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Stern S, Wang J, Li RJ, Hon YY, Weis SL, Wang YMC, Schuck R, Pacanowski M. Clinical pharmacology considerations for first-in-human clinical trials for enzyme replacement therapy. J Inherit Metab Dis 2024. [PMID: 38740427 DOI: 10.1002/jimd.12746] [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: 01/13/2024] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 05/16/2024]
Abstract
Inborn errors of metabolism (IEM) such as lysosomal storage disorders (LSDs) are conditions caused by deficiency of one or more key enzymes, cofactors, or transporters involved in a specific metabolic pathway. Enzyme replacement therapy (ERT) provides an exogenous source of the affected enzyme and is one of the most effective treatment options for IEMs. In this paper, we review the first-in-human (FIH) protocols for ERT drug development programs supporting 20 Biologic License Applications (BLA) approved by the Center for Drug Evaluation and Research (CDER) at the US Food and Drug Administration (FDA) in the period of May 1994 to September 2023. We surveyed study design elements across these FIH protocols including study population, dosage form, dose selection, treatment duration, immunogenicity, biomarkers, and study follow-up. A total of 18 FIH trials from 20 BLAs were identified and of those, 72% (13/18) used single ascending dose (SAD) and/or multiple ascending dose (MAD) study design, 83% (15/18) had a primary objective of assessing the safety and tolerability, 72% (13/18) included clinical endpoint assessments, and 94% (17/18) included biomarker assessments as secondary or exploratory endpoints. Notably, the majority of ERT products tested the approved route of administration and the approved dose was tested in 83% (15/18) of FIH trials. At last, we offer considerations for the design of FIH studies.
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Affiliation(s)
- Sydney Stern
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jie Wang
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ruo-Jing Li
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yuen Yi Hon
- Office of Rare Disease, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shawna L Weis
- Office of Rare Disease, Pediatrics, Urologic and Reproductive Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yow-Ming C Wang
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Schuck
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael Pacanowski
- Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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İnci A, Ezgü FS, Tümer L. Advances in Immune Tolerance Induction in Enzyme Replacement Therapy. Paediatr Drugs 2024; 26:287-308. [PMID: 38664313 PMCID: PMC11074017 DOI: 10.1007/s40272-024-00627-9] [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] [Accepted: 03/11/2024] [Indexed: 05/07/2024]
Abstract
Inborn errors of metabolism (IEMs) are a group of genetic diseases that occur due to the either deficiency of an enzyme involved in a metabolic/biochemical pathway or other disturbances in the metabolic pathway including transport protein or activator protein deficiencies, cofactor deficiencies, organelle biogenesis, maturation or trafficking problems. These disorders are collectively significant due to their substantial impact on both the well-being and survival of affected individuals. In the quest for effective treatments, enzyme replacement therapy (ERT) has emerged as a viable strategy for patients with many of the lysosomal storage disorders (LSD) and enzyme substitution therapy in the rare form of the other inborn errors of metabolism including phenylketonuria and hypophosphatasia. However, a major challenge associated with enzyme infusion in patients with these disorders, mainly LSD, is the development of high antibody titres. Strategies focusing on immunomodulation have shown promise in inducing immune tolerance to ERT, leading to improved overall survival rates. The implementation of immunomodulation concurrent with ERT administration has also resulted in a decreased occurrence of IgG antibody development compared with cases treated solely with ERT. By incorporating the knowledge gained from current approaches and analysing the outcomes of immune tolerance induction (ITI) modalities from clinical and preclinical trials have demonstrated significant improvement in the efficacy of ERT. In this comprehensive review, the progress in ITI modalities is assessed, drawing insights from both clinical and preclinical trials. The focus is on evaluating the advancements in ITI within the context of IEM, specifically addressing LSDs managed through ERT.
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Affiliation(s)
- Aslı İnci
- Department of Paediatric Metabolism and Nutrition, Gazi University School of Medicine, Emniyet Street, Yenimahalle, Ankara, Turkey.
| | - Fatih Süheyl Ezgü
- Department of Paediatric Metabolism and Nutrition, Gazi University School of Medicine, Emniyet Street, Yenimahalle, Ankara, Turkey
- Department of Paediatric Genetic, Gazi University School of Medicine, Ankara, Turkey
| | - Leyla Tümer
- Department of Paediatric Metabolism and Nutrition, Gazi University School of Medicine, Emniyet Street, Yenimahalle, Ankara, Turkey
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Chen HA, Hsu RH, Fang CY, Desai AK, Lee NC, Hwu WL, Tsai FJ, Kishnani PS, Chien YH. Optimizing treatment outcomes: immune tolerance induction in Pompe disease patients undergoing enzyme replacement therapy. Front Immunol 2024; 15:1336599. [PMID: 38715621 PMCID: PMC11074348 DOI: 10.3389/fimmu.2024.1336599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 04/05/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Pompe disease, a lysosomal storage disorder, is characterized by acid α-glucosidase (GAA) deficiency and categorized into two main subtypes: infantile-onset Pompe disease (IOPD) and late-onset Pompe disease (LOPD). The primary treatment, enzyme replacement therapy (ERT) with recombinant human GAA (rhGAA), faces challenges due to immunogenic responses, including the production of anti-drug antibody (ADA), which can diminish therapeutic efficacy. This study aims to assess the effectiveness of immune tolerance induction (ITI) therapy in cross-reactive immunologic material (CRIM)-positive Pompe disease patients with established high ADA levels. Method In a single-center, open-label prospective study, we assessed ITI therapy's efficacy in Pompe disease patients, both IOPD and LOPD, with persistently elevated ADA titers (≥1:12,800) and clinical decline. The ITI regimen comprised bortezomib, rituximab, methotrexate, and intravenous immunoglobulin. Biochemical data, biomarkers, ADA titers, immune status, and respiratory and motor function were monitored over six months before and after ITI. Results This study enrolled eight patients (5 IOPD and 3 LOPD). After a 6-month ITI course, median ADA titers significantly decreased from 1:12,800 (range 1:12,800-1:51,200) to 1:1,600 (range 1:400-1:12,800), with sustained immune tolerance persisting up to 4.5 years in some cases. Serum CK levels were mostly stable or decreased, stable urinary glucose tetrasaccharide levels were maintained in four patients, and no notable deterioration in respiratory or ambulatory status was noted. Adverse events included two treatable infection episodes and transient symptoms like numbness and diarrhea. Conclusion ITI therapy effectively reduces ADA levels in CRIM-positive Pompe disease patients with established high ADA titers, underscoring the importance of ADA monitoring and timely ITI initiation. The findings advocate for personalized immunogenicity risk assessments to enhance clinical outcomes. In some cases, prolonged immune suppression may be necessary, highlighting the need for further studies to optimize ITI strategies for Pompe disease treatment. ClinicalTrials.gov NCT02525172; https://clinicaltrials.gov/study/NCT02525172.
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Affiliation(s)
- Hui-An Chen
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Rai-Hseng Hsu
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Ya Fang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Ni-Chung Lee
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wuh-Liang Hwu
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Center for Precision Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Fuu-Jen Tsai
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Yin-Hsiu Chien
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
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Desai AK, Shrivastava G, Grant CL, Wang RY, Burt TD, Kishnani PS. An updated management approach of Pompe disease patients with high-sustained anti-rhGAA IgG antibody titers: experience with bortezomib-based immunomodulation. Front Immunol 2024; 15:1360369. [PMID: 38524130 PMCID: PMC10959098 DOI: 10.3389/fimmu.2024.1360369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/26/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction High sustained anti-rhGAA antibody titers (HSAT; ≥12,800) are directly linked to reduced efficacy of enzyme replacement therapy (ERT) and subsequent clinical deterioration in infantile-onset Pompe disease (IOPD). We have previously demonstrated the safety and effectiveness of a bortezomib-based immune-tolerance induction (ITI) regimen (bortezomib, rituximab, methotrexate, and IVIG) in eliminating HSAT. Methods Here, we describe two IOPD cases (patients 6 and 8) who developed HSAT at 8 and 10 weeks on ERT despite transient low-dose methotrexate ITI administration in the ERT-naïve setting and were treated with a bortezomib-based ITI regimen, and we compare their courses to a series of six historical patients (patients 1-5, and 7) with a similar presentation who exemplify our evolving approach to treatment. Results In total, patients 6 and 8 received 16 and 8 doses of bortezomib (4 doses=1 cycle) respectively reducing titers from 25,600 to seronegative, but differences in the course of their therapy were instructive regarding the optimal approach to initial treatment of HSAT; specifically, patient 6 was treated initially with only a single course of bortezomib rescue therapy, while patient 8 received two back-to-back courses. Patient 8 received IVIG therapy throughout the immunosuppression whereas patient 6 received IVIG therapy and was switched to subcutaneous IgG replacement. Patient 6 had a transient reduction in anti-rhGAA antibodies, after receiving a single initial cycle of bortezomib, but had a recurrence of high anti-rhGAA antibody titer after 160 weeks that required 3 additional cycles of bortezomib to ultimately achieve tolerance. In contrast, patient 8 achieved tolerance after being given two consecutive cycles of bortezomib during their initial treatment and had B cell recovery by week 54. Since the reduction in anti-rhGAA antibodies, both patients are doing well clinically, and have decreasing ALT, AST, and CK. No major infections leading to interruption of treatment were observed in either patient. The bortezomib-based ITI was safe and well-tolerated, and patients continue to receive ERT at 40 mg/kg/week. Discussion These case studies and our previous experience suggest that to achieve an effective reduction of anti-rhGAA antibodies in the setting of HSAT, bortezomib should be initiated at the earliest sign of high anti-rhGAA antibodies with a minimum of two consecutive cycles as shown in the case of patient 8. It is important to note that, despite initiation of ERT at age 2.3 weeks, patient 8 quickly developed HSAT. We recommend close monitoring of anti-rhGAA antibodies and early intervention with ITI as soon as significantly elevated anti-rhGAA antibody titers are noted.
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Affiliation(s)
- Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Garima Shrivastava
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Christina L. Grant
- Division of Genetics and Metabolism, Children’s National Hospital, Washington, DC, United States
| | - Raymond Y. Wang
- Division of Metabolic Disorders, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Pediatrics, University of California-Irvine School of Medicine, Orange, CA, United States
| | - Trevor D. Burt
- Division of Neonatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Children’s Health and Discovery Initiative, Duke University School of Medicine, Durham, NC, United States
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
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Ditters IAM, van Kooten HA, van der Beek NAME, van der Ploeg AT, Huidekoper HH, van den Hout JMP. Are Anti-rhGAA Antibodies a Determinant of Treatment Outcome in Adults with Late-Onset Pompe Disease? A Systematic Review. Biomolecules 2023; 13:1414. [PMID: 37759814 PMCID: PMC10526476 DOI: 10.3390/biom13091414] [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: 07/14/2023] [Revised: 09/08/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Pompe disease is a lysosomal storage disease characterised by skeletal and respiratory muscle weakness. Since 2006, enzyme replacement therapy (ERT) with alglucosidase alfa has been available. ERT significantly improves the prognosis of patients with Pompe disease. The effect of high antibody titres on treatment response in adults with late-onset Pompe disease (LOPD) remains unclear but may contribute to interpatient variation. We therefore conducted a systematic review on this subject. METHODS A systematic search was performed in Embase, Medline Ovid, Web of Science, Psych Info Ovid, Cochrane (Clinical Trials only), and Google Scholar (random top-200). Articles were included if they involved adults with LOPD treated with alglucosidase alfa and mentioned anti-rhGAA antibodies or antibody titres. In addition, articles mentioning dosages different from the standard recommended dosage were included. RESULTS Our literature search retrieved 2562 publications, and 17 fulfilled our selection criteria, describing 443 cases. Seven publications reported on anti-rhGAA antibody titres on a group level, with the percentage of patients with a high titre as defined in the included articles ranging from 0-33%. Six publications reported on the effect of anti-rhGAA antibody titre on clinical course, and four found no correlation. Two studies reported a negative effect on treatment. The first study found a greater improvement in Medical Research Council (MRC) score in patients with no detectable antibody titre. In the second study, a patient discontinued ERT due to a declining neuromuscular state as a result of high anti-rhGAA antibody titres. Seven publications reported on 17 individual patients with a high antibody titre (range 1:12,800-1:3,906,250). In only two cases were high-sustained neutralising antibodies reported to interfere with treatment efficacy. CONCLUSIONS No clear effect of anti-rhGAA IgG antibodies on treatment response could be established for the majority of LOPD patients with a high antibody titre. In a minority of patients, a clinical decline related to (possible) interference of anti-rhGAA antibodies was described.
