Novel therapies for inborn errors of fatty acid oxidation: A - PowerPoint PPT Presentation

Novel therapies for inborn errors of fatty acid oxidation: A personalized medicine approach Jerry Vockley, M.D., Ph.D. University of Pittsburgh Cleveland Family Endowed Chair in Pediatric Research Children’s Hospital of Pittsburgh Chief of Medical Genetics Director of the Center for Rare Disease Therapy Center for Rare Disease Therapy

Conflicts of Interest • Research funding • Consulting – NIH – American Gene Technologies – Ultragenyx Pharmaceuticals – Moderna Pharmaceuticals – Reneo Phamaceuticals – Cobalt, Inc – Reata Pharmaceuticals – DNARx – Moderna Pharmaceuticals – Rand Corporation – Biomarin Pharmaceuticals Center for Rare Disease Therapy

The central dogma DNA replication DNA transcription RNA Splicing mRNA translation Center for Rare Disease Therapy

Energy metabolism interactions • Multiple pathways • Functionally and physically interact • Overlap in clinical symptoms • Secondary symptoms may dominate clinical picture Center for Rare Disease Therapy

The mitochondrion Center for Rare Disease Therapy

Mitochondria • 100s-1000s per cell • Bacterial origins • Cytoplasmic • Subcellular organelles • Dynamic, pleomorphic, motile Center for Rare Disease Therapy

Energy protein complex model ETF 4 ETF ETF 9 Matrix ACADs TFP ETF 7 6 ETF 5 NADH ETF 10 ETF ETF 11 Com I ETFDH Membrane 3 ACADs Mitochondrial 2 Matrix QH 2 Com III 8 Inner Com IV CPTII Membrane QH 2 Inter Membrane 1 Space H+ H+ Center for Rare Disease Therapy

Clinical implications Center for Rare Disease Therapy

A house of cards Center for Rare Disease Therapy

Harvesting energy Complete oxidation to CO 2 and H 2 0 Source ATP/molecule Total ATP 7 FADH 2 2 14 7 NADH 3 21 8 Acetyl-CoA 10 80 Activation -2 -2 NET 123 Center for Rare Disease Therapy

Energy in long chain FAODs Interupted oxidation to CO 2 and H 2 0 Sourcec ATP/molecule Total ATP 7 FADH 2 0 0 7 NADH 0 0 8 Acetyl-CoA 0 0 Activation -2 -2 NET -2 Center for Rare Disease Therapy

Anaplerotic therpy X X PC Center for Rare Disease Therapy

FDA triheptanoin trial • Double blind comparison of C7 vs C8 • 4 month treatment • Functional and metabolite before and after treatment Doubly-labeled water (DLW) measure of TEE completed at home. Center for Rare Disease Therapy

Conclusions 180 MCT (beats per minute) CHO 160 • Triheptanoin similarly tolerated as Heart Rate Heart Rate 140 MCT 120 • No observed skeletal muscle effect 100 • Cardiac effect of triheptanoin 80 warm-up 1-10 11-20 21-30 31-40 – Improved LV ejection fraction Time (min) 180 – Lower HR for same work (beats per minute) MCT 160 performed Triheptanoin Heart Rate 140 • Similar CPK, acylcarnitines & ketones 120 100 80 31-40 warm-up 1-10 11-20 21-30 31-40 Time (min) Center for Rare Disease Therapy

Ultragenyx clinical trial Characteristic n (%) Prior treatment with MCT 27 (93) Clinical Manifestations 25 (86) Skeletal Myopathy Hepatic Disease 3 (10) Cardiac Disease 2 (7) Disease History a Rhabdomyolysis 26 (90) Muscle Pain 22 (76) Exercise Intolerance 21 (72) Hypoglycemia 18 (62) Muscle Weakness 16 (55) Cardiomyopathy 13 (45) a Occurring in >32% of subjects. Center for Rare Disease Therapy

78 Week outcomes Mean (SD) Annualized Event/Year Post- P Value b Major Clinical Event Pre-treatment treatment % Change Overall MCEs 1.69 (1.61) 0.88 (1.14) -48.1 0.021 Rhabdomyolysis Events 1.30 (1.50) 0.83 (1.15) -36.1 0.119 Hypoglycemia Events 0.32 (0.91) 0.02 (0.12) -92.8 0.068 Cardiac Events 0.07 (0.27) 0.02 (0.12) -69.6 0.309 Hospitalizations a 1.39 (1.35) 0.65 (1.01) -53.1 0.016 Rhabdomyolysis 1.03 (1.90) 0.63 (1.00) -38.7 0.104 Hypoglycemia 0.30 (0.83) 0 -100.0 0.067 Cardiomyopathy 0.07 (0.27) 0.02 (0.12) -69.6 0.309 Center for Rare Disease Therapy

Safety • 29 subjects (100%) with ≥1 treatment emergent adverse Most Frequent TEAEs % event (TEAE) Diarrhea 55 • 19/29 subjects (66%) had treatment-related AEs Rhabdomyolysis 48 • 19 subjects (66%) serious AEs – 1 SAE (gastroenteritis) was considered possibly Vomiting 48 related to study drug Upper respiratory tract infection 41 • No subjects died Viral gastroenteritis 34 • 1 subject discontinued from study (moderate diarrhea) Headache 31 • 3 subjects discontinued UX007 (unrelated to study drug) Pyrexia 31 – Moderate myalgia Abdominal pain 28 – Mild GE reflux and vomiting Gastroenteritis 21 – Mild pain Center for Rare Disease Therapy

