Volker Straub

Newcastle

Disclosure statement • I am or have been a chief/principal investigator for trials sponsored by Sanofi Genzyme, GSK, Prosensa/Biomarin, Ionis Pharmceuticals, and Sarepta and a sub- investigator for many other commercial studies. • I received speaker honoraria from Sanofi Genzyme. • I am or have been on advisory boards for Audentes Therapeutics, Biogen, Biomarin, Bristol-Myer Squibb, Exonics Therapeutics, Italfarmaco S.p.A., Pfizer, Roche, Sanofi Genzyme, Sarepta Therapeutics, Summit Therapeutics, Tivorsan, TrophyNOD, and Wave Therapeutics • I have/had research collaborations with Ultragenyx and Sanofi Genzyme. “Muscular Dystrophies – treatable diseases?”

Volker Straub Institute of Genetic Medicine Newcastle University, Newcastle upon Tyne, UK “Muscular Dystrophies – treatable diseases?”

• classification and principles • pathophysiology • diagnostics • treatment strategies Duchenne muscular dystrophy dystrophin

control

source: Heart © 2012 BMJ Publishing Group Ltd

DMD

Joseph Sarrazin, GBA Duchenne (1862) Straub et al. JCB 1992 Album de photographies pathologiques

LGMD1A 5q31.2 MYOT LGMD2A 15q15 CAPN3 LGMD1B 1q22 LMNA LGMD2B 2p13 DYSF LGMD1C 3p25.3 CAV3 LGMD2C 13q12 SGCG LGMD1D 7q36 DNAJB6 LGMD2D 17q12 SGCA LGMD1E 2q35 DES LGMD2E 4q12 SGCB LGMD1F 7q32 TNPO3 LGMD2F 5q33 SGCD LGMD1G 4q21 HNRNPDL LGMD2G 17q11 TCAP LGMD2H 9q31 TRIM32 LGMD1H 3p23 ? LGMD2I 19q13 FKRP LGMD2J 2q TTN LGMD2K 9q34 POMT1 LGMD2L 11p13 ANO5 LGMD2M 9q3 FKTN LGMD2N 14q24 POMT2 LGMD2O 1p3 POMGnT1 LGMD2P 3p21 DAG1 LGMD2Q 8q24 PLEC LGMD2R 2q35 DES 90% LGMD2 (CK-  ) LGMD2S 4q35 TRAPPC11 LGMD2T 3p21 GMPPB 10% LGMD1 (CK n - ) LGMD2U 7p21 ISPD LGMD2V 17q25 GAA LGMD2W 2q14 PINCH2 LGMD2X 6q21 BVES LGMD2Y 1q25.2 TOR1AIP1 LGMD2Z 3q13 POGLUT1 Proposed definition of LGMD

• “Limb girdle muscular dystrophy is a genetically inherited condition that primarily affects skeletal muscle leading to progressive, predominantly proximal muscle weakness at presentation caused by a loss of muscle fibres. To be considered a form of LGMD the condition must be described in at least two unrelated families with affected individuals achieving independent walking, must have an elevated serum creatinine kinase activity, must demonstrate degenerative changes on muscle imaging over the course of the disease, and have dystrophic changes on muscle histology ultimately leading to end-stage pathology for the most affected muscles.”

229 ENMC workshop DMD pathomechanism

5 y Structural defect

Membrane instability 11 y

Apoptosis / Necrosis 18 y

Inflammation

Fibrosis Is a precise diagnosis necessary?

Genetic counselling; prenatal diagnosis Patient counselling  job, education, driving license, etc.  Prognosis (towards life, towards disability) Prevention of complications Pace maker, ventilation etc. Inclusion in clinical trials Future molecular therapies Principle: Know your population

• 28% myotonic dystrophy • 20% DMD/BMD • 10% FSHD • 4% SMA • 6.3% LGMD • <3% each: – Bethlem – congenital muscular dystrophy, – congenital myopathies • 2% myofibrillar myopathies distal myopathies • 25% undiagnosed/ under investigation Local clinic population of ~1200 patients

Norwood et al., Brain, 2009 Hicks et al., Brain, 2010 Know your population https://commons.wikimedia.org/wiki/File:Territories_and_Voyages_of_the_Vikings_blank.png Know your population

Viking founder mutations in Northumberland:

• LGMD2I • LGMD2L • calpainopathy

Vissing et al., Brain. 2016 Jun 3

Local clinic population of ~1200 patients • LGMD2I (FKRP) 21% • LGMD2L (anoctamin 5) 15-20% • LGMD2A (calpain 3) 15% • LGMD2C-F (sarcoglycans) 13% • LGMD1B (lamin A/C) 7% • LGMD2B (dysferlin) <2% Norwood et al., Brain, 2009 Hicks, Sarkozy et al., Brain, 2010 “Muscular Dystrophies – treatable diseases?”

• classification and principles • pathophysiology • diagnostics • treatment strategies Muscular Dystrophies - Clinical and Genetic Heterogeneity February 2018 > 50 known muscular dystrophy genes

Prevalence: 1/2000 bis 1/3000  ~ 300.000 patients in Europe

Sarcolemma07/02/2018 / ECM Golgi / ER Sarcomer Nuclear Lamina Dystrophin-Glycoprotein Complex Laminin-2

ECM a-, b-Dystroglycan Sarcoglycans

Sarcospan Dysferlin Caveolin-3

d a b g Sarcolemma

Grb2

NOS1 Dystrobrevin

Syntrophins

Dystrophin

F-Actin Cytoskeleton LGMD2C LGMD2I MDC1B FCMD LGMD2D LGMD2K MDC1C WWS LGMD2E LGMD2M-P MDC1D MEB LGMD2F LGMD2T, U Laminin-2 MDC1A a-, b-Dystroglycan Sarcoglycans LGMD1C

Dysferlin LGMD2B Caveolin-3

d a b g

Grb2

NOS1

Dystrophin DMD / BMD

F-Actin Evans Blue before after Control

mdx

Straub et al., JCB 1997 “Muscular Dystrophies – treatable diseases?”

