Successful Within-Patient Dose Escalation of Olipudase Alfa in Acid Sphingomyelinase Deficiency

Molecular Genetics and Metabolism 116 (2015) 88–97

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Molecular Genetics and Metabolism

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Successful within-patient dose escalation of olipudase alfa in acid sphingomyelinase deﬁciency☆

Melissa P. Wasserstein a, Simon A. Jones b,HandreanSoranc,GeorgeA.Diaza, Natalie Lippa a,BethL.Thurbergd, Kerry Culm-Merdek e,EliasShamiyehe, Haig Inguilizian f,GeraldF.Coxg, Ana Cristina Puga g,⁎ a Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA b Manchester Centre for Genomic Medicine, St. Mary's Hospital, CMFT, University of Manchester, Manchester, UK c Cardiovascular Trials Unit, Central Manchester University Hospital, Manchester, UK d Pathology, Genzyme, a Sanofi company, Cambridge, MA, USA e Clinical and Experimental Pharmacology, Sanofi, Bridgewater, NJ, USA f Global Safety, Genzyme, a Sanofi company, Cambridge, MA, USA g Clinical Development, Genzyme, a Sanofi company, Cambridge, MA, USA article info abstract

Article history: Background: Olipudase alfa, a recombinant human acid sphingomyelinase (rhASM), is an investigational enzyme Received 14 April 2015 replacement therapy (ERT) for patients with ASM deficiency [ASMD; Niemann–Pick Disease (NPD) A and B]. This Received in revised form 27 May 2015 open-label phase 1b study assessed the safety and tolerability of olipudase alfa using within-patient dose escala- Accepted 27 May 2015 tion to gradually debulk accumulated sphingomyelin and mitigate the rapid production of metabolites, which Available online 30 May 2015 can be toxic. Secondary objectives were pharmacokinetics, pharmacodynamics, and exploratory efficacy. Methods: Five adults with nonneuronopathic ASMD (NPD B) received escalating doses (0.1 to 3.0 mg/kg) of Keywords: olipudase alfa intravenously every 2 weeks for 26 weeks. Olipudase alfa Recombinant human acid sphingomyelinase Results: All patients successfully reached 3.0 mg/kg without serious or severe adverse events. One patient repeat- Dose escalation ed a dose (2.0 mg/kg) and another had a temporary dose reduction (1.0 to 0.6 mg/kg). Most adverse events (97%) Nonneuronopathic ASMD were mild and all resolved without sequelae. The most common adverse events were headache, arthralgia, nau- Niemann–Pick disease type B sea and abdominal pain. Two patients experienced single acute phase reactions. No patient developed hypersensitivity or anti-olipudase alfa antibodies. The mean circulating half-life of olipudase alfa ranged from 20.9 to 23.4 h across doses without accumulation. Ceramide, a sphingomyelin catabolite, rose transiently in plasma after each dose, but decreased over time. Reductions in sphingomyelin storage, spleen and liver volumes, and serum chitotriosidase activity, as well as improvements in infiltrative lung disease, lipid profiles, platelet counts, and quality of life assessments, were observed. Conclusions: This study provides proof-of-concept for the safety and efficacy of within-patient dose escalation of olipudase alfa in patients with nonneuronopathic ASMD. © 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction severe systemic manifestations, including hepatosplenomegaly, liver dysfunction, infiltrative lung disease, thrombocytopenia, anemia, and Acid sphingomyelinase deficiency [ASMD; Niemann–Pick dis- bone disease. In the most severe form with acute neuronopathic disease ease (NPD) types A and B] is a rare lysosomal storage disorder that (NPD A), patients have little to no residual ASM activity, with onset of affects 0.25–.40 per 100,000 births depending on NPD subtype [1, systemic manifestations, failure-to-thrive, and rapidly progressive neu- 2]. Mutations in the SMPD1 gene encoding the lysosomal enzyme rodegeneration during infancy, and death by 3 years of age [4].Incon- acid sphingomyelinase (ASM) result in the accumulation of trast, patients with chronic nonneuronopathic ASMD (NPD B) have sphingomyelin primarily within reticuloendothelial cells and hepato- higher residual ASM activity and variable ages of onset from infancy cytes of affected patients [3]. Sphingomyelin accumulation produces to adulthood. Systemic manifestations are heterogeneous and include hepatosplenomegaly, pancytopenia, infiltrative lung disease, and a pro-atherogenic lipid profile. Growth restriction during childhood and delayed puberty are common manifestations [5–7]. Patients with NPD ☆ Trial registration: Clintrials.gov trial registration # NCT01722526. B may have a normal lifespan; however, some die prematurely from ⁎ Corresponding author at: Genzyme, a Sanofi company, 500 Kendall St., Cambridge, MA, USA. pulmonary or liver disease, or from hemorrhage, including splenic E-mail address: [email protected] (A.C. Puga). rupture [5].

http://dx.doi.org/10.1016/j.ymgme.2015.05.013 1096-7192/© 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97 89

