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Bai YR, Seng DJ, Xu Y, Zhang YD, Zhou WJ, Jia YY, Song J, He ZX, Liu HM, Yuan S. A comprehensive review of small molecule drugs approved by the FDA in 2023: Advances and prospects. Eur J Med Chem 2024; 276:116706. [PMID: 39053188 DOI: 10.1016/j.ejmech.2024.116706] [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: 06/03/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024]
Abstract
In 2023, the U.S. Food and Drug Administration has approved 55 novel medications, consisting of 17 biologics license applications and 38 new molecular entities. Although the biologics license applications including antibody and enzyme replacement therapy set a historical record, the new molecular entities comprising small molecule drugs, diagnostic agent, RNA interference therapy and biomacromolecular peptide still account for over 50 % of the newly approved medications. The novel and privileged scaffolds derived from drugs, active molecules and natural products are consistently associated with the discovery of new mechanisms, the expansion of clinical indications and the reduction of side effects. Moreover, the structural modifications based on the promising scaffolds can provide the clinical candidates with the improved biological activities, bypass the patent protection and greatly shorten the period of new drug discovery. Therefore, conducting an appraisal of drug approval experience and related information will expedite the identification of more potent drug molecules. In this review, we comprehensively summarized the pertinent information encompassing the clinical application, mechanism, elegant design and development processes of 28 small molecule drugs, and expected to provide the promising structural basis and design inspiration for pharmaceutical chemists.
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Affiliation(s)
- Yi-Ru Bai
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China; School of Pharmaceutical Sciences & Key Laboratory of Advanced Drug Preparation Technologies, Zhengzhou University, Zhengzhou, 450001, China
| | - Dong-Jie Seng
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Ying Xu
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Yao-Dong Zhang
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Wen-Juan Zhou
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Yang-Yang Jia
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Jian Song
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China
| | - Zhang-Xu He
- Pharmacy College, Henan University of Chinese Medicine, Zhengzhou, 450046, China.
| | - Hong-Min Liu
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China; School of Pharmaceutical Sciences & Key Laboratory of Advanced Drug Preparation Technologies, Zhengzhou University, Zhengzhou, 450001, China.
| | - Shuo Yuan
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China; School of Pharmaceutical Sciences & Key Laboratory of Advanced Drug Preparation Technologies, Zhengzhou University, Zhengzhou, 450001, China.
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Saldaris JM, Ayalde J, Kankanange S, Keeley J, Leonard H, Jacoby P, Marsh ED, Benke TA, Demarest ST, Downs J. Parent-reported outcome measures evaluating communication in individuals with rare neurodevelopmental disorders: A systematic review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024. [PMID: 39141588 DOI: 10.1111/1460-6984.13100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/25/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Communication impairments are a leading concern for parent caregivers of individuals with rare neurodevelopmental disorders (RNDDs). Clinical trials of disease modifying therapies require valid and responsive outcome measures that are relevant to individuals with RNDDs. Identifying and evaluating current psychometric properties for communication measures is a critical step towards the selection and use of appropriate instruments. AIMS This systematic review offers (1) a description of parent-reported communication measures and (2) evidence for their psychometric properties, in RNDDs. METHODS The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022334649). MEDLINE (Ovid), Embase, PsychINFO, Web of Science, CINAHL Plus, Cochrane Library, ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry were searched from inception to August 2023. Methodological assessment of quality was completed using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. Parent-reported measures used in observational studies and clinical trials were identified. Data on utility, reliability and validity for RNDDs were extracted. MAIN CONTRIBUTION Sixteen parent-reported communication measures were used in RNDD research, the Vineland Adaptive Behavior Scales being most commonly used. Validation data in RNDDs were identified for six of these measures. Limitations related to sample size or the scope of psychometric testing. CONCLUSIONS Many communication measures have been used for RNDDs but there are few data validating their use. Valid and reliable methods of measuring communication in persons with RNDDs is a priority for future high-quality clinical trials. WHAT THIS PAPER ADDS What is already known on the subject Communication is a critical domain for families with a child with a rare neurodevelopmental disorder (RNDD). Validated outcome measures are essential for accurate evaluation and interpretation of responses to treatments in clinical trials. What this paper adds to existing knowledge We identified 16 parent-reported communication measures that have been used with RNDDs, but only six measures had validation data for at least one RNDD. High quality evidence is accumulating, with all validation studies in this review published between 2020 to 2023. Modifications of existing measures may be required to assess communication for RNDDs. What are the clinical implications of this work? This systematic review catalogues the available psychometric data for communication measures and indicates an ongoing need for new validation studies to ensure they are fit-for-purpose for upcoming clinical trials in RNDDs. This review will inform the selection of communication measures for clinical trials and research studies.
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Affiliation(s)
- Jacinta M Saldaris
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- The University of Western Australia, Centre for Child Health Research, Crawley, Western Australia, Australia
| | - Jeremiah Ayalde
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | | | - Jessica Keeley
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- The University of Western Australia, Centre for Child Health Research, Crawley, Western Australia, Australia
| | - Peter Jacoby
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Eric D Marsh
- Children's Hospital of Philadelphia, Division of Child Neurology, Philadelphia, Pennsylvania, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Tim A Benke
- Children's Hospital Colorado, Neurology and Pharmacology, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott T Demarest
- Children's Hospital Colorado, Neurology and Pharmacology, Aurora, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, Nedlands, Western Australia, Australia
- The University of Western Australia, Centre for Child Health Research, Crawley, Western Australia, Australia
- Curtin University, School of Allied Health, Bentley, Western Australia, Australia
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Singh J, Wilkins G, Goodman-Vincent E, Chishti S, Bonilla Guerrero R, Fiori F, Ameenpur S, McFadden L, Zahavi Z, Santosh P. Using Precision Medicine to Disentangle Genotype-Phenotype Relationships in Twins with Rett Syndrome: A Case Report. Curr Issues Mol Biol 2024; 46:8424-8440. [PMID: 39194714 DOI: 10.3390/cimb46080497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/20/2024] [Accepted: 07/26/2024] [Indexed: 08/29/2024] Open
Abstract
Rett syndrome (RTT) is a paediatric neurodevelopmental disorder spanning four developmental stages. This multi-system disorder offers a unique window to explore genotype-phenotype relationships in a disease model. However, genetic prognosticators of RTT have limited clinical value due to the disorder's heterogeneity on multiple levels. This case report used a precision medicine approach to better understand the clinical phenotype of RTT twins with an identical pathogenic MECP2 mutation and discordant neurodevelopmental profiles. Targeted genotyping, objective physiological monitoring of heart rate variability (HRV) parameters, and clinical severity were assessed in a RTT twin pair (5 years 7 months old) with an identical pathogenic MECP2 mutation. Longitudinal assessment of autonomic HRV parameters was conducted using the Empatica E4 wristband device, and clinical severity was assessed using the RTT-anchored Clinical Global Impression Scale (RTT-CGI) and the Multi-System Profile of Symptoms Scale (MPSS). Genotype data revealed impaired BDNF function for twin A when compared to twin B. Twin A also had poorer autonomic health than twin B, as indicated by lower autonomic metrics (autonomic inflexibility). Hospitalisation, RTT-CGI-S, and MPSS subscale scores were used as measures of clinical severity, and these were worse in twin A. Treatment using buspirone shifted twin A from an inflexible to a flexible autonomic profile. This was mirrored in the MPSS scores, which showed a reduction in autonomic and cardiac symptoms following buspirone treatment. Our findings showed that a combination of a co-occurring rs6265 BDNF polymorphism, and worse autonomic and clinical profiles led to a poorer prognosis for twin A compared to twin B. Buspirone was able to shift a rigid autonomic profile to a more flexible one for twin A and thereby prevent cardiac and autonomic symptoms from worsening. The clinical profile for twin A represents a departure from the disorder trajectory typically observed in RTT and underscores the importance of wider genotype profiling and longitudinal objective physiological monitoring alongside measures of clinical symptoms and severity when assessing genotype-phenotype relationships in RTT patients with identical pathogenic mutations. A precision medicine approach that assesses genetic and physiological risk factors can be extended to other neurodevelopmental disorders to monitor risk when genotype-phenotype relationships are not so obvious.
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Affiliation(s)
- Jatinder Singh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Georgina Wilkins
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Ella Goodman-Vincent
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Samiya Chishti
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | | | - Federico Fiori
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Shashidhar Ameenpur
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Leighton McFadden
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
| | - Zvi Zahavi
- Myogenes Limited, Borehamwood WD6 4PJ, UK
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK
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Darwish M, Obianom ON, Youakim JM, Darling I, Lukacova V, Bradley H. Effect of Hepatic Impairment on Trofinetide Exposures Using an In Silico Physiologically Based Pharmacokinetic Model. Adv Ther 2024; 41:3328-3341. [PMID: 38963587 PMCID: PMC11263405 DOI: 10.1007/s12325-024-02926-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/11/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Trofinetide is the first drug to be approved for the treatment of Rett syndrome. Hepatic impairment is not expected to affect the pharmacokinetic (PK) profile of trofinetide because of predominant renal excretion. This study was conducted to help understand the potential impact of any hepatic impairment on trofinetide PK. METHODS This study used physiologically based PK modeling to estimate trofinetide exposure (maximum drug concentration and area under the concentration-time curve from time zero to infinity) in virtual patients with mild, moderate, and severe hepatic impairment (per Child-Pugh classification) compared with virtual healthy subjects following a 12 g oral trofinetide dose. RESULTS In individual deterministic simulations for matched individuals and stochastic simulations at the population level (100 virtual individuals simulated per population), as anticipated, predicted plasma exposures were similar for healthy subjects and for patients with mild, moderate, and severe hepatic impairment. However, predicted blood concentration exposures slightly increased with increasing severity of hepatic impairment because of change in hematocrit levels. CONCLUSION This study indicates that hepatic impairment is not expected to have a clinically relevant effect on exposure to trofinetide.
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Affiliation(s)
- Mona Darwish
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA.
| | | | - James M Youakim
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA
| | | | | | - Heather Bradley
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA
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Fuchs C, ‘t Hoen PAC, Müller AR, Ehrhart F, Van Karnebeek CDM. Drug repurposing in Rett and Rett-like syndromes: a promising yet underrated opportunity? Front Med (Lausanne) 2024; 11:1425038. [PMID: 39135718 PMCID: PMC11317438 DOI: 10.3389/fmed.2024.1425038] [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: 04/29/2024] [Accepted: 07/12/2024] [Indexed: 08/15/2024] Open
Abstract
Rett syndrome (RTT) and Rett-like syndromes [i.e., CDKL5 deficiency disorder (CDD) and FOXG1-syndrome] represent rare yet profoundly impactful neurodevelopmental disorders (NDDs). The severity and complexity of symptoms associated with these disorders, including cognitive impairment, motor dysfunction, seizures and other neurological features significantly affect the quality of life of patients and families. Despite ongoing research efforts to identify potential therapeutic targets and develop novel treatments, current therapeutic options remain limited. Here the potential of drug repurposing (DR) as a promising avenue for addressing the unmet medical needs of individuals with RTT and related disorders is explored. Leveraging existing drugs for new therapeutic purposes, DR presents an attractive strategy, particularly suited for neurological disorders given the complexities of the central nervous system (CNS) and the challenges in blood-brain barrier penetration. The current landscape of DR efforts in these syndromes is thoroughly examined, with partiuclar focus on shared molecular pathways and potential common drug targets across these conditions.
