Compositions and methods for improved treatment of X-linked myotubular myopathy

Abstract

The present invention provides methods for treating coexisting cholestatic liver dysfunction (e.g., cholestasis and hyperbilirubinemia) associated with neuromuscular disorders. In certain embodiments, the present invention provides methods for assessing the readiness of a subject with X-linked myotubular myopathy (XLMTM) for combination therapy with an anti-cholestatic agent.

Description

[Technical Field]

[0001] Sequence Listing This application contains a Sequence Listing that has been submitted electronically in ASCII format and is incorporated herein by reference in its entirety. The ASCII copy, created on May 24, 2022, is entitled "51037-057WO3_Sequence_Listing_5_24_22_ST25" and is 69,743 bytes in size.

[0002] The present invention relates to methods for the treatment of cholestatic liver dysfunction associated with current treatments for neuromuscular disorders in patients, such as human patients. [Background technology]

[0003] X-linked myotubular myopathy (XLMTM) is a fatal monogenic disease of skeletal muscle resulting from loss-of-function mutations in myotubularin 1 (MTM1). Approximately 1 in 50,000 newborn boys has XLMTM and typically presents with severe hypotonia and respiratory failure. In extremely rare cases, girls may develop a severe form of XLMTM. Intensive support is required for postnatal survival; for example, 85-90% of patients require respiratory assistance (i.e., mechanical ventilation) at birth, nearly 50% require continuous 24-hour mechanical ventilation, and approximately 60% undergo tracheostomy. Until recently, only supportive treatment options, such as mechanical ventilation or tube feeding, were available. Recently, gene therapy approaches involving the delivery of MTM1 have been developed for the treatment of XLMTM. However, there is a need in the art for improved methods of gene therapy for patients with XLMTM. Summary of the Invention

[0004] The present disclosure provides methods of treating X-linked myotubular myopathy (XLMTM) in a human patient in need thereof. In some embodiments, the patient is administered a therapeutically effective amount of a viral vector containing a transgene encoding myotubularin 1 (MTM1) and an anti-cholestatic agent.

[0005] In one aspect, the disclosure provides a method of treating XLMTM in a human patient in need thereof, comprising administering to the patient (i) a therapeutically effective amount of a transgene encoding MTM1 and (ii) an anti-cholestasis agent, wherein the anti-cholestasis agent is administered to the patient in one or more doses beginning within about 6 weeks (e.g., about 6 weeks before or about 6 weeks after) administration of the transgene to the patient.

[0006] In a second aspect, the present disclosure provides a method for reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM, comprising administering to the patient (i) a therapeutically effective amount of a viral vector comprising a transgene encoding MTM1 and (ii) an anti-cholestasis agent, wherein the anti-cholestasis agent is administered to the patient in one or more doses beginning within about 6 weeks (e.g., about 6 weeks before or about 6 weeks after) of administration of the viral vector to the patient.

[0007] In another aspect, the disclosure provides a method for increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM, comprising administering to the patient (i) a viral vector comprising a transgene encoding MTM1 in a therapeutically effective amount and (ii) an anti-cholestasis agent, wherein the anti-cholestasis agent is administered to the patient in one or more doses beginning within about 6 weeks (e.g., about 6 weeks before or about 6 weeks after) administration of the viral vector to the patient.

[0008] In some embodiments, the anti-cholestasis agent is administered to the patient in one or more doses beginning about 5 weeks (e.g., about 5 weeks before or about 5 weeks after) of administration of the transgene to the patient, and optionally, the anti-cholestasis agent is administered to the patient in one or more doses beginning about 4 weeks (e.g., about 4 weeks before or about 4 weeks after), about 3 weeks (e.g., about 3 weeks before or about 3 weeks after), about 2 weeks (e.g., about 2 weeks before or about 2 weeks after), or about 1 week (e.g., about 1 week before or about 1 week after, about 6 days before or about 5 days after, about 4 days before or about 3 days after, about 2 days before or about 2 days after, or about 1 day before or about 1 day after) of administration of the transgene to the patient.

[0009] In some embodiments, the anti-cholestatic agent is administered to the patient in one or more doses beginning on the same day as administration of the transgene to the patient.

[0010] In another aspect, the disclosure provides a method of treating XLMTM in a human patient in need thereof who has previously received an anti-cholestasis agent, comprising administering to the patient a therapeutically effective amount of a transgene encoding MTM1.

[0011] In another aspect, the present disclosure provides a method for reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM and who has previously received an anti-cholestatic agent, the method comprising administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1.

[0012] In another aspect, the present disclosure provides a method for increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM and who has previously received an anti-cholestatic agent, the method comprising administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1.

[0013] In some embodiments of any of the aforementioned aspects, the method further comprises monitoring the patient for the development of cholestasis or hyperbilirubinemia.

[0014] In some embodiments of any of the aforementioned aspects, the patient is monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof by evaluating a parameter in a blood sample obtained from the patient, and a finding that the parameter is above a reference level identifies the patient as having cholestasis, hyperbilirubinemia, or one or more symptoms thereof.

[0015] In some embodiments, the parameter includes the level of a serum bile acid in the blood sample. In some embodiments, the serum bile acid is cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid.

[0016] In some embodiments, the parameters include one or more results of liver function tests.

[0017] In some embodiments of any of the aforementioned aspects, the parameter includes a level of aspartate aminotransferase or alanine aminotransferase in the blood sample.

[0018] In another aspect, the disclosure provides a method of treating XLMTM in a human patient in need thereof, comprising: (a) administering to the patient a transgene encoding MTM1; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering to the patient an anti-cholestasis agent.

[0019] In another aspect, the disclosure provides a method of treating XLMTM in a human patient in need thereof, comprising: (a) administering a viral vector containing a transgene encoding MTM1 to about 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less) to the patient; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering an anti-cholestasis agent to the patient.

[0020] In another aspect, the disclosure provides a method of reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM, comprising: (a) administering a viral vector comprising a transgene encoding MTM1 to a patient in a dose of about 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8vg / kg or less) to the patient; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering an anti-cholestasis agent to the patient.

[0021] In another aspect, the disclosure provides a method of increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM, comprising: a) administering a viral vector containing a transgene encoding MTM1 to approximately 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less) to the patient; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering an anti-cholestasis agent to the patient.

[0022] In another aspect, the disclosure provides a method of treating XLMTM in a human patient in need thereof, comprising: (a) administering to the patient a transgene encoding MTM1; (b) determining that the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and (c) administering to the patient an anti-cholestasis agent.

[0023] In another aspect, the disclosure provides a method of treating XLMTM in a human patient in need thereof, comprising: (a) administering a viral vector containing a transgene encoding MTM1 to about 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 1014 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less) to the patient; (b) determining that the patient is exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and (c) administering an anti-cholestasis agent to the patient.

[0024] In another aspect, the disclosure provides a method of reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM, comprising: (a) administering a viral vector comprising a transgene encoding MTM1 to a patient in a dose of about 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less) to the patient; (b) determining that the patient is exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and (c) administering an anti-cholestasis agent to the patient.

[0025] In another aspect, the disclosure provides a method of increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM, comprising: (a) administering a viral vector containing a transgene encoding MTM1 to approximately 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 1014 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less) to the patient; (b) determining that the patient is exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and (c) administering an anti-cholestasis agent to the patient.

[0026] In another aspect, the disclosure provides a method of treating XLMTM in a human patient 5 years of age or younger (e.g., 5 years of age or younger, 4 years of age or younger, 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, 12 months of age or younger, 11 months of age or younger, 10 months of age or younger, 9 months of age or younger, 8 months of age or younger, 7 months of age or younger, 6 months of age or younger, 5 months of age or younger, 4 months of age or younger, 3 months of age or younger, 2 months of age or younger, or 1 month of age or younger) in need thereof, the method comprising: (a) administering to the patient a therapeutically effective amount of a transgene encoding MTM1; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering to the patient an anti-cholestasis agent.

[0027] In another aspect, the disclosure provides a method for reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM, the method comprising: (a) administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering to the patient an anti-cholestasis agent.

[0028] In another aspect, the disclosure provides a method for increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM, the method comprising: (a) administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1; (b) monitoring the patient for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, (c) administering an anti-cholestasis agent to the patient.

[0029] In another aspect, the disclosure provides a method of treating XLMTM in a human patient 5 years of age or younger (e.g., 5 years of age or younger, 4 years of age or younger, 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, 12 months of age or younger, 11 months of age or younger, 10 months of age or younger, 9 months of age or younger, 8 months of age or younger, 7 months of age or younger, 6 months of age or younger, 5 months of age or younger, 4 months of age or younger, 3 months of age or younger, 2 months of age or younger, or 1 month of age or younger) in need thereof, the method comprising: (a) administering to the patient a therapeutically effective amount of a transgene encoding MTM1; (b) determining that the patient is exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and (c) administering to the patient an anti-cholestasis agent.

[0030] In another aspect, the disclosure provides a method of treating XLMTM in a human patient 5 years of age or younger (e.g., 5 years of age or younger, 4 years of age or younger, 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, 12 months of age or younger, 11 months of age or younger, 10 months of age or younger, 9 months of age or younger, 8 months of age or younger, 7 months of age or younger, 6 months of age or younger, 5 months of age or younger, 4 months of age or younger, 3 months of age or younger, 2 months of age or younger, or 1 month of age or younger) in need thereof, the method comprising: (a) administering to the patient a therapeutically effective amount of a transgene encoding MTM1; (b) determining that the patient is exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof; and (c) administering to the patient an anti-cholestasis agent.

[0031] In another aspect, the disclosure provides a method for treating or preventing cholestasis or hyperbilirubinemia in a human patient having XLMTM and who has previously received a transgene encoding MTM1, the method comprising administering an anti-cholestasis agent to the patient.

[0032] In another embodiment, the present disclosure provides for administration of a viral vector having XLMTM and comprising a transgene encoding MTM1 in a patient receiving approximately 3×10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8

[0003] The present invention provides a method for treating or preventing cholestasis or hyperbilirubinemia in a human patient who has previously received an anticholestasis agent (less than 100 mg / kg or less), the method comprising administering an anticholestasis agent to the patient.

[0033] In another aspect, the disclosure provides a method of treating or preventing cholestasis or hyperbilirubinemia in a human patient having XLMTM, who has previously been administered a transgene encoding MTM1, and who was 5 years of age or younger (e.g., 5 years of age or younger, 4 years of age or younger, 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, 12 months of age or younger, 11 months of age or younger, 10 months of age or younger, 9 months of age or younger, 8 months of age or younger, 7 months of age or younger, 6 months of age or younger, 5 months of age or younger, 4 months of age or younger, 3 months of age or younger, 2 months of age or younger, or 1 month of age or younger) at the time of administration of the transgene, comprising administering an anti-cholestatic agent to the patient.

[0034] In some embodiments of any of the foregoing aspects, the transgene encoding MTM1 was administered to the patient by transduction with a viral vector containing the transgene encoding MTM1.

[0035] In some embodiments of any of the foregoing aspects, the patient is 5 years of age or younger (e.g., 5 years of age or younger, 4 years of age or younger, 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, 12 months of age or younger, 11 months of age or younger, 10 months of age or younger, 9 months of age or younger, 8 months of age or younger, 7 months of age or younger, 6 months of age or younger, 5 months of age or younger, 4 months of age or younger, 3 months of age or younger, 2 months of age or younger, or 1 month of age or younger) at the time of administration of the transgene or viral vector.

[0036] In some embodiments of any of the foregoing aspects, the patient is 4 years old or younger (e.g., 4 years old or younger, 3 years old or younger, 2 years old or younger, 1 year old or younger, 12 months old or younger, 11 months old or younger, 10 months old or younger, 9 months old or younger, 8 months old or younger, 7 months old or younger, 6 months old or younger, 5 months old or younger, 4 months old or younger, 3 months old or younger, 2 months old or younger, or 1 month old or younger) at the time of administration of the transgene or viral vector, and optionally the patient is 3 years old or younger (e.g., 3 years old or younger, 2 years old or younger, 1 year old or younger, 12 months old or younger, 11 months old or younger, 10 months old or younger, 9 months old or younger, 8 months old or younger, 7 months old or younger, 6 months old or younger, 5 months old or younger, 4 months old or younger, 3 months old or younger, 2 months old or younger, months or younger, or 1 month or younger), 2 years or younger (e.g., 2 years or younger, 1 year or younger, 12 months or younger, 11 months or younger, 10 months or younger, 9 months or younger, 8 months or younger, 7 months or younger, 6 months or younger, 5 months or younger, 4 months or younger, 3 months or younger, 2 months or younger, or 1 year or younger), 1 year or younger (e.g., 1 year or younger, 12 months or younger, 11 months or younger, 10 months or younger, 9 months or younger, 8 months or younger, 7 months or younger, 6 months or younger, 5 months or younger, 4 months or younger, 3 months or younger, 2 months or younger, or 1 month or younger), or 6 months or younger (e.g., 6 months or younger, 5 months or younger, 4 months or younger, 3 months or younger, 2 months or younger, or 1 month or younger).

[0037] In some embodiments of any of the foregoing aspects, the patient was about 1 month to about 5 years old (e.g., about 1 month to about 5 years old, about 2 months to about 5 years old, about 3 months to about 5 years old, about 4 months to about 5 years old, about 5 months to about 5 years old, about 6 months to about 5 years old, about 1 year to about 5 years old, about 2 years to about 5 years old, about 3 years to about 5 years old, or about 4 years to about 5 years old) at the time of administration of the transgene or viral vector.

[0038] In some embodiments of any of the aforementioned aspects, the viral vector is about 3 x 10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 The dose is administered to patients in amounts less than 1000 mg / kg or less.

[0039] In some embodiments of any of the aforementioned aspects, the viral vector is about 2.5 x 10 14 Amounts less than 2.5 × 10 vg / kg (e.g., about 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 1014 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less), and optionally the viral vector is administered to the patient at about 2×10 14 Amounts less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less), approximately 1.5 × 10 14 Amounts less than 1.5 × 10 vg / kg (e.g., about 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 vg / kg or less), or approximately 1.4 × 10 14 Amounts less than 1 × 10 vg / kg (e.g., about 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 The dose is administered to patients in amounts less than 1000 mg / kg or less.

[0040] In some embodiments of any of the aforementioned aspects, the viral vector is about 3 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg, and optionally the viral vector is administered to the patient in an amount of about 8×10 13 vg / kg ~ approx. 1.8×10 14 vg / kg, approximately 1×10 14 vg / kg ~ approx. 1.6×10 14 vg / kg, approximately 1.1×1014 vg / kg ~ approx. 1.5×10 14 vg / kg, or approximately 1.2 × 10 14 vg / kg ~ approx. 1.4×10 14 For example, the viral vector is administered to a patient in an amount of about 3×10 13 vg / kg, 3.1 × 10 13 vg / kg, 3.2 × 10 13 vg / kg, 3.3 × 10 13 vg / kg, 3.4 × 10 13 vg / kg, 3.5 × 10 13 vg / kg, 3.6 × 10 13 vg / kg, 3.7 × 10 13 vg / kg, 3.8 × 10 13 vg / kg, 3.9 × 10 13 vg / kg, 4 × 10 13 vg / kg, 4.1 × 10 13 vg / kg, 4.2 × 10 13 vg / kg, 4.3 × 10 13 vg / kg, 4.4 × 10 13 vg / kg, 4.5 × 10 13 vg / kg, 4.6 × 10 13 vg / kg, 4.7 × 10 13 vg / kg, 4.8 × 10 13 vg / kg, 4.9 × 10 13 vg / kg, 5 × 10 13 vg / kg, 5.1 × 10 13 vg / kg, 5.2 × 10 13 vg / kg, 5.3 × 10 13 vg / kg, 5.4 × 10 13 vg / kg, 5.5 × 10 13 vg / kg, 5.6 × 10 13 vg / kg, 5.7 × 10 13 vg / kg, 5.8 × 10 13 vg / kg, 5.9 × 10 13 vg / kg, 6 × 10 13 vg / kg, 6.1 × 10 13 vg / kg, 6.2 × 10 13 vg / kg, 6.3 × 10 13 vg / kg, 6.4 × 10 13 vg / kg, 6.5 × 1013 vg / kg、6.6×10 13 vg / kg、6.7×10 13 vg / kg、6.8×10 13 vg / kg、6.9×10 13 vg / kg、7×10 13 vg / kg、7.1×10 13 vg / kg、7.2×10 13 vg / kg、7.3×10 13 vg / kg、7.4×10 13 vg / kg、7.5×10 13 vg / kg、7.6×10 13 vg / kg、7.7×10 13 vg / kg、7.8×10 13 vg / kg、7.9×10 13 vg / kg、8×10 13 vg / kg、8.1×10 13 vg / kg、8.2×10 13 vg / kg、8.3×10 13 vg / kg、8.4×10 13 vg / kg、8.5×10 13 vg / kg、8.6×10 13 vg / kg、8.7×10 13 vg / kg、8.8×10 13 vg / kg、8.9×10 13 vg / kg、9×10 13 vg / kg、9.1×10 13 vg / kg、9.2×10 13 vg / kg、9.3×10 13 vg / kg、9.4×10 13 vg / kg、9.5×10 13 vg / kg、9.6×10 13 vg / kg、9.7×10 13 vg / kg、9.8×10 13 vg / kg、9.9×10 13 vg / kg、1×10 14 vg / kg、1.1×10 14 vg / kg、1.2×10 14 vg / kg、1.3×10 14 vg / kg、1.4×10 14 vg / kg、1.5×10 14vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 The amount may be administered to the patient in an amount of vg / kg.

[0041] In some embodiments of any of the aforementioned aspects, the viral vector is about 1.3 x 10 14 It is administered to patients in an amount of vg / kg.

[0042] In some embodiments of any of the aforementioned aspects, the transgene or viral vector is administered to the patient in a single dose comprising that amount.

[0043] In some embodiments of any of the foregoing aspects, the transgene or viral vector is administered to the patient in two or more doses (e.g., two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, or ten or more) that total comprise that amount.

[0044] In some embodiments of any of the foregoing aspects, the transgene or viral vector is administered to the patient in two or more doses (e.g., two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, or ten or more) each individually comprising such an amount.

[0045] In some embodiments of any of the aforementioned aspects, the two or more (e.g., two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, or ten or more) doses are separated from each other by one year or more (e.g., one year or more, one year and six months or more, two years or more, three years or more, four years or more, or five years or more).

[0046] In some embodiments of any of the aforementioned aspects, the two or more doses are administered to the patient within about 12 months (e.g., about 12 months, about 11 months, about 10 months, about 9 months, about 8 months, about 7 months, about 6 months, about 5 months, about 4 months, about 3 months, about 2 months, or about 1 month) of each other.

[0047] In some embodiments of any of the foregoing aspects, the viral vector is selected from the group consisting of adeno-associated virus (AAV), adenovirus, lentivirus, retrovirus, poxvirus, baculovirus, herpes simplex virus, vaccinia virus, and synthetic viruses.

[0048] In some embodiments, the viral vector is AAV, hi some embodiments, the AAV is of the AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAVrhlO, or AAVrhl74 serotype.

[0049] In some embodiments, the viral vector is a pseudotyped AAV. In some embodiments, the pseudotyped AAV is AAV2 / 8 or AAV2 / 9, and optionally, the pseudotyped AAV is AAV2 / 8.

[0050] In some embodiments, the transgene encoding MTM1 is operably linked to a muscle-specific promoter. In some embodiments, the muscle-specific promoter is a desmin promoter, a muscle creatine kinase promoter, a myosin light chain promoter, a myosin heavy chain promoter, a cardiac troponin C promoter, a troponin I promoter, a myoD gene family promoter, an actin alpha promoter, an actin beta promoter, an actin gamma promoter, or a promoter within intron 1 of eye paired-like homeodomain 3. In some embodiments, the muscle-specific promoter is a desmin promoter.

[0051] In some embodiments of any of the aforementioned aspects, the viral vector is resamirigene bilparvovec.

[0052] In some embodiments of any of the aforementioned aspects, the viral vector is administered to the patient by intravenous, intramuscular, intradermal, or subcutaneous administration.

[0053] In some embodiments of any of the aforementioned aspects, the anti-cholestatic agent is selected from the group consisting of a bile acid, a farnesoid X receptor (FXR) ligand, a fibroblast growth factor 19 (FGF-19) mimetic, a Takeda G-protein receptor 5 (TGR5) agonist, a peroxisome proliferator-activated receptor (PPAR) agonist, a PPAR-alpha agonist, a PPAR-delta agonist, a dual PPAR-alpha and PPAR-delta agonist, an luminal sodium-dependent bile acid transporter (ASBT) inhibitor, an immunomodulatory agent, an antifibrotic therapy, and a nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitor.

[0054] In some embodiments, (i) the FXR ligand is obeticholic acid, cilofexor, tropifexor, tretinoin, or EDP-305; (ii) the FGF-19 mimetic is aldafermin; (iii) the TGR5 agonist is INT-777 or INT-767; (iv) the PPAR agonist is bezafibrate, seradelpar, or elafibrinol; (v) the PPAR-alpha agonist is fenofibrate; and (vi) the PPAR-delta agonist is , seladelpar; (vii) the PPAR-alpha and PPAR-delta dual agonist is elafibranor; (viii) the ASBT inhibitor is odevixibat, maralixibat, or linelixibat; (ix) the immunomodulatory agent is rituximab, abatacept, ustekinumab, infliximab, baricitinib, or FFP-104; (x) the antifibrotic therapy is a vitamin D receptor agonist or simtuzumab; and / or (xi) the NOX inhibitor is setanaxib.

[0055] In some embodiments, the bile acid is ursodeoxycholic acid (e.g., ursodiol), norursodeoxycholic acid, or a pharmaceutically acceptable salt thereof. In some embodiments, the bile acid is ursodiol.

[0056] In some embodiments of any of the aforementioned aspects, the bile acid is administered to the patient in a single dose. In some embodiments, the bile acid is administered to the patient in multiple doses.

[0057] In some embodiments, the bile acid is administered to the patient in an amount of about 5 mg / kg / dose to about 20 mg / kg / dose, optionally, the bile acid is administered to the patient in an amount of about 6 mg / kg / dose to about 19 mg / kg / dose, about 7 mg / kg / dose to about 18 mg / kg / dose, about 8 mg / kg / dose to about 17 mg / kg / dose, about 10 mg / kg / dose to about 15 mg / kg / dose, or about 12 mg / kg / dose to about 13 mg / kg / dose. For example, bile acids are administered to a patient in an amount of about 5 mg / kg / dose, 6 mg / kg / dose, 7 mg / kg / dose, 8 mg / kg / dose, 9 mg / kg / dose, 10 mg / kg / dose, 11 mg / kg / dose, 12 mg / kg / dose, 13 mg / kg / dose, 14 mg / kg / dose, 15 mg / kg / dose, 16 mg / kg / dose, 17 mg / kg / dose, 18 mg / kg / dose, 19 mg / kg / dose, or 20 mg / kg / dose.

[0058] In some embodiments, the bile acid is administered to the patient in an amount of about 5 mg / kg / dose to about 11 mg / kg / dose, and optionally, the bile acid is administered to the patient in an amount of about 6 mg / kg / dose to about 10 mg / kg / dose, or about 7 mg / kg / dose to about 9 mg / kg / dose. For example, the bile acid is administered to the patient in an amount of about 5 mg / kg / dose, 6 mg / kg / dose, 7 mg / kg / dose, 8 mg / kg / dose, 9 mg / kg / dose, 10 mg / kg / dose, or 11 mg / kg / dose.

[0059] In some embodiments, bile acids are administered to a patient in one or more (e.g., one or more, two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, or ten or more) doses per day, week, or month.

[0060] In some embodiments, the bile acids are administered to the patient in one or more doses per day, e.g., one or more, two or more, three or more, four or more, five or more, six or more, seven or more, eight or more, nine or more, or ten or more doses), optionally the bile acids are administered to the patient in a single dose per day, two doses per day, three doses per day, four doses per day, or five doses per day.

[0061] In some embodiments, the bile acids are administered to the patient in a single daily dose.

[0062] In some embodiments, the bile acid is administered to the patient in an amount of about 5 mg / kg / day to about 40 mg / kg / day, optionally (i) the bile acid is administered to the patient in an amount of about 6 mg / kg / day to about 39 mg / kg / day, about 8 mg / kg / day to about 37 mg / kg / day, about 13 mg / kg / day to about 32 mg / kg / day, or about 20 mg / kg / day to about 25 mg / kg / day, or (ii) the bile acid is administered to the patient in an amount of about 17 mg / kg / day to about 23 mg / kg / day, about 18 mg / kg / day to about 22 mg / kg / day, or about 19 mg / kg / day to about 21 mg / kg / day. For example, bile acids are administered to a patient in an amount of about 5 mg / kg / day, 6 mg / kg / day, 7 mg / kg / day, 8 mg / kg / day, 9 mg / kg / day, 10 mg / kg / day, 11 mg / kg / day, 12 mg / kg / day, 13 mg / kg / day, 14 mg / kg / day, 15 mg / kg / day, 16 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 25 mg / kg / day, 30 mg / kg / day, 35 mg / kg / day, or 40 mg / kg / day. In some embodiments, bile acids are administered to a patient in an amount of 20 mg / kg / day.

[0063] In some embodiments, the bile acid is administered to the patient in a unit dosage form comprising 250 mg of bile acid. In some embodiments of any of the aforementioned aspects, the bile acid is administered to the patient in a unit dosage form comprising 500 mg of bile acid.

[0064] In some embodiments of any of the aforementioned aspects, bile is administered to the patient by enteral administration.

[0065] In some embodiments of any of the foregoing aspects, the patient does not have a history of cholestasis or hyperbilirubinemia, hi some embodiments, the patient does not have a history of any underlying liver disease.

[0066] In some embodiments of any of the foregoing aspects, the patient is born at a gestational age of 35 weeks or greater and is between full term (e.g., adjusted full term) and about 5 years old (e.g., 1 day old to about 5 years old, 2 days old to about 5 years old, 3 days old to about 5 years old, 4 days old to about 5 years old, 5 days old to about 5 years old, 6 days old to about 5 years old, 7 days old to about 5 years old, 8 days old to about 5 years old, 9 days old to about 5 years old, 10 days old to about 5 years old, 11 days old to about 5 years old, 12 days old to about 5 years old) at the time of administration of the transgene or viral vector. , 13 days to about 5 years old, 14 days to about 5 years old, 15 days to about 5 years old, 16 days to about 5 years old, 17 days to about 5 years old, 18 days to about 5 years old, 19 days to about 5 years old, 20 days to about 5 years old, 25 days to about 5 years old, 1 month to about 5 years old, 2 months to about 5 years old, 3 months to about 5 years old, 4 months to about 5 years old, 5 months to about 5 years old, 6 months to about 5 years old, 1 year to about 5 years old, 2 years to about 5 years old, 3 years to about 5 years old, and 4 years to about 5 years old).

[0067] In some embodiments of any of the aforementioned aspects, the patient is male.

[0068] In some embodiments of any of the aforementioned aspects, the patient requires mechanical ventilatory support, and optionally the mechanical ventilatory support includes invasive mechanical ventilatory support and non-invasive mechanical ventilatory support.

[0069] In some embodiments of any of the foregoing aspects, upon administration of the transgene or viral vector to the patient, the patient exhibits a change from baseline in the number of hours on mechanical ventilatory support over time, optionally the patient exhibits a change from baseline in the number of hours on mechanical ventilatory support over time by about 24 weeks after administration of the transgene or viral vector to the patient, and optionally the patient exhibits a change from baseline in the number of hours on mechanical ventilatory support over time by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient.

[0070] In some embodiments of any of the aforementioned aspects, upon administration of the transgene or viral vector to the patient, the patient achieves functional independent sitting for at least 30 seconds, optionally the patient achieves functional independent sitting by about 24 weeks after administration of the transgene or viral vector to the patient, and optionally the patient demonstrates functional independent sitting for at least 30 seconds by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient.

[0071] In some embodiments of any of the aforementioned aspects, upon administration of the transgene or viral vector to the patient, the patient exhibits a reduction in required mechanical ventilator assistance to about 16 hours or less per day, optionally, the patient exhibits a reduction in required mechanical ventilator assistance by about 24 weeks after administering the viral vector to the patient, and optionally, the patient exhibits a reduction in required mechanical ventilator assistance by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient.

[0072] In some embodiments of any of the foregoing aspects, upon administration of the transgene or viral vector to the patient, the patient exhibits a change from baseline in the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND), optionally, the patient exhibits a change from baseline in CHOP INTEND by about 24 weeks after administration of the transgene or viral vector to the patient, and optionally, the patient exhibits a change from baseline in CHOP INTEND by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient.

[0073] In some embodiments of any of the foregoing aspects, upon administration of the transgene or viral vector to the patient, the patient exhibits a change from baseline in (MIP), optionally the patient exhibits a change from baseline in MIP by about 24 weeks after administering the viral vector to the patient, and optionally the patient exhibits a change from baseline in MIP by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient.

[0074] In some embodiments of any of the foregoing aspects, upon administration of the transgene or viral vector to the patient, the patient exhibits a change from baseline in quantitative analysis of myotubularin expression in muscle biopsies, and optionally, the patient exhibits a change from baseline in quantitative analysis of myotubularin expression in muscle biopsies by about 24 weeks after administration of the transgene or viral vector to the patient, and optionally, the patient exhibits a change from baseline in quantitative analysis of myotubularin expression in muscle biopsies by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient. In some embodiments, the change from baseline in quantitative analysis of myotubularin expression in muscle biopsies persists for at least 48 weeks (e.g., 49 weeks, 50 weeks, 51 weeks, 52 weeks, 1 year, or 2 years) after administration of the viral vector to the patient.

[0075] In some embodiments of any of the foregoing aspects, upon administration of the viral vector to the patient, the patient exhibits a decrease in stiffness and / or joint contracture, optionally the patient exhibits a decrease in stiffness and / or joint contracture by about 24 weeks after administration of the viral vector to the patient, and optionally the patient exhibits a decrease in stiffness and / or joint contracture by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient.

[0076] In some embodiments of any of the foregoing aspects, upon administration of the viral vector to the patient, the patient exhibits diaphragm and / or respiratory muscle development, optionally the patient exhibits diaphragm and / or respiratory muscle development by about 24 weeks after administration of the viral vector to the patient, optionally the patient exhibits diaphragm and / or respiratory muscle development by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient.

[0077] In some embodiments of any of the foregoing aspects, the patient is determined to exhibit cholestasis or one or more symptoms thereof by a finding that the patient exhibits a serum total bile acid level greater than 14 μmol / L (e.g., 14 μmol / L, 15 μmol / L, 16 μmol / L, 17 μmol / L, 18 μmol / L, 19 μmol / L, 20 μmol / L, 21 μmol / L, 22 μmol / L, 23 μmol / L, 24 μmol / L, 25 μmol / L, 26 μmol / L, 27 μmol / L, 28 μmol / L, 29 μmol / L, 30 μmol / L, 31 μmol / L, 32 μmol / L, 33 μmol / L, 34 μmol / L, 35 μmol / L, 36 μmol / L, 37 μmol / L, 38 μmol / L, 39 μmol / L, 40 μmol / L, 41 μmol / L, 42 μmol / L, 43 μmol / L, 44 μmol / L, 45 μmol / L, 46 μmol / L, 47 μmol / L, 48 μmol / L, 49 μmol / L, 50 μmol / L, 51 μmol / L, 52 μmol / L, 53 μmol / L, 54 μmol / L, 55 μmol / L, 56 μmol / L, 57 μmol / L, 58 μmol / L, 59 μmol / L, 60 μmol / L, 61 μmol / L, 62 μmol / L, 63 μmol / L, 64 μmol / L, 65 μmol / L, 66 μmol / L, 67 μmol / L, 68 μmol / L, 69 μmol / L, 70 μmol / L, 71 μmol / L, 72 μmol / L, 73 μmol / L, 74 μmol / L, 75 μmol / L, 76 μmol / L, 77 μmol / L, 78 μmol / L, 79 μmol / L, 80 μmol / L, 81 μmol / L, 82 μmol / L, 83 μmol / L, 84 μmol / L, 85 μmol / L, 86 μmol / L, 87 μmol / L, 88 μmol / L, 89 μmol / L, 90 μmol / L, 91 μmol / L, 92 μmol / L, 93 μmol / L, 94 μmol / L, 95 μmol / L, 96 μmol / L, 97 μmol / L, 98 μmol / L, 99 μmol / L, or greater than 100 μmol / L).

[0078] In some embodiments of any of the aforementioned aspects, the patient is determined to exhibit cholestasis or one or more symptoms thereof by a finding in a blood test that the patient exhibits an increase or decrease in one or more parameters relative to a reference level.

[0079] In some embodiments of any of the aforementioned aspects, the blood test is a liver function test.

[0080] In some embodiments of any of the aforementioned aspects, the one or more parameters include levels of gamma-glutamyltransferase, alkaline phosphatase, aspartate aminotransferase, and / or alanine aminotransferase.

[0081] In some embodiments of any of the aforementioned aspects, the patient has a bilirubin test in which the patient has a bilirubin level greater than 1 mg / dL (e.g., 1 mg / dL, 1.1 mg / dL, 1.2 mg / dL, 1.3 mg / dL, 1.4 mg / dL, 1.5 mg / dL, 1.6 mg / dL, 1.7 mg / dL, 1.8 mg / dL, 1.9 mg / dL, 2 mg / dL, 2.1 mg / dL, 2.2 mg / dL, 2.3 mg / dL, 2.4 mg / dL, 2.5 mg / dL, 2.6 mg / dL, 2.7 mg / dL, 2.8 mg / dL, 2.9 mg / dL, 3 mg / dL, 3.1 mg / dL, 3.2 mg / dL, 3.3 mg / dL, 3.4 mg / dL, 3.5 mg / dL, Hyperbilirubinemia or one or more of its symptoms is determined to be present by the finding of a bilirubin level greater than 3.6 mg / dL, 3.7 mg / dL, 3.8 mg / dL, 3.9 mg / dL, 4 mg / dL, 4.1 mg / dL, 4.2 mg / dL, 4.3 mg / dL, 4.4 mg / dL, 4.5 mg / dL, 4.6 mg / dL, 4.7 mg / dL, 4.8 mg / dL, 4.9 mg / dL, 5 mg / dL, 10 mg / dL, 15 mg / dL, 20 mg / dL, 30 mg / dL, 40 mg / dL, 50 mg / dL, 60 mg / dL, 70 mg / dL, 80 mg / dL, 90 mg / dL, or 100 mg / dL.

[0082] In some embodiments of any of the aforementioned aspects, upon administration of the viral vector to the patient, the patient may have a bilirubin test of greater than 1 mg / dL (e.g., 1 mg / dL, 1.1 mg / dL, 1.2 mg / dL, 1.3 mg / dL, 1.4 mg / dL, 1.5 mg / dL, 1.6 mg / dL, 1.7 mg / dL, 1.8 mg / dL, 1.9 mg / dL, 2 mg / dL, 2.1 mg / dL, 2.2 mg / dL, 2.3 mg / dL, 2.4 mg / dL, 2.5 mg / dL, 2.6 mg / dL, 2.7 mg / dL, 2.8 mg / dL, 2.9 mg / dL, 3 mg / dL, 4 mg / dL, 5 mg / dL, 6 mg / dL, 7 mg / dL, 8 mg / dL, 9 mg / dL, 10 mg / dL, 11 mg / dL, 12 mg / dL, 13 mg / dL, 14 mg / dL, 15 mg / dL, 16 mg / dL, 17 mg / dL, 18 mg / dL, 19 mg / dL, 20 mg / dL, 21 mg / dL, 22 mg / dL, 23 mg / dL, 24 mg / dL, 25 mg / dL, 26 mg / dL, 27 mg / dL, 28 mg / dL, 29 mg / dL, 30 mg / dL, 31 mg / dL, 32 mg / dL, 33 mg / dL, 34 mg / dL, 35 mg / dL, 36 mg / dL, 37 mg / dL, 38 mg / dL, 39 mg / dL, bilirubin levels greater than 0.1 mg / dL, 3.2 mg / dL, 3.3 mg / dL, 3.4 mg / dL, 3.5 mg / dL, 3.6 mg / dL, 3.7 mg / dL, 3.8 mg / dL, 3.9 mg / dL, 4 mg / dL, 4.1 mg / dL, 4.2 mg / dL, 4.3 mg / dL, 4.4 mg / dL, 4.5 mg / dL, 4.6 mg / dL, 4.7 mg / dL, 4.8 mg / dL, 4.9 mg / dL, 5 mg / dL, 10 mg / dL, 15 mg / dL, 20 mg / dL, 30 mg / dL, 40 mg / dL, 50 mg / dL, 60 mg / dL, 70 mg / dL, 80 mg / dL, 90 mg / dL, or 100 mg / dL.

