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
(Chromosome 17 duplication / PMP22) )
(> 100 causative genes)
9 09/07/2019
10 09/07/2019
11 09/07/2019
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 gene 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 protein
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 / phenotype
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 Dynein / dynactin 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