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Affiliation(s)
| | - Peter A. C. ‘t Hoen
- Center for Molecular and Biomolecular Informatics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Annelieke R. Müller
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Emma Center for Personalized Medicine, Amsterdam, Netherlands
- Department of Human Genetics, Amsterdam Reproduction and Development, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Friederike Ehrhart
- Department of Bioinformatics – BiGCaT, Research Institute of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Clara D. M. Van Karnebeek
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Emma Center for Personalized Medicine, Amsterdam, Netherlands
- Department of Human Genetics, Amsterdam Reproduction and Development, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
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May D, Kponee-Shovein K, Neul JL, Percy AK, Mahendran M, Downes N, Chen G, Watson T, Pichard DC, Kennedy M, Lefebvre P. Characterizing the journey of Rett syndrome among females in the United States: a real-world evidence study using the Rett syndrome natural history study database. J Neurodev Disord 2024; 16:42. [PMID: 39061009 PMCID: PMC11282812 DOI: 10.1186/s11689-024-09557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND With the advent of the first targeted therapy for Rett Syndrome (RTT), a comprehensive assessment of the journey of RTT is needed to elucidate on present unmet needs in this population. This study characterized females with RTT in the United States and their disease journey with respect to longitudinal treatment patterns, RTT-related outcomes, and changes in disease severity. METHODS This retrospective cohort study used registry data of females with RTT from the 5211 RTT Natural History Study (RNHS) (November 2015-July 2021). Pharmacological and supportive therapy use, RTT-related outcomes, and RTT severity, as measured by the Clinical Severity Scale and Motor Behavioral Assessment scale, were evaluated following the first RNHS visit. Analyses were conducted overall and in subgroups by RTT type (classic and atypical RTT) and age at first visit (pediatric and adult). RESULTS A total of 455 females with RTT were included in the study, of whom 90.5% had classic RTT and 79.8% were pediatric individuals. Over a median follow-up of 4 years, use of pharmacological therapies, including prokinetic agents (42.7% vs. 28.3%), and supportive therapies, including physical therapy (87.3% vs. 40.2%) and speech-language therapy (86.8% vs. 23.9%), were more common in pediatric than adult individuals (all p < 0.05). Nearly half (44.6%) of all individuals had a hospital or emergency room visit, with a higher proportion of visits in individuals with classic RTT than atypical RTT and pediatric than adult individuals (both p = 0.001). An increasing trend in clinical severity was observed in pediatric individuals (mean change per year: 0.24; 95% confidence interval [CI]: 0.03, 0.44), while an increasing trend in motor-behavioral dysfunction was observed in pediatric individuals (mean change per year: 1.12; 95% CI: 0.63, 1.60) and those with classic RTT (mean change per year: 0.97; 95% CI: 0.53, 1.41). CONCLUSIONS Findings from this study highlight the considerable burden of RTT across disease subtype and age. Despite reliance on supportive therapies and healthcare encounters, individuals with RTT experience increasing disease severity and motor-behavioral dysfunction in childhood and adolescence, underscoring the unmet needs of this population and the value of early intervention to manage RTT in the long-term.
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Affiliation(s)
- Damian May
- Acadia Pharmaceuticals, San Diego, CA, USA.
| | | | - Jeffrey L Neul
- Vanderbilt Kennedy Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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Mohammed HE, Bady Z, Haseeb ME, Aboeldahab H, Sharaf-Eldin WE, Zaki MS. Is trofinetide a future treatment for Rett syndrome? A comprehensive systematic review and meta-analysis of randomized controlled trials. BMC Med 2024; 22:299. [PMID: 39020317 PMCID: PMC11256568 DOI: 10.1186/s12916-024-03506-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 06/27/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Rett syndrome (RTT) is a rare, life-threatening, genetic neurodevelopmental disorder. Treatment in RTT encounters many challenges. Trofinetide, a modified amino-terminal tripeptide of insulin-like growth factor 1, has demonstrated clinically promising results in RTT. In this study, trofinetide efficacy and safety in RTT are systematically reviewed and meta-analyzed. METHODS A systematic search of five electronic databases was conducted until January 2024. Review Manager 5.4 software was used for the analysis. The analysis was based on a weighted mean difference and standard error with a confidence interval (CI) of 95%, and a statistically significant P-value was considered if it was < 0.05. The study was registered on PROSPERO with registration number CRD42024499849. Quality of evidence was assessed using GRADE. RESULTS Three randomized controlled trials (RCTs) with 276 patients were included in the analysis. Trofinetide improved both caregiver outcomes and clinical scales by improving the Rett Syndrome Behavior Questionnaire (RSBQ) (mean difference (MD): - 3.46 points, 95% CI: - 5.63 to - 1.27, P = 0.0002) and Clinical Global Impression Scale-Improvement (CGI-I) (MD: - 0.35, 95% CI: - 0.51 to - 0.18, P < 0.0001), respectively. However, trofinetide neither improved the Caregiver Top 3 Concerns Visual Analog Scale nor the Rett Motor Behavioral Assessment. Regarding safety, trofinetide was significantly associated with vomiting compared to placebo (odds ratio (OR): 3.17, 95% CI: 1.57 to 6.43, P = 0.001). After solving heterogeneity, results showed a statistically significant incidence of diarrhea in the trofinetide (200 mg) group compared to placebo (OR: 18.51, 95% CI: 9.30 to 36.84, P ≤ 0.00001). CONCLUSIONS Trofinetide demonstrated statistically significant improvements in CGI-I and RSBQ in pediatrics and adult patients with Rett. Side effects are limited to vomiting and diarrhea. Although diarrhea yielded an insignificant result in our analysis, it emerged as a cause for treatment discontinuation in the participating trials, and a statistically significant risk for diarrhea emerged when excluding the study using a lower dose of the drug, hence causing heterogeneity, in the meta-analysis. Given the diverse genetic landscape of RTT, future RCTs investigating correlations between RTT genotype and phenotypic improvements by trofinetide will be beneficial. RCTs encompassing male patients with larger and longer cohorts are recommended.
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Affiliation(s)
| | - Zeyad Bady
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Heba Aboeldahab
- Medical Research Group of Egypt (MRGE), Negida Academy, Cairo, Egypt
- Clinical Research Department, El-Gomhoria General Hospital, MOHP, Alexandria, Egypt
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Wessam E Sharaf-Eldin
- Medical Molecular Genetics Department, Human Genetics and Genome Research Institute, National Research Centre, Cairo, Egypt
| | - Maha S Zaki
- Clinical Genetics Department, Human Genetics and Genome Research Institute, National Research Centre, Cairo, Egypt.
- Medical Genetics Department, Armed Forces College of Medicine (AFCM), Cairo, Egypt.
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Percy AK, Neul JL, Benke TA, Berry-Kravis EM, Glaze DG, Marsh ED, Barrett AM, An D, Bishop KM, Youakim JM. Trofinetide for the treatment of Rett syndrome: Long-term safety and efficacy results of the 32-month, open-label LILAC-2 study. MED 2024:S2666-6340(24)00253-8. [PMID: 39025065 DOI: 10.1016/j.medj.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/23/2024] [Accepted: 06/19/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Trofinetide was approved for the treatment of Rett syndrome (RTT) in patients aged ≥2 years based on the results of the 12-week, randomized, phase 3 LAVENDER study. In LILAC, a 40-week, open-label extension study of LAVENDER, trofinetide continued to improve the symptoms of RTT, with a similar safety profile as LAVENDER. Here, we report long-term safety and efficacy results of LILAC-2, a 32-month, open-label extension study. METHODS Females aged 5-22 years who completed LILAC were eligible to enter LILAC-2. Safety and tolerability were assessed with the incidence of adverse events (AEs). Efficacy was assessed with Rett Syndrome Behaviour Questionnaire (RSBQ) and Clinical Global Impression-Improvement (CGI-I) scores. Caregiver interviews explored the patient's experience with RTT and the efficacy of trofinetide during study participation. FINDINGS In total, 77 participants were enrolled in LILAC-2. The most common AEs were diarrhea (53.2%), COVID-19 (27.3%), and vomiting (19.5%). The mean (standard error [SE]) change in RSBQ score from LAVENDER baseline to week 104 of LILAC-2 was -11.8 (2.45). The mean (SE) CGI-I score from LILAC baseline to week 12 of LILAC-2 was 3.1 (0.10). Most caregivers (96%; n = 24/25) were satisfied or very satisfied with the benefits of trofinetide. CONCLUSIONS Long-term treatment with trofinetide continued to improve RTT symptoms, without new safety concerns. Caregivers reported satisfaction with trofinetide related to improvements that were meaningful for their child and themselves. FUNDING The study was supported by Acadia Pharmaceuticals (San Diego, CA, USA). This study was registered at ClinicalTrials.gov: NCT04776746.
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Affiliation(s)
- Alan K Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey L Neul
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy A Benke
- Department of Pediatrics, Children's Hospital of Colorado/University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth M Berry-Kravis
- Departments of Pediatrics, Neurological Sciences and Biochemistry, Rush University Medical Center, Chicago, IL, USA
| | - Daniel G Glaze
- Department of Pediatrics and Neurology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Eric D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amy M Barrett
- Patient-Centered Outcomes Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Di An
- Acadia Pharmaceuticals, Inc., San Diego, CA, USA
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Shen J, Liu L, Yang Y, Zhou M, Xu S, Zhang W, Zhang C. Insulin-Like Growth Factor 1 Has the Potential to Be Used as a Diagnostic Tool and Treatment Target for Autism Spectrum Disorders. Cureus 2024; 16:e65393. [PMID: 39188438 PMCID: PMC11346671 DOI: 10.7759/cureus.65393] [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] [Accepted: 07/16/2024] [Indexed: 08/28/2024] Open
Abstract
Autism spectrum disorder (ASD), a heterogeneous group of neurodevelopmental disorders, is characterized by social impairment and repetitive and stereotypic behaviors. Because of the lack of approved laboratory diagnostic markers and effective therapeutic medications, it is one of the most challenging diseases. Therefore, it is urgent to explore potential diagnosis markers or therapeutic targets. Insulin-like growth factor 1 (IGF-1) is a neurotrophic growth factor that enhances brain development. IGF-1 levels in body fluids are lower in preschool children with ASD than in typically developing children, which may serve as a potential diagnostic marker. In various ASD models associated with genetic or environmental exposure, IGF-1 treatment can improve core symptoms or pathological changes, including neuronal development, neural cell survival, balance of synaptic excitation and inhibition, neuroimmunology, and oxidative stress status. In March 2023 an IGF-1 derivative was approved as the first drug for treating Rett syndrome, an ASD-related neurodevelopmental disorder, to improve fundamental symptoms such as social communication. Thus, in this review, we present accumulating evidence of altered IGF-1 levels in ASD patients and the possible mechanisms, as well as evidence that IGF-1 treatment improves the pathophysiology in various ASD models. IGF-1 has the potential to be an early diagnosis marker and an effective therapeutic for ASD.
