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Fazio TN, Healy L, Heise T, Inwood A, Manolikos C, Rahman Y, Woerle HJ, Hendriksz CJ. Pharmacodynamics, safety, tolerability and pharmacokinetics of a single oral dose of an engineered phenylalanine ammonia-lyase in patients with phenylketonuria. Mol Genet Metab Rep 2023; 37:101012. [PMID: 38053938 PMCID: PMC10694774 DOI: 10.1016/j.ymgmr.2023.101012] [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: 09/04/2023] [Accepted: 09/20/2023] [Indexed: 12/07/2023] Open
Abstract
The cornerstone treatment of hyperphenylalaninemia (HPA) and phenylketonuria (PKU) is a lifelong low-protein diet with phenylalanine (Phe) free L-amino acid supplements. However, the PKU diet has significant shortcomings, and there is a clinically unmet need for new therapeutics to improve patient outcomes. CDX-6114 is a modified phenylalanine ammonia-lyase (PAL) enzyme obtained by a mutation in the Anabaena variabilis PAL sequence. CodeEvolver® protein engineering technology has been applied to improve the degradation resistance of the enzyme. In our first phase I trial, 19 patients were given a single oral dose of CDX-6114 at 7.5 g, 2.5 g, 0.7 g, or placebo in a cross-over design. After an overnight fast, patients received a standardised breakfast of 20 g of protein, thus exceeding the dietary recommendations for a single meal in patients with PKU. Plasma levels of Phe and cinnamic acid (CA) were measured over a 5-h period following CDX-6114 dosing. During the development of CDX-6114, a stability assessment using reverse-phase high-performance liquid chromatography (HPLC) assay revealed two peaks. The second peak was identified as CA. It was not previously known that as part of the mechanism of action, the CA remained associated with the protein following the conversion of Phe. Thus, recalculating the historical PAL enzyme amounts in CDX-6114 bulk substance was necessary. An updated extinction coefficient was achieved by applying a correction factor of 0.771 to previously reported doses. Postprandial plasma levels of Phe increased in all dose cohorts over time between 10% and 30% from baseline, although the actual peak of Phe levels was not achieved within the 5-h observation. When accounting for the interquartile ranges, these concentrations were similar to the placebo. As plasma levels of Phe were no longer a reliable marker for pharmacodynamics, the consistently detectable amount of CA seen in all patients who received CDX-6114 provided proof of the enzymatic activity of CDX-6114 in metabolising gastrointestinal Phe. Peak levels of CA were seen shortly after CDX-6114 intake, with a rapid decline, and remained low compared with the plasma Phe levels. This pattern indicates a short half-life, possibly due to the liquid formulation or the inability to withstand the lower pH in the human stomach compared with animal models in earlier studies. This was the first trial in patients with PKU to establish the safety and tolerability of CDX-6114. A single dose of CDX-6114 was safe and well tolerated, with no serious adverse events or presence of anti-drug antibodies detected. Efficacy will be explored in future trials using an optimised formulation.
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Affiliation(s)
- Timothy Nicholas Fazio
- Royal Melbourne Hospital, Melbourne, Victoria, Australia; Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Healy
- Metabolic Dietary Disorders Association, PO Box 33, Montrose, Victoria, 3765, Australia
| | | | - Anita Inwood
- Queensland Lifespan Metabolic Medicine Service, Brisbane, Queensland, Australia
| | | | - Yusof Rahman
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
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Martinelli S, Nannini G, Cianchi F, Staderini F, Coratti F, Amedei A. Microbiota Transplant and Gynecological Disorders: The Bridge between Present and Future Treatments. Microorganisms 2023; 11:2407. [PMID: 37894065 PMCID: PMC10609601 DOI: 10.3390/microorganisms11102407] [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: 07/31/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Fecal microbiota transplantation (FMT) is a procedure that involves transferring fecal bacteria from a healthy donor to a patients' intestines to restore gut-immunity homeostasis. While FMT was primarily supposed to treat gastrointestinal disorders such as inflammatory bowel disease and irritable bowel syndrome-and especially Clostridium difficile infection (currently the only used as clinical treatment)-recent research has suggested that it may also become a potential treatment for gynecological disorders, including endometriosis and polycystic ovary syndrome (PCOS). On the contrary, vaginal microbiota transplantation (VMT) is a newer and less commonly used procedure than the FMT approach, and its potential applications are still being explored. It involves direct grafting of the entire vaginal microbiota of healthy women into the vaginal tract of patients to easily rebuild the local microbiota environment, restoring vaginal eubiosis and relieving symptoms. Like FMT, VMT is thought to have potential in treating different microbiota-related conditions. In fact, many gynecological disorders, such as bacterial vaginosis and vulvovaginal candidiasis, are thought to be caused by an imbalance in the vaginal microbiota. In this review, we will summarize the development, current challenges, and future perspectives of microbiota transplant, with the aim of exploring new strategies for its employment as a promising avenue for treating a broad range of gynecological diseases.
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Affiliation(s)
- Serena Martinelli
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy; (S.M.); (G.N.); (F.C.); (F.S.); (F.C.)
| | - Giulia Nannini
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy; (S.M.); (G.N.); (F.C.); (F.S.); (F.C.)
| | - Fabio Cianchi
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy; (S.M.); (G.N.); (F.C.); (F.S.); (F.C.)
| | - Fabio Staderini
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy; (S.M.); (G.N.); (F.C.); (F.S.); (F.C.)
| | - Francesco Coratti
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy; (S.M.); (G.N.); (F.C.); (F.S.); (F.C.)
| | - Amedeo Amedei
- Department of Clinical and Experimental Medicine, University of Florence, 50139 Florence, Italy; (S.M.); (G.N.); (F.C.); (F.S.); (F.C.)
- SOD of Interdisciplinary Internal Medicine, Azienda Ospedaliera Universitaria Careggi (AOUC), 50139 Florence, Italy
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