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Hypophosphatasia: Enzyme Replacement Therapy Brings New Opportunities and New Challenges

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Hypophosphatasia: Enzyme Replacement Therapy Brings New Opportunities and New Challenges PERSPECTIVE JBMR Hypophosphatasia: Enzyme Replacement Therapy Brings New Opportunities and New Challenges Michael P Whyte Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine, and Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO, USA ABSTRACT Hypophosphatasia (HPP) is caused by loss-of-function mutation(s) of the gene that encodes the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP). Autosomal inheritance (dominant or recessive) from among more than 300 predominantly missense defects of TNSALP (ALPL) explains HPP’s broad-ranging severity, the greatest of all skeletal diseases. In health, TNSALP is linked to cell surfaces and richly expressed in the skeleton and developing teeth. In HPP,TNSALP substrates accumulate extracellularly, including inorganic pyrophosphate (PPi), an inhibitor of mineralization. The PPi excess can cause tooth loss, rickets or osteomalacia, calcific arthropathies, and perhaps muscle weakness. Severely affected infants may seize from insufficient hydrolysis of pyridoxal 5‘- phosphate (PLP), the major extracellular vitamin B6. Now, significant successes are documented for newborns, infants, and children severely affected by HPP given asfotase alfa, a hydroxyapatite-targeted recombinant TNSALP. Since fall 2015, this biologic is approved by regulatory agencies multinationally typically for pediatric-onset HPP. Safe and effective treatment is now possible for this last rickets to have a medical therapy, but a number of challenges involving diagnosis, understanding prognosis, and providing this treatment are reviewed herein. © 2017 American Society for Bone and Mineral Research. KEY WORDS: ALKALINE PHOSPHATASE; CALCIFICATION; CHONDROCALCINOSIS; HYDROXYAPATITE; HYPERCALCEMIA; INBORN-ERROR-OF- METABOLISM; INORGANIC PYROPHOSPHATE; MATRIX VESICLE; MINERALIZATION; OSTEOMALACIA; RICKETS; VITAMIN B6 Introduction phosphohydrolase activity leads to extracellular accumulation of its natural substrates,(3,4) including inorganic pyrophosphate (9) n fall 2015, our field achieved a milestone in the management (PPi), a potent inhibitor of hydroxyapatite (HA) crystal (10) Iof rickets and osteomalacia. Among the disorders that feature formation and propagation. Mineralization that should occur, generalized impairment of hard tissue mineralization and its including after rupture of matrix vesicles (MVs) containing consequences,(1) the final entity lacking a medical treatment nascent HA crystals, is instead blocked by the superabundance (11) acquired one sanctioned internationally by regulatory agencies. of extracellular PPi (ePPi). Consequently, patients suffer (5,6) The holdout was hypophosphatasia (HPP), the inborn-error-of- dental disease and a distinctive rickets or osteomalacia. In metabolism identified in 1948(2) and caused by loss-of-function severely affected neonates and infants, insufficient dephos- 0 mutation(s) of the TNSALP (ALPL) gene that encodes the “tissue- phorylation of pyridoxal 5 -phosphate (PLP), the major circulat- (3,4) nonspecific” isoenzyme of alkaline phosphatase (TNSALP). ing form of vitamin B6, can compromise neurotransmitter (12) The therapy is asfotase alfa (AA), a recombinant bone-targeted synthesis in the brain and cause epilepsy. Reports now ALP now typically approved for pediatric-onset HPP.(5–7) This totaling several hundred HPP patients have delineated the advance ended hopelessness for many HPP patients and offers disorder’s key clinical and biochemical features and its physicians important successes in treating an orphan disease. radiographic and histopathological findings in the skeleton. However, as I will discuss, a number of challenges call for further The genetic basis is established, and its pathophysiology is (3,4,8) progress and an especially thorough understanding of HPP, largely understood. The extraordinarily broad expressivity particularly its wide-ranging severity.(3,4) Reviews concerning of HPP is known to span at one extreme death in utero due to an HPP,(3,4,8) including comprehensive reports from testing this unmineralized skeleton, and at the other extreme dental biologic in pediatric patients,(5–7) have been published recently. complications or arthropathy without bone disease presenting in middle age or later.(3,4,13) I see HPP’s range of severity as Background greatest among all skeletal diseases.(3) Life-threatening HPP reflects autosomal recessive inheritance(14,15) and occurs in 1 TNSALP (liver/bone/kidney ALP) is found on cell surfaces, richly per 100,000 and 300,000 births in Canada(16) and in Europe,(17) in the skeleton and developing teeth.