Treatment methods for Fabry disease

Abstract

To provide treatment methods for Fabry disease in patients, such as reducing the risk of composite clinical outcomes. [Solution] The method comprises administering to the patient an effective amount of a preparation containing migalastat or a salt thereof every other day for at least 18 months, wherein the effective amount is approximately 100 mg to approximately 150 mg free base equivalent (FBE).

Description

[Technical Field]

[0001] The principles and embodiments of the present invention generally relate to the treatment of Fabry disease.

[0002] Cross-referencing of array lists The sequence list identified as "AT20-01_Sequence_Listing.txt" (21,991 bytes), created on February 10, 2021, is incorporated herein by reference. [Background technology]

[0003] Fabry disease is a progressive X-linked congenital anomaly of glycosphingolipid metabolism resulting from a deficiency of the lysosomal enzyme α-galactosidase A (α-Gal A) as a result of a mutation in the α-Gal A gene (GLA). Despite being an X-linked disorder, females can exhibit varying degrees of clinical manifestation. Fabry is a rare disease, estimated to occur in 1 in 40,000 to 1 in 117,000 males in the general population. Furthermore, there is a late-onset phenotypic variant of Fabry disease that may be underdiagnosed because it does not present with the classic signs and symptoms. This, along with newborn screening for Fabry disease, suggests that the actual incidence of Fabry disease may be higher than currently estimated.

[0004] If left untreated, vascular disease affects the kidneys, heart, and / or central nervous system, reducing the life expectancy of Fabry patients, who typically die in their 30s or 40s. The enzyme deficiency leads to intracellular accumulation of the substrate globotriaosylceramide (GL-3) in vascular endothelium and visceral tissues throughout the body. Progressive deterioration of renal function and azotemia due to glycosphingolipid deposition usually occur in the 20s to 40s, but can also occur as early as the teens. Renal lesions are found in both hemizygous (male) and heterozygous (female) patients.

[0005] Cardiac disease occurs in most men and many women as a result of Fabry disease. Early cardiac findings include left ventricular enlargement, valvular dysfunction, and conduction abnormalities. Mitral valve insufficiency is the most common valvular lesion, typically present in childhood or adolescence. Cerebrovascular symptoms mainly arise from multifocal microvascular complications and may include thrombosis, transient ischemic attacks, basilar artery ischemia and aneurysms, seizures, hemiplegia, unilateral anesthesia, aphasia, labyrinthine disorder, or cerebral hemorrhage. The mean age of onset for cerebrovascular symptoms is 33.8 years. Personality changes and psychotic behaviors may appear with increasing age.

[0006] One approved therapy for treating Fabry disease is enzyme replacement therapy (ERT), which typically involves intravenous infusion of the corresponding wild-type protein in a purified form. Two α-Gal A preparations: agalsidase alfa (Replagal®, Shire Human Genetic Therapies) and agalsidase beta (Fabrazyme®, Sanofi Genzyme Corporation) are currently available for the treatment of Fabry disease. While ERT is effective in many cases, the treatment also has limitations. ERT has not been demonstrated to reduce the risk of stroke, the myocardium responds gradually, and GL-3 efflux from some renal cell types is limited. Some patients also develop an immune response to ERT.

[0007] Therefore, the need for therapies to treat Fabry disease remains. [Overview of the project] [Means for solving the problem]

[0008] Various aspects of the present invention relate to the treatment of Fabry disease.

[0009] One aspect of the present invention relates to a method for reducing the risk of composite clinical outcomes (CCO) in patients with Fabry disease, the method comprising administering a formulation containing an effective amount of migrastat or a salt thereof to the patient every other day for at least 18 months, the effective amount being approximately 100 mg to approximately 150 mg free base equivalent (FBE).

[0010] In one or more embodiments, CCO includes renal events, cardiac events, cerebrovascular events, and death. In one or more embodiments, renal events are defined as a decrease in eGFR < 90 mL / min / 1.73 m² relative to baseline. 2 Having eGFR CKD-EPI Decrease ≥ 15 mL / min / 1.73 m 2 Or, one or more of the following: having an elevated protein level of ≥300 mg relative to baseline and an increase in 24-hour urinary protein of ≥33%. In one or more embodiments, cardiac events include one or more of the following: myocardial infarction, unstable angina, a new symptomatic arrhythmia requiring an antiarrhythmic drug, DC cardioversion, pacemaker, or defibrillator implantation, or congestive heart failure [New York Association Class III or IV]. In one or more embodiments, cerebrovascular events include one or more of the following: stroke or transient ischemic attack.

[0011] In one or more embodiments, migalastat or a salt thereof enhances α-Gal A activity.

[0012] In one or more embodiments, the patient is administered approximately 123 mg FBE of migalastat or a salt thereof every other day.

[0013] In one or more embodiments, the patient is administered approximately 123 mg of migalastat free base every other day.

[0014] In one or more embodiments, the patient is administered approximately 150 mg of migalastat hydrochloride every other day.

[0015] In one or more embodiments, the formulation includes an oral dosage form. In one or more embodiments, the oral dosage form includes a tablet, a capsule, or a solution.

[0016] In one or more embodiments, migalastat or a salt thereof is administered for at least two years.

[0017] In one or more embodiments, migalastat or a salt thereof is administered for at least three years.

[0018] In one or more embodiments, migalastat or a salt thereof is administered for at least four years.

[0019] In one or more embodiments, the incidence of CCO in the patient group with migrastat therapy over 18 months is less than 1.0 / patient-year. In one or more embodiments, the incidence of CCO in the patient group with migrastat therapy over 18 months is less than 0.5 / patient-year.

[0020] In one or more embodiments, the patient is male.

[0021] In one or more embodiments, the patient is female.

[0022] In one or more embodiments, the patient is a patient who has never undergone ERT.

[0023] In one or more embodiments, the patient is a patient with an ERT history.

[0024] In one or more embodiments, the patient has a HEK assay applicable mutation in alpha-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 formulation label of migalastat formulations approved for the treatment of Fabry disease. In one or more embodiments, the pharmacological reference table is provided in the formulation label of GALAFOLD®. 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.

[0025] Another aspect of the present invention relates to a method for determining a gastrointestinal (GI) outcome in a patient having Fabry disease, the method comprising determining the severity of the patient's disease-related GI symptoms, determining the frequency of the patient's bowel movements, determining the frequency of the patient's diarrhea, and determining the character of the patient's diarrhea.

[0026] In one or more embodiments, determining the severity of the patient's disease-related GI symptoms comprises determining the severity of one or more of flatulence, stomach pain, cramps, nausea, acid reflux, heartburn, constipation, or diarrhea.

[0027] In one or more embodiments, determining the severity of the patient's disease-related GI symptoms comprises determining the severity of one or more of the worst flatulence over a period of time, the worst stomach pain over a period of time, the worst cramps over a period of time, the worst nausea over a period of time, the worst nausea over a period of time, the worst nausea over a period of time, the worst nausea over a period of time, or the worst nausea over a period of time.

[0028] In one or more embodiments, the GI outcome is determined based on a 24-hour period. In other embodiments, the determination is based on a period of 6 hours, 8 hours, 12 hours, 36 hours, 48 hours, 3 days, 4 days, 5 days, 6 days, or 7 days.

[0029] In one or more embodiments, the GI outcome is determined based on patient-reported symptoms.

[0030] In one or more embodiments, each item is evaluated using a score on a scale of 0 to 10.

[0031] Another aspect of the present invention relates to a method for evaluating therapeutic treatment for Fabry disease, the method comprising: determining a baseline GI; determining a GI outcome after a period of therapeutic treatment; and comparing the baseline GI outcome with the GI outcome after a period of therapeutic treatment.

[0032] Another aspect of the present invention relates to a method for treating Fabry disease, the method comprising: determining the GI to obtain a first GI score; initiating or continuing therapeutic therapy for Fabry disease for a certain period of time; determining the GI outcome after a certain period of therapeutic therapy to obtain a second GI outcome score after the therapeutic therapy period; and comparing the first GI outcome score with the second GI outcome score.

[0033] In one or more embodiments, the therapeutic therapy includes ERT.

[0034] In one or more embodiments, the therapeutic therapy includes substrate reduction therapy.

[0035] In one or more embodiments, the therapeutic therapy includes gene therapy.

[0036] In one or more embodiments, the therapeutic therapy includes pharmacological chaperone therapy. In one or more embodiments, the pharmacological chaperone therapy includes administration of an effective dose of migrastat or a salt thereof. In one or more embodiments, migrastat or a salt thereof is administered every other day. In one or more embodiments, the effective dose is about 100 mg to about 150 mg FBE.

[0037] In one or more embodiments, the patient is administered approximately 123 mg FBE of migalastat or a salt thereof every other day.

[0038] In one or more embodiments, the patient is administered approximately 123 mg of migalastat free base every other day.

[0039] In one or more embodiments, the patient is administered approximately 150 mg of migalastat hydrochloride every other day.

[0040] In one or more embodiments, the formulation includes an oral dosage form. In one or more embodiments, the oral dosage form includes a tablet, a capsule, or a solution.

[0041] In one or more embodiments, migalastat or a salt thereof is administered for at least two years.

[0042] In one or more embodiments, migalastat or a salt thereof is administered for at least three years.

[0043] In one or more embodiments, migalastat or a salt thereof is administered for at least four years.

[0044] In one or more embodiments, the patient is male.

[0045] In one or more embodiments, the patient is female.

[0046] In one or more embodiments, the patient is a patient who has never undergone ERT.

[0047] In one or more embodiments, the patient is a patient with an ERT history.

[0048] In one or more embodiments, the patient has an 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 on the formulation label of a migalastat formulation approved for the treatment of Fabry disease. In one or more embodiments, the pharmacological reference table is provided on the formulation label of GALAFOLD®. 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.

[0049] Another aspect of the present invention relates to a method for evaluating therapeutics for Fabry disease, the method comprising determining one or more parameters in a patient population treated with therapeutics, wherein the one or more parameters include one or more of the occurrence of Fabry signs and symptoms, renal parameters, and cardiac parameters, and determining one or more parameters in an untreated patient population.

[0050] In one or more embodiments, the Fabry sign and symptoms include one or more of the following: acrosensory deficiency, GI sign and symptoms, hearing loss, keratoid, angiokeratomas, decreased sweating, pulmonary changes, lymphedema, or brain MRI changes.

[0051] In one or more embodiments, the renal parameter is eGFR CKD-EPI This includes one or more of the following: creatinine levels, urinary protein levels, or the presence of detectable urinary protein.

[0052] In one or more embodiments, the cardiac parameters include one or more of the left ventricular mass index (LVMi) or the occurrence of left ventricular hypertrophy.

[0053] In one or more embodiments, the method further includes determining one or more parameters in a patient population treated with different therapeutic therapies for Fabry disease.

[0054] In one or more embodiments, the method further includes determining the patient age in each of the patient populations.

[0055] In one or more embodiments, the method further includes determining the patient genotype in each of the patient populations.

[0056] In one or more embodiments, the method further includes determining the gender of each patient in the patient population.

[0057] In one or more embodiments, the therapeutic therapy includes ERT.

[0058] In one or more embodiments, the therapeutic therapy includes substrate reduction therapy.

[0059] In one or more embodiments, the therapeutic therapy includes gene therapy.

[0060] In one or more embodiments, the therapeutic therapy includes pharmacological chaperone therapy. In one or more embodiments, the pharmacological chaperone therapy includes administration of an effective dose of migrastat or a salt thereof. In one or more embodiments, migrastat or a salt thereof is administered every other day. In one or more embodiments, the effective dose is about 100 mg to about 150 mg FBE.

[0061] In one or more embodiments, the patient is administered approximately 123 mg of FBE migalastat or a salt thereof every other day.

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

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

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

[0065] In one or more embodiments, migalastat or a salt thereof is administered for at least two years.

[0066] In one or more embodiments, migalastat or a salt thereof is administered for at least three years.

[0067] In one or more embodiments, migalastat or a salt thereof is administered for at least four years.

[0068] In one or more embodiments, the patient is male.

[0069] In one or more embodiments, the patient is female.

[0070] In one or more embodiments, the patient is a patient who has never undergone ERT.

[0071] In one or more embodiments, the patient is a patient with an ERT history.

