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Garrido Montes M, Pertusa Mataix R, Garcia Morillo JS. Personalized dosage of Givosiran in acute intermittent porphyria. Med Clin (Barc) 2024:S0025-7753(24)00276-8. [PMID: 38839445 DOI: 10.1016/j.medcli.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Manuel Garrido Montes
- Rare and Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Virgen del Rocío University Hospital, Avenida Manuel Siurot, s/n, 41013 Seville, Spain.
| | - Roberto Pertusa Mataix
- Rare and Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Virgen del Rocío University Hospital, Avenida Manuel Siurot, s/n, 41013 Seville, Spain
| | - Jose Salvador Garcia Morillo
- Rare and Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Virgen del Rocío University Hospital, Avenida Manuel Siurot, s/n, 41013 Seville, Spain
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2
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Lee MJ, Kuo HC, Chou LN, Sweetser MT, Wang JD. A randomized, placebo-controlled study of givosiran in patients with acute hepatic porphyrias (ENVISION): Final (36-month) analysis of the Taiwan Cohort. J Formos Med Assoc 2024; 123:679-686. [PMID: 38044204 DOI: 10.1016/j.jfma.2023.10.016] [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: 07/05/2023] [Revised: 09/28/2023] [Accepted: 10/19/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND/PURPOSE Acute hepatic porphyrias (AHP) are rare genetic disorders associated with acute neurovisceral attacks and chronic symptoms. This analysis was conducted to examine the long-term efficacy and safety of givosiran in Taiwanese participants in the ENVISION study (NCT03338816). METHODS Patients (age ≥12 years) with AHP and recurrent attacks were randomized to receive givosiran 2.5 mg/kg or placebo for 6 months during the double-blind period. Patients then switched from placebo to givosiran (placebo crossover group) or continued taking givosiran (continuous givosiran group) during a 30-month open-label extension period. The total study duration was 36 months. An analysis was conducted that included patients enrolled in Taiwan (N = 7). RESULTS During the double-blind period and open-label extension period, the median annualized attack rates were 0.0 and 0.0, respectively, in the continuous givosiran group (n = 5) and 15.1 and 4.6, respectively, in the placebo crossover group (n = 2; 70 % decrease). Median annualized days of hemin use in the double-blind period and open-label extension period were 0.0 and 0.0, respectively, in the continuous givosiran group, and 23.8 and 5.0, respectively, in the placebo crossover group (79 % decrease). EQ-5D VAS scores remained relatively stable in both groups, and PPEQ responses indicated improved functioning and satisfaction in both groups. Delta-aminolevulinic acid and porphobilinogen levels remained low with long-term givosiran treatment. Serious adverse events were reported by 3 patients (43 %). CONCLUSION Long-term efficacy and safety results in the Taiwan cohort are consistent with those in the global cohort.
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Affiliation(s)
- Ming-Jen Lee
- Department of Neurology and Medical Genetics, National Taiwan University Hospital, Taipei City, Taiwan.
| | - Hung-Chou Kuo
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan City, Taiwan.
| | - Lin-Na Chou
- Alnylam Pharmaceuticals, Cambridge, MA, USA.
| | | | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Taichung Veterans General Hospital, Taichung City, Taiwan; Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung City, Taiwan.
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Redonnet-Vernhet I, Mercié P, Lebreton L, Blouin JM, Bronnimann D, Mesli S, Guibet C, Ribeiro E, Gensous N, Duffau P, Gouya L, Richard E. Preventing hyperhomocysteinemia using vitamin B 6 supplementation in Givosiran-treated acute intermittent porphyria: Highlights from a case report and brief literature review. Mol Genet Metab Rep 2024; 39:101076. [PMID: 38601120 PMCID: PMC11004984 DOI: 10.1016/j.ymgmr.2024.101076] [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: 12/20/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
Acute hepatic porphyrias are inherited metabolic disorders of heme biosynthesis characterized by the accumulation of toxic intermediate metabolites responsible for disabling acute neurovisceral attacks. Givosiran is a newly approved siRNA-based treatment of acute hepatic porphyria targeting the first and rate-limiting δ-aminolevulinic acid synthase 1 (ALAS1) enzyme of heme biosynthetic pathway. We described a 72-year old patient who presented with severe inaugural neurological form of acute intermittent porphyria evolving for several years which made her eligible for givosiran administration. On initiation of treatment, the patient developed a major hyperhomocysteinemia (>400 μmol/L) which necessitated to discontinue the siRNA-based therapy. A thorough metabolic analysis in the patient suggests that hyperhomocysteinemia could be attributed to a functional deficiency of cystathionine β-synthase (CBS) enzyme induced by givosiran. Long-term treatment with vitamin B6, a cofactor of CBS, allowed to normalize homocysteinemia while givosiran treatment was maintained. We review the recently published cases of hyperhomocysteinemia in acute hepatic porphyria and its exacerbation under givosiran therapy. We also discuss the benefits of vitamin B6 supplementation in the light of hypothetic pathophysiological mechanisms responsible for hyperhomocysteinemia in these patients. Our results confirmed the importance of monitoring homocysteine metabolism and vitamin status in patients with acute intermittent porphyria in order to improve management by appropriate vitamin supplementation during givosiran treatment.
