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Gunther K, Lynch DR. Pharmacotherapeutic strategies for Friedreich Ataxia: a review of the available data. Expert Opin Pharmacother 2024; 25:529-539. [PMID: 38622054 DOI: 10.1080/14656566.2024.2343782] [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: 02/05/2024] [Accepted: 04/12/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Friedreich ataxia (FRDA) is a rare autosomal recessive disease, marked by loss of coordination as well as impaired neurological, endocrine, orthopedic, and cardiac function. There are many symptomatic medications for FRDA, and many clinical trials have been performed, but only one FDA-approved medication exists. AREAS COVERED The relative absence of the frataxin protein (FXN) in FRDA causes mitochondrial dysfunction, resulting in clinical manifestations. Currently, the only approved treatment for FRDA is an Nrf2 activator called omaveloxolone (Skyclarys). Patients with FRDA also rely on various symptomatic medications for treatment. Because there is only one approved medication for FRDA, clinical trials continue to advance in FRDA. Although some trials have not met their endpoints, many current and upcoming clinical trials provide exciting possibilities for the treatment of FRDA. EXPERT OPINION The approval of omaveloxolone provides a major advance in FRDA therapeutics. Although well tolerated, it is not curative. Reversal of deficient frataxin levels with gene therapy, protein replacement, or epigenetic approaches provides the most likely prospect for enduring, disease-modifying therapy in the future.
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Affiliation(s)
- Katherine Gunther
- Friedreich Ataxia Program, Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David R Lynch
- Friedreich Ataxia Program, Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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2
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Porcu L, Fichera M, Nanetti L, Rulli E, Giunti P, Parkinson MH, Durr A, Ewenczyk C, Boesch S, Nachbauer W, Indelicato E, Klopstock T, Stendel C, Rodríguez de Rivera FJ, Schöls L, Fleszar Z, Giordano I, Didszun C, Castaldo A, Rai M, Klockgether T, Pandolfo M, Schulz JB, Reetz K, Mariotti C. Longitudinal changes of SARA scale in Friedreich ataxia: Strong influence of baseline score and age at onset. Ann Clin Transl Neurol 2023; 10:2000-2012. [PMID: 37641437 PMCID: PMC10647003 DOI: 10.1002/acn3.51886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The Scale for Assessment and Rating of Ataxia (SARA) is widely used in different types of ataxias and has been chosen as the primary outcome measure in the European natural history study for Friedreich ataxia (FA). METHODS To assess distribution and longitudinal changes of SARA scores and its single items, we analyzed SARA scores of 502 patients with typical-onset FA (<25 years) participating in the 4-year prospective European FA Consortium for Translational Studies (EFACTS). Pattern of disease progression was determined using linear mixed-effects regression models. The chosen statistical model was re-fitted in order to estimate parameters and predict disease progression. Median time-to-change and rate of score progression were estimated using the Kaplan-Meier method and weighted linear regression models, respectively. RESULTS SARA score at study enrollment and age at onset were the major predictive factors of total score progression during the 4-year follow-up. To a less extent, age at evaluation also influenced the speed of SARA progression, while disease duration did not improve the prediction of the statistical model. Temporal dynamics of total SARA and items showed a great variability in the speed of score increase during disease progression. Gait item had the highest annual progression rate, with median time for one-point score increase of 1 to 2 years. INTERPRETATION Analyses of statistical properties of SARA suggest a variable sensitivity of the scale at different disease stages, and provide important information for population selection and result interpretation in future clinical trials.