[0072] In one or more embodiments, the patient has an 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 on the formulation label of a migalastat formulation approved for the treatment of Fabry disease. In one or more embodiments, the pharmacological reference table is provided on the formulation label of GALAFOLD®. 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.

[0073] In one or more embodiments, the method further includes determining one or more parameters in a patient population treated with ERT.

[0074] In one or more embodiments, one or more parameters are determined over a period of at least one year.

[0075] Further features of the present invention will become apparent from the description below and the accompanying drawings. [Brief explanation of the drawing]

[0076] [Figure 1A-1E] The complete DNA sequence of the human wild-type GLA gene (Sequence ID 1) is shown. [Figure 2] This shows the wild-type α-Gal A protein (SEQ ID NO: 2). [Figure 3] This shows the nucleic acid sequence (SEQ ID NO: 3) encoding the wild-type α-Gal A protein. [Figure 4A-4B] This shows the history of Fabry disease among patients currently registered in the followME registry (safety population). [Figure 5A-5B] Figure 5A shows the Fabry signs and symptoms of patients currently registered in the followME registry, and Figure 5B shows the median age of first occurrence of Fabry signs and symptoms by sex (safety population). [Modes for carrying out the invention]

[0077] Before describing some exemplary embodiments of the present invention, it should be understood that the present invention is not limited to the details of the construction or method steps set forth in the following description. Other embodiments of the present invention are possible and can be carried out or performed in a variety of ways.

[0078] Various aspects of the present invention relate to the administration of pharmacological chaperones such as migrastat for the treatment of Fabry disease. Various other aspects of the present invention relate to methods for determining various symptoms in Fabry patients, such as gastrointestinal (GI) symptoms. Various other aspects of the present invention relate to methods for evaluating therapeutic approaches for Fabry disease.

[0079] definition The terms used herein generally have their common meanings in the art within the context of the present invention and in the specific context in which each term is used. Certain terms are discussed below or elsewhere in this specification to provide further guidance to practitioners in describing the compositions and methods of the present invention and how they may be prepared and used.

[0080] The term "Fabry disease" refers to an X-linked congenital anomaly of sphingoglycolipid catabolism caused by a deficiency in 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 associated sphingoglycolipids in vascular endothelial lysosomes of the heart, kidneys, skin, and other tissues. Another substrate for this enzyme is plasma globotriaosylsphingosine ("plasma lyso-Gb3").

[0081] The term "atypical Fabry disease" primarily refers to patients with cardiac symptoms of α-Gal A deficiency, specifically progressive GL-3 accumulation in cardiomyocytes, which leads to significant hypertrophy of the heart (particularly the left ventricle).

[0082] A "carrier" is a woman in whom one X chromosome contains the defective α-Gal A gene and the other X chromosome contains the normal gene, and who has X chromosome inactivation of the normal allele in one or more cell types. Carriers are often diagnosed with Fabry disease.

[0083] "Patient" refers to a person who has been diagnosed with a specific disease or is suspected of having one. A patient may be a human or an animal.

[0084] A "Fabry patient" refers to an individual with the mutant α-Gal A as further defined below, who has been diagnosed with or is suspected of having Fabry disease. Characteristic markers of Fabry disease may appear with the same prevalence in hemizygous male and female carriers, but typically, women experience less severe symptoms if they develop the disease.

[0085] 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 number X14448.1 and is shown in Figures 1A-E (Sequence ID 1). The human α-Gal A enzyme consists of 429 amino acids and is available under GenBank accession numbers X14448.1 and U78027.1, and is shown in Figure 2 (Sequence ID 2). The nucleic acid sequence containing only the coding region (i.e., exon) of Sequence ID 1 is shown in Figure 3 (Sequence ID 3).

[0086] The term "mutant protein" refers to a protein whose gene has a mutation that prevents it from achieving stable conformation under normal conditions in the endoplasmic reticulum (ER). If stable conformation cannot be achieved, a significant amount of the enzyme will not be transported to lysosomes, but will instead be degraded. Such mutations are sometimes called "conformation mutants." Examples of such mutations include, but are not limited to, missense mutations and in-frame small deletions and insertions.

[0087] As used in one embodiment herein, the term “mutant α-Gal A” includes α-Gal A having a mutation in the gene encoding α-Gal A such that the enzyme cannot achieve stable conformation under conditions normally present in the ER. If stable conformation cannot be achieved, a significant amount of the enzyme will not be transported to the lysosomes but will instead be degraded.

[0088] As used herein, the term “pharmacological chaperone” (“PC”) means any molecule, including small molecules, proteins, peptides, nucleic acids, carbohydrates, etc., that specifically binds to a protein and has one or more of the following effects: (i) promotes the formation of a stable molecular conformation of the protein; (ii) induces the trafficking of the protein from the ER to another cellular site, preferably a native cellular site, i.e., prevents ER-associated degradation of the protein; (iii) prevents the aggregation of misfolded proteins; and / or (iv) restores or enhances at least some wild-type function and / or activity of the protein. For example, a compound that specifically binds to α-Gal A means that it binds to that enzyme and exerts a chaperone effect, rather than to a general group of related or unrelated enzymes. More specifically, this term does not refer to endogenous chaperones such as BiP, or nonspecific agents, i.e., chemical chaperones, such as glycerol, DMSO, or heavy water, that have demonstrated nonspecific chaperone activity to various proteins. In one or more embodiments of the present invention, PC may be a reversible competitive inhibitor. In one embodiment, PC is migalastat or a salt thereof. In another embodiment, PC is migalastat free base (e.g., 123 mg of migalastat free base). In yet another embodiment, PC is a salt of migalastat (e.g., 150 mg of migalastat HCl).

[0089] A "competitive inhibitor" of an enzyme can 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 position as the substrate. Therefore, the inhibitor competes with the substrate molecule for the same active site, thereby increasing Km. Competitive inhibition is usually reversible if enough substrate molecules are available to replace the inhibitor; that is, competitive inhibitors can bind reversibly. Therefore, the amount of enzyme inhibition depends on the inhibitor concentration, the substrate concentration, and the relative affinity of the inhibitor and substrate to the active site.

[0090] As used herein, the term “specifically binds” refers to the interaction between a pharmacological chaperone and a protein such as α-Gal A, specifically the interaction with an amino acid residue in the protein that is directly involved in contact with the pharmacological chaperone. A pharmacological chaperone specifically binds to a target protein, such as α-Gal A, and exerts a chaperone effect on that protein rather than on a general group of related or unrelated proteins. The amino acid residue in the protein that interacts with a given pharmacological chaperone may or may not be within the protein’s “active site.” Specific binding can be evaluated by routine binding assays or by structural studies, such as cocrystallization or NMR. The active site of α-Gal A is the substrate binding site.

[0091] "α-Gal A deficiency" refers to α-Gal A activity in cells from patients that falls below the normal range when compared (using the same method) to the activity of normal individuals who do not have or are not suspected of having Fabry disease or any other disease (especially blood disorders).

[0092] As used herein, the terms “enhance α-Gal A activity” or “increase α-Gal A activity” refer to increasing the amount of α-Gal A that maintains a stable conformation in cells contacted with an α-Gal A-specific pharmacological chaperone compared to the amount in cells not in contact with an α-Gal A-specific pharmacological chaperone (preferably of the same cell type, or the same cells, e.g., earlier in development). The term also refers to increasing the trafficking of α-Gal A to lysosomes in cells contacted with an α-Gal A-specific pharmacological chaperone compared to the trafficking of α-Gal A not in contact with a protein-specific pharmacological chaperone. These terms refer to both wild-type and mutant α-Gal A. In one embodiment, the increase in the amount of α-Gal A in cells is measured by measuring the hydrolysis of the artificial substrate in the lysate from cells treated with PC. The increase in hydrolysis is an indicator of increased α-Gal A activity.

[0093] The term "α-Gal A activity" refers to the normal physiological function of wild-type α-Gal A in cells. For example, α-Gal A activity includes the hydrolysis of GL-3.

[0094] A “response case” is an individual diagnosed with or suspected of having a lysosomal storage disorder (LSD), such as Fabry disease, in which the cells respond to contact with PC by exhibiting a substantial increase in α-Gal A activity and / or symptom reduction or enhancement of surrogate markers, respectively. Non-limiting examples of enhancement of Fabry's surrogate markers are disclosed in lyso-GB3 and in U.S. Patent Application Publication No. 2010 / 0113517, which is cited in its entirety by reference herein.

[0095] Non-limiting examples of improvements in surrogate markers for 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; decreased GL-3 accumulation; decreased plasma concentrations of homocysteine ​​and vascular cell adhesion molecule-1 (VCAM-1); decreased GL-3 accumulation in cardiomyocytes and valvular fibroblasts; decreased plasma lyso-Gb3; reduced cardiac hypertrophy (especially left ventricle), reduced valvular regurgitation and arrhythmias; reduced proteinuria; decreased urinary concentrations of lipids such as CTH, lactosylceramide, and ceramide, and increased urinary concentrations of glucosylceramide and sphingomyelin; absence of laminar inclusions (zebra bodies) in glomerular epithelial cells; enhanced renal function; alleviated decreased sweating; absence of angiokeratoma; and improvement in hearing abnormalities such as high-frequency sensorineural hearing loss, progressive hearing loss, sudden hearing loss, or tinnitus. Improvements in neurological symptoms include prevention of transient ischemic attacks (TIAs) or stroke, and reduction of neuropathic pain that manifests as acrosensory abnormalities (burning or stabbing pain in the extremities). Another clinical marker that can be used to diagnose Fabry disease is the prevalence of adverse cardiovascular symptoms.

[0096] The dose that achieves one or more of the responses described above is the "therapeutic effective dose."

[0097] The term “pharmaceutically 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, when used herein, the term “pharmaceutically acceptable” means that its use in animals, more particularly in humans, is approved by a federal or state regulatory agency, or that it is listed in the United States Pharmacopeia or other generally accepted pharmacopoeias. With respect to pharmaceutical carriers, the term “carrier” refers to a diluent, auxiliary, excipient, or medium with which the compound is administered. Such pharmaceutical carriers may be sterile solutions such as water and oil. Preferably, for injectable solutions, water or aqueous solutions, physiological saline solutions, and aqueous solutions of dextrose and glycerol are used as carriers. Suitable pharmaceutical carriers are described in “Remington's Pharmaceutical Sciences” by EW Martin, 18th Edition, or other editions.

[0098] As used herein, the term “isolated” means that the material being referred to is removed from the environment in which it is normally found. Therefore, isolated biological material may not contain cellular components, i.e., components of the cell in which the material is found or produced. In the case of nucleic acid molecules, isolated nucleic acids include PCR products, mRNA bands on a gel, cDNA, or restriction enzyme fragments. In another embodiment, an isolated nucleic acid is preferably excised from a chromosome in which it may be found, and more preferably no longer bound to non-regulatory regions, non-coding regions, or other genes located upstream or downstream of the genes contained in the isolated nucleic acid molecule when found in a chromosome. In yet another embodiment, the isolated nucleic acid lacks one or more introns. An isolated nucleic acid contains a sequence to be inserted into a plasmid, cosmid, artificial chromosome, etc. Therefore, in a specific embodiment, recombinant nucleic acid is an isolated nucleic acid. An isolated protein may be bound to other proteins or nucleic acids, or both, to which it is bound in the cell, or to 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. The isolated material may be purified, although this is not essential.

[0099] The term "enzyme replacement therapy" or "ERT" refers to the introduction of purified non-natural enzymes into individuals with such enzyme deficiencies. The administered proteins can be obtained from natural sources or by recombinant expression (as described in more detail below). The term also refers to the introduction of purified enzymes into individuals who require or respond to the administration of purified enzymes in other forms (e.g., individuals suffering from enzyme deficiency). The introduced enzymes may be purified recombinant enzymes produced in vitro, or proteins purified from isolated tissues or fluids, such as placenta, animal milk, or plant-derived materials.

[0100] The term "ERT-never experienced patient" refers to a Fabry patient who has never received ERT or who has not received ERT for at least six months prior to initiating migrastat therapy.

[0101] The term "ERT-experienced patient" refers to a Fabry patient who received ERT immediately prior to the initiation of migrastat therapy. In some embodiments, ERT-experienced patients had received ERT for at least 12 months immediately prior to the initiation of migrastat therapy.

