1
|
Audouard E, Khefif N, Mansat C, Nelcha O, Banchi EG, Lupiet C, Farabos D, Lamaziere A, Sevin C, Piguet F. Dose-response evaluation of intravenous gene therapy in a symptomatic mouse model of metachromatic leukodystrophy. Mol Ther Methods Clin Dev 2024; 32:101248. [PMID: 38680552 PMCID: PMC11046302 DOI: 10.1016/j.omtm.2024.101248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 04/03/2024] [Indexed: 05/01/2024]
Abstract
Metachromatic leukodystrophy (MLD) is a rare, autosomal recessive neurodegenerative disease caused by deficient activity of the lysosomal enzyme arylsulfatase A (ARSA), resulting in sulfatide accumulation and subsequent demyelination and neuronal damage within the central and peripheral nervous systems. Three clinical forms of MLD have been described, based on age at symptom onset. The most frequent and severe forms have an early onset, with the disease progressing rapidly toward severe motor and cognitive regression and ultimately premature death. There are currently no approved therapies for most of these early-onset patients once symptoms are present. Thus, it is crucial to develop new approaches to treat symptomatic patients. Here, we proposed a gene therapy approach based on the intravenous delivery of AAVPHP.eB encoding ARSA. MLD mice were treated at 6 months for a dose-response study and at 9 months to assess late-treatment efficacy. Therapeutic efficacy was evaluated 3 or 6 months after injection. We demonstrated a broad transduction in the central nervous system, a complete correction of sulfatide storage, and a significant improvement in neuroinflammation at low dose and late treatment. Taken together, this work establishes a strong rationale for proposing a phase I/II clinical trial in MLD patients.
Collapse
Affiliation(s)
- Emilie Audouard
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| | - Nicolas Khefif
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| | - Charlotte Mansat
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| | - Océane Nelcha
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| | - Elena-Gaia Banchi
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| | - Camille Lupiet
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| | - Dominique Farabos
- Sorbonne Université, Saint Antoine Research Center, INSERM UMR 938, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP Sorbonne Université, 75012 Paris, France
| | - Antonin Lamaziere
- Sorbonne Université, Saint Antoine Research Center, INSERM UMR 938, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP Sorbonne Université, 75012 Paris, France
| | - Caroline Sevin
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
- Bicêtre Hospital, Neuropediatrics Unit, Le Kremlin Bicêtre, 94275 Paris, France
| | - Françoise Piguet
- TIDU GENOV, Institut du Cerveau, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, 75013 Paris, France
| |
Collapse
|
2
|
Dobner S, Kulcsár A, Liptai Z, Vojnisek Z, Constantin T, Szabó L. Vaccination proposal for patients on onasemnogene abeparvovec therapy. Eur J Paediatr Neurol 2024; 49:95-99. [PMID: 38457958 DOI: 10.1016/j.ejpn.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/10/2024]
Abstract
The approval of disease-modifying treatment in spinal muscular atrophy made the condition less severe. The course of the disease changed, but some new concerns occurred with the different new therapies. The side effects of onasemnogene aboparvovec therapy can raise differential diagnostic challenges and necessitate immune therapy, leading to immunosuppression affecting response to vaccines. We provide a pretherapy screening proposal from an infectological point of view separately for newborns treated presymptomatically and children diagnosed with symptoms at any age. Furthermore, we summarise the guidelines on the vaccination before, during, and after immune therapy (steroids) in onasemnogene aboparvovec-treated patients.
Collapse
Affiliation(s)
- Sarolta Dobner
- Semmelweis University, Pediatric Center Tűzoltó Street Department, Hungary
| | - Andrea Kulcsár
- National Institute of Hematology and Infectious Diseases, Department of Special Immunization Services, Hungary
| | - Zoltán Liptai
- Semmelweis University, Pediatric Center Tűzoltó Street Department, Hungary
| | - Zsuzsanna Vojnisek
- Semmelweis University, Pediatric Center Tűzoltó Street Department, Hungary
| | - Tamás Constantin
- Semmelweis University, Pediatric Center Tűzoltó Street Department, Hungary
| | - Léna Szabó
- Semmelweis University, Pediatric Center Tűzoltó Street Department, Hungary.