[0083] In some embodiments of any of the aforementioned aspects, the bilirubin level comprises a direct bilirubin level or a total bilirubin level.

[0084] In some embodiments of any of the aforementioned aspects, the patient is determined to exhibit cholestasis, hyperbilirubinemia, or one or more symptoms thereof by a finding in a blood test where the patient exhibits an increase in a parameter relative to a reference level.

[0085] In some embodiments of any of the aforementioned aspects, the parameters include serum bile acid levels.

[0086] In some embodiments of any of the aforementioned aspects, the serum bile acid is cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid.

[0087] In some embodiments of any of the aforementioned aspects, the blood test is a liver function test.

[0088] In some embodiments of any of the aforementioned aspects, the parameter includes a level of aspartate aminotransferase or alanine aminotransferase.

[0089] In one aspect, the disclosure provides a kit comprising a transgene encoding MTM1 and an accompanying instruction sheet, the accompanying instruction sheet providing instructions to a user of the kit for administering the transgene to a patient with XLMTM according to the method of any one of the preceding aspects.

[0090] In one aspect, the disclosure provides a kit comprising a viral vector comprising a transgene encoding MTM1 and an accompanying instruction sheet, the accompanying instruction sheet providing instructions to a user of the kit for administering the viral vector to a patient with XLMTM according to the method of any one of the preceding aspects.

[0091] In one aspect, the disclosure provides a kit comprising an anticholestasis agent and a package insert, the package insert providing instructions to a user of the kit for administering the anticholestasis agent to a patient to treat or prevent cholestasis or hyperbilirubinemia according to the method of any one of the preceding aspects. [Brief explanation of the drawings]

[0092] [Figure 1]Schematic diagram of an exemplary pseudotyped adeno-associated virus (AAV) 2 / 8 (AAV2 / 8) viral vector (e.g., resamirigene bilparvovec) for expression of the human myotubularin 1 (hMTM1) gene. From left to right, the shaded arrow and rectangle represent a nucleic acid sequence encoding the human desmin (hDes) promoter (SEQ ID NO: 3), the hMTM1 gene (SEQ ID NO: 4), and the beta-globin polyadenylation signal (beta-globin_pA), operably linked to a beta-globin intron, flanked by AAV2 inverted terminal repeats (ITRs). Abbreviations: AAV2_ITR: adeno-associated virus 2 inverted terminal repeat; beta-globin_pA: human beta-globin polyadenylation signal; hDes: human desmin promoter; hMTM1: human myotubularin complementary DNA. [Figure 2] 1 is a graph showing the change in total and / or direct bilirubin (fold change relative to the upper limit of normal (ULN)) in human patients treated with 3.0 x 10 vg / kg (3e14; light gray) or 1.0 x 10 vg / kg (1e14; dark gray) resamirigene bilparvovec, as described in Example 2 below. The filled rectangle defines the 25th to 75th percentiles, the cross defines the mean, the lower whisker defines the minimum observed value above the lower boundary (excluding outliers), the upper whisker defines the maximum observed value below the upper boundary (excluding outliers), and the circle indicates an outlier, defined as any value above or below the upper boundary [greater than the 75th percentile + I.5*IQR; or less than the 25th percentile - I.5*] (IQR is the interquartile range (75th to 25th percentile)). [Figure 3]1 is a regression plot showing the change from baseline in total bilirubin (mg / dL) in human patients treated with 3.0×10 vg / kg (light gray solid line) or 1.0×10 vg / kg (dark gray solid line) of resamirigene bilparvovec, as shown in Example 2 below. The regression curve for each group was fitted to all individual subjects who received each dose (3.0×10 vg / kg or 1.0×10 vg / kg of resamirigene bilparvovec; light gray dashed line and dark gray dashed line, respectively). [Figure 4] Graphs depicting respiratory and motor outcomes after treatment with resamirigene bilparvovec for individual patients. Locally estimated scatterplot smoothed regression curves were fitted for low-dose patients, high-dose patients, and the control group, respectively. Time course of invasive ventilator dependence over 24 hours for ASPIRO-treated patients (A), MIP (B), and CHOP INTEND score (C). [Figure 5A]Heat maps show T cell and B cell responses from peripheral blood mononuclear cells (PBMCs) / serum samples to MTM1 administration after resamirigene bilparvovec. ELISpot assays measuring interferon-γ (IFN-γ) release over time upon stimulation of participants' PBMCs with MTM1 peptide pools using samples from treated participants, broken down by mutation type, are shown. IFN-γ cytokine secretion data measured by T cell ELISpot assay are shown. Results are expressed as the number of spot-forming cells (SFCs) per 106 PBMCs. Results were considered significant if the mean SFC / 106 cells minus two standard errors was greater than twice that of the respective negative control wells, with p<0.05. Additionally, a cutoff of ≥50 SFC / 106 was used to determine a positive response to AAV8 or MTM1 peptide pool stimulation. Common causes of "indeterminate" results include insufficient available PBMCs and failure of the sample to respond to stimulation with the positive control. Although definitive conclusions cannot be made based on ELISpot data, numerous clinical and histopathological observations do not support a T cell-mediated immune response as a causative factor in the development of hepatobiliary severe adverse events (SAEs). Among participants with negative ELISpot results at baseline, participants 12 and 01 later reported cholestatic SAEs. Participant 23 ultimately reported SAEs of thrombocytopenia and myocarditis. Participant 09's baseline sample was positive and developed severe cholestatic liver dysfunction and fatal sepsis, immune system damage, and liver damage during the study period. Subjects with only negative (or negative and indeterminable) results at the time of administration included participants 25, 12 (who ultimately developed severe cholestatic liver dysfunction and fatal gastrointestinal bleeding), and 06 (who ultimately developed severe cholestatic liver dysfunction and fatal sepsis). Participants 11, 33, and 38 did not have ELISpot data. [Figure 5B]Heatmap showing T and B cell responses from peripheral blood mononuclear cells (PBMC) / serum samples to MTM1 administration after resamirigene bilparvovec. Anti-MTM1 antibody titers over time in samples from treated participants are shown by mutation type. Anti-MTM1 antibody titer data measured in ASPIRO subjects before and after resamirigene bilparvovec administration are shown. The presence of antibody titers is indicated by a color gradient, although "not detectable" results are also shown. The types of MTM1 gene mutations present in ASPIRO subjects are shown as loss of function (LOF), partial loss of function (PLOF), and in-frame exon deletion (IFED). [Figure 6] 1 is an experimental design for patient enrollment and administration in the ASPIRO clinical trial. [Figure 7A] Figures A-D show respiratory and ventilatory outcomes after resamirigene bilparvovec. A and B are graphs and quantifications, respectively, of the percent change from baseline in least-squares mean ventilator hours per 24 hours in treated participants compared with pooled control participants. C and D are graphs and quantifications, respectively, of maximum inspiratory pressure (MIP). Participants in the high-dose cohort (3.0 x 10 vg / kg resamirigene bilparvovec) were gradually weaned from ventilation using more frequent timepoints and a more conservative algorithm compared with the low-dose cohort (1.0 x 10 vg / kg resamirigene bilparvovec). Error bars indicate standard error. F-tests and associated error bar values ​​are from a mixed-effects ANOVA model, demonstrating a large and significant decrease in the percent change from baseline in ventilation hours per day over time in the treated group compared with the control group. Ventilator dependence data were collected by electronic diary (ie, very frequent reporting) for control and high-dose participants and by unobtrusive site visits for low-dose participants. [Figure 7B]Figures A-D show respiratory and ventilatory outcomes after resamirigene bilparvovec. A and B are graphs and quantifications, respectively, of the percent change from baseline in least-squares mean ventilator hours per 24 hours in treated participants compared with pooled control participants. C and D are graphs and quantifications, respectively, of maximum inspiratory pressure (MIP). Participants in the high-dose cohort (3.0 x 10 vg / kg resamirigene bilparvovec) were gradually weaned from ventilation using more frequent timepoints and a more conservative algorithm compared with the low-dose cohort (1.0 x 10 vg / kg resamirigene bilparvovec). Error bars indicate standard error. F-tests and associated error bar values ​​are from a mixed-effects ANOVA model, demonstrating a large and significant decrease in the percent change from baseline in ventilation hours per day over time in the treated group compared with the control group. Ventilator dependence data were collected by electronic diary (ie, very frequent reporting) for control and high-dose participants and by unobtrusive site visits for low-dose participants. [Figure 7C]Figures A-D show respiratory and ventilatory outcomes after resamirigene bilparvovec. A and B are graphs and quantifications, respectively, of the percent change from baseline in least-squares mean ventilator hours per 24 hours in treated participants compared with pooled control participants. C and D are graphs and quantifications, respectively, of maximum inspiratory pressure (MIP). Participants in the high-dose cohort (3.0 x 10 vg / kg resamirigene bilparvovec) were gradually weaned from ventilation using more frequent timepoints and a more conservative algorithm compared with the low-dose cohort (1.0 x 10 vg / kg resamirigene bilparvovec). Error bars indicate standard error. F-tests and associated error bar values ​​are from a mixed-effects ANOVA model, demonstrating a large and significant decrease in the percent change from baseline in ventilation hours per day over time in the treated group compared with the control group. Ventilator dependence data were collected by electronic diary (ie, very frequent reporting) for control and high-dose participants and by unobtrusive site visits for low-dose participants. [Figure 7D]Figures A-D show respiratory and ventilatory outcomes after resamirigene bilparvovec. A and B are graphs and quantifications, respectively, of the percent change from baseline in least-squares mean ventilator hours per 24 hours in treated participants compared with pooled control participants. C and D are graphs and quantifications, respectively, of maximum inspiratory pressure (MIP). Participants in the high-dose cohort (3.0 x 10 vg / kg resamirigene bilparvovec) were gradually weaned from ventilation using more frequent timepoints and a more conservative algorithm compared with the low-dose cohort (1.0 x 10 vg / kg resamirigene bilparvovec). Error bars indicate standard error. F-tests and associated error bar values ​​are from a mixed-effects ANOVA model, demonstrating a large and significant decrease in the percent change from baseline in ventilation hours per day over time in the treated group compared with the control group. Ventilator dependence data were collected by electronic diary (ie, very frequent reporting) for control and high-dose participants and by unobtrusive site visits for low-dose participants. [Figure 8] Figure 1 shows a graph and quantification, respectively, of motor function after resamirigene bilparvovec. Figure 2 shows the change from baseline in least-squares mean motor function scores on the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND) scale for treated participants compared with pooled control participants. Scores on the CHOP INTEND scale range from 0 to 64, with higher scores indicating better function, and a 4-point increment is considered clinically meaningful. Error bars indicate standard error. [Figure 9]Graphs and quantification showing achievement of major motor milestones in individual resamirigene bilparvovec-treated and control patients, respectively. The white box begins at age at dosing or age at enrollment (INCEPTUS) in the X-linked Myotubular Myopathy Gene Transfer Clinical Trial (ASPIRO). The length of the box indicates the patient's time on study. The icon indicates age at achievement of the motor milestone. [Figure 10] (A) and (B) are a series of graphs and photomicrographs showing myotubularin (MTM1) protein expression and histopathological changes after resamirigene bilparvovec treatment. (B) are a series of images showing hematoxylin and eosin (H&E) staining and nicotinamide adenine dinucleotide (NADH) staining, respectively, of muscle biopsy samples taken at baseline, week 24, and week 48 from patients treated with resamirigene bilparvovec at 1 × 10 vg / kg (patient 08) or 3 × 10 vg / kg (patient 25) or age-matched controls. [Figure 11] 1 is a heat map showing the inflammatory response (e.g., none, very mild, mild, mild to moderate, moderate, moderate to severe, or severe) in patients receiving resamirigene bilparvovec, as assessed by CD3 expression levels in patients receiving low dose (1 x 1014 vg / kg) or high dose (3 x 1014 vg / kg) resamirigene bilparvovec. [Figure 12] A series of images showing the inflammatory response in patients receiving resamirigene bilparvovec at baseline, week 24, and week 48, as assessed by CD3 expression in patients receiving 1 x 1014 vg / kg (patients 17 and 8). [Figure 13]Graph showing Kaplan-Meier analysis of overall survival by time-to-event analysis, where an event is death from study entry onward. Subjects without an event at the cutoff time for the analysis were not included. [Figure 14] Histopathology of a liver biopsy taken from participant 12 on day 85 post-dose. Hemotoxylin and eosin (H&E) staining is shown along with staining for bile transport protein BSEP, demonstrating hepatocellular degeneration and giant cell formation, intracellular and extracellular bile accumulation, bile duct proliferation, and minimal inflammation. [Figure 15] Histopathology of a liver biopsy taken from Participant 06 during autopsy. Hemotoxylin and eosin (H&E) staining with staining for bile transport protein BSEP demonstrates hepatocellular degeneration, necrosis, and giant cell formation, intracellular and extracellular bile accumulation, bile duct proliferation, severe fibrosis, and no significant inflammation. DETAILED DESCRIPTION OF THE INVENTION

[0093] definition As used herein, the term "about" refers to a value within 10% above or below the stated value. For example, "100 pounds" used in the context of weights described herein includes amounts within 10% above or below 100 pounds. Furthermore, when used in the context of a list of numerical quantities, the term "about" preceding the list of numerical quantities should be understood to apply to each individual amount recited in the list.

[0094] As used herein, the terms "administering," "administration," and the like refer to providing a therapeutic agent (e.g., a pharmaceutical composition comprising a viral vector comprising a nucleic acid sequence encoding the myotubularin 1 (MTM1) gene operably linked to a muscle-specific promoter) directly to a patient by any effective route. Exemplary routes of administration are described herein and include systemic routes, such as intravenous injection, as well as routes of administration directly into the patient's central nervous system, particularly by intrathecal or intracerebroventricular injection.

[0095] As used herein, the term "age-adjusted standard" refers to the process of normalizing data by age, a technique used to allow comparison of subject populations when the populations have different age profiles. As used herein, the term "standard" refers to data that is not subjected to age normalization because the subject populations are similar across age profiles.

[0096] As used herein, the terms "alanine aminotransferase" and "ALT" refer to proteins comprising or consisting of the amino acid sequence of a naturally occurring wild-type ALT protein (e.g., ALT1 and ALT2) and a naturally occurring allelic variant of ALT (GPT or GPT2, e.g., a splice variant or allelic variant). The human GPT nucleic acid sequence is provided in NCBI RefSeq Acc. No. NM_005309.2 (SEQ ID NO: 6), and an exemplary wild-type ALT1 amino acid sequence is provided in NCBI RefSeq Acc. No. NP_005300.1 (SEQ ID NO: 7). The human GPT2 nucleic acid sequence is provided in NCBI RefSeq Acc. No. NM_001142466.2 (SEQ ID NO: 8), and an exemplary wild-type ALT2 amino acid sequence is provided in NCBI RefSeq Acc. No. NP_001135938.1 (SEQ ID NO: 9).

[0097] As used herein, the terms "alkaline phosphatase" and "ASP" refer to proteins that comprise or consist of the amino acid sequence of a naturally occurring wild-type ASP protein, and to proteins that comprise or consist of the amino acid sequence of an allelic variant (e.g., a splice variant or allelic variant) of a naturally occurring ASP. The human ASP nucleic acid sequence is provided in NCBI RefSeq Acc. No. NM_000478.5 (SEQ ID NO: 10), and an exemplary wild-type ASP amino acid sequence is provided in NCBI RefSeq Acc. No. NP_000469.3 (SEQ ID NO: 11).

[0098] As used herein, the term "anticholestatic agent" refers to a substance, such as a small molecule, that acts to increase bile formation and / or antagonize the action of hydrophobic bile acids on biological membranes. The term "antagonize," as used herein with respect to a protein, refers to a molecule that reduces signal transduction resulting from the interaction of a protein with one or more of its binding partners. An antagonist may reduce binding of a protein to one or more of its binding partners compared to binding of the two proteins in the absence of the antagonist.

[0099] As used herein, the terms "aspartate aminotransferase" and "AST" refer to proteins that comprise or consist of the amino acid sequence of a naturally occurring wild-type AST protein, and to proteins that comprise or consist of the amino acid sequence of a naturally occurring allelic variant (e.g., a splice variant or allelic variant) of AST. The human AST nucleic acid sequence is provided in NCBI RefSeq Acc. No. NM_002079.2 (SEQ ID NO: 12), and an exemplary wild-type AST amino acid sequence is provided in NCBI Ref Seq Acc. No. NP_002070.1 (SEQ ID NO: 13).

[0100] As used herein, the terms "bile acid test" and "serum bile acid test" refer to a procedure in which a preprandial (i.e., before eating) blood sample is taken as a baseline, followed by a meal and a postprandial (i.e., after eating) blood sample approximately two hours later. Both blood samples are tested for bile acid levels, with the preprandial sample used as the reference. As used herein, "bile acid" refers to steroid acids found primarily in the bile of mammals and other vertebrates.

[0101] As used herein, the terms "Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders" and "CHOP INTEND" refer to validated motor assessment indices developed for the evaluation of frail infants, e.g., infants with skeletal muscle disorders (e.g., X-linked myotubular myopathy (XLM™)). CHOP INTEND uses a 0-64 point scale, with higher scores indicating better motor function. As used herein, the term "motor function score" refers to a score on the CHOP INTEND 0-64 point scale (e.g., a CHOP INTEND scale of >45).

[0102] As used herein, the term "cholestasis" refers to the condition in which bile cannot flow from the liver to the duodenum.Clinically, there are two distinctions: "obstructive" cholestasis, which is caused by a physical blockage in the duct system, which can result from gallstones or malignant tumors, and "metabolic" cholestasis, which is a disorder of bile formation, which can result from genetic defects or can be acquired as a side effect of many medications.As used herein, the term "bile" refers to the digestive fluid secreted by the liver to aid in the digestion of fat.

[0103] As used herein, "combination therapy" refers to the administration or treatment of two (or more) different agents to a subject as part of a defined treatment regimen for a particular disease or condition (e.g., a neuromuscular disorder). In some embodiments, "combination therapy" can include treatment. The treatment regimen defines the dosage and frequency of each agent so that the effects of the individual agents on the subject are overlapping. In some embodiments, the delivery of two or more agents is simultaneous or concurrent, and the agents may be formulated together. In other embodiments, the two or more agents are not formulated together but are administered sequentially as part of a prescribed regimen. In some embodiments, the administration of two or more agents or combination treatments is such that the reduction in symptoms or other parameters related to the disorder is greater than that observed when one agent or treatment is delivered alone or in the absence of the other. The effect of the two treatments can be partially additive, fully additive, or more than additive (e.g., synergistic). Sequential or substantially simultaneous administration of each therapeutic agent can be performed by any suitable route, including, but not limited to, oral, intravenous, intramuscular, and direct absorption through mucosal tissue. The therapeutic agents can be administered by the same or different routes. For example, a first therapeutic agent of the combination can be administered by intravenous injection, and a second therapeutic agent of the combination can be administered enterally. In another example, the agents of the therapeutic combination can be administered by intravenous injection, and a therapeutic combination procedure (e.g., nasobiliary drainage (NBD)) can be performed.

[0104] As used herein, the term "dose" refers to the amount of a therapeutic agent, such as a viral vector described herein, administered to a subject at a particular time for the treatment of a disorder, such as the treatment or amelioration of one or more symptoms of a neuromuscular disorder (e.g., XLMTM) described herein. The therapeutic agents described herein, as defined herein, can be administered in a single dose or in multiple doses over a treatment period. In either case, the therapeutic agent can be administered using one or more unit dosage forms of the therapeutic agent, and the term unit dosage form refers to one or more separate compositions containing the therapeutic agent that collectively constitute a single dose of the agent.

[0105] As used herein, the terms "effective amount," "therapeutically effective amount," and the like, when used in reference to a therapeutic composition, such as a vector construct described herein, refer to an amount sufficient to effect a beneficial or desired result, such as a clinical result, when administered to a subject, including a mammal, e.g., a human. For example, in the context of treating a neuromuscular disorder, such as XLMTM, these terms refer to an amount of a composition sufficient to effect a therapeutic response compared to the response obtained when the composition of interest is not administered. An "effective amount," "therapeutically effective amount," and the like, of a composition, such as a vector construct, of the present disclosure includes an amount that effects a beneficial or desired result in a subject compared to a control.

[0106] As used herein, the terms "gamma-glutamyltransferase" and "GGT" refer to proteins that comprise or consist of the amino acid sequence of a naturally occurring wild-type GGT protein, and proteins that comprise or consist of the amino acid sequence of a naturally occurring allelic variant of GGT (GGT1, GGT2, and GGT3, e.g., a splice variant or allelic variant). The human GGT1 nucleic acid sequence is provided in NCBI RefSeq Acc. No. NM_001288833.1 (SEQ ID NO: 14), and an exemplary wild-type GGT1 amino acid sequence is provided in NCBI RefSeq Acc. No. NP_001275762.1 (SEQ ID NO: 15).

[0107] As used herein, the term "gestational age" refers to how far into a particular pregnancy a woman has progressed, measured from day 1 of the woman's last menstrual cycle to the current date. As used herein, the term "delivery" (also called birth) refers to the expulsion of the fetus and placenta from the woman's uterus. In a normal pregnancy, delivery can occur at approximately 40 weeks of gestation.

[0108] As used herein, the term "hyperbilirubinemia" refers to a condition in which higher-than-normal levels of bilirubin are present in the blood. As used herein, the term "bilirubin" refers to a compound produced in the normal catabolic pathway that breaks down heme in vertebrates. This catabolism is a necessary process for the body to eliminate waste products resulting from the destruction of aging or abnormal red blood cells. As used herein, a "bilirubin test" refers to measuring the amount of bilirubin in a patient's blood.

[0109] As used herein, the term "level" refers to the level of a protein compared to a reference. The reference can be any useful reference, as defined herein. A "decreased level" and an "increased level" of a protein refer to a decrease or increase in protein level compared to a reference (e.g., about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 100%, about 150%, about 200%, about 300%, about 400%, about 500% or more decrease or increase; a decrease or increase of about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 100%, about 150%, about 200%, about 300%, about 400%, about 500% or more compared to a reference). "A decrease or increase of more than about 20%, about 20%, about 50%, about 75%, about 100%, or about 200%; a decrease or increase of about 0.01-fold, about 0.02-fold, about 0.1-fold, about 0.3-fold, about 0.5-fold, about 0.8-fold or less; or an increase of about 1.2-fold, about 1.4-fold, about 1.5-fold, about 1.8-fold, about 2.0-fold, about 3.0-fold, about 3.5-fold, about 4.5-fold, about 5.0-fold, about 10-fold, about 15-fold, about 20-fold, about 30-fold, about 40-fold, about 50-fold, about 100-fold, about 1000-fold or more. Protein levels can be expressed in mass / volume (e.g., g / dL, mg / mL, μg / mL, or ng / mL) or as a percentage of total protein in the sample.

[0110] As used herein, the terms "liver function tests" and "LFTs" refer to a liver panel (e.g., a group of blood tests that provide information about the status of a patient's liver). A liver panel can include measurements of gamma-glutamyltransferase levels, alkaline phosphatase levels, aspartate aminotransferase levels, alanine aminotransferase levels, albumin levels, bilirubin levels, prothrombin time, activated partial thromboplastin time, or a combination thereof.

[0111] As used herein, the terms "maximum inspiratory pressure" and "MIP" refer to variables in mechanical ventilation that include the total delivered airway pressure, which is generally used to overcome both respiratory system compliance and airway resistance. In pressure-controlled modes, MIP includes the sum of positive end-expiratory pressure and "delta pressure." As used herein, the term "delta pressure" refers to variables in mechanical ventilation that include the difference between MIP and positive end-expiratory pressure.

[0112] As used herein, the term "mechanical ventilation support" refers to a medical term for artificial ventilation, in which a mechanical means is used to support or replace spontaneous breathing. As used herein, the term "invasive mechanical ventilation support" refers to a medical term for artificial ventilation, in which air is delivered via a tube inserted into the patient's mouth or nose and into the trachea, in which a mechanical means is used to support or replace spontaneous breathing. As used herein, the term "non-invasive mechanical ventilation support" refers to mechanical ventilation support that delivers air to a patient via a tight-fitting mask that can be placed over the mouth, nose, or entire face.

[0113] As used herein, the term "operably linked" refers to a first molecule linked to a second molecule, positioned such that the first molecule affects the function of the second molecule. The two molecules may or may not be part of a single, contiguous molecule, and may or may not be adjacent. For example, a promoter is operably linked to a transcribable polynucleotide molecule of interest if the promoter controls the transcription of the transcribable polynucleotide molecule in a cell. Furthermore, two portions of a transcriptional regulatory element are operably linked to each other if they are connected in such a way that the transcriptional activation function of one portion is not adversely affected by the presence of the other portion. Two transcriptional regulatory elements may be operably linked to each other by a linker nucleic acid (e.g., an intervening non-coding nucleic acid) or without any intervening nucleotides.

[0114] As used herein, the term "pharmaceutical composition" refers to a mixture containing therapeutic compounds that is administered to a subject, such as a mammal, e.g., a human, to prevent, treat, or control a particular disease or condition from which the subject is suffering or likely to suffer.

[0115] As used herein, the term "pharmaceutically acceptable" refers to compounds, materials, compositions and / or dosage forms that are suitable for contact with the tissues of a subject, such as a mammal (e.g., a human), without excessive toxicity, irritation, allergic response, and other significant complications, commensurate with a reasonable benefit / risk ratio.

[0116] As used herein, the term "promoter" refers to a recognition site on DNA to which RNA polymerase binds. The polymerase drives transcription of the transgene. Exemplary promoters suitable for use with the compositions and methods described herein are described, for example, in Sandelin et al., Nature Reviews Genetics 8:424 (2007), the disclosure of which is incorporated herein by reference with respect to nucleic acid regulatory elements. Additionally, the term "promoter" can refer to a synthetic promoter, which is a regulatory DNA sequence that does not naturally occur in a biological system. Synthetic promoters contain portions of naturally occurring promoters combined with non-naturally occurring polynucleotide sequences and can be optimized for recombinant DNA expression using a variety of transgenes, vectors, and target cell types.

[0117] As used herein, a therapeutic agent is considered to be "provided" to a patient when the therapeutic agent is administered directly to the patient or when a substance that is processed or metabolized in vivo to endogenously produce the therapeutic agent is administered to the patient. For example, a patient, such as a patient having a neuromuscular disorder described herein, can be provided with a nucleic acid molecule encoding a therapeutic protein (e.g., MTM1) by direct administration of the nucleic acid molecule or by administration of a substance (e.g., a viral vector or cells) that is processed in vivo to produce the desired nucleic acid molecule.

[0118] As used herein, the terms "patient" and "subject" refer to an organism receiving treatment for a particular disease or condition described herein (such as a neuromuscular disorder, e.g., XLMTM). Examples of subjects and patients include mammals, e.g., humans, receiving treatment for a disease or condition described herein.

[0119] "Reference" refers to any useful reference used to compare protein levels related to cholestasis, hyperbilirubinemia, or one or more symptoms thereof. The reference can be any sample, standard, standard curve, or level used for comparison purposes. The reference can be a normal reference sample, reference standard, or reference level. The term "reference sample" can refer to, for example, a control, e.g., a predetermined negative control value such as a "normal control," or a previous sample collected from the same subject; a sample from a normal, healthy subject, such as normal cells or normal tissue; a sample (e.g., cell or tissue) from a subject who does not have cholestasis, hyperbilirubinemia, or one or more symptoms thereof; a sample from a subject diagnosed with cholestasis, hyperbilirubinemia, or one or more symptoms thereof; a sample from a subject who has been treated for cholestasis, hyperbilirubinemia, or one or more symptoms thereof; or a sample of a purified protein with a known normal concentration (e.g., any of those described herein). "Reference standard or reference level" refers to a value or number obtained from a reference sample. A "normal control value" is a predetermined value indicative of a non-disease state, e.g., a value expected in a healthy control subject. Typically, a normal control value is expressed as a range ("X to Y"), a high threshold ("below X"), or a low threshold ("above X"). A subject whose measured value for a particular biomarker falls within the normal control value is typically referred to as "within the normal range" for that biomarker. A normal reference standard or reference level can be a value or number derived from a normal subject who does not have cholestasis, hyperbilirubinemia, or one or more symptoms thereof. In a preferred embodiment, the reference sample, reference standard, or reference level is matched to the subject sample for at least one of the following criteria: age, weight, sex, disease stage, and general health. A standard curve of purified proteins within the normal reference range, e.g., any of those described herein, can also be used as a reference.

[0120] As used herein, the term "term" refers to the age of a patient (e.g., a newborn) born between 37 and 42 weeks of gestation. For example, if a patient is born at 35 weeks of gestation, the patient will be full term on day 14 after birth.

[0121] As used herein, the term "transgene" refers to a recombinant nucleic acid (e.g., DNA or cDNA) that encodes a gene product (e.g., a gene product described herein). The gene product can be RNA, a peptide, or a protein. In addition to the coding region for the gene product, a transgene can include or be operably linked to one or more elements to promote or enhance expression, such as a promoter, enhancer(s), destabilization domain(s), response element(s), reporter element(s), insulator element(s), polyadenylation signal(s), and / or other functional elements. Embodiments of the present disclosure can utilize any known suitable promoter(s), enhancer(s), destabilization domain(s), response element(s), reporter element(s), insulator element(s), polyadenylation signal(s), and / or other functional elements.

[0122] As used herein, the terms "treat" and "treatment" refer to therapeutic procedures aimed at preventing or slowing (alleviating) undesirable physiological changes or disorders, such as the progression of neuromuscular disorders, particularly XLMTM. Beneficial or desired clinical results include, but are not limited to, alleviation of symptoms (e.g., stiffness and / or joint contracture), reduction in the extent of disease, a stable (i.e., not worsening) disease state, delay or slowing of disease progression, improvement or palliation of the disease state, and remission (whether partial or complete), whether detectable or undetectable. In the context of a neuromuscular disorder such as MTM1, treatment of a patient may result in one or more detectable changes, e.g., an increase in the concentration of MTM1 protein or nucleic acid (e.g., DNA or RNA such as mRNA) encoding MTM1, or an increase in MTM1 activity (e.g., 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 105%, 110%, 115%, 120%, 125%, 130%, 135%, 140%, 145%, 150%, 155%, 160%, 165%, 170%, 175%, 180%, 185%, 190%, 205%, 210%, 215%, 220%, 225%, 230%, 235%, 240%, 245%, 250%, 250%, 260%, 265%, 270%, 275%, 280%, 285%, 290%, 305%, 310%, 315%, 320%, 325%, 330%, 335%, 340%, 345%, 350%, 355%, 360%, 365%, 370%, 375%, 380%, 385%, 390%, 405%, 410%, 410%, 420%, 425%, 430%, 430%, 440%, 445%, 450%, 450%, 46 %, 80%, 85%, 90%, 95%, 100%, 200%, 300%, 400%, 500%, 600%, 700%, 800%, 900% or more may be demonstrated. The concentration of MTM1 protein can be determined using protein detection assays known in the art, including the ELISA assays described herein. The concentration of nucleic acids encoding MTM1 can be determined using nucleic acid detection assays described herein (e.g., RNA Seq assays). Furthermore, treatment of patients suffering from neuromuscular disorders such as XLMTM may demonstrate improvement in the patient's muscle function (e.g., skeletal muscle function) and muscle coordination. For example, manifestations of improvement may include increased development of the diaphragm and / or respiratory muscles.

[0123] As used herein, the terms "X-linked myotubular myopathy" and "XLMTM" refer to a genetically inherited neuromuscular disorder caused by mutations in the MTM1 gene and characterized by symptoms including mild to severe muscle weakness, hypotonia (reduced muscle tone), feeding difficulties, and / or severe respiratory complications. Human MTM1 has NCBI Gene ID NO 4534. An exemplary wild-type human MTM1 nucleic acid sequence is provided in NCBI RefSeq Acc. No. NM_000252.3 (SEQ ID NO: 1), and an exemplary wild-type myotubularin 1 amino acid sequence is provided in NCBI RefSeq Acc. No. NP_000243.1 (SEQ ID NO: 2).

[0124] As used herein, the term "vector" refers to a nucleic acid, e.g., DNA or RNA, that can function as a vehicle to deliver a gene of interest to a cell (e.g., a mammalian cell, such as a human cell), for purposes such as replication and / or expression. Exemplary vectors useful in connection with the compositions and methods described herein are plasmids, DNA vectors, RNA vectors, virions, or other suitable replicons (e.g., viral vectors). Various vectors have been developed for delivering polynucleotides encoding exogenous proteins to prokaryotic or eukaryotic cells. Examples of such expression vectors are disclosed, for example, in WO 1994 / 11026, the disclosure of which is incorporated herein by reference. The expression vectors described herein contain not only polynucleotide sequences but also additional sequence elements used, for example, for protein expression and / or integration of these polynucleotide sequences into the genome of a mammalian cell. Particular vectors that can be used to express the transgenes described herein include plasmids containing regulatory sequences, such as promoter and enhancer regions, that drive gene transcription. Other vectors useful for expressing transgenes contain polynucleotide sequences that increase the translation rate of these genes or improve the stability or nuclear export of mRNA resulting from gene transcription. These sequence elements include, for example, 5' and 3' untranslated regions, internal ribosome entry sites (IRES), and polyadenylation signal sites to direct efficient transcription of genes carried on the expression vector. The expression vectors described herein may also contain polynucleotides encoding markers for selecting cells containing such vectors. Examples of suitable markers include genes encoding resistance to antibiotics such as ampicillin, chloramphenicol, kanamycin, or nourseothricin.

[0125] chemical terms The scientific terminology used herein is for the purpose of describing various aspects and embodiments of the disclosure and is not intended to be limiting.

[0126] In the following chemical definitions, an atomic symbol followed immediately by an integer indicates the atomic weight of that element present in a particular chemical moiety. As understood, other atoms, such as hydrogen atoms or the substituents described herein, may be present, as necessary, to satisfy the valence of a particular atom. For example, an unsubstituted "C2 alkyl group" has the formula -CH2CH3. When used with groups defined herein, references to the number of carbon atoms include divalent carbons in acetal and ketal groups, but do not include the carbonyl carbon in acyl, ester, carbonate, amide, or carbamate groups. References to the number of oxygen, nitrogen, or sulfur atoms in heteroaryl groups include only those atoms that form part of the heterocyclic ring.

[0127] As used herein, phrases of the form "optionally substituted X" (e.g., optionally substituted alkyl) are intended to be equivalent to "X, where X is optionally substituted" (e.g., "alkyl, where alkyl is optionally substituted"). The "X" (e.g., alkyl) feature itself does not imply optionality. As described herein, certain compounds may contain one or more "optionally substituted" moieties. In general, the term "substituted," whether preceded by the term "optionally," means that one or more hydrogens of the specified moiety have been replaced with a suitable substituent, such as any of the substituents or groups described herein. Unless otherwise specified, an "optionally substituted" group may have a suitable substituent at each substitutable position of the group, and more than one position of any given structure may be substituted with more than one substituent selected from a specified group, which may be the same or different at each position. Combinations of substituents that may be used with the compounds of the present disclosure are preferably those that result in the formation of stable or chemically feasible compounds. The term "stable," as used herein, refers to a compound that is substantially unchanged when subjected to conditions that allow for the production, detection, and, in certain embodiments, recovery, purification, and use of the compound for one or more of the purposes disclosed herein.

[0128] As used herein, the term "aliphatic" refers to a saturated or unsaturated straight-chain, branched, or cyclic hydrocarbon. The term "aliphatic" includes, but is not limited to, alkyl, alkenyl, alkynyl, cycloalkyl, cycloalkenyl, and cycloalkynyl moieties, and thus encompasses each of these definitions. In some embodiments, "aliphatic" is used to refer to an aliphatic group having 1 to 20 carbon atoms. The aliphatic chain can be, for example, monounsaturated, diunsaturated, triunsaturated, or polyunsaturated, or alkynyl. Unsaturated aliphatic groups can be in a cis or trans configuration. In some embodiments, the aliphatic group contains 1 to about 12 carbon atoms, e.g., 1 to about 6 carbon atoms or 1 to about 4 carbon atoms. In some embodiments, the aliphatic group contains 1 to about 8 carbon atoms. In some embodiments, the aliphatic group is C1-C2, C1-C3, C1-C4, C1-C5, or C1-C6. As used herein, a specific range refers to an aliphatic group with each element of the range described as a separate species. For example, the term "C1-C6 aliphatic" as used herein is intended to refer to a linear or branched alkyl, alkenyl, or alkynyl group having 1, 2, 3, 4, 5, or 6 carbon atoms, each of which is described as a separate species. For example, the term "C1-C4 aliphatic" as used herein is intended to refer to a linear or branched alkyl, alkenyl, or alkynyl group having 1, 2, 3, or 4 carbon atoms, each of which is described as a separate species. In some embodiments, the aliphatic group is substituted with one or more functional groups that result in the formation of a stable moiety.

