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Kretzschmar AKM, Teixeira E, Galato D, da Silva EN. Judicialization of Zolgensma in the Ministry of Health: costs and clinical profile of patients. Rev Saude Publica 2024; 58:36. [PMID: 39140576 PMCID: PMC11319041 DOI: 10.11606/s1518-8787.2024058005899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/14/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVE To investigate the costs and profile of patients who have filed a lawsuit against the Ministry of Health for the treatment of spinal muscular atrophy (SMA) with the onasemnogene abeparvovec (Zolgensma®). METHODS This is a cross-sectional, descriptive study with a census design, based on records of lawsuits filed against the Ministry of Health between January 2019 and September 2022. Data was requested from the Ministry of Health via the Access to Information Act. Information was extracted on the epidemiological profile of the beneficiaries of the lawsuits, as well as the expenses spent by the Ministry of Health in cases where the requests were granted. RESULTS 136 lawsuits were identified, of which 113 (83%) were favorable to patients at a cost of R$ 944.8 million in the period analyzed. Demographic (gender and age), clinical (SMA subtypes, use of ventilatory or nutritional support), and lawsuit (type of legal service) characteristics were not associated with the granting of lawsuits. Prior use of medication (nusinersena or ridisplam) was associated with the dismissal of lawsuits. Of the 113 lawsuits granted in favor of patients, only six (5.3%) would meet the criteria currently established by the National Committee for Health Technology Incorporation - Conitec (children up to six months without ventilatory and nutritional support). R$ 146 million was spent on supplying Zolgensma to children over the age of two, which is outside the recommendation contained in the drug's package leaflet. CONCLUSIONS The Ministry of Health incurs a high cost with the judicialization of Zolgensma for SMA, representing 2.45% of total spending on medicines in the Unified Health System, including spending by the three administrative spheres. Some of the lawsuits have been granted in disagreement with the criteria established by health technology assessment agencies and the drug manufacturer's recommendations.
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Affiliation(s)
- Ana Katheryne Miranda Kretzschmar
- Universidade de BrasíliaFaculdade de CeilândiaPrograma de Pós-Graduação em Ciências e Tecnologias da SaúdeBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ceilândia. Programa de Pós-Graduação em Ciências e Tecnologias da Saúde. Brasília, DF, Brasil
| | - Ellen Teixeira
- Universidade de BrasíliaFaculdade de CeilândiaBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ceilândia. Curso de Farmácia. Brasília, DF, Brasil
| | - Dayani Galato
- Universidade de BrasíliaFaculdade de CeilândiaPrograma de Pós-Graduação em Ciências e Tecnologias da SaúdeBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ceilândia. Programa de Pós-Graduação em Ciências e Tecnologias da Saúde. Brasília, DF, Brasil
- Universidade de BrasíliaFaculdade de CeilândiaBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ceilândia. Curso de Farmácia. Brasília, DF, Brasil
| | - Everton Nunes da Silva
- Universidade de BrasíliaFaculdade de CeilândiaPrograma de Pós-Graduação em Ciências e Tecnologias da SaúdeBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ceilândia. Programa de Pós-Graduação em Ciências e Tecnologias da Saúde. Brasília, DF, Brasil
- Universidade de BrasíliaFaculdade de CeilândiaBrasíliaDFBrasilUniversidade de Brasília. Faculdade de Ceilândia. Curso de Saúde Coletiva. Brasília, DF, Brasil
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Cook SL, Stout C, Kirkeby L, Vidal-Folch N, Oglesbee D, Hasadsri L, Selcen D, Milone M, Anderson D, Staff NP. SMN1 c.5C>G (p.Ala2Gly) missense variant, a challenging molecular SMA diagnosis associated with mild disease, preserves SMN nuclear gems in patient-specific fibroblasts. Front Genet 2024; 15:1406819. [PMID: 39139818 PMCID: PMC11319185 DOI: 10.3389/fgene.2024.1406819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/25/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction Spinal muscular atrophy (SMA) is caused by homozygous loss of the SMN1 gene with SMN2 gene copy number correlating with disease severity. Rarely SMA is caused by a deletion on one allele and a pathogenic variant on the other. The pathogenic missense variant c.5C>G (p.Ala2Gly) correlates with a mild disease phenotype that does not correlate with SMN2 copy number. In a mouse model the c.5C>G transgene produces SMN that is thought to form partially functional SMN complexes, but levels in humans have not yet been investigated. Methods We identified two patients with mild SMA caused by a heterozygous deletion of SMN1 and the heterozygous variant, c.5C>G. Molecular findings were confirmed with deletion/duplication analysis and Sanger sequencing. Skin fibroblasts were collected and cultured, and SMN expression was analyzed using immunofluorescence. Results Two patients with slowly progressing mild weakness were confirmed to have heterozygous pathogenic missense variant c.5C>G and a heterozygous deletion of SMN1. Their clinical presentation revealed much milder disease progression than patients with matched SMN2 copy number. Analysis of the patients' fibroblasts revealed much higher numbers of SMN nuclear complexes than a patient with a homozygous SMN1 deletion and matched SMN2 copy number. Conclusions These case reports reinforce that the rare c.5C>G variant causes mild disease. Furthermore, the analysis of SMA nuclear gems in patient samples supports the theory that the p.Ala2Gly SMN can form partially functional SMN complexes that may carry out essential cellular functions and result in mild disease.
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Affiliation(s)
- Sara L. Cook
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christian Stout
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Lindsey Kirkeby
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Noemi Vidal-Folch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Devin Oglesbee
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Linda Hasadsri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Duygu Selcen
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | | | - Daniel Anderson
- Department of Neurology, Mayo Clinic Health System, La Crosse, WI, United States
| | - Nathan P. Staff
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Haque US, Yokota T. Recent Progress in Gene-Targeting Therapies for Spinal Muscular Atrophy: Promises and Challenges. Genes (Basel) 2024; 15:999. [PMID: 39202360 PMCID: PMC11353366 DOI: 10.3390/genes15080999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 09/03/2024] Open
Abstract
Spinal muscular atrophy (SMA) is a severe genetic disorder characterized by the loss of motor neurons, leading to progressive muscle weakness, loss of mobility, and respiratory complications. In its most severe forms, SMA can result in death within the first two years of life if untreated. The condition arises from mutations in the SMN1 (survival of motor neuron 1) gene, causing a deficiency in the survival motor neuron (SMN) protein. Humans possess a near-identical gene, SMN2, which modifies disease severity and is a primary target for therapies. Recent therapeutic advancements include antisense oligonucleotides (ASOs), small molecules targeting SMN2, and virus-mediated gene replacement therapy delivering a functional copy of SMN1. Additionally, recognizing SMA's broader phenotype involving multiple organs has led to the development of SMN-independent therapies. Evidence now indicates that SMA affects multiple organ systems, suggesting the need for SMN-independent treatments along with SMN-targeting therapies. No single therapy can cure SMA; thus, combination therapies may be essential for comprehensive treatment. This review addresses the SMA etiology, the role of SMN, and provides an overview of the rapidly evolving therapeutic landscape, highlighting current achievements and future directions.
