How to treat Fabry disease in pediatric patients

Abstract

Methods for treating Fabry disease in adolescent patients are provided.

Description

[Technical field]

[0001] Principles and embodiments of the present invention relate generally to the treatment of Fabry disease. [Background technology]

[0002] Many human diseases result from mutations that cause changes in the amino acid sequence of a protein, which can reduce the protein's stability and prevent it from folding properly. Proteins are generally folded in a specific region of the cell known as the endoplasmic reticulum, or ER. Cells have quality control mechanisms that ensure that proteins can fold into their correct three-dimensional shape and then move from the ER to their proper destination within the cell, a process generally referred to as protein trafficking. Misfolded proteins are often initially retained in the ER and then eliminated by the quality control mechanisms. In some cases, misfolded proteins can accumulate in the ER before being eliminated. Retention of misfolded proteins in the ER can impede their proper trafficking, resulting in reduced biological activity that can impair cell function and ultimately lead to disease. In addition, accumulation of misfolded proteins in the ER can also result in various stresses on the cell, which can also contribute to cell dysfunction and disease.

[0003] Such mutations can lead to lysosomal storage disorders (LSDs) characterized by the deficiency of a lysosomal enzyme due to a mutation in the gene encoding the lysosomal enzyme. The resulting disease causes pathological accumulation of the enzyme's substrates, including lipids, carbohydrates, and polysaccharides. Although there are many different mutant genotypes associated with each LSD, many of these mutations are missense mutations that can lead to the production of less stable enzymes. These less stable enzymes are sometimes prematurely degraded by the ER-associated degradation pathway. This results in enzyme deficiency in the lysosomes and pathological accumulation of the substrate. Such mutant enzymes are sometimes referred to in the art as "folding mutants" or "conformational mutants."

[0004] Fabry disease, an LSD, is a progressive, X-linked, inborn error of glycosphingolipid metabolism caused by deficiency of the lysosomal enzyme α-galactosidase A (α-Gal A) as a result of mutations in the α-Gal A gene (GLA). Females may develop clinical symptoms to varying degrees, despite being an X-linked disorder.

[0005] Fabry disease is classified into three groups according to clinical manifestations: the classic form with systemic vasculopathy, the atypical variant form with clinical manifestations limited to cardiac tissue, and the late-onset disease, which includes female carriers with mild to severe forms of the disease. Clinical manifestations include angiokeratoma (small, raised, reddish-purple spots on the skin), acrotactile dysesthesias (tingling of the hands and feet), hypohidrosis (reduced ability to sweat), and characteristic corneal and lenticular opacities (The Metabolic and Molecular Bases of Inherited Disease, 8th Edition 2001, Scriver et al., ed., pp. 3733-3774, McGraw-Hill, New York).

[0006] Fabry is a rare disorder with an estimated incidence between 1 in 40,000 and 1 in 117,000 males in the general population. In addition, there are late-onset phenotypic variants of Fabry disease that may be underdiagnosed because they do not present with the classic signs and symptoms. This screening of newborns for Fabry disease suggests that the actual incidence of Fabry disease may be higher than currently estimated.

[0007] Untreated Fabry patients have a reduced life expectancy and death usually occurs in the third or fourth decade due to vascular disease affecting the kidneys, heart, and / or central nervous system. Enzyme deficiency causes intracellular accumulation of the substrate globotriaosylceramide (GL-3) in vascular endothelium and visceral tissues throughout the body. The heart may also become enlarged and the kidneys may become progressively damaged. Slow deterioration of renal function and development of azotemia due to glycosphingolipid deposition usually occurs in the second to fourth decade of life but can occur as early as the first decade. Renal involvement is found in both hemizygous (male) and heterozygous (female) patients. Life expectancy of affected males is reduced and death usually occurs in the third or fourth decade as a result of vascular disease of the heart, brain, and / or kidneys. Other symptoms include fever, especially after meals, and gastrointestinal problems.

[0008] Cardiac disease as a result of Fabry disease occurs in most men and many women. Early cardiac findings include left ventricular hypertrophy, valvular disease, and conduction abnormalities. Mitral regurgitation is the most frequent valvular lesion, typically seen in childhood or adolescence. Cerebrovascular symptoms are primarily due to multifocal small vessel disease and may include thrombosis, transient ischemic attacks, basilar artery ischemia and aneurysms, seizures, hemiplegia, hemisensory loss, aphasia, labyrinthine disorders, or cerebral hemorrhage. The mean age at onset of cerebrovascular symptoms is 33.8 years. Personality changes and psychotic behavior may emerge with age.

[0009] Individuals with late-onset Fabry disease can be male or female. Late-onset Fabry disease manifests as an atypical variant form, and growing evidence indicates that there may be a significant number of unexplained "atypical variants" worldwide. Females who inherit an X chromosome containing an a-GAL mutation may present with symptoms later in life, significantly increasing the prevalence of the disease. These patients typically first experience symptoms in adulthood, and often have symptoms localized to a single organ. For example, many men and women with late-onset Fabry disease have left ventricular hypertrophy of the heart. Late-onset Fabry disease may also manifest in the form of strokes of unknown etiology. As the patient ages, cardiac complications of the disease progress and may cause death.

[0010] Patients with the milder "cardiac variant" of Fabry disease usually have 5-15% of normal a-Gal activity and present with left ventricular hypertrophy or cardiomyopathy. These cardiac variant patients remain essentially asymptomatic while their classically affected counterparts become severely impaired. The cardiac variant has been found in 11% of adult male patients with unexplained left ventricular hypertrophic cardiomyopathy, suggesting that Fabry disease may be more frequent than previously appreciated (Nakao et al., N. Engl. J. Med. 1995;333:288-293).

[0011] There are several approaches to treat Fabry disease. One therapy approved for the treatment of Fabry disease is enzyme replacement therapy (ERT), which typically involves intravenous infusion of the corresponding wild-type protein in purified form (Fabrazyme®, Genzyme Corp.). However, ERT has several drawbacks. One of the major complications of enzyme replacement therapy is the rapid degradation of the injected protein, which leads to the need for multiple, expensive, high-dose infusions. There are several additional caveats to ERT, such as the difficulty in large-scale production, purification, and storage of properly folded proteins; availability of glycosylated native proteins; development of anti-protein immune responses; and the inability of the proteins to cross the blood-brain barrier and alleviate central nervous system pathology (i.e., low bioavailability). In addition, the replacement enzyme cannot penetrate the heart or kidney in sufficient amounts to reduce substrate accumulation in renal podocytes or cardiomyocytes, which is prominent in Fabry disease.

[0012] In addition, ERT typically involves intravenous infusion of the corresponding wild-type protein in purified form. Two α-Gal A preparations are currently available for the treatment of Fabry disease: agalsidase alfa (Replagal®, Shire Human Genetic Therapies) and agalsidase beta (Fabrazyme®; Sanofi Genzyme Corporation). Although ERT is effective in many situations, the treatment also has limitations. ERT has not been demonstrated to reduce the risk of stroke, the heart muscle responds slowly, and clearance of GL-3 from some cell types in the kidney is limited. Also, some patients develop an immune response to ERT.

[0013] Another therapeutic approach for certain enzyme deficiencies involves the use of small molecule inhibitors to suppress production of the natural substrate of the defective enzyme protein, thereby alleviating the pathology. This "substrate inhibition" approach has been described for a class of about 40 related enzyme disorders called lysosomal storage disorders, including glycosphingolipid storage disorders in particular. The small molecule inhibitors proposed for use as therapy are specific for inhibiting enzymes involved in the synthesis of glycolipids, reducing the amount of cellular glycolipids that need to be degraded by the defective enzyme.

[0014] A third approach to treating Fabry disease involves treatment with so-called pharmacological chaperones (PCs), which contain small molecule inhibitors of α-Gal A that can bind to α-Gal A and increase the stability of both the mutant enzyme and its wild-type counterpart.

[0015] Thus, there remains a need for therapies to treat Fabry disease. Summary of the Invention [Means for solving the problem]

[0016] Various aspects of the invention relate to the treatment of Fabry disease.

[0017] One aspect of the invention relates to a method of treating Fabry disease in a human patient in need of such treatment. In one or more embodiments, the method comprises administering to the patient a formulation. In some embodiments, the formulation comprises a therapeutically effective dose of migalastat or a salt thereof. In some embodiments, the patient is a pediatric patient. In some embodiments, the age of the patient ranges from about 2 years to about <18 years. In some embodiments, the weight of the patient ranges from about <15 kg to about ≧50 kg. In some embodiments, a therapeutically effective dose of migalastat or a salt thereof ranges from about 15 mg to about 150 mg every other day. In some embodiments, a therapeutically effective dose of migalastat hydrochloride ranges from about 25 mg to about 150 mg every other day. In some embodiments, a therapeutically effective dose of migalastat FBE ranges from about 15 mg to about 123 mg every other day.

[0018] In one or more embodiments, the patient's age ranges from 12 to <18. In some embodiments, the patient's weight is about ≧25 kg. In some embodiments, the therapeutically effective dose of migalastat hydrochloride ranges from about 80 mg to about 150 mg every other day. In one or more embodiments, the patient's weight is about ≧45 kg. In some embodiments, the therapeutically effective dose of migalastat hydrochloride is about 150 mg every other day. In some embodiments, the therapeutically effective dose of migalastat FBE is about 123 mg every other day.

[0019] In one or more embodiments, the patient's age ranges from about 6 years to about <12 years. In some embodiments, the patient's weight is about ≧25 kg. In some embodiments, the therapeutically effective dose of migalastat hydrochloride ranges from about 80 mg to about 150 mg every other day.

[0020] In one or more embodiments, the patient's age ranges from about 2 years to about <6 years. In some embodiments, the patient's weight is about <35 kg. In some embodiments, the therapeutically effective dose of migalastat hydrochloride ranges from about 40 mg to about 80 mg every other day.

[0021] In one or more embodiments, the patient has a blood flow rate of about ≧60 mL / min / 1.73 m 2 have an eGFR of

[0022] In one or more embodiments, migalastat or a salt thereof enhances or prolongs α-galactosidase A activity.

[0023] In one or more embodiments, the formulation comprises an oral dosage form, hi some embodiments, the oral dosage form comprises a tablet, capsule, or solution.

[0024] In one or more embodiments, the patient is male.

[0025] In one or more embodiments, the patient is female.

[0026] In one or more embodiments, the patient is an ERT-naive patient.

[0027] In one or more embodiments, the patient is an ERT-experienced patient who has discontinued ERT for at least 14 days.

[0028] In one or more embodiments, the patient has a HEK assay applicable mutation in α-galactosidase A. In one or more embodiments, the mutation is disclosed in a pharmacological reference table. In one or more embodiments, the pharmacological reference table is provided in the package insert of a migalastat product approved for the treatment of Fabry disease. In one or more embodiments, the pharmacological reference table is provided in the GALAFOLD® package insert. In one or more embodiments, the pharmacological reference table is provided on a website. In one or more embodiments, the website is one or more of www.galafoldamenabilitytable.com or www.fabrygenevariantsearch.com.