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Affiliation(s)
- Luca Porcu
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeUK
| | - Mario Fichera
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
| | - Lorenzo Nanetti
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
| | - Eliana Rulli
- Laboratory of Methodology for Clinical Research, Oncology DepartmentIstituto di Ricerche Farmacologiche Mario Negri IRCCSMilanItaly
| | - Paola Giunti
- Department of Clinical and Movement NeurosciencesAtaxia Centre, UCL‐Queen Square Institute of NeurologyLondonWC1N 3BGUK
| | - Michael H. Parkinson
- Department of Clinical and Movement NeurosciencesAtaxia Centre, UCL‐Queen Square Institute of NeurologyLondonWC1N 3BGUK
| | - Alexandra Durr
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP‐HP, INSERM, CNRSUniversity Hospital Pitié‐SalpêtrièreParis75646France
| | - Claire Ewenczyk
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP‐HP, INSERM, CNRSUniversity Hospital Pitié‐SalpêtrièreParis75646France
| | - Sylvia Boesch
- Department of NeurologyMedical University InnsbruckInnsbruck6020Austria
| | | | | | - Thomas Klopstock
- Department of NeurologyFriedrich Baur Institute, University Hospital, LMUMunich80336Germany
- German Center for Neurodegenerative Diseases (DZNE)Munich81377Germany
- Munich Cluster for Systems Neurology (SyNergy)Munich81377Germany
| | - Claudia Stendel
- Department of NeurologyFriedrich Baur Institute, University Hospital, LMUMunich80336Germany
- German Center for Neurodegenerative Diseases (DZNE)Munich81377Germany
| | | | - Ludger Schöls
- Department of Neurology and Hertie‐Institute for Clinical Brain ResearchUniversity of TübingenTübingen72076Germany
- German Center for Neurodegenerative Diseases (DZNE)Tübingen72076Germany
| | - Zofia Fleszar
- Department of Neurology and Hertie‐Institute for Clinical Brain ResearchUniversity of TübingenTübingen72076Germany
| | - Ilaria Giordano
- Department of NeurologyUniversity Hospital of BonnBonn53127Germany
| | - Claire Didszun
- Department of NeurologyRWTH Aachen UniversityAachen52074Germany
| | - Anna Castaldo
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
| | - Myriam Rai
- Laboratory of Experimental NeurologyUniversité Libre de BruxellesBrussels1070Belgium
| | - Thomas Klockgether
- Department of NeurologyUniversity Hospital of BonnBonn53127Germany
- German Center for Neurodegenerative Diseases (DZNE)Bonn53127Germany
| | - Massimo Pandolfo
- Laboratory of Experimental NeurologyUniversité Libre de BruxellesBrussels1070Belgium
- Department of Neurology and NeurosurgeryMcGill UniversityMontrealQCH3A 0G4Canada
| | - Jörg B. Schulz
- Department of NeurologyRWTH Aachen UniversityAachen52074Germany
- JARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen UniversityAachen52056Germany
| | - Kathrin Reetz
- Department of NeurologyRWTH Aachen UniversityAachen52074Germany
- JARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen UniversityAachen52056Germany
| | - Caterina Mariotti
- Unit of Medical Genetics and NeurogeneticsFondazione IRCCS Istituto Neurologico Carlo BestaMilan20133Italy
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Georgiou-Karistianis N, Corben LA, Reetz K, Adanyeguh IM, Corti M, Deelchand DK, Delatycki MB, Dogan I, Evans R, Farmer J, França MC, Gaetz W, Harding IH, Harris KS, Hersch S, Joules R, Joers JJ, Krishnan ML, Lax M, Lock EF, Lynch D, Mareci T, Muthuhetti Gamage S, Pandolfo M, Papoutsi M, Rezende TJR, Roberts TPL, Rosenberg JT, Romanzetti S, Schulz JB, Schilling T, Schwarz AJ, Subramony S, Yao B, Zicha S, Lenglet C, Henry PG. A natural history study to track brain and spinal cord changes in individuals with Friedreich's ataxia: TRACK-FA study protocol. PLoS One 2022; 17:e0269649. [PMID: 36410013 PMCID: PMC9678384 DOI: 10.1371/journal.pone.0269649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Drug development for neurodegenerative diseases such as Friedreich's ataxia (FRDA) is limited by a lack of validated, sensitive biomarkers of pharmacodynamic response in affected tissue and disease progression. Studies employing neuroimaging measures to track FRDA have thus far been limited by their small sample sizes and limited follow up. TRACK-FA, a longitudinal, multi-site, and multi-modal neuroimaging natural history study, aims to address these shortcomings by enabling better understanding of underlying pathology and identifying sensitive, clinical trial ready, neuroimaging biomarkers for FRDA. METHODS 200 