| |
Collapse
|
3
|
Flotats-Bastardas M, Bitzan L, Grell C, Martakis K, Winter B, Zemlin M, Wurster CD, Uzelac Z, Weiß C, Hahn A. Paradoxical increase of neurofilaments in SMA patients treated with onasemnogene abeparvovec-xioi. Front Neurol 2023; 14:1269406. [PMID: 38162454 PMCID: PMC10756901 DOI: 10.3389/fneur.2023.1269406] [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: 07/29/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024] Open
Abstract
Background/Objective Neurofilament light chain (NfL) has been proposed as a biomarker reflecting disease severity and therapy response in children with spinal muscular atrophy type 1 and 2 (SMA1 and 2). The objective of this study was to examine how serum NfL changes after gene replacement therapy (GRT) with onasemnogene abeparvovec-xioi. Methods We measured NfL in serum probes from 19 patients (10 SMA 1 and 6 SMA 2; 15 previously treated with nusinersen or risdiplam; 12 male) before and at variable time points after GRT. These values were related to motor scores (CHOP-Intend, HFMSE and RULM). Results Median age at GRT was 19 months (range 2-46 months). Median NfL of all patients before GRT was 39 pg/ml (range 0-663 pg/ml; normal values <25 pg/ml), increased significantly to 297 pg/ml (range 61-1,696 pg/ml; p<0,002) 1 month after GRT, and decreased to 49 pg/ml (range 24-151 pg/ml) after 6 months. Subjects pre-treated with nusinersen or risdiplam had lower baseline NfL levels than naïve patients (p<0,005), but absolute increases of NfL were similar in both groups. While motor scores were improved in 14 out of 18 SMA patients (78%) 6 months after GRT NfL values differed not significantly from those measured at baseline (p = 0,959). Conclusion Serum NfL showed a paradoxical transient increase after GRT in both, pre-treated and naïve patients, which may reflect an immunological reaction in the CNS related to transfection of neuronal cells by AAV9. The clinical meaning of this increase should be assessed in future studies. Our findings encourage regular monitoring of NfL in OA treated patients.
Collapse
Affiliation(s)
- Marina Flotats-Bastardas
- Department of Pediatric Neurology, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Lisa Bitzan
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Charlotte Grell
- Department of Child Neurology, Justus Liebig University Giessen, Giessen, Germany
| | - Kyriakos Martakis
- Department of Child Neurology, Justus Liebig University Giessen, Giessen, Germany
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Benedikt Winter
- Department of Child Neurology, Mannheim University, Mannheim, Germany
| | - Michael Zemlin
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Saarland University, Homburg, Germany
| | | | - Zeljko Uzelac
- Department of Neurology, Ulm University, Ulm, Germany
| | - Claudia Weiß
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hahn
- Department of Child Neurology, Justus Liebig University Giessen, Giessen, Germany
| |
Collapse
|
4
|
Johannsen J, Weiss D, Driemeyer J, Olfe J, Stute F, Müller F, Schütt M, Trollmann R, Kölbel H, Schara-Schmidt U, Kirschner J, Pechmann A, Blaschek A, Horber V, Denecke J. High-sensitive cardiac troponin I (hs-cTnI) concentrations in newborns diagnosed with spinal muscular atrophy. Front Pediatr 2023; 11:1259293. [PMID: 38034835 PMCID: PMC10687177 DOI: 10.3389/fped.2023.1259293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
Background Spinal muscular atrophy (SMA) is a genetic neurodegenerative disease leading to muscular weakness and premature death. Three therapeutic options are currently available including gene replacement therapy (GRT), which is potentially cardiotoxic. High-sensitive cardiac troponin I (hs-cTnI) is widely used to monitor potential cardiac contraindications or side effects of GRT, but reference data in healthy newborns are limited and lacking in neonates with SMA. The aim of this study is to determine the range of pre-therapeutic hs-cTnI concentrations in neonates with SMA and to provide guidance for the assessment of these values. Methods Hs-cTnI levels, genetic and clinical data of 30 newborns (age range 2-26 days) with SMA were retrospectively collected from 6 German neuromuscular centers. In addition, hs-cTnI levels were measured in 16 neonates without SMA. Results The median hs-cTnI concentration in neonates with SMA was 39.5 ng/L (range: 4-1205). In 16 newborns with SMA, hs-cTnI levels were above the test-specific upper reference limit (URL). Exploratory statistical analysis revealed no relevant correlation between hs-cTnI levels and gender, gestational age, mode of delivery, SMN2 copy number, symptoms of SMA or abnormal cardiac findings. Discussion Our results suggest higher hs-cTnI plasma levels in newborns with and without SMA compared to assay-specific reference values generated in adults. Given the wide range of hs-cTnI values in neonates with SMA, hs-cTnI levels must be determined before treatment in each patient and post-treatment elevations should be interpreted in the context of the course rather than as individual values.