[0029] Further features of the present invention will become apparent from the following written description and the accompanying drawings. [Brief description of the drawings]

[0030] [Figure 1A-E] The complete DNA sequence of the human wild-type GLA gene (SEQ ID NO:1) is shown. [Diagram 2] The wild-type α-Gal A protein (SEQ ID NO:2) is shown. [Diagram 3] The nucleic acid sequence encoding the wild-type α-Gal A protein (SEQ ID NO:3) is shown. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0031] Before describing certain exemplary embodiments of the invention, it is to be understood that the invention is not limited to the details of construction or method steps set forth in the following description, as the invention is capable of other embodiments and of being practiced or carried out in various ways.

[0032] Various aspects of the present invention relate to the administration of pharmacological chaperones, such as migastat, to treat Fabry disease in pediatric and adolescent patients.

[0033] definition The terms used herein generally have their ordinary meaning in the art, within the context of this invention and in the specific context in which each term is used. Certain terms are discussed below, or elsewhere in the specification, to provide further guidance to the practitioner in describing the compositions and methods of the invention and how to make and use them.

[0034] The term "Fabry disease" refers to an X-linked inborn error of glycosphingolipid catabolism resulting from deficient lysosomal α-Gal A activity. This defect leads to the accumulation of the substrate globotriaosylceramide ("GL-3", also known as Gb3 or ceramide trihexoside) and related glycosphingolipids in vascular endothelial lysosomes in the heart, kidney, skin, and other tissues. Another substrate for this enzyme is plasma globotriaosylsphingosine ("plasma lyso-Gb3").

[0035] The term "atypical Fabry disease" refers to patients who have the predominant cardiac manifestation of α-Gal A deficiency, i.e., progressive GL-3 accumulation within cardiomyocytes leading to significant hypertrophy of the heart, particularly the left ventricle.

[0036] A "carrier" is a female in which one X chromosome contains a defective α-Gal A gene and one X chromosome contains a normal gene, and there is X chromosome inactivation of the normal allele in one or more cell types. Carriers are often diagnosed with Fabry disease.

[0037] "Patient" refers to a subject who has been diagnosed with or is suspected of having a particular disease. The patient may be a human or an animal.

[0038] "Fabry patient" refers to an individual with mutant α-Gal A, as further defined below, who has been diagnosed with or is suspected of having Fabry disease. Trait markers for Fabry disease may appear with equal prevalence in hemizygous male and female carriers, although females are typically affected with less severe disease.

[0039] Human α-galactosidase A (α-Gal A) refers to the enzyme encoded by the human GLA gene. The complete DNA sequence of α-Gal A, including introns and exons, is available under GenBank Accession No. X14448.1 and is shown in Figure 1A-E (SEQ ID NO:1). The human α-Gal A enzyme consists of 429 amino acids and is available under GenBank Accession Nos. X14448.1 and U78027.1 and is shown in Figure 2 (SEQ ID NO:2). The nucleic acid sequence including only the coding region (i.e., exons) of SEQ ID NO:1 is shown in Figure 3 (SEQ ID NO:3).

[0040] The term "mutant protein" includes proteins that have a mutation in the gene encoding the protein that prevents the protein from achieving a stable conformation under conditions normally present in the endoplasmic reticulum (ER). Failure to achieve a stable conformation results in significant amounts of the enzyme not being transported to lysosomes but rather being degraded. Such mutations are sometimes referred to as "conformational mutants." Such mutations include, but are not limited to, missense mutations, and small in-frame deletions and insertions.

[0041] As used herein in one embodiment, the term "mutant α-Gal A" includes α-Gal A that has a mutation in the gene encoding α-Gal A that prevents the enzyme from achieving a stable conformation under conditions normally present in the ER. The inability to achieve a stable conformation results in a significant amount of the enzyme not being transported to lysosomes but rather being degraded.

[0042] As used herein, the term "pharmacological chaperone" ("PC") or "specific pharmacological chaperone" ("SPC") refers to any molecule, including small molecules, proteins, peptides, nucleic acids, carbohydrates, etc., that specifically binds to a protein and has one or more of the following effects: (i) promotes the formation of a stable molecular conformation of the protein; (ii) induces trafficking of the protein from the ER to another cellular site, preferably the native cellular site, i.e., prevents ER-associated degradation of the protein; (iii) prevents aggregation of misfolded proteins; and / or (iv) restores or enhances at least some wild-type function and / or activity to a protein. For example, a compound that specifically binds to α-Gal A means that it binds to and exerts a chaperone effect on that enzyme and not on a general group of related or unrelated enzymes. More specifically, the term does not refer to endogenous chaperones such as BiP, or non-specific agents, i.e., chemical chaperones, that have demonstrated non-specific chaperone activity for various proteins, such as glycerol, DMSO, or deuterium oxide. In one or more embodiments of the present invention, the PC may be a reversible competitive inhibitor. In one or more embodiments, the PC is migalastat or a salt thereof. In another embodiment, the PC is migalastat free base (e.g., 123 mg migalastat free base). In yet another embodiment, the PC is a salt of migalastat (e.g., 150 mg migalastat HCl).

[0043] A "competitive inhibitor" of an enzyme may refer to a compound that is structurally similar to the chemical and molecular structure of the enzyme substrate and binds to the enzyme at approximately the same location as the substrate. Thus, the inhibitor competes for the same active site as the substrate molecule, thus increasing the Km. Competitive inhibition is usually reversible, i.e., a competitive inhibitor can bind reversibly, provided that sufficient substrate molecules are available to displace the inhibitor. Thus, the amount of enzyme inhibition depends on the inhibitor concentration, the substrate concentration, and the relative affinities of the inhibitor and substrate for the active site.

[0044] As used herein, the term "specifically binds" refers to the interaction of a pharmacological chaperone with a protein, such as α-Gal A, specifically with amino acid residues in the protein that are directly involved in contact with the pharmacological chaperone. A pharmacological chaperone specifically binds to a target protein, such as α-Gal A, to exert a chaperone effect on that protein and not on a general group of related or unrelated proteins. The amino acid residues in a protein that interact with a given pharmacological chaperone may or may not be within the "active site" of the protein. Specific binding can be assessed by routine binding assays or by structural studies, such as co-crystallization, NMR, etc. The active site of α-Gal A is the substrate binding site.

[0045] "Deficient α-Gal A activity" refers to α-Gal A activity in cells from a patient that is below the normal range when compared (using the same methods) to the activity in normal individuals who do not have or are not suspected of having Fabry disease or any other disease (particularly hematological disorders).

[0046] As used herein, the term "enhancing a-Gal A activity" or "increasing a-Gal A activity" refers to increasing the amount of a-Gal A in a stable conformation in a cell contacted with an a-Gal A specific pharmacological chaperone compared to the amount in a cell (preferably of the same cell type, or the same cell, e.g., at an earlier stage) that is not contacted with the a-Gal A specific pharmacological chaperone. The term also refers to increasing the trafficking of a-Gal A to lysosomes in a cell contacted with an a-Gal A specific pharmacological chaperone compared to the trafficking of a-Gal A not contacted with the pharmacological chaperone specific for that protein. These terms refer to both wild type and mutant a-Gal A. In one embodiment, the increase in the amount of a-Gal A in a cell is measured by measuring the hydrolysis of an artificial substrate in lysates from cells treated with PC. Increased hydrolysis is indicative of increased a-Gal A activity.

[0047] The term "α-Gal A activity" refers to the normal physiological function of wild-type α-Gal A in a cell. For example, α-Gal A activity includes the hydrolysis of GL-3.

[0048] A "responder" is an individual diagnosed with or suspected of having a lysosomal storage disorder (LSD), e.g., Fabry disease, whose cells respond to contact with PC by displaying a sufficient increase in α-Gal A activity and / or alleviation of symptoms or enhancement of a surrogate marker, respectively. Non-limiting examples of enhanced Fabry surrogate markers include lyso-GB3 and those disclosed in U.S. Patent Application Publication No. 2010 / 0113517, which is hereby incorporated by reference in its entirety.

[0049] Non-limiting examples of improvements in surrogate markers of Fabry disease disclosed in U.S. Patent Application Publication No. 2010 / 0113517 include increased α-Gal A levels or activity in cells (e.g., fibroblasts) and tissues; reduced GL-3 accumulation; reduced plasma concentrations of homocysteine ​​and vascular cell adhesion molecule-1 (VCAM-1); reduced GL-3 accumulation in cardiomyocytes and valvular fibrocytes; reduced plasma lyso-Gb3; reduced cardiac hypertrophy (especially the left ventricle), reduced valvular regurgitation, and arrhythmias; reduced proteinuria; reduced urinary concentrations of lipids such as CTH, lactosylceramide, ceramide, and increased urinary concentrations of glucosylceramide and sphingomyelin; absence of lamellar inclusions (zebra bodies) in glomerular epithelial cells; improved renal function; reduced hypohidrosis; absence of angiokeratoma; and improvement in hearing abnormalities such as high frequency sensorineural hearing loss, progressive hearing loss, sudden hearing loss, or tinnitus. Improvement of neurological symptoms includes prevention of transient ischemic attacks (TIA) or stroke; and reduction of neuropathic pain manifested as acroparesthesia (burning or tingling pain in the extremities). Another clinical marker that may determine Fabry disease is the prevalence of adverse cardiovascular symptoms. Common cardiac-related signs and symptoms in Fabry disease include left ventricular hypertrophy, valvular disease (especially mitral valve prolapse and / or regurgitation), premature coronary artery disease, angina, myocardial infarction, conduction abnormalities, arrhythmias, and congestive heart failure.

[0050] A dose which achieves one or more of the aforementioned responses is a "therapeutically effective dose."

[0051] The phrase "pharmaceutical acceptable" refers to molecular entities and compositions that are physiologically tolerable and typically do not produce adverse reactions when administered to humans. In some embodiments, as used herein, the term "pharmaceutical acceptable" means approved by a federal or state regulatory agency for use in animals, more particularly humans, or listed in the United States Pharmacopeia or other generally recognized pharmacopoeias. With respect to pharmaceutical carriers, the term "carrier" refers to a diluent, adjuvant, excipient, or vehicle with which the compound is administered. Such pharmaceutical carriers may be sterile liquids, such as water and oils. As carriers, water or aqueous solutions, saline solutions, and aqueous dextrose and glycerol solutions are preferably employed, particularly for injectable solutions. Suitable pharmaceutical carriers are described in "Remington's Pharmaceutical Sciences" by E. W. Martin, 18th Edition, or other editions.

[0052] As used herein, the term "isolated" means that the material being referred to is removed from the environment in which it is normally found. Thus, an isolated biological material may be free of cellular components, i.e., components of the cell in which it is found or produced. In the case of a nucleic acid molecule, an isolated nucleic acid includes a PCR product, an mRNA band on a gel, a cDNA, or a restriction fragment. In another embodiment, an isolated nucleic acid is preferably excised from the chromosome in which it may be found, and more preferably is no longer connected to non-regulatory regions, non-coding regions, or other genes located upstream or downstream of the gene contained in the isolated nucleic acid molecule when found in the chromosome. In yet another embodiment, an isolated nucleic acid lacks one or more introns. An isolated nucleic acid includes sequences that are inserted into a plasmid, cosmid, artificial chromosome, and the like. Thus, in a specific embodiment, a recombinant nucleic acid is an isolated nucleic acid. An isolated protein may be associated with other proteins or nucleic acids, or both, with which it is associated in the cell, or with the cell membrane if it is a membrane-bound protein. An isolated organelle, cell, or tissue is removed from the anatomical site in which it is found in an organism. An isolated material may, but need not, be purified.