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Affiliation(s)
- Umme Sabrina Haque
- Department of Neuroscience, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2H7, Canada;
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2H7, Canada
| | - Toshifumi Yokota
- Department of Neuroscience, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2H7, Canada;
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2H7, Canada
- The Friends of Garrett Cumming Research & Muscular Dystrophy Canada HM Toupin Neurological Science Research, Edmonton, AB T6G 2H7, Canada
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Romanelli Tavares VL, Mendonça RH, Toledo MS, Hadachi SM, Grindler CM, Zanoteli E, Marques W, Oliveira ASB, Breinis P, Morita MDPA, França MC. Integrated Approaches and Practical Recommendations in Patient Care Identified with 5q Spinal Muscular Atrophy through Newborn Screening. Genes (Basel) 2024; 15:858. [PMID: 39062637 PMCID: PMC11276409 DOI: 10.3390/genes15070858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/24/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
In recent years, significant progress has been made in 5q Spinal Muscular Atrophy therapeutics, emphasizing the importance of early diagnosis and intervention for better clinical outcomes. Characterized by spinal cord motor neuron degeneration, 5q-SMA leads to muscle weakness, swallowing difficulties, respiratory insufficiency, and skeletal deformities. Recognizing the pre-symptomatic phases supported by screening and confirmatory genetic tests is crucial for early diagnosis. This work addresses key considerations in implementing 5q-SMA screening within the Brazilian National Newborn Screening Program and explores Brazil's unique challenges and opportunities, including genetic tests, time-to-patient referral to specialized centers, program follow-up, and treatment algorithms. We aim to guide healthcare professionals and policymakers, facilitating global discussions, including Latin American countries, and knowledge-sharing on this critical subject to improve the care for newborns identified with 5q SMA.
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Affiliation(s)
| | - Rodrigo Holanda Mendonça
- Department of Neurology, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo 05403-010, Brazil
| | - Maytê S. Toledo
- Newborn Screening Reference Center, Instituto Jô Clemente (IJC), São Paulo 04040-033, Brazil
| | - Sônia M. Hadachi
- Newborn Screening Reference Center, Instituto Jô Clemente (IJC), São Paulo 04040-033, Brazil
| | - Carmela M. Grindler
- Secretaria de Estado da Saúde (Governo do Estado de São Paulo), São Paulo 01027-000, Brazil
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo 05403-010, Brazil
| | - Wilson Marques
- Hospital das Clínicas da Faculdade de Medicina da USP de Ribeirão Preto (HC/FMUSP-RP, São Paulo), Ribeirão Preto 14015-010, Brazil
| | - Acary S. B. Oliveira
- Motor Neuron Disease Unit, Division of Neuromuscular Diseases, Federal University of Sao Paulo (UNIFESP), Sao Paulo 04039-060, Brazil
| | - Paulo Breinis
- Faculdade de Medicina do ABC, Santo André 09060-870, Brazil
- Department of Pediatric Neurology, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo 01221-010, Brazil
| | | | - Marcondes C. França
- Department of Neurology, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-888, Brazil
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Zanoteli E, França MC, Marques W. Gene-based therapies for neuromuscular disorders. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-10. [PMID: 38325390 PMCID: PMC10849828 DOI: 10.1055/s-0043-1777755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 02/09/2024]
Abstract
Neuromuscular diseases (NMD) include a broad group of medical conditions with both acquired and genetic causes. In recent years, important advances have been made in the treatment of genetically caused NMD, and most of these advances are due to the implementation of therapies aimed at gene regulation. Among these therapies, gene replacement, small interfering RNA (siRNA), and antisense antinucleotides are the most promising approaches. More importantly, some of these therapies have already gained regulatory approval or are in the final stages of approval. The review focuses on motor neuron diseases, neuropathies, and Duchenne muscular dystrophy, summarizing the most recent developments in gene-based therapies for these conditions.
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Affiliation(s)
- Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Marcondes Cavalcante França
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.
| | - Wilson Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil.
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Dosi C, Masson R. The impact of three SMN2 gene copies on clinical characteristics and effect of disease-modifying treatment in patients with spinal muscular atrophy: a systematic literature review. Front Neurol 2024; 15:1308296. [PMID: 38487326 PMCID: PMC10937544 DOI: 10.3389/fneur.2024.1308296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
Objective To review the clinical characteristics and effect of treatment in patients with spinal muscular atrophy (SMA) and three copies of the SMN2 gene. Methods We conducted a literature search in October 2022 to identify English-language clinical research on SMA that included SMN2 copy number according to PRISMA guidelines. Results Our search identified 44 studies examining the impact of three SMN2 copies on clinical characteristics (21 on phenotype, 13 on natural history, and 15 on functional status and other signs/symptoms). In children with type I SMA or presymptomatic infants with an SMN1 deletion, three SMN2 copies was associated with later symptom onset, slower decline in motor function and longer survival compared with two SMN2 copies. In patients with SMA type II or III, three SMN2 copies is associated with earlier symptom onset, loss of ambulation, and ventilator dependence compared with four SMN2 copies. Eleven studies examined treatment effects with nusinersen (nine studies), onasemnogene abeparvovec (one study), and a range of treatments (one study) in patients with three SMN2 copies. In presymptomatic infants, early treatment delayed the onset of symptoms and maintained motor function in those with three SMN2 copies. The impact of copy number on treatment response in symptomatic patients is still unclear. Conclusion SMN2 copy number is strongly correlated with SMA phenotype in patients with SMN1 deletion, while no correlation was found in patients with an SMN1 mutation. Patients with three SMN2 copies show a highly variable clinical phenotype. Early initiation of treatment is highly effective in presymptomatic patients with three SMN2 copies.
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Affiliation(s)
| | - Riccardo Masson
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Developmental Neurology Unit, Milan, Italy
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Zanoteli E, Araujo APDQC, Becker MM, Fortes CPDD, França MC, Machado-Costa MC, Marques W, Matsui Jr C, Mendonça RH, Nardes F, Oliveira ASB, Pessoa ALS, Saute JAM, Sgobbi P, Van der Linden H, Gurgel-Giannetti J. Consensus from the Brazilian Academy of Neurology for the diagnosis, genetic counseling, and use of disease-modifying therapies in 5q spinal muscular atrophy. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-18. [PMID: 38316428 PMCID: PMC10843933 DOI: 10.1055/s-0044-1779503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/14/2023] [Indexed: 02/07/2024]
Abstract
Spinal muscular atrophy linked to chromosome 5 (SMA-5q) is an autosomal recessive genetic disease caused by mutations in the SMN1. SMA-5q is characterized by progressive degeneration of the spinal cord and bulbar motor neurons, causing severe motor and respiratory impairment with reduced survival, especially in its more severe clinical forms. In recent years, highly effective disease-modifying therapies have emerged, either acting by regulating the splicing of exon 7 of the SMN2 gene or adding a copy of the SMN1 gene through gene therapy, providing a drastic change in the natural history of the disease. In this way, developing therapeutic guides and expert consensus becomes essential to direct the use of these therapies in clinical practice. This consensus, prepared by Brazilian experts, aimed to review the main available disease-modifying therapies, critically analyze the results of clinical studies, and provide recommendations for their use in clinical practice for patients with SMA-5q. This consensus also addresses aspects related to diagnosis, genetic counseling, and follow-up of patients under drug treatment. Thus, this consensus provides valuable information regarding the current management of SMA-5q, helping therapeutic decisions in clinical practice and promoting additional gains in outcomes.
