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Paquet Luzy C, Doppler E, Polasek TM, Giorgino R. First-in-human single-dose study of nizubaglustat, a dual inhibitor of ceramide glucosyltransferase and non-lysosomal glucosylceramidase: Safety, tolerability, pharmacokinetics, and pharmacodynamics of single ascending and multiple doses in healthy adults. Mol Genet Metab 2024; 141:108113. [PMID: 38113551 DOI: 10.1016/j.ymgme.2023.108113] [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: 10/31/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023]
Abstract
Nizubaglustat is a novel, orally available, brain penetrant, potent, and selective dual inhibitor of ceramide glucosyltranferase and non-lysosomal neutral glucosylceramidase (NLGase), which is currently under development for the treatment of subjects with neurological manifestations in primary and secondary gangliosidoses. The objectives of this first-in-human study were to evaluate the safety and tolerability, pharmacokinetics, and pharmacodynamics (PD) of single oral doses of nizubaglustat after single (1, 3, and 9 mg) and multiple oral doses (9 mg once per day (QD) over 14 days) in healthy adults. Nizubaglustat was rapidly absorbed and systemic exposure was dose-proportional. Steady-state was achieved after three days of QD multiple dosing with minimal accumulation. Renal clearance accounted for around 15% of nizubaglustat elimination. Following multiple dosing, plasma concentrations of glucosylceramide (GlcCer), lactosylceramide (LacCer), and monosialodihexosylganglioside (GM3) decreased to a nadir at Day 10. PD target engagement of GCS inhibition was shown by a median decrease from baseline of plasma concentrations of GlcCer, LacCer, and GM3 ganglioside by 70%, 50%, and 48%, respectively. NLGase inhibition was also manifested by increased concentrations of GlcCer in cerebrospinal fluid from Day 1 to Day 14. Nizubaglustat was safe and well-tolerated at all doses tested. Consistent with the high selectivity, and the absence of intestinal disaccharidases inhibition, no cases of diarrhea were reported. No decreased appetite or weight loss was noted. Only treatment-emergent adverse events with preferred terms belonging to the system organ class skin and subcutaneous disorders of mild intensity were reported as drug-related in the nizubaglustat arm, in line with the pharmacological mechanism targeting glucosylceramide metabolism. Taken together, these data support QD dosing of nizubaglustat and its ongoing development in patients with primary and secondary forms of gangliosidoses.
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Affiliation(s)
| | | | - Thomas M Polasek
- Principal Investigator, CMAX Research Phase 1 Unit, Ground Floor 21-24 North Terrace, Adelaide, 5000, SA, Australia; Department of Clinical Pharmacology, Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia
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Camou F, Lagadec A, Coutinho A, Berger MG, Cador-Rousseau B, Gaches F, Belmatoug N. Patient reported outcomes of patients with Gaucher disease type 1 treated with eliglustat in real-world settings: The ELIPRO study. Mol Genet Metab 2023; 140:107667. [PMID: 37597334 DOI: 10.1016/j.ymgme.2023.107667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Gaucher disease type 1 (GD1) is a rare genetic lysosomal storage disorder. Eliglustat is a first-line oral therapy for adult patients with GD1. The aim of the ELIPRO (ELIglustat Patient Reported Outcomes) study was to assess real-world outcomes of eliglustat treatment for over 1 year in patients with GD1, with a focus on patient-reported outcomes (PROs), including treatment adherence. METHODS This was a non-interventional, prospective, multicentric study. Patients were stratified according to their previous time on eliglustat: >6 months (Group1) and ≤ 6 months (Group2). The primary endpoint was adherence to eliglustat, measured by the eight-items Morisky Medication Adherence Scale (MMAS-8; scale of 0-8) at 6 months in Group2. Secondary endpoints were quality of life (QoL) measured by patient input using the European Quality of Life five-dimensional three-level [EQ-5D-3L] questionnaire, fatigue and pain measured by numeric rating scale [NRS; on a scale of 0-10], the evaluation of patient satisfaction level regarding eliglustat treatment measured by Likert scale [scale of 0-7] and treatment adherence at 12 months in both groups. The study also evaluated the safety and effectiveness of eliglustat in the adult GD1 population. RESULTS Sixty patients with GD1 (approximatively 52% male, mean age: 46.6 ± 13.9 years) were analyzed: 29 in Group1 and 31 in Group2. GD1 was mostly of mild severity (90%) and 95% of patients had extensive CYP2D6 metabolizer phenotype. Fifty-seven patients had previously received treatment for GD1 (91% enzyme replacement therapy) and 15% were splenectomized. Groups1 and 2 were not necessarily matching for all characteristics. At 6 months, 58% of Group2 patients showed medium adherence (6 < MMAS-8 < 7.75) while 21% showed high adherence (MMAS-8: 8) (mean MMAS-8: 6.7 ± 1.0); similar results were obtained in Group1 (50% showed high compliance, 35% showed medium compliance; mean MMAS-8: 6.8 ± 1.4). The mean MMAS-8 for Group1 and Group2 were 7.1 ± 1.2 (vs 7.0 ± 1.0 at baseline) and 6.5 ± 1.0, respectively, at 12 months. At 12 months, the mean NRS scores in Group1 and Group2 were 72.0 ± 18.5 and 77.3 ± 13.7 for QoL (vs. 71.7 ± 18.4 and 80.2 ± 12.4, respectively at baseline), 4.8 ± 2.6 and 3.6 ± 2.7 for fatigue (vs. 4.6 ± 2.7 and 3.6 ± 2.6, respectively at baseline) and 3.3 ± 2.7 and 2.3 ± 2.3 for pain (vs. 3.3 ± 2.7 and 2.0 ± 2.4, respectively at baseline). GD1 assessments (biological, clinical and imaging parameters) remained stable during 12 months in both groups. At the end of the study, majority (97.4%) of patients were satisfied with their treatment with eliglustat (satisfaction score over 5 out of 7). Sixty-six percent of patients (n = 41) experienced mostly mild adverse events (AE) (including four study withdrawals), of whom 27.4% (n = 17) of patients experienced eliglustat-related AEs. Treatment adherence remained stable during 12 months in both groups. CONCLUSIONS Eliglustat treatment compliance was good and sustained, along with overall health state, fatigue and pain levels, which was consistent with overall patients' clinical status. Eliglustat was well tolerated, and had a good safety profile, aligned with a good patient satisfaction. Our study should encourage greater use of PROs for evaluation of impact of the GD treatment on patient's symptoms and well-being.
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Affiliation(s)
| | | | - Angela Coutinho
- Vaincre les Maladies Lysosomales Patient Association, Massy, France
| | - Marc G Berger
- CHU Clermont-Ferrand, Hematology department, and EA 7453 CHELTER, University Clermont Auvergne, Clermont-Ferrand, France
| | | | | | - Nadia Belmatoug
- Referral Center for Lysosomal Diseases, Paris Cité University, APHP-Nord, France
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Long-term effects of eliglustat on skeletal manifestations in clinical trials of patients with Gaucher disease type 1. Genet Med 2023; 25:100329. [PMID: 36469032 DOI: 10.1016/j.gim.2022.10.011] [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: 06/12/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Most patients with Gaucher disease have progressive and often disabling skeletal manifestations. We examined the long-term effect of eliglustat treatment on bone outcomes in clinical trials in adults with Gaucher disease type 1. METHODS Data from 4 completed phase 2 and 3 trials were evaluated in treatment-naïve patients or patients switching to eliglustat from enzyme replacement therapy (ERT). RESULTS Overall, 319 of 393 (81%) eliglustat-treated patients remained in their trials until completion or commercial eliglustat became available. Mean eliglustat treatment duration ranged from 3.3 to 6.5 years. In treatment-naïve patients and ERT-switch patients, frequency and severity of bone pain decreased during eliglustat treatment. Mean lumbar spine T-scores shifted from abnormal to normal in treatment-naïve patients and remained in the healthy reference range or improved modestly in ERT-switch patients. Mean total bone marrow burden score shifted from marked-to-severe to moderate in treatment-naïve patients and remained moderate in ERT-switch patients. MIP-1β (marker of active bone disease) was elevated at baseline and decreased to the healthy reference range in treatment-naïve patients and remained in the healthy reference range among ERT-switch patients. CONCLUSION These findings confirm the long-term efficacy of eliglustat on skeletal complications of Gaucher disease in treatment-naïve and ERT-switch patients.
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Torralba-Cabeza MÁ, Morado-Arias M, Pijierro-Amador A, Fernández-Canal MC, Villarrubia-Espinosa J. Recommendations for oral treatment for adult patients with type 1 Gaucher disease. Rev Clin Esp 2022; 222:S2254-8874(22)00043-1. [PMID: 35676195 DOI: 10.1016/j.rceng.2022.02.008] [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: 10/27/2021] [Accepted: 02/12/2022] [Indexed: 11/17/2022]
Abstract
This work is a review of the scientific evidence on the oral treatment of adult patients with Gaucher disease type 1 (GD1) with a clinical guideline format according to the Agree II regulations. It describes the main differences between the two oral treatments currently available for treating this disease (miglustat and eliglustat). This review reminds us that the criteria for starting oral treatment in patients with GD1 must be assessed individually. Although miglustat and eliglustat are both glucosylceramide synthase (GCS) enzyme inhibitors, they have different mechanisms of action and pharmacological properties and should never be considered equivalent. Miglustat is indicated in patients with non-severe GD1 who cannot receive other first-line treatments, while eliglustat is indicated as first-line treatment for patients with GD1 of any severity without the need for prior stabilization with enzyme replacement therapy (ERT). It is important to emphasize that in order to start treatment with eliglustat, we must know the CYP2D6 metabolic phenotype and its association with drugs metabolized through the CYP2D6 and CYP3A4 cytochromes-or alternatively those that use P-Glycoprotein must be evaluated on an individual basis. During pregnancy, the use of eliglustat should be avoided; only ERT can be used. Unlike miglustat, whose adverse effects have limited its use, eliglustat has not only demonstrated similar efficacy to ERT but has also been shown to improve the quality of life of patients with GD1.
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Affiliation(s)
- M Á Torralba-Cabeza
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna (SEMI), Spain; Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain.
| | - M Morado-Arias
- Servicio de Hematología, Hospital Universitario La Paz, Madrid, Spain
| | - A Pijierro-Amador
- Servicio de Medicina Interna, Hospital Universitario de Badajoz, Badajoz, Spain; Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna (SEMI), Spain
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Torralba-Cabeza M, Morado-Arias M, Pijierro-Amador A, Fernández-Canal M, Villarrubia-Espinosa J. Recomendaciones para el tratamiento oral de pacientes adultos con enfermedad de Gaucher tipo 1. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Aşantoğrol F, Dursun H, Canger EM, Bayram F. Clinical and radiological evaluation of dentomaxillofacial involvement in Type I Gaucher disease. Oral Radiol 2022; 38:210-223. [PMID: 34302573 DOI: 10.1007/s11282-021-00546-2] [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: 05/04/2021] [Accepted: 06/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to evaluate the oral findings and dentomaxillofacial involvement of patients diagnosed with Type I Gaucher Disease (GD), and to compare these findings with the control group. METHODS A total of 32 patients, 5 males, and 11 females in both the study (range 19-60, mean age 34.56) and control group (range 18-49, mean age 34.63) were included in the study. The file records of all patients obtained in the first evaluation were examined, and the hematological, visceral, and bone examination findings were recorded. Subsequently, oral examinations were performed for oral findings and dentomaxillofacial involvement, and radiological examinations were performed in panoramic images and cone-beam computed tomography (CBCT) images. RESULTS There was mandible involvement in 9 (56.3%), and involvement in both jaws in 4 (25.0%) of the patients with Type I GD. According to the CBCT findings, generalized rarefaction in 10 (62.5%) patients, enlarged marrow spaces in 12 (75.0%) patients, thinning of the lamina dura in 10 (62.5%) patients, and loss in the cortical borders of the mandibular canal in 7 (43.8%) patients were among the common radiographic findings. When the control and study group were compared, in panoramic images, a significant difference was found in terms of generalized rarefaction and enlarged marrow spaces, while significant differences were found in CBCT images regarding generalized rarefaction, enlarged marrow spaces, loss in the cortical margins of the mandibular canal and widening in the periodontal ligament space. CONCLUSIONS The roadmap for the diagnosis of Gaucher lesions in the jawbones includes a comprehensive medical history and a clinical and radiological examination. In conclusion, dentists should be familiar with the dentomaxillofacial findings of GD and be aware of possible oral and dental complications that may develop.