[0053] The term "enzyme replacement therapy" or "ERT" refers to the introduction of a non-naturally occurring purified enzyme into an individual deficient in such an enzyme. The administered protein may be obtained from a natural source or by recombinant expression (as described in more detail below). The term also refers to the introduction of a purified enzyme in an individual who would otherwise require or benefit from the administration of a purified enzyme, such as an individual suffering from an enzyme deficiency. The introduced enzyme may be a purified recombinant enzyme made in vitro, or may be a protein purified from isolated tissues or body fluids, such as placenta or animal milk, or purified from plants.

[0054] The term "ERT naive patient" refers to a Fabry patient who has never received ERT or has not received ERT for at least 6 months prior to initiating migalastat therapy.

[0055] The term "ERT-experienced patient" refers to a Fabry patient who was receiving ERT immediately prior to initiating migalastat therapy. In some embodiments, an ERT-experienced patient has been receiving ERT for at least 12 months immediately prior to initiating migalastat therapy.

[0056] As used herein, the term "free base equivalent" or "FBE" refers to the amount of migalastat present in migalastat or its salt. In other words, the term "FBE" refers to either the amount of migalastat free base or the equivalent of migalastat free base provided by a salt of migalastat. For example, due to the weight of the hydrochloride salt, only 150 mg of migalastat hydrochloride provides the same amount of migalastat as 123 mg of migalastat in free base form. Other salts are expected to have different conversion factors depending on the molecular weight of the salt.

[0057] The term "migalastat," unless specifically indicated to the contrary, includes migalastat free base or a pharma- ceutically acceptable salt thereof (eg, migalastat HCl).

[0058] The terms "mutation" and "variant" (e.g., as in "applicable mutation or variant") refer to a change in the nucleotide sequence of a gene or chromosome. The two terms mentioned herein are typically used together - e.g., as "mutation or variant" referring to the change in the nucleotide sequence mentioned in the perforation sequence. If only one of these two terms is mentioned for any reason, the missing term is included and should be understood as such. Furthermore, the terms "applicable mutation" and "applicable variant" refer to a mutation or variant that is applicable to PC therapy, e.g., applicable to migalastat therapy. A particular type of applicable mutation or variant is a "HEK assay applicable mutation or variant" which is a mutation or variant that has been determined to be applicable to migalastat therapy according to the criteria in the in vitro HEK assay described herein and in U.S. Pat. No. 8,592,362, which is hereby incorporated by reference in its entirety.

[0059] The terms "about" and "approximately" are generally intended to mean an acceptable degree of error of the measured quantity, given the nature or precision of the measurement. Typical exemplary degrees of error are within 20 percent (%), preferably within 10%, and more preferably within 5% of a given value or range of values. Alternatively, particularly in biological systems, the terms "about" and "approximately" can mean values ​​within an order of magnitude, preferably within 10-fold or 5-fold, and more preferably within 2-fold, of a given value. Numerical quantities provided herein are approximate unless otherwise stated, i.e., the terms "about" or "approximately" can be implied even when not explicitly stated.

[0060] Fabry disease Fabry disease is a rare, progressive, severe, X-linked lysosomal storage disorder (LSD). Mutations in the GLA gene cause deficiency of the lysosomal enzyme α-Gal A, which is required for glycosphingolipid metabolism. Decreased α-Gal A activity, beginning in early childhood, causes accumulation of glycosphingolipids, including GL-3 and plasma lyso-Gb3, leading to the symptomatic and fatal sequelae of Fabry disease, including pain, gastrointestinal symptoms, renal failure, cardiomyopathy, cerebrovascular events, and premature death. Early initiation of therapy and lifelong treatment offers the opportunity to slow disease progression and extend life expectancy.

[0061] Fabry disease encompasses a range of disease severity and age of onset, but is traditionally divided into two major phenotypes, "classic" and "late-onset." The classic phenotype is considered primarily in males with undetectable to low α-Gal A activity and early onset of renal, cardiac and / or cerebrovascular symptoms. The late-onset phenotype is considered primarily in males with higher residual α-Gal A activity and later onset of these disease symptoms. Heterozygous female carriers typically express the late-onset phenotype, but may also exhibit the classic phenotype depending on the pattern of X-chromosome inactivation.

[0062] Over 1,000 GLA mutations that cause Fabry disease have been identified. GLA mutations include, but are not limited to, missense, nonsense, and splicing mutations, in addition to small deletions and insertions and larger gene rearrangements. Approximately 60% are missense mutations that result in a single amino acid substitution in the α-Gal A enzyme. Missense GLA mutations often result in the production of abnormally folded, unstable forms of α-Gal A, the majority of which are associated with the classic phenotype. Normal cellular quality control mechanisms in the ER prevent these abnormal proteins from trafficking to lysosomes, targeting them for early degradation and removal. Many missense mutant forms are targets of migalastat, an α-Gal A specific pharmacological chaperone.

[0063] The clinical symptoms of Fabry disease range in severity and roughly correlate with the patient's residual α-Gal A levels. The majority of patients currently receiving treatment are referred to as classic Fabry patients, most of whom are male. These patients develop disease in various organs, including the kidneys, heart, and brain, with disease symptoms first appearing in adolescence and progressing in severity until death, typically in the third or fourth decade of life. Several recent studies suggest that there are many undiagnosed men and women with various Fabry disease symptoms that usually first appear in adulthood, such as cardiac or renal dysfunction and strokes. This type of Fabry patient, referred to as late-onset Fabry disease, tends to have higher residual α-Gal A levels than classic Fabry patients. Late-onset Fabry patients typically experience their first disease symptoms in adulthood and often have disease symptoms localized to a single organ, such as left ventricular hypertrophy or progressive renal failure. In addition, late-onset Fabry disease can also be seen in the form of strokes of unknown etiology.

[0064] Proper diagnosis is challenging because Fabry disease is rare, involves many organs, and has a wide and heterogeneous age range for onset. For example, Fabry patients have progressive renal dysfunction, and untreated patients present with end-stage renal disease by their fourth decade of life. Deficiency of α-Gal A activity leads to the accumulation of globotriaosylceramide (Gb3) and related glycosphingolipids in many cell types, including those of the kidney. Gb3 accumulates in podocytes, distal tubules, and epithelial and tubular cells of the loops of Henle. Renal dysfunction can manifest as proteinuria and reduced glomerular filtration rate.

[0065] Furthermore, awareness is low even among medical professionals, leading to frequent misdiagnosis. The diagnosis of Fabry disease is most often confirmed after a patient presents with symptoms, based on reduced α-Gal A activity in plasma or peripheral white blood cells (WBCs) in conjunction with mutation analysis. In females, diagnosis is even more challenging, as enzymatic identification of carrier females is unreliable due to random X-chromosome inactivation in some cells of carriers. For example, some obligate carriers (daughters of classically affected men) have α-Gal A enzyme activity ranging from normal to very low activity. Since carriers may have normal α-Gal A enzyme activity in white blood cells, only identification of the α-Gal A mutation by genetic testing provides accurate carrier identification and / or diagnosis.

[0066] In one or more embodiments, mutant forms of a-Gal A that are considered migalastat applicable are defined as those that exhibit a ≥ 1.20-fold relative increase (+10 μM migalastat) and a ≥ 3.0% absolute increase (+10 μM migalastat) over wild-type (WT) when the mutant form of a-Gal A is expressed in HEK-293 cells according to a Good Laboratory Practice (GLP) validated in vitro assay (GLP HEK or migalastat applicability assay) (referred to as the "HEK assay"). Such mutations are also referred to herein as "HEK assay applicable" mutations.

[0067] Prior screening methods have been provided to determine enzyme enhancement before treatment begins. For example, an assay using HEK-293 cells has been utilized in clinical trials to predict whether a given mutation will be responsive to pharmacological chaperone (e.g., migalastat) treatment. In this assay, a cDNA construct is created. The corresponding α-Gal A mutant form is transiently expressed in HEK-293 cells. The cells are then incubated with ± migalastat (17 nM to 1 mM) for 4-5 days. The α-Gal A levels are then measured in cell lysates using a synthetic fluorogenic substrate (4-MU-α-Gal) or by Western blot. This has been done for known disease-causing missense or small in-frame insertion / deletion mutations. Mutations previously identified as responsive to PC (e.g., migalastat) using these methods are listed in U.S. Pat. No. 8,592,362, which is hereby incorporated by reference in its entirety.

[0068] Pharmacological Chaperones Binding of small molecule inhibitors of LSD-related enzymes can increase the stability of both mutant and corresponding wild-type enzymes (see U.S. Patent Nos. 6,274,597; 6,583,158; 6,589,964; 6,599,919; 6,916,829, and 7,141,582, all of which are incorporated herein by reference). In particular, administration of small molecule derivatives of glucose and galactose, which are specific and selective competitive inhibitors of some target lysosomal enzymes, effectively increases the stability of the enzymes in cells in vitro, thereby increasing the trafficking of the enzymes to lysosomes. Thus, increasing the amount of enzymes in lysosomes is expected to increase the hydrolysis of enzyme substrates. The original theory behind this strategy was as follows: Because mutant enzyme proteins are unstable in the ER (Ishii et al., Biochem. Biophys. Res. Comm. 1996;220:812-815), they are delayed in the normal trafficking pathway (ER → Golgi → endosomes → lysosomes) and are prematurely degraded. Therefore, compounds that bind to and increase the stability of mutant enzymes may act as "chaperones" for the enzymes, increasing the amount that can leave the ER and be transported to lysosomes. In addition, because folding and trafficking of some wild-type proteins is incomplete, and in some cases up to 70% of some wild-type proteins are degraded before reaching their final cellular location, chaperones can be used to stabilize wild-type enzymes, increasing the amount of enzyme that can leave the ER and be transported to lysosomes.

[0069] In one or more embodiments, the pharmacological chaperone comprises migalastat or a salt thereof. The compound migalastat, also known as 1-deoxygalactonojirimycin (1-DGJ) or (2R,3S,4R,5S)-2-(hydroxymethyl)piperdine-3,4,5-triol, is a compound having the following chemical formula: [ka]

[0070] As discussed herein, pharma- ceutically acceptable salts of migalastat may also be used in the present invention.When a salt of migalastat is used, the dosage of the salt will be adjusted so that the patient receives an equivalent dose of migalastat to the amount that they would have received if migalastat free base had been used.An example of a pharma-ceutically acceptable salt of migalastat is migalastat HCl: [ka]

[0071] Migalastat is a low molecular weight iminosugar and an analogue of the terminal galactose of GL-3. In vitro and in vivo pharmacological studies have demonstrated that migalastat acts as a pharmacological chaperone, binding selectively and reversibly with high affinity to the active site of wild-type α-Gal A and specific mutant forms of α-Gal A, the genotypes of which are referred to as HEK assay-compatible mutations. Binding of migalastat stabilizes these mutant forms of α-Gal A in the endoplasmic reticulum and promotes their proper trafficking to lysosomes, while dissociation of migalastat allows α-Gal A to reduce levels of GL-3 and other substrates. Approximately 30-50% of patients with Fabry disease have HEK assay-compatible mutations; the majority of which are associated with the classical phenotype of the disease.

