Yoga Devaera, Damayanti Rusli Sjarif

Div Pediatric Nutrition and Metabolic Diseases

Dept of Child Health FKUI/RSCM
Jakarta - Indonesia

After the lecture you should make a flowchart of how the
enzyme replacement therapy generated
Collect it tomorrow to your chief of the class
Assignment

Introduction

Enzyme replacement therapy

Summary

Outlines

They are looking for the answers to three basic
questions:
Is there a disease?
What causes it?
Can we prevent, treat, or cure it?

How do scientists investigate diseases?

Is there a disease ?

Whats wrong with this child?
Splenomegaly
In 1882, the French
medical student
Phillipe Charles Ernest
Gaucher described a
32-year old woman
whose spleen was
very enlarged.



Gaucher cells
A postmortem exam
revealed that spleen
infiltrated by cells, which
typically are large, pale,
polyhedral shaped cells
possessing a single,
relatively small,
eccentrically located
nucleus


Phillipe Charles Ernest Gaucher


Gaucher disease

Did people with Gaucher disease exist before
1882 ?

Yes, they did. But because a set of symptoms wasn't
identified with the condition, "Gaucher disease" as a
disease diagnosis did not exist.

Question 1

What causes it?
What Causes It?
In 1934, the French
chemist A. Aghion
discovered the
chemical cause of the
enlarged spleens and
liver: a buildup of a
lipid (fatty substance)
called
"glucocerebroside."

did people with Gaucher disease make too much of
the lipid for their bodies to handle?
Or did their bodies not break it down and dispose of
it?
Why there was too much lipid in
Gaucher cell ?

The answer to this question came during the
early 1960s, when Dr. Roscoe Brady's group
showed that
people with Gaucher disease made the lipid normally
but did not make enough of the enzyme
"glucocerebrosidase" to break it down and clear it out
of the body.


Development of a Gaucher cell

Gauchers disease is resulting from either
severely decreased functioning
or a complete lack of lysosomal acid -glucosidase or
glucocerebrosidase
Causes?

A single mutation in the gene coding for GCase can result
in partial (60-70%) or complete lack of enzyme activity
(Lieberman et al. 2007).
In affected cells, glucosylceramide accumulates and is
difficult to remove (glucosylceramide forms deposits
within macrophages called Lewy bodies that these cells
can't break down)
Buildup of glucosylceramide within macrophages can lead
to simultaneous enlargement of the spleen and liver,
abnormal bone turnover, and diseases of the central
nervous system in more severe cases (Lieberman et al.
2007).
Next findings

In 1967, Brady's group developed a convenient
diagnostic test for Gaucher disease which works
by measuring the activity of the enzyme
glucocerebrosidase in white blood cells.
The amount of enzyme directly relates to how
severe a case of Gaucher disease
The enzyme activity is also one way that may help
to distinguish the three types of Gaucher disease
described in this chart.
Enzyme activity
The Three Types of Gaucher Disease
Type 1 Type 2 Type 3
Whom it Strikes young adults /
adults
infants children/young
adults
Distinguishing
symptom
no nervous
system
problems
early nervous
system
problems
later onset of
nervous
system
problems
Effects of disease varies from
mild to
severe
dies in infancy becomes
severe
Glucocerebrosidase
Activity
some activity
but much
less than
normal
very little
activity
little activity
"Why do some people make too little enzyme?"
The answer to this
question came in
1987, when the first
gene mutation that
causes Gaucher
disease was
discovered by Dr. Shoji
Tsuji and coworkers.

chromosome 1

How Gaucher disease is passed on ?
Autosomal recessive

In the early 1970s, Dr. Brady's group devised
an enzymatic test based on the enzyme's activity to
tell people if they were carriers or not, and
a procedure for prenatal diagnosis.
These tests give people information about their
genetic status so that they can prepare for the
future.
Enzymatic based diagnosis

Can We Prevent, Treat, or
Cure It?

The third question that medical researchers try to
answer is the most important, and often depends
on the answer to the question what the cause of
it ?
To be truly successful, a treatment would have to
address the cause of the disease, not just the
symptoms.