[0129] As used herein, the term "heteroaliphatic" refers to an aliphatic moiety that contains at least one heteroatom in its chain, such as an amine, carbonyl, carboxy, oxo, thio, phosphate, phosphonate, nitrogen, phosphorus, silicon, or boron atom, instead of a carbon atom. In some embodiments, the heteroatom present is nitrogen. In some embodiments, the heteroatom present is oxygen. In some embodiments, the heteroatom present is sulfur. The term "heteroaliphatic" includes, but is not limited to, heteroalkyl, heteroalkenyl, heteroalkynyl, heterocycloalkyl, heterocycloalkenyl, and heterocycloalkynyl moieties. In some embodiments, "heteroaliphatic" is used to refer to heteroaliphatic groups (cyclic, acyclic, substituted, unsubstituted, branched, or unbranched) having 1 to 20 carbon atoms. In some embodiments, heteroaliphatic groups are optionally substituted to result in the formation of a stable moiety. Non-limiting examples of heteroaliphatic moieties are polyethylene glycol, polyalkylene glycol, amide, polyamide, glycolide, polylactide, polyglycolide, thioether, ether, alkyl-heterocycle-alkyl, -O-alkyl-O-alkyl, and alkyl-O-haloalkyl.

[0130] As used herein, the term "acyl" refers to a carbonyl substituent, e.g., a carbonyl substituent in which the carbonyl carbon is bound to an alkyl group, an alkenyl group, an alkynyl group, an optionally substituted oxygen moiety, an optionally substituted nitrogen moiety, or the like. Exemplary acyl groups include, but are not limited to, formyl (i.e., a carboxaldehyde group), acetyl, trifluoroacetyl, propionyl, and butanoyl. Exemplary unsubstituted acyl groups contain 1 to 6, 1 to 11, or 1 to 21 carbons.

[0131] As used herein, the term "acyloxy" refers to the chemical moiety -OC(O)R, where R is C1-C6 alkyl, aryl, heteroaryl, C1-C6 alkylaryl, or C1-C6 alkylheteroaryl.

[0132] As used herein, the term "alkyl" refers to a branched or straight-chain monovalent saturated aliphatic hydrocarbon radical of 1 to 20 carbon atoms (e.g., 1 to 16 carbon atoms, 1 to 10 carbon atoms, 1 to 6 carbon atoms, or 1 to 3 carbon atoms). As used herein, the term "alkylene" refers to a divalent alkyl group.

[0133] As used herein, the term "alkenyl," whether recited alone or in combination with other groups, refers to a straight- or branched-chain hydrocarbon residue having a carbon-carbon double bond and having 2 to 20 carbon atoms (e.g., 2 to 16 carbon atoms, 2 to 10 carbon atoms, 2 to 6, or 2 carbon atoms). As used herein, the term "alkenylene" refers to a divalent alkenyl group.

[0134] As used herein, the term "alkynyl," whether recited alone or in combination with other groups, refers to a straight- or branched-chain hydrocarbon residue having a carbon-carbon triple bond and having 2 to 20 carbon atoms (e.g., 2 to 16 carbon atoms, 2 to 10 carbon atoms, 2 to 6, or 2 carbon atoms). As used herein, the term "alkynylene" refers to a divalent alkynyl group.

[0135] As used herein, the term “amino” refers to —N(R N1 )2, wherein each R N1 are independently H, OH, NO2, N(R N2 )2, SO2OR N2 , SO2R N2 , SOR N2, an N-protecting group, alkyl, alkoxy, aryl, arylalkyl, cycloalkyl, acyl (e.g., acetyl, trifluoroacetyl, and others described herein), and these R N1 Each of the groups may be optionally substituted, or two R N1 are bonded to form an alkylene or heteroalkylene, and each R N2 are independently H, alkyl, or aryl. The amino group of the compounds described herein may be unsubstituted amino (i.e., —NH) or substituted amino (i.e., —N(R N1 )2).

[0136] As used herein, the term "aryl" refers to a carbocyclic monocyclic or polycyclic aromatic radical having at least one aromatic ring, e.g., 6 to 12 carbon atoms. Examples of such groups include, but are not limited to, phenyl, naphthyl, 1,2,3,4-tetrahydronaphthyl, 1,2-dihydronaphthyl, indanyl, and 1H-indenyl.

[0137] As used herein, the term "arylalkyl" refers to an alkyl group substituted with an aryl group. Exemplary unsubstituted arylalkyl groups include those having 7 to 30 carbons (e.g., 7 to 16 or 7 to 20 carbons, e.g., C-C alkyl, C-C 10 Aryl, C1-C 10 Alkyl C6-C 10 Aryl, or C1-C 20 Alkyl C6-C 10 aryl), for example, benzyl and phenethyl. In some embodiments, alkyl and aryl can each be further substituted with 1, 2, 3, or 4 substituents, as defined herein for each group.

[0138] As used herein, the term "bridged cyclyl" refers to a bridged polycyclic group of 5 to 20 atoms containing 1 to 3 bridges. Bridged cyclyls include bridged carbocyclyls (e.g., norbornyl) and bridged heterocyclyls (e.g., 1,4-diazabicyclo[2.2.2]octane).

[0139] As used herein, the term "carbocyclyl" refers to a non-aromatic C-C ring in which the ring is formed by carbon atoms. 12 " refers to a monocyclic or polycyclic (e.g., bicyclic or tricyclic) structure. Carbocyclyl structures include cycloalkyl groups (e.g., cyclohexyl) and unsaturated carbocyclyl radicals (e.g., cyclohexenyl). Polycyclic carbocyclyls include spirocyclic carbocyclyls, bridged carbocyclyls, and fused carbocyclyls. As used herein, the term "carbocyclylene" refers to a divalent carbocyclyl group.

[0140] As used herein, the term "cycloalkyl" refers to a saturated non-aromatic monovalent carbocyclic monocyclic or polycyclic radical of 3 to 10, preferably 3 to 6, carbon atoms. This term is further exemplified by radicals such as cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, norbornyl, and adamantyl.

[0141] As used herein, the terms "halo" and "halogen" refer to a radical of fluorine (fluoro), chlorine (chloro), bromine (bromo), or iodine (iodo).

[0142] As used herein, the term "heteroalkyl" refers to an alkyl group, as defined herein, in which one or more of the constituent carbon atoms has been replaced by nitrogen, oxygen, or sulfur. In some embodiments, a heteroalkyl group can be further substituted with 1, 2, 3, or 4 substituents, as described herein for alkyl groups. Examples of heteroalkyl groups include "alkoxy" (as used herein, refers to alkyl-O- (e.g., methoxy and ethoxy)), and "alkylamino" (as used herein, refers to -N(alkyl)R Na In the formula, R Na is H or alkyl (e.g., methylamino). As used herein, the term "heteroalkylene" refers to a divalent heteroalkyl group.

[0143] As used herein, the term "heteroalkenyl" refers to an alkenyl group, as defined herein, in which one or more of the constituent carbon atoms is replaced by nitrogen, oxygen, or sulfur. In some embodiments, heteroalkenyl groups can be further substituted with 1, 2, 3, or 4 substituents, as described herein for alkenyl groups. An example of a heteroalkenyl group is "alkenoxy," which, as used herein, refers to alkenyl-O-. As used herein, the term "heteroalkenylene" refers to a divalent heteroalkenyl group.

[0144] As used herein, the term "heteroalkynyl" refers to an alkynyl group, as defined herein, in which one or more of the constituent carbon atoms has been replaced by nitrogen, oxygen, or sulfur. In some embodiments, a heteroalkynyl group can be further substituted with 1, 2, 3, or 4 substituents, as described herein for an alkynyl group. An example of a heteroalkynyl group is "alkynoxy," as used herein, alkynyl-O-. As used herein, the term "heteroalkynylene" refers to a divalent heteroalkynyl group.

[0145] As used herein, the term "heteroaryl" refers to a monocyclic or polycyclic aromatic structure of 5 to 12 atoms having at least one aromatic ring containing 1, 2, or 3 ring atoms selected from nitrogen, oxygen, and sulfur, with the remaining ring atoms being carbon. In some embodiments, one or two ring carbon atoms of the heteroaryl group are replaced with a carbonyl group. Examples of heteroaryl groups are pyridyl, pyrazolyl, benzoxazolyl, benzimidazolyl, benzothiazolyl, imidazolyl, oxaxolyl, and thiazolyl. As used herein, the term "heteroarylene" refers to a divalent heteroaryl group.

[0146] As used herein, the term "heteroarylalkyl" refers to an alkyl group substituted with a heteroaryl group. Exemplary unsubstituted heteroarylalkyl groups include those having 7 to 30 carbons (e.g., 7 to 16 or 7 to 20 carbons, e.g., C1-C6 alkyl, C2-C9 heteroaryl, C1-C 10 alkyl C2-C9 heteroaryl, or C1-C 20 In some embodiments, alkyl and heteroaryl can each be further substituted with 1, 2, 3, or 4 substituents, as defined herein for each group.

[0147] As used herein, the term "heterocyclyl" refers to a monocyclic or polycyclic radical (e.g., bicyclic or tricyclic) having 3 to 12 atoms, having at least one non-aromatic ring containing 1, 2, 3, or 4 ring atoms selected from N, O, or S, and not having any aromatic rings containing N, O, or S atoms. Polycyclic heterocyclyls include spirocyclic heterocyclyls, bridged heterocyclyls, and fused heterocyclyls. Examples of heterocyclyls include, but are not limited to, morpholinyl, thiomorpholinyl, furyl, piperazinyl, piperidinyl, pyranyl, pyrrolidinyl, tetrahydropyranyl, tetrahydrofuranyl, and 1,3-dioxanyl. As used herein, the term "heterocyclylene" refers to a divalent heterocyclyl group.

[0148] As used herein, the term "heterocyclylalkyl" refers to an alkyl group substituted with a heterocyclyl group. Exemplary unsubstituted heterocyclylalkyl groups include those having 7 to 30 carbons (e.g., 7 to 16 or 7 to 20 carbons, e.g., C1-C6 alkyl, C2-C9 heterocyclyl, C1-C 10 alkyl C2-C9 heterocyclyl, or C1-C 20 alkylC2-C9 heterocyclyl). In some embodiments, the alkyl and heterocyclyl can each be further substituted with 1, 2, 3, or 4 substituents, as defined herein for each group.

[0149] As used herein, the term "hydroxyalkyl" refers to an alkyl group substituted with an --OH group.

[0150] As used herein, the term "hydroxyl" refers to an --OH group.

[0151] As used herein, the term "imine" refers to a group having a structure of ═NR N refers to a group, wherein R N is, for example, H or alkyl.

[0152] As used herein, the term "N-protecting group" refers to a group intended to protect an amino group against undesired reactions during synthetic procedures. Commonly used N-protecting groups are disclosed in Greene, "Protective Groups in Organic Synthesis," 3rd Edition (John Wiley & Sons, New York, 1999).N-protecting groups include acyl, aryloyl, or carbamyl groups, such as formyl, acetyl, propionyl, pivaloyl, t-butylacetyl, 2-chloroacetyl, 2-bromoacetyl, trifluoroacetyl, trichloroacetyl, phthalyl, o-nitrophenoxyacetyl, α-chlorobutyryl, benzoyl, 4-chlorobenzoyl, 4-bromobenzoyl, 4-nitrobenzoyl, as well as chiral auxiliaries, such as protected or unprotected D, L, or D,L-amino acids, such as arabinanyl. amine, leucine, and phenylalanine; sulfonyl-containing groups, such as benzenesulfonyl and p-toluenesulfonyl; carbamate-forming groups, such as benzyloxycarbonyl, p-chlorobenzyloxycarbonyl, p-methoxybenzyloxycarbonyl, p-nitrobenzyloxycarbonyl, 2-nitrobenzyloxycarbonyl, p-bromobenzyloxycarbonyl, 3,4-dimethoxybenzyloxycarbonyl, 3,5-dimethoxybenzyloxycarbonyl, 2,4-20-dimethylbenzyloxycarbonyl, ethoxybenzyloxycarbonyl, 4-methoxybenzyloxycarbonyl, 2-nitro-4,5-dimethoxybenzyloxycarbonyl, 3,4,5-trimethoxybenzyloxycarbonyl, 1-(p-biphenylyl)-1-methylethoxycarbonyl, α,α-dimethyl-3,5-dimethoxybenzyloxycarbonyl, benzhydryloxycarbonyl, t-butyloxycarbonyl, diisopropylmethoxycarbonyl, isopropyloxycarbonyl, ethoxycarbonyl, methoxycarbonyl Examples of aryl groups include, but are not limited to, aryl, allyloxycarbonyl, 2,2,2-trichloroethoxycarbonyl, phenoxycarbonyl, 4-nitrophenoxycarbonyl, fluorenyl-9-methoxycarbonyl, cyclopentyloxycarbonyl, adamantyloxycarbonyl, cyclohexyloxycarbonyl, and phenylthiocarbonyl, arylalkyl groups such as benzyl, triphenylmethyl, and benzyloxymethyl, and silyl groups such as trimethylsilyl.Preferred N-protecting groups are alloc, formyl, acetyl, benzoyl, pivaloyl, t-butylacetyl, alanyl, phenylsulfonyl, benzyl, t-butyloxycarbonyl (Boc), and benzyloxycarbonyl (Cbz).

[0153] As used herein, the term "nitro" refers to the group --NO.sub.2.

[0154] As used herein, the term "oxo" refers to the group ═O.

[0155] As used herein, the term "sulfonyl" refers to the chemical moiety -SO2-R, where R is hydrogen, aryl, heteroaryl, C1-C6 alkyl, C1-C6 alkyl substituted with one or more halogens, e.g., a -SO2-CF3 substituent, C1-C6 alkylaryl, or C1-C6 alkylheteroaryl.

[0156] As used herein, the term "sulfonylamino" refers to the chemical moiety -NRSO2-R', where each of R and R' is independently hydrogen, C1-C6 alkyl, aryl, heteroaryl, C1-C6 alkylaryl, or C1-C6 alkylheteroaryl.

[0157] As used herein, the term "sulfonyloxy" refers to the chemical moiety -OSO2-R, where R is hydrogen, C1-C6 alkyl, C1-C6 alkyl substituted with one or more halogens, e.g., -OSO2-CF3 substituents, aryl, heteroaryl, C1-C6 alkylaryl, or C1-C6 alkylheteroaryl.

[0158] As used herein, the term "thiol" refers to a -SH group.

[0159] Each of the alkyl, alkenyl, alkynyl, heteroalkyl, heteroalkenyl, heteroalkynyl, carbocyclyl (e.g., cycloalkyl), aryl, heteroaryl, and heterocyclyl groups described herein can be substituted or unsubstituted. If substituted, there can generally be 1 to 4 substituents, unless otherwise specified. Substituents include, for example, alkyl (e.g., unsubstituted and substituted; where substituents include any group described herein, e.g., aryl, halo, hydroxy), aryl (e.g., substituted and unsubstituted phenyl), carbocyclyl (e.g., substituted and unsubstituted cycloalkyl), halogen (e.g., fluoro), hydroxyl, heteroalkyl (e.g., substituted and unsubstituted methoxy, ethoxy, or thioalkoxy), heteroaryl, heterocyclyl, amino (e.g., NH or mono- or dialkylamino), azido, cyano, nitro, oxo, sulfonyl, or thiol. Aryl, carbocyclyl (eg, cycloalkyl), heteroaryl, and heterocyclyl groups may also be substituted with alkyl (unsubstituted and substituted, for example, arylalkyl (eg, substituted and unsubstituted benzyl)).

[0160] Chemical structure description The compounds of the present disclosure may have one or more asymmetric carbon atoms and may exist in the form of optically pure enantiomers, mixtures of enantiomers (e.g., racemates), optically pure diastereoisomers, mixtures of diastereoisomers, diastereoisomeric racemates, or mixtures of diastereoisomeric racemates.Optical active forms can be obtained, for example, by resolving racemates, by asymmetric synthesis, or asymmetric chromatography (chromatography using chiral adsorbents or eluents).Therefore, the compounds disclosed herein may exist in various stereoisomeric forms.

[0161] Stereoisomers are compounds that differ only in spatial arrangement. Enantiomers are a pair of stereoisomers whose mirror images are not superimposable, most commonly because they contain asymmetrically substituted carbon atoms that act as chiral centers. The term "enantiomer" refers to one of a pair of molecules that are mirror images of each other and are not superimposable. Diastereomers are stereoisomers that are not related to mirror images, most commonly because they contain two or more asymmetrically substituted carbon atoms, representing the arrangement of substituents around one or more chiral carbon atoms.

[0162] Enantiomers of a compound can be prepared, for example, by separating enantiomers from a racemate using one or more well-known techniques and methods, such as chiral chromatography and separation methods based thereon. The term "racemate" or "racemic mixture" refers to a compound containing two enantiomers; such mixtures do not exhibit optical activity, i.e., they do not rotate the plane of polarized light. The term "geometric isomer" refers to isomers that differ in the orientation of substituent atoms with respect to a carbon-carbon double bond, a cycloalkyl ring, or a bridged bicyclic ring system. Atoms (other than H) on either side of a carbon-carbon double bond can be in the E configuration (substituents are on opposite sides of the carbon-carbon double bond) or the Z configuration (substituents are facing the same side of the carbon-carbon double bond). "R," "S," "S*," "R*," "E," "Z," "cis," and "trans" refer to configurations relative to the core molecule.

[0163] When the stereochemistry of a compound disclosed herein is named or depicted by structure, the named or depicted stereoisomer is more than 50% enriched (e.g., at least 60%, 70%, 80%, 90%, 99%, or 99.9% by weight) relative to other stereoisomers. For example, when a single enantiomer is named or depicted by structure, the depicted or named enantiomer is more than 50% optically pure (e.g., at least 60%, 70%, 80%, 90%, 99%, or 99.9% by weight). Similarly, when a single diastereomer is named or depicted by structure, the depicted or named diastereomer is more than 50% pure (e.g., at least 60%, 70%, 80%, 90%, 99%, or 99.9% by weight) by weight. Percent optical purity is the ratio of the weights of the enantiomers or the weight of the enantiomer plus the weight of its optical isomer. Diastereomeric purity by weight is the ratio of the weight of one diastereomer or the weight of all diastereomers.

[0164] Furthermore, when the stereochemistry of a compound disclosed herein is named or depicted by structure, the named or depicted stereoisomer is enriched relative to the other stereoisomers by more than 50% (e.g., at least 60%, 70%, 80%, 90%, 99%, or 99.9% mole fraction). For example, when a single enantiomer is named or depicted by structure, the depicted or named enantiomer is enriched relative to the other enantiomers by more than 50% (e.g., at least 60%, 70%, 80%, 90%, 99%, or 99.9% mole fraction). When a single diastereomer is named or depicted by structure, the depicted or named diastereomer is more than 50% more abundant (e.g., at least 60%, 70%, 80%, 90%, 99%, or 99.9% more abundant) by mole fraction relative to the other diastereomer(s) of the depicted compound. For enantiomeric compounds, percent purity by mole fraction is calculated as the ratio of the molar amount of the desired enantiomer to the sum of the molar amounts of (i) the desired enantiomer and (ii) the optical isomer. Similarly, for diastereomeric compounds, percent purity by mole fraction is calculated as the ratio of the molar amount of the desired diastereomer to the sum of the molar amounts of all diastereomers present for the depicted compound.

[0165] Where a disclosed compound is named or depicted by structure without indicating stereochemistry, and the compound has at least one chiral center, the name or structure shall be understood to encompass any enantiomer of the compound free of the corresponding optical isomer, a racemic mixture of the compound, or a mixture in which one enantiomer is enriched over its corresponding optical isomer.

[0166] When a disclosed compound is named or depicted by structure without indicating stereochemistry and has two or more chiral centers, the name or structure is to be understood to encompass diastereomers free of other diastereomers, some diastereomers free of other diastereomeric pairs, mixtures of diastereomers, mixtures of diastereomeric pairs, mixtures of diastereomers enriched in one diastereomer over the other(s), or mixtures of diastereomers enriched in one or more diastereomers over the other(s). The present disclosure encompasses all of these forms.

[0167] polymorphic compound As will be appreciated by those skilled in the art, many chemical entities can exist in a variety of different solid forms, such as, for example, amorphous or crystalline forms (e.g., polymorphs, hydrates, solvates). In some embodiments, the compounds of the present disclosure may be utilized in any such form, including any solid form. In some embodiments, the compounds described or illustrated herein may be provided or utilized in the form of a hydrate or solvate.

[0168] [Detailed Description of the Invention] The present disclosure provides compositions and methods that can be used to treat neuromuscular disorders, particularly X-linked myotubular myopathy (XLMTM). According to the compositions and methods described herein, a patient (e.g., a human patient) with XLMTM can be administered a viral vector, such as an adeno-associated viral (AAV) vector, containing a transgene encoding myotubularin 1 (MTM1). The AAV vector can be a pseudotyped AAV vector, such as an AAV vector containing AAV2 inverted terminal repeats packaged within an AAV8-derived capsid protein (AAV2 / 8). In some embodiments, the transgene is operably linked to a transcriptional regulatory element, such as a promoter, that drives gene expression in muscle cells. An exemplary promoter that can be used with the compositions and methods of the present disclosure is the desmin promoter. In some embodiments, the AAV2 / 8 viral vector containing a transgene encoding MTM1 is resamirigene bilparvovec.

[0169] The present disclosure is based, at least in part, on the discovery of therapeutic and prophylactic treatment methods that address important medical needs associated with existing gene therapy approaches involving the delivery of MTM1 in patients in need thereof (e.g., XLMTM patients). The present disclosure is also based, in part, on the discovery that existing gene therapy approaches involving the delivery of MTM1 in patients in need thereof (e.g., XLMTM patients) carry risks, including cholestatic syndromes, such as cholestasis, hyperbilirubinemia, or one or more symptoms thereof. More specifically, the present invention relates to the discovery of methods for the prophylactic treatment of cholestatic syndromes associated with existing gene therapy approaches involving the delivery of MTM1 in patients in need thereof (e.g., patients with XLMTM), including the administration of a viral vector containing a transgene encoding MTM1 (e.g., resamirigene bilparvovec) and an anti-cholestatic agent (e.g., bile acids, farnesoid X receptor (FXR) ligands, fibroblast growth factor 19 (FGF-19) mimetics, Takeda G-protein receptor 5 (TGR5) agonists, peroxisome proliferator-activated receptor (PPAR) agonists, PPAR-alpha agonists, PPAR-delta agonists, dual PPAR-alpha and PPAR-delta agonists, luminal sodium-dependent bile acid transporter (ASBT) inhibitors, immunomodulatory agents, antifibrotic therapies, and nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitors). In some embodiments, the anti-cholestatic agent is a bile acid, hi some embodiments, the bile acid is ursodeoxycholic acid (e.g., ursodiol).

[0170] In some embodiments, the present disclosure describes a method for treating or preventing cholestasis or hyperbilirubinemia in a human patient having XLMTM and having been administered a viral vector containing a therapeutically effective amount of a transgene encoding MTM1, the method comprising administering an anti-cholestasis agent to the patient.

[0171] In some embodiments, the present disclosure describes a method of treating XLMTM in a human patient in need thereof who has previously received an anti-cholestasis agent, comprising administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1.

[0172] In some embodiments, the present disclosure describes a method of reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM, comprising administering to the patient a viral vector comprising a transgene encoding MTM1 and an anti-cholestatic agent.

[0173] In some embodiments, the present disclosure describes a method of increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM, comprising administering to the patient a viral vector containing a transgene encoding MTM1 and an anti-cholestatic agent.

[0174] In some embodiments, the present disclosure describes a method for reducing stiffness and / or joint contracture in a human patient diagnosed with XLMTM and who has previously received an anti-cholestatic agent, comprising administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1.

[0175] In some embodiments, the present disclosure provides a method for increasing diaphragm and / or respiratory muscle development in a human patient diagnosed with XLMTM and who has previously received an anti-cholestatic agent, the method comprising administering to the patient a viral vector comprising a therapeutically effective amount of a transgene encoding MTM1.

[0176] The following sections provide a description of therapeutic agents and parameters for assessing cholestasis, hyperbilirubinemia, or one or more symptoms thereof, which require administration of an anti-cholestatic agent as described herein. The following sections also describe various transduction agents that may be used with the compositions and methods of the present disclosure.

[0177] Treatment method In some embodiments, the patient is a newborn (e.g., 0-4 months old), an infant (e.g., 0-5 months old), a toddler (e.g., 6-12 months old), a child aged 1-3 years, or a child aged 3-5 years at the time of administration of the viral vector.

[0178] In some embodiments, the patient is a newborn (e.g., 0 to 4 months old) at the time of administration of the viral vector. For example, in some embodiments, the patient is a newborn about 0 to about 4 months old (e.g., 0 to about 4 months old, 1 to about 4 months old, 2 to about 4 months old, or 3 to about 4 months old). In some embodiments, the patient is 0 months old. In some embodiments, the patient is 1 month old. In some embodiments, the patient is 2 months old. In some embodiments, the patient is 3 months old. In some embodiments, the patient is 4 months old.

[0179] In some embodiments, the patient is a neonate (e.g., less than about 4 months old) at the time of administration of the viral vector. For example, in some embodiments, the patient is a neonate less than about 4 months old. In some embodiments, the patient is less than about 4 months old. In some embodiments, the patient is less than about 3 months old. In some embodiments, the patient is less than about 2 months old. In some embodiments, the patient is less than about 1 month old.

[0180] In some embodiments, the patient is an infant (e.g., 0 to 5 months old) at the time of administration of the viral vector. For example, in some embodiments, the patient is an infant about 0 to about 5 months old (e.g., 0 to about 5 months old, 1 to about 5 months old, 2 to about 5 months old, 3 to about 5 months old, or 4 to about 5 months old). In some embodiments, the patient is 0 months old. In some embodiments, the patient is 1 month old. In some embodiments, the patient is 2 months old. In some embodiments, the patient is 3 months old. In some embodiments, the patient is 4 months old. In some embodiments, the patient is 3 months old. In some embodiments, the patient is 5 months old.

[0181] In some embodiments, the patient is an infant (e.g., less than about 5 months old) at the time of administration of the viral vector. For example, in some embodiments, the patient is an infant less than about 5 months old. In some embodiments, the patient is less than about 5 months old. In some embodiments, the patient is less than about 4 months old. In some embodiments, the patient is less than about 3 months old. In some embodiments, the patient is less than about 2 months old. In some embodiments, the patient is less than about 1 month old.

[0182] In some embodiments, the patient is an infant (e.g., 6 to 12 months of age) at the time of administration of the viral vector. For example, in some embodiments, the patient is an infant about 6 to about 12 months of age (e.g., 6 to about 12 months of age, 7 to about 12 months of age, 8 to about 12 months of age, 9 to about 12 months of age, 10 to about 12 months of age, or 11 to about 12 months of age). In some embodiments, the patient is 6 months of age. In some embodiments, the patient is 7 months of age. In some embodiments, the patient is 8 months of age. In some embodiments, the patient is 9 months of age. In some embodiments, the patient is 10 months of age. In some embodiments, the patient is 11 months of age. In some embodiments, the patient is 12 months of age.

[0183] In some embodiments, the patient is an infant (e.g., less than about 12 months of age) at the time of administration of the viral vector. For example, in some embodiments, the patient is an infant less than about 12 months of age. In some embodiments, the patient is less than about 12 months of age. In some embodiments, the patient is less than about 11 months of age. In some embodiments, the patient is less than about 10 months of age. In some embodiments, the patient is less than about 9 months of age. In some embodiments, the patient is less than about 8 months of age. In some embodiments, the patient is less than about 7 months of age. In some embodiments, the patient is less than about 6 months of age. In some embodiments, the patient is less than about 5 months of age. In some embodiments, the patient is less than about 4 months of age. In some embodiments, the patient is less than about 3 months of age. In some embodiments, the patient is less than about 2 months of age. In some embodiments, the patient is less than about 1 month of age.

[0184] In some embodiments, the patient is a child between 1 and 3 years of age at the time of administration of the viral vector. For example, in some embodiments, the patient is a child between about 1 year of age and about 3 years of age (e.g., 1 year of age to about 3 years of age or 2 years of age to about 3 years of age). In some embodiments, the patient is 1 year old. In some embodiments, the patient is 2 years old. In some embodiments, the patient is 3 years old.

[0185] In some embodiments, the patient is a child (e.g., under about 3 years of age) at the time of administration of the viral vector. For example, in some embodiments, the patient is a child under about 3 years of age. In some embodiments, the patient is under about 3 years of age. In some embodiments, the patient is under about 2 years of age. In some embodiments, the patient is under about 1 year of age. In some embodiments, the patient is under about 12 months of age. In some embodiments, the patient is under about 11 months of age. In some embodiments, the patient is under about 10 months of age. In some embodiments, the patient is under about 9 months of age. In some embodiments, the patient is under about 8 months of age. In some embodiments, the patient is under about 7 months of age. In some embodiments, the patient is under about 6 months of age. In some embodiments, the patient is under about 5 months of age. In some embodiments, the patient is under about 4 months of age. In some embodiments, the patient is under about 3 months of age. In some embodiments, the patient is under about 2 months of age. In some embodiments, the patient is under about 1 month of age.

[0186] In some embodiments, the patient is a child between 3 and 5 years of age at the time of administration of the viral vector. For example, in some embodiments, the patient is a child between about 3 and about 5 years of age (e.g., between 3 and about 5 years of age or between 4 and about 5 years of age). In some embodiments, the patient is 3 years of age. In some embodiments, the patient is 4 years of age. In some embodiments, the patient is 5 years of age.

[0187] In some embodiments, the patient is a child (e.g., under about 5 years of age) at the time of administration of the viral vector. For example, in some embodiments, the patient is a child under about 5 years of age. In some embodiments, the patient is under about 5 years of age. In some embodiments, the patient is under about 4 years of age. In some embodiments, the patient is under about 3 years of age. In some embodiments, the patient is under about 2 years of age. In some embodiments, the patient is under about 1 year of age. In some embodiments, the patient is under about 12 months of age. In some embodiments, the patient is under about 11 months of age. In some embodiments, the patient is under about 10 months of age. In some embodiments, the patient is under about 9 months of age. In some embodiments, the patient is under about 8 months of age. In some embodiments, the patient is under about 7 months of age. In some embodiments, the patient is under about 6 months of age. In some embodiments, the patient is under about 5 months of age. In some embodiments, the patient is under about 4 months of age. In some embodiments, the patient is under about 3 months of age. In some embodiments, the patient is under about 2 months of age. In some embodiments, the patient is less than about 1 month old.

[0188] In some embodiments, the patient is about 1 month to about 5 years old (e.g., about 1 month to about 5 years old, about 2 months to about 5 years old, about 3 months to about 5 years old, about 4 months to about 5 years old, about 5 months to about 5 years old, about 6 months to about 5 years old, about 1 year to about 5 years old, about 2 years to about 5 years old, about 3 years to about 5 years old, or about 4 years to about 5 years old) at the time of administration of the viral vector.

[0189] In some embodiments, the patient is born at a gestational age of 35 weeks or greater (e.g., 35 weeks gestational age, 36 weeks gestational age, 37 weeks gestational age, 38 weeks gestational age, 39 weeks gestational age, 40 weeks gestational age, 41 weeks gestational age, and 42 weeks gestational age) and is adjusted for full term (e.g., 37 weeks gestational age or greater) to about 5 years of age at the time of administration of the viral vector. For example, if the patient is born at a gestational age of 35 weeks, the patient will be full term at 14 days after birth.

[0190] In some embodiments, the patient is born at a gestational age of 35 weeks and is between full-term and about 5 years old (e.g., 14 days to about 5 years old, 15 days to about 5 years old, 16 days to about 5 years old, 17 days to about 5 years old, 18 days to about 5 years old, 19 days to about 5 years old, 20 days to about 5 years old, 25 days to about 5 years old, 1 month to about 5 years old, 2 months to about 5 years old, 3 months to about 5 years old, 4 months to about 5 years old, 5 months to about 5 years old, 6 months to about 5 years old, 1 year to about 5 years old, 2 years to about 5 years old, 3 years to about 5 years old, and 4 years to about 5 years old) at the time of administration of the viral vector.

[0191] In some embodiments, the patient is born at a gestational age of 36 weeks and is between adjusted term and about 5 years of age (e.g., 7 days to about 5 years of age, 8 days to about 5 years of age, 9 days to about 5 years of age, 10 days to about 5 years of age, 11 days to about 5 years of age, 12 days to about 5 years of age, 13 days to about 5 years of age, 14 days to about 5 years of age, 15 days to about 5 years of age, 16 days to about 5 years of age, 1 day to about 5 years, 17 days to about 5 years, 18 days to about 5 years, 19 days to about 5 years, 20 days to about 5 years, 25 days to about 5 years, 1 month to about 5 years, 2 months to about 5 years, 3 months to about 5 years, 4 months to about 5 years, 5 months to about 5 years, 6 months to about 5 years, 1 year to about 5 years, 2 years to about 5 years, 3 years to about 5 years, and 4 years to about 5 years).

[0192] In some embodiments, the patient is born at a gestational age of 37 weeks and is between adjusted term and about 5 years of age (e.g., 1 day to about 5 years of age, 2 days to about 5 years of age, 3 days to about 5 years of age, 4 days to about 5 years of age, 5 days to about 5 years of age, 6 days to about 5 years of age, 7 days to about 5 years of age, 8 days to about 5 years of age, 9 days to about 5 years of age, 10 days to about 5 years of age, 11 days to about 5 years of age, 12 days to about 5 years of age, 13 days to about 5 years of age) at the time of administration of the viral vector. 5 years old, 14 days to about 5 years old, 15 days to about 5 years old, 16 days to about 5 years old, 17 days to about 5 years old, 18 days to about 5 years old, 19 days to about 5 years old, 20 days to about 5 years old, 25 days to about 5 years old, 1 month to about 5 years old, 2 months to about 5 years old, 3 months to about 5 years old, 4 months to about 5 years old, 5 months to about 5 years old, 6 months to about 5 years old, 1 year old to about 5 years old, 2 years old to about 5 years old, 3 years old to about 5 years old, and 4 years old to about 5 years old.

[0193] In some embodiments, the patient is male.

[0194] In some embodiments, the patient is a female.

[0195] X-linked myotubular myopathy XLMTM is a rare, life-threatening congenital myopathy caused by loss-of-function mutations in the MTM1 gene. In most patients, it is characterized by severe muscle weakness and hypotonia at birth, resulting in severe respiratory failure, inability to sit, stand, or walk, and early death.

[0196] The myopathy associated with XLMTM interferes with the development of motor skills such as sitting, standing, and walking. Affected infants may also have difficulty feeding due to muscle weakness. Individuals with this condition often lack the muscle strength to breathe on their own and require mechanical ventilation. Some affected individuals only require mechanical ventilation periodically, such as during sleep, while others require continuous mechanical ventilation. Patients with XLMTM may also have weakness of the muscles that control eye movement (ophthalmoplegia), weakness of other facial muscles, and absence of reflexes (areflexia).

[0197] In XLMTM, muscle weakness often interferes with normal bone development, resulting in weak bones, an abnormal curvature of the spine (scoliosis), and deformed hip and knee joints (contractures). Patients with XLMTM may also have a large head, an elongated face, and a high-arched mouth (palate). Patients may also have liver disease, recurrent ear and respiratory infections, or seizures.

[0198] Due to severe respiratory impairment, patients with XLMTM typically survive only into infancy, although some patients with this condition have survived into adulthood. The compositions and methods of the present disclosure provide an important medical benefit by restoring functional MTM1 expression, potentially extending the lifespan of such patients. Furthermore, the compositions and methods described herein can be used to improve a patient's quality of life after treatment (e.g., reducing stiffness and / or joint contractures or increasing diaphragm and / or respiratory muscle development), as the present disclosure provides a set of guidelines that can be used to determine a patient's eligibility to be weaned from mechanical ventilation.

[0199] Cholestasis and hyperbilirubinemia Cholestasis is any condition in which the flow of bile acids from the liver is slowed or blocked, and hyperbilirubinemia is a condition in which bilirubin accumulates in the blood while serum bile acids remain apparently normal. In contrast, cholestatic syndrome is characterized by marked bile acidemia, with normal to slightly elevated bilirubin levels.

[0200] In some embodiments, the patient is monitored for the development of cholestasis. In some embodiments, the patient is monitored for the development of hyperbilirubinemia. In some embodiments, the patient is monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof. In some embodiments, the patient is monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof by evaluating a parameter in a blood sample obtained from the patient, and a finding that the parameter is above a reference level identifies the patient as having cholestasis, hyperbilirubinemia, or one or more symptoms thereof.

