Disorders of Cholesterol Homeostasis

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(No Transcript)
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Disorders of Cholesterol Homeostasis

• Niemann-Pick disease, type C

• Autosomal recessive, progressive, lethal,
  neurodegenerative disorder due to mutation of
  either NPC1
• or NPC2
• Endolysosomal storage of unesterified cholesterol
  and
• lipids
• Incidence 1/100,000-120,000
• No FDA approved therapies

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Niemann-Pick Disease, type C1

• Variable phenotype and age of onset
• Classical Disease Late-infantile and juvenile
  (60-70)
• Infantile (20)
• Adult
• Late-infantile and juvenile (classical)
• Transient neonatal jaundice
• Splenomegaly
• Neurological symptoms (insidious onset)
• Vertical supranuclear ophthalmoplegia
• Cerebellar ataxia and dysfunction
• Cognitive impairment and dementia
• Gelastic cataplexy
• Seizures

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Niemann-Pick Disease, type C1

• Therapeutic trial issues
• Rare Disease
• Heterogeneous phenotype
• Variable age of onset
• Variable symptom complex
• Clinical progression occurs over years
• Goal Stabilization or delay of neurological
  disease
• Optimal treatment may be prior to the onset of
  neurological signs and symptoms
• Significant diagnostic delay
• Lack of defined and accepted outcome measures

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Niemann-Pick disease, type C1

• Natural History Trial
• 78 patients enrolled since August 2006
• Age range 3 months to 54 years
• (median 10 years)
• NPC1 Neurological Severity
• (range 0-50, median 14)
• Miglustat therapy (42)
• Goals
• Identify clinical or biochemical markers that can
  be used as an outcome measure in a therapeutic
  trial
• Identify a biochemical marker that can be used
  for diagnostic testing or screening

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Niemann-Pick Disease, type C1
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Niemann-Pick Disease, type C

• Biomarker Development
• (Assembling a Tool Box)

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Niemann-Pick disease, type C1

• Biomarkers
• Insight into pathology
• Diagnostic/screening test
• Tools to guide therapeutic trials
• Biomarker identification
• Candidate proteins/lipids
• Multi-analyte profiling
• Expression analysis
• Proteomics

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Oxysterols Blood-based diagnostic test
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Niemann-Pick Disease, type C

• Filipin Staining
• Fluorescent antibiotic that binds unesterified
  cholesterol
• Specialized testing
• Requires a skin biopsy-invasive
• Variable staining
• 80-85 classical
• Molecular Testing
• Expensive and requires a high index of suspicion
• 80 sensitive
• 4-5 year diagnostic delay

Dan Ory (personal communication)
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NPC1 Clinical Science

• Oxysterols
• Hypothesis In NPC1 the unique combination of
  increased oxidative stress and intracellular
  accumulation of unesterified cholesterol will
  result in increased nonenzymatic oxysterols.

Intracellular Cholesterol Accumulation in NPC1
Decreased Serum Antioxidant Capacity in NPC1
Subjects
Fu et al (2010) MGM, 101214
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Niemann-Pick Disease, type C1
Plasma Oxysterols 3ß,5a,6ß-cholestane-triol
7-ketocholesterol
Porter et al. (2010) STM, 2 56ra81
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Niemann-Pick Disease, type C1
Triol (24.5 ng/ml) Sensitivity 97
Specificity 100
Porter et al. (2010) STM, 2 56ra81 Jiang et al.
(2011) JLR, 521435
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Niemann-Pick Disease, type C1
CSF Protein Biomarkers
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Niemann-Pick Disease, type C1
Calbindin D
plt0.001
p0.28
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Niemann-Pick Disease, type C
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Niemann-Pick disease, type C1

• Fatty Acid Binding Protein 3 (FABP3)

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Niemann-Pick disease, type C1

• Macrophage Inflammatory Protein 1-alpha (Mip1a,
  CCL3)
• Proinflammatory cytokine
• Activated microglia

CSF
Control 4.8 1.9 pg/ml NPC 14.7 4.2
Confidential
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CSF Biomarkers

• CSF Biomarkers
• Lipid-based
• 3ß,5a,6ß-cholestane-triol and cholesterol esters
• Protein-based
• Markers of inflammation
• MIP-1a, IL1a, IL3, IL4, IL12p40, IL13, IL15, and
  MMP2
• Markers of neuronal injury
• Aß(42), phosphorylated tau, fatty acid binding
  protein 3 (FABP3), and calbindin-D
• Markers of oxidative stress
• glutathione S-transferase alpha (GSTa) and
• superoxide dismutase 1 (SOD1)

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2-Hydroxypropyl-ß-cyclodextrin
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NPC1 HPßCD Trial

• 2-Hydroxypropyl-ß-cyclodextrin (HPßCD)
• Cyclic oligosaccharide with a hydrophobic core
• Pharmaceutical excipient
• Drug repurposing

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NPC1 HPßCD Trial

• Npc1 mouse model

Ramirez et al. (2010) Ped. Res. 68 309
Liu et al. (2009) PNAS 106 2377
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NPC1 HPßCD Trial

