Introduction
Natural history of systemic manifestations of NPC
Methods
Patient identification | Age at start of IV HPβCD treatment | Symptom progression at start of IV treatment | Intravenous treatment Dose/Interval; Length of treatment | Time interval between start of IV and IT HPβCD treatment | Intrathecal treatment Dose/Interval; Length of treatment | Adverse effects, IV HPβCD | Adverse effects, IT HPβCD |
---|---|---|---|---|---|---|---|
SEQ1 | 5 years | Ataxia, VSGP, loss of language, dysphagia, global developmental delay | 80 mg/kg/day to 2800 mg/kg twice weekly; stable at 2500 mg Q2 weeks; 92 months | 18 months | 175 mg every 2 weeks; advanced to 350 mg every 2 weeks (IO 50 mg substituted); 74 months | None | Seizures, increased frequency 24 h post IT |
SEQ2 | 5 years | Ataxia, VSGP, loss of language, dysphagia, global developmental delay | 80 mg/kg/day to 2800 mg/kg twice weekly; stable at 2500 mg Q2 weeks; 92 months | 18 months | 175 mg Q2weeks; advanced to 350 mg every 2 weeks (IO 50 mg substituted); 74 months | None | Seizures, increased frequency 24 h post IT; Intracranial hemorrhage secondary to Ommaya insertion, removal of Ommaya |
SEQ3 | 15 years | VSGP, progressive cognitive impairment, seizures, fine motor coordination, psychosis, ataxia | 1200 mg/kg with increase over 8 months to 2500 mg/kg weekly; 83 months | 16 months | 175 mg (advanced to max 875 mg), then stabilized at 350 mg Q15 days; IO 100 to 350 mg every 15 days prior to removal at 10 months; 67 months | Port-a-Cath infection (twice), removal after 2nd infection | Meningitis, removal of Ommaya |
SEQ4 | 11 years | VSGP, progressive cognitive impairment, seizures, fine motor coordination, psychosis, ataxia, gelastic cataplexy | 1200 mg/kg with increase over 8 months to 2500 mg/kg weekly; 83 months | 16 months | IT advanced from 175 to 875 mg Q15 days; now receives IO 100 mg every 15 days; 67 months | Port-a-Cath infection (twice), removal after 2nd infection | None |
SEQ5 | 13 years | Dysarthria, dysphagia, partial complex seizures, worsening ataxia and VSGP, obstructive sleep apnea | 500 mg/kg advanced to 2000 mg/kg twice weekly; 72 months | 13 months | 350 mg Q2 weeks, advanced to 600 mg Q2 weeks, then dropped to 500 mgQ2 weeks; 59 months aLP | None | Nausea, emesis thought secondary to dehydration; Increased frequency seizures for 24 h post IT; Mild high frequency hearing loss at 500–600 mg |
SEQ6 | 10 years | Splenomegaly, mild VSGP; precocious puberty (not related to NPC) | 500 mg/kg advanced to 2000 mg/kg twice weekly; 68 months | 10 months | 350 mg Q2 weeks, advanced to 500 mg Q2 weeks; 59 months | None | Mild high frequency hearing loss at 500 mg |
SEQ7 | 2 years | Progressive neurocognitive decline, VSGP, lung disease, thrombocytopenia, leukopenia | 1500 mg/kg weekly to 2000 mg/kg weekly; 58 months | 23 months | 150 mg every 2 weeks, dose escalation to 750 mg every 2 weeks; 35 months | Pneumonia, viral illnesses | None reported |
SEQ8 | 21 months | Worsened hepatosplenomegaly, severe growth retardation, tracheomalacia/ bronchomalacia (not related to NPC), tracheostomy, ventilator assist | 500 mg/kg weekly, escalated by 500 mg/kg monthly to 2000 mg/kg weekly; 30 months | 4 months | 175 mg every 4 weeks; dose escalated to 400 mg, then decreased to 300 mg every 2 weeks; 26 months | CVC malfunction; Seizures | Increased seizures frequency for 24 h post IT at higher doses (400 mg) |
SEQ9 | 24 years | Progressive neurocognitive decline, memory impairment, falling, gaze palsy, swallowing problems | 2500 mg/kg weekly, transitioned to every 2 weeks; 21 months | 1 month | 350 mg every 2 weeks; 20 months aLP | Nausea | Nausea |
IV1 | 18 years | Spastic quadriplegia, recurrent pneumonia (tracheostomy, ventilator dependent), dysphagia and enterally fed, refractory seizure disorder | 500 mg/kg weekly, escalated by 500 mg/kg monthly to 2000 mg/kg weekly; 17 months | N/A | N/A | Port-a-Cath infection; proteinuria, elevated transaminases 5x baseline; fevers, hypertension | N/A |
IV2 | 27 years | Hepatosplenomegaly, mild thrombocytopenia, severe neurocognitive impairment, wheelchair dependent, VSGP, nasogastric tube fed, severe dysmetria, seizures | 1700 mg/kg weekly; unknown total length of treatment; report of 26 months for safety data | N/A | N/A | Pneumonia, sinus infection, rash with infusion | N/A |