[0102] As used herein, the term “free base equivalent” or “FBE” refers to the amount of migrastat present in migrastat or a salt thereof. In other words, the term “FBE” refers to either the amount of migrastat free base or the equivalent amount of migrastat free base provided by a salt of migrastat. For example, based on the weight of the hydrochloride, 150 mg of migrastat hydrochloride provides only the same amount of migrastat as 123 mg of migrastat in free base form. Other salts are expected to have different conversion factors depending on the molecular weight of the salt.

[0103] The term "migrastat" encompasses migrastat free base or its pharmaceutically acceptable salt (e.g., migrastat HCl) unless otherwise specifically designated.

[0104] The terms “mutation” and “variation” (as seen, for example, in “applicable mutation or variation”) refer to changes in the nucleotide sequence of a gene or chromosome. As used herein, the two terms are typically used collectively, as seen, for example, in “mutation or variation,” and refer to the nucleotide sequence changes specified in the preceding sentence. If for any reason only one of the two terms is mentioned, the omitted term is intended to be included and should be understood as such. Furthermore, the terms “applicable mutation” and “applicable variation” refer to mutations or variations applicable to PC therapy, for example, mutations applicable to migrastat therapy. A specific type of applicable mutation or variation is “HEK assay applicable mutation or variation,” which is a mutation or variation determined to be applicable to migrastat therapy according to the criteria of the in vitro HEK assay described herein and in U.S. Patent No. 8,592,362 (which is incorporated herein by reference in its entirety).

[0105] The terms “about” and “approximately” generally mean the acceptable degree of error of a measured quantity, given the nature or precision of the measurement. A typical exemplary degree of error is within 20 percent (%) of a given value or range of values, preferably within 10 percent, and more preferably within 5 percent. Alternatively, particularly in biological systems, the terms “about” and “approximately” may mean a value within the order of a given value, preferably within 10 times or 5 times, and more preferably within 2 times. The quantities provided herein are approximate unless otherwise specified; that is, the terms “about” or “approximately” may be implied even when not explicitly stated.

[0106] Fabry disease Fabry disease is a rare, progressive, and severe X-linked LSD. Mutations in the GLA gene cause a deficiency in the lysosomal enzyme α-Gal A, which is essential for sphingoglycolipid metabolism. Reduced α-Gal A activity, which begins in infancy, leads to the accumulation of sphingoglycolipids, including GL-3 and plasma lyso-Gb3, resulting in the symptoms and fatal complications of Fabry disease, including pain, gastrointestinal symptoms, renal failure, cardiomyopathy, cerebrovascular events, and early death. Early initiation of therapy and lifelong treatment offer an opportunity to slow disease progression and extend life expectancy.

[0107] Fabry disease encompasses a range of disease severities and ages of onset, but has traditionally been divided into two main phenotypes: "classical" and "late-onset." The classical phenotype is primarily considered to be present in males with undetectable or low α-Gal A activity and early onset of renal, cardiac, and / or cerebrovascular symptoms. The late-onset phenotype is primarily considered to be present in males with higher residual α-Gal A activity and later onset of these disease symptoms. Heterozygous female carriers typically exhibit the late-onset phenotype, but may also present with the classical phenotype depending on the pattern of X chromosome inactivation.

[0108] Over 1,000 GLA mutations causing Fabry disease have been identified. Approximately 60% are missense mutations resulting in a single amino acid substitution in the α-Gal A enzyme. Missense GLA mutations often lead to the production of an abnormally folded and unstable form of α-Gal A, most of which are associated with the classical phenotype. Normal cellular quality control mechanisms in the ER prevent these abnormal proteins from moving to lysosomes, targeting them for premature degradation and removal. Many missense mutation forms are targeted by migrastat, an α-Gal A-specific pharmacological chaperone.

[0109] The clinical manifestations of Fabry disease range widely in severity and largely correlate with the patient's residual α-Gal A levels. The majority of patients currently treated are considered to have classical Fabry disease, and most are male. These patients experience disease in various organs, including the kidneys, heart, and brain, with symptoms typically appearing in adolescence and progressing in severity until death, usually in their 30s or 40s. Several recent studies suggest a large number of undiagnosed men and women with various Fabry disease symptoms that usually first appear in adulthood, such as cardiac or renal dysfunction and stroke. These patients, referred to as late-onset Fabry disease, tend to have higher residual α-Gal A levels than classical Fabry disease patients. Late-onset Fabry disease patients typically first experience symptoms in adulthood and often have symptoms concentrated in a single organ, such as left ventricular hypertrophy or progressive renal failure. In addition, late-onset Fabry disease can also manifest as stroke of unknown cause.

[0110] Patients with Fabry disease have progressive renal impairment, and untreated patients develop end-stage renal disease by their 40s. Deficiency in α-Gal A activity leads to the accumulation of GL-3 and related sphingoglycolipids in many cell types, including kidney cells. GL-3 accumulates in podocytes, distal tubules, and epithelial and tubular cells of the loop of Henle. Renal dysfunction can manifest as proteinuria and a decrease in glomerular filtration rate.

[0111] Fabry disease is rare, involves multiple organs, and has a wide and heterogeneous age range of onset, making accurate diagnosis challenging. Awareness among medical professionals is low, leading to frequent misdiagnosis. Diagnosis of Fabry disease is almost always confirmed after the patient presents with symptoms, based on decreased α-Gal A activity in plasma or peripheral leukocytes (WBCs), along with mutation analysis. In women, diagnosis is even more difficult due to the unreliability of enzymatic identification of carrier women, caused by random X chromosome inactivation in some carrier cells. For example, some absolute carriers (daughters of classically affected men) have α-Gal A enzyme activity ranging from normal to extremely low. Since carriers may have normal α-Gal A enzyme activity in leukocytes, accurate carrier identification and / or diagnosis can only be given by identifying α-Gal A mutations through genetic testing.

[0112] In one or more embodiments, a mutant form of α-Gal A considered to be migrastat-applicable is defined as one that, when expressed in HEK-293 cells according to a GLP-validated in vitro assay (GLP HEK or migrastat applicability assay) (referred to as the "HEK assay"), exhibits a relative increase of ≥1.20 times (+10 μM migrastat) and an absolute increase of ≥3.0% (+10 μM migrastat) compared to the wild type (WT). Such a mutation is also referred to herein as a "HEK assay-applicable" mutation.

[0113] Prior screening methods are provided to determine enzyme enhancement before initiating treatment. For example, an assay using HEK-293 cells has been used in clinical trials to predict whether a given mutation is responsive to pharmacological chaperone (e.g., migrastat) treatment. In this assay, a cDNA construct is created. The corresponding α-Gal A mutation is transiently expressed in HEK-293 cells. The cells are then incubated with ± migrastat (17 nM to 1 mM) for 4 to 5 days. Subsequently, α-Gal A levels in the cell lysate are measured using a synthetic fluorescent substrate (4-MU-α-Gal) or by Western blotting. This has been done for known missense or small in-frame insertion / deletion mutations that cause disease. Mutations identified to date as responsive to PC (e.g., migrastat) using these methods are listed in U.S. Patent No. 8,592,362.

[0114] Pharmacological chaperones The binding of small molecule inhibitors to LSD-related enzymes can increase the stability of both mutant enzymes and their corresponding wild-type enzymes (see U.S. Patents No. 6,274,597; No. 6,583,158; No. 6,589,964; No. 6,599,919; No. 6,916,829; and No. 7,141,582, all incorporated herein by reference). In particular, administration of small molecule derivatives of glucose and galactose, which are specific and selective competitive inhibitors of several target lysosomal enzymes, effectively increased intracellular enzyme stability in vitro, leading to increased enzyme trafficking to lysosomes. Therefore, it is expected that the increased amount of enzyme in lysosomes will lead to increased hydrolysis of enzyme substrates. The initial 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), the enzyme proteins are delayed or accelerated in the normal transport pathway (ER → Golgi apparatus → endosomes → lysosomes). Therefore, compounds that bind to mutant enzymes and increase their stability can act as "chaperones" for the enzymes, increasing the amount that can leave the ER and move to lysosomes. In addition, the folding and trafficking of some wild-type proteins are incomplete, and in some cases up to 70% of some wild-type proteins are degraded before reaching their final cellular site, so chaperones can be used to stabilize wild-type enzymes, increasing the amount of enzyme that can leave the ER and be transported to lysosomes.

[0115] In one or more embodiments, the pharmacological chaperone comprises migrastat or a salt thereof. Migrastat, also known as 1-deoxygalactonojirimycin (1-DGJ) or (2R,3S,4R,5S)-2-(hydroxymethyl)piperidine-3,4,5triol, is a compound having the following chemical formula: [ka]

[0116] As discussed herein, pharmaceutically acceptable salts of migalastat may also be used in the present invention. When using a salt of migalastat, the dosage of the salt will be adjusted so that the amount of migalastat ingested by the patient is equivalent to the amount that would have been ingested if migalastat free base had been used. An example of a pharmaceutically acceptable salt of migalastat is migalastat HCl. [ka]

[0117] Migalastat is a low molecular weight iminosaccharide and an analog of the terminal galactose of GL-3. In vitro and in vivo pharmacological studies have demonstrated that migalastat acts as a pharmacological chaperone, binding with high affinity, selectively, and reversibly to the active site of wild-type α-Gal A and specific mutant forms of α-Gal A (these genotypes are referred to as HEK assay-applicable mutations). Upon binding of migalastat, these mutant forms of α-Gal A are stabilized in the endoplasmic reticulum, promoting their proper trafficking to lysosomes. In lysosomes, migalastat dissociates, allowing α-Gal A to lower GL-3 and other substrate levels. Approximately 30–50% of Fabry disease patients have HEK assay-applicable mutations; the majority of these are associated with the classical phenotype of the disease.

[0118] HEK assay-applicable mutations include at least those listed in the pharmacological reference table (e.g., those listed on the U.S. or international formulation label for migrastat formulations such as GALAFOLD®). As used herein, “pharmacological reference table” means any publicly accessible documentary or electronic record contained in either the formulation label on the packaging of a migrastat formulation (e.g., GALAFOLD®) or on a website accessible by the healthcare provider, which informs whether a particular mutation or variant responds to migrastat (e.g., GALAFOLD®) PC therapy, and is not necessarily limited to documentary records presented in tabular format. Therefore, in one embodiment of the present invention, “pharmacological reference table” means any depositary of information containing one or more applicable mutations or variants. Exemplary pharmacological reference tables for HEK assay-applicable mutations can be found in the GALAFOLD® formulation characteristics summary and / or prescription information for the various countries where GALAFOLD® is approved for use, or on websites such as www.galafoldamenabilitytable.com and www.fabrygenevariantsearch.com (each of which is referenced herein in its entirety).

[0119] A exemplary pharmacological reference table for HEK assay-applicable mutations is provided in Table 1 below. In one or more embodiments, if a double mutation is present on the same chromosome (male and female), the patient is considered HEK assay-applicable if the double mutation is present in one entry in Table 1 (e.g., D55V / Q57L). In some embodiments, if the double mutation is present on different chromosomes (female only), the patient is considered HEK assay-applicable if either of the individual mutations is present in Table 1.

[0120] [Table 1]

[0121] Table 2

[0122] Table 3

[0123] Table 4

[0124] Table 5

[0125] Table 6

[0126] Table 7

[0127] Table 8

[0128] Table 9

[0129] Table 10

[0130] Table 11

[0131] Table 12

[0132] Table 13

[0133] Table 14

[0134] Table 15

[0135] Table 16

[0136] Table 17

[0137] Table 18

[0138] Table 19

[0139] Table 20

[0140] Table 21

[0141] Table 22

[0142] Table 23

[0143] Table 24

[0144] Table 25

[0145] Table 26

[0146] Table 27

[0147] Table 28

[0148] Table 29

[0149] Table 30

[0150] Table 31

[0151] Table 32

[0152] Dosage, formulation and administration Accordingly, in one or more embodiments, migrastat or a salt thereof is administered to Fabry patients once every other day (also referred to as “QOD”). In various embodiments, the doses described herein relate to migrastat hydrochloride or an equivalent dose of migrastat or a salt thereof other than hydrochloride. In some embodiments, these doses relate to the free base of migrastat. In alternative embodiments, these doses relate to a salt of migrastat. In further embodiments, the salt of migrastat is migrastat hydrochloride. The administration of migrastat or a salt of migrastat is referred to herein as “migrastat therapy”.

