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Yang EC, Fang Z, Tan R, Guo Y, He S, Kruger E, Nedzesky J, Marsden D. Clinical manifestations, healthcare resource utilization, and costs among patients with long-chain fatty acid oxidation disorders: a retrospective claims database analysis. Curr Med Res Opin 2024:1-40. [PMID: 39291999 DOI: 10.1080/03007995.2024.2405124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 09/12/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare genetic inborn errors of metabolism. Clinical manifestations may result in frequent healthcare visits, hospitalizations, and early death. This retrospective cohort study assessed manifestations, healthcare resource use (HRU), direct medical costs, and the impact of COVID-19 on HRU among patients with LC-FAOD. METHODS The IQVIA PharMetrics Plus database was searched for pediatric (0-17 years) and adult (≥18 years) patients with confirmed LC-FAOD (ICD-10-CM Diagnosis Code E71.310) and ≥12 months continuous enrollment (CE) between January 2016-February 2020. A non-LC-FAOD general population cohort was randomly selected and matched using 1:20 exact matching on age, gender, payer type, and CE start year. Manifestations were identified via ICD-10 diagnosis codes (any billing position). Overall HRU and attributable costs were stratified by care setting. Pre-COVID-19 (March 2019-February 2020) and during COVID-19 (March 2020-February 2021) HRU was assessed among a subgroup of patients and the general population. Outcomes were evaluated among children and adults, respectively. RESULTS 423 patients with LC-FAOD (47% female; 79.7% children) were included. Mean enrollment duration was 2.6 ± 1.2 years. 22.6% of children with LC-FAOD had at least one major clinical event (MCE), consisting of rhabdomyolysis (10.1%), hypoglycemia (9.8%), or cardiomyopathy (8.6%) versus 1.5% overall occurrence in the general population. Adults with LC-FAOD had higher incidence of MCEs (37.2%) than children with LC-FAOD. Annualized all-cause HRU in all care settings and mean total annualized medical costs (children: $17,082 vs $4,144; adults: $43,602 vs $3,949) were higher in patients with LC-FAOD versus the general population. Patients with LC-FAOD had substantially fewer healthcare visits during COVID-19 across care settings than during the pre-COVID-19 period. CONCLUSIONS LC-FAOD impart a high burden on patients. Extended hospital stays and increased outpatient management were especially pronounced for adults and for patients with ≥1 MCE, resulting in substantially higher medical costs than the general population.
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Affiliation(s)
| | - Zhenzhen Fang
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
| | - Ruixin Tan
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
| | - Yun Guo
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
| | - Siyi He
- Tianjin Happy Life Technology Co., Ltd, Beijing, China
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De Giorgis V, Bhatia KP, Boespflug-Tanguy O, Gras D, Marina AD, Desurkar A, Toledo M, Miller I, Rotstein M, Schneider SA, Tarquinio DC, Weber Y, Brandabur M, Mayhew J, Koutsoukos T, De Vivo DC. Triheptanoin Did Not Show Benefit versus Placebo for the Treatment of Paroxysmal Movement Disorders in Glut1 Deficiency Syndrome: Results of a Randomized Phase 3 Study. Mov Disord 2024; 39:1386-1396. [PMID: 38725190 DOI: 10.1002/mds.29822] [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: 02/14/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Paroxysmal movement disorders are common in Glut1 deficiency syndrome (Glut1DS). Not all patients respond to or tolerate ketogenic diets. OBJECTIVES The objective was to evaluate the effectiveness and safety of triheptanoin in reducing the frequency of disabling movement disorders in patients with Glut1DS not receiving a ketogenic diet. METHODS UX007G-CL301 was a randomized, double-blind, placebo-controlled, phase 3 crossover study. After a 6-week run-in, eligible patients were randomized 1:1 to the first sequence (triheptanoin/placebo or placebo/triheptanoin) titration plus maintenance, followed by washout and the opposite sequence titration plus maintenance. The placebo (safflower oil) matched the appearance, taste, and smell of triheptanoin. Open-label triheptanoin was administered in the extension. The frequency of disabling paroxysmal movement disorder events per 4 weeks (recorded by diary during maintenance; primary endpoint) was assessed by Wilcoxon rank-sum test. RESULTS Forty-three patients (children, n = 16; adults, n = 27) were randomized and treated. There was no difference between triheptanoin and placebo in the mean (interquartile range) number of disabling paroxysmal movement disorder events (14.3 [4.7-38.3] vs. 11.8; [3.2-28.7]; Hodges-Lehmann estimated median difference: 1.46; 95% confidence interval, -1.12 to 4.36; P = 0.2684). Treatment-emergent adverse events were mild/moderate in severity and included diarrhea, vomiting, upper abdominal pain, headache, and nausea. Two patients discontinued the study because of non-serious adverse events that were predominantly gastrointestinal. The study was closed early during the open-label extension because of lack of effectiveness. Seven patients continued to receive triheptanoin compassionately. CONCLUSION There were no significant differences between the triheptanoin and placebo groups in the frequency of disabling movement disorder events during the double-blind maintenance period. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Odile Boespflug-Tanguy
- Service de Neurologie Pédiatrique, Centre de Référence Leucodystrophies et Leucoencephalopathies de Cause Rare (LEUKOFRANCE), APHP Robert-Debré, Paris, France
| | - Domitille Gras
- Service de Neurologie Pédiatrique, Centre de Référence Leucodystrophies et Leucoencephalopathies de Cause Rare (LEUKOFRANCE), APHP Robert-Debré, Paris, France
| | - Adela Della Marina
- Department of Pediatric Neurology, Centre for Neuromuscular Disorders, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Archana Desurkar
- Neurology Department, Sheffield Children's National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Ian Miller
- Department of Neurology and Comprehensive Epilepsy Program, Brain Institute, Miami Children's Hospital, Miami, Florida, USA
| | - Michael Rotstein
- Pediatric Movement Disorders Service, The Pediatric Neurology Unite and Child Development Center, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Susanne A Schneider
- Department of Neurology, Ludwig-Maximilians-University of München, Munich, Germany
| | | | - Yvonne Weber
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Section of Epileptology, Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Jill Mayhew
- Ultragenyx Pharmaceutical Inc., Novato, California, USA
| | | | - Darryl C De Vivo
- Department of Neurology and Pediatrics, Columbia University, New York, New York, USA
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3
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Yang E, Kruger E, Yin D, Mace K, Tierney M, Liao N, Cibelli E, Drozd D, Ross N, Deering KL, Herout P, Harshaw Q, Shillington A, Thomas N, Marsden D, Kritzer A, Vockley J. Major clinical events and healthcare resource use among patients with long-chain fatty acid oxidation disorders in the United States: Results from LC-FAOD Odyssey program. Mol Genet Metab 2024; 142:108350. [PMID: 38458123 DOI: 10.1016/j.ymgme.2024.108350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Major clinical events (MCEs) related to long-chain fatty acid oxidation disorders (LC-FAOD) in triheptanoin clinical trials include inpatient or emergency room (ER) visits for three major clinical manifestations: rhabdomyolysis, hypoglycemia, and cardiomyopathy. However, outcomes data outside of LC-FAOD clinical trials are limited. The non-interventional cohort LC-FAOD Odyssey study examines data derived from US medical records and patient reported outcomes to quantify LC-FAOD burden according to management strategy including MCE frequency and healthcare resource utilization (HRU). Thirty-four patients were analyzed of which 21 and 29 patients had received triheptanoin and/or medium chain triglycerides (MCT), respectively. 36% experienced MCEs while receiving triheptanoin versus 54% on MCT. Total mean annualized MCE rates on triheptanoin and MCT were 0.1 and 0.7, respectively. Annualized disease-related inpatient and ER events were lower on triheptanoin (0.2, 0.3, respectively) than MCT (1.2, 1.0, respectively). Patients were managed more in an outpatient setting on triheptanoin (8.9 annualized outpatient visits) vs MCT (7.9). Overall, this shows that those with LC-FAOD in the Odyssey program experienced fewer MCEs and less HRU in inpatient and ER settings during triheptanoin-treated periods compared with the MCT-treated periods. The MCE rate was lower after initiation of triheptanoin, consistent with clinical trials.
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Affiliation(s)
- Erru Yang
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA.
| | | | - David Yin
- PicnicHealth, San Francisco, CA, USA
| | | | | | | | | | - Dan Drozd
- PicnicHealth, San Francisco, CA, USA
| | | | | | | | | | | | - Nina Thomas
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
| | | | - Amy Kritzer
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Jerry Vockley
- Division of Medical Genetics and Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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4
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Karunanidhi A, Basu S, Zhao XJ, D'Annibale O, Van't Land C, Vockley J, Mohsen AW. Heptanoic and medium branched-chain fatty acids as anaplerotic treatment for medium chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab 2023; 140:107689. [PMID: 37660571 PMCID: PMC10840664 DOI: 10.1016/j.ymgme.2023.107689] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
Triheptanoin (triheptanoylglycerol) has shown value as anaplerotic therapy for patients with long chain fatty acid oxidation disorders but is contraindicated in medium-chain acyl-CoA dehydrogenase (MCAD) deficiency. In search for anaplerotic therapy for patients with MCAD deficiency, fibroblasts from three patients homozygous for the most common mutation, ACADMG985A/G985A, were treated with fatty acids hypothesized not to require MCAD for their metabolism, including heptanoic (C7; the active component of triheptanoin), 2,6-dimethylheptanoic (dMC7), 6-amino-2,4-dimethylheptanoic (AdMC7), or 4,8-dimethylnonanoic (dMC9) acids. Their effectiveness as anaplerotic fatty acids was assessed in live cells by monitoring changes in cellular oxygen consumption rate (OCR) and mitochondrial protein lysine succinylation, which reflects cellular succinyl-CoA levels, using immunofluorescence (IF) staining. Krebs cycle intermediates were also quantitated in these cells using targeted metabolomics. The four fatty acids induced positive changes in OCR parameters, consistent with their oxidative catalysis and utilization. Increases in cellular IF staining of succinylated lysines were observed, indicating that the fatty acids were effective sources of succinyl-CoA in the absence of media glucose, pyruvate, and lipids. The ability of MCAD deficient cells to metabolize C7 was confirmed by the ability of extracts to enzymatically utilize C7-CoA as substrate but not C8-CoA. To evaluate C7 therapeutic potential in vivo, Acadm-/- mice were treated with triheptanoin for seven days. Dose dependent increase in plasma levels of heptanoyl-, valeryl-, and propionylcarnitine indicated efficient metabolism of the medication. The pattern of the acylcarnitine profile paralleled resolution of liver pathology including reversing hepatic steatosis, increasing hepatic glycogen content, and increasing hepatocyte protein succinylation, all indicating improved energy homeostasis in the treated mice. These results provide the impetus to evaluate triheptanoin and the medium branched chain fatty acids as potential therapeutic agents for patients with MCAD deficiency.
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Affiliation(s)
- Anuradha Karunanidhi
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Shakuntala Basu
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Xue-Jun Zhao
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Olivia D'Annibale
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA; Department of Human Genetics, School of Public Health, University of Pittsburgh; Pittsburgh, PA 15260, USA
| | - Clinton Van't Land
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA; Department of Human Genetics, School of Public Health, University of Pittsburgh; Pittsburgh, PA 15260, USA
| | - Al-Walid Mohsen
- Division of Genetic and Genomic Medicine, Department of Pediatrics, School of Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh; Pittsburgh, PA 15224, USA; Department of Human Genetics, School of Public Health, University of Pittsburgh; Pittsburgh, PA 15260, USA.