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Affiliation(s)
- Isabelle Redonnet-Vernhet
- Univ. Bordeaux, INSERM, MRGM, U1211, F-33076 Bordeaux, France
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
| | - Patrick Mercié
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
| | - Louis Lebreton
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
| | - Jean-Marc Blouin
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
| | - Didier Bronnimann
- Service de Médecine Interne et Maladies Infectieuses, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075, France
| | - Samir Mesli
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
| | - Claire Guibet
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
| | - Emmanuel Ribeiro
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
| | - Noémie Gensous
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
- Univ-Bordeaux, CNRS UMR5164 Immunoconcept, Bordeaux, France
| | - Pierre Duffau
- Service de Médecine Interne et Immunologie Clinique, Groupe Hospitalier Saint-André, CHU de Bordeaux, F-33075 Bordeaux, France
- Univ-Bordeaux, CNRS UMR5164 Immunoconcept, Bordeaux, France
| | - Laurent Gouya
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
- Centre de Référence Maladies Rares Porphyries et anémies rares du métabolisme du fer, Centre Français des Porphyries, Hôpital Louis Mourier, AP-HP, Paris, France
| | - Emmanuel Richard
- Service de Biochimie, Laboratoire de Biologie Médicale de Référence (LBMR) Métabolisme des acides Aminés et Métabolisme de l'hème, Groupe hospitalier Pellegrin, CHU de Bordeaux, France
- Centre de Compétence Maladies Rares Porphyries et Anémies rares du Métabolisme du fer, CHU de Bordeaux, France
- Univ. Bordeaux, INSERM, BRIC, UMR1312, F-33076 Bordeaux, France
- Laboratory of Excellence Gr-Ex, F-75015 Paris, France
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Jericó D, Córdoba KM, Urigo F, Enríquez de Salamanca R, Anderson KE, Deybach JC, Ávila MA, Fontanellas A. Exploring current and emerging therapies for porphyrias. Liver Int 2024. [PMID: 38813953 DOI: 10.1111/liv.15979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
Porphyrias are rare, mostly inherited disorders resulting from altered activity of specific enzymes in the haem synthesis pathway that lead to accumulation of pathway intermediates. Photocutaneous symptoms occur when excess amounts of photoreactive porphyrins circulate in the blood to the skin, whereas increases in potentially neurotoxic porphyrin precursors are associated with neurovisceral symptoms. Current therapies are suboptimal and their mechanisms are not well established. As described here, emerging therapies address underlying disease mechanisms by introducing a gene, RNA or other specific molecule with the potential to cure or slow progression of the disease. Recent progress in nanotechnology and nanoscience, particularly regarding particle design and formulation, is expanding disease targets. More secure and efficient drug delivery systems have extended our toolbox for transferring specific molecules, especially into hepatocytes, and led to proof-of-concept studies in animal models. Repurposing existing drugs as molecular chaperones or haem synthesis inhibitors is also promising. This review summarizes key examples of these emerging therapeutic approaches and their application for hepatic and erythropoietic porphyrias.