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Affiliation(s)
- Firdevs Aşantoğrol
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, 38060, Kayseri, Turkey.
| | - Hüseyin Dursun
- Department of Endocrinology and Metabolism, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Emin Murat Canger
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, 38060, Kayseri, Turkey
| | - Fahri Bayram
- Department of Endocrinology and Metabolism, Faculty of Medicine, Erciyes University, Kayseri, Turkey
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Glucocerebrosidase dysfunction in neurodegenerative disease. Essays Biochem 2021; 65:873-883. [PMID: 34528667 DOI: 10.1042/ebc20210018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/26/2021] [Accepted: 09/01/2021] [Indexed: 12/12/2022]
Abstract
Parkinson's disease (PD) and related neurodegenerative disorders, termed the synucleinopathies, are characterized pathologically by the accumulation of protein aggregates containing α-synuclein (aSyn), resulting in progressive neuronal loss. There is considerable need for the development of neuroprotective strategies to halt or slow disease progression in these disorders. To this end, evaluation of genetic mutations associated with the synucleinopathies has helped to elucidate crucial mechanisms of disease pathogenesis, revealing key roles for lysosomal and mitochondrial dysfunction. The GBA1 gene, which encodes the lysosomal hydrolase β-glucocerebrosidase (GCase) is the most common genetic risk factor for PD and is also linked to other neurodegenerative disorders including dementia with Lewy bodies (DLB). Additionally, homozygous mutations in GBA1 are associated with the rare lysosomal storage disorder, Gaucher's disease (GD). In this review, we discuss the current knowledge in the field regarding the diverse roles of GCase in neurons and the multifactorial effects of loss of GCase enzymatic activity. Importantly, GCase has been shown to have a bidirectional relationship with aSyn, resulting in a pathogenic feedback loop that can lead to progressive aSyn accumulation. Alterations in GCase activity have furthermore been linked to multiple distinct pathways involved in neurodegeneration, and therefore GCase has emerged as a promising target for therapeutic drug development for PD and related neurodegenerative disorders, particularly DLB.
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Glucosylceramide in cerebrospinal fluid of patients with GBA-associated and idiopathic Parkinson's disease enrolled in PPMI. NPJ Parkinsons Dis 2021; 7:102. [PMID: 34811369 PMCID: PMC8608962 DOI: 10.1038/s41531-021-00241-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 10/07/2021] [Indexed: 02/06/2023] Open
Abstract
Protein-coding variants in the GBA gene modulate susceptibility and progression in ~10% of patients with Parkinson’s disease (PD). GBA encodes the β-glucocerebrosidase enzyme that hydrolyzes glucosylceramide. We hypothesized that GBA mutations will lead to glucosylceramide accumulation in cerebrospinal fluid (CSF). Glucosylceramide, ceramide, sphingomyelin, and lactosylceramide levels were measured by liquid chromatography-tandem mass spectrometry in CSF of 411 participants from the Parkinson’s Progression Markers Initiative (PPMI) cohort, including early stage, de novo PD patients with abnormal dopamine transporter neuroimaging and healthy controls. Forty-four PD patients carried protein-coding GBA variants (GBA-PD) and 227 carried wild-type alleles (idiopathic PD). The glucosylceramide fraction was increased (P = 0.0001), and the sphingomyelin fraction (a downstream metabolite) was reduced (P = 0.0001) in CSF of GBA-PD patients compared to healthy controls. The ceramide fraction was unchanged, and lactosylceramide was below detection limits. We then used the ratio of glucosylceramide to sphingomyelin (the GlcCer/SM ratio) to explore whether these two sphingolipid fractions altered in GBA-PD were useful for stratifying idiopathic PD patients. Idiopathic PD patients in the top quartile of GlcCer/SM ratios at baseline showed a more rapid decline in Montreal Cognitive Assessment scores during longitudinal follow-up compared to those in the lowest quartile with a P-value of 0.036. The GlcCer/SM ratio was negatively associated with α-synuclein levels in CSF of PD patients. This study highlights glucosylceramide as a pathway biomarker for GBA-PD patients and the GlcCer/SM ratio as a potential stratification tool for clinical trials of idiopathic PD patients. Our sphingolipids data together with the clinical, imaging, omics, and genetic characterization of PPMI will contribute a useful resource for multi-modal biomarkers development.
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Mistry PK, Lukina E, Ben Turkia H, Shankar SP, Feldman H, Ghosn M, Mehta A, Packman S, Lau H, Petakov M, Assouline S, Balwani M, Danda S, Hadjiev E, Ortega A, Foster MC, Gaemers SJM, Peterschmitt MJ. Clinical outcomes after 4.5 years of eliglustat therapy for Gaucher disease type 1: Phase 3 ENGAGE trial final results. Am J Hematol 2021; 96:1156-1165. [PMID: 34161616 PMCID: PMC8457136 DOI: 10.1002/ajh.26276] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/06/2021] [Accepted: 06/12/2021] [Indexed: 01/31/2023]
Abstract
Eliglustat, an oral substrate reduction therapy, is approved for eligible adults with Gaucher disease type 1. In the Phase 3 ENGAGE trial of previously untreated adults with Gaucher disease type 1, eliglustat‐treated patients had statistically significant improvements in organ volumes and hematologic parameters compared with placebo in the 9‐month primary analysis. We report final outcomes by time on eliglustat among all patients who participated in the ENGAGE trial and extension. No patient deteriorated clinically or withdrew due to adverse events; 39/40 patients entered the open‐label extension period and 34/40 (85%) remained in the trial until completion or switching to commercial eliglustat after its approval (2.3–6 years). Clinically meaningful improvements in Gaucher disease manifestations were seen in all patients concomitant with reductions in pathological lipid substrate levels (glucosylceramide and glucosylsphingosine). Among patients with 4.5 years of eliglustat exposure, mean spleen volume decreased by 66% (from 17.1 to 5.8 multiples of normal [MN], n = 13), mean liver volume decreased by 23% (from 1.5 to 1.1 MN, n = 13), mean hemoglobin increased 1.4 g/dl (from 11.9 to 13.4 g/dl, n = 12), mean platelet count increased by 87% (from 67.6 to 122.6 × 109/L, n = 12), median chitotriosidase decreased by 82% (from 13 394 to 2312 nmol/h/ml, n = 11), median glucosylceramide decreased by 79% (from 11.5 to 2.4 μg/ml, n = 11), median glucosylsphingosine decreased by 84% (from 518.5 to 72.1 ng/ml, n = 10), and mean spine T‐score increased from −1.07 (osteopenia) to −0.53 (normal) (n = 9). The magnitude of improvement in Gaucher disease manifestations and biomarkers over time was similar among the full trial cohort. Eliglustat was well‐tolerated and led to clinically significant improvements in previously untreated patients with Gaucher disease type 1 during 4.5 years of treatment.
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Affiliation(s)
| | - Elena Lukina
- National Research Center for Hematology Moscow Russia
| | | | | | - Hagit Feldman
- The Genetics Institute, Tel Aviv Sourasky Medical Center, and Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Marwan Ghosn
- Hôtel‐Dieu de France University Hospital Beirut Lebanon
| | | | | | - Heather Lau
- New York University School of Medicine New York New York USA
| | - Milan Petakov
- Clinical Center of Serbia Belgrade University Medical School Belgrade Serbia
| | | | - Manisha Balwani
- Icahn School of Medicine at Mt. Sinai Hospital New York New York USA
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Marchetti M, Faggiano S, Mozzarelli A. Enzyme Replacement Therapy for Genetic Disorders Associated with Enzyme Deficiency. Curr Med Chem 2021; 29:489-525. [PMID: 34042028 DOI: 10.2174/0929867328666210526144654] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/23/2021] [Accepted: 03/17/2021] [Indexed: 11/22/2022]
Abstract
Mutations in human genes might lead to loss of functional proteins, causing diseases. Among these genetic disorders, a large class is associated with the deficiency in metabolic enzymes, resulting in both an increase in the concentration of substrates and a loss in the metabolites produced by the catalyzed reactions. The identification of therapeutic actions based on small molecules represents a challenge to medicinal chemists because the target is missing. Alternative approaches are biology-based, ranging from gene and stem cell therapy, CRISPR/Cas9 technology, distinct types of RNAs, and enzyme replacement therapy (ERT). This review will focus on the latter approach that since the 1990s has been successfully applied to cure many rare diseases, most of them being lysosomal storage diseases or metabolic diseases. So far, a dozen enzymes have been approved by FDA/EMA for lysosome storage disorders and only a few for metabolic diseases. Enzymes for replacement therapy are mainly produced in mammalian cells and some in plant cells and yeasts and are further processed to obtain active, highly bioavailable, less degradable products. Issues still under investigation for the increase in ERT efficacy are the optimization of enzymes interaction with cell membrane and internalization, the reduction in immunogenicity, and the overcoming of blood-brain barrier limitations when neuronal cells need to be targeted. Overall, ERT has demonstrated its efficacy and safety in the treatment of many genetic rare diseases, both saving newborn lives and improving patients' life quality, and represents a very successful example of targeted biologics.
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Affiliation(s)
- Marialaura Marchetti
- Biopharmanet-TEC Interdepartmental Center, University of Parma, Parco Area delle Scienze, Bldg 33., 43124, Parma, Italy
| | - Serena Faggiano
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 23/A, 43124, Parma, Italy
| | - Andrea Mozzarelli
- Institute of Biophysics, National Research Council, Via Moruzzi 1, 56124, Pisa, Italy
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Lukina E, Balwani M, Belmatoug N, Watman N, Hughes D, Gaemers SJM, Foster MC, Lewis G, Peterschmitt MJ. Pregnancy outcome in women with Gaucher disease type 1 who had unplanned pregnancies during eliglustat clinical trials. JIMD Rep 2021; 57:76-84. [PMID: 33473343 PMCID: PMC7802626 DOI: 10.1002/jmd2.12172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/12/2020] [Accepted: 09/16/2020] [Indexed: 11/20/2022] Open
Abstract
Gaucher disease type 1 (GD1) is an inherited lysosomal storage disorder caused by deficient enzymatic activity of acid β-glucosidase, resulting in accumulation of its substrate glucosylceramide, leading to debilitating visceral, hematologic, and skeletal manifestations. Women with GD1 are at increased risk for complications during pregnancy, delivery, and postpartum. Treatment with enzyme replacement therapy is generally recommended before and during pregnancy to reduce risks. Eliglustat, an oral substrate-reduction therapy, is a first-line treatment for adults with GD1 adults who have extensive, intermediate, or poor CYP2D6-metabolizer phenotypes (>90% of patients). We report on pregnancy outcomes among women in eliglustat trials who had unplanned pregnancies and female partners of men in the trials. In four phase 2 and 3 eliglustat trials of 393 adults with GD1, women of childbearing potential were required to use contraception, have monthly pregnancy tests, and discontinue eliglustat promptly if pregnant. In phase 2 and 3 trials, 18 women had 19 pregnancies, resulting in 14 healthy infants from 13 pregnancies (one set of twins), three elective terminations, one ectopic pregnancy, one spontaneous abortion, and one in utero death. Median estimated eliglustat exposure duration during pregnancy was 38 days. In phase 1 trials (non-GD1 subjects), one woman had a spontaneous abortion. Partners of 16 eliglustat-treated men with GD1 had 18 pregnancies, all resulting in healthy infants. Eliglustat is not approved during pregnancy due to limited data. Guidelines for clinicians and patients with GD that address use of eliglustat in women of childbearing potential are needed.
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Affiliation(s)
- Elena Lukina
- National Research Center for HematologyMoscowRussia
| | | | - Nadia Belmatoug
- Beaujon Hospital, University of Paris, Assistance Publique‐Hopitaux de ParisParisFrance
| | | | - Derralynn Hughes
- Royal Free London NHS Foundation Trust, University College LondonLondonUK
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Cheng J, Fuller J, Feldman R, Tap W, Owa T, Fuks Z, Kolesnick R. Enhancement of Soft Tissue Sarcoma Response to Gemcitabine through Timed Administration of a Short-Acting Anti-Angiogenic Agent. Cell Physiol Biochem 2020; 54:707-718. [PMID: 32722909 DOI: 10.33594/000000250] [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: 07/10/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND/AIMS Despite enormous effort, anti-angiogenic drugs have not lived up to the promise of globally-enhancing anti-cancer therapies. Clinically, anti-angiogenic drugs have been used to persistently suppress vascular endothelial growth factor (VEGF) in order to "normalize" dysfunctional neo-angiogenic microvasculature and prevent recruitment of endothelial progenitors. Recently, we showed that a 1h pre-treatment with anti-angiogenic drugs prior to ultra-high single dose radiotherapy and specific chemotherapies transiently de-represses acid sphingomyelinase (ASMase), leading to enhanced cancer therapy-induced, ceramide-mediated vascular injury and tumor response. Here we formally decipher parameters of chemotherapy induction of endothelial sphingolipid signaling events and define principles for optimizing anti-angiogenic chemosensitization. METHODS These studies examine the antimetabolite chemotherapeutic gemcitabine in soft tissue sarcoma (STS), a clinically-relevant combination. RESULTS Initial studies address the theoretic problem that anti-angiogenic drugs such as bevacizumab, an IgG with a 3-week half-life, have the potential for accumulating during the 3-week chemotherapeutic cycles currently standard-of-care for STS treatment. We show that anti-angiogenic ASMase-dependent enhancement of the response of MCA/129 fibrosarcomas in sv129/BL6 mice to gemcitabine progressively diminishes as the level of the VEGFR2 inhibitor DC101, an IgG, accumulates, suggesting a short-acting anti-angiogenic drug might be preferable in multi-cycle chemotherapeutic regimens. Further, we show lenvatinib, a VEGFR2 tyrosine kinase inhibitor with a short half-life, to be superior to DC101, enhancing gemcitabine-induced endothelial cell apoptosis and tumor response in a multi-cycle treatment schedule. CONCLUSION We posit that a single delivery of a short-acting anti-angiogenic agent at 1h preceding each dose of gemcitabine and other chemotherapies may be more efficacious for repeated sensitization of the ASMase pathway in multi-cycle chemotherapy regimens than current treatment strategies.
