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Torres-Herrero B, Armenia I, Ortiz C, de la Fuente JM, Betancor L, Grazú V. Opportunities for nanomaterials in enzyme therapy. J Control Release 2024; 372:619-647. [PMID: 38909702 DOI: 10.1016/j.jconrel.2024.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024]
Abstract
In recent years, enzyme therapy strategies have rapidly evolved to catalyze essential biochemical reactions with therapeutic potential. These approaches hold particular promise in addressing rare genetic disorders, cancer treatment, neurodegenerative conditions, wound healing, inflammation management, and infectious disease control, among others. There are several primary reasons for the utilization of enzymes as therapeutics: their substrate specificity, their biological compatibility, and their ability to generate a high number of product molecules per enzyme unit. These features have encouraged their application in enzyme replacement therapy where the enzyme serves as the therapeutic agent to rectify abnormal metabolic and physiological processes, enzyme prodrug therapy where the enzyme initiates a clinical effect by activating prodrugs, and enzyme dynamic or starving therapy where the enzyme acts upon host substrate molecules. Currently, there are >20 commercialized products based on therapeutic enzymes, but approval rates are considerably lower than other biologicals. This has stimulated nanobiotechnology in the last years to develop nanoparticle-based solutions that integrate therapeutic enzymes. This approach aims to enhance stability, prevent rapid clearance, reduce immunogenicity, and even enable spatio-temporal activation of the therapeutic catalyst. This comprehensive review delves into emerging trends in the application of therapeutic enzymes, with a particular emphasis on the synergistic opportunities presented by incorporating enzymes into nanomaterials. Such integration holds the promise of enhancing existing therapies or even paving the way for innovative nanotherapeutic approaches.
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Affiliation(s)
- Beatriz Torres-Herrero
- Instituto de Nanociencia y Materiales de Aragón (INMA), CSIC/Universidad de Zaragoza, c/ Edificio I+D, Mariano Esquillor Gómez, 50018 Zaragoza, Spain
| | - Ilaria Armenia
- Instituto de Nanociencia y Materiales de Aragón (INMA), CSIC/Universidad de Zaragoza, c/ Edificio I+D, Mariano Esquillor Gómez, 50018 Zaragoza, Spain
| | - Cecilia Ortiz
- Laboratorio de Biotecnología, Facultad de Ingeniería, Universidad ORT Uruguay, Mercedes 1237, 11100 Montevideo, Uruguay
| | - Jesús Martinez de la Fuente
- Instituto de Nanociencia y Materiales de Aragón (INMA), CSIC/Universidad de Zaragoza, c/ Edificio I+D, Mariano Esquillor Gómez, 50018 Zaragoza, Spain; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Avenida Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Lorena Betancor
- Laboratorio de Biotecnología, Facultad de Ingeniería, Universidad ORT Uruguay, Mercedes 1237, 11100 Montevideo, Uruguay
| | - Valeria Grazú
- Instituto de Nanociencia y Materiales de Aragón (INMA), CSIC/Universidad de Zaragoza, c/ Edificio I+D, Mariano Esquillor Gómez, 50018 Zaragoza, Spain; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Avenida Monforte de Lemos, 3-5, 28029 Madrid, Spain.
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Chen HA, Hsu RH, Fang CY, Desai AK, Lee NC, Hwu WL, Tsai FJ, Kishnani PS, Chien YH. Optimizing treatment outcomes: immune tolerance induction in Pompe disease patients undergoing enzyme replacement therapy. Front Immunol 2024; 15:1336599. [PMID: 38715621 PMCID: PMC11074348 DOI: 10.3389/fimmu.2024.1336599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 04/05/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Pompe disease, a lysosomal storage disorder, is characterized by acid α-glucosidase (GAA) deficiency and categorized into two main subtypes: infantile-onset Pompe disease (IOPD) and late-onset Pompe disease (LOPD). The primary treatment, enzyme replacement therapy (ERT) with recombinant human GAA (rhGAA), faces challenges due to immunogenic responses, including the production of anti-drug antibody (ADA), which can diminish therapeutic efficacy. This study aims to assess the effectiveness of immune tolerance induction (ITI) therapy in cross-reactive immunologic material (CRIM)-positive Pompe disease patients with established high ADA levels. Method In a single-center, open-label prospective study, we assessed ITI therapy's efficacy in Pompe disease patients, both IOPD and LOPD, with persistently elevated ADA titers (≥1:12,800) and clinical decline. The ITI regimen comprised bortezomib, rituximab, methotrexate, and intravenous immunoglobulin. Biochemical data, biomarkers, ADA titers, immune status, and respiratory and motor function were monitored over six months before and after ITI. Results This study enrolled eight patients (5 IOPD and 3 LOPD). After a 6-month ITI course, median ADA titers significantly decreased from 1:12,800 (range 1:12,800-1:51,200) to 1:1,600 (range 1:400-1:12,800), with sustained immune tolerance persisting up to 4.5 years in some cases. Serum CK levels were mostly stable or decreased, stable urinary glucose tetrasaccharide levels were maintained in four patients, and no notable deterioration in respiratory or ambulatory status was noted. Adverse events included two treatable infection episodes and transient symptoms like numbness and diarrhea. Conclusion ITI therapy effectively reduces ADA levels in CRIM-positive Pompe disease patients with established high ADA titers, underscoring the importance of ADA monitoring and timely ITI initiation. The findings advocate for personalized immunogenicity risk assessments to enhance clinical outcomes. In some cases, prolonged immune suppression may be necessary, highlighting the need for further studies to optimize ITI strategies for Pompe disease treatment. ClinicalTrials.gov NCT02525172; https://clinicaltrials.gov/study/NCT02525172.
