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Lapp HS, Freigang M, Hagenacker T, Weiler M, Wurster CD, Günther R. Biomarkers in 5q-associated spinal muscular atrophy-a narrative review. J Neurol 2023; 270:4157-4178. [PMID: 37289324 PMCID: PMC10421827 DOI: 10.1007/s00415-023-11787-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
5q-associated spinal muscular atrophy (SMA) is a rare genetic disease caused by mutations in the SMN1 gene, resulting in a loss of functional SMN protein and consecutive degeneration of motor neurons in the ventral horn. The disease is clinically characterized by proximal paralysis and secondary skeletal muscle atrophy. New disease-modifying drugs driving SMN gene expression have been developed in the past decade and have revolutionized SMA treatment. The rise of treatment options led to a concomitant need of biomarkers for therapeutic guidance and an improved disease monitoring. Intensive efforts have been undertaken to develop suitable markers, and numerous candidate biomarkers for diagnostic, prognostic, and predictive values have been identified. The most promising markers include appliance-based measures such as electrophysiological and imaging-based indices as well as molecular markers including SMN-related proteins and markers of neurodegeneration and skeletal muscle integrity. However, none of the proposed biomarkers have been validated for the clinical routine yet. In this narrative review, we discuss the most promising candidate biomarkers for SMA and expand the discussion by addressing the largely unfolded potential of muscle integrity markers, especially in the context of upcoming muscle-targeting therapies. While the discussed candidate biomarkers hold potential as either diagnostic (e.g., SMN-related biomarkers), prognostic (e.g., markers of neurodegeneration, imaging-based markers), predictive (e.g., electrophysiological markers) or response markers (e.g., muscle integrity markers), no single measure seems to be suitable to cover all biomarker categories. Hence, a combination of different biomarkers and clinical assessments appears to be the most expedient solution at the time.
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Affiliation(s)
- H S Lapp
- Department of Neurology, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - M Freigang
- Department of Neurology, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - T Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Science (C-TNBS), University Medicine Essen, Essen, Germany
| | - M Weiler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - C D Wurster
- Department of Neurology, University Hospital Ulm, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE) Ulm, Ulm, Germany
| | - René Günther
- Department of Neurology, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- German Center for Neurodegenerative Diseases (DZNE) Dresden, Dresden, Germany.
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2
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Faravelli I, Gagliardi D, Abati E, Meneri M, Ongaro J, Magri F, Parente V, Petrozzi L, Ricci G, Farè F, Garrone G, Fontana M, Caruso D, Siciliano G, Comi GP, Govoni A, Corti S, Ottoboni L. Multi-omics profiling of CSF from spinal muscular atrophy type 3 patients after nusinersen treatment: a 2-year follow-up multicenter retrospective study. Cell Mol Life Sci 2023; 80:241. [PMID: 37543540 PMCID: PMC10404194 DOI: 10.1007/s00018-023-04885-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/07/2023]
Abstract
Spinal muscular atrophy (SMA) is a neurodegenerative disorder caused by mutations in the SMN1 gene resulting in reduced levels of the SMN protein. Nusinersen, the first antisense oligonucleotide (ASO) approved for SMA treatment, binds to the SMN2 gene, paralogue to SMN1, and mediates the translation of a functional SMN protein. Here, we used longitudinal high-resolution mass spectrometry (MS) to assess both global proteome and metabolome in cerebrospinal fluid (CSF) from ten SMA type 3 patients, with the aim of identifying novel readouts of pharmacodynamic/response to treatment and predictive markers of treatment response. Patients had a median age of 33.5 [29.5; 38.25] years, and 80% of them were ambulant at time of the enrolment, with a median HFMSE score of 37.5 [25.75; 50.75]. Untargeted CSF proteome and metabolome were measured using high-resolution MS (nLC-HRMS) on CSF samples obtained before treatment (T0) and after 2 years of follow-up (T22). A total of 26 proteins were found to be differentially expressed between T0 and T22 upon VSN normalization and LIMMA differential analysis, accounting for paired replica. Notably, key markers of the insulin-growth factor signaling pathway were upregulated after treatment together with selective modulation of key transcription regulators. Using CombiROC multimarker signature analysis, we suggest that detecting a reduction of SEMA6A and an increase of COL1A2 and GRIA4 might reflect therapeutic efficacy of nusinersen. Longitudinal metabolome profiling, analyzed with paired t-Test, showed a significant shift for some aminoacid utilization induced by treatment, whereas other metabolites were largely unchanged. Together, these data suggest perturbation upon nusinersen treatment still sustained after 22 months of follow-up and confirm the utility of CSF multi-omic profiling as pharmacodynamic biomarker for SMA type 3. Nonetheless, validation studies are needed to confirm this evidence in a larger sample size and to further dissect combined markers of response to treatment.
