Treatment of fabry disease in ert-naive and ert-experienced patients

Abstract

This invention provides dosing regimens for treating Fabry disease in patients. Some methods involve treating Fabry disease patients who have undergone ERT or are ERT-naïve. Some methods include administering approximately 123 mg of the free base equivalent of migastrol to the patient to improve left ventricular quality and / or improve podocyte ceramide trihexoside.

Description

Technical Field

[0001] The principles and embodiments of the present invention generally relate to the use of pharmacological companions for the treatment of lysosomal storage disorders, particularly the use of migalastat for the treatment of Fabry disease. Prior Art

[0002] Fabry disease is a progressive, X-linked, congenital disorder of glycosphingolipid metabolism, resulting from a deficiency of the lysosomal enzyme α-galactosidase A (α-Gal A) as a result of a mutation in the α-Gal A gene (GLA). Despite being an X-linked disorder, females may present with varying degrees of clinical manifestations. Fabry disease is a rare condition, with an estimated incidence of 1 in 40,000 males to 1 in 117,000 in the general population. Furthermore, there are late-onset variants of Fabry disease that may appear below the diagnostic criteria because they do not present with typical signs and symptoms. This situation, along with newborn screening for Fabry disease, suggests that the actual incidence of Fabry disease may be higher than currently estimated.

[0003] Without treatment, life expectancy is reduced in patients with Fabry disease, typically leading to death around age 40 or 50 due to vascular disease affecting the kidneys, heart, and / or central nervous system. Enzyme deficiency results in the accumulation of the substrate, globular triacetin (GL-3), within cells of the vascular endothelium and visceral tissues throughout the body. Progressive renal function decline and the development of azotemia due to glycosphingolipid deposition usually occur between the ages of 30 and 50, but can occur as early as age 20. Kidney damage has been observed in both hemizygous (male) and heterozygous (female) patients.

[0004] Heart disease caused by Fabry disease occurs in most men and many women. Early cardiac findings include left ventricular enlargement, valvular involvement, and conduction abnormalities. Mitral regurgitation is the most common valvular injury typically present in children or adolescents. Cerebrovascular manifestations primarily arise from multifocal small vessel involvement and may include thrombosis, transient ischemic attacks, basilar artery ischemia and aneurysm, seizures, hemiplegia, hemisensory loss, aphasia, labyrinthine disorder, or cerebral hemorrhage. The average age of onset of cerebrovascular manifestations is 33.8 years. Personality changes and psychotic behaviors may appear with age.

[0005] Currently, the FDA-approved treatment for Fabry disease is enzyme replacement therapy (ERT). Two α-GAL A products are currently available for the treatment of Fabry disease: α-galactosidase (Replagal®, Shire Human Genetic Therapies) and β-galactosidase (Fabrazyme®, Genzyme Corporation). Both forms of ERT are designed for intravenous administration of the recombinant enzyme form to compensate for insufficient α-Gal A activity in patients. While ERT is effective in many cases, this treatment has limitations. ERT has not been shown to reduce the risk of stroke, myocardial response is slow, and GL-3 elimination from some cell types in the kidneys is limited. Some patients also develop an immune response to ERT.

[0006] Therefore, there remains a need for therapies to treat Fabry disease. Summary of the Invention

[0007] Different aspects of the present invention relate to the use of migastricostat to treat Fabry disease in ERT-naïve and ERT-previous patients.

[0008] One aspect of the present invention relates to a method of reducing left ventricular mass index (LVMi) in a patient with Fabry's disease who has undergone ERT, the method comprising administering to the patient every other day a formulation comprising an effective amount of migalastat or a salt thereof, wherein the effective amount is about 123 mg free base equivalent (FBE).

[0009] In one or more embodiments, the patient has left ventricular hypertrophy (LVH) before starting administration of migastrol or its salts.

[0010] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0011] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0012] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0013] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0014] In one or more embodiments, migalastat or a salt thereof is administered for at least 18 months.

[0015] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0016] In one or more embodiments, administration of migasstat or its salts for 18 months provided a mean reduction of at least about 5 g / m² in LVMi in patients who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 18 months provided a mean reduction of about 6.6 g / m² in LVMi in patients who had undergone ERT.

[0017] In one or more embodiments, administration of migasstat or its salts for 30 months provided a mean reduction of at least about 2 g / m² in LVMi in patients who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 30 months provided a mean reduction of about 3.8 g / m² in LVMi in patients who had undergone ERT.

[0018] In one or more embodiments, administration of migasstat or its salts for 30 months provided an average reduction of at least about 5 g / m² in LVMi in the group of LVH patients who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 30 months provided an average reduction of about 9 g / m² in LVMi in the group of LVH patients who had undergone ERT.

[0019] Another aspect of the invention relates to a method for reducing LVM in ERT-naïve patients with Fabry disease, the method comprising administering to the patient every other day a formulation containing an effective amount of migastrol or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0020] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0021] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0022] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0023] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0024] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0025] In one or more embodiments, migastrol or its salts are administered for at least 18 months.

[0026] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0027] In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of at least about 5 g / m² in LVMi in ERT-naïve patients. In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of about 7.7 g / m² in LVMi in ERT-naïve patients.

[0028] In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided an average reduction of at least about 10 g / m² in LVMi in ERT-naïve patients. In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided an average reduction of about 17 g / m² in LVMi in ERT-naïve patients.

[0029] In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided a mean reduction of at least about 15 g / m² in LVMi in patients with LVH who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided a mean reduction of about 20.8 g / m² in LVMi in patients with LVH who had not undergone ERT.

[0030] Another aspect of the invention relates to a method for normalizing LVMi in a patient with Fabry disease, the method comprising administering the patient every other day a formulation containing an effective amount of migastrol or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0031] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0032] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0033] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0034] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0035] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0036] In one or more embodiments, migalastat or a salt thereof is administered for at least 18 months.

[0037] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0038] Another aspect of the invention relates to a method for normalizing LVMi in patients with Fabry disease who have undergone ERT, the method comprising administering the patient every other day a formulation containing an effective amount of migastrol or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0039] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0040] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0041] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0042] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0043] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0044] In one or more embodiments, migastrol or its salts are administered for at least 18 months.

[0045] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0046] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 5 g / m 2 in a group of patients who have undergone ERT after 18 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 6.6 g / m 2 in a group of patients who have undergone ERT after 18 months of administration of migalastat or a salt thereof.

[0047] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 2 g / m 2 in a group of patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 3.8 g / m 2 in a group of patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof.

[0048] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 5 g / m 2 in a group of LVH patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 9 g / m 2 in a group of LVH patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof.

[0049] Another aspect of the invention relates to a method for normalizing LVM in ERT-naïve patients with Fabry disease, the method comprising administering to the patient every other day a formulation containing an effective amount of migastrol or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0050] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0051] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0052] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0053] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0054] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0055] In one or more embodiments, migastrol or its salts are administered for at least 18 months.

[0056] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0057] In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of at least about 5 g / m² in LVMi in ERT-naïve patients. In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of about 7.7 g / m² in LVMi in ERT-naïve patients.

[0058] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 10 g / m 2 in a group of patients who are ERT-naive after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 17 g / m 2 in a group of patients who are ERT-naive after 30 to 36 months of administration of migalastat or a salt thereof.

[0059] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 15 g / m 2 in a group of ERT-naive LVH patients 30 to 36 months after administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 20.8 g / m 2 in a group of ERT-naive LVH patients 30 to 36 months after administration of migalastat or a salt thereof.

[0060] Another aspect of the present invention relates to a method of reducing podocyte GL-3 in a patient with Fabry's disease, the method comprising administering to the patient every other day a formulation comprising an effective amount of migalastat or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0061] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0062] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0063] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0064] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0065] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0066] In one or more embodiments, the patient is an ERT-naïve patient.

[0067] In one or more embodiments, the patient is a patient who has undergone ERT.

[0068] Another aspect of the invention relates to a method for reducing podocyte volume in a patient with Fabry disease, the method comprising administering to the patient every other day a formulation containing an effective amount of migastrol or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0069] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0070] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0071] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0072] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0073] In one or more embodiments, migalastat or a salt thereof is administered for at least 6 months.

[0074] In one or more embodiments, administration of migastrol or its salts for 6 months provided an average reduction in podocyte volume of at least about 30% in ERT-naïve patients.

[0075] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in podocyte volume of about 47% in the ERT-naive patient group six months after administration of migalastat or a salt thereof.

[0076] In one or more embodiments, the patient is an ERT-naïve patient.

[0077] In one or more embodiments, the patient is a patient who has undergone ERT.

[0078] Another aspect of the invention relates to a method for reducing the volume of GL-3 inclusions in each podocyte in a patient with Fabry disease, the method comprising administering to the patient every other day a formulation containing an effective amount of migastamine or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0079] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0080] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0081] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0082] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0083] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0084] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in the volume of GL-3 content per podocyte of at least about 30% in a group of ERT-naive patients six months after administration of migalastat or a salt thereof.

[0085] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in the volume of GL-3 content per podocyte of about 50% in the ERT-naive patient group six months after administration of migalastat or a salt thereof.

[0086] In one or more embodiments, the patient is an ERT-naïve patient.

[0087] In one or more embodiments, the patient is a patient who has undergone ERT.

[0088] Another aspect of the present invention relates to a method of treating a Fabry patient who has experienced ERT by reducing left ventricular mass (LVM), the method comprising administering to a patient in need thereof every other day a formulation comprising an effective amount of migalastat or a salt thereof, wherein the effective amount is about 123 mg of FBE.

[0089] In one or more embodiments, the patient has left ventricular hypertrophy (LVH) before starting administration of migastrol or its salts.

[0090] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0091] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0092] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0093] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0094] In one or more embodiments, migastrol or its salts are administered for at least 18 months.

[0095] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0096] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 5 g / m 2 in a group of patients who have undergone ERT after 18 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 6.6 g / m 2 in a group of patients who have undergone ERT after 18 months of administration of migalastat or a salt thereof.

[0097] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 2 g / m 2 in a group of patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 3.8 g / m 2 in a group of patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof.

[0098] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 5 g / m 2 in a group of LVH patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 9 g / m 2 in a group of LVH patients who have undergone ERT after 30 months of administration of migalastat or a salt thereof.

[0099] Another aspect of the invention relates to a method for treating ERT-naïve Fabry disease patients by reducing LVM, the method comprising administering, every other day, a formulation containing an effective amount of migastrol or a salt thereof to the patient in need, wherein the effective amount is approximately 123 mg of FBE.

[0100] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0101] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0102] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0103] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0104] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0105] In one or more embodiments, migalastat or a salt thereof is administered for at least 18 months.

[0106] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0107] In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of at least about 5 g / m² in LVMi in ERT-naïve patients. In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of about 7.7 g / m² in LVMi in ERT-naïve patients.