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Affiliation(s)
- Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.
| | | | - Michele Michelin Becker
- Hospital de Clínicas de Porto Alegre, Departamento de Pediatria, Unidade de Neurologia Infantil, Porto Alegre RS, Brazil.
| | | | - Marcondes Cavalcante França
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Neurologia, Campinas SP, Brazil.
| | | | - Wilson Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil.
| | - Ciro Matsui Jr
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Rodrigo Holanda Mendonça
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Flávia Nardes
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro RJ, Brazil.
| | | | | | - Jonas Alex Morales Saute
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Serviços de Genética Médica e de Neurologia, Porto Alegre RS, Brazil.
| | - Paulo Sgobbi
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | - Hélio Van der Linden
- Centro de Reabilitação Dr. Henrique Santillo, Serviço de Neurologia Infantil e Neurofisiologia, Goiânia GO, Brazil.
| | - Juliana Gurgel-Giannetti
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Departamento de Pediatria, Belo Horizonte MG, Brazil.
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Alghamdi A, AlDossary S, Abdulaziz Alabdulqader W, Amer F, Ali M, Almomen M, Alghamdi F. Identifying Clinical and Genetic Characteristics of Spinal Muscular Atrophy Patients and Families in Saudi Arabia. Cureus 2023; 15:e46452. [PMID: 37927698 PMCID: PMC10623204 DOI: 10.7759/cureus.46452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION Spinal muscular atrophy (SMA) is an inherited, neuromuscular disease characterized by the deterioration of spinal motor neurons, causing progressive muscular atrophy and weakening. It is an autosomal recessive disease with the mutation of the survival motor neuron 1 (SMN1) gene as a hallmark. Evidence suggests that the SMN2 gene modulates the severity of the disease. SMA is classified based on the maximum motor function achieved. This study aims to describe the genetic makeup and characteristics of an SMA cohort in the Kingdom of Saudi Arabia (KSA). METHODS Data from families presenting with SMA children was collected between January 2018 and December 2020. Blood samples were collected from patients and family members. Genetic testing for SMA and mutations was performed at a European central lab. RESULTS AND DISCUSSION Seventeen families were enrolled in the study, including 52 children. Among 34 parents, 28 were carriers with heterozygous deletion (82.3%), one (2.9%) had no deletion detected by multiplex ligation-dependent probe amplification (MLPA) but had point mutation by sequencing, one (2.9%) had homozygous deletion and was symptomatic, three (8.8%) had no deletion or point mutation and were presumed to have 2+0, and one (2.9%) was not tested. CONCLUSION This study provides insight into the carrier mutational analysis of families with SMA disease manifestations in KSA. Further studies are needed to understand the burden and impact of SMA among the Saudi population.
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Affiliation(s)
- Alaa Alghamdi
- Primary Care and Population Health, King Fahad University Hospital, Dammam, SAU
| | - Shaikhah AlDossary
- Primary Care and Population Health, University College London, London, GBR
| | | | - Fawzia Amer
- Pediatric Neurology, King Fahad Specialist Hospital, Dammam, SAU
- Pediatric Neurology and Metabolic, Cairo University Children Hospital, Cairo, EGY
| | - Mona Ali
- Neurology, Neuroscience Center, King Fahad Specialist Hospital, Dammam, SAU
| | - Momen Almomen
- Pediatric Neurology, King Fahad Specialist Hospital, Dammam, SAU
| | - Fouad Alghamdi
- Pediatric Neurology, Neuroscience Center, King Fahad Specialist Hospital, Dammam, SAU
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Votsi C, Koutsou P, Ververis A, Georghiou A, Nicolaou P, Tanteles G, Christodoulou K. Spinal muscular atrophy type I associated with a novel SMN1 splicing variant that disrupts the expression of the functional transcript. Front Neurol 2023; 14:1241195. [PMID: 37799281 PMCID: PMC10548546 DOI: 10.3389/fneur.2023.1241195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/31/2023] [Indexed: 10/07/2023] Open
Abstract
Introduction Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder caused by pathogenic variants in the SMN1 gene. The majority of SMA patients harbor a homozygous deletion of SMN1 exon 7 (95%). Heterozygosity for a conventional variant and a deletion is rare (5%) and not easily detected, due to the highly homologous SMN2 gene interference. SMN2 mainly produces a truncated non-functional protein (SMN-d7) instead of the full-length functional (SMN-FL). We hereby report a novel SMN1 splicing variant in an infant with severe SMA. Methods MLPA was used for SMN1/2 exon dosage determination. Sanger sequencing approaches and long-range PCR were employed to search for an SMN1 variant. Conventional and improved Real-time PCR assays were developed for the qualitative and quantitative SMN1/2 RNA analysis. Results The novel SMN1 splice-site variant c.835-8_835-5delinsG, was identified in compound heterozygosity with SMN1 exons 7/8 deletion. RNA studies revealed complete absence of SMN1 exon 7, thus confirming a disruptive effect of the variant on SMN1 splicing. No expression of the functional SMN1-FL transcript, remarkable expression of the SMN1-d7 and increased levels of the SMN2-FL/SMN2-d7 transcripts were observed. Discussion We verified the occurrence of a non-deletion SMN1 variant and supported its pathogenicity, thus expanding the SMN1 variants spectrum. We discuss the updated SMA genetic findings in the Cypriot population, highlighting an increased percentage of intragenic variants compared to other populations.
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Affiliation(s)
- Christina Votsi
- Neurogenetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Pantelitsa Koutsou
- Neurogenetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Antonis Ververis
- Neurogenetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Anthi Georghiou
- Neurogenetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Paschalis Nicolaou
- Neurogenetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - George Tanteles
- Clinical Genetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Kyproula Christodoulou
- Neurogenetics Department, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
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Nishio H, Niba ETE, Saito T, Okamoto K, Takeshima Y, Awano H. Spinal Muscular Atrophy: The Past, Present, and Future of Diagnosis and Treatment. Int J Mol Sci 2023; 24:11939. [PMID: 37569314 PMCID: PMC10418635 DOI: 10.3390/ijms241511939] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
Spinal muscular atrophy (SMA) is a lower motor neuron disease with autosomal recessive inheritance. The first cases of SMA were reported by Werdnig in 1891. Although the phenotypic variation of SMA led to controversy regarding the clinical entity of the disease, the genetic homogeneity of SMA was proved in 1990. Five years later, in 1995, the gene responsible for SMA, SMN1, was identified. Genetic testing of SMN1 has enabled precise epidemiological studies, revealing that SMA occurs in 1 of 10,000 to 20,000 live births and that more than 95% of affected patients are homozygous for SMN1 deletion. In 2016, nusinersen was the first drug approved for treatment of SMA in the United States. Two other drugs were subsequently approved: onasemnogene abeparvovec and risdiplam. Clinical trials with these drugs targeting patients with pre-symptomatic SMA (those who were diagnosed by genetic testing but showed no symptoms) revealed that such patients could achieve the milestones of independent sitting and/or walking. Following the great success of these trials, population-based newborn screening programs for SMA (more precisely, SMN1-deleted SMA) have been increasingly implemented worldwide. Early detection by newborn screening and early treatment with new drugs are expected to soon become the standards in the field of SMA.
