly.
Collapse
Affiliation(s)
- Julie C Ullman
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Annie Arguello
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Jennifer A Getz
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Akhil Bhalla
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Cathal S Mahon
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Junhua Wang
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Tina Giese
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Catherine Bedard
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Do Jin Kim
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Jessica R Blumenfeld
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Nicholas Liang
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Ritesh Ravi
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Alicia A Nugent
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Sonnet S Davis
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Connie Ha
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Joseph Duque
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Hai L Tran
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Robert C Wells
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Steve Lianoglou
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Vinay M Daryani
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Wanda Kwan
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Hilda Solanoy
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Hoang Nguyen
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Timothy Earr
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Jason C Dugas
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Michael D Tuck
- Mass Spectrometry Research Center, Vanderbilt University, 9160 MRB III, 465 21 Avenue South, Nashville, TN 37240, USA
| | - Jennifer L Harvey
- Mass Spectrometry Research Center, Vanderbilt University, 9160 MRB III, 465 21 Avenue South, Nashville, TN 37240, USA
| | - Michelle L Reyzer
- Mass Spectrometry Research Center, Vanderbilt University, 9160 MRB III, 465 21 Avenue South, Nashville, TN 37240, USA
| | - Richard M Caprioli
- Mass Spectrometry Research Center, Vanderbilt University, 9160 MRB III, 465 21 Avenue South, Nashville, TN 37240, USA
| | - Sejal Hall
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Suresh Poda
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Pascal E Sanchez
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Mark S Dennis
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Kannan Gunasekaran
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Ankita Srivastava
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Thomas Sandmann
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Kirk R Henne
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Robert G Thorne
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Gilbert Di Paolo
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Giuseppe Astarita
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Dolores Diaz
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Adam P Silverman
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Ryan J Watts
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Zachary K Sweeney
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA
| | - Mihalis S Kariolis
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA.
| | - Anastasia G Henry
- Denali Therapeutics Inc., 161 Oyster Point Blvd., South San Francisco, CA 94080, USA.
| |
Collapse
|
7
|
Choudhari M, Hejmady S, Narayan Saha R, Damle S, Singhvi G, Alexander A, Kesharwani P, Kumar Dubey S. Evolving new-age strategies to transport therapeutics across the blood-brain-barrier. Int J Pharm 2021; 599:120351. [PMID: 33545286 DOI: 10.1016/j.ijpharm.2021.120351] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 12/25/2022]
Abstract
A basic understanding of the blood-brain barrier (BBB) is essential for the novel advancements in targeting drugs specific to the brain. Neoplasm compromising the internal structure of BBB that results in impaired vasculature is called as blood tumor barrier (BTB). Besides, the BBB serves as a chief hindrance to the passage of a drug into the brain parenchyma. The small and hydrophilic drugs majorly display an absence of desired molecular characteristics required to cross the BBB. Furthermore, all classes of biologics have failed in the clinical trials of brain diseases over the past years since these biologics are large molecules that do not cross the BBB. Also, new strategies have been discovered that use the Trojan horse technology with the re-engineered biologics for BBB transport. Thus, this review delivers information about the different grades of tumors (I-IV) i.e. examples of BBB/BTB heterogenicity along with the different mechanisms for transporting the therapeutics into the brain tumors by crossing BBB. This review also provides insights into the emerging approaches of peptide delivery and the non-invasive and brain-specific molecular Trojan horse targeting technologies. Also, the several challenges in the clinical development of BBB penetrating IgG fusion protein have been discussed.
Collapse
Affiliation(s)
- Manisha Choudhari
- Department of Pharmacy, Birla Institute of Technology and Science, Pilani, Pilani Campus, Rajasthan 333031, India
| | - Siddhanth Hejmady
- Department of Pharmacy, Birla Institute of Technology and Science, Pilani, Pilani Campus, Rajasthan 333031, India
| | - Ranendra Narayan Saha
- Birla Institute of Technology and Science, Pilani, Dubai Campus, United Arab Emirates
| | - Shantanu Damle
- Colorcon Asia Pvt. Ltd., Verna Industrial Estate, Verna 403722, Goa, India
| | - Gautam Singhvi
- Department of Pharmacy, Birla Institute of Technology and Science, Pilani, Pilani Campus, Rajasthan 333031, India
| | - Amit Alexander
- National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Department of Pharmaceutical Technology (Formulations), Department of Pharmaceuticals, Ministry of Chemical and Fertilizers, Government of India, Sila Village, Nizsundarighopa, Changsari, Kamrup (R), Guwahati, Assam 781101, India
| | - Prashant Kesharwani
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Sunil Kumar Dubey
- Department of Pharmacy, Birla Institute of Technology and Science, Pilani, Pilani Campus, Rajasthan 333031, India; R&D Healthcare Division Emami Ltd., 13, BT Road, Belgharia, Kolkata 700056, India.