(8) In HPP, deficient TNSALP respectively. For Mennonites in Manitoba, Canada, 1in25 Received in original form November 4, 2016; revised form December 9, 2016; accepted December 26, 2016. Accepted manuscript online January 13, 2017. Address correspondence to: Dr. Michael P Whyte, MD, Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, 4400 Clayton Avenue, St. Louis, MO 63110, USA. E-mail: [email protected] Additional Supporting Information may be found in the online version of this article. Journal of Bone and Mineral Research, Vol. 32, No. 4, April 2017, pp 667–675 DOI: 10.1002/jbmr.3075 © 2017 American Society for Bone and Mineral Research 667 individuals carries a TNSALP founder mutation, and 1 in 2500 (Fig. 2A) and bone biopsy show no abnormalities, and health is newborns manifests perinatal HPP.(18) Two TNSALP founder otherwise good (Supplemental Video S1). mutations underlie severe HPP in the Japanese.(19) In the United Adult HPP typically presents in middle age,(26–28) yet some States, white ancestry seems disproportionately predominant patients recount early shedding of deciduous teeth or past for HPP,(14,20) and two prevalent TNSALP missense defects rickets.(3,4) Loss of secondary dentition seems common.(26) Then, explain relatively many occurrences from autosomal dominant recurrent metatarsal stress fractures beginning in adult life inheritance.(21,22) TNSALP mutation analysis has suggested eventually fail to heal.(26–28) Subsequently, hip or thigh pain may “moderately” severe HPP affects 1 in 6370 Europeans.(17) HPP indicate femoral pseudofractures,(29) a radiographic hallmark of carrier prevalence in the United States and in Europe (E Mornet, osteomalacia resembling the prodromal lesion of atypical personal communication) might be 1 per 250 to 300 people. subtrochanteric femoral fractures associated with bone anti- resorptive treatment (Fig. 3).(30) Excessive ePPi can also cause HPP Nosology calcium pyrophosphate dihydrate crystal deposition (chondro- calcinosis) and PPi arthropathy including pseudogout.(31,32) Beginning in 1957,(16) a clinical nosology for HPP evolved that Seemingly paradoxical in HPP, calcific periarthritis is deposition helps organize its remarkable range of severity that is largely of HA near joints(13) and syndesmophytes can cause ankylosing explained by autosomal recessive or autosomal dominant spinal hyperostosis (Forestier disease).(31) Recurrent fracturing, transmission from among at least 310 mutations (typically skeletal and joint pain, and muscle weakness sometimes missense) scattered throughout TNSALP (ALPL).(15) This nosol- become debilitating.(33) ogy emphasizes whether only dental manifestations are Childhood HPP presents during growth after age 6 months. present, or patient age when skeletal or other significant Premature exfoliation of one or more primary teeth is nearly complications have emerged.(3,4) Now, seven major forms of inevitable,(14,20) and sometimes all are lost early.(14) Health is HPP guide recurrence risk prediction, prognostication, and generally good in mild childhood HPP (Supplemental Video S2), research.(23–25) Dental issues alone denote “odonto” HPP, the with only subtle bone changes disclosed radiographically mildest and likely most common HPP. Then, ranked by (Fig. 2B). In contrast, severe childhood HPP substantially increasing severity with younger age at presentation and compromises health (Supplemental Video S3) and skeletal perhaps diminishing prevalence, clinicians can encounter pain and muscle weakness can be significant. These patients can “adult” HPP, “mild childhood” HPP, “severe childhood” HPP, have a misshapen skull, bowed legs or knock knees, and “infantile” HPP, and “perinatal” HPP.(3,4) Finally, “benign enlarged “joints” from metaphyseal flaring. Muscle weakness prenatal” HPP refers to the newborn with skeletal abnormali- helps explain their delayed walking and waddling gait.(6,34) ties in utero or at birth from HPP that improve spontaneously Craniosynostosis can raise intracranial pressure and damage the during late pregnancy and ex utero.(23) I refer to the many brain. Radiographs of major long bones reveal characteristic people who harbor one TNSALP mutation yet have good “tongues” of lucency projecting from growth plates into health as “carriers” of HPP (see Challenges). These principal metaphyses where there is patchy osteosclerosis and osteope- forms of HPP are described briefly below. nia (Fig. 2C).(3–6) Physes can be wide and irregular and Odonto HPP refers to dental complications of HPP at any age metaphyses flared. Dental pulp chambers and root canals but without other physical or radiographic signs of the disease. may be large and resemble “shell teeth.” Nevertheless, HPP in Painless premature (ie, age <5 years) loss of one or more children is typically a stable condition.(25) In
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