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Yska HAF, Turk BR, Fatemi A, Goodman J, Voermans M, Amos D, Amanat M, van de Stadt S, Engelen M, Smith-Fine A, Keller J. International validation of meaningfulness of postural sway and gait to assess myeloneuropathy in adults with adrenoleukodystrophy. J Inherit Metab Dis 2024. [PMID: 38795020 DOI: 10.1002/jimd.12753] [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: 01/19/2024] [Revised: 04/10/2024] [Accepted: 05/06/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND The most common manifestation of X-linked adrenoleukodystrophy (ALD) is a slowly progressive myeloneuropathy, which leads to imbalance and gait disturbances. The variable progression of the disease complicates evaluation of its progression rate. Wearable sensors allow for easy and frequent balance and gait collection. This study reports baseline data from a longitudinal study on the quantitative assessment of balance and gait with wearable sensors and their clinical relevance. METHODS Data were collected from adult patients in two institutions. Postural body sway and gait parameters were measured using accelerometers. Disease severity was measured by the Expanded Disability Severity Scale (EDSS). Falling frequency and quality of life (QOL) were collected in men. The relationship between sway and gait variables and EDSS score, participants' use of a walking aid, and falling frequency was evaluated. RESULTS One hundred twenty individuals with ALD were included. Sway variables significantly differentiate participants' assistive device use. Sway and gait variables were correlated to the EDSS in both sexes. Both gait speed and sway were correlated with falling frequency in men from one institution. Select QOL subscores were correlated with the EDSS in males from one institution. Accelerometry generated comparable results across sites. DISCUSSION This study confirms the clinical correlation between spinal cord disease and imbalance and gait in ALD. For the first time, this study shows clinically meaningful relationships for sway and gait with use of an assistive device, falling frequency and QOL. Wearable accelerometers are a valid means to measure sway and gait in ALD. These measures are promising outcomes for clinical trial designs to assess myeloneuropathy in ALD and to monitor disease progression in individuals.
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Affiliation(s)
- Hemmo A F Yska
- Emma Children's Hospital, Department of Neurology and Pediatric Neurology, Amsterdam Leukodystrophy Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Bela R Turk
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ali Fatemi
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Marije Voermans
- Emma Children's Hospital, Department of Neurology and Pediatric Neurology, Amsterdam Leukodystrophy Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Dan Amos
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Man Amanat
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Stephanie van de Stadt
- Emma Children's Hospital, Department of Neurology and Pediatric Neurology, Amsterdam Leukodystrophy Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Engelen
- Emma Children's Hospital, Department of Neurology and Pediatric Neurology, Amsterdam Leukodystrophy Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Amena Smith-Fine
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Keller
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Köhler W, Engelen M, Eichler F, Lachmann R, Fatemi A, Sampson J, Salsano E, Gamez J, Molnar MJ, Pascual S, Rovira M, Vilà A, Pina G, Martín-Ugarte I, Mantilla A, Pizcueta P, Rodríguez-Pascau L, Traver E, Vilalta A, Pascual M, Martinell M, Meya U, Mochel F. Safety and efficacy of leriglitazone for preventing disease progression in men with adrenomyeloneuropathy (ADVANCE): a randomised, double-blind, multi-centre, placebo-controlled phase 2-3 trial. Lancet Neurol 2023; 22:127-136. [PMID: 36681445 DOI: 10.1016/s1474-4422(22)00495-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/11/2022] [Accepted: 11/24/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Adult patients with adrenoleukodystrophy have a poor prognosis owing to development of adrenomyeloneuropathy. Additionally, a large proportion of patients with adrenomyeloneuropathy develop life-threatening progressive cerebral adrenoleukodystrophy. Leriglitazone is a novel selective peroxisome proliferator-activated receptor gamma agonist that regulates expression of key genes that contribute to neuroinflammatory and neurodegenerative processes implicated in adrenoleukodystrophy disease progression. We aimed to assess the effect of leriglitazone on clinical, imaging, and biochemical markers of disease progression in adults with adrenomyeloneuropathy. METHODS ADVANCE was a 96-week, randomised, double-blind, placebo-controlled, phase 2-3 trial done at ten hospitals in France, Germany, Hungary, Italy, the Netherlands, Spain, the UK, and the USA. Ambulatory men aged 18-65 years with adrenomyeloneuropathy without gadolinium enhancing lesions suggestive of progressive cerebral adrenoleukodystrophy were randomly assigned (2:1 without stratification) to receive daily oral suspensions of leriglitazone (150 mg starting