Collapse
Affiliation(s)
- Jessika Johannsen
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Deike Weiss
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joenna Driemeyer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Olfe
- Clinic for Children’s Heart Medicine and Adult Congenital Heart Disease, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fridrike Stute
- Clinic for Children’s Heart Medicine and Adult Congenital Heart Disease, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ferdinand Müller
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marion Schütt
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Regina Trollmann
- Department of Pediatrics, Division of Pediatric Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Heike Kölbel
- Department of Pediatric Neurology, Centre for Neuromuscular Disorders, Center for Translational Neuro and Behavioral Sciences, University of Duisburg-Essen, Duisburg, Germany
| | - Ulrike Schara-Schmidt
- Department of Pediatric Neurology, Centre for Neuromuscular Disorders, Center for Translational Neuro and Behavioral Sciences, University of Duisburg-Essen, Duisburg, Germany
| | - Janbernd Kirschner
- 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
| | - Astrid Blaschek
- Dr. v. Hauner Children’s Hospital, Department of Pediatric Neurology and Developmental Medicine, LMU Munich University Hospital, Munich, Germany
| | - Veronka Horber
- Department of Paediatric Neurology, University Children’s Hospital Tübingen, Tübingen, Germany
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
5
|
Balla Y, Tirunagari S, Windridge D. Pediatrics in Artificial Intelligence Era: A Systematic Review on Challenges, Opportunities, and Explainability. Indian Pediatr 2023; 60:561-569. [PMID: 37424120 DOI: 10.1007/s13312-023-2936-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
BACKGROUND The emergence of artificial intelligence (AI) tools such as ChatGPT and Bard is disrupting a broad swathe of fields, including medicine. In pediatric medicine, AI is also increasingly being used across multiple subspecialties. However, the practical application of AI still faces a number of key challenges. Consequently, there is a requirement for a concise overview of the roles of AI across the multiple domains of pediatric medicine, which the current study seeks to address. AIM To systematically assess the challenges, opportunities, and explainability of AI in pediatric medicine. METHODOLOGY A systematic search was carried out on peer-reviewed databases, PubMed Central, Europe PubMed Central, and grey literature using search terms related to machine learning (ML) and AI for the years 2016 to 2022 in the English language. A total of 210 articles were retrieved that were screened with PRISMA for abstract, year, language, context, and proximal relevance to research aims. A thematic analysis was carried out to extract findings from the included studies. RESULTS Twenty articles were selected for data abstraction and analysis, with three consistent themes emerging from these articles. In particular, eleven articles address the current state-of-the-art application of AI in diagnosing and predicting health conditions such as behavioral and mental health, cancer, syndromic and metabolic diseases. Five articles highlight the specific challenges of AI deployment in pediatric medicines: data security, handling, authentication, and validation. Four articles set out future opportunities for AI to be adapted: the incorporation of Big Data, cloud computing, precision medicine, and clinical decision support systems. These studies collectively critically evaluate the potential of AI in overcoming current barriers to adoption. CONCLUSION AI is proving disruptive within pediatric medicine and is presently associated with challenges, opportunities, and the need for explainability. AI should be viewed as a tool to enhance and support clinical decision-making rather than a substitute for human judgement and expertise. Future research should consequently focus on obtaining comprehensive data to ensure the generalizability of research findings.
Collapse
Affiliation(s)
- Yashaswini Balla
- Neurosciences Department, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Santosh Tirunagari
- Department of Psychology, Middlesex University, London, United Kingdom. Correspondence to: Dr Santosh Tirunagari, Department of Psychology, Middlesex University, London, United Kingdom.
| | - David Windridge
- Department of Computer Science, Middlesex University, London, United Kingdom
| |
Collapse
|
6
|
Kölbel H, Hagenacker T. [Update on drug treatment of spinal muscular atrophy]. DER NERVENARZT 2023:10.1007/s00115-023-01462-y. [PMID: 36995385 DOI: 10.1007/s00115-023-01462-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND The 5q-associated spinal muscular atrophy (SMA) is a hereditary motor neuron disease leading to progressive tetraplegia, often involving the bulbopharyngeal and respiratory muscle groups. The disease usually manifests in early childhood and, if untreated, is progressive throughout life and associated with numerous complications depending on the severity. Since 2017, genetically based therapeutic mechanisms are now available that correct the causative deficiency of survival motor neuron (SMN) protein and lead to significant modifications in disease progression. As the number of treatment options increases, the question of which patient is suitable for which treatment also arises. OBJECTIVE This review article provides an update on the current treatment strategies for SMA in children and adults.