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Affiliation(s)
- Hisahide Nishio
- Faculty of Rehabilitation, Kobe Gakuin University, 518 Arise, Ikawadani-cho, Nishi-ku, Kobe 651-2180, Japan
| | - Emma Tabe Eko Niba
- Laboratory of Molecular and Biochemical Research, Biomedical Research Core Facilities, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan;
| | - Toshio Saito
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka 560-8552, Japan;
| | - Kentaro Okamoto
- Department of Pediatrics, Ehime Prefectural Imabari Hospital, 4-5-5 Ishi-cho, Imabari 794-0006, Japan;
| | - Yasuhiro Takeshima
- Department of Pediatrics, Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya 663-8501, Japan;
| | - Hiroyuki Awano
- Organization for Research Initiative and Promotion, Research Initiative Center, Tottori University, 86 Nishi-cho, Yonago 683-8503, Japan;
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11
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Moreira AL, Mendonça RH, Polido GJ, Oliveira MCB, Silva AMS, Zanoteli E. Muscle Ultrasound Changes Correlate With Functional Impairment in Spinal Muscular Atrophy. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1569-1574. [PMID: 37037685 DOI: 10.1016/j.ultrasmedbio.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/18/2023] [Accepted: 02/28/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE We investigated ultrasound patterns of muscle involvement in different types of spinal muscular atrophy (SMA) and their correlation with functional status to determine the pattern of muscle compromise in patients with SMA and the potential role of ultrasound to evaluate disease progression. METHODS We examined muscles (biceps brachii, rectus femoris, diaphragm, intercostals and thoracic multifidus) of 41 patients with SMA (types 1 to 4) and 46 healthy age- and sex-matched control individuals using B-mode ultrasound for gray-scale analysis (GSA), area (biceps brachii and rectus femoris) and diaphragm thickening ratio. Functional scales were applied to patients only. We analyzed ultrasound abnormalities in specific clinical subtypes and correlated findings with functional status. RESULTS Compared with controls, patients had reduced muscle area and increased mean GSA for all muscles (p < 0.001), with an established correlation between the increase in GSA and the severity of SMA for biceps brachii, rectus femoris and intercostals (p = 0.03, 0.01 and 0.004 respectively) when using the Hammersmith Functional Motor Scale Expanded. Diaphragm thickening ratio was normal in the majority of patients, and intercostal muscles had higher GSA than diaphragm in relation to the controls. CONCLUSION Ultrasound is useful for quantifying muscular changes in SMA and correlates with functional status. Diaphragm thickening ratio can be normal even with severe compromise of respiratory muscles in quantitative analysis, and intercostal muscles were more affected than diaphragm.
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Affiliation(s)
- Ana Lucila Moreira
- Departament of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | | | - Graziela Jorge Polido
- Departament of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Edmar Zanoteli
- Departament of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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12
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Jain M, Patil N, Abdi G, Abbasi Tarighat M, Mohammed A, Ahmad Mohd Zain MR, Goh KW. Mechanistic Insights and Potential Therapeutic Approaches in PolyQ Diseases via Autophagy. Biomedicines 2023; 11:biomedicines11010162. [PMID: 36672670 PMCID: PMC9856063 DOI: 10.3390/biomedicines11010162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 01/11/2023] Open
Abstract
Polyglutamine diseases are a group of congenital neurodegenerative diseases categorized with genomic abnormalities in the expansion of CAG triplet repeats in coding regions of specific disease-related genes. Protein aggregates are the toxic hallmark for polyQ diseases and initiate neuronal death. Autophagy is a catabolic process that aids in the removal of damaged organelles or toxic protein aggregates, a process required to maintain cellular homeostasis that has the potential to fight against neurodegenerative diseases, but this pathway gets affected under diseased conditions, as there is a direct impact on autophagy-related gene expression. The increase in the accumulation of autophagy vesicles reported in neurodegenerative diseases was due to an increase in autophagy or may have been due to a decrease in autophagy flux. These reports suggested that there is a contribution of autophagy in the pathology of diseases and regulation in the process of autophagy. It was demonstrated in various disease models of polyQ diseases that autophagy upregulation by using modulators can enhance the dissolution of toxic aggregates and delay disease progression. In this review, interaction of the autophagy pathway with polyQ diseases was analyzed, and a therapeutic approach with autophagy inducing drugs was established for disease pathogenesis.
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Affiliation(s)
- Mukul Jain
- Department of Lifesciences, Parul Institute of Applied Sciences, Parul University, Vadodara 391760, India
- Lab 209 Cell and Developmental Biology Lab, Centre of Research for Development, Parul University, Vadodara 391760, India
| | - Nil Patil
- Department of Lifesciences, Parul Institute of Applied Sciences, Parul University, Vadodara 391760, India
- Lab 209 Cell and Developmental Biology Lab, Centre of Research for Development, Parul University, Vadodara 391760, India
| | - Gholamreza Abdi
- Department of Biotechnology, Persian Gulf Research Institute, Persian Gulf University, Bushehr, 75169, Iran
- Correspondence: (G.A.); (M.R.A.M.Z.); (K.W.G.)
| | - Maryam Abbasi Tarighat
- Faculty of Nano and Bio Science and Technology, Persian Gulf University, Bushehr 75169, Iran
| | - Arifullah Mohammed
- Department of Agriculture, Faculty of Agro-Based Industry, Universiti Malaysia Kelantan, Jeli 17600, Malaysia
| | - Muhammad Rajaei Ahmad Mohd Zain
- Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia
- Correspondence: (G.A.); (M.R.A.M.Z.); (K.W.G.)
| | - Khang Wen Goh
- Faculty of Data Science and Information Technology, INTI International University, Nilai 71800, Malaysia
- Correspondence: (G.A.); (M.R.A.M.Z.); (K.W.G.)
