Roscoe O. Brady, M.D.
Chief, Developmental and Metabolic
Neurology Branch
National Institute of Neurological
Disorders and Stroke
National Institutes of Health
Bethesda, Maryland
CURRENT AND FUTURE STRATEGIES FOR THE
TREATMENT OF METABOLIC STORAGE DISORDERS
1. BONE MARROW TRANSPLANTATION
2. ENZYME REPLACEMENT THERAPY
3. SUBSTRATE REDUCTION THERAPY
4. MOLECULAR CHAPERONE THERAPY
5. GENE THERAPY
Hereditary Lipid Storage Disorders
Sphingolipidoses
SPHINGOSINE
18
3
2
1
CH3 -(CH2)12-CH=CH-CH-CH-CH2OH
OH NH2
Carbon atoms 1 and 2 arise from the amino acid serine
Carbon atoms 3 to 18 arise from palmitic acid
CERAMIDE
Sphingosine
CH3 -(CH2)12-CH=CH-CH-CH-CH2OH
OH NH
CH3 - (CH2)22 - C = 0
Long Chain Fatty Acid
GAUCHER DISEASE
Gaucher
Disease
Type 1
(NonNeuronopathic)
Anemia
Easy bruising
due to low
blood platelets
Bone damage
Enlarged
liver
Huge spleen
ACCUMULATING LIPID IN GAUCHER DISEASE
GLUCOCEREBROSIDE
SPHINGOSINE
FATTY ACID
GLUCOSE
ENZYMATIC DEFECT IN GAUCHER DISEASE
DEFICIENCY OF GLUCOCEREBROSIDASE
SPHINGOSINE
GLUCOSE
FATTY ACID
R. O. Brady et al. Biochem Biophys Res Commun 1965; 18: 221
WHAT IS THE ORIGIN OF THE ACCUMULATING LIPID?
MAJOR LIPID OF WHITE BLOOD CELLS
CERAMIDELACTOSIDE
SPHINGOSINE
FATTY ACID
GLUCOSE
GALACTOSE
MAJOR LIPID OF RED BLOOD CELLS
GLOBOSIDE
SPHINGOSINE—GLUCOSE—GALACTOSE—GALACTOSE—N-ACETYGALACTOSAMINE
FATTY ACID
• 20-40 times more glucocerebroside arises from senescent
white blood cells than red blood cells
TREATMENT OF PATIENTS WITH
LYSOSOMAL STORAGE DISORDERS
1. Bone Marrow Transplantation
BONE MARROW TRANSPLANTATION (BMT)
If a suitable match is available, BMT can cure a
patient with type 1 Gaucher disease
Risks
Graft-versus host disease
Continuous immunosuppression probably necessary
Implication
? Gene therapy using transduced bone marrow stem cells
TREATMENT STRATEGIES
2.
ENZYME REPLACEMENT THERAPY
R. O. BRADY N Engl J Med 1966; 275: 312
GAUCHER DISEASE
The required enzyme glucocerebrosidase is currently
produced recombinantly in Chinese hamster ovary cells.
It is necessary to modify the glycoform of this enzyme
in order to target it to macrophages, the principal lipidstoring cells in the body of patients.
Amino Acid Chain
GLUCOCEREBROSIDASE IS TREATED WITH
3 EXOGLYCOSIDASES
Amino Acid Chain
Delivery of mannose-terminal glucocerebrosidase
to lipid-storing macrophages (Kupffer cells in the
liver) is increased 50-fold over that of unmodified
glucocerebrosidase
RESULTS OF ENZYME REPLACEMENT THERAPY
IN GAUCHER PATIENTS USING MACROPHAGETARGETED GLUCOCEREBROSIDASE
Spleen size decreases
Liver size decreases
Hemoglobin increases
Blood platelets increase
Skeleton improves
SPLEEN
MRI OF
ABDOMEN
ERT
7 months ERT
MORE THAN 4,300 PATIENTS WITH GAUCHER
DISEASE ARE NOW RECEIVING ENZYME
REPLACEMENT THERAPY
TYPE 2 GAUCHER DISEASE
Acute Neuronopathic Gaucher Disease
Neuronophagia in the brain of a patient with Type 2 Gaucher disease
WHAT IS THE SOURCE OF GLUCOCEREBROSIDE
IN THE BRAIN?
Ganglioside GDIa
SPHINGOSINE -GLUCOSE -GALACTOSE- N-ACETYGALACTOSAMINE- GALACTOSE
FATTY ACID
N-ACETYLNEURAMINIC ACID
N-ACETYLNEURAMINIC ACID
ENZYME REPLACEMENT THERAPY IN
PATIENTS WITH TYPE 2 GAUCHER DISEASE
No benefit of intravenous glucocerebrosidase on brain
WOULD DIRECT INTRACEREBRAL INJECTION
OF GLUCOCEREBROSIDASE BE EFFECTIVE?
(CONVECTION-ENHANCED DELIVERY)
Safety and Distribution of Mannose-terminal
Glucocerebrosidase Injected into the Brain of Normal Rats
G.C. Zirzow et al. Neurochemical Res 1999; 24: 301
NEURONAL UPTAKE OF INTRA-CEREBRALLY
ADMINISTERED GLUCOCEREBROSIDASE
Safety Study of Intracerebrally Injected Glucocerebrosidase
in Non-human Primates
R. Lonser et al, Annals of Neurology 2005; 57: 543
TREATMENT STRATEGIES
3.