Collapse
Affiliation(s)
- Heike Kölbel
- Klinik für Kinderheilkunde, Center for Translational Neuro- and Behavioral Science, Universitätsmedizin Essen (UME), Universitätsmedizin Essen (UME), Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Tim Hagenacker
- Klinik für Neurologie und Center for Translational Neuro- and Behavioral Science, Universitätsmedizin Essen (UME), Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| |
Collapse
|
7
|
Stettner GM, Hasselmann O, Tscherter A, Galiart E, Jacquier D, Klein A. Treatment of spinal muscular atrophy with Onasemnogene Abeparvovec in Switzerland: a prospective observational case series study. BMC Neurol 2023; 23:88. [PMID: 36855136 PMCID: PMC9971686 DOI: 10.1186/s12883-023-03133-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a rare neuromuscular disorder leading to early death in the majority of affected individuals without treatment. Recently, targeted treatment approaches including Onasemnogene Abeparvovec (OA) were introduced. This study describes the first real-world experience with OA in Switzerland. METHODS Prospective observational case series study using data collected within the Swiss Registry for Neuromuscular Disorders from SMA patients treated with OA. Development of motor, bulbar and respiratory function, appearance of scoliosis, and safety data (platelet count, liver function, and cardiotoxicity) were analyzed. RESULTS Nine individuals were treated with OA and followed for 383 ± 126 days: six SMA type 1 (of which two with nusinersen pretreatment), one SMA type 2, and two pre-symptomatic individuals. In SMA type 1, CHOP Intend score increased by 28.1 from a mean score of 20.5 ± 7.6 at baseline. At end of follow-up, 50% of SMA type 1 patients required nutritional support and 17% night-time ventilation; 67% developed scoliosis. The SMA type 2 patient and two pre-symptomatically treated individuals reached maximum CHOP Intend scores. No patient required adaptation of the concomitant prednisolone treatment, although transient decrease of platelet count and increase of transaminases were observed in all patients. Troponin-T was elevated prior to OA treatment in 100% and showed fluctuations in 57% thereafter. CONCLUSIONS OA is a potent treatment for SMA leading to significant motor function improvements. However, the need for respiratory and especially nutritional support as well as the development of scoliosis must be thoroughly evaluated in SMA type 1 patients even in the short term after OA treatment.
Collapse
Affiliation(s)
- Georg M. Stettner
- grid.7400.30000 0004 1937 0650Neuromuscular Center Zurich and Department of Pediatric Neurology, University Children’s Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - Oswald Hasselmann
- grid.414079.f0000 0004 0568 6320Department of Neuropediatrics, Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Anne Tscherter
- grid.5734.50000 0001 0726 5157Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Elea Galiart
- grid.7400.30000 0004 1937 0650Neuromuscular Center Zurich and Department of Pediatric Neurology, University Children’s Hospital Zurich, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - David Jacquier
- grid.8515.90000 0001 0423 4662Pediatric Neurology and Neurorehabilitation Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea Klein
- grid.5734.50000 0001 0726 5157Division of Neuropediatrics, Development and Rehabilitation, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW The development of new therapies has brought spinal muscular atrophy (SMA) into the spotlight. However, this was preceded by a long journey - from the first clinical description to the discovery of the genetic cause to molecular mechanisms of RNA and DNA technology. RECENT FINDINGS Since 2016, the antisense oligonucleotide nusinersen has been (FDA) approved for the treatment of SMA, followed by the gene replacement therapy onasemnogene abeparvovec-xioi in 2019 and the small-molecule risdiplam in 2020. These drugs, all targeting upregulation of the SMN protein not only showed remarkable effects in clinical trials but also in real-world settings. SMA has been implemented in newborn screening in many countries around the world. SMN-independent strategies targeting skeletal muscle, for example, may play another therapeutic approach in the future. SUMMARY This review aims to summarize the major clinical and basic science achievements in the field of SMA.