| |
Collapse
|
8
|
Zaghmi A, Drouin-Ouellet J, Brambilla D, Gauthier MA. Treating brain diseases using systemic parenterally-administered protein therapeutics: Dysfunction of the brain barriers and potential strategies. Biomaterials 2020; 269:120461. [PMID: 33218788 DOI: 10.1016/j.biomaterials.2020.120461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/23/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2022]
Abstract
The parenteral administration of protein therapeutics is increasingly gaining importance for the treatment of human diseases. However, the presence of practically impermeable blood-brain barriers greatly restricts access of such pharmaceutics to the brain. Treating brain disorders with proteins thus remains a great challenge, and the slow clinical translation of these therapeutics may be largely ascribed to the lack of appropriate brain delivery system. Exploring new approaches to deliver proteins to the brain by circumventing physiological barriers is thus of great interest. Moreover, parallel advances in the molecular neurosciences are important for better characterizing blood-brain interfaces, particularly under different pathological conditions (e.g., stroke, multiple sclerosis, Parkinson's disease, and Alzheimer's disease). This review presents the current state of knowledge of the structure and the function of the main physiological barriers of the brain, the mechanisms of transport across these interfaces, as well as alterations to these concomitant with brain disorders. Further, the different strategies to promote protein delivery into the brain are presented, including the use of molecular Trojan horses, the formulation of nanosystems conjugated/loaded with proteins, protein-engineering technologies, the conjugation of proteins to polymers, and the modulation of intercellular junctions. Additionally, therapeutic approaches for brain diseases that do not involve targeting to the brain are presented (i.e., sink and scavenging mechanisms).
Collapse
Affiliation(s)
- A Zaghmi
- Institut National de la Recherche Scientifique (INRS), EMT Research Center, Varennes, QC, J3X 1S2, Canada
| | - J Drouin-Ouellet
- Faculty of Pharmacy, Université de Montréal, CP 6128, succ. Centre-ville, Montréal, QC, H3C 3J7, Canada
| | - D Brambilla
- Faculty of Pharmacy, Université de Montréal, CP 6128, succ. Centre-ville, Montréal, QC, H3C 3J7, Canada
| | - M A Gauthier
- Institut National de la Recherche Scientifique (INRS), EMT Research Center, Varennes, QC, J3X 1S2, Canada.
| |
Collapse
|
9
|
Zhou Z, Austin GL, Shaffer R, Armstrong DD, Gentry MS. Antibody-Mediated Enzyme Therapeutics and Applications in Glycogen Storage Diseases. Trends Mol Med 2019; 25:1094-1109. [PMID: 31522955 PMCID: PMC6889062 DOI: 10.1016/j.molmed.2019.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 01/18/2023]
Abstract
The use of antibodies as targeting molecules or cell-penetrating tools has emerged at the forefront of pharmaceutical research. Antibody-directed therapies in the form of antibody-drug conjugates, immune modulators, and antibody-directed enzyme prodrugs have been most extensively utilized as hematological, rheumatological, and oncological therapies, but recent developments are identifying additional applications of antibody-mediated delivery systems. A novel application of this technology is for the treatment of glycogen storage disorders (GSDs) via an antibody-enzyme fusion (AEF) platform to penetrate cells and deliver an enzyme to the cytoplasm, nucleus, and/or other organelles. Exciting developments are currently underway for AEFs in the treatment of the GSDs Pompe disease and Lafora disease (LD). Antibody-based therapies are quickly becoming an integral part of modern disease therapeutics.
Collapse
Affiliation(s)
- Zhengqiu Zhou
- Department of Molecular and Cellular Biochemistry, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - Grant L Austin
- Department of Molecular and Cellular Biochemistry, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | | | | | - Matthew S Gentry
- Department of Molecular and Cellular Biochemistry, University of Kentucky College of Medicine, Lexington, KY 40536, USA; Lafora Epilepsy Cure Initiative, University of Kentucky College of Medicine, Lexington, KY 40536, USA; Epilepsy and Brain Metabolism Alliance, University of Kentucky College of Medicine, Lexington, KY 40536, USA.
| |
Collapse
|
10
|
Mohamed S, He QQ, Singh AA, Ferro V. Mucopolysaccharidosis type II (Hunter syndrome): Clinical and biochemical aspects of the disease and approaches to its diagnosis and treatment. Adv Carbohydr Chem Biochem 2019; 77:71-117. [PMID: 33004112 DOI: 10.1016/bs.accb.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Mucopolysaccharidosis type II (MPS II, Hunter syndrome) is a rare X-linked lysosomal storage disease caused by mutations of the gene encoding the lysosomal enzyme iduronate-2-sulfatase (IDS), the role of which is to hydrolytically remove O-linked sulfates from the two glycosaminoglycans (GAGs) heparan sulfate (HS) and dermatan sulfate (DS). HS and DS are linear, heterogeneous polysaccharides composed of repeating disaccharide subunits of l-iduronic acid (IdoA) or d-glucuronic acid, (1→4)-linked to d-glucosamine (for HS), or (1→3)-linked to 2-acetamido-2-deoxy-d-galactose (N-acetyl-d-galactosamine) (for DS). In healthy cells, IDS cleaves the sulfo group found at the C-2 position of terminal non-reducing end IdoA residues in HS and DS. The loss of IDS enzyme activity leads to progressive lysosomal storage of HS and DS in tissues and organs such as the brain, liver, spleen, heart, bone, joints and airways. Consequently, this leads to the phenotypic features characteristic of the disease. This review provides an overview of the disease profile and clinical manifestation, with a particular focus on the biochemical basis of the disease and chemical approaches to the development of new diagnostics, as well as discussing current treatment options and emerging new therapies.