individuals with FRDA and 104 control participants will be recruited across seven international study sites. Inclusion criteria for participants with genetically confirmed FRDA involves, age of disease onset ≤ 25 years, Friedreich's Ataxia Rating Scale (FARS) functional staging score of ≤ 5, and a total modified FARS (mFARS) score of ≤ 65 upon enrolment. The control cohort is matched to the FRDA cohort for age, sex, handedness, and years of education. Participants will be evaluated at three study visits over two years. Each visit comprises of a harmonized multimodal Magnetic Resonance Imaging (MRI) and Spectroscopy (MRS) scan of the brain and spinal cord; clinical, cognitive, mood and speech assessments and collection of a blood sample. Primary outcome measures, informed by previous neuroimaging studies, include measures of: spinal cord and brain morphometry, spinal cord and brain microstructure (measured using diffusion MRI), brain iron accumulation (using Quantitative Susceptibility Mapping) and spinal cord biochemistry (using MRS). Secondary and exploratory outcome measures include clinical, cognitive assessments and blood biomarkers. DISCUSSION Prioritising immediate areas of need, TRACK-FA aims to deliver a set of sensitive, clinical trial-ready neuroimaging biomarkers to accelerate drug discovery efforts and better understand disease trajectory. Once validated, these potential pharmacodynamic biomarkers can be used to measure the efficacy of new therapeutics in forestalling disease progression. CLINICAL TRIAL REGISTRATION ClinicalTrails.gov Identifier: NCT04349514.
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Affiliation(s)
- Nellie Georgiou-Karistianis
- School of Psychological Sciences, The Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- * E-mail:
| | - Louise A. Corben
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kathrin Reetz
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Isaac M. Adanyeguh
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Manuela Corti
- Powell Gene Therapy Centre, University of Florida, Gainesville, Florida, United States of America
| | - Dinesh K. Deelchand
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Martin B. Delatycki
- School of Psychological Sciences, The Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Imis Dogan
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Rebecca Evans
- Takeda Pharmaceutical Company Ltd, Cambridge, Massachusetts, United States of America
| | - Jennifer Farmer
- Friedreich’s Ataxia Research Alliance (FARA), Downingtown, Pennsylvania, United States of America
| | - Marcondes C. França
- Department of Neurology, University of Campinas, Campinas, Sao Paulo, Brazil
| | - William Gaetz
- Department of Radiology, Lurie Family Foundations MEG Imaging Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Ian H. Harding
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Karen S. Harris
- School of Psychological Sciences, The Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
| | - Steven Hersch
- Neurology Business Group, Eisai Inc., Nutley, New Jersey, United States of America
| | | | - James J. Joers
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Michelle L. Krishnan
- Translational Medicine, Novartis Institutes for Biomedical Research, Cambridge, MA, United States of America
| | | | - Eric F. Lock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | - David Lynch
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Thomas Mareci
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, FL, United States of America
| | - Sahan Muthuhetti Gamage
- School of Psychological Sciences, The Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
| | - Massimo Pandolfo
- Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
| | | | | | - Timothy P. L. Roberts
- Department of Radiology, Lurie Family Foundations MEG Imaging Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Jens T. Rosenberg
- McKnight Brain Institute, Department of Neurology, University of Florida, Gainesville, Florida, United States of America
| | - Sandro Romanzetti
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Jörg B. Schulz
- Department of Neurology, RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Traci Schilling
- PTC Therapeutics, Inc, South Plainfield, New Jersey, United States of America
| | - Adam J. Schwarz
- Takeda Pharmaceutical Company Ltd, Cambridge, Massachusetts, United States of America
| | - Sub Subramony