Collapse
Affiliation(s)
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
9
|
Abstract
BACKGROUND The 5q-associated spinal muscular atrophy (SMA) affects ~ 80-120 newborns annually. The disease is characterized by progressive paresis involving the bulbar and respiratory musculatures. The phenotypes are very heterogeneous ranging from severe courses with early death in the first years of life to loss of gait in older age. OBJECTIVE There are now an increasing number of causally targeted therapies available that can either directly interfere with the transcription of the gene causing the disease or replace the homozygous loss of the SMN1 gene. This work aims to elucidate the current state of therapy in different groups of patients with SMA. MATERIAL AND METHODS Presentation of clinical trials and basic studies with a focus on patients with disease onset in adulthood. RESULTS The clinical studies all show improvement or stabilization of motor function; however, in individual cases, the burden of the therapy for severely immobilized patients must be considered in addition to the efficacy in the treatment decision. Even if the drugs show a good safety profile, observations on the long-term efficacy and safety of the new substance classes are still lacking. CONCLUSION The study landscape shows a good efficacy of the currently approved therapies across all degrees of severity and age groups. Due to the lack of comparative studies, the decision on the appropriate therapy should therefore be made according to an individual risk-benefit assessment.
Collapse
|
10
|
Ziegler A. [Precision medicine in pediatric neurology exemplified by the new treatment forms]. DER NERVENARZT 2022; 93:122-134. [PMID: 35037966 PMCID: PMC8825642 DOI: 10.1007/s00115-021-01251-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND In recent years the possibilities for molecular diagnostics and treatment of rare childhood diseases have greatly improved. The first gene-modifying drugs have now been approved, leading to a new era of precision treatment in pediatric neurology. OBJECTIVE This article describes the dynamic developments of precision medicine in pediatric neurology in the areas of prevention, diagnostics and targeted treatment. DISCUSSION The paradigm shift as a result of precision medicine is based on a treatment approach focused more strongly on the individual and the corresponding unique characteristics. Modern methods of genetic and molecular diagnostics are used to accurately describe and characterize affected children, complemented by a precise description of the clinical phenotype. Nevertheless, the success of the best individual treatment strategy derived from this information is often dependent on the time of diagnosis. Therefore, methods for disease prevention, particularly newborn screening programs, become increasingly more important to achieve the best possible success of novel therapies even before the onset of disease symptoms. In addition to a precise stratification of therapies, special attention should be paid in the future to the consideration of the individual perspective of patients and parents/guardians. Furthermore, a normative framework for a quality-ensured application of gene-modifying therapies in the German healthcare system must be created.
Collapse
Affiliation(s)
- Andreas Ziegler
- Zentrum für Kinder- und Jugendmedizin, Sektion für Neuropädiatrie und Stoffwechselmedizin, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Deutschland.
| |
Collapse
|
11
|
[Spinal muscular atrophy]. DER NERVENARZT 2022; 93:191-200. [PMID: 35037967 DOI: 10.1007/s00115-021-01256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by biallelic mutations in the SMN1 (survival motor neuron 1) gene on chromosome 5q13.2, which leads to a progressive degeneration of alpha motor neurons in the spinal cord and in motor nerve nuclei in the caudal brainstem. It is characterized by progressive proximally accentuated muscle weakness with loss of already acquired motor skills, areflexia and, depending on the phenotype, varying degrees of weakness of the respiratory and bulbar muscles, although the facial muscles and eye muscles are not affected. The previously purely symptom-oriented treatment has undergone a significant expansion since 2017 with the approval of three drugs (nusinersen, onasemnogene abeparvovec and risdiplam) that modify the course of the disease at the gene expression level and have led to a change in the natural disease course of SMA. The effect of these new forms of treatment can only be fully assessed in the coming years. New aspects and challenges in this context are discussed in this article.