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Affiliation(s)
- Jiamin Shen
- Department of Children Health Care, Jingmen Maternity and Child Health Care Hospital, Jingmen, CHN
| | - Lijuan Liu
- Department of Medical Microbiology, School of Basic Medical Sciences, Wuhan University, Wuhan, CHN
| | - Yifan Yang
- Department of Children Health Care, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College, Huazhong University of Science and Technology, Wuhan, CHN
| | - Miao Zhou
- Department of Children Health Care, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College, Huazhong University of Science and Technology, Wuhan, CHN
| | - Shan Xu
- Department of Children Health Care, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College, Huazhong University of Science and Technology, Wuhan, CHN
| | - Wanqing Zhang
- Department of Children Health Care, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College, Huazhong University of Science and Technology, Wuhan, CHN
| | - Chuanjie Zhang
- Department of Children Health Care, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College, Huazhong University of Science and Technology, Wuhan, CHN
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10
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Singh J, Wilkins G, Goodman-Vincent E, Chishti S, Bonilla Guerrero R, McFadden L, Zahavi Z, Santosh P. Co-Occurring Methylenetetrahydrofolate Reductase ( MTHFR) rs1801133 and rs1801131 Genotypes as Associative Genetic Modifiers of Clinical Severity in Rett Syndrome. Brain Sci 2024; 14:624. [PMID: 39061365 PMCID: PMC11275218 DOI: 10.3390/brainsci14070624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
AIM Remethylation disorders such as 5,10-methylenetetrahydrofolate reductase (MTHFR) deficiency reduce the remethylation of homocysteine to methionine. The resulting hyperhomocysteinemia can lead to serious neurological consequences and multisystem toxicity. The role of MTHFR genotypes has not been investigated in patients with Rett Syndrome (RTT). In this study, we sought to assess the impact of co-occurring MTHFR genotypes on symptom profiles in RTT. METHOD Using pharmacogenomic (PGx) testing, the MTHFR genetic polymorphisms rs1801133 (c.665C>T mutation) and rs1801131 (c.1286A>C mutation) were determined in 65 patients (18.7 years ± 12.1 [mean ± standard deviation]) with RTT as part of routine clinical care within the Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, a National and Specialist Child and Adolescent Mental Health Service (CAMHS) in the UK. The clinical severity of patients was assessed using the RTT-anchored Clinical Global Impression Scale (RTT-CGI). RESULTS The clinical severity symptom distribution varied between the homozygous and heterozygous MTHFR rs1801133 and rs1801131 genotypes. Those with the homozygous genotype had a narrower spread of severity scores across several domains (language and communication, ambulation, hand-use and eye contact clinical domains). Patients with the homozygous genotype had statistically significantly greater CGI-Severity scores than individuals with a non-homozygous MTHFR genotype (Z = -2.44, p = 0.015). When comparing the ratings of moderately impaired (4), markedly impaired (5), severely impaired (6) and extremely impaired (7), individuals with the homozygous MTHFR genotype were more impaired than those with the non-homozygous MTHFR genotype (Z = -2.06, p = 0.039). There was no statistically significant difference in the number of prescribed anti-epileptic drugs between the genotypes. CONCLUSIONS Our findings show that in those with a pathogenic RTT genetic variant, co-occurring homozygotic MTHFR rs1801133 and rs1801131 polymorphisms may act as associative genetic modifiers of clinical severity in a subset of patients. Profiling of rs1801133 and rs1801131 in RTT may therefore be useful, especially for high-risk patients who may be at the most risk from symptom deterioration.
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Affiliation(s)
- Jatinder Singh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; (J.S.); (G.W.); (E.G.-V.); (S.C.); (L.M.)
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Georgina Wilkins
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; (J.S.); (G.W.); (E.G.-V.); (S.C.); (L.M.)
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Ella Goodman-Vincent
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; (J.S.); (G.W.); (E.G.-V.); (S.C.); (L.M.)
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Samiya Chishti
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; (J.S.); (G.W.); (E.G.-V.); (S.C.); (L.M.)
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | | | - Leighton McFadden
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; (J.S.); (G.W.); (E.G.-V.); (S.C.); (L.M.)
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Zvi Zahavi
- Myogenes Limited, Borehamwood WD6 4PJ, UK;
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK; (J.S.); (G.W.); (E.G.-V.); (S.C.); (L.M.)
- Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
- Centre for Interventional Paediatric Psychopharmacology (CIPP) Rett Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
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11
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Dong HW, Weiss K, Baugh K, Meadows MJ, Niswender CM, Neul JL. Potentiation of the muscarinic acetylcholine receptor 1 modulates neurophysiological features in a mouse model of Rett syndrome. Neurotherapeutics 2024; 21:e00384. [PMID: 38880672 DOI: 10.1016/j.neurot.2024.e00384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024] Open
Abstract
Rett syndrome (RTT) is a neurodevelopmental disorder primarily caused by mutations in the X chromosome-linked gene Methyl-CpG Binding Protein 2 (MECP2). Restoring MeCP2 expression after disease onset in a mouse model of RTT reverses phenotypes, providing hope for development of treatments for RTT. Translatable biomarkers of improvement and treatment responses have the potential to accelerate both preclinical and clinical evaluation of targeted therapies in RTT. Studies in people with and mouse models of RTT have identified neurophysiological features, such as auditory event-related potentials, that correlate with disease severity, suggesting that they could be useful as biomarkers of disease improvement or early treatment response. We recently demonstrated that treatment of RTT mice with a positive allosteric modulator (PAM) of muscarinic acetylcholine subtype 1 receptor (M1) improved phenotypes, suggesting that modulation of M1 activity is a potential therapy in RTT. To evaluate whether neurophysiological features could be useful biomarkers to assess the effects of M1 PAM treatment, we acutely administered the M1 PAM VU0486846 (VU846) at doses of 1, 3, 10 and 30 mg/kg in wildtype and RTT mice. This resulted in an inverted U-shaped dose response with maximal improvement of AEP features at 3 mg/kg but with no marked effect on basal EEG power or epileptiform discharges in RTT mice and no significant changes in wildtype mice. These findings suggest that M1 potentiation can improve neural circuit synchrony to auditory stimuli in RTT mice and that neurophysiological features have potential as pharmacodynamic or treatment-responsive biomarkers for preclinical and clinical evaluation of putative therapies in RTT.
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Affiliation(s)
- Hong-Wei Dong
- Department of Pediatrics, Division of Neurology, Vanderbilt University Medical Center, USA; Vanderbilt University Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly Weiss
- Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, TN, USA; Warren Center for Neuroscience Drug Discovery, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Kathryn Baugh
- Department of Pediatrics, Division of Neurology, Vanderbilt University Medical Center, USA
| | - Mac J Meadows
- Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, TN, USA; Warren Center for Neuroscience Drug Discovery, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Colleen M Niswender
- Vanderbilt University Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, TN, USA; Warren Center for Neuroscience Drug Discovery, School of Medicine, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute for Chemical Biology, Nashville, TN, USA; Vanderbilt Brain Institute, Nashville, TN, USA.
| | - Jeffrey L Neul
- Department of Pediatrics, Division of Neurology, Vanderbilt University Medical Center, USA; Vanderbilt University Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pharmacology, School of Medicine, Vanderbilt University, Nashville, TN, USA; Vanderbilt Brain Institute, Nashville, TN, USA.
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12
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Vogt L, Quiroz V, Ebrahimi-Fakhari D. Emerging therapies for childhood-onset movement disorders. Curr Opin Pediatr 2024; 36:331-341. [PMID: 38655812 PMCID: PMC11047116 DOI: 10.1097/mop.0000000000001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW We highlight novel and emerging therapies in the treatment of childhood-onset movement disorders. We structured this review by therapeutic entity (small molecule drugs, RNA-targeted therapeutics, gene replacement therapy, and neuromodulation), recognizing that there are two main approaches to treatment: symptomatic (based on phenomenology) and molecular mechanism-based therapy or 'precision medicine' (which is disease-modifying). RECENT FINDINGS We highlight reports of new small molecule drugs for Tourette syndrome, Friedreich's ataxia and Rett syndrome. We also discuss developments in gene therapy for aromatic l-amino acid decarboxylase deficiency and hereditary spastic paraplegia, as well as current work exploring optimization of deep brain stimulation and lesioning with focused ultrasound. SUMMARY Childhood-onset movement disorders have traditionally been treated symptomatically based on phenomenology, but focus has recently shifted toward targeted molecular mechanism-based therapeutics. The development of precision therapies is driven by increasing capabilities for genetic testing and a better delineation of the underlying disease mechanisms. We highlight novel and exciting approaches to the treatment of genetic childhood-onset movement disorders while also discussing general challenges in therapy development for rare diseases. We provide a framework for molecular mechanism-based treatment approaches, a summary of specific treatments for various movement disorders, and a clinical trial readiness framework.
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Affiliation(s)
- Lindsey Vogt
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto Ontario, Canada
| | - Vicente Quiroz
- Movement Disorders Program, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Darius Ebrahimi-Fakhari
- Movement Disorders Program, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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13
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Mori M, Yoshii S, Noguchi M, Takagi D, Shimizu T, Ito H, Matsuo-Takasaki M, Nakamura Y, Takahashi S, Hamada H, Ohnuma K, Shiohama T, Hayashi Y. Generation of human induced pluripotent stem cell lines derived from four Rett syndrome patients with MECP2 mutations. Stem Cell Res 2024; 77:103432. [PMID: 38703668 DOI: 10.1016/j.scr.2024.103432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/16/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
Rett syndrome is characterized by severe global developmental impairments with autistic features and loss of purposeful hand skills. Here we show that human induced pluripotent stem cell (hiPSC) lines derived from four Japanese female patients with Rett syndrome are generated from peripheral blood mononuclear cells using Sendai virus vectors. The generated hiPSC lines showed self-renewal and pluripotency and carried heterozygous frameshift, missense, or nonsense mutations in the MECP2 gene. Since the molecular pathogenesis caused by MECP2 dysfunction remains unclear, these cell resources are useful tools to establish disease models and develop new therapies for Rett syndrome.
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Affiliation(s)
- Miyu Mori
- iPS Cell Advanced Characterization and Development Team, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan; Department of Materials Science and Bioengineering, Nagaoka University of Technology, 1603-1 Kami-Tomioka, Nagaoka, Niigata 940-2188, Japan
| | - Shoko Yoshii
- Department of Pediatrics, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-0856, Japan
| | - Michiya Noguchi
- Cell Engineering Division, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan
| | - Daigo Takagi
- iPS Cell Advanced Characterization and Development Team, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan
| | - Tomoya Shimizu
- iPS Cell Advanced Characterization and Development Team, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan
| | - Hidenori Ito
- iPS Cell Advanced Characterization and Development Team, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan
| | - Mami Matsuo-Takasaki
- iPS Cell Advanced Characterization and Development Team, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan
| | - Yukio Nakamura
- Cell Engineering Division, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan
| | - Satoru Takahashi
- Department of Pediatrics, Asahikawa Medical University, 2-1-1-1 Midorigaoka Higashi, Asahikawa City, Hokkaido 078-8510, Japan
| | - Hiromichi Hamada
- Department of Pediatrics, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-0856, Japan
| | - Kiyoshi Ohnuma
- Department of Materials Science and Bioengineering, Nagaoka University of Technology, 1603-1 Kami-Tomioka, Nagaoka, Niigata 940-2188, Japan; Department of Science of Technology Innovation, Nagaoka University of Technology, 1603-1 Kami-Tomioka, Nagaoka, Niigata 940-2188, Japan
| | - Tadashi Shiohama
- Department of Pediatrics, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-0856, Japan.
| | - Yohei Hayashi
- iPS Cell Advanced Characterization and Development Team, BioResource Research Center, RIKEN, 3-1-1 Koyadai, Tsukuba, Ibaraki 305-0074, Japan.