- McKnight Brain Institute, Department of Neurology, University of Florida, Gainesville, Florida, United States of America
| | - Bert Yao
- PTC Therapeutics, Inc, South Plainfield, New Jersey, United States of America
| | - Stephen Zicha
- Takeda Pharmaceutical Company Ltd, Cambridge, Massachusetts, United States of America
| | - Christophe Lenglet
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Pierre-Gilles Henry
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, Minneapolis, Minnesota, United States of America
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Rummey C, Harding IH, Delatycki MB, Tai G, Rezende T, Corben LA. Harmonizing results of ataxia rating scales: mFARS, SARA, and ICARS. Ann Clin Transl Neurol 2022; 9:2041-2046. [PMID: 36394163 PMCID: PMC9735370 DOI: 10.1002/acn3.51686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/18/2022] Open
Abstract
The ever-increasing body of ataxia research provides opportunities for large-scale meta-analyses, systematic reviews, and data aggregation. Because multiple standardized scales are used to quantify ataxia severity, harmonization of these measures is necessary for quantitative data pooling. We applied the modified Friedreich Ataxia Rating Scale (mFARS), the Scale for the Assessment and Rating of Ataxia (SARA), and the International Cooperative Ataxia Rating Scale (ICARS) to a large cohort of people with Friedreich's ataxia. We provide regression coefficients for scale interconversion and discuss the reliability of this approach, together with insights into the differential sensitivities of mFARS and SARA to disease progression.
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Affiliation(s)
| | - Ian H. Harding
- Department of Neuroscience, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Martin B. Delatycki
- Bruce Lefroy Centre for Genetic Health ResearchMurdoch Children's Research InstituteParkville3052VictoriaAustralia,Department of PaediatricsUniversity of MelbourneParkville3052VictoriaAustralia
| | - Geneieve Tai
- Bruce Lefroy Centre for Genetic Health ResearchMurdoch Children's Research InstituteParkville3052VictoriaAustralia
| | - Thiago Rezende
- Department of NeurologyUniversity of CampinasCampinasBrazil
| | - Louise A. Corben
- Bruce Lefroy Centre for Genetic Health ResearchMurdoch Children's Research InstituteParkville3052VictoriaAustralia,Department of PaediatricsUniversity of MelbourneParkville3052VictoriaAustralia
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5
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Hohenfeld C, Terstiege U, Dogan I, Giunti P, Parkinson MH, Mariotti C, Nanetti L, Fichera M, Durr A, Ewenczyk C, Boesch S, Nachbauer W, Klopstock T, Stendel C, Rodríguez de Rivera Garrido FJ, Schöls L, Hayer SN, Klockgether T, Giordano I, Didszun C, Rai M, Pandolfo M, Rauhut H, Schulz JB, Reetz K. Prediction of the disease course in Friedreich ataxia. Sci Rep 2022; 12:19173. [PMID: 36357508 PMCID: PMC9649725 DOI: 10.1038/s41598-022-23666-z] [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: 06/15/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
We explored whether disease severity of Friedreich ataxia can be predicted using data from clinical examinations. From the database of the European Friedreich Ataxia Consortium for Translational Studies (EFACTS) data from up to five examinations of 602 patients with genetically confirmed FRDA was included. Clinical instruments and important symptoms of FRDA were identified as targets for prediction, while variables such as genetics, age of disease onset and first symptom of the disease were used as predictors. We used modelling techniques including generalised linear models, support-vector-machines and decision trees. The scale for rating and assessment of ataxia (SARA) and the activities of daily living (ADL) could be predicted with predictive errors quantified by root-mean-squared-errors (RMSE) of 6.49 and 5.83, respectively. Also, we were able to achieve reasonable performance for loss of ambulation (ROC-AUC score of 0.83). However, predictions for the SCA functional assessment (SCAFI) and presence of cardiological symptoms were difficult. In conclusion, we demonstrate that some clinical features of FRDA can be predicted with reasonable error; being a first step towards future clinical applications of predictive modelling. In contrast, targets where predictions were difficult raise the question whether there are yet unknown variables driving the clinical phenotype of FRDA.