For Gaucher disease, physicians initially attempted to
address the symptoms that accompany the disease.
They removed enlarged spleens, and performed liver
transplants, blood transfusions, and orthopedic
procedures.
Only bone marrow transplantation for people with Type I
Gaucher disease was sometimes successful.

mutation in gene coding enzyme
mutated enzyme
loss of
enzyme activity
accumulation of substrate
cell dysfunction /
biochemical and pathological change
clinical symptoms
The Pathophysiology of IEMs
The Principle of Treatment
gene mutation
mutated lysosome enzyme
loss of
enzyme activity
accumulation of substrate
cell dysfunction /
biochemical and pathological change
clinical symptoms
modification of
mutated protein
Chemical
Chaperone
inhibition of
substrate synthesis
Substrate
Deprivation
supplementation
of enzyme protein
ERT
BMT
Gene Therapy
ERT

In 1966, Dr. Roscoe Brady suggested a therapy for
Gaucher disease based on replacing the enzyme.
Using human placentas, Dr. Peter Pentchev of Dr.
Brady's team isolated a tiny sample of purified
glucocerebrosidase.
Enzyme Replacement Therapy

In 1973, Brady put that enzyme into two splenectomised
patients with Gaucher disease.
The first patient was a 15 year old boy with Type 3 Gauchers
disease.
a liver biopsy was obtained, the enzyme at u/kg/bw (unit
per kilo of bodyweight) was given and two days later
performed another liver biopsy a 26% reduction of the
accumulation of glucocerebroside in the liver biopsy.
The second patient also showed a 26% decrease.
The third patient received 2 u/kg/bw but the reduction was
only 8%
Development ERT

A large-scale purification method was completed in 1977.
The enzyme had to be treated with an alcohol to make it stick to
the purifying columns.
But this preparation of the enzyme produced inconsistent
results during clinical trials.
No reduction of hepatic (liver) glucocerebroside occurred in 4 out
7 patients who received this preparation
The alcohol had removed a lipid (fat) that activates the
enzyme and targets it to the affected cells, called
macrophages.
Development ERT

The problem was
the glucocerebrosidase was not going into the
macrophages, the cells in the liver, spleen and bone
marrow
that accumulate glucocerebroside: 95% of the infused
enzyme was going to other cells, primarily hepatocytes
in the liver, and being wasted.
Dr. Brady's challenge was now to get the purified
enzyme into the targeted cells.
Development ERT

John Barranger, Clifford Steer and Scott Furbish removed
oligosaccharides from the enzyme so that the mannose (a
sugar at the end of the sugar side chains) would attach to
the macrophage.
Modified Enzyme

In the first clinical trial with macrophage-targeted
glucocerebrosidase, eight people with Gaucher disease
received a fixed dose of the modified enzyme.
Only the smallest one - a child - experienced beneficial
effects. He was given 13 u/kg/bw every week.His
hemoglobin and platelet counts increased; the size of
his spleen and liver decreased; and the damage to his
bones lessened.
Then deliberately stopped the enzyme infusions and
his haemoglobin and platelets gradually decreased to
pre-infusion values.
Development ERT

When re-instated his enzyme infusions at 30 u/kg/bw, his
blood counts rose to normal range, there was a reduction in
the size of his spleen and liver and the damage to his bones
improved.
The other seven people were adults and had not received
enough of the enzyme to improve their condition.

It was at this point that Henri Termeer (now President
and Chief Executive Officer of Genzyme Corporation)
learned about the work.
Henri raised 10 million dollars to produce enough enzyme
for a clinical efficacy trial.
Brady's team then carried out a dose response study and
elected to give patients 60 u/kg/bw every two weeks. In
this clinical efficacy trial, all 12 patients improved.
All of these people had strikingly good clinical responses
within a few months. For example, their height and
weight increased; their anemia improved; their liver and
spleen sizes decreased; and their bone damage lessened.
Dose Response Study

Hemoglobin Chart

Before and after X-
Rays

Macrophage-targeted glucocerebrosidase was
approved as a specific treatment for Gaucher
disease by the Federal Drug Administration on
April 5, 1991.
Enzyme replacement therapy worked. Ceredase
worked and the recombinant enzyme Cerezyme is
just as good.
Enzyme replacement therapy is an effective
treatment for most people with Type 1 Gaucher
disease.
FDA approval

FDA approval

ERT for Gaucher Diseases

Pretreatment
Female; Age 8 Years, 8 Months
Post-treatment
Female; Age 10 Years, 10 Months
Gauchers patient Response to Enzyme Therapy
Courtesy of NW Barton. Developmental and Metabolic Neurology Branch of the NINDS.