[0201] In some embodiments, the patient is monitored for the development of hyperbilirubinemia, and if the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0202] In some embodiments, the patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and the patient is administered an anti-cholestasis agent.

[0203] In some embodiments, a patient is determined to exhibit cholestasis or one or more symptoms thereof if the patient exhibits one or more parameters (e.g., total bile acid levels, gamma-glutamyltransferase (GGT) levels, alkaline phosphatase (ASP) levels, aspartate aminotransferase (AST) levels, and / or alanine aminotransferase (ALT) levels) that are greater than or less than age-adjusted normal as measured by serum bile acid tests and / or blood tests (e.g., liver function tests (LFTs)).

[0204] In some embodiments, a patient is determined to exhibit hyperbilirubinemia or one or more symptoms thereof if the patient exhibits a bilirubin level greater than normal as measured by a blood test (e.g., a bilirubin test).

[0205] In some embodiments, the present disclosure provides a method of treating cholestasis in a human patient having XLMTM and who has previously received a viral vector (e.g., resamirigene bilparvovec) containing a transgene encoding MTM1, comprising administering an anti-cholestasis agent to the patient.

[0206] In some embodiments, the present disclosure provides a method for treating hyperbilirubinemia in a human patient who has XLMTM and who has previously received a viral vector (e.g., resamirigene bilparvovec) containing a transgene encoding MTM1, comprising administering an anti-cholestastic agent to the patient.

[0207] In some embodiments, the present disclosure provides a method for preventing cholestasis in a human patient having XLMTM and who has previously received a viral vector (e.g., resamirigene bilparvovec) containing a transgene encoding MTM1, the method comprising administering an anti-cholestasis agent to the patient.

[0208] In some embodiments, the present disclosure provides a method for preventing hyperbilirubinemia in a human patient who has XLMTM and who has previously received a viral vector (e.g., resamirigene bilparvovec) containing a transgene encoding MTM1, the method comprising administering an anti-cholestastic agent to the patient.

[0209] In some embodiments, the patient has no history of cholestasis or hyperbilirubinemia, hi some embodiments, the patient has no history of any underlying liver disease.

[0210] Vectors for delivering exogenous nucleic acids to target cells Viral vectors for nucleic acid delivery Viral genomes provide a rich source of vectors that can be used to efficiently deliver a gene of interest (e.g., a transgene encoding MTM1) into the genome of a target cell (e.g., a mammalian cell, such as a human cell). Viral genomes are particularly useful gene delivery vectors because the polynucleotides contained within their genomes are typically integrated into the genome of target cells by general transduction or specific transduction. These processes occur as part of the natural viral replication cycle and do not require additional proteins or reagents to induce gene integration. Examples of viral vectors include AAV, retroviruses, adenoviruses (e.g., Ad5, Ad26, Ad34, Ad35, and Ad48), parvoviruses (e.g., adeno-associated viruses), coronaviruses, negative-strand RNA viruses such as orthomyxoviruses (e.g., influenza viruses), rhabdoviruses (e.g., rabies virus and vesicular stomatitis virus), paramyxoviruses (e.g., measles and Sendai), positive-strand RNA viruses such as picornaviruses and alphaviruses, as well as double-stranded DNA viruses, including adenoviruses, herpesviruses (e.g., herpes simplex virus types 1 and 2, Epstein-Barr virus, cytomegalovirus), and poxviruses (e.g., vaccinia, modified vaccinia Ankara (MVA), fowlpox, and canarypox). Other viruses useful for delivering polynucleotides encoding the antibody light and heavy chains or antibody fragments of the invention include, for example, Norwalk virus, togavirus, flavivirus, reovirus, papovavirus, hepadnavirus, and hepatitis virus. Examples of retroviruses include avian leukosis-sarcoma mammalian types C, B, and D viruses, the HTLV-BLV complex, lentiviruses, and spumaviruses (Coffin, J.M., Retroviridae: The viruses and their replication, In Fundamental Virology, Third Edition, B.N. Fields, et al., Eds., Lippincott-Raven Publishers, Philadelphia, 1996).Other examples include murine leukemia viruses, murine sarcoma viruses, mouse mammary tumor viruses, bovine leukemia viruses, feline leukemia viruses, feline sarcoma viruses, avian leukemia viruses, human T-cell leukemia viruses, baboon endogenous viruses, gibbon leukemia viruses, Mason-Pfizer monkey viruses, simian immunodeficiency viruses, simian sarcoma viruses, Rous sarcoma viruses, and lentiviruses. Other examples of vectors are described, for example, in U.S. Patent No. 5,801,030, the disclosure of which is incorporated herein by reference with respect to viral vectors for use in gene therapy.

[0211] AAV vectors for nucleic acid delivery In some embodiments, the nucleic acids of the compositions and methods described herein are incorporated into recombinant AAV (rAAV) vectors and / or virions to facilitate their introduction into cells. rAAV vectors useful in the present invention are recombinant nucleic acid constructs containing (1) a transgene to be expressed (e.g., a polynucleotide encoding an MTM1 protein) and (2) viral nucleic acid that facilitates the integration and expression of a heterologous gene. The viral nucleic acid may contain AAV sequences in cis required for DNA replication and packaging into virions (e.g., functional inverted terminal repeats (ITRs)). In a typical application, the transgene encodes MTM1, which is useful for correcting MTM1 mutations in patients suffering from neuromuscular disorders such as XLMTM. Such rAAV vectors may also contain a marker or reporter gene. Useful rAAV vectors lack one or more AAV wild-type genes, either in whole or in part, but retain functional flanking ITR sequences. The AAV ITRs may be of any serotype suitable for the particular application (e.g., those derived from serotype 2). Methods for using rAAV vectors are described, for example, in Tal et al., J. Biomed. Sci. 7:279-291 (2000), and Monahan and Samulski, Gene Delivery 7:24-30 (2000), the disclosures of each of which are incorporated herein by reference with respect to AAV vectors for gene delivery.

[0212] The nucleic acids and vectors described herein can be incorporated into rAAV virions to facilitate the introduction of the nucleic acid or vector into cells. The AAV capsid protein constitutes the outer, non-nucleic acid portion of the virion and is encoded by the AAV cap gene. The cap gene encodes three viral coat proteins, VP1, VP2, and VP3, required for virion assembly. Construction of rAAV virions is described, for example, in U.S. Patent Nos. 5,173,414; 5,139,941; 5,863,541; 5,869,305; 6,057,152; and 6,376,237; as well as Rabinowitz et al., J. Virol. 76:791-801 (2002) and Bowles et al., J. Virol. 77:423-432 (2003), the disclosures of each of which are incorporated herein by reference with respect to AAV vectors for gene delivery.

[0213] rAAV virions useful in connection with the compositions and methods described herein include those derived from various AAV serotypes, including AAV1, 2, 3, 4, 5, 6, 7, 8, and 9. For targeting muscle cells, rAAV virions containing at least one serotype 1 capsid protein may be particularly useful. rAAV virions containing at least one serotype 6 capsid protein may also be particularly useful, as this protein is structurally similar to the serotype 1 capsid protein and is therefore expected to result in high expression of MTM1 in muscle cells. rAAV serotype 9 has also been shown to be an efficient transducer of muscle cells. The construction and use of AAV vectors and AAV proteins of different serotypes are described, for example, in Chao et al., Mol. Ther. 2:619-623 (2000); Davidson et al., Proc. Natl. Acad. Sci. USA 97:3428-3432 (2000); Xiao et al., J. Virol. 72:2224-2232 (1998); Halbert et al., J. Virol. 74:1524-1532 (2000); Halbert et al., J. Virol. 75:6615-6624 (2001); and Auricchio et al., Hum. Molec. Genet. 10:3075-3081 (2001), the disclosures of each of which, with respect to AAV vectors for gene delivery, are incorporated herein by reference.

[0214] Pseudotyped rAAV vectors are also useful in connection with the compositions and methods described herein. Pseudotyped vectors include AAV vectors of a given serotype (e.g., AAV9) pseudotyped with a capsid gene derived from a serotype other than the given serotype (e.g., AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, etc.). For example, a representative pseudotyped vector is AAV8 encoding a therapeutic protein pseudotyped with a capsid gene derived from AAV serotype 2. Techniques for the construction and use of pseudotyped rAAV virions are known in the art and are described, for example, in Duan et al., J. Virol. 75:7662-7671 (2001); Halbert et al., J. Virol. 74:1524-1532 (2000); Zolotukhin et al., Methods, 28:158-167 (2002); and Auricchio et al., Hum. Molec. Genet., 10:3075-3081 (2001).

[0215] AAV virions with mutations in the virion capsid can be used to infect specific cell types more efficiently than capsid virions without the mutation. For example, suitable AAV mutants can have ligand insertion mutations that facilitate targeting of AAV to specific cell types. The construction and characterization of AAV capsid mutants, including insertion mutants, alanine screening mutants, and epitope tag mutants, are described in Wu et al., J. Virol. 74:8635-45 (2000). Other rAAV virions that can be used in the methods of the present invention include capsid hybrids generated by viral molecular breeding and exon shuffling. See, for example, Soong et al., Nat. Genet., 25:436-439 (2000) and Kolman and Stemmer, Nat. Biotechnol. 19:423-428 (2001).

[0216] Resamirigene Bilparvovec As described herein, a pseudotyped AAV vector (AAV2 / 8) comprising a nucleic acid sequence encoding the MTM1 gene (SEQ ID NO: 4) operably linked to the desmin promoter (SEQ ID NO: 3), flanked by AAV2 ITRs, packaged within capsid proteins from AAV8, and the other genetic elements listed in Table 1, refers to the compound known by the International Nonproprietary Name (INN) of resamirigene bilparvovec.

[0217] Resamirigene bilparvovec is a non-replicating recombinant AAV8 vector expressing a non-codon-optimized human MTM1 cDNA under the control of the muscle-specific human desmin promoter. The MTM1 expression cassette was constructed by cloning a synthetic DNA sequence complementary to the coding portion (nucleotides 43–1864) of the wild-type human MTM1 transcript (NCBI Ref. Seq NM_000252.3) downstream of the 1.05 kb human desmin enhancer / promoter region. The second intron and polyadenylation sequence of the human β-globin gene (HBB), which mediate RNA processing, were inserted upstream and downstream of the MTM1 synthetic cDNA, respectively. The expression cassette was flanked by AAV serotype 2 (AAV2) inverted terminal repeats (ITRs). The vector was produced into AAV8 capsids by transfecting HEK293 cells with the two plasmids and culturing them in suspension in a bioreactor in a fully GMP process.

[0218] In some embodiments, a method for treating a disorder (e.g., XLMTM) or alleviating one or more symptoms of a disorder (e.g., XLMTM) (e.g., stiffness and / or joint contracture or the need for diaphragm and / or respiratory muscle development) in a human patient in need thereof comprises administering a therapeutically effective amount of resamirigene bilparvovec to the patient for a treatment period.

[0219] In some embodiments, the method of weaning a human patient from mechanical ventilation includes the patient having previously received a therapeutically effective amount of resamirigene bilparvovec, the components of which are set forth in Table 1 below.

[0220] [Table 1]

[0221] As used herein, resamirigene bilparvovec refers to an AAV vector having the nucleic acid sequence of SEQ ID NO:5, shown below: TCGCGCGTTT CGGTGATGAC GGTGAAAACC TCTGACACAT GCAGCTCCCG 50 GACGTCATTG TCGATCCTGC AGGCGTACGG TAAAAAAAGG CATAGCTAAC 100 AAGGTGTGGA AAAAGAATTA GTGGTTAGAG AGTGAGCTAT TCGTTGAAAC 150 AATTGCGTTC TTGAAACAAT TCTTGCTGGT AAAATGTCAC ATTTTATGTG 200 ACTACAGGTG GAGGATTGGC ACATAACCTA ACCAGTGGGG GAAACAATTG 250 ACCTCTGGAT TTGTCCAAGT GTATAGTAGC ATTTGCCCAA TCGAATGGTC 300 CTGGTAAGGT GTTAATGTTG ACTAGAACCA AAGGTGGAAG TTGCAGGGAA 350 ACTGGTTTAG TACAAGGGTG GACACCAGGC AGTCATCCAG AGGCCCATTA 400 AAGGCCTTGG AATGTTTTTC CGAAGGAGAA TCACTCCCTC TTCTCTCGCT 450 TAAAGTTTTA GGGGATTCAT GAACAGCTGC TGTGGGATAG TTTCATGTCC 500 CTAGCAATTG TAAAGCAACT GAGGGTGGCT TAAACCAGTT TTAGCTTTAG 550 GGTTAGGGTT ACTGGACTAA AATTTGAGAA ATTCATAAT CTTAAGGAAA 600 TCCATTGTGA GTTTTCATTA TGAGTGCATC CAATGTATAA TTTCCATGAC 650 CCTCCCATGC AAGTGAGCAT GTGAATCAGG AAACGTTACA AGAACCCAAC 700 AACATCAACC ACTACTAGAC AGGCGATCAC TTCCAGTTAG TATGCAACTT 750 TCTGTGTAAT TTTAGTTACC ATTAAAATCT GGATGACCTT AGTGTAAGGA 800 AAAATACCT TGAATAGTGT TAAAGATGTA CACTTGGTGT CAGGCATTGT 850 AACATTGATA AATCTGTGTA AGGTGCTTTT TGAAAACTTC AAAGCTGCAT 900 CAAGTCAAGT ACAAGAAAGG CCATGGCTGC TAAAGCTGTT GAAGATGTGG 950 GATGGAACTG GGTCACATTG GTGTTAACAG CGTTGTGCAG AGCCGGCAGG 1000 ATCTTGGTGT GAGCGAACAT TAGTCTATTT AATAAAGCTG TGTGAATGTT 1050 GTAGAGGTGA GGATGCTCAC TTGAAAACTC ACTGAAGAAC ACTTGGCCCC 1100 TTGAACTAAA GTGCTTCTAT CAAGTTCAGT GAGAAATTCC GAATTACAAG 1150 HELPGTACT CONTINUOUS HEADTACT HEADLINE 1200 TTCATAAAAT TAGGATGTA GAAAGTGAAA TTTCCACGTA TGGTCACTCC 1250 CAGAGAAAAA AAATACGTTT ATTTACCTTT TTTAAAAATA GGGGATTTCA 1300 GGCCGGGTGA GGTGGCTCAC GCCTGTAATC CCAGCACTTT GGGAGGCCCA 1350 GGTGGGCGGA TCACCTGAGG TCAGGAGTTG GAGGGATGGC AAATCCCATC 1400 TCTACAAAAT ATACAAAAAA ATAGCTGGGT GTGTTGGCAG GCGCCTGTAA 1450 TCCCAGCTAC TCGGAAGGCT GAGGCAGGAG AATCCCTGGA ACCAGGGATG 1500 TGGAGGTTGC AGTGAGCCGA GATTGTGTAA CTGCATTCCA GCCTGGGCAA 1550 CHANGE ACTCCGTATC AGAAAAAAAAAAAAGGGGGGG TTGGATTTCG 1600 CTTGTTGCAT AGGTTGGTCT CAAACTCCTG GCCTCAAGTG ATTCTCCTGC 1650 CTCTGCCTCC CAAAGTGCTG AGATTACAGG TGTGAGGCAC CATGCCAGGT 1700 CTCTTACTGT TTGTAATTAA ATACATACAC ATTTTGTGTG TTTGTGTGCA 1750 CCTTTATAAA GTCAAAGGTG ATAGTAACCC ATTTAAGTTC CTACTCAATT 1800 TTACTTTCCA GGGATAACTA ACTACTTTTT CTTTTTGAGA TGGAGTCTCG 1850 CTGTGTAGCC CAGGCTGGAG TGCAGTGGCA CCATCTCGGC TCACTGCAAG 1900 CTCCTCCTCC CTGGTTCACG CTATTCTCCT GCCTCAGCCT CCCCAACAAC 1950 TAGGACTACA GGCTCACCTC GCCATACCTG GCTAATTTTT TGTATTTTTA 2000 GTAGAGACAG GGTTTCACTG TGTTAGCCAG GATGGTCTCG ATCTCCTGAC 2050 CTTGTGATCC GCCTGCCTCT GCCTCCCAAA GTGCTGGGAT TACAGGCATG 2100 AGCAACCTCA CCCAGCTGGG ATAACTACTT TTTACAGGTT GATATTCTTT 2150 TGGACTTTTC CCCTGTGTAA AAATATACTA TATTTGTTAT GTACATATTA 2200 TGTACATACA GACACAAATT GGACCATTCT CAGTATAATG ATTCTCAGGT 2250 TTTTTTTTTT TTTTTGAGGT GGGGAACTAG ATAATTATGG ACATCTTTCC 2300 ATACTAGCAT ATCAATATCT ACCTCATTCT TTTTAATATT TTTGCTAGTA 2350 TTCCATTGTA TGAATGTCCT ATGATTTACT TAACCTGTCC ATCAATATTT 2400 GTTTCCAGGT TTTTGCTATT ATAATGCTGC TGCAAAGTAC ATCCTCACAC 2450 ATCTTTATTT TGTCTATTCA TATTTCTGTA AGATAGGTTA CTAAAGTTGG 2500 AACTGCCAAA TTAACACTAT CATACTATTT TGTTTTTTAA TTTTAATTTT 2550 TTAAAAAATG TAAAATGTGC AATTTCAAGA GGAGAAACTT GAACACAAGG 2600 AGCAAAATCT ATTTTTATAA CATCCTATTA AAAGCTTGCT TTACATAAAG 2650 ATTTTGAAAG AATAGCATAA ATACAAGATT TCTATTTTAA TTGGATTCTT 2700 AGGGCTAATA AAATAATCAG CCTTAGCACT TATTTATTTA TTTTTTTTGA 2750 GAGGGAGTCT CGCTCTGTTG TCCATGCTGG AGTGCAGTGG CGTGATCTCG 2800 GCTCACTGCA AGCTCCACCT CATGAGTTCA CACCATTCTC CTGCCTCAGT 2850 CTCCCGAGTA GCTGGGACTC CAGGCGCCCT CTACAAAGCC CGTCTAATTT 2900 TTTTTGTATT TTTAGTAGAG ACAGGGTTTC ACTGTGTTAG CCAGGATGGT 2950 CTTGATCTCC TGACCTTGTG ATCTGCCCGC CTCGGCCTCC CAAAGTGCTG 3000 GGATTATAGG CTTGAGCCAC TGCTCCCGGC CAGCACTTAT TTTTATAATT 3050 CTTCATGATT ACTGTGTTAC TGTCCCATGG GCCGCCAGGG CCAGCTAGGT 3100 TGGCCACTCC CTCTCTGCGC GCTCGCTCGC TCACTGAGGC CGGGCGACCA 3150 AAGGTCGCCC GACGCCCGGG CTTTGCCCGG GCGGCCTCAG TGAGCGAGCG 3200 AGCGCGCAGA GAGGGAGTGG CCAACTCCAT CACTAGGGGT TCCTCCTAGC 3250 ACGCGCTACC CCCTGCCCCC CACAGCTCCT CTCCTGTGCC TTGTTTCCCA 3300 GCCATGCGTT CTCCTCTATA AATACCCGCT CTGGTATTTG GGGTTGGCAG 3350 CTGTTGCTGC CAGGGAGATG GTTGGGTTGA CATGCGGCTC CTGACAAAAC 3400 ACAAACCCCT GGTGTGTGTG GGCGTGGGTG GTGTGAGTAG GGGGATGAAT 3450 CAGGGAGGGG GCGGGGGACC CAGGGGGCAG GAGCCACACA AAGTCTGTGC 3500 GGGGGTGGGA GCGCACATAG CAATTGGAAA CTGAAAGCTT ATCAGACCCT 3550 TTCTGGAAAT CAGCCCACTG TTTATAAACT TGAGGCCCCA CCCTCGACAG 3600 TACCGGGGAG GAAGAGGGCC TGCACTAGTC CAGAGGGAAA CTGAGGCTCA 3650 GGGCCAGCTC GCCCATAGAC ATACATGGCA GGCAGGCTTT GGCCAGGATC 3700 CCTCCGCCTG CCAGGCGTCT CCCTGCCCTC CCTTCCTGCC TAGAGACCCC 3750 CACCCTCAAG CCTGGCTGGT CTTTGCCTGA GACCCAAACC TCTTCGACTT 3800 CAAGAGAATA TTTAGGAACA AGGTGGTTTA GGGCCTTTCC TGGGAACAGG 3850 CCTTGACCCT TTAAGAAATG ACCCAAAGTC TCTCCTTGAC CAAAAAGGGG 3900 ACCCTCAAAC TAAAGGGAAG CCTCTCTTCT GCTGTCTCCC CTGACCCCAC 3950 TCCCCCCCAC CCCAGGACGA GGAGATAACC AGGGCTGAAA GAGGCCCGCC 4000 TGGGGGCTGC AGACATGCTT GCTGCCTGCC CTGGCGAAGG ATTGGTAGGC 4050 TTGCCCGTCA CAGGACCCCC GCTGGCTGAC TCAGGGGCGC AGGCCTCTTG 4100 CGGGGGAGCT GGCCTCCCCCG CCCCCACGGC CACGGGCCGC CCTTTCCTGG 4150 CAGGACAGCG GGATCTTGCA GCTGTCAGGG GAGGGGAGGC GGGGGCTGAT 4200 GTCAGGAGGG ATACAAATAG TGCCGACGGC TGGGGGCCCT GTCTCCCCTC 4250 GCCGCATCCA CTCTCCGGCC GGCCGCCTGC CCGCCGCCTC CTCCGTGCGC 4300 CCGCCAGCCT CGCCCGGACT CTAGAGGATC CAGATCTAAG CTTCTCTGGT 4350 CACCGATCCT GAGAACTTCA GGGTGAGTCT ATGGGACCCT TGATGTTTTC 4400 TTTCCCCTTC TTTTCTATGG TTAAGTTCAT GTCATAGGAA GGGGAGAAGT 4450 AACAGGGTAC ACATATTGAC CAAATCAGGG TAATTTTGCA TTTGTAATTT 4500 TAAAAAATGC TTTCTTCTTT TAATATACTT TTTTGTTTAT CTTATTTCTA 4550 ATACTTTCCC TAATCTCTTT CTTTCAGGGC AATAATGATA CAATGTATCA 4600 TGCCTCTTTG CACCATTCTA AAGAATAACA GTGATAATTT CTGGGTTAAG 4650 GCAATAGCAA TATTTCTGCA TATAAATATT TCTGCATATA AATTGTAACT 4700 GATGTAAGAG GTTTCATATT GCTAATAGCA GCTACAATCC AGCTACCATT 4750 CTGCTTTTAT TTTATGGTTG GGATAAGGCT GGATTATTCT GAGTCCAAGC 4800 TAGGCCCTTT TGCTAATCAT GTTCATACCT CTTATCTTCC TCCCACAGCT 4850 CCTGGGCAAC GTGCTGGTCT GTGTGCTGGC CCATCACTTT GGCAAAGAAT 4900 TCCGCGGGCG GCCGCAAGTT TCCAGGATGG CTTCTGCATC AACTTCTAAA 4950 TATAATTCAC ACTCCTTGGA GAATGAGTCT ATTAAGAGGA CGTCTCGAGA 5000 TGGAGTCAAT CGAGATCTCA CTGAGGCTGT TCCTCGACTT CCAGGAGAAA 5050 CACTAATCAC TGACAAAGAA GTTATTTACA TATGTCCTTT CAATGGCCCC 5100 ATTAAGGGAA GAGTTTACAT CACAAATTAT CGTCTTTATT TAAGAAGTTT 5150 GGAAACGGAT TCTTCTCTAA TACTTGATGT TCCTCTGGGT GTGATCTCGA 5200 GAATTGAAAA AATGGGAGGC GCGACAAGTA GAGGAGAAAA TTCCTATGGT 5250 CTAGATATTTA CTTGTAAAGA CATGAGAAAC CTGAGGTTCG CTTTGAAACA 5300 GGAAGGCCAC AGCAGAAGAG ATATGTTTGA GATCCTCACG AGATACGCGT 5350 TTCCCCTGGC TCACAGTCTG CCATTATTTG CATTTTTAAA TGAAGAAAAG 5400 TTTAACGTGG ATGGATGGAC AGTTTACAAT CCAGTGGAAG AATACAGGAG 5450 GCAGGGCTTG CCCAATCACC ATTGGAGAAT AACTTTTATT AATAAGTGCT 5500 ATGAGCTCTG TGACACTTAC CCTGCTCTTT TGGTGGTTCC GTATCGTGCC 5550 TCAGATGATG ACCTCCGGAG AGTTGCAACT TTTAGGTCCC GAAATCGAAT 5600 TCCAGTGCTG TCATGGATTC ATCCAGAAAA TAAGACGGTC ATTGTGCGTT 5650 GCAGTCAGCC TCTTGTCGGT ATGAGTGGGA AACGAAATAA AGATGATGAG 5700 AAATATCTCG ATGTTATCAG GGAGACTAAT AAACAAATTT CTAAACTCAC 5750 CATTTATGAT GCAAGACCCA GCGTAAATGC AGTGGCCAAC AAGGCAACAG 5800 GAGGAGGATA TGAAAGTGAT GATGCATATC ATAACGCCGA ACTTTTCTTC 5850 TTAGACATTC ATAATATTCA TGTTATGCGG GAATCTTTAA AAAAAGTGAA 5900 GGACATTGTT TATCCTAATG TAGAAGAATC TCATTGGTTG TCCAGTTTGG 5950 AGTCTACTCA TTGGTTAGAA CATATCAAGC TCGTTTTGAC AGGAGCCATT 6000 CAAGTAGCAG ACAAAGTTTC TTCAGGGAAG AGTTCAGTGC TTGTGCATTG 6050 CAGTGACGGA TGGGACAGGA CTGCTCAGCT GACATCCTTG GCCATGCTGA 6100 TGTTGGATAG CTTCTATAGG AGCATTGAAG GGTTCGAAAT ACTGGTACAA 6150 AAAGAATGGA TAAGTTTTGG ACATAAATTT GCATCTCGAA TAGGTCATGG 6200 TGATAAAAAC CACACCGATG CTGACCGTTC TCCTATTTTT CTCCAGTTTA 6250 TTGATTGTGT GTGGCAAATG TCAAAACAGT TCCCTACAGC TTTTGAATTC 6300 AATGAACAAT TTTTGATTAT AATTTTGGAT CATCTGTATA GTTGCCGATT 6350 TGGTACTTTC TTATTCAACT GTGAATCTGC TCGAGAAAGA CAGAAGGTTA 6400 CAGAAAGGAC TGTTTCTTTA TGGTCACTGA TAAACAGTAA TAAAGAAAAA 6450 TTCAAAACC CCTTCTATAC TAAAGAAATC AATCGAGTTT TATATCCAGT 6500 TGCCAGTATG CGTCACTTGG AACTCTGGGT GAATTACTAC ATTAGATGGA 6550 ACCCCAGGAT CAAGCAACAA CAGCCGAATC CAGTGGAGCA GCGTTACATG 6600 GAGCTCTTAG CCTTACGCGA CGAATACATA AAGCGGCTTG AGGAACTGCA 6650 GCTCGCCAAC TCTGCCAAGC TTTCTGATCC CCCAACTTCA CCTTCCAGTC 6700 CTTCGCAAAT GATGCCCCAT GTGCAAACTC ACTTCTGACC GGTCCGAGGG 6750 CCCAGATCTA ATTCACCCCA CCAGTGCAGG CTGCCTATCA GAAAGTGGTG 6800 GCTGGTGTGG CTAATGCCCT GGCCCACAAG TATCACTAAG CTCGCTTTCT 6850 TGCTGTCCAA TTTCTATTAA AGGTTCCTTT GTTCCCTAAG TCCAACTACT 6900 AAACTGGGGG ATATTATGAA GGGCCTTGAG CATCTGGATT CTGCCTAATA 6950 AAAAACATTT ATTTTCATTG CAATGATGTA TTTAAATTAT TTCTGAATAT 7000 TTTACTAAAA AGGGAATGTG GGAGGTCAGT GCATTTAAAA CATAAAGAAA 7050 TGAAGAGCTA GTTCAAACCT TGGGAAAATA CACTATATCT TAAACTCCAT 7100 GAAAGAAGGT GAGGCTGCAA ACAGCTAATG CACATTGGCA ACAGCCCCTG 7150 ATGCCTATGC CTTATTCATC CCTCAGAAAA GGATTCAAGT AGAGGCTTGA 7200 TTTGGAGGTT AAAGTTTTGC TATGCTGTAT TTTACATTAC TTATTGTTTT 7250 AGCTGTCCTC ATGAATGTCT TTTCACTACC CATTTGCTTA TCCTGCATCT 7300 CTCAGCCTTG ACTCCACTCA GTTCTCTTGC TTAGAGATAC CACCTTTCCC 7350 CTGAAGTGTT CCTTCCATGT TTTACGGCGA GATGGTTTCT CCTCGCCTGG 7400 CCACTCAGCC TTAGTTGTCT CTGTTGTCTT ATAGAGGTCT ACTTGAAGAA 7450 GGAAAAACAG GGGGCATGGT TTGACTGTCC TGTGAGCCCT TCTTCCCTGC 7500 CTCCCCCACT CACAGTGACC GGCCGCTCTA GGAGGAACCC CTAGTGATGG 7550 AGTTGGCCAC TCCCTCTCTG CGCGCTCGCT CGCTCACTGA GGCCGGGCGA 7600 CCAAAGGTCG CCCGACGCCC GGGCTTTGCC CGGGCGGCCT CAGTGAGCGA 7650 GCGAGCGCGC AGAGAGGGAG TGGCCAACCT AGAGGCCGCC AGGGCCATAT 7700 TTCTCAATTT TTAAATTTTT CAAAAAAATT AATCCTTTAAT GTGCATATTT 7750 TTGAATTGTT AATATAACTT TTTGAGGTGA TGTCTTCATG TGTTTCAACT 7800 ACTTAAAAAC TTTAAACAG TATATAATAA AAAATCTTCC AGGCCACTCA 7850 CACCTGTAAT CCCAGCACTT TGGGAGGCTG AGGTGGGCAG ATCACCTGAG 7900 GGCAGGAGTT CGAGACCAGC CTGGCCATA TATATATATT CATATATTCA 7950 FATHER FATHER FATHER FATHER FATHER TATATTCATA TATATATATA TATATATA TAGCAAAACC TCATCTCTAA TAAATACAA 8050 AAATTAGCTG AGCGTGGTGA TGGATGCCTG TAGTCCCAGC TACTCGGGAG 8100 GCTGAGGCAG GAGAATCTCT TGAACCTGGG AGGTGGAGGT TGCAGTGAGC 8150 TGAGATGGTG CCACTGCCCT CCAGCCTGAG TGACAGAGCG AGACTCGGTC 8200 TCCAAAAAAA AACAACAAAA AAATCTTCCA TCCTTGCTC CCATCCACCC 8250 CTTCCCCCCA GCATGTACTT GCAGACTTTA TGCATATACA GTGAGTACTG 8300 TATATACACA AATAAAAAAAATCATATA TATAATAT GTAATTCCCC 8350 TTTACATGAA AGGTAGCACA CTGGTCTGTA CAGTCTGTCT GCACTGTGCT 8400 ATTTCACTTT ATATTTTTAT AGTTTGACAG AGTTCTAACA TTTCTTTTTT 8450 TTTTTTTTTA ACAGAGTCTT GTTCCTGATT GTTAAATTTT AAAGCATCCT 8500 AAAGTTTGGT TTCACACTTG AATGATACC ATGTAAGGAT TCACTTACAT 8550 NATIONGTGGTT GCCTGAATCT WINDOW ATAACATTGT TTGTATTTAT 8600 TTAAATTAGT GTTCCTTTTA TGGTTTGCCT GAAAGCACAA CAAAATCCTC 8650 ACCAAGATAT TACAATTATG ACTCCCATAC AGGTAAACTG TTTAGAGATT 8700 GGCAAGCACC TTTTAATGAA AGGAGTCAGC CAGCTTAGTG TGCAGTATTT 8750 ATTTCTGCCG GAAGAGGGAG CTTCAGGGAC AGACTTTGGT TTAGTCATGA 8800 AGCCTCCAGC ACTCCCAAGC GGTTGTGGTT GACCAAGCAA TTTATGCTTT 8850 TACCTTTCTA CTTCCAGAGG CTTGTTTACT TATCAGTAAG CATTAATTTA 8900 GTGTCCCCTC AGATGCCTTT TACTTTCTTC TTTTCTGCCT AGAATAAGCT 8950 GCTCTTCCAA TTTTGCAGCT ACATGTTTCC ACCCCAGTTG GAATTTCTCC 9000 ATAACATCCA TTGTAGCTAT CCTTCAATCT ACAGCCTCTA TTTCCTGTTA 9050 TAGCTGGTCA GGTCTAATCC CTCAAAATAC TCTGTCCCCT GCTTCCCTTA 9100 TCTGCTGGCC ACCTTTTTCC CCCACATACA CACTGCCATG TCCCACCCTT 9150 CACTCAAGTT GTTCCCTGCC ACCTCAACAA ATTTAAGTCC ATAAAATAGA 9200 GTAAGTGTTC CTGACTGTTA AATTTTAAAG CATCCCAAAG TCTGATTTCA 9250 CACTCGAATG AATACTATGT ACGGATTCAT TTACATAGAT GCGGTTGCAT 9300 AGTACTTAAC AAAAAAAATA HELPTTGTGT ATTTATTCAA AGTACTGTCA 9350 NATIONAL ATG TCAAGACCTA ATTCAAAGGT TCCACAAAGC CTTCCTTGAC 9400 TGCCCCCAAC GAAGATTATC CATTTTCCCT GAAATCCCAT TGACTTTTCT 9450 ATTTTGTAAG GAGGCTCGTG AGACTCTGTC TAAAAACAAA ACAAAACAAA 9500 AAGAAACAAT CAAACGGCTT GCTTCTGTTC TTTGATCTGC TAGTAAGCAA 9550 AAATTACACA TGGTGACAGG AGCTATGTGA GGCTGTCAGG TTGAATGGGA 9600 GGAGTTTGGG ATCCTGCTTG TGGATGGTTG GAAGAGGCTT TCGGGAAAGA 9650 CAGTATTTAT GTGAGACCTG GAAGATGGGC CTTAGCTTTG CAGAAGGTGG 9700 AGAGGCAGGA AATAGCACGG GGGCCCTGGG GCTGGAAGAC TTGGGCATAT 9750 TTREQUISITE FREQUENCY REQUIREMENT REFERENCE 9800 AGAGATGGGG CTGGAGGAGG CCGGGAGTGG TGGCTCACGC CTGTAATCCC 9850 AGCACTTTGG GAGGCCAAGG CAGGCGGATC ATGAGCTCAG GAGATTGAGA 9900 CCATCCTGGC TAACACGGTG AAACCCCCTC TCTACTAAAA ATACAAAAAA 9950 AAAAAAAAAA AAAATTAGCT GGGCGTGGTG GCAGGAGCCT GTAGTCCCAG 10000 CTACCTGGGA GGCTGAGGCA GGAGAATGGC GTGAACCTGG AAGGCTGAGC 10050 TTGCAGTGAG CCGAGATTGC ACCACTGCAC TCCAGCCTGG GAGACAGAGA 10100 GAGACTCCCT CTCAAAAAAA CAAACAAACG AAACAAAACA AAACAAAAAT 10150 TAGCCAGGCG TGGTGGTATG CACCTGTAAT CCCAGCTACT CGGGAGGTTG 10200 AGGCAGGAGA AACGCTTGAA CTCAGGAGGC GGAGGTTGCA GTGAGCCGAG 10250 ACTGCGCCAC TGCACTCCAG CCTGGGTGAC AGAGGGAGAC TCCATCTCAA 10300 AAAAAAAAAT TTTTTTTTTT TTACAAACGG TGTCTCCCTC TGTCGCCCAG 10350 GCTGGAGTGC AGTGGTGTGA TCACAGCTCA CTCCAGCCTC AACCTCCCCA 10400 GCTGAAGCCA TCCTCTTGCC TCAGCCTCCT AAGTAGCTGG GACTACAGGC 10450 GCGCACCTCC AGGCTTGGCT CTTATTCTTT TTATTGTTTT TGAAACTATA 10500 GAACCTATTT TTAAAAAATG TTTTGGTTGT TTTTATTGCT GCTTTTCCTT 10550 TTGGGGTTAG AACACAAGTT TTGATGGGAA ACAGGTTAGA ACACATTCAT 10600 CTCTTCCCAT AGCGATGGTC ATAGAAAAAC GGGGCATATT TATAAACTCT 10650 CAGTTGATCT TAAAATGTGC AAAAGCTGCC GAACTCCTGG GAGTGAGCTC 10700 GAGCCCTGCA GGATCATTGT CACATGTGAG CAAAAGGCCA GCAAAAGGCC 10750 AGGAACCGTA AAAAGGCCGC GTTGCTGGCG TTTTTCCATA GGCTCCGCCC 10800 CCCTGACGAG CATCACAAAA ATCGACGCTC AAGTCAGAGG TGGCGAAACC 10850 CGACAGGACT ATAAAGATAC CAGGCGTTTC CCCCTGGAAG CTCCCTCGTG 10900 CGCTCTCCTG TTCCGACCCT GCCGCTTACC GGATACCTGT CCGCCTTTCT 10950 CCCTTCGGGA AGCGTGGCGC TTTCTCATAG CTCACGCTGT AGGTATCTCA 11000 GTTCGGTGTA GGTCGTTCGC TCCAAGCTGG GCTGTGTGCA CGAACCCCCC 11050 GTTCAGCCCG ACCGCTGCGC CTTATCCGGT AACTATCGTC TTGAGTCCAA 11100 CCCGGTAAGA CACGACTTAT CGCCACTGGC AGCAGCCACT GGTAACAGGA 11150 TTAGCAGAGC GAGGTATGTA GGCGGTGCTA CAGAGTTCTT GAAGTGGTGG 11200 CCTAACTACG GCTACACTAG AAGAACAGTA TTTGGTATCT GCGCTCTGCT 11250 GAAGCCAGTT ACCTTCGGAA AAAGAGTTGG TAGCTCTTGA TCCGGCAAAC 11300 AAACCACCGC TGGTAGCGGT GGTTTTTTTG TTTGCAAGCA GCAGATTACG 11350 CGCAGAAAAA AAGGATCTCA AGAAGATCCT TTGATCTTTT CTACGGGGTC 11400 TGACGCTCAG TGGAACGAAA ACTCACGTTA AGGGATTTTG GTCATGAGAT 11450 TATCAAAAAG GATCTTCACC TAGATCCTTT TAAATTAAAA ATGAAGTTTT 11500 AAATCAAGCC CAATCTGAAT AATGTTACAA CCAATTAACC AATTCTGATT 11550 AGAAAAACTC ATCGAGCATC AAATGAAACT GCAATTTTATT CATATCAGGA 11600 TTATCAATAC CATATTTTTG AAAAAGCCGT TTCTGTAATG AAGGAGAAAA 11650 CTCACCGAGG CAGTTCCATA GGATGGCAAG ATCCTGGTAT CGGTCTGCGA 11700 TTCCGACTCG TCCAACATCA ATACAACCTA TTAATTTTCCC CTCGTCAAAA 11750 ATAAGGTTAT CAAGTGAGAA ATCACCATGA GTGACGACTG AATCCGGTGA 11800 GAATGGCAAA AGTTTATGCA TTTCTTTCCA GACTTGTCCA ACAGGCCAGC 11850 CATTACGCTC GTCATCAAAA TCACTCGCAT CAACCAAACC GTTATTCATT 11900 CGTGATTGCG CCTGAGCGAG ACGAAATACG CGATCGCTGT TAAAAGGACA 11950 ATTACAAACA GGAATCGAAT GCAACCGGCG CAGGAACACT GCCAGCGCAT 12000 CAACAATATT TTCACCTGAA TCAGGATATT CTTCTAATAC CTGGAATGCT 12050 GTTTTTCCGG GGATCGCAGT GGTGAGTAAC CATGCATCAT CAGGAGTACG 12100 GATAAAATGC TTGATGGTCG GAAGAGGCAT AAATTCCGTC AGCCAGTTTA 12150 GTCTGACCAT CTCATCTGTA ACATCATTGG CAACGCTACC TTTGCCATGT 12200 TTCAGAAACA ACTCTGGCGC ATCGGGCTTC CCATACAAGC GATAGATTGT 12250 CGCACCTGAT TGCCCGACAT TATCGCGAGC CCATTTATAC CCATATAAAT 12300 CAGCATCCAT GTTGGAATTT AATCGCGGCC TCGACGTTTC CCGTTGAATA 12350 TGGCTCATAA CACCCCTTGT ATTACTGTTT ATGTAAGCAG ACAGTTTTAT 12400 TGTTCATGAT GATATATTTT TATCTTGTGC AATGTAACAT CAGAGATTTT 12450 GAGACACGGG CCAGAGCTGC A 12500

[0222] Methods for delivering exogenous nucleic acids to target cells Transfection technology Techniques that can be used to introduce transgenes, such as the MTM1 transgene described herein, into target cells are known in the art. For example, electroporation can be used to permeabilize mammalian cells (e.g., human target cells) by applying an electrostatic potential to the cells of interest. Mammalian cells, such as human cells, exposed to this external electric field then become susceptible to the uptake of exogenous nucleic acids (e.g., nucleic acids that can be expressed in neurons, glial cells, or non-neuronal cells such as colon cells and kidney cells). Electroporation of mammalian cells is described in detail, for example, in Chu et al., Nucleic Acids Research 15:1311 (1987), the disclosure of which is incorporated herein by reference. A similar technique, NUCLEOFECTION™, utilizes the application of an electric field to stimulate the uptake of exogenous polynucleotides into the nucleus of eukaryotic cells. NUCLEOFECTION™ and protocols useful for carrying out this technique are described in detail, for example, in Distler et al., Experimental Dermatology 14:315 (2005) and US 2010 / 0317114, the disclosures of each of which are incorporated herein by reference.