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Affiliation(s)
- Christian Hohenfeld
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
| | - Ulrich Terstiege
- grid.1957.a0000 0001 0728 696XChair for Mathematics of Information Processing, RWTH Aachen University, 52062 Aachen, Germany
| | - Imis Dogan
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
| | - Paola Giunti
- grid.83440.3b0000000121901201Department of Clinical and Movement Neurosciences, Ataxia Centre, UCL-Queen Square Institute of Neurology, London, WC1N 3BG UK
| | - Michael H. Parkinson
- grid.83440.3b0000000121901201Department of Clinical and Movement Neurosciences, Ataxia Centre, UCL-Queen Square Institute of Neurology, London, WC1N 3BG UK
| | - Caterina Mariotti
- grid.417894.70000 0001 0707 5492Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Lorenzo Nanetti
- grid.417894.70000 0001 0707 5492Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Mario Fichera
- grid.417894.70000 0001 0707 5492Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy ,grid.7563.70000 0001 2174 1754PhD Program in Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Alexandra Durr
- grid.411439.a0000 0001 2150 9058Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP-HP, INSERM, CNRS, University Hospital Pitié-Salpêtrière, 75646 Paris, France
| | - Claire Ewenczyk
- grid.411439.a0000 0001 2150 9058Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), AP-HP, INSERM, CNRS, University Hospital Pitié-Salpêtrière, 75646 Paris, France
| | - Sylvia Boesch
- grid.5361.10000 0000 8853 2677Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Wolfgang Nachbauer
- grid.5361.10000 0000 8853 2677Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Thomas Klopstock
- grid.5252.00000 0004 1936 973XDepartment of Neurology, Friedrich Baur Institute, University Hospital, LMU, 80336 Munich, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 81377 Munich, Germany ,grid.452617.3Munich Cluster for Systems Neurology (SyNergy), 81377 Munich, Germany
| | - Claudia Stendel
- grid.5252.00000 0004 1936 973XDepartment of Neurology, Friedrich Baur Institute, University Hospital, LMU, 80336 Munich, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 81377 Munich, Germany
| | | | - Ludger Schöls
- grid.10392.390000 0001 2190 1447Department of Neurology and Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076 Tübingen, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 72076 Tübingen, Germany
| | - Stefanie N. Hayer
- grid.10392.390000 0001 2190 1447Department of Neurology and Hertie-Institute for Clinical Brain Research, University of Tübingen, 72076 Tübingen, Germany
| | - Thomas Klockgether
- grid.15090.3d0000 0000 8786 803XDepartment of Neurology, University Hospital of Bonn, 53127 Bonn, Germany ,grid.424247.30000 0004 0438 0426German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
| | - Ilaria Giordano
- grid.15090.3d0000 0000 8786 803XDepartment of Neurology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Claire Didszun
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany
| | - Myriam Rai
- grid.4989.c0000 0001 2348 0746Laboratory of Experimental Neurology, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Massimo Pandolfo
- grid.4989.c0000 0001 2348 0746Laboratory of Experimental Neurology, Université Libre de Bruxelles, 1070 Brussels, Belgium ,grid.14709.3b0000 0004 1936 8649Department of Neurology and Neurosurgery, McGill University, Montreal, QC H3A 0G4 Canada
| | - Holger Rauhut
- grid.1957.a0000 0001 0728 696XChair for Mathematics of Information Processing, RWTH Aachen University, 52062 Aachen, Germany
| | - Jörg B. Schulz
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
| | - Kathrin Reetz
- grid.1957.a0000 0001 0728 696XDepartment of Neurology, RWTH Aachen University, 52074 Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA Brain Institute Molecular Neuroscience and Neuroimaging, Research Centre Jülich and RWTH Aachen University, 52056 Aachen, Germany
