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Berry-Kravis E, Abbeduto L, Hagerman R, Coffey CS, Cudkowicz M, Erickson CA, McDuffie A, Hessl D, Ethridge L, Tassone F, Kaufmann WE, Friedmann K, Bullard L, Hoffmann A, Veenstra-VanderWeele J, Staley K, Klements D, Moshinsky M, Harkey B, Long J, Fedler J, Klingner E, Ecklund D, Costigan M, Huff T, Pearson B. Effects of AFQ056 on language learning in fragile X syndrome. J Clin Invest 2023; 134:e171723. [PMID: 37651202 PMCID: PMC10904045 DOI: 10.1172/jci171723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUNDFXLEARN, the first-ever large multisite trial of effects of disease-targeted pharmacotherapy on learning, was designed to explore a paradigm for measuring effects of mechanism-targeted treatment in fragile X syndrome (FXS). In FXLEARN, the effects of metabotropic glutamate receptor type 5 (mGluR5) negative allosteric modulator (NAM) AFQ056 on language learning were evaluated in 3- to 6-year-old children with FXS, expected to have more learning plasticity than adults, for whom prior trials of mGluR5 NAMs have failed.METHODSAfter a 4-month single-blind placebo lead-in, participants were randomized 1:1 to AFQ056 or placebo, with 2 months of dose optimization to the maximum tolerated dose, then 6 months of treatment during which a language-learning intervention was implemented for both groups. The primary outcome was a centrally scored videotaped communication measure, the Weighted Communication Scale (WCS). Secondary outcomes were objective performance-based and parent-reported cognitive and language measures.RESULTSFXLEARN enrolled 110 participants, randomized 99, and had 91 who completed the placebo-controlled period. Although both groups made language progress and there were no safety issues, the change in WCS score during the placebo-controlled period was not significantly different between the AFQ056 and placebo-treated groups, nor were there any significant between-group differences in change in any secondary measures.CONCLUSIONDespite the large body of evidence supporting use of mGluR5 NAMs in animal models of FXS, this study suggests that this mechanism of action does not translate into benefit for the human FXS population and that better strategies are needed to determine which mechanisms will translate from preclinical models to humans in genetic neurodevelopmental disorders.TRIAL REGISTRATIONClincalTrials.gov NCT02920892.FUNDING SOURCESNeuroNEXT network NIH grants U01NS096767, U24NS107200, U24NS107209, U01NS077323, U24NS107183, U24NS107168, U24NS107128, U24NS107199, U24NS107198, U24NS107166, U10NS077368, U01NS077366, U24NS107205, U01NS077179, and U01NS077352; NIH grant P50HD103526; and Novartis IIT grant AFQ056X2201T for provision of AFQ056.
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Affiliation(s)
- Elizabeth Berry-Kravis
- Departments of Pediatrics, Neurological Sciences, and Anatomy & Cell Biology, Rush University Medical Center, Chicago, Illinois, USA
| | - Leonard Abbeduto
- MIND Institute and Department of Psychiatry and Behavioral Sciences and
| | - Randi Hagerman
- MIND Institute and Department of Pediatrics, UCD, Sacramento, California, USA
| | | | - Merit Cudkowicz
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Craig A. Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrea McDuffie
- MIND Institute and Department of Psychiatry and Behavioral Sciences and
| | - David Hessl
- MIND Institute and Department of Psychiatry and Behavioral Sciences and
| | - Lauren Ethridge
- Department of Psychology, University of Oklahoma, Norman, Oklahoma, and Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Flora Tassone
- MIND Institute and Department of Biochemistry and Molecular Medicine, UCD, Sacramento, California, USA
| | - Walter E. Kaufmann
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Lauren Bullard
- MIND Institute and Department of Psychiatry and Behavioral Sciences and
| | - Anne Hoffmann
- Departments of Pediatrics and Communication Disorders and Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jeremy Veenstra-VanderWeele
- Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, New York, USA
| | - Kevin Staley
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David Klements
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Moshinsky
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brittney Harkey
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeff Long
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | - Janel Fedler
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | | | - Dixie Ecklund
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | - Michele Costigan
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | - Trevis Huff
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | - Brenda Pearson
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA
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Albert OK, Friedmann K, Jaeger R, Berry-Kravis E. Low Risk Profile of Long-Term Repeated Lumbar Puncture for Intrathecal Delivery of 2-Hydroxypropyl-Beta-Cyclodextrin in Patients With Niemann-Pick Type C. Pediatr Neurol 2023; 144:99-103. [PMID: 37201244 DOI: 10.1016/j.pediatrneurol.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/11/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Intrathecal delivery of 2-hydroxypropyl-beta-cyclodextrin (VTS-270, adrabetadex) by lumbar puncture (LP) has been performed on a biweekly schedule for over nine years for the treatment of Niemann-Pick type C1 (NPC1) at Rush University Medical Center. METHODS Over this time 59 patients with NPC1 have been treated with 2935 infusions, performed with either a 22-G 3-inch Whitacre or a 22-G 2-inch Gertie Marx atraumatic needles, with or without general anesthesia. Adverse events potentially related to the LP infusion were collected from records for all patients treated for NPC. The NPC1 cohort ranged in age from one to 31 years at the initiation of treatment. RESULTS Of the 59 patients treated 33 (55.9%) had no adverse events ever after an LP and 26 (44.1%) had adverse effects at some time. Of the 2935 LPs, adverse events occurred after 3.3% of LPs. Adverse events most observed were headache (1.2% of LPs), nausea (0.3%), vomiting (1.0%), and back pain (1.3%). CONCLUSIONS This study shows that frequent repeated LPs are possible for delivery of intrathecal therapy and can be accomplished with a very low rate of post-LP adverse events.