There are no approved, etiology-based therapies for ASMD. Intrave- which they were monitored for at least 3 h post-infusion. Patients nous administration of enzyme replacement therapy (ERT) with who experienced adverse events greater than mild in severity were to olipudase alfa (recombinant human acid sphingomyelinase), has repeat the same dose or receive a reduced dose at the next infusion. shown promising results in the ASM knock-out (ASMKO) mouse with Dose escalation could only proceed if adverse events were mild or dose-dependent reductions in tissue sphingomyelin levels up to absent. 3.0 mg/kg [8,9]. Doses up to 3.0 mg/kg were able to reduce sphingomyelin levels in hard to reach target tissues, including lung. 2.3. Outcome measures High doses (≥10.0 mg/kg), however, caused severe toxicity characterized by systemic inflammation and cardiovascular shock. Concomitant Safety was the primary objective and assessments included physical elevations in plasma ceramide and cytokine levels in ASMKO animals, examinations and vital signs, cardiac evaluations, clinical laboratory along with the absence of toxicity in normal mice administered up to tests, safety biomarkers [ceramide, high-sensitivity C-reactive protein 30 mg/kg olipudase alfa, suggested that the observed toxicity in the (hsCRP), interleukin (IL)-6, IL-8], liver function [aspartate aminotrans- ASMKO mice was a result of rapid production of sphingomyelin ferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl catabolite(s) rather than a nonspecific drug reaction. Consistent with transferase (GGT)], immune responses, continuous monitoring of treat- this hypothesis, the high-dose toxicity could be completely prevented ment emergent adverse events (TEAEs) and infusion associated reac- by prior treatment of ASMKO mice with several low doses of olipudase tions (IARs), and histopathological evaluations of liver biopsy samples. alfa to gradually debulk accumulated sphingomyelin [9]. Secondary objectives included pharmacodynamic and pharmacoki- Olipudase alfa is in clinical development for treatment of the system- netic assessments of olipudase alfa. Pharmacodynamic parameters in- ic (nonneurological) manifestations of ASMD, as the enzyme is unable cluded measurement of plasma sphingomyelin, and ceramide levels to cross the blood–brain barrier. A phase 1 single-ascending-dose by liquid chromatography-tandem mass spectrometry (LC/MS/MS) study of olipudase alfa in adult patients with NPD B identified and liver sphingomyelin content by both LC/MS/MS and computer- 0.6 mg/kg as the maximum tolerated first dose [10]. The dose-limiting assisted morphometric analysis of hepatic histopathology (MetaMorph toxicity manifested as hyperbilirubinemia in a patient later diagnosed Imaging Processing and Analysis software (Version 6.3; Universal Imag- with Gilbert syndrome who received a dose of 1.0 mg/kg. At ing Corporation)) [11]. Serial blood samples for pharmacokinetic evalu- doses ≥ 0.3 mg/kg, constitutional symptoms (e.g., pyrexia, myalgia, ations were collected at doses ≥0.3 mg/kg before and immediately after and nausea) and changes in inflammatory mediators (e.g., C-reactive infusion plus 1, 4, 8, 12, 24, 48, and 72 h after infusion. Plasma concen- protein and cytokines) began 12 to 24 h postinfusion and were consis- trations of olipudase alfa were determined using a validated enzyme tent with an acute phase response triggered by the innate immune sys- linked immunosorbent assay (ELISA) at Genzyme. tem [10]. This is in contrast to the typical hypersensitivity-type, Exploratory efficacy outcomes included quantitative measurement infusion-associated reactions (IARs), e.g., pyrexia, rash, urticaria, chills, of spleen and liver volumes using abdominal MRI; qualitative assess- and chest tightness, observed with other ERTs that develop in some pa- ment of infiltrative lung disease using high-resolution computed to- tients after several infusions, and which are often associated with the mography (HRCT) [12] and chest x-ray; and pulmonary function tests formation of antibodies against the infused protein. (PFT) using American Thoracic Society guidelines [13]. Fasting lipid pro- The unique adverse drug reactions to olipudase alfa, which were dose- files included measurement of total cholesterol (TC), low density lipo- dependent and attributable to the rapid production of sphingomyelin protein (LDL-C) very low density lipoprotein (VLDL-C) high density catabolites, coupled with the variable amount of sphingomyelin storage lipoprotein (HDL-C), apo-lipoprotein B100 (Apo B) and triglycerides. across patients, led to a novel phase 1b study design that employed Exploratory disease biomarkers included those related to macrophage within-patient, dose-escalation to gradually debulk accumulated proliferation [chitotriosidase, CCL18, and angiotensin converting en- sphingomyelin, thereby mitigating toxicity and enabling efficacious enzyme (ACE)] and bone-specific biomarkers including alkaline phospha- zyme concentrations to be achieved in target tissues, including the lung. tase and C-telopeptide. The validated Brief Fatigue Inventory (BFI) and Brief Pain Inventory- 2. Methods Short Form (BPI-SF) questionnaires [14,15] were used by patients to rate the severity of their fatigue and pain and assess interference with 2.1. Study design and participants daily activities at baseline and week 26. Patients rated fatigue from 0 (no fatigue) to 10 (worst fatigue) and scores were categorized as mild This phase 1, open-label, within-patient, repeat-dose, dose- [1–3], moderate [4–6], and severe [7–10]. Patients rated average, cur- escalation study was conducted at two sites in the US and UK between rent and last 24-hour pain intensity from 0 (no pain) to 10 (worst March 2013 and January 2014. Adults between 18 and 65 years of age pain), which was categorized as mild [1–4], moderate [5,6] and severe with confirmed nonneuronopathic ASMD, diffusing capacity for carbon [7–10,16]. BPI pain interference was graded from 0 (no interference) monoxide (DLCO) N20% and ≤80% of the predicted normal value, spleen to 10 (completely interferes) as the mean of 7 interference items report- volume ≥6 multiples of normal (MN), platelet count ≥60 × 103/μL, and ed during the last 24 h: general activity, mood, walking ability, normal international normalized ratio (INR) N1.5 were eligible to participate. work (both work outside the home and housework), relations with Patients with a history of major organ transplant, or who required med- other people, sleep, and enjoyment of life. ications that could decrease olipudase alfa activity (e.g., chlorpromazine, imipramine, or desipramine), were excluded. Patients on a stable dose 2.4. Analyses and regimen of lipid-lowering therapy were eligible. All patients were included in efficacy, safety, pharmacokinetic, and 2.2. Procedures pharmacodynamic analyses. Histopathological evaluations of inflammation and fibrosis in liver samples were performed using the Laennec Patients received intravenous infusions of olipudase alfa once every scoring system [17] to grade the extent of fibrosis on a scale from 0–4(0, 2 weeks for 26 weeks at an initial dose of 0.1 mg/kg (day 1) followed no fibrosis; 1, minimal; 2, mild; 3, moderate; 4, cirrhosis). Percent pre- 2 weeks later by 0.3 mg/kg. After tolerating two consecutive dicted values were calculated for PFT parameters [18,19]. Raw data 0.3 mg/kg doses, dose escalation proceeded to 0.6, 1.0, 2.0, and and change (absolute and percent) from baseline for exploratory effica- 3.0 mg/kg, which was maintained for the remainder of the 26-week cy endpoints were summarized by time point using descriptive statis- study. All patients were monitored in the hospital pre-infusion and for tics. Liver and spleen volumes were reported as absolute volumes 72 h after each infusion until the second 3.0 mg/kg infusion, after (cm3) and were calculated as MN where normal spleen volume was 90 M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97 assumed to be 0.2% of body weight and normal liver volume to be 2.5% osteoporosis, and three had a history of short stature, thrombocytope- body weight. nia, shortness of breath, and/or fatigue.

3.2. Dose escalation and drug exposure 2.4.1. Study approval The Institutional Review Board (US) or Ethics Committee (UK) at All patients successfully escalated from the initial dose of 0.1 mg/kg each site approved the protocol, and all patients provided written in- to the target dose of 3.0 mg/kg and completed 26 weeks of olipudase formed consent prior to inclusion in the study. The study was conducted alfa treatment. There were 70 total infusions with 5, 10, 6, 6, 6, and 37 according to Good Clinical Practice and in accordance with the princi- infusions at the 0.1, 0.3, 0.6, 1.0, 2.0 and 3.0 mg/kg dose levels, respec- ples of the Declaration of Helsinki. tively (Table 2,partC). Three patients completed dose escalation by week 12 (seven doses) as planned and remained at the 3.0 mg/kg dose. Two patients had IARs 3. Results requiring a longer period of dose escalation. Patient 1 had an IAR (flu- like symptoms) with moderate pyrexia following the week 8 infusion 3.1. Patient demography and baseline characteristics of 1.0 mg/kg and was administered a reduced dose of 0.6 mg/kg at week 10. Patient 2 had an IAR (moderate adverse events of worsening Five of six screened patients were enrolled in the study. One patient migraine headache, abdominal gas pain, splenic pain, nausea, and head- was ineligible due to prohibited medication use and excluded baseline ache) following the week 10 infusion of 2.0 mg/kg and repeated the hematology and bilirubin levels. Patients ranged in age from 23 to same dose at week 12. Both patients resumed dose escalation without 48 years, included 3 males and 2 females, and all were Caucasian. Resid- incident and remained at the 3.0 mg/kg dose through week 26. ual ASM enzyme activity in leukocytes ranged from 12 to 29% of normal in patients for whom historical data were available (n = 4), and all had low ASM activity in dried blood spots (DBS) consistent with ASMD [20]. 3.3. Pharmacokinetics Patient genotypes are shown in Table 1. All patients had splenomegaly (range 7.4 to 16.1 MN), hepatomegaly Olipudase alfa plasma levels increased in a close to dose- (range 1.2 to 2.2 MN), impaired gas exchange (range 43 to 80% of pre- proportional manner from a mean (SD) of 3270 (458) ng/mL after the dicted DLCO), and a pro-atherogenic lipid profile (Table 1). All patients first 0.3 mg/kg infusion to 23,100 (2230) ng/mL after the final had TC to HDL-C ratios above 5 (range 5.5 to 15.0) despite two being 3.0 mg/kg infusion at week 26. The Cmax of olipudase alfa was at the on a stable regimen of lipid-modifying agents. Four patients had throm- end of the infusion for each patient. Mean t1/2z values ranged from bocytopenia and none were anemic. All patients had a history of 20.9 to 23.8 h across all doses. There was no apparent relationship be- hepatosplenomegaly, excessive bleeding/bruising and joint/abdomi- tween dose and terminal t1/2z, clearance (Cl), or volume of distribution nal/back pain; four had a history of delayed puberty and osteopenia/ at steady state (Vss). All plasma concentrations measured before each

Table 1 Patient demographics and baseline characteristics.