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Dunn J, Tamaroff J, DeDio A, Nguyen S, Wade K, Cilenti N, Weber DR, Lynch DR, McCormack SE. Bone Mineral Density and Current Bone Health Screening Practices in Friedreich's Ataxia. Front Neurosci 2022; 16:818750. [PMID: 35368287 PMCID: PMC8964400 DOI: 10.3389/fnins.2022.818750] [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: 11/19/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Friedreich's Ataxia (FRDA) is a progressive neurological disorder caused by mutations in both alleles of the frataxin (FXN) gene. Impaired bone health is a complication of other disorders affecting mobility, but there is little information regarding bone health in FRDA. Methods Dual energy X-ray absorptiometry (DXA) scan-based assessments of areal bone mineral density (aBMD) in individuals with FRDA were abstracted from four studies at the Children's Hospital of Philadelphia (CHOP). Disease outcomes, including the modified FRDA Rating Scale (mFARS), were abstracted from the FRDA Clinical Outcomes Measures Study (FACOMS), a longitudinal natural history study. A survey regarding bone health and fractures was sent to individuals in FACOMS-CHOP. Results Adults with FRDA (n = 24) have lower mean whole body (WB) (-0.45 vs. 0.33, p = 0.008) and femoral neck (FN) (-0.71 vs. 0.004, p = 0.02) aBMD Z-scores than healthy controls (n = 24). Children with FRDA (n = 10) have a lower WB-less-head (-2.2 vs. 0.19, p < 0.0001) and FN (-1.1 vs. 0.04, p = 0.01) aBMD than a reference population (n = 30). In adults, lower FN aBMD correlated with functional disease severity, as reflected by mFARS (R = -0.56, p = 0.04). Of 137 survey respondents (median age 27 y, 50% female), 70 (51%) reported using wheelchairs as their primary ambulatory device: of these, 20 (29%) reported a history of potentially pathologic fracture and 11 (16%) had undergone DXA scans. Conclusions Low aBMD is prevalent in FRDA, but few of even the highest risk individuals are undergoing screening. Our findings highlight potential missed opportunities for the screening and treatment of low aBMD in FRDA.
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Affiliation(s)
- Julia Dunn
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jaclyn Tamaroff
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Ian M. Burr Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Anna DeDio
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sara Nguyen
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kristin Wade
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicolette Cilenti
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - David R Weber
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - David R Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Shana E McCormack
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Tamaroff J, DeDio A, Wade K, Wells M, Park C, Leavens K, Rummey C, Kelly A, Lynch DR, McCormack SE. Friedreich's Ataxia related Diabetes: Epidemiology and management practices. Diabetes Res Clin Pract 2022; 186:109828. [PMID: 35301072 PMCID: PMC9075677 DOI: 10.1016/j.diabres.2022.109828] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 01/21/2023]
Abstract
AIMS Friedreich's Ataxia (FRDA) is a progressive neuromuscular disorder typically caused by GAA triplet repeat expansions in both frataxin gene alleles. FRDA can be complicated by diabetes mellitus (DM). The objective of this study was to describe the prevalence of, risk factors for, and management practices of FRDA-related DM. METHODS FACOMS, a prospective, multi-site natural history study, includes 1,104 individuals. Extracted data included the presence of DM and other co-morbidities, genetic diagnosis, and markers of disease severity. We performed detailed medical record review and a survey for the subset of individuals with FRDA-related DM followed at one FACOMS site, Children's Hospital of Philadelphia. RESULTS FRDA-related DM was reported by 8.7% of individuals. Age, severe disease, and FRDA cardiac complications were positively associated with DM risk. FRDA-related DM was generally well-controlled, as reflected by HbA1c, though diabetic ketoacidosis did occur. Insulin is the mainstay of treatment (64-74% overall); in adults, metformin use was common and newer glucose-lowering agents were used rarely. CONCLUSIONS Clinical factors identify individuals at increased risk for FRDA-related DM. Future studies should test strategies for FRDA-related DM screening and management, in particular the potential role for novel glucose-lowering therapies in preventing or delaying FRDA-related cardiac disease.