Collapse
Affiliation(s)
- Shifaza Mohamed
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia
| | - Qi Qi He
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia
| | - Arti A Singh
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia
| | - Vito Ferro
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia.
| |
Collapse
|
11
|
Cardon F, Pallisse R, Bardor M, Caron A, Vanier J, Ele Ekouna JP, Lerouge P, Boitel‐Conti M, Guillet M. Brassica rapa hairy root based expression system leads to the production of highly homogenous and reproducible profiles of recombinant human alpha-L-iduronidase. PLANT BIOTECHNOLOGY JOURNAL 2019; 17:505-516. [PMID: 30058762 PMCID: PMC6335068 DOI: 10.1111/pbi.12994] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/02/2018] [Accepted: 07/22/2018] [Indexed: 05/28/2023]
Abstract
The Brassica rapa hairy root based expression platform, a turnip hairy root based expression system, is able to produce human complex glycoproteins such as the alpha-L-iduronidase (IDUA) with an activity similar to the one produced by Chinese Hamster Ovary (CHO) cells. In this article, a particular attention has been paid to the N- and O-glycosylation that characterize the alpha-L-iduronidase produced using this hairy root based system. This analysis showed that the recombinant protein is characterized by highly homogeneous post translational profiles enabling a strong batch to batch reproducibility. Indeed, on each of the 6 N-glycosylation sites of the IDUA, a single N-glycan composed of a core Man3 GlcNAc2 carrying one beta(1,2)-xylose and one alpha(1,3)-fucose epitope (M3XFGN2) was identified, highlighting the high homogeneity of the production system. Hydroxylation of proline residues and arabinosylation were identified during O-glycosylation analysis, still with a remarkable reproducibility. This platform is thus positioned as an effective and consistent expression system for the production of human complex therapeutic proteins.
Collapse
Affiliation(s)
| | | | - Muriel Bardor
- Laboratoire Glyco‐MEV EA4358UNIROUENNormandie UniversitéRouenFrance
- Institut Universitaire de France (I.U.F.)Paris Cedex 05France
| | | | - Jessica Vanier
- Laboratoire Glyco‐MEV EA4358UNIROUENNormandie UniversitéRouenFrance
| | - Jean Pierre Ele Ekouna
- Biologie des Plantes et Innovation (BIOPI)Université de Picardie Jules VerneAmiensFrance
| | - Patrice Lerouge
- Laboratoire Glyco‐MEV EA4358UNIROUENNormandie UniversitéRouenFrance
| | - Michèle Boitel‐Conti
- Biologie des Plantes et Innovation (BIOPI)Université de Picardie Jules VerneAmiensFrance
| | | |
Collapse
|
12
|
Pulgar VM. Transcytosis to Cross the Blood Brain Barrier, New Advancements and Challenges. Front Neurosci 2019; 12:1019. [PMID: 30686985 PMCID: PMC6337067 DOI: 10.3389/fnins.2018.01019] [Citation(s) in RCA: 235] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/18/2018] [Indexed: 01/21/2023] Open
Abstract
The blood brain barrier (BBB) presents a formidable challenge to the delivery of drugs into the brain. Several strategies aim to overcome this obstacle and promote efficient and specific crossing through BBB of therapeutically relevant agents. One of those strategies uses the physiological process of receptor-mediated transcytosis (RMT) to transport cargo through the brain endothelial cells toward brain parenchyma. Recent developments in our understanding of intracellular trafficking and receptor binding as well as in protein engineering and nanotechnology have potentiated the opportunities for treatment of CNS diseases using RMT. In this mini-review, the current understanding of BBB structure is discussed, and recent findings exemplifying critical advances in RMT-mediated brain drug delivery are briefly presented.
Collapse
Affiliation(s)
- Victor M Pulgar
- Department of Pharmaceutical Sciences, Campbell University, Buies Creek, NC, United States.,Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| |
Collapse
|
13
|
Pardridge WM. Delivery of Biologics Across the Blood–Brain Barrier with Molecular Trojan Horse Technology. BioDrugs 2017; 31:503-519. [DOI: 10.1007/s40259-017-0248-z] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
14
|
Whiteman DA, Kimura A. Development of idursulfase therapy for mucopolysaccharidosis type II (Hunter syndrome): the past, the present and the future. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2467-2480. [PMID: 28860717 PMCID: PMC5574592 DOI: 10.2147/dddt.s139601] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Mucopolysaccharidosis type II (MPS II; Hunter syndrome; OMIM 309900) is a rare, multisystemic, progressive lysosomal storage disease caused by deficient activity of the iduronate-2-sulfatase (I2S) enzyme. Accumulation of the glycosaminoglycans dermatan sulfate and heparan sulfate results in a broad range of disease manifestations that are highly variable in presentation and severity; notably, approximately two-thirds of individuals are affected by progressive central nervous system involvement. Historically, management of this disease was palliative; however, during the 1990s, I2S was purified to homogeneity for the first time, leading to cloning of the corresponding gene and offering a means of addressing the underlying cause of MPS II using enzyme replacement therapy (ERT). Recombinant I2S (idursulfase) was produced for ERT using a human cell line and was shown to be indistinguishable from endogenous I2S. Preclinical studies utilizing the intravenous route of administration provided valuable insights that informed the design of the subsequent clinical studies. The pivotal Phase II/III clinical trial of intravenous idursulfase (Elaprase®; Shire, Lexington, MA, USA) demonstrated improvements in a range of clinical parameters; based on these findings, intravenous idursulfase was approved for use in patients with MPS II in the USA in 2006 and in Europe and Japan in 2007. Evidence gained from post-approval programs has helped to improve our knowledge and understanding of management of patients with the disease; as a result, idursulfase is now available to young pediatric patients, and in some countries patients have the option to receive their infusions at home. Although ERT with idursulfase has been shown to improve somatic signs and symptoms of MPS II, the drug does not cross the blood–brain barrier and so treatment of neurological aspects of the disease remains challenging. A number of novel approaches are being investigated, and these may help to improve the care of patients with MPS II in the future.