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13
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Elkins K, Wittenauer A, Hagar AF, Logan R, Sekul E, Xiang Y, Verma S, Wilcox WR. Georgia state spinal muscular atrophy newborn screening experience: Screening assay performance and early clinical outcomes. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2022; 190:187-196. [PMID: 36164257 DOI: 10.1002/ajmg.c.32003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
The purpose of this study is to provide the results of the newborn screening (NBS) program for Spinal Muscular Atrophy (SMA) in the state of Georgia to determine disease incidence, time to diagnosis and treatment, and early outcomes. NBS for SMA was performed using real time PCR assays from February 2019 through February 2020 in a pilot phase of screening. This method continued as part of our official state panel, and here we describe the pilot period as well as the first year of standard screening through February 2021. Medical records of infants with a positive NBS were reviewed for time to confirmation and neurologic evaluation, SMN2 copy number, clinical information, and treatment. Descriptive statistics were applied. Of the 301,418 samples screened, there were 15 true positive (eight males) and 24 false positive cases. One patient was missed due to human error early in the pilot phase and presented after symptom onset. The incidence of SMA in Georgia is approximately 1 in 18,840 births per year. After the pilot phase, the false positive rate was found to be so low that all patients who test positive were immediately referred to neurology for further care. Four patients died prior to intervention. Ten patients received intervention. Gene therapy was the preferred treatment. One patient was lost to follow-up; another was clinically followed. In conclusion, trends for treated patients show improved or stable motor function. Long-term follow-up will help determine the durability of treatment.
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Affiliation(s)
- Kathryn Elkins
- Department of Neurology, Division of Pediatric Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Angela Wittenauer
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arthur F Hagar
- Georgia Department of Public Health, Atlanta, Georgia, USA
| | - Rachel Logan
- Division of Pediatric Neurology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Elizabeth Sekul
- Department of Neurology, Division of Child Neurology, Medical College of Georgia, Augusta, Georgia, USA
| | - Yijin Xiang
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sumit Verma
- Department of Neurology, Division of Pediatric Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Pediatric Neurology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - William R Wilcox
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
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14
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Caracterización clínica y funcional de pacientes con atrofia muscular espinal en el centro-occidente colombiano. BIOMÉDICA 2022; 42:89-99. [PMID: 35866733 PMCID: PMC9410705 DOI: 10.7705/biomedica.6178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Indexed: 11/21/2022]
Abstract
Introducción. La atrofia muscular espinal es una enfermedad neurodegenerativa huérfana de origen genético que afecta las neuronas motoras del asta anterior de la médula espinal, y produce atrofia y debilidad muscular. En Colombia, son pocos los estudios publicados sobre la enfermedad y no hay ninguno con análisis funcional. Objetivo. Caracterizar clínica y funcionalmente una serie de casos de atrofia muscular espinal del centro-occidente colombiano. Materiales y métodos. Se hizo un estudio descriptivo transversal, entre el 2007 y el 2020, de pacientes con diagnóstico clínico y molecular de atrofia muscular espinal que consultaron en el centro de atención. La evaluación funcional se realizó con las escalas Hammersmith y Chop Intend. En la sistematización de los datos, se empleó el programa Epi-Info, versión 7.0. Resultados. Se analizaron 14 pacientes: 8 mujeres y 6 hombres. La atrofia muscular espinal más prevalente fue la de tipo II, la cual se presentó en 10 casos. Se encontró variabilidad fenotípica en términos de funcionalidad en algunos pacientes con atrofia muscular espinal de tipo II, cinco de los cuales lograron alcanzar la marcha. La estimación de la supervivencia fue de 28,6 años. Conclusiones. Los hallazgos en el grupo de pacientes analizados evidenciaron que los puntajes de la escala de Hammersmith revisada y expandida, concordaron con la gravedad de la enfermedad.
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15
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Niba ETE, Nishio H, Wijaya YOS, Ar Rochmah M, Takarada T, Takeuchi A, Kimizu T, Okamoto K, Saito T, Awano H, Takeshima Y, Shinohara M. Stability and Oligomerization of Mutated SMN Protein Determine Clinical Severity of Spinal Muscular Atrophy. Genes (Basel) 2022; 13:genes13020205. [PMID: 35205250 PMCID: PMC8872419 DOI: 10.3390/genes13020205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/10/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a common autosomal recessive neuromuscular disease characterized by defects of lower motor neurons. Approximately 95% of SMA patients are homozygous for survival motor neuron 1 (SMN1) gene deletion, while ~5% carry an intragenic SMN1 mutation. Here, we investigated the stability and oligomerization ability of mutated SMN1 proteins. Plasmids containing wild- and mutant-type SMN1 cDNA were constructed and transfected into HeLa cells. Reverse transcription-polymerase chain reaction (RT-PCR) demonstrated similar abundances of transcripts from the plasmids containing SMN cDNA, but Western blotting showed different expression levels of mutated SMN1 proteins, reflecting the degree of their instability. A mutated SMN1 protein with T274YfsX32 exhibited a much lower expression level than other mutated SMN1 proteins with E134K, Y276H, or Y277C. In immunoprecipitation analysis, the mutated SMN1 protein with T274YfsX32 did not bind to endogenous SMN1 protein in HeLa cells, suggesting that this mutation completely blocks the oligomerization with full-length SMN2 protein in the patient. The patient with T274YfsX32 showed a much more severe phenotype than the other patients with different mutations. In conclusion, the stability and oligomerization ability of mutated SMN1 protein may determine the protein stability and may be associated with the clinical severity of SMA caused by intragenic SMN1 mutation.
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Affiliation(s)
- Emma Tabe Eko Niba
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Hyogo, Japan; (E.T.E.N.); (Y.O.S.W.); (M.S.)
| | - Hisahide Nishio
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Hyogo, Japan; (E.T.E.N.); (Y.O.S.W.); (M.S.)
- Department of Occupational Therapy, Faculty of Rehabilitation, Kobe Gakuin University, 518 Arise, Ikawadani-cho, Nishi-ku, Kobe 651-2180, Hyogo, Japan
- Correspondence: ; Tel.: +81-789-745-073
| | - Yogik Onky Silvana Wijaya
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Hyogo, Japan; (E.T.E.N.); (Y.O.S.W.); (M.S.)
| | - Mawaddah Ar Rochmah
- Department of Neurology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Farmako, Sekip Utara, Yogyakarta 55281, Indonesia;
| | - Toru Takarada
- Laboratory of Functional Molecular Chemistry, Kobe Pharmaceutical University, 4-19-1 Motoyamakitamachi, Higashinada-ku, Kobe 658-8558, Hyogo, Japan;
| | - Atsuko Takeuchi
- Instrumental Analysis Center, Kobe Pharmaceutical University, 4-19-1 Motoyamakitamachi, Higashinada-ku, Kobe 658-8558, Hyogo, Japan;
| | - Tomokazu Kimizu
- Department of Pediatric Neurology, Osaka Women’s and Children’s Hospital, 840 Murodo-cho, Izumi 594-1101, Osaka, Japan;
| | - Kentaro Okamoto
- Department of Pediatrics, Ehime Prefectural Imabari Hospital, 4-5-5 Ishii-cho, Imabari 794-0006, Ehime, Japan;
| | - Toshio Saito
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center, 5-1-1 Toneyama, Toyonaka 560-8552, Osaka, Japan;
| | - Hiroyuki Awano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Hyogo, Japan;
| | - Yasuhiro Takeshima
- Department of Pediatrics, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Hyogo, Japan;
| | - Masakazu Shinohara
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Hyogo, Japan; (E.T.E.N.); (Y.O.S.W.); (M.S.)