[0108] In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided an average reduction of at least about 10 g / m² in LVMi in ERT-naïve patients. In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided an average reduction of about 17 g / m² in LVMi in ERT-naïve patients.

[0109] In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided a mean reduction of at least about 15 g / m² in LVMi in patients with LVH who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 30 to 36 months provided a mean reduction of about 20.8 g / m² in LVMi in patients with LVH who had not undergone ERT.

[0110] Another aspect of the invention relates to a method of treating Fabry disease patients by normalizing LVMi, the method comprising administering, every other day, a formulation containing an effective amount of migastrol or a salt thereof to a patient in need, wherein the effective amount is approximately 123 mg of FBE.

[0111] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0112] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0113] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0114] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0115] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0116] In one or more embodiments, migastrol or its salts are administered for at least 18 months.

[0117] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0118] Another aspect of the invention relates to a method for treating Fabry disease patients who have undergone ERT by normalizing LVMi, the method comprising administering, every other day, a formulation containing an effective amount of migastrol or a salt thereof to the patient in need, wherein the effective amount is about 123 mg of FBE.

[0119] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0120] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0121] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0122] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0123] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0124] In one or more embodiments, migalastat or a salt thereof is administered for at least 18 months.

[0125] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0126] In one or more embodiments, administration of migasstat or its salts for 18 months provided a mean reduction of at least about 5 g / m² in LVMi in patients who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 18 months provided a mean reduction of about 6.6 g / m² in LVMi in patients who had undergone ERT.

[0127] In one or more embodiments, administration of migasstat or its salts for 30 months provided a mean reduction of at least about 2 g / m² in LVMi in patients who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 30 months provided a mean reduction of about 3.8 g / m² in LVMi in patients who had undergone ERT.

[0128] In one or more embodiments, administration of migasstat or its salts for 30 months provided an average reduction of at least about 5 g / m² in LVMi in the group of LVH patients who had undergone ERT. In one or more embodiments, administration of migasstat or its salts for 30 months provided an average reduction of about 9 g / m² in LVMi in the group of LVH patients who had undergone ERT.

[0129] Another aspect of the invention relates to a method of treating ERT-naïve Fabry disease patients by normalizing LVMi, the method comprising administering, every other day, a formulation containing an effective amount of migastrol or a salt thereof to the patient in need, wherein the effective amount is approximately 123 mg of FBE.

[0130] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0131] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0132] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0133] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0134] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0135] In one or more embodiments, migalastat or a salt thereof is administered for at least 18 months.

[0136] In one or more embodiments, migastrol or its salts are administered for at least 30 months.

[0137] In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of at least about 5 g / m² in LVMi in ERT-naïve patients. In one or more embodiments, administration of migasstat or its salts for 18 to 24 months provided an average reduction of about 7.7 g / m² in LVMi in ERT-naïve patients.

[0138] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 10 g / m 2 in a group of patients who are ERT-naive after 30 to 36 months of administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 17 g / m 2 in a group of patients who are ERT-naive after 30 to 36 months of administration of migalastat or a salt thereof.

[0139] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of at least about 15 g / m 2 in a group of ERT-naive LVH patients 30 to 36 months after administration of migalastat or a salt thereof. In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in LVMi of about 20.8 g / m 2 in a group of ERT-naive LVH patients 30 to 36 months after administration of migalastat or a salt thereof.

[0140] Another aspect of the invention relates to a method of treating Fabry disease patients by reducing podocyte GL-3, the method comprising administering, every other day, a formulation containing an effective amount of migastrol or a salt thereof to a patient in need, wherein the effective amount is approximately 123 mg of FBE.

[0141] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0142] In one or more embodiments, the patient is administered about 123 mg of migalastat free base every other day.

[0143] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0144] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0145] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0146] In one or more embodiments, the patient is an ERT-naïve patient.

[0147] In one or more embodiments, the patient is a patient who has undergone ERT.

[0148] Another aspect of the invention relates to a method for treating Fabry disease patients by reducing podocyte volume, the method comprising administering, every other day, a formulation containing an effective amount of migastrol or a salt thereof to a patient in need, wherein the effective amount is approximately 123 mg of FBE.

[0149] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0150] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0151] In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every other day.

[0152] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0153] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0154] In one or more embodiments, administration of migastrol or its salts for 6 months provided an average reduction in podocyte volume of at least about 30% in ERT-naïve patients.

[0155] In one or more embodiments, administration of migastrol or its salts for 6 months provided an average reduction in podocyte volume of approximately 47% in ERT-naïve patients.

[0156] In one or more embodiments, the patient is an ERT-naïve patient.

[0157] In one or more embodiments, the patient is a patient who has undergone ERT.

[0158] Another aspect of the present invention relates to a method of treating a patient with Fabry's disease by reducing the volume of GL-3 content per podocyte, the method comprising administering to a patient in need thereof a formulation comprising an effective amount of migalastat or a salt thereof every other day, wherein the effective amount is about 123 mg of FBE.

[0159] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0160] In one or more embodiments, the patient is given approximately 123 mg of migastart free base every other day.

[0161] In one or more embodiments, the patient is given approximately 150 mg of migastart hydrochloride every other day.

[0162] In one or more embodiments, the formulation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0163] In one or more embodiments, migalastat or a salt thereof is administered for at least 6 months.

[0164] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in the volume of GL-3 content per podocyte of at least about 30% in a group of ERT-naive patients six months after administration of migalastat or a salt thereof.

[0165] In one or more embodiments, administration of migalastat or a salt thereof provides a mean reduction in the volume of GL-3 content per podocyte of about 50% in the ERT-naive patient group six months after administration of migalastat or a salt thereof.

[0166] In one or more embodiments, the patient is an ERT-naïve patient.

[0167] In one or more embodiments, the patient is a patient who has undergone ERT. Simple Explanation of the Diagram

[0168] Other features of the invention will become apparent from the following written description and accompanying drawings, wherein:

[0169] Figures 1A-E show the complete DNA sequence of the human wild-type GLA gene (SEQ ID NO: 1).

[0170] Figure 2 shows the wild-type α-Gal A protein (SEQ ID NO: 3).

[0171] Figure 3 shows the mean LVMi changes from baseline to 6 / 12, 18 / 24 and 30 / 36 months after migastrol therapy, as described in Example 1.

[0172] Figure 4 shows, as described in Example 1, (A) individual changes in the GL-3 inclusion volume of each podocyte from baseline to 6 months after migastrol treatment; (B) glomeruli from Fabry disease patients at baseline; and (C) glomeruli after 6 months of treatment.

[0173] Figure 5 shows, as described in Example 1, (A) individual changes in podocyte volume from baseline to 6 months after migastrol treatment; (B) the correlation between podocyte volume and podocyte inclusion volume after 6 months of treatment; and (C) the volume fraction of GL-3 inclusions in podocytes (podocyte inclusion volume / podocyte volume) at baseline and 6 months after treatment.

[0174] Figure 6 shows, as described in Example 1, (A) the mean width of the foot process in patients with Fabry disease at baseline or after 6 months of migastric treatment compared with 9 healthy controls; and (B) the correlation between changes in foot process width and changes in the volume of GL-3 inclusions per podocyte.

[0175] Figure 7 shows, as described in Example 1, (A) individual changes in plasma hemolytic GB3 from baseline to 6 months after migastrol treatment; and individual comparisons between changes in plasma hemolytic GB3 and (B) changes in the volume fraction of GL-3 inclusions in podocytes and (C) changes in the volume of GL-3 inclusions.

[0176] Figure 8 shows an independent comparison of 24-hour urinary protein changes with (A) changes in the volume fraction of GL-3 inclusions in podocytes and (B) the volume of GL-3 inclusions, as described in Example 1.

[0177] Figure 9 shows the urinary GL-3 levels in female patients undergoing migastric therapy, as described in Example 3.

[0178] Figure 10 shows the urinary GL-3 levels in male patients undergoing migastric therapy, as described in Example 3. Implementation Method

[0179] Before describing several exemplary embodiments of the present invention, it should be understood that the present invention is not limited to the details of the construction or method steps listed in the following description. The present invention can be implemented in other ways and can be practiced or carried out in different manners.

[0180] Different aspects of the present invention relate to dosing regimens for administering a pharmacological companion, such as migastric valerate, for the treatment of Fabry disease. In one or more embodiments, the migastric valerate dosing regimen improves one or more cardiac parameters and / or one or more renal parameters in a patient. definition

[0181] In the context of this invention and in the specific context in which each term is used, the terms used in this specification generally have their general meaning in the art. Some terms are discussed below or elsewhere in the specification to provide practitioners with additional guidance on describing the components and methods of the invention and how to make and use them.

[0182] The term "Fabry disease" refers to an X-linked congenital error in the catabolism of glycosphingolipids due to a lack of lysosomal α-Gal A activity. This defect leads to the accumulation of the substrate ceramide trihexoside ("GL-3", also known as Gb 3 or ceramide trihexoside) and associated glycosphingolipids in the endothelial lysosomes of the heart, kidneys, skin, and other tissues.

[0183] The term "atypical Fabry disease" refers to patients with cardiac manifestations primarily characterized by α-Gal A deficiency, namely, progressive GL-3 accumulation in cardiomyocytes, leading to marked enlargement of the heart, particularly the left ventricle.

[0184] A "carrier" is a female who has one X chromosome with a defective α-Gal A gene and one X chromosome with a normal gene, and the normal allele on one or more cell types is inactivated on the X chromosome. Carriers are usually diagnosed with Fabry disease.

[0185] "Patient" refers to a subject who has been diagnosed with or is suspected of having a specific disease. Patients can be humans or animals.

[0186] "Fabry disease patient" refers to an individual who has been diagnosed with or is suspected of having Fabry disease and has an α-Gal A mutation as further defined below. The characteristic markers of Fabry disease can occur in both male hemizygotes and female carriers with the same prevalence, but women are usually less severely affected.

[0187] The term “ERT-naïve patient” refers to a Fabry disease patient who has never received ERT or has not received ERT for at least 6 months prior to starting migastric therapy.

[0188] The term "patients who have undergone ERT" refers to Fabry disease patients who received ERT just before starting migastric therapy. In some implementations, patients who have undergone ERT have received ERT for at least 12 months before starting migastric therapy.

[0189] Human α-galactosidase A (α-Gal A) refers to the enzyme encoded by the human GLA gene. The complete DNA sequence of α-Gal A, including introns and exons, is available in GenBank accession number X14448.1 and is shown in SEQ ID NO: 1 and Figures 1A-E. The human α-Gal A enzyme consists of 429 amino acids and is available in GenBank accession numbers X14448.1 and U78027.1 and is shown in SEQ ID NO: 2 and Figure 2.