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Affiliation(s)
- Irene Faravelli
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy.
| | - Delia Gagliardi
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Abati
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Megi Meneri
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jessica Ongaro
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Magri
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Parente
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lucia Petrozzi
- Department of Clinical and Experimental Medicine, Neurological Clinics, University of Pisa, Pisa, Italy
| | - Giulia Ricci
- Department of Clinical and Experimental Medicine, Neurological Clinics, University of Pisa, Pisa, Italy
| | | | | | | | - Donatella Caruso
- Unitech OMICs, University of Milan, Milan, Italy
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurological Clinics, University of Pisa, Pisa, Italy
| | - Giacomo Pietro Comi
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Govoni
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy
| | - Stefania Corti
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy.
- Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Linda Ottoboni
- Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, University of Milan, Milan, Italy.
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3
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Lumpkin CJ, Harris AW, Connell AJ, Kirk RW, Whiting JA, Saieva L, Pellizzoni L, Burghes AHM, Butchbach MER. Evaluation of the orally bioavailable 4-phenylbutyrate-tethered trichostatin A analogue AR42 in models of spinal muscular atrophy. Sci Rep 2023; 13:10374. [PMID: 37365234 PMCID: PMC10293174 DOI: 10.1038/s41598-023-37496-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 06/22/2023] [Indexed: 06/28/2023] Open
Abstract
Proximal spinal muscular atrophy (SMA) is a leading genetic cause for infant death in the world and results from the selective loss of motor neurons in the spinal cord. SMA is a consequence of low levels of SMN protein and small molecules that can increase SMN expression are of considerable interest as potential therapeutics. Previous studies have shown that both 4-phenylbutyrate (4PBA) and trichostatin A (TSA) increase SMN expression in dermal fibroblasts derived from SMA patients. AR42 is a 4PBA-tethered TSA derivative that is a very potent histone deacetylase inhibitor. SMA patient fibroblasts were treated with either AR42, AR19 (a related analogue), 4PBA, TSA or vehicle for 5 days and then immunostained for SMN localization. AR42 as well as 4PBA and TSA increased the number of SMN-positive nuclear gems in a dose-dependent manner while AR19 did not show marked changes in gem numbers. While gem number was increased in AR42-treated SMA fibroblasts, there were no significant changes in FL-SMN mRNA or SMN protein. The neuroprotective effect of this compound was then assessed in SMNΔ7 SMA (SMN2+/+;SMNΔ7+/+;mSmn-/-) mice. Oral administration of AR42 prior to disease onset increased the average lifespan of SMNΔ7 SMA mice by ~ 27% (20.1 ± 1.6 days for AR42-treated mice vs. 15.8 ± 0.4 days for vehicle-treated mice). AR42 treatment also improved motor function in these mice. AR42 treatment inhibited histone deacetylase (HDAC) activity in treated spinal cord although it did not affect SMN protein expression in these mice. AKT and GSK3β phosphorylation were both significantly increased in SMNΔ7 SMA mouse spinal cords. In conclusion, presymptomatic administration of the HDAC inhibitor AR42 ameliorates the disease phenotype in SMNΔ7 SMA mice in a SMN-independent manner possibly by increasing AKT neuroprotective signaling.