[0223] Another useful technique for transfecting target cells is squeezeporation. This technique induces rapid physical deformation of cells to stimulate the uptake of exogenous DNA through membrane pores formed in response to applied stress. This technique is advantageous in that it does not require a vector to deliver nucleic acids to cells, such as human target cells. Squeezeporation is described in detail, for example, in Sharei et al., J. Vis. Exp. 81: e50980 (2013), the disclosure of which is incorporated herein by reference.

[0224] Lipofection is another technique useful for transfecting target cells. This method involves encapsulating nucleic acids in liposomes, which often present cationic functional groups, such as quaternary amines or protonated amines, on the exterior of the liposomes. This promotes electrostatic interactions between the liposomes and cells, due to the anionic nature of the cell membrane, ultimately leading to the uptake of exogenous nucleic acids, for example, by direct fusion of the liposome with the cell membrane or by endocytosis of the complex. Lipofection is described in detail, for example, in US Pat. No. 7,442,386, the disclosure of which is incorporated herein by reference. A similar technique that utilizes ionic interactions with the cell membrane to induce the uptake of exogenous nucleic acids is to contact cells with a complex of a cationic polymer and nucleic acid. Exemplary cationic molecules that associate with polynucleotides to impart a positive charge favorable for interaction with cell membranes are activated dendrimers (described, e.g., in Dennig, Top Curr Chem. 228:227 (2003), the disclosure of which is incorporated herein by reference), polyethyleneimine, and DEAE-dextran, the use of which as transfection agents is described in detail, e.g., in Gulick et al., Curr Protoc Mol Biol. 40:1:9.2:9.2.1 (1997), the disclosure of which is incorporated herein by reference.

[0225] Another useful tool for inducing the uptake of exogenous nucleic acids by target cells is laser transfection, also known as optical transfection, which is a technique that involves exposing cells to electromagnetic radiation of a specific wavelength to gently permeabilize the cells and allow polynucleotides to penetrate the cell membrane. The biological activity of this technique is similar to, and in some cases superior to, electroporation.

[0226] Impalefection is another technique that can be used to deliver genetic material to target cells. This technique relies on the use of nanomaterials such as carbon nanofibers, carbon nanotubes, and nanowires. Needle-shaped nanostructures are synthesized perpendicular to the surface of a substrate. DNA containing genes for intracellular delivery is attached to the surface of the nanostructures. The chip containing the array of needles is then pressed against cells or tissues. Cells pierced by the nanostructures can express the delivered gene(s). An example of this technique is described in Shalek et al., PNAS 107:25 1870 (2010), the disclosure of which is incorporated herein by reference.

[0227] MAGNETOFECTION™ can also be used to deliver nucleic acids to target cells. The principle of MAGNETOFECTION™ is to associate nucleic acids with cationic magnetic nanoparticles. The magnetic nanoparticles are made of fully biodegradable iron oxide and are coated with specific cationic molecules depending on the application. Association with gene vectors (DNA, siRNA, viral vectors, etc.) is achieved through salt-induced colloidal aggregation and electrostatic interactions. The magnetic particles are then concentrated in target cells by the influence of an external magnetic field generated by a magnet. This technique is described in detail in Scherer et al., Gene Ther. 9:102 (2002), the disclosure of which is incorporated herein by reference. Magnetic beads are another tool that can be used to gently and efficiently transfect target cells, as this method utilizes an applied magnetic field to induce nucleic acid uptake. This technique is described in detail, for example, in US2010 / 0227406, the disclosure of which is incorporated herein by reference.

[0228] Another useful tool for inducing the uptake of exogenous nucleic acid by target cells is sonoporation, which is a technique that involves using sound waves (typically ultrasonic frequency) to modify the permeability of the plasma membrane of cells, making cells permeable and allowing polynucleotides to penetrate the cell membrane.This technique is described in detail in, for example, Rhodes et al., Methods Cell Biol.82:309 (2007), the disclosure of which is incorporated herein by reference.

[0229] Microvesicles are another vehicle that can potentially be used to modify the genome of target cells according to the methods described herein. For example, microvesicles induced by simultaneously overexpressing the glycoprotein VSV-G and a genome-modifying protein, such as a nuclease, can be used to efficiently deliver proteins into cells, and the protein then catalyzes the site-specific cleavage of endogenous polynucleotide sequences to prepare the cellular genome for covalent integration of a target polynucleotide, such as a gene or regulatory sequence. The use of such vesicles, also known as gesicles, for genetically modifying eukaryotic cells is described in detail, for example, in Quinn et al., Genetic Modification of Target Cells by Direct Delivery of Active Protein [abstract]. In: Methylation changes in early embryonic genes in cancer [abstract], in: Proceedings of the 18th Annual Meeting of the American Society of Gene and Cell Therapy; 2015 May 13, Abstract No. 122.

[0230] Targeted gene integration using gene editing technology In addition to the above, various tools have been developed that can be used to integrate a gene of interest into a target cell, such as a human cell. One such method that can be used to integrate a polynucleotide encoding a target gene into a target cell is the use of transposons. A transposon is a polynucleotide that encodes a transposase enzyme and contains a polynucleotide sequence or gene of interest flanked by 5' and 3' cleavage sites. Once the transposon is delivered to a cell, expression of the transposase gene begins, producing an active enzyme that cleaves the gene of interest from the transposon. This activity is mediated by the transposase's site-specific recognition of transposon cleavage sites. In some cases, these cleavage sites can be terminal repeats or inverted terminal repeats. Once the gene of interest is cleaved from the transposon, similar cleavage sites present in the nuclear genome of the mammalian cell can be cleaved by the transposase, allowing it to be integrated into the genome of the mammalian cell. This allows the gene of interest to be inserted into the complementary cleavage site of the cleaved nuclear DNA, followed by covalent ligation of a phosphodiester bond connecting the gene of interest to the DNA of the mammalian cell genome, completing the integration process. In certain cases, the transposon may be a retrotransposon, in which the gene encoding the target gene is first transcribed into an RNA product, then reverse-transcribed into DNA, and then integrated into the mammalian cell genome. Exemplary transposon systems are the piggybac transposon (described in detail, for example, in WO2010 / 085699) and the sleeping beauty transposon (described in detail, for example, in US2005 / 0112764), the disclosures of which are incorporated herein by reference with respect to transposons for use in gene delivery into cells of interest.

[0231] Another tool for integrating target genes into the genome of target cells is the clustered regularly interspaced short palindromic repeats (CRISPR) / Cas system, which originally evolved as an adaptive defense mechanism against bacterial and archaeal viral infections. The CRISPR / Cas system contains palindromic repeats within plasmid DNA and the associated Cas9 nuclease. This DNA-protein complex first integrates foreign DNA into the CRISPR locus, thereby inducing site-specific DNA cleavage of the target sequence. A polynucleotide containing these foreign sequences and the repeat-spacer element of the CRISPR locus is transcribed in the host cell to generate a guide RNA, which then anneals to the target sequence and localizes the Cas9 nuclease to that site. Thus, the proximity of Cas9 to the target DNA molecule is governed by RNA:DNA hybridization, enabling highly site-specific Cas9-mediated DNA cleavage of the foreign polynucleotide. As a result, CRISPR / Cas systems can be designed to cleave any target DNA molecule of interest. This technology has been utilized to edit eukaryotic genomes (Hwang et al., Nature Biotechnology 31:227 (2013)) and can be used as an efficient means of site-specifically editing target cell genomes to integrate a gene encoding a target gene after DNA cleavage. The use of CRISPR / Cas to control gene expression is described, for example, in U.S. Patent No. 8,697,359, the disclosure of which is incorporated herein by reference with respect to the use of the CRISPR / Cas system for genome editing. Alternative methods for site-specific cleavage of genomic DNA followed by integration of a gene of interest into a target cell include the use of zinc finger nucleases (ZFNs) and transcription activator-like effector nucleases (TALENs). Unlike CRISPR / Cas systems, these enzymes do not contain a guide polynucleotide that positions them at a specific target sequence. Instead, target specificity is controlled by a DNA-binding domain within these enzymes.The use of ZFNs and TALENs in genome editing applications is described, for example, in Urnov et al., Nat. Rev. Genet. 11:636 (2010); and Joung et al., Nat. Rev. Mol. Cell Biol. 14:49 (2013), the disclosures of each of which are incorporated herein by reference with respect to compositions and methods for genome editing.

[0232] Further genome editing techniques that can be used to integrate a polynucleotide encoding a target gene into the genome of a target cell include the use of ARCUS™ meganucleases, which can be rationally designed to site-specifically cleave genomic DNA. Using these enzymes to integrate a gene encoding a target gene into the genome of a mammalian cell is advantageous in view of the clear structure-activity relationship established for these enzymes. By modifying single-chain meganucleases at specific amino acid positions, it is possible to create nucleases that selectively cleave DNA at desired positions, thereby enabling site-specific integration of the target gene into the nuclear DNA of the target cell. These single-chain nucleases are extensively described, for example, in U.S. Patent Nos. 8,021,867 and 8,445,251, the disclosures of which are incorporated herein by reference with respect to compositions and methods for genome editing.

[0233] Pharmaceutical Compositions and Routes of Administration The gene therapy agents described herein may contain a transgene, such as a transgene encoding MTM1, and may be incorporated into a vehicle for administration to a patient, such as a human patient suffering from a neuromuscular disorder (e.g., XLMTM). Pharmaceutical compositions containing a vector, such as a viral vector, containing a transcriptional regulatory element (e.g., a desmin promoter) described herein operably linked to a therapeutic transgene can be prepared using methods known in the art. For example, such compositions can be prepared in a desired form, such as a lyophilized formulation or aqueous solution, using, for example, physiologically acceptable carriers, excipients, or stabilizers (Remington's Pharmaceutical Sciences 16th edition, Osol, A. Ed. (1980); incorporated herein by reference).

[0234] Viral vectors, such as the AAV vectors and other vectors described herein, containing a transcriptional regulatory element operably linked to a therapeutic transgene can be administered to a patient (e.g., a human patient) via a variety of routes of administration. Routes of administration can vary, for example, depending on the onset and severity of the disease, and can include, for example, intradermal, transdermal, parenteral, intravenous, intramuscular, intranasal, subcutaneous, transdermal, intratracheal, intraperitoneal, intraarterial, intravascular, inhalation, perfusion, lavage, and oral administration. Intravascular administration includes delivery into the patient's vascular system. In some embodiments, administration occurs within a blood vessel considered a vein (intravenous), and in some administrations, administration occurs within a blood vessel considered an artery (intraarterial). Veins include, but are not limited to, the internal jugular vein, peripheral veins, coronary veins, hepatic veins, portal vein, saphenous vein, pulmonary veins, superior vena cava, inferior vena cava, gastric vein, splenic vein, inferior mesenteric vein, superior mesenteric vein, cephalic vein, and / or femoral vein. Arteries include, but are not limited to, coronary arteries, pulmonary arteries, brachial arteries, internal carotid arteries, aortic arches, femoral arteries, peripheral arteries, and / or ciliary arteries. Delivery via or to arterioles or capillaries is contemplated.

[0235] Mixtures of the nucleic acids and viral vectors described herein can be prepared in water, suitably mixed with one or more excipients, carriers, or diluents. Dispersions can also be prepared in glycerol, liquid polyethylene glycol, and mixtures thereof, as well as in oils. These preparations may contain preservatives to prevent the growth of microorganisms under ordinary conditions of storage and use. Pharmaceutical forms suitable for injectable use include sterile aqueous solutions or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions (described in U.S. Pat. No. 5,466,468, the disclosure of which is incorporated herein by reference). In either case, the formulation can be sterile and fluid to the extent that easy syringability exists. The formulation can be stable under the conditions of manufacture and storage and can be preserved against the contaminating action of microorganisms, such as bacteria and fungi. The carrier can be a solvent or dispersion medium containing, for example, water, ethanol, a polyol (e.g., glycerol, propylene glycol, and liquid polyethylene glycol), suitable mixtures thereof, and / or vegetable oils. Proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. Prevention of microbial action can be brought about by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and the like. In many cases, it is preferable to include an isotonic agent, for example, sugar or sodium chloride. Prolonged absorption of injectable compositions can be brought about by the use in the compositions of agents delaying absorption, for example, aluminum monostearate and gelatin.

[0236] For example, solutions containing the pharmaceutical compositions described herein are suitably buffered, if necessary, and the liquid diluent is first rendered isotonic with sufficient saline or glucose. These particular aqueous solutions are particularly suitable for intravenous, intramuscular, subcutaneous, and intraperitoneal administration. In this regard, sterile aqueous media that can be employed will be known to those skilled in the art in light of the present disclosure. For example, one dose may be dissolved in 1 mL of NaCl isotonic solution and added to 1000 mL of subcutaneous infusion solution or injected at the intended injection site. Some variation in dosage will inevitably occur depending on the condition of the subject being treated. In any event, the person responsible for administration will determine the appropriate dosage for each individual subject. Furthermore, for human administration, preparations may meet the sterility, pyrogenicity, general safety, and purity standards required by FDA Office of Biologics standards.

[0237] kit The compositions described herein can be provided in a kit for use in treating neuromuscular disorders (e.g., XLM™). In some embodiments, the kit can include one or more viral vectors described herein. The kit can include a package insert providing instructions to a user of the kit, such as a physician of skill in the art, for performing any one of the methods described herein. The kit can optionally include a syringe or other device for administering the composition. In some embodiments, the kit can include one or more additional therapeutic agents.

[0238] In some embodiments, the kit can include one or more anti-cholestasis agents described herein.The kit can include a package insert that provides instructions for the user of the kit, such as a physician skilled in the art, to perform any one of the methods described herein.The kit can optionally include a syringe or other device for administering the composition.In some embodiments, the kit can include one or more additional therapeutic agents.

[0239] Dosing regimen Dosage regimen containing AAV-MTM1 vector Using the compositions and methods of the present disclosure, patients with neuromuscular disorders (e.g., XLMTM) receive approximately 1.3 x 10 14 vg / kg. By administering such an amount of vector to a patient, the beneficial effect of enhancing MTM1 expression in the patient, for example, to within 50% or 200% of wild-type levels, can be achieved without inducing toxic side effects.

[0240] In some embodiments, the AAV vector is about 3 x 10 14 Amounts less than 3 × 10 vg / kg (e.g., about 3 × 10 14 vg / kg, less than 2.9 × 10 14 vg / kg, less than 2.8 × 10 14 vg / kg, less than 2.7 × 10 14 vg / kg, less than 2.6 × 10 14 vg / kg, less than 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14 vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 1010 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 For example, the AAV vector is administered to a patient at approximately 3×10 14 vg / kg, 2.9 × 10 14 vg / kg, 2.8 × 10 14 vg / kg, 2.7 × 10 14 vg / kg, 2.6 × 10 14 vg / kg, 2.5 × 10 14 vg / kg, 2.4 × 10 14 vg / kg, 2.3 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 13 vg / kg, 1 × 10 12 vg / kg, 1 × 10 11 vg / kg, 1 × 10 10 vg / kg, 1 × 10 9 vg / kg, 1 × 10 8 The amount may be administered to the patient in an amount of vg / kg.

[0241] In some embodiments, the AAV vector is about 2.5 x 10 14 Amounts less than 2.5 × 10 vg / kg (e.g., about 2.5 × 10 14 vg / kg, less than 2.4 × 10 14 vg / kg, less than 2.3 × 10 14 vg / kg, less than 2.2 × 10 14vg / kg, less than 2.1 × 10 14 vg / kg, less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 For example, the AAV vector may be administered to a patient at a dose of about 2.5×10 14 vg / kg, 2.4 × 10 14 vg / kg, 2.3 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 13 vg / kg, 1 × 10 12vg / kg, 1 × 10 11 vg / kg, 1 × 10 10 vg / kg, 1 × 10 9 vg / kg, 1 × 10 8 The amount may be administered to the patient in an amount of vg / kg.

[0242] In some embodiments, the AAV vector is about 2 x 10 14 Amounts less than 2 × 10 14 vg / kg, less than 1.9 × 10 14 vg / kg, less than 1.8 × 10 14 vg / kg, less than 1.7 × 10 14 vg / kg, less than 1.6 × 10 14 vg / kg, less than 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 For example, the AAV vector is administered to a patient at approximately 2×10 14 vg / kg, 1.9 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 14vg / kg, 1 × 10 13 vg / kg, 1 × 10 12 vg / kg, 1 × 10 11 vg / kg, 1 × 10 10 vg / kg, 1 × 10 9 vg / kg, 1 × 10 8 The amount may be administered to the patient in an amount of vg / kg.

[0243] In some embodiments, the AAV vector is about 1.5 x 10 14 Amounts less than 1.5 × 10 vg / kg (e.g., about 1.5 × 10 14 vg / kg, less than 1.4 × 10 14 vg / kg, less than 1.3 × 10 14 vg / kg, less than 1.2 × 10 14 vg / kg, less than 1.1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 For example, the AAV vector may be administered to a patient at a dose of about 1.5×10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 13 vg / kg, 1 × 10 12 vg / kg, 1 × 10 11 vg / kg, 1 × 10 10 vg / kg, 1 × 10 9 vg / kg, 1 × 10 8 The amount may be administered to the patient in an amount of vg / kg.

[0244] In some embodiments, the AAV vector is about 1 x 10 14 Amounts less than 1 × 10 vg / kg (e.g., about 1 × 10 14 vg / kg, less than 1 × 10 14 vg / kg, less than 1 × 10 13 vg / kg, less than 1 × 10 12 vg / kg, less than 1 × 10 11 vg / kg, less than 1 × 10 10 vg / kg, less than 1 × 10 9 vg / kg, less than 1 × 10 8 For example, the AAV vector may be administered to a patient at a dose of about 1×10 14 vg / kg, 1 × 10 14 vg / kg, 1 × 10 13 vg / kg, 1 × 10 12 vg / kg, 1 × 10 11 vg / kg, 1 × 10 10 vg / kg, 1 × 10 9 vg / kg, 1 × 10 8 The amount may be administered to the patient in an amount of vg / kg.

[0245] In some embodiments, the AAV vector is about 3 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg (e.g., approximately 3 × 10 13 vg / kg ~ approx. 2.3×10 14 For example, AAV vectors are administered to patients in a dose of approximately 3 × 10 13 vg / kg, 3.1 × 10 13 vg / kg, 3.2 × 10 13 vg / kg, 3.3 × 10 13 vg / kg, 3.4 × 10 13 vg / kg, 3.5 × 10 13 vg / kg, 3.6 × 10 13 vg / kg, 3.7 × 10 13 vg / kg, 3.8 × 10 13 vg / kg, 3.9 × 10 13 vg / kg, 4 × 10 13 vg / kg, 4.1 × 10 13 vg / kg, 4.2 × 10 13vg / kg、4.3×10 13 vg / kg、4.4×10 13 vg / kg、4.5×10 13 vg / kg、4.6×10 13 vg / kg、4.7×10 13 vg / kg、4.8×10 13 vg / kg、4.9×10 13 vg / kg、5×10 13 vg / kg、5.1×10 13 vg / kg、5.2×10 13 vg / kg、5.3×10 13 vg / kg、5.4×10 13 vg / kg、5.5×10 13 vg / kg、5.6×10 13 vg / kg、5.7×10 13 vg / kg、5.8×10 13 vg / kg、5.9×10 13 vg / kg、6×10 13 vg / kg、6.1×10 13 vg / kg、6.2×10 13 vg / kg、6.3×10 13 vg / kg、6.4×10 13 vg / kg、6.5×10 13 vg / kg、6.6×10 13 vg / kg、6.7×10 13 vg / kg、6.8×10 13 vg / kg、6.9×10 13 vg / kg、7×10 13 vg / kg、7.1×10 13 vg / kg、7.2×10 13 vg / kg、7.3×10 13 vg / kg、7.4×10 13 vg / kg、7.5×10 13 vg / kg、7.6×10 13 vg / kg、7.7×10 13 vg / kg、7.8×10 13 vg / kg、7.9×10 13 vg / kg、8×10 13 vg / kg、8.1×10 13 vg / kg、8.2×10 13vg / kg, 8.3 × 10 13 vg / kg, 8.4 × 10 13 vg / kg, 8.5 × 10 13 vg / kg, 8.6 × 10 13 vg / kg, 8.7 × 10 13 vg / kg, 8.8 × 10 13 vg / kg, 8.9 × 10 13 vg / kg, 9 × 10 13 vg / kg, 9.1 × 10 13 vg / kg, 9.2 × 10 13 vg / kg, 9.3 × 10 13 vg / kg, 9.4 × 10 13 vg / kg, 9.5 × 10 13 vg / kg, 9.6 × 10 13 vg / kg, 9.7 × 10 13 vg / kg, 9.8 × 10 13 vg / kg, 9.9 × 10 13 vg / kg, 1 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 The amount may be administered to the patient in an amount of vg / kg.

[0246] In some embodiments, the AAV vector is about 4 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg, e.g., about 4 × 10 13 vg / kg, 4.1 × 10 13 vg / kg, 4.2 × 10 13vg / kg、4.3×10 13 vg / kg、4.4×10 13 vg / kg、4.5×10 13 vg / kg、4.6×10 13 vg / kg、4.7×10 13 vg / kg、4.8×10 13 vg / kg、4.9×10 13 vg / kg、5×10 13 vg / kg、5.1×10 13 vg / kg、5.2×10 13 vg / kg、5.3×10 13 vg / kg、5.4×10 13 vg / kg、5.5×10 13 vg / kg、5.6×10 13 vg / kg、5.7×10 13 vg / kg、5.8×10 13 vg / kg、5.9×10 13 vg / kg、6×10 13 vg / kg、6.1×10 13 vg / kg、6.2×10 13 vg / kg、6.3×10 13 vg / kg、6.4×10 13 vg / kg、6.5×10 13 vg / kg、6.6×10 13 vg / kg、6.7×10 13 vg / kg、6.8×10 13 vg / kg、6.9×10 13 vg / kg、7×10 13 vg / kg、7.1×10 13 vg / kg、7.2×10 13 vg / kg、7.3×10 13 vg / kg、7.4×10 13 vg / kg、7.5×10 13 vg / kg、7.6×10 13 vg / kg、7.7×10 13 vg / kg、7.8×10 13 vg / kg、7.9×10 13 vg / kg、8×10 13 vg / kg、8.1×10 13 vg / kg、8.2×10 13vg / kg, 8.3 × 10 13 vg / kg, 8.4 × 10 13 vg / kg, 8.5 × 10 13 vg / kg, 8.6 × 10 13 vg / kg, 8.7 × 10 13 vg / kg, 8.8 × 10 13 vg / kg, 8.9 × 10 13 vg / kg, 9 × 10 13 vg / kg, 9.1 × 10 13 vg / kg, 9.2 × 10 13 vg / kg, 9.3 × 10 13 vg / kg, 9.4 × 10 13 vg / kg, 9.5 × 10 13 vg / kg, 9.6 × 10 13 vg / kg, 9.7 × 10 13 vg / kg, 9.8 × 10 13 vg / kg, 9.9 × 10 13 vg / kg, 1 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1. 8×10 14 vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 It is administered to patients in an amount of vg / kg.

[0247] In some embodiments, the AAV vector is about 5 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg, e.g., about 5 × 10 13 vg / kg, 5.1 × 10 13 vg / kg, 5.2 × 10 13 vg / kg, 5.3 × 1013 vg / kg、5.4×10 13 vg / kg、5.5×10 13 vg / kg、5.6×10 13 vg / kg、5.7×10 13 vg / kg、5.8×10 13 vg / kg、5.9×10 13 vg / kg、6×10 13 vg / kg、6.1×10 13 vg / kg、6.2×10 13 vg / kg、6.3×10 13 vg / kg、6.4×10 13 vg / kg、6.5×10 13 vg / kg、6.6×10 13 vg / kg、6.7×10 13 vg / kg、6.8×10 13 vg / kg、6.9×10 13 vg / kg、7×10 13 vg / kg、7.1×10 13 vg / kg、7.2×10 13 vg / kg、7.3×10 13 vg / kg、7.4×10 13 vg / kg、7.5×10 13 vg / kg、7.6×10 13 vg / kg、7.7×10 13 vg / kg、7.8×10 13 vg / kg、7.9×10 13 vg / kg、8×10 13 vg / kg、8.1×10 13 vg / kg、8.2×10 13 vg / kg、8.3×10 13 vg / kg、8.4×10 13 vg / kg、8.5×10 13 vg / kg、8.6×10 13 vg / kg、8.7×10 13 vg / kg、8.8×10 13 vg / kg、8.9×10 13 vg / kg、9×10 13 vg / kg、9.1×10 13 vg / kg、9.2×10 13 vg / kg、9.3×10 13vg / kg, 9.4 × 10 13 vg / kg, 9.5 × 10 13 vg / kg, 9.6 × 10 13 vg / kg, 9.7 × 10 13 vg / kg, 9.8 × 10 13 vg / kg, 9.9 × 10 13 vg / kg, 1 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 It is administered to patients in an amount of vg / kg.

[0248] In some embodiments, the AAV vector is about 6 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg, e.g., about 6 × 10 13 vg / kg, 6.1 × 10 13 vg / kg, 6.2 × 10 13 vg / kg, 6.3 × 10 13 vg / kg, 6.4 × 10 13 vg / kg, 6.5 × 10 13 vg / kg, 6.6 × 10 13 vg / kg, 6.7 × 10 13 vg / kg, 6.8 × 10 13 vg / kg, 6.9 × 10 13 vg / kg, 7 × 10 13 vg / kg, 7.1 × 10 13 vg / kg, 7.2 × 10 13 vg / kg, 7.3 × 10 13 vg / kg, 7.4 × 10 13vg / kg, 7.5 × 10 13 vg / kg, 7.6 × 10 13 vg / kg, 7.7 × 10 13 vg / kg, 7.8 × 10 13 vg / kg, 7.9 × 10 13 vg / kg, 8 × 10 13 vg / kg, 8.1 × 10 13 vg / kg, 8.2 × 10 13 vg / kg, 8.3 × 10 13 vg / kg, 8.4 × 10 13 vg / kg, 8.5 × 10 13 vg / kg, 8.6 × 10 13 vg / kg, 8.7 × 10 13 vg / kg, 8.8 × 10 13 vg / kg, 8.9 × 10 13 vg / kg, 9 × 10 13 vg / kg, 9.1 × 10 13 vg / kg, 9.2 × 10 13 vg / kg, 9.3 × 10 13 vg / kg, 9.4 × 10 13 vg / kg, 9.5 × 10 13 vg / kg, 9.6 × 10 13 vg / kg, 9.7 × 10 13 vg / kg, 9.8 × 10 13 vg / kg, 9.9 × 10 13 vg / kg, 1 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, or 2 × 10 14 It is administered to patients in an amount of vg / kg.

[0249] In some embodiments, the AAV vector is about 7 x 10 13vg / kg to approximately 2.3×10 14 in an amount of vg / kg, for example, approximately 7×10 13 vg / kg, 7.1×10 13 vg / kg, 7.2×10 13 vg / kg, 7.3×10 13 vg / kg, 7.4×10 13 vg / kg, 7.5×10 13 vg / kg, 7.6×10 13 vg / kg, 7.7×10 13 vg / kg, 7.8×10 13 vg / kg, 7.9×10 13 vg / kg, 8×10 13 vg / kg, 8.1×10 13 vg / kg, 8.2×10 13 vg / kg, 8.3×10 13 vg / kg, 8.4×10 13 vg / kg, 8.5×10 13 vg / kg, 8.6×10 13 vg / kg, 8.7×10 13 vg / kg, 8.8×10 13 vg / kg, 8.9×10 13 vg / kg, 9×10 13 vg / kg, 9.1×10 13 vg / kg, 9.2×10 13 vg / kg, 9.3×10 13 [[ID=...]]vg / kg, 9.4×10 13 vg / kg, 9.5×10 13 vg / kg, 9.6×10 13 vg / kg, 9.7×10 13 vg / kg, 9.8×10 13 vg / kg, 9.9×10 13 vg / kg, 1×10 14 vg / kg, 1.1×10 14 vg / kg, 1.2×10 14 vg / kg, 1.3×10 14 vg / kg, 1.4×10 14 vg / kg, 1.5×10 14 vg / kg, 1.6×10 14 vg / kg, 1.7×10 14 vg / kg, 1.8×10 14 It seems there are some consecutive line numbers with the same content in the original text which might be a formatting issue. I've translated it as accurately as possible while maintaining the original structure. If you have any further clarifications or corrections regarding the input, please let me know.vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 It is administered to patients in an amount of vg / kg.

[0250] In some embodiments, the AAV vector is about 8 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg, e.g., about 8 × 10 13 vg / kg, 8.1 × 10 13 vg / kg, 8.2 × 10 13 vg / kg, 8.3 × 10 13 vg / kg, 8.4 × 10 13 vg / kg, 8.5 × 10 13 vg / kg, 8.6 × 10 13 vg / kg, 8.7 × 10 13 vg / kg, 8.8 × 10 13 vg / kg, 8.9 × 10 13 vg / kg, 9 × 10 13 vg / kg, 9.1 × 10 13 vg / kg, 9.2 × 10 13 vg / kg, 9.3 × 10 13 vg / kg, 9.4 × 10 13 vg / kg, 9.5 × 10 13 vg / kg, 9.6 × 10 13 vg / kg, 9.7 × 10 13 vg / kg, 9.8 × 10 13 vg / kg, 9.9 × 10 13 vg / kg, 1 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 It is administered to patients in an amount of vg / kg.

[0251] In some embodiments, the AAV vector is about 9 x 10 13 vg / kg ~ approx. 2.3×10 14 vg / kg, e.g., 9 x 10 13 vg / kg, 9.1 × 10 13 vg / kg, 9.2 × 10 13 vg / kg, 9.3 × 10 13 vg / kg, 9.4 × 10 13 vg / kg, 9.5 × 10 13 vg / kg, 9.6 × 10 13 vg / kg, 9.7 × 10 13 vg / kg, 9.8 × 10 13 vg / kg, 9.9 × 10 13 vg / kg, 1 × 10 14 vg / kg, 1.1 × 10 14 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 It is administered to patients in an amount of vg / kg.

[0252] In some embodiments, the AAV vector is about 1 x 10 14 vg / kg ~ approx. 2.3×10 14 vg / kg, e.g., 1 x 10 14 vg / kg, 1.1 × 1014 vg / kg, 1.2 × 10 14 vg / kg, 1.3 × 10 14 vg / kg, 1.4 × 10 14 vg / kg, 1.5 × 10 14 vg / kg, 1.6 × 10 14 vg / kg, 1.7 × 10 14 vg / kg, 1.8 × 10 14 vg / kg, 1.9 × 10 14 vg / kg, 2 × 10 14 vg / kg, 2.1 × 10 14 vg / kg, 2.2 × 10 14 vg / kg, or 2.3 × 10 14 It is administered to patients in an amount of vg / kg.

[0253] In some embodiments, the AAV vector is about 3 x 10 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 4×10 vg / kg. 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 5×10 vg / kg. 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 6×10 vg / kg. 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 7×10 vg / kg. 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 8×10 vg / kg. 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 9 x 10 vg / kg. 13 In some embodiments, the AAV vector is administered to a patient in an amount of about 1 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.1 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.2 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.3 x 10 vg / kg. 14In some embodiments, the AAV vector is administered to a patient in an amount of about 1.4 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.5 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.6 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.7 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.8 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 1.9 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2×10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.1 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.2 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.3 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.4 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.5 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.6 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.7 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.8 x 10 vg / kg. 14 In some embodiments, the AAV vector is administered to a patient in an amount of about 2.9 x 10 vg / kg. 14In some embodiments, the AAV vector is administered to a patient in an amount of about 3 x 10 vg / kg. 14 It is administered to patients in an amount of vg / kg.