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14
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Motil KJ, Beisang A, Smith-Hicks C, Lembo A, Standridge SM, Liu E. Recommendations for the management of gastrointestinal comorbidities with or without trofinetide use in Rett syndrome. Expert Rev Gastroenterol Hepatol 2024; 18:227-237. [PMID: 38869952 DOI: 10.1080/17474124.2024.2368014] [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: 05/21/2024] [Accepted: 06/11/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Although gastrointestinal (GI) comorbidities are experienced by over 90% of individuals with Rett syndrome (RTT), a neurodevelopmental disorder associated with mutations in the MECP2 gene, many neurologists and pediatricians do not rank the management of these comorbidities among the most important treatment goals for RTT. Trofinetide, the first approved pharmacologic treatment for RTT, confers improvements in RTT symptoms but is associated with adverse GI events, primarily diarrhea and vomiting. Treatment strategies for GI comorbidities and drug-associated symptoms in RTT represent an unmet clinical need. AREAS COVERED This perspective covers GI comorbidities experienced by those with RTT, either with or without trofinetide treatment. PubMed literature searches were undertaken on treatment recommendations for the following conditions: constipation, diarrhea, vomiting, aspiration, dysphagia, gastroesophageal reflux, nausea, gastroparesis, gastritis, and abdominal bloating. EXPERT OPINION The authors recommend a proactive approach to management of symptomatic GI comorbidities and drug-associated symptoms in RTT to enhance drug tolerance and improve the quality of life of affected individuals. Management strategies for common GI comorbidities associated with RTT are reviewed based on authors' clinical experience and augmented by recommendations from the literature.
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Affiliation(s)
- Kathleen J Motil
- Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Arthur Beisang
- Department of Pediatrics, Gillette Children's Hospital, Saint Paul, MN, USA
| | - Constance Smith-Hicks
- Center for Synaptic Disorders, Rett and Related Disorders Clinic, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Anthony Lembo
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Shannon M Standridge
- Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Edwin Liu
- Digestive Health Institute, Children's Hospital Colorado, Denver, CO, USA
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15
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Abbott M, Angione K, Forbes E, Stoecker M, Saenz M, Neul JL, Marsh ED, Skinner SA, Percy AK, Benke TA. Rett syndrome diagnostic odyssey: Limitations of NextGen sequencing. Am J Med Genet A 2024:e63725. [PMID: 38775384 DOI: 10.1002/ajmg.a.63725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 05/09/2024] [Indexed: 05/30/2024]
Abstract
Typical (or classic) Rett syndrome (RTT) is an X-linked neurodevelopmental disorder characterized by a period of regression, partial or complete loss of purposeful hand movements, and acquired speech, impaired gait, and stereotyped hand movements. In over 95% of typical RTT, a pathogenic variant is found in the methyl-CPG binding protein 2 gene (MECP2). Here, we describe a young woman with clinically diagnosed typical RTT syndrome who lacked a genetic diagnosis despite 20 years of investigation and multiple rounds of sequencing the MECP2 gene. Recently, additional genetic testing using next-generation sequencing was completed, which revealed a partial insertion of the BCL11A gene within exon 4 of MECP2, resulting in a small deletion in MECP2, causing likely disruption of MeCP2 function due to a frameshift. This case demonstrates the ever-changing limitations of genetic testing, as well as the importance of continual pursuit of a diagnosis as technologies improve and are more widely utilized.
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Affiliation(s)
- Megan Abbott
- Department of Child Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
- School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado, USA
| | - Katie Angione
- Department of Child Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
- School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado, USA
| | - Emily Forbes
- School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Margarita Saenz
- Department of Child Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
- School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jeffrey L Neul
- Departments of Pediatrics and Pharmacology, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric D Marsh
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Alan K Percy
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tim A Benke
- Department of Child Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
- School of Medicine, University of Colorado Denver | Anschutz Medical Campus, Aurora, Colorado, USA
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16
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Abo Zeid M, Elrosasy A, Mohamed RG, Ghazou A, Goufa E, Hassan N, Abuzaid Y. A meta-analysis of the efficacy and safety of trofinetide in patients with rett syndrome. Neurol Sci 2024:10.1007/s10072-024-07584-8. [PMID: 38771525 DOI: 10.1007/s10072-024-07584-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Rett syndrome (RTT) is an uncommon inherited neurodevelopmental disorder that affects brain development, mostly in females. It results from mutation in MECP2 gene in the long arm (q) of the X chromosome. OBJECTIVE Trofinetide is a recently developed drug that has a neuroprotective effect on neurons, and it is our aim in this meta-analysis to evaluate its efficacy and safety in treating Rett syndrome patients. METHODS We searched 5 databases (PubMed, Scopus, Embase, Web of Science, and Cochrane Library databases) to identify randomized controlled trials (RCTs) comparing Trofinetide and placebo in patients with Rett syndrome until August 13, 2023.Our primary outcomes were the Clinical Global Impression-Improvement (CGI) and the Rett syndrome Behavior Questionnaire (RSBQ). We used Risk of Bias Assessment tool-2 (ROB2) to assess the methodological quality of the included randomized controlled trials. RESULTS Three RCTs with a total of 325 patients were included with a follow-up duration ranging from one month to three months. 186 patients received the intervention drug (Trofinetide) and 138 received the placebo. Trofinetide was found to reduce CGI and RSBQ significantly more than placebo (MD = -0.35, 95% CI [-0.52 to -0.18], P 0.0001), (MD = -3.40, 95% CI [-3.69 to -3.12], P 0.00001) respectively. Most adverse events did not show any statistical difference between Trofinetide and the placebo. CONCLUSION Trofinetide offers promise as a potential effective and safe therapeutic opportunity for a population without many available treatments, with improvements seen on both CGI and RSBQ assessments and no severe adverse effects reported.
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Affiliation(s)
| | - Amr Elrosasy
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rashad G Mohamed
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alina Ghazou
- Faculty of Medicine, Jordan University of Science and Technology, Ar-Ramtha, Jordan
| | - Elarbi Goufa
- Faculty of Medicine, University of Oran 1 - Ahmed Ben Bella, Es Senia, Algeria
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17
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Sharifi O, Haghani V, Neier KE, Fraga KJ, Korf I, Hakam SM, Quon G, Johansen N, Yasui DH, LaSalle JM. Sex-specific single cell-level transcriptomic signatures of Rett syndrome disease progression. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.16.594595. [PMID: 38798575 PMCID: PMC11118571 DOI: 10.1101/2024.05.16.594595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Dominant X-linked diseases are uncommon due to female X chromosome inactivation (XCI). While random XCI usually protects females against X-linked mutations, Rett syndrome (RTT) is a female neurodevelopmental disorder caused by heterozygous MECP2 mutation. After 6-18 months of typical neurodevelopment, RTT girls undergo poorly understood regression. We performed longitudinal snRNA-seq on cerebral cortex in a construct-relevant Mecp2e1 mutant mouse model of RTT, revealing transcriptional effects of cell type, mosaicism, and sex on progressive disease phenotypes. Across cell types, we observed sex differences in the number of differentially expressed genes (DEGs) with 6x more DEGs in mutant females than males. Unlike males, female DEGs emerged prior to symptoms, were enriched for homeostatic gene pathways in distinct cell types over time, and correlated with disease phenotypes and human RTT cortical cell transcriptomes. Non-cell-autonomous effects were prominent and dynamic across disease progression of Mecp2e1 mutant females, indicating wild-type-expressing cells normalizing transcriptional homeostasis. These results improve understanding of RTT progression and treatment.
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Affiliation(s)
- Osman Sharifi
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
- MIND Institute, University of California, Davis, CA 95616
| | - Viktoria Haghani
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
- MIND Institute, University of California, Davis, CA 95616
| | - Kari E. Neier
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
- MIND Institute, University of California, Davis, CA 95616
| | - Keith J. Fraga
- Cellular and Molecular Biology, College of Biological Sciences, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
| | - Ian Korf
- Cellular and Molecular Biology, College of Biological Sciences, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
| | - Sophia M. Hakam
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
- MIND Institute, University of California, Davis, CA 95616
| | - Gerald Quon
- Cellular and Molecular Biology, College of Biological Sciences, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
| | - Nelson Johansen
- Cellular and Molecular Biology, College of Biological Sciences, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
| | - Dag H. Yasui
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
- MIND Institute, University of California, Davis, CA 95616
| | - Janine M. LaSalle
- Medical Microbiology and Immunology, School of Medicine, University of California, Davis, CA 95616
- Genome Center, University of California, Davis, CA 95616
- MIND Institute, University of California, Davis, CA 95616
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18
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Merritt JK, Fang X, Caylor RC, Skinner SA, Friez MJ, Percy AK, Neul JL. Normalized Clinical Severity Scores Reveal a Correlation between X Chromosome Inactivation and Disease Severity in Rett Syndrome. Genes (Basel) 2024; 15:594. [PMID: 38790223 PMCID: PMC11120815 DOI: 10.3390/genes15050594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/01/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Rett Syndrome (RTT) is a severe neurodevelopmental disorder predominately diagnosed in females and primarily caused by pathogenic variants in the X-linked gene Methyl-CpG Binding Protein 2 (MECP2). Most often, the disease causing the MECP2 allele resides on the paternal X chromosome while a healthy copy is maintained on the maternal X chromosome with inactivation (XCI), resulting in mosaic expression of one allele in each cell. Preferential inactivation of the paternal X chromosome is theorized to result in reduced disease severity; however, establishing such a correlation is complicated by known MECP2 genotype effects and an age-dependent increase in severity. To mitigate these confounding factors, we developed an age- and genotype-normalized measure of RTT severity by modeling longitudinal data collected in the US Rett Syndrome Natural History Study. This model accurately reflected individual increase in severity with age and preserved group-level genotype specific differences in severity, allowing for the creation of a normalized clinical severity score. Applying this normalized score to a RTT XCI dataset revealed that XCI influence on disease severity depends on MECP2 genotype with a correlation between XCI and severity observed only in individuals with MECP2 variants associated with increased clinical severity. This normalized measure of RTT severity provides the opportunity for future discovery of additional factors contributing to disease severity that may be masked by age and genotype effects.