Patient ID

12345

Male Female Female Male Male Mean (SD)

Symptom onset age (years) 2 1 6 0 12 4.2 (4.9) Diagnosis age (years) 2 2 12 8 12 7.2 (5.0) Age at ﬁrst olipudase alfa infusion (years) 31 32 47 28 22 32.6 (9.4) ASM activity in leukocytes (% of normal)a NA 17% 29% 13% 12% 17.8 (7.8) ASM activity in DBS (μmol/L/h)b 1.00 1.67 1.15 1.12 0.25 1.04 (0.46) Genotype G232D/E515V fsP330/ΔR608 G242R/N383S R600H/ΔR608 fsV143/R441X Spleen volume (MN)c 14.49 17.92 7.41 16.07 7.96 12.77 (4.81) Liver volume (MN)c 2.23 2.20 1.21 1.76 1.29 1.74 (0.48) Hemoglobin (g/L)d 136 139 132 134 152 139 (8) Platelet count (109/L)e 73 119.5 127 169 101 117.6 (35.3) f DLCO (% predicted) 43.7 48.0 77.0 43.0 80.0 58.3 (18.5) TC (mmol/L)g 4.70 3.83 5.26 4.66 3.63 4.42 (0.67) HDL-C (mmol/L)h 0.32 0.36 0.96 0.31 0.57 0.50 (0.28) TC/HDL-C ratio 14.7 10.6 5.5 15.0 6.4 10.4 (4.5) LDL-C (mmol/L)i 3.38 2.59 3.32 2.69 2.25 2.85 (0.49) VLDL-C (mmol/L)j 0.88 0.88 0.98 1.66 0.80 1.04 (0.35) Triglycerides (mmol/L)k 2.20 1.55 1.14 4.35 1.38 2.12 (1.31) Apo B (g/L)l 1.41 0.96 0.92 1.32 0.59 1.04 (0.33)

Apo B = apo-lipoprotein B100; ASM = acid sphingomyelinase; C = cholesterol; DBS = dried blood spot; DLCO = lung diffusion of carbon monoxide; HDL = high-density lipoprotein; LDL = low-density lipoprotein; MN = multiples of normal; NA = not available; SD = standard deviation; TC = total cholesterol; VLDL = very low-density lipoprotein. a Historical data. b ASM activity in normal adults: 4.96 μmol/L/h [21]. c MN, multiples of normal calculated assuming normal spleen volume is 0.2% body weight (kg), and normal liver volume is 2.5% body weight (kg). d Hemoglobin normal range: UK male 130–180 g/L; US female 117–150 g/L; US male 139–163 g/L. e Platelet count normal range: UK 150–400 × 109/L; US 150–450 × 109/L. f Normal DLCO N80%; mildly reduced N60% to ≤80%; moderately reduced 40–60%; severely reduced b40%. g Total cholesterol normal range: US b5.18 mmol/L; UK 0–3.9 mmol/L. h HDL normal range: US male N0.777; US female N0.9065 mmol/L; UK N1.2 mmol/L. i LDL normal range: US b3.3411 mmol/L; UK 0–2 mmol/L. j VLDL normal range: US b0.518 mmol/L; UK 0.09–0.71 mmol/L. k Triglycerides normal range: b1.7 mmol/L. l Apo B normal range: US male 0.55–1.4 g/L; US female 0.55–1.25 g/L; UK 0.52–1.09 g/L. M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97 91

Table 2 infusion were below the lower limit of quantitation (LLOQ), indicating Summary of TEAE proﬁle and common events by olipudase alfa dose. no accumulation of olipudase alfa in the circulation with biweekly TEAE proﬁle Patients Events dosing. n (%) n

Any TEAE 5 (100) 216 Mild 5 (100) 210 3.4. Adverse events Moderate 2 (40) 6 Severe 0 0 The dose escalation regimen was well-tolerated with no serious or Related TEAE 4 (80) 107 Related TEAEs considered IARs 4 (80) 55 severe TEAEs, and no TEAEs resulted in study discontinuation. Most ad- Mild 4 (80) 49 verse events (210/216, 97%) were mild. The overall TEAE profile is Moderate 2 (40) 6 shown in Table 2. There were 6 adverse events of moderate severity as- Serious adverse events, deaths, discontinuations 0 0 sociated with IARs in two patients: Patient 1, a 31-year-old male, had pyrexia after the 1.0 mg/kg infusion, and Patient 2, a 32-year-old female, Commona TEAEs Patients Events Common IARsb Patients Events n (%) n n (%) n had 5 adverse events (abdominal gas pain, spleen pain, nausea, headache, and migraine) following the 2.0 mg/kg infusion. The most com- Headache 4 (80) 18 Headache 3 (60) 14 Arthralgia 4 (80) 16 Nausea 2 (40) 7 mon TEAEs and IARs (including headache, arthralgia, nausea and Nausea 3 (60) 14 Abdominal pain 2 (40) 6 abdominal pain) and the common TEAEs reflecting cumulative expo- Abdominal pain 4 (80) 14 Musculoskeletal 1 (20) 6 sure by dose are shown in Table 2. The TEAE profile was similar at pain each dose. Back pain 5 (100) 8 Arthralgia 2 (40) 3 Approximately half (107/216, 49.5%) of all TEAEs were considered Pain in extremity 3 (60) 6 fi Abdominal 3 (60) 5 related to olipudase alfa treatment, with 55 identi ed as IARs in 4 pa- discomfort tients during 32 of the 70 infusions. The IAR profile and common IARs Pyrexia 3 (60) 5 are also summarized in Table 2 parts A and B. The majority of IARs (39/55, 67%) occurred N3 h post-infusion: 10 during infusion, 6 be- Commona TEAEs by olipudase alfa dose (mg/kg) and exposure (# infusions) tween 0–3 h post-infusion, 17 between 3–24 h post-infusion, 20 be- Dose (exposure) TEAE Patients Events tween 24–72 h post-infusion, and 2 N 72 h post-infusion. There were n (%) n 0, 2, 12, 10, 9, and 22 IARs at the 0.1, 0.3, 0.6, 1.0, 2.0, and 3.0 mg/kg 0.1 (5 infusions) dose levels, respectively. The number of IARs per infusion was lowest Headache 1 (20) 1 at the 0.1 and 0.3 mg/kg dose levels (0 and 0.2 IARs/infusion, respective- Abdominal pain 1 (20) 1 Pain in extremity 1 (20) 1 ly), and highest at the intermediate dose levels of 0.6, 1.0 and 2.0 mg/kg doses (2, 1.7 and 1.5 IARs/infusion, respectively). The number of IARs/ 0.3 (10 infusions) infusion at the 3.0 kg/kg dose level was 0.6, even though the greatest ex- Headache 2 (40) 2 Abdominal pain 2 (40) 2 posure was at this dose with 37 infusions. Nausea 1 (20) 2 Patient 1 had laboratory findings and clinical symptoms consistent Back pain 1 (20) 1 with an acute phase reaction, including elevated ferritin (from μ μ 0.6 (6 infusions) 37.3 g/L preinfusion to 153.4 g/L postinfusion day 2), and hsCRP Arthralgia 2 (40) 3 (from 0.4 mg/L preinfusion to 31.9 mg/L postinfusion day 2) following Nausea 2 (40) 3 the 1.0 mg/kg infusion at week 8. Following dose reduction to Abdominal 2 (40) 3 0.6 mg/kg at week 10 without incident, dose escalation at 1.0 mg/kg re- discomfort Headache 2 (40) 2 sumed at week 12. Findings consistent with an acute phase reaction also Abdominal pain 1 (20) 1 occurred in Patient 5, a 23-year-old male, following the 2.0 mg/kg dose. Fatigue 1 (20) 1 Elevations in hsCRP postinfusion day 2 (from 0.8 mg/L preinfusion to Pyrexia 1 (20) 1 16.5 mg/L) at week 10 were associated with changes in at least one of 1.0 (6 infusions) thenegativeand/orpositiveacutephasereactants,includingdecreased Arthralgia 2 (40) 3 iron (from 14 μmol/L preinfusion to 5.4 μmol/L postinfusion day 2) and Headache 1 (20) 1 increased ferritin levels (from 14 μg/L preinfusion to 27 μg/L postinfusion Nausea 1 (20) 1 day 2). No dose reduction or repetition was required. Abdominal pain 1 (20) 1 Abdominal 1 (20) 1 No adverse events, including IARs associated with acute phase reac- discomfort tions, were consistent with hypersensitivity reactions or cytokine re- Pyrexia 1 (20) 1 lease syndrome, and no patient developed antibodies (IgG or IgE) to