Collapse
|
12
|
Weiß C, Ziegler A, Becker LL, Johannsen J, Brennenstuhl H, Schreiber G, Flotats-Bastardas M, Stoltenburg C, Hartmann H, Illsinger S, Denecke J, Pechmann A, Müller-Felber W, Vill K, Blaschek A, Smitka M, van der Stam L, Weiss K, Winter B, Goldhahn K, Plecko B, Horber V, Bernert G, Husain RA, Rauscher C, Trollmann R, Garbade SF, Hahn A, von der Hagen M, Kaindl AM. Gene replacement therapy with onasemnogene abeparvovec in children with spinal muscular atrophy aged 24 months or younger and bodyweight up to 15 kg: an observational cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 6:17-27. [PMID: 34756190 DOI: 10.1016/s2352-4642(21)00287-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Given the novelty of gene replacement therapy with onasemnogene abeparvovec in spinal muscular atrophy, efficacy and safety data are limited, especially for children older than 24 months, those weighing more than 8·5 kg, and those who have received nusinersen. We aimed to provide real-world data on motor function and safety after gene replacement therapy in different patient subgroups. METHODS We did a protocol-based, multicentre prospective observational study between Sept 21, 2019, and April 20, 2021, in 18 paediatric neuromuscular centres in Germany and Austria. All children with spinal muscular atrophy types 1 and 2 receiving onasemnogene abeparvovec were included in our cohort, and there were no specific exclusion criteria. Motor function was assessed at the time of gene replacement therapy and 6 months afterwards, using the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND) and Hammersmith Functional Motor Scale-Expanded (HFMSE) scores. Additionally, in children pretreated with nusinersen, motor function was assessed before and after treatment switch. Off-target adverse events were analysed with a focus on liver function, thrombocytopaenia, and potential cardiotoxicity. FINDINGS 76 children (58 pretreated with nusinersen and 18 who were nusinersen naive) with spinal muscular atrophy were treated with onasemnogene abeparvovec at a mean age of 16·8 months (range 0·8-59·0, IQR 9-23) and a mean weight of 9·1 kg (range 4·0-15·0, IQR 7·4-10·6). In 60 patients with available data, 49 had a significant improvement on the CHOP-INTEND score (≥4 points) and HFMSE score (≥3 points). Mean CHOP INTEND scores increased significantly in the 6 months after therapy in children younger than 8 months (n=16; mean change 13·8 [SD 8·5]; p<0·0001) and children aged between 8 and 24 months (n=34; 7·7 [SD 5·2]; p<0·0001), but not in children older than 24 months (n=6; 2·5 [SD 5·2]; p=1·00). In the 45 children pretreated with nusinersen and had available data, CHOP INTEND score increased by 8·8 points (p=0·0003) at 6 months after gene replacement therapy. No acute complications occurred during infusion of onasemnogene abeparvovec, but 56 (74%) patients had treatment-related side-effects. Serious adverse events occurred in eight (11%) children. Liver enzyme elevation significantly increased with age and weight at treatment. Six (8%) patients developed acute liver dysfunction. Other adverse events included pyrexia (n=47 [62%]), vomiting or loss of appetite (41 [54%]), and thrombocytopenia (n=59 [78%]). Prednisolone treatment was significantly prolonged with a mean duration of 15·7 weeks (IQR 9-19), mainly due to liver enzyme elevation. Cardiac adverse events were rare; only two patients had abnormal echocardiogram and echocardiography findings. INTERPRETATION This study provides class IV evidence that children with spinal muscular atrophy aged 24 months or younger and patients pretreated with nusinersen significantly benefit from gene replacement therapy, but adverse events can be severe and need to be closely monitored. FUNDING None. TRANSLATION For the German translation of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Claudia Weiß
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Ziegler
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Lena-Luise Becker
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany; Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jessika Johannsen
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heiko Brennenstuhl
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gudrun Schreiber
- Department of Pediatric Neurology, Klinikum Kassel, Kassel, Germany
| | | | - Corinna Stoltenburg
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hans Hartmann
- Hannover Medical School, Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover, Germany
| | - Sabine Illsinger
- Hannover Medical School, Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover, Germany
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Astrid Pechmann
- Department of Neuropediatrics and Muscle Disorders, Medical Center, University of Freiburg, Freiburg, Germany
| | - Wolfgang Müller-Felber
- Department of Paediatric Neurology and Developmental Medicine, Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Katharina Vill
- Department of Paediatric Neurology and Developmental Medicine, Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Astrid Blaschek
- Department of Paediatric Neurology and Developmental Medicine, Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Martin Smitka