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Affiliation(s)
- Jin Cheng
- Laboratory of Signal Transduction, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John Fuller
- Laboratory of Signal Transduction, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Regina Feldman
- Laboratory of Signal Transduction, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William Tap
- Sarcoma Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Takashi Owa
- Oncology Business Group, Eisai Co Ltd, Koishikawa, Bunkyo-Ku, Tokyo, Japan
| | - Zvi Fuks
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard Kolesnick
- Laboratory of Signal Transduction, Memorial Sloan Kettering Cancer Center, New York, NY, USA,
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Pant DC, Aguilera-Albesa S, Pujol A. Ceramide signalling in inherited and multifactorial brain metabolic diseases. Neurobiol Dis 2020; 143:105014. [PMID: 32653675 DOI: 10.1016/j.nbd.2020.105014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/13/2020] [Accepted: 07/07/2020] [Indexed: 12/14/2022] Open
Abstract
In recent years, research on sphingolipids, particularly ceramides, has attracted increased attention, revealing the important roles and many functions of these molecules in several human neurological disorders. The nervous system is enriched with important classes of sphingolipids, e.g., ceramide and its derivatives, which compose the major portion of this group, particularly in the form of myelin. Ceramides have also emerged as important nodes for lipid signalling, both inside the cell and between cells. Until recently, knowledge about ceramides in the nervous system was limited, but currently, multiple links between ceramide signalling and neurological diseases have been reported. Alterations in the regulation of ceramide pathobiology have been shown to influence the risk of developing neurometabolic diseases. Thus, these molecules are critically important in the maintenance and development of the nervous system and are culprits or major contributors to the development of brain disorders, either inherited or multifactorial. In the present review, we highlight the critical role of ceramide signalling in several different neurological disorders as well as the effects of their perturbations and discuss how this emerging class of bioactive sphingolipids has attracted interest in the field of neurological diseases.
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Affiliation(s)
- Devesh C Pant
- Department of Biology, Georgia State University, Atlanta, GA 30303, USA
| | - Sergio Aguilera-Albesa
- Pediatric Neurology Unit, Department of Pediatrics, Navarra Health Service Hospital, Irunlarrea 4, 310620 Pamplona, Spain; Navarrabiomed-Miguel Servet Research Foundation, Pamplona, Spain
| | - Aurora Pujol
- Neurometabolic Diseases Laboratory, IDIBELL, Hospital Duran i Reynals, Gran Via 199, 08908, L'Hospitalet de Llobregat, Barcelona, Spain; Catalan Institution of Research and Advanced Studies (ICREA), Barcelona, Catalonia, Spain; Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, Madrid, Spain.
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14
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Engineering monocyte/macrophage-specific glucocerebrosidase expression in human hematopoietic stem cells using genome editing. Nat Commun 2020; 11:3327. [PMID: 32620863 PMCID: PMC7335164 DOI: 10.1038/s41467-020-17148-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
Gaucher disease is a lysosomal storage disorder caused by insufficient glucocerebrosidase activity. Its hallmark manifestations are attributed to infiltration and inflammation by macrophages. Current therapies for Gaucher disease include life-long intravenous administration of recombinant glucocerebrosidase and orally-available glucosylceramide synthase inhibitors. An alternative approach is to engineer the patient's own hematopoietic system to restore glucocerebrosidase expression, thereby replacing the affected cells, and constituting a potential one-time therapy for this disease. Here, we report an efficient CRISPR/Cas9-based approach that targets glucocerebrosidase expression cassettes with a monocyte/macrophage-specific element to the CCR5 safe-harbor locus in human hematopoietic stem and progenitor cells. The targeted cells generate glucocerebrosidase-expressing macrophages and maintain long-term repopulation and multi-lineage differentiation potential with serial transplantation. The combination of a safe-harbor and a lineage-specific promoter establishes a universal correction strategy and circumvents potential toxicity of ectopic glucocerebrosidase in the stem cells. Furthermore, it constitutes an adaptable platform for other lysosomal enzyme deficiencies.
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Abrams R, Kaddi CD, Tao M, Leiser RJ, Simoni G, Reali F, Tolsma J, Jasper P, van Rijn Z, Li J, Niesner B, Barrett JS, Marchetti L, Peterschmitt MJ, Azer K, Neves-Zaph S. A Quantitative Systems Pharmacology Model of Gaucher Disease Type 1 Provides Mechanistic Insight Into the Response to Substrate Reduction Therapy With Eliglustat. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 9:374-383. [PMID: 32558397 PMCID: PMC7376290 DOI: 10.1002/psp4.12506] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/17/2020] [Indexed: 12/27/2022]
Abstract
Gaucher’s disease type 1 (GD1) leads to significant morbidity and mortality through clinical manifestations, such as splenomegaly, hematological complications, and bone disease. Two types of therapies are currently approved for GD1: enzyme replacement therapy (ERT), and substrate reduction therapy (SRT). In this study, we have developed a quantitative systems pharmacology (QSP) model, which recapitulates the effects of eliglustat, the only first‐line SRT approved for GD1, on treatment‐naïve or patients with ERT‐stabilized adult GD1. This multiscale model represents the mechanism of action of eliglustat that leads toward reduction of spleen volume. Model capabilities were illustrated through the application of the model to predict ERT and eliglustat responses in virtual populations of adult patients with GD1, representing patients across a spectrum of disease severity as defined by genotype‐phenotype relationships. In summary, the QSP model provides a mechanistic computational platform for predicting treatment response via different modalities within the heterogeneous GD1 patient population.
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Affiliation(s)
- Ruth Abrams
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Chanchala D Kaddi
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Mengdi Tao
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Randolph J Leiser
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Giulia Simoni
- Fondazione The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
| | - Federico Reali
- Fondazione The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
| | | | | | - Zachary van Rijn
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Jing Li
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Bradley Niesner
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Jeffrey S Barrett
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Luca Marchetti
- Fondazione The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto, Italy
| | | | - Karim Azer
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
| | - Susana Neves-Zaph
- Translational Disease Modelling, Digital Data Science, Sanofi, Bridgewater, New Jersey, USA
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Leal AF, Espejo-Mojica AJ, Sánchez OF, Ramírez CM, Reyes LH, Cruz JC, Alméciga-Díaz CJ. Lysosomal storage diseases: current therapies and future alternatives. J Mol Med (Berl) 2020; 98:931-946. [PMID: 32529345 DOI: 10.1007/s00109-020-01935-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 02/07/2023]
Abstract
Lysosomal storage disorders (LSDs) are a group of monogenic diseases characterized by progressive accumulation of undegraded substrates into the lysosome, due to mutations in genes that encode for proteins involved in normal lysosomal function. In recent years, several approaches have been explored to find effective and successful therapies, including enzyme replacement therapy, substrate reduction therapy, pharmacological chaperones, hematopoietic stem cell transplantation, and gene therapy. In the case of gene therapy, genome editing technologies have opened new horizons to accelerate the development of novel treatment alternatives for LSD patients. In this review, we discuss the current therapies for this group of disorders and present a detailed description of major genome editing technologies, as well as the most recent advances in the treatment of LSDs. We will further highlight the challenges and current bioethical debates of genome editing.
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Affiliation(s)
- Andrés Felipe Leal
- Institute for the Study of Inborn Errors of Metabolism, Faculty of Science, Pontificia Universidad Javeriana, Cra. 7 No. 43-82 Building 54, Room 305A, Bogotá D.C, 110231, Colombia
| | - Angela Johana Espejo-Mojica
- Institute for the Study of Inborn Errors of Metabolism, Faculty of Science, Pontificia Universidad Javeriana, Cra. 7 No. 43-82 Building 54, Room 305A, Bogotá D.C, 110231, Colombia
| | - Oscar F Sánchez
- Neurobiochemistry and Systems Physiology, Biochemistry and Nutrition Department, Faculty of Science, Pontificia Universidad Javeriana, Bogotá D.C., Colombia
| | - Carlos Manuel Ramírez
- Department of Chemical and Food Engineering, Universidad de los Andes, Bogotá D.C., Colombia
| | - Luis Humberto Reyes
- Department of Chemical and Food Engineering, Universidad de los Andes, Bogotá D.C., Colombia
| | - Juan C Cruz
- Department of Biomedical Engineering, Universidad de los Andes, Bogotá D.C., Colombia
| | - Carlos Javier Alméciga-Díaz
- Institute for the Study of Inborn Errors of Metabolism, Faculty of Science, Pontificia Universidad Javeriana, Cra. 7 No. 43-82 Building 54, Room 305A, Bogotá D.C, 110231, Colombia.
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Poletto E, Baldo G, Gomez-Ospina N. Genome Editing for Mucopolysaccharidoses. Int J Mol Sci 2020; 21:E500. [PMID: 31941077 PMCID: PMC7014411 DOI: 10.3390/ijms21020500] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 02/07/2023] Open
Abstract
Genome editing holds the promise of one-off and potentially curative therapies for many patients with genetic diseases. This is especially true for patients affected by mucopolysaccharidoses as the disease pathophysiology is amenable to correction using multiple approaches. Ex vivo and in vivo genome editing platforms have been tested primarily on MSPI and MPSII, with in vivo approaches having reached clinical testing in both diseases. Though we still await proof of efficacy in humans, the therapeutic tools established for these two diseases should pave the way for other mucopolysaccharidoses. Herein, we review the current preclinical and clinical development studies, using genome editing as a therapeutic approach for these diseases. The development of new genome editing platforms and the variety of genetic modifications possible with each tool provide potential applications of genome editing for mucopolysaccharidoses, which vastly exceed the potential of current approaches. We expect that in a not-so-distant future, more genome editing-based strategies will be established, and individual diseases will be treated through multiple approaches.
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Affiliation(s)
- Edina Poletto
- Gene Therapy Center, Hospital de Clinicas de Porto Alegre, Porto Alegre 90035-007, Brazil; (E.P.); (G.B.)
- Post-Graduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre 91501-970, Brazil
| | - Guilherme Baldo
- Gene Therapy Center, Hospital de Clinicas de Porto Alegre, Porto Alegre 90035-007, Brazil; (E.P.); (G.B.)
- Post-Graduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre 91501-970, Brazil
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Mohamed YSA, Zayet MK, Omar OM, El-Beshlawy AM. Jaw bones' involvement and dental features of type I and type III Gaucher disease: a radiographic study of 42 paediatric patients. Eur Arch Paediatr Dent 2019; 21:241-247. [PMID: 31531808 DOI: 10.1007/s40368-019-00471-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/19/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE Gaucher disease (GD) is a lysosomal storage disease caused by an autosomal recessive inherited deficiency of the lysosomal enzyme glucocerebrosidase. The aim of this study is to describe jaw bones' involvement and dental radiographic features in paediatric Gaucher disease patients (type I and type III). METHODS The study population of this case-control study included: 42 Gaucher patients (study group) and 84 medically free children (control group). The radiographic images of both groups were analysed for the following findings: generalised bone rarefaction, localised rarefaction and enlarged bone marrow spaces, thinning of cortex, pseudocystic radiolucent lesions, anodontia and dental anomalies. Dental age assessment of Gaucher patients using the Demirjian's method was also performed. RESULTS Generalised rarefaction showed almost similar percentages in both types of Gaucher disease cases. Localised rarefaction was noted in 30.77% and 18.75% of Gaucher disease type III and type I, respectively. Pseudocystic radiolucent lesions, thinning of cortex, anodontia and dental anomalies were more prevalent in type III Gaucher patients. The mean chronological and mean dental ages in both sexes of Gaucher patients were not statistically significant. CONCLUSION Thinning of cortex, localised rarefaction and generalised rarefaction are the most common jaw bone findings in Gaucher patients.
