Treatment plan for Pompe disease

Abstract

To provide medicines useful for treating Pompe disease. [Solution] A pharmaceutical is provided for treating Pompe disease in a subject, the pharmaceutical comprising 1-deoxynojirimycin and recombinant human α-glucosidase having a molecular weight of about 110 kDa, and for administering a single dose of about 250 mg to about 600 mg of 1-deoxynojirimycin and an effective amount of α-glucosidase enzyme replacement therapy agent.

Description

[Technical Field]

[0001] Cross-reference of related applications This application claims the benefits of U.S. Provisional Patent Application No. 61 / 642,311 filed 3 May 2012, U.S. Provisional Patent Application No. 61 / 664,011 filed 25 June 2012, U.S. Provisional Patent Application No. 61 / 697,179 filed 5 September 2012, U.S. Provisional Patent Application No. 61 / 749,132 filed 4 January 2013, and U.S. Provisional Patent Application No. 61 / 749,234 filed 4 January 2013, each claiming priority and each incorporated herein by whole by reference.

[0002] This application provides a dosing plan and schedule for the use of 1-deoxynojirimycin and enzyme replacement therapy for the treatment of Pompe disease. [Background technology]

[0003] Mutations in the lysosomal enzyme acid α-glucosidase (GAA) alter lysosomal glycogen catabolism, leading to Pompe disease, also known as glycogen storage disease type II or acid maltase deficiency. GAA normally hydrolyzes glycogen at α-1,4 and α-1,6 links to provide glucose. Mutations in the GAA gene result in a deficiency or absence of GAA activity, which leads to glycogen accumulation. Glycogen accumulation is thought to cause progressive muscle disease throughout the body, affecting various body tissues, particularly the heart, skeletal muscle, liver, and nervous system. In some cases of Pompe disease, a decrease in 110-kDa GAA precursor protein levels is observed, while in others, normal levels of 110-kDa precursor protein are synthesized but not processed into mature, properly glycosylated 76- and 70-kDa GAA forms.

[0004] Pompe disease was historically divided into three main phenotypic forms (infant, adolescent, and adult-onset). However, the disease is now recognized as a range of phenotypes, from more severe early-onset forms to relatively less severe late-onset forms. The disease is clinically heterogeneous in terms of age of onset, range of affected organs, and rate of progression. The early-onset form of the disease is the most severe, most rapidly progressing, and glycogen storage is most prevalent in the myocardium, skeletal muscle, and liver tissue. This form of the disease is generally characterized by musculoskeletal, pulmonary, gastrointestinal, and cardiac symptoms. Death due to cardiac and respiratory failure usually occurs between 1 and 2 years of age. The late-onset form of the disease usually begins in childhood or adulthood, has a slower rate of progression, and usually does not have cardiac complications. This phenotype is characterized by musculoskeletal and pulmonary symptoms leading to progressive weakness and respiratory failure. The symptoms tend to be relatively mild, and glycogen storage is less pronounced in later-onset stages of the disease than in earlier stages, leading to longer survival times. Death usually results from cardiac and respiratory failure.

[0005] Current treatment for Pompe disease includes symptomatic treatment for cardiac and respiratory symptoms. There are no approved treatments for the underlying genetic defect. The use of alternative GAAs, alglucosidase α (Myozyme® (Genzyme Corporation) and Lumizyme® (Genzyme Corporation)) is approved by the FDA in the United States. However, clinical evaluations of enzyme replacement therapy (ERT) to replace GAA deficiency in infant Pompe patients have shown only moderate success in improving cardiac and skeletal function (Klinge et al., Neurodiatrics. 2005;36(1):6-11). Recombinant GAAs have been shown to be more effective in restoring cardiomyopathy compared to skeletal muscle myopathy (Raben et al., Mol). (Ther. 2005;11(1):48-56), this is largely because recombinant enzymes cannot penetrate connective tissue. Treatment methods for Pompe disease using recombinant GAA are described in detail in U.S. Patent No. 6,537,785 granted to Canfield. One of the main complicating factors with ERT is obtaining and maintaining therapeutically effective levels of enzyme, because the injected enzyme is rapidly degraded.