[0254] In some embodiments, the AAV vector is administered in an amount (e.g., about 3×10 14 The patient is given a single dose containing less than 100 mg / kg of vasopressin.

[0255] In some embodiments, the AAV vectors are administered in a total amount (e.g., about 3×10 14 The patient is administered two or more (e.g., 2, 3, 4, 5, 6, 7, 8, 9, or 10) doses containing 100 mg / kg or less of the active ingredient (e.g., 100 mg / kg or less of the active ingredient).

[0256] In some embodiments, the AAV vector is administered in an amount (e.g., about 3×10 14 The patient is administered two or more (e.g., 2, 3, 4, 5, 6, 7, 8, 9, or 10) doses each individually containing less than 100 mg / kg of the active ingredient.

[0257] In some embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, 9, or 10) doses are separated from each other by more than one year (e.g., 1 year, 1 year and 1 day, 1 year and 1 month, 1 year and 6 months, 2 years, 3 years, 4 years, or 5 years).

[0258] In some embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, 9, or 10) doses are administered to a patient within about 12 months (e.g., about 12 months, about 11 months, about 10 months, about 9 months, about 8 months, about 7 months, about 6 months, about 5 months, about 4 months, about 3 months, about 2 months, or about 1 month) of each other.

[0259] Combination therapy AAV vectors containing a transgene encoding MTM1 described herein (e.g., resamirigene bilparvovec) can be administered in combination with one or more additional therapeutic treatments (e.g., nasobiliary drainage (NBD)) and / or agents (e.g., anti-cholestasis agents) for the treatment of neuromuscular disorders (e.g., XLMTM).

[0260] Therapeutic treatment In some embodiments, the one or more additional therapeutic treatments are NBD. NBD is a therapeutic treatment performed to help with bile drainage (for example, when the bile duct is blocked, a bile drainage duct facilitates bile flow from the liver to the intestine). In some embodiments, NBD is performed using a bile drainage duct (also known as a biliary stent), which is a thin, hollow, flexible tube with several small holes along the side. A bile drainage duct can be inserted into a patient's bile duct to allow bile to drain.

[0261] therapeutic agent In some embodiments, the one or more additional therapeutic agents are anti-cholestatic agents (e.g., bile acids, farnesoid X receptor (FXR) ligands, fibroblast growth factor 19 (FGF-19) mimetics, Takeda-G protein receptor 5 (TGR5) agonists, peroxisome proliferator-activated receptor (PPAR) agonists, PPAR-alpha agonists, PPAR-delta agonists, dual PPAR-alpha and PPAR-delta agonists, luminal sodium-dependent bile acid transporter (ASBT) inhibitors, immunomodulatory agents, antifibrotic therapies, and nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitors), or combinations thereof.

[0262] In some embodiments, the anti-cholestasis agent is administered to the patient in one or more (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, and 70) doses beginning within about 6 weeks before or after (e.g., about 6 weeks before or after, about 5 weeks before or after, about 4 weeks before or after, about 3 weeks before or after, about 2 weeks before or after, or about 1 week before or after) administration of the viral vector to the patient.

[0263] In some embodiments, the anti-cholestasis agent is administered to the patient in one or more (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, and 70) doses beginning within about 5 weeks before or after (e.g., about 5 weeks before or after, about 4 weeks before or after, about 3 weeks before or after, about 2 weeks before or after, or about 1 week before or after) administration of the viral vector to the patient.

[0264] In some embodiments, the anti-cholestasis agent is administered to the patient in one or more (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, and 70) doses beginning within about one week before or after (e.g., about one week before or after, about six days before or after, about five days before or after, about four days before or after, about three days before or after, about two days before or after, or about one day before or after) administration of the viral vector to the patient.

[0265] In some embodiments, the anti-cholestatic agent is administered on the same day as the administration of the viral vector to the patient (e.g., 24 hours, 23 hours, 22 hours, 21 hours, 20 hours, 19 hours, 18 hours, 17 hours, 16 hours, 15 hours, 14 hours, 13 hours, 12 hours, 11 hours, 10 hours, 9 hours, 8 hours, 7 hours, 6 hours, 5 hours, 4 hours after administration). The patient may be administered one or more (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 30, 40, 50, 60, and 70) doses beginning at the following time points: 1 hour, 3rd hour, 2nd hour, 1st hour, 60th minute, 59th minute, 58th minute, 57th minute, 56th minute, 55th minute, 50th minute, 40th minute, 30th minute, 20th minute, 10th minute, or the same minute).

[0266] In some embodiments, the anticholestatic agent is a bile acid. In some embodiments, the bile acid is ursodeoxycholic acid or a derivative thereof, or norursodeoxycholic acid. In some embodiments, the bile acid is ursodiol.

[0267] In some embodiments, the anti-cholestasis agent is an FXR ligand. In some embodiments, the FXR ligand is obeticholic acid, cilofexor, tropifexor, tretinoin, or EDP-305.

[0268] In some embodiments, the one or more anti-cholestasis agents is an FGF-19 mimetic. In some embodiments, the FGF-19 mimetic is aldafermin.

[0269] In some embodiments, the anti-cholestatic agent is a TGR5 agonist. In some embodiments, the TGR5 agonist is INT-777 or INT-767.

[0270] In some embodiments, the anti-cholestatic agent is a PPAR agonist. In some embodiments, the PPAR agonist is bezafibrate, seladelpar, or elafibrinol.

[0271] In some embodiments, the anti-cholestatic agent is a PPAR-alpha agonist. In some embodiments, the PPAR-alpha agonist is fenofibrate.

[0272] In some embodiments, the anti-cholestatic agent is a PPAR-delta agonist. In some embodiments, the PPAR-delta agonist is seladelpar.

[0273] In some embodiments, the anti-cholestatic agent is a dual PPAR-alpha and PPAR-delta agonist, hi some embodiments, the PPAR-alpha-delta dual agonist is elafibranor.

[0274] In some embodiments, the one or more anti-cholestatic agents is an ASBT inhibitor, hi some embodiments, the ASBT inhibitor is odevixibat, maralixibat, or linelixibat.

[0275] In some embodiments, the anti-cholestatic agent is an immunomodulatory agent, hi some embodiments, the immunomodulatory agent is rituximab, abatacept, ustekinumab, infliximab, baricitinib, or FFP104.

[0276] In some embodiments, the anti-cholestatic agent is an anti-fibrotic therapy. In some embodiments, the anti-fibrotic therapy is a vitamin D receptor (VDR) agonist or simtuzumab.

[0277] In some embodiments, the anti-cholestatic agent is a NOX inhibitor. In some embodiments, the NOX inhibitor is setanaxib.

[0278] In some embodiments, a therapeutically effective amount of a viral vector (e.g., resamirigene bilparvovec) comprising a transgene encoding MTM1 and an anti-cholestatic agent are administered to a patient in need thereof. In some embodiments, a therapeutically effective amount of resamirigene bilparvovec and an anti-cholestatic agent are administered to a patient in need thereof. In some embodiments, a therapeutically effective amount of resamirigene bilparvovec and an anti-cholestatic agent are administered to a patient in need thereof, wherein the anti-cholestatic agent is a bile acid. In some embodiments, a therapeutically effective amount of resamirigene bilparvovec and an anti-cholestatic agent are administered to a patient in need thereof, wherein the anti-cholestatic agent is ursodiol. In some embodiments, a therapeutically effective amount of resamirigene bilparvovec and an anti-cholestatic agent are administered to a patient in need thereof.

[0279] Anticholestatic drugs Using the compositions and methods of the present disclosure, patients with neuromuscular disorders (e.g., XLMTM) can be administered an AAV vector containing a transgene encoding MTM1 and an anti-cholestatic agent.

[0280] In some embodiments, the patient is administered an anti-cholestasis agent.

[0281] In some embodiments, the patient is monitored for cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic is administered if the patient is determined to exhibit cholestasis or hyperbilirubinemia, or one or more symptoms thereof.

[0282] In some embodiments, a patient is administered an anti-cholestatic if the patient is determined to be exhibiting cholestasis or hyperbilirubinemia or one or more symptoms thereof.

[0283] In some embodiments, the anti-cholestatic agent is selected from the list including bile acids, farnesoid X receptor (FXR) ligands, fibroblast growth factor 19 (FGF-19) mimetics, Takeda-G protein receptor 5 (TGR5) agonists, peroxisome proliferator-activated receptor (PPAR) agonists, PPAR-alpha agonists, PPAR-delta agonists, dual PPAR-alpha and PPAR-delta agonists, luminal sodium-dependent bile acid transporter (ASBT) inhibitors, immunomodulatory agents, antifibrotic therapies, and nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitors.

[0284] In some embodiments, the anticholestatic agent is a bile acid. In some embodiments, the bile acid is ursodeoxycholic acid or a derivative thereof, or norursodeoxycholic acid. In some embodiments, the bile acid is ursodiol.

[0285] In some embodiments, the anti-cholestasis agent is an FXR ligand. In some embodiments, the FXR ligand is obeticholic acid, cilofexor, tropifexor, tretinoin, or EDP-305.

[0286] In some embodiments, the one or more anti-cholestasis agents is an FGF-19 mimetic. In some embodiments, the FGF-19 mimetic is aldafermin.

[0287] In some embodiments, the anti-cholestatic agent is a TGR5 agonist. In some embodiments, the TGR5 agonist is INT-777 or INT-767.

[0288] In some embodiments, the anti-cholestatic agent is a PPAR agonist. In some embodiments, the PPAR agonist is bezafibrate, seladelpar, or elafibrinol.

[0289] In some embodiments, the anti-cholestatic agent is a PPAR-alpha agonist. In some embodiments, the PPAR-alpha agonist is fenofibrate.

[0290] In some embodiments, the anti-cholestatic agent is a PPAR-delta agonist. In some embodiments, the PPAR-delta agonist is seladelpar.

[0291] In some embodiments, the anti-cholestatic agent is a dual PPAR-alpha and PPAR-delta agonist, hi some embodiments, the PPAR-alpha-delta dual agonist is elafibranor.

[0292] In some embodiments, the one or more anti-cholestatic agents is an ASBT inhibitor, hi some embodiments, the ASBT inhibitor is odevixibat, maralixibat, or linelixibat.

[0293] In some embodiments, the anti-cholestatic agent is an immunomodulatory agent, hi some embodiments, the immunomodulatory agent is rituximab, abatacept, ustekinumab, infliximab, baricitinib, or FFP104.

[0294] In some embodiments, the anti-cholestatic agent is an anti-fibrotic therapy. In some embodiments, the anti-fibrotic therapy is a vitamin D receptor (VDR) agonist or simtuzumab.

[0295] In some embodiments, the anti-cholestatic agent is a NOX inhibitor. In some embodiments, the NOX inhibitor is setanaxib.

[0296] I. Bile acids Using the methods described herein, bile acids can be administered to a subject. In some embodiments, the bile acid is ursodeoxycholic acid or a derivative thereof, or norursodeoxycholic acid. In some embodiments, the bile acid is ursodiol.

[0297] Ursodiol and other known variants have the generic structure shown below:

[0298] [ka] wherein each of R and R is independently hydrogen, optionally substituted alkyl, optionally substituted alkenyl, optionally substituted alkynyl, optionally substituted cycloalkyl, optionally substituted heterocyclyl, optionally substituted aryl, or optionally substituted heteroaryl; R3 is OR4, NHR4, or SR4; R4 is hydrogen, optionally substituted alkyl, optionally substituted alkenyl, optionally substituted alkynyl, optionally substituted cycloalkyl, optionally substituted heterocyclyl, optionally substituted aryl, or optionally substituted heteroaryl; n is an integer from 0 to 4. or a pharmaceutically acceptable salt thereof.

[0299] Such compounds are described, for example, in US Pat. No. 4,828,763, the disclosure of which is incorporated herein by reference.

[0300] Bile acid-containing dosing regimens The bile acids described herein can be administered in an amount of about 5 mg / kg / dose to about 20 mg / kg / dose (eg, an amount of about 5 mg / kg / dose to about 20 mg / kg / dose). For example, bile acids can be administered to a patient in an amount of about 5 mg / kg / dose, 5.1 mg / kg / dose, 5 mg / kg / dose, 5.1 mg / kg / dose, 5.2 mg / kg / dose, 5.3 mg / kg / dose, 5.4 mg / kg / dose, 5.5 mg / kg / dose, 6 mg / kg / dose, 6.5 mg / kg / dose, 7 mg / kg / dose, 8 mg / kg / dose, 9 mg / kg / dose, 10 mg / kg / dose, 11 mg / kg / dose, 12 mg / kg / dose, 13 mg / kg / dose, 14 mg / kg / dose, 15 mg / kg / dose, 16 mg / kg / dose, 17 mg / kg / dose, 18 mg / kg / dose, 19 mg / kg / dose, or 20 mg / kg / dose.

[0301] For example, in some embodiments, bile acids are administered in an amount of about 5 mg / kg / dose to about 11 mg / kg / dose, e.g., about 5 mg / kg / dose, 5.1 mg / kg / dose, 5.2 mg / kg / dose, 5.3 mg / kg / dose, 5.4 mg / kg / dose, 5.5 mg / kg / dose, 5.6 mg / kg / dose, 5.7 mg / kg / dose, 5.8 mg / kg / dose, 5.9 mg / kg / dose, 6 mg / kg / dose, 6.1 mg / kg / dose, 6.2 mg / kg / dose, kg / dose, 6.3mg / kg / dose, 6.4mg / kg / dose, 6.5mg / kg / dose, 6.6mg / kg / dose, 6.7mg / kg / dose, 6.8mg / kg / dose, 6.9mg / kg / dose, 7mg / kg / dose , 7.1mg / kg / dose, 7.2mg / kg / dose, 7.3mg / kg / dose, 7.4mg / kg / dose, 7.5mg / kg / dose, 7.6mg / kg / dose, 7.7mg / kg / dose, 7.8mg / kg / dose, 7.9 mg / kg / dose, 8mg / kg / dose, 8.1mg / kg / dose, 8.2mg / kg / dose, 8.3mg / kg / dose, 8.4mg / kg / dose, 8.5mg / kg / dose, 8.6mg / kg / dose, 8.7mg / kg / dose, 8.8mg / kg / dose, 8.9mg / kg / dose, 9mg / kg / dose, 9.1mg / kg / dose, 9.2mg / kg / dose, 9.3mg / kg / dose, 9.4mg / kg / dose, 9.5mg / kg / dose, 9. It is administered to patients in amounts of 6 mg / kg / dose, 9.7 mg / kg / dose, 9.8 mg / kg / dose, 9.9 mg / kg / dose, 10 mg / kg / dose, 10.1 mg / kg / dose, 10.2 mg / kg / dose, 10.3 mg / kg / dose, 10.4 mg / kg / dose, 10.5 mg / kg / dose, 10.6 mg / kg / dose, 10.7 mg / kg / dose, 10.8 mg / kg / dose, 10.9 mg / kg / dose, or 11 mg / kg / dose.

[0302] In some embodiments, the bile acids are administered to the patient in a single dose.

[0303] In some embodiments, the bile acids are administered to the patient in multiple doses.

[0304] In some embodiments, bile acids are administered in one or more doses per day (one dose per day, two doses per day, three doses per day, four doses per day, five doses per day, six doses per day, seven doses per day, eight doses per day, nine doses per day, and ten doses per day), one or more doses per week (one dose per week, two doses per week, three doses per week, four doses per week, five doses per week, six doses per week, seven doses per week, eight doses per week, nine doses per week, ten doses per week, eleven doses per week, 12 doses per week, 13 doses per week, and 14 doses per week), or one or more doses per month. The drug is administered to patients at doses of once a month, twice a month, three times a month, four times a month, five times a month, six times a month, seven times a month, eight times a month, nine times a month, ten times a month, and eleven times a month, twelve times a month, thirteen times a month, fourteen times a month, fifteen times a month, sixteen times a month, seventeen times a month, eighteen times a month, nineteen times a month, twenty times a month, twenty-one times a month, twenty-two times a month, twenty-three times a month, twenty-fourth times a month, twenty-five times a month, twenty-sixth times a month, twenty-seventh times a month, twenty-eighth times a month, twenty-ninth times a month, and thirtyth times a month.

[0305] For example, in some embodiments, bile acids are administered to a patient in one or more doses per day, e.g., once a day, twice a day, three times a day, four times a day, five times a day, six times a day, seven times a day, eight times a day, nine times a day, or ten times a day.

[0306] In some embodiments, two or more doses of bile acids totaling a particular amount are separated from each other, e.g., by one hour or more. In some embodiments, the two or more doses are administered to a patient within about 24 hours of each other (e.g., within about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 hours of each other).

[0307] In some embodiments, bile acids are administered to a patient in doses once daily, twice daily, three times daily, four times daily, or five times daily.

[0308] In some embodiments, the bile acids are administered to the patient in a single daily dose.

[0309] In some embodiments, ursodiol is administered in an amount of about 5 mg / kg / day to about 40 mg / kg / day (eg, an amount of about 5 mg / kg / day to about 40 mg / kg / day). For example, ursodiol may be administered to a patient in an amount of about 5 mg / kg / day, 5.1 mg / kg / day, 5 mg / kg / day, 5.1 mg / kg / day, 5.2 mg / kg / day, 5.3 mg / kg / day, 5.4 mg / kg / day, 5.5 mg / kg / day, 6 mg / kg / day, 6.5 mg / kg / day, 7 mg / kg / day, 8 mg / kg / day, 9 mg / kg / day, 10 mg / kg / day, 11 mg / kg / day, 12 mg / kg / day, 13 mg / kg / day, 14 mg / kg / day, 15 mg / kg / day, 16 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 25 mg / kg / day, 30 mg / kg / day, 35 mg / kg / day, or 40 mg / kg / day.

[0310] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 15 mg / kg / day to about 25 mg / kg / day, e.g., about 15 mg / kg / day, 15.1 mg / kg / day, 15.2 mg / kg / day, 15.3 mg / kg / day, 15.4 mg / kg / day, 15.5 mg / kg / day, 15.6 mg / kg / day, 15.7 mg / kg / day, 15.8 mg / kg / day, 15.9 mg / kg / day, 16 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, 22 mg / kg / day, 23 mg / kg / day, 24 mg / kg / day, or 25 mg / kg / day.

[0311] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 16 mg / kg / day to about 24 mg / kg / day, e.g., about 16 mg / kg / day, 16.1 mg / kg / day, 16.2 mg / kg / day, 16.3 mg / kg / day, 16.4 mg / kg / day, 16.5 mg / kg / day, 16.6 mg / kg / day, 16.7 mg / kg / day, 16.8 mg / kg / day, 16.9 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, 22 mg / kg / day, 23 mg / kg / day, or 24 mg / kg / day.

[0312] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 17 mg / kg / day to about 23 mg / kg / day, e.g., about 17 mg / kg / day, 17.1 mg / kg / day, 17.2 mg / kg / day, 17.3 mg / kg / day, 17.4 mg / kg / day, 17.5 mg / kg / day, 17.6 mg / kg / day, 17.7 mg / kg / day, 17.8 mg / kg / day, 17.9 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, 22 mg / kg / day, or 23 mg / kg / day.

[0313] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 18 mg / kg / day to about 22 mg / kg / day, e.g., about 18 mg / kg / day, 18.1 mg / kg / day, 18.2 mg / kg / day, 18.3 mg / kg / day, 18.4 mg / kg / day, 18.5 mg / kg / day, 18.6 mg / kg / day, 18.7 mg / kg / day, 18.8 mg / kg / day, 18.9 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, or 22 mg / kg / day.

[0314] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 19 mg / kg / day to about 21 mg / kg / day, e.g., about 19 mg / kg / day, 19.1 mg / kg / day, 19.2 mg / kg / day, 19.3 mg / kg / day, 19.4 mg / kg / day, 19.5 mg / kg / day, 19.6 mg / kg / day, 19.7 mg / kg / day, 19.8 mg / kg / day, 19.9 mg / kg / day, 20 mg / kg / day, 20.1 mg / kg / day, 20.2 mg / kg / day, 20.3 mg / kg / day, 20.4 mg / kg / day, 20.5 mg / kg / day, 20.6 mg / kg / day, 20.7 mg / kg / day, 20.8 mg / kg / day, 20.9 mg / kg / day, or 21 mg / kg / day.

[0315] In some embodiments, ursodiol is administered to the patient in an amount of 20 mg / kg / day.

[0316] In some embodiments, ursodiol is administered to a patient in one or more doses per week, e.g., once a week, twice a week, three times a week, four times a week, five times a week, ten times a week, fifteen times a week, twenty times a week, thirty times a week, fifty times a week, sixty times a week, and seventy times a week.

[0317] In some embodiments, ursodiol is administered to a patient one or more times per month, e.g., once a month, twice a month, three times a month, four times a month, five times a month, ten times a month, fifteen times a month, twenty times a month, thirty times a month, fifty times a month, sixty times a month, seventy times a month, eighty times a month, ninety times a month, one hundred times a month, two hundred times a month, and three hundred times a month.

[0318] In some embodiments, ursodiol is administered to a patient in a unit dosage form containing 250 mg of ursodiol.

[0319] In some embodiments, ursodiol is administered to a patient in a unit dosage form containing 500 mg of ursodiol.

[0320] Ia. Norursodeoxycholic acid Using the methods described herein, norursodeoxycholic acid can be administered to a subject.

[0321] Norursodeoxycholic acid is an INN for the compound of the chemical structure shown below.

[0322] [ka]

[0323] Ib. Ursodeoxycholic Acid and Derivatives Using the methods described herein, ursodeoxycholic acid or a derivative thereof can be administered to a subject.

[0324] Ursodeoxycholic acid is an INN for the compound also known by the pharmaceutical names 128-13-2 and ursodiol.

[0325] The chemical structure of ursodiol is shown below.

[0326] [ka]

[0327] Ibi. Ursodiol-containing dosage regimen The ursodiol described herein can be administered in an amount of about 5 mg / kg / dose to about 20 mg / kg / dose (e.g., an amount of about 5 mg / kg / dose to about 20 mg / kg / dose). For example, ursodiol may be administered to a patient in an amount of about 5 mg / kg / dose, 5.1 mg / kg / dose, 5 mg / kg / dose, 5.1 mg / kg / dose, 5.2 mg / kg / dose, 5.3 mg / kg / dose, 5.4 mg / kg / dose, 5.5 mg / kg / dose, 6 mg / kg / dose, 6.5 mg / kg / dose, 7 mg / kg / dose, 8 mg / kg / dose, 9 mg / kg / dose, 10 mg / kg / dose, 11 mg / kg / dose, 12 mg / kg / dose, 13 mg / kg / dose, 14 mg / kg / dose, 15 mg / kg / dose, 16 mg / kg / dose, 17 mg / kg / dose, 18 mg / kg / dose, 19 mg / kg / dose, or 20 mg / kg / dose.

[0328] For example, in some embodiments, ursodiol is administered in an amount of about 5 mg / kg / dose to about 11 mg / kg / dose, e.g., about 5 mg / kg / dose, 5.1 mg / kg / dose, 5.2 mg / kg / dose, 5.3 mg / kg / dose, 5.4 mg / kg / dose, 5.5 mg / kg / dose, 5.6 mg / kg / dose, 5.7 mg / kg / dose, 5.8 mg / kg / dose, 5.9 mg / kg / dose, 6 mg / kg / dose, 6.1 mg / kg / dose, 6. 2mg / kg / dose, 6.3mg / kg / dose, 6.4mg / kg / dose, 6.5mg / kg / dose, 6.6mg / kg / dose, 6.7mg / kg / dose, 6.8mg / kg / dose, 6.9mg / kg / dose, 7mg / kg / dose, 7.1mg / kg / dose, 7.2mg / kg / dose, 7.3mg / kg / dose, 7.4mg / kg / dose, 7.5mg / kg / dose, 7.6mg / kg / dose, 7.7mg / kg / dose, 7.8mg / kg / dose, 7.9mg / kg / dose, 8mg / kg / dose, 8.1mg / kg / dose, 8.2mg / kg / dose, 8.3mg / kg / dose, 8.4mg / kg / dose, 8.5mg / kg / dose, 8.6mg / kg / dose, 8.7mg / dose kg / dose, 8.8mg / kg / dose, 8.9mg / kg / dose, 9mg / kg / dose, 9.1mg / kg / dose, 9.2mg / kg / dose, 9.3mg / kg / dose, 9.4mg / kg / dose, 9.5mg / kg / dose, It is administered to patients in amounts of 9.6 mg / kg / dose, 9.7 mg / kg / dose, 9.8 mg / kg / dose, 9.9 mg / kg / dose, 10 mg / kg / dose, 10.1 mg / kg / dose, 10.2 mg / kg / dose, 10.3 mg / kg / dose, 10.4 mg / kg / dose, 10.5 mg / kg / dose, 10.6 mg / kg / dose, 10.7 mg / kg / dose, 10.8 mg / kg / dose, 10.9 mg / kg / dose, or 11 mg / kg / dose.

[0329] In some embodiments, ursodiol is administered to the patient in a single dose.

[0330] In some embodiments, ursodiol is administered to the patient in multiple doses.

[0331] In some embodiments, ursodiol is administered in one or more doses per day (once a day, twice a day, three times a day, four times a day, five times a day, six times a day, seven times a day, eight times a day, nine times a day, and ten times a day), one or more doses per week (once a week, twice a week, three times a week, four times a week, five times a week, six times a week, seven times a week, eight times a week, nine times a week, ten times a week, eleven times a week, twelve times a week, thirteen times a week, and fourteen times a week), or one or more doses per month. The drug is administered to patients in one or more doses (once a month, twice a month, three times a month, four times a month, five times a month, six times a month, seven times a month, eight times a month, nine times a month, ten times a month, and eleven times a month, twelve times a month, thirteen times a month, fourteen times a month, fifteen times a month, sixteen times a month, seventeen times a month, eighteen times a month, nineteen times a month, twenty times a month, twenty-one times a month, twenty-two times a month, twenty-three times a month, twenty-fourth times a month, twenty-five times a month, twenty-sixth times a month, twenty-seventh times a month, twenty-eighth times a month, twenty-ninth times a month, and thirtyth times a month).

[0332] For example, in some embodiments, ursodiol is administered to a patient in one or more doses per day, e.g., once a day, twice a day, three times a day, four times a day, five times a day, six times a day, seven times a day, eight times a day, nine times a day, or ten times a day.

[0333] In some embodiments, two or more doses of ursodiol totaling a particular amount are separated from each other, for example, by at least one hour. In some embodiments, two or more doses are administered to a patient within about 24 hours of each other (e.g., within about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 hours of each other).

[0334] In some embodiments, ursodiol is administered to a patient in doses once daily, twice daily, three times daily, four times daily, or five times daily.

[0335] In some embodiments, ursodiol is administered to the patient in a single dose per day.

[0336] In some embodiments, ursodiol is administered in an amount of about 5 mg / kg / day to about 40 mg / kg / day (eg, an amount of about 5 mg / kg / day to about 40 mg / kg / day). For example, ursodiol may be administered to a patient in an amount of about 5 mg / kg / day, 5.1 mg / kg / day, 5 mg / kg / day, 5.1 mg / kg / day, 5.2 mg / kg / day, 5.3 mg / kg / day, 5.4 mg / kg / day, 5.5 mg / kg / day, 6 mg / kg / day, 6.5 mg / kg / day, 7 mg / kg / day, 8 mg / kg / day, 9 mg / kg / day, 10 mg / kg / day, 11 mg / kg / day, 12 mg / kg / day, 13 mg / kg / day, 14 mg / kg / day, 15 mg / kg / day, 16 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 25 mg / kg / day, 30 mg / kg / day, 35 mg / kg / day, or 40 mg / kg / day.

[0337] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 15 mg / kg / day to about 25 mg / kg / day, e.g., about 15 mg / kg / day, 15.1 mg / kg / day, 15.2 mg / kg / day, 15.3 mg / kg / day, 15.4 mg / kg / day, 15.5 mg / kg / day, 15.6 mg / kg / day, 15.7 mg / kg / day, 15.8 mg / kg / day, 15.9 mg / kg / day, 16 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, 22 mg / kg / day, 23 mg / kg / day, 24 mg / kg / day, or 25 mg / kg / day.

[0338] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 16 mg / kg / day to about 24 mg / kg / day, e.g., about 16 mg / kg / day, 16.1 mg / kg / day, 16.2 mg / kg / day, 16.3 mg / kg / day, 16.4 mg / kg / day, 16.5 mg / kg / day, 16.6 mg / kg / day, 16.7 mg / kg / day, 16.8 mg / kg / day, 16.9 mg / kg / day, 17 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, 22 mg / kg / day, 23 mg / kg / day, or 24 mg / kg / day.

[0339] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 17 mg / kg / day to about 23 mg / kg / day, e.g., about 17 mg / kg / day, 17.1 mg / kg / day, 17.2 mg / kg / day, 17.3 mg / kg / day, 17.4 mg / kg / day, 17.5 mg / kg / day, 17.6 mg / kg / day, 17.7 mg / kg / day, 17.8 mg / kg / day, 17.9 mg / kg / day, 18 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, 22 mg / kg / day, or 23 mg / kg / day.

[0340] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 18 mg / kg / day to about 22 mg / kg / day, e.g., about 18 mg / kg / day, 18.1 mg / kg / day, 18.2 mg / kg / day, 18.3 mg / kg / day, 18.4 mg / kg / day, 18.5 mg / kg / day, 18.6 mg / kg / day, 18.7 mg / kg / day, 18.8 mg / kg / day, 18.9 mg / kg / day, 19 mg / kg / day, 20 mg / kg / day, 21 mg / kg / day, or 22 mg / kg / day.

[0341] For example, in some embodiments, ursodiol is administered to a patient in an amount of about 19 mg / kg / day to about 21 mg / kg / day, e.g., about 19 mg / kg / day, 19.1 mg / kg / day, 19.2 mg / kg / day, 19.3 mg / kg / day, 19.4 mg / kg / day, 19.5 mg / kg / day, 19.6 mg / kg / day, 19.7 mg / kg / day, 19.8 mg / kg / day, 19.9 mg / kg / day, 20 mg / kg / day, 20.1 mg / kg / day, 20.2 mg / kg / day, 20.3 mg / kg / day, 20.4 mg / kg / day, 20.5 mg / kg / day, 20.6 mg / kg / day, 20.7 mg / kg / day, 20.8 mg / kg / day, 20.9 mg / kg / day, or 21 mg / kg / day.

[0342] In some embodiments, ursodiol is administered to the patient in an amount of 20 mg / kg / day.

[0343] In some embodiments, ursodiol is administered to a patient in one or more doses per week, e.g., once a week, twice a week, three times a week, four times a week, five times a week, ten times a week, fifteen times a week, twenty times a week, thirty times a week, fifty times a week, sixty times a week, and seventy times a week.

[0344] In some embodiments, ursodiol is administered to a patient one or more times per month, e.g., once a month, twice a month, three times a month, four times a month, five times a month, ten times a month, fifteen times a month, twenty times a month, thirty times a month, fifty times a month, sixty times a month, seventy times a month, eighty times a month, ninety times a month, one hundred times a month, two hundred times a month, and three hundred times a month.

[0345] In some embodiments, ursodiol is administered to a patient in a unit dosage form containing 250 mg of ursodiol.

[0346] In some embodiments, ursodiol is administered to a patient in a unit dosage form containing 500 mg of ursodiol.

[0347] II. FXR Ligands Using the methods described herein, an FXR ligand can be administered to a subject. In some embodiments, the FXR ligand is obeticholic acid, cilofexor, tropifexor, tretinoin, or EDP-305.

[0348] IIa. Obeticholic acid Using the methods described herein, obeticholic acid can be administered to a subject. Obeticholic acid is an INN for a compound also known as INT-747. Obeticholic acid has the chemical structure shown below.

[0349] [ka]

[0350] IIb. Cilofexor Using the methods described herein, cilofexol can be administered to a subject. Cilofexol is an INN for a compound also known by the code name GS-9674. Cilofexol has the chemical structure shown below.

[0351] [ka]

[0352] IIc. Tropifexol Using the methods described herein, tropifexol can be administered to a subject. Tropifexol is an INN for a compound also known by the code name LJN452. Tropifexol has the chemical structure shown below.

[0353] [ka]

[0354] IId. Tretinoin Using the methods described herein, tretinoin can be administered to a subject. Tretinoin is an INN for the compound also known as 302-79-4. Retinoin has the chemical structure shown below.

[0355] [ka]

[0356] IIe.EDP-305 Using the methods described herein, EDP-305 can be administered to a subject. EDP-305 is a code name for a compound having the chemical structure shown below.

[0357] [ka]

[0358] III. Fibroblast Growth Factor 19 (FGF-19) Mimetics Using the methods described herein, an FGF-19 mimetic can be administered to a subject. In some embodiments, the FGF-19 mimetic is aldafermin.

[0359] IIIa. Aldafermin Using the methods described herein, aldafermin can be administered to a subject. Aldafermin is available under the code name NGM282 and C 940 -H 1472 N 266 O 279 S 11 The chemical formula for the compound is also known as INN.

[0360] IV. Takeda - G Protein Receptor 5 (TGR5) Agonist Using the methods described herein, a TGR5 agonist can be administered to a subject. In some embodiments, the TGR5 agonist is INT-777 or INT-767.

[0361] IVa.INT-777 The methods described herein can be used to administer to a subject INT-777, which is the code name for the compound also known as S-EMCA.

[0362] [ka]

[0363] IVb.INT-767 Using the methods described herein, INT-767 can be administered to a subject. INT-767 is a code name for a compound having the chemical structure shown below.

[0364] [ka]

[0365] V. Peroxisome Proliferator-Activated Receptor (PPAR) Agonists Using the methods described herein, a PPAR agonist can be administered to a subject. In some embodiments, the PPAR agonist is bezafibrate, seladelpar, or elafibrinol.

[0366] Va. Bezafibrate Using the methods described herein, bezafibrate can be administered to a subject.Bezafibrate is an INN for a compound also known as C10AB02.Bezafibrate has the chemical structure shown below.

[0367] [ka]

[0368] Vb. Serra del Par Using the methods described herein, seladelpal can be administered to a subject. Seladelpal is an INN for a compound also known by the code name MBX-8025. Seladelpal has the chemical structure shown below.

[0369] [ka]

[0370] Vc. elafibrinol Using the methods described herein, elafibrinol can be administered to a subject. Elafibrinol is an INN for a compound also known by the code name GFT505. Elafibrinol has the chemical structure shown below.

[0371] [ka]

[0372] VI. PPAR-alpha agonists Using the methods described herein, a PPAR-alpha agonist can be administered to a subject. In some embodiments, the PPAR-alpha agonist is fenofibrate.

[0373] VIa. Fenofibrate Using the methods described herein, fenofibrate can be administered to a subject. Fenofibrate is an INN to the compound of the chemical structure shown below.

[0374] [ka]

[0375] VII. PPAR-delta agonists Using the methods described herein, a PPAR-delta agonist can be administered to a subject. In some embodiments, the PPAR-delta agonist is seradelpar.

[0376] VIIa. Serra del Par Using the methods described herein, seladelpal can be administered to a subject. Seladelpal is an INN for a compound also known by the code name MBX-8025. Seladelpal has the chemical structure shown below.

[0377] [ka]

[0378] VIII. Dual PPAR-alpha and PPAR-delta agonists Using the methods described herein, a PPAR-alpha and PPAR-delta dual agonist can be administered to a subject. In some embodiments, the PPAR-alpha-delta dual agonist is elafibranor.

[0379] VIIIa. Elafibranor Using the methods described herein, elafibrinol can be administered to a subject. Elafibrinol is an INN for a compound also known by the code name GFT505. Elafibrinol has the chemical structure shown below.

[0380] [ka]

[0381] IX. Apical sodium-dependent bile acid transporter (ASBT) inhibitors Using the methods described herein, an ASBT inhibitor can be administered to a subject. In some embodiments, the ASBT inhibitor is odevixibat, maralixibat, or linelixibat.

[0382] IXa. Odevixibat Using the methods described herein, odevixibat can be administered to a subject.Odevixibat is an INN for a compound also known as code name A4250.Odevixibat has the chemical structure shown below.

[0383] [ka]

[0384] IXb. Malalixibat Using the methods described herein, maralixibat can be administered to a subject. Maralixibat is an INN to the compound of the chemical structure shown below.

[0385] [ka]

[0386] IXc. Linerixibat Using the methods described herein, linelixibat can be administered to a subject. Linelixibat is an INN for the compound of the chemical structure shown below.

[0387] [ka]

[0388] X. Immunomodulatory Drugs Using the methods described herein, an immunomodulatory agent can be administered to a subject. In some embodiments, the immunomodulatory agent is rituximab, abatacept, ustekinumab, infliximab, baricitinib, or FFP104.