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5
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Vockley J, Burton BK, Berry G, Longo N, Phillips J, Sanchez-Valle A, Chapman KA, Tanpaiboon P, Grunewald S, Murphy E, Lu X, Rahman S, Ray K, Reineking B, Pisani L, Ramirez AN. Triheptanoin for the treatment of long-chain fatty acid oxidation disorders: Final results of an open-label, long-term extension study. J Inherit Metab Dis 2023; 46:943-955. [PMID: 37276053 DOI: 10.1002/jimd.12640] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) result in life-threatening energy metabolism deficiencies/energy source depletion. Triheptanoin is an odd-carbon, medium chain triglyceride (that is an anaplerotic substrate of calories and fatty acids) for treating pediatric and adult patients with LC-FAODs. Study CL202 (NCT02214160), an open-label extension study of study CL201 (NCT01886378), evaluated the long-term safety/efficacy of triheptanoin in patients with LC-FAODs (N = 94), including cohorts who were triheptanoin naïve (n = 33) or had received triheptanoin in study CL201 (n = 24) or in investigator-sponsored trials/expanded access programs (IST/EAPs; n = 37). Primary endpoint was the annualized rate of LC-FAOD major clinical events (MCEs; rhabdomyolysis, hypoglycemia, cardiomyopathy). Mean ± standard deviation (SD) triheptanoin treatment durations were 27.4 ± 19.9, 46.9 ± 13.6, and 49.6 ± 21.4 months for the triheptanoin-naïve, CL201 rollover, and IST/EAP cohorts, respectively. In the triheptanoin-naïve cohort, median (interquartile range [IQR]) MCE rate significantly decreased from 2.00 (0.67-3.33) events/patient/year pre-triheptanoin to 0.28 (0.00-1.43) events/patient/year with triheptanoin (p = 0.0343), a reduction of 86%. In the CL201 rollover cohort, mean ± SD MCE rate significantly decreased from 1.76 ± 1.64 events/patient/year pre-triheptanoin to 1.00 ± 1.00 events/patient/year with triheptanoin (p = 0.0347), a reduction of 43%. In the IST/EAP cohort, mean ± SD MCE rate was 1.40 ± 2.37 (median [IQR] 0.57 [0.00-1.67]) events/patient/year with triheptanoin. Safety data were consistent with previous observations. Treatment-related treatment-emergent adverse events (TEAEs) occurred in 68.1% of patients and were mostly mild/moderate in severity. Five patients had seven serious treatment-related TEAEs; all resolved. Our results confirm the long-term efficacy of triheptanoin for patients with LC-FAOD.
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Affiliation(s)
- Jerry Vockley
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Barbara K Burton
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Gerard Berry
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicola Longo
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - John Phillips
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amarilis Sanchez-Valle
- Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Kimberly A Chapman
- Section Genetics and Metabolism, Children's National Health System, Washington, District of Columbia, USA
| | - Pranoot Tanpaiboon
- Section Genetics and Metabolism, Children's National Health System, Washington, District of Columbia, USA
| | - Stephanie Grunewald
- Metabolic Unit, Great Ormond Street Hospital and UCL Institute of Child Health NIHR BRC, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | - Syeda Rahman
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | - Kathryn Ray
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
| | | | - Laura Pisani
- Ultragenyx Pharmaceutical Inc, Novato, California, USA
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6
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Vockley J, Burton B, Jurecka A, Ganju J, Leiro B, Zori R, Longo N. Challenges and strategies for clinical trials in propionic and methylmalonic acidemias. Mol Genet Metab 2023; 139:107612. [PMID: 37245378 DOI: 10.1016/j.ymgme.2023.107612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 05/30/2023]
Abstract
Clinical trial development in rare diseases poses significant study design and methodology challenges, such as disease heterogeneity and appropriate patient selection, identification and selection of key endpoints, decisions on study duration, choice of control groups, selection of appropriate statistical analyses, and patient recruitment. Therapeutic development in organic acidemias (OAs) shares many challenges with other inborn errors of metabolism, such as incomplete understanding of natural history, heterogenous disease presentations, requirement for sensitive outcome measures and difficulties recruiting a small sample of participants. Here, we review strategies for the successful development of a clinical trial to evaluate treatment response in propionic and methylmalonic acidemias. Specifically, we discuss crucial decisions that may significantly impact success of the study, including patient selection, identification and selection of endpoints, determination of the study duration, consideration of control groups including natural history controls, and selection of appropriate statistical analyses. The significant challenges associated with designing a clinical trial in rare disease can sometimes be successfully met through strategic engagement with experts in the rare disease, seeking regulatory and biostatistical guidance, and early involvement of patients and families.
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Affiliation(s)
- Jerry Vockley
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh, School of Medicine, Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Barbara Burton
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Agnieszka Jurecka
- CoA Therapeutics, Inc., a BridgeBio company, San Francisco, CA, USA.
| | - Jitendra Ganju
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Beth Leiro
- Independent Consultant to BridgeBio, San Francisco, CA, USA
| | - Roberto Zori
- Department of Pediatrics, Division of Genetics and Metabolism, University of Florida, Gainesville, FL, USA
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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7
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Bianchi M, Rossi L, Pierigè F, Biagiotti S, Bregalda A, Tasini F, Magnani M. Preclinical and clinical developments in enzyme-loaded red blood cells: an update. Expert Opin Drug Deliv 2023; 20:921-935. [PMID: 37249524 DOI: 10.1080/17425247.2023.2219890] [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: 02/01/2023] [Accepted: 05/26/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION We have previously described the preclinical developments in enzyme-loaded red blood cells to be used in the treatment of several rare diseases, as well as in chronic conditions. AREA COVERED Since our previous publication we have seen further progress in the previously discussed approaches and, interestingly enough, in additional new studies that further strengthen the idea that red blood cell-based therapeutics may have unique advantages over conventional enzyme replacement therapies in terms of efficacy and safety. Here we highlight these investigations and compare, when possible, the reported results versus the current therapeutic approaches. EXPERT OPINION The continuous increase in the number of new potential applications and the progress from the encapsulation of a single enzyme to the engineering of an entire metabolic pathway open the field to unexpected developments and confirm the role of red blood cells as cellular bioreactors that can be conveniently manipulated to acquire useful therapeutic metabolic abilities. Positioning of these new approaches versus newly approved drugs is essential for the successful transition of this technology from the preclinical to the clinical stage and hopefully to final approval.
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Affiliation(s)
- Marzia Bianchi
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Luigia Rossi
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
- EryDel SpA, Bresso, MI, Italy
| | - Francesca Pierigè
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Sara Biagiotti
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Alessandro Bregalda
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Filippo Tasini
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
| | - Mauro Magnani
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, Urbino, Italy
- EryDel SpA, Bresso, MI, Italy
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8
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Lasio MLD, Leshinski AC, Ducich NH, Flore LA, Lehman A, Shur N, Jayakar PB, Hainline BE, Basinger AA, Wilson WG, Diaz GA, Erbe RW, Koeberl DD, Vockley J, Bedoyan JK. Clinical, biochemical and molecular characterization of 12 patients with pyruvate carboxylase deficiency treated with triheptanoin. Mol Genet Metab 2023; 139:107605. [PMID: 37207470 PMCID: PMC10330474 DOI: 10.1016/j.ymgme.2023.107605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/21/2023]
Abstract
Pyruvate carboxylase (PC) deficiency is a rare autosomal recessive mitochondrial neurometabolic disorder of energy deficit resulting in high morbidity and mortality, with limited therapeutic options. The PC homotetramer has a critical role in gluconeogenesis, anaplerosis, neurotransmitter synthesis, and lipogenesis. The main biochemical and clinical findings in PC deficiency (PCD) include lactic acidosis, ketonuria, failure to thrive, and neurological dysfunction. Use of the anaplerotic agent triheptanoin on a limited number of individuals with PCD has had mixed results. We expand on the potential utility of triheptanoin in PCD by examining the clinical, biochemical, molecular, and health-related quality-of-life (HRQoL) findings in a cohort of 12 individuals with PCD (eight with Type A and two each with Types B and C) treated with triheptanoin ranging for 6 days to about 7 years. The main endpoints were changes in blood lactate and HRQoL scores, but collection of useful data was limited to about half of subjects. An overall trend of lactate reduction with time on triheptanoin was noted, but with significant variability among subjects and only one subject reaching close to statistical significance for this endpoint. Parent reported HRQoL assessments with treatment showed mixed results, with some subjects showing no change, some improvement, and some worsening of overall scores. Subjects with buried amino acids in the pyruvate carboxyltransferase domain of PC that undergo destabilizing replacements may be more likely to respond (with lactate reduction or HRQoL improvement) to triheptanoin compared to those with replacements that disrupt tetramerization or subunit-subunit interface contacts. The reason for this difference is unclear and requires further validation. We observed significant variability but an overall trend of lactate reduction with time on triheptanoin and mixed parent reported outcome changes by HRQoL assessments for subjects with PCD on long-term triheptanoin. The mixed results noted with triheptanoin therapy in this study could be due to endpoint data limitation, variability of disease severity between subjects, limitation of the parent reported HRQoL tool, or subject genotype variability. Alternative designed trials and more study subjects with PCD will be needed to validate important observations from this work.
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Affiliation(s)
- M Laura Duque Lasio
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Angela C Leshinski
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nicole H Ducich
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Leigh Anne Flore
- Division of Genetic, Genomic and Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI and Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - April Lehman
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Genetic, Genomic and Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI and Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - Natasha Shur
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, DC, USA
| | - Parul B Jayakar
- Division of Genetics and Metabolism, Nicklaus Children's Hospital, Miami, FL, USA
| | - Bryan E Hainline
- Department of Medical and Molecular Genetics, Riley Hospital at Indiana University Health, Indianapolis, IN, USA
| | | | - William G Wilson
- Department of Pediatrics, University of Virginia Health, Charlottesville, VA, USA
| | - George A Diaz
- Division of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard W Erbe
- Departments of Pediatrics and Medicine, University at Buffalo, Buffalo, NY, USA
| | - Dwight D Koeberl
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Jirair K Bedoyan
- Division of Genetic and Genomic Medicine, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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9
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Successful management of rhabdomyolysis with triheptanoin in a child with severe long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency. Neuromuscul Disord 2023; 33:315-318. [PMID: 36893607 DOI: 10.1016/j.nmd.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/04/2023] [Accepted: 02/15/2023] [Indexed: 02/21/2023]
Abstract
Early-onset long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency is a fatty acid β-oxidation disorder with a poor prognosis. Triheptanoin, an anaplerotic oil with odd-chain fatty acids can improve the disease course. The female patient presented here was diagnosed at the age of 4 months, and treatment was started as fat restriction, frequent feeding, and standard medium-chain triglyceride supplementation. In follow-up, she had frequent rhabdomyolysis episodes (∼8 per year). At the age of six, she had 13 episodes in 6 months, and triheptanoin was started as part of a compassionate use program. Following unrelated hospital stays due to multisystem inflammatory syndrome in children and a bloodstream infection, she had only 3 rhabdomyolysis episodes, and hospitalized days decreased from 73 to 11 during her first year with triheptanoin. Triheptanoin drastically decreased the frequency and severity of rhabdomyolysis, but progression of retinopathy was not altered.
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10
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Lund M, Heaton R, Hargreaves IP, Gregersen N, Olsen RKJ. Odd- and even-numbered medium-chained fatty acids protect against glutathione depletion in very long-chain acyl-CoA dehydrogenase deficiency. Biochim Biophys Acta Mol Cell Biol Lipids 2023; 1868:159248. [PMID: 36356723 DOI: 10.1016/j.bbalip.2022.159248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 10/09/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022]
Abstract
Recent trials have reported the ability of triheptanoin to improve clinical outcomes for the severe symptoms associated with long-chain fatty acid oxidation disorders, including very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. However, the milder myopathic symptoms are still challenging to treat satisfactorily. Myopathic pathogenesis is multifactorial, but oxidative stress is an important component. We have previously shown that metabolic stress increases the oxidative burden in VLCAD-deficient cell lines and can deplete the antioxidant glutathione (GSH). We investigated whether medium-chain fatty acids provide protection against GSH depletion during metabolic stress in VLCAD-deficient fibroblasts. To investigate the effect of differences in anaplerotic capacity, we included both even-(octanoate) and odd-numbered (heptanoate) medium-chain fatty acids. Overall, we show that modulation of the concentration of medium-chain fatty acids in culture media affects levels of GSH retained during metabolic stress in VLCAD-deficient cell lines but not in controls. Lowered glutamine concentration in the culture media during metabolic stress led to GSH depletion and decreased viability in VLCAD deficient cells, which could be rescued by both heptanoate and octanoate in a dose-dependent manner. Unlike GSH levels, the levels of total thiols increased after metabolic stress exposure, the size of this increase was not affected by differences in cell culture medium concentrations of glutamine, heptanoate or octanoate. Addition of a PPAR agonist further exacerbated stress-related GSH-depletion and viability loss, requiring higher concentrations of fatty acids to restore GSH levels and cell viability. Both odd- and even-numbered medium-chain fatty acids efficiently protect VLCADdeficient cells against metabolic stress-induced antioxidant depletion.