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Affiliation(s)
- Y S A Mohamed
- Pediatric Dentistry Department, Faculty of Dentistry, October 6 University, Giza, Egypt
| | - M K Zayet
- Oral and Maxillofacial Radiology Department, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - O M Omar
- Department of Pediatric Dentistry, Faculty of Dentistry, Cairo University, 11 Al Saraya Str., Al Manial, Kasr Al Ainy, Cairo, Egypt.
| | - A M El-Beshlawy
- Pediatric Hematology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Degnan AJ, Ho-Fung VM, Ahrens-Nicklas RC, Barrera CA, Serai SD, Wang DJ, Ficicioglu C. Imaging of non-neuronopathic Gaucher disease: recent advances in quantitative imaging and comprehensive assessment of disease involvement. Insights Imaging 2019; 10:70. [PMID: 31289964 PMCID: PMC6616606 DOI: 10.1186/s13244-019-0743-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/29/2019] [Indexed: 12/17/2022] Open
Abstract
Gaucher disease is an inherited metabolic disorder resulting in deficiency of lysosomal enzyme β-glucocerebrosidase causing the accumulation of abnormal macrophages (“Gaucher cells”) within multiple organs, most conspicuously affecting the liver, spleen, and bone marrow. As the most common glycolipid metabolism disorder, it is important for radiologists encountering these patients to be familiar with advances in imaging of organ and bone marrow involvement and understand the role of imaging in clinical decision-making. The recent advent of commercially available, reliable, and reproducible quantitative MRI acquisitions to measure fat fractions prompts revisiting the role of quantitative assessment of bone marrow involvement. This manuscript reviews the diverse imaging manifestations of Gaucher disease and discusses more optimal quantitative approaches to ascertain solid organ and bone marrow involvement with an emphasis on future applications of other quantitative methods including elastography.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Victor M Ho-Fung
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rebecca C Ahrens-Nicklas
- Division of Human Genetics, The Children's Hospital of Philadelphia, Colket Translational Research Building, 3501 Civic Center Blvd, Floor 9, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Suraj D Serai
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Dah-Jyuu Wang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Can Ficicioglu
- Division of Human Genetics, The Children's Hospital of Philadelphia, Colket Translational Research Building, 3501 Civic Center Blvd, Floor 9, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
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Peterschmitt MJ, Freisens S, Underhill LH, Foster MC, Lewis G, Gaemers SJM. Long-term adverse event profile from four completed trials of oral eliglustat in adults with Gaucher disease type 1. Orphanet J Rare Dis 2019; 14:128. [PMID: 31174576 PMCID: PMC6555985 DOI: 10.1186/s13023-019-1085-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/29/2019] [Indexed: 11/17/2022] Open
Abstract
Background Eliglustat is a first-line oral treatment for adults with Gaucher disease type 1 who have an extensive, intermediate or poor CYP2D6 metabolizer phenotype (> 90% of patients). Whereas enzyme replacement therapy for Gaucher disease has been widely used for more than two decades, eliglustat has only been in commercial use since 2014. Clinicians and patients want to better understand which adverse events are most commonly associated with eliglustat, as well as their severity, frequency, and duration. Methods This pooled analysis of treatment-emergent adverse events combines data from four completed eliglustat clinical trials involving 393 Gaucher disease type 1 patients. It represents 1400 patient-years of eliglustat exposure and a mean treatment duration of 3.6 years (maximum: 9.3 years). Results Eighty-one percent of patients remained in their respective trial until commercial availability of eliglustat (US patients only) or until trial completion. Nine patients (2.3%) withdrew from their respective trial due to one or more adverse events reported as eliglustat treatment-related; all but one of these events were mild or moderate. Overall, 97% of adverse events were mild or moderate and 86% were reported by the investigator as unrelated to eliglustat treatment. The overall rate of adverse events decreased over time and did not increase with increasing eliglustat dose. We evaluated frequency, duration, and severity of 14 adverse event terms reported at least once as treatment-related in 2% or more of all patients: dyspepsia (5.9%), headache (5.3%), abdominal pain upper (5.1%), dizziness (5.1%), diarrhea (4.6%), nausea (4.6%), arthralgia (3.6%), constipation (3.3%), abdominal pain (2.8%), gastroesophageal reflux disease (2.8%), fatigue (2.8%), palpitations (2.8%), abdominal distension (2.5%), and gastritis (2.3%). For abdominal pain upper, diarrhea, nausea, abdominal pain, and headache events, median duration was less than 14 days. All 14 adverse event terms, except for arthralgia and headache, were reported only once per patient in more than 70% of patients experiencing the event. Conclusions This final pooled analysis of treatment-emergent adverse events reinforces the favorable safety profile of eliglustat. The majority of the most frequently reported treatment-related adverse events were mild or moderate, transient, and occurred only once per patient. Electronic supplementary material The online version of this article (10.1186/s13023-019-1085-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | - Grace Lewis
- Sanofi Genzyme, Cambridge, Massachusetts, United States
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Lukina E, Watman N, Dragosky M, Lau H, Avila Arreguin E, Rosenbaum H, Zimran A, Foster MC, Gaemers SJM, Peterschmitt MJ. Outcomes after 8 years of eliglustat therapy for Gaucher disease type 1: Final results from the Phase 2 trial. Am J Hematol 2019; 94:29-38. [PMID: 30264864 PMCID: PMC6587500 DOI: 10.1002/ajh.25300] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 01/02/2023]
Abstract
Eliglustat is a first‐line oral therapy for adults with Gaucher disease type 1 (GD1) and poor, intermediate or extensive CYP2D6‐metabolizer phenotypes (>90% of patients). We report the final results of a Phase 2 trial and extension (NCT00358150) in previously untreated adult GD1 patients who had splenomegaly with thrombocytopenia and/or anemia and received 50 or 100 mg eliglustat tartrate (equivalent to 42 or 84 mg eliglustat) twice daily for 8 years. In total, 19 of 26 patients completed the trial. After 8 years of eliglustat, mean spleen and liver volumes decreased by 69% and 34%, respectively. Mean hemoglobin concentration and platelet count increased by 2.2 g/dL and 113%, respectively. All patients met at least 3 of 4 therapeutic goals established for patients on long‐term enzyme replacement therapy. Mean final values for patients with severe splenomegaly (n = 6), moderate‐to‐severe anemia (n = 6), or severe thrombocytopenia (n = 8) were similar to patients with milder disease at baseline and within long‐term therapeutic goal thresholds. Biomarker median percent changes from baseline were ‐91% for chitotriosidase, ‐87% for CCL18, ‐92% for glucosylsphingosine, and ‐80% for plasma glucosylceramide. Mean lumbar spine T‐score increased by 0.96, moving from the osteopenic to the normal range. Mean quality‐of‐life scores, mostly below normal at baseline, moved into ranges seen in healthy adults. Eliglustat was well‐tolerated; 98% of adverse events were mild or moderate and 94% were considered unrelated to treatment. Clinically meaningful improvements in all parameters continued or were maintained over 8 years, with the largest margins of improvement seen in the most severely affected patients.
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Affiliation(s)
- Elena Lukina
- Department of Orphan DiseasesNational Research Center for HematologyMoscowRussia
| | - Nora Watman
- Division of HematologyHospital Ramos MejiaBuenos AiresArgentina
| | - Marta Dragosky
- Department of HematologyIMAI‐ResearchBuenos AiresArgentina
| | - Heather Lau
- Department of NeurologyNew York University School of MedicineNew YorkNew York
| | - Elsa Avila Arreguin
- Department of HematologyInstituto Mexicano del Seguro Social Hospital de EspecialidadesCol. La RazaMexico
| | | | - Ari Zimran
- Gaucher Clinic, Department of Medicine, Shaare Zedek Medical CenterJerusalemIsrael
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Nalysnyk L, Sugarman R, Cele C, Uyei J, Ward A. Budget Impact Analysis of Eliglustat for the Treatment of Gaucher Disease Type 1 in the United States. J Manag Care Spec Pharm 2018; 24:1002-1008. [PMID: 30247105 PMCID: PMC10397643 DOI: 10.18553/jmcp.2018.24.10.1002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Gaucher disease type 1 (GD1) is a rare, genetic, lysosomal storage disease with no cure. Current treatment options include intravenous (IV) enzyme replacement therapy ([ERT]; imiglucerase, velaglucerase alfa, or taliglucerase alfa) or oral substrate reduction therapy ([SRT]; eliglustat or miglustat). The cost to U.S. payers of an IV-administered drug can vary depending on the site of care (i.e., home, outpatient clinic, or hospital setting). Treatment with oral eliglustat may present an opportunity for cost savings. OBJECTIVE To evaluate the budget impact from a U.S. payer perspective associated with transitioning patients receiving ERTs to the oral SRT eliglustat for the treatment of adults with GD1. METHODS A budget impact model estimated the change in pharmaceutical and administration costs resulting from increasing the market share of eliglustat from 12% (current) to 44% (new). The market share for eliglustat was drawn equally from existing shares of imiglucerase (40%) and velaglucerase alfa (40%) and assumed to be static over the analysis period. ERT costs were adjusted to account for site of care-based markup and the proportion of patients receiving infusions in each site of care (home, infusion center, or hospital outpatient). Annual ERT costs were calculated assuming a biweekly dose of 47.4 U per kg, a 72-kg patient weight, and 24 infusions per year. The effect of key variables was tested in the sensitivity analyses. All costs are expressed in 2017 U.S. dollars. RESULTS In a new plan with 5 million members and 25 GD1 treated patients, increased use of eliglustat resulted in an annual savings of $1,526,710 and a total savings of $4,580,130 (13.6%) over 3 years. The corresponding annual per member per month savings was $0.025. This is further illustrated in the sensitivity and scenario analyses where the use of eliglustat was cost saving in all cases. Shifting more patients receiving ERT in the hospital outpatient setting to eliglustat resulted in increased savings. CONCLUSIONS Based on these analyses, increased use of eliglustat resulted in meaningful cost savings to a payer's overall budget. Cost savings are highest among patients switching from ERT administered in a hospital outpatient setting. The results suggest that cost savings are also likely achievable from initiating patients on oral eliglustat instead of infusion-based therapy from the outset of treatment. DISCLOSURES This study was sponsored by Sanofi Genzyme. Evidera received funding from Sanofi Genzyme to conduct this study and prepare the manuscript. The sponsor collaborated on the study design, analysis, interpretation of results, and writing of the manuscript. Nalysnyk is an employee of and shareholder in Sanofi Genzyme. Ward, Cele, and Uyei are employees of Evidera, which provides consulting and other research services to biopharmaceutical companies. Sugarman was also an Evidera employee when the study was being conducted and the manuscript written. This study was presented as a poster at the Academy of Managed Care Pharmacy Nexus 2016, October 3-6, 2016; National City, MD, and at the International Society for Pharmacoeconomics and Outcomes Research, 22nd Annual International Meeting; May 20-24, 2017; Boston, MA.
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Diagnosis and Management of Gaucher Disease in India – Consensus Guidelines of the Gaucher Disease Task Force of the Society for Indian Academy of Medical Genetics and the Indian Academy of Pediatrics. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1249-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Justification
Gaucher disease (GD) is amongst the most frequently occurring lysosomal storage disorder in all ethnicities. The clinical manifestations and natural history of GD is highly heterogeneous with extreme geographic and ethnic variations. The literature on GD has paucity of information and optimal management guidelines for Indian patients.
Process
Gaucher Disease Task Force was formed under the auspices of the Society for Indian Academy of Medical Genetics. Invited experts from various specialties formulated guidelines for the management of patients with GD. A writing committee was formed and the draft guidelines were circulated by email to all members for comments and inputs. The guidelines were finalized in December 2016 at the annual meeting of the Indian Academy of Medical Genetics.
Objectives
These guidelines are intended to serve as a standard framework for treating physicians and the health care systems for optimal management of Gaucher disease in India and to define unique needs of this patient population.
Recommendations
Manifestations of GD are protean and a high index of suspicion is essential for timely diagnosis. Patients frequently experience diagnostic delays during which severe irreversible complications occur. Leucocyte acid β-glucosidase activity is mandatory for establishing the diagnosis of Gaucher disease; molecular testing can help identify patients at risk of neuronopathic disease. Enzyme replacement therapy for type 1 and type 3 Gaucher disease is the standard of care. Best outcomes are achieved by early initiation of therapy before onset of irreversible complications. However, in setting of progressive neurological symptoms such as seizures and or/neuroregression, ERT is not recommended, as it cannot cross the blood brain barrier. The recommendations herein are for diagnosis, for initiation of therapy, therapeutic goals, monitoring and follow up of patients. We highlight that prevention of recurrence of the disease through genetic counseling and prenatal diagnosis is essential in India, due to uniformly severe phenotypes encountered in our population.