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Affiliation(s)
- Hui-An Chen
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Rai-Hseng Hsu
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Ya Fang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Ni-Chung Lee
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wuh-Liang Hwu
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Center for Precision Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Fuu-Jen Tsai
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Yin-Hsiu Chien
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
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Ditters IAM, van Kooten HA, van der Beek NAME, van der Ploeg AT, Huidekoper HH, van den Hout JMP. Are Anti-rhGAA Antibodies a Determinant of Treatment Outcome in Adults with Late-Onset Pompe Disease? A Systematic Review. Biomolecules 2023; 13:1414. [PMID: 37759814 PMCID: PMC10526476 DOI: 10.3390/biom13091414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/08/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Pompe disease is a lysosomal storage disease characterised by skeletal and respiratory muscle weakness. Since 2006, enzyme replacement therapy (ERT) with alglucosidase alfa has been available. ERT significantly improves the prognosis of patients with Pompe disease. The effect of high antibody titres on treatment response in adults with late-onset Pompe disease (LOPD) remains unclear but may contribute to interpatient variation. We therefore conducted a systematic review on this subject. METHODS A systematic search was performed in Embase, Medline Ovid, Web of Science, Psych Info Ovid, Cochrane (Clinical Trials only), and Google Scholar (random top-200). Articles were included if they involved adults with LOPD treated with alglucosidase alfa and mentioned anti-rhGAA antibodies or antibody titres. In addition, articles mentioning dosages different from the standard recommended dosage were included. RESULTS Our literature search retrieved 2562 publications, and 17 fulfilled our selection criteria, describing 443 cases. Seven publications reported on anti-rhGAA antibody titres on a group level, with the percentage of patients with a high titre as defined in the included articles ranging from 0-33%. Six publications reported on the effect of anti-rhGAA antibody titre on clinical course, and four found no correlation. Two studies reported a negative effect on treatment. The first study found a greater improvement in Medical Research Council (MRC) score in patients with no detectable antibody titre. In the second study, a patient discontinued ERT due to a declining neuromuscular state as a result of high anti-rhGAA antibody titres. Seven publications reported on 17 individual patients with a high antibody titre (range 1:12,800-1:3,906,250). In only two cases were high-sustained neutralising antibodies reported to interfere with treatment efficacy. CONCLUSIONS No clear effect of anti-rhGAA IgG antibodies on treatment response could be established for the majority of LOPD patients with a high antibody titre. In a minority of patients, a clinical decline related to (possible) interference of anti-rhGAA antibodies was described.