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Affiliation(s)
- Jonathan K. Merritt
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Xiaolan Fang
- Department of Pathology, Henry Ford Health System, Detroit, MI 48202, USA;
- Greenwood Genetic Center, Greenwood, SC 29646, USA; (R.C.C.); (S.A.S.); (M.J.F.)
| | - Raymond C. Caylor
- Greenwood Genetic Center, Greenwood, SC 29646, USA; (R.C.C.); (S.A.S.); (M.J.F.)
| | - Steven A. Skinner
- Greenwood Genetic Center, Greenwood, SC 29646, USA; (R.C.C.); (S.A.S.); (M.J.F.)
| | - Michael J. Friez
- Greenwood Genetic Center, Greenwood, SC 29646, USA; (R.C.C.); (S.A.S.); (M.J.F.)
| | - Alan K. Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35294, USA;
| | - Jeffrey L. Neul
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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19
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Arezoumand KS, Roberts CT, Rastegar M. Metformin Induces MeCP2 in the Hippocampus of Male Mice with Sex-Specific and Brain-Region-Dependent Molecular Impact. Biomolecules 2024; 14:505. [PMID: 38672521 PMCID: PMC11048179 DOI: 10.3390/biom14040505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/29/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Rett Syndrome (RTT) is a progressive X-linked neurodevelopmental disorder with no cure. RTT patients show disease-associated symptoms within 18 months of age that include developmental regression, progressive loss of useful hand movements, and breathing difficulties, along with neurological impairments, seizures, tremor, and mental disability. Rett Syndrome is also associated with metabolic abnormalities, and the anti-diabetic drug metformin is suggested to be a potential drug of choice with low or no side-effects. Previously, we showed that in vitro exposure of metformin in a human brain cell line induces MECP2E1 transcripts, the dominant isoform of the MECP2 gene in the brain, mutations in which causes RTT. Here, we report the molecular impact of metformin in mice. Protein analysis of specific brain regions in the male and female mice by immunoblotting indicated that metformin induces MeCP2 in the hippocampus, in a sex-dependent manner. Additional experiments confirm that the regulatory role of metformin on the MeCP2 target "BDNF" is brain region-dependent and sex-specific. Measurement of the ribosomal protein S6 (in both phosphorylated and unphosphorylated forms) confirms the sex-dependent role of metformin in the liver. Our results can help foster a better understanding of the molecular impact of metformin in different brain regions of male and female adult mice, while providing some insight towards its potential in therapeutic strategies for the treatment of Rett Syndrome.
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Affiliation(s)
| | | | - Mojgan Rastegar
- Department of Biochemistry and Medical Genetics, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0J9, Canada
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20
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Darwish M, Passarell J, Youakim JM, Bradley H, Bishop KM. Exposure-Response Efficacy Modeling to Support Trofinetide Dosing in Individuals with Rett Syndrome. Adv Ther 2024; 41:1462-1480. [PMID: 38363467 PMCID: PMC10960884 DOI: 10.1007/s12325-024-02796-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Trofinetide was recently approved for the treatment of Rett syndrome (RTT) on the basis of the efficacy and safety findings of the phase 3 LAVENDER study, which used a body weight-based dosing regimen. Exposure-response (E-R) efficacy modeling was used to characterize relationships between trofinetide exposure measures (maximum drug concentration and area under the concentration-time curve for the dosing interval of 0-12 h [AUC0-12]) and efficacy endpoints in RTT clinical studies to support the trofinetide dosing regimen. METHODS Efficacy endpoints were modeled using trofinetide exposure measures predicted from the population pharmacokinetic model and Bayesian estimates. The analysis population for each E-R model comprised individuals receiving placebo or trofinetide who had available trofinetide exposure measures. Efficacy endpoints were scores from the Rett Syndrome Behaviour Questionnaire (RSBQ), the Clinical Global Impression-Improvement, the Communication and Symbolic Behavior Scales Developmental Profile™ Infant-Toddler Checklist (CSBS-DP-IT) Social Composite, and the Rett Syndrome Clinician Rating of Ability to Communicate Choices (RTT-COMC). RESULTS Higher trofinetide exposure was associated with improvements in RSBQ, CSBS-DP-IT Social Composite, and RTT-COMC scores. Assuming target trofinetide AUC0-12 values of 800-1200 μg·h/mL, the reductions in RSBQ total scores at week 12 were approximately five- to seven-fold greater with trofinetide (range 3.55-4.94) versus placebo (0.76). Significant E-R relationships were also found for the CSBS-DP-IT Social Composite and RTT-COMC scores. CONCLUSION E-R efficacy modeling demonstrated significant relationships between trofinetide exposure and RSBQ, CSBS-DP-IT Social Composite, and RTT-COMC scores. Trofinetide is efficacious within the target exposure range, supporting the approved dosing regimen for trofinetide. TRIAL REGISTRATION NCT01703533, NCT02715115, NCT04181723.
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Affiliation(s)
- Mona Darwish
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA.
| | - Julie Passarell
- Cognigen Corporation (a Simulations Plus Company), Buffalo, NY, USA
| | - James M Youakim
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA
| | - Heather Bradley
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA
| | - Kathie M Bishop
- Acadia Pharmaceuticals Inc., 12830 El Camino Real, Suite 400, San Diego, CA, 92130, USA
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21
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Moore R, Poulsen J, Reardon L, Samples-Morris C, Simmons H, Ramsey KM, Whatley ML, Lane JB. Managing Gastrointestinal Symptoms Resulting from Treatment with Trofinetide for Rett Syndrome: Caregiver and Nurse Perspectives. Adv Ther 2024; 41:1305-1317. [PMID: 38378975 PMCID: PMC10960750 DOI: 10.1007/s12325-024-02782-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/04/2024] [Indexed: 02/22/2024]
Abstract
Rett syndrome (RTT) is a rare genetic neurodevelopmental disorder mainly affecting female individuals. Trofinetide was recently approved as the first treatment for RTT, largely on the basis of results from the phase 3 LAVENDER trial, in which trofinetide showed improvements in core symptoms of RTT compared with placebo. However, gastrointestinal (GI) symptoms such as diarrhea and vomiting were commonly reported side effects, and taste was also a reported issue. The objective of this article is to describe the perspectives of five caregivers of girls in trofinetide clinical trials as well as those of three nurse trial coordinators, with a focus on management of GI symptoms of trofinetide treatment.Audio Abstract available for this article. Audio Abstract: Jane Lane provides an overview and discusses key findings of the article titled "Managing Gastrointestinal Symptoms Resulting from Treatment with Trofinetide for Rett Syndrome: Caregiver and Nurse Perspectives." (MP4 83274 KB).
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Affiliation(s)
| | | | | | | | | | - Keri M Ramsey
- Center for Rare Childhood Disorders, Translational Genomics Research Institute, Phoenix, AZ, USA
| | | | - Jane B Lane
- University of Alabama at Birmingham, Birmingham, AL, USA.
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22
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Abbas A, Fayoud AM, El Din Moawad MH, Hamad AA, Hamouda H, Fouad EA. Safety and efficacy of trofinetide in Rett syndrome: a systematic review and meta-analysis of randomized controlled trials. BMC Pediatr 2024; 24:206. [PMID: 38521908 PMCID: PMC10960414 DOI: 10.1186/s12887-024-04526-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/01/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Rett syndrome is a rare genetic neurodevelopmental disorder that predominantly impacts females. It presents with loss of acquired skills, impaired communication, and stereotypic hand movements. Given the limited treatment options for Rett syndrome, there is a dire need for effective interventions. OBJECTIVE To evaluate the safety and efficacy of trofinetide in Randomized Controlled Trials (RCTs) that report on Rett syndrome patients. METHODS We identified 109 articles from four databases (Scopus, PubMed, Web of Science, and Cochrane CENTRAL). After removing the duplicates, we narrowed them down to 59 articles for further assessment. We included RCTs that evaluated the efficacy and safety of trofinetide in patients with Rett syndrome. Three studies were eligible for inclusion. Two independent reviewers evaluated the identified studies' titles, abstracts, and full texts, extracting pertinent data. We assessed the quality of the studies using the Cochrane Risk of Bias (RoB) 2.0 tool. We then conducted a meta-analysis using the fixed effects model in the case of insignificant heterogeneity; otherwise, we used the random effects model. Based on the nature of the outcome, we analyzed the mean difference or the odds ratio. Analysis was conducted using RevMan version 5.3. RESULTS Among the analyzed outcomes in 181 patients in the trofinetide group and 134 patients in the placebo group, significant improvement in Rett Syndrome Behavior Questionnaire (RSBQ) scores was observed at 200 mg dosage (overall mean difference: -3.53, p = 0.001). Clinical Global Impression-Improvement (CGI-I) scores improved considerably at 200 mg dosage (overall mean difference: -0.34, p < 0.0001). No substantial changes were observed in Motor Behavioral Assessment (MBA) or Top 3 Caregiver Concerns. We evaluated Treatment Emergent Adverse Events (TEAEs) across the various dosages and noted significant associations with diarrhea (200 mg), vomiting (200 mg), and irritability (200 mg). However, we did not find a significant association between any of the dosages and the incidence of decreased appetite. CONCLUSION Trofinetide demonstrated potential in improving RSBQ and CGI-I scores at 200 mg dosage. Although no substantial changes were found in MBA and top 3 caregiver concerns. Adverse events were linked to specific dosages.
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Affiliation(s)
- Abdallah Abbas
- Faculty of Medicine, Al-Azhar University, Damietta, Egypt.
| | - Aya M Fayoud
- Faculty of Pharmacy, Kafr El sheik university, Kafr El Sheik, Egypt
| | - Mostafa Hossam El Din Moawad
- Faculty of Pharmacy Clinical Department, Alexandria University, Alexandria, Egypt
- Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Heba Hamouda
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Eman A Fouad
- Department of Pediatrics, Ubbo-Emmius-Klinik, Aurich, Germany
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23
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Anderson CD. Therapeutic potential for mRNA-based IGF-I regenerative therapy. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102143. [PMID: 38419942 PMCID: PMC10899049 DOI: 10.1016/j.omtn.2024.102143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Cynthia D Anderson
- The Center for Cardiovascular Research, Department of Medicine, John A. Burns School of Medicine, 651 Ilalo Street, Honolulu, HI 96813, USA
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24
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Raspa M, Gwaltney A, Bann C, von Hehn J, Benke TA, Marsh ED, Peters SU, Ananth A, Percy AK, Neul JL. Psychometric Assessment of the Rett Syndrome Caregiver Assessment of Symptom Severity (RCASS). J Autism Dev Disord 2024:10.1007/s10803-024-06238-0. [PMID: 38438817 DOI: 10.1007/s10803-024-06238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 03/06/2024]
Abstract
Rett syndrome is a severe neurodevelopmental disorder that affects about 1 in 10,000 females. Clinical trials of disease modifying therapies are on the rise, but there are few psychometrically sound caregiver-reported outcome measures available to assess treatment benefit. We report on a new caregiver-reported outcome measure, the Rett Caregiver Assessment of Symptom Severity (RCASS). Using data from the Rett Natural History Study (n = 649), we examined the factor structure, using both exploratory and confirmatory factor analysis, and the reliability and validity of the RCASS. The four-factor model had the best overall fit, which covered movement, communication, behavior, and Rett-specific symptoms. The RCASS had moderate internal consistency. Strong face validity was found with age and mutation type, and convergent validity was established with other similar measures, including the Revised Motor-Behavior Assessment Scale, Clinical Severity Scale, Clinical Global Impression Scale, and the Child Health Questionnaire. These data provide initial evidence that the RCASS is a viable caregiver-outcome measure for use in clinical trials in Rett syndrome. Future work to assess sensitivity to change and other measures of reliability, such as test-retest and inter-rater agreement, are needed.