[0072] HEK assay applicable mutations include at least those mutations listed in a pharmacological reference table (e.g., those listed in the U.S. or international package insert for a migalastat product such as GALAFOLD®). As used herein, a "pharmacological reference table" refers to any publicly accessible written or electronic record contained either in the packaging of a migalastat product (e.g., GALAFOLD®) or in the package insert in a website accessible to a healthcare provider that communicates whether a particular mutation or variant is responsive to migalastat (e.g., GALAFOLD®) PC therapy, and is not necessarily limited to written records presented in the form of a table. Thus, in one embodiment of the present invention, a "pharmacological reference table" refers to any repository of information that includes one or more applicable mutations or variants. Exemplary pharmacological reference tables for HEK assay applicable mutations can be found in the Summary of Product Characteristics and / or Prescribing Information for GALAFOLD® in the various countries in which GALAFOLD® is approved for use, or on websites such as www.galafoldamenabilitytable.com or www.fabrygenevariantsearch.com, each of which is hereby incorporated by reference in its entirety.

[0073] Although the majority of a-Gal mutations are missense mutations, most lie outside the catalytic site, making it difficult to predict which mutations will result in an unstable enzyme that can be "rescued" by a pharmacological chaperone (PC) that stabilizes the enzyme, and which will not be stabilized by PC.

[0074] An exemplary pharmacological reference table for HEK assay amenable mutations is provided below in Table 1. In one or more embodiments, if the double mutations are present on the same chromosome (male and female), the patient is considered HEK assay amenable if the double mutations are present in one entry of Table 1 (e.g., D55V / Q57L). In some embodiments, if the double mutations are present on different chromosomes (female only), the patient is considered HEK assay amenable if any one of the individual mutations are present in Table 1.

[0075] [Table 1]

[0076] [Table 2]

[0077] [Table 3]

[0078] [Table 4]

[0079] [Table 5]

[0080] [Table 6]

[0081] [Table 7]

[0082] [Table 8]

[0083]

Table 9

[0084]

Table 10

[0085]

Table 11

[0086]

Table 12

[0087]

Table 13

[0088]

Table 14

[0089]

Table 15

[0090]

Table 16

[0091]

Table 17

[0092]

Table 18

[0093]

Table 19

[0094]

Table 20

[0095]

Table 21

[0096]

Table 22

[0097]

Table 23

[0098]

Table 24

[0099]

Table 25

[0100]

Table 26

[0101]

Table 27

[0102]

Table 28

[0103]

Table 29

[0104] [Table 30]

[0105] [Table 31]

[0106] [Table 32]

[0107] [Table 33]

[0108] Dosing, Formulation and Administration In one or more embodiments, Fabry patients are administered migalastat or a salt thereof once every other day (also referred to as "QOD"). In various embodiments, the doses described herein relate to migalastat hydrochloride or equivalent doses of migalastat or a salt thereof other than the hydrochloride salt. In some embodiments, these doses relate to the free base of migalastat. In alternative embodiments, these doses relate to a salt of migalastat. In further embodiments, the salt of migalastat is migalastat hydrochloride. The administration of migalastat or a salt of migalastat is referred to herein as "migalastat therapy."

[0109] Thus, in one or more embodiments, a Fabry patient is administered a dose of migalastat or a salt thereof in the range of about 15 mg to about 300 mg, about 15 mg to about 250 mg, about 15 mg to about 200 mg, about 15 mg to about 150 mg, or about 15 mg to about 123 mg once every other day, once every 3 days, once every 4 days, once every 5 days, once every 6 days, or once every 7 days. In one or more embodiments, migalastat or a salt thereof is administered once every other day (also referred to as "QOD" or "Q48H"), once every 4 days (also referred to as "Q4D" or "Q96H"), or once every 7 days (also referred to as "Q7D" or "Q168H"). In some embodiments, the dosing interval may include any dosing interval that is greater than 48 hours between doses. For example, dosing intervals may include dosing every 72, 96, 120, 144, or 168 hours.

[0110] In one or more embodiments, Fabry patients receive between about 15 mg and about 300 mg, between about 15 mg and about 250 mg, between about 15 mg and about 200 mg, between about 15 mg and about 150 mg, between about 15 mg and about 123 mg, between about 15 mg and about 100 mg, between about 15 mg and about 50 mg, between about 50 mg and about 300 mg, between about 50 mg and about 250 mg, between about 50 mg and about 200 mg, between about 50 mg and about 150 mg, between about 50 mg and about 123 mg, between about 50 mg and about 100 mg, between about 100 mg and about 300 mg, between about 100 mg and about migalastat FBE in the range of about 250 mg, about 100 mg to about 200 mg, about 100 mg to about 150 mg, about 100 mg to about 123 mg, about 150 mg to about 300 mg, about 150 mg to about 250 mg, about 150 mg to about 200 mg, about 200 mg to about 300 mg, about 200 mg to about 250 mg, or about 250 mg to about 300 mg is administered at a frequency of once every other day, once every three days, once every four days, once every five days, once every six days, or once every seven days.

[0111] In one or more embodiments, a Fabry patient may receive about 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 85 mg, about 90 mg, about 95 mg, about 100 mg, about 105 mg, about 110 mg, about 115 mg, about 120 mg, about 123 mg, about 125 mg, about 130 mg, about 135 mg, about 140 mg, about 145 mg, about 150 mg, about 155 mg, about 160 mg, about 165 mg, about 170 mg, about 175 mg, or about 180 mg. 80 mg, about 185 mg, about 190 mg, about 195 mg, about 200 mg, about 205 mg, about 210 mg, about 215 mg, about 220 mg, about 225 mg, about 230 mg, about 235 mg, about 240 mg, about 245 mg, about 250 mg, about 255 mg, about 260 mg, about 265 mg, about 270 mg, about 275 mg, about 280 mg, about 285 mg, about 290 mg, about 295 mg or about 300 mg of migalastat FBE is administered once every other day, once every 3 days, once every 4 days, once every 5 days, once every 6 days or once every 7 days.

[0112] It is noted again that 150 mg of migalastat hydrochloride is equivalent to 123 mg of the free base form of migalastat. Thus, in one or more embodiments, the dose is 150 mg of migalastat hydrochloride or an equivalent dose of migalastat or its salt other than hydrochloride administered once every other day, once every 3 days, once every 4 days, once every 5 days, once every 6 days, or once every 7 days. In a further embodiment, the dose is 150 mg of migalastat hydrochloride administered once every other day. In another embodiment, the dose is 123 mg of migalastat free base administered once every other day.

[0113] In one or more embodiments, Fabry patients receive between about 15 mg and about 300 mg, between about 15 mg and about 250 mg, between about 15 mg and about 200 mg, between about 15 mg and about 150 mg, between about 15 mg and about 123 mg, between about 15 mg and about 100 mg, between about 15 mg and about 50 mg, between about 50 mg and about 300 mg, between about 50 mg and about 250 mg, between about 50 mg and about 200 mg, between about 50 mg and about 150 mg, between about 50 mg and about 123 mg, between about 50 mg and about 100 mg, between about 100 mg and about 300 mg, between about 100 mg and about about 250 mg, about 100 mg to about 200 mg, about 100 mg to about 150 mg, about 100 mg to about 123 mg, about 150 mg to about 300 mg, about 150 mg to about 250 mg, about 150 mg to about 200 mg, about 200 mg to about 300 mg, about 200 mg to about 250 mg, or about 250 mg to about 300 mg of migalastat hydrochloride is administered at a frequency of once every other day, once every three days, once every four days, once every five days, once every six days, or once every seven days.

[0114] In one or more embodiments, Fabry patients receive about 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg, about 40 mg, about 42 mg, about 45 mg, about 50 mg, about 55 mg, about 57 mg, about 60 mg, about 65 mg, about 67 mg, about 70 mg, about 75 mg, about 77 mg, about 79 mg, about 80 mg, about 85 mg, about 90 mg, about 94 mg, about 95 mg, about 97 mg, about 100 mg, about 105 mg, about 110 mg, about 115 mg, about 120 mg, about 125 mg, about 128 mg, about 130 mg, about 135 mg, about 140 mg, about 144 mg, about 145 mg, about 150 mg, about 155 mg, about 160 mg, g, about 165 mg, about 170 mg, about 175 mg, about 180 mg, about 185 mg, about 190 mg, about 195 mg, about 200 mg, about 205 mg, about 210 mg, about 215 mg, about 220 mg, about 225 mg, about 230 mg, about 235 mg, about 240 mg, about 245 mg, about 250 mg, about 255 mg, about 260 mg, about 265 mg, about 270 mg, about 275 mg, about 280 mg, about 285 mg, about 290 mg, about 295 mg or about 300 mg of migalastat hydrochloride is administered once every other day, once every 3 days, once every 4 days, once every 5 days, once every 6 days or once every 7 days.

[0115] In some embodiments, the patient is administered 20 kg to about ≥ 50 kg, 20 kg to about ≤ 50 kg, 20 kg to about ≤ 45 kg, 20 kg to about ≤ 40 kg, 20 kg to about ≤ 35 kg, 20 kg to about ≤ 30 kg, 25 kg to about ≤ 20 kg, 10 kg to about ≤ 15 kg, 15 kg to about ≥ 50 kg, 15 kg to about ≤ 50 kg, 15 kg to about ≤ 45 kg, 15 kg to about ≤ 40 kg, 15 kg to about ≤ 35 kg, 15 kg to about ≤ 30 kg, 15 kg to about ≤ 25 kg, 20 kg to about ≥ 50 kg, 20 kg to about ≤ 50 kg, 20 kg to about ≤ 45 kg, 20 kg to about ≤ 40 kg, 20 kg to about ≤ 35 kg, The weight is within the range of about ≦30kg, about 20kg to about ≦25kg, about 25kg to about ≧50kg, about 25kg to about ≦50kg, about 25kg to about ≦45kg, about 25kg to about ≦40kg, about 25kg to about ≦35kg, about 25kg to about ≦30kg, about 30kg to about ≧50kg, about 30kg to about ≦50kg, about 30kg to about ≦45kg, about 30kg to about ≦40kg, about 30kg to about ≦35kg, about 35kg to about ≧50kg, about 35kg to about ≦50kg, about 35kg to about ≦45kg, about 35kg to about ≦40kg, about 40kg to about ≧50kg, about 40kg to about ≦50kg, about 40kg to about ≦45kg, about 45kg to about ≧50kg, or about 45kg to about ≦50kg.

[0116] Administration of migalastat or its salts according to the present invention may be in a formulation suitable for any route of administration, but is preferably administered in oral dosage form such as tablets, capsules, or solutions. For example, a patient is orally administered capsules, each containing 25 mg, 40 mg, 50 mg, 60 mg, 75 mg, 80 mg, 100 mg, or 150 mg of migalastat hydrochloride (i.e., 1-deoxygalactonojirimycin hydrochloride) or an equivalent dose of migalastat or its salts other than hydrochloride. In another example, a patient is orally administered capsules, each containing 150 mg of migalastat hydrochloride or an equivalent dose of migalastat or its salts other than hydrochloride.