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Affiliation(s)
- Casey J Lumpkin
- Division of Neurology, Nemours Children's Hospital Delaware, 4462 E400 DuPont Experimental Station, 200 Powder Mill Road, Wilmington, DE, 19803, USA
- Department of Biological Sciences, University of Delaware, Newark, DE, USA
| | - Ashlee W Harris
- Division of Neurology, Nemours Children's Hospital Delaware, 4462 E400 DuPont Experimental Station, 200 Powder Mill Road, Wilmington, DE, 19803, USA
| | - Andrew J Connell
- Division of Neurology, Nemours Children's Hospital Delaware, 4462 E400 DuPont Experimental Station, 200 Powder Mill Road, Wilmington, DE, 19803, USA
| | - Ryan W Kirk
- Division of Neurology, Nemours Children's Hospital Delaware, 4462 E400 DuPont Experimental Station, 200 Powder Mill Road, Wilmington, DE, 19803, USA
| | - Joshua A Whiting
- Division of Neurology, Nemours Children's Hospital Delaware, 4462 E400 DuPont Experimental Station, 200 Powder Mill Road, Wilmington, DE, 19803, USA
| | - Luciano Saieva
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Livio Pellizzoni
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
- Department of Neurology, Columbia University, New York, NY, USA
- Center for Motor Neuron Biology and Disease, Columbia University, New York, NY, USA
| | - Arthur H M Burghes
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew E R Butchbach
- Division of Neurology, Nemours Children's Hospital Delaware, 4462 E400 DuPont Experimental Station, 200 Powder Mill Road, Wilmington, DE, 19803, USA.
- Department of Biological Sciences, University of Delaware, Newark, DE, USA.
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA.
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4
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Biomarkers of disease progression in adolescents and adults with 5q spinal muscular atrophy: a systematic review and meta-analysis. Neuromuscul Disord 2022; 32:185-194. [DOI: 10.1016/j.nmd.2021.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/07/2021] [Accepted: 12/29/2021] [Indexed: 12/14/2022]
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Pino MG, Rich KA, Kolb SJ. Update on Biomarkers in Spinal Muscular Atrophy. Biomark Insights 2021; 16:11772719211035643. [PMID: 34421296 PMCID: PMC8371741 DOI: 10.1177/11772719211035643] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022] Open
Abstract
The availability of disease modifying therapies for spinal muscular atrophy (SMA) has created an urgent need to identify clinically meaningful biomarkers. Biomarkers present a means to measure and evaluate neurological disease across time. Changes in biomarkers provide insight into disease progression and may reveal biologic, physiologic, or pharmacologic phenomena occurring prior to clinical detection. Efforts to identify biomarkers for SMA, a genetic motor neuron disease characterized by motor neuron degeneration and weakness, have culminated in a number of putative molecular and physiologic markers that evaluate biological media (eg, blood and cerebrospinal fluid [CSF]) or nervous system function. Such biomarkers include SMN2 copy number, SMN mRNA and protein levels, neurofilament proteins (NFs), plasma protein analytes, creatine kinase (CK) and creatinine (Crn), and various electrophysiology and imaging measures. SMN2 copy number inversely correlates with disease severity and is the best predictor of clinical outcome in untreated individuals. SMN mRNA and protein are commonly measured in the blood or CSF of patients receiving SMA therapies, particularly those aimed at increasing SMN protein expression, and provide insight into current disease state. NFs have proven to be robust prognostic, disease progression, and pharmacodynamic markers for SMA infants undergoing treatment, but less so for adolescents and adults. Select plasma proteins are altered in SMA individuals and may track response to therapy. CK and Crn from blood correlate with motor function and disease severity status and are useful for predicting which individuals will respond to therapy. Electrophysiology measures comprise the most reliable means for monitoring motor function throughout disease course and are sensitive enough to detect neuromuscular changes before overt clinical manifestation, making them robust predictive and pharmacodynamic biomarkers. Finally, magnetic resonance imaging and muscle ultrasonography are non-invasive techniques for studying muscle structure and physiology and are useful diagnostic tools, but cannot reliably track disease progression. Importantly, biomarkers can provide information about the underlying mechanisms of disease as well as reveal subclinical disease progression, allowing for more appropriate timing and dosing of therapy for individuals with SMA. Recent therapeutic advancements in SMA have shown promising results, though there is still a great need to identify and understand the impact of biomarkers in modulating disease onset and progression.
