5th Congress of the European Academy of Neurology

Oslo, Norway, June 29 - July 2, 2019

Teaching Course 3

EAN/PNS: Novel approach in the treatment of neuropathy (Level3)

Inherited neuropathies: Emerging genetic therapies

Mary M. Reilly London, United Kingdom

Email: [email protected] 09/07/2019

Mary M Reilly MRC centre for Neuromuscular Diseases, Institute of Neurology, Queen Square, London, UK.

IONIS TTR trial

Consultancy Alnylam Inflectis Acceleron Akcea Myotherix

1 09/07/2019

1. Introduction

2. Barriers to therapy development

3. Classification of therapies

4. Emerging therapies

2. Barriers to therapy development

3. Classification of therapies

4. Emerging therapies

2 09/07/2019

Charcot Marie Tooth disease

1. Sole / primary e.g. CMT

2. Part of multisystem disorder

3 09/07/2019

2. Part of multisystem disorder

1. Charcot-Marie-Tooth disease (CMT)

2. Hereditary Neuropathy with liability to pressure palsies (HNPP)

3. Hereditary sensory neuropathies (HSN / HSAN)

4. Distal hereditary motor neuropathies (HMN)

4 09/07/2019

5 09/07/2019

17p, LITAF, DYNC1H1, BICD2, REEP1, HSPB3, EGR2, FBLN5, SLC5A7, FBXO38, SETX, PMP22, PMP2 DCTN1, 7q34, WARS, MFN2, NEFL, MYH14 SPTLC1, GDAP1, MPZ, GJB1, SPTLC2, LRSAM1, YARS, INF2, ATL1, NEFH, DRP2, Xq27.1, MARS, ATL3, DNM2, KIF5A, DNMT1, GNB4 ATP1A1, SCN11A, VCP, TFG, SCN9A DHTKD1, TUBB3, NAGLU, DCAF8, PRNP, DGAT2, PDK3 COL6A5, RNF170 MORC2, HSPB8, HSPB1, TRPV4, GARS, BSCL2 AARS, HARS, CHCHD10 RAB7

SH3TC2, EGR2, MTMR2, NDRG1, SIGMAR1, SBF2, SBF1, CTDP1, SURF1, VRK1, ATP7A, UBA1, FGD4, FIG4, HK1, PRX, GLE1, LAS1L WNK1, LMNA, CNTNAP1, NEFL, FAM134B, PNKP, GDAP1, ADCY6 KIF1A, TRIM2, KARS, DST, SPG11, COX6A1 NTRK1, MME, PIEZO2, MCM3AP, SCN9A, SLC25A46, IKBKAP, SCO2, MPV17, PLEKHG5 PRDM12, LRSAM1, CLTCL1, C12orf65, CCT5, AIFM1, FLVCR1, PRPS1 NGF HINT1, DNAJB2, IGHMBP2

6 09/07/2019

1. Sole / primary e.g. CMT

7 09/07/2019

Considerations when developing therapies

8 09/07/2019

( 17 duplication / PMP22) )

(> 100 causative )

9 09/07/2019

10 09/07/2019

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1. Sole / primary e.g. CMT

2. Part of multisystem disorder

CMT1

Missense Nonsense Deletions Duplications Promoter

CMT2 / HMN / HSN

12 09/07/2019

Cortese A, ....Reilly M M and Houlden H

cerebellar ataxia, neuropathy, vestibular areflexia syndrome

0.7% carrier frequency in Caucasian population

13 09/07/2019

1. Introduction

3. Classification of therapies

4. Emerging therapies

Rigorously conducted clinical trials

Ideally 2 different animal models

Target engagement

Pathology most reliable neuropathy outcome measure

14 09/07/2019

Responsive outcome measure (bridgeable biomarkers)

Evidence of target engagement

15 09/07/2019

Ongoing studies

1. Introduction

2. Barriers to therapy development

4. Emerging therapies

16 09/07/2019

1. Generic therapy

2. Target pathogenesis of disease

3. Pathway therapies

antisense oligonucleotides (AONs)

small interfering RNA

Genome editing CRISPR / Cas 9

viral vector-mediated gene therapy

17 09/07/2019

Genome editing CRISPR / Cas 9 viral vector-mediated gene therapy

18 09/07/2019

19 09/07/2019

TTR gene

TTR

Antisense oligonucleotides* Small interfering RNA TTR tetramer

TTR monomer

Misfolded monomer

Amyloid fibrils

1. Generic gene therapy

3. Pathway therapies

20 09/07/2019

Gene identification

Description Diagnosis of families

Gene / protein Genotype function /

Disease pathogenesis

1. Generic gene therapy

2. Target pathogenesis of disease

21 09/07/2019

1. Introduction

2. Barriers to therapy development

3. Classification of therapies

22 09/07/2019

1. Generic gene therapy

2. Target pathogenesis of disease

3. Pathway therapies

3. Pathway therapies

23 09/07/2019

61% CMT1A

Onset 1st two decades

Foot weakness or deformity

Hands later

Length dependent

Slowly progressive

Foot deformity a problem

Need for walking aids

24 09/07/2019

1.4 Mb

Proximal (a) CMT1A-REP

24 kb (b)