Collapse
Affiliation(s)
- David Ah Whiteman
- Research & Development, Shire Human Genetic Therapies, Inc., Lexington, MA, USA
| | - Alan Kimura
- Research & Development, Shire Human Genetic Therapies, Inc., Lexington, MA, USA
| |
Collapse
|
15
|
Boado RJ, Lu JZ, Hui EKW, Lin H, Pardridge WM. Insulin Receptor Antibody-α-N-Acetylglucosaminidase Fusion Protein Penetrates the Primate Blood-Brain Barrier and Reduces Glycosoaminoglycans in Sanfilippo Type B Fibroblasts. Mol Pharm 2016; 13:1385-92. [PMID: 26910785 DOI: 10.1021/acs.molpharmaceut.6b00037] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Mucopolysaccharidosis Type IIIB (MPSIIIB) is caused by mutations in the gene encoding the lysosomal enzyme, α-N-acetylglucosaminidase (NAGLU). MPSIIIB presents with severe disease of the central nervous system, but intravenous NAGLU enzyme replacement therapy has not been developed because the NAGLU enzyme does not cross the blood-brain barrier (BBB). A BBB-penetrating form of the enzyme was produced by re-engineering NAGLU as an IgG-enzyme fusion protein, where the IgG domain is a monoclonal antibody (mAb) against the human insulin receptor (HIR). The HIRMAb traverses the BBB via transport on the endogenous insulin receptor and acts as a molecular Trojan horse to ferry the fused NAGLU across the BBB from blood. The NAGLU was fused to the carboxyl terminus of each heavy chain of the HIRMAb via an extended 31-amino acid linker, and the fusion protein is designated HIRMAb-LL-NAGLU. The fusion protein retains high affinity binding to the HIR, and on a molar basis has an enzyme activity equal to that of recombinant human NAGLU. Treatment of MPSIIIB fibroblasts with the fusion protein normalizes intracellular NAGLU enzyme activity and reduces sulfate incorporation into intracellular glycosoaminoglycan. The fusion protein is targeted to the lysosomal compartment of the cells as shown by confocal microscopy. The fusion protein was radiolabeled with the [(125)I]-Bolton-Hunter reagent and injected intravenously in the adult Rhesus monkey. The fusion protein was rapidly cleared from plasma by all major peripheral organs. The high brain uptake of the fusion protein, 1% injected dose/brain, enables normalization of brain NAGLU enzyme activity with a therapeutic dose of 1 mg/kg. The HIRMAb-LL-NAGLU fusion protein is a new treatment of the brain in MPSIIIB, which can be administered by noninvasive intravenous infusion.
Collapse
Affiliation(s)
- Ruben J Boado
- ArmaGen, Inc., Calabasas, California 91302, United States
| | | | | | - Huilan Lin
- ArmaGen, Inc., Calabasas, California 91302, United States
| | | |
Collapse
|
16
|
Peluffo H, Unzueta U, Negro-Demontel ML, Xu Z, Váquez E, Ferrer-Miralles N, Villaverde A. BBB-targeting, protein-based nanomedicines for drug and nucleic acid delivery to the CNS. Biotechnol Adv 2015; 33:277-87. [PMID: 25698504 DOI: 10.1016/j.biotechadv.2015.02.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 01/14/2015] [Accepted: 02/09/2015] [Indexed: 01/17/2023]
Abstract
The increasing incidence of diseases affecting the central nervous system (CNS) demands the urgent development of efficient drugs. While many of these medicines are already available, the Blood Brain Barrier and to a lesser extent, the Blood Spinal Cord Barrier pose physical and biological limitations to their diffusion to reach target tissues. Therefore, efforts are needed not only to address drug development but specially to design suitable vehicles for delivery into the CNS through systemic administration. In the context of the functional and structural versatility of proteins, recent advances in their biological fabrication and a better comprehension of the physiology of the CNS offer a plethora of opportunities for the construction and tailoring of plain nanoconjugates and of more complex nanosized vehicles able to cross these barriers. We revise here how the engineering of functional proteins offers drug delivery tools for specific CNS diseases and more transversally, how proteins can be engineered into smart nanoparticles or 'artificial viruses' to afford therapeutic requirements through alternative administration routes.
Collapse
Affiliation(s)
- Hugo Peluffo
- Neuroinflammation Gene Therapy Laboratory, Institut Pasteur de Montevideo, Montevideo, Uruguay; Departamento de Histología y Embriología, Facultad de Medicina, Universidad de la República (UDELAR), Montevideo, Uruguay
| | - Ugutz Unzueta
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; Department de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Bellaterra, 08193 Barcelona, Spain
| | - María Luciana Negro-Demontel
- Neuroinflammation Gene Therapy Laboratory, Institut Pasteur de Montevideo, Montevideo, Uruguay; Departamento de Histología y Embriología, Facultad de Medicina, Universidad de la República (UDELAR), Montevideo, Uruguay
| | - Zhikun Xu
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; Department de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Bellaterra, 08193 Barcelona, Spain
| | - Esther Váquez
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; Department de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Bellaterra, 08193 Barcelona, Spain
| | - Neus Ferrer-Miralles
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; Department de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Bellaterra, 08193 Barcelona, Spain
| | - Antonio Villaverde
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; Department de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain; CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Bellaterra, 08193 Barcelona, Spain
| |
Collapse
|
17
|
Lajoie JM, Shusta EV. Targeting receptor-mediated transport for delivery of biologics across the blood-brain barrier. Annu Rev Pharmacol Toxicol 2014; 55:613-31. [PMID: 25340933 DOI: 10.1146/annurev-pharmtox-010814-124852] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Biologics are an emerging class of medicines with substantial promise to treat neurological disorders such as Alzheimer's disease, stroke, and multiple sclerosis. However, the blood-brain barrier (BBB) presents a formidable obstacle that appreciably limits brain uptake and hence the therapeutic potential of biologics following intravenous administration. One promising strategy for overcoming the BBB to deliver biologics is the targeting of endogenous receptor-mediated transport (RMT) systems that employ vesicular trafficking to transport ligands across the BBB endothelium. If a biologic is modified with an appropriate targeting ligand, it can gain improved access to the brain via RMT. Various RMT-targeting strategies have been developed over the past 20 years, and this review explores exciting recent advances, emphasizing studies that show brain targeting in vivo.