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Affiliation(s)
- Daniel Jericó
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Karol M Córdoba
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Francesco Urigo
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
| | - Rafael Enríquez de Salamanca
- Department of Internal Medicine, Reference Center for Inherited Metabolic Disease-MetabERN, University Hospital 12 de Octubre, UCM, Madrid, Spain
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jean-Charles Deybach
- French Porphyria Reference Center (CRMR Porphyries France), Université Paris, Paris, France
| | - Matías A Ávila
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Fontanellas
- Solid Tumors Program, Hepatology: Porphyrias & Carcinogenesis Laboratory, CIMA-University of Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Abstract
The porphyrias are a group of rare diseases, each resulting from a defect in a different enzymatic step of the heme biosynthetic pathway. They can be broadly divided into two categories, hepatic and erythropoietic porphyrias, depending on the primary site of accumulation of heme intermediates. These disorders are multisystemic with variable symptoms that can be encountered by physicians in any specialty. Here, we review the porphyrias and describe their clinical presentation, diagnosis, and management. We discuss novel therapies that are approved or in development. Early diagnosis is key for the appropriate management and prevention of long-term complications in these rare disorders.
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Affiliation(s)
- Amy K Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA;
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Karp Leaf
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA;
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA;
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Yasuda M, Keel S, Balwani M. RNA interference therapy in acute hepatic porphyrias. Blood 2023; 142:1589-1599. [PMID: 37027823 PMCID: PMC10656724 DOI: 10.1182/blood.2022018662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/27/2023] [Accepted: 03/25/2023] [Indexed: 04/09/2023] Open
Abstract
The acute hepatic porphyrias (AHPs) are inherited disorders of heme biosynthesis characterized by life-threatening acute neurovisceral attacks precipitated by factors that upregulate hepatic 5-aminolevulinic acid synthase 1 (ALAS1) activity. Induction of hepatic ALAS1 leads to the accumulation of porphyrin precursors, in particular 5-aminolevulinic acid (ALA), which is thought to be the neurotoxic mediator leading to acute attack symptoms such as severe abdominal pain and autonomic dysfunction. Patients may also develop debilitating chronic symptoms and long-term medical complications, including kidney disease and an increased risk of hepatocellular carcinoma. Exogenous heme is the historical treatment for attacks and exerts its therapeutic effect by inhibiting hepatic ALAS1 activity. The pathophysiology of acute attacks provided the rationale to develop an RNA interference therapeutic that suppresses hepatic ALAS1 expression. Givosiran is a subcutaneously administered N-acetylgalactosamine-conjugated small interfering RNA against ALAS1 that is taken up nearly exclusively by hepatocytes via the asialoglycoprotein receptor. Clinical trials established that the continuous suppression of hepatic ALAS1 mRNA via monthly givosiran administration effectively reduced urinary ALA and porphobilinogen levels and acute attack rates and improved quality of life. Common side effects include injection site reactions and increases in liver enzymes and creatinine. Givosiran was approved by the US Food and Drug Administration and European Medicines Agency in 2019 and 2020, respectively, for the treatment of patients with AHP. Although givosiran has the potential to decrease the risk of chronic complications, long-term data on the safety and effects of sustained ALAS1 suppression in patients with AHP are lacking.
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Affiliation(s)
- Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Siobán Keel
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
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Brito Avô L, Pereira L, Oliveira A, Ferreira F, Filipe P, Coelho Rodrigues I, Couto E, Ferreira F, Airosa Pardal A, Morgado P, Moreira S. Portuguese Consensus on Acute Porphyrias: Diagnosis, Treatment, Monitoring and Patient Referral. ACTA MEDICA PORT 2023; 36:753-764. [PMID: 37924314 DOI: 10.20344/amp.20323] [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: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 11/06/2023]
Abstract
Acute porphyrias are a group of rare genetic metabolic disorders, caused by a defect in one of the enzymes involved in the heme biosynthesis, which results in an abnormally high accumulation of toxic intermediates. Acute porphyrias are characterized by potentially life-threatening attacks and, for some patients, by chronic manifestations that negatively impact daily functioning and quality of life. Clinical manifestations include a nonspecific set of gastrointestinal, neuropsychiatric, and/or cutaneous symptoms. Effective diagnostic methods are widely available, but due to their clinical heterogeneity and non-specificity, many years often elapse from symptom onset to diagnosis of acute porphyrias, delaying the treatment and increasing morbidity. Therefore, increased awareness of acute porphyrias among healthcare professionals is paramount to reducing disease burden. Treatment of acute porphyrias is centered on eliminating the potential precipitants, symptomatic treatment, and suppressing the hepatic heme pathway, through the administration of hemin or givosiran. Moreover, properly monitoring patients with acute porphyrias and their relatives is fundamental to preventing acute attacks, hospitalization, and long-term complications. Considering this, a multidisciplinary panel elaborated a consensus paper, aiming to provide guidance for an efficient and timely diagnosis of acute porphyrias, and evidence-based recommendations for treating and monitoring patients and their families in Portugal. To this end, all authors exhaustively reviewed and discussed the current scientific evidence on acute porphyrias available in the literature, between November 2022 and May 2023.