PMP22 Distal gene CMT1A-REP (a) (b)

CMT1A HNPP deletion duplication

Increased dosage Duplication CMT1A, DSS

Decreased dosage Deletion HNPP

Loss of function HNPP

Point mutations

Gain of function DSS, CMT1A

In vitro models, animal models, humans

25 09/07/2019

26 09/07/2019

272 patients

2 years

1.5 gram AA daily

27 09/07/2019

Progesterone antagonists reduce PMP22 expression (Ulipristal acetate trial ongoing)

Axonally overexpressed neurogulin-1 drives diseased Schwann cells towards differentiation and axonal preservation (not in clinical trials in CMT1A)

28 09/07/2019

Hypothesis polytherapy to normalise PMP22 gene expression and improve axonal dysfunction (Pleiotropic)

Baclofen, Naltrexone, D-sorbitol

Action on G-protein coupled receptor signalling pathways - suppress PMP22

29 09/07/2019

PXT3003 is safe and well tolerated

80 patients placebo controlled 1 year study

CMTNS / ONLS

High dose suggested improvement in ONLS and CMTNS

Initial results presented PNS Genoa last week

2 doses versus placebo (3/6mg Baclofen, 0.35/0.7mg naltrexone, 105/210mg sorbitol)

Randomisation 323 1:1:1

15 months mild moderate severity (maximum CMTNS 18)

Primary endpoint ONLS

10 meter walk, CMTNS etc.

30 09/07/2019

Initial results presented PNS Genoa last week

Met the primary end point reduction 0.37-point ONLS

10 meter walk reduction 0.47 sec

Issue with high dose crystallisation so low dose x 2 used for part of trial

0-12 scale

31 09/07/2019

32 09/07/2019

Increased dosage Duplication CMT1A, DSS

Decreased dosage Deletion HNPP

Loss of function HNPP

Point mutations

Gain of function DSS, CMT1A

In vitro models, animal models, humans

Successful ASO treatment C22 mice / CMT1A rat

Behavioural / NCS / Pathology / PMP22 expression

33 09/07/2019

34 09/07/2019

1. Generic gene therapy

2. Target pathogenesis of disease

3. Pathway therapies

2. Target pathogenesis of disease

3. Pathway therapies

35 09/07/2019

antisense oligonucleotides (AONs)

small interfering RNA

viral vector-mediated gene therapy

antisense oligonucleotides (AONs)

small interfering RNA

Genome editing CRISPR / Cas 9

36 09/07/2019

CMT1 CMT2 X-linked Intermediate CMT CMT

AD AR AD AR DI others

PMP22 GDAP1 MFN2 GDAP1 DNM2 GJB1 MPZ MTMR2 KIFIB LMNA PRPS1 YARS NEFL SIMPLE MTMR13 RAB7 MED25 KARS MPZ EGR2 SH3TC2 GARS NEFL GDAP1 NEFL NDRG1 NEFL MFN2 EGR2 HSPB1 HSPB1 PRX HSPB8 LRSAM1 CTDP1 MPZ HINT1 PMP22 GDAP1 MPZ TRPV4 FGD4 AARS FIG4 LRSAM1 HK1 DYNC1H1

24 year old man, family history males > females, no male to male

Left median MRC 2/5 CMAP ms

Left ulnar MRC 4/5 CMAP ms

37 09/07/2019

11.4% (25/194) of CMTX1 is due to non coding mutations

38 09/07/2019

Further update confirm these results PNS 2019

Also NEFL is a responsive biomarker

39 09/07/2019

CMT1 CMT2 X-linked Intermediate CMT CMT

AD AR AD AR DI others

PMP22 GDAP1 MFN2 GDAP1 GJB1 DNM2 GJB1 MPZ MTMR2 KIFIB LMNA PRPS1 YARS NEFL SIMPLE MTMR13 RAB7 MED25 KARS MPZ EGR2 GARS NEFL GDAP1 NEFL NDRG1 NEFL MFN2 EGR2 HSPB1 HSPB1 PRX HSPB8 LRSAM1 CTDP1 MPZ HINT1 PMP22 GDAP1 MPZ TRPV4 FGD4 AARS FIG4 LRSAM1 HK1 DYNC1H1

40 09/07/2019

NEFL responsive biomarker

1. Generic gene therapy

3. Pathway therapies

41 09/07/2019

1. Generic gene therapy

3. Pathway therapies

(PMP22, MPZ, GJB1, MFN2 >90%)