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Affiliation(s)
- Imke A. M. Ditters
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Harmke A. van Kooten
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Nadine A. M. E. van der Beek
- Department of Neurology, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Ans T. van der Ploeg
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Hidde H. Huidekoper
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Johanna M. P. van den Hout
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Erasmus University Medical Center, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Hannah WB, Derks TGJ, Drumm ML, Grünert SC, Kishnani PS, Vissing J. Glycogen storage diseases. Nat Rev Dis Primers 2023; 9:46. [PMID: 37679331 DOI: 10.1038/s41572-023-00456-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/09/2023]
Abstract
Glycogen storage diseases (GSDs) are a group of rare, monogenic disorders that share a defect in the synthesis or breakdown of glycogen. This Primer describes the multi-organ clinical features of hepatic GSDs and muscle GSDs, in addition to their epidemiology, biochemistry and mechanisms of disease, diagnosis, management, quality of life and future research directions. Some GSDs have available guidelines for diagnosis and management. Diagnostic considerations include phenotypic characterization, biomarkers, imaging, genetic testing, enzyme activity analysis and histology. Management includes surveillance for development of characteristic disease sequelae, avoidance of fasting in several hepatic GSDs, medically prescribed diets, appropriate exercise regimens and emergency letters. Specific therapeutic interventions are available for some diseases, such as enzyme replacement therapy to correct enzyme deficiency in Pompe disease and SGLT2 inhibitors for neutropenia and neutrophil dysfunction in GSD Ib. Progress in diagnosis, management and definitive therapies affects the natural course and hence morbidity and mortality. The natural history of GSDs is still being described. The quality of life of patients with these conditions varies, and standard sets of patient-centred outcomes have not yet been developed. The landscape of novel therapeutics and GSD clinical trials is vast, and emerging research is discussed herein.
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Affiliation(s)
- William B Hannah
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA.
| | - Terry G J Derks
- Division of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mitchell L Drumm
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Sarah C Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Medical Centre-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Paediatrics, Duke University Medical Center, Durham, NC, USA
| | - John Vissing
- Copenhagen Neuromuscular Center, Copenhagen University Hospital, Copenhagen, Denmark
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Kim KH, Desai AK, Vucko ER, Boggs T, Kishnani PS, Burton BK. Development of high sustained anti-drug antibody titers and corresponding clinical decline in a late-onset Pompe disease patient after 11+ years on enzyme replacement therapy. Mol Genet Metab Rep 2023; 36:100981. [PMID: 37342670 PMCID: PMC10277605 DOI: 10.1016/j.ymgmr.2023.100981] [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: 11/21/2022] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
A late-onset Pompe disease patient developed high sustained antibody titers (HSAT) of ≥51,200 after 11+ years on alglucosidase alfa and previous tolerance. There was a corresponding worsening of motor function and rise in urinary glucose tetrasaccharide (Glc4). Following immunomodulation therapy, HSAT were eliminated with improved clinical outcomes and biomarker trends. This report highlights the importance of continued surveillance of antibody titers and biomarkers, the negative impact of HSAT, and improved outcomes with immunomodulation therapy.
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Affiliation(s)
- Katherine H. Kim
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Genetics, Genomics and Metabolism, Ann & Robert H Lurie Children's Hospital of Chicago, 225 E Chicago Ave Box 59, Chicago, IL 60611, USA
| | - Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Box 103856 DUM, Durham, NC 27710, USA
| | - Erika R. Vucko
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Genetics, Genomics and Metabolism, Ann & Robert H Lurie Children's Hospital of Chicago, 225 E Chicago Ave Box 59, Chicago, IL 60611, USA
| | - Tracy Boggs
- Department of Rehabilitation Services, Duke University Health System, 234 Crooked Creek Pkwy, Suite 310, Durham, NC 27713, USA
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Box 103856 DUM, Durham, NC 27710, USA
| | - Barbara K. Burton
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Genetics, Genomics and Metabolism, Ann & Robert H Lurie Children's Hospital of Chicago, 225 E Chicago Ave Box 59, Chicago, IL 60611, USA
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El Haddad L, Khan M, Soufny R, Mummy D, Driehuys B, Mansour W, Kishnani PS, ElMallah MK. Monitoring and Management of Respiratory Function in Pompe Disease: Current Perspectives. Ther Clin Risk Manag 2023; 19:713-729. [PMID: 37680303 PMCID: PMC10480292 DOI: 10.2147/tcrm.s362871] [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: 05/13/2023] [Accepted: 08/14/2023] [Indexed: 09/09/2023] Open
Abstract
Pompe disease (PD) is a neuromuscular disorder caused by a deficiency of acid alpha-glucosidase (GAA) - a lysosomal enzyme responsible for hydrolyzing glycogen. GAA deficiency leads to accumulation of glycogen in lysosomes, causing cellular disruption. The severity of PD is directly related to the extent of GAA deficiency - if no or minimal GAA is produced, symptoms are severe and manifest in infancy, known as infantile onset PD (IOPD). If left untreated, infants with IOPD experience muscle hypotonia and cardio-respiratory failure leading to significant morbidity and mortality in the first year of life. In contrast, late-onset PD (LOPD) patients have more GAA activity and present later in life, but also have significant respiratory function decline. Despite FDA-approved enzyme replacement therapy, respiratory insufficiency remains a major cause of morbidity and mortality, emphasizing the importance of early detection and management of respiratory complications. These complications include impaired cough and airway clearance, respiratory muscle weakness, sleep-related breathing issues, and pulmonary infections. This review aims to provide an overview of the respiratory pathology, monitoring, and management of PD patients. In addition, we discuss the impact of novel approaches and therapies on respiratory function in PD.
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Affiliation(s)
- Léa El Haddad
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Mainur Khan
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Rania Soufny
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - David Mummy
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Bastiaan Driehuys
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Wissam Mansour
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Mai K ElMallah
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Rana J, Muñoz MM, Biswas M. Oral tolerance to prevent anti-drug antibody formation in protein replacement therapies. Cell Immunol 2022; 382:104641. [PMID: 36402002 PMCID: PMC9730862 DOI: 10.1016/j.cellimm.2022.104641] [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: 09/21/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
Protein based therapeutics have successfully improved the quality of life for patients of monogenic disorders like hemophilia, Pompe and Fabry disease. However, a significant proportion of patients develop immune responses towards intravenously infused therapeutic protein, which can complicate or neutralize treatment and compromise patient safety. Strategies aimed at circumventing immune responses following therapeutic protein infusion can greatly improve therapeutic efficacy. In recent years, antigen-based oral tolerance induction has shown promising results in the prevention and treatment of autoimmune diseases, food allergies and can prevent anti-drug antibody formation to protein replacement therapies. Oral tolerance exploits regulatory mechanisms that are initiated in the gut associated lymphoid tissue (GALT) to promote active suppression of orally ingested antigen. In this review, we outline general perceptions and current knowledge about the mechanisms of oral tolerance, including tissue specific sites of tolerance induction and the cells involved, with emphasis on antigen presenting cells and regulatory T cells. We define several factors, such as cytokines and metabolites that impact the stability and expansion potential of these immune modulatory cells. We highlight preclinical studies that have been performed to induce oral tolerance to therapeutic proteins or enzymes for single gene disorders, such as hemophilia or Pompe disease. These studies mainly utilize a transgenic plant-based system for oral delivery of antigen in conjugation with fusion protein technology that favors the prevention of antigen degradation in the stomach while enhancing uptake in the small intestine by antigen presenting cells and regulatory T cell induction, thereby promoting antigen specific systemic tolerance.
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Affiliation(s)
- Jyoti Rana
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maite Melero Muñoz
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Moanaro Biswas
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
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Al-Hassnan Z, Hashmi NA, Makhseed N, Omran TB, Al Jasmi F, Teneiji AA. Expert Group Consensus on early diagnosis and management of infantile-onset pompe disease in the Gulf Region. Orphanet J Rare Dis 2022; 17:388. [PMID: 36303251 PMCID: PMC9615381 DOI: 10.1186/s13023-022-02545-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Infantile-onset Pompe disease (IOPD) is a rare and devastating, autosomal recessive lysosomal storage disorder that manifests immediately after birth. In severe IOPD cases, complete/almost-complete acid alpha-glucosidase enzyme deficiency is observed. Considering the rapid progression of the disease, timely diagnosis and treatment are important; even slight delays can remarkably alter the course of the disease. Enzyme replacement therapy (ERT) with recombinant human acid alpha-glucosidase is safe and beneficial for IOPD patients. However, there is heterogeneity in the patient response to ERT. The factors influencing treatment effectiveness include the patient's age at the time of treatment initiation, pre-existing muscle damage, and cross-reactive immunologic material (CRIM) status at baseline. Immunomodulation along with ERT is the recently developed therapeutic approach that has been included in the therapeutic armamentarium of IOPD for optimizing clinical benefits, particularly in CRIM-negative IOPD patients. However, there is a dearth of published data on the early diagnosis and clinical position of the immunomodulation protocol along with ERT in the treatment of IOPD in the Gulf region. METHODS AND RESULTS Expert panel meetings, involving six experts from the Kingdom of Saudi Arabia, Kuwait, Oman, Qatar, and the United Arab Emirates, were convened to develop consensus-based recommendations addressing current diagnostic and management challenges for patients with IOPD in the Gulf region. Furthermore, this consensus guideline may be implemented in clinical practice for the timely diagnosis and management of patients with IOPD. CONCLUSION The expert consensus will help clinicians to make appropriate and timely decisions regarding immunomodulation initiation and ERT treatment in IOPD patients in the Gulf region.
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Affiliation(s)
- Zuhair Al-Hassnan
- Department of Medical Genetics, MBC-75 King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
| | - Nadia Al Hashmi
- Department of Child Health, National Genetic Center, Royal Hospital, Muscat, Sultanate of Oman
| | - Nawal Makhseed
- Pediatric Department, Al-Farwaniya Hospital, and Maternity Hospital, Al-Jahra Hospital, Kuwait, Kuwait
| | - Tawfeg Ben Omran
- Division of Genetic and Genomic Medicine, Sidra Medicine, Doha, Qatar
- Department of Medical Genetics, Hamad Medical Corporation, Doha, Qatar
| | - Fatma Al Jasmi
- Department of Genetics and Genomic Medicine, United Arab Emirates University, Abu Dhabi, United Arab Emirates
- Division of Metabolic Genetics, Department of Pediatrics, Tawam Hospital, Al Ain, United Arab Emirates
| | - Amal Al Teneiji
- Division of Metabolic Genetics, Department of Pediatrics, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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11
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Curelaru S, Desai AK, Fink D, Zehavi Y, Kishnani PS, Spiegel R. A favorable outcome in an infantile-onset Pompe patient with cross reactive immunological material (CRIM) negative disease with high dose enzyme replacement therapy and adjusted immunomodulation. Mol Genet Metab Rep 2022; 32:100893. [PMID: 35813979 PMCID: PMC9263520 DOI: 10.1016/j.ymgmr.2022.100893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 11/30/2022] Open
Abstract
Infantile onset Pompe disease (IOPD) is a rare devastating disease that presents in early infancy with rapidly progressive hypertrophic cardiomyopathy, severe generalized myopathy and death within the first year of life. The emergence of enzyme replacement therapy (ERT) with recombinant human acid alpha glucosidase (rhGAA) has improved the natural course of IOPD with a significant impact on cardiomyopathy but has a more limited effect on the progression of myopathy and consequently the later deterioration of the disease. Possible reasons for reduced ERT efficacy include insufficient enzyme, partial targeting of skeletal muscle and the development of IgG rhGAA antibodies especially in patients who are cross-reactive immunological material (CRIM) negative. We report a CRIM-negative IOPD female patient who started treatment upon diagnosis at 4.5 months with ERT at 20 mg/kg every other week and a course of combined immunomodulation with rituximab, methotrexate and IVIG according to the published Duke protocol and increased ERT within a month to 40 mg/kg/week. Despite initial good clinical response to ERT and immunomodulation, monthly monitoring identified a gradual increase of serum antibody titers to rhGAA necessitating a second course of immunomodulation with bortezomib and maintenance rituximab and methotrexate. A gradual reduction in frequency of immunotherapy was instituted and over a period of 14 months was discontinued. Serum anti-rhGAA antibody titers remained negative for 5 months since cessation of immunomodulation and the patient is now immune tolerant with recovery of CD19. At the age of 30 months the patient is walking independently and has normal cardiac function and anatomy. We recommend initiating ERT at 40 mg/kg/week in CRIM-negative IOPD patients, concomitant with immunomodulation and monthly monitoring of serum anti-rhGAA IgG titers upon confirmation of the diagnosis.