[0153] The effective dose of migrastat or its salt may range from approximately 100 mg FBE to approximately 150 mg FBE. Exemplary doses include approximately 100 mg FBE, 105 mg FBE, 110 mg FBE, 115 mg FBE, 120 mg FBE, 123 mg FBE, 125 mg FBE, 130 mg FBE, 135 mg FBE, 140 mg FBE, 145 mg FBE, or 150 mg FBE.

[0154] Here again, it should be noted that 150 mg of migrastat hydrochloride is equivalent to 123 mg of migrastat in free base form. Therefore, in one or more embodiments, the dose is 150 mg of migrastat hydrochloride or an equivalent dose of migrastat or its salt other than hydrochloride, administered once every other day. As indicated above, this dose is referred to as 123 mg of migrastat FBE. In a further embodiment, the dose is 150 mg of migrastat hydrochloride, administered once every other day. In another embodiment, the dose is 123 mg of migrastat free base, administered once every other day.

[0155] In various embodiments, the effective dose is approximately 122 mg, 128 mg, 134 mg, 140 mg, 146 mg, 150 mg, 152 mg, 159 mg, 165 mg, 171 mg, 177 mg, or 183 mg of migalastat hydrochloride.

[0156] Therefore, in various embodiments, migrastat therapy includes administering 123 mg FBE once every other day, such as 150 mg migrastat hydrochloride every other day.

[0157] The administration of migrastat or a salt thereof may be over a certain period of time. In one or more embodiments, migrastat or a salt thereof is administered for a duration of at least 28 days, for example, at least 30, 60 or 90 days or at least 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 various embodiments, migrastat therapy is long-term migrastat therapy lasting at least about 2, 3, 4 or 5 years.

[0158] The administration of migrastat or its salt according to the present invention may be in the form of a formulation suitable for any route of administration, but preferably in the form of an oral dosage form such as a tablet, capsule, or solution. For example, a patient may be orally administered a capsule containing 150 mg of migrastat hydrochloride or an equivalent dose of migrastat or a salt other than its hydrochloride.

[0159] In some embodiments, PC (e.g., migrastat or a salt thereof) is administered orally. In one or more embodiments, PC (e.g., migrastat or a salt thereof) is administered by injection. PC may also be accompanied by a pharmaceutically acceptable carrier, which may depend on the method of administration.

[0160] In one or more embodiments, the PC (e.g., migrastat or a salt thereof) is administered as monotherapy and may be in a form suitable for any route of administration, such as orally in the form of tablets, capsules, or liquids, or in a sterile aqueous solution for injection. In other embodiments, the PC is provided as a lyophilized powder that is added to the supplement enzyme formulation during or immediately after reconstitution to prevent enzyme aggregation in vitro before administration.

[0161] When PC (e.g., migalastat or a salt thereof) is formulated for oral administration, tablets or capsules may be prepared by conventional means with pharmaceutically acceptable excipients such as binders (e.g., pregelatinized corn starch, polyvinylpyrrolidone, or hydroxypropyl methylcellulose); 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). The tablets may be coated by methods well known in the art. Liquid formulations for oral administration may take the form of solutions, syrups, or suspensions, or may be prepared as dry formulations to be mixed with water or another suitable medium before use. Such liquid formulations may be prepared by conventional means with pharmaceutically acceptable additives such as suspending agents (e.g., sorbitol syrup, cellulose derivatives, or hydrogenated edible fats); emulsifiers (e.g., lecithin or acacia); non-aqueous media (e.g., tonsil 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 optionally contain buffer salts, flavoring agents, coloring agents, and sweeteners. Formulations for oral administration may be suitably formulated to provide controlled release of the active chaperone compound.

[0162] Suitable pharmaceutical formulations of polypropylene (PC) (e.g., migrastat or its salts) for parenteral / injectable use generally include sterile aqueous solutions (if water-soluble), or dispersions and sterile powders for the immediate preparation of sterile injection solutions or dispersions. In all cases, the form must be sterile and have sufficient fluidity to allow for easy passage through an injection needle. It must be stable under manufacturing and storage conditions and protected from contamination by microorganisms such as bacteria and fungi. The carrier may be a solvent or dispersion medium containing, for example, water, ethanol, polyols (e.g., glycerol, propylene glycol, and polyethylene glycol), suitable mixtures thereof, and vegetable oils. Adequate fluidity can be maintained, for example, by the use of coatings such as lecithin, maintaining the required particle size in the case of dispersions, and using surfactants. Prevention of microbial activity can be achieved by various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, benzyl alcohol, and sorbic acid. In many cases, it may be appropriate to include isotonic agents, such as sugars or sodium chloride. By using absorption-delaying agents, such as aluminum monostearate and gelatin, in the composition, sustained absorption of the injectable composition can be achieved.

[0163] Sterile injectable solutions are prepared by compounding the required amount of purified enzyme (if present) and PC (e.g., migrastat or its salt) in a suitable solvent, along with various other components listed above as needed, followed by filtration or final sterilization. Generally, dispersions are prepared by compounding various sterilizing active ingredients in a sterilizing medium containing a basic dispersion medium and other necessary components listed above. For sterilizing powders for the preparation of sterilizing injectable solutions, preferred preparation methods are vacuum drying and freeze-drying, which yield a powder of the active ingredient + any additional desired components from a pre-sterilized filtered solution.

[0164] The formulation may contain excipients. Pharmaceutically acceptable excipients that may be included in the formulation include buffers, such as citrate buffer, phosphate buffer, acetate buffer, and bicarbonate buffer; amino acids, urea, alcohols, ascorbic acid, phospholipids; proteins such as serum albumin, collagen, and gelatin; salts such as EDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrrolidone; sugars such as dextran, mannitol, sorbitol, and glycerol; propylene glycol and polyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol; glycine or other amino acids; and lipids. Buffer systems to be used with the formulation include citrate; acetate; bicarbonate; and phosphate buffer. A phosphate buffer is a preferred embodiment.

[0165] The route of administration of chaperone compounds may be oral or parenteral, including intravenous, subcutaneous, intraarterial, intraperitoneal, intraocular, intramuscular, buccal, rectal, vaginal, orbital, intracerebral, intradermal, intracranial, intraspinal, intraventricular, intramedullary, intrathecal, intracisional, intrapulmonary, intranasal, transmucosal, transdermal, or by inhalation.

[0166] The chaperone compounds of the parenteral formulations described above may be administered by periodic injection of a bolus of the formulation, or by intravenous or intraperitoneal administration from an external (e.g., intravenous infusion bag) or internal (e.g., biodegradable implant) reservoir.

[0167] Embodiments relating to pharmaceutical formulations and administration may be combined with any other embodiment of the present invention, such as a method for treating patients with Fabry disease, a method for treating Fabry patients who have not experienced ERT, a method for treating Fabry patients who have experienced ERT, a method for reducing the risk of CBV events, a method for reducing the risk of composite clinical outcomes, a method for determining symptoms or outcomes in a patient or patient group, a method for evaluating therapeutic interventions, a method for enhancing α-Gal A in patients diagnosed with or suspected of having Fabry disease, an embodiment relating to the use of a pharmacological chaperone for α-Gal A for the manufacture of a pharmaceutical for treating patients diagnosed with Fabry disease, or an embodiment relating to a pharmacological chaperone for α-Gal A for use in the treatment of patients diagnosed with Fabry disease, as well as any embodiment relating to applicable mutations, PCs and their preferred dosages.

[0168] In one or more embodiments, PC (e.g., migrastat or a salt thereof) 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 LSD such as Fabry disease, as described above. After injection, the exogenous enzyme is assumed to be taken up by tissues via nonspecific or receptor-specific mechanisms. Generally, the uptake efficiency is not high, and the circulation time of the exogenous protein is short. In addition, the exogenous protein is unstable and subject to rapid intracellular degradation, as well as the possibility of adverse immune responses with subsequent treatment. In one or more embodiments, the chaperone is administered simultaneously with a replacement enzyme (e.g., replacement α-Gal A). In some embodiments, the chaperone is formulated together with a replacement enzyme (e.g., replacement α-Gal A).

[0169] In one or more embodiments, the patient is switched from ERT to migrastat therapy. In some embodiments, a patient receiving ERT is identified, the patient's ERT is discontinued, and the patient begins migrastat therapy. Migrastat therapy may follow any of the methods described herein.

[0170] Composite clinical outcomes The dosing regimens described herein can reduce the risk of composite clinical outcome (CCO) in Fabry patients. As further described in the following examples, migrastat therapy has been found in a Phase 3 trial to reduce the incidence of CCO in Fabry patients. Therefore, migrastat therapy can be used to reduce the risk of CCO in Fabry patients and / or to treat Fabry patients at high risk of CCO, including patients with a history of cardiovascular, renal, or cerebrovascular events, or patients without a history of such events.

[0171] In one or more embodiments, CCO includes renal events, cardiac events, cerebrovascular events, and death. In one or more embodiments, renal events include eGFR < 90 mL / min / 1.73 m2 with reduced eGFR relative to baseline. CKD-EPI Decrease ≥ 15 mL / min / 1.73 m 2 Or, one or more of the following: having an elevated protein level of ≥300 mg relative to baseline and an increase in 24-hour urinary protein of ≥33%. In one or more embodiments, cardiac events include one or more of the following: myocardial infarction, unstable angina, a new symptomatic arrhythmia requiring an antiarrhythmic drug, DC cardioversion, pacemaker, or defibrillator implantation, or congestive heart failure [New York Association Class III or IV]. In one or more embodiments, cerebrovascular events include one or more of the following: stroke or transient ischemic attack.

[0172] In one or more embodiments, the incidence of CCO is less than 1.0 / patient-year, for example, less than 0.9, 0.8, 0.7, 0.6, 0.5, or 0.4 / patient-year.

[0173] In one or more embodiments, migrastat therapy provides a lower incidence of CCO than other therapeutic therapies. In one or more embodiments, the other therapeutic therapy includes one or more of ERT, substrate reduction therapy, or gene therapy. In one or more embodiments, the other therapy is ERT.

[0174] In one or more embodiments, the incidence of CCO is evaluated after 18 months of treatment. In one or more embodiments, the incidence of CCO is evaluated over a long-term treatment period of at least 2, 3, 4 years or longer.

[0175] In one or more embodiments, the median time to the first CCO is greater than 0.5 years, for example, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, or greater than 1 year.

[0176] In one or more embodiments, migrastat therapy provides a longer time to the first CCO than other therapeutic therapies. In one or more embodiments, the other therapeutic therapy includes one or more ERT, substrate reduction therapy, or gene therapy. In one or more embodiments, the other therapy is ERT. [Examples]

[0177] Example 1: Composite clinical outcomes during migrastat therapy This embodiment describes the occurrence of composite clinical outcome (CCO) in migrastat-treated patients previously treated with ERT.

[0178] Test design The analysis included data from three Phase 3 clinical trials with a data cutoff of May 25, 2019, as shown below. The analysis included patients with migalastat-applicable GLA mutations who had undergone ERT and received migalastat in the ATTRACT and subsequent open-label extension (OLE) trials (AT1001-041 [NCT01458119] and / or AT1001-042 [NCT02194985]). Patients initiated ERT ≥ 12 months prior to the trial.

[0179] ATTRACT (AT1001-012, NCT01218659) was a Phase 3 open-label, active-controlled trial comparing the efficacy and safety of migalastat HCl 150 mg QOD to ERT for 18 months in ERT-treated patients with migalastat-applicable GLA mutations, followed by an OLE of migalastat for 12 months.

[0180] AT1001-041 (NCT01458119) was a long-term OLE study evaluating the long-term safety and efficacy of migalastat in patients who had completed a previous migalastat trial.

[0181] AT1001-042 (NCT02194985) is a continuing long-term OLE study evaluating the long-term safety and efficacy of migalastat in patients who participated in AT1001-012 or AT1001-041.

