1
|
Abstract
PURPOSE OF REVIEW Metabolic myopathies are disorders that affect skeletal muscle substrate oxidation. Although some drugs and hormones can affect metabolism in skeletal muscle, this review will focus on the genetic metabolic myopathies. RECENT FINDINGS Impairments in glycogenolysis/glycolysis (glycogen storage disease), fatty acid transport/oxidation (fatty acid oxidation defects), and mitochondrial metabolism (mitochondrial myopathies) represent most metabolic myopathies; however, they often overlap clinically with structural genetic myopathies, referred to as pseudometabolic myopathies. Although metabolic myopathies can present in the neonatal period with hypotonia, hypoglycemia, and encephalopathy, most cases present clinically in children or young adults with exercise intolerance, rhabdomyolysis, and weakness. In general, the glycogen storage diseases manifest during brief bouts of high-intensity exercise; in contrast, fatty acid oxidation defects and mitochondrial myopathies usually manifest during longer-duration endurance-type activities, often with fasting or other metabolic stressors (eg, surgery, fever). The neurologic examination is often normal between events (except in the pseudometabolic myopathies) and evaluation requires one or more of the following tests: exercise stress testing, blood (eg, creatine kinase, acylcarnitine profile, lactate, amino acids), urine (eg, organic acids, myoglobin), muscle biopsy (eg, histology, ultrastructure, enzyme testing), and targeted (specific gene) or untargeted (myopathy panels) genetic tests. SUMMARY Definitive identification of a specific metabolic myopathy often leads to specific interventions, including lifestyle, exercise, and nutritional modifications; cofactor treatments; accurate genetic counseling; avoidance of specific triggers; and rapid treatment of rhabdomyolysis.
Collapse
|
2
|
Santos CGM, Rolim-Filho NG, Domingues CA, Dornelas-Ribeiro M, King JL, Budowle B, Moura-Neto RS, Silva R. Association of whole mtDNA, an NADPH G11914A variant, and haplogroups with high physical performance in an elite military troop. ACTA ACUST UNITED AC 2021; 54:e10317. [PMID: 33909855 PMCID: PMC8075130 DOI: 10.1590/1414-431x202010317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/29/2020] [Indexed: 11/22/2022]
Abstract
Physical performance is a multifactorial and complex trait influenced by environmental and hereditary factors. Environmental factors alone have been insufficient to characterize all outstanding phenotypes. Recent advances in genomic technologies have enabled the investigation of whole nuclear and mitochondrial genome sequences, increasing our ability to understand interindividual variability in physical performance. Our objective was to evaluate the association of mitochondrial polymorphic loci with physical performance in Brazilian elite military personnel. Eighty-eight male military personnel who participated in the Command Actions Course of the Army were selected. Total DNA was obtained from blood samples and a complete mitochondrial genome (mtDNA) was sequenced using Illumina MiSeq platform. Twenty-nine subjects completed the training program (FINISHED, 'F'), and fifty-nine failed to complete (NOT_FINISHED, 'NF'). The mtDNA from NF was slightly more similar to genomes from African countries frequently related to endurance level. Twenty-two distinct mtDNA haplogroups were identified corroborating the intense genetic admixture of the Brazilian population, but their distribution was similar between the two groups (FST=0.0009). Of 745 polymorphisms detected in the mtDNA, the position G11914A within the NADPH gene component of the electron transport chain, was statistically different between F and NF groups (P=0.011; OR: 4.286; 95%CI: 1.198-16.719), with a higher frequency of the G allele in group F individuals). The high performance of military personnel may be mediated by performance-related genomic traits. Thus, mitochondrial genetic markers such as the ND4 gene may play an important role on physical performance variability.