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Affiliation(s)
- Martin Lund
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus, Denmark.
| | - Robert Heaton
- School of Pharmacy, Liverpool John Moore University, Byrom Street, Liverpool L3 3AF, United Kingdom
| | - Iain P Hargreaves
- School of Pharmacy, Liverpool John Moore University, Byrom Street, Liverpool L3 3AF, United Kingdom
| | - Niels Gregersen
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Rikke K J Olsen
- Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus, Denmark.
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11
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Lee SK, Gosselin NH, Jomphe C, McKeever K, Putnam W. Population Pharmacokinetics of Heptanoate in Healthy Subjects and Patients With Long-Chain Fatty Acid Oxidation Disorders Treated With Triheptanoin. Clin Pharmacol Drug Dev 2022; 11:1264-1272. [PMID: 35908210 PMCID: PMC9795984 DOI: 10.1002/cpdd.1145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/28/2022] [Indexed: 01/27/2023]
Abstract
Triheptanoin is an odd-carbon, medium-chain triglyceride consisting of three fatty acids with seven carbons each on a glycerol backbone, indicated for the treatment of adult and pediatric patients with long-chain fatty acid oxidation disorders (LC-FAOD). A total of 562 plasma concentrations of heptanoate, the most abundant and pharmacologically active metabolite of triheptanoin, from 13 healthy adult subjects and 30 adult and pediatric subjects with LC-FAOD were included in the population pharmacokinetic (PK) analyses. Multiple peaks of heptanoate observed in several subjects were characterized by dual first-order absorption with a lag time in the second absorption compartment. The disposition of heptanoate in human plasma was adequately described by one-compartmental distribution with a linear elimination. The apparent clearance (CL/F) and apparent volume of distribution were allometrically scaled with body weight to describe PK data across a wide range of age groups in subjects with LC-FAOD. The typical CL/F in adult subjects with LC-FAOD was ≈19% lower than that in healthy subjects. Model-estimated elimination half-life for LC-FAOD patients was ∼1.7 hours, supporting a recommended dosing frequency of ≥4 times per day. Covariate analyses indicate that age, race, and sex did not lead to clinically meaningful changes in the exposure of heptanoate.
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Affiliation(s)
- Sun Ku Lee
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
| | | | | | | | - Wendy Putnam
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
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12
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Kruger E, Voorhees K, Thomas N, Judge M, Galla J, Kung J, Rodriguez D. Understanding the impact of long-chain fatty acid oxidation disorders for patients and caregivers. Mol Genet Metab Rep 2022; 32:100903. [PMID: 36046395 PMCID: PMC9421447 DOI: 10.1016/j.ymgmr.2022.100903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 11/12/2022] Open
Abstract
Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare, autosomal recessive genetic disorders that impair conversion of long-chain fatty acids into energy. Here we describe the impact of LC-FAOD in terms of effects on work and school, absenteeism and presenteeism at work, importance of symptoms, physical activity, participation in social activities, and quality of life (QoL). A convenience sample of adults (≥18 years) and caregivers of patients with LC-FAOD was invited to take the online survey (Confirmit). To be included, patients must have been receiving medical care from a healthcare provider for their LC-FAOD, and caregivers must not have been compensated for their care. Degree of physical activity, represented by metabolic equivalents (METs), was calculated using the NHANES Physical Activity Questionnaire. Absenteeism and presenteeism at work were calculated using the WHO Health Productivity Questionnaire. QoL was assessed using the 12-Item Short Form of the Medical Outcomes Survey. Significance was assessed using two tailed independent sample t-tests and z-tests at α = 0.1. Fourteen adults and 30 caregivers of LC-FAOD patients (answering for 37 patients) answered the survey (51 unique respondents). 59.2% of LC-FAOD patients experienced effects on their schooling due to LC-FAOD. 84.2% of working patients experienced effects on their work due to LC-FAOD. 70% of caregivers experienced effects on their work due to their child's LC-FAOD. Unique respondents report that muscle weakness (69%), physical fatigue (49%), and rhabdomyolysis (39%) are the most impactful symptoms of LC-FAOD. Adults (n = 14) scored significantly below the normalized average (50) on both physical (34.51, p < 0.001) and mental (45.27, p = 0.04) component scores of the SF-12 health-related quality of life measure. LC-FAOD impart a high disease impact on patients and their caregivers. In particular, symptoms relating to energy production were rated as highly impactful and limiting. Activities that may be considered normal for many people can prove to be very difficult or impossible for respondents with LC-FAOD, with respondents reporting lower physical and mental health-related quality of life measures than the average American. LC-FAOD has a measurable impact on patient and caregiver education and employment (83/85). Muscle weakness was the most impactful symptom of LC-FAOD on individuals' lives (82/85). Physical and mental health were significantly lower in individuals with LC-FAOD (82/85).
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Affiliation(s)
| | | | - Nina Thomas
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
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13
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Vockley J, Enns GM, Ramirez AN, Bedrosian CL, Reineking B, Lu X, Ray K, Rahman S, Marsden D. Response to triheptanoin therapy in critically ill patients with LC-FAOD: Report of patients treated through an expanded access program. Mol Genet Metab 2022; 136:152-162. [PMID: 35459555 DOI: 10.1016/j.ymgme.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 12/31/2022]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of inborn errors of metabolism wherein patients are unable to process long-chain fatty acids into useable energy in the mitochondria. LC-FAOD commonly affects organ systems with high energy demand, manifesting as hypoketotic hypoglycemia, liver dysfunction, cardiomyopathy, rhabdomyolysis, and skeletal myopathy, as well as peripheral neuropathy and retinopathy in some subtypes. Collectively, LC-FAOD have a high mortality rate, especially in cases of early onset disease, and in the presence of cardiomyopathy. Triheptanoin is a synthetic medium-odd chain triglyceride, produced using a GMP-compliant process, which was designed to replenish mitochondrial metabolic deficits and restore energy homeostasis. Prior to its approval, triheptanoin was only available through clinical trials or to seriously ill patients as part of an expanded access program (EAP) following physician request. This retrospective study examined the impact of triheptanoin on cardiovascular parameters, in critically ill patients who participated in the EAP from February 2013 to January 2018. These patients persisted in critical condition despite receiving standard treatment in highly qualified centers by expert metabolic physicians and dietitians. Physician-completed questionnaires and narrative summaries were used to evaluate the disease presentation and management prior to the trigger event leading to triheptanoin request and use, and the response to triheptanoin treatment. Following triheptanoin initiation, most patients survived the initial trigger event (e.g., severe urinary tract infection, pneumonia) and demonstrated improvements in both short-term and long-term LC-FAOD manifestations. In patients with cardiomyopathy, stabilization or improvement from pretreatment levels was reported in left ventricular ejection fraction and left ventricular mass, in particular, all infants with cardiomyopathy showed improvement in cardiac function during triheptanoin therapy. Triheptanoin therapy was generally well tolerated. The study results are consistent with the existing positive benefit/risk profile of triheptanoin and reflect the effect of triheptanoin improving cardiac function in patients experiencing severe episodes of metabolic decompensation despite standard therapy.
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Affiliation(s)
- Jerry Vockley
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Gregory M Enns
- Stanford University, Division of Medical Genetics, Palo Alto, CA, United States of America
| | | | | | - Bridget Reineking
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Kathryn Ray
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Syeda Rahman
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
| | - Deborah Marsden
- Ultragenyx Pharmaceutical Inc., Novato, CA, United States of America
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14
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Veenvliet AR, Garrelfs MR, Udink ten Cate FE, Ferdinandusse S, Denis S, Fuchs SA, Schwantje M, Geurtzen R, van Wegberg AM, Huigen MC, Kluijtmans LA, Wanders RJ, Derks TG, de Boer L, Houtkooper RH, de Vries MC, van Karnebeek CD. Neonatal Long-Chain 3-Ketoacyl-CoA Thiolase deficiency: Clinical-biochemical phenotype, sodium-D,L-3-hydroxybutyrate treatment experience and cardiac evaluation using speckle echocardiography. Mol Genet Metab Rep 2022; 31:100873. [PMID: 35782614 PMCID: PMC9248206 DOI: 10.1016/j.ymgmr.2022.100873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 02/08/2023] Open
Abstract
Isolated long-chain 3-keto-acyl CoA thiolase (LCKAT) deficiency is a rare long-chain fatty acid oxidation disorder caused by mutations in HADHB. LCKAT is part of a multi-enzyme complex called the mitochondrial trifunctional protein (MTP) which catalyzes the last three steps in the long-chain fatty acid oxidation. Until now, only three cases of isolated LCKAT deficiency have been described. All patients developed a severe cardiomyopathy and died before the age of 7 weeks. Here, we describe a newborn with isolated LCKAT deficiency, presenting with neonatal-onset cardiomyopathy, rhabdomyolysis, hypoglycemia and lactic acidosis. Bi-allelic 185G > A (p.Arg62His) and c1292T > C (p.Phe431Ser) mutations were found in HADHB. Enzymatic analysis in both lymphocytes and cultured fibroblasts revealed LCKAT deficiency with a normal long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD, also part of MTP) enzyme activity. Clinically, the patient showed recurrent cardiomyopathy, which was monitored by speckle tracking echocardiography. Subsequent treatment with special low-fat formula, low in long chain triglycerides (LCT) and supplemented with medium chain triglycerides (MCT) and ketone body therapy in (sodium-D,L-3-hydroxybutyrate) was well tolerated and resulted in improved carnitine profiles and cardiac function. Resveratrol, a natural polyphenol that has been shown to increase fatty acid oxidation, was also considered as a potential treatment option but showed no in vitro benefits in the patient's fibroblasts. Even though our patient deceased at the age of 13 months, early diagnosis and prompt initiation of dietary management with addition of sodium-D,L-3-hydroxybutyrate may have contributed to improved cardiac function and a much longer survival when compared to the previously reported cases of isolated LCKAT-deficiency.
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15
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Karunanidhi A, Van’t Land C, Rajasundaram D, Grings M, Vockley J, Mohsen AW. Medium branched chain fatty acids improve the profile of tricarboxylic acid cycle intermediates in mitochondrial fatty acid β-oxidation deficient cells: A comparative study. J Inherit Metab Dis 2022; 45:541-556. [PMID: 35076099 PMCID: PMC9090965 DOI: 10.1002/jimd.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/09/2022] [Accepted: 01/24/2022] [Indexed: 12/06/2022]
Abstract
Inherited errors of mitochondrial fatty acid β-oxidation (FAO) are life threatening, even with optimum care. FAO is the major source of energy for heart and is critical for skeletal muscles especially during physiologic stress. Clinical trials revealed that triheptanoin (commercially known as Dojolvi; C7G), improved heart function and decreased hypoglycemia in long chain FAO disorders, but other symptoms including rhabdomyolysis persisted, suggesting suboptimal tissue distribution/utilization of heptanoic acid (C7) conjugates and/or rapid liver breakdown. In this study, medium branched chain fatty acids were tested as potential anaplerotic treatments in fibroblasts from patients deficient in very long chain acyl-CoA dehydrogenase (VLCAD), long chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD), trifunctional protein (TFP), and carnitine palmitoyltransferase II (CPT II). Cells were cultured to near confluency and treated with C7, 2,6-dimethylheptanoic acid (dMC7), 6-amino-2,4-dimethylheptanoic acid (AdMC7), or 4,8-dimethylnonanoic acid (dMC9) for 72 h and targeted metabolomics performed. The profile of TCA cycle intermediates was improved in cells treated with these branched chain fatty acids compared with C7. Intracellular propionate was higher in AdMC7 treated cells compared with C7 in VLCAD, LCHAD, and TFP deficient cell lines. With AdMC7 treatment, succinate was higher in CPT II and VLCAD deficient cells, compared with C7. Malate and glutamate were consistently higher in AdMC7 treated VLCAD, LCHAD, TFP, and CPT II deficient cells compared with the C7 treatment. The results provide the impetus to further evaluate and consider branched chain fatty acids as viable anaplerotic therapy for fatty acid oxidation disorders and other diseases.