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Affiliation(s)
- Jaclyn Tamaroff
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Anna DeDio
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kristin Wade
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - McKenzie Wells
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Courtney Park
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karla Leavens
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David R Lynch
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shana E McCormack
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Recessive cerebellar and afferent ataxias - clinical challenges and future directions. Nat Rev Neurol 2022; 18:257-272. [PMID: 35332317 DOI: 10.1038/s41582-022-00634-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 02/07/2023]
Abstract
Cerebellar and afferent ataxias present with a characteristic gait disorder that reflects cerebellar motor dysfunction and sensory loss. These disorders are a diagnostic challenge for clinicians because of the large number of acquired and inherited diseases that cause cerebellar and sensory neuron damage. Among such conditions that are recessively inherited, Friedreich ataxia and RFC1-associated cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) include the characteristic clinical, neuropathological and imaging features of ganglionopathies, a distinctive non-length-dependent type of sensory involvement. In this Review, we discuss the typical and atypical phenotypes of Friedreich ataxia and CANVAS, along with the features of other recessive ataxias that present with a ganglionopathy or polyneuropathy, with an emphasis on recently described clinical features, natural history and genotype-phenotype correlations. We review the main developments in understanding the complex pathology that affects the sensory neurons and cerebellum, which seem to be most vulnerable to disorders that affect mitochondrial function and DNA repair mechanisms. Finally, we discuss disease-modifying therapeutic advances in Friedreich ataxia, highlighting the most promising candidate molecules and lessons learned from previous clinical trials.
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Abstract
INTRODUCTION Friedreich ataxia (FRDA) is an autosomal recessive disorder caused by deficiency of frataxin, an essential mitochondrial protein involved in iron sulfur cluster biogenesis, oxidative phosphorylation and other processes. FRDA most notably affects the heart, sensory neurons, spinal cord, cerebellum, and other brain regions, and manifests clinically as ataxia, sensory loss, dysarthria, spasticity, and hypertrophic cardiomyopathy. Therapeutic approaches in FRDA have consisted of two different approaches: (1) augmenting or restoring frataxin production and (2) modulating a variety of downstream processes related to mitochondrial dysfunction, including reactive oxygen species production, ferroptosis, or Nrf2 activation. AREAS COVERED In this review, we summarize data from major phase II clinical trials in FRDA published between 2015 and 2020, which includes A0001/EPI743, Omaveloxolone, RT001, and Actimmune. EXPERT OPINION A growing number of drug candidates are being tested in phase II clinical trials for FRDA; however, most have not met their primary endpoints, and none have received FDA approval. In this review, we aim to summarize completed phase II clinical trials in FRDA, outlining critical lessons that have been learned and that should be incorporated into future trial design to ultimately optimize drug development in FRDA.
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Mueller A, Paterson E, McIntosh A, Praestgaard J, Bylo M, Hoefling H, Wells M, Lynch DR, Rummey C, Krishnan ML, Schultz M, Malanga CJ. Digital endpoints for self-administered home-based functional assessment in pediatric Friedreich's ataxia. Ann Clin Transl Neurol 2021; 8:1845-1856. [PMID: 34355532 PMCID: PMC8419399 DOI: 10.1002/acn3.51438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/18/2023] Open
Abstract
Background Friedreich’s ataxia is an inherited, progressive, neurodegenerative disease that typically begins in childhood. Disease severity is commonly assessed with rating scales, such as the modified Friedreich’s Ataxia Rating Scale, which are usually administered in the clinic by a neurology specialist. Objective This study evaluated the utility of home‐based, self‐administered digital endpoints in children with Friedreich’s ataxia and unaffected controls and their relationship to standard clinical rating scales. Methods In a cross‐sectional study with 25 participants (13 with Friedreich’s ataxia and 12 unaffected controls, aged 6–15 years), home‐based digital endpoints that reflect activities of daily living were recorded over 1 week. Domains analyzed were hand motor function with a digitized drawing, automated analysis of speech with a recorded oral diadochokinesis test, and gait and balance with wearable sensors. Results Hand‐drawing and speech tests were easy to conduct and generated high‐quality data. The sensor‐based gait and balance tests suffered from technical limitations in this study setup. Several parameters discriminated between groups or correlated strongly with modified Friedreich’s Ataxia Rating Scale total score and activities of daily living total score in the Friedreich’s ataxia group. Hand‐drawing parameters also strongly correlated with standard 9‐hole peg test scores. Interpretation Deploying digital endpoints in home settings is feasible in this population, results in meaningful and robust data collection, and may allow for frequent sampling over longer periods of time to track disease progression. Care must be taken when training participants, and investigators should consider the complexity of the tasks and equipment used.