2.0 (6 infusions) olipudase alfa during the 26-week study. Pain in extremity 3 (60) 3 With the exception of the two patients with acute phase reactions, Headache 2 (40) 2 no clinically significant changes in laboratory findings or safety bio- Back pain 2 (40) 3 markers were observed. Transient elevations from baseline and from Arthralgia 1 (20) 1 pre-infusion levels were observed in IL-6, IL-8, and hsCRP during dose 3.0 (37 infusions) escalation. The peak elevations in these biomarkers occurred between Headache 4 (80) 10 weeks 6 and 10 and were associated with the acute phase responses Arthralgia 4 (80) 12 that occurred in Patient 1 at the 1.0 mg/kg and Patient 5 at the Nausea 3 (60) 5 Abdominal pain 3 (60) 4 2.0 mg/kg dose. Fig. 1 shows the mean hsCRP levels pre- and post- Back pain 3 (60) 4 infusion for weeks 0 through 16. No transient increases in hsCRP Pyrexia 2 (40) 3 Pain in extremity 1 (20) 2 Abdominal 1 (20) 1 Notes to Table 2: discomfort IAR = infusion associated reaction; TEAE = treatment emergent adverse events. a Common TEAEs defined as 5 or more events in greater than 2 patients for all doses combined. b Common IARs defined as 3 or more events for all doses combined. 92 M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97

Fig. 1. Mean high sensitivity C-reactive protein (hsCRP) levels pre- and post-infusion from baseline to week 16. Arrow indicates when patients escalated to the 3.0 mg/kg dose (3 patients at week 12 and 2 patients at week 14) Post-infusion hsCRP levels remained in the normal range for the remainder of the study (data not shown). Fig. 2. Mean plasma ceramide levels pre- and post-infusion from baseline to week 26. Ab- solute values ± SD. occurred after week 14, by which time all patients were receiving the maximum 3.0 mg/kg dose. Mean liver function enzyme levels were within normal ranges at specific alkaline phosphatase, a bone formation biomarker, and C- baseline (AST, ALT, GGT) and bilirubin was slightly elevated. All trended telopeptide, a bone resorption biomarker, were within normal limits downward from baseline over time with mean values within normal at baseline and week 26 (data not shown). ranges (data not shown). Liver pathology assessments showed no signs of acute inflammation at baseline. Patient 1 had a single focus of 3.7. Liver sphingomyelin content lymphocytic infiltrate at week 26 consistent with chronic inflammation. Fibrosis scores varied at baseline from no fibrosis (0) to moderate fi- Representative high-resolution light microscopy (HRLM) images of brosis [3]. A one-point change in score was reported for Patient 3, who liver biopsy tissue sections (Patient 2) stained for sphingomyelin and had no fibrosis (0) at baseline and a score of 1 (mild, periportal fibrosis) used for histomorphometric analysis at baseline and week 26 are at week 26. Patient 4 had a score of 2 (mild) at baseline and had a shown in Fig. 4A. Abundant sphingomyelin staining was present in change to 3 (moderate) at week 26, although the liver biopsy sample both hepatocytes (H) and Kupffer (K) cells at baseline, and staining at baseline was less than the minimum length (1.5 cm) adequate for was markedly decreased at week 26. In the four patients with evaluable scoring fibrosis. Baseline and week 26 fibrosis scores for Patient 1 liver biopsy samples, mean (SD) liver sphingomyelin levels measured were 3 (moderate) and 4 (cirrhosis) at baseline and week 26 respective- histomorphometrically decreased from 33.3% (17.8%) of total tissue ly, however, these liver biopsy samples were also less than 1.5 cm. area occupied by sphingomyelin at baseline, to 4.3% (3.6%) of total tissue There were no clinically significant changes in vital signs, physical area occupied by sphingomyelin at week 26, corresponding to a relative findings or cardiac safety parameters. decrease of 86.6% (4.29%) (Fig. 4B). Liver sphingomyelin content measured by LC/MS/MS yielded similar results with reductions observed 3.5. Sphingomyelin metabolism in all 5 patients. The mean (SD) sphingomyelin level decreased by 66.3% (24.6), from 2414.8 (1284.5) μg/mg protein at baseline to 968.4 Plasma sphingomyelin levels remained within the normal range (1000.4) μg/mg protein at week 26 (individual and LC/MS/MS data (b200 to 703 μg/mL) for all patients throughout the study, with levels not shown). tending to peak transiently 48 h following each olipudase alfa infusion. The mean (SD) plasma ceramide level was slightly elevated at baseline 3.8. Hepatosplenomegaly (6.62 (1.08) μg/mL; normal range, 1.8 to 6.5 μg/mL). All doses of olipudase alfa elicited similar and transient increases in plasma cer- Corresponding reductions in splenomegaly and hepatomegaly were amide levels that generally peaked at 48 h post-infusion. Both pre- also observed after 26 weeks. Mean (SD) spleen volume decreased by and post-infusion ceramide levels steadily decreased with each succes- 25.3% [1646.5 (665.1) cm3 to 1233.0 (505.8) cm3], and mean (SD) sive olipudase alfa infusion and then plateaued after week 14 (Fig. 2). liver volume decreased by 17.1% [2800.6 (934.4) cm3 to 2191.9 (311.3) cm3]. Slightly greater reductions were observed when organ 3.6. Biomarkers volumes were normalized for body weight owing to weight gain, with mean (SD) spleen volume decreasing by 29.4% [12.77 (4.81) MN to Changes in the exploratory biomarkers chitotriosidase, CCL18, and 9.07 (3.53) MN], and mean (SD) liver volume decreasing by 21.9% ACE after 26 weeks of treatment with olipudase alfa are presented in [1.74 (0.48) MN at baseline to 1.30 (0.13) MN at week 26] [22]. Spleen Table 3,andovertimeinFig. 3. Chitotriosidase and CCL18, which are se- and liver volume reductions occurred in 5 and 4 patients, respectively, creted by activated macrophages, were moderately elevated at baseline with one patient with mild hepatomegaly at baseline having no change (4-fold and 6-fold the upper limits of normal, respectively) and steadily at week 26 (Fig. 4Cand4D). decreased through week 26 by 56% and 38%, respectively. Mean levels for both biomarkers remained above normal at week 26. Mean ACE ac- 3.9. Hematology tivity, which reflects the size of the macrophage pool, was mildly elevated at baseline (1.2-fold the upper limit of normal). Although levels Hematology variables are negatively correlated with splenomegaly fluctuated over the course of treatment, mean ACE activity was de- [2], and were therefore part of the exploratory efficacy analyses. There creased by 33% at week 26 and was within normal limits. Bone- was a minor decrease in mean hemoglobin at the end of study M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97 93

Table 3 Effect of olipudase alfa on exploratory efﬁcacy endpoints.