Energy protein complex model ETF 4 ETF ETF 9 Matrix ACADs TFP ETF 7 6 ETF 5 NADH ETF 10 ETF ETF 11 Com I ETFDH Membrane 3 ACADs Mitochondrial 2 Matrix QH 2 Com III 8 Inner Com IV CPTII Membrane QH 2 Inter Membrane 1 Space H+ H+ Center for Rare Disease Therapy

VLCADD oxygen consumption is impaired A B + Glucose - Glucose 150 200 + Glucose **** **** pmol/min/cells pmol/min/cells 150 **** 100 Rotenone / WT **** Basal respiration Oligomycin FCCP Antimycin A 100 **** FB671 **** 400 50 FB773 50 OCR (pmol/min) 300 FB833 0 0 WT FB671 FB773 FB833 WT FB671 FB773 FB833 FB777 C 200 + Glucose - Glucose 300 400 100 pmol/min/cells pmol/min/cells 300 **** 200 Reserve capacity 0 **** 200 **** 20 40 60 80 100 **** 100 **** **** 100 -100 Time (minutes) 0 0 WT FB671 FB773 FB833 WT FB671 FB773 FB833 D ose ose ose e / WT ells ells cin FCCP 671 *** *** *** *** 773 *** *** Center for Rare Disease Therapy in) 833 774 777 E 780 ose ose ells ells * tes)

Superoxide production is increased in LC-FAODs VLCADD LCHADD + Glucose + Glucose + Glucose – Glucose Center for Rare Disease Therapy

Cytokines in VLCAD patients Center for Rare Disease Therapy

Antioxidant treatment of VLCADD 6000 *** 4000 AFU ## 2000 JP4-039 0 D 40 D 40 WT FB671 Center for Rare Disease Therapy

JP4 Rx of LCHADD deficiency LCHAD LCHAD HADHA common mutation 1528G>C mutation Center for Rare Disease Therapy

Inhibitor induced chaperonin effect Center for Rare Disease Therapy

TMZ stabilization of FAO proteins VLCADD fibroblasts Trimetazidine (TMZ) Center for Rare Disease Therapy

Cardiolipin (CL) • Dimeric phospholipid • Conical shape maintains membrane curvature, optimizes electron transfer • Anionic CL serves as a proton trap on the outer leaflet of the IMM channeling protons to ATP synthase • Monolysocardiolipin acetyltransferase contained on C-terminus of αTFP (HADHA) doi: 10.3389/fgene.2015.00359 Center for Rare Disease Therapy

Cardiolipin binding peptide Rx LCHADD Center for Rare Disease Therapy

Transcriptional activators A C A D V L P ro te in A C A D V L m R N A 4 0 0 0 + 1 1 2 % 1 .0 + 1 8 0 % + 9 3 % * * * * * (N o rm a lize d C o u n ts ) * * * * + 6 5 % PPAR d agnonists more potent than 0 .8 • 3 0 0 0 (V L C A D /G A P D H ) * * * E x p re s s io n E x p re s s io n 0 .6 bezafibrate 2 0 0 0 0 .4 • Increase in expression and function of 1 0 0 0 0 .2 VLCAD 0 0 .0 D M S O 0 .3 n M 3 n M 3 0 n M M M O S n n 3 0 M 3 • Clinical trial starting this year D M A-0211 M A-0211 P a lm ita te fa tty a c id C 1 6 S p e c ific A c tiv ity o x id a tio n 4 * 2 .5 -1 p ro te in V L C A D , S p . A c tiv ity * * * * 2 .0 3 -1 mg 1 .5 2 3 H -FA h 1 .0 1 0 .5 nm ol 0 0 .0 VLCAD patient derived fibroblasts M M O n n M M M S O 3 0 n n n M 3 S 3 3 0 D M . 0 3 D M A-0211 M A-0211 Center for Rare Disease Therapy

VLCAD mRNA Treatment VLCAD 100 (42 kDa) 80 Average specific activity KO KO 0.5 µg/g 0.5 µg/g WT WT nmol/min/mg 60 40 20 0 WT Null +0.25 +0.5 +1 +2 +4 VLCAD mRNA added Center for Rare Disease Therapy

MCAD deficiency • K304E MCAD mutation is a folding defect • MCAD metabolizes phenylbutyryl- CoA as substrate • Binding pocket analogues are strong chaperonins • Phenylbutyryl-CoA as a chaperonin therapy for MCAD deficiency Center for Rare Disease Therapy

MCAD and phenylbutyrate Center for Rare Disease Therapy

Clinical trial urine acylglycines Urine Acylglycines Subject 1: 3-Phenypropionylglycine Subject 3: 3-Phenypropionylglycine Subject 4: n-Hexanoylglycine 16.69 14.55 mg/g Creatinine 12.69 12.15 7.31 6.87 6.6 5.18 4.21 3.19 2.11 1.71 0 G 2 G/M2/DAY 4 G/M2/DAY 6 G/M2/DAY Pheylbutyrate Dose Center for Rare Disease Therapy

Collaborators • Ben Van Houten • Peter Wipf • Abbe de Vallejo • Melanie Gillingham • James Conway • Simon Watkins Center for Rare Disease Therapy

Thank you! Center for Rare Disease Therapy