[0006] 1-Deoxynojirimycin and its salts, including 1-deoxynojirimycin hydrochloride, act as pharmacological chaperones for mutant GAA by selectively binding to the enzyme, thereby increasing its stability and helping the enzyme fold into its correct three-dimensional shape. This stabilization of GAA enables cellular quality control mechanisms to recognize that the enzyme is properly folded, thus increasing the transport of the enzyme to lysosomes and enabling the enzyme to perform its intended biological function, namely glycogen metabolism. As a result of restoring proper transport of GAA from the ER to lysosomes, 1-deoxynojirimycin hydrochloride also reduces the accumulation of misfolded proteins in the ER, which can alleviate cellular stress and some inflammatory responses that may be contributing factors in Pompe disease. Multiple in vitro and in vivo preclinical and clinical trials of 1-deoxynojirimycin hydrochloride have been conducted. 1-Deoxynojirimycin hydrochloride has been shown to increase the amount of intracellular GAA protein and improve the transport of mutant enzymes to lysosomes. [Overview of the project] [Means for solving the problem]

[0007] This application provides a dosage plan and schedule for the use of 1-deoxynojirimycin and enzyme replacement therapy for the treatment of Pompe disease. In a given embodiment, this application provides a dosage plan and schedule for the use of 1-deoxynojirimycin hydrochloride and alglucosidase α for the treatment of Pompe disease.

[0008] In one embodiment, the method comprises administering approximately 25 mg to approximately 1000 mg of 1-deoxynojirimycin and an effective amount of GAA enzyme replacement therapy to a patient in need. 1-deoxynojirimycin may be administered before, after, or concurrently with the GAA enzyme replacement therapy. In one embodiment, the patient fasts for a period beginning approximately 0.5 to approximately 4 hours before the administration of 1-deoxynojirimycin and ending approximately 0.5 to approximately 4 hours later. In a further embodiment, the patient fasts for at least approximately 2 hours before the administration of 1-deoxynojirimycin and for at least approximately 2 hours after the administration.

[0009] In another embodiment, 1-deoxynojirimycin is administered concurrently with or approximately 4 hours before GAA enzyme replacement therapy (T=-4 hours to T=0 hours). In yet another embodiment, 1-deoxynojirimycin is administered approximately 2 hours before the administration of GAA enzyme replacement therapy.

[0010] In certain embodiments, 1-deoxynojirimycin is 1-deoxynojirimycin hydrochloride. In one embodiment, the GAA enzyme replacement therapy is rhGAA. In further embodiments, the GAA enzyme replacement therapy is alglucosidase α.

[0011] In one embodiment, 1-deoxynojirimycin is administered as an adjunct to GAA enzyme replacement therapy. In another embodiment, 1-deoxynojirimycin and GAA enzyme replacement therapy are administered as a combination therapy.

[0012] In certain embodiments, the amount of 1-deoxynojirimycin administered according to the method described above is approximately 50 mg to approximately 600 mg. In one embodiment, the amount of 1-deoxynojirimycin administered is selected from 50 mg, 100 mg, 250 mg, and 600 mg.

[0013] In certain embodiments, 1-deoxynojirimycin is administered immediately before or concurrently with the administration of GAA enzyme replacement therapy. In alternative embodiments, the patient receives a second dose of 1-deoxynojirimycin between the administration of GAA enzyme replacement therapy and approximately 4 hours later.

[0014] In a given embodiment, 1-deoxynojirimycin is administered every 1 to 4 weeks to patients also receiving GAA enzyme replacement therapy. In a further embodiment, 1-deoxynojirimycin is administered every 12 to 16 days to patients also receiving GAA enzyme replacement therapy. In a given embodiment, GAA enzyme replacement therapy is administered every 14 days to patients also receiving 1-deoxynojirimycin as part of an adjunct therapy.

[0015] The present invention also provides a kit for the treatment of Pompe disease in subjects, the kit comprising approximately 25 mg to approximately 1000 mg of 1-deoxynojirimycin and an effective amount of GAA enzyme replacement therapy. In a given embodiment, the amount of 1-deoxynojirimycin in the kit is selected from 50 mg, 100 mg, 250 mg, and 600 mg.

[0016] This application provides a dosing plan and schedule for the use of 1-deoxynojirimycin (1-DNJ) derivatives and enzyme replacement therapy for the treatment of Pompe disease.

[0017] In one embodiment, the method comprises administering about 25 mg to about 1000 mg of a 1-deoxynojirimycin derivative and an effective amount of GAA enzyme replacement therapy to a patient in need. The 1-deoxynojirimycin derivative may be administered before, after, or concurrently with the GAA enzyme replacement therapy. In one embodiment, the patient fasts for a period beginning about 0.5 to about 4 hours before administration of the 1-deoxynojirimycin derivative and ending about 0.5 to about 4 hours later. In a further embodiment, the patient fasts for at least about 2 hours before administration of the 1-deoxynojirimycin derivative and for at least about 2 hours after administration.

[0018] In another embodiment, the 1-deoxynojirimycin derivative is administered concurrently with or approximately 4 hours before GAA enzyme replacement therapy (T=-4 hours to T=0 hours). In yet another embodiment, the 1-deoxynojirimycin derivative is administered approximately 2 hours before the administration of GAA enzyme replacement therapy.