- Department of Neuropediatrics, Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Lieske van der Stam
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Katja Weiss
- Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Klaus Goldhahn
- Department of Pediatrics and Neuropediatrics, DRK Klinikum Westend, Berlin, Germany
| | - Barbara Plecko
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Veronka Horber
- Department of Paediatric Neurology, University Children's Hospital, Tübingen, Germany
| | | | - Ralf A Husain
- Department of Neuropediatrics, Jena University Hospital, Jena, Germany
| | - Christian Rauscher
- Department of Pediatrics, Paracelsus Medical University, Salzburg, Austria
| | - Regina Trollmann
- Department of Pediatrics, Division of Pediatric Neurology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Sven F Garbade
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Hahn
- Department of Child Neurology, University Hospital, Gießen, Germany
| | - Maja von der Hagen
- Department of Neuropediatrics, Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Angela M Kaindl
- Department of Pediatric Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Center for Chronically Sick Children, Charité-Universitätsmedizin Berlin, Berlin, Germany; Institute of Cell Biology and Neurobiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| |
Collapse
|
13
|
Opladen T, Brennenstuhl H, Kuseyri Hübschmann O, Call D, Green K, Schara U, Rascher W, Hövel A, Assmann B, Kölker S, Westhoff JH, Walter M, Ziegler A, Hoffmann GF, Kiening K. Die intrazerebrale Gentherapie des Aromatischen-L-Aminosäure-Decarboxylase-Mangels mit Eladocagene exuparvovec. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01232-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
14
|
Neugeborenenscreening auf spinale Muskelatrophie. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ZusammenfassungIm Dezember 2020 hat der Gemeinsame Bundesausschuss beschlossen, dass das Screening auf spinale Muskelatrophie (SMA) in das allgemeine Neugeborenenscreening aufgenommen werden soll. Grundlage dieser Entscheidung war die Tatsache, dass inzwischen gezielte Behandlungsmöglichkeiten für die Patienten mit SMA zur Verfügung stehen und der Zeitpunkt, zu dem die Behandlung begonnen wird, entscheidend für den Erfolg der Therapie ist.Das Neugeborenenscreening auf eine SMA basiert auf dem Nachweis einer homozygoten Deletion von Exon 7 im SMN1-Gen durch eine molekulargenetische Analyse aus der Trockenblutkarte. In allen Fällen muss eine Bestätigungsdiagnostik aus einer zweiten Blutprobe im Rahmen der Konfirmationsdiagnostik mit Bestimmung der SMN2-Kopien-Zahl durchgeführt werden. Die weitere Beratung und Therapie sollten in einer neuropädiatrischen Ambulanz mit Erfahrung in der Betreuung von Kindern mit SMA erfolgen.
Collapse
|
15
|
Friese J, Geitmann S, Holzwarth D, Müller N, Sassen R, Baur U, Adler K, Kirschner J. Safety Monitoring of Gene Therapy for Spinal Muscular Atrophy with Onasemnogene Abeparvovec -A Single Centre Experience. J Neuromuscul Dis 2021; 8:209-216. [PMID: 33427694 PMCID: PMC8075402 DOI: 10.3233/jnd-200593] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Recently gene therapy with onasemnogene abeparvovec has been approved for the treatment of spinal muscular atrophy (SMA). As the experience from clinical trials is limited, there are still uncertainties for which patient population the treatment can be considered safe and effective. METHODS We report our experience with eight consecutive patients with SMA who were treated with the standard dose of onasemnogene abeparvovec (1.1×1014 vg/kg) at the University Hospital Bonn, Germany. All patients received prophylactic immunosuppression with 1 mg/kg/d prednisolone for four weeks starting on the day before gene therapy. RESULTS We treated eight patients (4 male, 4 female, age range 10-37 months) with a body weight between 7.1 and 11.9 kg. All patients had 2 or 3 copies of the SMN2-gene and were previously treated with nusinersen. Following treatment with onasemnogene abeparvovec all patients showed a temporary increase of the body temperature and an increase of transaminase levels. In all but one patient it was necessary to increase or prolong the standard steroid dose to control the immune response. In one severe case, liver damage was associated with impaired liver function. This patient received a steroid pulse therapy for five days. Blood counts revealed asymptomatic thrombocytopenia (<150×109/L) in 6/8 patients and a significant increase of monocytes following gene therapy. Liver values and blood counts returned to almost normal levels during the post-treatment observation period. Troponin I increased above normal limit in 4/8 patients but was not associated with any abnormalities on cardiac evaluation. CONCLUSIONS In a broader spectrum of patients, treatment with onasemnogene abeparvovec was associated with a higher rate of adverse events. In our cases it was possible to control the immune response by close monitoring and adaptation of the immunosuppressive regimen. Further research is needed to better understand the immune response following gene therapy and ideally to identify patients at risk for a more severe reaction.
