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Dobelmann V, Roos A, Hentschel A, Della Marina A, Leo M, Schmitt LI, Maggi L, Schara-Schmidt U, Hagenacker T, Ruck T, Kölbel H. Thrombospondin-4 as potential cerebrospinal fluid biomarker for therapy response in pediatric spinal muscular atrophy. J Neurol 2024:10.1007/s00415-024-12670-0. [PMID: 39240344 DOI: 10.1007/s00415-024-12670-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/26/2024] [Accepted: 08/27/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND AND PURPOSE Spinal muscular atrophy (SMA) as the second most common neurodegenerative disorder in childhood is characterized by the deficiency of survival of motor neuron (SMN) protein leading predominantly to degeneration of alpha motor neurons and consequently to progressive muscle weakness and atrophy. Besides some biomarkers like SMN2 copy number therapeutic biomarkers for SMA with known relevance for neuromuscular transmission are lacking. Here, we examined the potential of Thrombospondin-4 (TSP4) to serve as a cerebrospinal fluid (CSF) biomarker, which may also indicate treatment response. METHODS We used untargeted proteomic analyses to determine biomarkers in CSF samples derived from pediatric pre-symptomatic (n = 6) and symptomatic (n = 4) SMA patients. The identified biomarker TSP4 was then validated in additional 68 CSF samples (9 adult and 24 pediatric SMA patients, 5 adult and 13 pediatric non-disease controls in addition to 17 pediatric disease controls) by enzyme-linked immunosorbent assay (ELISA) as an additional analytical approach. RESULTS Untargeted proteomic analyses of CSF identified a dysregulation of TSP4 and revealed a difference between pre-symptomatic SMA patients and patients identified after the onset of first symptoms. Subsequent ELISA-analyses showed that TSP4 is decreased in pediatric but not adult SMA patients. CSF of pediatric patients with other neurological disorders demonstrated no alteration of TSP4 levels. Furthermore, CSF TSP4 levels of pediatric SMA patients increased after first dose of Nusinersen. CONCLUSIONS We found that TSP4 levels are exclusively reduced in CSF of pediatric SMA patients and increase after treatment, leading us to the hypothesis that TSP4 could serve as a CSF biomarker with the potential to monitor treatment response in pediatric SMA patients. Moreover, TSP4 enable to distinguish pre-symptomatic and symptomatic patients suggesting a potential to serve as a stratification marker.
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Affiliation(s)
- Vera Dobelmann
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Andreas Roos
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
- Department of Pediatric Neurology, Developmental Neurology, and Social Pediatrics, Center for Neuromuscular Disorders in Children and Adolescents, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, ON, K1H 5B2, Canada
| | | | - Adela Della Marina
- Department of Pediatric Neurology, Developmental Neurology, and Social Pediatrics, Center for Neuromuscular Disorders in Children and Adolescents, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Markus Leo
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Linda-Isabell Schmitt
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Lorenzo Maggi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Ulrike Schara-Schmidt
- Department of Pediatric Neurology, Developmental Neurology, and Social Pediatrics, Center for Neuromuscular Disorders in Children and Adolescents, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Heike Kölbel
- Department of Pediatric Neurology, Developmental Neurology, and Social Pediatrics, Center for Neuromuscular Disorders in Children and Adolescents, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
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Hahn A, Günther R, Ludolph A, Schwartz O, Trollmann R, Weydt P, Weiler M, Neuland K, Schwaderer MS, Hagenacker T. Short-term safety results from compassionate use of risdiplam in patients with spinal muscular atrophy in Germany. Orphanet J Rare Dis 2022; 17:276. [PMID: 35854272 PMCID: PMC9295446 DOI: 10.1186/s13023-022-02420-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The oral, selective SMN2-splicing modifier risdiplam obtained European approval in March 2021 for the treatment of patients ≥ 2 months old with a clinical diagnosis of 5q-associated spinal muscular atrophy (SMA) 1/2/3 or with 1-4 SMN2 gene copies. For the preceding 12 months, this compassionate use program (CUP) made risdiplam available to patients with SMA1/2 in Germany who