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Shirinezhad A, Esmaeili S, Azarboo A, Tavakoli Y, Hoveidaei AH, Zareshahi N, Ghaseminejad-Raeini A. Efficacy and safety of asfotase alfa in patients with hypophosphatasia: A systematic review. Bone 2024; 188:117219. [PMID: 39089608 DOI: 10.1016/j.bone.2024.117219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/18/2024] [Accepted: 07/28/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Hypophosphatasia (HPP) is a rare genetic disorder characterized by defective bone mineralization, leading to skeletal abnormalities and systemic complications. Asfotase alfa, a recombinant human tissue-nonspecific alkaline phosphatase (TNSALP) enzyme replacement therapy, has emerged as a promising treatment for HPP. However, a comprehensive evaluation of its efficacy and safety is warranted to guide clinical practice effectively. METHODS The study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered in Prospective Register of Systematic Reviews (PROSPERO). A search strategy across databases found studies on asfotase alfa for HPP. Two researchers independently extracted and assessed data. This systematic review examined how the drug impacted clinical outcomes such as survival rates, musculoskeletal symptoms, respiratory function, growth measurements, dental health, quality of life, and laboratory results. RESULTS This systematic review included 15 articles with a total of 455 HPP patients. Asfotase alfa was predominantly administered at a dose of 6 mg per kg per week among the reviewed studies. Notable findings included enhanced survival rates, relief from musculoskeletal pain, improvements in respiratory outcomes, growth parameters, dental health, and quality of life. Changes in laboratory variables indicated positive responses to treatment, including changes such as increase in alkaline phosphatase (ALP), decline in pyridoxal 5'-phosphate (PLP) and inorganic pyrophosphate (PPi) levels. CONCLUSION Asfotase alfa demonstrates efficacy in improving clinical outcomes and safety in patients with HPP. Its therapeutic benefits extend across various domains. However, Larger, age-stratified comparative studies are needed to further investigate the drug's effects in HPP patients.
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Affiliation(s)
| | - Sina Esmaeili
- Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Azarboo
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Yasaman Tavakoli
- Student Research Committee, Department of Medicine, Mazandaran University of Medical Sciences, Mazandaran, Iran
| | - Amir Human Hoveidaei
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Negar Zareshahi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Michałus I, Gawlik A, Wieczorek-Szukała K, Lewiński A. The Clinical Picture of Patients Suffering from Hypophosphatasia—A Rare Metabolic Disease of Many Faces. Diagnostics (Basel) 2022; 12:diagnostics12040865. [PMID: 35453912 PMCID: PMC9031194 DOI: 10.3390/diagnostics12040865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022] Open
Abstract
Hypophosphatasia (HPP) is a rare, and usually diagnosed with delay, genetic disease caused by a mutation in the alkaline phosphatase liver/bone/kidney type (ALPL) gene. Low activity of the alkaline phosphatase (ALP) impairs the hydroxyapatite formation, reducing skeletal mineralization. The aim of the study was to present patients diagnosed with HPP. The data from the history and medical records of patients were analyzed. In the study group, one patient was diagnosed with perinatal type of HPP, three were diagnosed with infant variant, eight were diagnosed with children variant, two were diagnosed with odontohypophosphatasia, and two were diagnosed with the adult type of the disease. The most frequently presented symptoms included premature loss of teeth in 11/16 (68.75%) patients, bone deformities in 10/16 (62.5%) patients, chronic bone pain in 9/16 (56.25%) patients, and fractures in 8/16 (50%) patients. Reduction in bone mineral density in at least one examined projection has been found in 11/14 patients. Conclusions: The correct diagnosis of HPP is difficult due to the variety of types and clinical symptoms, as well as the very rare occurrence of this disease. Both lower and upper reference values of the determined biochemical parameters may be important in HPP diagnostics.