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Affiliation(s)
- Melissa Raspa
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27708, USA.
| | - Angela Gwaltney
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27708, USA
| | - Carla Bann
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, 27708, USA
| | | | - Timothy A Benke
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, USA
| | - Eric D Marsh
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Sarika U Peters
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, USA
| | - Amitha Ananth
- University of Alabama at Birmingham, Birmingham, USA
| | - Alan K Percy
- University of Alabama at Birmingham, Birmingham, USA
| | - Jeffrey L Neul
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, USA.
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25
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Neul JL, Percy AK, Benke TA, Berry-Kravis EM, Glaze DG, Peters SU, Marsh ED, An D, Bishop KM, Youakim JM. Trofinetide Treatment Demonstrates a Benefit Over Placebo for the Ability to Communicate in Rett Syndrome. Pediatr Neurol 2024; 152:63-72. [PMID: 38232652 DOI: 10.1016/j.pediatrneurol.2023.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/27/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Trofinetide was approved by the US Food and Drug Administration for the treatment of Rett syndrome (RTT) in March 2023. Benefiting the ability to communicate in RTT is often identified as the most important caregiver goal for new therapies. This analysis reports the communication-related end points from the phase 3 LAVENDER study of trofinetide in RTT. METHODS Females with RTT, aged five to 20 years, were randomized 1:1 to trofinetide or placebo for 12 weeks. Secondary efficacy end points related to communication were based on change from baseline to week 12 and included the caregiver-rated Communication and Symbolic Behavior Scales Developmental Profile™ Infant-Toddler Checklist (CSBS-DP-IT) Social Composite score (key secondary end point; scores ranged from 0 to 26 [higher scores indicated better communication]) and novel clinician rating scales (0 [normal] to 7 [severe impairment]) measuring the ability to communicate choices nonverbally (RTT-COMC) and verbally (RTT-VCOM). RESULTS Trofinetide demonstrated a statistically significant difference versus placebo for the CSBS-DP-IT Social Composite score (least squares mean [LSM] difference = 1.0; 95% confidence interval [CI], 0.3 to 1.7; P = 0.0064; Cohen's d effect size = 0.43) and a nominally significant difference for the RTT-COMC (LSM difference: -0.3; 95% CI, -0.6 to -0.0; P = 0.0257; Cohen's d effect size = 0.36). As expected, there was no difference for the RTT-VCOM. CONCLUSIONS Significant treatment benefit for trofinetide versus placebo was observed in scales measuring the ability to communicate. These scales may be appropriate for future clinical studies in RTT and other neurodevelopmental disorders.
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Affiliation(s)
- Jeffrey L Neul
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan K Percy
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy A Benke
- Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Daniel G Glaze
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sarika U Peters
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric D Marsh
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Di An
- Acadia Pharmaceuticals Inc, San Diego, California
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26
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Neul JL. Challenges in developing therapies in fragile X syndrome: how the FXLEARN trial can guide research. J Clin Invest 2024; 134:e175036. [PMID: 38426491 PMCID: PMC10904042 DOI: 10.1172/jci175036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Fragile X syndrome (FXS), the most common inherited cause of intellectual disability and the single-gene cause of autism, is caused by decreased expression of the fragile X messenger ribonucleoprotein protein (FMRP), a ribosomal-associated RNA-binding protein involved in translational repression. Extensive preclinical work in several FXS animal models supported the therapeutic potential of decreasing metabotropic glutamate receptor (mGluR) signaling to correct translation of proteins related to synaptic plasticity; however, multiple clinical trials failed to show conclusive evidence of efficacy. In this issue of the JCI, Berry-Kravis and colleagues conducted the FXLEARN clinical trial to address experimental design concerns from previous trials. Unfortunately, despite treatment of young children with combined pharmacological and learning interventions for a prolonged period, no efficacy of blocking mGluR activity was observed. Future systematic evaluation of potential therapeutic approaches should evaluate consistency between human and animal pathophysiological mechanisms, utilize innovative clinical trial design from FXLEARN, and incorporate translatable biomarkers.
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27
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Potenzieri A, Uccella S, Preiti D, Pisoni M, Rosati S, Lavarello C, Bartolucci M, Debellis D, Catalano F, Petretto A, Nobili L, Fellin T, Tucci V, Ramenghi LA, Savardi A, Cancedda L. Early IGF-1 receptor inhibition in mice mimics preterm human brain disorders and reveals a therapeutic target. SCIENCE ADVANCES 2024; 10:eadk8123. [PMID: 38427732 PMCID: PMC10906931 DOI: 10.1126/sciadv.adk8123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/29/2024] [Indexed: 03/03/2024]
Abstract
Besides recent advances in neonatal care, preterm newborns still develop sex-biased behavioral alterations. Preterms fail to receive placental insulin-like growth factor-1 (IGF-1), a major fetal growth hormone in utero, and low IGF-1 serum levels correlate with preterm poor neurodevelopmental outcomes. Here, we mimicked IGF-1 deficiency of preterm newborns in mice by perinatal administration of an IGF-1 receptor antagonist. This resulted in sex-biased brain microstructural, functional, and behavioral alterations, resembling those of ex-preterm children, which we characterized performing parallel mouse/human behavioral tests. Pharmacological enhancement of GABAergic tonic inhibition by the U.S. Food and Drug Administration-approved drug ganaxolone rescued functional/behavioral alterations in mice. Establishing an unprecedented mouse model of prematurity, our work dissects the mechanisms at the core of abnormal behaviors and identifies a readily translatable therapeutic strategy for preterm brain disorders.
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Affiliation(s)
- Alberto Potenzieri
- Brain Development and Disease Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
- Università degli Studi di Genova, via Balbi, 5, 16126 Genoa, Italy
| | - Sara Uccella
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genoa, Italy
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Patologia Neonatale, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Deborah Preiti
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Patologia Neonatale, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Pisoni
- Optical Approaches to Brain Function Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Silvia Rosati
- Brain Development and Disease Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Chiara Lavarello
- Core Facilities - Clinical Proteomics and Metabolomics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Martina Bartolucci
- Core Facilities - Clinical Proteomics and Metabolomics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Doriana Debellis
- Electron Microscopy Facility, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Federico Catalano
- Electron Microscopy Facility, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Andrea Petretto
- Core Facilities - Clinical Proteomics and Metabolomics, IRCCS Istituto Giannina Gaslini, via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Lino Nobili
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genoa, Italy
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Tommaso Fellin
- Optical Approaches to Brain Function Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Valter Tucci
- Genetics and Epigenetics of Behavior (GEB) Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Luca A. Ramenghi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genoa, Italy
- Patologia Neonatale, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Annalisa Savardi
- Brain Development and Disease Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
| | - Laura Cancedda
- Brain Development and Disease Laboratory, Istituto Italiano di Tecnologia, via Morego, 30, 16163 Genoa, Italy
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28
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Darwish M, Youakim JM, Darling I, Lukacova V, Owen JS, Bradley H. A Physiologically Based Pharmacokinetic Modeling Approach to Assess the Potential for Drug Interactions Between Trofinetide and CYP3A4-Metabolized Drugs. Clin Ther 2024; 46:194-200. [PMID: 38307724 DOI: 10.1016/j.clinthera.2023.12.007] [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: 08/23/2023] [Revised: 11/01/2023] [Accepted: 12/24/2023] [Indexed: 02/04/2024]
Abstract
PURPOSE Trofinetide is the first drug to be approved by the US Food and Drug Administration for use in the treatment of patients with Rett syndrome, a multisystem disorder requiring multimodal therapies. Cytochrome P450 (CYP) 3A4 metabolizes >50% of therapeutic drugs and is the CYP isozyme most commonly expressed in the liver and intestines. In vitro studies suggest the concentration of trofinetide producing 50% inhibition (IC50) of CYP3A4 is >15 mmol/L; that concentration was much greater than the target clinical concentration associated with the maximal intended therapeutic dose (12 g). Thus, trofinetide has a low potential for drug-drug interactions in the liver. However, there is potential for drug-drug interactions in the intestines given the oral route of administration and expected relatively high concentration in the gastrointestinal tract after dose administration. METHODS Using a validated physiologically based pharmacokinetic (PBPK) model, deterministic and stochastic simulations were used for assessing the PK properties related to exposure and bioavailability of midazolam (sensitive index substrate for CYP3A4) following an oral (15 mg) or intravenous (2 mg) dose, with and without single-dose and steady-state (12 g) coadministration of oral trofinetide. FINDINGS Following coadministration of intravenous midazolam and oral trofinetide, the PK properties of midazolam were unchanged. The trofinetide concentration in the gut wall was >15 mmol/L during the first 1.5 hours after dosing. With the coadministration of oral midazolam and trofinetide, the model predicted increases in fraction of dose reaching the portal vein, bioavailability, Cmax, and AUCinf of 30%, 30%, 18%, and 30%, respectively. IMPLICATIONS In this study that used a PBPK modeling approach, it was shown that CYP3A4 enzyme activity in the liver was not affected by trofinetide coadministration, but trofinetide was predicted to be a weak inhibitor of intestinal CYP3A4 metabolism after oral administration at therapeutic doses.
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Affiliation(s)
- Mona Darwish
- Acadia Pharmaceuticals Inc, San Diego, California.
| | | | - Inger Darling
- Division of Cognigen Simulations Plus Inc, Buffalo, New York
| | | | - Joel S Owen
- Division of Cognigen Simulations Plus Inc, Buffalo, New York
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Wong LC, Hsu CJ, Wu YT, Chu HF, Lin JH, Wang HP, Hu SC, Tsai YC, Tsai WC, Lee WT. Investigating the impact of probiotic on neurological outcomes in Rett syndrome: A randomized, double-blind, and placebo-controlled pilot study. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2024:13623613231225899. [PMID: 38361371 DOI: 10.1177/13623613231225899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
LAY ABSTRACT Rett syndrome often involves gastrointestinal symptoms and gut microbiota imbalances. We conducted a study to explore the feasibility of probiotic Lactobacillus plantarum PS128 and the impact on neurological functions in Rett syndrome. The results of our investigation demonstrated that the supplementation of probiotic L. plantarum PS128 was feasible and well tolerated, with 100% retention rate and 0% withdrawal rate. In addition, there was only one participant who had loose stool after taking L. plantarum PS128. Further, there was a tendency to enhance overall cognitive developmental level, as assessed using Mullen Scales of Early Learning. In addition, it significantly improved dystonia, as assessed using the Burke-Fahn-Marsden Movement Scale, in comparison with the placebo group. This study provides a strong foundation for future research and clinical trials exploring the potential of L. plantarum PS128 probiotics as a complementary therapy for individuals with Rett syndrome.