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Affiliation(s)
- Shiri Curelaru
- Department of Pediatrics B, Emek Medical Center, Afula, Israel
| | - Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - Daniel Fink
- Pediatric Cardiology Unit, Emek Medical Center, Afula, Israel
| | - Yoav Zehavi
- Department of Pediatrics B, Emek Medical Center, Afula, Israel
- Rappaport School of Medicine, Technion, Haifa, Israel
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - Ronen Spiegel
- Department of Pediatrics B, Emek Medical Center, Afula, Israel
- Rappaport School of Medicine, Technion, Haifa, Israel
- Corresponding author at: Department of Pediatrics B, Emek Medical Center, Afula 1834111, Israel.
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12
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Gragnaniello V, Deodato F, Gasperini S, Donati MA, Canessa C, Fecarotta S, Pascarella A, Spadaro G, Concolino D, Burlina A, Parenti G, Strisciuglio P, Fiumara A, Casa RD. Immune responses to alglucosidase in infantile Pompe disease: recommendations from an Italian pediatric expert panel. Ital J Pediatr 2022; 48:41. [PMID: 35248118 PMCID: PMC8898438 DOI: 10.1186/s13052-022-01219-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background Classic infantile onset of Pompe disease (c-IOPD) leads to hypotonia and hypertrophic cardiomyopathy within the first days to weeks of life and, without treatment, patients die of cardiorespiratory failure in their first 1–2 years of life. Enzymatic replacement therapy (ERT) with alglucosidase alfa is the only available treatment, but adverse immune reactions can reduce ERT’s effectiveness and safety. It is therefore very important to identify strategies to prevent and manage these complications. Several articles have been written on this disease over the last 10 years, but no univocal indications have been established. Methods Our study presents a review of the current literature on management of immune responses to ERT in c-IOPD as considered by an Italian study group of pediatric metabolists and immunologists in light of our shared patient experience. Results We summarize the protocols for the management of adverse reactions to ERT, analyzing their advantages and disadvantages, and provide expert recommendations for their optimal management, to the best of current knowledge. However, further studies are needed to improve actual management protocols, which still have several limitations.
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13
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Lenders M, Brand E. Mechanisms of Neutralizing Anti-drug Antibody Formation and Clinical Relevance on Therapeutic Efficacy of Enzyme Replacement Therapies in Fabry Disease. Drugs 2021; 81:1969-1981. [PMID: 34748189 PMCID: PMC8602155 DOI: 10.1007/s40265-021-01621-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by mutations in the α-galactosidase A (AGAL/GLA) gene. The lysosomal accumulation of the substrates globotriaosylceramide (Gb3) and globotriaosylsphingosine (lyso-Gb3) results in progressive renal failure, cardiomyopathy associated with cardiac arrhythmia, and recurrent strokes, significantly limiting life expectancy in affected patients. Current treatment options for FD include recombinant enzyme-replacement therapies (ERTs) with intravenous agalsidase-α (0.2 mg/kg body weight) or agalsidase-β (1 mg/kg body weight) every 2 weeks, facilitating cellular Gb3 clearance and an overall improvement of disease burden. However, ERT can lead to infusion-associated reactions, as well as the formation of neutralizing anti-drug antibodies (ADAs) in ERT-treated males, leading to an attenuation of therapy efficacy and thus disease progression. In this narrative review, we provide a brief overview of the clinical picture of FD and diagnostic confirmation. The focus is on the biochemical and clinical significance of neutralizing ADAs as a humoral response to ERT. In addition, we provide an overview of different methods for ADA measurement and characterization, as well as potential therapeutic approaches to prevent or eliminate ADAs in affected patients, which is representative for other ERT-treated lysosomal storage diseases.
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Affiliation(s)
- Malte Lenders
- Department of Internal Medicine D, Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Eva Brand
- Department of Internal Medicine D, Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster (IFAZ), University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
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14
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Nguyen NH, Glassman FY, Dingman RK, Shenoy GN, Wohlfert EA, Kay JG, Bankert RB, Balu-Iyer SV. Rational design of a nanoparticle platform for oral prophylactic immunotherapy to prevent immunogenicity of therapeutic proteins. Sci Rep 2021; 11:17853. [PMID: 34497305 PMCID: PMC8426360 DOI: 10.1038/s41598-021-97333-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/11/2021] [Indexed: 12/31/2022] Open
Abstract
The safety and efficacy of several life-saving therapeutic proteins are compromised due to their immunogenicity. Once a sustained immune response against a protein-based therapy is established, clinical options that are safe and cost-effective become limited. Prevention of immunogenicity of therapeutic proteins prior to their initial use is critical as it is often difficult to reverse an established immune response. Here, we discuss a rational design and testing of a phosphatidylserine-containing nanoparticle platform for novel oral prophylactic reverse vaccination approach, i.e., pre-treatment of a therapeutic protein in the presence of nanoparticles to prevent immunogenicity of protein therapies.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, SUNY-University at Buffalo, 359 Pharmacy Building, Buffalo, NY, 14214, USA
| | - Fiona Y Glassman
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, SUNY-University at Buffalo, 359 Pharmacy Building, Buffalo, NY, 14214, USA
- CSL Behring, King of Prussia, PA, USA
| | - Robert K Dingman
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, SUNY-University at Buffalo, 359 Pharmacy Building, Buffalo, NY, 14214, USA
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | - Gautam N Shenoy
- Department of Microbiology and Immunology, Jacobs School of Medicine and Biomedical Sciences, SUNY-University at Buffalo, Buffalo, NY, USA
| | - Elizabeth A Wohlfert
- Department of Microbiology and Immunology, Jacobs School of Medicine and Biomedical Sciences, SUNY-University at Buffalo, Buffalo, NY, USA
| | - Jason G Kay
- Department of Oral Biology, School of Dental Medicine, SUNY-University at Buffalo, Buffalo, NY, USA
| | - Richard B Bankert
- Department of Microbiology and Immunology, Jacobs School of Medicine and Biomedical Sciences, SUNY-University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, SUNY-University at Buffalo, 359 Pharmacy Building, Buffalo, NY, 14214, USA.
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15
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Cell type-selective targeted delivery of a recombinant lysosomal enzyme for enzyme therapies. Mol Ther 2021; 29:3512-3524. [PMID: 34400331 DOI: 10.1016/j.ymthe.2021.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/15/2021] [Accepted: 08/08/2021] [Indexed: 11/21/2022] Open
Abstract
Lysosomal diseases are a class of genetic disorders predominantly caused by loss of lysosomal hydrolases, leading to lysosomal and cellular dysfunction. Enzyme replacement therapy (ERT), where recombinant enzyme is given intravenously, internalized by cells, and trafficked to the lysosome, has been applied to treat several lysosomal diseases. However, current ERT regimens do not correct disease phenotypes in all affected organs because the biodistribution of enzyme uptake does not match that of the affected cells that require the enzyme. We present here targeted ERT, an approach that utilizes antibody-enzyme fusion proteins to target the enzyme to specific cell types. The antibody moiety recognizes transmembrane proteins involved in lysosomal trafficking and that are also preferentially expressed in those cells most affected in disease. Using Pompe disease (PD) as an example, we show that targeted ERT is superior to ERT in treating the skeletal muscle phenotypes of PD mice both as a protein replacement therapeutic and as a gene therapy.
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16
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Simonetta I, Tuttolomondo A, Daidone M, Miceli S, Pinto A. Treatment of Anderson-Fabry Disease. Curr Pharm Des 2021; 26:5089-5099. [PMID: 32183665 DOI: 10.2174/1381612826666200317142412] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/10/2020] [Indexed: 12/25/2022]
Abstract
Fabry disease is an X-linked disorder of glycosphingolipid metabolism that results in progressive accumulation of neutral glycosphingolipids, predominantly globotriaosylsphingosine (Gb3) in lysosomes, as well as other cellular compartments of several tissues, causing multi-organ manifestations (acroparesthesias, hypohidrosis, angiokeratomas, signs and symptoms of cardiac, renal, cerebrovascular involvement). Pathogenic mutations lead to a deficiency of the lysosomal enzyme alpha-galactosidase A (GLA). In the presence of high clinical suspicion, a careful physical examination and specific laboratory tests are required. Finally, the diagnosis of Fabry's disease is confirmed by the demonstration of the absence of or reduced alpha-galactosidase A enzyme activity in hemizygous men and gene typing in heterozygous females. Measurement of the biomarkers Gb3 and Lyso Gb3 in biological specimens may facilitate diagnosis. The current treatment of Anderson-Fabry disease is represented by enzyme replacement therapy (ERT) and oral pharmacological chaperone. Future treatments are based on new strategic approaches such as stem cell-based therapy, pharmacological approaches chaperones, mRNA therapy, and viral gene therapy. This review outlines the current therapeutic approaches and emerging treatment strategies for Anderson-Fabry disease.
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Affiliation(s)
- Irene Simonetta
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
| | - Antonino Tuttolomondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
| | - Mario Daidone
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
| | - Salvatore Miceli
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
| | - Antonio Pinto
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Piazza delle Cliniche n.2, 90127 Palermo, Italy
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17
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Blasco-Alonso J, Gil-Gómez R, Jurado AL, Macías RY. Immunomodulation for Pompe Disease with high sustained antibodies against enzyme replacement therapy. Med Clin (Barc) 2021; 157:403-405. [PMID: 33526273 DOI: 10.1016/j.medcli.2020.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Javier Blasco-Alonso
- UGC Pediatría. Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Spain; Grupo IBIMA Multidisciplinar de Investigación Pediátrica, Universidad de Málaga, Spain.
| | - Raquel Gil-Gómez
- Unidad de Gestión Clínica de Cuidados Críticos y Urgencias de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Spain
| | | | - Raquel Yahyaoui Macías
- Unidad de Gestión Clínica Laboratorio, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Spain
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18
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Manta A, Spendiff S, Lochmüller H, Thompson R. Targeted Therapies for Metabolic Myopathies Related to Glycogen Storage and Lipid Metabolism: a Systematic Review and Steps Towards a 'Treatabolome'. J Neuromuscul Dis 2021; 8:401-417. [PMID: 33720849 PMCID: PMC8203237 DOI: 10.3233/jnd-200621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Metabolic myopathies are a heterogenous group of muscle diseases typically characterized by exercise intolerance, myalgia and progressive muscle weakness. Effective treatments for some of these diseases are available, but while our understanding of the pathogenesis of metabolic myopathies related to glycogen storage, lipid metabolism and β-oxidation is well established, evidence linking treatments with the precise causative genetic defect is lacking. OBJECTIVE The objective of this study was to collate all published evidence on pharmacological therapies for the aforementioned metabolic myopathies and link this to the genetic mutation in a format amenable to databasing for further computational use in line with the principles of the "treatabolome" project. METHODS A systematic literature review was conducted to retrieve all levels of evidence examining the therapeutic efficacy of pharmacological treatments on metabolic myopathies related to glycogen storage and lipid metabolism. A key inclusion criterion was the availability of the genetic variant of the treated patients in order to link treatment outcome with the genetic defect. RESULTS Of the 1,085 articles initially identified, 268 full-text articles were assessed for eligibility, of which 87 were carried over into the final data extraction. The most studied metabolic myopathies were Pompe disease (45 articles), multiple acyl-CoA dehydrogenase deficiency related to mutations in the ETFDH gene (15 articles) and systemic primary carnitine deficiency (8 articles). The most studied therapeutic management strategies for these diseases were enzyme replacement therapy, riboflavin, and carnitine supplementation, respectively. CONCLUSIONS This systematic review provides evidence for treatments of metabolic myopathies linked with the genetic defect in a computationally accessible format suitable for databasing in the treatabolome system, which will enable clinicians to acquire evidence on appropriate therapeutic options for their patient at the time of diagnosis.