[0182] Clinical trials included in the analysis

Number

[0183] The CCO was defined prior to the analysis plan and included the following. · Renal events (decreased eGFR < 90 mL / min / 1.73m² relative to baseline with a decrease in eGFR 2 having CKD-EPI a decrease ≥ 15 mL / min / 1.73m² 2 or an increase in 24-hour urinary protein ≥ 300 mg relative to baseline with an increase in 24-hour urinary protein ≥ 33%) · Cardiac events (myocardial infarction, unstable angina, new symptomatic arrhythmia requiring antiarrhythmic medications, direct current cardioversion, pacemaker, or implantable defibrillator, or congestive heart failure [New York Association class III or IV]) · Cerebrovascular events (stroke or transient ischemic attack) · Death

[0184] Data analysis Exposure to migalastat was calculated from the first dose to the last available data point or discontinuation date, and in this analysis, exposure to ERT lasted for 18 months, including the duration of participation in the ATTRACT trial.

[0185] Incidence rates were calculated separately for renal, cerebrovascular, and cardiac events, as well as for the composite clinical outcome. All individual events were considered in the incidence calculation. The median time to the first clinical event was calculated based on the same data used for the incidence rate.

[0186] Direct comparisons between migrastat and ERT were based on 18 months of exposure (ERT data were only available for the first 18 months of ATTRACT), and the incidence of CCO over the entire follow-up period was calculated for migrastat (ATTRACT and the subsequent OLE trial).

[0187] Long-term occurrences for migrastat were calculated based on all available data on migrastat.

[0188] result Demographics and baseline characteristics The mean (standard deviation) age of patients was 49.4 (14.1) years, and on average, patients had received 3.4 years of ERT prior to migrastat treatment (Table 2). The median (Q1-Q3) migrastat exposure was 4.8 (2.1, 5.5) years, with individual patient values ​​ranging from 0.1 to 7.2 years. Patients either received migrastat at the start of ATTRACT or switched from ERT after 18 months.

[0189] [Table 33]

[0190] Occurrence of a clinical event During the first 18 months of migrastat or ERT treatment, the incidence of chronic coagulation (CCO) was 0.41 / patient-year with migrastat and 0.85 / patient-year with ERT. In male and female patients receiving migrastat treatment, the incidence of CCO during the first 18 months was 0.50 and 0.34 / patient-year, respectively (Table 3).

[0191] The incidence of CCO remained low throughout long-term follow-up, at 0.45 / patient-year at the data cutoff. Over long-term follow-up, the incidence of CCO was 0.56 / patient-year in male patients and 0.37 / patient-year in female patients at the data cutoff (Table 3).

[0192] [Table 34]

[0193] Duration of clinical events Overall, the median time to the first CCO was 1.17 and 0.25 years for migalastat and ERT, respectively. Median time to the first CCO by treatment and sex is shown in Table 4.

[0194] [Table 35]

[0195] As can be seen from the table above, the incidence of CCO was lower in patients treated with migrastat, and the time to the first CCO was longer with migrastat compared to ERT over the 18-month treatment period in the ATTRACT trial. This CCO incidence was maintained in patients who continued migrastat for up to 7.2 years in the open-label extension (median follow-up: 4.8 years). These data demonstrate the long-term benefits of migrastat treatment in ERT-experienced Fabry disease patients with applicable GLA mutations.

[0196] Example 2: Patient-reported outcomes of Fabry disease - gastrointestinal (FABPRO-GI) This embodiment describes the development of a novel Fabry disease-specific gastrointestinal (GI) outcome measure.

[0197] Current GI methods While the gastrointestinal symptom severity scale has been used to assess GI symptoms in clinical trials of migrastat, no validated Fabry disease-specific tool is available to adequately evaluate the treatment's impact on Fabry disease-related GI symptoms (Table 5).

[0198] [Table 36]

[0199] Based on the shortcomings of these other methods, we developed the Fabry Disease Patient Reported Outcomes-Gastrointestinal (FABPRO-GI) method, a literature review and quantitative analysis-based method designed to assess GI symptoms in Fabry disease patients.

[0200] method Based on a comprehensive literature review, expert advisory meetings, and patient concept derivation interview results, the FABPRO-GI method was developed to align with best practices and regulatory guidelines.

[0201] Patient perspectives on Fabry disease-related GI symptoms were obtained through concept derivation interviews. The study included 15 patients who self-reported Fabry disease, were fluent in English, were ≥16 years old, and had ≥1 self-reported GI symptom 14 days prior to study entry. After developing the initial FABPRO-GI tool, cognitive debriefing interviews were conducted with an additional 15 patients, their content was evaluated, and the final FABPRO-GI tool was developed. The demographics of the patients interviewed in the concept derivation and cognitive debriefing interviews are shown in Table 6.

[0202] [Table 37]

[0203] The three sets of conceptual models originate from literature reviews, expert advisory meetings, and patient concept-development interviews, and primarily exhibit overlapping GI symptoms.

number

[0204] Based on feedback from cognitive debriefing interviews, the initial FABPRO-GI tools were revised, and the final 11-item FABPRO-GI tools (Table 7) were created.

[0205] [Table 38]

[0206] Among the Fabry disease-related GI symptoms identified by experts, abdominal pain, diarrhea, and early satiety were considered to be some of the most important targets for treatment. The most commonly reported Fabry disease-related GI symptoms cited by patients during concept derivation interviews included diarrhea, flatulence, and constipation. On a 0-10 scale, where higher scores indicated more trouble, worry, and shock, patients most frequently ranked diarrhea, flatulence, and constipation as their top symptoms (Table 8).

[0207] [Table 39]

[0208] Based on the above, FABPRO-GI is a novel content validation tool developed based on literature review, expert advice, and patient perspectives, usable for evaluating GI symptoms over a 24-hour recall period in patients with Fabry disease. The general comprehensibility, relevance, and comprehensiveness of the FABPRO-GI tool were validated in a subset of patients with Fabry disease.

[0209] Example 3: Baseline patient characteristics of a novel patient-centered prospective observational Fabry registry for evaluating migrastat, ERT, and natural history cohorts using followME. This embodiment describes followME's unique patient-focused prospective observational multinational registry, designed to assess the real-world impact of migrastat treatment through safety, efficacy, and patient-reported outcomes (PROs). The demographic and baseline characteristics of patients currently enrolled in the followME registry are analyzed and presented below.

[0210] Test design Patients receiving migrastat therapy, ERT therapy, or those not receiving Fabry disease-specific therapy (natural history control) were enrolled and followed for up to 5 years. The eligibility criteria are presented below.

number

[0211] method After obtaining patient consent, the physician collects baseline data for each patient, including demographics, genotype, and medical history (e.g., Fabry disease history and clinical event history), when registering them in the registry.

[0212] The safety population includes all Fabry disease patients who have consented to participate in the registry and have taken migrastat or ERT at least once, or who have never received treatment.

[0213] Demographics, baseline characteristics, and medical history (e.g., Fabry disease history and clinical event history) are grouped by initial treatment group.

[0214] result Patient Demographics A total of 144 patients (Migalastat: 67, ERT: 35, untreated: 42) were registered in the registry from 15 centers in North America and Europe. Patient demographics are shown in Table 9. Female patients comprised 41.8%, 48.6%, and 88.1% of the Migalastat, ERT, and untreated cohorts, respectively.

[0215]

Table 40

[0216] Fabry disease history Overall, the median age at symptom onset was 45.5 years for males and 28 years for females across all treatment groups, and the distribution of age at symptom onset by treatment group and gender is shown in Figure 4A. The median interval between first symptom onset and diagnosis was 1.2 years for males and 1.4 years for females (Figure 4B).

[0217] In the Migalastat cohort, the median interval between diagnosis and start of treatment was 2.4 years for males and % years for females, and in the ERT cohort, the median interval between diagnosis and start of treatment was 0.6 years for males and 9.6 years for females (Figure 4B).

[0218] Treatment history In the Migalastat cohort, 3.0% of patients had been previously treated with ERT.

[0219] In the ERT cohort, 85.7% had been treated with ERT prior to registration (median [range] ERT treatment duration: 1.3 (0 - 15.6) years).

[0220] Patient genotype The GLA genotype was determined in 86.6%, 82.9%, and 100% of the Migalastat, ERT, and untreated cohorts, respectively. Seventeen mutations were present in two or more patients, accounting for 74.2% of patients with known genotypes (Table 10). The most common mutation was p.N215S, which is associated with the late-onset phenotype of Fabry disease (n = 24 [18.8%]).

[0221]

Table 41

[0222] Fabry Signs and Symptoms Fabry signs and symptoms reported by patients involved multiple organ systems (Figure 5A). The signs and symptoms most commonly reported in male patients were paresthesia (37.7%), hearing loss (36.1%), and GI signs and symptoms (32.8%) across the entire treatment group. In female patients, the signs and symptoms most commonly reported were GI signs and symptoms (40.2%), vortex keratopathy (34.1%), and paresthesia (34.1%).

[0223] Only a subset of patients provided the age of onset of specific signs and symptoms (Figure 5B). In male patients with data, anhidrosis, gastrointestinal signs and symptoms, and paresthesia were the earliest signs and symptoms. In female patients with data, vortex keratopathy, GI signs and symptoms, and paresthesia were the earliest signs and symptoms.

[0224] In Figures 5A and 5B, a = white matter lesions, b = in a small subset of patients, symptom data: vortex keratopathy (1 ERT patient and 1 migalastat patient), angled subcapsular angioma (4 migalastat patients), GI signs and symptoms (1 migalastat patient), MRI changes (4 migalastat patients), lymphoedema (7 migalastat patients), lung changes (5 migalastat patients) were not collected, c = symptom data for 1 untreated patient and 1 migalastat patient were not collected regarding vortex keratopathy, angled subcapsular angioma, paresthesia, anhidrosis, GI signs and symptoms, hearing loss, lymphoedema, and lung changes. Brain MRI history was not collected for 1 untreated patient and 3 migalastat patients.

[0225] Heart Symptoms Table 11 shows summary statistics for left ventricular mass index (LVMi). Untreated female patients had minimal cardiac impairment in terms of both mean LVMi and the percentage of patients with left ventricular hypertrophy (LVH). However, approximately 40% of female patients in the migalastat and ERT groups developed LVH.

[0226] [Table 42]

[0227] renal symptoms Most patients had renal impairment based on the percentage of patients with detectable urinary protein (all except one ERT-treated patient) and reduced estimated glomerular filtration rate (33.3%–55%) in each of the untreated, ERT, and migrastat cohorts (Table 12). Patients were not undergoing dialysis at enrollment, and one female ERT patient had received a kidney transplant.

[0228] [Table 43]

[0229] History of cardiac, renal, and cerebrovascular events In male patients, a history of cardiac events (18.0%) was more common than renal events (8.2%) or cerebrovascular events (1.6%). In female patients, a history of renal events (7.3%) was more common than cardiac events (4.9%) or cerebrovascular events (4.9%) (Table 13).

[0230] [Table 44]

[0231] Analysis of baseline characteristics of currently registered patients suggests that patients in the followME registry are representative of Fabry disease patients in real-world situations.

[0232] Paresthesias and GI signs and symptoms are the most common initial Fabry signs and symptoms. Most patients have renal impairment, and approximately 26% of patients experienced LVH.

[0233] Compared to male patients, female patients are more likely to be untreated, even if some experience classical Fabry signs and symptoms. Female patients experienced a significantly longer delay between diagnosis and initiation of ERT treatment than male patients.

[0234] Follow-up of such patients will generate long-term outcome data on the migalastat history, ERT history, and natural history of Fabry disease, providing valuable insights into real-world experience with migalastat and other treatments for Fabry disease.

[0235] The embodiments described herein are intended to illustrate the compositions and methods and are not intended to limit the scope of the invention. All modifications and changes that are consistent with the overall description and are readily understood by those skilled in the art are intended to be included. The appended claims should not be limited by the specific embodiments shown in the examples, but should be given the broadest interpretation consistent with the overall description.