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Cox TM, Mistry PK. Therapeutic position of eliglustat. Blood Cells Mol Dis 2018; 69:117-118. [DOI: 10.1016/j.bcmd.2017.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 11/20/2017] [Indexed: 11/30/2022]
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Peterschmitt MJ, Cox GF, Ibrahim J, MacDougall J, Underhill LH, Patel P, Gaemers SJ. A pooled analysis of adverse events in 393 adults with Gaucher disease type 1 from four clinical trials of oral eliglustat: Evaluation of frequency, timing, and duration. Blood Cells Mol Dis 2018; 68:185-191. [DOI: 10.1016/j.bcmd.2017.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/16/2022]
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Zimran A, Belmatoug N, Bembi B, Deegan P, Elstein D, Fernandez-Sasso D, Giraldo P, Goker-Alpan O, Lau H, Lukina E, Panahloo Z, Schwartz IVD. Demographics and patient characteristics of 1209 patients with Gaucher disease: Descriptive analysis from the Gaucher Outcome Survey (GOS). Am J Hematol 2018; 93:205-212. [PMID: 29090476 PMCID: PMC5814927 DOI: 10.1002/ajh.24957] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 12/24/2022]
Abstract
The Gaucher Outcome Survey (GOS) is an international Gaucher disease (GD) registry established in 2010 for patients with a confirmed GD diagnosis, regardless of GD type or treatment status, designed to evaluate the safety and long‐term effectiveness of velaglucerase alfa and other GD‐related treatments. As of February 25, 2017, 1209 patients had enrolled, the majority from Israel (44.3%) and the US (31.4%). Median age at GOS entry was 40.4 years, 44.1% were male, and 13.3% had undergone a total splenectomy. Most patients had type 1 GD (91.5%) and were of Ashkenazi Jewish ethnicity (55.8%). N370S/N370S was the most prevalent genotype, accounting for 44.2% of genotype‐confirmed individuals (n = 847); however, there was considerable variation between countries. A total of 887 (73.4%) patients had received ≥1 GD‐specific treatment at any time, most commonly imiglucerase (n = 587), velaglucerase alfa (n = 507), and alglucerase (n = 102). Hematological and visceral findings at the time of GOS entry were close to normal for most patients, probably a result of previous treatment; however, spleen volume of patients in Israel was almost double that of patients elsewhere (7.2 multiples of normal [MN] vs. 2.7, 2.9 and 4.9 MN in the US, UK and rest of world), which may be explained by a greater disease severity in this cohort. This analysis aimed to provide an overview of GOS and present baseline demographic and disease characteristics of participating patients to help improve the understanding of the natural history of GD and inform the overall management of patients with the disease.
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Affiliation(s)
- Ari Zimran
- Gaucher Clinic, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School; Jerusalem Israel
| | - Nadia Belmatoug
- Centre de Référence des Maladies Lysosomales; Hôpitaux universitaires Paris Nord Val de Seine, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service de Médecine Interne; Clichy France
| | - Bruno Bembi
- Regional Coordinator Centre for Rare Diseases; University Hospital “Santa Maria della Misericordia”; Udine Italy
| | - Patrick Deegan
- Department of Medicine; University of Cambridge and Lysosomal Disorders Unit; Cambridge UK
| | | | | | - Pilar Giraldo
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto Salud Carlos III; Zaragoza Spain
- Translational Research Unit, Aragon Institute of Health Research (IISAragon); Zaragoza Spain
- Spanish Foundation for the Study and Therapy of Gaucher Disease (FEETEG); Zaragoza Spain
- Unidad de Investigación Traslacional, Pta Baja, Hospital Universitario Miguel Servet; Zaragoza Spain
| | - Ozlem Goker-Alpan
- Lysosomal Disorders Unit and Center for Clinical Trials, O&O Alpan, LLC; Fairfax VA USA
| | - Heather Lau
- New York University Langone Medical Center; New York NY USA
| | - Elena Lukina
- Department of Orphan Diseases; National Research Center for Hematology; Moscow Russia
| | | | - Ida Vanessa D. Schwartz
- Hospital de Clínicas de Porto Alegre; Porto Alegre Brazil
- Department of Genetics; Universidade Federal do Rio Grande do Sul; Brazil
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Mistry PK, Lukina E, Ben Turkia H, Shankar SP, Baris H, Ghosn M, Mehta A, Packman S, Pastores G, Petakov M, Assouline S, Balwani M, Danda S, Hadjiev E, Ortega A, Gaemers SJM, Tayag R, Peterschmitt MJ. Outcomes after 18 months of eliglustat therapy in treatment-naïve adults with Gaucher disease type 1: The phase 3 ENGAGE trial. Am J Hematol 2017; 92:1170-1176. [PMID: 28762527 PMCID: PMC5656936 DOI: 10.1002/ajh.24877] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/25/2017] [Accepted: 07/28/2017] [Indexed: 12/31/2022]
Abstract
Eliglustat, an oral substrate reduction therapy, is a first‐line treatment for adults with Gaucher disease type 1 (GD1) who are poor, intermediate, or extensive CYP2D6 metabolizers (>90% of patients). In the primary analysis of the Phase 3 ENGAGE trial (NCT00891202), eliglustat treatment for 9 months resulted in significant reductions in spleen and liver volumes and increases in hemoglobin concentration and platelet count compared with placebo. We report 18‐month outcomes of patients who entered the trial extension period, in which all patients received eliglustat. Of 40 trial patients, 39 entered the extension period, and 38 completed 18 months. Absolute values and percent change over time were determined for spleen and liver volume, hemoglobin concentration, platelet count, bone mineral density, bone marrow burden, and Gaucher disease biomarkers. For patients randomized to eliglustat in the double‐blind period, continuing treatment with eliglustat for 9 more months resulted in incremental improvement of all disease parameters. For patients randomized to placebo in the double‐blind period, eliglustat treatment during the 9‐month, open‐label period resulted in significant decrease of spleen and liver volumes and significant increase of hemoglobin and platelets, with a similar rate of change to patients who had received eliglustat in the double‐blind period. Eliglustat treatment was also associated with improvement in bone marrow burden score, bone mineral density, and established biomarkers of Gaucher disease, including reduction of the bioactive lipid, glucosylsphingosine. These findings underscore the efficacy of eliglustat in treatment‐naïve patients. Eliglustat was well‐tolerated, and there were no new safety concerns with longer‐term exposure.
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Affiliation(s)
- Pramod K. Mistry
- Department of Internal Medicine and Pediatrics; Yale University School of Medicine; New Haven CT USA
| | - Elena Lukina
- Department of Orphan Diseases; National Research Center for Hematology; Moscow Russia
| | | | - Suma P. Shankar
- Department of Human Genetics; Emory University School of Medicine; Atlanta GA USA
| | - Hagit Baris
- Raphael Recanati Genetic Institute; Rabin Medical Center; Petach Tikvah Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- The Genetics Institute, Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine; Technion - Israel Institute of Technology; Haifa Israel
| | - Marwan Ghosn
- Department of Hematology-Oncology; Hôtel-Dieu de France University Hospital; Beirut Lebanon
| | - Atul Mehta
- Department of Haematology, The Royal Free Hospital; University College; London UK
| | - Seymour Packman
- Department of Pediatrics; UCSF School of Medicine; San Francisco CA USA
| | - Gregory Pastores
- Department of Neurology and Pediatrics; New York University School of Medicine; New York NY USA
| | - Milan Petakov
- Department of Neuroendocrinology, Clinical Center of Serbia; Belgrade University Medical School; Serbia
| | - Sarit Assouline
- Department of Medicine, Division of Hematology; Jewish General Hospital; Montreal Quebec Canada
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences; Icahn School of Medicine at Mt. Sinai Hospital; New York NY USA
| | - Sumita Danda
- Department of Medical Genetics; Christian Medical College; Vellore Tamil Nadu India
| | - Evgueniy Hadjiev
- Medical University - Sofia, Faculty of Medicine, Department of Internal diseases; UMHAT “Alexandrovska”- Clinic of Hematology; Sofia Bulgaria
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Mehta A, Belmatoug N, Bembi B, Deegan P, Elstein D, Göker-Alpan Ö, Lukina E, Mengel E, Nakamura K, Pastores GM, Pérez-López J, Schwartz I, Serratrice C, Szer J, Zimran A, Di Rocco M, Panahloo Z, Kuter DJ, Hughes D. Exploring the patient journey to diagnosis of Gaucher disease from the perspective of 212 patients with Gaucher disease and 16 Gaucher expert physicians. Mol Genet Metab 2017; 122:122-129. [PMID: 28847676 DOI: 10.1016/j.ymgme.2017.08.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 11/17/2022]
Abstract
Gaucher disease (GD) is a rare hereditary disorder caused by a deficiency of the lysosomal enzyme β-glucocerebrosidase. Diagnosis is challenging owing to a wide variability in clinical manifestations and severity of symptoms. Many patients may experience marked delays in obtaining a definitive diagnosis. The two surveys reported herein aimed to explore the patient journey to diagnosis of GD from the perspectives of Gaucher expert physicians and patients. Findings from the surveys revealed that many patients experienced diagnostic delays and misdiagnoses, with nearly 1 in 6 patients stating that they were not diagnosed with GD for 7years or more after first consulting a doctor. Physicians and patients both reported multiple referrals to different specialties before a diagnosis of GD was obtained, with primary care, haematology/haematology-oncology and paediatrics the main specialties to which patients first presented. Splenomegaly, thrombocytopenia, anaemia and bone pain were reported as the most common medical problems at first presentation in both surveys. These findings support a clear need for straightforward and easy-to-follow guidance designed to assist non-specialists to identify earlier patients who are at risk of GD.
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Affiliation(s)
- Atul Mehta
- Lysosomal Storage Disorders Unit, Department of Haematology, Royal Free Hospital, UCL Medical School, London, UK.
| | - Nadia Belmatoug
- Referral Centre for Lysosomal Diseases, University Hospital Paris Nord Val de Seine, Clichy, France.
| | - Bruno Bembi
- Academic Medical Centre Hospital of Udine, Regional Coordinator Centre for Rare Diseases, Udine, Italy.
| | | | | | - Özlem Göker-Alpan
- Lysosomal Disorders Unit and Center for Clinical Trials, O&O Alpan, LLC, Fairfax, VA, USA.
| | - Elena Lukina
- National Research Center for Hematology, Moscow, Russia.
| | - Eugen Mengel
- Villa Metabolica, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
| | | | - Gregory M Pastores
- University College Dublin, and Mater Misericordiae University Hospital, Dublin, Ireland.
| | | | - Ida Schwartz
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Christine Serratrice
- Foundation Hospital Saint Joseph, Marseille, France and Geneva University Hospital, Thonex, Switzerland.
| | - Jeffrey Szer
- Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Ari Zimran
- Gaucher Clinic, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel.
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy.
| | | | - David J Kuter
- Center for Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Derralynn Hughes
- Lysosomal Storage Disorders Unit, Department of Haematology, Royal Free Hospital, UCL Medical School, London, UK.
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Mejía-Turizo JC, Rojas-Múnera S, Orrego-Betancur SR, Franco-Echeverri CM, Arango-Simoni K. Manifestaciones oculares de la enfermedad de Gaucher: presentación de un caso y revisión del tema. IATREIA 2017. [DOI: 10.17533/udea.iatreia.v30n3a05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Eliglustat maintains long-term clinical stability in patients with Gaucher disease type 1 stabilized on enzyme therapy. Blood 2017; 129:2375-2383. [PMID: 28167660 DOI: 10.1182/blood-2016-12-758409] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/27/2017] [Indexed: 11/20/2022] Open
Abstract
In the phase 3 Study of Eliglustat Tartrate (Genz-112638) in Patients With Gaucher Disease Who Have Reached Therapeutic Goals With Enzyme Replacement Therapy (ENCORE), at 1 year, eliglustat was noninferior to imiglucerase enzyme therapy in maintaining stable platelet counts, hemoglobin concentrations, and spleen and liver volumes. After this primary analysis period, patients entered a long-term extension phase in which all received eliglustat. Duration on eliglustat ranged from 2 to 5 years, depending on timing of enrollment (which spanned 2 years), treatment group to which patients were randomized, and whether they lived in the United States when commercial eliglustat became available. Here we report long-term safety and efficacy of eliglustat for 157 patients who received eliglustat in the ENCORE trial; data are available for 46 patients who received eliglustat for 4 years. Mean hemoglobin concentration, platelet count, and spleen and liver volumes remained stable for up to 4 years. Year to year, all 4 measures remained collectively stable (composite end point relative to baseline values) in ≥85% of patients as well as individually in ≥92%. Mean bone mineral density z scores (lumbar spine and femur) remained stable and were maintained in the healthy reference range throughout. Eliglustat was well tolerated over 4 years; 4 (2.5%) patients withdrew because of adverse events that were considered related to the study drug. No new or long-term safety concerns were identified. Clinical stability assessed by composite and individual measures was maintained in adults with Gaucher disease type 1 treated with eliglustat who remained in the ENCORE trial for up to 4 years. This trial was registered at www.clinicaltrials.gov as #NCT00943111.