Collapse
Affiliation(s)
- C G M Santos
- Instituto de Biologia do Exército, Rio de Janeiro, RJ, Brasil
| | - N G Rolim-Filho
- Centro de Instrução de Operações Especiais do Exército Brasileiro, Rio de Janeiro, RJ, Brasil
| | - C A Domingues
- Centro de Instrução de Operações Especiais do Exército Brasileiro, Rio de Janeiro, RJ, Brasil
| | | | - J L King
- Center for Human Identification, Department of Microbiology, Immunology, and Genetics, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - B Budowle
- Center for Human Identification, Department of Microbiology, Immunology, and Genetics, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - R S Moura-Neto
- Instituto de Biologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - R Silva
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| |
Collapse
|
3
|
Karaa A, Haas R, Goldstein A, Vockley J, Cohen BH. A randomized crossover trial of elamipretide in adults with primary mitochondrial myopathy. J Cachexia Sarcopenia Muscle 2020; 11:909-918. [PMID: 32096613 PMCID: PMC7432581 DOI: 10.1002/jcsm.12559] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND This study aims to evaluate the effect of subcutaneous (SC) elamipretide dosing on exercise performance using the 6 min walk test (6MWT), patient-reported outcomes measuring fatigue, functional assessments, and safety to guide the development of the Phase 3 trial. METHODS MMPOWER-2 was a randomized, double-blind, placebo-controlled, crossover trial that enrolled participants (N = 30) with genetically confirmed primary mitochondrial myopathy. Participants were randomly assigned (1:1) to 40 mg/day SC elamipretide for 4 weeks followed by placebo SC for 4 weeks, separated by a 4-week washout period, or the opposite sequence. The primary endpoint was the distance walked on the 6MWT. RESULTS The distance walked on the 6MWT by the elamipretide-treated participants was 398.3 (±134.16) meters compared with 378.5 (±125.10) meters in the placebo-treated group, a difference of 19.8 m (95% confidence interval, -2.8, 42.5; P = 0.0833). The results of the Primary Mitochondrial Myopathy Symptom Assessment Total Fatigue and Total Fatigue During Activities scores showed that participants treated with elamipretide reported less fatigue and muscle complaints compared with placebo (P = 0.0006 and P = 0.0018, respectively). Additionally, the Neuro-QoL Fatigue Short Form and Patient Global Assessment showed reductions in symptoms (P = 0.0115 and P = 0.0421, respectively). In this 4-week treatment period, no statistically significant change was observed in the Physician Global Assessment (P = 0.0636), the Triple Timed Up and Go (P = 0.8423) test, and wrist/hip accelerometry (P = 0.9345 and P = 0.7326, respectively). Injection site reactions were the most commonly reported adverse events with elamipretide (80%), the majority of which were mild. No serious adverse events or deaths were reported. CONCLUSIONS Participants who received a short-course treatment of daily SC elamipretide for 4 weeks experienced a clinically meaningful change in the 6MWT, which did not achieve statistical significance as the primary endpoint of the study. Secondary endpoints were suggestive of an elamipretide treatment effect compared with placebo. Nominal statistically significant and clinically meaningful improvements were seen in patient-reported outcomes. The results of this trial provided an efficacy signal and data to support the initiation of MMPOWER-3, a 6-month long, Phase 3 treatment trial in patients with primary mitochondrial myopathy.