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Affiliation(s)
- Izabela Michałus
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland;
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences, Medical University of Silesia, 40-759 Katowice, Poland;
| | | | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland;
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, 90-419 Lodz, Poland;
- Correspondence:
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Sugiyama Y, Watanabe T, Tajika M, Matsuhashi T, Shimura M, Fushimi T, Ichimoto K, Matsunaga A, Ebihara T, Tsuruoka T, Akiyama T, Murayama K. A Japanese single-center experience of the efficacy and safety of asfotase alfa in pediatric-onset hypophosphatasia. Orphanet J Rare Dis 2022; 17:78. [PMID: 35197081 PMCID: PMC8867653 DOI: 10.1186/s13023-022-02230-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 02/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hypophosphatasia (HPP) is a rare inherited metabolic disorder caused by mutations in the ALPL gene, which encodes tissue nonspecific alkaline phosphatase. The severity of HPP is widely diverse from the perinatal form to the adult mild form. The former represents the most severe form and was earlier associated with high mortality due to pneumonia which was caused by severe hypomineralization of the bones—such as chest deformity and fractured ribs—and muscle weakness. Enzyme replacement therapy using asfotase alfa (AA) was approved in 2015 in Japan for treating patients with HPP and has improved their pulmonary function and life prognosis. There are several practical and ethical challenges related to using orphan drugs for a rare disorder in a publicly funded healthcare system. Sharing experiences about their application is essential towards formulating guidelines to assist clinicians with decisions about their initiation and withdrawal. We report the details of AA experience in ten cases of pediatric-onset HPP in nine families from January 2015 to November 2019 (median [interquartile range] age 11.0 [7.6–12.5] years; 60% male). This is a study of a single-center cohort describing the clinical course of patients with HPP, mainly consisting of the mild childhood form of HPP, treated with AA in Japan. Results One case of perinatal form of HPP, two cases of benign prenatal form, and seven cases of childhood form were observed. The most common symptom at onset was pain. All patients had low serum alkaline phosphatase levels as compared to the age-matched reference range before the commencement of AA. All HPP patients seem to have responded to AA treatment, as evidenced by pain alleviation, increased height standard deviation, improvement in respiratory condition and 6-min walk test result improvement, disappearance of kidney calcification, alleviation of fatigue, and/or increases in bone mineralization. There were no serious adverse events, but all patients had an injection site reaction and skin changes at the injection sites. Genetic analysis showed that eight out of ten patients had compound heterozygosity. Conclusions AA may be effective in patients with mild to severe pediatric-onset forms of HPP. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02230-y.
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Affiliation(s)
- Yohei Sugiyama
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan.,Department of Neonatology, Chiba Children's Hospital, Chiba, Japan
| | - Taijiro Watanabe
- Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Makiko Tajika
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Tetsuro Matsuhashi
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Masaru Shimura
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Takuya Fushimi
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Keiko Ichimoto
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Ayako Matsunaga
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan
| | - Tomohiro Ebihara
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Neonatology, Chiba Children's Hospital, Chiba, Japan
| | - Tomoko Tsuruoka
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan.,Department of Neonatology, Chiba Children's Hospital, Chiba, Japan
| | - Tomoyuki Akiyama
- Department of Child Neurology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama city, Okayama Prefecture, 700-8558, Japan
| | - Kei Murayama
- Center for Medical Genetics, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba City, Chiba Prefecture, 266-0007, Japan. .,Department of Metabolism, Chiba Children's Hospital, Chiba, Japan.
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Abstract
Hypophosphatasia (HPP) is an inherited metabolic disease caused by loss-of-function mutations in the tissue non-specific alkaline phosphatase (TNAP) gene. Reduced activity of TNAP leads to the accumulation of its substrates, mainly inorganic pyrophosphate and pyridoxal-5′-phosphate, metabolic aberrations that largely explain the musculoskeletal and systemic features of the disease. More than 400 ALPL mutations, mostly missense, are reported to date, transmitted by either autosomal dominant or recessive mode. Severe disease is rare, with incidence ranging from 1:100,000 to 1:300,000 live births, while the estimated prevalence of the less severe adult form is estimated to be between 1:3100 to 1:508, in different countries in Europe. Presentation largely varies, ranging from death in utero to asymptomatic adults. In infants and children, clinical features include skeletal, respiratory and neurologic complications, while recurrent, poorly healing fractures, muscle weakness and arthropathy are common in adults. Persistently low serum alkaline phosphatase is the cardinal biochemical feature of the disease. Management requires a dedicated multidisciplinary team. In mild cases, treatment is usually symptomatic. Severe cases, with life-threating or debilitating complications, can be successfully treated with enzyme replacement therapy with asfotase alfa.