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Affiliation(s)
- Imke A. M. Ditters
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Harmke A. van Kooten
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Nadine A. M. E. van der Beek
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Ans T. van der Ploeg
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Hidde H. Huidekoper
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Johanna M. P. van den Hout
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Domínguez-González C, Díaz-Marín C, Juntas-Morales R, Nascimiento-Osorio A, Rivera-Gallego A, Díaz-Manera J. Survey on the management of Pompe disease in routine clinical practice in Spain. Orphanet J Rare Dis 2022; 17:426. [PMID: 36471448 PMCID: PMC9724265 DOI: 10.1186/s13023-022-02574-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite the availability of several clinical guidelines, not all health professionals use their recommendations to manage patients with Pompe disease, a rare genetic disorder involving high-impact therapy. Through several discussion meetings and a survey, the present study aimed to learn about the management of Pompe disease in routine clinical practice in Spain, to improve clinical care in a real-life situation. RESULTS The survey was sent to 42 healthcare professionals who manage patients with Pompe disease in their clinical practice. Although most respondents followed the clinical guidelines, clinical practice differed from the expert recommendations in many cases. Approximately 7% did not request a genetic study to confirm the diagnosis before starting treatment, and 21% considered that only two dried blood spot determinations suffice to establish the diagnosis. About 76% requested anti-GAA antibodies when there is a suspicion of lack of treatment efficacy, though a significant percentage of respondents have never requested such antibodies. According to 31% of the respondents, significant impairment of motor function and/or respiratory insufficiency is a requirement for authorizing medication at their hospital. Up to 26% waited for improvements over the clinical follow-up to maintain treatment and withdrew it in the absence of improvement since they did not consider disease stabilization to be a satisfactory outcome. CONCLUSIONS The results highlight the lack of experience and/or knowledge of some professionals caring for patients with Pompe disease. It is necessary to develop and disseminate simple guidelines that help to apply the expert recommendations better or centralize patient follow-up in highly specialized centers.
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Affiliation(s)
- Cristina Domínguez-González
- grid.413448.e0000 0000 9314 1427Neuromuscular Unit, Neurology Department, Hospital Universitario 12 de Octubre, imas12 Research Institute, Biomedical Network Research Center on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Av. de Córdoba, s/n, 28041 Madrid, Spain
| | - Carmina Díaz-Marín
- grid.513062.30000 0004 8516 8274Neurology Department, Hospital General Universitario de Alicante Doctor Balmis, Instituto de Investigación Biosanitaria de Alicante (ISABIAL), Alicante, Spain
| | - Raúl Juntas-Morales
- grid.430994.30000 0004 1763 0287Neuromuscular Unit, Neurology Department, Hospital Universitario Vall d’Hebron. Peripheral Nervous System Group, Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Andrés Nascimiento-Osorio
- grid.413448.e0000 0000 9314 1427Neuromuscular Unit, Neurology Department, Hospital Sant Joan de Déu, Applied Research in Neuromuscular Diseases, Institut de Recerca Sant Joan de Déu, Center for Biomedical Research Network On Rare Diseases (CIBERER), ISCIII, Barcelona, Spain
| | - Alberto Rivera-Gallego
- grid.411855.c0000 0004 1757 0405Systemic Rare Diseases Unit, Department of Internal Medicine, Hospital Universitario Alvaro Cunqueiro, Vigo, Spain
| | - Jordi Díaz-Manera
- grid.1006.70000 0001 0462 7212John Walton Muscular Dystrophy Research Center, Newcastle University Translational and Clinical Research Institute, Newcastle Upon Tyne, UK ,grid.413396.a0000 0004 1768 8905Institut de Recerca de l’Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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van Kooten HA, Ditters IAM, Hoogeveen-Westerveld M, Jacobs EH, van den Hout JMP, van Doorn PA, Pijnappel WWMP, van der Ploeg AT, van der Beek NAME. Antibodies against recombinant human alpha-glucosidase do not seem to affect clinical outcome in childhood onset Pompe disease. Orphanet J Rare Dis 2022; 17:31. [PMID: 35109913 PMCID: PMC8812154 DOI: 10.1186/s13023-022-02175-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/16/2022] [Indexed: 01/16/2023] Open
Abstract
Background Enzyme replacement therapy (ERT) with recombinant human alpha-glucosidase (rhGAA, alglucosidase alfa) has improved survival, motor outcomes, daily life activity and quality of life in Pompe patients. However, ERT in Pompe disease often induces formation of antibodies, which may reduce the efficacy of treatment and can lead to adverse events. In this study antibody formation and their effect on clinical outcome in patients with childhood onset Pompe disease treated with enzyme replacement therapy (ERT) with recombinant human alpha-glucosidase (rhGAA) are analyzed. Methods Enzyme-linked immunosorbent assay (ELISA) was used to determine anti-rhGAA antibody titers at predefined time points. The effect of antibodies on rhGAA activity (neutralizing effects) was measured in vitro. Clinical effects were evaluated by assessing muscle strength (MRC score) and function (QMFT-score), pulmonary function and infusion associated reactions (IARs). Results Twenty-two patients were included (age at start ERT 1.1–16.4 years, median treatment duration 12.4 years). Peak antibody titers were low (< 1:1250) in 9%, intermediate (1:1250–1:31,250) in 68% and high (≥ 1:31250) in 23% of patients; three patients (14%) had more than one titer of ≥ 1:31,250. Four patients (18%) experienced IARs; two patients from the high titer group had 86% of all IARs. Inhibition of intracellular GAA activity (58%) in vitro was found in one sample. The clinical course did not appear to be influenced by antibody titers. Conclusions Ninety-one percent of childhood onset Pompe patients developed anti-rhGAA antibodies (above background level), a minority of whom had high antibody titers at repeated time points, which do not seem to interfere with clinical outcome. High antibody titers may be associated with the occurrence of IARs. Although the majority of patients does not develop high titers; antibody titers should be determined in case of clinical deterioration. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02175-2.