[0236] Patents, patent applications, publications, formulation descriptions, GenBank accession numbers, and protocols are cited throughout this application, and their disclosures are incorporated herein by reference in their entirety for all purposes. (Sequence Listing) SEQUENCE LISTING <110> AMICUS THERAPEUTICS, INC. <120> METHODS OF TREATING FABRY DISEASE <130> AT20-001 <160> 3 <170> PatentIn version 3.5 <210> 1 <211> 12436 <212> DNA <213> Homo sapiens <400> 1 cccttctgta ggggcagaga ggttctactt cattactgcg tctcctggga aggccatcag 60 gactgctggc taaagtggga accaggactc tttgtgagtt aagaatttgt gtatttatat 120 gtgtgtata cacattttt aaaaaactgt aacgacatca ggttgagcag tcgtctccgg 180 gtggtgaatt atgtgtattt ttaaatttta tactatattg ttattttca aatgttcgaa 240 attgaatatg tagattgttg ttatcagcag aaaaataaac attattcaaa tactctattc 300 agtaaagtaa tttattgggc gcctttgtca agcacgcatt tgcctagatg tgactctaca 360 gataaaattc acttggggcc tccccttaca gacaatcagg cagtggagac tgagtgcctg 420 aatggataga ccagcactca gaccactatt ttcagtatct gtttttctta actcagggcc 480 gtggttttca aacgtttttc gccttacggt cacccttagg gtccccccgag accggcccag 540 agacagat atacaaaaac acatacacag tcatgagcgt ccaccatttc cccaccaggc 600 gcagcacagg cggcttcccg gcactgagat gggggggagg agggagagg cgcgagggg 660 gaggggaaag cagagaacga aagaggcgga ggcggcccccc gaacccgct ctggtcttca 720 tcatcaccac ccctgggtcc ccagttccca cccacacacc aacctctaac gataccgggt 780 aattttcctc cttcttccct caaacggcta tagcgagacg gtagacgacg accagaacta 840 cttctgctca cgtaagcgag taatcacgtg agcgcctacg tcatgtgaga tctcggtcac 900 gtgagcaact ctcggcttaa actcgggatc actaaggtgc cgcacttcct tctggtatgg 960 aaatagggcg ggtcaatatc aagaaagga gagggtgatt ggttagcgga acgtcttacg 1020 tgactgatta ttggtctacc tctggggata accgtcccag ttgccagaga aaataacg 1080 tcattattta ataagtcatc ggtgattggt ccgcccctga ggttaatctt aaaagcccag 1140 gttacccgcg gaaatttatg ctgtccggtc accgtgacaa tgcagctgag gaacccagaa 1200 ctacatctgg gctgcgcgct tgcgcttcgc ttcctggccc tcgtttcctg ggacatccct 1260 ggggctagag cactggacaa tggattggca aggacgccta ccatgggctg gctgcactgg 1320 gagcgcttca tgtgcaacct tgactgccag gaagagccag attcctgcat caggtatcag 1380 atattgggta ctcccttccc tttgcttttc catgtgtttg ggtgtgtttg gggaactgga 1440 gagtctcaac gggaacagtt gagcccgagg gagagctccc ccacccgact ctgctgctgc 1500 ttttttatcc ccagcaaact gtcccgaatc aggactagcc ctaaactttc tctgtgtgac 1560 ctttcctggg atgggagtcc ggccagcggc ccctgtttct ttctctctct ctctctctct 1620 cgttctcctt ctctttctct ttctcttctt tcctctctct ttctctctct ccctgcccgg 1680 1740 agccctgccc gttctattc agaccctct tgtgaacttc tgctctcct ctgccgggtg 1800 ctaaccgtta gaacatctag ggtgggtagg aggaatgggg aactaagatt cgtgccattt 1860 tttctccttt tggggtcgtg gatttctcgg cagtatctcg agggagttag agagaccata 1920 aggtcgctga gatctctccc acctcgccca tgagcgtggc atcaggctgg aaggttgaca 1980 tggaggaact ttatacattt acacctttgc gtgaggttg aggctggatt agataggtat 2040 tgaacatatc tgaccctcac atccttatc tgtaattgg gattacaac ttttaatttc 2100 agggagctga caaaaaaaat ctgaaaaata gttcttatct cacacaggtg agttttcaag 2160 gagataacct atttaaagta catagcacag cgcttgacca ttcaactgcg cttacagagc 2220 aaatgttcaa tgggaaatg atgtaaatc tacaaatctg atgaattg tgtatttttc 2280 tggagagagg atatttacct ttctcaaat tctcaaaggg ctctgtgatt taaaaaaggt 2340 taggaatcac tgatagatgt tggtaaaagg tggcagtcac agtacattc tgtgtccata 2400 agttattcct atgaatatct ttatagata agtcaggatg tggtcagac atcacagag 2460 aaattggcct tgtaagtttc atgtgaccct gtggtacagt atgtgtgca attttgccca 2520 tcacggattt ttttg gtatttgcat ctgattataa aactaatgca tgatcattgc 2580 aaaaaatgta gataaagaag agcaaatga aaataagat ttcccccac cgttccacca 2640 cccagaaata atcatggttt aaatgttaat atacaacctt acaatgttt tctatataaa 2700 tgaaaacata gatttcttta ttcattatt ttccataaaa atggatcat gtttatgtca 2760 tgtttggcta atggcaagc cctggcaccc agtctgggct caattctgc ctcattgtta 2820 cttagccctg tgacattgggg taaattacac tttttttt tttttttt tgagacgggg 2880 tctcgctctg tcgcccaggc tggagtgcag tggcacgatc tcggctcact gcaagtccgc 2940 ctcctgggtt cacgccattc ttctgcctca gcctcccgag tagctgggac tacaggcgcc 3000 tgccaccacg cctggctctt tttttttttt tttttttttt tagtacagac ggggtttcac 3060 catgttagcc agggtggtct caatctcctg acctcgtgat tcgcccgcct cagcctccca 3120 aagtgctggt gtgagccacc gtgcccagcc ttactttttt ttttgagagg gggtctcact 3180 ctgtcaccca ggttggagtg cagtggcgcg atctctgctc agtgcaaact ccacctcccg 3240 ggtttaagca gttctcctgt cgtagtctcc tgagtagctg ggattacagg cacaccacca 3300 cggccagcta atttttgtat tttcagtaga gacgggtttc accatgttgc ccaagctggt 3360 ctcgaactcc tggcctcaag tgatctgccc gccttggcct cccagagtgc tgggattaca 3420 ggtgtgagcc accgcacccg gcctcttttt tcttttttag tctatcatac cttgcaaata 3480 cagtggttct tcctatgtgt tggttttgat attatgtaa tcaaacacat cagtttttcc 3540 tttctgattt ctgactttgg ggtcatgctg agaaagtcct ttcctacctg aagataatac 3600 agtatatacg tttcttacta gtatttttgt ggatttttaa aatatttaaa tctttagtcc 3660 atctgaactt gttcttctat cagaaatgcc acatttaata aataataagt cccatggtat 3720 cagatggctg gaaggacctc tttcgaaact ttgtttaatt cattaatct gtgtattctt 3780 attctaatgc tatagttcc acactagctt cctttatcttt ttttttcttt tttttttttt 3840 ttttgagctg gagtttcgct cttgttgccc aggctggagt acaatgtcac gatctcggtt 3900 caccgcaacc tccgcctccc aggttcaagc aattctcctg cctcatcctc gcgagtagct 3960 ggaattacag gcatgcgcca ccacgcctag ctattttgta tttttagtag agatggggtt 4020 tctccatgtt ggtcaggctg gtctcaaact cccagcctca ggtgatctgc ctgcctcggc 4080 ctcccaaaat gctgttatta caggcgtgag ccaccacgcc cagccttcat cttttaatga 4140 atgtacatgt atgtaatctt ttaggtgaac tttttgtaat gttgtgccaa gttccttaaa 4200 aagccctttt ggaagctggg caggtggcca cgcctgtaat cccagcattt tgggagtctg 4260 aggcaggtgg atcacttgag gccaggagtt caagactagc ctagccaaaa tgcaaaaccc 4320 tgtctctact aaagatacaa aaattagccg gatgcgatgg cacatgcctg taatctcagc 4380 tactcgggag gctgaggtag aagaatcgct tgaaccgggg aggcagaggt tgcagtgagc 4440 aagatggcgc cactgcactc cagcctgggt gacagaggga gactccatct caaaaaaaaa 4500 aaaaaaaaaa aagataaaaa ggaaacctaa gtactcttgg gctttgttaa ggattttgtt 4560 aaatatacaa aggattgcag ggaaaattaa cttattttta atattgagta tgcttatcca 4620 agagcaaaat aatatttctc catttattca aatcatttag gagcatcata gttttaacat 4680 atgggccttg cacgtatctt aaatttatct ctaggcattt taggttgttc agttgttctt 4740 gtgaatggga tctttttctc caaataggat tattgttgat atctgttgat tatgttaact 4800 ttgtagtttc tgactttact gaactgtctt cttagatcta atactctttt caatttcatc 4860 atatatttct cattcctatt ttgtttgggg tttttagggc gggaatatta acgggataag 4920 agagacaaaa gaaaatctgg aaaaacaatt cattttacct tacattgctt gtgattacta 4980 ccacactatt actgggttgg aaaaaattgt gaaatcccaa ggtgcctaat aaatgggagg 5040 tacctaagtg ttcatttaat gaattgtaat gattattgga atttctcttt cagtgagaag 5100 ctcttcatgg agatggcaga gctcatggtc tcagaaggct ggaaggatgc aggttatgag 5160 tacctctgca ttgatgactg ttggatggct ccccaaagag attcagaagg cagacttcag 5220 gcagaccctc agcgctttcc tcatgggatt cgccagctag ctaattatgt gagtttatag 5280 5340 cagccctcat ggccgggcgt ggtggctcac gctgtaatcc caacactttg ggaggccgag 5400 gcgggtggat cacctgaggt caagagttca agaccagcct ggccaacatg gtgaaacccc 5460 aactcttatta aaagtacaaa aaattagctg ggcatggtgg tgaacgcctg taaccccagc 5520 tacttgggag gctgaggcag gagaatcgct tgaacccagg aggtggaagt ttcagtgagc 5580 tgagatcacg ccattgcact ctagcctggg caaaaaga gaaactccat ctcaaaaaaa 5640 aaaaaaaaaaaaaaaaa cagccctcat gacacttaga aagtagaata gctggctggtt 5700 atctgaaacat tgaattgtaa ggcttatcag gtggactttg cattccatca gcagacaatt 5760 tttttttttt tttttttttg agatggagtc tcattctgtc tcccaggctg gagggcagtg 5820 gtgcgatctc ggctcactgc aagctccacc tcctgggttc atgccattct cctgcctcag 5880 cctcccaagt agctgggacc acaggcaccc gccaccatgc ccagttaattt tttgtattt 5940 ttagtagaga cggggtttca ccatgttagc cagatggtc tcgatctcct gacctcgtga 6000 tccgcccacc tcggcctccc aaagtgctgg gattacaggc atgagccacc gcgcctagcc 6060 tacaaatgtt tgtaatagc tcttgaggcc catcttggag ttctcctttt gctaaaacca 6120 ctgaactctc taggaggaa aaggaacttg gttcttgaca tatgtgtgca tgtatttcca 6180 tataaccttt aggaagctat tgcaatggta ctataaacta gatttttaga agatagaagg 6240 aaatattct ggagatcatt gagagaat ggagtccaac actagttaaa gatgatgaag 6300 acgattttt tttttgacg gagtctcgct ctgtcgccca ggctggagtg cagtggcaca 6360 atctcagctc actgcaaccc tccacctt gggttcaagt gattctcctg cctcagccctc 6420 ccaagtagct gggactacag gcgcacacca ccacgcccgg ctaattttg tattttagt 6480 agagacaagg tttcaccata ttcgccaggc tggtctcgaa ctcctgacct tgtaatccgc 6540 ccaccttggc ctcccaaagt gctgggatta caggcatgag ccaccacgcc cggccgatga 6600 agacagattt tattcagtac taccacagta gaggaaagag ccaagttcaa ttccaaatac 6660 aacaaagaca ggtggagatt tatagccaat gagcagattg agggggtcag tggatggaat 6720 atttaagaag acatcaaggg tagggagctt cttgctaaag cttcatgtac ttaaacaaga 6780 agggtggggg atgagggaaa ttgatcagat atcaatggtg gcagtattga cttagcagga 6840 ttcttgctaa gaggtcttgc taggacagac ataggaagcc aaggtggagg tctagtcgaa 6900 aagaaggctc atcagagaag tctaactaaa gtttggtcaa gaagagtctt tgtcaaggta 6960 aatctatcat ttccctcaaa aggtaatttt caggatccca tcaggaagat tagcatggct 7020 gctagctttc tcctcagttc tgggctatag ctcacatgcc tagtttgaac tagctcagca 7080 gaactggggg atttattctt tgtcttccaa caaactcatc tggatgattt tgggggtttg 7140 tggggaaaag cccccaatac ctggtgaagt aaccttgtct cttcccccag cctggaatgg 7200 ttctctcttt ctgctacctc acgattgtgc ttctacaatg gtgactcttt tcctccctct 7260 catttcaggt tcacagcaaa ggactgaagc tagggattta tgcagatgtt ggaaataaaa 7320 cctgcgcagg cttccctggg agttttggat actacgacat tgatgcccag acctttgctg 7380 actggggagt agatctgcta aaatttgatg gttgttactg tgacagtttg gaaaatttgg 7440 cagatggtaa tgtttcattc cagagattta gccacaaagg aaagaacttt gaggccatgg 7500 tagctgagcc aaagaaccaa tcttcagaat tttaaatacc ctgtcacaat actggaaata 7560 attattctcc atgtgccaga gctcccatct cttctctttc agttcattaa ttaattaatt 7620 aattcatgta