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Affiliation(s)
- A. Manta
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - S. Spendiff
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - H. Lochmüller
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Neuropediatrics and Muscle Disorders, Medical Center –University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Centro Nacional de Análisis Genómico (CNAG-CRG), Center for Genomic Regulation, Barcelona Institute of Science and Technology (BIST), Barcelona, Catalonia, Spain
- Division of Neurology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Canada
- Brain and Mind Research Institute, University of Ottawa, Ottawa, Canada
| | - R. Thompson
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
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19
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Vaisman-Mentesh A, Gutierrez-Gonzalez M, DeKosky BJ, Wine Y. The Molecular Mechanisms That Underlie the Immune Biology of Anti-drug Antibody Formation Following Treatment With Monoclonal Antibodies. Front Immunol 2020; 11:1951. [PMID: 33013848 PMCID: PMC7461797 DOI: 10.3389/fimmu.2020.01951] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/20/2020] [Indexed: 12/25/2022] Open
Abstract
Monoclonal antibodies (mAbs) are a crucial asset for human health and modern medicine, however, the repeated administration of mAbs can be highly immunogenic. Drug immunogenicity manifests in the generation of anti-drug antibodies (ADAs), and some mAbs show immunogenicity in up to 70% of patients. ADAs can alter a drug's pharmacokinetic and pharmacodynamic properties, reducing drug efficacy. In more severe cases, ADAs can neutralize the drug's therapeutic effects or cause severe adverse events to the patient. While some contributing factors to ADA formation are known, the molecular mechanisms of how therapeutic mAbs elicit ADAs are not completely clear. Accurate ADA detection is necessary to provide clinicians with sufficient information for patient monitoring and clinical intervention. However, ADA assays present unique challenges because both the analyte and antigen are antibodies, so most assays are cumbersome, costly, time consuming, and lack standardization. This review will discuss aspects related to ADA formation following mAb drug administration. First, we will provide an overview of the prevalence of ADA formation and the available diagnostic tools for their detection. Next, we will review studies that support possible molecular mechanisms causing the formation of ADA. Finally, we will summarize recent approaches used to decrease the propensity of mAbs to induce ADAs.
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Affiliation(s)
- Anna Vaisman-Mentesh
- George S. Wise Faculty of Life Sciences, School of Molecular Cell Biology and Biotechnology, Tel Aviv University, Tel Aviv, Israel
| | | | - Brandon J. DeKosky
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, KS, United States
- Department of Chemical and Petroleum Engineering, The University of Kansas, Lawrence, KS, United States
| | - Yariv Wine
- George S. Wise Faculty of Life Sciences, School of Molecular Cell Biology and Biotechnology, Tel Aviv University, Tel Aviv, Israel
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20
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Predicting the Development of Anti-Drug Antibodies against Recombinant alpha-Galactosidase A in Male Patients with Classical Fabry Disease. Int J Mol Sci 2020; 21:ijms21165784. [PMID: 32806627 PMCID: PMC7460974 DOI: 10.3390/ijms21165784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022] Open
Abstract
Fabry Disease (FD) is a rare, X-linked, lysosomal storage disease that mainly causes renal, cardiac and cerebral complications. Enzyme replacement therapy (ERT) with recombinant alpha-galactosidase A is available, but approximately 50% of male patients with classical FD develop inhibiting anti-drug antibodies (iADAs) that lead to reduced biochemical responses and an accelerated loss of renal function. Once immunization has occurred, iADAs tend to persist and tolerization is hard to achieve. Here we developed a pre-treatment prediction model for iADA development in FD using existing data from 120 classical male FD patients from three European centers, treated with ERT. We found that nonsense and frameshift mutations in the α-galactosidase A gene (p = 0.05), higher plasma lysoGb3 at baseline (p < 0.001) and agalsidase beta as first treatment (p = 0.006) were significantly associated with iADA development. Prediction performance of a Random Forest model, using multiple variables (AUC-ROC: 0.77) was compared to a logistic regression (LR) model using the three significantly associated variables (AUC-ROC: 0.77). The LR model can be used to determine iADA risk in individual FD patients prior to treatment initiation. This helps to determine in which patients adjusted treatment and/or immunomodulatory regimes may be considered to minimize iADA development risk.
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21
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Julien DC, Woolgar K, Pollard L, Miller H, Desai A, Lindstrom K, Kishnani PS. Immune Modulation for Enzyme Replacement Therapy in A Female Patient With Hunter Syndrome. Front Immunol 2020; 11:1000. [PMID: 32508845 PMCID: PMC7253587 DOI: 10.3389/fimmu.2020.01000] [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: 02/01/2020] [Accepted: 04/27/2020] [Indexed: 12/21/2022] Open
Abstract
A 3.5 year old Hispanic female presented with signs and symptoms concerning for MPS II (Hunter Syndrome). The diagnosis of MPS II was confirmed by enzyme and molecular testing. Genetic evaluation revealed undetectable plasma iduronate-2-sulfatase enzyme activity and an inversion between intron 7 of the IDS gene and a region near exon 3 of IDS-2. This inversion is the molecular cause for ~8% of cases of MPS II and often results in a severe phenotype. X-inactivation studies revealed an inactivation ratio of 100:0. Given the patient's undetectable enzyme level, in combination with a severe IDS gene mutation, classic features at time of presentation, and the significantly skewed X inactivation, there was concern that she was at high risk of developing high and sustained antibody titers to idursulfase which would limit her benefit from enzyme replacement therapy (ERT). Anti-drug neutralizing antibodies to idursulfase have been associated with reduced systemic exposure to idursulfase and poorer clinical outcomes. Therefore, the decision was made to concurrently treat the patient with immune tolerance induction therapy during the first month of treatment with idursulfase in order to decrease the risk of developing high sustained antibody titers. The immune tolerance induction protocol consisted of rituximab weekly for 4 weeks, methotrexate three times a week for 3 weeks and monthly IVIG through B-cell and immunoglobulin recovery. Immune tolerance induction was initiated concurrently with the start of ERT. The patient had no significant adverse effects related to undergoing immune tolerance induction therapy and two and half years later is doing well with significantly reduced urine glycosaminoglycans and very low anti-drug antibody titers. This immune tolerance induction protocol could be considered for other patients with MPS II as well as patients with other lysosomal storage disorders who are starting on enzyme replacement therapy and are at high risk of developing neutralizing anti-drug antibodies.
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Affiliation(s)
- Daniel C Julien
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Kara Woolgar
- Division of Genetics and Metabolism, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Laura Pollard
- Division of Medical Genetics, Greenwood, SC, United States
| | - Holly Miller
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Ankit Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Kristin Lindstrom
- Division of Genetics and Metabolism, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
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22
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Tsai HM. Thrombotic Thrombocytopenic Purpura: Beyond Empiricism and Plasma Exchange. Am J Med 2019; 132:1032-1037. [PMID: 30928346 DOI: 10.1016/j.amjmed.2019.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 01/04/2023]
Abstract
For many years after its first description in 1924, thrombotic thrombocytopenic purpura was an intriguing puzzle for clinicians and researchers, not only for its unique pathology, perplexing changes in von Willebrand factor multimers, and high rate of rapid fatality but also for its dramatic response to plasma infusion or exchange. The discovery of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats member-13) and its deficiency in patients with thrombotic thrombocytopenic purpura, due to inhibitory autoantibodies or genetic mutations, provides a mechanistic scheme for understanding its pathogenesis. This new knowledge quickly led to the use of rituximab to promote its remission and prevent recurrence. Recombinant ADAMTS13 is also under development to replace plasma infusion as the therapy for hereditary thrombotic thrombocytopenic purpura. Recently, caplacizumab, a bivalent nanobody targeting the glycoprotein 1b binding epitope of von Willebrand factor A1 domain, was approved as an addition to the current regimen of plasma exchange and immunomodulation for adult patients of acquired thrombotic thrombocytopenic purpura. This review discusses how the new treatment may improve patient outcomes and its potential pitfalls.
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Affiliation(s)
- Han-Mou Tsai
- Division of Hematology/Oncology, State University of New York Downstate Medical Center, Brooklyn.
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23
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Desai AK, Li C, Rosenberg AS, Kishnani PS. Immunological challenges and approaches to immunomodulation in Pompe disease: a literature review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:285. [PMID: 31392197 PMCID: PMC6642943 DOI: 10.21037/atm.2019.05.27] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 01/30/2023]
Abstract
Pompe disease is an autosomal recessive disorder caused by a deficiency of acid alpha-glucosidase resulting in intralysosomal glycogen accumulation in multiple tissue types, especially cardiac, skeletal, and smooth muscle. Enzyme replacement therapy (ERT) with alglucosidase alfa has led to improved clinical outcomes and prolonged survival in patients with Pompe disease. While ERT has changed the natural course of Pompe disease, with many long-term survivors, several factors affect the response to ERT. Previous studies in Pompe disease have shown that IgG antibodies to ERT can lead to a decline in muscle strength, pulmonary function, and overall and ventilator-free survival. Additionally, antibody responses to ERT can also cause hypersensitivity reactions. Various strategies to prevent or eliminate the IgG antibody response have been attempted in patients with Pompe disease. A detailed literature search was performed to compile data regarding the consequences of IgG antibodies, clinical approaches to prevent or eliminate IgG antibodies in patients with Pompe disease, and to expand our understanding of new modalities being developed in non-clinical settings. All qualifying articles describing the impact of IgG antibodies on the response to ERT, immunomodulation in patients with Pompe disease, and non-clinical settings identified via a PubMed database search were included in the review. Here, we provide a comprehensive review of combination- and single-agent therapies that have been investigated in the context of immune tolerance induction to ERT in Pompe disease to date. Immunomodulation strategies that successfully induce immune tolerance to ERT have improved overall survival, especially reflected in the decreased number of ventilator-dependent or deceased cross-reactive immunologic material (CRIM)-negative infantile Pompe disease (IPD) patients due to development of IgG antibodies when treated with ERT alone. Immunomodulation in CRIM-positive patients at the time they receive ERT also results in a decrease in the development of IgG antibodies compared to cases treated with ERT alone. Lessons learned from current approaches, alongside results from trials of novel immunomodulation strategies, may provide important insights into the development of next-generation therapies.
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Affiliation(s)
- Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Cindy Li
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Amy S. Rosenberg
- Division of Biologics Review and Research 3, Office of Biotechnology Products, Center for Drug Evaluation and Research, US FDA, Bethesda, MD, USA
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
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Do HV, Khanna R, Gotschall R. Challenges in treating Pompe disease: an industry perspective. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:291. [PMID: 31392203 DOI: 10.21037/atm.2019.04.15] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pompe disease is a rare inherited metabolic disorder of defective lysosomal glycogen catabolism due to a deficiency in acid alpha-glucosidase (GAA). Alglucosidase alfa enzyme replacement therapy (ERT) using recombinant human GAA (rhGAA ERT) is the only approved treatment for Pompe disease. Alglucosidase alfa has provided irrefutable clinical benefits, but has not been an optimal treatment primarily due to poor drug targeting of ERT to skeletal muscles. Several critical factors contribute to this inefficiency. Some are inherent to the anatomy of the body that cannot be altered, while others may be addressed with better drug design and engineering. The knowledge gained from alglucosidase alfa ERT over the past 2 decades has allowed us to better understand the challenges that hinder its effectiveness. In this review, we detail the problems which must be overcome for improving drug targeting and clinical efficacy. These same issues may also impact therapeutic enzymes derived from gene therapies, and thus, have important implications for the development of next generation therapies for Pompe.
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Affiliation(s)
- Hung V Do
- Amicus Therapeutics, Inc., Cranbury, NJ, USA
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25
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Dingman R, Balu-Iyer SV. Immunogenicity of Protein Pharmaceuticals. J Pharm Sci 2019; 108:1637-1654. [PMID: 30599169 PMCID: PMC6720129 DOI: 10.1016/j.xphs.2018.12.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 02/07/2023]
Abstract
Protein therapeutics have drastically changed the landscape of treatment for many diseases by providing a regimen that is highly specific and lacks many off-target toxicities. The clinical utility of many therapeutic proteins has been undermined by the potential development of unwanted immune responses against the protein, limiting their efficacy and negatively impacting its safety profile. This review attempts to provide an overview of immunogenicity of therapeutic proteins, including immune mechanisms and factors influencing immunogenicity, impact of immunogenicity, preclinical screening methods, and strategies to mitigate immunogenicity.
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Affiliation(s)
- Robert Dingman
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York 14214
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York 14214.