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Affiliation(s)
- Lee Chin Wong
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Jui Hsu
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yen-Tzu Wu
- School and Graduate Institute of Physical Therapy, National Taiwan University College of Medicine, Taiwan
- Department of Physical Medicine and Rehabilitation, National Taiwan University, Taipei, Taiwan
| | - Hsu-Feng Chu
- Biomedical Industry Ph.D. Program, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jui-Hsiang Lin
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Hsin-Pei Wang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital YunLin Branch, YunLin, Taiwan
| | - Su-Ching Hu
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Ying-Chieh Tsai
- Institute of Biochemistry and Molecular Biology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Che Tsai
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei, Taiwan
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Al Shaer D, Al Musaimi O, Albericio F, de la Torre BG. 2023 FDA TIDES (Peptides and Oligonucleotides) Harvest. Pharmaceuticals (Basel) 2024; 17:243. [PMID: 38399458 PMCID: PMC10893093 DOI: 10.3390/ph17020243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
A total of nine TIDES (pepTIDES and oligonucleoTIDES) were approved by the FDA during 2023. The four approved oligonucleotides are indicated for various types of disorders, including amyotrophic lateral sclerosis, geographic atrophy, primary hyperoxaluria type 1, and polyneuropathy of hereditary transthyretin-mediated amyloidosis. All oligonucleotides show chemically modified structures to enhance their stability and therapeutic effectiveness as antisense or aptamer oligomers. Some of them demonstrate various types of conjugation to driving ligands. The approved peptides comprise various structures, including linear, cyclic, and lipopeptides, and have diverse applications. Interestingly, the FDA has granted its first orphan drug designation for a peptide-based drug as a highly selective chemokine antagonist. Furthermore, Rett syndrome has found its first-ever core symptoms treatment, which is also peptide-based. Here, we analyze the TIDES approved in 2023 on the basis of their chemical structure, medical target, mode of action, administration route, and common adverse effects.
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Affiliation(s)
- Danah Al Shaer
- Department of Medicinal Chemistry, Evotec (UK) Ltd., Abingdon OX14 4R, UK
| | - Othman Al Musaimi
- School of Pharmacy, Faculty of Medical Sciences, Newcastle upon Tyne NE1 7RU, UK
- Department of Chemical Engineering, Imperial College London, London SW7 2AZ, UK
| | - Fernando Albericio
- School of Chemistry and Physics, University of KwaZulu-Natal, Durban 4001, South Africa
- CIBER-BBN, Networking Centre on Bioengineering, Biomaterials and Nanomedicine, Department of Organic Chemistry, University of Barcelona, 08028 Barcelona, Spain
| | - Beatriz G de la Torre
- KRISP, College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa
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Kennedy M, Glass L, Glaze DG, Kaminsky S, Percy AK, Neul JL, Jones NE, Tropea D, Horrigan JP, Nues P, Bishop KM, Youakim JM. Development of trofinetide for the treatment of Rett syndrome: from bench to bedside. Front Pharmacol 2024; 14:1341746. [PMID: 38318312 PMCID: PMC10839050 DOI: 10.3389/fphar.2023.1341746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/18/2023] [Indexed: 02/07/2024] Open
Abstract
Rett syndrome (RTT) is rare neurodevelopmental disorder caused by mutations in the MECP2 gene that encodes methyl-CpG-binding protein 2 (MeCP2), a DNA-binding protein with roles in epigenetic regulation of gene expression. Functional loss of MeCP2 results in abnormal neuronal maturation and plasticity, characterized by loss of verbal communication and loss of fine and gross motor function, among others. Trofinetide, a synthetic analog of glycine-proline-glutamate, was approved by the US Food and Drug Administration for the treatment of RTT in adult and pediatric patients aged 2 years and older. Here, we present the development of trofinetide from bench research to clinical studies and emphasize how the collaboration between academia, the pharmaceutical industry, and patient advocacy led to the recent approval. The bench-to-bedside development of trofinetide underscores the value of collaboration between these groups in the development and approval of treatments for rare diseases.
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Affiliation(s)
- Melissa Kennedy
- International Rett Syndrome Foundation, Cincinnati, OH, United States
| | - Larry Glass
- Neuren Pharmaceuticals Ltd., Melbourne, VIC, Australia
| | - Daniel G. Glaze
- Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Steve Kaminsky
- International Rett Syndrome Foundation, Cincinnati, OH, United States
| | - Alan K. Percy
- Division of Pediatric Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeffrey L. Neul
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Daniela Tropea
- Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - Joseph P. Horrigan
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States
| | - Paige Nues
- International Rett Syndrome Foundation, Cincinnati, OH, United States
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Darwish M, Nunez R, Youakim JM, Robertson P. Characterization of the Pharmacokinetics and Mass Balance of a Single Oral Dose of Trofinetide in Healthy Male Subjects. Clin Drug Investig 2024; 44:21-33. [PMID: 38017349 PMCID: PMC10769996 DOI: 10.1007/s40261-023-01322-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Trofinetide is the first drug to be approved for the treatment of Rett syndrome, a neurodevelopmental disorder. The purpose of the study is to fully characterize the metabolic and excretion profiles of trofinetide in humans. METHODS This Phase 1, open-label, single-dose trial conducted in healthy male adults was designed to characterize the pharmacokinetics of trofinetide (absorption, metabolism, and excretion), mass balance of [14C]-trofinetide, and safety profile of trofinetide following administration of an oral 12-g dose administered as a mixture of trofinetide and [14C]-trofinetide. Blood, urine, and fecal samples were collected at prespecified timepoints. The pharmacokinetics of trofinetide were assessed in blood and urine samples using high-performance liquid chromatography (HPLC) with tandem mass spectrometric detection. Bioanalysis of radioactivity was conducted in blood, plasma, urine, and fecal samples using liquid scintillation counting. Metabolite profiling was conducted in blood, plasma, urine, and fecal samples using HPLC with liquid scintillation counting of chromatographic fractions. Safety and tolerability, including treatment-emergent adverse events (TEAEs), were assessed. RESULTS Blood concentration-time profiles of trofinetide and total radioactivity were almost superimposable up to ~12 h after dosing. Urine concentration-time profiles of trofinetide and total radioactivity were similar. Trofinetide was rapidly absorbed into the circulation with an initial rapid decline (half-life [t½] alpha ~2.6 h), followed by a relatively slow terminal elimination phase (t½ beta ~20 h). The blood-to-plasma total radioactivity ratios were 0.529-0.592, indicating a lack of affinity for the cellular portion of blood. Renal excretion accounted for 83.8% of the administered radiochemical dose; 15.1% was recovered in feces. Urine and fecal recovery of radioactivity accounted for 99% of the administered dose at 168 h after dosing. Parent [14C]-trofinetide was the major radiolabeled entity in blood and plasma (88.4% and 93.1% in area under the concentration-time curves from 0 to 12 h [AUC0-12] in pooled blood and plasma samples, respectively) and the major entity excreted in urine (91.5% in 0-48-h pooled urine samples) and in feces (52.7% in 0-192-h pooled fecal samples). Only small levels of metabolites were present. In blood and plasma, only two minor metabolites were identified (each metabolite ≤ 2.24% of the AUC0-12 pool). These two metabolites were also observed in urine and fecal samples (≤ 2.41% of dose). In feces, one additional metabolite (0.84% of dose) was identified. Two mild TEAEs were reported in two participants and were not considered related to trofinetide. There were no clinically meaningful changes in individual laboratory parameters, vital signs, physical findings, or electrocardiogram results. CONCLUSIONS Metabolic and excretion profiles confirm that trofinetide undergoes minimal hepatic or intestinal metabolism and is primarily excreted unchanged in the urine. Trofinetide containing radiolabeled [14C]-trofinetide was well tolerated.
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Affiliation(s)
- Mona Darwish
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, Suite 400, San Diego, CA, USA.
| | - Rene Nunez
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, Suite 400, San Diego, CA, USA
| | - James M Youakim
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, Suite 400, San Diego, CA, USA
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Furqan M. Trofinetide-a new chapter in rett syndrome's treatment. Front Pharmacol 2023; 14:1284035. [PMID: 38035006 PMCID: PMC10687465 DOI: 10.3389/fphar.2023.1284035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/09/2023] [Indexed: 12/02/2023] Open
Abstract
Trofinetide is the first drug approved by the FDA to treat Rett Syndrome in children aged 2 years or above. The drug significantly improved Rett syndrome behavioral scores Rett syndrome behavioral questionnaire in clinical studies. Although further research is needed to assess potential adverse events, Trofinetide's notable efficacy signifies a significant advancement in Rett syndrome treatment, offering a new therapeutic avenue with the potential to ameliorate the condition.
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Affiliation(s)
- Muhammad Furqan
- Department of Medicine, Mayo Hospital, King Edward Medical University, Lahore, Punjab, Pakistan
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Singh A, Balasundaram MK, Gupta D. Trofinetide in Rett syndrome: A brief review of safety and efficacy. Intractable Rare Dis Res 2023; 12:262-266. [PMID: 38024580 PMCID: PMC10680160 DOI: 10.5582/irdr.2023.01060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/31/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Rett syndrome (RTT) is a rare genetic neurological disorder that primarily affects girls and is caused by mainly mutations in the methyl-CpG-binding protein 2 (MECP2) gene, leading to critical issues in normal brain function. The condition has a global prevalence of 5 to 10 cases per 100,000 females, and there is currently no cure for RTT. However, therapy is available to manage the symptoms and improve quality of life. Trofinetide, an insulin-like growth factor 1, was originally developed as a stroke medication and progressed to Phase II clinical trials, where it exhibited favorable safety and efficacy profiles by improving several core RTT symptoms. Recently, Trofinetide received the US Food and Drug Administration (FDA) approval and orphan drug designation for the treatment of RTT, making it the first approved drug for this rare genetic disorder. It has also shown to be safe, well-tolerated and with no known drug interactions. These findings suggest that Trofinetide is a promising treatment option for individuals with RTT.