[0389] Xa. Rituximab Using the methods described herein, rituximab can be administered to a subject. Rituximab has the chemical formula C 6416 -H 9874-N 1688 -O 1987 -S 44 It is an INN for antibodies with

[0390] Xb. Abatacept Using the methods described herein, abatacept can be administered to a subject. Abatacept has the chemical formula C 3498 H 5458 N 922 O 1090 S 32 It is an INN for antibodies with

[0391] Xc. Ustekinumab Using the methods described herein, ustekinumab can be administered to a subject. Ustekinumab has the chemical formula C 6482 H 10004 N 1712 O 2016 S 46 It is an INN for antibodies with

[0392] Xd. Infliximab Using the methods described herein, infliximab can be administered to a subject. Infliximab has the chemical formula C 6428 H 9912 N 1694 O 1987 S 46 It is an INN for antibodies with

[0393] Xe.Baricitinib Using the methods described herein, baricitinib can be administered to a subject. Baricitinib is an INN for the compound of the chemical structure shown below.

[0394] [ka]

[0395] Xf.FFP104 Using the methods described herein, FFP104 can be administered to a subject. FFP104 is an anti-CD40 monoclonal antibody.

[0396] XI. Anti-fibrotic therapy Using the methods described herein, an anti-fibrotic therapy can be administered to a subject. In some embodiments, the anti-fibrotic therapy is a vitamin D receptor (VDR) agonist or simtuzumab.

[0397] XIa.VDR agonist Using the methods described herein, a VDR agonist can be administered to a subject. Exemplary VDR agonists include, but are not limited to, compounds known by the INN names seocalcitol, elocalcitol, and calcipotriol.

[0398] XIai. Seocalcitol Using the methods described herein, seocalcitol can be administered to a subject. Seocalcitol is an INN to the compound of the chemical structure shown below.

[0399] [ka]

[0400] Elocalcitol Using the methods described herein, elocalcitol can be administered to a subject. Elocalcitol is an INN to the compound of the chemical structure shown below.

[0401] [ka]

[0402] XIaiii. Calcipotriol Using the methods described herein, calcipotriol can be administered to a subject. Calcipotriol is an INN to the compound of the chemical structure shown below.

[0403] [ka]

[0404] XIb. Simtuzumab Using the methods described herein, simtuzumab can be administered to a subject. Simtuzumab is also known by the code name GS-6624 and is available in the US Pat. No. 4,662,291. 6558 H 10134 N 1736 O 2037 S 50 It is an INN for an antibody having the chemical formula:

[0405] XII. Nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitors Using the methods described herein, a NOX inhibitor can be administered to a subject. In some embodiments, the NOX inhibitor is setanaxib.

[0406] XIIa. Cetanaxib Using the method described herein, setanaxib can be administered to the subject.Setanaxib is the INN for the compound also known as code name GKT831.Setanaxib has the chemical structure shown below.

[0407] [ka]

[0408] Recommended clinical parameters for monitoring patients for the development of cholestasis or hyperbilirubinemia In some embodiments, patients are monitored for the development of cholestasis by serum bile acid testing and / or blood tests (eg, LFTs) as described herein.

[0409] In some embodiments, patients are monitored for the development of hyperbilirubinemia by blood tests (eg, bilirubin tests) as described herein.

[0410] In some embodiments, the patient is monitored for the development of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0411] In some embodiments, the patient is monitored for the development of hyperbilirubinemia, and if the patient exhibits hyperbilirubinemia or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0412] In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by blood tests (e.g., serum bile acid tests or liver function tests). In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by blood tests (e.g., serum bile acid tests or liver function tests), and if the patient exhibits cholestasis or hyperbilirubinemia or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0413] In some embodiments, a patient is determined to exhibit cholestasis, hyperbilirubinemia, or one or more symptoms thereof, by a finding in a blood test (e.g., a serum bile acid test) that the patient exhibits an increase in a parameter (e.g., serum bile acid level) relative to a reference level.

[0414] In some embodiments, a patient is determined to exhibit cholestasis, hyperbilirubinemia, or one or more symptoms thereof, by a finding in a blood test (e.g., a serum bile acid test) that the patient exhibits an increased level of a serum bile acid (e.g., cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid) relative to a reference level.

[0415] In some embodiments, the blood test is a liver function test.

[0416] In some embodiments, the patient is monitored by liver function tests for the development of cholestasis or hyperbilirubinemia, and if the patient exhibits cholestasis or hyperbilirubinemia or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0417] In some embodiments, a patient is determined to exhibit cholestasis, hyperbilirubinemia, or one or more symptoms thereof, by a finding in a liver function test that the patient exhibits an increase or decrease in a parameter (e.g., aspartate aminotransferase level or alanine aminotransferase level) relative to a reference level.

[0418] I. Serum bile acid test In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia. In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by serum bile acid testing. In some embodiments, the patient is monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent. In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by serum bile acid testing, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0419] In some embodiments, patients are monitored for cholestasis or hyperbilirubinemia by their level of bile acids (e.g., cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid) measured in a serum bile acid test.

[0420] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if one or more of the patient's bile acid (e.g., cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid) levels measured in a serum bile acid test are greater than normal, and an anti-cholestatic agent is administered.

[0421] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's cholic acid level, as measured by a serum bile acid test, is greater than 5 nmol / mL (e.g., 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0422] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's cholic acid level, as measured by a serum bile acid test, is greater than 5 nmol / mL (e.g., 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0423] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's chenodeoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0424] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's chenodeoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0425] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's deoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0426] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's deoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0427] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's ursodeoxycholic acid level, as measured by a serum bile acid test, is greater than 2 nmol / mL (e.g., 2 nmol / mL, 3 nmol / mL, 4 nmol / mL, 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 nmol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0428] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's ursodeoxycholic acid level, as measured by a serum bile acid test, is greater than 5 nmol / mL (e.g., 2 nmol / mL, 3 nmol / mL, 4 nmol / mL, 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 nmol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0429] II. Liver function tests In some embodiments, the patient is monitored by LFTs for the development of cholestasis or hyperbilirubinemia. In some embodiments, the patient is monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent. In some embodiments, the patient is monitored by LFTs for the development of cholestasis or hyperbilirubinemia, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0430] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's LFT parameter (e.g., ASP level or AST level) is greater than the age-adjusted norms described herein, and an anti-cholestatic agent is administered.

[0431] IIa. Aspartate aminotransferase In some embodiments, patients are monitored for the development of cholestasis or hyperbilirubinemia by measuring their AST levels with LFTs. In some embodiments, patients are monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent. In some embodiments, patients are monitored for the development of cholestasis or hyperbilirubinemia by measuring their AST levels with LFTs, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0432] In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by measuring the patient's AST level with an LFT, and if the patient's AST level is greater than normal, the patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0433] In some embodiments, the patient is diagnosed with AST if the patient's AST level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, L, 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), cholestasis, hyperbilirubinemia, or one or more of its symptoms are determined to be present.

[0434] In some embodiments, the patient is diagnosed with AST if the patient's AST level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, 69 U / L, L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anticholestatic agent is administered.

[0435] IIb. Alanine aminotransferase In some embodiments, patients are monitored for the development of cholestasis or hyperbilirubinemia by measuring their ALT levels with LFTs. In some embodiments, patients are monitored for the development of cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent. In some embodiments, patients are monitored for the development of cholestasis or hyperbilirubinemia by measuring their ALT levels with LFTs, and if the patient exhibits cholestasis or hyperbilirubinemia, or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0436] In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by measuring the patient's ALT level with an LFT, and if the patient's ALT level is greater than normal, the patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0437] In some embodiments, the patient is diagnosed with idiopathic steroid therapy if the patient's ALT level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, , 68U / L, 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms.

[0438] In some embodiments, the patient is diagnosed with idiopathic steroid therapy if the patient's ALT level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, , 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0439] Recommended clinical parameters for monitoring patients for the development of cholestasis I. Serum bile acid test In some embodiments, the patient is monitored for the development of cholestasis. In some embodiments, the patient is monitored for the development of cholestasis by serum bile acid testing. In some embodiments, the patient is monitored for the development of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the development of cholestasis by serum bile acid testing, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0440] In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient's total bile acid level, as measured by a serum bile acid test, is greater than normal, and an anti-cholestatic agent is administered.

[0441] It is a good idea to have a nice smile on your face The solvent concentration was 14μmol / L and (from 15µmol / L, 16µmol / L, 17µmol / L, 18µmol / L, 19µmol / L, 20µ mol / L、21µmol / L、22µmol / L、23µmol / L、24µmol / L、25µmol / L、26µm ol / L、27µmol / L、28µmol / L、29µmol / L、30µmol / L、31µmol / L、32µmo l / L、33µmol / L、34µmol / L、35µmol / L、36µmol / L、37µmol / L、38µmol / L、39µmol / L、40µmol / L、41µmol / L、42µmol / L、43µmol / L、44µmol / L、45µmol / L、46µmol / L、47µmol / L、48µmol / L、49µmol / L、50µmol / L 、51µmol / L、52µmol / L、53µmol / L、54µmol / L、55µmol / L、56µmol / L 7µmol / L、58µmol / L、59µmol / L、60µmol / L、61µmol / L、62µmol / L、63 µmol / L、64µmol / L、65µmol / L、66µmol / L、67µmol / L、68µmol / L、69µ mol / L、70µmol / L、71µmol / L、72µmol / L、73µmol / L、74µmol / L、75µm ol / L、76µmol / L、77µmol / L、78µmol / L、79µmol / L、80µmol / L、81µmol / L、82µmol / L、83µmol / L、84µmol / L、85µmol / L、86µmol / L、87µmol / L、88µmol / L、89µmol / L、90µmol / L、91µmol / L、92µmol / L、93µmol / L 94µmol / L、95µmol / L、96µmol / L、97µmol / L、98µmol / L、99µmol / L At a concentration of 100μmol / L), the concentration is about 1.000 μmol / L The dressing goes on and on.

[0442] II.Environment In some embodiments, the patient is monitored for the development of cholestasis by blood tests (e.g., LFTs or bilirubin tests). In some embodiments, the patient is monitored for the development of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the development of cholestasis by LFTs, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0443] In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered, if one or more parameters (e.g., GGT level, ASP level, AST level, ALT level, and bilirubin level) of the patient's blood tests (e.g., LFT or bilirubin tests) are greater than the age-adjusted norms described herein.

[0444] IIa. Liver function tests In some embodiments, the patient is monitored for the development of cholestasis by LFTs. In some embodiments, the patient is monitored for the development of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the development of cholestasis by LFTs, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0445] In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered, if one or more parameters of the patient's LFTs (e.g., GGT level, ASP level, AST level, and ALT level) are greater than the age-adjusted norms described herein.

[0446] IIai. Gamma-glutamyltransferase In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's GGT levels with an LFT. In some embodiments, the patient is monitored for the development of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's GGT levels with an LFT, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0447] In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient exhibits GGT levels greater than age-adjusted norms, and an anti-cholestatic agent is administered.

[0448] In some embodiments, the patient is a newborn (e.g., 0-6 months old), a toddler (e.g., 6-12 months old), or a child aged 1-5 years. In some embodiments, the patient is a newborn aged 0-6 months. In some embodiments, the patient is a toddler aged 6-12 months. In some embodiments, the patient is a child aged 1-5 years.

[0449] In some embodiments, the patient is a newborn (e.g., 0-6 months old) and the patient's GGT level is between about 12-122 U / L (e.g., 12-122 U / L, 13-122 U / L, 14-122 U / L, 15-122 U / L, 16-122 U / L, 17-122 U / L, 18-122 U / L, 19-122 U / L, 20-122 U / L, 25-122 U / L, 30-122 U / L, 31-32 U / L, 32-33 U / L, 33-34 U / L, 34-35 U / L, 35-36 U / L, 36-37 U / L, 37-38 U / L, 38-39 U / L, 39-40 U / L, 40-41 U / L, 41-42 U / L, 42-43 U / L, 43-44 U / L, 44-45 U / L, 45-46 U / L, 46-47 U / L, 47-48 U / L, 48-49 U / L, 49-50 U / L, 50-51 U / L, 51-52 U / L, 52-53 U / L, 53-54 U / L, 54-55 U / L, 55-56 U / L, 56-57 U / L, 57-58 U / L, 58-59 U / L, 59-60 U / L, 60-61 U / L, 61-62 U / L, 62-63 U / L, 63-64 U / L, 64-65 U / L, If the serum cholesterol level is outside the normal range (40-122 U / L, 50-122 U / L, 60-122 U / L, 70-122 U / L, 80-122 U / L, 90-122 U / L, 100-122 U / L, 110-122 U / L, 120-122 U / L, or 121-122 U / L), the patient is determined to have cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0450] In some embodiments, the patient is a newborn male (e.g., 0-6 months old), and if the patient's GGT level is less than 12 U / L (e.g., 11 U / L, 10 U / L, 9 U / L, 8 U / L, 7 U / L, 6 U / L, 5 U / L, 4 U / L, 3 U / L, 2 U / L, or 1 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0451] In some embodiments, the patient is a newborn male (e.g., 0-6 months of age), and if the patient's GGT level is greater than 122 U / L (e.g., 123 U / L, 124 U / L, 125 U / L, 126 U / L, 127 U / L, 128 U / L, 129 U / L, 130 U / L, 135 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0452] In some embodiments, the patient is a male infant (e.g., 6-12 months of age), and the patient's GGT level is between about 1 and 39 U / L (e.g., 2-39 U / L, 3-39 U / L, 4-39 U / L, 5-39 U / L, 6-39 U / L, 7-39 U / L, 8-39 U / L, 9-39 U / L, 10-39 U / L, 11-39 U / L, 12-39 U / L, 13-39 U / L, 14-39 U / L, 15-39 U / L, 16-39 U / L, 17-39 U / L, 18-39 U / L, 19-39 U / L, 20-39 U / L, If the serum cholesterol level is outside the normal range (21-39U / L, 22-39U / L, 23-39U / L, 24-39U / L, 25-39U / L, 26-39U / L, 27-39U / L, 28-39U / L, 29-39U / L, 30-39U / L, 31-39U / L, 32-39U / L, 33-39U / L, 34-39U / L, 35-39U / L, 36-39U / L, 37-39U / L, or 38-39U / L), the patient is determined to have cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0453] In some embodiments, the patient is a male infant (e.g., 6-12 months of age) and if the patient's GGT level is greater than 39 U / L (e.g., 40 U / L, 41 U / L, 42 U / L, 43 U / L, 44 U / L, 45 U / L, 46 U / L, 47 U / L, 48 U / L, 49 U / L, 50 U / L, 55 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0454] In some embodiments, the patient is a male child between 1 and 5 years of age, and if the patient's GGT level is outside the normal range of about 3-22 U / L (e.g., about 3-22 U / L, 4-22 U / L, 5-22 U / L, 6-22 U / L, 7-22 U / L, 8-22 U / L, 9-22 U / L, 10-22 U / L, 11-22 U / L, 12-22 U / L, 13-22 U / L, 14-22 U / L, 15-22 U / L, 16-22 U / L, 17-22 U / L, 18-22 U / L, 19-22 U / L, 20-22 U / L, and 21-22 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0455] In some embodiments, the patient is a male child between 1 and 5 years of age, and if the patient's GGT level is less than 3 U / L (e.g., between 2 U / L and 1 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0456] In some embodiments, the patient is a male child between 1 and 5 years of age, and if the patient's GGT level is greater than 22 U / L (e.g., 23 U / L, 24 U / L, 25 U / L, 26 U / L, 27 U / L, 28 U / L, 29 U / L, 30 U / L, 35 U / L, 40 U / L, 50 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0457] In some embodiments, the patient is a newborn female (e.g., 0-6 months old) and the patient's GGT level is about 15-132 U / L (e.g., 15-132 U / L, 16-132 U / L, 17-132 U / L, 18-132 U / L, 19-132 U / L, 20-132 U / L, 25-132 U / L, 30-132 U / L, 40-132 U / L, 50-132 U / L, 60-132 U / L, 70-132 U / L, 80-132 U / L, 90-132 U / L, 100-132 U / L, 110-132 U / L, 120-132 U / L, 130-132 U / L, 140-132 U / L, 150-132 U / L, 160-132 U / L, 170-132 U / L, 180-132 U / L, 190-132 U / L, 200-132 U / L, 250-132 U / L, 260-132 U / L, 270-132 U / L, 280-132 U / L, 290-132 U / L, 300-132 U / L, 310-132 U / L, 320-132 U / L, 330-132 U / L, 340-132 U / L, 350-132 U / L, 360-132 U / L, 370-132 U / L, 380-132 U / L, 390-40 If the serum cholesterol level is outside the normal range (2 U / L, 60-132 U / L, 70-132 U / L, 80-132 U / L, 90-132 U / L, 100-132 U / L, 110-132 U / L, 120-132 U / L, 130-132 U / L, and 131-132 U / L), the patient is determined to have cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0458] In some embodiments, the patient is a newborn female (e.g., 0-6 months old), and if the patient's GGT level is less than 15 U / L (e.g., 14 U / L, 13 U / L, 12 U / L, 11 U / L, 10 U / L, 9 U / L, 8 U / L, 7 U / L, 6 U / L, 5 U / L, 4 U / L, 3 U / L, 2 U / L, or 1 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0459] In some embodiments, the patient is a newborn female (e.g., 0-6 months of age), and if the patient's GGT level is greater than 132 U / L (e.g., 133 U / L, 134 U / L, 135 U / L, 136 U / L, 137 U / L, 138 U / L, 139 U / L, 140 U / L, 145 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0460] In some embodiments, the patient is an infant female (e.g., 6-12 months of age) and the patient's GGT level is between about 1 and 39 U / L (e.g., 2-39 U / L, 3-39 U / L, 4-39 U / L, 5-39 U / L, 6-39 U / L, 7-39 U / L, 8-39 U / L, 9-39 U / L, 10-39 U / L, 11-39 U / L, 12-39 U / L, 13-39 U / L, 14-39 U / L, 15-39 U / L, 16-39 U / L, 17-39 U / L, 18-39 U / L, 19-39 U / L, 20-39 U / L, If the serum cholesterol level is outside the normal range (21-39U / L, 22-39U / L, 23-39U / L, 24-39U / L, 25-39U / L, 26-39U / L, 27-39U / L, 28-39U / L, 29-39U / L, 30-39U / L, 31-39U / L, 32-39U / L, 33-39U / L, 34-39U / L, 35-39U / L, 36-39U / L, 37-39U / L, or 38-39U / L), the patient is determined to have cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0461] In some embodiments, the patient is an infant female (e.g., 6-12 months of age) and if the patient's GGT level is greater than 39 U / L (e.g., 40 U / L, 41 U / L, 42 U / L, 43 U / L, 44 U / L, 45 U / L, 46 U / L, 47 U / L, 48 U / L, 49 U / L, 50 U / L, 55 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0462] In some embodiments, the patient is a female pediatric patient between 1 and 5 years of age, and if the patient's GGT level is outside the normal range of about 3-22 U / L (e.g., about 3-22 U / L, 4-22 U / L, 5-22 U / L, 6-22 U / L, 7-22 U / L, 8-22 U / L, 9-22 U / L, 10-22 U / L, 11-22 U / L, 12-22 U / L, 13-22 U / L, 14-22 U / L, 15-22 U / L, 16-22 U / L, 17-22 U / L, 18-22 U / L, 19-22 U / L, 20-22 U / L, and 21-22 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0463] In some embodiments, the patient is a female child between 1 and 5 years of age, and if the patient's GGT level is less than 3 U / L (e.g., between 2 U / L and 1 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0464] In some embodiments, the patient is a female pediatric patient between 1 and 5 years of age, and if the patient's GGT level is greater than 22 U / L (e.g., 23 U / L, 24 U / L, 25 U / L, 26 U / L, 27 U / L, 28 U / L, 29 U / L, 30 U / L, 35 U / L, 40 U / L, 50 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0465] IIaii. Alkaline phosphatase In some embodiments, the patient is monitored for the occurrence of cholestasis by measuring the patient's ASP levels with LFTs. In some embodiments, the patient is monitored for the occurrence of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the occurrence of cholestasis by measuring the patient's ASP levels with LFTs, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0466] In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's ASP level with an LFT, and if the patient's ASP level is greater than normal, the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0467] In some embodiments, the patient's ASP level is between about 50 and 300 U / L (e.g., between about 51 and 300 U / L, between about 52 and 53 U / L, between about 54 and 300 U / L, between about 55 and 300 U / L, between about 56 and 300 U / L, between about 57 and 300 U / L, between about 58 and 300 U / L, between about 59 and 300 U / L, between about 60 and 300 U / L, between about 65 and 300 U / L, between about 70 and 300 U / L, between about 80 and 85 U / L, between about 85 and 85 U / L, between about 86 and 87 U / L, between about 88 and 89 U / L, between about 90 and 91 U / L, between about 92 and 93 U / L, between about 94 and 95 U / L, between about 96 and 97 U / L, between about 97 and 98 U / L, between about 98 and 99 U / L, between about 100 and 101 U / L, between about 101 and 102 U / L, between about 102 and 103 U / L, between about 103 and 104 U / L, between about 105 and 106 U / L, between about 106 and 107 U / L, between about 108 and 110 U / L, between about 119 and 120 U / L, between about 121 and 122 U / L, between about 122 and 123 U / L, between about 123 and 124 U / L, between about 125 and 126 U / L, between about 126 and 127 U / L, between about If the serum cholesterol level is outside the normal range (0 U / L, about 90-300 U / L, about 100-300 U / L, about 125-300 U / L, about 150-300 U / L, about 175-300 U / L, about 200-300 U / L, about 225-300 U / L, about 250-300 U / L, or about 275-300 U / L), the patient is determined to be experiencing cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0468] In some embodiments, the patient is diagnosed with an ASP level of the patient less than 50 U / L (e.g., 50 U / L, 49 U / L, 48 U / L, 47 U / L, 46 U / L, 45 U / L, 44 U / L, 43 U / L, 42 U / L, 41 U / L, 40 U / L, 39 U / L, 38 U / L, 37 U / L, 36 U / L, 35 U / L, 34 U / L, 33 U / L, 32 U / L, 31 U / L, 30 U / L, 29 U / L, 28 U / L, 27 U / L, 26 U / L, 28 U / L, 29 ... If the blood cholesterol level is greater than 5U / L, 24U / L, 23U / L, 22U / L, 21U / L, 20U / L, 19U / L, 18U / L, 17U / L, 16U / L, 15U / L, 14U / L, 13U / L, 12U / L, 11U / L, 10U / L, 9U / L, 8U / L, 7U / L, 6U / L, 5U / L, 4U / L, 3U / L, 2U / L, and 1U / L), cholestasis or one or more of its symptoms is determined to be present, and an anticholestatic agent is administered.

[0469] In some embodiments, the patient is diagnosed with vasopressin if the patient's ASP level is greater than 300 U / L (e.g., 300 U / L, 301 U / L, 302 U / L, 303 U / L, 304 U / L, 305 U / L, 306 U / L, 307 U / L, 308 U / L, 309 U / L, 310 U / L, 311 U / L, 312 U / L, 313 U / L, 314 U / L, 315 U / L, 316 U / L, 317 U / L, 318 U / L, 319 U / L, 320 U / L, 321 U / L, 322 U / L, 323 U / L, 324 U / L, 325 U / L, 326 U / L, 327 U / L, 328 U / L, 329 U / L, 330 U / L, 331 U / L, 332 U / L, 333 U / L, 334 U / L, 335 U / L, 336 U / L, 337 U / L, 338 U / L, 339 U / L, 340 U / L, 341 U / L, 342 U / L, 343 U / L, 344 U / L, 345 U / L, 346 U / L, 347 U / L, 348 U / L, 349 U / L, 350 U / L, 351 U / L, 352 U / L, 353 U / L, 354 U / L, 355 U / L, 356 U / L, 357 U / L, 358 U / L, U / L, 316U / L, 317U / L, 318U / L, 319U / L, 320U / L, 321U / L, 322U / L, 323U / L, 324U / L, 325U / L, 330U / L, 340U / L, 350U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0470] IIaiii. Aspartate aminotransferase In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's AST levels with LFTs. In some embodiments, the patient is monitored for the development of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's AST levels with LFTs, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0471] In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's AST level with an LFT, and if the patient's AST level is greater than normal, the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0472] In some embodiments, the patient is diagnosed with AST if the patient's AST level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, , 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0473] IIaiv. Alanine aminotransferase In some embodiments, the patient is monitored for the occurrence of cholestasis by measuring the patient's ALT levels with an LFT. In some embodiments, the patient is monitored for the occurrence of cholestasis, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent. In some embodiments, the patient is monitored for the occurrence of cholestasis by measuring the patient's ALT levels with an LFT, and if the patient exhibits cholestasis or one or more symptoms thereof, the patient is administered an anti-cholestasis agent.

[0474] In some embodiments, the patient is monitored for the development of cholestasis by measuring the patient's ALT level with an LFT, and if the patient's ALT level is greater than normal, the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0475] In some embodiments, the patient is diagnosed with idiopathic steroid therapy if the patient's ALT level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, , 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0476] Recommended clinical parameters for monitoring patients for the development of hyperbilirubinemia Bilirubin test In some embodiments, the patient is monitored for the development of hyperbilirubinemia. In some embodiments, the patient is monitored for the development of hyperbilirubinemia by bilirubin testing. In some embodiments, the patient is monitored for the development of hyperbilirubinemia, and if the patient exhibits hyperbilirubinemia or one or more symptoms thereof, the patient is administered an anti-cholestatic agent. In some embodiments, the patient is monitored for the development of hyperbilirubinemia by bilirubin testing, and if the patient exhibits hyperbilirubinemia or one or more symptoms thereof, the patient is administered an anti-cholestatic agent.

[0477] In some embodiments, a patient is determined to be exhibiting hyperbilirubinemia or one or more symptoms thereof if the patient exhibits bilirubin levels greater than normal, and an anti-cholestatic agent is administered.

[0478] In some embodiments, the patient is diagnosed with urinary tract infection if the patient's total bilirubin level is greater than 1.2 mg / dL (e.g., 1.2 mg / dL, 1.3 mg / dL, 1.4 mg / dL, 1.5 mg / dL, 1.6 mg / dL, 1.7 mg / dL, 1.8 mg / dL, 1.9 mg / dL, 2 mg / dL, 2.1 mg / dL, 2.2 mg / dL, 2.3 mg / dL, 2.4 mg / dL, 2.5 mg / dL, 2.6 mg / dL, 2.7 mg / dL, 2.8 mg / dL, 2.9 mg / dL, 3 mg / dL, 3.1 mg / dL, 3.2 mg / dL, 3.3 mg / dL, 3.4 mg / dL, 3.5 mg / dL, 3.6 mg / dL, 3.7 mg / dL, 3.8 mg / dL, 3.9 mg / dL, 3.1 mg / dL, 3.2 mg / dL, 3.3 mg / dL, 3.4 mg / dL, 3.5 mg / dL, 3.6 mg / dL, 3.7 mg / dL, 3.8 mg / dL, 3.9 mg / dL, 3.9 mg / dL, 3.1 ... 6mg / dL, 3.7mg / dL, 3.8mg / dL, 3.9mg / dL, 4mg / dL, 4.1mg / dL, 4.2mg / dL, 4.3mg / dL, 4.4mg / dL, 4.5mg / dL, 4.6mg / dL, 4.7mg / dL, 4.8mg / dL, 4.9mg / dL, 5mg / dL, 10mg / dL, 15mg / dL, 20mg / dL, 30mg / dL, 40mg / dL, 50mg / dL, 60mg / dL, 70mg / dL, 80mg / dL, 90mg / dL, and 100mg / dL), is determined to be indicative of hyperbilirubinemia or one or more of its symptoms, and an anticholestatic agent is administered.

[0479] In some embodiments, the patient is diagnosed with urinary tract infection if the patient's direct bilirubin level is greater than 0.2 mg / dL (e.g., 0.2 mg / dL, 0.3 mg / dL, 0.4 mg / dL, 0.5 mg / dL, 0.6 mg / dL, 0.7 mg / dL, 0.8 mg / dL, 0.9 mg / dL, 1 mg / dL, 1.1 mg / dL, 1.2 mg / dL, 1.3 mg / dL, 1.4 mg / dL, 1.5 mg / dL, 1.6 mg / dL, 1.7 mg / dL, 1.8 mg / dL, 1.9 mg / dL, 2.1 mg / dL, 2.2 mg / dL, 2.3 mg / dL, 2.4 mg / dL, 2.5 mg / dL, 2.6 mg / dL, 2.7 mg / dL, 2.8 mg / dL, 2.9 mg / dL, 3.1 mg / dL, 3.2 mg / dL, 3.3 mg / dL, 3.4 mg / dL, 3.5 mg / dL, 3.6 mg / dL, 3.7 mg / dL, 3.8 mg / dL, 3.9 mg / dL, 4.1 mg / dL, 4.2 mg / dL, 4.3 mg / dL, 4.4 mg / dL, 4.5 mg / dL, 4.6 mg / dL, 4.7 mg / dL, 4.8 mg / dL, 4.9 mg / dL, 5.1 mg / dL, 5.2 mg / dL, 5.3 mg / dL, 5.4 mg / dL, 5.5 mg / dL, 5.6 mg / dL, 5.7 mg / dL, dL, 1.4mg / dL, 1.5mg / dL, 1.6mg / dL, 1.7mg / dL, 1.8mg / dL, 1.9mg / dL, 2mg / dL, 2.1mg / dL, 2.2mg / dL, 2.3mg / dL, 2.4mg / dL, 2.5mg / dL, 2.6mg / dL, 2.7mg / dL, 2.8mg / dL, 2.9mg / dL, 3mg / dL, 3.1m g / dL, 3.2mg / dL, 3.3mg / dL, 3.4mg / dL, 3.5mg / dL, 3.6mg / dL, 3.7mg / dL, 3.8mg / dL, 3.9mg / dL , 4mg / dL, 4.1mg / dL, 4.2mg / dL, 4.3mg / dL, 4.4mg / dL, 4.5mg / dL, 4.6mg / dL, 4.7mg / dL, 4.8mg / d L, 4.9 mg / dL, 5 mg / dL, 10 mg / dL, 15 mg / dL, 20 mg / dL, 30 mg / dL, 40 mg / dL, 50 mg / dL, 60 mg / dL, 70 mg / dL, 80 mg / dL, 90 mg / dL, and 100 mg / dL), is determined to have hyperbilirubinemia or one or more of its symptoms, and an anticholestatic agent is administered.

[0480] In some embodiments, the patient has a bilirubin test showing that the patient has a bilirubin level greater than 1 mg / dL (e.g., 1 mg / dL, 1.1 mg / dL, 1.2 mg / dL, 1.3 mg / dL, 1.4 mg / dL, 1.5 mg / dL, 1.6 mg / dL, 1.7 mg / dL, 1.8 mg / dL, 1.9 mg / dL, 2 mg / dL, 2.1 mg / dL, 2.2 mg / dL, 2.3 mg / dL, 2.4 mg / dL, 2.5 mg / dL, 2.6 mg / dL, 2.7 mg / dL, 2.8 mg / dL, 2.9 mg / dL, 3 mg / dL, 3.1 mg / dL, 3.2 mg / dL, 3.3 mg / dL, 3.4 mg / dL, 3.5 mg / dL, 3.6 mg / dL, 4.9mg / dL, 5mg / dL, 10mg / dL, 15mg / dL, 20mg / dL, 30mg / dL, 40mg / dL, 50mg / dL, 60mg / dL, 70mg / dL, 80mg / dL, 90mg / dL, or 100mg / dL), a patient is determined to have hyperbilirubinemia or one or more of its symptoms, and an anticholestatic agent is administered.

[0481] Recommended clinical parameters to determine if a patient has cholestasis or hyperbilirubinemia or its symptoms In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof by determining whether one or more parameters of the patient's serum bile acid test and / or blood test (e.g., LFTs) (e.g., total bile acid level, GGT level, ASP level, AST level, and ALT level) are greater than or less than the age-adjusted standards described herein, and an anti-cholestatic agent is administered.

[0482] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof by determining that one or more parameters (e.g., bilirubin level) of the patient's blood test (e.g., bilirubin test) are greater than a normal described herein, and an anti-cholestatic agent is administered.

[0483] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if one or more of the patient's bile acid (e.g., cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid) levels measured in a serum bile acid test are greater than normal, and an anti-cholestatic agent is administered.

[0484] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's LFT parameter (e.g., ASP level or AST level) is greater than the age-adjusted norms described herein, and an anti-cholestatic agent is administered.

[0485] I. Serum bile acid test In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if one or more of the patient's bile acid (e.g., cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid) levels measured in a serum bile acid test are greater than normal, and an anti-cholestatic agent is administered.

[0486] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's cholic acid level, as measured by a serum bile acid test, is greater than 5 nmol / mL (e.g., 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0487] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's cholic acid level, as measured by a serum bile acid test, is greater than 5 nmol / mL (e.g., 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0488] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's chenodeoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0489] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's chenodeoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0490] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's deoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0491] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's deoxycholic acid level, as measured by a serum bile acid test, is greater than 6 nmol / mL (e.g., 6 nmol / mL, 7 nmol / mL, 8 mol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0492] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's ursodeoxycholic acid level, as measured by a serum bile acid test, is greater than 2 nmol / mL (e.g., 2 nmol / mL, 3 nmol / mL, 4 nmol / mL, 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 nmol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0493] In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered if the patient's ursodeoxycholic acid level, as measured by a serum bile acid test, is greater than 5 nmol / mL (e.g., 2 nmol / mL, 3 nmol / mL, 4 nmol / mL, 5 nmol / mL, 6 nmol / mL, 7 nmol / mL, 8 nmol / mL, 9 nmol / mL, 10 nmol / mL, 15 nmol / mL, 20 nmol / mL, 30 nmol / mL, 40 nmol / mL, 50 nmol / mL, 60 nmol / mL, 70 nmol / mL, 80 nmol / mL, 90 nmol / mL, and 100 nmol / mL).

[0494] II. Liver function tests In some embodiments, a patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, if the patient's LFT parameter (e.g., ASP level or AST level) is greater than the age-adjusted norms described herein, and an anti-cholestatic agent is administered.

[0495] IIa. Aspartate aminotransferase In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by measuring the patient's AST level with an LFT, and if the patient's AST level is greater than normal, the patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0496] In some embodiments, the patient is diagnosed with AST if the patient's AST level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, L, 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), cholestasis, hyperbilirubinemia, or one or more of its symptoms are determined to be present.

[0497] In some embodiments, the patient is diagnosed with AST if the patient's AST level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, 69 U / L, L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anticholestatic agent is administered.

[0498] IIb. Alanine aminotransferase In some embodiments, the patient is monitored for the development of cholestasis or hyperbilirubinemia by measuring the patient's ALT level with an LFT, and if the patient's ALT level is greater than normal, the patient is determined to be exhibiting cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0499] In some embodiments, the patient is diagnosed with idiopathic steroid therapy if the patient's ALT level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, , 68U / L, 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms.

[0500] In some embodiments, the patient is diagnosed with idiopathic steroid therapy if the patient's ALT level is greater than 50 U / L (e.g., 51 U / L, 52 U / L, 53 U / L, 54 U / L, 55 U / L, 56 U / L, 57 U / L, 58 U / L, 59 U / L, 60 U / L, 61 U / L, 62 U / L, 63 U / L, 64 U / L, 65 U / L, 66 U / L, 67 U / L, 68 U / L, , 69U / L, 70U / L, 75U / L, 80U / L, 85U / L, 90U / L, 100U / L, 110U / L, 120U / L, 130U / L, 140U / L, 150U / L, 200U / L, 300U / L, 400U / L, and 500U / L), is determined to be indicative of cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0501] Recommended clinical parameters to determine if a patient has cholestasis or its symptoms I. Serum bile acid test In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient exhibits greater than normal bile acid levels as measured by serum bile acid testing, and an anti-cholestatic agent is administered.