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26
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Poelman E, Hoogeveen-Westerveld M, van den Hout JMP, Bredius RGM, Lankester AC, Driessen GJA, Kamphuis SSM, Pijnappel WWM, van der Ploeg AT. Effects of immunomodulation in classic infantile Pompe patients with high antibody titers. Orphanet J Rare Dis 2019; 14:71. [PMID: 30902109 PMCID: PMC6431009 DOI: 10.1186/s13023-019-1039-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/28/2019] [Indexed: 08/26/2023] Open
Abstract
Purpose To evaluate whether immunomodulation can eliminate high sustained antibody levels, and thereby improve clinical outcome in classic infantile Pompe patients receiving enzyme replacement therapy (ERT) with recombinant human alpha-glucosidase (rhGAA). Methods Three patients (two cross-reactive immunologic material (CRIM) negative) with high sustained antibodies received a three-week treatment protocol with Rituximab and Bortezomib, followed by daily Rapamycin and monthly IVIG. Patients received 40 mg/kg/week rhGAA. Antibody titers were measured using ELISA. Neutralizing effects on cellular uptake were determined. Clinical efficacy was measured in terms of (ventilator-free) survival, reduction in left ventricular mass index (LVMI) and improvement in motor function. Results Before immunomodulation anti-rhGAA antibody titers ranged from 1:156,250 to 1:781,250 and at last assessment from 1:31,250 to 1:156,250. Neutralizing effects of anti-rhGAA antibody titers (observed in two patients) disappeared. Infusion-associated reactions were no longer present. Immunomodulation resulted in substantial increases of aspartate transaminase, alanine transaminase, and creatine kinase levels. The two CRIM-negative patients who could walk at start of immunomodulation maintained their ability to walk; the patient who had lost this ability did not regain it. Conclusions To some extent, the immunomodulation protocol used in our study reduced antibody titers, but it did not eliminate them. Overall, there have been few reports on secondary immunomodulation, and various protocols have been applied. Future research should seek to identify the most successful immunomodulation protocol in patients with high sustained titers. Electronic supplementary material The online version of this article (10.1186/s13023-019-1039-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E Poelman
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, P.O. BOX 2060, 3000, CB, Rotterdam, The Netherlands
| | - M Hoogeveen-Westerveld
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, P.O. BOX 2060, 3000, CB, Rotterdam, The Netherlands
| | - J M P van den Hout
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, P.O. BOX 2060, 3000, CB, Rotterdam, The Netherlands
| | - R G M Bredius
- Department of Pediatrics, Leiden Medical University Center, Leiden, The Netherlands
| | - A C Lankester
- Department of Pediatrics, Leiden Medical University Center, Leiden, The Netherlands
| | - G J A Driessen
- Department of Pediatrics, Juliana Children's Hospital, The Hague, The Netherlands
| | - S S M Kamphuis
- Department of Pediatric Rheumatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W W M Pijnappel
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, P.O. BOX 2060, 3000, CB, Rotterdam, The Netherlands
| | - A T van der Ploeg
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, P.O. BOX 2060, 3000, CB, Rotterdam, The Netherlands.
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27
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De Groot AS, Kazi ZB, Martin RF, Terry FE, Desai AK, Martin WD, Kishnani PS. HLA- and genotype-based risk assessment model to identify infantile onset pompe disease patients at high-risk of developing significant anti-drug antibodies (ADA). Clin Immunol 2019; 200:66-70. [PMID: 30711607 PMCID: PMC6554735 DOI: 10.1016/j.clim.2019.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/26/2018] [Accepted: 01/31/2019] [Indexed: 11/23/2022]
Abstract
In Pompe disease, anti-drug antibodies (ADA) to acid alpha-glucosidase (GAA) enzyme replacement therapy contribute to early mortality. Assessing individual risk for ADA development is notoriously difficult in (CRIM-positive) patients expressing endogenous GAA. The individualized T cell epitope measure (iTEM) scoring method predicts patient-specific risk of developing ADA against therapeutic recombinant human GAA (rhGAA) using individualized HLA-binding predictions and GAA genotype. CRIM-negative patients were six times more likely to develop high ADA titers than CRIM-positive patients in this retrospective study, whereas patients with high GAA-iTEM scores were 50 times more likely to develop high ADA titers than patients with low GAA-iTEM scores. This approach identifies high-risk IOPD patients requiring immune tolerance induction therapy to prevent significant ADA response to rhGAA leading to a poor clinical outcome and can assess ADA risk in patients receiving replacement therapy for other enzyme or blood factor deficiency disorders.
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Affiliation(s)
| | - Z B Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | | | | | - A K Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | | | - P S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
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28
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Tsai HM. Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndromes. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00042-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Lenders M, Neußer LP, Rudnicki M, Nordbeck P, Canaan-Kühl S, Nowak A, Cybulla M, Schmitz B, Lukas J, Wanner C, Brand SM, Brand E. Dose-Dependent Effect of Enzyme Replacement Therapy on Neutralizing Antidrug Antibody Titers and Clinical Outcome in Patients with Fabry Disease. J Am Soc Nephrol 2018; 29:2879-2889. [PMID: 30385651 DOI: 10.1681/asn.2018070740] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/12/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Use of enzyme replacement therapy (ERT) to treat Fabry disease, caused by deficient lysosomal α-galactosidase A activity, can lead to formation of neutralizing antidrug antibodies (ADAs). These antibodies are associated with increased accumulation of plasma globotriaosylceramide (Gb3) and disease progression. Because agalsidase ERT can saturate ADA-binding sites during infusions (achieving agalsidase/antibody equilibrium), we investigated in this open cohort study whether saturated patients (who have excess agalsidase after infusions) experience better clinical outcomes compared with not saturated patients (who have excess ADAs after infusions). METHODS We isolated ADAs from sera of 26 men with Fabry disease receiving ERT (for a median of 94 months) and determined the amount of agalsidase necessary for antibody saturation. Clinical and biochemical outcomes included measurements of eGFR, interventricular septum thickness, and lyso-Gb3. RESULTS ADA titers decreased significantly in all patients during infusion. Agalsidase-α and agalsidase-β had similar ADA-binding capacity and comparable ADA saturation frequency. Fourteen patients with saturated ADAs presented with mild (but significant) loss of eGFR, stable septum thickness, and significantly decreased lyso-Gb3 levels. The 12 not saturated patients had a more pronounced and significant loss of eGFR, increased septum thickness, and a smaller, nonsignificant reduction in lyso-Gb3, over time. In three patients, dose escalation resulted in partially elevated ADA titers, but importantly, also in reduced lyso-Gb3 levels. CONCLUSIONS A not saturated ADA status during infusion is associated with progressive loss of eGFR and ongoing cardiac hypertrophy. Dose escalation can result in saturation of ADAs and decreasing lyso-Gb3 levels, but may lead to increased ADA titers.
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Affiliation(s)
- Malte Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology and
| | - Leon Paul Neußer
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology and
| | - Michael Rudnicki
- Department of Internal Medicine IV - Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Nordbeck
- Department of Internal Medicine I, Comprehensive Heart Failure Center, and Fabry Center for Interdisciplinary Therapy, University Hospital and University of Wuerzburg, Wuerzburg, Germany
| | - Sima Canaan-Kühl
- Division of Nephrology, Department of Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Albina Nowak
- University Heart Center, Cardiology Department, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Markus Cybulla
- Center of Internal Medicine, Department of Nephrology and Rheumatology, Fachinternistische Gemeinschaftspraxis Markgraeflerland, Muellheim, Germany; and
| | - Boris Schmitz
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - Jan Lukas
- Albrecht Kossel Institute for Neuroregeneration, University Rostock Medical Center, Rostock, Germany
| | - Christoph Wanner
- Department of Internal Medicine I, Comprehensive Heart Failure Center, and Fabry Center for Interdisciplinary Therapy, University Hospital and University of Wuerzburg, Wuerzburg, Germany
| | - Stefan-Martin Brand
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - Eva Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology and
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30
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Abstract
Pompe disease is a rare and deadly muscle disorder. As a clinical entity, the disease has been known for over 75 years. While an optimist might be excited about the advances made during this time, a pessimist would note that we have yet to find a cure. However, both sides would agree that many findings in basic science-such as the Nobel prize-winning discoveries of glycogen metabolism, the lysosome, and autophagy-have become the foundation of our understanding of Pompe disease. The disease is a glycogen storage disorder, a lysosomal disorder, and an autophagic myopathy. In this review, we will discuss how these past discoveries have guided Pompe research and impacted recent therapeutic developments.
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Affiliation(s)
- Lara Kohler
- Cell Biology and Physiology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rosa Puertollano
- Cell Biology and Physiology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Nina Raben
- Cell Biology and Physiology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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31
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Kazi ZB, Desai AK, Troxler RB, Kronn D, Packman S, Sabbadini M, Rizzo WB, Scherer K, Abdul-Rahman O, Tanpaiboon P, Nampoothiri S, Gupta N, Feigenbaum A, Niyazov DM, Sherry L, Segel R, McVie-Wylie A, Sung C, Joseph AM, Richards S, Kishnani PS. An immune tolerance approach using transient low-dose methotrexate in the ERT-naïve setting of patients treated with a therapeutic protein: experience in infantile-onset Pompe disease. Genet Med 2018; 21:887-895. [PMID: 30214072 PMCID: PMC6417984 DOI: 10.1038/s41436-018-0270-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/03/2018] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate immune tolerance induction with transient low-dose methotrexate (TLD-MTX) initiated with recombinant human acid α-glucosidase (rhGAA), in treatment-naïve cross-reactive immunologic material (CRIM)-positive infantile-onset Pompe disease (IOPD) patients. METHODS Newly diagnosed IOPD patients received subcutaneous or oral 0.4 mg/kg TLD-MTX for 3 cycles (3 doses/cycle) with the first 3 rhGAA infusions. Anti-rhGAA IgG titers, classified as high-sustained (HSAT; ≥51,200, ≥2 times after 6 months), sustained intermediate (SIT; ≥12,800 and <51,200 within 12 months), or low (LT; ≤6400 within 12 months), were compared with those of 37 CRIM-positive IOPD historic comparators receiving rhGAA alone. RESULTS Fourteen IOPD TLD-MTX recipients at the median age of 3.8 months (range, 0.7-13.5 months) had a median last titer of 150 (range, 0-51,200) at median rhGAA duration ~83 weeks (range, 36-122 weeks). One IOPD patient (7.1%) developed titers in the SIT range and one patient (7.1%) developed titers in the HSAT range. Twelve of the 14 patients (85.7%) that received TLD-MTX remained LT, versus 5/37 HSAT (peak 51,200-409,600), 7/37 SIT (12,800-51,000), and 23/37 LT (200-12,800) among comparators. CONCLUSION Results of TLD-MTX coinitiated with rhGAA are encouraging and merit a larger longitudinal study.
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Affiliation(s)
- Zoheb B Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Ankit K Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - R Bradley Troxler
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Kronn
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Seymour Packman
- Division of Medical Genetics, Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Marta Sabbadini
- Division of Medical Genetics, Department of Pediatrics, University of California, San Francisco, CA, USA
| | - William B Rizzo
- Department of Pediatrics, University of Nebraska Medical Center, Nebraska Medical Center Omaha, Omaha, NE, USA
| | - Katalin Scherer
- Department of Neurology, University of Arizona, Tucson, AZ, USA
| | - Omar Abdul-Rahman
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pranoot Tanpaiboon
- Quest Diagnostics and Children's National Health System, Washington, DC, USA
| | - Sheela Nampoothiri
- Amrita Institute of Medical Sciences & Research Centre, Kochi, Kerala, India
| | - Neerja Gupta
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Dmitriy M Niyazov
- Department of Pediatrics, Ochsner Health System, New Orleans, LA, USA
| | - Langston Sherry
- Department of Pediatrics, Ochsner Health System, New Orleans, LA, USA
| | - Reeval Segel
- Medical Genetics Institute, Shaare Zedek Medical Center and the Hebrew University School of Medicine, Jerusalem, Israel
| | | | | | | | | | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA.