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16
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Sarv S, Kahre T, Vaidla E, Pajusalu S, Muru K, Põder H, Gross-Paju K, Ütt S, Žordania R, Talvik I, Õiglane-Shlik E, Muhu K, Õunap K. The Birth Prevalence of Spinal Muscular Atrophy: A Population Specific Approach in Estonia. Front Genet 2022; 12:796862. [PMID: 35003227 PMCID: PMC8729775 DOI: 10.3389/fgene.2021.796862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Rare diseases are an important population health issue and many promising therapies have been developed in recent years. In light of novel genetic treatments expected to significantly improve spinal muscular atrophy (SMA) patients' quality of life and the urgent need for SMA newborn screening (NBS), new epidemiological data were needed to implement SMA NBS in Estonia. Objective: We aimed to describe the birth prevalence of SMA in the years 1996-2020 and to compare the results with previously published data. Methods: We retrospectively analyzed clinical and laboratory data of SMA patients referred to the Department of Clinical Genetics of Tartu University Hospital and its branch in Tallinn. Results: Fifty-seven patients were molecularly diagnosed with SMA. SMA birth prevalence was 1 per 8,286 (95% CI 1 per 6,130-11,494) in Estonia. Patients were classified as SMA type 0 (1.8%), SMA I (43.9%), SMA II (22.8%), SMA III (29.8%), and SMA IV (1.8%). Two patients were compound heterozygotes with an SMN1 deletion in trans with a novel single nucleotide variant NM_000344.3:c.410dup, p.(Asn137Lysfs*11). SMN2 copy number was assessed in 51 patients. Conclusion: In Estonia, the birth prevalence of SMA is similar to the median birth prevalence in Europe. This study gathered valuable information on the current epidemiology of SMA, which can guide the implementation of spinal muscular atrophy to the newborn screening program in Estonia.
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Affiliation(s)
- Siiri Sarv
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Tiina Kahre
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Eve Vaidla
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Sander Pajusalu
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Kai Muru
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Haide Põder
- Tallinn Children's Hospital, Tallinn, Estonia
| | - Katrin Gross-Paju
- Centre for Neurological Diseases, West-Tallinn Central Hospital, Tallinn, Estonia.,Department of Health Technologies, eMed Lab, TalTech, Tallinn, Estonia
| | - Sandra Ütt
- Centre for Neurological Diseases, West-Tallinn Central Hospital, Tallinn, Estonia
| | - Riina Žordania
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
| | - Inga Talvik
- Tallinn Children's Hospital, Tallinn, Estonia
| | - Eve Õiglane-Shlik
- Children's Clinic, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Kristina Muhu
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Katrin Õunap
- Department of Clinical Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.,Department of Clinical Genetics, United Laboratories, Tartu University Hospital, Tartu, Estonia
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Klotz J, Tesi Rocha C, Dunaway Young S, Duong T, Buu M, Sampson J, Day JW. Advances in the Therapy of Spinal Muscular Atrophy. J Pediatr 2021; 236:13-20.e1. [PMID: 34197889 DOI: 10.1016/j.jpeds.2021.06.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Jenna Klotz
- Stanford University School of Medicine, Palo Alto, CA.
| | | | | | - Tina Duong
- Stanford University School of Medicine, Palo Alto, CA
| | - MyMy Buu
- Stanford University School of Medicine, Palo Alto, CA
| | | | - John W Day
- Stanford University School of Medicine, Palo Alto, CA
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18
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The Importance of Digging into the Genetics of SMN Genes in the Therapeutic Scenario of Spinal Muscular Atrophy. Int J Mol Sci 2021; 22:ijms22169029. [PMID: 34445733 PMCID: PMC8396600 DOI: 10.3390/ijms22169029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 12/12/2022] Open
Abstract
After 26 years of discovery of the determinant survival motor neuron 1 and the modifier survival motor neuron 2 genes (SMN1 and SMN2, respectively), three SMN-dependent specific therapies are already approved by FDA and EMA and, as a consequence, worldwide SMA patients are currently under clinical investigation and treatment. Bi-allelic pathogenic variants (mostly deletions) in SMN1 should be detected in SMA patients to confirm the disease. Determination of SMN2 copy number has been historically employed to correlate with the phenotype, predict disease evolution, stratify patients for clinical trials and to define those eligible for treatment. In view that discordant genotype-phenotype correlations are present in SMA, besides technical issues with detection of SMN2 copy number, we have hypothesized that copy number determination is only the tip of the iceberg and that more deepen studies of variants, sequencing and structures of the SMN2 genes are necessary for a better understanding of the disease as well as to investigate possible influences in treatment responses. Here, we highlight the importance of a comprehensive approach of SMN1 and SMN2 genetics with the perspective to apply for better prediction of SMA in positive neonatal screening cases and early diagnosis to start treatments.
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19
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Wijaya YOS, Ar Rohmah M, Niba ETE, Morisada N, Noguchi Y, Hidaka Y, Ozasa S, Inoue T, Shimazu T, Takahashi Y, Tozawa T, Chiyonobu T, Inoue T, Shiroshita T, Yokoyama A, Okamoto K, Awano H, Takeshima Y, Saito T, Saito K, Nishio H, Shinohara M. Phenotypes of SMA patients retaining SMN1 with intragenic mutation. Brain Dev 2021; 43:745-758. [PMID: 33892995 DOI: 10.1016/j.braindev.2021.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/17/2021] [Accepted: 03/21/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disorder caused by homozygous deletion or intragenic mutation of the SMN1 gene. It is well-known that high copy number of its homologous gene, SMN2, modifies the phenotype of SMN1-deleted patients. However, in the patients with intragenic SMN1 mutation, the relationship between phenotype and SMN2 copy number remains unclear. METHODS We have analyzed a total of 515 Japanese patients with SMA-like symptoms (delayed developmental milestones, respiratory failures, muscle weakness etc.) from 1996 to 2019. SMN1 and SMN2 copy numbers were determined by quantitative polymerase chain reaction (PCR) method and/or multiplex ligation-dependent probe amplification (MLPA) method. Intragenic SMN1 mutations were identified through DNA and RNA analysis of the fresh blood samples. RESULTS A total of 241 patients were diagnosed as having SMA. The majority of SMA patients showed complete loss of SMN1 (n = 228, 95%), but some patients retained SMN1 and carried an intragenic mutation in the retaining SMN1 (n = 13, 5%). Ten different mutations were identified in these 13 patients, consisting of missense, nonsense, frameshift and splicing defect-causing mutations. The ten mutations were c.275G > C (p.Trp92Ser), c.819_820insT (p.Thr274Tyrfs*32), c.830A > G (p.Tyr277Cys), c.5C > T (p.Ala2Val), c.826 T > C (p.Tyr276His), c.79C > T (p.Gln27*), c.188C > A (p.Ser63*), c.422 T > C (p.Leu141Pro), c.835-2A > G (exon 7 skipping) and c.835-3C > A (exon 7 skipping). It should be noted here that some patients with milder phenotype carried only a single SMN2 copy (n = 3), while other patients with severe phenotype carried 3 SMN2 copies (n = 4). CONCLUSION Intragenic mutations in SMN1 may contribute more significantly to clinical severity than SMN2 copy numbers.