• Npc1 cat model
• 24 week Npc1 mutant cats (HPßCD, miglustat,
  untreated)

Personal Communication Charles Vite
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NPC1 HPßCD Trial

• HPßCD Therapeutic trial
• Pilot project for TRND/NCATS
• Goal Improve drug development for rare and
  neglected diseases
• HPßCD does not cross the blood-brain barrier
• Dose limiting toxicity Ototoxicity
• Cat, dog, and mouse

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NPC1 HPßCD Trial
Lancet (1963) 282 983-984
Risks Bleeding/strokes Infection
Seizure
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NPC1 HPßCD Trial

• Phase 1 trial
• Goal Establish a safe and biochemically
  effective dose
• Cohort dose-escalation
• Safety
• Pharmacokinetics
• Quantitative and validated assay for HPßCD
• Pharmacodynamics (Biochemical efficacy)
• Quantitative and validated assays for
  24-hydroxycholesterol
• Pathological efficacy
• CSF protein and lipid biomarkers

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NPC1 HPßCD Trial

• Pharmacodynamic response
• Plasma 24(S)-hydroxycholesterol

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NPC1 HPßCD Trial

• Pharmacodynamic response
• Plasma 24(S)-hydroxycholesterol

CYP46
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NPC1 HPßCD Trial

• Baseline standard deviation of the saline area
  under the curve (AUC) estimated by resampling
  (bootstrapping)
• Biochemical response defined as
• In an individual patient the difference between
  the drug and saline AUC greater than 2.3 x SD is
  considered a positive response
• Positive response observed in at least 2 out of 3
  patients

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NPC1 HPßCD Trial

• 50 mg HPßCD
• No drug related adverse events or reactions
• 2/3 patients had a biochemical response
• AUC8-72
• Patient 1 3.1 x sd
• Patient 2 0.8 x sd
• Patient 3 4.1 x sd
• P. acnes
• Infection/Colonization

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Niemann-Pick disease, type C1

• ICV versus lumbar IT
• Dose escalation response
• Repetitive dosing response Attenuation
• Response of other biomarkers
• Safety-Ototoxicity

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Cohort Dose-escalation
Cohort 3
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Niemann-Pick disease, type C1

• No significant response at 50 and 200 mg IT
• Positive response in 2/3 subjects at 300 mg IT
• Response similar to 50 mg ICV
• Grade 1 Ototoxicity in 2 subjects (siblings)
• 400 mg cohort completed this week

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Niemann-Pick disease, type C1

• Clinical efficacy trial
• Multicenter Funding and IRB complexity
• Multinational Funding, IRB and regulatory
  complexity
• NeuroNext Network
• Concept proposal accepted
• Clinical outcome measures
• Ataxia (Cerebellar Function)
• Gross motor
• Fine motor
• Swallowing

• US Sites
• Common IRB
• Common Trial Agreement

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NPC1 HPßCD Trial

• HPßCD selected as a TRND clinical candidate in
  February 2011
• PreIND meetings with FDA in October and December
  2011
• Juvenile dog toxicity study, formulation, and
  device compatibility studies performed in 2012
• IRB approval July 2012 and IND filing November
  2012
• First ICV infusion February 4, 2013
• First IT infusion September 28. 2013

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NPC1 TRND Team
NICHD Washington University School of
Medicine Nicole Yanjanin Daniel
Ory Aiyi Liu (DESPR) Roopa
Shankar University of Pennsylvania NHGRI
Charles Vite Bill Pavan NINDS Albert
Einstein Collage of Medicine Russell Lonser
Steven Walkley John
Heiss TRND/NCATS Johnson and
Johnson SAIC/Leidos Chris Austin Steven
Silber Jon Stocker John McKew Mark
Kao Molly Buehn Nuria Carrillo Marcus
Brewster Leah Giambarresi Liz Ottinger
Juan Marugan RRD International Pramod Terse
Charles Finn Patrick Frenchick Xin
Xu Frank Hurley Sandra Morseth Wei
Zheng Joy Vanderwal Kimberly
Lilly Clinical Center Carmen Brewer Beth
Solomon Naomi OGrady Kelly King
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Acknowledgements
SMD, PDEGEN, NICHD Nicole Yanjanin Lee Ann
Knight Roopa Shankar Chris Wassif Celine
Cluzeau Stephanie Cologna Ryan Lee Cynthia
Toth Jiang Xiao-Sheng Ian Williams Antony
Cougnoux ORD/CC Bench to Bedside Awards
Ara Parseghian Medical Research
Foundation National Niemann Pick Disease
Foundation SOAR-NPC Danas Angels Research Trust
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Niemann-Pick disease, type C1
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Niemann-Pick disease, type C1
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Hydroxypropyl-ß-Cyclodextrin
Mouse Cat
Mouse 0.5 g Cat 30.0 Human
1400.0 Newborn 375.0
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Niemann-Pick Disease, type C1
Vertical supranuclear ophthalmoplegia Diffe
rential -Niemann-Pick Disease, type C1
-Progressive Supranuclear Palsy -Midbrain
lesions
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Niemann-Pick disease, type C1
Attenuation of the 24OHC response with repetitive
dosing