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32
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Lenders M, Brand E. Effects of Enzyme Replacement Therapy and Antidrug Antibodies in Patients with Fabry Disease. J Am Soc Nephrol 2018; 29:2265-2278. [PMID: 30093456 DOI: 10.1681/asn.2018030329] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Malte Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - Eva Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
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Lenders M, Oder D, Nowak A, Canaan-Kühl S, Arash-Kaps L, Drechsler C, Schmitz B, Nordbeck P, Hennermann JB, Kampmann C, Reuter S, Brand SM, Wanner C, Brand E. Impact of immunosuppressive therapy on therapy-neutralizing antibodies in transplanted patients with Fabry disease. J Intern Med 2017; 282:241-253. [PMID: 28682471 DOI: 10.1111/joim.12647] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Inhibitory antibodies towards enzyme replacement therapy (ERT) are associated with disease progression and poor outcome in affected male patients with lysosomal disorders such as Fabry disease (FD). However, little is known about the impact of immunosuppressive therapy on ERT inhibition in these patients with FD. METHODS In this retrospective study, we investigated the effect of long-term immunosuppression on ERT inhibition in male patients with FD (n = 26) receiving immunosuppressive therapy due to kidney (n = 24) or heart (n = 2) transplantation. RESULTS No ERT-naïve transplanted patient (n = 8) developed antibodies within follow-up (80 ±72 months) after ERT initiation. Seven (26.9%) patients were tested ERT inhibition positive prior to transplantation. No de novo ERT inhibition was observed after transplantation (n = 18). In patients treated with high dosages of immunosuppressive medication such as prednisolone, tacrolimus and mycophenolate-mofetil/mycophenolate acid, ERT inhibition decreased after transplantation (n = 12; P = 0.0160). Tapering of immunosuppression (especially prednisolone) seemed to re-increase ERT inhibition (n = 4, median [range]: 16.6 [6.9; 36.9] %; P = 0.0972) over time. One ERT inhibition-positive patient required interventions with steroid therapy and increased doses of tacrolimus, which also lowered ERT inhibition. CONCLUSION We conclude that the immunosuppressive maintenance therapy after transplantations seems to be sufficient to prevent de novo ERT inhibition in ERT-naïve patients. Intensified high dosages of immunosuppressive drugs are associated with decreased antibody titres and decreased ERT inhibition in affected patients, but did not result in long-term protection. Future studies are needed to establish ERT inhibition-specific immunosuppressive protocols with long-term modulating properties to warrant an improved disease course in ERT inhibition-positive males.
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Affiliation(s)
- M Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - D Oder
- Department of Internal Medicine I, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center (CHFC), Fabry Center for Interdisciplinary Therapy (FAZIT), University of Wuerzburg, Wuerzburg, Germany
| | - A Nowak
- Department of Internal Medicine, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - S Canaan-Kühl
- Department of Medicine, Division of Nephrology, Campus Virchow-Klinikum, University Hospital Charité, Berlin, Germany
| | - L Arash-Kaps
- Villa Metabolica, Department for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - C Drechsler
- Department of Internal Medicine I, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center (CHFC), Fabry Center for Interdisciplinary Therapy (FAZIT), University of Wuerzburg, Wuerzburg, Germany
| | - B Schmitz
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - P Nordbeck
- Department of Internal Medicine I, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center (CHFC), Fabry Center for Interdisciplinary Therapy (FAZIT), University of Wuerzburg, Wuerzburg, Germany
| | - J B Hennermann
- Villa Metabolica, Department for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - C Kampmann
- Villa Metabolica, Department for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - S Reuter
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - S-M Brand
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Muenster, Muenster, Germany
| | - C Wanner
- Department of Internal Medicine I, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center (CHFC), Fabry Center for Interdisciplinary Therapy (FAZIT), University of Wuerzburg, Wuerzburg, Germany
| | - E Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
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34
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Kazi ZB, Desai AK, Berrier KL, Troxler RB, Wang RY, Abdul-Rahman OA, Tanpaiboon P, Mendelsohn NJ, Herskovitz E, Kronn D, Inbar-Feigenberg M, Ward-Melver C, Polan M, Gupta P, Rosenberg AS, Kishnani PS. Sustained immune tolerance induction in enzyme replacement therapy-treated CRIM-negative patients with infantile Pompe disease. JCI Insight 2017; 2:94328. [PMID: 28814660 DOI: 10.1172/jci.insight.94328] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/06/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Cross-reactive immunological material-negative (CRIM-negative) infantile Pompe disease (IPD) patients develop an immune response against enzyme replacement therapy (ERT) with alglucosidase alfa that nullifies ERT efficacy. Prophylactic immune tolerance induction (ITI) with rituximab, methotrexate, and IVIG successfully prevents development of deleterious rhGAA IgG antibodies; however, safety, likelihood of success, and long-term efficacy of ITI in a larger cohort remain unknown. METHODS Clinical data were analyzed for 19 CRIM-negative IPD patients who received ITI with rituximab, methotrexate, and IVIG in the ERT-naive setting (ERT+ITI) and compared to a historical cohort of 10 CRIM-negative IPD patients on ERT monotherapy. RESULTS ITI was safely tolerated, although infections were reported in 4 patients. Fourteen (74%) ERT+ITI patients were alive, with a median age of 44.2 months at their final assessment. The eldest survivor was 103.9 months old, with 100.2 months of follow-up after initiation of ERT+ITI. Death (n = 5) occurred at a median age of 29.2 months and was unrelated to the administration of ITI. Fifteen patients either did not seroconvert (n = 8) or maintained low titers (n = 7; defined as titers of ≤6,400 throughout the course of ERT) following ERT+ITI. Only one patient developed high and sustained antibody titers (defined as titers of ≥51,200 at or beyond 6 months on ERT). Left ventricular mass index (LVMI) decreased from a median of 248.5 g/m2 at baseline to 76.8 g/m2 at a median time from ERT+ITI initiation to 59 weeks. ERT+ITI significantly improved overall survival (P = 0.001), eliminated/reduced antibodies at values of ≤6,400 at week 52 on ERT (P = 0.0004), and improved LVMI at week 52 on ERT (P = 0.02) when compared with ERT monotherapy. CONCLUSION Evidence from this international cohort of CRIM-negative IPD patients further supports the safety, feasibility, and efficacy of ITI in the prevention of immune responses to ERT. TRIAL REGISTRATION Clinicaltrials.gov NCT01665326. FUNDING This research was supported in part by the Lysosomal Disease Network, a part of NIH Rare Diseases Clinical Research Network, and by a grant from Genzyme, a Sanofi company.
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Affiliation(s)
- Zoheb B Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Ankit K Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Kathryn L Berrier
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Raymond Y Wang
- Division of Metabolic Disorders, Children's Hospital of Orange County, Orange, California, USA
| | - Omar A Abdul-Rahman
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Pranoot Tanpaiboon
- Division of Genetics and Metabolism, Children's National Health System, Washington, DC, USA
| | - Nancy J Mendelsohn
- Genomics Medicine Program, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Eli Herskovitz
- Pediatric Endocrinology and Metabolism Unit, Soroka Medical Center, Beer Sheva, Israel
| | - David Kronn
- Department of Pediatrics, New York Medical College, Valhalla, New York, USA
| | - Michal Inbar-Feigenberg
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Michelle Polan
- Division of Medical Genetics, Akron Children's Hospital, Akron, Ohio, USA
| | - Punita Gupta
- Division of Medical Genetics, Department of Pediatrics, St. Joseph's Regional Medical Center Genetics, Paterson, New Jersey, USA
| | - Amy S Rosenberg
- Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, US FDA, Bethesda, Maryland, USA
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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Lim HH, Yi H, Kishimoto TK, Gao F, Sun B, Kishnani PS. A pilot study on using rapamycin-carrying synthetic vaccine particles (SVP) in conjunction with enzyme replacement therapy to induce immune tolerance in Pompe disease. Mol Genet Metab Rep 2017; 13:18-22. [PMID: 28761815 PMCID: PMC5524423 DOI: 10.1016/j.ymgmr.2017.03.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 02/07/2023] Open
Abstract
A major obstacle to enzyme replacement therapy (ERT) with recombinant human acid-α-glucosidase (rhGAA) for Pompe disease is the development of high titers of anti-rhGAA antibodies in a subset of patients, which often leads to a loss of treatment efficacy. In an effort to induce sustained immune tolerance to rhGAA, we supplemented the rhGAA therapy with a weekly intravenous injection of synthetic vaccine particles carrying rapamycin (SVP-Rapa) during the first 3 weeks of a 12-week course of ERT in GAA-KO mice, and compared this with three intraperitoneal injections of methotrexate (MTX) per week for the first 3 weeks. Empty nanoparticles (NP) were used as negative control for SVP-Rapa. Co-administration of SVP-Rapa with rhGAA resulted in more durable inhibition of anti-rhGAA antibody responses, higher efficacy in glycogen clearance in skeletal muscles, and greater improvement of motor function than mice treated with empty NP or MTX. Body weight loss was observed during the MTX-treatment but not SVP-Rapa-treatment. Our data suggest that co-administration of SVP-Rapa may be an innovative and safe strategy to induce durable immune tolerance to rhGAA during the ERT in patients with Pompe disease, leading to improved clinical outcomes.
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Affiliation(s)
- Han-Hyuk Lim
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Haiqing Yi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | | | - Fengqin Gao
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Baodong Sun
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
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Mohamed FE, Al-Gazali L, Al-Jasmi F, Ali BR. Pharmaceutical Chaperones and Proteostasis Regulators in the Therapy of Lysosomal Storage Disorders: Current Perspective and Future Promises. Front Pharmacol 2017; 8:448. [PMID: 28736525 PMCID: PMC5500627 DOI: 10.3389/fphar.2017.00448] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/22/2017] [Indexed: 02/05/2023] Open
Abstract
Different approaches have been utilized or proposed for the treatment of lysosomal storage disorders (LSDs) including enzyme replacement and hematopoietic stem cell transplant therapies, both aiming to compensate for the enzymatic loss of the underlying mutated lysosomal enzymes. However, these approaches have their own limitations and therefore the vast majority of LSDs are either still untreatable or their treatments are inadequate. Missense mutations affecting enzyme stability, folding and cellular trafficking are common in LSDs resulting often in low protein half-life, premature degradation, aggregation and retention of the mutant proteins in the endoplasmic reticulum. Small molecular weight compounds such as pharmaceutical chaperones (PCs) and proteostasis regulators have been in recent years to be promising approaches for overcoming some of these protein processing defects. These compounds are thought to enhance lysosomal enzyme activity by specific binding to the mutated enzyme or by manipulating components of the proteostasis pathways promoting protein stability, folding and trafficking and thus enhancing and restoring some of the enzymatic activity of the mutated protein in lysosomes. Multiple compounds have already been approved for clinical use to treat multiple LSDs like migalastat in the treatment of Fabry disease and others are currently under research or in clinical trials such as Ambroxol hydrochloride and Pyrimethamine. In this review, we are presenting a general overview of LSDs, their molecular and cellular bases, and focusing on recent advances on targeting and manipulation proteostasis, including the use of PCs and proteostasis regulators, as therapeutic targets for some LSDs. In addition, we present the successes, limitations and future perspectives in this field.
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Affiliation(s)
- Fedah E Mohamed
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates UniversityAl Ain, United Arab Emirates
| | - Lihadh Al-Gazali
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates UniversityAl Ain, United Arab Emirates
| | - Fatma Al-Jasmi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates UniversityAl Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates UniversityAl Ain, United Arab Emirates.,Zayed Bin Sultan Center for Health Sciences, United Arab Emirates UniversityAl-Ain, United Arab Emirates
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Sato Y, Ida H, Ohashi T. Anti-BlyS antibody reduces the immune reaction against enzyme and enhances the efficacy of enzyme replacement therapy in Fabry disease model mice. Clin Immunol 2017; 178:56-63. [PMID: 28161408 DOI: 10.1016/j.clim.2017.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 11/24/2016] [Accepted: 01/30/2017] [Indexed: 11/30/2022]
Abstract
Formation of antibodies against a therapeutic enzyme is an important complication during enzyme replacement therapy (ERT) for lysosomal storage diseases. Fabry disease (FD) is caused by a deficiency of alpha-galactosidase (GLA), which results in the accumulation of globotriaosylceramide (GL-3). We have shown immune tolerance induction (ITI) during ERT in FD model mice by using an anti-B lymphocyte stimulator (anti-BlyS) antibody (belimumab). A single dose of the anti-BlyS antibody temporarily lowered the percentage of B cells and IgG antibody titer against recombinant human GLA. Administration of a low maintenance dose of the anti-BlyS antibody suppressed the B cell population and immunotolerance was induced in 20% of mice, but antibody formation could not be prevented. We then increased the maintenance dose of the anti-BlyS antibody and immunotolerance was induced in 50% of mice. Therapeutic enzyme distribution and clearance of GL-3 were also enhanced by a high maintenance dose of the anti-BlyS antibody.
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Affiliation(s)
- Yohei Sato
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan; Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ida
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan; Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Toya Ohashi
- Division of Gene Therapy, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan; Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan.