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Affiliation(s)
- Luís Brito Avô
- Serviço de Medicina Interna. Hospital CUF Tejo. Lisboa; Unidade de Doenças Raras. Hospital CUF Tejo. Lisboa; Nucleo de Estudos de Doenças Raras da Sociedade Portuguesa de Medicina Interna. Lisboa. Portugal
| | - Luísa Pereira
- Nucleo de Estudos de Doenças Raras da Sociedade Portuguesa de Medicina Interna. Lisboa; Unidade de Cuidados Paliativos. Hospital CUF Tejo. Lisboa. Portugal
| | - Anabela Oliveira
- Serviço de Medicina I. Centro de Referência de Doenças Hereditárias do Metabolismo. Centro Hospitalar Universitário Lisboa Norte. Lisboa. Portugal
| | - Filipa Ferreira
- Unidade de Rastreio Neonatal, Metabolismo e Genética. Departamento de Genética Humana. Instituto Nacional de Saúde Doutor Ricardo Jorge. Porto. Portugal
| | - Paulo Filipe
- Unidade de Investigação de Dermatologia. Instituto de Medicina Molecular João Lobo Antunes. Lisboa. Portugal
| | - Inês Coelho Rodrigues
- Serviço de Gastrenterologia. Centro Hospitalar e Universitário de Lisboa Norte. Lisboa. Portugal
| | - Eduarda Couto
- Departamento de Medicina Interna. Serviço de Hematologia Clínica. Centro Hospitalar Póvoa de Varzim - Vila do Conde. Póvoa de Varzim. Portugal
| | - Fátima Ferreira
- Serviço de Hematologia Clínica. Centro Hospitalar e Universitário de São João. Porto. Portugal
| | - André Airosa Pardal
- Serviço de Hematologia Clínica. Centro Hospitalar Universitário de São João. Porto. Portugal
| | - Pedro Morgado
- Instituto de Investigação em Ciências da Vida e Saúde. Escola de Medicina. Universidade do Minho. Braga; Laboratório Associado do Governo Português ICVS/3B's. Braga/Guimarães; Serviço de Psiquiatria. Hospital de Braga. Braga. Portugal
| | - Sónia Moreira
- Nucleo de Estudos de Doenças Raras da Sociedade Portuguesa de Medicina Interna. Lisboa; Serviço de Medicina Interna. Centro de Referência de Doenças Hereditárias do Metabolismo. Centro Hospitalar e Universitário de Coimbra. Coimbra; Faculdade de Medicina. Universidade de Coimbra. Coimbra. . Portugal
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Kuter DJ, Bonkovsky HL, Monroy S, Ross G, Guillén-Navarro E, Cappellini MD, Minder AE, Hother-Nielsen O, Ventura P, Jia G, Sweetser MT, Thapar M. Efficacy and safety of givosiran for acute hepatic porphyria: Final results of the randomized phase III ENVISION trial. J Hepatol 2023; 79:1150-1158. [PMID: 37479139 DOI: 10.1016/j.jhep.2023.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/24/2023] [Accepted: 06/15/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND & AIMS Acute hepatic porphyria (AHP) is caused by defects in hepatic heme biosynthesis, leading to disabling acute neurovisceral attacks and chronic symptoms. In ENVISION (NCT03338816), givosiran treatment for 6 months reduced attacks and other disease manifestations compared with placebo. Herein, we report data from the 36-month final analysis of ENVISION. METHODS Ninety-four patients with AHP (age ≥12 years) and recurrent attacks were randomized 1:1 to monthly double-blind subcutaneous givosiran 2.5 mg/kg (n = 48) or placebo (n = 46) for 6 months. In the open-label extension (OLE) period, 93 patients received givosiran 2.5 or 1.25 mg/kg for 6 months or more before transitioning to 2.5 mg/kg. Endpoints were exploratory unless otherwise noted. RESULTS During givosiran treatment, the median annualized attack rate (AAR) was 0.4. Through Month 36, annualized days of hemin use remained low in the continuous givosiran group (median, 0.0 to 0.4) and decreased in the placebo crossover group (16.2 to 0.4). At end of OLE, in the continuous givosiran and placebo crossover groups, 86% and 92%, respectively, had 0 attacks. AAR was lower than historical AAR in 98% and 100%, respectively (post hoc analysis), and there were 0 days of hemin use in 88% and 90%, respectively. The 12-item short-form health survey physical and mental component summary scores increased by 8.6 and 8.1, respectively (continuous givosiran) and 9.4 and 3.2, respectively (placebo crossover). EQ-5D health-related questionnaire scores