Collapse
Affiliation(s)
- Amel Karaa
- Genetics Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Richard Haas
- Rady Children's Hospital, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Amy Goldstein
- Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bruce H Cohen
- Department of Pediatrics, Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH, USA
| |
Collapse
|
4
|
Degani-Costa LH, Nery LE, Rodrigues MT, Gimenes AC, Ferreira EV, Ota-Arakaki JS, Neder JA, Ramos RP. Does oxygen pulse trajectory during incremental exercise discriminate impaired oxygen delivery from poor muscle oxygen utilisation? ERJ Open Res 2019; 5:00108-2018. [PMID: 31249840 PMCID: PMC6589444 DOI: 10.1183/23120541.00108-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 05/13/2019] [Indexed: 11/05/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) is often helpful to shed light on the mechanisms of exercise intolerance in different clinical populations. Although specific response patterns are rarely pathognomonic, an integrative approach considering metabolic and mechanical–ventilatory responses in addition to limiting symptoms has been valuable to guide further investigations [1]. A flattened or decreasing O2 pulse trajectory during incremental CPET is commonly found in patents with low exercise stroke volume but not in those with severely impaired muscle O2 utilisation. This finding should prompt additional cardiovascular work-up.http://bit.ly/2HRE739
Collapse
Affiliation(s)
- Luiza H Degani-Costa
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luiz E Nery
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Maíra T Rodrigues
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Cristina Gimenes
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eloara V Ferreira
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - J Alberto Neder
- Laboratory of Clinical Exercise Physiology, Respiratory and Critical Care Division, Dept of Medicine, Queen's University, Kingston, ON, Canada
| | - Roberta P Ramos
- Respiratory Division, Dept of Medicine, Sao Paulo School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
5
|
Abstract
Exertional (exercise-induced) rhabdomyolysis is a potentially life threatening condition that has been the subject of research, intense discussion, and media attention. The causes of rhabdomyolysis are numerous and can include direct muscle injury, unaccustomed exercise, ischemia, extreme temperatures, electrolyte abnormalities, endocrinologic conditions, genetic disorders, autoimmune disorders, infections, drugs, toxins, and venoms. The objective of this article is to review the literature on exertional rhabdomyolysis, identify precipitating factors, and examine the role of the dietary supplement creatine monohydrate. PubMed and SPORTDiscus databases were searched using the terms rhabdomyolysis, muscle damage, creatine, creatine supplementation, creatine monohydrate, and phosphocreatine. Additionally, the references of papers identified through this search were examined for relevant studies. A meta-analysis was not performed. Although the prevalence of rhabdomyolysis is low, instances still occur where exercise is improperly prescribed or used as punishment, or incomplete medical history is taken, and exertional rhabdomyolysis occurs. Creatine monohydrate does not appear to be a precipitating factor for exertional rhabdomyolysis. Healthcare professionals should be able to recognize the basic signs of exertional rhabdomyolysis so prompt treatment can be administered. For the risk of rhabdomyolysis to remain low, exercise testing and prescription must be properly conducted based on professional standards.
Collapse
Affiliation(s)
- Eric S Rawson
- Department of Health, Nutrition and Exercise Science, Messiah College, One College Avenue Suite 4501, Mechanicsburg, PA, 17055, USA.
| | | | - Mark A Tarnopolsky
- Department of Pediatrics and Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
6
|
Abstract
Skeletal muscle requires a large increase in its ATP production to meet the energy needs of exercise. Normally, most of this increase in ATP is supplied by the aerobic process of oxidative phosphorylation. The main defects in muscle metabolism that interfere with production of ATP are (1) disorders of glycogenolysis and glycolysis, which prevent both carbohydrate entering the tricarboxylic acid cycle and the production of lactic acid; (2) mitochondrial myopathies where the defect is usually within the electron transport chain, reducing the rate of oxidative phosphorylation; and (3) disorders of lipid metabolism. Gas exchange measurements derived from exhaled gas analysis during cardiopulmonary exercise testing can identify defects in muscle metabolism because [Formula: see text]o2 and [Formula: see text]co2 are abnormal at the level of the muscle. Cardiopulmonary exercise testing may thus suggest a likely diagnosis and guide additional investigation. Defects in glycogenolysis and glycolysis are identified by a low peak [Formula: see text]o2 and absence of excess [Formula: see text]co2 from buffering of lactic acid by bicarbonate. Defects in the electron transport chain also result in low peak [Formula: see text]o2, but because there is an overreliance on anaerobic processes, lactic acid accumulation and excess carbon dioxide from buffering occur early during exercise. Defects in lipid metabolism result in only minor abnormalities during cardiopulmonary exercise testing. In defects of glycogenolysis and glycolysis and in mitochondrial myopathies, other features may include an exaggerated cardiovascular response to exercise, a low oxygen-pulse, and excessive ammonia release.
