UX007 for the treatment of long chain-fatty acid oxidation disorders: Safety and efficacy in children and adults following 24weeks of treatment

BACKGROUND

Long-chain fatty acid oxidation disorders (LC-FAOD) lead to accumulation of high concentrations of potentially toxic fatty acid intermediates. Newborn screening and early intervention have reduced mortality, but most patients continue to experience frequent hospitalizations and significant morbidity despite treatment. The deficient energy state can cause serious liver, muscle, and heart disease, and may be associated with an increased risk of sudden death. Triheptanoin is a medium odd-chain fatty acid. Anaplerotic metabolites of triheptanoin have the potential to replace deficient tricarboxylic acid (TCA) cycle intermediates, resulting in net glucose production as a novel energy source for the treatment of LC-FAOD.

STUDY DESIGN

A single-arm, open-label, multicenter Phase 2 safety and efficacy study evaluated patients with severe LC-FAOD evidenced by ongoing related musculoskeletal, cardiac, and/or hepatic events despite treatment. After a four-week run-in on current regimen, investigational triheptanoin (UX007) was titrated to a target dose of 25-35% of total daily caloric intake. Patients were evaluated on several age/condition-eligible endpoints, including submaximal exercise tests to assess muscle function/endurance (12-minute walk test; 12MWT) and exercise tolerance (cycle ergometry), and health related quality of life (HR-QoL). Results through 24weeks of treatment are presented; total study duration is 78weeks.

RESULTS

Twenty-nine patients (0.8 to 58years) were enrolled; most qualified based on severe musculoskeletal disease. Twenty-five patients (86%) completed the 24-week treatment period. At Week 18, eligible patients (n=8) demonstrated a 28% increase (LS mean=+181.9 meters; p=0.087) from baseline (673.4meters) in 12MWT distance. At Week 24, eligible patients (n=7) showed a 60% increase in watts generated (LS mean=+409.3W; p=0.149) over baseline (744.6W) for the exercise tolerance test. Improvements in exercise tests were supported by significant improvements from baseline in the adult (n=5) self-reported SF-12v2 physical component summary score (LS mean=+8.9; p<0.001). No difference from baseline was seen in pediatric parent-reported (n=5) scores (SF-10) at Week 24. Eighteen patients (62%) had treatment-related adverse events, predominantly gastrointestinal (55%), mild-to-moderate in severity, similar to that seen with prior treatment with medium chain triglyceride (MCT) oil. One patient experienced a treatment-related serious adverse event of gastroenteritis. One patient discontinued from study due to diarrhea of moderate severity; the majority of patients (25/29; 86%) elected to continue treatment in the extension period.

CONCLUSIONS

In patients with severe LC-FAOD, UX007 interim study results demonstrated improved exercise endurance and tolerance, and were associated with positive changes in self-reported HR-QoL.

Role diversification in the education of advanced practice psychiatric nurses

The mode, location, and focus of health care services are changing rapidly, especially delivery of psychiatric services. The high prevalence of psychiatric and medical comorbidity, the national shift in health care to a managed care arrangement with one professional designated as principle provider, and problems with access to comprehensive services for individuals with psychiatric problems interact to create a compelling need for a clear definition of advanced psychiatric-mental health nursing practice. This article is, in part, a response to the national dialogue and debate sparked by the beginning development of a psychiatric nurse practitioner certification exam. However, this debate will be used merely as a starting point to articulate and document the need for a flexible, diverse, and evolving definition of advanced psychiatric-mental health nursing practice that can inform and shape educational programs in the discipline.

Murine monoclonal anti-DNA antibodies bind directly to glomerular antigens and form immune deposits

The capacity of monoclonal anti-DNA antibodies, derived spontaneously from MRL-lpr/lpr mice, to bind directly to intrinsic glomerular antigens and form immune deposits was evaluated. Two antibodies, H130 (IgM-kappa) and H241 (IgG2a-kappa), bound to normal glomeruli in vitro. This binding was not inhibited by DNAase, but it was, in the case of H130, inhibited by the anti-idiotype anti-H130. Both antibodies also bound to glomerular digests on nitrocellulose. After i.v. injection, however, H241 bound to glomeruli and formed glomerular immune deposits, whereas H130 did not. Similarly, after i.p. injection of H241 hybridomas to normal mice, all mice developed glomerular immune deposits. In contrast, administration of H130 hybridomas, other anti-DNA-producing hybridomas, and other unrelated hybridomas did not lead to glomerular immune deposit formation. We conclude that certain lupus auto-antibodies can form glomerular immune deposits by binding directly to non-DNA antigenic structures that are normally present in extracellular locations within normal glomeruli.

Murine monoclonal anti-DNA antibodies bind directly to glomerular antigens and form immune deposits

The capacity of monoclonal anti-DNA antibodies, derived spontaneously from MRL-lpr/lpr mice, to bind directly to intrinsic glomerular antigens and form immune deposits was evaluated. Two antibodies, H130 (IgM-kappa) and H241 (IgG2a-kappa), bound to normal glomeruli in vitro. This binding was not inhibited by DNAase, but it was, in the case of H130, inhibited by the anti-idiotype anti-H130. Both antibodies also bound to glomerular digests on nitrocellulose. After i.v. injection, however, H241 bound to glomeruli and formed glomerular immune deposits, whereas H130 did not. Similarly, after i.p. injection of H241 hybridomas to normal mice, all mice developed glomerular immune deposits. In contrast, administration of H130 hybridomas, other anti-DNA-producing hybridomas, and other unrelated hybridomas did not lead to glomerular immune deposit formation. We conclude that certain lupus auto-antibodies can form glomerular immune deposits by binding directly to non-DNA antigenic structures that are normally present in extracellular locations within normal glomeruli.