[0117] In various embodiments, the doses described herein relate to migalastat hydrochloride or an equivalent dose of migalastat or a salt thereof other than the hydrochloride salt. In some embodiments, these doses relate to the free base of migalastat. In alternative embodiments, these doses relate to a salt of migalastat. In further embodiments, the salt of migalastat is migalastat hydrochloride. The administration of migalastat or a salt of migalastat is referred to herein as "migalastat therapy."

[0118] The administration of migalastat or its salt may be for a certain period of time. In one or more embodiments, migalastat or its salt is administered for at least 28 days, for example at least 30, 60 or 90 days, or at least 4, 6, 8, 12, 16, 26 or 52 weeks, or at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30 or 36 months, or at least 1, 2, 3, 4 or 5 years. In some embodiments, the migalastat therapy is at least about 4 weeks. In various embodiments, the migalastat therapy is a long-term migalastat therapy for at least about 2, 3, 4 or 5 years.

[0119] In some embodiments, the PC (e.g., migalastat or a salt thereof) is administered orally. In one or more embodiments, the PC (e.g., migalastat or a salt thereof) is administered by injection. The PC may be accompanied by a pharma- ceutically acceptable carrier, which may depend on the method of administration.

[0120] In one or more embodiments, the PC (e.g., migastat or a salt thereof) is administered as a monotherapy and can be in a form suitable for any route of administration, such as orally in tablet or capsule or liquid form, or in a sterile aqueous solution for injection, etc. In other embodiments, the PC is provided as a lyophilized powder that is added to the replacement enzyme formulation during or immediately after reconstitution to prevent enzyme aggregation in vitro prior to administration.

[0121] When the PC (e.g., migalastat or a salt thereof) is formulated for oral administration, tablets or capsules may be prepared by conventional means with pharma- ceutically acceptable excipients, such as binders (e.g., pregelatinized maize starch, polyvinylpyrrolidone, or hydroxypropylmethylcellulose); fillers (e.g., lactose, microcrystalline cellulose, or calcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talc, or silica); disintegrants (e.g., potato starch or sodium starch glycolate); or wetting agents (e.g., sodium lauryl sulfate). Tablets may be coated by methods well known in the art. Liquid preparations for oral administration may take the form, for example, of solutions, syrups, or suspensions, or may be prepared as a dry preparation for constitution with water or another suitable vehicle before use. Such liquid preparations may be prepared by conventional means with pharma- ceutically acceptable additives such as suspending agents (e.g., sorbitol syrup, cellulose derivatives, or hydrogenated edible fats); emulsifying agents (e.g., lecithin or acacia); non-aqueous vehicles (e.g., almond oil, oily esters, ethyl alcohol, or fractionated vegetable oils); and preservatives (e.g., methyl or propyl p-hydroxybenzoate or sorbic acid). The formulations may also contain buffer salts, flavoring, coloring, and sweetening agents as appropriate. Formulations for oral administration may be suitably formulated to give controlled release of the active chaperone compound.

[0122] Pharmaceutical formulations of PC (e.g., migastat or its salts) suitable for parenteral / injectable use generally include sterile aqueous solutions (if water soluble), or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and fluid to the extent that easy syringability exists. It must be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms, such as bacteria and fungi. The carrier may be a solvent or dispersion medium containing, for example, water, ethanol, polyol (e.g., glycerol, propylene glycol, polyethylene glycol, and the like), suitable mixtures thereof, and 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, benzyl alcohol, sorbic acid, and the like. In many cases, it may be advisable to include isotonic agents, for example, sugars or sodium chloride. Prolonged absorption of the injectable compositions can be brought about by the use in the compositions of agents which delay absorption, for example, aluminum monostearate and gelatin.

[0123] Sterile injectable solutions are prepared by blending the required amount of purified enzyme (if present) and PC (e.g., migalastat or its salt) in an appropriate solvent with various other ingredients as listed above as needed, followed by filtration or terminal sterilization. In general, dispersions are prepared by blending the various sterilized active ingredients in a sterile vehicle containing the basic dispersion medium and other required ingredients from those listed above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and freeze-drying, which yield a powder of the active ingredient plus any additional desired ingredients from a previously sterile-filtered solution thereof.

[0124] The formulation may contain excipients. Pharmaceutically acceptable excipients that may be included in the formulation are buffers, such as citrate buffer, phosphate buffer, acetate buffer, bicarbonate buffer, amino acids, urea, alcohols, ascorbic acid, and phospholipids; proteins such as serum albumin, collagen, and gelatin; salts such as EDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrollidone; sugars such as dextran, mannitol, sorbitol, and glycerol; propylene glycol and polyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol; glycine or other amino acids; and lipids. Buffer systems for use with the formulation include citrate; acetate; bicarbonate; and phosphate buffers. Phosphate buffers are a preferred embodiment.

[0125] The route of administration of the chaperone compound may be oral or parenteral, including intravenous, subcutaneous, intra-arterial, intraperitoneal, intraocular, intramuscular, buccal, rectal, intravaginal, intraorbital, intracerebral, intradermal, intracranial, intraspinal, intraventricular, intrathecal, intracisternal, intravesicular, intrapulmonary, intranasal, transmucosal, transdermal, or by inhalation.

[0126] Administration of the chaperone compound in the above-mentioned parenteral formulations may be by periodic injection of a bolus of the formulation, or by intravenous or intraperitoneal administration from an external (e.g., an IV bag) or internal (e.g., a bioerodible implant) reservoir.

[0127] The embodiments relating to pharmaceutical formulations and administration may be combined with any of the other embodiments of the invention, such as with the embodiments relating to methods of treating a patient with Fabry disease, methods of treating an ERT-naive Fabry patient, methods of treating an ERT-experienced Fabry patient, methods of reducing the risk of a CBV event, methods of reducing the risk of a composite clinical outcome, methods of assessing the symptoms or outcome of a patient or population of patients, methods of evaluating a therapy, methods of enhancing a-Gal A in a patient diagnosed with or suspected of having Fabry disease, use of a pharmacological chaperone to a-Gal A in the manufacture of a medicament for treating a patient diagnosed with Fabry disease or a pharmacological chaperone to a-Gal A for use in treating a patient diagnosed with Fabry disease, and with the embodiments relating to applicable mutations, PCs and suitable doses thereof.

[0128] In one or more embodiments, the PC (e.g., migalastat or its salt) is administered in combination with ERT. ERT increases the amount of protein by exogenously introducing wild-type or biologically functional enzymes by injection. This therapy has been developed for many genetic disorders, including LSDs such as Fabry disease, as described above. After injection, the exogenous enzyme is assumed to be taken up by tissues via non-specific or receptor-specific mechanisms. In general, the uptake efficiency is not high and the circulation time of exogenous proteins is short. In addition, exogenous proteins are unstable and subject to rapid intracellular degradation, as well as the possibility of adverse immune reactions with subsequent treatment. In one or more embodiments, the chaperone is administered simultaneously with the replacement enzyme (e.g., replacement α-Gal A). In some embodiments, the chaperone is formulated with the replacement enzyme (e.g., replacement α-Gal A).

[0129] In one or more embodiments, the patient is switched from ERT to migalastat therapy. In some embodiments, the patient is identified as being on ERT, the patient's ERT is discontinued, and the patient begins receiving migalastat therapy. The migalastat therapy can be according to any of the methods described herein. In various embodiments, the patient has some degree of renal dysfunction, for example, mild, moderate, or severe renal dysfunction.

[0130] Administration of migalastat In some embodiments, migalastat or a salt thereof is administered to an adult patient. In some embodiments, the age of the adult patient is > 18 years old. In some embodiments, migalastat or a salt thereof is administered to an adolescent patient. In some embodiments, the adolescent patient is of age within the range of 12 to <18 years, 13 to <18 years, 14 to <18 years, 15 to <18 years, 16 to <18 years, 17 to <18 years, 12 to ≦17 years, 13 to ≦17 years, 14 to ≦17 years, 15 to ≦17 years, 16 to ≦17 years, 12 to ≦16 years, 13 to ≦16 years, 14 to ≦16 years, 15 to ≦16 years, 12 to ≦15 years, 13 to ≦15 years, 14 to ≦15 years, 12 to ≦14 years, 13 to ≦14 years, or 12 to ≦13 years.

[0131] In some embodiments, migalastat or a salt thereof is administered to a patient having a body weight in the range of <15kg to ≥45kg, 15kg to <25kg, 25kg to <35kg, or 35kg to <45kg. In some embodiments, migalastat or a salt thereof is administered to a patient having a body weight <15kg. In some embodiments, migalastat or a salt thereof is administered to a patient having a body weight ≥45kg.

[0132] In some embodiments, about 25 mg of migalastat or a salt thereof is administered to a patient weighing <15 kg. In some embodiments, about 50 mg of migalastat or a salt thereof is administered to a patient weighing in the range of 15 kg to <25 kg. In some embodiments, about 75 mg of migalastat or a salt thereof is administered to a patient weighing in the range of 25 kg to <35 kg. In some embodiments, about 75 mg of migalastat or a salt thereof is administered to a patient weighing in the range of 35 kg to <50 kg.

[0133] In some embodiments, migalastat or a salt thereof is administered at a first frequency for a first period of time, and then at a second frequency for a second period of time. The first frequency is greater (i.e., more frequent) than the second frequency. The first frequency and the second frequency may be any administration interval disclosed herein. In some embodiments, the first frequency is every other day, and the second frequency is every 3, 4, 5, 6, or 7 days. In some embodiments, the first frequency is every 4 days, and the second frequency is every 5, 6, or 7 days.

[0134] In some embodiments, migalastat or a salt thereof is administered at a first frequency for a first period, then at a second frequency for a second period, then at a third frequency for a third period. The first frequency is greater (i.e., more frequent) than the second frequency, and the second frequency is greater than the third frequency. For example, in some embodiments, migalastat or a salt thereof is administered at a first frequency of once every other day for a first period, then migalastat or a salt thereof is administered at a second frequency of once every 4 days for a second period, then migalastat or a salt thereof is administered at a third frequency of once every 7 days for a third period.

[0135] Monitoring Lyso-Gb3 and Migalastat levels Lyso-Gb3 (globotriaosylsphingosine) can be monitored to determine if the substrate is being cleared from the body of a Fabry patient. Higher levels of lyso-Gb3 correlate with higher levels of substrate. If the patient is being successfully treated, lyso-Gb3 levels are expected to decrease. One dosing regimen for Fabry disease is to administer about 20 mg to about 300 mg FBE of migalastat or a salt thereof to the patient once every other day.

[0136] In some embodiments, the method further comprises measuring migalastat levels. In one or more embodiments, the migalastat concentration (e.g., ng / mL) is measured. In some embodiments, the area under the curve (AUC 0-∞ In one or more embodiments, the minimum concentration (C) that migalastat reaches before the next dose is measured. trough ) is measured.