aaatccatgc atacctaacc atagctaata ttgtgcactt ataattcaag 7680 agggctctaa gagttaatta gtaattgtaa ctctctataa catcatttag gggagtccag 7740 gttgtcaatc ggtcacagag aaagaagcat cttcattcct gcctttcctc aatacaca 7800 ccatctctgc actacttcct cagaacaatc ccagcagtct gggaggtact ttacacaatt 7860 tagcacaga gcaactgcct gtccctgctg ctagtttaaa catgaacctt ccaggtagcc 7920 tcttcttaaa atatacagcc ccagctgggc atgatggctc atgcctgtaa tcctagcact 7980 ttgggaggct gaggcgggtg gattacttga ggtcaggagt tcgagaccac cctggccaac 8040 atggtgaaac cccatctcta gtaaaaatac aaaaattagc tgactttggt ggcacatgcc 8100 tgtaatccca gctacttggg aagctgagac agaagagtca cttgaacctg ggaaacagag 8160 gttgcagtga gccaagatcg caccactgca ctccaccctg gatgacagac tgaaccccat 8220 ctcaaaaaat taaaataaa taaaataaaa taactatata tatagcccca gctggaaatt 8280 catttctttc ccttatttta cccattgttt tctcatacag gttataagca catgtccttg 8340 gccctgaata ggactggcag aagcattgtg tactcctgtg agtggcctct ttatatgtgg 8400 ccctttcaaa aggtgagata gtgagcccag aatccaatag aactgtactg atagatagaa 8460 cttgacaaca aaggaaacca aggtctcctt caaagtccaa cgttacttac tatcatccta 8520 ccatctctcc caggttccaa cacttctca ccatccccac tgctgtaatt atagcctaag 8580 ctaccatcac ctggaaagtc atccttgtgt cttccccttt atttcaccat tcatgtcctg 8640 tctatcaaca gtccttccac cagtatctct aaaatatctc ctgaatcagc cacttcctt 8700 ccatcttcac tacatgcacc ctggccttcc aagctactat cggctctcaa ccagactgct 8760 gggaccacct gatctctctg cttccactct gtctcaaccc ccatctattt tccaagcagc 8820 actagagtta tcatattaaa atgtaaatat cagttttttt tttaaagaaa aaaaccctga 8880 gacttaacag agttataaaa aatataaatg tcatcatcag ttccctgctt aaaaccctta 8940 actcgcttcc aattgcactt ggaatgaaac caaactgcac tgatccagcc cttgcctgcc 9000 tccccaaagt ccaaggggtc atggctcttt ccctggctac actggttttc tttctgtccc 9060 tcaacactgc aagcctattg ctgccccagg gcctttacac ttgctttttt tctgcctaga 9120 acagttcttc cccaaagatt tttaaagggc cgggctcctt aacattgaag tcgcagacca 9180 aacgccacat atgcagacag ttcttctcta actactttaa aatagccctc tgtccattca 9240 ttcttcatca cattaacctg tttaattttc ttctcagagc tccacactat ttggaagtat 9300 ttgttgactt gttaccatgt ctccccacta gagtgtaagt ttcatgaggg cagggacctt 9360 gtctgacttt gactgtatct ctcgcatatg gttaagtgtt aaatagttat ttatggaatg 9420 aatccctatt attccctcat tatctctgca aaatagtctt ttttctcaac atcttaaacc 9480 tgatatccca cctgcctatc tacaaacttt ttttttgcga cagagtctca ctgtcaccca 9540 ggctagagtg cagtggcgcc atctcggctc actgcaacct ccgcctccg ggttaagcg 9600 attctcttgc ctcagcctcc cagtagctgg gattataggc gtgcgctacc acatctggct 9660 aatttttgta tttttagtag agatggttc accatgttgg ccaggcttgt ctcgaactcc 9720 tgacctcaga tgatccacct gcctcggcct cccaaagtgc tgggattaca ggcatgagcc 9780 accgtgccca gcctctacaa actttttatt ccattaacaa actatatgct gggatttaag 9840 ttttcttaat acttgatgga gtcctatgta atttcgagc ttttaatttt actaagacca 9900 ttttagttct gattatagaa gtaaattaac tttaagggat ttcaagttat atggcctact 9960 tctgaagcaa acttcttaca gtgaaaattc attataaggg tttagacctc cttatggaga 10020 cgttcaatct gtaaactcaa gagaaggcta caagtgcctc ctttaaactg ttttcatctc 10080 acaaggatgt tagtagaaag taaacagaag agtcatatct gttttcacag cccaattata 10140 cagaaatccg acagtactgc aatcactggc gaaattttgc tgacattgat gattcctgga 10200 aaagtataaa gagtatcttg gactggacat cttttaacca ggagagaatt gttgatgttg 10260 ctggaccagg gggttggaat gacccagata tggtaaaaac ttgagccctc cttgttcaag 10320 accctgcggt aggcttgttt cctattttga cattcaaggt aaatacaggt aaagttcctg 10380 ggaggaggct ttatgtgaga gtacttagag caggatgctg tggaaagtgg tttctccata 10440 tgggtcatct aggtaacttt aagaatgttt cctcctctct tgtttgaatt atttcattct 10500 ttttctcagt tagtgattgg caactttggc ctcagctgga atcagcaagt aactcagatg 10560 gccctctggg ctatcatggc tgctccttta ttcatgtcta atgacctccg acacatcagc 10620 cctcaagcca aagctctcct tcaggataag gacgtaattg ccatcaatca ggaccccttg 10680 ggcaagcaag ggtaccagct tagacaggta aataagagta tatattttaa gatggcttta 10740 tatacccaat accaactttg tcttgggcct aaatctattt ttttcccttg ctcttgatgt 10800 tactatcagt aataaagctt cttgctagaa acattacttt atttccaaaa taatgctaca 10860 ggatcattt aatttttcct acaagtgctt gatagttctg acattaagaa tgaatgccaa 10920 actaacaggg ccacttatca ctagttgcta agcaaccaca ctttcttggt ttttcaggga 10980 gacaactttg aagtgtggga acgacctctc tcaggcttag cctgggctgt agctatgata 11040 aaccggcagg agattggtgg acctcgctct tataccatcg cagttgcttc cctgggtaaa 11100 ggagtggcct gtaatcctgc ctgcttcatc acacagctcc tccctgtgaa aaggaagcta 11160 gggttctatg aatggacttc aaggttaaga agtcacataa atcccacagg cactgttttg 11220 cttcagctag aaaatacaat gcagatgtca ttaaaagact tactttaaaa tgtttatttt 11280 attgccaact actacttcct gtccacctttt ttctccattc actttaaaag ctcaaggcta 11340 ggtggctcat gcctgtaatc ccagcacttt gggaggctga ggcgggcaga tcacctgagg 11400 tcgggacttt gagacccgcc tggacaacat ggtgaaaccc catttctaat aaaataataa 11460 aaattagcca ggtgtggtgg cgcacctgtg gtcccagcta ctctgggggc tgaggcatga 11520 gaatcgcttg aacccgggag tggaggttgc attgagctga gatcatgcca cctcactcca 11580 gcctgggcaa caaagattcc atctcaaaaa aaaaaaaaa gccaggcaca gtggctcatg 11640 cctggaatcc cagcactttt ggaagctgag gcaggcagat cacttgaggt taggatttca 11700 agaccagcct ggctaacata gtaaagccct gtctctacta aaaatacaaa aattagccag 11760 gtatggtggc gagcttctgt agccccagct actcaggaga ctgaggcagg agaatcactt 11820 gaacccggga agtggggggg tgcagtgacc caagatcacg ccactgcatt ccagcctggg 11880 11940. 11940. 11940. 11940. 11940. 11940. 11940. 11940. 11940 aagtttaac tttaggaata aaactatta acccgtattt actcatccag atacccaccc cccttgttga gattctctcc caattatcaa aatgtgtagc atatttaact accaagagct aaacatcatt aagactgaaa tgtattaaga aggatgtata ggccaggcac ggtgtctcac gcctgtaatc ccaacacttt gggaggccaa gtcgggcgga tcacgaggtc aggagatgga gaccatcctg gccaacatgg tgaaccccc tctctacta aatacaaaa attagccagg caggtggcag gcacctgtaa tcccagctac tccagaggct caggcaggac aatcacttga acctgggagg cagaggctgc agtgagctga ggttgtacca attgcactcc agcctaggta acgagcaaca ctccatctca aaaaaagaaa aaaaaaaaga tgtataattt ggaactgtta agaggcattt tag 12436 <210> 2 <211> 429 <212> PRT <213> Homo sapiens <400> 2 Met Gln Leu Arg Asn Pro Glu Leu His Leu Gly Cys Ala Leu Ala Leu 1 5 10 15 Arg Phe Leu Ala Leu Val Ser Trp Asp Ile Pro Gly Ala Arg Ala Leu 20 25 30 Asp Asn Gly Leu Ala Arg Thr Pro Thr Met Gly Trp Leu His Trp Glu 35 40 45 Arg Phe Met Cys Asn Leu Asp Cys Gln Glu Glu Pro Asp Ser Cys Ile 50 55 60 Ser Glu Lys Leu Phe Met Glu Met Ala Glu Leu Met Val Ser Glu Gly 65 70 75 80 Trp Lys Asp Ala Gly Tyr Glu Tyr Leu Cys Ile Asp Asp Cys Trp Met 85 90 95 Ala Pro Gln Arg Asp Ser Glu Gly Arg Leu Gln Ala Asp Pro Gln Arg 100 105 110 Phe Pro His Gly Ile Arg Gln Leu Ala Asn Tyr Val His Ser Lys Gly 115 120 125 Leu Lys Leu Gly Ile Tyr Ala Asp Val Gly Asn Lys Thr Cys Ala Gly 130 135 140 Phe Pro Gly Ser Phe Gly Tyr Tyr Asp Ile Asp Ala Gln Thr Phe Ala 145 150 155 160 Asp Trp Gly Val Asp Leu Leu Lys Phe Asp Gly Cys Tyr Cys Asp Ser 165 170 175 Leu Glu Asn Leu Ala Asp Gly Tyr Lys His Met Ser Leu Ala Leu Asn 180 185 190 Arg Thr Gly Arg Ser Ile Val Tyr Ser Cys Glu Trp Pro Leu Tyr Met 195 200 205 Trp Pro Phe Gln Lys Pro Asn Tyr Thr Glu Ile Arg Gln Tyr Cys Asn 210 215 220 His Trp Arg Asn Phe Ala Asp Ile Asp Asp Ser Trp Lys Ser Ile Lys 225 230 235 240 Ser Ile Leu Asp Trp Thr Ser Phe Asn Gln Glu Arg Ile Val Asp Val 245 250 255 Ala Gly Pro Gly Gly Trp Asn Asp Pro Asp Met Leu Val Ile Gly Asn 260 265 270 Phe Gly Leu Ser Trp Asn Gln Gln Val Thr Gln Met Ala Leu Trp Ala 275 280 285 Ile Met Ala Ala Pro Leu Phe Met Ser Asn Asp Leu Arg His Ile Ser 290 295 300 Pro Gln Ala Lys Ala Leu Leu Gln Asp Lys Asp Val Ile Ala Ile Asn 305 310 315 320 Gln Asp Pro Leu Gly Lys Gln Gly Tyr Gln Leu Arg Gln Gly Asp Asn 325 330 335 Phe Glu Val Trp Glu Arg Pro Leu Ser Gly Leu Ala Trp Ala Val Ala 340 345 350 Met Ile Asn Arg Gln Glu Ile Gly Gly Pro Arg Ser Tyr Thr Ile Ala 355 360 365 Val Ala Ser Leu Gly Lys Gly Val Ala Cys Asn Pro Ala Cys Phe Ile 370 375 380 Thr Gln Leu Leu Pro Val Lys Arg Lys Leu Gly Phe Tyr Glu Trp Thr 385 390 395 400 Ser Arg Leu Arg Ser His Ile Asn Pro Thr Gly Thr Val Leu Leu Gln 405 410 415 Leu Glu Asn Thr Met Gln Met Ser Leu Lys Asp Leu Leu 420 425 <210> 3 <211> 1290 <212> DNA <213> Homo sapiens <400> 3 atgcagctga ggaatcccga gctccacctg ggctgtgctc tggctctgcg gttcctggcc 60 ctcgtgtcct gggacatccc tggcgctagg gccctcgata acggactggc ccggaccccc 120 acaatgggat ggctccactg ggaaaggttc atgtgcaatc tggactgtca ggaggaaccc 180 gactcctgca tcagcgaaaa gctcttcatg gagatggccg agctgatggt gagcgaggggc 240 tggaaggacg ccggctacga gtatctgtgc atcgatgact gctggatggc ccctcaaagg 360. gactccgaag gcaggctgca ggctgatccc caaaggtttc cccacggaat ccggcagctc gccaactacg tgcattccaa gggcctcaag ctcggcatct acgccgacgt gggcaacaaa acatgcgccg gattccccgg cagcttcggc tactacgaca tcgacgccca gacattcgct gattggggag tggacctgct gaagttcgac ggctgttact gcgattccct ggaaaacctg 540 gccgacggct acaaacacat gtccctcgcc ctgaaccgga caggcaggtc catcgtgtac agctgcgagt ggcccctgta catgtggcct ttccagaagc ccaactacac agagatcagg 660 cagtactgca accactggag gaacttcgct gacatcgacg actcctggaa gagcatcaag agcatcctgg actggaccag cttcaaccag gagaggatcg tggacgtggc tggacccgga ggctggaacg accccgatat gctggtgatt ggcaacttcg gactgagctg gaaccagcag gtgacccaga tggccctgtg ggccattatg gccgctcccc tgttcatgtc caacgacctg 900 aggcacatca gcccccaggc caaggctctg ctgcaggaca aggatgtgat cgccatcaac 960 caggaccccc tgggcaagca gggctaccag ctgaggcaag gagataactt cgaggtgtgg 1020 gagaggcccc tgtccggact ggcttgggcc gtggccatga tcaatcggca ggagatcggc 1080 ggaccccggt cctacaccat tgctgtggcc agcctgggaa aaggagtcgc ctgcaacccc 1140 gcctgcttca ttacccagct gctccccgtg aagcggaagc tgggcttcta tgagtggacc 1200 agcaggctga ggtcccatat caatcctacc ggcaccgtcc tcctccagct cgagaatacc 1260 atgcagatga gcctcaagga tctgctgtga 1290