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31
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Belmatoug N, Di Rocco M, Fraga C, Giraldo P, Hughes D, Lukina E, Maison-Blanche P, Merkel M, Niederau C, Plӧckinger U, Richter J, Stulnig TM, Vom Dahl S, Cox TM. Management and monitoring recommendations for the use of eliglustat in adults with type 1 Gaucher disease in Europe. Eur J Intern Med 2017; 37:25-32. [PMID: 27522145 DOI: 10.1016/j.ejim.2016.07.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/13/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE In Gaucher disease, diminished activity of the lysosomal enzyme, acid β-glucosidase, leads to accumulation of glucosylceramides and related substrates, primarily in the spleen, liver, and bone marrow. Eliglustat is an oral substrate reduction therapy approved in the European Union and the United States as a first-line treatment for adults with type 1 Gaucher disease who have compatible CYP2D6 metabolism phenotypes. A European Advisory Council of experts in Gaucher disease describes the characteristics of eliglustat that are distinct from enzyme augmentation therapy (the standard of care) and miglustat (the other approved substrate reduction therapy) and recommends investigations and monitoring for patients on eliglustat therapy within the context of current recommendations for Gaucher disease management. RESULTS Eliglustat is a selective, potent inhibitor of glucosylceramide synthase, the enzyme responsible for biosynthesis of glucosylceramides which accumulate in Gaucher disease. Extensive metabolism of eliglustat by CYP2D6, and, to a lesser extent, CYP3A of the cytochrome P450 pathway, necessitates careful consideration of the patient's CYP2D6 metaboliser status and use of concomitant medications which share metabolism by these pathways. Guidance on specific assessments and monitoring required for eliglustat therapy, including an algorithm to determine eligibility for eliglustat, are provided. CONCLUSIONS As a first-line therapy for type 1 Gaucher disease, eliglustat offers eligible patients a daily oral therapy alternative to biweekly infusions of enzyme therapy. Physicians will need to carefully assess individual Gaucher patients to determine their appropriateness for eliglustat therapy. The therapeutic response to eliglustat and use of concomitant medications will require long-term monitoring.
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Affiliation(s)
- Nadia Belmatoug
- Referral Center for Lysosomal Diseases, University Beaujon Hospital Paris Nord Val de Seine, Assistance-Publique Hôpitaux de Paris, Department of Internal Medicine, 100 Boulevard du Général Leclerc, 92110 Clichy, France.
| | - Maja Di Rocco
- Unit of Rare Diseases, Department Pediatrics, Gaslini Institute, Largo Gaslini 3, 16147 Genoa, Italy.
| | - Cristina Fraga
- Department of Haematology, HDES Hospital, Ponta Delgada, Av. D. Manuel I, PDL, Açores, Portugal.
| | - Pilar Giraldo
- Translational Research Unit, Instituto Investigación Sanitaria Aragon, CIBER Enfermedades Raras (CIBERER), Zaragoza, Spain.
| | - Derralynn Hughes
- Royal Free London NHS Foundation Trust, University College London, Department of Haematology, Pond St., London NW1 2QG, United Kingdom
| | - Elena Lukina
- Department of Orphan Diseases, Hematology Research Center, 4 Novy Zykovsky Lane, 125167 Moscow, Russia.
| | - Pierre Maison-Blanche
- Bichat University Hospital, Cardiology Unit, 46 Rue Henri Huchard, 75018 Paris, France.
| | - Martin Merkel
- Department of Internal Medicine, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099 Hamburg, Germany.
| | - Claus Niederau
- Katholisches Klinikum Oberhausen GmbH, St. Josef Hospital, Department of Medicine, Academic Teaching Hospital, Universität Duisburg-Essen, Mülheimer Str. 83, 46045 Oberhausen, Germany.
| | - Ursula Plӧckinger
- Interdisziplinares Stoffwechsel-Centrum: Diabetes, Endokrinologie und Stoffwechsel, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13352 Berlin, Germany.
| | - Johan Richter
- Department of Hematology and Vascular Diseases, Skåne University Hospital, 221 85 Lund, Sweden.
| | - Thomas M Stulnig
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Stephan Vom Dahl
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital, University of Duesseldorf, Moorenstrasse 5, D-40225, Germany.
| | - Timothy M Cox
- Department of Medicine, University of Cambridge, Box 157, Level 5, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom.
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Deegan P, Fernandez-Sasso D, Giraldo P, Lau H, Panahloo Z, Zimran A. Treatment patterns from 647 patients with Gaucher disease: An analysis from the Gaucher Outcome Survey. Blood Cells Mol Dis 2016; 68:218-225. [PMID: 27829541 DOI: 10.1016/j.bcmd.2016.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/19/2016] [Indexed: 11/27/2022]
Abstract
The Gaucher Outcome Survey (GOS) is an international disease-specific registry established in 2010 for patients with a confirmed diagnosis of Gaucher disease (GD), regardless of GD type or treatment status. For insight into how GD management varies among countries, we analyzed treatment patterns in GOS. As of October 30, 2015, data on GD-specific treatment (enzyme replacement therapy, substrate reduction therapy, or chemical chaperone therapy) received at any time were available for 647 patients. At analysis, velaglucerase alfa (316/573, 55.1%) and imiglucerase (184/573, 32.1%) were the treatments most widely used. Of the 647 treated patients, 446 (68.9%) had been treated for >5years and 368 (56.9%) had received only one GD-specific drug therapy. There were 377 patients who received velaglucerase alfa. Velaglucerase alfa was most widely used at 60U/kg every other week (134/492 dose entries, 27.2%), but there were differences in dosing between the three highest-enrolling countries (defined as >100 GOS patients enrolled in each), with most patients in Israel receiving <20U/kg, most patients in the United Kingdom receiving 20 to <40U/kg, and most in the United States receiving 60U/kg. This analysis provides a foundation upon which to examine real-life outcomes data from different treatment regimens globally.
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Affiliation(s)
- P Deegan
- Addenbrooke's Hospital, Cambridge, United Kingdom.
| | | | - P Giraldo
- Translational Research Unit, IIS Aragon, Zaragoza, Spain; CIBER de Enfermedades Raras, IIS Aragon, Zaragoza, Spain.
| | - H Lau
- Division of Neurogenetics, New York University School of Medicine, New York, NY, United States.
| | | | - A Zimran
- Gaucher Clinic, Shaare Zedek Medical Center, The Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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Pleat R, Cox TM, Burrow TA, Giraldo P, Goker-Alpan O, Rosenbloom BE, Croal LR, Underhill LH, Gaemers SJM, Peterschmitt MJ. Stability is maintained in adults with Gaucher disease type 1 switched from velaglucerase alfa to eliglustat or imiglucerase: A sub-analysis of the eliglustat ENCORE trial. Mol Genet Metab Rep 2016; 9:25-28. [PMID: 27722092 PMCID: PMC5050260 DOI: 10.1016/j.ymgmr.2016.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/24/2016] [Accepted: 08/24/2016] [Indexed: 11/01/2022] Open
Abstract
Gaucher disease type 1 is an autosomal recessive disorder caused by deficient activity of the lysosomal enzyme acid β-glucosidase resulting in accumulation of glucosylceramide and clinical manifestations of anemia, thrombocytopenia, hepatosplenomegaly, and skeletal disease. The historic standard of care is intravenous recombinant enzyme therapy with imiglucerase. Eliglustat, an oral substrate reduction therapy, is a first-line treatment for adults with Gaucher disease type 1 who have a compatible CYP2D6-metabolizer phenotype (≈ 95% of patients). The 12-month ENCORE trial (NCT00943111) found eliglustat non-inferior to imiglucerase in maintaining stability in adult Gaucher patients previously stabilized after ≥ 3 years of enzyme therapy (imiglucerase or velaglucerase alfa). This post-hoc analysis examined safety and efficacy in the 30 ENCORE patients who were receiving velaglucerase alfa at study entry and were randomized to eliglustat (n = 22) or imiglucerase (n = 8). Efficacy and safety in velaglucerase alfa-transitioned patients were consistent with the full ENCORE trial population; 90% of patients switched to eliglustat and 88% of patients switched to imiglucerase met the composite endpoint (stable hemoglobin concentration, platelet count, spleen volume, and liver volume). Clinical stability was maintained for 12 months in Gaucher disease type 1 patients in the ENCORE trial who switched from velaglucerase alfa to either eliglustat or imiglucerase.
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Affiliation(s)
| | - Timothy M Cox
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - T Andrew Burrow
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Pilar Giraldo
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), IISAragón, Zaragoza, Spain
| | - Ozlem Goker-Alpan
- Lysosomal Disorders Research and Treatment Unit, Center for Clinical Trials, O&O Alpan, LLC, Fairfax, VA, USA
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Van Rossum A, Holsopple M. Enzyme Replacement or Substrate Reduction? A Review of Gaucher Disease Treatment Options. Hosp Pharm 2016; 51:553-63. [PMID: 27559188 DOI: 10.1310/hpj5107-553] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Gaucher disease is a rare lysosomal storage disease resulting from a deficiency or reduced activity in the acid β-glucocosidase enzyme. Only 1 treatment option was available for 15 years, but several new treatment options have come to market since 2003. OBJECTIVE The article will detail the pathophysiology and review current therapies in the literature for all 3 major clinical types of Gaucher disease, with a focus on considerations for selecting therapy in type 1 disease. METHODS Extracted and summarized applicable studies and reviews from Cochrane Review, ClinicalTrials.gov, CINAHL, IPA, and PubMed. RESULTS Enzyme replacement therapy is preferred for the management of Gaucher disease. Current literature does not favor any enzyme replacement product over another. However, velaglucerase alfa and taliglucerase alfa theoretically have a lower risk of immunogenicity reactions compared with imiglucerase. Alternative treatments for type 1 disease include substrate reduction therapy; however, these treatments require evaluation of patient-specific variables (eg, genotype evaluation, renal function) and consideration of adverse effect and dosing profiles. Evaluation of current literature found no substrate reduction therapy is preferred over another. There are no approved therapies for type 2 and type 3 disease, but enzyme replacement therapy may be used with limited efficacy for symptom management. CONCLUSION Enzyme replacement therapy is preferred for treating type 1 Gaucher disease and substrate replacement therapy may be considered in patients who do not tolerate or cannot receive enzyme replacement therapy.
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Coutinho MF, Santos JI, Alves S. Less Is More: Substrate Reduction Therapy for Lysosomal Storage Disorders. Int J Mol Sci 2016; 17:ijms17071065. [PMID: 27384562 PMCID: PMC4964441 DOI: 10.3390/ijms17071065] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 12/11/2022] Open
Abstract
Lysosomal storage diseases (LSDs) are a group of rare, life-threatening genetic disorders, usually caused by a dysfunction in one of the many enzymes responsible for intralysosomal digestion. Even though no cure is available for any LSD, a few treatment strategies do exist. Traditionally, efforts have been mainly targeting the functional loss of the enzyme, by injection of a recombinant formulation, in a process called enzyme replacement therapy (ERT), with no impact on neuropathology. This ineffectiveness, together with its high cost and lifelong dependence is amongst the main reasons why additional therapeutic approaches are being (and have to be) investigated: chaperone therapy; gene enhancement; gene therapy; and, alternatively, substrate reduction therapy (SRT), whose aim is to prevent storage not by correcting the original enzymatic defect but, instead, by decreasing the levels of biosynthesis of the accumulating substrate(s). Here we review the concept of substrate reduction, highlighting the major breakthroughs in the field and discussing the future of SRT, not only as a monotherapy but also, especially, as complementary approach for LSDs.
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Affiliation(s)
- Maria Francisca Coutinho
- Department of Human Genetics, Research and Development Unit, National Health Institute Doutor Ricardo Jorge, Rua Alexandre Herculano, 321 4000-055 Porto, Portugal.
| | - Juliana Inês Santos
- Department of Human Genetics, Research and Development Unit, National Health Institute Doutor Ricardo Jorge, Rua Alexandre Herculano, 321 4000-055 Porto, Portugal.
| | - Sandra Alves
- Department of Human Genetics, Research and Development Unit, National Health Institute Doutor Ricardo Jorge, Rua Alexandre Herculano, 321 4000-055 Porto, Portugal.
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Astudillo L, Therville N, Colacios C, Ségui B, Andrieu-Abadie N, Levade T. Glucosylceramidases and malignancies in mammals. Biochimie 2016; 125:267-80. [DOI: 10.1016/j.biochi.2015.11.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/09/2015] [Indexed: 01/11/2023]
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Ward C, Martinez-Lopez N, Otten EG, Carroll B, Maetzel D, Singh R, Sarkar S, Korolchuk VI. Autophagy, lipophagy and lysosomal lipid storage disorders. Biochim Biophys Acta Mol Cell Biol Lipids 2016; 1861:269-84. [DOI: 10.1016/j.bbalip.2016.01.006] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 12/30/2022]
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Smid BE, Ferraz MJ, Verhoek M, Mirzaian M, Wisse P, Overkleeft HS, Hollak CE, Aerts JM. Biochemical response to substrate reduction therapy versus enzyme replacement therapy in Gaucher disease type 1 patients. Orphanet J Rare Dis 2016; 11:28. [PMID: 27008851 PMCID: PMC4806476 DOI: 10.1186/s13023-016-0413-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/16/2016] [Indexed: 11/30/2022] Open
Abstract
Background We retrospectively compared biochemical responses in type 1 Gaucher disease patients to treatment with glycosphingolipid synthesis inhibitors miglustat and eliglustat and ERT. Methods Seventeen GD1 patients were included (n = 6 eliglustat, (two switched from ERT), n = 9 miglustat (seven switchers), n = 4 ERT (median dose 60U/kg/m). Plasma protein markers reflecting disease burden (chitotriosidase, CCL18) and lipids reflecting substrate accumulation (glucosylsphingosine, glucosylceramide) were determined. Also, liver and spleen volumes, hemoglobin, platelets, and fat fraction were measured. Results In patients naïve to treatment, chitotriosidase, CCL18 and glucosylsphingosine decreased comparably upon eliglustat and ERT treatment, while the response to miglustat was less. After 2 years, median decrease of chitotriosidase was 89 % (range 77–98), 88 % (78–92) and 37 % (29–46) for eliglustat, ERT and miglustat naïve patients respectively; decrease of CCL18 was 73 % (63–78), 54 % (43–86), and 10 % (3–18); decrease of glucosylsphingosine was 86 % (78–93), 78 % (65–91), 48 % (46–50). Plasma glucosylceramide in eliglustat treated patients (n = 4) reached values below the normal range (n = 20 healthy controls). Biochemical markers decreased or stabilized in switchers from ERT to eliglustat (n = 2), but less in miglustat switchers (n = 7). Clinical parameters responded comparably upon eliglustat and ERT treatment. Conclusions Our explorative study provides evidence that biochemical markers respond comparably in patients receiving eliglustat treatment and ERT, while the corresponding response to miglustat treatment is less.