[0137] Migalastat levels can be measured via methods known in the art. For example, when measuring migalastat from tissue samples, tissue aliquots can be homogenized (7 μL water per mg tissue) using a homogenizer (e.g., FastPrep-24 from MP Biomedical, Irvine, CA). Then, 500 ng / mL 13C d2-AT1001 HCl internal standard (MDS Pharma Services) can be added to a microcentrifuge tube containing 100 μl of tissue homogenate or 50 μl of plasma. A volume of 600 μl of 5 mM HCl in 95 / 5 MeOH:H2O can then be added, and the tube can be vortexed for 2 minutes, followed by centrifugation at 21000×g for 10 minutes at room temperature. The supernatant may then be collected in a clear 96-well plate, diluted with 5 mM HCl in dH2O, and applied to a 96-well solid phase extraction (SPE) plate (Waters Corp., Milford MA). After several washing steps and elution into a clear 96-well plate, the extract may be dried down under N2 and reconstituted with mobile phase A. Migalastat levels can then be measured by liquid chromatography-tandem mass spectrometry (LC-MS / MS) (e.g., LC: Shimadzu; MS / MS: ABSciex API 5500 MS / MS). Liquid chromatography can be performed on a Halo HILIC column (150 × 4.6 mm, 2.7 μm) (Advanced Materials Technology, Inc.) at a flow rate of 0.7 mL / min using a binary mobile phase system of ACN:water:formate (mobile phase A: 5 mM ammonium formate, 0.5% formic acid, 95:5 ACN:water; mobile phase B: 5 mM ammonium formate, 0.5% formic acid, 5:47.5:47.5 ACN:MeOH:water). MS / MS analysis may be performed under APCi positive ion mode. For migalastat measurements in plasma, the same procedure may be followed, except without homogenization. The following precursor ion → product ion transitions may be monitored: mass / charge (m / z) 164.1 → m / z 80.1 for migalastat and m / z 167.1 → m / z 83.1 for the internal standard.A 12-point calibration curve and quality control samples may be prepared. The ratio of the area under the curve for migalastat to that for the internal standard is then determined, and the final concentration of migalastat in each sample is calculated using a linear least squares fit equation applied to the calibration curve. To derive the approximate molar concentration, 1 g of tissue may be estimated as a volume of 1 mL.

[0138] In some embodiments, samples may be taken 0, 1, 2, 3, 4, 6, 8, 12, 24, 48, 72, 96, 120, 144, and / or 168 hours after administration. In some embodiments, the migalastat concentration is measured 48 hours after administration. In some embodiments, the second period of administration begins after greater than about 5, 10, 15, 20, 25, 40, 50, 60, 70, 80, 90, 100, 125, 150, 175, or 200 ng / mL of migalastat is measured 48 hours after the first period of administration of migalastat is measured.

[0139] In some embodiments, Lyso-Gb3 can be measured using a validated assay via methods known in the art. As with migalastat, lyso-Gb3 levels may be measured using liquid chromatography-tandem mass spectrometry (LC-MS / MS) (e.g., LC: Shimadzu; MS / MS: ABSciex API 5500 MS / MS). For example, one process for measuring plasma lyso-Gb3 is described in Hamler, Rick, et al. "Accurate quantitation of plasma globotriaosylsphingosine (lyso-Gb3) in normal individuals and Fabry disease patients by liquid chromatography-tandem mass spectrometry (LC-MS / MS)." Molecular Genetics and Metabolism, Volume 114.2 (2015): S51. In one or more embodiments, lyso-Gb3 is measured in a sample from the patient's urine.

[0140] Dose adjustment In some embodiments, the administration frequency of migalastat or a salt thereof is adjusted in response to changes in the patient's eGFR. In an exemplary embodiment, the patient's eGFR is greater than or equal to 60 mL / min / 1.73 m 2 Less than 45mL / min / 1.73m 2 Less than 30mL / min / 1.73m 2 Less than 15mL / min / 1.73m 2 The frequency of administration can be reduced when the patient's eGFR drops below 60 mL / min / 1.73 m. 2 Less than 45mL / min / 1.73m 2 Less than 30mL / min / 1.73m 2 Less than 15mL / min / 1.73m 2 When the blood pressure drops below 100° C., the patient is not administered migalastat or a salt thereof.

[0141] Migalastat concentrations can be measured from plasma samples at various time points to monitor clearance from the body. trough A clinically relevant increase in C indicates significant accumulation of plasma migalastat concentrations. If migalastat is not sufficiently cleared from the body before the next dose is administered, the levels of migalastat may accumulate, possibly causing inhibitory effects. Thus, in one or more embodiments, the C of normal renal function is trough Compared to C trough After a 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9 or 3.0 fold increase in dose, a change in dosing frequency is made.

[0142] In one or more embodiments, the AUC of normal renal function 0-∞ Compared with,AUC 0-∞ After a 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9 or 3.0 fold increase in dose, a change in dosing frequency is made.

[0143] In some embodiments, the method further comprises measuring lyso-Gb3 in one or more plasma samples from the patient. A first baseline lyso-Gb3 level may be measured during the first period. As used herein, "baseline lyso-Gb3 level" refers to the lowest plasma lyso-Gb3 value measured during a given period or dosing regimen. Thus, if the lyso-Gb3 level significantly increases from the baseline lyso-Gb3 level, this may indicate progression of renal disease and / or inappropriate clearance of migalastat. Thus, in further embodiments, a second period of administration is initiated after an increase (e.g., at least about 20, 25, 30, 33, 35, 40, 45, or 50% and / or 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, or 3 nM) above the first baseline lyso-Gb3 level is measured. A 33% and / or 2 nM increase from baseline in plasma lyso-Gb3 is considered clinically relevant based on Phase 3 data in Fabry patients signaling either inhibition-induced migalastat exposure from declining renal function and / or disease progression. Lyso-Gb3 levels may be measured at various frequencies (e.g., about once every 2, 3, 4, or 5 months). It is expected that baseline lyso-Gb3 levels will take approximately 3 months to be established once a dosing regimen has been initiated.

[0144] In some embodiments, administration of the second period may begin after an increase over the first baseline lyso-Gb3 level of at least about 30% or 33% and / or greater than 2 nM and / or about 50 ng / mL migalastat is measured 48 hours after administration of migalastat during the first period. In some embodiments, administration of the second period may begin after an increase over the first baseline lyso-Gb3 level of at least about 30% or 33% and / or greater than 2 nM and / or greater than about 50 ng / mL migalastat is measured 48 hours after administration of migalastat during the first period, or after AUC 0-∞ and / or C troughmay be initiated after a greater than 1.5-fold increase in renal function compared to normal renal function during the first period. EXAMPLES

[0145] Example 1: Dosage regimens for treatment of ERT-experienced and ERT-naive Fabry patients with migalastat hydrochloride This example describes a phase 2 and 3 trial of migalastat therapy in ERT-experienced and ERT-naive patients with Fabry disease.

[0146] Study design These analyses included data from four Phase 2 and four Phase 3 clinical trials with a data cutoff date of February 10, 2017, as shown in Figure X1 below.

[0147] FAB-CL-202 (NCT00283959), FAB-CL-203 (NCT00283933), and FAB-CL-204 (NCT00304512) were phase 2, open-label, uncontrolled studies evaluating the safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of migalastat (dose range: 50–250 mg) in patients with Fabry disease.

[0148] FAB-CL-205 (NCT0052607) was a Phase 2 long-term open-label extension (OLE) study in patients who completed Phase 2 clinical trials including FAB-CL-202, FAB-CL-203, and FAB-CL-204. The study included a period of migalastat 150 mg every other day (QOD), followed by a dose escalation period, followed by 150 mg QOD.

[0149] FACETS (AT1001-011, NCT00925301) was a phase 3 placebo-controlled study designed to evaluate the efficacy, safety, and PD of migalastat 150 mg QOD for 6 months compared with placebo in ERT-naive patients with Fabry disease and migalastat-eligible GLA variants, followed by an 18-month open-label extension (OLE) of migalastat.

[0150] ATTRACT (AT1001-012, NCT01218659) was a phase 3, open-label, active-controlled study comparing the efficacy and safety of 18 months of migalastat 150 mg QOD compared with ERT in ERT-treated patients with migalastat-eligible GLA variants, followed by 12 months of OLE with migalastat.

[0151] AT1001-041 (NCT01458119) was a long-term OLE study evaluating the long-term safety and efficacy of migalastat in patients who completed FAB-CL-205, AT1001-011, or AT1001-012.

[0152] AT1001-042 (NCT02194985) is an ongoing long-term OLE study evaluating the long-term safety and efficacy of migalastat in patients who participated in AT1001-012 or AT1001-041.

[0153] analysis The analysis will evaluate CBV events reported as treatment-emergent adverse events (TEAEs) during migalastat 150 mg QOD treatment in patients with applicable mutations in phase 2 and 3 clinical trials.

[0154] CBV events were identified by searching medical history and TEAE listings for stroke-related terms including brain stem ischemia, cerebral infarction, cerebral hemorrhage, cerebral ischemia, cerebrovascular accident, embolic stroke, and TIA.

[0155] This analysis included only eligible patients who received at least one dose of migalastat 150 mg QOD.

[0156] Applicability was based on the results of a Good Laboratory Practice (GLP) validated in vitro migastat applicability assay.

[0157] [Table 34]

[0158] result Migalastat 150mg QOD total exposure The mean (SD) total duration of exposure to migalastat 150 mg QOD was 4.0 (2.0) years (N=114).

[0159] Duration of exposure to migalastat 150 mg QOD ranged from 0.1 to 8.3 years, with a median of 4.4 years.

[0160] Demographic information and baseline characteristics The mean (SD) age of all eligible patients who received at least one dose of migalastat 150 mg QOD was 46.2 (13.1) years (range: 16-72 years) (Table 2). The majority were white, and 57.0% were female. The mean (SD) time since diagnosis of Fabry disease was 9.8 (10.1) years (range: 1-44 years).

[0161] [Table 35]

[0162] History of CBV events Sixteen of 114 patients (14%) had a CBV event prior to migalastat treatment (Table 3). One patient in study AT1001-012 had two reported CBV events in his medical history.

[0163] In 5 of 16 patients, the CBV event was considered an ongoing condition at the time of study entry, as reported in the medical history. One patient in AT1001-011 had ongoing cerebral ischemia; another had ongoing brain stem infarction. Two patients in AT1001-012 had ongoing TIA and one had an ongoing cerebrovascular accident, specifically a left middle cerebral artery stroke.

[0164] The mean (SD) age at first CBV event was 43.6 (14.4) years.

[0165] [Table 36]

[0166] Incidence of CBV events during migalastat 150mg QOD treatment During treatment with migalastat 150 mg QOD, 11 CBV events were reported in 8 patients (7%) (Table 4). Seven CBV events were classified as serious adverse events (SAEs); however, most (82%) events were mild or moderate in severity (Table 5). Two CBV events led to treatment discontinuation (Table 5). None of the 11 CBV events were considered related to treatment.