Claims

1. A method for reducing the risk of a composite clinical outcome (CCO) in a patient with Fabry disease, the method comprising administering to the patient an effective amount of a formulation containing migrastat or a salt thereof every other day for at least 18 months, wherein the effective amount is about 100 mg to about 150 mg free base equivalent (FBE).

2. The method according to claim 1, wherein the CCO includes renal events, cardiac events, cerebrovascular events, and death.

3. The aforementioned renal events were reduced by eGFR < 90 mL / min / 1.73 m² relative to baseline. ２ Having eGFR ＣＫＤ－ＥＰＩ Decrease ≥ 15 mL / min / 1.73 m ２ The method according to claim 2, comprising one or more of the following: having an elevated protein of ≥300 mg relative to baseline and an increase of ≥33% in 24-hour urinary protein.

4. The method according to claim 2 or 3, wherein the cardiac event includes one or more of the following: myocardial infarction, unstable angina, a new symptomatic arrhythmia requiring an antiarrhythmic drug, DC cardioversion, pacemaker or defibrillator implantation, or congestive heart failure [New York Association Class III or IV].

5. The method according to any one of claims 2 to 4, wherein the cerebrovascular event includes one or more strokes or transient ischemic attacks.

6. The method according to any one of claims 1 to 5, wherein the migalastat or a salt thereof enhances α-galactosidase A activity.

7. The method according to any one of claims 1 to 6, wherein the patient is administered approximately 123 mg FBE of migalastat or a salt thereof every other day.

8. The method according to any one of claims 1 to 7, wherein the patient is administered approximately 123 mg of migalastat free base every other day.

9. The method according to any one of claims 1 to 7, wherein the patient is administered approximately 150 mg of migalastat hydrochloride every other day.

10. The method according to any one of claims 1 to 9, wherein the preparation includes an oral dosage form.

11. The method according to claim 10, wherein the oral dosage form includes tablets, capsules, or solutions.

12. The method according to any one of claims 1 to 11, wherein migalastat or a salt thereof is administered for at least three years.

13. The method according to any one of claims 1 to 12, wherein migalastat or a salt thereof is administered for at least four years.

14. The method according to any one of claims 1 to 13, wherein the incidence of CCO in the patient group during 18 months of migrastat therapy is less than 1.0 / patient-year.

15. The method according to any one of claims 1 to 14, wherein the incidence of CCO in the patient group during 18 months of migrastat therapy is less than 0.5 / patient-year.

16. The method according to any one of claims 1 to 15, wherein the patient is male.

17. The method according to any one of claims 1 to 15, wherein the patient is female.

18. The method according to any one of claims 1 to 17, wherein the patient is a patient who has not previously undergone enzyme replacement therapy (ERT).

19. The method according to any one of claims 1 to 17, wherein the patient is a patient who has undergone ERT.

20. The method according to any one of claims 1 to 19, wherein the patient has a HEK assay-applicable mutation in α-galactosidase A.

21. The method according to claim 20, wherein the mutation is disclosed in a pharmacological reference table.

22. The method according to claim 21, wherein the pharmacological reference table is provided on the formulation label of a migrastat formulation approved for the treatment of Fabry disease.

23. The method according to claim 22, wherein the pharmacological reference table is provided on the formulation label of GALAFOLD®.

24. The method according to claim 22, wherein the pharmacological reference table is provided on a website.

25. The method according to claim 24, wherein the website is one or more of www.galafoldamenabilitytable.com or www.fabrygenevariantsearch.com.

26. A method for determining gastrointestinal (GI) outcomes in patients with Fabry disease, wherein the method is To determine the severity of disease-related GI symptoms in the aforementioned patient, To determine the frequency of bowel movements of the aforementioned patient, To determine the frequency of diarrhea in the aforementioned patient, To determine the nature of the diarrhea in the aforementioned patient, Methods that include...

27. The method according to claim 26, wherein determining the severity of disease-related GI symptoms in the patient includes determining the severity of one or more of the following: flatulence, stomach pain, cramps, nausea, acid reflux, heartburn, constipation, or diarrhea.

28. The method according to claim 26 or 27, wherein determining the severity of disease-related GI symptoms in the patient includes determining the severity of one or more of the worst flatulence over a period of time, the worst stomach pain over a period of time, the worst convulsions over a period of time, the worst nausea over a period of time, the worst nausea over a period of time, or the worst nausea over a period of time.

29. The method according to any one of claims 26 to 28, wherein the GI outcome is determined based on a 24-hour period.

30. The method according to any one of claims 26 to 29, wherein the GI outcome is determined based on patient-reported symptoms.

31. The method according to any one of claims 26 to 30, wherein each item is determined using a score on a scale of 0 to 10.

32. A method for evaluating therapeutic treatments for Fabry disease, wherein the method is Determining the GI outcome according to any one of claims 26 to 31 at baseline, Determining the GI outcome described in any one of claims 26 to 31 after a certain period of treatment, Comparing the baseline GI outcome with the GI outcome after the treatment during the aforementioned period, Methods that include...

33. A method for treating Fabry disease, wherein the method is Determining the GI outcome described in any one of claims 26 to 31 to obtain a first GI outcome score, Initiating or continuing treatment for Fabry disease for a certain period of time, After the treatment period described above, the GI outcome described in any one of claims 26 to 31 is determined to obtain a second GI outcome score, Comparing the first GI outcome score with the second GI outcome score, Methods that include...

34. The method according to claim 32 or 33, wherein the therapeutic treatment includes enzyme replacement therapy (ERT).

35. The method according to claim 32 or 33, wherein the therapeutic treatment includes substrate reduction therapy.

36. The method according to claim 32 or 33, wherein the therapeutic treatment includes gene therapy.

37. The method according to claim 32 or 33, wherein the therapeutic treatment includes pharmacological chaperone therapy.

38. The method according to claim 37, wherein the pharmacological chaperone therapy comprises the administration of an effective amount of migalastat or a salt thereof.

39. The method according to claim 38, wherein the migalastat or a salt thereof is administered every other day.

40. The method according to claim 39, wherein the effective amount is approximately 100 mg to approximately 150 mg free base equivalent (FBE).

41. A method for evaluating therapeutic treatments for Fabry disease, wherein the method is Determining one or more parameters in a patient population treated with the aforementioned therapeutic therapy, wherein the one or more parameters include one or more of the occurrence of Fabry signs and symptoms, renal parameters, and cardiac parameters. Determining one or more of the above parameters in a population of untreated patients, Methods that include...

42. The method according to claim 41, wherein the Fabry sign and symptoms include one or more of the following: acrosensory deficiency, gastrointestinal (GI) sign and symptoms, hearing loss, keratoid, angiokeratomas, decreased sweating, pulmonary changes, lymphedema, or brain MRI changes.

43. The aforementioned renal parameters are eGFR ＣＫＤ－ＥＰＩ The method according to claim 41 or 42, comprising one or more of the following: creatinine levels, urinary protein levels, or the occurrence of detectable urinary protein.

44. The method according to any one of claims 41 to 43, wherein the cardiac parameters include one or more of the left ventricular mass index (LVMi) or the occurrence of left ventricular hypertrophy.

45. The method according to any one of claims 41 to 44, further comprising determining one or more of the parameters in a patient population treated with different therapeutic therapies for Fabry disease.

46. The method according to any one of claims 41 to 45, further comprising determining the patient age in each of the aforementioned patient populations.

47. The method according to any one of claims 41 to 46, further comprising determining the patient genotype in each of the patient populations.

48. The method according to any one of claims 41 to 47, further comprising determining the gender of the patient in each of the aforementioned patient populations.

49. The method according to any one of claims 41 to 48, wherein the therapeutic treatment includes enzyme replacement therapy (ERT).

50. The method according to any one of claims 41 to 48, wherein the therapeutic treatment includes substrate reduction therapy.

51. The method according to any one of claims 41 to 48, wherein the therapeutic treatment includes gene therapy.

52. The method according to any one of claims 41 to 48, wherein the therapeutic treatment includes pharmacological chaperone therapy.

53. The method according to claim 52, wherein the pharmacological chaperone therapy comprises the administration of an effective amount of migalastat or a salt thereof.

54. The method according to claim 53, wherein the migalastat or a salt thereof is administered every other day.

55. The method according to claim 54, wherein the effective amount is approximately 100 mg to approximately 150 mg free base equivalent (FBE).

56. The method according to any one of claims 52 to 55, further comprising determining one or more of the parameters in a patient population treated with ERT.

57. The method according to any one of claims 41 to 56, wherein the one or more parameters are determined over a period of at least one year.

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