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Affiliation(s)
- Bouwien E Smid
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - Maria J Ferraz
- Department of Medical Biochemistry, Academic Medical Centre, Amsterdam, The Netherlands
| | - Marri Verhoek
- Department of Biochemistry, Leiden Institute of Chemistry, Leiden University, Leiden, The Netherlands
| | - Mina Mirzaian
- Department of Medical Biochemistry, Academic Medical Centre, Amsterdam, The Netherlands
| | - Patrick Wisse
- Department of Bio-Organic Synthesis, Leiden Institute of Chemistry, Leiden University, Leiden, The Netherlands
| | - Herman S Overkleeft
- Department of Bio-Organic Synthesis, Leiden Institute of Chemistry, Leiden University, Leiden, The Netherlands
| | - Carla E Hollak
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - Johannes M Aerts
- Department of Biochemistry, Leiden Institute of Chemistry, Leiden University, Leiden, The Netherlands. .,Leiden Institute of Chemistry, Gorlaeus Laboratory, room number 0.3.15, Einsteinweg 55, 2300 RA, Leiden, The Netherlands.
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Balwani M, Burrow TA, Charrow J, Goker-Alpan O, Kaplan P, Kishnani PS, Mistry P, Ruskin J, Weinreb N. Recommendations for the use of eliglustat in the treatment of adults with Gaucher disease type 1 in the United States. Mol Genet Metab 2016; 117:95-103. [PMID: 26387627 DOI: 10.1016/j.ymgme.2015.09.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 12/30/2022]
Abstract
In Gaucher disease, deficient activity of acid β-glucosidase results in accumulation of its substrates, glucosylceramide and glucosylsphingosine, within the lysosomes of cells primarily in the spleen, liver, bone marrow, and occasionally the lung. The multisystem disease is predominantly characterized by hepatosplenomegaly, anemia, thrombocytopenia, and skeletal disease. Enzyme replacement therapy with recombinant human acid β-glucosidase has been the first-line therapy for Gaucher disease type 1 for more than two decades. Eliglustat, a novel oral substrate reduction therapy, was recently approved in the United States and the European Union as a first-line treatment for adults with Gaucher disease type 1. Eliglustat inhibits glucosylceramide synthase, thereby decreasing production of the substrate glucosylceramide and reducing its accumulation. Although existing recommendations for the care of patients with Gaucher disease remain in effect, unique characteristics of eliglustat require additional investigation and monitoring. A panel of physicians with expertise in Gaucher disease and experience with eliglustat in the clinical trials provide guidance regarding the use of eliglustat, including considerations before starting therapy and monitoring of patients on eliglustat therapy.
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences, One Gustave L. Levy Place, Box 1497, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Thomas Andrew Burrow
- Cincinnati Children's Hospital Medical Center, Division of Human Genetics, 3333 Burnet Avenue, MLC 4006, Cincinnati, OH 45229, USA.
| | - Joel Charrow
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Genetics, Birth Defects and Metabolism, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL 60611, USA.
| | - Ozlem Goker-Alpan
- Lysosomal Disorders Unit, O&O Alpan, LLC, 11212 Waples Mill Road, Fairfax, VA 22030, USA.
| | - Paige Kaplan
- Lysosomal Center, Division of Genetics, Children's Hospital of Philadelphia, Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Priya S Kishnani
- Duke University School of Medicine, Department of Pediatrics, DUMC 103856, 595 Lasalle Street, GSRB 1, 4th Floor, Room 4010, Durham, NC 27710, USA.
| | - Pramod Mistry
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA.
| | - Jeremy Ruskin
- Massachusetts General Hospital, Electrophysiology Lab/Arrhythmia Service, 55 Fruit Street, Boston, MA 02114-2696, USA.
| | - Neal Weinreb
- University Research Foundation for Lysosomal Storage Diseases, Inc., 7367 Wexford Terrace, Boca Raton, FL 33433, USA.
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Dandana A, Ben Khelifa S, Chahed H, Miled A, Ferchichi S. Gaucher Disease: Clinical, Biological and Therapeutic Aspects. Pathobiology 2015; 83:13-23. [PMID: 26588331 DOI: 10.1159/000440865] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 09/02/2015] [Indexed: 11/19/2022] Open
Abstract
We present a brief review of Gaucher disease (GD), the most common lysosomal storage disease. GD is a rare autosomal recessive disorder characterized by the defective function of the catabolic enzyme β-glucocerebrosidase (GBA), leading to an accumulation of its substrate, glucocerebroside. Clinical signs and symptoms include neurological dysfunctions, bone infarcts and malformations, hepatosplenomegaly and hypersplenism leading to anemia, neutropenia and thrombocytopenia. Enzyme replacement therapy with recombinant GBA is the mainstay of treatment for GD, which became the first successfully managed lipid storage disease. Future treatments may include oral enzyme replacement and/or gene therapy interventions.
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Affiliation(s)
- Azza Dandana
- Laboratory of Biochemistry, Farhat Hached Hospital, Sousse, Tunisia
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Abstract
Lysosomal storage diseases are a group of rare, inborn, metabolic errors characterized by deficiencies in normal lysosomal function and by intralysosomal accumulation of undegraded substrates. The past 25 years have been characterized by remarkable progress in the treatment of these diseases and by the development of multiple therapeutic approaches. These approaches include strategies aimed at increasing the residual activity of a missing enzyme (enzyme replacement therapy, hematopoietic stem cell transplantation, pharmacological chaperone therapy and gene therapy) and approaches based on reducing the flux of substrates to lysosomes. As knowledge has improved about the pathophysiology of lysosomal storage diseases, novel targets for therapy have been identified, and innovative treatment approaches are being developed.
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Abstract
Eliglustat [Cerdelga™ (US, EU)], a small-molecule oral glucosylceramide analogue that inhibits the enzyme glucosylceramide synthase has been developed by Genzyme Corporation (a subsidiary of Sanofi) for the treatment of Gaucher disease type 1 in adults. Inhibition of this enzyme reduces the accumulation of the lipid glucosylceramide in the liver, spleen, bone marrow and other organs. Eliglustat received its first global approval in this indication in the US, for use in treatment-naïve and treatment-experienced adult patients. It is also under regulatory review in the EU and Japan. This article summarizes the milestones in the development of eliglustat leading to this first approval for Gaucher disease type 1.
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Affiliation(s)
- Raewyn M Poole
- Springer, Private Bag 65901, Mairangi Bay 0754, Auckland, New Zealand,
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Bennett LL, Turcotte K. Eliglustat tartrate for the treatment of adults with type 1 Gaucher disease. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:4639-47. [PMID: 26345314 PMCID: PMC4554398 DOI: 10.2147/dddt.s77760] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The purpose of this article is to review eliglustat tartrate, a substrate reduction therapy, for the treatment of Gaucher disease type 1 (GD1). GD is an rare inborn error of metabolism caused by accumulation of lipid substrates such as glucosylceramide within the monocyte-macrophage system that affects the body by causing enlargement of the spleen and liver, destruction of bone, and abnormalities of the lungs and blood, such as anemia, thrombocytopenia, and leukopenia. GD is classified into three types: GD1, a chronic and non-neuronopathic disease accounting for 95% of GD cases; and types 2 and 3 (GD2 GD3) which are more progressive diseases with no approved drugs available at this time. Treatment options for GD1 include enzyme replacement therapy and substrate reduction therapy. Eliglustat works by inhibiting UDP-glucosylceramide synthase, the first enzyme that catalyzes the biosynthesis of glycosphingolipids, thus reducing the load of glucosylceramide influx into the lysosome. Eliglustat was approved by the US Food and Drug Administration after three Phase I, two Phase II, and two Phase III clinical trials. The dose of eliglustat is 84 mg twice a day or once daily depending on the cytochrome P450 2D6 genotype of the patient.
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Cox TM, Drelichman G, Cravo R, Balwani M, Burrow TA, Martins AM, Lukina E, Rosenbloom B, Ross L, Angell J, Puga AC. Eliglustat compared with imiglucerase in patients with Gaucher's disease type 1 stabilised on enzyme replacement therapy: a phase 3, randomised, open-label, non-inferiority trial. Lancet 2015; 385:2355-62. [PMID: 25819691 DOI: 10.1016/s0140-6736(14)61841-9] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The mainstay of treatment for Gaucher's disease type 1 is alternate-week infusion of enzyme replacement therapy (ERT). We investigated whether patients stable on such treatment would remain so after switching to oral eliglustat, a selective inhibitor of glucosylceramide synthase. METHODS In this phase 3, randomised, multinational, open-label, non-inferiority trial, we enrolled adults (aged ≥18 years) who had received ERT for 3 years or more for Gaucher's disease. Patients were randomly allocated 2:1 at 39 clinics (stratified by ERT dose; block sizes of four; computer-generated centrally) to receive either oral eliglustat or imiglucerase infusions for 12 months. Participants and investigators were aware of treatment assignment, but the central reader who assessed organ volumes was masked. The composite primary efficacy endpoint was percentage of patients whose haematological variables and organ volumes remained stable for 12 months (ie, haemoglobin decrease not more than 15 g/L, platelet count decrease not more than 25%, spleen volume increase not more than 25%, and liver volume increase not more than 20%, in multiples of normal from baseline). The non-inferiority margin was 25% for eliglustat relative to imiglucerase, assessed in all patients who completed 12 months of treatment. This trial is registered with ClinicalTrials.gov, number NCT00943111, and EudraCT, number 2008-005223-28. FINDINGS Between Sept 15, 2009, and Nov 9, 2011, we randomly allocated 106 (66%) patients to eliglustat and 54 (34%) to imiglucerase. In the per-protocol population, 84 (85%) of 99 patients who completed eliglustat treatment and 44 (94%) of 47 patients who completed imiglucerase treatment met the composite primary endpoint (between-group difference -8·8%; 95% CI -17·6 to 4·2). The lower bound of the 95% CI of -17·6% was within the prespecified threshold for non-inferiority. Dropouts occurred due to palpitations (one patient on eliglustat), myocardial infarction (one patient on eliglustat), and psychotic disorder (one patient on imiglucerase). No deaths occurred. 97 (92%) of 106 patients in the eliglustat group had treatment-emergent adverse events, as did 42 (79%) of 53 in the imiglucerase group (mostly mild or moderate in severity). INTERPRETATION Oral eliglustat maintained haematological and organ volume stability in adults with Gaucher's disease type 1 already controlled by intravenous ERT and could be a useful therapeutic option. FUNDING Genzyme, a Sanofi company.