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Affiliation(s)
- Anuradha Karunanidhi
- Department of Pediatrics, School of Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clinton Van’t Land
- Department of Pediatrics, School of Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dhivyaa Rajasundaram
- Department of Pediatrics, School of Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mateus Grings
- Department of Pediatrics, School of Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- PPG Ciências Biológicas: Bioquímica, Departamento de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jerry Vockley
- Department of Pediatrics, School of Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Al-Walid Mohsen
- Department of Pediatrics, School of Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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16
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Striano P, Auvin S, Collins A, Horvath R, Scheffer IE, Tzadok M, Miller I, Koenig MK, Lacy A, Davis R, Garcia-Cazorla A, Saneto RP, Brandabur M, Blair S, Koutsoukos T, De Vivo D. A randomized, double-blind trial of triheptanoin for drug-resistant epilepsy in glucose transporter I deficiency syndrome (Glut1DS). Epilepsia 2022; 63:1748-1760. [PMID: 35441706 PMCID: PMC9546029 DOI: 10.1111/epi.17263] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evaluate efficacy and long-term safety of triheptanoin in patients >1 year old, not on a ketogenic diet, with drug-resistant seizures associated with Glucose Transporter Type 1 Deficiency Syndrome (Glut1DS). METHODS UX007G-CL201 was a randomized, double-blind, placebo-controlled trial. Following a 6-week baseline period, eligible patients were randomized 3:1 to triheptanoin or placebo. Dosing was titrated to 35% total daily calories over 2 weeks. After an 8-week placebo-controlled period, all patients received open-label triheptanoin through Week 52. RESULTS The study included 36 patients (15 children; 13 adolescents; 8 adults). A median 12.6% reduction in overall seizure frequency was observed in the triheptanoin arm relative to baseline and a 13.5% difference was observed relative to placebo (p = .58). In patients with absence seizures only (n = 9), a median 62.2% reduction in seizure frequency was observed in the triheptanoin arm relative to baseline. Only one patient with absence seizures only was present in the control group, preventing comparison. No statistically significant differences in seizure frequency were observed. Common treatment-emergent adverse events (TEAEs) included diarrhea, vomiting, abdominal pain, and nausea, most mild or moderate in severity. No serious AEs were considered treatment related. One patient discontinued due to status epilepticus. SIGNIFICANCE Triheptanoin did not significantly reduce seizure frequency in patients with Glut1DS not on the ketogenic diet. Treatment was associated with mild to moderate GI treatment-related events; most resolved following dose reduction or interruption and/or medication for treatment. Triheptanoin was not associated with any long-term safety concerns when administered at dose levels up to 35% total daily caloric intake for up to one year.
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Affiliation(s)
- Pasquale Striano
- IRCCS Istituto 'G. Gaslini', Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Stéphane Auvin
- Robert-Debré University Hospital and Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
| | | | - Rita Horvath
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ingrid E Scheffer
- Austin and Royal Children's Hospital, Florey and Murdoch Institutes, University of Melbourne, Melbourne, Vic., Australia
| | - Michal Tzadok
- Pediatric Neurology Units, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Ian Miller
- Miami Children's Research Institute, Miami, Florida, USA
| | | | - Adrian Lacy
- Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Ronald Davis
- Neurology & Epilepsy Research Center, DBO Pediatric Neurology, P.A., Orlando, Florida, USA
| | | | - Russell P Saneto
- Department of Neurology, Division of Pediatric Neurology, University of Washington/ Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Susan Blair
- Ultragenyx Pharmaceutical Inc., Novato, California, USA
| | | | - Darryl De Vivo
- Columbia University Irving Medical Center, New York, New York, USA
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17
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Williams-Hall R, Tinsley K, Kruger E, Johnson C, Bowden A, Cimms T, Gater A. Qualitative evaluation of the symptoms and quality of life impacts of long-chain fatty acid oxidation disorders. Ther Adv Endocrinol Metab 2022; 13:20420188211065655. [PMID: 35035873 PMCID: PMC8755934 DOI: 10.1177/20420188211065655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare autosomal-recessive genetic disorders characterized by metabolic deficiencies in which the body is unable to convert long-chain fatty acids into energy. To date, however, there is limited understanding of the patient experience of LC-FAOD. METHODS The symptoms, observable signs, and quality of life (QoL) impacts associated with LC-FAOD were explored via a focus group (n = 8) and semi-structured interviews (n = 6) with patients and caregivers of patients with LC-FAOD, and interviews (n = 4) with expert clinicians. Data were analyzed via thematic analysis and summarized in a conceptual model. RESULTS Participants reported a wide range of signs and symptoms associated with LC-FAOD, broadly categorized as musculoskeletal, endocrine/nutritional/metabolic, neurological, gastrointestinal/digestive, sensory, cardiovascular, respiratory, urological, and constitutional. LC-FAOD were reported to have a significant impact on various aspects of patients' lives including physical functioning, participation in daily activities, emotional/psychological wellbeing, and social functioning. Lifestyle modifications (such as diet and exercise restrictions) were necessary because of the condition. Symptoms were typically episodic in presentation often arising or exacerbated during catabolic conditions such as prolonged exercise, fasting, physiological stress, and illness/infection. Symptoms were also commonly reported to lead to emergency room visits, hospitalization, and clinical complications. CONCLUSION LC-FAOD have a considerable impact on patients' lives. There is a high degree of concordance in the signs, symptoms, and impacts of LC-FAOD reported by patients, caregivers, and clinicians; however, there were many symptoms and impacts that were only reported by patients and caregivers, thus demonstrating that insights from patient/caregiver experience data are integral for informing medical product development and facilitating patient-centered care.
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18
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Lee SK, Gupta M, Shi J, McKeever K. The Pharmacokinetics of Triheptanoin and Its Metabolites in Healthy Subjects and Patients With Long-Chain Fatty Acid Oxidation Disorders. Clin Pharmacol Drug Dev 2021; 10:1325-1334. [PMID: 33789001 PMCID: PMC8597155 DOI: 10.1002/cpdd.944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/07/2021] [Indexed: 12/31/2022]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) are a group of life-threatening autosomal recessive disorders caused by defects in nuclear genes encoding mitochondrial enzymes involved in the conversion of dietary long-chain fatty acids into energy. Triheptanoin is an odd-carbon, medium-chain triglyceride consisting of 3 fatty acids with 7 carbons each on a glycerol backbone developed to treat adult and pediatric patients with LC-FAODs. The pharmacokinetics of triheptanoin and circulating metabolites were explored in healthy subjects and patients with LC-FAODs using noncompartmental analyses. Systemic exposure to triheptanoin following an oral administration was negligible, as triheptanoin is extensively hydrolyzed to glycerol and heptanoate in the gastrointestinal tract. Multiple peaks for triheptanoin metabolites were observed in the plasma following oral administration of triheptanoin, generally coinciding with the time that meals were served. Heptanoate, the pharmacologically active metabolite of triheptanoin supplementing energy sources in patients with LC-FAODs, showed the greatest exposure among the metabolites of triheptanoin in human plasma following oral administration of triheptanoin. The exposure of heptanoate was approximately 10-fold greater than that of beta-hydroxypentoate, a downstream metabolite of heptanoate. Exposure to triheptanoin metabolites appeared to increase following multiple doses as compared with the single dose, and with the increase in triheptanoin dose levels.
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Affiliation(s)
- Sun Ku Lee
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
| | - Manju Gupta
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
| | - Jack Shi
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
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19
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Rücklová K, Hrubá E, Pavlíková M, Hanák P, Farolfi M, Chrastina P, Vlášková H, Kousal B, Smolka V, Foltenová H, Adam T, Friedecký D, Ješina P, Zeman J, Kožich V, Honzík T. Impact of Newborn Screening and Early Dietary Management on Clinical Outcome of Patients with Long Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency and Medium Chain Acyl-CoA Dehydrogenase Deficiency-A Retrospective Nationwide Study. Nutrients 2021; 13:nu13092925. [PMID: 34578803 PMCID: PMC8469775 DOI: 10.3390/nu13092925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/21/2021] [Accepted: 08/22/2021] [Indexed: 12/27/2022] Open
Abstract
Long chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD/MTPD) and medium chain acyl-CoA dehydrogenase deficiency (MCADD) were included in the expanded neonatal screening program (ENBS) in Czechia in 2009, allowing for the presymptomatic diagnosis and nutritional management of these patients. The aim of our study was to assess the nationwide impact of ENBS on clinical outcome. This retrospective study analysed acute events and chronic complications and their severity in pre-ENBS and post-ENBS cohorts. In total, 28 children (12 before, 16 after ENBS) were diagnosed with LCHADD/MTPD (incidence 0.8/100,000 before and 1.2/100,000 after ENBS). In the subgroup detected by ENBS, a significantly longer interval from birth to first acute encephalopathy was observed. In addition, improvement in neuropathy and cardiomyopathy (although statistically non-significant) was demonstrated in the post-ENBS subgroup. In the MCADD cohort, we included 69 patients (15 before, 54 after ENBS). The estimated incidence rose from 0.7/100,000 before to 4.3/100,000 after ENBS. We confirmed a significant decrease in the number of episodes of acute encephalopathy and lower proportion of intellectual disability after ENBS (p < 0.0001). The genotype-phenotype correlations suggest a new association between homozygosity for the c.1528C > G variant and more severe heart involvement in LCHADD patients.
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Affiliation(s)
- Kristina Rücklová
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
- Department of Paediatrics, 3rd Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, 100 34 Prague, Czech Republic
- Correspondence: (K.R.); (T.H.)
| | - Eva Hrubá
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Markéta Pavlíková
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University, 121 16 Prague, Czech Republic;
| | - Petr Hanák
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Martina Farolfi
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Petr Chrastina
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Hana Vlášková
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Bohdan Kousal
- Department of Ophthalmology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic;
| | - Vratislav Smolka
- Department of Paediatrics, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (V.S.); (H.F.)
| | - Hana Foltenová
- Department of Paediatrics, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (V.S.); (H.F.)
| | - Tomáš Adam
- Institute of Molecular and Translational Medicine, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (T.A.); (D.F.)
| | - David Friedecký
- Institute of Molecular and Translational Medicine, Czech Advanced Technology and Research Institute (CATRIN), Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (T.A.); (D.F.)
| | - Pavel Ješina
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Jiří Zeman
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Viktor Kožich
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
| | - Tomáš Honzík
- Department of Paediatrics and Inherited Metabolic Disorders, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 128 08 Prague, Czech Republic; (E.H.); (P.H.); (M.F.); (P.C.); (H.V.); (P.J.); (J.Z.); (V.K.)
- Correspondence: (K.R.); (T.H.)
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Abstract
Triheptanoin (Dojolvi™), a synthetic medium-chain triglyceride, is being developed by Ultragenyx Pharmaceutical as a pharmaceutical-grade anaplerotic compound for use in the treatment of inherited metabolic disorders. In June 2020, triheptanoin received its first regulatory approval, in the USA, for use as a source of calories and fatty acids for the treatment of pediatric and adult patients with molecularly confirmed long-chain fatty acid oxidation disorders (LC-FAOD). Triheptanoin has also been investigated for use as a treatment in a range of other metabolic disorders or other diseases where energy deficiency is implicated. This article summarizes the milestones in the development of triheptanoin leading to this first regulatory approval for use in the treatment of pediatric and adult patients with LC-FAOD.