Collapse
Affiliation(s)
- Johannes Friese
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
| | | | | | - Nicole Müller
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Robert Sassen
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
| | - Ute Baur
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
| | - Kristin Adler
- Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
| | | |
Collapse
|
16
|
Vu-Han TL, Weiß C, Pumberger M. Novel therapies for spinal muscular atrophy are likely changing the patient phenotype. Spine J 2020; 20:1893-1898. [PMID: 32858169 DOI: 10.1016/j.spinee.2020.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Tu-Lan Vu-Han
- Center for Musculoskeletal Surgery Berlin Mitte; Charité University Medicine Berlin, Charitéplatz 1, Berlin 10117, Germany.
| | - Claudia Weiß
- Center for chronically sick children, Department of Neuropediatrics; Charité University, Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery Berlin Mitte; Charité University Medicine Berlin, Charitéplatz 1, Berlin 10117, Germany
| |
Collapse
|
17
|
Rascher W, Klingebiel T, Herting E, Hoffmann GF, Berner R, Krägeloh-Mann I, Gärtner J, Zepp F, Schara U. Arzneimittel für neuartige Therapien – Perspektiven, Chancen, Herausforderungen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01056-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
ZusammenfassungArzneimittel für neuartige Therapien (ATMP) wie somatische Gentherapie und Zelltherapie besitzen ein hohes therapeutisches Potenzial für Krankheiten, die sehr früh im Leben beginnen, und die bisher nicht behandelbar waren. Sie werden oft in einem sehr frühen Entwicklungsstadium zugelassen, wenn an wenigen Betroffenen die Wirksamkeit gezeigt wurde und sich ein bisher nie dagewesener Therapieerfolg auftut, vor allem, wenn die Therapie vor Eintritt von Organschäden greift. Dadurch ergeben sich für Pädiater neue arzneimittelrechtliche und ethische Fragen.Um die neuen Behandlungsmöglichkeiten adäquat einzusetzen, muss die Diagnose früher als bisher gestellt werden, oder neue Screeningmethoden müssen zur Verfügung stehen. Denkbar ist, dass das Neugeborenenscreening in zeitkritische Krankheiten in den ersten 72 h nach Geburt und ein genetisches Screening (z. B. in der 4. bis 5. Lebenswoche) aufgeteilt wird.ATMP sind bei ihrer Zulassung noch nicht in ausreichender Anzahl angewendet worden, sodass die notwendigen Erkenntnisse für Wirksamkeit und Sicherheit noch nicht vorliegen (Nutzen-Risiko-Verhältnis). Deswegen werden sie unter strengen Auflagen in spezialisierten Behandlungszentren nach Qualitätskriterien eingesetzt, die der Gemeinsame Bundesausschuss (G-BA) nach Beratung mit den Fachgesellschaften festlegt. Der Aufwand der Therapie und der Dokumentation des Verlaufes in Registern ist erheblich und muss entsprechend vergütet werden.Der Wert eines ATMP wird erst mit seiner breiteren Anwendung nach der Zulassung klar, ähnlich wie die Sicherheit eines Arzneimittels nicht mit der Zulassung vollumfänglich bekannt ist. Für die Pädiatrie ergeben sich neue Herausforderungen und Chancen.
Collapse
|
18
|
Spinal muscular atrophy - insights and challenges in the treatment era. Nat Rev Neurol 2020; 16:706-715. [PMID: 33057172 DOI: 10.1038/s41582-020-00413-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 01/05/2023]
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive motor neuron disease caused by deletion or mutation of SMN1. Four subtypes exist, characterized by different clinical severities. New therapeutic approaches have become available in the past few years, dramatically changing the natural history of all SMA subtypes, including substantial clinical improvement with the severe and advanced SMA type 1 variant. Trials have now demonstrated that phenotypic rescue is even more dramatic when pre-symptomatic patients are treated, and emerging real-world data are demonstrating the benefits of intervention even in the chronic phase of the condition. Here, we critically review how the field is rapidly evolving in response to the new therapies and questions that the new treatments have posed, including the effects of treatment at different ages and stages of disease, new phenotypes and long-term outcomes in patients who would not have survived without treatment, and decisions of who to treat and when. We also discuss how the outcomes associated with different timing of therapeutic intervention are contributing to our understanding of the biology and pathogenesis of SMA.
Collapse
|
19
|
Zur Gentherapie der Spinalen Muskelatrophie mit Onasemnogene Abeparvovec. Stellungnahme der Gesellschaft für Neuropädiatrie. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00944-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|