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Vockley J, Burton BK, Berry G, Longo N, Phillips J, Sanchez-Valle A, Chapman KA, Tanpaiboon P, Grunewald S, Murphy E, Lu X, Rahman S, Ray K, Reineking B, Pisani L, Ramirez AN. Triheptanoin for the treatment of long-chain fatty acid oxidation disorders: Final results of an open-label, long-term extension study. J Inherit Metab Dis 2023; 46:943-955. [PMID: 37276053 DOI: 10.1002/jimd.12640] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) result in life-threatening energy metabolism deficiencies/energy source depletion. Triheptanoin is an odd-carbon, medium chain triglyceride (that is an anaplerotic substrate of calories and fatty acids) for treating pediatric and adult patients with LC-FAODs. Study CL202 (NCT02214160), an open-label extension study of study CL201 (NCT01886378), evaluated the long-term safety/efficacy of triheptanoin in patients with LC-FAODs (N = 94), including cohorts who were triheptanoin naïve (n = 33) or had received triheptanoin in study CL201 (n = 24) or in investigator-sponsored trials/expanded access programs (IST/EAPs; n = 37). Primary endpoint was the annualized rate of LC-FAOD major clinical events (MCEs; rhabdomyolysis, hypoglycemia, cardiomyopathy). Mean ± standard deviation (SD) triheptanoin treatment durations were 27.4 ± 19.9, 46.9 ± 13.6, and 49.6 ± 21.4 months for the triheptanoin-naïve, CL201 rollover, and IST/EAP cohorts, respectively. In the triheptanoin-naïve cohort, median (interquartile range [IQR]) MCE rate significantly decreased from 2.00 (0.67-3.33) events/patient/year pre-triheptanoin to 0.28 (0.00-1.43) events/patient/year with triheptanoin (p = 0.0343), a reduction of 86%. In the CL201 rollover cohort, mean ± SD MCE rate significantly decreased from 1.76 ± 1.64 events/patient/year pre-triheptanoin to 1.00 ± 1.00 events/patient/year with triheptanoin (p = 0.0347), a reduction of 43%. In the IST/EAP cohort, mean ± SD MCE rate was 1.40 ± 2.37 (median [IQR] 0.57 [0.00-1.67]) events/patient/year with triheptanoin. Safety data were consistent with previous observations. Treatment-related treatment-emergent adverse events (TEAEs) occurred in 68.1% of patients and were mostly mild/moderate in severity. Five patients had seven serious treatment-related TEAEs; all resolved. Our results confirm the long-term efficacy of triheptanoin for patients with LC-FAOD.
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Affiliation(s)
- Jerry Vockley
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Barbara K Burton
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Gerard Berry
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicola Longo
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - John Phillips
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amarilis Sanchez-Valle
- Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Kimberly A Chapman
- Section Genetics and Metabolism, Children's National Health System, Washington, District of Columbia, USA
| | - Pranoot Tanpaiboon
- Section Genetics and Metabolism, Children's National Health System, Washington, District of Columbia, USA
| | - Stephanie Grunewald
- Metabolic Unit, Great Ormond Street Hospital and UCL Institute of Child Health NIHR BRC, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | - Syeda Rahman
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | - Kathryn Ray
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | | | - Laura Pisani
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
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Vockley J, Burton B, Jurecka A, Ganju J, Leiro B, Zori R, Longo N. Challenges and strategies for clinical trials in propionic and methylmalonic acidemias. Mol Genet Metab 2023; 139:107612. [PMID: 37245378 DOI: 10.1016/j.ymgme.2023.107612] [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: 04/05/2023] [Revised: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
Clinical trial development in rare diseases poses significant study design and methodology challenges, such as disease heterogeneity and appropriate patient selection, identification and selection of key endpoints, decisions on study duration, choice of control groups, selection of appropriate statistical analyses, and patient recruitment. Therapeutic development in organic acidemias (OAs) shares many challenges with other inborn errors of metabolism, such as incomplete understanding of natural history, heterogenous disease presentations, requirement for sensitive outcome measures and difficulties recruiting a small sample of participants. Here, we review strategies for the successful development of a clinical trial to evaluate treatment response in propionic and methylmalonic acidemias. Specifically, we discuss crucial decisions that may significantly impact success of the study, including patient selection, identification and selection of endpoints, determination of the study duration, consideration of control groups including natural history controls, and selection of appropriate statistical analyses. The significant challenges associated with designing a clinical trial in rare disease can sometimes be successfully met through strategic engagement with experts in the rare disease, seeking regulatory and biostatistical guidance, and early involvement of patients and families.