Endpoint Baseline Week 26 Week 26 change from baseline Week 26% change from baselinea

Mean (SD)

Exploratory biomarkers Normal ranges Chitotriosidase (nmol/h/mL) 735.0 (494.8) 319.8 (232.5) −415.2 (298.9) −56.0 (22.4) 15–181 CCL18 (μg/mL) 1033.14 (623.75) 573.46 (274.04) −459.68 (480.78) −38.3 (23.3) 16.5–169.5 ACE (IU/L) 91.56 (50.76) 62.16 (41.85) −29.40 (27.52) −33.4 (19.2) 12–70

Lipid proﬁle TC (mmol/L) 4.42 (0.67) 3.37 (0.75) −1.05 (0.86) −22.8 (18.0) b5.18 US, 0–3.9 UK HDL-C (mmol/L) 0.50 (0.28) 0.71 (0.28) 0.21 (0.10) 49.5 (27.0) N0.777 US male, N0.9065 US female, N1.2 UK Ratiob 10.4 (4.5) 5.3 (2.3) −5.2 (3.6) −46.2 (16.8) LDL-C (mmol/L) 2.85 (0.49) 2.21 (0.67) −0.64 (0.82) −20.7 (24.3) b3.3411 US, 0–2UK VLDL-C (mmol/L) 1.04 (0.35) 0.43 (0.28) −0.67 (0.20) −62.1 (16.9) b0.518 US, 0.09–0.71 UK Triglycerides (mmol/L) 2.12 (1.31) 1.06 (0.41) −1.06 (0.98) −43.4 (19.5) b1.7 Apo-lipoprotein B100 (g/L) 1.04 (0.33) 0.77 (0.20) −0.27 (0.38) −20.6 (26.9) 0.55–1.4 US male; 0.55–1.25 US female; 0.52–1.09 UK

ACE = angiotensin converting enzyme; C = cholesterol; CCL18 = chemokine (C–C motif) ligand 18; HDL = high density lipoprotein; LDL = low density lipoprotein; VLDL = very low density lipoprotein; TC = total cholesterol. a Mean percent changes from baseline over time for biomarkers and lipids are shown in Figs. 3 and 6, respectively. b RatioofTCtoHDL-C.

(138.3 g/L at baseline versus 132.8 g/L at week 26), which remained and ground glass appearance, were evident at all four anatomic levels within the normal range and was likely related to frequent phlebotomy (Fig. 5A), with the lowest scores recorded for ground glass appearance [23]. Mean ferritin concentration decreased over the course of the study and highest for interstitial lung disease. By week 26, consistent reduc- (76.6 μg/L at baseline and 22.8 μg/L at week 26), but remained within tions were observed for all disease patterns at all anatomic levels and the normal range and was not associated with a reduction in mean in both lungs (Fig. 5B). Moreover, 2 patients with a severe interstitial iron levels (12.5 μmol/L at baseline versus 14.1 μmol/L at week 26) or lung disease pattern improved to mild or moderate, while 3 patients low hemoglobin levels. The mean platelet count at baseline of with a severe reticulo-nodular density pattern improved to mild or 117.6 × 109/L indicated moderate thrombocytopenia and increased by moderate at week 26. Chest X-rays corroborated the HRCT results, 18% to 138.8 × 109/L (mild thrombocytopenia) at week 26. with measurable improvements from baseline in the patterns of interstitial lung disease, lung nodules, and reticulo-nodular densities noted 3.10. Pulmonary imaging and function in 4 of 5 patients (data not shown; ground glass pattern was not assessed by X-ray). Baseline HRCT conﬁrmed the presence of inﬁltrative lung disease in Spirometry was normal (percent predicted ≥80%) for forced vital ca- all 5 patients, ranging from mild (score of 1) to severe (score of 3) [12]. pacity, forced expiratory volume in 1 s, and total lung capacity through- Observed patterns of interstitial lung disease, reticulo-nodular densities, out the study. In contrast, all 5 patients displayed reduced percent

predicted DLCO at baseline with a mean (SD) of 58.3% (18.5%) indicating moderate impairment of gas exchange [24]. By week 26, percent pre-

dicted DLCO had increased in 4 of 5 patients, resulting in a mean group (SD) DLCO of 64.4% (14.3%), reﬂecting a 13.4% relative increase from baseline and improvement to the mildly impaired range (Fig. 5C).

3.11. Plasma lipid levels

Patients were at mild-to-moderate risk for cardiovascular disease based on their baseline lipid proﬁles, with elevated mean TC, LDL-C, VLDL-C and triglyceride levels, and a low mean HDL-C level (Table 3). TC/HDL-C ratios were above 5 in each patient, with a mean TC/HDL-C ratio of 10.4. The mean Apo B level was normal at baseline. Treatment with olipudase alfa was associated with gradual improvements in all lipid parameters (Fig. 6). By week 26, the mean TC (−22.8%), VLDL-C (−62.1%) and triglyceride (−43.4%) levels normalized, while LDL-C (−20.7%) and HDL-C (+49.5%) levels approached normal ranges, and the Apo B level (−20.6%) decreased (Table 3). TC and LDL-C levels normalized in all 5 patients and VLDL-C levels normalized in 3 patients by Fig. 3. Exploratory disease biomarkers. Mean percentage changes in ACE, chitotriosidase, and CCL18 levels from baseline to week 26. Absolute values ± SD at baseline and week week 26. The mean ratio of TC/HDL-C at week 26 was 5.3, and the 26 are shown in Table 3. ACE = angiotensin converting enzyme; CCL18 = chemokine mean change from baseline at week 26 represented a 46% reduction in (C–C motif) ligand 18. the TC/HDL-C ratio. 94 M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97

Fig. 4. Effect of olipudase alfa on liver sphingomyelin content and spleen and liver volumes after 26 weeks. A. High-resolution light microscopy (HRLM) images of liver biopsy tissue sections stained with modified toluidine blue (600×) from Patient 2. Arrows indicate sphingomyelin (dark purple) accumulation in lysosomes of hepatocytes (H) and Kupffer cells (K). B. Mean sphingomyelin content in the liver quantified using histomorphometric analysis of HLRM at baseline and week 26 using MetaMorph Imaging Processing and Analysis software (version 6.3; Universal Imaging Corporation). All sphingomyelin identified and measured by this method represents the disease process. The normal value for this parameter in a non- ASMD liver sample is zero. C. By-patient spleen volumes in multiples of normal (MN) at baseline and week 26 [22]; D. By-patient liver volumes (MN) at baseline and week 26 [22].