increased by 18.9 (continuous givosiran) and 9.9 (placebo crossover). Lower urinary delta-aminolevulinic acid and porphobilinogen levels were sustained. Safety findings demonstrated a continued positive risk/benefit profile for givosiran. CONCLUSIONS Long-term monthly givosiran treatment provides sustained and continued improvement in clinical manifestations of AHP. CLINICALTRIALS GOV IDENTIFIER NCT03338816. EUDRACT NUMBER 2017-002432-17. IMPACT AND IMPLICATIONS Acute hepatic porphyria (AHP) is a group of rare, chronic, multisystem disorders associated with overproduction and accumulation of neurotoxic heme intermediates (delta-aminolevulinic acid and porphobilinogen), sometimes resulting in recurrent acute attacks and long-term complications. Givosiran, a small-interfering RNA that prevents accumulation of delta-aminolevulinic acid and porphobilinogen, is approved for the treatment of AHP. These final 36-month results of ENVISION, a phase III study of givosiran in patients with AHP and recurrent attacks, show that long-term monthly treatment with givosiran leads to continuous and sustained reductions in annualized attack rate and use of hemin over time, as well as improved quality of life, with an acceptable safety profile. These results are important for physicians, patients, families, and caregivers who are grappling with this debilitating and potentially life-threatening disease with few effective and tolerable treatment options.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, Boston, MA, USA.
| | | | - Susana Monroy
- Instituto Nacional de Pediatría, Mexico City, Mexico
| | - Gayle Ross
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Encarna Guillén-Navarro
- Medical Genetics Section, Virgen de la Arrixaca University Hospital, IMIB Pascual Parrilla, University of Murcia (UMU), Murcia, Spain; CIBERER-ISCIII, Madrid, Spain
| | | | - Anna-Elisabeth Minder
- Division of Endocrinology, Diabetes and Porphyria, Stadtspital Zürich, Triemli, Zürich, Switzerland
| | | | - Paolo Ventura
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Gang Jia
- Alnylam Pharmaceuticals, Cambridge, MA, USA
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Recent Insights into the Pathogenesis of Acute Porphyria Attacks and Increasing Hepatic PBGD as an Etiological Treatment. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111858. [PMID: 36430993 PMCID: PMC9694773 DOI: 10.3390/life12111858] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
Rare diseases, especially monogenic diseases, which usually affect a single target protein, have attracted growing interest in drug research by encouraging pharmaceutical companies to design and develop therapeutic products to be tested in the clinical arena. Acute intermittent porphyria (AIP) is one of these rare diseases. AIP is characterized by haploinsufficiency in the third enzyme of the heme biosynthesis pathway. Identification of the liver as the target organ and a detailed molecular characterization have enabled the development and approval of several therapies to manage this disease, such as glucose infusions, heme replenishment, and, more recently, an siRNA strategy that aims to down-regulate the key limiting enzyme of heme synthesis. Given the involvement of hepatic hemoproteins in essential metabolic functions, important questions regarding energy supply, antioxidant and detoxifying responses, and glucose homeostasis remain to be elucidated. This review reports recent insights into the pathogenesis of acute attacks and provides an update on emerging treatments aimed at increasing the activity of the deficient enzyme in the liver and restoring the physiological regulation of the pathway. While further studies are needed to optimize gene therapy vectors or large-scale production of liver-targeted PBGD proteins, effective protection of PBGD mRNA against the acute attacks has already been successfully confirmed in mice and large animals, and mRNA transfer technology is being tested in several clinical trials for metabolic diseases.
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