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Affiliation(s)
- Matt Shirley
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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21
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Vallejo AN, Mroczkowski HJ, Michel JJ, Woolford M, Blair HC, Griffin P, McCracken E, Mihalik SJ, Reyes‐Mugica M, Vockley J. Pervasive inflammatory activation in patients with deficiency in very-long-chain acyl-coA dehydrogenase (VLCADD). Clin Transl Immunology 2021; 10:e1304. [PMID: 34194748 PMCID: PMC8236555 DOI: 10.1002/cti2.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 05/06/2021] [Accepted: 06/03/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Very-long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is a disorder of fatty acid oxidation. Symptoms are managed by dietary supplementation with medium-chain fatty acids that bypass the metabolic block. However, patients remain vulnerable to hospitalisations because of rhabdomyolysis, suggesting pathologic processes other than energy deficit. Since rhabdomyolysis is a self-destructive process that can signal inflammatory/immune cascades, we tested the hypothesis that inflammation is a physiologic dimension of VLCADD. METHODS All subjects (n = 18) underwent informed consent/assent. Plasma cytokine and cytometry analyses were performed. A prospective case analysis was carried out on a patient with recurrent hospitalisation. Health data were extracted from patient medical records. RESULTS Patients showed systemic upregulation of nine inflammatory mediators during symptomatic and asymptomatic periods. There was also overall abundance of immune cells with high intracellular expression of IFNγ, IL-6, MIP-1β (CCL4) and TNFα, and the transcription factors p65-NFκB and STAT1 linked to inflammatory pathways. A case analysis of a patient exhibited already elevated plasma cytokine levels during diagnosis in early infancy, evolving into sustained high systemic levels during recurrent rhabdomyolysis-related hospitalisations. There were corresponding activated leukocytes, with higher intracellular stores of inflammatory molecules in monocytes compared to T cells. Exposure of monocytes to long-chain free fatty acids recapitulated the cytokine signature of patients. CONCLUSION Pervasive plasma cytokine upregulation and pre-activated immune cells indicate chronic inflammatory state in VLCADD. Thus, there is rationale for practical implementation of clinical assessment of inflammation and/or translational testing, or adoption, of anti-inflammatory intervention(s) for personalised disease management.
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Affiliation(s)
- Abbe N Vallejo
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of ImmunologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
| | - Henry J Mroczkowski
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Present address:
Department of PediatricsUniversity of Tennessee Health Sciences CenterMemphisTNUSA
| | - Joshua J Michel
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Michael Woolford
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Harry C Blair
- Department of PathologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Cell BiologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Pittsburgh Veterans Administration Medical CenterPittsburghPAUSA
| | - Patricia Griffin
- Division of Pediatric Rheumatology, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Elizabeth McCracken
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Rare Disease and TherapyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Stephanie J Mihalik
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of PathologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Miguel Reyes‐Mugica
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Department of PathologyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Jerry Vockley
- Children's Hospital of PittsburghUniversity of Pittsburgh Medical CenterPittsburghPAUSA
- Division of Genetic and Genomic Medicine, Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Rare Disease and TherapyUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Human GeneticsUniversity of Pittsburgh Graduate School of Public HealthPittsburghPAUSA
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22
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Huang L, Gao L, Chen C. Role of Medium-Chain Fatty Acids in Healthy Metabolism: A Clinical Perspective. Trends Endocrinol Metab 2021; 32:351-366. [PMID: 33832826 DOI: 10.1016/j.tem.2021.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/22/2022]
Abstract
Medium-chain fatty acids (MCFAs) serve not only as an energy source but also regulate glucose and lipid metabolism. The unique transport and rapid metabolism of MCFAs provide additional clinical benefits over other substrates such as long-chain fatty acids (LCFAs) and have prompted interest in the use of MCFAs for treating metabolic and neurological disorders. This review focuses on the metabolic role of MCFAs in modulating cellular signaling and regulating key circulating metabolites and hormones. The potential of MCFAs in treating various metabolic diseases in a clinical setting has also been analyzed.
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Affiliation(s)
- Lili Huang
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia
| | - Lin Gao
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia
| | - Chen Chen
- School of Biomedical Science and Institute for Molecular Bioscience, University of Queensland, St Lucia, Brisbane, Australia.
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23
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Triheptanoin in the management of long-chain fatty acid oxidation disorders: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-021-00816-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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24
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Zand D, Doan J, Yi S, Wang J, Ma L, Akinshola E, Chakder S, Meyer J, Pacanowski M, Johnson LL, Donohue K, Beitz J. Regulatory news: Dojolvi (triheptanoin) as a source of calories and fatty acids in long-chain fatty acid oxidation disorders: FDA approval summary. J Inherit Metab Dis 2021; 44:515-517. [PMID: 33729583 DOI: 10.1002/jimd.12377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Dina Zand
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jenny Doan
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sojeong Yi
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jie Wang
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lian Ma
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Emmanuel Akinshola
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sushanta Chakder
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Joette Meyer
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael Pacanowski
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Laura Lee Johnson
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Kathleen Donohue
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Julie Beitz
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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25
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Tandon PK, Kakkis ED. The multi-domain responder index: a novel analysis tool to capture a broader assessment of clinical benefit in heterogeneous complex rare diseases. Orphanet J Rare Dis 2021; 16:183. [PMID: 33874971 PMCID: PMC8054393 DOI: 10.1186/s13023-021-01805-5] [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: 09/08/2020] [Accepted: 03/30/2021] [Indexed: 11/24/2022] Open
Abstract
In traditional clinical trial design, efficacy is typically assessed using a single primary endpoint in a randomized controlled trial to detect an expected treatment effect of a therapy in a narrowly selected patient population. This accepted paradigm is based on clinical evaluations that may not actually capture the breadth of the impact of a disease, which is especially true in the setting of complex, multisystem, rare diseases with small, extremely heterogeneous patient populations. The multi-domain responder index (MDRI) is a novel approach that accommodates complex and heterogeneous disease manifestations and evaluates a broad array of clinical disease without impairing the power or rigor of a study to fully understand a treatment. The MDRI sums the scores corresponding to clinically significant thresholds of change for each component domain in each individual patient, capturing the mean clinically meaningful change across multiple domains within individuals. This novel approach combines and then sums the results of independent domain endpoint responder analyses into one responder score to provide a broad basis for the assessment of efficacy. The impact of a treatment across multiple, physiologically independent domains, can be assessed clinically, reducing the adverse impact of heterogeneity on trial outcomes and allowing eligibility criteria to enroll a wider range of patients, ultimately resulting in efficacy and safety assessments of a therapy across a broad group of heterogeneous patients in rare disease programs. Trial registration The following studies are referenced within this manuscript (CLINICALTRIALS.GOV registration numbers): NCT00912925; NCT00146770; NCT00067470; NCT00104234; NCT00069641; NCT02230566; NCT02377921; NCT02432144.
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Affiliation(s)
- P K Tandon
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA. .,Ultragenyx Gene Therapy, 840 Memorial Drive, Cambridge, MA, 02139, USA.
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26
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Guffon N, Mochel F, Schiff M, De Lonlay P, Douillard C, Vianey-Saban C. Clinical outcomes in a series of 18 patients with long chain fatty acids oxidation disorders treated with triheptanoin for a median duration of 22 months. Mol Genet Metab 2021; 132:227-233. [PMID: 33610471 DOI: 10.1016/j.ymgme.2021.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Triheptanoin provides long-chain fatty acid oxidation disorder (LC-FAOD) patients with an alternative to medium-even-chain triglycerides therapy. MATERIAL-METHODS Retrospective analysis of 18 French LC-FAOD patients benefiting from early access to triheptanoin treatment. RESULTS Eight female and 10 male patients with LC-FAOD (VLCAD, LCHAD, CACT, CPTII and MTP) were treated with triheptanoin for a median duration of 22 months (range: 9-228 months). At last consultation, triheptanoin accounted for 15-35% of their daily caloric intake. In the year following the introduction of triheptanoin, patients reported a reduction of intermittent snacking and nocturnal meals. Three patients, including 1 adult, became free of severe hypoglycaemic events. Ten of 12 paediatric patients and 4 of 6 adult patients reported reduced fatigue with reductions in the number and severity of episodes of myalgia. Of 6 patients, including 1 adult, that had required the use of a wheelchair in the year prior to triheptanoin, all but one no longer required its use. The number of emergency hospitalizations decreased, and none were recorded for paediatric patients during these 12 months. Cumulative annual days of emergency care in the home were reduced from 286 to 51 days in the year before and after initiation, respectively, and 13 patients required no such interventions. Adverse events were limited to digestive issues that dissipated over time. CONCLUSIONS Our case-series suggests that long-term treatment of LC-FAOD paediatric and adult patients with triheptanoin is safe and leads to marked improvement of symptoms and an improved quality of life.
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Affiliation(s)
- Nathalie Guffon
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hospices Civiles de Lyon, Hôpital Femme Mère Enfant, F-69500 Bron, France.
| | - Fanny Mochel
- AP-HP, Hôpital Pitié-Salpêtrière, Département de Génétique and Centre de Référence Neurométabolique Adulte, Paris, France; Institut du Cerveau et de la Moelle épinière (ICM), Sorbonne Université, UMR S 1127, Inserm U1127, CNRS UMR 7225, Paris, France
| | - Manuel Schiff
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker, Institut Imagine Université de Paris, Filière G2M, Paris, France; Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Pascale De Lonlay
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Necker, Institut Imagine Université de Paris, Filière G2M, Paris, France; Inserm U1151, Institut Necker Enfants-Malades, Paris, France
| | - Claire Douillard
- CHU de Lille, Département d'Endocrinologie et Métabolisme, Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Huriez, Lille, France
| | - Christine Vianey-Saban
- CHU de Lyon, Centre de Biologie et de Pathologie Est, Unité Maladies Héréditaires du Métabolisme, Service de Biochimie et Biologie Moléculaire, Bron, France
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Vockley J, Longo N, Madden M, Dwyer L, Mu Y, Chen CY, Cataldo J. Dietary management and major clinical events in patients with long-chain fatty acid oxidation disorders enrolled in a phase 2 triheptanoin study. Clin Nutr ESPEN 2021; 41:293-298. [PMID: 33487279 PMCID: PMC8567087 DOI: 10.1016/j.clnesp.2020.11.018] [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: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 12/31/2022]
Abstract
Background & aims: Long-chain fatty acid oxidation disorders (LC-FAOD) are rare, life-threatening, autosomal recessive disorders that lead to energy depletion and major clinical events (MCEs), such as acute metabolic crises of hypoglycemia, cardiomyopathy, and rhabdomyolysis. The aim of this study was to report a post hoc analysis of diet diary data from the phase 2 UX007-CL201 study (NCT01886378). Methods: In the single-arm, open-label, phase 2 UX007-CL201 study, the safety and efficacy of 78 weeks of treatment with triheptanoin, an odd-carbon, medium-chain triglyceride consisting of three 7-carbon fatty acids on a glycerol backbone, was investigated in subjects with LC-FAOD versus a retrospective 78-week period when subjects were optimally managed under published dietary guidelines. Subject dietary reports were collected to analyze the relationship between diet, triheptanoin treatment, and MCEs. Referring metabolic physicians completed a survey on patient management and clinical outcomes before and after initiation of triheptanoin. Before initiating triheptanoin, subjects received a mean daily caloric intake (DCI) of 17.4% from medium-chain triglycerides (MCT). During the study, subjects received a mean of 27.5% DCI from triheptanoin. Protein (13.7% vs 14.5% DCI), long-chain fat (13.1% vs 10.5% DCI), and carbohydrate (55.3% vs 47.1% DCI) intake were consistent between the pre-triheptanoin and triheptanoin treatment periods, respectively. Results: Following 78 weeks of treatment, mean annualized MCE rate decreased by 48.1% (p = 0.021) and mean annualized MCE event-day rate decreased by 50.3% (p = 0.028). A weak association existed between improvement in annualized MCE rate and change in percent DCI from MCT (Spearman rank correlation: r = −0.38; 95% CI: −0.675, 0.016). However, there was large variability in the association and no specific pattern of change for larger or smaller changes in dose. Seventy-two percent of physicians reported that triheptanoin had a clinically meaningful benefit on medical management of their patients. Conclusions: Treatment with triheptanoin at the protocol-specified dose decreased the rate of MCEs in patients with LC-FAOD independently from other dietary changes between the pre-triheptanoin and triheptanoin treatment periods. Trial registration:ClinicalTrials.gov identifier: NCT01886378.