[0167] Six of eight patients had a CBV prior to receiving migalastat treatment; thus, only 2 of 114 (2%) patients had their first CBV event while taking migalastat (Table 5). The mean (SD) age of patients at the time of their first event while taking migalastat was 50.6 (14.6) years (Table 5). The mean (SD) duration of taking migalastat 150 mg QOD at the time of the first event was 1.1 (1.1) years.

[0168] For 10 of 16 patients (63%) who had a CBV event before migalastat, no new CBV events occurred during migalastat treatment.

[0169] [Table 37]

[0170] [Table 38]

[0171] [Table 39]

[0172] As can be seen in the table above, the overall incidence of CBV events during migalastat treatment was low. Over a median of 4 years on migalastat, 8 of 114 (7%) patients experienced a CBV event, primarily in patients with a prior CBV event.

[0173] Example 2: Simulation of PK / PD parameters in adolescents PK / PD modeling Population pharmacokinetic (popPK) models previously developed from healthy adult volunteers and adult Fabry disease patients following oral migalastat administration. Pooled plasma concentration-time data from Phase I, II, and III studies of AT1001 administered orally to adults using doses ranging from 25 mg to 675 mg and regimens under fasting conditions. Conclusions made based on the AT1001 studies include the following: · A two-compartment population pharmacokinetic model with linear time-dependent absorption characterizes the pharmacokinetics of migalastat in plasma after oral administration. Renal function was the most important determinant of variability in migalastat exposure, ranging from 30 to 120 mL / min / 1.73 m 2 The average range is three times that of the eGFR value. Subject weight was the second largest determinant of variability in migalastat exposure, with an average difference of less than two-fold for subjects weighing 50–170 kg. The dosing rationale for adults (123 mg every other day (QOD)) was supported by evaluation of several dose levels and regimens in four Phase II studies (50, 150, and 250 mg QOD; 50 mg once daily; 25, 100, and 250 mg twice daily; and 250 and 500 mg x 3 days with 4 days off). This population PK model was deemed appropriate for adults; however, it is less feasible for pediatric predictions due to the lack of allometric components using standard exponents (e.g., 0.75 for CLT / F). Thus, some adjustments are required to make this adult population PK model capable of extrapolating migalastat PK to the pediatric age subpopulations of 2 to <6, 6 to <12, and 12 to <18 years. The population PK model of migalastat showed that baseline subject body weight (WT) and / or renal function (estimated glomerular filtration rate, eGFR) significantly influenced the apparent oral plasma clearance (CLT / F) and the apparent oral volume of distribution of the central compartment (V2 / F). In contrast, other covariates such as sex, age, and drug formulation (solution or suspension vs. 25 mg capsule vs. 150 mg capsule) were not statistically / clinically significant. Because renal function increases gradually from birth and reaches adult levels by the second year of life (Rubin 1949), no age-dependent changes in eGFR are expected in the pediatric population aged 2 years and older compared to adults. In addition, pediatric patients with Fabry disease usually have normal renal function or may exhibit renal hyperfiltration (Hopkin 2008); therefore, for the simulation of pediatric Fabry disease patients, weight-based dosing regimens were planned assuming that children have normal renal function.

[0174] The NONMEM program was used to develop a population PK model of migalastat in adults using first-order conditional estimation with interaction method (FOCE-I). Simulations were performed using NONMEM to obtain plasma concentration-time; all graphical analyses were performed using R; noncompartmental analysis and summary of pharmacokinetic parameters were performed using Phoenix WinNonlin. Bootstrapping and visual predictive check (VPC) were performed using the Perl-speaks-NONMEM (PsN) R package in popED, using mrgsolve with optimal sampling strategy.

[0175] The population PK model was optimized by one or more of: revisiting the absorption model; adding allometric scaling components with allometric exponents equal to 0.75 for CLT / F and Q / F and equal to 1.0 for V2 / F and V3 / F; and evaluating whether the allometric exponents should account for the entire CLT / F or only for non-renal clearance.

[0176] Among the various absorption models, the original linear time-dependent absorption model was chosen because it produced substantially improved plots of the conditional weighted residuals (CWRES) over time, with much less bias and variation across the profile. a According to the model, K a is allowed to increase continuously, so that the time-dependent absorption coefficient K a The upper limit of K was set at 24 hours after administration to obtain a reasonable K for simulation / prediction. a values ​​were provided; this was considered a minimal modification to the original model since the drug is expected to be substantially completely absorbed within 7-10 hours, regardless of the model chosen.

[0177] The overall aim of model development was to come up with a model for pediatric extrapolation. Theoretical power model exponents of 0.75 (for CL and Q) and 1 (for V2 and V3) were applied and evaluated. Diagnostic plots suggested that allometric scaling was only appropriate for those <70 kg.

[0178] The final formulas for CLT / F, Q / F, V2 / F and V3 / F were presented as follows: ·WTCO = WT / 70 when WT ≤ 70; WTCO = 1 when WT > 70, where WTCO was the allometric weighting coefficient in the allometric scaling for subjects weighing ≤ 70 kg. ·CL T / F=tvCL×(RF) CLEGFR ×WTCO 0.75 ×(1+CLHVT) 1-FBRY×exp(ETA of IIV on CL / F) ·V2 / F=tvV2×WTCO 1 ×(1+V2HVT) 1-FBRY ×exp(ETA of IIV on V2 / F) Q / F=TVQ×WTCO 0.75 and V3 / F=TVV3×WTCO 1 , where TVQ and TVV3 were typical values ​​of Q / F or V3 / F, respectively.

[0179] Given that renal function is comparable between pediatric patients aged 2 years and older and adults, the model was modified to apply an allometric exponent to the nonrenal clearance component only. The model successfully converged, suggesting that nonrenal clearance explains only a small portion of CLT / F; therefore, allometric scaling applied to this small amount of nonrenal clearance was calculated to be 1 / 100 of CLT / F. T The diagnostic plots also showed that subjects <70 kg had a significantly lower CL T It was also suggested that applying the allometric index to the entire / F range was better than applying it to nonrenal clearance. Furthermore, pediatric CL extrapolated from the nonrenal model T / F value is CL T The pediatric dose to achieve adult-equivalent exposure was higher than that of the total CL / F approach, which is a less conservative approach. T The / F overall scaling approach was more conservative and was selected for the final model, which is shown in Table 6.

[0180] [Table 40]

[0181] [Table 41]

[0182] The estimated parameters from the bootstrap (see Table 6) were nearly identical to those from the original dataset. All parameters were estimated with sufficient precision. The NONMEM estimates (which assume that the parameters are normally distributed) were nearly identical to the nonparametric bootstrap estimates (which do not assume that the parameters are normally distributed).

[0183] Model performance was compared for the adult population. Simulations were performed using a simulated adult data set following administration of a 150 mg QOD dose of migalastat salt, and model parameters as well as steady-state AUC tau and C max The results shown in Table 7 were comparable between the original and optimized / updated models, indicating good model performance.

[0184] [Table 42]

[0185] Clinical trial simulations were then performed to predict exposure in pediatric patients receiving various initial weight-based dosing schedules (equivalent to a dose of approximately 3 mg / kg). The dosing schedules used in the simulations are listed in Table 8.

[0186] [Table 43]

[0187] The dose was chosen to achieve a steady-state AUC similar to that of adults with normal renal function receiving 150 mg of migalastat salt every other day (QOD). tau (and C max Or C min The goal was to achieve this in the pediatric subgroup.

[0188] For the pediatric simulations, we assumed the following: (1) 100 subjects per group, 50% male and 50% female, for four groups, including three groups of children with Fabry disease (ages 2 to <6, 6 to <12, and 12 to <18 years) and one group of adults (with Fabry disease and normal renal function); (2) all children (and adults) had normal renal function; (3) ages of pediatric subjects were sampled from a uniform distribution within the age limits of each group; (4) weights of pediatric subjects were sampled from a normal distribution using the World Health Organization (WHO) weight table for each age for subjects aged <5.08 years and the Centers for Disease Control and Prevention (CDC) weight table for subjects aged 5.08 to 17.99 years; and (5) weights of the adult groups were sampled from a probability normal distribution (mean = 75, standard deviation (SD) = 15).

[0189] From the simulation results shown in Table 9, C max While values ​​were comparable between groups, AUC tau (0–48 h) was approximately 25% lower in the 2–<6 year age group (5570 vs. 7580 h·ng / ml) and approximately 10% lower in the 6–<12 year age group (6850 vs. 7580 h·ng / ml).

[0190] [Table 44]

[0191] Analysis of the simulated data in 5 kg weight ranges was applied and is shown in Table 10. AUC for adults with normal renal function given a 150 mg QOD dose tau Using the geometric mean value as the target (7580 h·ng / ml), for subjects in each weight group, Equation 1: dose adj,i =dose org,i ×AUC tau,a / AUC tau,i formula 1 (In the formula, dose adj,i is the adjusted dose for each weight group to achieve an AUC exposure equivalent to that of adults, and dose org,i is the original dose used for each weight group, and AUC tau,ais the geometric mean value for the adult group of 7580 h·ng / ml, and AUC tau,i Dose adjustment was performed to consider dose proportionality by (wherein is the geometric mean value of each weight group). In addition, the adjusted dose was rounded to the nearest practical dose level to ensure simplicity in formulation preparation.

[0192] [Table 45]

[0193] The resulting adjusted dosing scheme for the pediatric group is summarized in Table 11.

[0194] [Table 46]

[0195] Based on the dose adjustment analysis and the newly revised dose administration scheme, the simulations were run again for the three pediatric groups (ages 2 to < 6, 6 to < 12, and 12 to < 18 years) with all other assumptions and settings unchanged. The results are shown in Table 12.

[0196] [Table 47]

[0197] Population PK data in adults and adolescents weighing ≧45 kg receiving 150 mg migalastat HCL capsules qod are presented in Table 13.

[0198] [Table 48]

[0199] The results of the ANOVA analysis are presented in Table 14.

[0200] [Table 49]

[0201] Limited pharmacokinetic data support a dose of 150 mg migalastat HCL capsules QOD in adolescents weighing ≥ 45 kg.

[0202] Example 3: PK / PD Model Validation for Adolescents This example describes study AT1001-020, an open-label study of the safety, pharmacokinetics, and pharmacodynamics of migalastat in pediatric subjects (ages 12 to <18 years) with Fabry disease and applicable GLA variants.

[0203] This disclosure includes an analysis of interim clinical trial data presenting Stage 1 (1 month) safety and PK data results for only subjects with Fabry disease in the 12 to <16 year age group who had Stage 1 plasma concentration-time data available as of the cut-off date.

[0204] the purpose The objectives of Stage 1 are to characterize the PK of migalastat in adolescents with Fabry disease and to validate the extrapolation from adult migalastat plasma exposure to adolescents weighing ≥45 kg for a 123 mg migalastat capsule administered once every other day (QOD).

[0205] Another Stage 1 objective is to evaluate the safety of migalastat treatment in pediatric subjects with Fabry disease who have mutations in the gene encoding α-GalA (GLA) that are amenable to treatment with migalastat.