could not receive any approved SMA therapy. PATIENTS AND METHODS Patients with SMA1/2, aged ≥ 2 months at enrollment, could be included if they were not eligible for, no longer responsive to, or not able to tolerate nusinersen or not able to receive onasemnogene abeparvovec. Oral risdiplam dosing ranged from 0.2 mg/kg to 5 mg depending on age and weight. All treatment decisions were made by the attending physicians, who were required to report all adverse events (AEs). RESULTS Between March 12, 2020 and March 30, 2021, 36 patients with SMA1 and 98 patients with SMA2 were enrolled, with 31 patients and 80 patients receiving ≥ 1 risdiplam dose, respectively. The median (range) age was 10.5 (3-52) years in the SMA1 cohort, and 26.5 (3-60) years in the SMA2 cohort. 22.2% of patients with SMA1 and 48.0% with SMA2 were treatment-naïve. Most patients were not eligible/could not continue to receive nusinersen due to scoliosis/safety risk (SMA1: 75.0%; SMA2: 96.9%), risks associated with sedation (77.8%; 63.3%), or loss of efficacy (30.6%; 12.2%). Safety data were generally in line with the safety profile of risdiplam in ongoing clinical studies. Gastrointestinal disorders were the most common AEs. For patients with SMA1, 30 AEs were reported in 13 cases with 2 serious AEs in 1 patient. For SMA2, 100 AEs were documented in 31 case reports, including 8 serious AEs in 2 patients. CONCLUSIONS We present the first real-world safety data of risdiplam in patients with SMA in Germany. Our observations indicated no new safety signals under real-world conditions. Real-world SMA1/2 populations comprise considerable numbers of patients who are not eligible for gene therapy and cannot tolerate or have failed nusinersen treatment. This medical need may be addressed by oral risdiplam.
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Affiliation(s)
- Andreas Hahn
- Department of Child Neurology, University of Gießen, Giessen, Germany
| | - René Günther
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Albert Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Oliver Schwartz
- Department of Pediatric Neurology, Münster University Hospital, Münster, Germany
| | - Regina Trollmann
- Division of Pediatric Neurology, Department of Pediatrics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Patrick Weydt
- Department of Neurodegenerative Diseases and Gerontopsychiatry/Neurology, University of Bonn Medical Center, Bonn, Germany
| | - Markus Weiler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany.
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Schorling DC, Kölbel H, Hentschel A, Pechmann A, Meyer N, Wirth B, Rombo R, Sickmann A, Kirschner J, Schara-Schmidt U, Lochmüller H, Roos A. Cathepsin D as biomarker in CSF of nusinersen-treated patients with spinal muscular atrophy. Eur J Neurol 2022; 29:2084-2096. [PMID: 35318785 DOI: 10.1111/ene.15331] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The therapeutic landscape of spinal muscular atrophy (SMA) has changed dramatically during the last 4 years but treatment responses differ remarkably between individuals and therapeutic decision-making remains challenging - underlining the persistent need for validated biomarkers. METHODS We applied untargeted proteomic analyses to determine biomarkers in cerebrospinal fluid (CSF) samples of SMA patients under treatment with nusinersen. Identified candidate proteins were validated in CSF samples of SMA patients by Western blot and ELISA. Further, levels of peripheral neurofilament H and L were determined. RESULTS Untargeted proteomic analysis of CSF samples of 3 SMA type 1 patients revealed the lysosomal protease Cathepsin D as a candidate biomarker. Subsequent validation analysis in a larger cohort of 31 pediatric SMA patients (type 1=12, type 2=9, type 3=6, presymptomatically treated=4; age 0-16 years) revealed a significant decline of Cathepsin D levels in SMA patients ≥2 months at the start of treatment. While evident in all older age categories, this decline was only significant in the group of patients that showed a positive motor-response. Moreover, downregulation of Cathepsin D was evident in muscle biopsies of SMA patients. CONCLUSIONS We identified a decline of Cathepsin D levels in CSF samples of SMA patients under nusinersen treatment that was more pronounced in the group of 'treatment responders' than in 'non-responders'. We believe that our results indicate a suitability of Cathepsin D levels as possible biomarker in SMA also in older patients - in combination with analysis of pNF-L in adolescents or alone in adult patients.