Collapse
Affiliation(s)
- Jason M Lajoie
- Department of Chemical and Biological Engineering, University of Wisconsin-Madison, Madison, Wisconsin 53706;
| | | |
Collapse
|
18
|
Boado RJ, Ka-Wai Hui E, Zhiqiang Lu J, Pardridge WM. Insulin receptor antibody-iduronate 2-sulfatase fusion protein: pharmacokinetics, anti-drug antibody, and safety pharmacology in Rhesus monkeys. Biotechnol Bioeng 2014; 111:2317-25. [PMID: 24889100 DOI: 10.1002/bit.25289] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 04/28/2014] [Accepted: 05/05/2014] [Indexed: 11/06/2022]
Abstract
Mucopolysaccharidosis (MPS) Type II is caused by mutations in the gene encoding the lysosomal enzyme, iduronate 2-sulfatase (IDS). The majority of MPSII cases affect the brain. However, enzyme replacement therapy with recombinant IDS does not treat the brain, because IDS is a large molecule drug that does not cross the blood-brain barrier (BBB). To enable BBB penetration, IDS has been re-engineered as an IgG-IDS fusion protein, where the IgG domain is a monoclonal antibody (MAb) against the human insulin receptor (HIR). The HIRMAb crosses the BBB via receptor-mediated transport on the endogenous BBB insulin receptor, and the HIRMAb domain of the fusion protein acts as a molecular Trojan horse to ferry the fused IDS into brain from blood. The present study reports on the first safety pharmacology and pharmacokinetics study of the HIRMAb-IDS fusion protein. Juvenile male Rhesus monkeys were infused intravenously (IV) weekly for 26 weeks with 0, 3, 10, or 30 mg/kg of the HIRMAb-IDS fusion protein. The plasma clearance of the fusion protein followed a linear pharmacokinetics profile, which was equivalent either with measurements of the plasma concentration of immunoreactive HIRMAb-IDS fusion protein, or with assays of plasma IDS enzyme activity. Anti-drug antibody (ADA) titers were monitored monthly, and the ADA response was primarily directed against the variable region of the HIRMAb domain of the fusion protein. No infusion related reactions or clinical signs of immune response were observed during the course of the study. A battery of safety pharmacology, clinical chemistry, and tissue histopathology showed no signs of adverse events, and demonstrate the safety profile of chronic treatment of primates with 3-30 mg/kg weekly IV infusion doses of the HIRMAb-IDS fusion protein.
Collapse
Affiliation(s)
- Ruben J Boado
- ArmaGen Technologies, Inc., 26679, Agoura Road, Calabasas, California, 91302
| | | | | | | |
Collapse
|
19
|
Giugliani R, Villarreal MLS, Valdez CAA, Hawilou AM, Guelbert N, Garzón LNC, Martins AM, Acosta A, Cabello JF, Lemes A, Santos MLSF, Amartino H. Guidelines for diagnosis and treatment of Hunter Syndrome for clinicians in Latin America. Genet Mol Biol 2014; 37:315-29. [PMID: 25071396 PMCID: PMC4094607 DOI: 10.1590/s1415-47572014000300003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 03/26/2014] [Indexed: 11/24/2022] Open
Abstract
This review aims to provide clinicians in Latin America with the most current information on the clinical aspects, diagnosis, and management of Hunter syndrome, a serious and progressive disease for which specific treatment is available. Hunter syndrome is a genetic disorder where iduronate-2-sulfatase (I2S), an enzyme that degrades glycosaminoglycans, is absent or deficient. Clinical manifestations vary widely in severity and involve multiple organs and tissues. An attenuated and a severe phenotype are recognized depending on the degree of cognitive impairment. Early diagnosis is vital for disease management. Clinical signs common to children with Hunter syndrome include inguinal hernia, frequent ear and respiratory infections, facial dysmorphisms, macrocephaly, bone dysplasia, short stature, sleep apnea, and behavior problems. Diagnosis is based on screening urinary glycosaminoglycans and confirmation by measuring I2S activity and analyzing I2S gene mutations. Idursulfase (recombinant I2S) (Elaprase®, Shire) enzyme replacement therapy (ERT), designed to address the underlying enzyme deficiency, is approved treatment and improves walking capacity and respiratory function, and reduces spleen and liver size and urinary glycosaminoglycan levels. Additional measures, responding to the multi-organ manifestations, such as abdominal/inguinal hernia repair, carpal tunnel surgery, and cardiac valve replacement, should also be considered. Investigational treatment options such as intrathecal ERT are active areas of research, and bone marrow transplantation is in clinical practice. Communication among care providers, social workers, patients and families is essential to inform and guide their decisions, establish realistic expectations, and assess patients’ responses.