[0502] In some embodiments, the patient is diagnosed with urinary tract infection if the patient's total bile acid level, as determined by a serum bile acid test, is greater than 14 μmol / L (e.g., 15 μmol / L, 16 μmol / L, 17 μmol / L, 18 μmol / L, 19 μmol / L, 20 μmol / L, 21 μmol / L, 22 μmol / L, 23 μmol / L, 24 μmol / L, 25 μmol / L, 26 μmol / L, 27 μmol / L, 28 μmol / L, 29 μmol / L, 30 μmol / L, 31 μmol / L, 32 μmol / L, 33 μmol / L, 34 μmol / L, 35 μmol / L, 36 μmol / L, 37 μmol / L, 38 μmol / L, 39 μmol / L, 40 μmol / L, 41 μmol / L, 42 μmol / L, 43 μmol / L, 44 μmol / L, 45 μmol / L, 46 μmol / L, 47 μmol / L, 48 μmol / L, 49 μmol / L, 50 μmol / L, 51 μmol / L, 52 μmol / L, 53 μmol / L, 54 μmol / L, 55 μmol / L, 56 μmol / L, 57 μmol / L, 58 μmol / L, 59 μmol / L, 60 μmol / L, 61 μmol / L, 62 μmol / L, 63 μmol / L, 64 μmol / L, 65 μmol / L, 66 μmol / L, 67 μmol / L, 68 μmol / L, 69 μmol / L, 70 μmol / L, 72 μmol / L, 7 ol / L, 33μmol / L, 34μmol / L, 35μmol / L, 36μmol / L, 37μmol / L, 38μmol / L, 39μmol / L, 40μmol / L, 41μmol / L, 42μmol / L, 43μmol / L, 44μmol / L, 45 μmol / L, 46 μmol / L, 47 μmol / L, 48 μmol / L, 49 μmol / L, 50 μmol / L, 51 μmol / L, 52 μmol / L, 53 μmol / L, 54 μmol / L, 55 μmol / L, 56 μmol / L, 57μmol / L, 58μmol / L, 59μmol / L, 60μmol / L, 61μmol / L, 62μmol / L, 63μmol / L, 64μmol / L, 65μmol / L, 66μmol / L, 67μmol / L, 68μmol / L, 69 μmol / L, 70 μmol / L, 71 μmol / L, 72 μmol / L, 73 μmol / L, 74 μmol / L, 75 μmol / L, 76 μmol / L, 77 μmol / L, 78 μmol / L, 79 μmol / L, 80 μmol / L, 81 μmol l / L, 82 μmol / L, 83 μmol / L, 84 μmol / L, 85 μmol / L, 86 μmol / L, 87 μmol / L, 88 μmol / L, 89 μmol / L, 90 μmol / L, 91 μmol / L, 92 μmol / L, 93 μmol / L, 94 μmol / L, 95 μmol / L, 96 μmol / L, 97 μmol / L, 98 μmol / L, 99 μmol / L, and 100 μmol / L), is determined to exhibit cholestasis or one or more of its symptoms, and an anticholestatic agent is administered.

[0503] II. Blood Test In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered, if one or more parameters (e.g., GGT level, ASP level, AST level, ALT level, and bilirubin level) of the patient's blood tests (e.g., LFT or bilirubin tests) are greater than the age-adjusted norms described herein.

[0504] IIa. Liver function tests In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered, if one or more parameters of the patient's LFTs (e.g., GGT level, ASP level, AST level, and ALT level) are greater than the age-adjusted norms described herein.

[0505] IIai. Gamma-glutamyltransferase In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered, if the patient exhibits GGT levels greater than age-adjusted norms, as measured by LFTs.

[0506] In some embodiments, the patient is a newborn (e.g., 0-6 months old), a toddler (e.g., 6-12 months old), or a child aged 1-5 years. In some embodiments, the patient is a newborn aged 0-6 months. In some embodiments, the patient is a toddler aged 6-12 months. In some embodiments, the patient is a child aged 1-5 years.

[0507] In some embodiments, the patient is a newborn (e.g., 0-6 months old) and the patient's GGT level is between about 12-122 U / L (e.g., 12-122 U / L, 13-122 U / L, 14-122 U / L, 15-122 U / L, 16-122 U / L, 17-122 U / L, 18-122 U / L, 19-122 U / L, 20-122 U / L, 25-122 U / L, 30-122 U / L, 31-122 U / L, 32-122 U / L, 33-122 U / L, 34-122 U / L, 35-122 U / L, 36-122 U / L, 37-122 U / L, 38-122 U / L, 39-40 U / L, 41-42 U / L, 42-43 U / L, 43-44 U / L, 44-45 U / L, 45-46 U / L, 46-47 U / L, 47-48 U / L, 48-49 U / L, 49-50 U / L, 50-51 U / L, 51-52 U / L, 52-53 U / L, 53-54 U / L, 54-55 U / L, 55-56 U / L, 56-57 U / L, 57-58 U / L, 58-59 U / L, 59-60 U / L, 60-61 U / L, 61-62 U / L, 62-63 U / L, 63-64 U / L, 64-65 U / L, 6 If the serum cholesterol level is outside the normal range (22U / L, 40-122U / L, 50-122U / L, 60-122U / L, 70-122U / L, 80-122U / L, 90-122U / L, 100-122U / L, 110-122U / L, 120-122U / L, or 121-122U / L), cholestasis or one or more of its symptoms is determined, and an anticholestatic agent is administered.

[0508] In some embodiments, the patient is a newborn male (e.g., 0-6 months old) and is determined to exhibit cholestasis or one or more symptoms thereof if the patient's GGT level is less than 12 U / L (e.g., 11 U / L, 10 U / L, 9 U / L, 8 U / L, 7 U / L, 6 U / L, 5 U / L, 4 U / L, 3 U / L, 2 U / L, or 1 U / L), and an anti-cholestatic agent is administered.

[0509] In some embodiments, the patient is a newborn male (e.g., 0-6 months of age) and is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient's GGT level is greater than 122 U / L (e.g., 123 U / L, 124 U / L, 125 U / L, 126 U / L, 127 U / L, 128 U / L, 129 U / L, 130 U / L, 135 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), and an anti-cholestatic agent is administered.

[0510] In some embodiments, the patient is a male infant (e.g., 6-12 months of age), and the patient's GGT level is between about 1 and 39 U / L (e.g., 2-39 U / L, 3-39 U / L, 4-39 U / L, 5-39 U / L, 6-39 U / L, 7-39 U / L, 8-39 U / L, 9-39 U / L, 10-39 U / L, 11-39 U / L, 12-39 U / L, 13-39 U / L, 14-39 U / L, 15-39 U / L, 16-39 U / L, 17-39 U / L, 18-39 U / L, 19-39 U / L, 20-39 U / L, 21-39 U / L, 22-39 U / L, 23-39 U / L, 24-39 U / L, 25-39 U / L, 26-39 U / L, 27-39 U / L, 28-39 U / L, 29-39 U / L, 30-39 U / L, 31-39 U / L, 32-39 U / L, 33-39 U / L, 34-39 U / L, 35-39 U / L, 36-39 U / L, 37-39 U / L, 38-39 U / L, 39-39 U / L, 39-39 U / L, 39-39 U / L, 40-39 U / L, 41-39 U / L, 42-39 U / L, 43-39 U / L, 44-39 U / L, 45-39 U / L, 46-39 U / If the blood cholesterol level is outside the normal range (21-39U / L, 22-39U / L, 23-39U / L, 24-39U / L, 25-39U / L, 26-39U / L, 27-39U / L, 28-39U / L, 29-39U / L, 30-39U / L, 31-39U / L, 32-39U / L, 33-39U / L, 34-39U / L, 35-39U / L, 36-39U / L, 37-39U / L, or 38-39U / L), cholestasis or one or more of its symptoms is determined, and an anticholestatic agent is administered.

[0511] In some embodiments, the patient is a male infant (e.g., 6-12 months of age) and is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient's GGT level is greater than 39 U / L (e.g., 40 U / L, 41 U / L, 42 U / L, 43 U / L, 44 U / L, 45 U / L, 46 U / L, 47 U / L, 48 U / L, 49 U / L, 50 U / L, 55 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), and an anti-cholestatic agent is administered.

[0512] In some embodiments, the patient is a male child between 1 and 5 years of age, and the patient is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient's GGT level is outside the normal range of about 3-22 U / L (e.g., about 3-22 U / L, 4-22 U / L, 5-22 U / L, 6-22 U / L, 7-22 U / L, 8-22 U / L, 9-22 U / L, 10-22 U / L, 11-22 U / L, 12-22 U / L, 13-22 U / L, 14-22 U / L, 15-22 U / L, 16-22 U / L, 17-22 U / L, 18-22 U / L, 19-22 U / L, 20-22 U / L, and 21-22 U / L), and an anti-cholestatic agent is administered.

[0513] In some embodiments, the patient is a male child between 1 and 5 years of age, and is determined to exhibit cholestasis or one or more symptoms thereof if the patient's GGT level is less than about 3 U / L (e.g., between 2 U / L and 1 U / L), and an anti-cholestatic agent is administered.

[0514] In some embodiments, the patient is a male child between 1 and 5 years of age, and if the patient's GGT level is greater than 22 U / L (e.g., 23 U / L, 24 U / L, 25 U / L, 26 U / L, 27 U / L, 28 U / L, 29 U / L, 30 U / L, 35 U / L, 40 U / L, 50 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0515] In some embodiments, the patient is a newborn female (e.g., 0-6 months old) and the patient's GGT level is about 15-132 U / L (e.g., 15-132 U / L, 16-132 U / L, 17-132 U / L, 18-132 U / L, 19-132 U / L, 20-132 U / L, 25-132 U / L, 30-132 U / L, 40-132 U / L, 50-132 U / L, 60-132 U / L, 70-132 U / L, 80-132 U / L, 90-132 U / L, 100-132 U / L, 110-132 U / L, 120-132 U / L, 130-132 U / L, 140-132 U / L, 150-132 U / L, 160-132 U / L, 170-132 U / L, 180-132 U / L, 190-132 U / L, 200-132 U / L, 250-132 U / L, 260-132 U / L, 270-132 U / L, 280-132 U / L, 290-290 U / L, 300-300 U / L, 310-310 U / L, 320-320 U / L, 330-332 U / L, 340-340 U / L, 350-350 U / L, 360-360 U / L, 370-370 U / L, 380-380 U / L, 390-40 If the serum cholesterol level is outside the normal range (132U / L, 60-132U / L, 70-132U / L, 80-132U / L, 90-132U / L, 100-132U / L, 110-132U / L, 120-132U / L, 130-132U / L, and 131-132U / L), cholestasis or one or more of its symptoms is determined to be present, and an anticholestatic agent is administered.

[0516] In some embodiments, the patient is a newborn female (e.g., 0-6 months of age) and is determined to exhibit cholestasis or one or more symptoms thereof if the patient's GGT level is less than about 15 U / L (e.g., 14 U / L, 13 U / L, 12 U / L, 11 U / L, 10 U / L, 9 U / L, 8 U / L, 7 U / L, 6 U / L, 5 U / L, 4 U / L, 3 U / L, 2 U / L, or 1 U / L), and an anti-cholestatic agent is administered.

[0517] In some embodiments, the patient is a newborn female (e.g., 0-6 months of age) and is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient's GGT level is greater than 132 U / L (e.g., 133 U / L, 134 U / L, 135 U / L, 136 U / L, 137 U / L, 138 U / L, 139 U / L, 140 U / L, 145 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), and an anti-cholestatic agent is administered.

[0518] In some embodiments, the patient is an infant female (e.g., 6-12 months of age) and the patient's GGT level is between about 1 and 39 U / L (e.g., 2-39 U / L, 3-39 U / L, 4-39 U / L, 5-39 U / L, 6-39 U / L, 7-39 U / L, 8-39 U / L, 9-39 U / L, 10-39 U / L, 11-39 U / L, 12-39 U / L, 13-39 U / L, 14-39 U / L, 15-39 U / L, 16-39 U / L, 17-39 U / L, 18-39 U / L, 19-39 U / L, 20-39 U / L, 21-39 U / L, 22-39 U / L, 23-39 U / L, 24-39 U / L, 25-39 U / L, 26-39 U / L, 27-39 U / L, 28-39 U / L, 29-39 U / L, 30-39 U / L, 31-39 U / L, 32-39 U / L, 33-39 U / L, 34-39 U / L, 35-39 U / L, 36-39 U / L, 37-39 U / L, 38-39 U / L, 39-39 U / L, 39-39 U / L, 39-39 U / L, 40-40 U / L, 41-41 U / L, 42-42 U / L, 43-43 U / L, 44-44 U / L, 45-45 U / L, 46-46 U / If the blood cholesterol level is outside the normal range (21-39U / L, 22-39U / L, 23-39U / L, 24-39U / L, 25-39U / L, 26-39U / L, 27-39U / L, 28-39U / L, 29-39U / L, 30-39U / L, 31-39U / L, 32-39U / L, 33-39U / L, 34-39U / L, 35-39U / L, 36-39U / L, 37-39U / L, or 38-39U / L), cholestasis or one or more of its symptoms is determined, and an anticholestatic agent is administered.

[0519] In some embodiments, the patient is an infant female (e.g., 6-12 months of age) and is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient's GGT level is greater than 39 U / L (e.g., 40 U / L, 41 U / L, 42 U / L, 43 U / L, 44 U / L, 45 U / L, 46 U / L, 47 U / L, 48 U / L, 49 U / L, 50 U / L, 55 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), and an anti-cholestatic agent is administered.

[0520] In some embodiments, the patient is a female child between 1 and 5 years of age, and if the patient's GGT level is outside the normal range of about 3-22 U / L (e.g., about 3-22 U / L, 4-22 U / L, 5-22 U / L, 6-22 U / L, 7-22 U / L, 8-22 U / L, 9-22 U / L, 10-22 U / L, 11-22 U / L, 12-22 U / L, 13-22 U / L, 14-22 U / L, 15-22 U / L, 16-22 U / L, 17-22 U / L, 18-22 U / L, 19-22 U / L, 20-22 U / L, and 21-22 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0521] In some embodiments, the patient is a female child between 1 and 5 years of age, and is determined to exhibit cholestasis or one or more symptoms thereof if the patient's GGT level is less than about 3 U / L (e.g., between 2 U / L and 1 U / L), and an anti-cholestatic agent is administered.

[0522] In some embodiments, the patient is a female child between 1 and 5 years of age, and if the patient's GGT level is greater than 22 U / L (e.g., 23 U / L, 24 U / L, 25 U / L, 26 U / L, 27 U / L, 28 U / L, 29 U / L, 30 U / L, 35 U / L, 40 U / L, 50 U / L, 60 U / L, 70 U / L, 80 U / L, 90 U / L, 100 U / L, 110 U / L, 1120 U / L, 130 U / L, 140 U / L, 150 U / L, 160 U / L, 170 U / L, 180 U / L, 190 U / L, and 200 U / L), the patient is determined to be exhibiting cholestasis or one or more symptoms thereof, and an anti-cholestatic agent is administered.

[0523] IIaii. Alkaline phosphatase In some embodiments, a patient is determined to be exhibiting cholestasis or one or more symptoms thereof if the patient exhibits ASP levels greater than normal as measured by LFTs, and an anti-cholestatic agent is administered.

[0524] In some embodiments, the patient is monitored for an ASP level in the patient that is between about 50 and 300 U / L (e.g., between about 51 and 300 U / L, between about 52 and 53 U / L, between about 54 and 300 U / L, between about 55 and 300 U / L, between about 56 and 300 U / L, between about 57 and 300 U / L, between about 58 and 300 U / L, between about 59 and 300 U / L, between about 60 and 300 U / L, between about 65 and 300 U / L, between about 70 and 300 U / L, between about 80 and 85 U / L, between about 85 ... If the serum cholesterol level is outside the normal range (0-300 U / L, about 90-300 U / L, about 100-300 U / L, about 125-300 U / L, about 150-300 U / L, about 175-300 U / L, about 200-300 U / L, about 225-300 U / L, about 250-300 U / L, or about 275-300 U / L), cholestasis or one or more of its symptoms is determined to be present, and an anticholestatic agent is administered.

[0525] In some embodiments, the patient is diagnosed with a vasopressin-dependent inflammatory response (ASP) level in the patient that is less than about 50 U / L (e.g., 50 U / L, 49 U / L, 48 U / L, 47 U / L, 46 U / L, 45 U / L, 44 U / L, 43 U / L, 42 U / L, 41 U / L, 40 U / L, 39 U / L, 38 U / L, 37 U / L, 36 U / L, 35 U / L, 34 U / L, 33 U / L, 32 U / L, 31 U / L, 30 U / L, 29 U / L, 28 U / L, 27 U / L, 26 U / L, If the serum cholesterol level is 25U / L, 24U / L, 23U / L, 22U / L, 21U / L, 20U / L, 19U / L, 18U / L, 17U / L, 16U / L, 15U / L, 14U / L, 13U / L, 12U / L, 11U / L, 10U / L, 9...

Claims

A composition for use in the following methods, comprising a viral vector comprising a transgene encoding myotubularin 1 (MTM1): (i) A method of treating a human patient in need thereof with X-linked myotubular myopathy (XLMTM); (ii) A method of reducing rigidity and / or joint contracture in a human patient diagnosed with XLMTM; or (iii) A method of increasing the development of the diaphragm and / or respiratory muscles in a human patient diagnosed with XLMTM wherein the method comprises administering to the patient (i) a therapeutically effective amount of the viral vector and (ii) an anti-cholestatic agent, the anti-cholestatic agent administered is administered to the patient in one or more doses initiated within about 6 weeks of administration of the viral vector to the patient, the composition. **Claim 2** The anti-cholestatic agent is administered to the patient in one or more doses initiated within about 5 weeks of administration of the viral vector to the patient, and optionally, the anti-cholestatic agent administered is administered to the patient in one or more doses initiated within about 4 weeks, about 3 weeks, about 2 weeks, or about 1 week of administration of the viral vector to the patient, and optionally, the anti-cholestatic agent is administered to the patient in one or more doses initiated on the same day as administration of the viral vector to the patient, the composition according to claim 1.

3. (i) The viral vector is administered to the patient in an amount less than about 3×10 １４ vg / kg, and optionally, the viral vector is administered to the patient in an amount less than about 2.5×10 14 vg / kg, and optionally, the viral vector is administered to the patient in an amount less than about 2×10 14 vg / kg, less than about 1.5×10 14 vg / kg, or less than about 1.4×10 14 vg / kg; (ii) The viral vector is administered to the patient in an amount of about 3×10¹³ vg / kg to about 2.3×10¹⁴ vg / kg, and optionally, the viral vector is about 8×10¹³ vg / kg to about 1.8×10¹⁴ vg / kg, about 1×10¹⁴ vg / kg to about 1.6×10¹⁴ vg / kg, about 1.1×10¹⁴ vg / kg to about 1.5×10¹⁴ vg / kg, or about 1.2×10¹⁴ vg / kg to about 1.4×10¹⁴ vg / kg administered to the patient; (iii) The viral vector is administered to the patient in an amount of about 1.3×10¹⁴ vg / kg; (iv) The patient is 5 years of age or younger at the time of administration of the viral vector, and optionally, the patient is 4 years of age or younger at the time of administration of the viral vector, and optionally, the patient is 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, or 6 months of age or younger at birth; (v) the patient is from about 1 month to about 5 years old at the time of administration of the viral vector; or (vi) further comprising monitoring the patient for the occurrence of cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and optionally, by evaluating parameters of a blood sample obtained from the patient, monitoring for the occurrence of cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and based on the finding that the parameters exceed a reference level, the patient is identified as having cholestasis, hyperbilirubinemia, or one or more symptoms thereof, The composition according to claim 1.

4. (i) the parameter includes the level of serum bile acids in the blood sample, and optionally, the serum bile acids are cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid, or (ii) the parameter includes one or more results of liver function tests, and optionally, the parameter includes the levels of aspartate aminotransferase or alanine aminotransferase in the blood sample, The composition according to claim 3.

5. A composition comprising a viral vector containing a transgene encoding MTM1, for use in the following methods: (i) A method of treating XLMTM in a human patient in need thereof; (ii) A method of reducing rigidity and / or joint contracture in a human patient diagnosed with XLMTM; or (iii) A method of increasing the development of the diaphragm and / or respiratory muscles in a human patient diagnosed with XLMTM wherein the method comprises (a) administering the viral vector to the patient in an amount less than about 3×10 １４ vg / kg, and (b) determining that the patient exhibits cholestasis, hyperbilirubinemia, or one or more symptoms thereof, and (c) administering an anti-cholestatic agent to the patient The composition comprising. **Claim 6**: (i) the viral vector to be administered is administered to the patient in an amount of less than about 2.5×10 １４ vg / kg, and optionally, the viral vector to be administered is administered to the patient in an amount of less than about 2×10 １４ vg / kg, less than about 1.5×10 １４ vg / kg, or less than about 1.4×10 １４ vg / kg; (ii) the viral vector to be administered is administered to the patient in an amount of about 3×10¹³ vg / kg to about 2.3×10¹⁴ vg / kg, and optionally, the viral vector to be administered is about 8×10¹³ vg / kg to about 1.8×10¹⁴ vg / kg, about 1×10¹⁴ vg / kg to about 1.6×10¹⁴ vg / kg, about 1.1×10¹⁴ vg / kg to about 1.5×10¹⁴ vg / kg, or about 1.2×10¹⁴ vg / kg to about 1.4×10¹⁴ vg / kg; (iii) the viral vector to be administered is administered to the patient in an amount of about 1.3×10¹⁴ vg / kg; (iv) the patient is 5 years of age or younger at the time of administration of the viral vector; (v) the patient is 4 years of age or younger at the time of administration of the viral vector, and optionally, the patient is 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, or 6 months of age or younger; or (vi) the patient is about 1 month to about 5 years of age at the time of administration of the viral vector. The composition according to claim 5.

7. A composition comprising a viral vector containing a transgene encoding MTM1 and for use in the following methods: (iv) A method of treating XLMTM in a human patient 5 years of age or younger in need thereof; (v) A method of reducing rigidity and / or joint contracture in a human patient diagnosed with XLMTM; or (vi) A method of increasing the development of the diaphragm and / or respiratory muscles in a human patient diagnosed with XLMTM wherein the method comprises (a) administering to the patient a therapeutically effective amount of the viral vector; (b) determining that the patient exhibits cholestasis, hyperbilirubinemia, or one or more of its symptoms; (c) administering an anti-cholestatic agent to the patient The composition comprising the above.

8. (i) the patient is 4 years of age or younger at the time of administration of the viral vector, and optionally, the patient is 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, or 6 months of age or younger; (ii) the patient is about 1 month to about 5 years of age at the time of administration of the viral vector; (iii) the viral vector to be administered is administered to the patient in an amount less than about 3 × 10¹⁴ vg / kg, optionally, the viral vector to be administered is administered to the patient in an amount less than about 2.5 × 10¹⁴ vg / kg, and optionally, the viral vector is administered to the patient in an amount less than about 2 × 10¹⁴ vg / kg, less than about 1.5 × 10¹⁴ vg / kg, or less than about 1.4 × 10¹⁴ vg / kg; (iv) the viral vector to be administered is administered to the patient in an amount from about 3 × 10¹³ vg / kg to about 2.3 × 10¹⁴ vg / kg, optionally, the viral vector to be administered is administered to the patient in an amount from about 8 × 10¹³ vg / kg to about 1.8 × 10¹⁴ vg / kg, from about 1 × 10¹⁴ vg / kg to about 1.6 × 10¹⁴ vg / kg, from about 1.1 × 10¹⁴ vg / kg to about 1.5 × 10¹⁴ vg / kg, or from about 1.2 × 10¹⁴ vg / kg to about 1.4 × 10¹⁴ vg / kg; or (v) the viral vector to be administered is administered to the patient in an amount of about 1.3 × 10¹⁴ vg / kg The composition according to claim 7.

9. An anti-cholestatic agent for use in a method of treating or preventing cholestasis or hyperbilirubinemia in the following human patients having XLMTM: (i) a human patient who has previously received administration of a viral vector containing a transgene encoding MTM1 in an amount less than about 3 × 10¹⁴ vg / kg, or (ii) a human patient who has previously received administration of a viral vector containing a transgene encoding MTM1 and who was 5 years of age or younger at the time of administration of the viral vector.

10. (i) The viral vector is administered to the patient in an amount less than about 2.5 × 10 １４ vg / kg, and optionally, the viral vector is administered to the patient in an amount less than about 2 × 10 １４ vg / kg, less than about 1.5 × 10 １４ vg / kg, or less than about 1.4 × 10 １４ vg / kg; (ii) the viral vector is administered to the patient in an amount from about 3 × 10¹³ vg / kg to about 2.3 × 10¹⁴ vg / kg, optionally, the viral vector is administered to the patient in an amount from about 8 × 10¹³ vg / kg to about 1.8 × 10¹⁴ vg / kg, from about 1 × 10¹⁴ vg / kg to about 1.6 × 10¹⁴ vg / kg, from about 1.1 × 10¹⁴ vg / kg to about 1.5 × 10¹⁴ vg / kg, or from about 1.2 × 10¹⁴ vg / kg to about 1.4 × 10¹⁴ vg / kg; (iii) the viral vector is administered to the patient in an amount of about 1.3 × 10¹⁴ vg / kg; (iv) the patient is 5 years of age or younger at the time of administration of the viral vector, optionally, the patient is 4 years of age or younger at the time of administration of the viral vector, optionally, the patient is 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, or 6 months of age or younger at birth; or (v) the patient is from about 1 month to about 5 years of age at birth at the time of administration of the viral vector, The anti-cholestatic agent according to claim 9.

11. (i) the patient was 4 years of age or younger at the time of administration of the viral vector, optionally, the patient was 3 years of age or younger, 2 years of age or younger, 1 year of age or younger, or 6 months of age or younger at birth; (ii) the patient was from about 1 month to about 5 years of age at birth at the time of administration of the viral vector; (iii) the viral vector is administered to the patient in an amount less than about 3 × 10^14 vg / kg, optionally, the viral vector is administered to the patient in an amount less than about 2.5 × 10^14 vg / kg, optionally, the viral vector is administered to the patient in an amount less than about 2 × 10^14 vg / kg, less than about 1.5 × 10^14 vg / kg, or less than about 1.4 × 10^14 vg / kg; (iv) the viral vector is administered to the patient in an amount from about 3 × 10^13 vg / kg to about 2.3 × 10^14 vg / kg, optionally, the viral vector is administered to the patient in an amount from about 8 × 10^13 vg / kg to about 1.8 × 10^14 vg / kg, from about 1 × 10^14 vg / kg to about 1.6 × 10^14 vg / kg, from about 1.1 × 10^14 vg / kg to about 1.5 × 10^14 vg / kg, or from about 1.2 × 10^14 vg / kg to about 1.4 × 10^14 vg / kg; or (v) the viral vector is administered to the patient in an amount of about 1.3 × 10^14 vg / kg, The anti-cholestatic agent according to claim 9.

12. (i) the viral vector is administered to the patient in a single dose containing the amount; (ii) the viral vector is administered to the patient in two or more doses containing the amount in total, optionally, the two or more doses are separated from each other by 1 year or more, or the two or more doses are administered to the patient within about 12 months of each other; (iii) the viral vector is administered to the patient in two or more doses each individually containing said amount, and optionally, the two or more doses are separated from each other by one year or more, or the two or more doses are administered to the patient within about 12 months of each other; (iv) the viral vector is selected from the group consisting of adeno-associated virus (AAV), adenovirus, lentivirus, retrovirus, poxvirus, baculovirus, herpes simplex virus, vaccinia virus, and synthetic virus, optionally, the viral vector is AAV, optionally, the AAV is of a serotype of AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAVrh10, or AAVrh74, or the viral vector is pseudotyped AAV, optionally, the pseudotyped AAV is AAV2 / 8 or AAV2 / 9, and optionally, the pseudotyped AAV is AAV2 / 8; (v) the transgene encoding MTM1 is operably linked to a muscle-specific promoter, optionally, the muscle-specific promoter is a desmin promoter, a muscle creatine kinase promoter, a myosin light chain promoter, a myosin heavy chain promoter, a cardiac troponin C promoter, a troponin I promoter, a myoD gene family promoter, an actin alpha promoter, an actin beta promoter, an actin gamma promoter, or a promoter within intron 1 of paired-like homeodomain 3 of the eye, and optionally, the muscle-specific promoter is a desmin promoter; (vi) the viral vector is resamigenene bilparvovec; (vii) the viral vector is administered to the patient by intravenous, intramuscular, intradermal, or subcutaneous administration; (viii) the anti-cholestatic agent is selected from the group consisting of bile acids, farnesoid X receptor (FXR) ligands, fibroblast growth factor 19 (FGF-19) mimetics, Takeda-G protein receptor 5 (TGR5) agonists, peroxisome proliferator-activated receptor (PPAR) agonists, PPAR-alpha agonists, PPAR-delta agonists, dual agonists of PPAR-alpha and PPAR-delta, apical sodium-dependent bile acid transporter (ASBT) inhibitors, immunomodulatory agents, antifibrotic therapies, and nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitors; (ix) the patient does not have a history of cholestasis or hyperbilirubinemia, and optionally, the patient does not have a history of any underlying liver disease; (x) the patient was born at a gestational age of 35 weeks or more and was full term to about 5 years old or that age at the time of administration of the viral vector; (xi) the patient is male; (xii) the patient requires mechanical ventilation assistance, and optionally, the mechanical ventilation assistance includes invasive mechanical ventilation assistance and non-invasive mechanical ventilation assistance; (xiii) when the viral vector is administered to the patient, the patient shows a change over time from baseline in the number of hours of mechanical ventilation assistance, and optionally, the patient shows a change over time from baseline in the number of hours of mechanical ventilation assistance by about 24 weeks after administration of the viral vector to the patient, and optionally, the patient shows a change over time from baseline in the number of hours of mechanical ventilation assistance by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient; (xiv) when the viral vector is administered to the patient, the patient achieves functional independent sitting for at least 30 seconds, and optionally, the patient achieves the functional independent sitting by about 24 weeks after administration of the viral vector to the patient, and optionally, the patient shows functional independent sitting for at least 30 seconds by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administration of the viral vector to the patient; (xv) When the viral vector is administered to the patient, the patient shows a decrease in the required mechanical ventilator assistance to about 16 hours or less per day, and optionally, the patient shows a decrease in the required mechanical ventilator assistance by about 24 weeks after administering the viral vector to the patient, and optionally, the patient shows a decrease in the required mechanical ventilator assistance by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient; (xvi) When the viral vector is administered to the patient, the patient shows a change from baseline in the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND), and optionally, the patient shows a change from baseline in the CHOP INTEND by about 24 weeks after administering the viral vector to the patient, and optionally, the patient shows a change from baseline in the CHOP INTEND by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient; (xvii) When the viral vector is administered to the patient, the patient shows a change from baseline in the maximum inspiratory pressure (MIP), and optionally, the patient shows a change from baseline in the MIP by about 24 weeks after administering the viral vector to the patient, and optionally, the patient shows a change from baseline in the MIP by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient; (xviii) When the viral vector is administered to the patient, the patient shows a change from baseline in the quantitative analysis of myotubularin expression in muscle biopsy, and optionally, the patient shows a change from baseline in the quantitative analysis of myotubularin expression in muscle biopsy by about 24 weeks after administering the viral vector to the patient, and optionally, the patient shows a change from baseline in the quantitative analysis of myotubularin expression in muscle biopsy by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient, and optionally, the change from baseline in the quantitative analysis of myotubularin expression in muscle biopsy persists for at least 48 weeks after administering the viral vector to the patient; (xix) When the viral vector is administered to the patient, the patient shows a decrease in rigidity and / or joint contracture, and optionally, the patient shows a decrease in rigidity and / or joint contracture by about 24 weeks after administering the viral vector to the patient, and optionally, the patient shows a decrease in rigidity and / or joint contracture by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient; or (xx) When the viral vector is administered to the patient, the patient shows development of the diaphragm and / or respiratory muscles, and optionally, the patient shows development of the diaphragm and / or respiratory muscles by about 24 weeks after administering the viral vector to the patient, and optionally, the patient shows development of the diaphragm and / or respiratory muscles by about 20 weeks, 16 weeks, 12 weeks, 8 weeks, or 4 weeks after administering the viral vector to the patient. The composition according to claim 1.

13. (a) (i) The FXR ligand is obeticholic acid, silofexol, tropifexor, tretinoin, or EDP-305, (ii) The FGF-19 mimetic is aldafeldin, (iii) The TGR5 agonist is INT-777 or INT-767, (iv) The PPAR agonist is bezafibrate, ceradelpar, or elafibranor, (v) the PPAR-alpha agonist is fenofibrate, (vi) the PPAR-delta agonist is seladelpar, (vii) the dual agonist of PPAR-alpha and PPAR-delta is elafibranor, (viii) the ASBT inhibitor is odipixibat, maralixibat, or linaclotide, (ix) the immunomodulatory agent is rituximab, abatacept, ustekinumab, infliximab, baricitinib, or FFP-104, (x) the antifibrotic therapy is a vitamin D receptor agonist or simtuzumab, and / or (xi) the NOX inhibitor is cetanixib; (b) the bile acid is ursodeoxycholic acid, norursodeoxycholic acid, or a pharmaceutically acceptable salt thereof, and optionally, the bile acid is ursodiol; (c) the bile acid is administered to the patient in a single dose; (d) the bile acid is administered to the patient in multiple doses; (e) the bile acid is administered to the patient in an amount of about 5 mg / kg / day to about 40 mg / kg / day, and optionally, (i) the bile acid is administered to the patient in an amount of about 6 mg / kg / day to about 39 mg / kg / day, about 8 mg / kg / day to about 37 mg / kg / day, about 13 mg / kg / day to about 32 mg / kg / day, or about 20 mg / kg / day to about 25 mg / kg / day, or (ii) the bile acid is administered to the patient in an amount of about 17 mg / kg / day to about 23 mg / kg / day, about 18 mg / kg / day to about 22 mg / kg / day, or about 19 mg / kg / day to about 21 mg / kg / day; (f) the bile acid is administered to the patient in an amount of 20 mg / kg / day; (g) the bile acid is administered to the patient in a unit dosage form containing 250 mg of the bile acid; (h) the bile acid is administered to the patient in a unit dosage form containing 500 mg of the bile acid; or (i) the bile is administered to the patient by enteral administration, The composition according to claim 12.

14. The bile acid is administered to the patient in an amount of about 5 mg / kg / dose to about 20 mg / kg / dose, and optionally, the bile acid is about 6 mg / kg / dose to about 19 mg / kg / dose, about 7 mg / kg / dose to about 18 mg / kg / dose, about 8 mg / kg / dose to about 17 mg / kg / dose, about 10 mg / kg / dose to about 15 mg / kg / dose, or about 12 mg / kg / dose to about 13 mg / kg / dose, and optionally, the bile acid is administered to the patient in an amount of about 5 mg / kg / dose to about 11 mg / kg / dose, and optionally, the bile acid is administered to the patient in an amount of about 6 mg / kg / dose to about 10 mg / kg / dose, or about 7 mg / kg / dose to about 9 mg / kg / dose, and optionally, the bile acid is administered to the patient in a dose of one or more times per day, per week, or per month, and optionally, the bile acid is administered to the patient in a dose of one or more times per day, and optionally, the bile acid is administered to the patient in a dose of once a day, twice a day, three times a day, four times a day, or five times a day, and optionally, the bile acid is administered to the patient in a dose of once a day, the composition according to claim 13.

15. (i) It is determined that the patient exhibits cholestasis or one or more of its symptoms based on the finding that the patient has a serum total bile acid level greater than 14 μmol / L; (ii) It is determined that the patient exhibits cholestasis or one or more of its symptoms based on the finding that the patient shows an increase or decrease in one or more parameters relative to the reference level in a blood test; (iii) It is determined that the patient exhibits hyperbilirubinemia or one or more of its symptoms based on the finding that the patient has a bilirubin level greater than 1 mg / dL in a bilirubin test; or (iv) It is determined that the patient exhibits cholestasis, hyperbilirubinemia, or one or more of its symptoms based on the finding that the patient shows an increase in a parameter relative to the reference level in a blood test, The composition according to claim 5.

16. (i) The blood test is a liver function test; (ii) the one or more parameters include levels of gamma-glutamyltransferase, alkaline phosphatase, aspartate aminotransferase, and / or alanine aminotransferase; (iii) when the viral vector is administered to the patient, the patient exhibits a bilirubin level greater than 1 mg / dL in a bilirubin test by about 3 weeks after administering the viral vector to the patient; (iv) the bilirubin level includes a direct bilirubin level or a total bilirubin level; (v) the parameter includes a level of serum bile acids, and optionally, the serum bile acids are cholic acid, chenodeoxycholic acid, deoxycholic acid, or ursodeoxycholic acid; or (vi) the parameter includes one or more results of liver function tests, and optionally, the parameter includes levels of aspartate aminotransferase or alanine aminotransferase, The composition according to claim 15.

17. A kit comprising a viral vector containing a transgene encoding MTM1 and an accompanying document, wherein the accompanying document gives instructions to the user of the kit to administer the viral vector to a patient having XLMTM according to the composition of claim 1.

18. A kit comprising an anti-cholestatic agent and an accompanying document, wherein the accompanying document gives instructions to the user of the kit to administer the anti-cholestatic agent to a patient to treat or prevent cholestasis or hyperbilirubinemia according to the anti-cholestatic agent of claim 9.

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