RoscoeO.Brady,M.D.

Chief,DevelopmentalandMetabolic
NeurologyBranch
NationalInstituteofNeurological
DisordersandStroke
NationalInstitutesofHealth
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

HereditaryLipidStorageDisorders
Sphingolipidoses

SPHINGOSINE
3

18

CH3 -(CH2)12-CH=CH-CH-CH-CH2OH
OH NH2
Carbonatoms1and2arisefromtheaminoacidserine
Carbonatoms3to18arisefrompalmiticacid

CERAMIDE
Sphingosine
CH3 -(CH2)12-CH=CH-CH-CH-CH2OH
OH NH
CH3 - (CH2)22 - C = 0
Long Chain Fatty Acid

GAUCHERDISEASE

Gaucher
Disease
Type1
(Non

Anemia

Neuronopathic)

Easybruising
duetolow
bloodplatelets

Bonedamage

Enlarged
liver

Hugespleen

ACCUMULATING LIPID IN GAUCHER DISEASE

GLUCOCEREBROSIDE
SPHINGOSINE
GLUCOSE
FATTY ACID

ENZYMATIC DEFECT IN GAUCHER DISEASE

DEFICIENCY OF GLUCOCEREBROSIDASE

SPHINGOSINE
GLUCOSE
FATTY ACID
R.O.Bradyetal.BiochemBiophysResCommun1965;18:221

WHAT IS THE ORIGIN OF THE ACCUMULATING LIPID?

MAJORLIPIDOFWHITEBLOODCELLS
CERAMIDELACTOSIDE
SPHINGOSINE
GALACTOSE

GLUCOSE

FATTY ACID

MAJOR LIPID OF RED BLOOD CELLS

GLOBOSIDE

SPHINGOSINEGLUCOSEGALACTOSEGALACTOSEN-ACETYGALACTOSAM
FATTY ACID

2040timesmoreglucocerebrosidearisesfromsenescent
whitebloodcellsthanredbloodcells

TREATMENTOFPATIENTSWITH
LYSOSOMALSTORAGEDISORDERS
1. BoneMarrowTransplantation

BONEMARROWTRANSPLANTATION(BMT)

Ifasuitablematchisavailable,BMTcancurea
patientwithtype1Gaucherdisease
Risks
Graftversushostdisease
Continuousimmunosuppressionprobablynecessary
Implication
?Genetherapyusingtransducedbonemarrowstemcells

TREATMENTSTRATEGIES
2.ENZYMEREPLACEMENTTHERAPY

R.O.BRADYNEnglJMed1966;275:312

GAUCHERDISEASE

Therequiredenzymeglucocerebrosidaseiscurrently

producedrecombinantlyinChinesehamsterovarycells.

Itisnecessarytomodifytheglycoformofthisenzyme

inordertotargetittomacrophages,theprincipallipid

storingcellsinthebodyofpatients.

AminoAcidChain

GLUCOCEREBROSIDASEISTREATEDWITH
3EXOGLYCOSIDASES

AminoAcidChain

Deliveryofmannoseterminalglucocerebrosidase
tolipidstoringmacrophages(Kupffercellsinthe
liver)isincreased50foldoverthatofunmodified
glucocerebrosidase

RESULTSOFENZYMEREPLACEMENTTHERAPY

INGAUCHERPATIENTSUSINGMACROPHAGE
TARGETEDGLUCOCEREBROSIDASE

Spleensizedecreases
Liversizedecreases
Hemoglobinincreases
Bloodplateletsincrease
Skeletonimproves

SPLEEN
MRIOF
ABDOMEN

ERT

7monthsERT

MORETHAN4,300PATIENTSWITHGAUCHER
DISEASEARENOWRECEIVINGENZYME
REPLACEMENTTHERAPY

TYPE2GAUCHERDISEASE

AcuteNeuronopathicGaucherDisease

NeuronophagiainthebrainofapatientwithType2Gaucherdisease

WHATISTHESOURCEOFGLUCOCEREBROSIDE

INTHEBRAIN?