Collapse
Affiliation(s)
- Roberto Giugliani
- Serviço de Génetica Médica , Hospital de Clinicas de Porto Alegre , Porto Alegre, RS , Brazil . ; Departamento de Génetica , Universidade Federal do Rio Grande do Sul , Porto Alegre, RS , Brasil . ; Instituto Nacional de Genética Médica Populacional , Porto Alegre, RS , Brazil
| | | | | | | | | | | | - Ana Maria Martins
- Centro de Referência em Erros Inatos do Metabolismo , Universidade Federal de São Paulo , São Paulo, SP , Brazil
| | | | - Juan Francisco Cabello
- Instituto de Nutrición y Tecnología de los Alimentos , Universidad de Chile , Santiago , Chile
| | - Aída Lemes
- Instituto de Genética Médica , Hospital Italiano , Montevideo , Uruguay
| | | | | |
Collapse
|
20
|
Boado RJ, Lu JZ, Hui EKW, Pardridge WM. Insulin receptor antibody-sulfamidase fusion protein penetrates the primate blood-brain barrier and reduces glycosoaminoglycans in Sanfilippo type A cells. Mol Pharm 2014; 11:2928-34. [PMID: 24949884 PMCID: PMC4137762 DOI: 10.1021/mp500258p] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
![]()
Mutations in the lysosomal enzyme, N-sulfoglucosamine
sulfohydrolase (SGSH), also called sulfamidase, cause accumulation
of lysosomal inclusion bodies in the brain of children born with mucopolysaccharidosis
type IIIA, also called Sanfilippo type A syndrome. Enzyme replacement
therapy with recombinant SGSH does not treat the brain because the
enzyme is a large molecule drug that does not cross the blood–brain
barrier (BBB). A BBB-penetrating form of SGSH was produced by re-engineering
the enzyme as an IgG fusion protein, where the IgG domain is a monoclonal
antibody (mAb) against the human insulin receptor (HIR). The HIRMAb
domain of the HIRMAb–SGSH fusion protein acts as a molecular
Trojan horse to ferry the fused enzyme across the BBB. The HIRMAb–SGSH
was produced in stably transfected host cells and purified to homogeneity
by protein A chromatography. The fusion protein reacted with antibodies
against either human IgG or SGSH on Western blotting. High affinity
binding to the HIR was retained following SGSH fusion to the HIRMAb,
with an EC50 of 0.33 ± 0.05 nM in an HIR binding ELISA.
The SGSH enzyme activity of the HIRMAb–SGSH fusion protein
was 4712 ± 388 units/mg protein based on a two-step fluorometric
enzyme assay. The HIRMAb–SGSH was taken up by lysosomes in
MPSIIIA fibroblasts, and treatment of these cells with the fusion
protein caused an 83% reduction in sulfate incorporation into lysosomal
glycosoaminoglycans. The HIRMAb–SGSH fusion protein was radiolabeled
with the [125I]-Bolton–Hunter reagent and injected
intravenously in the Rhesus monkey. The brain uptake of the fusion
protein was high, ∼1% injected dose/brain. Calculations, based
on this level of brain uptake, suggest normalization of brain SGSH
enzyme activity is possible following administration of therapeutic
doses of the fusion protein. These studies describe a novel IgG–SGSH
fusion protein that is a new noninvasive treatment of the brain in
MPS type IIIA.
Collapse
Affiliation(s)
- Ruben J Boado
- ArmaGen Technologies, Inc. , 26679 Agoura Road, Suite 100, Calabasas, California 91302, United States
| | | | | | | |
Collapse
|
21
|
Enhanced brain drug delivery: safely crossing the blood-brain barrier. DRUG DISCOVERY TODAY. TECHNOLOGIES 2013; 9:e71-e174. [PMID: 24064276 DOI: 10.1016/j.ddtec.2011.12.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
22
|
Boado RJ, Hui EKW, Lu JZ, Sumbria RK, Pardridge WM. Blood-brain barrier molecular trojan horse enables imaging of brain uptake of radioiodinated recombinant protein in the rhesus monkey. Bioconjug Chem 2013; 24:1741-9. [PMID: 24059813 DOI: 10.1021/bc400319d] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recombinant proteins are large molecule drugs that do not cross the blood-brain barrier (BBB). However, BBB-penetration of protein therapeutics is enabled by re-engineering the recombinant protein as IgG fusion proteins. The IgG domain is a monoclonal antibody (mAb) against an endogenous BBB receptor-mediated transport system, such as the human insulin receptor (HIR), and acts as a molecular Trojan horse to ferry the fused protein across the BBB. In the present study, a recombinant lysosomal enzyme, iduronate 2-sulfatase (IDS), is fused to the HIRMAb, and BBB penetration of the IDS alone vs the HIRMAb-IDS fusion protein is compared in the Rhesus monkey. Recombinant IDS and the HIRMAb-IDS fusion protein were radiolabeled with indirect iodination with the [(125)I]-Bolton-Hunter reagent and with direct iodination with Iodogen/[(125)I]-idodine. IDS and the HIRMAb-IDS fusion protein have comparable plasma pharmacokinetics and uptake by peripheral organs. IDS does not cross the BBB. The HIRMAb-IDS fusion protein crosses the BBB and the brain uptake is 1% of injected dose/brain. Brain imaging shows HIRMAb-IDS penetration to all parts of brain, and immunoprecipitation of brain radioactivity shows intact fusion protein in brain. The use of BBB molecular Trojan horses enables brain imaging of recombinant proteins that are re-engineered for BBB transport.