Collapse
|
7
|
Karaa A, Haas R, Goldstein A, Vockley J, Weaver WD, Cohen BH. Randomized dose-escalation trial of elamipretide in adults with primary mitochondrial myopathy. Neurology 2018; 90:e1212-e1221. [PMID: 29500292 PMCID: PMC5890606 DOI: 10.1212/wnl.0000000000005255] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 12/12/2017] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To assess the safety and efficacy of elamipretide, an aromatic-cationic tetrapeptide that readily penetrates cell membranes and transiently localizes to the inner mitochondrial membrane where it associates with cardiolipin, in adults with primary mitochondrial myopathy (PMM). METHODS A Study Investigating the Safety, Tolerability, and Efficacy of MTP-131 for the Treatment of Mitochondrial Myopathy (MMPOWER) was a phase I/II multicenter, randomized, double-blind, placebo-controlled trial of elamipretide in 36 participants with genetically confirmed PMM. Participants were randomized to intravenous elamipretide (0.01, 0.1, and 0.25 mg/kg/h or placebo for 2 hours in a dose-escalating sequence). The primary efficacy measure was the change in distance walked in the 6-minute walk test (6MWT) after 5 days of treatment. Other efficacy measures included changes in cardiopulmonary exercise testing parameters, in participant-reported symptoms, and in serum and urinary biomarkers. Safety, tolerability, and pharmacokinetics were also measured. RESULTS Participants who received the highest dose of elamipretide walked a mean of 64.5 m farther at day 5 compared to a change of 20.4 m in the placebo group (p = 0.053). In addition, there was a dose-dependent increase in distance walked on the 6MWT with elamipretide treatment (p = 0.014). In a model that adjusted for additional covariates possibly affecting response, the adjusted change for the highest dose of elamipretide was 51.2 vs 3.0 m in the placebo group (p = 0.0297). No significant differences were observed in other efficacy and safety endpoints. CONCLUSIONS Elamipretide increased exercise performance after 5 days of treatment in patients with PMM without increased safety concerns. These findings, as well as additional functional and patient-reported measures, remain to be tested in larger trials with longer treatment periods to detect other potential therapeutic benefits in individuals affected by this condition. CLASSIFICATION OF EVIDENCE This trial provides Class I evidence that for patients with PMM, elamipretide improved the distance walked on the 6MWT.
Collapse
Affiliation(s)
- Amel Karaa
- From the Genetics Unit (A.K.), Massachusetts General Hospital, Boston; UC San Diego School of Medicine (R.H.), La Jolla, CA; Children's Hospital of Pittsburgh (A.G., J.V.), PA; Stealth BioTherapeutics (W.D.W.), Newton, MA; and Akron Children's Hospital (B.H.C.), OH.
| | - Richard Haas
- From the Genetics Unit (A.K.), Massachusetts General Hospital, Boston; UC San Diego School of Medicine (R.H.), La Jolla, CA; Children's Hospital of Pittsburgh (A.G., J.V.), PA; Stealth BioTherapeutics (W.D.W.), Newton, MA; and Akron Children's Hospital (B.H.C.), OH
| | - Amy Goldstein
- From the Genetics Unit (A.K.), Massachusetts General Hospital, Boston; UC San Diego School of Medicine (R.H.), La Jolla, CA; Children's Hospital of Pittsburgh (A.G., J.V.), PA; Stealth BioTherapeutics (W.D.W.), Newton, MA; and Akron Children's Hospital (B.H.C.), OH
| | - Jerry Vockley
- From the Genetics Unit (A.K.), Massachusetts General Hospital, Boston; UC San Diego School of Medicine (R.H.), La Jolla, CA; Children's Hospital of Pittsburgh (A.G., J.V.), PA; Stealth BioTherapeutics (W.D.W.), Newton, MA; and Akron Children's Hospital (B.H.C.), OH
| | - W Douglas Weaver
- From the Genetics Unit (A.K.), Massachusetts General Hospital, Boston; UC San Diego School of Medicine (R.H.), La Jolla, CA; Children's Hospital of Pittsburgh (A.G., J.V.), PA; Stealth BioTherapeutics (W.D.W.), Newton, MA; and Akron Children's Hospital (B.H.C.), OH
| | - Bruce H Cohen
- From the Genetics Unit (A.K.), Massachusetts General Hospital, Boston; UC San Diego School of Medicine (R.H.), La Jolla, CA; Children's Hospital of Pittsburgh (A.G., J.V.), PA; Stealth BioTherapeutics (W.D.W.), Newton, MA; and Akron Children's Hospital (B.H.C.), OH