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Affiliation(s)
- Megan G Pino
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Kelly A Rich
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Stephen J Kolb
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
- Department of Biological Chemistry and
Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH,
USA
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6
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McCormack NM, Abera MB, Arnold ES, Gibbs RM, Martin SE, Buehler E, Chen YC, Chen L, Fischbeck KH, Burnett BG. A high-throughput genome-wide RNAi screen identifies modifiers of survival motor neuron protein. Cell Rep 2021; 35:109125. [PMID: 33979606 PMCID: PMC8679797 DOI: 10.1016/j.celrep.2021.109125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/17/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022] Open
Abstract
Spinal muscular atrophy (SMA) is a debilitating neurological disorder marked by degeneration of spinal motor neurons and muscle atrophy. SMA results from mutations in survival motor neuron 1 (SMN1), leading to deficiency of survival motor neuron (SMN) protein. Current therapies increase SMN protein and improve patient survival but have variable improvements in motor function, making it necessary to identify complementary strategies to further improve disease outcomes. Here, we perform a genome-wide RNAi screen using a luciferase-based activity reporter and identify genes involved in regulating SMN gene expression, RNA processing, and protein stability. We show that reduced expression of Transcription Export complex components increases SMN levels through the regulation of nuclear/cytoplasmic RNA transport. We also show that the E3 ligase, Neurl2, works cooperatively with Mib1 to ubiquitinate and promote SMN degradation. Together, our screen uncovers pathways through which SMN expression is regulated, potentially revealing additional strategies to treat SMA. Treatments for spinal muscular atrophy aim to increase survival motor neuron (SMN) protein. Using a genome-wide RNAi screen, McCormack et al. identify modifiers of SMN expression, including genes that are involved in transcription regulation, RNA processing, and protein stability.
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Affiliation(s)
- Nikki M McCormack
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, MD 20814, USA
| | - Mahlet B Abera
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, MD 20814, USA
| | - Eveline S Arnold
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892, USA
| | - Rebecca M Gibbs
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892, USA
| | - Scott E Martin
- Functional Genomics Lab, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20850, USA
| | - Eugen Buehler
- Functional Genomics Lab, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20850, USA
| | - Yu-Chi Chen
- Functional Genomics Lab, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20850, USA
| | - Lu Chen
- Functional Genomics Lab, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20850, USA
| | - Kenneth H Fischbeck
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD 20892, USA
| | - Barrington G Burnett
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, MD 20814, USA.
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Elsheikh B, King W, Peng J, Swoboda KJ, Reyna SP, LaSalle B, Prior TW, Arnold WD, Kissel JT, Kolb SJ. Outcome measures in a cohort of ambulatory adults with spinal muscular atrophy. Muscle Nerve 2019; 61:187-191. [DOI: 10.1002/mus.26756] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/10/2019] [Accepted: 11/12/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Bakri Elsheikh
- Department of Neurology, Division of Neuromuscular MedicineThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Wendy King
- Department of Neurology, Division of Neuromuscular MedicineThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Juan Peng
- Department of Biomedical Informatics, Center for BiostatisticsThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Kathy J. Swoboda
- Department of NeurologyMassachusetts General Hospital Boston Massachusetts
| | | | - Bernard LaSalle
- Department of Biomedical InformaticsUniversity of Utah School of Medicine Salt Lake City Utah
| | - Thomas W. Prior
- Department of Molecular PathologyThe Ohio State University Wexner Medical Center Columbus Ohio
| | - W. David Arnold
- Department of Neurology, Division of Neuromuscular MedicineThe Ohio State University Wexner Medical Center Columbus Ohio
| | - John T. Kissel
- Department of Neurology, Division of Neuromuscular MedicineThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Stephen J. Kolb
- Department of Neurology, Division of Neuromuscular MedicineThe Ohio State University Wexner Medical Center Columbus Ohio
- Department of Biological Chemistry & PharmacologyThe Ohio State University Wexner Medical Center Columbus Ohio