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Affiliation(s)
- Harmke A van Kooten
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Imke A M Ditters
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marianne Hoogeveen-Westerveld
- Department of Pediatrics, Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Edwin H Jacobs
- Department of Pediatrics, Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johanna M P van den Hout
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W W M Pim Pijnappel
- Department of Pediatrics, Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ans T van der Ploeg
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nadine A M E van der Beek
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Neurology, Erasmus University Medical Center, Mailbox 2040, 3000 CA, Rotterdam, the Netherlands.
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The increasing role of muscle MRI to monitor changes over time in untreated and treated muscle diseases. Curr Opin Neurol 2021; 33:611-620. [PMID: 32796278 DOI: 10.1097/wco.0000000000000851] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This review aims to discuss the recent results of studies published applying quantitative MRI sequences to large cohorts of patients with neuromuscular diseases. RECENT FINDINGS Quantitative MRI sequences are now available to identify and quantify changes in muscle water and fat content. These two components have been associated with acute and chronic injuries, respectively. Studies show that the increase in muscle water is not only reversible if therapies are applied successfully but can also predict fat replacement in neurodegenerative diseases. Muscle fat fraction correlates with muscle function tests and increases gradually over time in parallel with the functional decline of patients with neuromuscular diseases. There are new spectrometry-based sequences to quantify other components, such as glycogen, electrolytes or the pH of the muscle fibre, extending the applicability of MRI to the study of several processes in neuromuscular diseases. SUMMARY The latest results obtained from the study of long cohorts of patients with various neuromuscular diseases open the door to the use of this technology in clinical trials, which would make it possible to obtain a new measure for assessing the effectiveness of new treatments. The challenge is currently the popularization of these studies and their application to the monitoring of patients in the daily clinic.
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Sarah B, Giovanna B, Emanuela K, Nadi N, Josè V, Alberto P. Clinical efficacy of the enzyme replacement therapy in patients with late-onset Pompe disease: a systematic review and a meta-analysis. J Neurol 2021; 269:733-741. [PMID: 33851281 PMCID: PMC8782782 DOI: 10.1007/s00415-021-10526-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 01/10/2023]
Abstract
In patients with late-onset Pompe disease (LOPD), the efficacy of the enzyme replacement therapy (ERT) with recombinant human alpha-glucosidase (rhGAA) is difficult to evaluate, due to the clinical heterogeneity and the small sample sizes in published studies. Therefore, we conduct a systematic literature review and meta-analysis of the literature to evaluate the efficacy of ERT in LOPD patients considering the walking distance, respiratory function and muscle strength. Particularly, six-minute walk test (6MWT), forced vital capacity (FVC), medical research council (MRC) grading, quantitative muscle testing (QMT), and quick motor function test (QMFT) were outcomes of interest. Overall, 619 studies were identified in PubMed, EMBASE and by manual search on July 18th, 2020. After an initial assessment, 16 studies were included in the meta-analysis, containing clinical data from 589 patients with LOPD. For the 6MWT, 419 patients were analyzed. Walking distance improved on average, 32.2 m greater during the observed period (p = 0.0003), compared to the distance at the baseline. The meta-analysis did not show any improvement in FVC and only a tendency towards better muscle strength after treatment with ERT, but the difference was not statistically significant. In conclusion, the available data showed that ERT has a significant beneficial efficacy in the improvement of walking distance in LOPD patients and a non-significant improvement of muscle strength. No improvement in respiratory capacity was found. More prospective and controlled trials are needed to demonstrate a clear clinical benefit of ERT.
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Affiliation(s)
- Berli Sarah
- Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Brandi Giovanna
- Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Keller Emanuela
- Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.,Department of Neurosurgery and Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Najia Nadi
- Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Vitale Josè
- Intensive Care Unit, Regional Hospital Mendrisio, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Centro Medico, Mendrisio, Switzerland
| | - Pagnamenta Alberto
- Intensive Care Unit, Regional Hospital Mendrisio, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Unit of Biostatistics, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Division of Pneumology, University Hospital of Geneva, Geneva, Switzerland
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