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Affiliation(s)
- David C Schorling
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Heike Kölbel
- Department of Pediatric Neurology, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in children and adolescents, University of Duisburg-Essen, Essen, Germany
| | - Andreas Hentschel
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V., 44227, Dortmund, Germany
| | - Astrid Pechmann
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Nancy Meyer
- Department of Pediatric Neurology, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in children and adolescents, University of Duisburg-Essen, Essen, Germany
| | - Brunhilde Wirth
- Institute of Human Genetics, Center for Molecular Medicine Cologne, Institute of Genetics, and Center for Rare Disorders, University of Cologne, Cologne, Germany
| | - Roman Rombo
- Institute of Human Genetics, Center for Molecular Medicine Cologne, Institute of Genetics, and Center for Rare Disorders, University of Cologne, Cologne, Germany
| | | | - Albert Sickmann
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V., 44227, Dortmund, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.,Department of Neuropediatrics, Faculty of Medicine, University Hospital Bonn, Germany
| | - Ulrike Schara-Schmidt
- Department of Pediatric Neurology, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in children and adolescents, University of Duisburg-Essen, Essen, Germany
| | - Hanns Lochmüller
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.,Division of Neurology, Department of Medicine, Children's Hospital of Eastern Ontario Research Institute, The Ottawa Hospital and Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada.,Centro Nacional de Análisis Genómico (CNAG-CRG), Center for Genomic Regulation, Barcelona Institute of Science and Technology (BIST), Barcelona, Catalonia, Spain
| | - Andreas Roos
- Department of Pediatric Neurology, Developmental Neurology and Social Pediatrics, Centre for Neuromuscular Disorders in children and adolescents, University of Duisburg-Essen, Essen, Germany.,Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V., 44227, Dortmund, Germany.,Department of Neurology, Heimer Institute for Muscle Research, University Hospital Bergmannsheil, Ruhr-University Bochum, 44789, Bochum, Germany
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Wataya T, Takasaki S, Hoshino M, Makioka H, Nakamura G, Matsuda N. Real-world safety of nusinersen in Japan: results from an interim analysis of a post-marketing surveillance and safety database. Int J Neurosci 2021:1-13. [PMID: 34809526 DOI: 10.1080/00207454.2021.1995382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Nusinersen is the first disease-modifying therapy to treat spinal muscular atrophy (SMA). This report describes the safety and effectiveness of nusinersen in Japanese clinical use using two data sources: an ongoing Japanese post-marketing surveillance (PMS) and the safety database of the marketing authorisation holder, Biogen . MATERIALS AND METHODS The PMS is evaluating the safety and effectiveness of nusinersen in all patients treated with nusinersen in Japan between August 2017 and August 2025; this interim analysis included data up to May 30, 2019. Biogen safety database data up to June 30, 2019 were also included to capture adverse events (AEs) from after the interim analysis cutoff date. Collected data included medical history, dosage and administration, and AEs. Safety assessment included AEs and serious AEs (SAEs). Effectiveness analyses included motor function assessments and clinical global impressions of improvement. RESULTS Of 271 patients in the PMS population, 94 had SMA type I (34.7%), and 177 had SMA types II-IV (65.3%). AEs occurred in 67 patients (24.7%) and SAEs in 23 patients (8.5%). The Biogen safety database contained reports of 345 AEs; the most common were pneumonia, headache, and pyrexia, consistent with symptoms of SMA and lumbar puncture. In the analysis set, 26.2% of patients receiving nusinersen showed motor function improvements and 99.6-100.0% showed overall improvement. CONCLUSION In this interim analysis of the PMS and Biogen safety database, nusinersen had a favourable benefit-risk profile in Japanese patients with SMA.
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Schorling DC, Pechmann A, Kirschner J. Advances in Treatment of Spinal Muscular Atrophy - New Phenotypes, New Challenges, New Implications for Care. J Neuromuscul Dis 2020; 7:1-13. [PMID: 31707373 PMCID: PMC7029319 DOI: 10.3233/jnd-190424] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Spinal Muscular Atrophy (SMA) is caused by autosomal recessive mutations in SMN1 and results in the loss of motor neurons and progressive muscle weakness. The spectrum of disease severity ranges from early onset with respiratory failure during the first months of life to a mild, adult-onset type with slow rate of progression. Over the past decade, new treatment options such as splicing modulation of SMN2 and SMN1 gene replacement by gene therapy have been developed. First drugs have been approved for treatment of patients with SMA and if initiated early they can significantly modify the natural course of the disease. As a consequence, newborn screening for SMA is explored and implemented in an increasing number of countries. However, available evidence for these new treatments is often limited to a small spectrum of patients concerning age and disease stage. In this review we provide an overview of available and emerging therapies for spinal muscular atrophy and we discuss new phenotypes and associated challenges in clinical care. Collection of real-world data with standardized outcome measures will be essential to improve both the understanding of treatment effects in patients of all SMA subtypes and the basis for clinical decision-making in SMA.
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Affiliation(s)
- David C. Schorling
- Department of Neuropediatrics and Muscle Disorders, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Astrid Pechmann
- Department of Neuropediatrics and Muscle Disorders, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neuropediatrics, University Hospital Bonn, Germany
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