3.12. Patient-reported outcomes all patients reached and maintained the target dose of 3.0 mg/kg with no discontinuations or serious or severe adverse events. In contrast, Global fatigue scores at baseline ranged from mild (score of 1–3) to the maximum tolerated single dose of olipudase alfa achieved in the moderate (score of 4–6). The mean (SD) baseline score was 3.0 (2.3) absence of a regimen to gradually reduce sphingomyelin stores was and decreased to 2.1 (2.1) at week 26, reflecting a reduction in global fa- five-fold lower at 0.6 mg/kg [10]. Two patients with IARs required a re- tigue in 3 of 5 patients. Two patients who reported increase in fatigue at peat or reduced dose during dose escalation, and a longer period of dose week 26 had no change in severity scale, remaining in the mild (0.4 to escalation with an additional 0.6 mg/kg dose will be implemented in fu- 0.8) and moderate (5.1 to 5.8) categories, respectively. ture clinical trials. Pain severity ratings for worst pain at baseline ranged from no pain Almost all adverse events observed in the study were mild, with half (score of 0) in 1 patient to severe pain (score of 7) in 2 patients. Median considered related to treatment. The large number of reported adverse (range) “worst pain” severity score decreased by 3.0 points, from mod- events likely reflects the extent of continuous monitoring (72 h post- erate pain of 6 (0, 7) at baseline to mild pain of 3 (0, 5) at week 26. The infusion) of hospitalized patients along with the stringent criteria used two patients with severe pain at baseline (scores of 7) reported mild to identify IARs and determine whether the next ascending olipudase (score of 3) or moderate (score of 5) pain at week 26. alfa dose could be administered. Headache was the most common At baseline, pain interfered with life activities, work, and/or relation- event overall, as well as the most common IAR. Overall, IARs were pre- ships in 4 patients. Concomitant with improvement in worst pain sever- dominantly mild and there were no hypersensitivity reactions or events ity, median (range) scores for pain interference improved from 1.9 (0, of cytokine release syndrome. There were no adverse events associated 4.3) at baseline to 0 (0, 1.6) at week 26, and reflected improvement in with hematologic variables, and in fact, thrombocytopenia, which is all 4 patients. common in patients with ASMD [2] improved from moderate at baseline to mild at week 26, with a mean increase in platelet count of 18%. Hypersensitivity IARs arising after several doses and typically occur- 4. Discussion ring during or immediately after infusions are common with ERT, and are often associated with the induction of enzyme-specific antibodies The primary objective of the study was to apply a within-patient [25,26]. None of the patients in this study developed antibodies to dose escalation strategy for olipudase alfa to slowly reduce accumulated olipudase alfa or displayed characteristic hypersensitivity IARs. Patients sphingomyelin in order to address dose-limiting toxicities observed in a with ASMD are known to have residual levels of ASM protein [27].Given previous single dose clinical trial and in nonclinical studies and enable that the 5 patients enrolled in this trial have detectable residual enzyme the safe, tolerable, and effective repeat dosing of olipudase alfa in pa- activity (as shown in Table 1), and are therefore not naïve to the protein tients with ASMD [8–10]. The study results support this approach as sequence of olipudase alfa, it is perhaps not surprising that antibodies to M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97 95

Fig. 5. Effect of olipudase alfa on lung infiltrative lung disease and function. A. High-resolution CT images (level 2) of the lung at baseline and week 26 (Patient 1). The straight arrow in each image refers to reticular changes best seen at the periphery. The block arrow refers to ground glass opacity. Both were improved from baseline to week 26, with only mild residual abnormality at week 26. B. Qualitative assessment of infiltrative lung disease showing the interstitial, reticulonodular, and ground glass appearance components. There were no findings of con- solidation, or pleural thickening. Areas of the right and left lungs were evaluated at 4 anatomic levels (1 = level of the aortic arch; 2 = level of the carina; 3 = midway between the tracheal carina and 1 cm above the hemidiaphragm; 4 = 1 cm above the hemidiaphragm) based on a 4-point scale: 0 = no disease; 1 = mild disease affecting 1–25% of lung volume (green); 2 = moderate, affecting 26–50% of lung volume (yellow); 3 = severe, affecting 51–100% of lung volume (red). Imaging data were evaluated by external central readers blinded to patient and time point; C. By-patient percent predicted DLCO levels at baseline and week 26. Normal DLCO: N80%; mildly reduced: N60% to ≤80%; moderately reduced: 40–60%; severely reduced: b40%.

the enzyme were not generated, and immunologically-driven IARs characterized by “flu-like” symptoms attributed to increased levels of were not observed. Single IARs occurring in two patients during dose es- inflammatory mediators have been reported following other drugs, calation were consistent with an acute phase response involving tran- such as bisphosphonate administration [28], and similar responses ac- sient elevations in total bilirubin (one patient), ferritin, and hsCRP companied by transient increases in hsCRP and ferritin were observed peaking between 24–48 h post-infusion. Acute phase responses in four patients receiving single doses of olipudase alfa in the previous phase 1 study [10]. A possible initiator of the acute phase reaction following olipudase alfa treatment is ceramide, a major product of sphingomyelin metabolism and a well-known signaling molecule in cytokine release, inflammation, and apoptosis [29,30]. Increased concentrations of plasma ceramide were observed by 24 h in both patients with acute phase reactions in the present study and in 3 of 4 patients with acute phase reactions in the single-dose study [10], and tended to precede elevations in inflammatory mediators. However, in the cur- rent repeat-dose study, the acute phase reactions occurred at intermediate doses (1.0 and 2.0 mg/kg) when plasma ceramide levels were lower than baseline levels. If ceramide or another sphingomyelin me- tabolite is triggering the inflammatory response, the repeat-dosing results indicate that the pool of ceramide involved is distinct from that measured in plasma. The rises in hsCRP, IL6 and IL8 appear to be more informative biomarkers of the acute phase response. The source of the transient elevations in plasma ceramide also is unknown, but could re- flect the metabolism of sphingomyelin in circulating cells, lipoproteins, or endothelial cell surfaces. Both pre- and 48-hour post-infusion ceramide levels declined with each successive dosing step and coincided with the reduction in organomegaly and normalization of the lipid pro- fi Fig. 6. Mean percentage changes in fasting lipid profiles from baseline to week 26. Abso- le, suggesting that the strategy of escalating olipudase alfa doses to lute values ± SD at baseline and week 26 are shown in Table 3. HDL = high density lipo- gradually debulk accumulated sphingomyelin in tissues helped to miti- protein; LDL = low density lipoprotein; VLDL = very low density lipoprotein. gate the impact of ceramide release. 96 M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97

