Current and emerging pharmacotherapy for Gaucher disease in pediatric populations

INTRODUCTION

The past decades have witnessed a remarkable improvement in the health of patients with Gaucher disease, the inherited deficiency of the lysosomal enzyme glucocerebrosidase, resulting from the availability of enzyme replacement and substrate reduction therapies. Especially in pediatric populations, early diagnosis and initiation of treatment is essential to achieving optimal outcomes.

AREAS COVERED

The authors review the literature pertaining to the effectiveness of currently available therapies and describe new pharmacotherapies under development, especially for young patients.

EXPERT OPINION

For pediatric patients with non-neuronopathic Gaucher disease, there may be new therapeutic options on the horizon in the form of gene therapy or small molecule glucocerebrosidase chaperones. These have the potential to result in a cure for systemic disease manifestations and/or to reduce the cost and convenience of treatment. For children with neuronopathic Gaucher disease, the challenge of targeting therapy to the central nervous system is being explored through new modalities including brain-targeted gene therapy, in-utero therapy, brain-penetrant small molecule chaperones, and other methods that convey enzyme across the blood-brain barrier. Indeed, these are exciting times for both pediatric patients with Gaucher disease and those with other lysosomal storage disorders.

Small Molecule Chaperones for the Treatment of Gaucher Disease and GBA1-Associated Parkinson Disease

Parkinson disease, the second most common movement disorder, is a complex neurodegenerative disorder hallmarked by the accumulation of alpha-synuclein, a neural-specific small protein associated with neuronal synapses. Mutations in the glucocerebrosidase gene (GBA1), implicated in the rare, autosomal recessive lysosomal disorder Gaucher disease, are the most common known genetic risk factor for Parkinson disease. Insights into the inverse relationship between glucocerebrosidase and alpha-synuclein have led to new therapeutic approaches for the treatment of Gaucher disease and GBA1-associated Parkinson disease. Unlike the current drugs used to treat Gaucher disease, which are highly expensive and do not cross the blood-brain-barrier, new small molecules therapies, including competitive and non-competitive chaperones that enhance glucocerebrosidase levels are being developed to overcome these limitations. Some of these include iminosugars, ambroxol, other competitive glucocerebrosidase inhibitors, and non-inhibitory chaperones or activators that do not compete for the active site. These drugs, which have been shown in different disease models to increase glucocerebrosidase activity, could have potential as a therapy for Gaucher disease and GBA1- associated Parkinson disease. Some have been demonstrated to reduce α-synuclein levels in pre-clinical studies using cell-based or animal models of GBA1-associated Parkinson disease, and may also have utility for idiopathic Parkinson disease.