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Sklirou E, Alodaib AN, Dobrowolski SF, Mohsen AWA, Vockley J. Physiological Perspectives on the Use of Triheptanoin as Anaplerotic Therapy for Long Chain Fatty Acid Oxidation Disorders. Front Genet 2021; 11:598760. [PMID: 33584796 PMCID: PMC7875087 DOI: 10.3389/fgene.2020.598760] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Inborn errors of mitochondrial fatty acid oxidation (FAO) comprise the most common group of disorders identified through expanded newborn screening mandated in all 50 states in the United States, affecting 1:10,000 newborns. While some of the morbidity in FAO disorders (FAODs) can be reduced if identified through screening, a significant gap remains between the ability to diagnose these disorders and the ability to treat them. At least 25 enzymes and specific transport proteins are responsible for carrying out the steps of mitochondrial fatty acid metabolism, with at least 22 associated genetic disorders. Common symptoms in long chain FAODs (LC-FAODs) in the first week of life include cardiac arrhythmias, hypoglycemia, and sudden death. Symptoms later in infancy and early childhood may relate to the liver or cardiac or skeletal muscle dysfunction, and include fasting or stress-related hypoketotic hypoglycemia or Reye-like syndrome, conduction abnormalities, arrhythmias, dilated or hypertrophic cardiomyopathy, and muscle weakness or fasting- and exercise-induced rhabdomyolysis. In adolescent or adult-onset disease, muscular symptoms, including rhabdomyolysis, and cardiomyopathy predominate. Unfortunately, progress in developing better therapeutic strategies has been slow and incremental. Supplementation with medium chain triglyceride (MCT; most often a mixture of C8–12 fatty acids containing triglycerides) oil provides a fat source that can be utilized by patients with long chain defects, but does not eliminate symptoms. Three mitochondrial metabolic pathways are required for efficient energy production in eukaryotic cells: oxidative phosphorylation (OXPHOS), FAO, and the tricarboxylic (TCA) cycle, also called the Krebs cycle. Cell and mouse studies have identified a deficiency in TCA cycle intermediates in LC-FAODs, thought to be due to a depletion of odd chain carbon compounds in patients treated with a predominantly MCT fat source. Triheptanoin (triheptanoyl glycerol; UX007, Ultragenyx Pharmaceuticals) is chemically composed of three heptanoate (seven carbon fatty acid) molecules linked to glycerol through ester bonds that has the potential to replete TCA cycle intermediates through production of both acetyl-CoA and propionyl-CoA through medium chain FAO. Compassionate use, retrospective, and recently completed prospective studies demonstrate significant reduction of hypoglycemic events and improved cardiac function in LC-FAOD patients, but a less dramatic effect on muscle symptoms.
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Affiliation(s)
- Evgenia Sklirou
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ahmad N Alodaib
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Newborn Screening and Biochemical Genetics Lab, Department of Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Steven F Dobrowolski
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Al-Walid A Mohsen
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jerry Vockley
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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29
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Zöggeler T, Stock K, Jörg-Streller M, Spenger J, Konstantopoulou V, Hufgard-Leitner M, Scholl-Bürgi S, Karall D. Long-term experience with triheptanoin in 12 Austrian patients with long-chain fatty acid oxidation disorders. Orphanet J Rare Dis 2021; 16:28. [PMID: 33446227 PMCID: PMC7807521 DOI: 10.1186/s13023-020-01635-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/27/2020] [Indexed: 12/31/2022] Open
Abstract
Background Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare inborn errors of metabolism with autosomal recessive inheritance that may cause life-threatening events.
Treatment with triheptanoin, a synthetic seven-carbon fatty acid triglyceride compound with an anaplerotic effect, seems beneficial, but clinical experience is limited. We report our long-term experience in an Austrian cohort of LC-FAOD patients. Methods We retrospectively assessed clinical outcome and total hospitalization days per year before and after start with triheptanoin by reviewing medical records of 12 Austrian LC-FAOD patients Results For 12 Austrian LC-FAOD patients at three metabolic centers, triheptanoin was started shortly after birth in 3/12, and between 7.34 and 353.3 (median 44.5; mean 81.1) months of age in 9/12 patients. For 11 pediatric patients, mean duration of triheptanoin intake was 5.3 (median 3.9, range 1.2–15.7) years, 10/11 pediatric patients have an ongoing intake of triheptanoin. One patient quit therapy due to reported side effects. Total hospitalization days per year compared to before triheptanoin treatment decreased by 82.3% from 27.1 (range 11–65) days per year to 4.8 (range 0–13) days per year, and hospitalization days in the one year pre- compared to the one year post-triheptanoin decreased by 69.8% from 27.1 (range 4–75) days to 8.2 (range 0–25) days. All patients are in good clinical condition, show normal psychomotor development and no impairment in daily life activities. Conclusion In this retrospective observational study in an Austrian LC-FAOD cohort, triheptanoin data show improvement in disease course. Triheptanoin appears to be a safe and beneficial treatment option in LC-FAOD. For further clarification, additional prospective randomized controlled trials are needed.
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Affiliation(s)
- Thomas Zöggeler
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Katharina Stock
- Department of Pediatrics III (Cardiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Monika Jörg-Streller
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Johannes Spenger
- University Children's Hospital, Salzburger Landeskliniken (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
| | | | - Miriam Hufgard-Leitner
- Department of Internal Medicine III (Clinical Division of Endocrinology and Inherited Metabolic Disorders), Medical University of Vienna, Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I (Inherited Metabolic Disorders), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Affiliation(s)
- Jerry Vockley
- University of Pittsburgh School of Medicine and Graduate School of Public Health, UPMC Children's Hospital of Pittsburgh, Center for Rare Disease Therapy, Pittsburgh, Pennsylvania, USA
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Vockley J, Burton B, Berry G, Longo N, Phillips J, Sanchez‐Valle A, Chapman K, Tanpaiboon P, Grunewald S, Murphy E, Lu X, Cataldo J. Effects of triheptanoin (UX007) in patients with long-chain fatty acid oxidation disorders: Results from an open-label, long-term extension study. J Inherit Metab Dis 2021; 44:253-263. [PMID: 32885845 PMCID: PMC7891391 DOI: 10.1002/jimd.12313] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAOD) are autosomal recessive conditions that impair conversion of long-chain fatty acids into energy, leading to significant clinical symptoms. Triheptanoin is a highly purified, 7-carbon chain triglyceride approved in the United States as a source of calories and fatty acids for treatment of pediatric and adult patients with molecularly confirmed LC-FAOD. CL202 is an open-label, long-term extension study evaluating triheptanoin (Dojolvi) safety and efficacy in patients with LC-FAOD. Patients rolled over from the CL201 triheptanoin clinical trial (rollover); were triheptanoin-naïve (naïve); or had participated in investigator-sponsored trials/expanded access programs (IST/other). Results focus on rollover and naïve groups, as pretreatment data allow comparison. Primary outcomes were annual rate and duration of major clinical events (MCEs; rhabdomyolysis, hypoglycemia, and cardiomyopathy events). Seventy-five patients were enrolled (24 rollover, 20 naïve, 31 IST/other). Mean study duration was 23.0 months for rollover, 15.7 months for naïve, and 34.7 months for IST/other. In the rollover group, mean annualized MCE rate decreased from 1.76 events/year pre-triheptanoin to 0.96 events/year with triheptanoin (P = .0319). Median MCE duration was reduced by 66%. In the naïve group, median annualized MCE rate decreased from 2.33 events/year pre-triheptanoin to 0.71 events/year with triheptanoin (P = .1072). Median MCE duration was reduced by 80%. The most common related adverse events (AEs) were diarrhea, abdominal pain/discomfort, and vomiting, most mild to moderate. Three patients had serious AEs (diverticulitis, ileus, rhabdomyolysis) possibly related to drug; all resolved. Two patients had AEs leading to death; neither drug related. Triheptanoin reduced rate and duration of MCEs. Safety was consistent with previous observations.
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Affiliation(s)
| | - Barbara Burton
- Ann & Robert H. Lurie Children's HospitalChicagoIllinoisUSA
| | - Gerard Berry
- Boston Children's HospitalBostonMassachusettsUSA
| | | | - John Phillips
- Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Kimberly Chapman
- Children's National Health SystemWashingtonDistrict of ColumbiaUSA
| | | | - Stephanie Grunewald
- Great Ormond Street Hospital and Institute of Child HealthNIHR Biomedical Research Center (BRC), UCLLondonUK
| | - Elaine Murphy
- National Hospital for Neurology and NeurosurgeryLondonUK
| | - Xiaoxiao Lu
- Ultragenyx Pharmaceutical Inc.NovatoCaliforniaUSA
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Amaral AU, Wajner M. Recent Advances in the Pathophysiology of Fatty Acid Oxidation Defects: Secondary Alterations of Bioenergetics and Mitochondrial Calcium Homeostasis Caused by the Accumulating Fatty Acids. Front Genet 2020; 11:598976. [PMID: 33329744 PMCID: PMC7729159 DOI: 10.3389/fgene.2020.598976] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
Deficiencies of medium-chain acyl-CoA dehydrogenase, mitochondrial trifunctional protein, isolated long-chain 3-hydroxyacyl-CoA dehydrogenase, and very long-chain acyl-CoA dehydrogenase activities are considered the most frequent fatty acid oxidation defects (FAOD). They are biochemically characterized by the accumulation of medium-chain, long-chain hydroxyl, and long-chain fatty acids and derivatives, respectively, in tissues and biological fluids of the affected patients. Clinical manifestations commonly include hypoglycemia, cardiomyopathy, and recurrent rhabdomyolysis. Although the pathogenesis of these diseases is still poorly understood, energy deprivation secondary to blockage of fatty acid degradation seems to play an important role. However, recent evidence indicates that the predominant fatty acids accumulating in these disorders disrupt mitochondrial functions and are involved in their pathophysiology, possibly explaining the lactic acidosis, mitochondrial morphological alterations, and altered mitochondrial biochemical parameters found in tissues and cultured fibroblasts from some affected patients and also in animal models of these diseases. In this review, we will update the present knowledge on disturbances of mitochondrial bioenergetics, calcium homeostasis, uncoupling of oxidative phosphorylation, and mitochondrial permeability transition induction provoked by the major fatty acids accumulating in prevalent FAOD. It is emphasized that further in vivo studies carried out in tissues from affected patients and from animal genetic models of these disorders are necessary to confirm the present evidence mostly achieved from in vitro experiments.