Exposure increased in an approximately dose-proportional manner improved lipid profiles have also been reported with ERT in patients with no accumulation following repeated olipudase alfa infusions with Gaucher disease [36], indicating that lipoproteins can be respon- every other week. Mean t1/2z values ranged from 21 to 24 h. The sive biomarkers for some lysosomal storage diseases. Complementing half-life following administration of single olipudase alfa doses of the improvements at the cellular and organ system level, positive trends 0.1–1.0 mg/kg ranged from 10–15 h [10]. In contrast, the circulating in quality of life outcomes including reduced pain and fatigue were half-lives of approved ERTs typically range from b10 min (mannose- reported. exposed acid beta-glucosidase) to ~2 to 4 h (all others). While the Enzyme replacement therapy is a first-line treatment for several ly- cause and biological significance of the long circulating half-life of sosomal storage disorders including Gaucher, Pompe, and Fabry disease, olipudase alfa is unknown, binding of olipudase alfa to sphingomyelin and several mucopolysaccharidoses (I, II, IV, and VI) [37,38]. In the ab- contained within circulating lipoprotein particles or exposed on the sur- sence of any approved, etiology-based therapy, patients with ASMD faces of cell membranes [31] may be contributing to the enzyme's lon- must rely on palliative and supportive care for symptom management. ger circulating t1/2. This study demonstrates proof-of-concept for olipudase alfa in the treat- Consistent with a recent assessment of liver pathology in adult pa- ment of nonneurological manifestations of ASMD using dose escalation tients with NPD B [11], variable degrees of fibrosis were present in pa- to prevent toxicity. Over 26 weeks, treatment with every-other-week tients at baseline, and single-point increases in fibrosis scoring were infusions of olipudase alfa was well tolerated with no serious adverse noted in three patients. However, due to the small patient population events or hypersensitivity reactions. Two patients required an expand- size, the single (6-month) time point, and tissue samples less than the ed dose escalation period, thus, while the dose escalation approach recommended 1.5 cm for assessment of fibrosis in some instances, it is was successful, the regimen may need to be tailored based on individual unclear whether fibrosis truly increased, or whether scoring changes patient responses. Although interpretation of efficacy outcomes is limit- reflected liver biopsy sampling variation due to the heterogeneous na- ed by the small number of patients, olipudase alfa treatment was asso- ture of liver fibrosis, or a change in the appearance of fibrosis resulting ciated with improvement in objective biomarker responses, clinical from a reduction in liver volume. In this regard, the decrease in liver measures, and patient-reported quality of life outcomes. While this transaminases suggests improvement rather than disease progression. was a small, short-term trial in adult patients only, its results support One patient had a small inflammatory focus of lymphocytes at week the further clinical development of olipudase alfa. 26 in the absence of changes in liver enzymes or bilirubin. A patient in the single-dose phase 1 study also had small inflammatory foci of lym- Acknowledgments phocytes [10]. The relevance of these foci cannot be determined from these small studies. In the ASMKO mouse model, there was no liver- The authors thank the study patients and the staff of the Mount Sinai associated toxicity in animals administered up to 30 mg/kg following and Manchester NIHR/Wellcome Trust clinical research facilities. Assis- a debulking regimen using a lower dose [9]. tance with the HRCT images used in the manuscript was provided by The targeted maintenance dose of 3.0 mg/kg was selected in order to Charles S. White, MD, Univ. Maryland School of Medicine. Kathleen maximize penetration of olipudase alfa into hard-to-reach tissues such Melia, PhD and Patrice C Ferriola, PhD provided writing assistance and as lung. Although this study was not designed to evaluate efficacy or were funded by the study sponsor. dose–response relationships, promising effects of olipudase alfa were Genzyme, a Sanofi Company, was the sponsor and provided support observed at the cellular, organ, and functional levels, even with the rel- for the design and conduct of the study. The study was supported in part atively short duration of treatment. As observed in a natural history by Grant Number #UL1TR000067 from the National Center for Advanc- study of NPD B, spleen and liver volumes were enlarged in all patients ing Translational Sciences (NCATS), a component of the National Insti- at baseline [2,6]. Spleen volume has been proposed as a surrogate mark- tutes of Health (NIH) and contents are solely the responsibility of the er of NPD B disease burden and severity, correlating well with hepato- authors and do not necessarily represent the official views of NCATS megaly, growth impairment, lipid profile, hematologic parameters, or NIH. and pulmonary function [2]. Following olipudase alfa administration, liver sphingomyelin assessed by histomorphometry decreased by 87%, while spleen and liver volumes (as MN) decreased by 29% and 22%, re- References spectively. These results provide compelling pharmacodynamic evidence that olipudase alfa is engaging its intended target, lysosomal [1] Prevalence of rare diseases: bibliographic data listed in order of decreasing prevalence or number of published cases, Orphanet Report Series — Prevalence of Rare sphingomyelin, in biologically-relevant tissues. The reduction in Diseases: Bibliographic Data Number 1 May 2014, 2014 (http://www.orpha.net/ sphingomyelin and organ volumes was accompanied by improvements orphacom/cahiers/docs/GB/Prevalence_of_rare_diseases_by_alphabetical_list.pdf in several biomarkers in the downstream pathophysiology of ASMD Accessed April 2015). – [2] M.M. McGovern, M.P. Wasserstein, R. Giugliani, et al., A prospective, cross-sectional [32 34], including those related to macrophage proliferation survey study of the natural history of Niemann–Pick disease type B, Pediatrics 122 (chitotriosidase, CCL18, and ACE) and hepatocyte function (ALT, AST, (2) (2008) e341–e349. GGT and bilirubin). In most patients, ALT, AST, and bilirubin decreased [3] E.H. Schuchman, R.J. Desnick, Niemann–Pick disease types A and B: acid sphingomyelinase deficiencies, in: D. Valle, A. Beaudet, B. Vogelstein, K. Kinzler, S. relative to baseline by week 26 of treatment with olipudase alfa, with Antonarakis, A. Ballabio, K. Gibson, G. Mitchell (Eds.), OMMBID—TheOnlineMeta- bilirubin that was elevated at baseline normalizing. These reductions bolic and Molecular Bases of Inherited Disease, McGraw Hill, New York, 2013 tended to be associated with reductions in spleen and liver volumes. (http://ommbid.mhmedical.com/content.aspx?bookid=474&Sectionid=45374145. Accessed April 2015). Improvements were also seen in radiographic and functional mea- [4] M.M. McGovern, A. Aron, S.E. Brodie, R.J. Desnick, M.P. Wasserstein, Natural history sures of infiltrative lung disease (including improvement in DLCO from of type A Niemann–Pick disease: possible endpoints for therapeutic trials, Neurolo- moderate to mild impairment in gas exchange), which, if untreated, gy 66 (2) (2006) 228–232. tend to worsen with age in patients with NPD B [6]. Coronary artery dis- [5] M.M.McGovern,N.Lippa,E.Bagiella,E.H.Schuchman,R.J.Desnick,M.P. Wasserstein, Morbidity and mortality in type B Niemann–Pick disease, Genet. ease was identified as an under-recognized and serious morbidity in pa- Med. 15 (8) (2013) 618–623. tients with NPD B [5]. Lipid parameters, including HDL-C and LDL-C, [6] M.P. Wasserstein, R.J. Desnick, E.H. Schuchman, et al., The natural history of type B – improved with olipudase alfa treatment regardless of whether patients Niemann Pick disease: results from a 10-year longitudinal study, Pediatrics 114 (6) (2004) e672–e677. were on a stable regimen of lipid-modifying drugs. In untreated patients [7] M. Wasserstein, J. Godbold, M.M. McGovern, Skeletal manifestations in pediatric and with NPD B, atherogenic lipid profiles typically worsen with age [6],and adult patients with Niemann Pick disease type B, J. Inherit. Metab. Dis. 36 (1) (2013) lipid abnormalities may be associated with early coronary artery disease 123–127. fi [8] S.R. Miranda, X. He, C.M. Simonaro, et al., Infusion of recombinant human acid as in the general population [35]. While the impact of lipid pro le sphingomyelinase into Niemann–Pick disease mice leads to visceral, but not neuro- improvements on cardiac disease risk following ERT is unknown, logical, correction of the pathophysiology, FASEB J. 14 (13) (2000) 1988–1995. M.P. Wasserstein et al. / Molecular Genetics and Metabolism 116 (2015) 88–97 97