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Affiliation(s)
- Orsolya K Albert
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - Katherine Friedmann
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois; College of Nursing, Rush University Medical Center, Chicago, Illinois
| | - Rebecca Jaeger
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - Elizabeth Berry-Kravis
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois; Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois; Department of Anatomy and Cell Biology, Rush University Medical Center, Chicago, Illinois.
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Farhat N, Bailey L, Friedmann K, Bushnell DM, Rodriguez D, Berry-Kravis E, Porter FD. Consistently High Agreement Between Independent Raters of Niemann-Pick Type C1 Clinical Severity Scale in Phase 2/3 Trial. Pediatr Neurol 2022; 127:32-38. [PMID: 34952292 PMCID: PMC8900058 DOI: 10.1016/j.pediatrneurol.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Niemann-Pick disease, type C1 (NPC1) is a rare neurodegenerative genetic disorder characterized by impaired intracellular transport of cholesterol and other lipids. The Niemann-Pick Disease, type C1 Severity Scale (NPC-SS) was developed to quantify neurological progression of NPC; it is used to monitor the natural history of disease progression and assess response to treatment. The objective of the study was to examine the interrater reliability of the NPC-SS in a phase 2/3 trial. METHODS Study data were from a multicenter, prospective, randomized, double-blind trial of adrabetadex in 56 subjects with NPC1. Clinical data recorded at each study site were distributed to two independent blinded central raters to generate a severity score. A composite four-item score was utilized as the primary clinical study end point, whereas a five-item focused score has been utilized in other NPC1 trials. Interrater reliability was assessed using two-way mixed models for instrument stability, Cohen kappa, weighted kappa, and percent agreement for the four- and five-item scores. RESULTS The frequency distribution and mean (S.D.) of the NPC-SS domain assessments by the raters were almost identical. Evaluation at the patient visit level showed wide variability between visits; however, weighted kappa calculation provided a lower variability between visits. The average kappa coefficients ranged between 0.69 and 0.89, indicating good to very good agreement between raters. CONCLUSIONS These results support the NPC-SS, including derived four- and five-item composite scores, as reliable measures for use in a clinical trial setting.
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Affiliation(s)
- Nicole Farhat
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
| | - Laurie Bailey
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine Friedmann
- Department of Pediatrics, Neurological Sciences and Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Elizabeth Berry-Kravis
- Department of Pediatrics, Neurological Sciences and Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
| | - Forbes D. Porter
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Berry-Kravis E, Chin J, Hoffmann A, Winston A, Stoner R, LaGorio L, Friedmann K, Hernandez M, Ory DS, Porter FD, O'Keefe JA. Long-Term Treatment of Niemann-Pick Type C1 Disease With Intrathecal 2-Hydroxypropyl-β-Cyclodextrin. Pediatr Neurol 2018; 80:24-34. [PMID: 29429782 PMCID: PMC5857219 DOI: 10.1016/j.pediatrneurol.2017.12.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/23/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intrathecal 2-hydoxypropyl-β-cyclodextrin has been found to mobilize cholesterol, extend life, reduce cerebellar pathology, and delay onset of ataxia in the mouse and cat models of Niemann-Pick disease, type C1, a clinically variable progressive and ultimately fatal neurodegenerative storage disorder characterized by endolysosomal accumulation of unesterified cholesterol. OBJECTIVE In this study, the long-term effects of intrathecal 2-hydoxypropyl-β-cyclodextrin treatment for 2.5 to three years in humans with Niemann-Pick disease, type C, were evaluated. METHODS Three patients with Niemann-Pick disease, type C, in different stages of progression and displaying varying disease manifestations were treated with intrathecal 2-hydoxypropyl-β-cyclodextrin (VTS-270) delivered by lumbar puncture infusion through an intermediate-size patient population investigational new drug application for expanded access. Disease progression was monitored with the Niemann-Pick disease, type C, Neurological Severity Scale and numerous objective measures of function in five neurological domains typically impacted by the disease: cognitive/language, gait/balance, fine motor, swallowing, and eye movement. RESULTS No worsening in any domain except eye movements (vertical pursuit gain) was seen for any of the three patients, and in the other domains, improved scores on measures were seen over time for one or more patients. The Niemann-Pick disease type C (NPC) Neurological Severity Scale (NSS) showed stable to slightly improved ratings. CONCLUSIONS These trajectories are not consistent with the typical trajectory of the disease and suggest that intrathecal 2-hydoxypropyl-β-cyclodextrin has stabilized the disease over an extended period of time, supporting the current phase 2/3 controlled registration trial with VTS-270.
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Affiliation(s)
- Elizabeth Berry-Kravis
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois; Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois; Department of Biochemistry, Rush University Medical Center, Chicago, Illinois.
| | - Jamie Chin
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - Anne Hoffmann
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois; Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, Illinois
| | - Amy Winston
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, Illinois
| | - Robin Stoner
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, Illinois
| | - Lisa LaGorio
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, Illinois
| | | | - Mariana Hernandez
- Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - Daniel S Ory
- Diabetic Cardiovascular Disease Center, Washington University School of Medicine, St. Louis, Missouri
| | - Forbes D Porter
- Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland
| | - Joan A O'Keefe
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois; Department of Cell and Molecular Medicine, Rush University Medical Center, Chicago, Illinois
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