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Affiliation(s)
- Alexandre Umpierrez Amaral
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Departamento de Ciências Biológicas, Universidade Regional Integrada do Alto Uruguai e das Missões, Erechim, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Norris MK, Scott AI, Sullivan S, Chang IJ, Lam C, Sun A, Hahn S, Thies JM, Gunnarson M, McKean KN, Merritt JL. Tutorial: Triheptanoin and Nutrition Management for Treatment of Long-Chain Fatty Acid Oxidation Disorders. JPEN J Parenter Enteral Nutr 2020; 45:230-238. [PMID: 33085788 DOI: 10.1002/jpen.2034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with severe long-chain fatty acid oxidation disorders (LC-FAODs) experience serious morbidity and mortality despite traditional dietary management including medium-chain triglyceride (MCT)-supplemented, low-fat diets. Triheptanoin is a triglyceride oil that is broken down to acetyl-coenzyme A (CoA) and propionyl-CoA, which replenishes deficient tricarboxylic acid cycle intermediates. We report the complex medical and nutrition management of triheptanoin therapy initiated emergently for 3 patients with LC-FAOD. METHODS Triheptanoin (Ultragenyx Pharmaceutical, Inc, Novato, CA, USA) was administered to 3 patients with LC-FAOD on a compassionate-use basis. Triheptanoin was mixed with non-MCT-containing low-fat formula. Patients were closely followed with regular cardiac and laboratory monitoring. RESULTS Cardiac ejection fraction normalized after triheptanoin initiation. Patients experienced fewer hospitalizations related to metabolic crises while on triheptanoin. Patient 1 has tolerated oral administration without difficulty since birth. Patients 2 and 3 experienced increased diarrhea. Recurrent breakdown of the silicone gastrostomy tube occurred in patient 3, whereas the polyurethane nasogastric tube for patient 2 remained intact. Patient 3 experiences recurrent episodes of elevated creatine kinase levels and muscle weakness associated with illness. Patient 3 had chronically elevated C10-acylcarnitines while on MCT supplementation, which normalized after initiation of triheptanoin and discontinuation of MCT oil. CONCLUSIONS Triheptanoin can ameliorate acute cardiomyopathy and increase survival in patients with severe LC-FAOD. Substituting triheptanoin for traditional MCT-based treatment improves clinical outcomes. MCT oil might be less effective in carnitine-acylcarnitine translocase deficiency patients compared with other FAODs and needs further investigation.
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Affiliation(s)
- Marie K Norris
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA.,Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Anna I Scott
- Department of Laboratories, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah Sullivan
- Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Irene J Chang
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Christina Lam
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Angela Sun
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sihoun Hahn
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jenny M Thies
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Melissa Gunnarson
- Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kelly N McKean
- Department of Nutrition, Biochemical Genetics, Seattle Children's Hospital, Seattle, Washington, USA
| | - J Lawrence Merritt
- Department of Pediatrics, Biochemical Genetics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
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Wanders RJA, Visser G, Ferdinandusse S, Vaz FM, Houtkooper RH. Mitochondrial Fatty Acid Oxidation Disorders: Laboratory Diagnosis, Pathogenesis, and the Complicated Route to Treatment. J Lipid Atheroscler 2020; 9:313-333. [PMID: 33024728 PMCID: PMC7521971 DOI: 10.12997/jla.2020.9.3.313] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 12/14/2022] Open
Abstract
Mitochondrial fatty acid (FA) oxidation deficiencies represent a genetically heterogeneous group of diseases in humans caused by defects in mitochondrial FA beta-oxidation (mFAO). A general characteristic of all mFAO disorders is hypoketotic hypoglycemia resulting from the enhanced reliance on glucose oxidation and the inability to synthesize ketone bodies from FAs. Patients with a defect in the oxidation of long-chain FAs are at risk to develop cardiac and skeletal muscle abnormalities including cardiomyopathy and arrhythmias, which may progress into early death, as well as rhabdomyolysis and exercise intolerance. The diagnosis of mFAO-deficient patients has greatly been helped by revolutionary developments in the field of tandem mass spectrometry (MS) for the analysis of acylcarnitines in blood and/or urine of candidate patients. Indeed, acylcarnitines have turned out to be excellent biomarkers; not only do they provide information whether a certain patient is affected by a mFAO deficiency, but the acylcarnitine profile itself usually immediately points to which enzyme is likely deficient. Another important aspect of acylcarnitine analysis by tandem MS is that this technique allows high-throughput analysis, which explains why screening for mFAO deficiencies has now been introduced in many newborn screening programs worldwide. In this review, we will describe the current state of knowledge about mFAO deficiencies, with particular emphasis on recent developments in the area of pathophysiology and treatment.
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Affiliation(s)
- Ronald J A Wanders
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gepke Visser
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sacha Ferdinandusse
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Frédéric M Vaz
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Riekelt H Houtkooper
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology and Metabolism, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Kritzer A, Tarrant S, Sussman‐Karten K, Barbas K. Use of skimmed breast milk for an infant with a long-chain fatty acid oxidation disorder: A novel therapeutic intervention. JIMD Rep 2020; 55:44-50. [PMID: 32905135 PMCID: PMC7463058 DOI: 10.1002/jmd2.12152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022] Open
Abstract
The focus of dietary therapy for long chain fatty acid oxidation disorders (LC-FAODs) is to minimize fatty acid oxidation by avoiding fasting and providing sufficient calories. Dietary therapy involves restriction of long-chain triglycerides (LCT), and provision of medium-chain triglycerides as an alternate energy source. It is well established that the use of breast milk through the first year of a newborn's life has significant health benefits. While very few medical contraindications to breastfeeding exist, feeding an infant with a severe carnitine acylcarnitine translocase (CACT) deficiency typically requires cessation of breastfeeding as approximately 50% of the calories in human milk come from LCT. In this case report, we present the innovative and successful use of skimmed breast milk incorporated into the dietary management of an infant with severe CACT deficiency. Given the poor prognosis for individuals with severe CACT deficiency on standard dietary therapy, the use of skimmed breast milk represents an important measure to try to improve short-term and long-term outcomes. Given the many proven benefits of breast milk, this case illustrates that skimmed breast milk can be combined with appropriate fat sources to provide complete nutrition for children with severe CACT deficiency. After over 12 months on this regimen, this patient has experienced normal growth and development and has had no acute decompensations.
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Affiliation(s)
- Amy Kritzer
- Division of Genetics and GenomicsBoston Children's HospitalBostonMassachusettsUSA
| | - Stacey Tarrant
- Division of Gastroenterology, Hepatology, and NutritionBoston Children's HospitalBostonMassachusettsUSA
| | - Karen Sussman‐Karten
- Department of Nursing, Lactation Support ProgramBoston Children's HospitalBostonMassachusettsUSA
| | - Kimberly Barbas
- Department of Nursing, Lactation Support ProgramBoston Children's HospitalBostonMassachusettsUSA
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36
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Vockley J. Long-chain fatty acid oxidation disorders and current management strategies. THE AMERICAN JOURNAL OF MANAGED CARE 2020; 26:S147-S154. [PMID: 32840329 PMCID: PMC9850137 DOI: 10.37765/ajmc.2020.88480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Long-chain fatty acid oxidation disorders (LC-FAODs) are rare, life-threatening, autosomal recessive genetic disorders characterized by acute crises of energy production and chronic energy deficiency. Patients may present with rhabdomyolysis induced by exercise; fasting or illness; hepatic dysfunction, including severe hypoglycemia and hyperammonemia; and cardiomyopathy. These clinical manifestations can lead to frequent hospitalizations and premature death. LC-FAODs are caused by mutations in nuclear genes encoding mitochondrial enzymes involved in the conversion of dietary long-chain fatty acids (LCFAs) into energy during times of fasting and physiologic stress. Despite newborn screening, current management options leave many patients continuing to experience major clinical events, and mortality rates remain elevated. The current standard therapy for LC-FAODs is avoidance of fasting and supplementation of medium-chain triglyceride oil, an even, medium-chain fatty acid that does not require the typical steps of LC-FAOD for metabolism. Despite this therapy, patients with LC-FAODs continue to experience recurring hospitalizations, and high morbidity and mortality rates. In recent years, the use of medium, odd-chain fatty acids, such as triheptanoin, have been studied as a treatment of LC-FAODs due to its anaplerotic properties. Due to favorable safety and efficacy data from clinical trials, this novel agent has the potential to transform the treatment of LC-FAODs and improve patient outcomes in this patient population. This article provides an overview of the epidemiology, pathophysiology, clinical manifestations, and current management approaches for the diagnosis and management of LC-FAODs. It also provides the most recent clinical safety and efficacy data for triheptanoin and other therapies under investigation.
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Affiliation(s)
- Jerry Vockley
- Chief of the Division of Medical Genetics and Director of The Center for Rare Disease Therapy, UPMC Children's Hospital of Pittsburgh; and Cleveland Family Endowed Chair in Pediatric Research and Professor of Human Genetics, University of Pittsburgh, both in Pittsburgh, PA.
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Borges K, Kaul N, Germaine J, Carrasco-Pozo C, Kwan P, O'Brien TJ. Open-label long-term treatment of add-on triheptanoin in adults with drug-resistant epilepsy. Epilepsia Open 2020; 5:230-239. [PMID: 32524048 PMCID: PMC7278596 DOI: 10.1002/epi4.12391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/09/2020] [Accepted: 03/19/2020] [Indexed: 12/30/2022] Open
Abstract
Objective To investigate feasibility, safety, and tolerability of long‐term (48 weeks) add‐on treatment with triheptanoin (UX007), the triglyceride of heptanoate, in adults with drug‐resistant epilepsy. Methods This extension study was offered to adult participants with drug‐resistant epilepsy who completed a 12‐week randomized controlled trial of add‐on medium‐chain triglycerides (MCT) vs triheptanoin. Participants were asked to titrate triheptanoin to their maximum tolerated dose over 3 weeks, followed by 48‐week maintenance before tapering or treatment extension. The primary aims were to assess retention and safety of the triheptanoin treatment, and secondary aims to assess the tolerated doses and changes in seizure frequency. Results Eleven adults were enrolled and ten people were analyzed (because one patient was diagnosed as having nonepileptic seizures while on the study). Two adults finished the study and extended their treatment. Eight participants withdrew from the study, due to lack of efficacy (n = 3), unknown reasons (n = 2), belief of weight gain (n = 1), wanting to try a different treatment (n = 1), and a colonoscopy (n = 1). Diarrhea in two people and bloating in one person were deemed possibly related to treatment, but other adverse events were not. The duration of maintenance treatment dose was 27‐513 days (median 247 days, range 27‐513 days), and 0.49 ‐1.1 mL/kg triheptanoin was taken per day (0.77 ± 0.19 mL/kg, mean ± standard deviation, 40‐100 mL/d). Two participants experienced >90% and three people >50% reduction in seizure frequency, and all had focal seizures. The median seizure reduction was 48% (average 38%). Significance Our results indicate antiseizure effects of triheptanoin on focal seizures in 5 out of 10 adults. However, only two people finished and extended the 48‐week add‐on treatment phase, despite lack of safety or tolerability issues. More studies focused on improved treatment formulations, the potential of lower dosages, and efficacy are needed. Trial registration number: ACTRN12615000406505.
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Affiliation(s)
- Karin Borges
- School of Biomedical Sciences Faculty of Medicine The University of Queensland St. Lucia QLD Australia
| | - Neha Kaul
- Department of Allied Health (Clinical Nutrition) Royal Melbourne Hospital University of Melbourne Parkville Vic Australia.,Departments of Medicine and Neurology Royal Melbourne Hospital University of Melbourne Parkville Vic Australia.,Departments of Neuroscience and Neurology The Central Clinical School Monash University and The Alfred Hospital Melbourne Vic Australia
| | - Jack Germaine
- Departments of Neuroscience and Neurology The Central Clinical School Monash University and The Alfred Hospital Melbourne Vic Australia
| | - Catalina Carrasco-Pozo
- Discovery Biology Griffith Institute for Drug Discovery Griffith University Nathan QLD Australia
| | - Patrick Kwan
- Departments of Medicine and Neurology Royal Melbourne Hospital University of Melbourne Parkville Vic Australia.,Departments of Neuroscience and Neurology The Central Clinical School Monash University and The Alfred Hospital Melbourne Vic Australia
| | - Terence J O'Brien
- Departments of Medicine and Neurology Royal Melbourne Hospital University of Melbourne Parkville Vic Australia.,Departments of Neuroscience and Neurology The Central Clinical School Monash University and The Alfred Hospital Melbourne Vic Australia
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Cecatto C, Amaral AU, Wajner A, Wajner SM, Castilho RF, Wajner M. Disturbance of mitochondrial functions associated with permeability transition pore opening induced by cis-5-tetradecenoic and myristic acids in liver of adolescent rats. Mitochondrion 2019; 50:1-13. [PMID: 31655165 DOI: 10.1016/j.mito.2019.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 12/30/2022]
Abstract
Patients affected by very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency commonly present liver dysfunction whose pathogenesis is poorly known. We demonstrate here that major metabolites accumulating in this disorder, namely cis-5-tetradecenoic acid (Cis-5) and myristic acid (Myr), markedly impair mitochondrial respiration, decreasing ATP production in liver mitochondrial preparations from adolescent rats. Other parameters of mitochondrial homeostasis such as membrane potential (ΔΨm) and Ca2+retention capacity were strongly compromised by these fatty acids, involving induction of mitochondrial permeability transition. The present data indicate that disruption of mitochondrial bioenergetics and Ca2+homeostasis may contribute to the liver dysfunction of VLCAD deficient patients.