[0019] In some embodiments, the 1-deoxynojirimycin derivative is (2R,3R,4R,5S)-1-butyl-2-(hydroxymethyl)piperidine-3,4,5-triol, i.e., miglustat, i.e., N-butyl DNJ. In one embodiment, the GAA enzyme replacement therapy is rhGAA. In further embodiments, the GAA enzyme replacement therapy is alglucosidase α.

[0020] In one embodiment, the 1-deoxynojirimycin derivative is administered as an adjunct to GAA enzyme replacement therapy. In another embodiment, the 1-deoxynojirimycin derivative and GAA enzyme replacement therapy are administered as a combination therapy.

[0021] In certain embodiments, the amount of 1-deoxynojirimycin derivative administered according to the method described above is about 50 mg to about 600 mg. In one embodiment, the amount of 1-deoxynojirimycin derivative administered is selected from 50 mg, 100 mg, 250 mg, and 600 mg.

[0022] In certain embodiments, the 1-deoxynojirimycin derivative is administered immediately before or concurrently with the administration of the GAA enzyme replacement therapy. In alternative embodiments, the patient receives a second dose of the 1-deoxynojirimycin derivative between the administration of the GAA enzyme replacement therapy and approximately 4 hours later.

[0023] In certain embodiments, the 1-deoxynojirimycin derivative is administered to a patient also receiving GAA enzyme replacement therapy every 1 to 4 weeks. In further embodiments, the 1-deoxynojirimycin derivative is administered to a patient also receiving GAA enzyme replacement therapy every 12 to 16 days. In certain embodiments, GAA enzyme replacement therapy is administered every 14 days to a patient who is also administered a 1-deoxynojirimycin derivative as an adjuvant combination therapy.

[0024] In a further embodiment of the claimed method, the 1-DNJ derivative is selected from the group consisting of N-methyl-DNJ, N-butyl-DNJ, N-cyclopropylmethyl-DNJ, N-(2-(N,N-dimethylamido)ethyloxy-DNJ, N-4-t-butyloxycarbonyl-piperidnylmethyl-DNJ, N-2-R-tetrahydrofuranylmethyl-DNJ, N-2-R-tetrahydrofuranylmethyl-DNJ, N-(2-(2,2,2-trifluoroethoxy)ethyl-DNJ, N-2-methoxyethyl-DNJ, N-2-ethoxyethyl-DNJ, N-4-trifluoromethylbenzyl-DNJ, N-α-cyano-4-trifluoromethylbenzyl-DNJ, N-4-trifluoromethoxybenzyl-DNJ, N-4-n-pentoxybenzyl-DNJ and N-4-n-butoxybenzyl-DNJ, or C1-nonyl DNJ.

[0025] The present application also provides a kit for the treatment of Pompe disease in a subject, wherein the kit comprises from about 25 mg to about 1000 mg of a 1-deoxynojirimycin derivative and an effective amount of GAA enzyme replacement therapy. In certain embodiments, the amount of the 1-deoxynojirimycin derivative in the kit is selected from 50 mg, 100 mg, 250 mg and 600 mg. BRIEF DESCRIPTION OF THE DRAWINGS