Collapse
Affiliation(s)
- Ruben J Boado
- Department of Medicine, University of California, Los Angeles , Los Angeles, California 90024, United States
| | | | | | | | | |
Collapse
|
23
|
Naz H, Islam A, Waheed A, Sly WS, Ahmad F, Hassan MI. Humanβ-Glucuronidase: Structure, Function, and Application in Enzyme Replacement Therapy. Rejuvenation Res 2013; 16:352-63. [DOI: 10.1089/rej.2013.1407] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Huma Naz
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, Jamia Nagar, New Delhi, India
| | - Asimul Islam
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, Jamia Nagar, New Delhi, India
| | - Abdul Waheed
- The Edward A. Doisy Department of Biochemistry and Molecular Biology, St. Louis, University School of Medicine, St. Louis, Missouri
| | - William S. Sly
- The Edward A. Doisy Department of Biochemistry and Molecular Biology, St. Louis, University School of Medicine, St. Louis, Missouri
| | - Faizan Ahmad
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, Jamia Nagar, New Delhi, India
| | - Md. Imtaiyaz Hassan
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, Jamia Nagar, New Delhi, India
| |
Collapse
|
24
|
Papademetriou J, Garnacho C, Serrano D, Bhowmick T, Schuchman EH, Muro S. Comparative binding, endocytosis, and biodistribution of antibodies and antibody-coated carriers for targeted delivery of lysosomal enzymes to ICAM-1 versus transferrin receptor. J Inherit Metab Dis 2013; 36:467-77. [PMID: 22968581 PMCID: PMC3556357 DOI: 10.1007/s10545-012-9534-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/30/2012] [Accepted: 08/13/2012] [Indexed: 12/13/2022]
Abstract
Targeting lysosomal enzymes to receptors involved in transport into and across cells holds promise to enhance peripheral and brain delivery of enzyme replacement therapies (ERTs) for lysosomal storage disorders. Receptors being explored include those associated with clathrin-mediated pathways, yet other pathways seem also viable. Well characterized examples are that of transferrin receptor (TfR) and intercellular adhesion molecule 1 (ICAM-1), involved in iron transport and leukocyte extravasation, respectively. TfR and ICAM-1 support ERT delivery via clathrin- vs. cell adhesion molecule-mediated mechanisms, displaying different valency and size restrictions. To comparatively assess this, we used antibodies vs. larger multivalent antibody-coated carriers and evaluated TfR vs. ICAM-1 binding and endocytosis in endothelial cells, as well as in vivo biodistribution and delivery of a model lysosomal enzyme required in peripheral organs and brain: acid sphingomyelinase (ASM), deficient in types A-B Niemann Pick disease. We found similar binding of antibodies to both receptors under control conditions, with enhanced binding to activated endothelium for ICAM-1, yet only anti-TfR induced endocytosis efficiently. Contrarily, antibody-coated carriers showed enhanced binding, engulfment, and endocytosis for ICAM-1. In mice, anti-TfR enhanced brain targeting over anti-ICAM, with an opposite outcome in the lungs, while carriers enhanced ICAM-1 targeting over TfR in both organs. Both targeted carriers enhanced ASM delivery to the brain and lungs vs. free ASM, with greater enhancement for anti-ICAM carriers. Therefore, targeting TfR or ICAM-1 improves lysosomal enzyme delivery. Yet, TfR targeting may be more efficient for smaller conjugates or fusion proteins, while ICAM-1 targeting seems superior for multivalent carrier formulations.
Collapse
Affiliation(s)
- Jason Papademetriou
- Fischell Department of Bioengineering, School of Engineering, University of Maryland College Park, College Park, MD 20742, USA
| | - Carmen Garnacho
- Department of Normal and Pathological Cytology and Histology, School of Medicine, University of Seville, Seville 41009, Spain
| | - Daniel Serrano
- Department of Cell Biology & Molecular Genetics and Biological Sciences Graduate Program, University of Maryland, College Park, MD 20742, USA
| | - Tridib Bhowmick
- Institute for Bioscience and Biotechnology Research, University of Maryland, College Park, MD 20742, USA
| | - Edward H. Schuchman
- Department of Human Genetics, Mount Sinai School of Medicine, New York, NY 10029, USA
| | - Silvia Muro
- Fischell Department of Bioengineering, School of Engineering, University of Maryland College Park, College Park, MD 20742, USA
- Institute for Bioscience and Biotechnology Research, University of Maryland, College Park, MD 20742, USA
- Author to whom correspondence should be addressed: Silvia Muro, Institute for Bioscience and Biotechnology Research, 5115 Plant Sciences Building, College Park, MD 20742-4450.
| |
Collapse
|
25
|
van Gelder CM, Vollebregt AAM, Plug I, van der Ploeg AT, Reuser AJJ. Treatment options for lysosomal storage disorders: developing insights. Expert Opin Pharmacother 2012; 13:2281-99. [PMID: 23009070 DOI: 10.1517/14656566.2012.729039] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Lysosomal storage disorders (LSDs) are clinically heterogeneous disorders that result primarily from lysosomal accumulation of macromolecules in various tissues. LSDs are always progressive, and often lead to severe symptoms and premature death. The identification of the underlying genetic and enzymatic defects has prompted the development of various treatment options. AREAS COVERED To describe the current treatment options for LSDs, the authors provide a focused overview of their pathophysiology. They discuss the current applications and challenges of enzyme-replacement therapy, stem-cell therapy, gene therapy, chaperone therapy and substrate-reduction therapy, as well as future therapeutic prospects. EXPERT OPINION Over recent decades, considerable progress has been made in the treatment of LSDs and in the outcome of patients. None of the current options are completely curative yet. They are complicated by the difficulty in efficiently targeting all affected tissues (particularly the central nervous system), in reaching sufficiently high enzyme levels in the target tissues, and by their high costs. The pathways leading from the genetic mutation to the clinical symptoms should be further elucidated, as they might prompt the development of new and ultimately curative therapies.