• classification and principles • pathophysiology • diagnostics • treatment strategies patient

UK5A elevated serum CK activity + + +

 LGMD Reilich P et al., Acta Myol 2006 Spuler S et al., Ann Neurol 2008 Liewluck T et al., Neuromuscul Disord 2013

Panel of antibodies used in immunoanalysis patient

Sample • 2-10µg high quality DNA

Sequencing • Targeted • Exome • Genome

 LGMD2I & A Whole exome sequencing in 1 001 patients with limb-girdle weakness • over 10 years of age • elevated serum CK activity

Collaborating centres Industry Academic not-for- profit

Patient organisations

1 001 patients submitted for WES

Late 4% Not Fluctuati Not reported Not ng 2% reported 7% reported 15% 20% Congenital Proximal Adult Distal Female 13% 39% CK < 10 x 42% 3% Normal 46% 15% 45% Male Childhood 54% 15% Distal and proximal CK > 10 x Juvenile 38% 23% 19% Sex Onset Weakness CK

30

25

20

15

10 Number of patients ofNumber

5

0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 n = 1 001 Age (years) 50% of patients harboured suspected causal variants

50% 50%

Likely causal variants detected No likely causal variants detected http://myo-seq.org/ Common diseases in our Caucasian cohort

• LGMD2A CAPN3 15% • CCD/MHS RYR1 10% • LGMD2B DYSF 9% • LGMD2L ANO5 6% • DMD DMD 6% • LGMD2J TTN 5% • Bethlem myopathy COL6A2/3 3% • LGMD2D SGCA 2% • MFM5 FLNC 2% http://myo-seq.org/ GENE mRNA (bp) EXONS dbSNPs MYO-SEQ variants (<1%) COL6A1 4238 35 1018 52 COL6A2 3461 28 1830 81 COL6A3 10749 44 3329 106 RYR1 15377 105 5157 162 TTN 109224 363 48597 692

ColVI RYR1 TTN “Muscular Dystrophies – treatable diseases?”

• classification and principles • pathophysiology • diagnostics • treatment strategies DMD pathomechanism

• Cell therapy DNA • Gene therapy

• protein upregulation RNA • RNA modulation Protein

Structural defect

Membrane instability

Apoptosis / Necrosis

• Inducing muscle growth Inflammation  myostatin inhibition

Fibrosis Clinical Trials in (D)MD 2005 2007 2008 2011 2013 2014 2015 2016 2017/18

Wyeth AVI AVI PRO051 PRO051 Heart study Heart study Heart study Heart study COMET PTC007 Heart Heart study FOR DMD FOR DMD FOR DMD FOR DMD EMG patterns study FOR DMD AFM AFM AFM AFM in NM diseases Trophos AFM PTC124 -019 PTC124 -019 PTC124 -019 SKIP-NMD ACE-083 in FSHD ERT PTC124 -019 PTC124 020 PTC124 020 PTC124 020 Pfizer ext. JEWELFISH PTC124-020 PRO045 PRO045 PRO045 Testosterone AveXis PRO045 PRO053 PRO053 PRO053 Summit Dysferlin SMA REACH SMA REACH SKIP Brain DMD NeoGAA Dysferlin SKIP Pfizer UNITE-DMD GNE NH NeoGAA Pfizer Testosterone BMS-986089 GNE NH Testosterone Summit Sarepta 4658-102 FSHD NH Dysferlin Brain DMD Idebenone NeoGAA Dysferlin Givinostat GNE NH NeoGAA VBP15 Phase2a FSHD NH GNE NH VBP15 Phase2b PhenoDM1 FSHD NH Essence Moonfish BMD NH Dysferlin MRI LGMD2I Optimistic NeoGAA Optimistic SAER GNE GNE NH SAER GNE PhenoDM1 FSHD NH IONIS CS3b MRI LGMD2I BMD NH GNE 3b Optimistic Trophos SAER GNE AMO in DM1 PhenoDM1 IONIS CS11 GNE 3b COMET Trophos EMG patterns AMO in DM1 in NM diseases IONIS CS11 1 10 22 33

The DMD gene

Chamberlain & Chamberlain, Molecular Therapy 2017

normal BMD

DMD carrier The dystrophin-glycoprotein Laminin complex serves:

 to maintain sarcolemmal integrity a-, b-Dystroglycan during repeated cycles of Sarcoglycans contraction and relaxation Dysferlin Sarcospan Caveolin-3  to repair membrane disruptions?

Aciculin Grb2 Filamin 2 NOS1 normal DMD BMD Dystrobrevin

Syntrophins Dystrophin

F-actin (non-sarcomeric, mainly g-actin) Duchenne muscular dystrophy

What do trials mean to patients and families?

Parents and patients’ voice: - Hope for a treatment - We want to do everything we can for our sons - Our contribution to research - For a better future - To receive the Best care available - Good relationship with clinicians and study staff

DMD is a treatable disease

Eagle M et al. Managing Duchenne muscular dystrophy - the additive effect of spinal surgery and home nocturnal ventilation in improving survival. Neuromuscul Disord. 2007

Thank you very much!