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Immune tolerance induction for laronidase treatment in mucopolysaccharidosis I. Mol Genet Metab Rep 2017; 10:61-66. [PMID: 28119821 PMCID: PMC5238455 DOI: 10.1016/j.ymgmr.2017.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/06/2017] [Accepted: 01/07/2017] [Indexed: 11/21/2022] Open
Abstract
Enzyme replacement therapy (ERT) can produce anti-drug antibody (ADA) responses that reduce efficacy or lead to hypersensitivity reactions. Six patients with severe mucopolysaccharidosis type I (MPS I/Hurler syndrome) who did not receive hematopoietic stem cell transplantation underwent an immunosuppression regimen prior to initiating ERT with laronidase. The primary endpoint for immune tolerance induction was the number of patients with an ADA titer ≤ 3200 after 24 weeks of laronidase at the labeled dose. Cyclosporine levels were measured weekly and doses adjusted to maintain trough levels above 400 mg/mL. A 6-week (Cohort 1) or 12-week (Cohort 2) immune tolerance induction period with cyclosporine (initial dose: 15 or 20 mg/kg/day), azathioprine (initial dose: 2.5 or 5 mg/kg/day) and low-dose laronidase infusions (0.058–0.29 mg/kg/week) was followed by an immune-challenge period with laronidase infusions at the labeled dose (0.58 mg/kg/week) for 24 weeks. Anti-laronidase IgG titers were determined following treatment. There were 147 treatment-emergent adverse events reported, most of which were mild and not related to the study treatment. While there was no evidence of immune tolerance in 3 of 3 patients in Cohort 1, there were some indications of immune tolerance induction in 2 of 3 patients in Cohort 2. Patients with lower ADA titers showed greater reductions in urinary glycosaminoglycan excretion. Routine monitoring of plasma cyclosporine parent-compound levels by high pressure liquid chromatography proved difficult for clinical practice. The evolving clinical management of MPS I and a better understanding of the clinical impact of laronidase-related immunogenicity require reassessment of immune modulation strategies in patients with MPS I receiving laronidase treatment. Clinical Trial Registration: NCT00741338.
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Salazar-Fontana LI, Desai DD, Khan TA, Pillutla RC, Prior S, Ramakrishnan R, Schneider J, Joseph A. Approaches to Mitigate the Unwanted Immunogenicity of Therapeutic Proteins during Drug Development. AAPS JOURNAL 2017; 19:377-385. [DOI: 10.1208/s12248-016-0030-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/15/2016] [Indexed: 12/17/2022]
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Masat E, Laforêt P, De Antonio M, Corre G, Perniconi B, Taouagh N, Mariampillai K, Amelin D, Mauhin W, Hogrel JY, Caillaud C, Ronzitti G, Puzzo F, Kuranda K, Colella P, Mallone R, Benveniste O, Mingozzi F. Long-term exposure to Myozyme results in a decrease of anti-drug antibodies in late-onset Pompe disease patients. Sci Rep 2016; 6:36182. [PMID: 27812025 PMCID: PMC5096052 DOI: 10.1038/srep36182] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/27/2016] [Indexed: 12/27/2022] Open
Abstract
Immunogenicity of recombinant human acid-alpha glucosidase (rhGAA) in enzyme replacement therapy (ERT) is a safety and efficacy concern in the management of late-onset Pompe disease (LOPD). However, long-term effects of ERT on humoral and cellular responses to rhGAA are still poorly understood. To better understand the impact of immunogenicity of rhGAA on the efficacy of ERT, clinical data and blood samples from LOPD patients undergoing ERT for >4 years (n = 28) or untreated (n = 10) were collected and analyzed. In treated LOPD patients, anti-rhGAA antibodies peaked within the first 1000 days of ERT, while long-term exposure to rhGAA resulted in clearance of antibodies with residual production of non-neutralizing IgG. Analysis of T cell responses to rhGAA showed detectable T cell reactivity only after in vitro restimulation. Upregulation of several cytokines and chemokines was detectable in both treated and untreated LOPD subjects, while IL2 secretion was detectable only in subjects who received ERT. These results indicate that long-term ERT in LOPD patients results in a decrease in antibody titers and residual production of non-inhibitory IgGs. Immune responses to GAA following long-term ERT do not seem to affect efficacy of ERT and are consistent with an immunomodulatory effect possibly mediated by regulatory T cells.
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Affiliation(s)
- Elisa Masat
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France
| | - Pascal Laforêt
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France.,Paris-Est neuromuscular center, Institute of Myology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | | | | | - Barbara Perniconi
- Paris-Est neuromuscular center, Institute of Myology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Nadjib Taouagh
- Paris-Est neuromuscular center, Institute of Myology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Kuberaka Mariampillai
- Department of Internal Medicine and Clinical Immunology, DHUI2B, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Damien Amelin
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France
| | - Wladimir Mauhin
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France
| | - Jean-Yves Hogrel
- Neuromuscular Physiology and Evaluation Lab, Institute of Myology, Paris, France
| | | | | | | | - Klaudia Kuranda
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France
| | | | - Roberto Mallone
- Institute Cochin, INSERM U1016, CNRS UMR8104, Paris, France.,University Paris Descartes, Faculty of Medicine, Paris, France.,Department of diabetology, Cochin Hospital, AP-HP, Paris, France
| | - Olivier Benveniste
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France.,Department of Internal Medicine and Clinical Immunology, DHUI2B, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Federico Mingozzi
- University Pierre and Marie Curie, INSERM, UMR974, Paris, France.,Genethon, INSERM, UMR951, Evry, France
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Natarajan P, Liu J, Santhanakrishnan M, Gibb DR, Slater LM, Hendrickson JE. Bortezomib decreases the magnitude of a primary humoral immune response to transfused red blood cells in a murine model. Transfusion 2016; 57:82-92. [PMID: 27734515 DOI: 10.1111/trf.13864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/11/2016] [Accepted: 08/19/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Few therapeutic options currently exist to prevent or to mitigate transfusion-associated red blood cell (RBC) alloimmunization. We hypothesized that bortezomib, a proteasome inhibitor currently being utilized for HLA alloantibody and ADAMTS13 autoantibody reduction, may be beneficial in a transfusion setting. Herein, we utilized a reductionist murine model to test our hypothesis that bortezomib would decrease RBC alloimmune responses. STUDY DESIGN AND METHODS Wild-type mice were treated with bortezomib or saline and transfused with murine RBCs expressing the human KEL glycoprotein. Levels of anti-KEL immunoglobulins in transfusion recipients were measured by flow cytometry. The impact of bortezomib treatment on recipient plasma cells (PCs) and other immune cells was also assessed by flow cytometry and immunofluorescence. RESULTS After bortezomib treatment, mice had a 50% reduction in splenic white blood cells and a targeted reduction in marrow PCs. Mice treated with bortezomib before the transfusion of KEL RBCs became alloimmunized in three of three experiments, although their serum anti-KEL IgG levels were 2.6-fold lower than those in untreated mice. Once a primary antibody response was established, bortezomib treatment did not prevent an anamnestic response from occurring. CONCLUSION To the extent that these findings are generalizable to other RBC antigens and to humans, bortezomib monotherapy is unlikely to be of significant clinical benefit in a transfusion setting where complete prevention of alloimmunization is desirable. Given the impact on PCs, however, it remains plausible that bortezomib therapy may be beneficial for RBC alloimmunization prevention or mitigation if used in combination with other immunomodulatory therapies.
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Affiliation(s)
- Prabitha Natarajan
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jingchun Liu
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - David R Gibb
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lewis M Slater
- Hematology-Oncology Section, Medicine Health Care Group Long Beach Veterans Affairs, and Division of Hematology-Oncology and Department of Medicine, University of California, Irvine, California
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Kazi ZB, Prater SN, Kobori JA, Viskochil D, Bailey C, Gera R, Stockton DW, McIntosh P, Rosenberg AS, Kishnani PS. Durable and sustained immune tolerance to ERT in Pompe disease with entrenched immune responses. JCI Insight 2016; 1:86821. [PMID: 27493997 DOI: 10.1172/jci.insight.86821] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Enzyme replacement therapy (ERT) has prolonged survival and improved clinical outcomes in patients with infantile Pompe disease (IPD), a rapidly progressive neuromuscular disorder. Yet marked interindividual variability in response to ERT, primarily attributable to the development of antibodies to ERT, remains an ongoing challenge. Immune tolerance to ongoing ERT has yet to be described in the setting of an entrenched immune response. METHODS Three infantile Pompe patients who developed high and sustained rhGAA IgG antibody titers (HSAT) and received a bortezomib-based immune tolerance induction (ITI) regimen were included in the study and were followed longitudinally to monitor the long-term safety and efficacy. A trial to taper the ITI protocol was attempted to monitor if true immune tolerance was achieved. RESULTS Bortezomib-based ITI protocol was safely tolerated and led to a significant decline in rhGAA antibody titers with concomitant sustained clinical improvement. Two of the 3 IPD patients were successfully weaned off all ITI protocol medications and continue to maintain low/no antibody titers. ITI protocol was significantly tapered in the third IPD patient. B cell recovery was observed in all 3 IPD patients. CONCLUSION This is the first report to our knowledge on successful induction of long-term immune tolerance in patients with IPD and HSAT refractory to agents such as cyclophosphamide, rituximab, and methotrexate, based on an approach using the proteasome inhibitor bortezomib. As immune responses limit the efficacy and cost-effectiveness of therapy for many conditions, proteasome inhibitors may have new therapeutic applications. FUNDING This research was supported by a grant from the Genzyme Corporation, a Sanofi Company (Cambridge, Massachusetts, USA), and in part by the Lysosomal Disease Network, a part of NIH Rare Diseases Clinical Research Network (RDCRN).
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Affiliation(s)
- Zoheb B Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Sean N Prater
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Joyce A Kobori
- Department of Genetics, Kaiser Permanente, San Jose, California, USA
| | - David Viskochil
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Carrie Bailey
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Renuka Gera
- Department of Pediatrics/Human Development, Michigan State University, East Lansing, Michigan, USA
| | - David W Stockton
- Division of Genetic, Genomic and Metabolic Disorders, Departments of Pediatrics and Internal Medicine, Wayne State University and Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Paul McIntosh
- School of Medicine, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Amy S Rosenberg
- Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, United States Food and Drug Administration, Bethesda, Maryland, USA
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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Broomfield A, Jones SA, Hughes SM, Bigger BW. The impact of the immune system on the safety and efficiency of enzyme replacement therapy in lysosomal storage disorders. J Inherit Metab Dis 2016; 39:499-512. [PMID: 26883220 DOI: 10.1007/s10545-016-9917-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 12/31/2022]
Abstract
In the light of clinical experience in infantile onset Pompe patients, the immunological impact on the tolerability and long-term efficacy of enzyme replacement therapy (ERT) for lysosomal storage disorders has come under renewed scrutiny. This article details the currently proposed immunological mechanisms involved in the development of anti-drug antibodies and the current therapies used in their treatment. Given the current understanding of the adaptive immune response, it focuses particularly on T cell dependent mechanisms and the paradigm of using lymphocytic negative selection as a predictor of antibody formation. This concept originally postulated in the 1970s, stipulated that the genotypically determined lack of production or production of a variant protein determines an individual's lymphocytic repertoire. This in turn is the key factor in determining the potential severity of an individual's immunological response to ERT. It also highlights the need for immunological assay standardization particularly those looking at describing the degree of functional impact, robust biochemical or clinical endpoints and detailed patient subgroup identification if the true evaluations of impact are to be realised.
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Affiliation(s)
- A Broomfield
- Willink Biochemical genetics unit, Manchester center for genomic medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK.
| | - S A Jones
- Willink Biochemical genetics unit, Manchester center for genomic medicine, St Mary's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - S M Hughes
- Department of Immunology, Royal Manchester children's Hospital, Central Manchester Foundation Trust, Manchester, M13 9WL, UK
| | - B W Bigger
- Stem Cell & Neurotherapies Laboratory, Faculty of Medical and Human Sciences, University of Manchester, Manchester, M13 9PT, UK
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Pompe disease in adulthood: effects of antibody formation on enzyme replacement therapy. Genet Med 2016; 19:90-97. [PMID: 27362911 DOI: 10.1038/gim.2016.70] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/20/2016] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To determine the effect of antibodies against recombinant human acid α-glucosidase (rhGAA) on treatment efficacy and safety, and to test whether the GAA genotype is involved in antibody formation. METHODS We used enzyme-linked immunosorbent assay (ELISA) to determine anti-rhGAA antibody titers at baseline and at 6, 12, and 36 months of rhGAA treatment. We measured the capacity of antibodies to neutralize rhGAA enzymatic activity or cellular uptake and the effects on infusion-associated reactions (IARs), muscle strength, and pulmonary function. RESULTS Of 73 patients, 45 developed antibodies. Maximal titers were high (≥1:31,250) in 22% of patients, intermediate (1:1,250-1:31,250) in 40%, and none or low (0-1:1,250) in 38%. The common IVS1/delex18 GAA genotype was absent only in the high-titer group. The height of the titer positively correlated with the occurrence and number of IARs (P ≤ 0.001). On the group level, antibody titers did not correlate with treatment efficacy. Eight patients (11%) developed very high maximal titers (≥156,250), but only one patient showed high sustained neutralizing antibodies that probably interfered with treatment efficacy. CONCLUSIONS In adults with Pompe disease, antibody formation does not interfere with rhGAA efficacy in the majority of patients, is associated with IARs, and may be attenuated by the IVS1/delex18 GAA genotype.Genet Med 19 1, 90-97.