Ganglioside GDIa

SPHINGOSINE -GLUCOSE -GALACTOSE- N-ACETYGALACTOSAMINE- GALACTOSE

FATTY ACID
N-ACETYLNEURAMINIC ACID
ACETYLNEURAMINIC ACID

N-


ENZYMEREPLACEMENTTHERAPYIN
PATIENTSWITHTYPE2GAUCHERDISEASE
Nobenefitofintravenousglucocerebrosidaseonbrain

WOULDDIRECTINTRACEREBRALINJECTION

OFGLUCOCEREBROSIDASEBEEFFECTIVE?

(CONVECTIONENHANCEDDELIVERY)

SafetyandDistributionofMannoseterminal
GlucocerebrosidaseInjectedintotheBrainofNormalRats

G.C.Zirzowetal.NeurochemicalRes1999;24:301

NEURONALUPTAKEOFINTRACEREBRALLY
ADMINISTEREDGLUCOCEREBROSIDASE

SafetyStudyofIntracerebrallyInjectedGlucocerebrosidase

inNonhumanPrimates

R.Lonseretal,AnnalsofNeurology2005;57:543

TREATMENTSTRATEGIES
3.SUBSTRATEREDUCTIONTHERAPY

REDUCE THE FORMATION OF

GLUCOCEREBROSIDE
SPHINGOSINE + UDPGLUCOSE
SPHINGOSINE
+ UDP
FATTY
FATTY
ACID
ACID

GLUCOSE

Glucocerebroside

UDP-GLUCOSE = URIDINE DIPHOSPHATE

GLUCOSE
= SITE OF INHIBITION OF GLUCOSYLTRANSFERASE

SmallMoleculeInhibitorofGlucocerebrosideFormation

MIGLUSTAT

SUBSTRATE DEPLETION

MiglustatOGT918(Zavesca)hasbeenapprovedfor
thetreatmentofpatientswithtype1Gaucherdisease
forwhomenzymereplacementtherapyisnot
appropriate.

(CoxT,LachmannR,HollakC,etal.Lancet2000;355:1481)

Patientwith
Type3aChronic
Neuronopathic
GaucherDisease

Slowhorizontal
eyemovement

SUBSTRATE DEPLETION

OngoingNIHInvestigationofOGT918in

PatientswithType3(ChronicNeuronopathic)

GaucherDiseaseWhoAlsoReceiveEnzyme

ReplacementTherapytoControltheSystemic

ManifestationsoftheDisease

TREATMENTSTRATEGIES
4.MOLECULARCHAPERONETHERAPY

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

EnzymaticDefectinGM1-Gangliosidosis

SPHINGOSINE-GLUCOSE-GALACTOSE-N-ACETYGALACTOSAMINEGALACTOSE
FATTY ACID
N-ACETYLNEURAMINIC
ACID

galactosidasedeficiency

OkadaandOBrien1968

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)

ChemicalChaperone

N0ctyl4epivalienamine(NOEV)

J. Matsuda et al. ProcNatlAcadSciUSA2003;100:1591

EFFECT OF N-OCTYL-4--VALIENAMINE (NOEV)

ON -GALACTOSIDASE ACTIVITY IN CULTURED
MURINE FIBROBLASTS
Additions
None
Fold

0.2 M 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 GM1GANGLIOSIDOSIS WITH THE NOEV
CHAPERONE IN THE DRINKING WATER

GangliosideGM1

? 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.

FABRYDISEASE

PRINCIPALACCUMULATINGLIPIDINFABRYDISEASE
CERAMIDETRIHEXOSIDE

SPHINGOSINEGLUCOSEGALACTOSEGALACTOSE
FATTYACID

ENZYMATICDEFECTINFABRYDISEASE
CERAMIDETRIHEXOSIDASE
(AlphaGalactosidaseA)
SPHINGOSINEGLUCOSEGALACTOSEGALACTOSE
FATTYACID

R.O.BradyetalNewEnglJMed1967

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 ?