[0026] [Figure 1A] It shows a composite graph of rhGAA plasma activity in 4 Cohort 1 subjects following the treatment described in Example 2. It shows rhGAA plasma activity after treatment with GAA ERT alone. [Figure 1B] This graph shows a composite of rhGAA plasma activity in four subjects from Cohort 1 who underwent the treatment described in Example 2. It shows rhGAA plasma activity after treatment with co-administration of GAA ERT and 50 mg 1-deoxynojirimycin hydrochloride. [Figure 2A] The mean rhGAA plasma activity in a cohort of four subjects treated with the procedure described in Example 2 is shown. [Figure 2B] The mean total rhGAA protein measured by Western blotting in four subjects of Cohort 1 who underwent the treatment described in Example 2 is shown. [Figure 3A] This graph shows a composite of rhGAA plasma activity in 6 subjects from Cohort 2 who underwent the treatment described in Example 2. It also shows rhGAA plasma activity after treatment with GAA ERT alone. [Figure 3B] This graph shows a composite of rhGAA plasma activity in 6 subjects from Cohort 2 who underwent the treatment described in Example 2. It shows rhGAA plasma activity after treatment with co-administration of GAA ERT and 100 mg 1-deoxynojirimycin hydrochloride. [Figure 4] This shows the mean rhGAA plasma activity in two cohorts of six subjects treated with the procedure. [Figure 5] The mean (SD) plasma 1-DNJ-HCl concentration-time profiles for cohorts 1 and 2, categorized by treatment, are shown. [Figure 6] The total plasma rhGAA protein concentration profiles of treated cohorts 1 and 2 subjects, measured by Western blotting, are shown. [Figure 7] This shows the urine Hex4 levels on the study day for cohorts 1 and 2, collected as part of the safety data. [Figure 8] This shows serum CPK levels on the study day for cohorts 1 and 2, collected as part of the safety data. [Figure 9A] This shows the combined plasma rhGAA activity for the three cohort subjects, broken down by treatment duration. [Figure 9B] This shows the combined plasma rhGAA activity for the three cohort subjects, broken down by treatment duration. [Figure 10A] This shows the mean (SD) plasma rhGAA activity for AT2220-010 in Cohort 1. [Figure 10B] This shows the mean (SD) plasma rhGAA activity for AT2220-010 in Cohort 2. [Figure 10C] This shows the mean (SD) plasma rhGAA activity for AT2220-010 in Cohort 3. [Figure 10D] This shows the mean (SD) plasma rhGAA activity for AT2220-010 in Cohort 4. [Figure 11] The AUC stick plot for plasma rhGAA activity in cohort 3 is shown. [Figure 12A] This shows muscle rhGAA activity from biopsies taken on day 3 of periods 1 and 2, and from baseline biopsies in optional follow-up, for subjects in Cohort 3. [Figure 12B] This shows muscle rhGAA activity from biopsies taken on days 7 of periods 1 and 2, and from baseline biopsies in optional follow-up, for subjects in Cohort 3. [Figure 13] The following shows an overview of compound muscle rhGAA activity as a result of treatment duration for subjects in cohorts 1-3. [Figure 14A] rhGAA activity in PBMCs (peripheral blood mononuclear cells): Composite data for 3 days after treatment for 3 subjects in the cohort. [Figure 14B] rhGAA activity in PBMCs (peripheral blood mononuclear cells): Composite data for 3 days after treatment for 3 subjects in the cohort. [Figure 15A] rhGAA activity in PBMCs: Composite data for cohort 3 subjects on day 7 after treatment. [Figure 15B] rhGAA activity in PBMCs: Composite data for cohort 3 subjects on day 7 after treatment. [Figure 16A] The composite and semilog plots of plasma AT2220 concentrations for Cohort 3 subjects are shown. [Figure 16B]The composite and semilog plots of plasma AT2220 concentrations for Cohort 3 subjects are shown. [Figure 17A] This shows the combined plasma rhGAA activity by treatment period for the four cohort subjects. [Figure 17B] This shows the combined plasma rhGAA activity by treatment period for the four cohort subjects. [Figure 18] The AUC stick plot for plasma rhGAA activity in cohort 4 is shown. [Figure 19] The following outlines the compound muscle rhGAA activity by treatment period for cohorts 1-4. [Figure 20] The images show MRI scans of the anterior (upper) and posterior (lower) thigh muscles during ERT. After one year, muscle mass in the anterior thigh decreased by 9.8%, muscle mass in the posterior thigh decreased by 11%, and intramuscular fat storage increased by +8.9% (6.6% subcutaneous fat). [Figure 21] The following shows a summary of rhGAA enzyme activity in terms of plasma area under the curve (AUC) for cohorts 1-4. [Figure 22] The following shows a summary of GAA enzyme activity in muscle tissue on day 3 for cohorts 2-4. [Figure 23] This study shows that the skeletal muscle distribution and half-life of N-butyl-DNJ (AT2221) are similar to those of 1-DNJ (AT2220); Cmax AT2220: 120 μM; AT2221: 140 μM. This was observed in 8-week-old wild-type C57BL / 6 mice administered an oral dose of 100 mg / kg of 1-DNJ or N-butyl-DNJ. Plasma and tissue samples were collected 0.5, 2, 4, 24, 48, 72, 96, 120, 144, and 168 hours after administration, and the presence of the drug was analyzed. Drug concentration in plasma is expressed as ng / ml. Drug concentration in tissue samples is expressed as ng / g. [Figure 23-2]This study shows that the skeletal muscle distribution and half-life of N-butyl-DNJ (AT2221) are similar to those of 1-DNJ (AT2220); Cmax AT2220: 120 μM; AT2221: 140 μM. This was observed in 8-week-old wild-type C57BL / 6 mice administered an oral dose of 100 mg / kg of 1-DNJ or N-butyl-DNJ. Plasma and tissue samples were collected 0.5, 2, 4, 24, 48, 72, 96, 120, 144, and 168 hours after administration, and the presence of the drug was analyzed. Drug concentration in plasma is expressed as ng / ml. Drug concentration in tissue samples is expressed as ng / g. [Figure 24] This study demonstrates that N-butyl-DNJ (AT2221) and 1-DNJ (AT2220) have similar effects on the pharmacokinetics of rhGAA. Eight-week-old GAAKO mice were administered rhGAA (10 mg / kg IV). Oral AT2220 or AT2221 (100 mg / kg) was administered 30 minutes prior to GAA (Myozyme) administration; plasma samples were collected before GAA administration and at 0.08, 0.25, 0.50, 0.75, 1, 2, 4, 8, and 24 hours after administration, and enzyme activity was determined. AT2220 and AT2221 increased the circulating half-life of rhGAA by at least approximately twofold. [Figure 25] These are Western blots of recombinant GAA in plasma 2, 8, and 24 hours after IV administration of GAA. [Figure 26] This study demonstrates that co-administration of DNJ or NB-DNJ with rhGAA has a similar effect on glycogen depletion. 12-week-old GAAKO mice were administered recombinant human GAA (Myozyme) 20 mg / kg iv every other week for 8 weeks. An oral dose of AT2220 or AT2221 (30 mg / kg) was administered 30 minutes before rhGAA Myozyme. Tissue was collected 21 days after the final dose of rhGAA, and glycogen (GAA substrate) levels were measured. n=5-mice / group; *p<0.05 vs untreated t-test; #p<0.05 vs Myozyme single t-test; dotted line indicates wild-type glycogen levels. Cmax ~40 μM after administration of 30 mg / kg AT2220 or AT2221; equivalent to approximately 600 mg in humans. [Figure 26-2] This study demonstrates that co-administration of DNJ or NB-DNJ with rhGAA has a similar effect on glycogen depletion. 12-week-old GAAKO mice were administered recombinant human GAA (Myozyme) 20 mg / kg iv every other week for 8 weeks. An oral dose of AT2220 or AT2221 (30 mg / kg) was administered 30 minutes before rhGAA Myozyme. Tissue was collected 21 days after the final dose of rhGAA, and glycogen (GAA substrate) levels were measured. n=5-mice / group; *p<0.05 vs untreated t-test; #p<0.05 vs Myozyme single t-test; dotted line indicates wild-type glycogen levels. Cmax ~40 μM after administration of 30 mg / kg AT2220 or AT2221; equivalent to approximately 600 mg in humans. [Figure 26-3] This study demonstrates that co-administration of DNJ or NB-DNJ with rhGAA has a similar effect on glycogen depletion. 12-week-old GAAKO mice were administered recombinant human GAA (Myozyme) 20 mg / kg iv every other week for 8 weeks. An oral dose of AT2220 or AT2221 (30 mg / kg) was administered 30 minutes before rhGAA Myozyme. Tissue was collected 21 days after the final dose of rhGAA, and glycogen (GAA substrate) levels were measured. n=5-mice / group; *p<0.05 vs untreated t-test; #p<0.05 vs Myozyme single t-test; dotted line indicates wild-type glycogen levels. Cmax ~40 μM after administration of 30 mg / kg AT2220 or AT2221; equivalent to approximately 600 mg in humans. [Modes for carrying out the invention]