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Affiliation(s)
- Cristiane Cecatto
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Alexandre Umpierrez Amaral
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Departamento de Ciências Biológicas, Universidade Regional Integrada do Alto Uruguai e das Missões, Erechim, RS, Brazil
| | - Alessandro Wajner
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Simone Magagnin Wajner
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Roger Frigério Castilho
- Departamento de Patologia Clínica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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McCalley S, Pirman D, Clasquin M, Johnson K, Jin S, Vockley J. Metabolic analysis reveals evidence for branched chain amino acid catabolism crosstalk and the potential for improved treatment of organic acidurias. Mol Genet Metab 2019; 128:57-61. [PMID: 31133529 PMCID: PMC6864255 DOI: 10.1016/j.ymgme.2019.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 01/07/2023]
Abstract
Branched chain amino acid (BCAA) metabolism occurs within the mitochondrial matrix and is comprised of multiple enzymes, some shared, organized into three pathways for the catabolism of leucine, isoleucine, and valine (LEU, ILE, and VAL respectively). Three different acyl-CoA dehydrogenases (ACADs) are active in each catabolic pathway and genetic deficiencies in each have been identified. While characteristic metabolites related to the enzymatic block accumulate in each deficiency, for reasons that are not clear, clinical symptoms are only seen in the context of deficiency of isovaleryl-CoA dehydrogenase (IVDH) in the leucine pathway. Metabolism of fibroblasts derived from patients with mutations in each of the BCAA ACADs were characterized using metabolomics to better understand the flux of BCAA through their respective pathways. Stable isotope labeled LEU, ILE, and VAL in patient and control cell lines revealed that mutations in isobutyryl-CoA dehydrogenase (IBDH in the valine pathway) lead to a significant increase in isobutyrylcarnitine (a surrogate for the enzyme substrate isobutyryl-CoA) leading to metabolism by short-branched chain acyl-CoA dehydrogenase (SBCADH in the isoleucine pathway) and production of the pathway end product propionylcarnitine (a surrogate for propionyl-CoA). Similar cross activity was observed for SBCADH deficient patient cells, leading to a significant increase in propionylcarnitine, presumably by metabolism of 2 methylbutyryl-CoA via IBDH activity. Labeled BCAA studies identified that the majority of the intracellular propionyl-CoA pool in fibroblasts is generated from isoleucine, but heptanoic acid (a surrogate for odd-chain fatty acids) is also efficiently converted to propionate.
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Affiliation(s)
- Stephen McCalley
- University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - David Pirman
- Agios Pharmaceuticals, 88 Sydney St, Cambridge, MA 02139, USA
| | | | - Kendall Johnson
- Agios Pharmaceuticals, 88 Sydney St, Cambridge, MA 02139, USA
| | - Shengfang Jin
- Agios Pharmaceuticals, 88 Sydney St, Cambridge, MA 02139, USA
| | - Jerry Vockley
- University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA.
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Zieger M, Keeler AM, Flotte TR, ElMallah MK. AAV9 gene replacement therapy for respiratory insufficiency in very-long chain acyl-CoA dehydrogenase deficiency. J Inherit Metab Dis 2019; 42:870-877. [PMID: 30993714 PMCID: PMC6739149 DOI: 10.1002/jimd.12101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/02/2019] [Accepted: 04/15/2019] [Indexed: 12/30/2022]
Abstract
Very-long chain acyl-CoA dehydrogenase (VLCAD) deficiency (VLCADD) is an autosomal recessive disorder of fatty acid oxidation. Fatty acids are a major source of energy during catabolic stress, so the absence of VLCAD can result in a metabolic crises and respiratory insufficiency. The etiology of this respiratory insufficiency is unclear. Thus, our aims were: (1) to characterize respiratory pathophysiology in VLCADD mice (VLCAD-/- ), and (2) to determine if AAV9-mediated gene therapy improves respiratory function. For the first aim, VLCAD-/- and wild-type (WT) mice underwent an exercise/fast "stress protocol" and awake spontaneous breathing was evaluated using whole-body plethysmography (WBP) both at baseline and during a hypercapnic respiratory challenge (FiO2 : 0.21; FiCO2 : 0.07; nitrogen balance). During hypercapnia, VLCAD -/- mice had a significantly lower frequency, tidal volume, minute ventilation, and peak inspiratory and expiratory flow, all of which indicate respiratory insufficiency. Histologically, the cardiac and respiratory muscles of stressed VLCAD -/- animals had an accumulation of intramyocellular lipids. For the second aim, a single systemic injection of AAV9-VLCAD gene therapy improved this respiratory pathology by normalizing breathing frequency and enhancing peak inspiratory flow. In addition, following gene therapy, there was a moderate reduction of lipid accumulation in the respiratory muscles. Furthermore, VLCAD protein expression was robust in cardiac and respiratory muscle. This was confirmed by immuno-staining with anti-human VLCAD antibody. In summary, stress with exercise and fasting induces respiratory insufficiency in VLCAD-/- mice and a single injection with AAV9-VLCAD gene therapy ameliorates breathing.
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Affiliation(s)
- Marina Zieger
- Department of Pediatrics, University of Massachusetts Medical School, Worcester MA
- The Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester MA
| | - Allison M. Keeler
- Department of Pediatrics, University of Massachusetts Medical School, Worcester MA
- The Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester MA
| | - Terence R. Flotte
- Department of Pediatrics, University of Massachusetts Medical School, Worcester MA
- The Li Weibo Institute for Rare Diseases Research, University of Massachusetts Medical School, Worcester MA
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Vockley J, Dobrowolski SF, Arnold GL, Guerrero RB, Derks TGJ, Weinstein DA. Complex patterns of inheritance, including synergistic heterozygosity, in inborn errors of metabolism: Implications for precision medicine driven diagnosis and treatment. Mol Genet Metab 2019; 128:1-9. [PMID: 31358473 PMCID: PMC8931500 DOI: 10.1016/j.ymgme.2019.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 01/03/2023]
Abstract
Inborn errors of metabolism have traditionally been viewed as the quintessential single gene disorders; defects in one gene leads to loss of activity of one enzyme causing a metabolic imbalance and clinical disease. However, reality has never been quite that simple, and the classic "one gene-one enzyme" paradigm has been upended in many ways. Multiple gene defects can lead to the same biochemical phenotype, often with different clinical symptoms. Additionally, different mutations in the same gene can cause variable phenotypes, often most dramatic when a disease can be identified by pre-symptomatic screening. Moreover, response to therapy is not homogeneous across diseases and specific mutations. Perhaps the biggest deviation from traditional monogenic inheritance is in the setting of synergistic heterozygosity, a multigenic inheritance pattern in which mutations in multiple genes in a metabolic pathway lead to sufficient disruption of flux through the pathway, mimicking a monogenic disorder caused by homozygous defects in one gene in that pathway. In addition, widespread adoption of whole exome and whole genome sequencing in medical genetics has led to the realization that individual patients with apparently hybrid phenotypes can have mutations in more than one gene, leading to a mixed genetic disorder. Each of these situations point to a need for as much precision as possible in diagnosing metabolic disease, and it is likely to become increasingly critical to drive therapy. This article examines examples in traditional monogenic disorders that illustrates these points and define inborn errors of metabolism as complex genetic traits on the leading edge of precision medicine.
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Affiliation(s)
- Jerry Vockley
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America.
| | - Steven F Dobrowolski
- University of Pittsburgh School of Medicine, Department of Pathology, Pittsburgh, PA. UPMC Children's Hospital of Pittsburgh. 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America
| | - Georgianne L Arnold
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, United States of America; UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America
| | | | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, PO box 30 001, 9700, RB, Groningen, the Netherlands
| | - David A Weinstein
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT 06030, United States of America; GSD Program, Connecticut Children's Medical Center, Hartford, CT 06106, United States of America
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Borges K, Kaul N, Germaine J, Kwan P, O'Brien TJ. Randomized trial of add-on triheptanoin vs medium chain triglycerides in adults with refractory epilepsy. Epilepsia Open 2019; 4:153-163. [PMID: 30868125 PMCID: PMC6398112 DOI: 10.1002/epi4.12308] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/22/2018] [Accepted: 01/24/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To investigate the feasibility, safety, and tolerability of add-on treatment of the triglycerides of heptanoate (triheptanoin) vs the triglycerides of octanoate and decanoate (medium chain triglycerides [MCTs]) in adults with treatment-refractory epilepsy. METHODS After an 8-week prospective baseline period, people with drug-resistant epilepsy were randomized in a double-blind fashion to receive triheptanoin or MCTs. Treatment was titrated over 3 weeks to a maximum of 100 mL/d to be distributed over 3 meals and mixed into food, followed by 12-week maintenance before tapering. The primary aims were to assess the following: (a) safety by comparing the number of intervention-related adverse events with triheptanoin vs MCT treatment and (b) adherence, measured as a percentage of the prescribed treatment doses taken. RESULTS Thirty-four people were randomized (17 to MCT and 17 to triheptanoin). There were no differences regarding (a) the number of participants completing the study (11 vs 9 participants), (b) the time until withdrawal, (c) the total number of adverse events or those potentially related to treatment, (d) median doses of oils taken (59 vs 55 mL/d, P = 0.59), or (e) change in seizure frequency (54% vs 102%, P = 0.13). Please note that people with focal unaware seizures were underrepresented in the triheptanoin treatment arm (P = 0.04). The most common adverse events were gastrointestinal disturbances (47% and 62.5% of participants). Five people taking on average 0.73 mL/kg body weight MCTs (0.64 mL/kg median) and one person taking 0.59 mL/kg triheptanoin showed >50% reduction in seizure frequency, specifically focal unaware seizures. SIGNIFICANCE Add-on treatment with MCTs or triheptanoin was feasible, safe, and tolerated for 12 weeks in two-thirds of people with treatment-resistant epilepsy. Our results indicate a protective effect of MCTs on focal unaware seizures. This warrants further study.
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Affiliation(s)
- Karin Borges
- School of Biomedical SciencesFaculty of MedicineThe University of QueenslandSt. LuciaQueenslandAustralia
| | - Neha Kaul
- Department of Allied Health (Clinical Nutrition)Royal Melbourne HospitalParkvilleVictoriaAustralia
- Departments of Medicine and NeurologyRoyal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia
| | - Jack Germaine
- Departments of Medicine and NeurologyRoyal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia
| | - Patrick Kwan
- Departments of Medicine and NeurologyRoyal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia
- Departments of Neuroscience and NeurologyThe Central Clinical SchoolMonash University and the Alfred HospitalMelbourneVictoriaAustralia
| | - Terence J. O'Brien
- Departments of Medicine and NeurologyRoyal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia
- Departments of Neuroscience and NeurologyThe Central Clinical SchoolMonash University and the Alfred HospitalMelbourneVictoriaAustralia
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