[0206] Outcomes / Evaluation Items Pharmacokinetic endpoints were as follows: A population PK model describing the relationship between weight and age and the pharmacokinetics of migalastat in pediatric subjects (primary PK parameter outputs are tabulated in the text below). PK parameters based on simulated plasma-concentration data for migalastat after multiple dose administration at steady-state concentrations C max : Highest observed plasma concentration C min :Minimum observed plasma concentration t max :C max Time to reach AUC 0-tau : Area under the plasma concentration-time curve from time 0 through the dosing interval (i.e., 48 hours) t 1 / 2 Terminal elimination half-life ·CL ss / F: Apparent oral clearance at steady-state concentration ·V ss / F: Apparent oral volume of distribution at steady-state concentration

[0207] Study participants This disclosure describes a PK / PD study in migalastat-treated patients who were either enzyme replacement therapy (ERT) naive or had discontinued ERT for at least 14 days at the time of screening.

[0208] To be included in this study, subjects must meet all of the following criteria: Males or females aged 12 to <18 years at baseline, diagnosed with Fabry disease and who, in the opinion of the investigator, could benefit from specific treatment for their condition. Have a confirmed applicable GLA variant as determined using the Migalastat Applicability Assay (for subjects with unknown applicable GLA variants, GLA genotyping must have been performed prior to Visit 2. Similarly, for subjects with GLA variants that were not yet tested with the Migalastat Applicability Assay, applicability testing must have been completed prior to Visit 2). Weight ≥ 45 kg (99 lbs) at screening. - Treatment naïve or had discontinued ERT treatment for at least 14 days prior to Screening 5. - Had at least one comorbidity of Fabry disease (i.e., previous or current abnormal laboratory findings and / or signs / symptoms). Moderate or severe renal impairment (estimated glomerular filtration rate [eGFR] < 60 mL / min / 1.73 m) at screening 2 ) or had no indications of renal disease requiring dialysis or transplantation.

[0209] treatment One migalastat 123 mg migalastat (=150 mg migalastat HCL) capsule was administered with water to adolescents weighing ≧45 kg every other day during the study.

[0210] Due to the capsule size and inclusion criteria of Study AT1001-020, the 123 mg migalastat capsule is not suitable for patients weighing less than 45 kg and for low body weight and young age groups. Thus, it was recommended to include a warning for the low body weight group within the proposed age group (<12 to <16 years).

[0211] Sparse sampling of plasma migastat concentrations to estimate exposure was performed at baseline and in one 24-hour period between Days 15 and 30. Subjects were randomized to one of three PK sampling groups, as shown in Table 15.

[0212] [Table 50]

[0213] This interim analysis included patients with one plasma concentration-time data available as of the cutoff date.

[0214] Plasma samples were analyzed using an LC-MS / MS method.

[0215] Interim analysis population The safety population included all subjects aged 12 to <16 years who received at least one dose or partial dose of study drug and had stage 1 plasma concentration-time data available as of the cutoff date. All safety analyses were performed using this safety population.

[0216] The PK population included data from subjects aged 12 to <16 years who completed Stage 1 and received at least one dose of migalastat with at least one quantifiable concentration. All subjects included in the interim analysis population PK had known body weight and eGFR.

[0217] result Baseline data A total of 22 subjects were enrolled in Study AT1001-020. As of the cutoff date, a total of 9 subjects, 4 females and 5 males, aged 12 to <16 years, had enrolled in Study AT1001-020, received study drug, and completed Stage 1 of the study with PK concentration data. These subjects represented the safety and PK population for this interim analysis. The mean time since diagnosis of Fabry disease was 10.2 (± 4.12) years. Four subjects reported a history of previous enzyme replacement therapy use.

[0218] The median duration of migalastat exposure for the nine subjects enrolled in Study AT1001-020 was 30 days, with a maximum exposure of 49 days.

[0219] Demographic information and baseline characteristics are presented in Error! Reference source not found.16 and Error! Reference source not found.17.

[0220] [Table 51]

[0221] [Table 52]

[0222] Medical history The most common system organ classes for medical history in the safety population were nervous system disorders (77.8%), ear and labyrinth disorders (66.7%), gastrointestinal disorders (66.7%), and general and administration site conditions, laboratory tests, psychiatric disorders, respiratory, thoracic and mediastinal disorders, and skin and subcutaneous tissue disorders (all 55.6%). The most common preferred terms for medical history (all reported by 55.6% of subjects) were tinnitus, abdominal pain, diarrhea, headache, and paraesthesia, most of which were consistent with Fabry disease.

[0223] Previous and concomitant medications All but one subject reported previous use of medication. The most common previous medication was paracetamol, taken by six (66.7%) subjects. No other medication was taken by more than two subjects.

[0224] The most frequently used concomitant medication was paracetamol, taken by six (66.7%) subjects. No other concomitant medication was taken by more than two subjects.

[0225] Adverse events An overall overview of TEAEs observed in subjects in the safety population during Stage 1 is presented in Tables 18 and 19.

[0226] [Table 53]

[0227] [Table 54]

[0228] Laboratory findings During Stage 1, urinalysis (albumin, protein, specific gravity, pH, and microscopy) were the only laboratory parameters collected at Month 1, therefore, these only laboratory parameters were evaluated for the interim analysis.

[0229] There were no clinically meaningful mean changes from baseline in urinalysis parameters at 1 month.

[0230] There were several shifts from baseline to month 1. Three subjects had pH values ​​that went from normal at baseline to elevated at month 1.

[0231] There were no potentially clinically significant abnormalities in urinalysis parameters.

[0232] A urine pregnancy test was performed at every visit for all female subjects of childbearing potential. No female subjects in the safety population had a positive pregnancy test during Stage 1.

[0233] Clinical Safety Conclusions Based on limited data available from adolescent patients aged 12-18 years (n=9), popPK data demonstrated similar exposure in adults and adolescents weighing ≥45 kg receiving 123 mg migalastat capsules qod.

[0234] C observed in pediatric patients max Levels were higher than those observed in adult patients in the pivotal study AT1001-011. max It matched the level.

[0235] No new safety findings were observed during stage 1 of this study, therefore treatment with migalastat 123 mg in pediatric patients aged ≥ 12-16 years does not lead to a safety profile different from the known one.

[0236] A novel formulation, migalastat HCl oral formulation (sachet and / or capsules), for the treatment of Fabry disease in pediatric and adolescent patients aged 2 to <18 years with applicable GLA mutations may be designed and evaluated.

[0237] Example 4: Clinical Efficacy of Migalastat Treatment in Adolescents This example describes the AT1001-020 trial, which can be an open-label study of the efficacy of 12 months of treatment with migalastat in pediatric subjects (ages 12 to <18 years) with Fabry disease and applicable GLA variants. In some embodiments, this clinical efficacy trial includes Stage 2.

[0238] Accordingly, in some embodiments, in Stage 2, a primary objective may include evaluating the safety of migalastat treatment in pediatric subjects diagnosed with Fabry disease and with GLA variants amenable to treatment with migalastat.

[0239] In some embodiments, in Stage 2, secondary objectives may include characterizing the pharmacodynamics (PD) of migalastat in pediatric subjects diagnosed with Fabry disease and with GLA variants amenable to treatment with migalastat.

[0240] In some embodiments, in Stage 2, secondary objectives may include evaluating the efficacy of migalastat in pediatric patients diagnosed with Fabry disease and with GLA variants amenable to treatment with migalastat.

[0241] In some embodiments, in Stage 2, secondary objectives may include evaluating the relationship between exposure to migalastat and response.

[0242] The patents and scientific literature referred to herein establish knowledge available to those skilled in the art. All U.S. patents and published or unpublished U.S. patent applications cited herein are incorporated by reference. All published foreign patents and patent applications cited herein are hereby incorporated by reference. All other published references, documents, articles and scientific literature cited herein are hereby incorporated by reference.

[0243] Although the present invention has been particularly shown and described with reference to preferred embodiments thereof, workers skilled in the art will understand that various changes in form and details may be made therein without departing from the scope of the invention as encompassed by the appended claims.

[0244] The embodiments described herein are intended to illustrate the compositions and methods, and are not intended to limit the scope of the present invention. Various modifications and changes that are consistent with the description as a whole and that are easily understood by those skilled in the art are intended to be included. The scope of the appended claims should not be limited by the specific embodiments shown in the examples, but should be given the broadest interpretation that is consistent with the description as a whole.

[0245] Patents, patent applications, publications, product descriptions, GenBank accession numbers, and protocols are cited throughout this application, the disclosures of which are incorporated herein by reference in their entireties for all purposes.

Claims

1. 1. A medicament for the treatment of Fabry disease in a human patient in need of such treatment, wherein the medicament comprises migastat or a salt thereof, and the patient is a pediatric patient having an age ranging from about 12 years to about <18 years and weighing about ≧45 kg.

2. The pharmaceutical composition of claim 1, wherein a therapeutically effective dose of migalastat or a salt thereof is administered in the range of about 15 mg to about 150 mg every other day.

3. The method of claim 1, wherein a therapeutically effective dose of migalastat hydrochloride is administered every other day in a dose range of about 25 mg to about 150 mg.

4. 2. The method of claim 1, wherein a therapeutically effective dose of migalastat FBE is administered in the range of about 15 mg to about 123 mg every other day.

5. The pharmaceutical composition of claim 1, wherein a therapeutically effective dose of migalastat hydrochloride is administered in the range of about 80 mg to about 150 mg every other day.

6. The pharmaceutical composition of claim 5, wherein a therapeutically effective dose of migalastat hydrochloride is administered every other day at about 150 mg.

7. The pharmaceutical composition of claim 4, wherein a therapeutically effective dose of migalastat FBE of approximately 123 mg is administered every other day.

8. The patient has a blood flow rate of about ≧60 mL / min / 1.73 m ２ The pharmaceutical composition according to claim 1 or 2, having an eGFR of

9. The pharmaceutical composition described in claim 1 or 2, wherein migalastat or a salt thereof enhances or prolongs α-galactosidase A activity.

10. The pharmaceutical composition of claim 1 or 2, wherein the formulation comprises an oral dosage form.

11. The pharmaceutical composition of claim 10, wherein the oral dosage form comprises a tablet, capsule or solution.

12. The pharmaceutical composition described in claim 1 or 2, wherein the patient is male.

13. The pharmaceutical composition described in claim 1 or 2, wherein the patient is female.

14. The pharmaceutical composition described in claim 1 or 2, wherein the patient is an enzyme replacement therapy (ERT) naive patient.

15. The pharmaceutical composition described in claim 1 or 2, wherein the patient is an ERT-experienced patient who has discontinued ERT for at least 14 days.

16. The pharmaceutical composition described in claim 1 or 2, wherein the patient has a mutation in α-galactosidase A that is applicable to the HEK assay.

17. The pharmaceutical agent described in claim 16, wherein the mutation is disclosed in a pharmacological reference table.

18. The pharmaceutical composition of claim 17, wherein a pharmacology reference table is provided in the product labeling of a migalastat product approved for the treatment of Fabry disease.

19. The pharmaceutical composition of claim 18, wherein a pharmacological reference table is provided in the product label of GALAFOLD (registered trademark).

20. The pharmaceutical composition of claim 19, wherein a pharmacological reference table is provided on a website.

21. The method of claim 20, wherein the website is one or more of www.galafoldamenabilitytable.com or www.fabrygenevariantsearch.com.

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