[0027] This application provides a dosing plan and schedule for the use of 1-deoxynojirimycin and enzyme replacement therapy for the treatment of Pompe disease.

[0028] definition Pompe disease, also known as acid maltase deficiency, type II glycogen storage disorder (GSDII), or type II glycogen storage disease, is a genetic lysosomal storage disorder characterized by mutations in the GAA gene, which metabolizes glycogen. As used herein, this term includes the infantile, adolescent, and adult-onset forms of the disease.

[0029] Acid α-glucosidase (GAA) is a lysosomal enzyme that hydrolyzes α-1,4- and α-1,6-linked D-glucose polymers present in glycogen, maltose, and isomaltose. Alternative names include: glucoamylase; 1,4-α-D-glucan glucohydrolase; amyloglucosidase; γ-amylase; and exo-1,4-α-glucosidase and γ-amylase.

[0030] The term "rhGAA" refers to human recombinant acid α-glucosidase. Non-exclusive examples of rhGAA include alglucosidase α, and U.S. Patent Nos. 7,560,424 and 7,396,811 granted to Lebowitz et al. Examples include U.S. Patent Publication No. 2009 / 0203575, U.S. Patent Publication No. 2009 / 0029467, U.S. Patent Publication No. 2008 / 0299640, U.S. Patent Publication No. 2008 / 0241118, U.S. Patent Publication No. 2006 / 0121018 and U.S. Patent Publication No. 2005 / 0244400, U.S. Patent No. 7,423,135, U.S. Patent No. 6,534,300 and U.S. Patent No. 6,537,785; International Publication No. 2005 / 077093, and U.S. Patent Publication No. 2007 / 0280925 and U.S. Patent Publication No. 2004 / 0029779. These references are incorporated herein by reference in their entirety.