| |
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW Metabolic myopathies are genetic disorders that impair intermediary metabolism in skeletal muscle. Impairments in glycolysis/glycogenolysis (glycogen-storage disease), fatty acid transport and oxidation (fatty acid oxidation defects), and the mitochondrial respiratory chain (mitochondrial myopathies) represent the majority of known defects. The purpose of this review is to develop a diagnostic and treatment algorithm for the metabolic myopathies. RECENT FINDINGS The metabolic myopathies can present in the neonatal and infant period as part of more systemic involvement with hypotonia, hypoglycemia, and encephalopathy; however, most cases present in childhood or in adulthood with exercise intolerance (often with rhabdomyolysis) and weakness. The glycogen-storage diseases present during brief bouts of high-intensity exercise, whereas fatty acid oxidation defects and mitochondrial myopathies present during a long-duration/low-intensity endurance-type activity or during fasting or another metabolically stressful event (eg, surgery, fever). The clinical examination is often normal between acute events, and evaluation involves exercise testing, blood testing (creatine kinase, acylcarnitine profile, lactate, amino acids), urine organic acids (ketones, dicarboxylic acids, 3-methylglutaconic acid), muscle biopsy (histology, ultrastructure, enzyme testing), MRI/spectroscopy, and targeted or untargeted genetic testing. SUMMARY Accurate and early identification of metabolic myopathies can lead to therapeutic interventions with lifestyle and nutritional modification, cofactor treatment, and rapid treatment of rhabdomyolysis.
Collapse
|
9
|
Mancuso M, McFarland R, Klopstock T, Hirano M. International Workshop:: Outcome measures and clinical trial readiness in primary mitochondrial myopathies in children and adults. Consensus recommendations. 16-18 November 2016, Rome, Italy. Neuromuscul Disord 2017; 27:1126-1137. [PMID: 29074296 PMCID: PMC6094160 DOI: 10.1016/j.nmd.2017.08.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/24/2017] [Accepted: 08/30/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Michelangelo Mancuso
- Department of Experimental and Clinical Medicine, Neurological Institute, University of Pisa, Italy.
| | - Robert McFarland
- Wellcome Trust Centre for Mitochondrial Research, Institute of Genetic Medicine, Department of Physiology and Functional Genomics NE1 3BZ, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas Klopstock
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU München, Ziemssenstr. 1a, 80336 München, Federal Republic of Germany
| | - Michio Hirano
- Department of Neurology, H. Houston Merritt Neuromuscular Research Center, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
10
|
Buber J, Rhodes J. Exercise Physiology and Testing in Adult Patients with Congenital Heart Disease. Heart Fail Clin 2014; 10:23-33. [DOI: 10.1016/j.hfc.2013.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
11
|
Abstract
The noninflammatory myopathies are a diverse group of diseases, some of which may mimic the autoimmune-mediated idiopathic inflammatory myopathies in their clinical presentation. They include certain metabolic, toxic, and infectious myopathies, as well as muscular dystrophies. In addition to muscle weakness, these forms of myopathy may present with exercise intolerance and muscle pain. Special testing techniques are often required to establish the diagnosis. This review focuses on those noninflammatory myopathies that should be included in the differential diagnosis of idiopathic inflammatory myopathy.
Collapse
Affiliation(s)
- Alan N Baer
- Division of Rheumatology, Johns Hopkins University School of Medicine, Suite 4000, Mason Lord Center Tower, 5200 Eastern Avenue, Baltimore, MD 21224, USA.
| | | |
Collapse
|
12
|
Reiner G, Panyard-Davis J. Mitochondrial diseases: Problems in the power plant. Nursing 2012; 42:51-56. [PMID: 22627823 DOI: 10.1097/01.nurse.0000413616.59485.cf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Gail Reiner
- Mitochondrial and Metabolic Disease Center, University of California-San Diego, San Diego, USA
| | | |
Collapse
|