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Affiliation(s)
- Yogik Onky Silvana Wijaya
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Mawaddah Ar Rohmah
- Department of Neurology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Emma Tabe Eko Niba
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Naoya Morisada
- Department of Clinical Genetics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan.
| | - Yoriko Noguchi
- Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan.
| | - Yasufumi Hidaka
- Department of Pediatrics, Kitakyushu Municipal Medical Center, Kitakyushu, Japan.
| | - Shiro Ozasa
- Department of Pediatrics, Kumamoto University, Kumamoto, Japan.
| | - Takeshi Inoue
- Department of Neonatology, Kumamoto City Hospital, Kumamoto, Japan.
| | - Tomoyuki Shimazu
- Department of Pediatrics, National Hospital Organization Kumamoto Saishunso Hospital, Kumamoto, Japan.
| | - Yuya Takahashi
- Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan.
| | - Takenori Tozawa
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Tomohiro Chiyonobu
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Takushi Inoue
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan.
| | | | - Atsushi Yokoyama
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Kentaro Okamoto
- Department of Pediatrics, Ehime Prefectural Imabari Hospital, Imabari, Japan.
| | - Hiroyuki Awano
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yasuhiro Takeshima
- Department of Pediatrics, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Toshio Saito
- Division of Child Neurology, Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Japan.
| | - Kayoko Saito
- Institute of Medical Genetics, Tokyo Women's Medical University, Tokyo, Japan.
| | - Hisahide Nishio
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, Kobe, Japan; Faculty of Medical Rehabilitation, Kobe Gakuin University, Kobe, Japan.
| | - Masakazu Shinohara
- Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, Kobe, Japan.
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20
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Butchbach MER. Genomic Variability in the Survival Motor Neuron Genes ( SMN1 and SMN2): Implications for Spinal Muscular Atrophy Phenotype and Therapeutics Development. Int J Mol Sci 2021; 22:ijms22157896. [PMID: 34360669 PMCID: PMC8348669 DOI: 10.3390/ijms22157896] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 02/07/2023] Open
Abstract
Spinal muscular atrophy (SMA) is a leading genetic cause of infant death worldwide that is characterized by loss of spinal motor neurons leading to muscle weakness and atrophy. SMA results from the loss of survival motor neuron 1 (SMN1) gene but retention of its paralog SMN2. The copy numbers of SMN1 and SMN2 are variable within the human population with SMN2 copy number inversely correlating with SMA severity. Current therapeutic options for SMA focus on increasing SMN2 expression and alternative splicing so as to increase the amount of SMN protein. Recent work has demonstrated that not all SMN2, or SMN1, genes are equivalent and there is a high degree of genomic heterogeneity with respect to the SMN genes. Because SMA is now an actionable disease with SMN2 being the primary target, it is imperative to have a comprehensive understanding of this genomic heterogeneity with respect to hybrid SMN1–SMN2 genes generated by gene conversion events as well as partial deletions of the SMN genes. This review will describe this genetic heterogeneity in SMA and its impact on disease phenotype as well as therapeutic efficacy.
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Affiliation(s)
- Matthew E. R. Butchbach
- Center for Applied Clinical Genomics, Nemours Children’s Health Delaware, Wilmington, DE 19803, USA;
- Center for Pediatric Research, Nemours Children’s Health Delaware, Wilmington, DE 19803, USA
- Department of Biological Sciences, University of Delaware, Newark, DE 19716, USA
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA 19107, USA
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21
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Mendonça RH, Machado LMS, Heise CO, Polido GJ, Matsui C, Silva AMS, Reed UC, Zanoteli E. Motor unit number index (MUNIX) in children and adults with 5q-spinal muscular atrophy: Variability and clinical correlations. Neuromuscul Disord 2021; 31:498-504. [PMID: 33824074 DOI: 10.1016/j.nmd.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/11/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
Spinal muscular atrophy (SMA) is a motor neuron disease associated with progressive muscle weakness and motor disability. The motor unit number index (MUNIX) is a biomarker used to assess loss of motor units in later-onset SMA patients. Twenty SMA patients (SMA types 3 and 4), aged between 7 and 41 years, were clinically evaluated through the Hammersmith Motor Functional Scale Expanded and the Spinal Muscular Atrophy-Functional Rating Scale. The patients underwent compound motor action potential (CMAP) and MUNIX studies of the right abductor pollicis brevis, abductor digiti minimi and tibialis anterior (TA) muscles. Age-matched healthy controls (n = 20) were enrolled to obtain normative CMAP and MUNIX values from the same muscles. Compared to healthy controls, SMA patients showed significant reductions in MUNIX values among all muscles studied, whereas CMAP showed reductions only in the weaker muscles (abductor digiti minimi and TA). MUNIX variability was significantly higher in the SMA group than in the control group. MUNIX variability in TA correlated with CMAP variability. Motor functional scores correlated with TA MUNIX. The MUNIX study is feasible in later-onset SMA patients, and TA MUNIX values correlate with disease severity in patients with mild motor impairment.
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Affiliation(s)
| | | | - Carlos Otto Heise
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Graziela Jorge Polido
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ciro Matsui
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Umbertina Conti Reed
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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22
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Mendonça RDH, Fernandes HDS, Pinto RBS, Matsui Júnior C, Polido GJ, Silva AMSD, Grossklauss LF, Reed UC, Zanoteli E. Managing intrathecal administration of nusinersen in adolescents and adults with 5q-spinal muscular atrophy and previous spinal surgery. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:127-132. [PMID: 33759979 DOI: 10.1590/0004-282x-anp-2020-0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neurodegenerative disease of lower motor neurons associated with frequent occurrence of spinal deformity. Nusinersen is an antisense oligonucleotide that increases SMN protein level and is administrated by frequent intrathecal lumbar injections. Thus, spinal deformities and previous spinal surgery are important challenges for drug delivery in SMA. OBJECTIVE To report imaging methods used for Nusinersen injection in SMA patients. METHODS Nusinersen injection procedures in SMA types 2 and 3 patients who had previous spinal surgery were analyzed retrospectively to describe the imaging and puncture procedures, as well as the occurrence of complications. RESULTS Nine SMA patients (14 to 50 years old) underwent 57 lumbar punctures for nusinersen injection. Six patients had no interlaminar space available; in five of them, a transforaminal approach was used, and another one underwent a surgery to open a posterior bone window for the injections. Transforaminal puncture was performed using CT scan in three cases and fluoroscopy in the other two, with a similar success rate. One patient in the transforaminal group had post-procedure radiculitis, and another one had vagal reaction (hypotension). In three cases, with preserved interlaminar space, injections were performed by posterior interlaminar puncture, and only one adverse event was reported (post-puncture headache). CONCLUSION In SMA patients with previous spinal surgery, the use of imaging-guided intervention is necessary for administering intrathecal nusinersen. Transforaminal technique is indicated in patients for whom the interlaminar space is not available, and injections should always be guided by either CT or fluoroscopy.