[0031] The term "AUC" represents a mathematical calculation that evaluates the total body exposure to a given drug over a given period of time. In a graph plotting the blood concentration after administration, the drug concentration variable is on the y-axis and time is on the x-axis. The area between the drug concentration curve and the x-axis at a given time interval is the AUC. AUC is used as a guide for administration planning and to compare the availability of different drugs in the body.

[0032] The term “C max This represents the maximum plasma concentration achieved after administration.

[0033] The terms “therapeutic effective dose” and “effective dose” refer to the amount of a particular pharmaceutical compound or composition sufficient to produce a beneficial therapeutic response. A beneficial therapeutic response may be any response that the user (e.g., clinician) recognizes as an effective response to treatment, including the aforementioned symptoms and surrogate clinical markers. Therefore, a therapeutic response is generally the remission of one or more symptoms of a disease or disorder, such as Pompe disease, as known in the art with respect to such disease.

[0034] Non-limiting examples of symptoms or surrogate clinical markers of Pompe disease include: decreased GAA tissue activity; cardiomyopathy; cardiomegaly; progressive muscle weakness, particularly in the trunk or lower extremities; severe hypotension; macroglossia (and in some cases, tongue protrusion); difficulty swallowing, suctioning, and / or feeding; respiratory failure; hepatomegaly (moderate); facial muscle flaccidity; loss of reflexes; exercise intolerance; exertional dyspnea; orthopnea; sleep apnea; morning headache; somnolence; lordosis and / or scoliosis; decreased deep tendon reflexes; low back pain; and impaired achievement of motor development milestones.

[0035] The phrase "pharmaceutically acceptable" refers to molecular entities and compositions that are physiologically acceptable and typically do not produce undesirable reactions when administered to humans. Preferably, as used herein, the term "pharmaceutically acceptable" means that it is approved by a federal or state regulatory authority for use in animals, and more specifically in humans, or is listed in the United States Pharmacopeia or other commonly recognized pharmacopoeias. The term "carrier" refers to a diluent, auxiliary, excipient, or vehicle with which the compound is administered. These pharmaceutical carriers may be sterile liquids such as water and oil. Particularly preferred as carriers for injectable solutions are water or aqueous saline solutions and aqueous solutions of dextrose and glycerol. Suitable pharmaceutical carriers are described in E.W. Martin's "Remington's Pharmaceutical Sciences," 18th edition or other editions, which are incorporated herein by reference in their entirety.

[0036] "1-Deoxynojirimycin" (DNJ) refers to (2R,3R,4R,5S)-2-hydroxymethyl-piperidine-3,4,5-triol. As used herein, references to "1-Deoxynojirimycin" or "DNJ" throughout this specification include both the free base and any pharmaceutically acceptable salt form thereof. The hydrochloride salt of DNJ is known as "1-Deoxynojirimycin hydrochloride" or "DNJ HCl".

[0037] "1-Deoxynojirimycin derivative" or "1-DNJ derivative" or "DNJ derivative" has the following structure: TIFF2026143438000001.tif43161(wherein R1 is H, or a linear or branched alkyl, cycloalkyl, alkenyl, alkoxyalkyl or aminoalkyl containing 1 to 12 carbon atoms, or an aryl, alkylaryl, heteroaryl or heteroarylalkyl containing 5 to 12 ring atoms, where R1 is optionally substituted with one or more -OH, -COOH, -Cl, -F, -CF3, -OCF3, -OC(=O)N-(alkyl)2; R2 is H; a linear or branched alkyl, cycloalkyl, alkenyl, alkylaryl or alkoxyalkyl group containing 1 to 9 carbon atoms, or an aryl group containing 5 to 12 carbon atoms, where R2 is optionally substituted with OH, -COOH, -CF3, -OCF3 or a heterocycle; This refers to a compound having (at least one of R1 and R2 is not H), or a pharmaceutically acceptable salt thereof.

[0038] In some embodiments, "1-deoxynojirimycin derivative" or "1-DNJ derivative" or "DNJ derivative" refers to (2R,3R,4R,5S)-1-butyl-2-(hydroxymethyl)piperidine-3,4,5-triol, i.e., miglustat, i.e., N-butyl-DNJ.