SUBSTRATE REDUCTION THERAPY
REDUCE THE FORMATION OF
GLUCOCEREBROSIDE
SPHINGOSINE + UDP–GLUCOSE
FATTY ACID
SPHINGOSINE
ACID
GLUCOSE + UDP
FATTY
Glucocerebroside
UDP-GLUCOSE = URIDINE DIPHOSPHATE GLUCOSE
= SITE OF INHIBITION OF GLUCOSYLTRANSFERASE
Small Molecule Inhibitor of Glucocerebroside Formation
MIGLUSTAT
SUBSTRATE DEPLETION
Miglustat OGT 918 (Zavesca) has been approved for
the treatment of patients with type 1 Gaucher disease
for whom enzyme replacement therapy is not
appropriate.
(Cox T, Lachmann R, Hollak C, et al. Lancet 2000; 355: 1481)
Patient with
Type 3a Chronic
Neuronopathic
Gaucher Disease
Slow horizontal
eye movement
SUBSTRATE DEPLETION
• Ongoing NIH Investigation of OGT 918 in
Patients with Type 3 (Chronic Neuronopathic)
Gaucher Disease Who Also Receive Enzyme
Replacement Therapy to Control the Systemic
Manifestations of the Disease
TREATMENT STRATEGIES
4.
MOLECULAR CHAPERONE THERAPY
GM1-GANGLIOSIDOSIS
GM1
Gangliosidosis
Phenotypes
Infantile
Juvenile
Chronic
Adult
Adult
Accumulation of Ganglioside GM1
SPHINGOSINE-GLUCOSE-GALACTOSE-N-ACETYGALACTOSAMINE-GALACTOSE
FATTY ACID
N-ACETYLNEURAMINIC ACID
Enzymatic Defect in GM1-Gangliosidosis
SPHINGOSINE-GLUCOSE-GALACTOSE-N-ACETYGALACTOSAMINE-GALACTOSE
FATTY ACID
N-ACETYLNEURAMINIC ACID
-galactosidase deficiency
Okada and O’Brien 1968
CHEMICAL CHAPERONE THERAPY FOR BRAIN
PATHOLOGY IN GM1-GANGLIOSIDOSIS
CREATED A MOUSE MODEL WITH THE
JUVENILE PHENOTYPE OF GM1GANGLIOSIDOSIS BY CHANGING
ARGININE AT POSITION 201 OF
-GALACTOSIDASE TO CYSTEINE
(R201C)
Chemical Chaperone
N-0ctyl-4-epi--valienamine (NOEV)
J. Matsuda et al. Proc Natl Acad Sci USA 2003; 100: 15912
EFFECT OF N-OCTYL-4--VALIENAMINE (NOEV)
ON -GALACTOSIDASE ACTIVITY IN CULTURED
MURINE FIBROBLASTS
Additions
Fold
None
0.2 mM NOEV
(nmols/h/mg protein)
Wild type
1.2
Juvenile GM1
5.1
68
23
79
116
REDUCTION OF GM1 IN THE BRAIN OF MICE
WITH THE JUVENILE PHENOTYPE OF GM1-
GANGLIOSIDOSIS WITH THE NOEV
CHAPERONE IN THE DRINKING WATER
Ganglioside GM1
? Chaperone Therapy for Gaucher
Disease
N-Octyl--valienamine up-regulates
activity of
F213I mutant -glucosidase in cultured
cells:
a potential chemical chaperone therapy
for
Gaucher disease.
FABRY DISEASE
PRINCIPAL ACCUMULATING LIPID IN FABRY DISEASE
CERAMIDETRIHEXOSIDE
SPHINGOSINE – GLUCOSE – GALACTOSE - GALACTOSE
FATTY ACID
ENZYMATIC DEFECT IN FABRY DISEASE
CERAMIDETRIHEXOSIDASE
(Alpha-Galactosidase A)
SPHINGOSINE – GLUCOSE – GALACTOSE - GALACTOSE
FATTY ACID
R. O. Brady et al New Engl J Med 1967
ENZYME REPLACEMENT THERAPY IN FABRY
PATIENTS HAS PRODUCED DISTINCT BENEFIT,
BUT NOT ALL OF THE MANIFESTATIONS ARE
COMPLETELY RESOLVED
MOLECULAR CHAPERONE THERAPY FOR
FABRY DISEASE
TREATMENT OF METABOLIC STORAGE DISORDERS
5. GENE THERAPY
1. GAUCHER DISEASE
Retroviral transduction of patients’ autologous bonemarrow stem and progenitor cells -- 2 patients no clinical
benefit
2. FABRY DISEASE
Intravenous injection of adeno-associated virus with
human -galactosidase A gene into -galactosidase A
knock-out mice -- spectacular results - ?neoplasms
CURRENT AND FUTURE STRATEGIES FOR THE
TREATMENT OF METABOLIC STORAGE DISORDERS
1. BONE MARROW TRANSPLANTATION
2. ENZYME REPLACEMENT THERAPY
3. SUBSTRATE REDUCTION THERAPY
4. MOLECULAR CHAPERONE THERAPY
5. GENE THERAPY ?