[0190] The term "mutant protein" includes proteins with mutations in the gene encoding them, causing the protein to fail to reach a stable conformation under conditions normally found in the endoplasmic reticulum. This failure to reach a stable conformation results in significant degradation of the enzyme instead of its transport to lysosomes. Such mutations are sometimes called "conformation mutants." These mutations include, but are not limited to, missense mutations, as well as small deletions and insertions within frames.

[0191] As used in one embodiment herein, the term "mutant α-Gal A" includes α-Gal A with a mutation in the gene encoding α-Gal A, which causes the enzyme to fail to reach a stable conformation under conditions normally present in the endoplasmic reticulum. This failure to reach a stable conformation results in significant degradation of the enzyme instead of its transport to lysosomes.

[0192] As used herein, the term "pharmacological chaperone" ("PC") means any molecule, including small molecules, proteins, peptides, nucleic acids, carbohydrates, etc., that specifically binds to a protein and has one or more of the following effects: (i) enhancing the formation of a stable molecular conformation of the protein; (ii) inducing the transport of the protein from the endoplasmic reticulum to another cellular location, preferably the native cellular location, i.e., preventing endoplasmic reticulum-related degradation of the protein; (iii) preventing the aggregation of misfolded proteins; and / or (iv) restoring or enhancing at least some of the wild-type function and / or activity of the protein. A compound specifically binding to, for example, α-Gal A means that it binds to that enzyme and exerts a chaperone effect on that enzyme, and not on a group of related or unrelated enzymes. More specifically, this term does not refer to endogenous chaperones such as BiP, or to nonspecific agents such as glycerol, DMSO, or deuterated water that exhibit nonspecific chaperone activity to different proteins, i.e., chemical chaperones. In one or more embodiments of the invention, the PC may be a reversible competitive inhibitor.

[0193] A "competitive inhibitor" of an enzyme can be a compound that is structurally similar to the enzyme substrate in terms of chemical structure and molecular geometry, binding to the enzyme at approximately the same site as the substrate. Therefore, the inhibitor competes with the substrate molecule for the same active site, thereby increasing Km. Competitive inhibition is usually reversible if sufficient substrate molecules are available to replace the inhibitor; that is, the competitive inhibitor can bind reversibly. Therefore, the amount of enzyme inhibition depends on the inhibitor concentration, the substrate concentration, and the relative affinities of the inhibitor and substrate to the active site.

[0194] As used herein, the term "specific binding" refers to the interaction between a pharmacological chaperone and a protein, such as α-Gal A, particularly with amino acid residues of that protein that are directly involved in contacting the pharmacological chaperone. The pharmacological chaperone specifically binds to a target protein, such as α-Gal A, to exert a chaperone effect on that protein rather than a group of related or unrelated proteins. The amino acid residues of the protein interacting with any given pharmacological chaperone may or may not be within the protein's "active site." Specific binding can be evaluated by conventional binding assays or by structural studies (e.g., co-crystallization, NMR, etc.). The active site of α-Gal A is the substrate binding site.

[0195] “Deficient α-Gal A activity” refers to α-Gal A activity in cells from patients that is below the normal range compared to the activity in normal individuals who do not have or are not suspected of having Fabry disease or any other disease (especially blood disorders) using the same method.

[0196] As used herein, the terms "enhancing α-Gal A activity" or "increasing α-Gal A activity" refer to increasing the amount of α-Gal A that adopts a stable conformation in cells that have been exposed to a pharmacological chaperone specific for α-Gal A relative to the amount of α-Gal A that adopts a stable conformation in cells that have not been exposed to the pharmacological chaperone specific for α-Gal A (preferably the same cell type or the same cell, e.g., at an earlier time). The terms also refer to increasing the trafficking of α-Gal A to lysosomes in cells that have been exposed to a pharmacological chaperone specific for α-Gal A relative to the trafficking of α-Gal A in cells that have not been exposed to the pharmacological chaperone specific for the protein α-Gal A. These terms refer to both wild-type and mutant α-Gal A. In one embodiment, the increase in the amount of α-Gal A in cells is measured by measuring the hydrolysis of an artificial substrate in lysates from cells that have been treated with PC. Increased hydrolysis indicates increased α-Gal A activity.

[0197] The term "α-Gal A activity" refers to the normal physiological function of wild-type α-Gal A in cells. For example, α-Gal A activity includes the hydrolysis of GL-3.

[0198] "Responder" refers to an individual diagnosed with or suspected of having a lysosomal storage disorder such as Fabry disease, whose cells, in response to exposure to SPCs, exhibit a sufficiently increased α-Gal A activity and / or a reduction in symptoms or improvement in alternative markers. Non-limiting examples of improvement in Fabry disease alternative markers are those disclosed in GB3 hemolysis and U.S. Patent Application Publication No. US 2010 / 0113517.

[0199] Non-limiting examples of Fabry disease alternative marker improvements disclosed in US 2010 / 0113517 include α-Gal in cells (e.g., fibroblasts) and tissues. Increased A levels or activity; decreased GL-3 accumulation; decreased plasma concentrations of homocysteine ​​and vascular cell adhesion molecule-1 (VCAM-1); decreased GL-3 accumulation in cardiomyocytes and valvular fibroblasts; decreased plasma sphingosine trihexyglycoside (hemolytic GB3); decreased cardiac hypertrophy (especially in the left ventricle), valvular insufficiency, and arrhythmias; reduced proteinuria; decreased urinary concentrations of lipids (such as CTH, lactosylceramide, and ceramide), and increased urinary concentrations of glucosylceramide and sphingomyelin; absence of cascaded inclusion bodies (zebra bodies) in glomerular epithelial cells; improved renal function; alleviated hypohidrosis; absence of angiokeratoma; and improved hearing abnormalities (such as high-frequency sensorineural hearing loss, progressive hearing loss, sudden deafness, or tinnitus). Improvements in neurological symptoms include prevention of transient ischemic attacks (TIAs) or stroke; and reduction of neuropathic pain manifested as paresthesia in the extremities (burning or tingling in the extremities). Another type of clinical marker that can be assessed for Fabry disease is the prevalence of harmful cardiovascular manifestations.

[0200] As used herein, the term "normalized LVMi" refers to reducing a patient's LVMi from above the normal range to within the normal range. The normal range for LVMi in women is 43–95 g / m², and for men it is 49–115 g / m². Therefore, normalizing LVMi in women means reducing LVMi from >95 g / m² to the range of 43–95 g / m², and normalizing LVMi in men means reducing LVMi from >115 g / m² to the range of 49–115 g / m².

[0201] The phrase “pharmacologically acceptable” refers to molecular entities and compositions that are physiologically tolerable and do not typically produce adverse effects when administered to humans. In some embodiments, as used herein, the term "pharmacologically acceptable" refers to use in an animal and more specifically in a human being approved by a governing body of the federal or state government or listed in the United States Pharmacopoeia or other universally recognized pharmacopoeia. The term “carrier” with respect to drug carriers means diluents, adjuvants, excipients, or carriers given with a compound. Such pharmaceutical carriers may be sterile liquids, such as water and oils. Preferably water or aqueous solutions of salt and aqueous solutions of glucose and glycerol are employed as carriers, particularly for injectable solutions. Suitable drug carriers are described in the following literature: EW Martin, “Remington’s Pharmaceutical Sciences [Remington’s Pharmaceutical Sciences],” 18th or otherwise.

[0202] The term “enzyme replacement therapy” or “ERT” refers to the introduction of an unnatural, purified enzyme into an individual with such enzyme defect. The given protein can be obtained from natural sources or by resorting to recombination performance (described in more detail below). The term also refers to the introduction of a purified enzyme into an individual who would otherwise need or benefit from the administration of the purified enzyme, such as the individual suffering an enzyme insufficiency. The introduced enzyme may be a purified recombinase produced in vitro or a protein purified from an ex vivo tissue or body fluid (e.g., like placenta or animal milk) or from a plant.

[0203] As used herein, the term “separated” means the removal of the reference material from the environment in which it is usually found. Accordingly, the isolated biomaterial can be free of the cellular fraction, the fraction of the cell in which the material was found or produced. In the case of nucleic acid molecules, isolated nucleic acids include PCR products, mRNA bands on the gel, cDNA, or restriction fragments. In another embodiment, the isolated nucleic acid is preferably excised from the chromosome on which it can be found, and more preferably is no longer linked to a non-regulatory noncoding region, or to other genes located upstream or downstream of the gene contained by the isolated nucleic acid molecule when found in the chromosome. In yet another embodiment, the isolated nucleic acid is missing one or more introns. The isolated nucleic acids included sequences inserted into plasmids, cosmids, artificial chromosomes, and others. Thus, in one specific embodiment, the recombinant nucleic acid is an isolated nucleic acid. The isolated protein may bind to other proteins or nucleic acids or both to which it binds in the cell, or to the cell membrane if it is a membrane-bound protein. The isolated organelle, cell, or tissue is removed from the anatomical site where it is found in the organism. The separated material can be but does not have to be purified.

[0204] The terms “about” and “approximately” generally refer to the acceptable degree of error of a measured quantity given the nature or precision of the measurement. A typical exemplary degree of error is within 20% of a given value or range of values, preferably within 10%, and more preferably within 5%. Alternatively, particularly in biological systems, the terms “about” and “approximately” may refer to a value within an order of magnitude of a given value, preferably within 10 or 5 times, and more preferably within 2 times. Unless otherwise stated, the numerical quantities given herein are approximate, meaning that the terms “about” or “approximately” can be inferred when not explicitly stated. Fabry disease

[0205] Fabry disease is a rare, progressive, and devastating X-linked lysosomal storage disorder. Mutations in the GLA gene lead to a deficiency in the lysosomal enzyme α-Gal A (essential for glycosphingolipid metabolism). From early life, reduced α-Gal A activity results in the accumulation of glycosphingolipids (including GL-3 and plasma hemolyzed GB3), contributing to the symptoms and life-limiting sequelae of Fabry disease, including pain, gastrointestinal symptoms, kidney failure, cardiomyopathy, cerebrovascular events, and early death. Early initiation of therapy and lifelong treatment offer opportunities to slow disease progression and extend life expectancy.

[0206] Fabry disease encompasses a wide range of disease severity and age of onset, although it is traditionally classified into two main phenotypes: "classical" and "late-onset." The classic phenotype has primarily been attributed to earlier-onset males with undetectable to low levels of α-Gal A activity and clinical manifestations of the kidneys, heart, and / or cerebrovascular system. The late-onset phenotype has primarily been attributed to later-onset males with higher residual α-Gal A activity and these disease manifestations. Heterozygous female carriers typically present with the late-onset phenotype, but depending on the pattern of X chromosome inactivation, they may also exhibit the classic phenotype.

[0207] More than 800 GLA mutations leading to Fabry disease have been identified. Approximately 60% are missense mutations, resulting in the substitution of a single amino acid in the α-Gal A enzyme. Missense GLA mutations typically lead to the production of abnormally folded and unstable forms of α-Gal A, and most are associated with the classical phenotype. Normal cytoquality control mechanisms in the endoplasmic reticulum block the transport of these abnormal proteins to lysosomes and target them for premature degradation and elimination. Many missense mutant forms are targets of migastrol (an α-Gal A-specific pharmacological chaperone).