dose; between baseline and week 12, doses were increased or decreased to achieve plasma concentrations of 200 μg·h/mL [SD 20%]) or placebo by means of an interactive response system and a computer-generated sequence. Investigators and patients were masked to group assignment. The primary efficacy endpoint was change from baseline in the Six-Minute Walk Test distance at week 96, analysed in the full-analysis set by means of a mixed model for repeated measures with restricted maximum likelihood and baseline value as a covariate. Adverse events were also assessed in the full-analysis set. This study was registered with ClinicalTrials.gov, NCT03231878; the primary study is complete; patients had the option to continue treatment in an open-label extension, which is ongoing. FINDINGS Between Dec 8, 2017, and Oct 16, 2018, of 136 patients screened, 116 were randomly assigned; 62 [81%] of 77 patients receiving leriglitazone and 34 [87%] of 39 receiving placebo completed treatment. There was no between-group difference in the primary endpoint (mean [SD] change from baseline leriglitazone: -27·7 [41·4] m; placebo: -30·3 [60·5] m; least-squares mean difference -1·2 m; 95% CI -22·6 to 20·2; p=0·91). The most common treatment emergent adverse events in both the leriglitazone and placebo groups were weight gain (54 [70%] of 77 vs nine [23%] of 39 patients, respectively) and peripheral oedema (49 [64%] of 77 vs seven [18%] of 39). There were no deaths. Serious treatment-emergent adverse events occurred in 14 (18%) of 77 patients receiving leriglitazone and ten (26%) of 39 patients receiving placebo. The most common serious treatment emergent adverse event, clinically progressive cerebral adrenoleukodystrophy, occurred in six [5%] of 116 patients, all of whom were in the placebo group. INTERPRETATION The primary endpoint was not met, but leriglitazone was generally well tolerated and rates of adverse events were in line with the expected safety profile for this drug class. The finding that cerebral adrenoleukodystrophy, a life-threatening event for patients with adrenomyeloneuropathy, occurred only in patients in the placebo group supports further investigation of whether leriglitazone might slow the progression of cerebral adrenoleukodystrophy. FUNDING Minoryx Therapeutics.
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Affiliation(s)
- Wolfgang Köhler
- Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany.
| | - Marc Engelen
- Department of Pediatric Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Florian Eichler
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Robin Lachmann
- Charles Dent Metabolic Unit, University College London Hospitals, London, UK
| | - Ali Fatemi
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Jacinda Sampson
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Ettore Salsano
- Unit of Rare Neurodegenerative and Neurometabolic Diseases, Fondazione IRCCS Istituto Neurologico C Besta, Milan, Italy
| | - Josep Gamez
- Department of Neurology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Judit Molnar
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Budapest, Hungary
| | | | | | - Anna Vilà
- Minoryx Therapeutics, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Uwe Meya
- Minoryx Therapeutics, Barcelona, Spain
| | - Fanny Mochel
- APHP-Brain and Spine Institute Department of Genetics, Reference Centre for Leukodystrophies, and Paris Brain Institute, Sorbonne University, La Pitié-Salpêtrière University Hospital, Paris, France
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3
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Honey MIJ, Jaspers YRJ, Engelen M, Kemp S, Huffnagel IC. Molecular Biomarkers for Adrenoleukodystrophy: An Unmet Need. Cells 2021; 10:3427. [PMID: 34943935 PMCID: PMC8699919 DOI: 10.3390/cells10123427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 01/06/2023] Open
Abstract
X-linked adrenoleukodystrophy (ALD) is an inherited progressive neurometabolic disease caused by mutations in the ABCD1 gene and the accumulation of very long-chain fatty acids in plasma and tissues. Patients present with heterogeneous clinical manifestations which can include adrenal insufficiency, myelopathy, and/or cerebral demyelination. In the absence of a genotype-phenotype correlation, the clinical outcome of an individual cannot be predicted and currently there are no molecular markers available to quantify disease severity. Therefore, there is an unmet clinical need for sensitive biomarkers to monitor and/or predict disease progression and evaluate therapy efficacy. The increasing amount of biological sample repositories ('biobanking') as well as the introduction of newborn screening creates a unique opportunity for identification and evaluation of new or existing biomarkers. Here we summarize and review the many studies that have been performed to identify and improve knowledge surrounding candidate molecular biomarkers for ALD. We also highlight several shortcomings of ALD biomarker studies, which often include a limited sample size, no collection of longitudinal data, and no validation of findings in an external cohort. Nonetheless, these studies have generated a list of interesting biomarker candidates and this review aspires to direct future biomarker research.