[0039] The term “adjuvant” or “adjuvant therapy” refers to any additional substance, treatment, or procedure used to enhance the effectiveness or safety of a primary substance, treatment, or procedure, or to otherwise promote or improve its performance.

[0040] The term "combination therapy" refers to any treatment that improves outcomes compared to the effects of each treatment when administered individually. Individual treatments in combination therapy may be administered simultaneously or sequentially.

[0041] Improvements include any enhancements to the effectiveness of various treatments that result in favorable outcomes compared to the outcomes achieved by the treatment when performed alone. Improved effects, and the determination of improved effects, can be measured by a variety of parameters, not limited to: transient parameters (e.g., length of treatment, recovery time, long-term effects of treatment, or reversibility of treatment); biological parameters (e.g., cell number, cell volume, cell composition, tissue volume, tissue size, tissue composition); spatial parameters (e.g., tissue strength, tissue size, or tissue accessibility); and physiological parameters (e.g., body contour, pain, discomfort, recovery time, or visible markers). Improved effects may include synergistic improvements, where the improved effect exceeds the additive effect of each treatment when performed alone. Alternatively, improved effects may include additive improvements, where the improved effect is substantially equal to the additive effect of each treatment when performed alone. The improved effect may include less than a synergistic effect, where the improved effect is lower than the additive effect of each treatment when each treatment is performed individually, but higher than the effect of each treatment when each treatment is performed individually.

[0042] The terms “about” and “approximately” generally mean an acceptable degree of error with respect to the measured quantity, in light of the nature or precision of the measurement. Generally, an 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, and especially in biological systems, the terms “about” and “approximately” may be an average value of the order of magnitude, preferably within 5 times a given value, and more preferably within 2 times a given value. The quantities provided herein are approximations unless otherwise specified.

[0043] Prescription and administration 1-Deoxynojirimycin may be administered in the form of a free base or a pharmacokinetically acceptable salt containing 1-deoxynojirimycin hydrochloride. 1-Deoxynojirimycin may be administered orally, for example, in the form of tablets, capsules, or liquids, or in a form suitable for any route of administration, including a sterile aqueous solution for injection. 1-Deoxynojirimycin may be administered orally in the form of tablets, capsules, obules, elixirs, liquids or suspensions, gels, syrups, mouthwashes, or a dry powder prepared before use with water or other suitable vehicle, along with flavoring and coloring agents, for optional rapid-, delayed-, altered-, sustained-, pulse-, or controlled-release applications. Solid compositions such as tablets, capsules, drops, lozenges, pills, boluses, powders, pastes, granules, bullets, or premix formulations may also be used. Solid and liquid compositions for oral use may be prepared according to methods well known in the art. These compositions may also include one or more pharmaceutically acceptable carriers and excipients, which may be in solid or liquid form. When the compound is formulated for oral administration, tablets or capsules may be prepared by conventional means with pharmaceutically acceptable excipients such as binders (e.g., pregelatinized 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 glycolate starch); or wetting agents (e.g., sodium lauryl sulfate). The tablets may be coated by methods well known in the art.

[0044] Pharmaceutically acceptable excipients also include, but are not limited to, disintegrants such as microcrystalline cellulose, lactose, sodium citrate, calcium carbonate, calcium hydrogen phosphate, and glycine, starch (preferably corn, potato, or tapioca starch), sodium glycolate starch, croscarmellose sodium, and certain complex silicates, as well as granulation binders such as polyvinylpyrrolidone, hydroxypropyl ethylcellulose (HPMC), hydroxypropylcellulose (HPC), sucrose, gelatin, and acacia. In addition, smoothing agents such as magnesium stearate, stearic acid, glyceryl behenate, and talc may also be included.

[0045] In certain embodiments, 1-deoxynojirimycin hydrochloride is formulated in white hard gelatin capsules together with magnesium stearate and pregelatinized starch.

[0046] Enzyme replacement therapy The currently approved treatment for Pompe disease is enzyme replacement therapy. Two alglucosidase α products are currently available for the treatment of Pompe disease: Myozyme® (Genzyme Corporation) and Lumizyme® (Genzyme Corporation). These two forms of ERT are intended to compensate for the patient's insufficient GAA activity through recombinant forms of enzymes administered intravenously. While ERT is effective in many situations, rhGAA has a short circulating half-life, low tissue uptake, and may elicit immune responses that negatively impact tolerance and efficacy.

[0047] The recommended dosage of alglucosidase α is 20 mg / kg body weight administered intravenously every two weeks. This infusion should be administered over a period of four hours.