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Yokoi K, Nakajima Y, Shinkai Y, Sano Y, Imamura M, Akiyama T, Yoshikawa T, Ito T, Kurahashi H. Clinical and genetic aspects of mild hypophosphatasia in Japanese patients. Mol Genet Metab Rep 2019; 21:100515. [PMID: 31641588 PMCID: PMC6796780 DOI: 10.1016/j.ymgmr.2019.100515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/05/2019] [Accepted: 09/02/2019] [Indexed: 11/29/2022] Open
Abstract
Background Hypophosphatasia (HPP) is a rare inborn error of metabolism that results from a dysfunctional tissue non-specific alkaline phosphatase enzyme (TNSALP). Although genotype-phenotype correlations have been described in HPP patients, only sparse information is currently available on the genetics of mild type HPP. Methods We investigated 5 Japanese patients from 3 families with mild HPP (patients 1 and 2 are siblings; patient 4 is a daughter of patient 5) who were referred to Fujita Health University due to the premature loss of deciduous teeth. Physical and dental examinations, and blood, urine and bone density tests were conducted. Genetic analysis of the ALPL gene was performed in all patients with their informed consent. Results After a detailed interview and examination, we found characteristic symptoms of HPP in some of the study cases. Mobile teeth or the loss of permanent teeth were observed in 2 patients, and 3 out of 5 patients had a history of asthma. The serum ALP levels of all patients were 30% below the lower limit of the age equivalent normal range. ALPL gene analysis revealed compound heterozygous mutations, including Ile395Val and Leu520Argfs in family 1, Val95Met and Gly491Arg in family 2, and a dominant missense mutation (Gly456Arg) in family 3. The 3D-modeling of human TNSALP revealed three mutations (Val95Met, Ile395Val and Gly456Arg) at the homodimer interface. Severe collisions between the side chains were predicted for the Gly456Arg variant. Discussion One of the characteristic findings of this present study was a high prevalence of coexisting asthma and a high level serum IgE level. These characteristics may account for the fragility of tracheal tissues and a predisposition to asthma in patients with mild HPP. The genotypes of the five mild HPP patients in our present study series included 1) compound heterozygous for severe and hypomorphic mutations, and 2) dominant-negative mutations. All of these mutations were at the homodimer interface, but only the dominant-negative mutation was predicted to cause a severe collision effect between the side chains. This may account for varying mechanisms leading to different effects on TNSALP function.
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Affiliation(s)
- Katsuyuki Yokoi
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake 470-1192, Japan.,Division of Molecular Genetics, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake 470-1192, Japan
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
| | - Yasuko Shinkai
- Division of Molecular Genetics, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake 470-1192, Japan
| | - Yoshimi Sano
- Department of Plastic Surgery, Division of Pediatric Dentistry & Orthodontics, Fujita Health University of Medicine, Toyoake 470-1192, Japan
| | - Mototaka Imamura
- Department of Plastic Surgery, Division of Pediatric Dentistry & Orthodontics, Fujita Health University of Medicine, Toyoake 470-1192, Japan
| | - Tomoyuki Akiyama
- Department of Child Neurology, Okayama University Hospital, Okayama 700-8558, Japan
| | - Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
| | - Tetsuya Ito
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
| | - Hiroki Kurahashi
- Division of Molecular Genetics, Institute for Comprehensive Medical Science, Fujita Health University, Toyoake 470-1192, Japan
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