42 09/07/2019

CMT1 CMT2 X-linked Intermediate CMT CMT

AD AR AD AR DI others

PMP22 GDAP1 MFN2 GDAP1 GJB1 DNM2 GJB1 MTMR2 KIFIB LMNA PRPS1 YARS NEFL SIMPLE MTMR13 RAB7 MED25 KARS EGR2 SH3TC2 GARS NEFL GDAP1 NEFL NDRG1 NEFL MFN2 EGR2 HSPB1 HSPB1 PRX HSPB8 LRSAM1 CTDP1 PMP22 GDAP1 TRPV4 FGD4 AARS FIG4 LRSAM1 HK1 DYNC1H1

43 09/07/2019

1. Early onset MNCVs < 15 m/s

2. Late onset MNCVs 30-60 m/s

44 09/07/2019

103 MPZ patients

45 09/07/2019

Successful treatment of a 2nd MPZ mouse model presented PNS Genoa 2019

Adapted from

The UPR is activated by a large proportion of CMT1B mutations (Wrabetz et al., J. Neurosci., 2006; Bai et al., Ann Clin Transl Neurol., 2018) Genetic inhibition of the phosphatase PPP1R15A/Gadd34 or treatment of P0S63del CMT1B mice with IFB088 largely rescues the neuropathic phenotype (D J Exp Med. 2013; Das et al., Science, 2015)

46 09/07/2019

Adapted from

The UPR is activated by a large proportion of CMT1B mutations (Wrabetz et al., J. Neurosci., 2006; Bai et al., Ann Clin Transl Neurol., 2018) Updated results PGNenSetGiceinhoibait2io0n1o9f tinheclpuhdoinspgheavtaidsenPcPePo1fRa1c5tAiv/Gataioddn3o4foUr PtreRatimn eCnMt oTf1PA0S63del CMT1B Promising data trmeiacteinwgithCMIFBT018A8cla3rgtrealynsregsecnuiecsmthieceneuropathic phenotype (D J Exp Med. 2013; Das et al., Science, 2015)

47 09/07/2019

1. Generic gene therapy

3. Pathway therapies

1. Charcot-Marie-Tooth disease (CMT)

2. Hereditary Neuropathy with liability to pressure palsies (HNPP)

4. Distal hereditary motor neuropathies (HMN)

48 09/07/2019

AD sensory neuropathy

Onset early teens sensory complications Neuropathic pain very common Very frequent sensory complications

Motor involvement variable

No significant autonomic involvement

49 09/07/2019

50 09/07/2019

Palm-CoA + Serine

CO2

3Keto-Sphinganine NADPH

Sphinganine Acyl-CoA

Dihydro-Cermide

NADPH

Ceramide

Sphingosine ATP

Sphingosine-1P

51 09/07/2019

Serine OH OH OOH H2 C OH H3C NH2 NH2 Sphinganine (SA)

OH Alanine Palmitoyl-CoA CH3 H C OOH 3 NH2 CH3

NH 2 Deoxy-Sphinganine (DoxSA)

Glycine OH

OOH H3C NH2

CH2 NH 2 Deoxy-methyl-Sphinganine (DoxmethSA)

Serine OH OH OOH H2 C OH H3C NH2 NH2 Sphinganine (SA)

OH

Palmitoyl-CoA Alanine CH3 H C OOH 3 NH2 CH3

NH 2 Deoxy-Sphinganine (DoxSA)

Glycine OH

OOH H3C NH2

CH2 NH 2 Deoxy-methyl-Sphinganine (DoxmethSA)

52 09/07/2019

Trial of serine in 18 HSN1 patients (16 completed)

No difference in primary outcome (number progressing >1 CMTNS)

Improvement in CMTNS in serine treated

Small study / better outcome measures

53 09/07/2019

Patient cohorts: nature of disease

Candidate therapies Trial centre

Trial ready Animal model

Trials

IPSc

DRG Motor neurones

25

54 09/07/2019

2019 under review NIHR Efficacy and Mechanism (EME) Programme

MRI muscle as primary outcome measure

56 patients (28 in each arm)

55 09/07/2019

1. Generic gene therapy

2. Target pathogenesis of disease

56 09/07/2019

57 09/07/2019

58 09/07/2019

Receptor degradation Endocytosis

Axonal retrograde transport Recycling / transcytosis

Transcriptional control

Neurotrophins BICD1/2 Signalling (BDNF, NGF) endosome Trk/p75NTR / Somatic sorting receptors complex endosome

Oates E*, Rossor A* M .

1. Introduction

2. Barriers to therapy development

3. Classification of therapies

4. Emerging therapies

59 09/07/2019

Alex Rossor Aisling Carr Matilde Laura Pedro Tomaselli Julian Blake Matt Evans Jasper Morrow Maiya Kugathasan Andrea Cortese Alex Horga Menelaos Pipis Emma Wilson Mahima Kapoor Carolynne Doherty Gita Ramdharry Mariola Skorupinska

NIH

60