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Affiliation(s)
- Jerry Vockley
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, School of Medicine, Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Barbara Burton
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Agnieszka Jurecka
- CoA Therapeutics, Inc., a BridgeBio company, San Francisco, CA, USA.
| | - Jitendra Ganju
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Beth Leiro
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Roberto Zori
- Department of Pediatrics, Division of Genetics and Metabolism, University of Florida, Gainesville, FL, USA
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Baker JJ, Burton BK. Diagnosis and Clinical Management of Long-chain Fatty-acid Oxidation Disorders: A Review. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 17:108-111. [PMID: 35118456 DOI: 10.17925/ee.2021.17.2.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022]
Abstract
Long-chain fatty-acid oxidation disorders (LC-FAODs) are autosomal recessive inherited metabolic conditions that occur due to a disruption in the body's ability to perform mitochondrial beta oxidation. Expanded newborn screening is widening phenotypic understanding of these disorders, as well improving our knowledge of disease incidence. Management of these disorders is focused on avoidance of fasting, dietary changes and supplementation with energy sources that bypass the metabolic block. Recent US Food and Drug Administration approval of triheptanoin has improved the outcome for affected individuals. New research into dietary modifications and novel pharmacologic therapies continues for these disorders. In this article, we review the major LC-FAODs and their clinical presentation.
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Affiliation(s)
- Joshua J Baker
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Barbara K Burton
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Lee SK, Gupta M, Shi J, McKeever K. The Pharmacokinetics of Triheptanoin and Its Metabolites in Healthy Subjects and Patients With Long-Chain Fatty Acid Oxidation Disorders. Clin Pharmacol Drug Dev 2021; 10:1325-1334. [PMID: 33789001 PMCID: PMC8597155 DOI: 10.1002/cpdd.944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/07/2021] [Indexed: 12/31/2022]
Abstract
Long‐chain fatty acid oxidation disorders (LC‐FAODs) are a group of life‐threatening autosomal recessive disorders caused by defects in nuclear genes encoding mitochondrial enzymes involved in the conversion of dietary long‐chain fatty acids into energy. Triheptanoin is an odd‐carbon, medium‐chain triglyceride consisting of 3 fatty acids with 7 carbons each on a glycerol backbone developed to treat adult and pediatric patients with LC‐FAODs. The pharmacokinetics of triheptanoin and circulating metabolites were explored in healthy subjects and patients with LC‐FAODs using noncompartmental analyses. Systemic exposure to triheptanoin following an oral administration was negligible, as triheptanoin is extensively hydrolyzed to glycerol and heptanoate in the gastrointestinal tract. Multiple peaks for triheptanoin metabolites were observed in the plasma following oral administration of triheptanoin, generally coinciding with the time that meals were served. Heptanoate, the pharmacologically active metabolite of triheptanoin supplementing energy sources in patients with LC‐FAODs, showed the greatest exposure among the metabolites of triheptanoin in human plasma following oral administration of triheptanoin. The exposure of heptanoate was approximately 10‐fold greater than that of beta‐hydroxypentoate, a downstream metabolite of heptanoate. Exposure to triheptanoin metabolites appeared to increase following multiple doses as compared with the single dose, and with the increase in triheptanoin dose levels.
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Affiliation(s)
- Sun Ku Lee
- Ultragenyx Pharmaceutical Inc., Novato, California, USA
| | - Manju Gupta
- Ultragenyx Pharmaceutical Inc., Novato, California, USA
| | - Jack Shi
- Ultragenyx Pharmaceutical Inc., Novato, California, USA
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