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Affiliation(s)
- Timothy M Cox
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | | | - Renata Cravo
- State Institute of Haematology 'Arthur de Siqueira Cavalcanti', Rio de Janeiro, Brazil
| | | | | | | | | | - Barry Rosenbloom
- Cedars-Sinai Oncology, and Tower Hematology Oncology, Beverly Hills, CA, USA
| | - Leorah Ross
- Genzyme, a Sanofi company, Cambridge, MA, USA
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Affiliation(s)
- Derralynn A Hughes
- Lysosomal Storage Disorders Unit, Department of Haematology, University College London, Royal Free London NHS Foundation Trust, London NW3 2QG, UK.
| | - Gregory M Pastores
- Department of Medicine, National Centre for Inherited Metabolic Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
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Shemesh E, Deroma L, Bembi B, Deegan P, Hollak C, Weinreb NJ, Cox TM. Enzyme replacement and substrate reduction therapy for Gaucher disease. Cochrane Database Syst Rev 2015; 2015:CD010324. [PMID: 25812601 PMCID: PMC8923052 DOI: 10.1002/14651858.cd010324.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Gaucher disease, a rare disorder, is caused by inherited deficiency of the enzyme glucocerebrosidase. It is unique among the ultra-orphan disorders in that four treatments are currently approved by various regulatory authorities for use in routine clinical practice. Hitherto, because of the relatively few people affected worldwide, many of whom started therapy during a prolonged period when there were essentially no alternatives to imiglucerase, these treatments have not been systematically evaluated in studies such as randomized controlled trials now considered necessary to generate the highest level of clinical evidence. OBJECTIVES To summarize all available randomized controlled study data on the efficacy and safety of enzyme replacement therapies and substrate reduction therapy for treating Gaucher disease. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Inborn Errors of Metabolism Trials Register. Additional searches were conducted on ClinicalTrials.gov for any ongoing studies with potential interim results, and through PubMed. We also searched the reference lists of relevant articles and reviews.Date of last search: 07 August 2014. SELECTION CRITERIA All randomized and quasi-randomized controlled studies (including open-label studies and cross-over studies) assessing enzyme replacement therapy or substrate reduction therapy, or both, in all types of Gaucher disease were included. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias in the included studies, and extracted relevant data. MAIN RESULTS Of the 488 studies retrieved by the electronic searches, eight met the inclusion criteria and were analysed (300 participants). Response parameters were restricted to haemoglobin concentration, platelet count, spleen and liver volume and serum biomarkers (chitotriosidase and CCL18). Only one publication reported a 'low risk of bias' score in all parameters assessed, and all studies included were randomized.Four studies reported the responses to enzyme replacement therapy of previously untreated individuals with type 1 Gaucher disease. Two studies investigated maintenance enzyme replacement therapy in people with stable type 1 Gaucher disease previously treated for at least two years. One study compared substrate reduction therapy, enzyme replacement therapy and a combination thereof as maintenance therapy in people with type 1 Gaucher disease previously treated with enzyme replacement therapy. One study examined substrate reduction therapy in people with chronic neuronopathic (type 3) Gaucher disease who continued to receive enzyme replacement therapy.Treatment-naïve participants had similar increases in haemoglobin when comparing those receiving imiglucerase or alglucerase at 60 units/kg, imiglucerase or velaglucerase alfa at 60 U/kg, taliglucerase alfa at 30 units/kg or 60 units/kg, and velaglucerase alfa at 45 units/g or 60 units/kg. For platelet count response in participants with intact spleens, a benefit for imiglucerase over velaglucerase alfa at 60 units/kg was observed, mean difference -79.87 (95% confidence interval -137.57 to -22.17). There were no other significant differences in platelet count response when comparing different doses of velaglucerase alfa and of taliglucerase alfa, and when comparing imiglucerase to alglucerase. Spleen and liver volume reductions were not significantly different in any enzyme replacement therapy product or dose comparison study. Although a dose effect on serum biomarkers was not seen after nine months, a significantly greater reduction with higher dose was reported after 12 months in the velaglucerase study, mean difference 16.70 (95% confidence intervaI 1.51 to 31.89). In the two enzyme replacement therapy maintenance studies comparing infusions every two weeks and every four weeks, there were no significant differences in haemoglobin concentration, platelet count, and spleen and liver volumes over a 6 to 12 month period when participants were treated with the same cumulative dose.A total of 25 serious adverse events were reported, nearly all deemed unrelated to treatment.There are, as yet, no randomized trials of substrate reduction therapy in treatment-naïve patients that can be evaluated. Miglustat monotherapy appeared as effective as continued enzyme replacement therapy for maintenance of hematological, organ and biomarker responses in people with type 1 Gaucher disease previously treated with imiglucerase for at least two years. In those with neuronopathic Gaucher disease, no significant improvements in haemoglobin concentration, platelet count or organ volumes occurred when enzyme replacement therapy was augmented with miglustat.One randomized controlled study assessing substrate reduction therapy was published immediately prior to producing the final version of this review, and this, along with a further ongoing study (expected to be published in the near future), will be assessed for eligibility in a future update of the review. AUTHORS' CONCLUSIONS The results reflect the limitations of analysing evidence restricted to prospective randomized controlled trials, especially when dealing with chronic rare diseases. This analysis suggests that, during the first year of treatment, different recombinant glucocerebrosidases are bio-similar and non-inferior in safety and efficacy for surrogate biological response parameters. Enzyme replacement therapy given at 30 to 45 units/kg body weight every two to four weeks was generally as effective as the 60 unit/kg dose for the assessed clinical outcomes. The analysis emphasise the need to determine whether it is realistic to carry out multi-decade prospective clinical trials for rare diseases such as type 1 Gaucher disease. With large treatment effects on the classical manifestations of the disorder, therapeutic investigations in Gaucher disease mandate innovative trial designs and methodology to secure decisive data concerning long-term efficacy and safety - with the realization that knowledge about disease-modifying actions that are sustained are of crucial importance to people with this chronic condition.
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Affiliation(s)
| | - Laura Deroma
- University Hospital "Santa Maria della Misericordia"Regional Coordinator Centre for Rare DiseasesPiazzale Santa Maria della Misericordia 15UdineItaly33100
| | - Bruno Bembi
- University Hospital "Santa Maria della Misericordia"Regional Coordinator Centre for Rare DiseasesPiazzale Santa Maria della Misericordia 15UdineItaly33100
| | - Patrick Deegan
- University of Cambridge and Lysosomal Disorders UnitDepartment of MedicineAddenbrooke's Hospital (PO Box 157)CambridgeUKCB2 0QQ
| | - Carla Hollak
- Academic Medical CenterDepartment of Internal Medicine, Division of Endocrinology & MetabolismPostbus 22660AmsterdamNetherlands1100 DD
| | - Neal J Weinreb
- Northwest Oncology Hematology Associates PAUniversity Research Foundation for Lysosomal Storage Diseases8170 Royal Palm BoulevardCoral SpringsFloridaUSA33433
- University of Miami Miller School of MedicineMiamiFloridaUSA
| | - Timothy M Cox
- Addenbrooke's Hospital (Box 157)Department of MedicineLevel 5, Hills RoadCambridgeCambridgeshireUKCB2 0QQ
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Pastores GM, Hughes DA. Non-neuronopathic lysosomal storage disorders: Disease spectrum and treatments. Best Pract Res Clin Endocrinol Metab 2015; 29:173-82. [PMID: 25987171 DOI: 10.1016/j.beem.2014.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Distinctive facial features, hepatosplenomegaly or cardiomyopathy with or without associated skeletal dysplasia are clinical manifestations that may be suggestive of an underlying lysosomal storage disorder (LSD), However, these features may not be evident in certain subtypes associated primarily with central nervous system involvement. Age at onset can be broad, ranging from infancy to adulthood. Diagnosis may be delayed, as manifestations may be slow to evolve (taking months to years), particularly in those with later (adult-)onset, and in isolated cases (i.e., those without a prior family history). Diagnosis of individual subtypes can be confirmed using a combination of biochemical and molecular assays. In a few LSDs, treatment with hematopoietic stem cell transplantation, enzyme replacement or substrate reduction therapy is available. Symptomatic and palliative measure may enhance quality of life for both treatable and currently untreatable cases. Genetic counseling is important, so patients and their families can be informed of reproductive risks, disease prognosis and therapeutic options. Investigations of underlying disease mechanisms are enhancing knowledge about rare diseases, but also other more common medical conditions, on account of potential convergent disease pathways.
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Affiliation(s)
- Gregory M Pastores
- National Center for Inherited Metabolic Diseases - Adult Services, Department of Medicine, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - Derralynn A Hughes
- Department of Haematology, Royal Free London NHS Foundation Trust and University College London, United Kingdom
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Scarpa M, Bellettato CM, Lampe C, Begley DJ. Neuronopathic lysosomal storage disorders: Approaches to treat the central nervous system. Best Pract Res Clin Endocrinol Metab 2015; 29:159-71. [PMID: 25987170 DOI: 10.1016/j.beem.2014.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pharmacological research has always focused on developing new therapeutic strategies capable of modifying a disease's natural history and improving patients' quality of life. Despite recent advances within the fields of medicine and biology, some diseases still represent a major challenge for successful therapy. Neuronopathic lysosomal storage disorders, in particular, have high rates of morbidity and mortality and a devastating socio-economic effect. Many of the available therapies, such as enzyme replacement therapy, can reverse the natural history of the disease in peripheral organs but, unfortunately, are still unable to reach the central nervous system effectively because they cannot cross the blood-brain barrier that surrounds and protects the brain. Moreover, many lysosomal storage disorders are characterized by a number of blood-brain barrier dysfunctions, which may further contribute to disease neuropathology and accelerate neuronal cell death. These issues, and their context in the development of new therapeutic strategies, will be discussed in detail in this chapter.
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Affiliation(s)
- Maurizio Scarpa
- Center for Rare Diseases, Horst Schmidt Kliniken, Department of Child and Adolescent Medicine, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, D, Germany; University of Padova, Department of Women and Children Health, Via Giustiniani 3, Padova, Italy; Brains for Brains Foundation, Department of Women and Children Health, Via Giustiniani 3, Padova, Italy.
| | - Cinzia Maria Bellettato
- Brains for Brains Foundation, Department of Women and Children Health, Via Giustiniani 3, Padova, Italy.
| | - Christina Lampe
- Center for Rare Diseases, Horst Schmidt Kliniken, Department of Child and Adolescent Medicine, Ludwig-Erhard-Straße 100, 65199 Wiesbaden, D, Germany.
| | - David J Begley
- Brains for Brains Foundation, Department of Women and Children Health, Via Giustiniani 3, Padova, Italy; Kings College London, Institute of Pharmaceutical Science, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, UK.
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Mistry PK, Lukina E, Turkia HB, Amato D, Baris H, Dasouki M, Ghosn M, Mehta A, Packman S, Pastores G, Petakov M, Assouline S, Balwani M, Danda S, Hadjiev E, Ortega A, Shankar S, Solano MH, Ross L, Angell J, Peterschmitt MJ. Effect of oral eliglustat on splenomegaly in patients with Gaucher disease type 1: the ENGAGE randomized clinical trial. JAMA 2015; 313:695-706. [PMID: 25688781 PMCID: PMC4962880 DOI: 10.1001/jama.2015.459] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE Gaucher disease type 1 is characterized by hepatosplenomegaly, anemia, thrombocytopenia, and skeletal disease. A safe, effective oral therapy is needed. OBJECTIVE To determine whether eliglustat, a novel oral substrate reduction therapy, safely reverses clinical manifestations in untreated adults with Gaucher disease type 1. DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled trial conducted at 18 sites in 12 countries from November 2009 to July 2012 among eligible patients with splenomegaly plus thrombocytopenia and/or anemia. Of 72 patients screened, 40 were enrolled. INTERVENTIONS Patients were stratified by spleen volume and randomized 1:1 to receive eliglustat (50 or 100 mg twice daily; n = 20) or placebo (n = 20) for 9 months. MAIN OUTCOMES AND MEASURES The primary efficacy end point was percentage change in spleen volume in multiples of normal from baseline to 9 months; secondary efficacy end points were change in hemoglobin level and percentage changes in liver volume and platelet count. RESULTS All patients had baseline splenomegaly and thrombocytopenia (mostly moderate or severe), most had mild or moderate hepatomegaly, and 20% had mild anemia. Least-square mean spleen volume decreased by 27.77% (95% CI, -32.57% to -22.97%) in the eliglustat group (from 13.89 to 10.17 multiples of normal) vs an increase of 2.26% (95% CI, -2.54% to 7.06%) in the placebo group (from 12.50 to 12.84 multiples of normal) for an absolute treatment difference of -30.03% (95% CI, -36.82% to -23.24%; P < .001). For the secondary end points, the least-square mean absolute differences between groups all favored eliglustat, with a 1.22-g/dL increase in hemoglobin level (95% CI, 0.57-1.88 g/dL; P < .001), 6.64% decrease in liver volume (95% CI, -11.37% to -1.91%; P = .007), and 41.06% increase in platelet count (95% CI, 23.95%-58.17%; P < .001). No serious adverse events occurred. One patient in the eliglustat group withdrew (non-treatment related); 39 of the 40 patients transitioned to an open-label extension study. CONCLUSIONS AND RELEVANCE Among previously untreated adults with Gaucher disease type 1, treatment with eliglustat compared with placebo for 9 months resulted in significant improvements in spleen volume, hemoglobin level, liver volume, and platelet count. The clinical significance of these findings is uncertain, and more definitive conclusions about clinical efficacy and utility will require comparison with the standard treatment of enzyme replacement therapy as well as longer-term follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00891202.
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Affiliation(s)
| | | | | | | | - Hagit Baris
- Rabin Medical Center, Petach Tikvah, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Majed Dasouki
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Marwan Ghosn
- Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | | | | | | | - Milan Petakov
- Clinical Center of Serbia, Belgrade University Medical School, Serbia
| | | | - Manisha Balwani
- Ikhan School of Medicine at Mt. Sinai Hospital, New York, NY, USA
| | - Sumita Danda
- Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | | | - Maria Helena Solano
- Hospital de San Jose-Fundacion Universitaria de Ciencias de la Salud San Jose, Bogota, Colombia
| | - Leorah Ross
- Genzyme, a Sanofi company, Cambridge, MA, USA
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