IV3 | 25 years | Schizophrenia type behavior, gaze palsy, dysarthria, dysphagia, hepatosplenomegaly, thrombocytopenia | 2600 mg/kg weekly; unknown total length of treatment; report of 32 months for safety data | N/A | N/A | Tremors, chills, emesis, fever or headache during infusion (3 occasions) | N/A |
Results
Demographics
Patient identification | Gender | Age at diagnosis | Signs/Symptoms at diagnosis | Diagnostic tests NPC1 filipin/Genotype | Miglustat treatment |
---|---|---|---|---|---|
SEQ1 | Female | 3 years | Splenomegaly, pancytopenia, cognitive impairment | Cultured fibroblast, positive filipin; genotype heterozygous for c.1920delG exon 12 and IVS9 c.1554-1009G > A missense mutation | yes |
SEQ2 | Female | 3 years | Splenomegaly, pancytopenia, cognitive impairment | Cultured fibroblast, positive filipin; genotype heterozygous for c.1920delG exon 12 and IVS9 c.1554-1009G > A missense mutation | yes |
SEQ3 | Female | 7 years | Cognitive impairment | Cultured fibroblast, equivocal filipin; genotype heterozygous for c.1552C > T, p.R518W (p.ARG518Trp) in exon 9 and c.2594C > T, p.5865 L (p.Ser865Leu) in exon 17 | yes |
SEQ4 | Female | 5 years | Ataxia | Cultured fibroblast, equivocal filipin; genotype heterozygous for c.1552C > T, p.R518W (p.ARG518Trp) in exon 9 and c.2594C > T, p.5865 L (p.Ser865Leu) in exon 17 | yes |
SEQ5 | Male | 10 years | Dysarthria, cognitive impairment, anxiety, hypotonia, VSGP | Cultured fibroblast, positive filipin; genotype heterozygous for R978C missense and IVS21–2 A > G splice site mutation | yes |
SEQ6 | Female | 7 years | Splenomegaly, VSGP | Cultured fibroblast, positive filipin; genotype heterozygous for R978C missense and IVS21–2 A > G splice site mutation | Yes |
SEQ7 | Male | 2 years | Neonatal hepatosplenomegaly, conjugated hyperbilirubinemia, hypotonia, global developmental delay, failure to thrive | Cultured fibroblast, positive filipin; Genotype heterozygous for c.2008_2011delITGCT and c.3565_3566insG | yes |
SEQ8 | Female | 1 year | Liver dysfunction, cholestatic jaundice, hepatosplenomegaly, developmental delay | Genotype heterozygous for c.2213C > A and c.3234_3237dupATTT | Yes |
SEQ9 | Female | 20 years | Cognitive decline, ataxia, hepatosplenomegaly | Cultured fibroblast, positive filipin; Genotype heterozygous for c.688_69delTCTGTG and c.3182 T > C | No |
IV1 | Female | 8 months | Hepatosplenomegaly, liver fibrosis, difficulty feeding | Cultured fibroblast, positive filipin; Genotype heterozygous for p.I923V and A1151T (c.2767A > G/3541G > A) | No |
IV2 | Male | 15 years | Hepatosplenomegaly, behavioral disturbance, epilepsy, cognitive decline | LS-509 biomarker normal; Confirmed NPC1 gene mutation, results not available | yes |
IV3 | Female | 16 years | Liver dysfunction at birth, hepatosplenomegaly, schizophrenia | LS-509 biomarker increased; genotype not available | yes |
Safety and adverse events
Clinical severity scores and assessments
Patient ID | Slope pre-IV | Slope post-IV | p-value |
---|---|---|---|
SEQ1 | 7.55 | 0.96 | < 0.001 |
SEQ2 | 7.55 | 0.72 | < 0.001 |
SEQ3 | 2.32 | −0.97 | < 0.001 |
SEQ4 | 3.60 | −0.75 | 0.015 |
SEQ5 | 1.00 | 1.39 | 0.616 |
SEQ6 | 0 | 0.18 | 0.236 |
SEQ7 | N/A | 4.19 | n/a |
SEQ8 | N/A | 0.37 | n/a |
SEQ9 | N/A | 1.29 | n/a |
IV1 | N/A | 1 | n/a |
Age at Liver MRI | Treatment IV, IT HPβCD | Liver volume (cm3) | Liver volume/ body weight (cm3/kg) | Normal range liver volume/body weight (cm3/kg) [72] | AST (U/L) RR 15–46 | ALT (U/L) RR 3–35 | GGT (U/L) RR 5–55 | AP (U/L) RR 80–270 |
---|---|---|---|---|---|---|---|---|
1 year 9 months, Baseline | Pre-IV | 772 | 91.4 | 28.56 +/−5.4 (1 year, 6 months) | 88 | 37 | 116 | 274 |
2 years 2 months | Continued IV, pre-IT | 767 | 71.1 | 31.83 +/− 5.9 (3 years 4 months) | 75 | 28 | 102 | 189 |
2 years 9 months | IV/IT | 699 | 58.5 | 31.83 +/− 5.9 (3 years 4 months) | 41 | 28 | 77 | 171 |
3 years 9 months | IV/IT | 777 | 49.8 | 31.83 +/− 5.9 (3 years 4 months) | 40 | 36 | < 10 | 159 |
4 years 11 months | IV/IT | 812 | 47.5 | 31.83 +/− 5.9 (3 years 4 months) | 41 | 37 | 113 | 169 |