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Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neuromuscular disorder classified into four types based on the age of onset of the disease. Early onset is correlated with a higher mortality rate, mainly due to respiratory complications. Valproic acid (VPA) is a histone deacetylase (HDAC) inhibitor that has shown positive results on SMA both in experimental and cohort studies. OBJECTIVES This systematic review and meta-analysis aimed to investigate the efficacy and safety of VPA in patients with SMA. METHODS Eleven databases were systematically searched on 30 May 2017 for clinical trials that reported the efficacy and safety of VPA in SMA patients. The primary outcome was the efficacy of VPA in terms of gross motor function and expression of both full-length spinal motor neuron (SMN) gene (FL-SMN) and exon 7-lacking SMN. The secondary outcome was the safety of VPA in terms of reported adverse effects. The protocol was registered at PROSPERO (CRD42017067203). RESULTS Five of the ten included studies were used in the meta-analysis (n = 126). The overall effect estimate, comparing pre- and post-VPA treatment, regardless of carnitine co-administration and design of the studies, showed significant improvement in gross motor function (standard mean difference [SMD] = 0.302, 95% confidence interval [CI] 0.048-0.556, P = 0.02) using the Hammersmith Functional Motor Scale (HFMS), Modified Hammersmith Functional Motor Scale (MHFMS), and MHFMS-Extend, with no significant heterogeneity. Similarly, in non-randomized controlled studies, the results indicated that there was a significant improvement detected (SMD = 0.335, 95% CI 0.041-0.628, P = 0.025), with no significant heterogeneity. Meanwhile, our results suggest that there was no significant improvement in treatment with co-administered carnitine (SMD = 0.28, 95% CI - 0.02 to 0.581, P = 0.067). No significant differences were found between pre- and post-VPA treatment co-administered with carnitine, in terms of the change in FL-SMN and exon 7-lacking SMN. Qualitative synthesis showed that other motor functions were not improved, while respiratory function test results were contradictory. Regarding the safety of the treatment, a double-blind, randomized, placebo-controlled trial reported no statistically significant differences for adverse events (AEs) between groups. Moreover, most of the included studies reported no serious AEs related to VPA use, although weight gain, gastrointestinal symptoms and respiratory symptoms were notable problems. CONCLUSIONS Our study suggests that VPA treatment results in an improvement in gross motor functions for SMA patients, but not in other assessments of motor function or, possibly, in respiratory function. Furthermore, VPA appears to be a relatively safe drug, although treatment may be associated with a wide range of AEs (including body weight increase, fatigue, fever, flu-like symptoms, irritability, and pain). Double-blind, randomized, controlled trials are required to confirm these findings.
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Iyer C, Wang X, Renusch SR, Duque SI, Wehr AM, Mo XM, McGovern VL, Arnold WD, Burghes AHM, Kolb SJ. SMN Blood Levels in a Porcine Model of Spinal Muscular Atrophy. J Neuromuscul Dis 2018; 4:59-66. [PMID: 28269795 DOI: 10.3233/jnd-170209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Spinal Muscular Atrophy (SMA) is an autosomal recessive motor neuron disease that results in loss of spinal motor neurons, muscular weakness and, in severe cases, respiratory failure and death. SMA is caused by a deletion or mutation of the SMN1 gene and retention of the SMN2 gene that leads to low SMN expression levels.The measurement of SMN mRNA levels in peripheral blood samples has been used in SMA clinical studies as a pharmacodynamic biomarker for response to therapies designed to increase SMN levels. We recently developed a postnatal porcine model of SMA by the viral delivery of a short-hairpin RNA (shRNA) targeting porcine SMN (pSMN). scAAV9-mediated knockdown of pSMN mRNA at postnatal day 5 results in denervation, weakness and motor neuron and ventral root axon loss that begins 3-4 weeks after viral delivery, and this phenotype can be ameliorated by subsequent viral delivery of human SMN (hSMN). OBJECTIVE To determine if the effect of modulating SMN levels using gene therapy can be measured in blood. METHODS We measured expression of pSMN mRNA and hSMN mRNA by quantitative droplet digital PCR (ddPCR). RESULTS We found that the endogenous expression of pSMN mRNA in blood increases in the first month of life. However, there were no significant differences in blood levels of pSMN mRNA after knock-down or of human SMN mRNA after gene therapy. CONCLUSIONS Our results, obtained in a large animal model of SMA that is similar in size and anatomy to human infants, suggest that measurement of SMN mRNA levels in blood may not be informative in SMA clinical trials involving intrathecal delivery of SMN-modulating therapies.