[0208] Fabry disease presents with a wide range of severity and is broadly correlated with a patient's residual alpha-Gal A levels. Most currently treated patients are referred to as classic Fabry disease patients, the majority of whom are male. These patients experience disease affecting multiple organs, including the kidneys, heart, and brain, with symptoms typically first appearing in adolescence and progressively worsening until death in the fourth or fifth decade of life. Numerous recent studies have identified a large number of undiagnosed men and women with a range of Fabry disease symptoms, such as impaired heart or kidney function and stroke, often first appearing in adulthood. Individuals with this type of Fabry disease, termed late-onset Fabry, tend to have higher residual alpha-Gal A levels compared to classic Fabry disease patients. Individuals with late-onset Fabry disease typically experience symptoms during adulthood, and the symptoms are often concentrated in a single organ, such as enlargement of the left ventricle or progressive kidney failure. Furthermore, late-onset Fabry disease can also present as a stroke of unknown cause.

[0209] Patients with Fabry disease exhibit progressive kidney damage, and untreated patients show end-stage renal impairment by their fifth decade of life. Defects in α-Gal A activity lead to the accumulation of GL-3 and associated glycosphingolipids in numerous cell types, including renal cells. GL-3 accumulates in podocytes, epithelial cells, and tubular cells in the distal tubules and the Ring of Henle. Kidney function impairment can manifest as proteinuria and a decreased glomerular filtration rate.

[0210] Due to the rarity, multi-organ involvement, wide age range of onset, and heterogeneity of Fabry disease, accurate diagnosis is challenging. Awareness among healthcare professionals is low, and misdiagnosis is frequent. Once a patient presents with symptoms, and with mutation analysis, the diagnosis of Fabry disease is most often confirmed based on reduced α-Gal A activity in plasma or peripheral white blood cells (WBCs). Diagnosis is even more challenging in women, as enzyme identification in carrier women is less reliable due to random X chromosome inactivation in some cells of the carrier. For example, some definitive carriers (daughters of orthodoxly affected men) have α-Gal A enzyme activity ranging from normal to very low levels. Because carriers have normal α-Gal A enzyme activity in their white blood cells, identifying α-Gal A mutations solely through genetic testing provides accurate carrier identification and / or diagnosis.

[0211] The mutant form of α-Gal A is considered compliant with migalastat. When the mutant form of α-Gal A is expressed in HEK-293 cells (referred to as the “HEK assay”), an in vitro assay validated according to Good Laboratory Practice (GLP) (GLP HEK or Migalastat Amenability Assay) is defined as showing a relative increase of ≥ 1.20-fold (± 10 μM migalastat) and an absolute increase of ≥ 3.0% of wild-type (WT) (± 10 μM migalastat). These mutations are also referred to herein as “HEK assay compliant” mutations.

[0212] Previous screening methods have been provided for assessing enzyme enhancement prior to the initiation of treatment. For example, assays using HEK-293 cells have been used in clinical trials to predict whether a given mutation will respond to treatment with a pharmacological chaperone (e.g., migastricostat). In this assay, a cDNA construct was constructed. The corresponding α-Gal A mutant form was transiently expressed in HEK-293 cells. Cells were then incubated with ± migastricostat (17 nM to 1 mM) for 4 to 5 days. Subsequently, α-Gal A levels were measured in cell lysates using a synthetic fluorescent substrate (4-MU-α-Gal) or by Western ink dot. This has been performed against known missense or small in-frame insertion / deletion mutations that cause disease. Mutations previously identified as responding to PCs (e.g., migastricostat) using such methods are listed in U.S. Patent No. 8,592,362. Pharmacological partners

[0213] Binding of small molecule inhibitors of LSD-related enzymes can increase the stability of both mutant and corresponding wild-type enzymes (see U.S. Patent Nos. 6,274,597; 6,583,158; 6,589,964; 6,599,919; 6,916,829; and 7,141,582, all incorporated herein by reference). In particular, administration of small molecule derivatives of glucose and galactose, which are specific, selective, competitive inhibitors of several target lysosomal enzymes, effectively increased enzyme stability in cells in vitro and, consequently, increased enzyme trafficking to lysosomes. Thus, by increasing the amount of enzyme in lysosomes, hydrolysis of the enzyme's substrate is expected to increase. The original theory behind this strategy is as follows: Because the mutant enzyme protein is unstable in the endoplasmic reticulum (ER) (Ishii et al., Biochem. Biophys. Res. Comm. 1996;220:812-815), it is delayed and prematurely degraded during the normal transport pathway (ER → basal bodies → endosomes → lysosomes). Therefore, compounds that bind to and increase the stability of the mutant enzyme could act as a "chaperone" for the enzyme, increasing the amount available to leave the ER and move to the lysosome. Furthermore, because the folding and trafficking of some wild-type proteins is incomplete, in some cases up to 70% of some wild-type proteins are degraded before reaching their final cellular location, such chaperones could serve to stabilize the wild-type enzyme and increase the amount available to leave the ER and be transported to the lysosome.

[0214] In one or more embodiments, the pharmacological partner comprises migalastat or a salt thereof. As used herein, "migalastat" refers to (2R,3S,4R,5S)-2-(hydroxymethyl)piperidine-3,4,5-triol, also known as 1-deoxygalactonojirimycin and known under the trade name Galafold™. In other embodiments, the pharmacological partner comprises the hydrochloride salt of migalastat. Migalastat has the following structure:

[0215] As used herein, the term "free base equivalent" or "FBE" refers to the amount of migalastat present in migalastat or its salt. In other words, the term "FBE" refers to an amount of migalastat free base, or the equivalent amount of migalastat free base provided by a salt of migalastat. For example, due to the weight of the chloride ion, 150 mg of migalastat hydrochloride provides only as much migalastat as 123 mg of the free base form of migalastat. Other salts have different conversion factors, depending on the molecular weight of the counterion.

[0216] Migastart is a low-molecular-weight iminosaccharide and an analogue of the GL-3 terminal galactose. In vitro and in vivo pharmacological studies have demonstrated that migastart acts as a pharmacological chaperone, selectively and reversibly binding with high affinity to the active site of wild-type (WT) α-Gal A and specific mutant forms of α-Gal A, genotypes of which are termed HEK assay compliant mutations. Migastart binding stabilizes these mutant forms of α-Gal A in the endoplasmic reticulum, facilitating their proper transport to lysosomes. Dissociation of migastartrate on lysosomes allows α-Gal A to reduce the levels of GL-3 and other substrates. Approximately 30%–50% of patients with Fabry disease have HEK assay compliant mutations; most of these are associated with the classic phenotype of the disease. The list of HEK assay compliant mutations includes at least those listed in Table 1 below. In one or more embodiments, if the double mutation is present on the same chromosome (male and female), the patient is considered to be HEK compliant if the double mutation is present in one of the entries in Table 1 (e.g., D55V / Q57L). In some embodiments, if the double mutation is present on different chromosomes (female only), the patient is considered to be HEK compliant if either of the individual mutations is present in Table 1. Table 1: Amenable mutations Dosage, formulation and administration

[0217] In one or more embodiments, migasstat or a salt thereof is administered to a patient with Fabry disease at a frequency of once every other day (also referred to as “QOD”). In different embodiments, the dosage described herein involves migasstat hydrochloride or an equivalent dose of migasstat or a salt thereof that is not a hydrochloride. In some embodiments, such dosage involves the free base of migasstat. In alternative embodiments, such dosage involves a salt of migasstat. In further embodiments, the salt of migasstat is migasstat hydrochloride. The administration of migasstat or a salt of migasstat is referred to herein as “migasstat therapy”.

[0218] It should be noted that 150 mg of migasstat hydrochloride is equivalent to 123 mg of migasstat in its free base form. Therefore, in one or more embodiments, this dose is 150 mg of migasstat hydrochloride or an equivalent dose of migasstat or a salt thereof that is not a hydrochloride, administered every other day. As mentioned above, this dose is referred to as 123 mg of migasstat in FBA. In another embodiment, this dose is 150 mg of migasstat hydrochloride administered every other day. In still other embodiments, this dose is 123 mg of migasstat free base administered every other day.

[0219] Thus, in various embodiments, migalastat therapy comprises administering 123 mg of FBE every other day, for example, 150 mg of migalastat hydrochloride every other day.

[0220] Milgastrol can be administered for a period of time. In one or more embodiments, milgastrol is administered for at least 28 days, such as at least 30, 60, or 90 days, or for at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30, or 36 months, or for at least 1, 2, 3, 4, or 5 years. In various embodiments, milgastrol therapy is long-term milgastrol therapy, lasting for at least 6 months, such as at least 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30, or 36 months, or for at least 1, 2, 3, 4, or 5 years.

[0221] The administration of migasstat according to the present invention can be in the form of a formulation suitable for any route of administration, but is preferably administered in an oral dosage form (e.g., tablets, capsules, or solution). As an example, the patient is given capsules orally, each capsule containing 150 mg of migasstat hydrochloride or an equivalent dose of migasstat or a salt thereof that is not hydrochloride.

[0222] In some embodiments, PC (e.g., migasstat or its salts) is administered orally. In one or more embodiments, PC (e.g., migasstat or its salts) is administered by injection. PC may be accompanied by a pharmaceutically acceptable carrier, depending on the method of administration.

[0223] In one embodiment of the invention, PC (e.g., migalastat or a salt thereof) is administered as a monotherapy and can be in a form suitable for any route of administration, including, for example, oral administration in the form of a tablet or capsule or liquid, in the form of a sterile aqueous solution for injection, or in the form of a dry lyophilized powder (added to the formulation of the replacement enzyme during or immediately after reconstitution to prevent enzyme aggregation in vitro prior to administration).

[0224] When formulating PC (e.g., migalastat or its salt) for oral administration, such tablets or capsules can be prepared by conventional means using pharmaceutically acceptable excipients such as binders (e.g., pregelatinized corn starch, polyvinylpyrrolidone, or hydroxypropylmethylcellulose); fillers (e.g., lactose, microcrystalline cellulose, or calcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talc, or silicon dioxide); disintegrants (e.g., potato starch or sodium starch glycolate); or wetting agents (e.g., sodium lauryl sulfate). Tablets can be coated using methods well known in the art. Liquid preparations for oral administration can take the form of solutions, syrups, or suspensions, for example, or they can be presented as a dry product for combination with water or other suitable vehicle prior to use. Such liquid preparations can be prepared by conventional means with pharmaceutically acceptable additives, such as: suspending agents (e.g., sorbitol syrup, cellulose derivatives, or hydrogenated edible fats); emulsifiers (e.g., lecithin or acacia); non-aqueous vehicles (e.g., almond oil, oily esters, ethanol, or fractionated vegetable oils); or preservatives (e.g., methyl or propyl paraben or sorbic acid). Where appropriate, the preparations may also contain buffer salts, flavoring agents, coloring agents, and sweeteners. Preparations for oral administration can be suitably formulated to provide controlled release of the active partner compound.