Therapeutic Goals and Monitoring for Type 1
Gaucher Disease
Recombinant Enzyme Disorder Comment
Imiglucerase
Nonneuronopathic (type 1)
Gaucher disease
reported to reduce hepatosplenomegaly,
improve anemia and thrombocytopenia, and
reduce episodes of pain crises in these
patients.Because the recombinant enzyme does
not cross the blood-brain barrier, it is not
effective in type 2 Gaucher disease patients
with severe CNS abnormalities
Alpha-galactosidase
(2003)
Fabry disease
Improvement in pain and gastrointestinal
symptoms has been reported, but long-term
studies are required for evaluating its efficacy
with respect to life-threatening complication
Laronidase (2003) MPS I
reported improvements in hepatosplenomegaly
and respiratory disease and showing a decrease
in urinary glycosaminoglycan excretion.
Hematopoietic Stem Cell Transplantation (HCT)
is currently the mainstay of therapy for MPS I
Arylsulfatase B (2005)
MPS VI (Maroteaux-Lamy
syndrome)
associated with improvements in
hepatosplenomegaly, joint movement,
cardiopulmonary function, and pain as well as
reduced excretion of urinary
glycosaminoglycans
Alglucosidase alpha Infantile Pompe disease
A portion of infants who are diagnosed and
treated with ERT before 6 months of age had
improved survival and quality of life compared
with the observed natural history of the
disease, yet, for unknown reasons, a subset of
the treated cohort did not show effects from
ERT
Idursulfase
MPS II (Hunter
syndrome)
Clinical trials showed improvement in
cardiopulmonary disease and
hepatosplenomegaly and decreased excretion of
urinary glycosaminoglycans
ERT in Pompe diseases
Pompe: patient response to enzyme therapy

MPS 1: Improved Joint Range of Motion
Pretreatment
Posttreatment 26weeks


Mean Changes in the Restriction of Range of Motion in
Patients with Mucopolysaccharidosis I during -l-
Iduronidase Therapy

ERT has little effect on the brain, skeletal tissue, and
valvular heart disease in LSDs.
ERT treats only the symptoms and not the underlying
disease
Lifelong frequent infusions (weekly to monthly depending
on the protocol)
The estimated cost of ERT is between $90,000 to $565,000
(US), depending on the disease (therapy) and patient size.
Intravenous infusions of GCase are administered
weekly and it can cost a patient from $100,000 to
$750,000 per year (Sawkar et. al, 2002).
Infusion reactions including fatal anaphylaxis have been
reported
Limitations of enzyme replacement therapy

Other therapy options are
highly desirable !!!!

K, female, 8 years old
Suspected Fabry since 3 years old
Diagnosed Fabry at 8 years old
ERT cost
Rp 180.000.000,-/month
Lifelong
Donation ?
Fabry Diseases : Waiting for ERT

Fabry disease progression

Clinical staging of Fabry disease in the kidney. (Reproduced
with permission from Branton MH, et al. Medicine.
2002;81:122-38.)

F, 3 years old boy diagnosed as MPS IVA (Morquio
Syndrome)
No ERT available yet
Trial of ERT beginning 2012 in Taiwan, refused because of
nationality
MPS IVA : Waiting for ERT (trial)

Thank you

Gaucher disease - massive splenomegaly
splenomegaly
The enlarged cells (now
called "Gaucher cells")
and spleen became signs
of the disease.
Gaucher's description of
the them enabled other
physicians to diagnose
people with Gaucher
disease, and introduce
the term into medical
literature



Lysosomal glucosylceramide accumulation in Gaucher
stabilizes -synuclein oligomers -synuclein inhibits
lysosomal trafficking of glucocerebrosidase in
synucleinopathies