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Affiliation(s)
- Chitra Iyer
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Xueqian Wang
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Samantha R Renusch
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Sandra I Duque
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Allison M Wehr
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Xiaokui-Molly Mo
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Vicki L McGovern
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - W David Arnold
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA.,Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Arthur H M Burghes
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
| | - Stephen J Kolb
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA.,Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Oh, USA
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10
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Groen EJN, Talbot K, Gillingwater TH. Advances in therapy for spinal muscular atrophy: promises and challenges. Nat Rev Neurol 2018; 14:214-224. [PMID: 29422644 DOI: 10.1038/nrneurol.2018.4] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Spinal muscular atrophy (SMA) is a devastating motor neuron disease that predominantly affects children and represents the most common cause of hereditary infant mortality. The condition results from deleterious variants in SMN1, which lead to depletion of the survival motor neuron protein (SMN). Now, 20 years after the discovery of this genetic defect, a major milestone in SMA and motor neuron disease research has been reached with the approval of the first disease-modifying therapy for SMA by US and European authorities - the antisense oligonucleotide nusinersen. At the same time, promising data from early-stage clinical trials of SMN1 gene therapy have indicated that additional therapeutic options are likely to emerge for patients with SMA in the near future. However, the approval of nusinersen has generated a number of immediate and substantial medical, ethical and financial implications that have the potential to resonate beyond the specific treatment of SMA. Here, we provide an overview of the rapidly evolving therapeutic landscape for SMA, highlighting current achievements and future opportunities. We also discuss how these developments are providing important lessons for the emerging second generation of combinatorial ('SMN-plus') therapies that are likely to be required to generate robust treatments that are effective across a patient's lifespan.
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Affiliation(s)
- Ewout J N Groen
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Thomas H Gillingwater
- Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh, Edinburgh, UK
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Butchbach MER, Lumpkin CJ, Harris AW, Saieva L, Edwards JD, Workman E, Simard LR, Pellizzoni L, Burghes AHM. Protective effects of butyrate-based compounds on a mouse model for spinal muscular atrophy. Exp Neurol 2016; 279:13-26. [PMID: 26892876 PMCID: PMC4834225 DOI: 10.1016/j.expneurol.2016.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/11/2016] [Accepted: 02/13/2016] [Indexed: 11/17/2022]
Abstract
Proximal spinal muscular atrophy (SMA) is a childhood-onset degenerative disease resulting from the selective loss of motor neurons in the spinal cord. SMA is caused by the loss of SMN1 (survival motor neuron 1) but retention of SMN2. The number of copies of SMN2 modifies disease severity in SMA patients as well as in mouse models, making SMN2 a target for therapeutics development. Sodium butyrate (BA) and its analog (4PBA) have been shown to increase SMN2 expression in SMA cultured cells. In this study, we examined the effects of BA, 4PBA as well as two BA prodrugs-glyceryl tributyrate (BA3G) and VX563-on the phenotype of SMNΔ7 SMA mice. Treatment with 4PBA, BA3G and VX563 but not BA beginning at PND04 significantly improved the lifespan and delayed disease end stage, with administration of VX563 also improving the growth rate of these mice. 4PBA and VX563 improved the motor phenotype of SMNΔ7 SMA mice and prevented spinal motor neuron loss. Interestingly, neither 4PBA nor VX563 had an effect on SMN expression in the spinal cords of treated SMNΔ7 SMA mice; however, they inhibited histone deacetylase (HDAC) activity and restored the normal phosphorylation states of Akt and glycogen synthase kinase 3β, both of which are altered by SMN deficiency in vivo. These observations show that BA-based compounds with favorable pharmacokinetics ameliorate SMA pathology possibly by modulating HDAC and Akt signaling.
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Affiliation(s)
- Matthew E R Butchbach
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Center for Applied Clinical Genomics, Nemours Biomedical Research, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Center for Pediatric Research, Nemours Biomedical Research, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA; Department of Biological Sciences, University of Delaware, Newark, DE, USA.