[0225] Pharmaceutical formulations of PCs (e.g., migasstat or its salts) suitable for parenteral / injection typically comprise sterile aqueous solutions (in the case of water solubility), or dispersions, as well as sterile powders for the ad hoc preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and must have a degree of flowability sufficient for easy injection. It must be stable under production and storage conditions and must be preserved against contamination by microorganisms (such as bacteria and fungi). The carrier can be a solvent or dispersion medium comprising, for example, water, ethanol, polyols (e.g., glycerol, propylene glycol, and polyethylene glycol, etc.), or suitable for... The mixture, and vegetable oils. Proper flowability can be maintained, for example, by using coatings (e.g., lecithin), by maintaining the desired particle size in the dispersed state, and by using surfactants. Microbial activity can be prevented by using various antibacterial and antifungal agents (e.g., parabens, trichlorobutanol, phenol, benzyl alcohol, sorbic acid, etc.). In many cases, isotonic agents such as sugars or sodium chloride are appropriate. Extended absorption of injectable compositions can be achieved by using compositions containing delayed-absorption agents (e.g., aluminum monostearate and gelatin).

[0226] As needed, sterile injectable solutions can be prepared by incorporating purified enzymes (if available) and the PC (mirastat or its salt) in the required amounts into a suitable solvent containing the various other components listed above, followed by filtration or final sterilization. Generally, dispersions are prepared by incorporating different sterilized active ingredients into a sterile carrier, which comprises a base dispersion medium and other desired components from those listed above. In the case of sterile powders used to prepare sterile injectable solutions, preferred methods are vacuum drying and freeze-drying techniques, which produce a powder containing the active ingredient plus any other desired components from the previously sterile filtered solution.

[0227] The formulation may contain excipients. Pharmaceutically acceptable excipients in the formulation may include buffers such as citrate buffers, phosphate buffers, acetate buffers, and bicarbonate buffers; amino acids, urea, alcohols, ascorbic acid, phospholipids; proteins such as serum albumin, collagen, and gelatin; salts such as EDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrrolidone; sugars such as dextran, mannitol, sorbitol, and glycerol; propylene glycol and polyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol; glycine or other amino acids; and lipids. Buffering systems for use with the formulation include citrate, acetate, bicarbonate, and phosphate buffers. Phosphate buffers are a preferred embodiment.

[0228] The chaperone compound can be administered orally or parenterally, including intravenously, subcutaneously, intra-arterially, intraperitoneally, intraocularly, intramuscularly, buccally, rectally, vaginally, intraorbitally, intracerebrally, intradermally, intracranially, intraspinally, intravenously, intrathecally, intrasheathally, intracisionally, intracapsularly, intrapulmonaryly, intranasally, via mucosa, via skin, or by inhalation.

[0229] The parenteral formulation of the companion compound can be administered by bolus injection of a periodic injectable formulation, or by intravenous or intraperitoneal administration from a reservoir, which can be external (e.g., an intravenous bag) or internal (e.g., a bioerosible implant).

[0230] The embodiments relating to pharmaceutical formulations and administration may be combined with any other embodiments of the invention, such as methods of treating patients with Fabry disease, methods of enhancing α-Gal A in patients diagnosed with or suspected of having Fabry disease, use of a pharmacological consortium of α-Gal A for manufacturing an agent for treating patients diagnosed with Fabry disease, or embodiments of a pharmacological consortium of α-Gal A for treating patients diagnosed with Fabry disease, together with embodiments relating to compliance mutations, PCs, and suitable dosages thereof.

[0231] In one or more embodiments, PC (e.g., migasstat or its salts) is administered in combination with ERT. By infusion, ERT increases the amount of protein by exogenously introducing a wild-type or biologically functional enzyme. This therapy has been developed for many genetic diseases, including lysosomal storage disorders as cited above (e.g., Fabry disease). After infusion, the exogenous enzyme is expected to be absorbed by tissues via nonspecific or receptor-specific mechanisms. Generally, absorption efficiency is low, and the circulation time of exogenous proteins is short. Furthermore, exogenous proteins are unstable and subject to rapid intracellular degradation, along with the potential for adverse immune responses in the event of subsequent treatment. In one or more embodiments, the chaperone is administered simultaneously with a replacement enzyme (e.g., a replacement for α-Gal A). In some embodiments, the chaperone is co-formulated with a replacement enzyme (e.g., a replacement for α-Gal A).

[0232] In one or more embodiments, a patient is switched from ERT to migastric therapy. In some embodiments, a patient receiving ERT is identified, the patient's ERT is interrupted, and the patient begins migastric therapy. Migastric therapy can be performed according to any of the methods described herein. Left ventricular mass index

[0233] The dosing regimen described in this article can improve LVMi in patients with Fabry disease. LVMi and the natural history of cardiac hypertrophy in untreated Fabry disease patients, regardless of phenotype (Patel, O'Mahony et al., 2015), are characterized by a gradual increase in LVMi at rates between +4.07 and +8.0 g / m² / year (Kampmann, Linhart et al., 2008; Wyatt, Henley et al., 2012; Germain, Weidemann et al., 2013). Since untreated Fabry disease patients typically exhibit an increase in LVMi over time, both a decrease and maintenance of LVMi indicate the benefit of migastrict therapy. As further detailed in the examples below, phase 3 studies have found that migastrict therapy reduced LVMi in both patients who had undergone ERT and those newly diagnosed with ERT, and showed even greater reductions in LVMi at baseline in patients with LVH. These phase 3 studies also found that migastrict therapy normalized LVMi in some patients with LVH.

[0234] The phase 3 study of migastric therapy evaluated LVMi, which was considered a more accurate measurement than LVM. Furthermore, in the phase 3 study, echocardiography was performed locally, but all echocardiograms were read centrally using the same reader. Using the same reader for centralized echocardiogram readings improved accuracy compared to localized readings.

[0235] Compared to the same patient who was not treated with migasstat, migasstat can reduce the increase in LVMi in patients with Fabry disease. In one or more embodiments, migasstat provides a change in LVMi for the patient that is less than (i.e., more negative) 0 g / m², for example less than or equal to about -0.5, -1, -1.5, -2, -2.5, -3, -3.5, -4, -4.5, -5, -5.5, -6, -7, -8, -9, -10, -11, -12, -13, -14, -15, -16, -17, -18, -19, or -20 g / m². Alternatively, in one or more embodiments, migasstat therapy provides a reduction in LVMi greater than 0 g / m², for example, a reduction of at least about 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4.5, 4.5, 5, 5.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 g / m².

[0236] In one or more embodiments, after 18 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in LVMi in patients who had previously experienced ERT. In different embodiments, after 18 months of administration of migasstat or its salts, the mean reduction in LVMi in patients who had previously experienced ERT was at least about 1, 2, 3, 4, 5, or 6 g / m², for example, about 6.6 g / m².

[0237] In one or more embodiments, after 18 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in LVMi in patients who had previously experienced ERT. In different embodiments, after 18 months of administration of migasstat or its salts, the mean reduction in LVMi in patients who had previously experienced ERT was at least about 1, 2, 3, 4, 5, 6, 7, or 8 g / m², for example, about 8.4 g / m².

[0238] In one or more embodiments, after 30 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 0.5 g / m² in LVMi in patients who had previously experienced ERT. In different embodiments, after 30 months of administration of migasstat or its salts, the mean reduction in LVMi in patients who had previously experienced ERT was at least about 0.5, 1, 1.5, 2, 2.5, 3, 3.5, or 4 g / m², for example, about 3.8 g / m².

[0239] In one or more embodiments, after 30 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in LVH patients who had undergone ERT. In different embodiments, after 30 months of administration of migasstat or its salts, the mean reduction in LVH patients who had undergone ERT was at least about 1, 2, 3, 4, 5, 6, 7, 8, or 9 g / m², for example, about 9 g / m².

[0240] In one or more embodiments, after 18 to 24 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in ERT-naïve patients. In different embodiments, after 18 to 24 months of administration of migasstat or its salts, the mean reduction in the ERT-naïve patient group was at least about 1, 2, 3, 4, 5, 6, or 7 g / m², for example, about 7.7 g / m².

[0241] In one or more embodiments, after 18 to 24 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in LVMi in ERT-naïve LVH patients. In different embodiments, after 18 to 24 months of administration of migasstat or its salts, the mean reduction in ERT-naïve LVH patients was at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, or 18 g / m², for example, about 18.6 g / m².

[0242] In one or more embodiments, after 30 to 36 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in ERT-naïve patients. In different embodiments, after 30 to 36 months of administration of migasstat or its salts, the mean reduction in the ERT-naïve patient group was at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, or 17 g / m², for example, about 17 g / m².

[0243] In one or more embodiments, after 30 to 36 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in LVMi in ERT-naïve LVH patients. In different embodiments, after 30 to 36 months of administration of migasstat or its salts, the mean reduction in the ERT-naïve LVH patients was at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 g / m², for example, about 20.8 g / m². Podocyte GL-3 and podocyte volume

[0244] The dosing regimen described in this article can improve one or more parameters related to podocytes in patients with Fabry disease. GL-3 typically accumulates in podocytes in Fabry disease patients. As further described in detail in the following examples, a phase 3 study found that migastrict therapy reduced mean podocyte volume and decreased mean podocyte GL-3 inclusion volume.

[0245] The Phase 3 study of migastric therapy evaluated podocyte GL-3 using two methods. In the first method, qualitative comparisons of podocyte GL-3 were performed because a reliable quantitative method was not available at the time of the study. Pathologists evaluated side-by-side digital images of baseline and post-baseline biopsies (double-blinded by treatment allocation and visit date) and categorized biopsies as having more, less, or equal GL-3 in podocytes. Notably, assigning a score for more or less GL-3 indicated a clearly visible change in GL-3 between baseline and post-baseline. Three pathologists determined, in a blind test, whether paired biopsies had “equal” amounts of GL-3 inclusions in each cell type, or whether one of the biopsies in the pair had “fewer” or “more” inclusions. If two pathologists agreed on “fewer” or “more,” a predetermined value was assigned; otherwise, the designation of “equal” was retained. Results were summarized as the percentage of samples with an increase, decrease, or no change in GL-3 inclusions relative to baseline.