Collapse
Affiliation(s)
- Carin M van Gelder
- Erasmus MC University Medical Center, Center for Lysosomal and Metabolic Diseases, Department of Paediatrics, Dr. Molewaterplein 60, Rotterdam, The Netherlands
| | | | | | | | | |
Collapse
|
26
|
Zhou QH, Boado RJ, Pardridge WM. Selective plasma pharmacokinetics and brain uptake in the mouse of enzyme fusion proteins derived from species-specific receptor-targeted antibodies. J Drug Target 2012; 20:715-9. [DOI: 10.3109/1061186x.2012.712132] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
27
|
Lalatsa A, Schätzlein AG, Uchegbu* IF. Nanostructures Overcoming the Blood-Brain Barrier: Physiological Considerations and Mechanistic Issues. NANOSTRUCTURED BIOMATERIALS FOR OVERCOMING BIOLOGICAL BARRIERS 2012. [DOI: 10.1039/9781849735292-00329] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
28
|
Zhou QH, Boado RJ, Lu JZ, Hui EKW, Pardridge WM. Brain-penetrating IgG-iduronate 2-sulfatase fusion protein for the mouse. Drug Metab Dispos 2011; 40:329-35. [PMID: 22065691 DOI: 10.1124/dmd.111.042903] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Mucopolysaccharidosis (MPS) type II (Hunter's syndrome) is caused by mutations in the iduronate 2-sulfatase (IDS) fusion protein. MPS-II affects the brain, and enzyme replacement therapy is not effective in the brain, because the enzyme does not cross the blood-brain barrier. To treat mouse models of MPS-II with brain-penetrating IDS, the lysosomal enzyme was reengineered as an IgG-IDS fusion protein. The mature human IDS was fused to the carboxyl terminus of both heavy chains of the chimeric monoclonal antibody (MAb) against the mouse transferrin receptor (TfR), and the fusion protein is designated cTfRMAb-IDS. The purity and identity of the fusion protein was confirmed by electrophoresis and Western blotting with antibodies to mouse IgG and human IDS. The EC₅₀ of binding of the cTfRMAb-IDS fusion protein to the mouse TfR (0.85 ± 0.15 nM) was comparable to the EC₅₀ of binding of the cTfRMAb (0.78 ± 0.05 nM). The IDS enzyme activity of the cTfRMAb-IDS fusion protein was 126 ± 1 nmol · h⁻¹ · μg⁻¹ protein. After intravenous injection in the mouse, the cTfRMAb-IDS fusion protein was rapidly removed from plasma and distributed to tissues, including brain and spinal cord. The uptake of the fusion protein by brain or spinal cord was 1.3 ± 0.1 and 2.2 ± 0.2% injected dose/g, respectively, which is 100-fold greater than the brain uptake of IDS alone. This work shows that a lysosomal sulfatase can be reengineered as an IgG-enzyme fusion protein that rapidly penetrates the brain after intravenous administration.
Collapse
Affiliation(s)
- Qing-Hui Zhou
- Department of Medicine, UCLA, Los Angeles, California, USA
| | | | | | | | | |
Collapse
|
29
|
Eliyahu E, Wolfson T, Ge Y, Jepsen KJ, Schuchman EH, Simonaro CM. Anti-TNF-alpha therapy enhances the effects of enzyme replacement therapy in rats with mucopolysaccharidosis type VI. PLoS One 2011; 6:e22447. [PMID: 21887218 PMCID: PMC3159569 DOI: 10.1371/journal.pone.0022447] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 06/22/2011] [Indexed: 11/19/2022] Open
Abstract
Background Although enzyme replacement therapy (ERT) is available for several lysosomal storage disorders, the benefit of this treatment to the skeletal system is very limited. Our previous work has shown the importance of the Toll-like receptor 4/TNF-alpha inflammatory pathway in the skeletal pathology of the mucopolysaccharidoses (MPS), and we therefore undertook a study to examine the additive benefit of combining anti-TNF-alpha therapy with ERT in a rat model of MPS type VI. Methodology/Principal Findings MPS VI rats were treated for 8 months with Naglazyme® (recombinant human N-acetyl-galactosamine-4-sulfatase), or by a combined protocol using Naglazyme® and the rat-specific anti-TNF-alpha drug, CNTO1081. Both protocols led to markedly reduced serum levels of TNF-alpha and RANKL, although only the combined treatment reduced TNF-alpha in the articular cartilage. Analysis of cultured articular chondrocytes showed that the combination therapy also restored collagen IIA1 expression, and reduced expression of the apoptotic marker, PARP. Motor activity and mobility were improved by ERT, and these were significantly enhanced by combination treatment. Tracheal deformities in the MPS VI animals were only improved by combination therapy, and there was a modest improvement in bone length. Ceramide levels in the trachea also were markedly reduced. MicroCT analysis did not demonstrate any significant positive effects on bone microarchitecture from either treatment, nor was there histological improvement in the bone growth plates. Conclusions/Significance The results demonstrate that combining ERT with anti-TNF- alpha therapy improved the treatment outcome and led to significant clinical benefit. They also further validate the usefulness of TNF-alpha, RANKL and other inflammatory molecules as biomarkers for the MPS disorders. Further evaluation of this combination approach in other MPS animal models and patients is warranted.
Collapse
Affiliation(s)
- Efrat Eliyahu
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Theodore Wolfson
- Department of Orthopaedics, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Yi Ge
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Karl J. Jepsen
- Department of Orthopaedics, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Edward H. Schuchman
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Calogera M. Simonaro
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, United States of America
- * E-mail:
| |
Collapse
|