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Rosenberg A, Pariser A, Diamond B, Yao L, Turka L, Lacana E, Kishnani P. A role for plasma cell targeting agents in immune tolerance induction in autoimmune disease and antibody responses to therapeutic proteins. Clin Immunol 2016; 165:55-9. [DOI: 10.1016/j.clim.2016.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 10/22/2022]
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Yang CF, Yang CC, Liao HC, Huang LY, Chiang CC, Ho HC, Lai CJ, Chu TH, Yang TF, Hsu TR, Soong WJ, Niu DM. Very Early Treatment for Infantile-Onset Pompe Disease Contributes to Better Outcomes. J Pediatr 2016; 169:174-80.e1. [PMID: 26685070 DOI: 10.1016/j.jpeds.2015.10.078] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/18/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate whether very early treatment in our patients would result in better clinical outcomes and to compare these data with other infantile-onset Pompe disease (IOPD) cohort studies. METHODS In this nationwide program, 669,797 newborns were screened for Pompe disease. We diagnosed IOPD in 14 of these newborns, and all were treated and followed in our hospital. RESULTS After 2010, the mean age at first enzyme-replacement therapy (ERT) was 11.92 days. Our patients had better biological, physical, and developmental outcomes and lower anti-rh acid α-glucosidase antibodies after 2 years of treatment, even compared with one group that began ERT just 10 days later than our cohort. No patient had a hearing disorder or abnormal vision. The mean age for independent walking was 11.6 ± 1.3 months, the same age as normal children. CONCLUSIONS ERT for patients with IOPD should be initiated as early as possible before irreversible damage occurs. Our results indicate that early identification of patients with IOPD allows for the very early initiation of ERT. Starting ERT even a few days earlier may lead to better patient outcomes.
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Affiliation(s)
- Chia-Feng Yang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Chen Chang Yang
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan; Division of Clinical Toxicology & Occupational Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsuan-Chieh Liao
- The Chinese Foundation of Health Neonatal Screening Center, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ling-Yi Huang
- Division of Nephrology, Department of Internal Medicine, Taipei City Hospital-Heping Fuyou Branch, Taipei, Taiwan
| | - Chuan-Chi Chiang
- The Chinese Foundation of Health Neonatal Screening Center, Taipei, Taiwan
| | - Hui-Chen Ho
- Taipei Institute of Pathology, Taipei, Taiwan
| | - Chih-Jou Lai
- Physical Medicine and Rehabilitation Department, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzu-Hung Chu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsui-Feng Yang
- Physical Medicine and Rehabilitation Department, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ting-Rong Hsu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Jue Soong
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Kishnani PS, Dickson PI, Muldowney L, Lee JJ, Rosenberg A, Abichandani R, Bluestone JA, Burton BK, Dewey M, Freitas A, Gavin D, Griebel D, Hogan M, Holland S, Tanpaiboon P, Turka LA, Utz JJ, Wang YM, Whitley CB, Kazi ZB, Pariser AR. Immune response to enzyme replacement therapies in lysosomal storage diseases and the role of immune tolerance induction. Mol Genet Metab 2016; 117:66-83. [PMID: 26597321 DOI: 10.1016/j.ymgme.2015.11.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 12/20/2022]
Abstract
The US Food and Drug Administration (FDA) and National Organization for Rare Disease (NORD) convened a public workshop titled "Immune Responses to Enzyme Replacement Therapies: Role of Immune Tolerance Induction" to discuss the impact of anti-drug antibodies (ADAs) on efficacy and safety of enzyme replacement therapies (ERTs) intended to treat patients with lysosomal storage diseases (LSDs). Participants in the workshop included FDA staff, clinicians, scientists, patients, industry, and advocacy group representatives. The risks and benefits of implementing prophylactic immune tolerance induction (ITI) to reduce the potential clinical impact of antibody development were considered. Complications due to immune responses to ERT are being recognized with increasing experience and lengths of exposure to ERTs to treat several LSDs. Strategies to mitigate immune responses and to optimize therapies are needed. Discussions during the workshop resulted in the identification of knowledge gaps and future areas of research, as well as the following proposals from the participants: (1) systematic collection of longitudinal data on immunogenicity to better understand the impact of ADAs on long-term clinical outcomes; (2) development of disease-specific biomarkers and outcome measures to assess the effect of ADAs and ITI on efficacy and safety; (3) development of consistent approaches to ADA assays to allow comparisons of immunogenicity data across different products and disease groups, and to expedite reporting of results; (4) establishment of a system to widely share data on antibody titers following treatment with ERTs; (5) identification of components of the protein that are immunogenic so that triggers and components of the immune responses can be targeted in ITI; and (6) consideration of early ITI in patients who are at risk of developing clinically relevant ADA that have been demonstrated to worsen treatment outcomes.
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Affiliation(s)
- Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
| | - Patricia I Dickson
- Division of Medical Genetics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90505-2006, USA.
| | - Laurie Muldowney
- Division of Gastroenterology and Inborn Errors of Metabolism Products, Office of New Drugs, Center for Drug Evaluation and Research (CDER), Food and Drug Administration (FDA), Silver Spring, MD 20993-0002, USA.
| | - Jessica J Lee
- Division of Gastroenterology and Inborn Errors of Metabolism Products, Office of New Drugs, Center for Drug Evaluation and Research (CDER), Food and Drug Administration (FDA), Silver Spring, MD 20993-0002, USA.
| | - Amy Rosenberg
- Division of Therapeutic Proteins, Office of Biotechnology Products, CDER, FDA, Silver Spring, MD 20993-0002, USA.
| | | | - Jeffrey A Bluestone
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94143-0540, USA.
| | - Barbara K Burton
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, IL 60611, USA.
| | - Maureen Dewey
- Division of Gastroenterology and Inborn Errors of Metabolism Products, Office of New Drugs, Center for Drug Evaluation and Research (CDER), Food and Drug Administration (FDA), Silver Spring, MD 20993-0002, USA.
| | - Alexandra Freitas
- National Organization for Rare Disorders, Washington, DC 20036, USA.
| | - Derek Gavin
- National Organization for Rare Disorders, Washington, DC 20036, USA.
| | - Donna Griebel
- Division of Gastroenterology and Inborn Errors of Metabolism Products, Office of New Drugs, Center for Drug Evaluation and Research (CDER), Food and Drug Administration (FDA), Silver Spring, MD 20993-0002, USA.
| | - Melissa Hogan
- Saving Case & Friends, Inc., a Hunter Syndrome Research Foundation, Thompson's Station, TN 37179, USA.
| | | | | | - Laurence A Turka
- Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA.
| | - Jeanine J Utz
- University of Minnesota, Masonic Children's Hospital, Minneapolis, MN 55455, USA.
| | - Yow-Ming Wang
- Division of Clinical Pharmacology III, Office of Clinical Pharmacology, Office of Translational Sciences (OTS), CDER, FDA, Silver Spring, MD 20993-0002, USA.
| | - Chester B Whitley
- University of Minnesota, Masonic Children's Hospital, Minneapolis, MN 55455, USA.
| | - Zoheb B Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
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Doerfler PA, Nayak S, Corti M, Morel L, Herzog RW, Byrne BJ. Targeted approaches to induce immune tolerance for Pompe disease therapy. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2016; 3:15053. [PMID: 26858964 PMCID: PMC4729315 DOI: 10.1038/mtm.2015.53] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/04/2015] [Accepted: 11/28/2015] [Indexed: 12/31/2022]
Abstract
Enzyme and gene replacement strategies have developed into viable therapeutic approaches for the treatment of Pompe disease (acid α-glucosidase (GAA) deficiency). Unfortunately, the introduction of GAA and viral vectors encoding the enzyme can lead to detrimental immune responses that attenuate treatment benefits and can impact patient safety. Preclinical and clinical experience in addressing humoral responses toward enzyme and gene therapy for Pompe disease have provided greater understanding of the immunological consequences of the provided therapy. B- and T-cell modulation has been shown to be effective in preventing infusion-associated reactions during enzyme replacement therapy in patients and has shown similar success in the context of gene therapy. Additional techniques to induce humoral tolerance for Pompe disease have been the targeted expression or delivery of GAA to discrete cell types or tissues such as the gut-associated lymphoid tissues, red blood cells, hematopoietic stem cells, and the liver. Research into overcoming preexisting immunity through immunomodulation and gene transfer are becoming increasingly important to achieve long-term efficacy. This review highlights the advances in therapies as well as the improved understanding of the molecular mechanisms involved in the humoral immune response with emphasis on methods employed to overcome responses associated with enzyme and gene therapies for Pompe disease.
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Affiliation(s)
- Phillip A Doerfler
- Department of Pediatrics, University of Florida , Gainesville, Florida, USA
| | - Sushrusha Nayak
- Department of Medicine, Karolinska Institute , Stockholm, Sweden
| | - Manuela Corti
- Department of Pediatrics, University of Florida , Gainesville, Florida, USA
| | - Laurence Morel
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida , Gainesville, Florida, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida , Gainesville, Florida, USA
| | - Barry J Byrne
- Department of Pediatrics, University of Florida , Gainesville, Florida, USA
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Abstract
Lysosomal storage diseases are a group of rare, inborn, metabolic errors characterized by deficiencies in normal lysosomal function and by intralysosomal accumulation of undegraded substrates. The past 25 years have been characterized by remarkable progress in the treatment of these diseases and by the development of multiple therapeutic approaches. These approaches include strategies aimed at increasing the residual activity of a missing enzyme (enzyme replacement therapy, hematopoietic stem cell transplantation, pharmacological chaperone therapy and gene therapy) and approaches based on reducing the flux of substrates to lysosomes. As knowledge has improved about the pathophysiology of lysosomal storage diseases, novel targets for therapy have been identified, and innovative treatment approaches are being developed.
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Stenger EO, Kazi Z, Lisi E, Gambello MJ, Kishnani P. Immune Tolerance Strategies in Siblings with Infantile Pompe Disease-Advantages for a Preemptive Approach to High-Sustained Antibody Titers. Mol Genet Metab Rep 2015; 4:30-34. [PMID: 26167453 PMCID: PMC4497810 DOI: 10.1016/j.ymgmr.2015.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Enzyme replacement therapy (ERT) has led to a significant improvement in the clinical course of patients with infantile Pompe disease (IPD), an autosomal recessive glycogen storage disorder characterized by the deficiency in lysosomal acid α-glucosidase. A subset of IPD patients mount a substantial immune response to ERT developing high sustained anti-rhGAA IgG antibody titers (HSAT) leading to the ineffectiveness of this treatment. HSAT have been challenging to treat, although preemptive approaches have shown success in high-risk patients (those who are cross-reactive immunological material [CRIM]-negative). More recently, the addition of bortezomib, a proteasome inhibitor known to target plasma cells, to immunotherapy with rituximab, methotrexate, and intravenous immunoglobulin has shown success at significantly reducing the anti-rhGAA antibody titers in three patients with HSAT. In this report, we present the successful use of a bortezomib-based approach in a CRIM-positive IPD patient with HSAT and the use of a preemptive approach to prevent immunologic response in an affected younger sibling. We highlight the significant difference in clinical course between the two patients, particularly that a pre-emptive approach was simple and effective in preventing the development of high antibody titers in the younger sibling, thus supporting the role of immune tolerance induction (ITI) in the ERT-naïve high-risk setting.
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Affiliation(s)
- Elizabeth O Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Zoheb Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Emily Lisi
- Division of Medical Genetics, Department of Human Genetics, Emory University, Atlanta, GA, United States
| | - Michael J Gambello
- Division of Medical Genetics, Department of Human Genetics, Emory University, Atlanta, GA, United States
| | - Priya Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
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