[0246] In the second approach, a post-hoc analysis using stereological principles is employed to estimate structural parameters, including mean podocyte volume, the volume fraction of GL-3 inclusions within podocytes, and the total volume of GL-3 inclusions per podocyte. These stereological principles, based on random geometry and statistics, are designed to be unbiased, efficient, and reproducible. Electron microscopic images (approximately 30,000 x) of the glomerulus are obtained using a systematic, unbiased, uniformly random sampling method to estimate the volume fraction of GL-3 inclusions in podocytes (Vv) [Vv(Inc / PC)]. Grids with appropriate dot density are superimposed on the images. These parameters are calculated by dividing the number of grid points hitting GL-3 inclusions by the number of grid points hitting the cytoplasm of glomerular podocytes.

[0247] In one or more embodiments, migalastat therapy can reduce podocyte volume in a patient with Fabry's disease compared to the same patient not receiving migalastat therapy. In one or more embodiments, migalastat therapy reduces podocyte volume by at least about 10%, such as by at least about 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50%.

[0248] In one or more embodiments, migalastat therapy provides a mean reduction in podocyte volume of at least about 10% in a group of ERT-naive patients six months after administration of migalastat or a salt thereof. In various embodiments, the mean reduction in a group of ERT-naive patients six months after administration of migalastat or a salt thereof is at least about 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50%, such as about 47%.

[0249] In one or more embodiments, migasstat therapy can reduce the total GL-3 inclusion volume per podocyte in Fabry disease patients compared to the same patients who have not been treated with migasstat therapy. In one or more embodiments, migasstat therapy reduces the GL-3 inclusion volume of podocytes by at least about 10%, such as at least about 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50%.

[0250] In one or more embodiments, after 6 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 10% in the total GL-3 inclusion volume per podocyte in ERT-naïve patients. In different embodiments, after 6 months of administration of migasstat or its salts, the mean reduction in the ERT-naïve patient group was at least about 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50%, such as about 50%. [ , Examples , ] [ , , ] [Example] [1] [:] [For treatment with migasstat hydrochloride] [ERT] [The First Treatment of Fabric] [Dosage regimen for patients with Reye's disease]

[0251] This case describes a phase 3 study of migastric therapy in ERT-naïve Fabry disease patients.

[0252] [ , Patients were enrolled. Eligible patients were aged 16–74 years and had genetically confirmed Fabry disease; had never received ERT or had not received ERT for ≥ 6 months; had a GLA mutation that produces a mutant protein that will respond to migastric 293, based on human embryonic kidney-293 (HEK) assays used at enrollment; had an eGFR > 30 ml / min / 1.73 m² and urinary GL-3 ≥ 4 times the upper limit of normal.

[0253] [ , Research design. Following eligibility-baseline assessment (2 months), patients were randomized to Phase 1 – receiving either 150 mg migasstat hydrochloride or placebo every other day in a double-blind manner for 6 months. All patients completing Phase 1 were eligible to receive unblinded migasstat in Phase 2 (months 6–12) and for an additional year thereafter (months 13–24) (FACETS study; AT1001-011 / NCT00925301). The primary objective was to compare the effects of migasstat on renal GL-3 levels, as assessed by histological scoring of the number of contents in interstitial capillaries, relative to placebo, after 6 months of treatment. Secondary objectives of Phase 1 were to compare the effects of migasstat on urinary GL-3 levels, renal function, 24-hour urinary protein, and safety and tolerability relative to placebo. A third objective was to assess cardiac function, patient-reported outcomes, exploratory renal analysis, and leukocyte α-Gal A activity. Research participants are eligible to participate in an unblinded extension study (OLE; AT1001-041 / NCT01458119) for up to 5 years.

[0254] [ , Renal histological evaluation. Each patient underwent a baseline renal biopsy, along with repeat renal biopsies at 6 and 12 months. The number of GL-3 contents in each renal interstitial capillary at baseline and at 6 and 12 months was quantitatively assessed by three independent pathologists (double-blind for treatment and visits) across 300 capillaries. All values ​​from each individual biopsy were averaged over a given time period prior to statistical analysis.

[0255] Changes in GL-3 in podocytes, endothelial cells, and mesangial cells, as well as glomerular sclerosis, were quantitatively assessed by the same three pathologists (in a double-blind treatment / visit process).

[0256] [ , Ceramide trihexoside and sphingosine trihexoside. Plasma hemolyzed GB3 and 24-hour urinary GL-3 were analyzed by liquid chromatography-mass spectrometry using a novel and stable isotope-labeled internal standard 13C6-hemolyzed GB3 (lower limit: 0.200 ng / mL, 0.254 nmol / L).

[0257] [ , Kidney function assessment.The annual change rate (mL / min / 1.73 m² / year) was calculated using the Chronic Kidney Disease Epidemiology Collaboration-eGFR CKD-EPI and the measured iohexol clearance rate-mGFR iohexol.

[0258] [ , Ultrasound cardiography. Parameters such as LVMi, left posterior wall thickness, diastolic blood pressure, interventricular septal thickness, and diastolic blood pressure were assessed using a blinded, centralized evaluation. The baseline visit of the extended study AT1001-041 / NCT01458119 was used as the final assessment.

[0259] [ , Patient-reported results. Patient-reported outcomes were assessed using the Gastrointestinal Symptoms Rating Scale (GSRS), the Short Form-36v2™, and the Brief Pain-Inventory Pain-Severity Component.

[0260] [ , Safety analysis and adverse events. Randomized patients receiving ≥ 1 dose were included in the safety analysis, which included vital signs, physical examination, electrocardiogram, clinical laboratory results, and adverse events.

[0261] [ , Renal interstitial capillaries , ] [ , GL-3 , ] [ , Substrate , ] [ , Statistical analysis. The primary Phase 1 (6-month) endpoint (ITT population with baseline biopsy, n = 64) was the proportion of patients in the migastat and placebo groups with a ≥ 50% reduction in GL-3 contents per interstitial capillary. Two additional Phase 1 endpoints were assessed (modified ITT population: randomized patients with paired baseline and 6-month biopsy; n = 60): the percentage change in GL-3 contents per interstitial capillary, and the percentage of interstitial capillaries without GL-3 contents.

[0262] The efficacy analyses of GL-3 inclusions and other pre-specified endpoints for each interstitial capillary in phase 2 (months 6–12) and the unblinded extension (months 12–24) were based on the following modified treatment intent (mITT): treatment of a randomized population of patients with mutant α-Gal A enzymes that were shown to be suitable for migastric treatment by validation assays; n = 50. [ , , ] [ , result , ] [ , , ]

[0263] [Baseline Characteristics.] Sixty-seven patients with potentially responsive mutant α-Gal A (aged 16–74 years, 64% female) were randomly assigned to the ITT population. Table 2 provides the baseline characteristics of 50 patients in the ITT population with suitable mutant α-Gal A. There were no statistically significant differences in baseline parameters. [surface] [2] [Baseline characteristics] [parameter] [Treatment Group] [Migastrostat hydrochloride] (N = 28) [Placebo to Milgastal Hydrochloride] (N = 22) [total] (N = 50) [Age (years) ()] [n] [)] 28 twenty two 50 Mean ± SD 41.5 ± 13 45.1 ± 8.0 43.1 ± 11 median 37.0 45.5 45.0 [weight(] [kg] [)(] [n] [)] 28 twenty two 50 Mean ± SD 72.6 ± 15.35 76.1 ± 16.52 74.1 ± 15.81 median 72.3 74.0 72.8 [Fabre] [Years since diagnosis of leukemia(] [n] [)] 28 twenty one 49 Mean ± SD 5.6 ± 6.89 7.3 ± 8.80 6.3 ± 7.73 median 4.1 4.1 4.1 [Previously accepted] [ERT] [(before baseline] [> 6] Number of patients (months) [%] [)] 4(14.3%) 7 (31.8%) 11(22.0%) [Use in baseline] [ACEi / ARB / Ri] yes(%) 9 (32.1%) 12 (54.5%) 21 (42.0%) no(%) 19 (67.9%) 10 (45.5%) 29 (58.0%) [Proteinuria] [> 150 mg / 24 h] [(] [%] [)] 17 (60.7%) 18 (81.8%) 35 (70.0%) [Proteinuria] [> 300 mg / 24 h] [(] [%] [)] 8 (28.6%) 11 (50.0%) 19 (38.0%) [Proteinuria] [> 1000 mg / 24 h] [(] [%] [)] 3 (10.7%) 3 (13.6%) 6 (12.0%) [mGFR] [ , 碘海醇 , ] [(] [mL / min / 1.73m, 2 , ] [)(] [n] [)] 27 twenty one 48 Mean ± SD 79.95 ± 30.9 83.12 ± 22.8 81.34 ± 27.5 median 84.90 82.20 83.40 [eGFR, CKD-EPI , ] [(] [mL / min / 1.73m, 2 , ] [)] 28 twenty two 50 Mean ± SD 94.4 ± 27.0 90.6 ± 17.1 92.7 ± 23.0 median 96.6 93.5 94.0 [Hemolysis] [GB3] [(] [n] [)] 18 13 31 Average value (nmol / L) ± SD 47.3 ± 62 41.9 ± 39 45.0 ± 53

[0264] Published reports of one or more clinical phenotypes associated with genotype in patients with eligible mutations (n ​​= 50) showed that 30 patients (60%) had mutations associated with the classic Fabry disease phenotype, one patient (2%) had mutations associated with the nonclassic phenotype, three patients (6%) had mutations associated with both phenotypes, and 16 patients (32%) were unclassified. Residual WBC α-Gal A activity < 3% was found in 14 of 16 males (87%); 29 of 31 males and females (94%) had elevated plasma hemolytic GB3; and 47 of 50 males and females (94%) had multiorgan system disease.

[0265] Migalastat and Renal Interstitial Capillary GL-3. In the 6-month primary outcome analysis (ITT), 13 of 32 patients (41%) treated with migalastat and 9 of 32 patients (28%) treated with placebo achieved a response (≥ 50% reduction in GL-3 content per interstitial capillary) (p = 0.30). The median change from baseline in interstitial capillary GL-3 was -40.8% in the migalastat group and -5.59% in the placebo group (p = 0.097). The mean difference in the percentage change in interstitial capillaries without GL-3 content was 7.3% in favor of migalastat (p = 0.042).

[0266] In both the Phase 1 (post-hoc 6-month) and Phase 2 (pre-specified 12-month) analyses (mITT-eligible population; n = 45), 6 months of migalastat were associated with significantly greater reductions in interstitial capillary GL-3 (± SEM) compared with placebo: -0.250 ± 0.103 vs. +0.071 ± 0.126; p = 0.008. After an additional 6 months of treatment, the reduction in interstitial capillary GL-3 remained stable at Month 6. Among patients who switched from placebo to migalastat at Month 6, a significant reduction in interstitial capillary GL-3 (± SEM) was observed at Month 12 (-0.330 ± 0.152; p = 0.014). Patients with mutant α-Gal A ineligible for migalastat therapy based on validated assays did not show any treatment effect on interstitial capillary GL-3.