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Affiliation(s)
- Madison I. J. Honey
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam University Medical Centers, Amsterdam Neuroscience, Vrije Universiteit, 1081 HV Amsterdam, The Netherlands;
| | - Yorrick R. J. Jaspers
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - Marc Engelen
- Department of Pediatric Neurology, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.E.); (I.C.H.)
| | - Stephan Kemp
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
- Department of Pediatric Neurology, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.E.); (I.C.H.)
| | - Irene C. Huffnagel
- Department of Pediatric Neurology, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam Neuroscience, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (M.E.); (I.C.H.)
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Godbole NP, Sadjadi R, DeBono MA, Grant NR, Kelly DC, James PF, Stephen CD, Balkwill MD, Lewis RF, Eichler FS. Gait Difficulties and Postural Instability in Adrenoleukodystrophy. Front Neurol 2021; 12:684102. [PMID: 34220690 PMCID: PMC8247575 DOI: 10.3389/fneur.2021.684102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/24/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Gait and balance difficulties are among the most common clinical manifestations in adults with X-linked adrenoleukodystrophy, but little is known about the contributions of sensory loss, motor dysfunction, and postural control to gait dysfunction and fall risk. Objective: To quantify gait and balance deficits in both males and females with adrenoleukodystrophy and evaluate how environmental perturbations (moving surfaces and visual surrounds) affect balance and fall risk. Methods: We assessed sensory and motor contributions to gait and postural instability in 44 adult patients with adrenoleukodystrophy and 17 healthy controls using three different functional gait assessments (25 Foot Walk test, Timed Up and Go, and 6 Minute Walk test) and computerized dynamic posturography. Results: The median Expanded Disability Status Scale score for the patient cohort was 3.0 (range 0.0–6.5). Both males and females with adrenoleukodystrophy showed impairments on all three functional gait assessments relative to controls (P < 0.001). Performance on walking tests and Expanded Disability Status Scale scores correlated with incidence of falls on computerized dynamic posturography, with the 25 Foot Walk being a moderately reliable predictor of fall risk (area under the ROC curve = 0.7675, P = 0.0038). Conclusion: We demonstrate that gait difficulties and postural control deficits occur in patients with adrenoleukodystrophy, albeit at an older age in females. Postural deficits were aggravated by eyes closed and dynamic conditions that rely on vestibular input, revealing challenges to the interplay of motor, sensory and vestibular circuitry in adrenoleukodystrophy.
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Affiliation(s)
- Neha P Godbole
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Reza Sadjadi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Madeline A DeBono
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Natalie R Grant
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Daniel C Kelly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Peter F James
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Christopher D Stephen
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | | | - Richard F Lewis
- Harvard Medical School, Boston, MA, United States.,Massachusetts Eye and Ear, Boston, MA, United States
| | - Florian S Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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