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Affiliation(s)
- Alok Singh
- Department of Pharmacology, All India Institute of Medical Sciences Raipur, Chhattisgarh, India
| | - Mahesh Kumar Balasundaram
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Dhyuti Gupta
- Department of Pharmacology, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
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35
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Neul JL, Benke TA, Marsh ED, Suter B, Silveira L, Fu C, Peters SU, Percy AK. Top caregiver concerns in Rett syndrome and related disorders: data from the US natural history study. J Neurodev Disord 2023; 15:33. [PMID: 37833681 PMCID: PMC10571464 DOI: 10.1186/s11689-023-09502-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVE Recent advances in the understanding of neurodevelopmental disorders such as Rett syndrome (RTT) have enabled the discovery of novel therapeutic approaches that require formal clinical evaluation of efficacy. Clinical trial success depends on outcome measures that assess clinical features that are most impactful for affected individuals. To determine the top concerns in RTT and RTT-related disorders we asked caregivers to list the top caregiver concerns to guide the development and selection of appropriate clinical trial outcome measures for these disorders. METHODS Caregivers of participants enrolled in the US Natural History Study of RTT and RTT-related disorders (n = 925) were asked to identify the top 3 concerning problems impacting the affected participant. We generated a weighted list of top caregiver concerns for each of the diagnostic categories and compared results between the disorders. Further, for classic RTT, caregiver concerns were analyzed by age, clinical severity, and common RTT-causing mutations in MECP2. RESULTS The top caregiver concerns for classic RTT were effective communication, seizures, walking/balance issues, lack of hand use, and constipation. The frequency of the top caregiver concerns for classic RTT varied by age, clinical severity, and specific mutations, consistent with known variation in the frequency of clinical features across these domains. Caregivers of participants with increased seizure severity often ranked seizures as the first concern, whereas caregivers of participants without active seizures often ranked hand use or communication as the top concern. Comparison across disorders found commonalities in the top caregiver concerns between classic RTT, atypical RTT, MECP2 duplication syndrome, CDKL5 deficiency disorder, and FOXG1 syndrome; however, distinct differences in caregiver concerns between these disorders are consistent with the relative prevalence and impact of specific clinical features. CONCLUSION The top caregiver concerns for individuals with RTT and RTT-related disorders reflect the impact of the primary clinical symptoms of these disorders. This work is critical in the development of meaningful therapies, as optimal therapy should address these concerns. Further, outcome measures to be utilized in clinical trials should assess these clinical issues identified as most concerning by caregivers.
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Affiliation(s)
- Jeffrey L Neul
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Timothy A Benke
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Eric D Marsh
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Lori Silveira
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Cary Fu
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarika U Peters
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- University of Alabama at Birmingham, Birmingham, AL, USA
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Réthelyi JM, Vincze K, Schall D, Glennon J, Berkel S. The role of insulin/IGF1 signalling in neurodevelopmental and neuropsychiatric disorders - Evidence from human neuronal cell models. Neurosci Biobehav Rev 2023; 153:105330. [PMID: 37516219 DOI: 10.1016/j.neubiorev.2023.105330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 07/15/2023] [Accepted: 07/26/2023] [Indexed: 07/31/2023]
Abstract
Insulin and insulin-like growth factor 1 (IGF1) signalling play a central role in the development and maintenance of neurons in the brain, and human neurodevelopmental as well as neuropsychiatric disorders have been linked to impaired insulin and IGF1 signalling. This review focuses on the impairments of the insulin and IGF1 signalling cascade in the context of neurodevelopmental and neuropsychiatric disorders, based on evidence from human neuronal cell models. Clear evidence was obtained for impaired insulin and IGF1 receptor downstream signalling in neurodevelopmental disorders, while the evidence for its role in neuropsychiatric disorders was less substantial. Human neuronal model systems can greatly add to our knowledge about insulin/IGF1 signalling in the brain, its role in restoring dendritic maturity, and complement results from clinical studies and animal models. Moreover, they represent a useful model for the development of new therapeutic strategies. Further research is needed to systematically investigate the exact role of the insulin/IGF1 signalling cascades in neurodevelopmental and neuropsychiatric disorders, and to elucidate the respective therapeutic implications.
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Affiliation(s)
- János M Réthelyi
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Katalin Vincze
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary; Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Dorothea Schall
- Institute of Human Genetics, Heidelberg University, Heidelberg, Germany
| | - Jeffrey Glennon
- Conway Institute of Biomedical and Biomolecular Research, School of Medicine, University College Dublin, Dublin, Ireland
| | - Simone Berkel
- Institute of Human Genetics, Heidelberg University, Heidelberg, Germany; Interdisciplinary Centre of Neurosciences (IZN), Heidelberg University, Germany.
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Parent H, Ferranti A, Niswender C. Trofinetide: a pioneering treatment for Rett syndrome. Trends Pharmacol Sci 2023; 44:740-741. [PMID: 37460385 PMCID: PMC10529922 DOI: 10.1016/j.tips.2023.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 08/09/2023]
Affiliation(s)
- Harrison Parent
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA; Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, USA
| | - Anthony Ferranti
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA; Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, USA
| | - Colleen Niswender
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA; Warren Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, TN, USA; Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN, USA; Vanderbilt Institute of Chemical Biology, Vanderbilt University School of Medicine, Nashville, TN, USA.
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38
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Neul JL, Benke TA, Marsh ED, Lane JB, Lieberman DN, Skinner SA, Glaze DG, Suter B, Heydemann PT, Beisang AA, Standridge SM, Ryther RCC, Haas RH, Edwards LJ, Ananth A, Percy AK. Distribution of hand function by age in individuals with Rett syndrome. ANNALS OF THE CHILD NEUROLOGY SOCIETY 2023; 1:228-238. [PMID: 38496825 PMCID: PMC10939125 DOI: 10.1002/cns3.20038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/14/2023] [Indexed: 03/19/2024]
Abstract
Objective To determine the longitudinal distribution of hand function skills in individuals with classic Rett Syndrome (RTT), an X-linked dominant neurodevelopmental disorder, and correlate with MECP2 variants. Method We conducted a longitudinal study of 946 girls and young women with typical RTT seen between 2006 and 2021 in the US Natural History Study (NHS) featuring a structured clinical evaluation to assess the level of hand function skills. The specific focus in this study was to assess longitudinal variation of hand skills from age 2 through age 18 years in relation to specific MECP2 variant groups. Results Following the initial regression period, hand function continues to decline across the age spectrum in individuals with RTT. Specific differences are noted with steeper declines in hand function among those with milder variants (Group A: R133C, R294X, R306C, and C-terminal truncations) compared to groups composed of individuals with more severe variants. Conclusions These temporal variations in hand use represent specific considerations which could influence the design of clinical trials that test therapies aiming to ameliorate specific functional limitations in individuals with RTT. Furthermore, the distinct impact of specific MECP2 variants on clinical severity, especially related to hand use, should be considered in such interventional trials.
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Affiliation(s)
| | - Tim A. Benke
- University of Colorado, School of Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Eric D. Marsh
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jane B. Lane
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | | | | | | | - Lloyd J. Edwards
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL
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Percy AK, Neul JL, Benke TA, Marsh ED, Glaze DG. A review of the Rett Syndrome Behaviour Questionnaire and its utilization in the assessment of symptoms associated with Rett syndrome. Front Pediatr 2023; 11:1229553. [PMID: 37635789 PMCID: PMC10450502 DOI: 10.3389/fped.2023.1229553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/03/2023] [Indexed: 08/29/2023] Open
Abstract
The Rett Syndrome Behaviour Questionnaire (RSBQ), which is completed by the caregiver, is one of the most widely used efficacy measures in clinical studies of Rett syndrome (RTT) due to its specificity to the core features of RTT. As healthcare providers participate in routine healthcare assessments of individuals with RTT in clinical practice, there is a need for these providers to understand the psychometric properties of the RSBQ and how it relates to the core clinical features of RTT. Here, we describe the characteristics of the RSBQ, review the literature on its validity and reliability as well as its performance in a phase 2 study and the recent phase 3 LAVENDER study. The RSBQ was first shown to discriminate RTT from other intellectual disorders with good inter-rater and test-retest reliability scores. It was subsequently validated as an appropriate instrument for measuring behavior in females with RTT and adopted as a clinical trial outcome. In LAVENDER, the FDA-approved drug trofinetide significantly improved the RSBQ total score over placebo in girls and women with RTT and change from baseline for all RSBQ subscores were directionally in favor of trofinetide. The change in RSBQ was aligned with the Clinical Global Impression-Improvement scale, suggesting that improvement in behavioral components may be related to overall clinical status. Given its validity and ubiquity in RTT clinical studies, it is important that the interplay of the domains and the psychometric profile of the RSBQ are understood.
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Affiliation(s)
- Alan K. Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeffrey L. Neul
- Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy A. Benke
- Children’s Hospital of Colorado/University of Colorado School of Medicine, Aurora, CO, United States
| | - Eric D. Marsh
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Daniel G. Glaze
- Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, United States
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Oluigbo DC. Rett Syndrome: A Tale of Altered Genetics, Synaptic Plasticity, and Neurodevelopmental Dynamics. Cureus 2023; 15:e41555. [PMID: 37554594 PMCID: PMC10405636 DOI: 10.7759/cureus.41555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/10/2023] Open
Abstract
Rett syndrome (RTT) is a neurodevelopmental disorder that is a leading cause of severe cognitive and physical impairment. RTT typically occurs in females, although rare cases of males with the disease exist. Its genetic cause, symptoms, and clinical progression timeline have also become well-documented since its initial discovery. However, a relatively late diagnosis and lack of an available cure signify that our understanding of the disease is incomplete. Innovative research methods and tools are thereby helping to fill gaps in our knowledge of RTT. Specifically, mouse models of RTT, video analysis, and retrospective parental analysis are well-established tools that provide valuable insights into RTT. Moreover, current and anticipated treatment options are improving the quality of life of the RTT patient population. Collectively, these developments are creating optimistic future perspectives for RTT.
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Affiliation(s)
- David C Oluigbo
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, USA
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May DM, Neul JL, Satija A, Cheng WY, Lema N, Boca A, Lefebvre P, Piña-Garza JE. Real-world clinical management of individuals with Rett syndrome: a physician survey. J Med Econ 2023; 26:1570-1580. [PMID: 37991281 DOI: 10.1080/13696998.2023.2286778] [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: 03/03/2023] [Accepted: 11/20/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Rett syndrome (RTT) is a severe neurodevelopmental disorder. Management strategies are heterogeneous with no clear definition of success. This study describes physician decision-making regarding diagnosis, therapeutic goals, and management strategies to better understand RTT clinical management in the US. METHODS This study was conducted among practicing physicians, specifically neurologists and pediatricians in the US with experience treating ≥2 individuals with RTT, including ≥1 individuals within the past two years. In-depth interviews with five physicians informed survey development. A cross-sectional survey was then conducted among 100 physicians. RESULTS Neurologists had treated more individuals with RTT (median: 12 vs. 5, p < 0.001) than pediatricians throughout their career and were more likely to report being "very comfortable" managing RTT (31 vs. 4%, p < 0.001). Among physicians with experience diagnosing RTT (93%), most evaluated symptoms (91%) or used genetic testing (86%) for RTT diagnoses; neurologists used the 2010 consensus diagnostic criteria more than pediatricians (54 vs. 29%; p = 0.012). Improving the quality of life (QOL) of individuals with RTT was the most important therapeutic goal among physicians, followed by improving caregivers' QOL. Most physicians used clinical practice guidelines to monitor the progress of individuals with RTT, although neurologists relied more on clinical scales than pediatricians. Among all physicians, the most commonly treated symptoms included behavioral issues, epilepsy/seizures, and feeding issues. Management strategies varied by symptom, with referral to appropriate specialists being common across symptoms. A large proportion of physicians (37%) identified the lack of novel therapies and reliance on symptom-specific management as an unmet need. CONCLUSION Although most physicians had experience and were comfortable diagnosing and treating individuals with RTT, better education and support among pediatricians is warranted. Additionally, novel treatments that target multiple symptoms associated with RTT could reduce the burden and improve the QOL of individuals with RTT and their caregivers.
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Affiliation(s)
| | - Jeffrey L Neul
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Neema Lema
- Analysis Group, Inc., Menlo Park, CA, USA
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