[0267] [Migalastat in glomerular cells and] [GL-3] [。] Based on a qualitative assessment of 23 renal biopsies, after 12 months of migastric treatment, patients with the responsive mutant α-Gal A showed a decrease in GL-3 in glomerular podocytes (5 out of 23 biopsies; 22%), endothelial cells (6 out of 23 biopsies; 26%), and renal diaphragmatic cells (11 out of 23 biopsies; 48%). No increase in GL-3 was observed in these samples; the remaining samples showed no change.

[0268] [Migastrostat and plasma hemolysis] [GB3] [Levels.] Compared with the placebo group, six months of miigalastat (mITT-suited) was significantly associated with a decrease in plasma hemolytic GB3 levels (p = .0033). After an additional 6 months of miigalastat, plasma hemolytic GB3 remained stable without further reduction. A significant decrease in plasma hemolytic GB3 was found in patients (ITT-suited) who switched from placebo to miigalastat between months 6 and 12 (p < 0.0001). Plasma levels remained unchanged in patients with unsuitable α-Gal A mutants.

[0269] [Migastrostat and urine] [GL-3] [Substrate] [。] In patients with suitable mutant α-Gal A, the mean changes in 24-hour urinary GL-3 substrate (± SEM) concentrations in migastrol and placebo (baseline to month 6) were -361 ± 169 (to 555 ± 151) and -147 ± 217 (to 1017 ± 218) ng / mg creatinine, respectively (p = 0.44).

[0270] [Migastrostat and Kidney Function] [.] From baseline to month 6, there were no statistically significant differences in changes in eGFR CKD-EPI or mGFR iohexol between the migastamine arm and the placebo arm (mITT appropriate).

[0271] In patients receiving migastric iodine for up to 24 months (mITT appropriate), the annualized changes in eGFR CKD-EPI and mGFR iohexol (± SEM) were -0.30 ± 6.6 and -1.51 ± 1.33 mL / min / 1.73 m², respectively. Male sex and higher baseline proteinuria were associated with a higher annualized reduction rate. There were no statistically significant differences in baseline levels or changes from baseline between the treatment groups for 24-hour urinary protein.

[0272] [Migastrostat and echocardiographic parameters.] Groups with no significant difference in left ventricular mass index at baseline in stage 1 are comparable.

[0273] In patients receiving migastric stearate for up to 24 months (ITT-suitable), a statistically significant decrease in left ventricular mass index (LVMi) was observed overall (p < 0.05, based on 95% CI, excluding 0), with a greater trend of decrease observed in patients with baseline LV hypertrophy. Table 3 shows the echocardiographic changes in LVMi from baseline to 18 / 24 months in ITT-suitable patients. [surface] [3] [:] [LVMi] [Change(] [ITT] [Suitable)] [With suitable mutants] [α-Gal A] [Patient] [ , 1 , ] [Baseline] [ , 2 , ] [average value] [± SEM] [(] [g / m , 2 , ] [)] [From baseline to the] [18 / 24] [Changes over the months] [ ,3 , ] [average value] [± SEM] [(] [95% CI] [)] [all] 96.5 ± 5.0 N = 44 -7.69 ± 3.7(-15.4,-0.009) 4 N = 27 [at baseline] [LVH] [patient] 138.9 ± 11 N = 11 -18.6 ± 8.3 (-38.2, 1.04) N = 8 LVMi, left ventricular mass index (g / m 2): normal: 43-95 (female), 49-115 (male); 1. This includes patients with baseline and post-baseline ECHO who have received migastricostat for ≥ 18 months. 2 Month 6 was used as the baseline for patients switched to migalastat after placebo; if there was no Month 6, baseline was used. 3. The baseline for the extended study was used at month 18 / 24. 4 Statistically significantly different from baseline based on 95% CI not overlapping with 0; P < 0.05

[0274] The interventricular septal wall thickness decreased by 0.061 cm ± 0.051 (5.2%) from baseline (1.17 cm ± 0.057) (95% CI: -1.67, 0.045); the left ventricular posterior wall thickness remained stable for up to 24 months. Changes in left ventricular mass index were associated with changes in IVSWT (R² = 0.26, p = 0.006), but not with changes in left ventricular posterior wall thickness (R² = 0.06, p = 0.230).

[0275] In the extended study, LVMi continued to decrease during the 30 / 36 months of migastric treatment, with a mean change from baseline of -17.0 g / m² ([95% CI -26.2, -7.9]; n = 15). In patients with baseline LVH (n = 11), the change from baseline was greater and statistically significant, at -20.8 g / m² [-95% CI -57.9, -2.2]. Changes in LVMi from baseline to 6 / 12, 18 / 24, and 30 / 36 months of migastric treatment are shown in Figure 3. When the study was extended to 30 / 36 months, 82% (9 / 11) of patients with baseline LVH and 46% (5 / 11) had a decrease in LVMi and normalization, respectively.

[0276] [Gastrointestinal Symptom Rating Scale.] As shown in Table 4 below, in ITT-eligible patients treated with migalastat, three of the five gastrointestinal symptom domains (diarrhea, regurgitation, and dyspepsia) improved.

[0277] In the diarrhea domain, a statistically significant decrease was observed between baseline and month 6 (phase 1) (p = 0.03; ITT-suited); a non-significant decrease was also observed in ITT-suited patients with baseline symptoms (p = 0.06). A statistically significant change was found within 24 months in both ITT-suited and ITT-suited patients with baseline symptoms (p < 0.05, based on 95% CI, excluding 0).

[0278] In ITT-suitable patients with baseline symptoms, statistically significant improvement was observed in the reflux domain during stage 1 (p = 0.047). For both ITT-suitable and ITT-suitable patients with baseline symptoms, statistically significant changes were observed in the dyspepsia domain over 24 months (p < 0.05, based on 95% CI, excluding 0). A trend toward improvement was observed in the constipation domain. [surface] [4] Changes in the Gastrointestinal Symptom Rating Scale [ , 1 , ] [(] [ITT-] [Suitable)] [GSRS] [field] [diarrhea] [Reverse flow] [indigestion] [constipate] [stomach ache] [Treatment Group] Migastrol Placebo Migastrol Placebo Migastrol Placebo Migastrol Placebo Migalastat Placebo [Average baseline value(] [n] [)] [All patients] 2.3(28) 2.1(22) 1.4(28) 1.4(22) 2.5(28) 2.4(22) 1.9(28) 2.0(22) 2.1(28) 2.3(22) [exist] [BL] [Patients with symptoms] 3.2(17) 3.1(11) 2.1(10) 2.6(6) 2.8(23) 2.7(19) 2.5(17) 2.4(15) 2.4(22) 2.9(15) [From baseline to the] [6] [Changes over the past month (number)] [1] [Phase, double-blind] [All patients] -0.3* 2 +0.2 -0.1 +0.2 -0.1 -0.1 +0.1 +0.2 0.0 0.0 [exist] [BL] [Patients with symptoms] -0.6 +0.2 -0.6* 3 +0.6 -0.2 -0.2 +0.2 +0.1 -0.1 -0.1 [From baseline (Migastrostat) or the] [6] [Months (placebo) to the next] [twenty four] [months()] [OLE] Changes in [Migalstat treatment] [All patients] -0.5(-0.9,-0.1)* 4 -0.2(-0.5,0.2) -0.4(-0.7,-0.04)* 4 -0.4(-0.7,+0.0)* 5 -0.2(-0.5,+0.1) [exist] [BL] [Patients with symptoms] -1.0(-1.5,-0.4)* 4 -0.6(-1.5,0.2) -0.5(-0.8,-0.06)* 4 -0.5(-1.1,+0.0)* 5 -0.2(-0.6,0.1) [*] [This indicates a significant change from the baseline or boundary line.] [ , 1 , ] [From baseline()] [BL] Least square mean of the changes in [) [| , 2 , , p = 0.03 [and] [ , 3 , ] [use] [ANCOVA, p = 0.047| , 4 , ] [Statistically significant or] [ , 5 , ] [Based on the upper limit] [0] [of] [95% CI] [Trend.]

[0279] [Migastrostat and podocytes] [GL-3] [。] Masked unbiased electron microscopy stereomicroscopy was used to study renal biopsy samples taken from ERT-naïve male patients with migastric-compliant GLA mutations (N = 8) at baseline and after 6 months of migastric treatment. The mean ± SD total volume V(Inc / Pc) of GL-3 inclusions per podocyte in all patients decreased from 2568 ± 1408 μm³ at baseline to 1282 ± 792 μm³ after 6 months of migastric treatment (p = 0.0182), as shown in Figure 4. Therefore, the decrease in V(Inc / PC) was approximately 50%. The mean podocyte volume decreased from 6680 ± 2835 μm³ at baseline to 3525 ± 2084 μm³ after 6 months of migastric administration (p = 0.004) (r = 0.98, p = 0.00003), as shown in Figure 5. Therefore, the mean podocyte volume decreased by approximately 47%. These findings indicate that podocyte cytoplasmic shrinkage is proportional to GL-3 loss; therefore, the volume fraction of podocyte cytoplasm attributable to GL-3 did not change significantly. The magnitude of the reduction in podocyte GL-3 volume after migastric administration was correlated with the improvement in foot process width (r = 0.82, p = 0.02), as shown in Figure 6. The mean plasma hemolytic GB3 also decreased from 118 ± 48 nM at baseline to 75 ± 42 nM after 6 months of migastric administration (p = 0.0004), as shown in Figure 7. This decrease was correlated with a percentage reduction in podocyte GL-3 volume (r = 0.79, p = 0.02). As shown in Figure 8, after 6 months of treatment with migastric streak, there was a trend toward decreased podocyte GL-3 volume and proteinuria (r = 0.69, p = 0.06), but this decrease was not found to be associated with glomerular filtration rate. In this study, migastric streak treatment was associated with loss of GL-3 inclusions in podocytes of patients with Fabry disease. The sensitive quantitative method used allows for assessment of the therapeutic effect on this important cell type over a relatively short period. This method is also more sensitive than other methods, including those previously used in the Phase 2 study and the first method for qualitative assessment of podocyte GL-3 described earlier in this example.

[0280] [Safety and Adverse Events.] In Phase 1, treatment-emergent adverse events were similar between groups. The most frequent adverse events in patients receiving miralstat compared to placebo were headache (12 / 34 patients - 35% vs. 7 / 33 patients - 21%) and nasopharyngitis (6 / 34 patients - 18% vs. 2 / 34 patients - 6%). The most frequently reported adverse events in Phase 2 were headache (9 / 63 patients - 14%) and procedural pain (7 / 63 patients - 11%, related to renal biopsy), while the most frequently reported adverse events in the extended unblinded phase were proteinuria (9 / 57 patients - 16%), headache (6 / 57 patients - 11%), and bronchitis (6 / 57 patients - 11%). Most adverse events were of mild to moderate severity. No adverse events led to discontinuation of miralstat.