| | - Casey J Lumpkin
- Center for Applied Clinical Genomics, Nemours Biomedical Research, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Biological Sciences, University of Delaware, Newark, DE, USA
| | - Ashlee W Harris
- Center for Applied Clinical Genomics, Nemours Biomedical Research, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Luciano Saieva
- Center for Motor Neuron Biology and Disease, Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Jonathan D Edwards
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eileen Workman
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Louise R Simard
- Department of Biochemistry and Medical Genetics, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Livio Pellizzoni
- Center for Motor Neuron Biology and Disease, Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Arthur H M Burghes
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Arnold W, McGovern VL, Sanchez B, Li J, Corlett KM, Kolb SJ, Rutkove SB, Burghes AH. The neuromuscular impact of symptomatic SMN restoration in a mouse model of spinal muscular atrophy. Neurobiol Dis 2015; 87:116-23. [PMID: 26733414 DOI: 10.1016/j.nbd.2015.12.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/20/2015] [Accepted: 12/25/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Significant advances in the development of SMN-restoring therapeutics have occurred since 2010 when very effective biological treatments were reported in mouse models of spinal muscular atrophy. As these treatments are applied in human clinical trials, there is pressing need to define quantitative assessments of disease progression, treatment stratification, and therapeutic efficacy. The electrophysiological measures Compound Muscle Action Potential and Motor Unit Number Estimation are reliable measures of nerve function. In both the SMN∆7 mouse and a pig model of spinal muscular atrophy, early SMN restoration results in preservation of electrophysiological measures. Currently, clinical trials are underway in patients at post-symptomatic stages of disease progression. In this study, we present results from both early and delayed SMN restoration using clinically-relevant measures including electrical impedance myography, compound muscle action potential, and motor unit number estimation to quantify the efficacy and time-sensitivity of SMN-restoring therapy. METHODS SMA∆7 mice were treated via intracerebroventricular injection with antisense oligonucleotides targeting ISS-N1 to increase SMN protein from the SMN2 gene on postnatal day 2, 4, or 6 and compared with sham-treated spinal muscular atrophy and control mice. Compound muscle action potential and motor unit number estimation of the triceps surae muscles were performed at day 12, 21, and 30 by a single evaluator blinded to genotype and treatment. Similarly, electrical impedance myography was measured on the biceps femoris muscle at 12days for comparison. RESULTS Electrophysiological measures and electrical impedance myography detected significant differences at 12days between control and late-treated (4 or 6days) and sham-treated spinal muscular atrophy mice, but not in mice treated at 2days (p<0.01). EIM findings paralleled and correlated with compound muscle action potential and motor unit number estimation (r=0.61 and r=0.50, respectively, p<0.01). Longitudinal measures at 21 and 30days show that symptomatic therapy results in reduced motor unit number estimation associated with delayed normalization of compound muscle action potential. CONCLUSIONS The incomplete effect of symptomatic treatment is accurately identified by both electrophysiological measures and electrical impedance myography. There is strong correlation between these measures and with weight and righting reflex. This study predicts that measures of compound muscle action potential, motor unit number estimation, and electrical impedance myography are promising biomarkers of treatment stratification and effect for future spinal muscular atrophy trials. The ease of application and simplicity of electrical impedance myography compared with standard electrophysiological measures may be particularly valuable in future pediatric clinical trials.
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Affiliation(s)
- W Arnold
- Department of Neurology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave, Columbus, OH 43210, United States; Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, 480 Medical Center Drive, Columbus, OH 43210, United States; Department of Neuroscience, The Ohio State University Wexner Medical Center, 480 Medical Center Drive, Columbus, OH 43210, United States
| | - Vicki L McGovern
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 363 Hamilton Hall, 1645 Neil Ave, Columbus, OH 43210, United States
| | - Benjamin Sanchez
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States
| | - Jia Li
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States
| | - Kaitlyn M Corlett
- Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 363 Hamilton Hall, 1645 Neil Ave, Columbus, OH 43210, United States
| | - Stephen J Kolb
- Department of Neurology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave, Columbus, OH 43210, United States; Department of Neuroscience, The Ohio State University Wexner Medical Center, 480 Medical Center Drive, Columbus, OH 43210, United States; Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 363 Hamilton Hall, 1645 Neil Ave, Columbus, OH 43210, United States
| | - Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, United States
| | - Arthur H Burghes
- Department of Neurology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave, Columbus, OH 43210, United States; Department of Biological Chemistry and Pharmacology, The Ohio State University Wexner Medical Center, 363 Hamilton Hall, 1645 Neil Ave, Columbus, OH 43210, United States
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