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Affiliation(s)
| | | | | | - Ciro Matsui Júnior
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Graziela Jorge Polido
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Luis Fernando Grossklauss
- Universidade Federal de São Paulo, Departamento de Neurologia, Divisão Neuromusculares, São Paulo SP, Brazil
| | - Umbertina Conti Reed
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Edmar Zanoteli
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
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23
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Keinath MC, Prior DE, Prior TW. Spinal Muscular Atrophy: Mutations, Testing, and Clinical Relevance. APPLICATION OF CLINICAL GENETICS 2021; 14:11-25. [PMID: 33531827 PMCID: PMC7846873 DOI: 10.2147/tacg.s239603] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/15/2021] [Indexed: 12/12/2022]
Abstract
Spinal muscular atrophy (SMA) is a heritable neuromuscular disorder that causes degeneration of the alpha motor neurons from anterior horn cells in the spinal cord, which causes severe progressive hypotonia and muscular weakness. With a carrier frequency of 1 in 40–50 and an estimated incidence of 1 in 10,000 live births, SMA is the second most common autosomal recessive disorder. Affected individuals with SMA have a homozygous loss of function of the survival motor neuron gene SMN1 on 5q13 but keep the modifying SMN2 gene. The most common mutation causing SMA is a homozygous deletion of the SMN1 exon 7, which can be readily detected and used as a sensitive diagnostic test. Because SMN2 produces a reduced number of full-length transcripts, the number of SMN2 copies can modify the clinical phenotype and as such, becomes an essential predictive factor. Population-based SMA carrier screening identifies carrier couples that may pass on this genetic disorder to their offspring and allows the carriers to make informed reproductive choices or prepare for immediate treatment for an affected child. Three treatments have recently been approved by the Food and Drug Administration (FDA). Nusinersen increases the expression levels of the SMN protein using an antisense oligonucleotide to alter splicing of the SMN2 transcript. Onasemnogene abeparvovec is a gene therapy that utilizes an adeno-associated virus serotype 9 vector to increase low functional SMN protein levels. Risdiplam is a small molecule that alters SMN2 splicing in order to increase functional SMN protein. Newborn screening for SMA has been shown to be successful in allowing infants to be treated before the loss of motor neurons and has resulted in improved clinical outcomes. Several of the recommendations and guidelines in the review are based on studies performed in the United States.
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Affiliation(s)
- Melissa C Keinath
- Pathology, University Hospitals Center for Human Genetics, Cleveland, OH, USA
| | - Devin E Prior
- Neurology, Mount Auburn Hospital, Cambridge, MA, USA
| | - Thomas W Prior
- Pathology, University Hospitals Center for Human Genetics, Cleveland, OH, USA
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24
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de Holanda Mendonça R, Jorge Polido G, Ciro M, Jorge Fontoura Solla D, Conti Reed U, Zanoteli E. Clinical Outcomes in Patients with Spinal Muscular Atrophy Type 1 Treated with Nusinersen. J Neuromuscul Dis 2021; 8:217-224. [PMID: 33459657 DOI: 10.3233/jnd-200533] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BackgroundSpinal muscular atrophy type 1 (SMA1) is a motor neuron disease associated with progressive muscle weakness, ventilatory failure, and reduced survival.Objective:To report the evaluation of the nusinersen, an antisense oligonucleotide, on the motor function of SMA1.MethodsThis was a longitudinal and observational study to assess the outcomes of nusinersen therapy in SMA1 patients using the HINE-2 and CHOP-INTEND scales.ResultsTwenty-one SMA1 patients (52.4% males) were included; the mean age at first symptoms was 2.7 months (SD =±1.5), and the mean disease duration at first dose was 34.1 (SD =±36.0) months. During posttreatment, the mean gain on the CHOP-INTEND was 4.9, 5.9, 6.6, and 14 points after 6, 12, 18, and 24 months, respectively. Starting medication with a disease duration of less than 12 months and/or without invasive ventilation were predictors of response on CHOP-INTEND. Of the patients, 28.6% acquired a motor milestone or gained at least three points on the HINE-2. The daily time for ventilatory support was reduced after treatment in most of the patients with noninvasive ventilation at baseline. No change in the daytime use of ventilation was observed in most of the patients using invasive ventilation at baseline.ConclusionsNusinersen produces improvements in motor and respiratory functions, even in long-term SMA1 patients. However, patients under invasive ventilation at the beginning of the treatment experience little benefit.
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Affiliation(s)
| | - Graziela Jorge Polido
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Matsui Ciro
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Umbertina Conti Reed
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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25
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Mendonça RH, Polido GJ, Matsui C, Silva AM, Solla DJ, Reed UC, Zanoteli E. Real-World Data from Nusinersen Treatment for Patients with Later-Onset Spinal Muscular Atrophy: A Single Center Experience. J Neuromuscul Dis 2021; 8:101-108. [DOI: 10.3233/jnd-200551] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Spinal muscular atrophy (SMA) is a motor neuron disease associated with progressive muscle weakness and motor disability. Objective This study aims to report the evaluation of nusinersen, an antisense oligonucleotide, on motor function in patients with SMA types 2 and 3. Methods This single-center retrospective observational study assessed nusinersen therapy outcomes, measured by HSMFSE or CHOP-INTEND scales, in patients with SMA types 2 and 3, compared to untreated patients, for at least 24 months. Results A total of 41 patients with SMA types 2 and 3 under nusinersen treatment were included. In 30 treated patients (mean age: 10.6 years; 14 with SMA type 2), the mean change in HFMSE scores was +1.47 points (SD = 0.4) and +1.60 points (SD = 0.6) after 12 and 24 months of treatment, respectively. In contrast, the control group (N = 37) (mean age: 10.2 years; 20 with SMA type 2) presented a mean change of −1.71 points (SD = 0.02) and −3.93 points (SD = 0.55) after 12 and 24 months of follow-up, respectively. The most severe patients under nusinersen treatment (N = 11) showed a change of +2.37 (SD = 1.13) on the CHOP-INTEND scale after 12 months of follow-up. Disease duration at the beginning of treatment was the main predictor of functional improvement. Despite functional gain and motor stabilization, treatment with nusinersen did not prevent the progression of scoliosis. Conclusions Our data provide evidence for the long-term safety and efficacy of nusinersen use in the treatment of later-onset SMA, and patients with shorter disease duration showed better response to treatment.
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Affiliation(s)
- Rodrigo H. Mendonça
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Graziela J. Polido
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Ciro Matsui
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - André M.S. Silva
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Davi J.F. Solla
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Umbertina C. Reed
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
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