[0281] Six patients experienced serious adverse events in Phase 1 (2: migastric; 4: placebo), five patients experienced serious adverse events in Phase 2, and eleven patients experienced serious adverse events during the unblinded extension period. Two serious adverse events (fatigue and paresthesia) were assessed by respondents as possibly related to migastric. Both occurred in the same patient between months 12 and 24 and were resolved. No individual serious adverse events were reported by >1 patient. Two patients discontinued migastric due to serious adverse events; both were considered unrelated to migastric. No deaths were reported.

[0282] Nine patients (16%) experienced treatment-induced proteinuria between 12 and 24 months, and one of these was determined to be related to migastricostat. In five patients, the 24-month values ​​were the same as baseline. Three patients with suitable mutations had significant baseline proteinuria (>1 g / 24-hr), which increased over 24 months. Among the 28 patients with baseline proteinuria <300 mg / 24-h, 23 had stable 24-hour urinary proteinuria during migastricostat treatment.

[0283] There was no progression to end-stage renal disease, cardiac death, or stroke as defined by Banicazemi et al. One case of transient ischemic attack was determined to be unrelated to migastric.

[0284] Analysis of vital signs, physical examination findings, laboratory and electrocardiogram parameters did not reveal the clinical relevance of migastine. [Example] [2] [:] [Treatment with migasstat hydrochloride has been ongoing] [ERT] [of Fabrizio] [Dosage regimen for patients with this condition]

[0285] This case describes a phase 3 study of migastric therapy in Fabry disease patients who had undergone ERT.

[0286] [ , Patients were selected. Eligible patients were 16–74 years old and had genetically confirmed Fabry disease; had received ERT for ≥ 12 months; had a GLA mutation that produces a mutant protein that will respond to migastric stearate, based on human embryonic kidney-293 (HEK) assays used at enrollment; had an eGFR ≥ 30 ml / min / 1.73 m²; and had maintained a stable ERT dose level and regimen for at least 3 months.

[0287] [ , Research design. Following baseline eligibility assessment, 57 patients were randomized to either 18 months of migasstat therapy or ERT, followed by 12 months of migasstat therapy (ATTRACT study; AT1001-012 / NCT01218659). The migasstat dosing regimen was 150 mg migasstat hydrochloride every other day. The primary objective was to compare the effects of migasstat on renal function relative to ERT, assessed by mGFR and iohexol after 18 months of treatment. Secondary objectives were to compare the effects of migasstat relative to ERT on the following: renal function (assessed by eGFR and 24-hour urinary protein); overall clinical outcomes (assessed by time to renal, cardiac, cerebrovascular events, or death); cardiac function (assessed by echocardiography); and patient-reported outcomes (pain and quality of life). [ , , ] [ , result , ] [ , , ]

[0288] [Migalstatin and echocardiographic parameters.] This study in patients who had undergone ERT found that migastricin therapy reduced LVMi. At month 18, the mean changes from baseline for migastricin and ERT were -6.6 g / m² (95% CI: -11.0, -2.1; n = 31) and -2.0 g / m² (95% CI: -11.0, 7.0; n = 13), respectively. At baseline, in patients with LVH, the changes from baseline to month 18 for migastricin and ERT were -8.4 g / m² (95% CI: -15.7, 2.6; n = 13) and 4.5 g / m² (95% CI: -10.7, 18.4; n = 5), respectively.

[0289] Patients treated with migastric continued to show a decrease in LVMi at month 30 (-3.8 g / m² [95% CI -8.9, 1.3]; N = 30). A greater decrease was observed in patients with baseline LVH (n = 13), with a change from baseline of -9.0 g / m² after 30 months of migastric therapy. In Fabry disease patients with baseline LVH, 85% (11 / 13) showed a decrease in LVMi after 30 months of migastric therapy, and 31% (4 / 13) showed normalization of LVMi. [Example] [3] [Treatment for Fabry Disease] [Comparison of migastric dosing regimens for Schizophrenia]

[0290] This case study describes a phase II study of migastrol therapy in a series of Fabry disease patients.

[0291] A range of dosages and regimens were explored in 27 participants (18 men and 9 women) across five phase 2 studies: • Administer migasstat hydrochloride twice daily (BID) at doses of 25 mg, 100 mg, and 250 mg; • Administer 50 mg of migasstat hydrochloride once daily (QD); • Administer migasstat hydrochloride at 50 mg, 150 mg, and 250 mg every other day (QOD); and • Administer 250 mg and 500 mg of migastart hydrochloride daily for 3 days, followed by no medication for 4 days.

[0292] In summary, nine different combinations of dosage and dosing regimens were investigated in these Phase 2 studies. Fabry disease is a rare genetic disorder, and due to the limited patient population and study sample size for this rare disease, some of the investigated dosages and regimens were compared within or across subjects, while others were compared across studies. These five Phase 2 studies aimed to evaluate the safety, pharmacokinetics, and pharmacodynamics of migasstat hydrochloride, focusing on measuring white blood cell (WBC) α-Gal A activity and urinary GL-3 reduction to assess the efficacy of different dosages and regimens. WBC α-Gal A activity provided a reproducible, minimally invasive measurement of the magnitude of the increase in enzyme activity associated with different doses of migasstat hydrochloride, and was correlated with less frequently assessed, invasive measurements of enzyme activity in the skin and kidneys. Urinary GL-3 provided a reproducible, minimally invasive measurement of GL-3 degradation in lysosomes (the penultimate step in the mechanism of action).

[0293] In these Phase 2 studies, every other day (QOD) 150 mg resulted in the largest decrease in urinary GL-3 in subjects with migastartrate-responsive mutations and was generally well tolerated. Urinary GL-3 levels for the QOD regimen are shown in Figures 9 and 10, with arrows indicating the 8 patients who received the 150 mg QOD regimen and had compliance mutations as determined by HEK-293 cell assays.

[0294] In one of the phase 2 studies, patients were given migastartrate hydrochloride according to the following dosing schedule: 25 mg BID for the first two weeks; 100 mg BID for weeks 2–4; 200 mg BID for weeks 4–6; 25 mg BID for weeks 6–12; and the daily dose of 50 mg was extended to week 96 as appropriate. The urinary GL-3 results for this study are shown in Table 5 below. Table 5: Urine GL-3

[0295] Dosing 25 mg, 100 mg, and 250 mg twice daily resulted in increased α-Gal A activity. This increase in α-Gal A activity was expected to have a positive therapeutic effect (e.g., reduced accumulation of the enzyme substrate GL-3). Unexpectedly, Table 5 above shows an increase in urinary GL-3 in most subjects with the BID regimen, indicating a possible adverse effect. This increase in urinary GL-3 may be due to the high-frequency dosing intervals. When these subjects with the BID regimen were switched to 50 mg daily, some patients showed a decrease in urinary GL-3, but the results were inconsistent across all patients. Although pharmacokinetic modeling suggests that the 50 mg daily dose should provide an exposure trough below IC50 (i.e., below inhibition), the decrease in urinary GL-3 was not as consistent as with the 150 mg QOD. By comparing Figures 9 and 10 with Table 5, it is clear that the 150 mg QOD provided a significantly larger and more consistent decrease in urinary GL-3 compared to daily or twice-daily dosing.

[0296] Further research aimed to explore the possibility that less frequent administration of higher doses of migasstat might provide a greater substrate reduction than a regimen of 150 mg every other day. Subjects were switched from 150 mg migasstat hydrochloride QOD to 250 mg once daily for 3 consecutive days (“drug” period), followed by 4 days off (“discontinuation” period) for 8 weeks, and then to 500 mg (3 days dosing, 4 days off) for at least 8 weeks. A small number of subjects showed elevated WBC α-Gal A levels at higher doses; however, some subjects also showed signs of elevated urinary GL-3. As shown in Table 6 below, mean and median urinary GL-3 levels increased after subjects switched from 150 mg QOD to 250 mg and 500 mg (3 days dosing, 4 days off). Mean and median urinary GL-3 levels then decreased when subjects switched back to 150 mg QOD. Additionally, some subjects could not tolerate higher doses. [surface] [6] [:Urine] [GL-3]

[0297] Based on the results of these studies, every-other-day dosing provides unexpected benefits not found with once-daily or twice-daily dosing. Specifically, every-other-day dosing resulted in the most consistent reduction in urinary GL-3 in subjects with migastric responsiveness mutations. In fact, many other dosing regimens actually lead to an increase in urinary GL-3. Every-other-day dosing also resulted in a more consistent decrease in urinary GL-3 compared to 3 days dosing followed by 4 days without dosing, and some patients receiving 3 days dosing followed by 4 days without dosing also showed an increase in urinary GL-3. Returning to 150 mg QOD after 3 days dosing followed by 4 days without dosing reduced mean and median urinary GL-3 levels.

[0298] The embodiments described herein are intended to illustrate the components and methods, and are not intended to limit the scope of the invention. Various modifications and alterations are intended to be included that are consistent with the overall description and readily understood by those skilled in the art. The appended claims should not be limited to the specific embodiments shown in the examples, but should be given the broadest interpretation consistent with the overall description.

[0299] Throughout this application, patent cases, patent applications, publications, product descriptions, gene bank registry numbers, and experimental protocols are cited, the disclosures of which are incorporated herein by reference in their entirety for all purposes.

[0300] none

[0301] Domestic storage information (please note the order of storage institution, date, and number) none

[0302] Overseas deposit information (please note the order of deposit country, institution, date, and number) none

[0303]

Claims

1. Use of a therapeutically effective amount of migalastat or a salt thereof in the preparation of a medicament for treating Fabry disease in a human patient in need of the medicament, wherein the patient’s α-galactosidase A has one or more HEK assay compliance mutations in the amino acid sequence SEQ ID NO: 2, the mutations being selected relative to SEQ ID NO: 2 from the group consisting of D55G, H125Y, Q157H, L166S, N215I, K240N, G261R, L275V, N278Y, W287L, K308E, and P343T.

2. The use as described in claim 1, wherein the mutation relative to SEQ ID NO:2 is selected from the group consisting of D55G, Q157H, L166S, N215I, K240N, G261R, L275V, N278Y, K308E and P343T.

3. The use as described in claim 1, wherein the mutation is selected relative to SEQ ID NO: 2 from the group consisting of Q157H, L166S and K240N.

4. The use as described in claim 1, wherein the mutation is selected relative to SEQ ID NO:2 from the group consisting of D55G, H125Y, Q157H, L166S, N215I, K240N, G261R, L275V, N278Y, W287L and K308E.

5. The use as described in claim 1, wherein the mutation is selected relative to SEQ ID NO:2 from the group consisting of D55G, H125Y, Q157H, L166S, K240N, G261R, L275V, N278Y, W287L and K308E.

6. The use as described in claim 1, wherein the mutation is selected relative to SEQ ID NO:2 from the group consisting of D55G, Q157H, L166S, N215I, K240N, G261R, L275V, N278Y and K308E.

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