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Affiliation(s)
- Arne Mueller
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Elaine Paterson
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | | | | | - Mary Bylo
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - Holger Hoefling
- NIBR Informatics, Novartis Institute of Biomedical Research, Basel, Switzerland
| | - McKenzie Wells
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - David R Lynch
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Michelle L Krishnan
- Translational Medicine, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Meredith Schultz
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - C J Malanga
- Translational Medicine, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
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Tai G, Corben LA, Woodcock IR, Yiu EM, Delatycki MB. Determining the Validity of Conducting Rating Scales in Friedreich Ataxia through Video. Mov Disord Clin Pract 2021; 8:688-693. [PMID: 34307740 DOI: 10.1002/mdc3.13204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/26/2022] Open
Abstract
Background The Friedreich Ataxia Rating Scale (FARS) and the Scale for the Assessment and Rating of Ataxia (SARA) are commonly used neurological rating scales in Friedreich ataxia (FRDA). The modified Friedreich Ataxia Rating Scale (mFARS) has been accepted as an appropriate outcome measure for clinical trials in FRDA. Objectives The COVID-19 pandemic has resulted in limited face-to-face interactions with individuals involved in natural history studies and clinical trials. The aim of this study was to determine the validity of conducting the mFARS and SARA through video. Methods Individuals who had the mFARS administered face-to-face in the previous 6 months were invited to participate. Participants were sent instructions and asked to have a carer present to assist. The mFARS and SARA were then administered by video. Differences between face-to-face and video scores and the reliability between scores obtained face-to-face and by video were examined. Results The mFARS and SARA were conducted by video with 19 individuals. Excellent test-retest reliability was seen in the mFARS lower limb coordination (ICC = 0.96, 95% CI 0.90-0.98) and upright stability sections (ICC = 0.97, 95% CI 0.93-0.99), total mFARS (ICC = 0.97, 95% CI 0.92-0.99) and SARA scores (ICC = 0.98, 95% CI 0.95-0.99). Conclusions Excellent test-retest reliability was demonstrated in the majority of the mFARS sections, and in the total mFARS and SARA scores, suggesting that video is a valid method of conducting these scales. This method enables inclusion of participants who are unable to travel to study sites. A larger cohort will be required to further validate the use of video mFARS and SARA for future studies.
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Affiliation(s)
- Geneieve Tai
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia
| | - Louise A Corben
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Parkville Victoria Australia.,School of Psychological Sciences Monash University Clayton Victoria Australia
| | - Ian R Woodcock
- Department of Paediatrics University of Melbourne Parkville Victoria Australia.,Department of Neurology Royal Children's Hospital Parkville Victoria Australia.,Division of Neuroscience Murdoch Children's Research Institute Parkville Victoria Australia
| | - Eppie M Yiu
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Parkville Victoria Australia.,Department of Neurology Royal Children's Hospital Parkville Victoria Australia.,Division of Neuroscience Murdoch Children's Research Institute Parkville Victoria Australia
| | - Martin B Delatycki
- Bruce Lefroy Centre for Genetic Health Research Murdoch Children's Research Institute Parkville Victoria Australia.,Department of Paediatrics University of Melbourne Parkville Victoria Australia.,School of Psychological Sciences Monash University Clayton Victoria Australia.,Victorian Clinical Genetics Service Parkville Victoria Australia
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