Altered immune phenotypes in subjects with Fabry disease and responses to switching from agalsidase alfa to agalsidase beta

Fabry disease (FD) is a rare X-linked genetic disorder caused by mutations in the GLA gene encoding the lysosomal enzyme, α-galactosidase A (α-gal A). The mutations lead to lack of or faulty enzyme causing accumulation of globotriaosylceramide (Gb3) and related glycosphingolipids including globotriaosylsphingosine (lyso-Gb₃). Treatment options for FD include enzyme replacement therapy. There are two different recombinant α-gal A enzymes, where agalsidase beta has been approved by FDA for use in the USA while both agalsidase beta and agalsidase alfa are being prescribed in many other countries. Several FD patients in the USA were switched to agalsidase alfa for a certain period of time due to supply shortage of agalsidase beta but were switched back to agalsidase beta upon availability. Due to the fact that some glycolipids may serve as antigens, various immune abnormalities have been associated with several lysosomal storage disorders (LSDs). In the present clinical study we evaluated alterations in peripheral immune cell subsets in patients with FD (n=27) compared to healthy control group (n=27). Patients with FD showed persistent T cell associated abnormalities, including skewed T helper to cytotoxic T cell ratio and elevated fraction of memory T cells and expression of activation markers on T cell subsets. Further, the study elucidated the effect of switching from agalsidase alfa to agalsidase beta on immune system as well as other clinical markers. While there was relative decrease in plasma lyso-Gb₃ as well as urine lyso-Gb₃ over time, their levels remained above the reference values. The immune abnormalities did not correlate with gender, age or lyso-Gb₃ levels, indicating that these persistent changes were inherent to FD irrespective of the extent of substrate accumulation.