[9] J.M. Murray, T., A.M., A. Vitsky, M. Hawes, W-L. Chuang, J. Pacheco, S. Wilson, J.M. [23] Z. Mozaheb, M. Khayami, D. Sayadpoor, Iron balance in regular blood donors, McPherson, B.L. Thurberg, K.P. Karey, L. Andrews, Nonclinical safety assessment of Transfus. Med. Hemother. 38 (2011) 190–194. recombinant human acid sphingomyelinase (rhASM) for the treatment of acid [24] R. Pellegrino, G. Viegi, V. Brusasco, et al., Interpretative strategies for lung function sphingomyelinase deficiency: The utility of animal models of disease in the toxico- tests, Eur. Respir. J. 26 (5) (2005) 948–968. logical evaluation of potential therapeutics, Mol. Genet. Metab. 114 (2) (2015) [25] S.M. Richards, Immunologic considerations for enzyme replacement therapy in the 217–225. treatment of lysosomal storage disorders, Clin. Appl. Immunol. Rev. 2 (4–5) [10] M. McGovern, M. Wasserstein, B. Kirmse, et al., Novel first-dose adverse drug reac- (2002) 241–253. tions during a phase 1 trial of recombinant human acid sphingomyelinase (rhASM) [26] K. Starzyk, S. Richards, J. Yee, S.E. Smith, W. Kingma, The long-term international in adults with Niemann–Pick disease type B (acid sphingomyelinase deficiency), safety experience of imiglucerase therapy for Gaucher disease, Mol. Genet. Metab. Genet. Med. (2015), http://dx.doi.org/10.1038/gim.2015.24. 90 (2) (2007) 157–163. [11] B.L. Thurberg, M.P. Wasserstein, T. Schiano, et al., Liver and skin histopathology in [27] I. Jones, X. He, F. Katouzian, P.I. Darroch, E.H. Schuchman, Characterization of com- adults with acid sphingomyelinase deficiency (Niemann–Pick disease type B), Am. mon SMPD1 mutations causing types A and B Niemann–Pick disease and generation J. Surg. Pathol. 36 (8) (2012) 1234–1246. of mutation-specific mouse models, Mol. Genet. Metab. 95 (2008) 152–162. [12] D.S. Mendelson, M.P. Wasserstein, R.J. Desnick, et al., Type B Niemann–Pick disease: [28] I.R. Reid, G.D. Gamble, P. Mesenbrink, P. Lakatos, D.M. Black, Characterization of and findings at chest radiography, thin-section CT, and pulmonary function testing, Ra- risk factors for the acute-phase response after zoledronic acid, J. Clin. Endocrinol. diology 238 (1) (2006) 339–345. Metab. 95 (9) (2010) 4380–4387. [13] M.R. Miller, J. Hankinson, V. Brusasco, et al., Standardisation of spirometry, Eur. [29] S. Spiegel, D. Foster, R. Kolesnick, Signal transduction through lipid second messen- Respir. J. 26 (2) (2005) 319–338. gers, Curr. Opin. Cell Biol. 8 (2) (1996) 159–167. [14] T.R. Mendoza, X.S. Wang, C.S. Cleeland, et al., The rapid assessment of fatigue sever- [30] E. Gulbins, S. Dreschers, B. Wilker, H. Grassme, Ceramide, membrane rafts and infec- ity in cancer patients: use of the Brief Fatigue Inventory, Cancer 85 (5) (1999) tions, J. Mol. Med. (Berl.) 82 (6) (2004) 357–363. 1186–1196. [31] S.L. Schissel, X. Jiang, J. Tweedie-Hardman, et al., Secretory sphingomyelinase, a [15] C.S. Cleeland, K.M. Ryan, Pain assessment: global use of the Brief Pain Inventory, product of the acid sphingomyelinase gene, can hydrolyze atherogenic lipoproteins Ann. Acad. Med. Singap. 23 (2) (1994) 129–138. at neutral pH. Implications for atherosclerotic lesion development, J. Biol. Chem. 273 [16] C. Cleeland, Pain assessment: the advantages of using pain scales in lysosomal stor- (5) (1998) 2738–2746. age diseases, Acta Paediatr. Suppl. 91 (439) (2002) 43–47. [32] C.E. Hollak, S. van Weely, M.H. van Oers, J.M. Aerts, Marked elevation of plasma [17] R. Odze, J. Goldblumm, J. Crawford, Surgical Pathology of the GI Tract, Liver, Billiary chitotriosidase activity. A novel hallmark of Gaucher disease, J. Clin. Invest. 93 (3) Tract and Pancreas, Saunders, Philadelphia, 2004. (1994) 1288–1292. [18] J.L. Hankinson, J.R. Odencrantz, K.B. Fedan, Spirometric reference values from a sam- [33] R.G. Boot, M. Verhoek, M. Langeveld, et al., CCL18: a urinary marker of Gaucher cell ple of the general U.S. population, Am. J. Respir. Crit. Care Med. 159 (1) (1999) burden in Gaucher patients, J. Inherit. Metab. Dis. 29 (4) (2006) 564–571. 179–187. [34] A. Vellodi, Y. Foo, T.J. Cole, Evaluation of three biochemical markers in the monitor- [19] A. Miller, J.C. Thornton, R. Warshaw, H. Anderson, A.S. Teirstein, I.J. Selikoff, Single ing of Gaucher disease, J. Inherit. Metab. Dis. 28 (4) (2005) 585–592. breath diffusing capacity in a representative sample of the population of Michigan, [35] M.M. McGovern, T. Pohl-Worgall, R.J. Deckelbaum, et al., Lipid abnormalities in chil- a large industrial state. Predicted values, lower limits of normal, and frequencies dren with types A and B Niemann Pick disease, J. Pediatr. 145 (1) (2004) 77–81. of abnormality by smoking history, Am. Rev. Respir. Dis. 127 (3) (1983) 270–277. [36] A. Zimmermann, P. Grigorescu-Sido, H. Rossmann, et al., Dynamic changes of lipid [20] E. Legnini, J.J. Orsini, A. Muhl, B. Johnson, A. Dajnoki, O.A. Bodamer, Analysis of acid profile in Romanian patients with Gaucher disease type 1 under enzyme replace- sphingomyelinase activity in dried blood spots using tandem mass spectrometry, ment therapy: a prospective study, J. Inherit. Metab. Dis. 36 (3) (2012) 555–563. Ann. Lab. Med. 32 (5) (2012) 319–323. [37] T. Ratko, A. Marbella, S. Godfrey, N. Aronson, Enzyme-Replacement Therapies for Ly- [21] X.K. Zhang, C.S. Elbin, W.L. Chuang, et al., Multiplex enzyme assay screening of dried sosomal Storage Diseases [Internet].; 2013 Jan. (Technical Briefs, No. 12.)Available blood spots for lysosomal storage disorders by using tandem mass spectrometry, from: http://www.ncbi.nlm.nih.gov/books/NBK117219/ Technical Briefs, Agency Clin. Chem. 54 (10) (2008) 1725–1728. for Healthcare Research and Quality (US), Rockville (MD), 2013. [22] G. Pastores, N. Weinreb, H. Aerts, G. Andria, T. Cox, M. Giralt, Therapeutic goals in the [38] M. Sanford, J.H. Lo, Elosulfase alfa: first global approval, Drugs 74 (6) (2014) treatment of Gaucher disease, Semin. Hematol. 41 (Supple 5) (2004) 4–14. 713–718.