[0048] 1-Deoxynojirimycin hydrochloride stabilizes rhGAA in vitro and in vivo. Binding of 1-deoxynojirimycin hydrochloride to rhGAA results in a significant concentration-dependent increase in the enzyme's physical stability in a neutral pH buffer, as measured by thermal denaturation and enzyme activity. In addition, the stability of rhGAA in human blood is significantly increased when incubated with 1-deoxynojirimycin hydrochloride, as measured by activity (half-life is approximately 6 hours in the absence of 1-deoxynojirimycin hydrochloride, while no measurable loss of enzyme activity occurred over 24 hours in the presence of 1-deoxynojirimycin hydrochloride).

[0049] In rats, bolus intravenous administration of 10 mg / kg rhGAA 30 minutes after a single oral administration of 3 or 30 mg / kg 1-deoxynojirimycin hydrochloride resulted in a 1.5-fold and 2.1-fold increase in the circulating half-life of rhGAA, as measured by activity and Western blotting. A similar effect on the circulating half-life of rhGAA was observed when 1-deoxynojirimycin hydrochloride (3 or 30 mg / kg PO) was administered to rats 30 minutes after a 1-hour intravenous infusion of rhGAA (10 mg / kg). Importantly, these doses of 1-deoxynojirimycin hydrochloride resulted in plasma exposure levels in rats equivalent to those that can be achieved after oral administration of 50 or 600 mg of 1-deoxynojirimycin hydrochloride in humans, respectively.

[0050] In GAA knockout mice, oral administration of 10, 100, or 1000 mg / kg of 1-deoxynojirimycin hydrochloride 30 minutes prior to bolus intravenous administration of rhGAA (10 mg / kg, once weekly for 1, 2, or 3 weeks) and 8, 16, and 24 hours later resulted in a significant and dose-dependent increase in tissue GAA levels, as measured by activity and Western blotting at 2, 4, and 7 days after administration. Co-administration of 10 mg / kg of 1-deoxynojirimycin hydrochloride (resulting in mouse exposure equivalent to that seen in humans after approximately 200 mg administration) resulted in higher maximal GAA increases in the heart, diaphragm, quadriceps, gastrocnemius, and triceps muscles, up to 2.5-fold, 2.3-fold, 2.2-fold, 4.0-fold, and 1.7-fold, respectively, compared to administration of rhGAA alone. Similar results were observed in wild-type C57BL / 6 mice after a single administration of 3, 30, or 100 mg / kg of 1-deoxynojirimycin hydrochloride 30 minutes prior to a single bolus intravenous administration of rhGAA (10 mg / kg). Importantly, doses of 3, 10, and 30 mg / kg of 1-deoxynojirimycin hydrochloride resulted in plasma exposure levels in mice equivalent to those that can be achieved after oral administration of 50, 150, or 600 mg of 1-deoxynojirimycin hydrochloride in humans, respectively.

[0051] The effects of single oral administration of 1-deoxynojirimycin hydrochloride on rhGAA tissue uptake were tested in GAA knockout mice. A single oral administration of 1-deoxynojirimycin hydrochloride (30 mg / kg every other week for 8 weeks; a total of 4 doses) was followed by a bolus intravenous administration of rhGAA (20 mg / kg) 30 minutes later, resulting in a significant increase in GAA activity, measured 7 days after the final infusion. The increase in GAA activity was approximately 2.1 times, 2.0 times, 1.5 times, 1.7 times, 1.6 times, and 2.0 times higher after co-administration of 1-deoxynojirimycin hydrochloride compared to rhGAA alone, in the heart, diaphragm, gastrocnemius muscle, quadriceps muscle, triceps muscle, and tongue, respectively. These data indicate that administration of 30 mg / kg of 1-deoxynojirimycin hydrochloride every other week for 8 weeks prior to rhGAA administration resulted in significantly higher rhGAA tissue uptake in GAA knockout mice compared to that observed after rhGAA administration alone.

[0052] The effect on tissue glycogen levels was evaluated by performing repeated rhGAA administration tests in GAA knockout mice. Single oral administration of 1-deoxynojirimycin hydrochloride (10 or 30 mg / kg once every week) followed by a bolus intravenous administration of rhGAA (20 mg / kg) 30 minutes after 8 weeks resulted in a dose-dependent decrease in tissue glycogen levels, measured 21 days after the final infusion. Glycogen reduction was approximately 2.3 times, 1.6 times, 2.6 times, 2.7 times, 2.2 times, 1.2 times, 1.4 times, and 1.3 times higher after co-administration of 1-deoxynojirimycin hydrochloride compared to rhGAA alone, in the heart, diaphragm, quadriceps, gastrocnemius, triceps, soleus, biceps, and tongue, respectively. Similar effects on tissue glycogen levels were observed after four bi-weekly oral administrations of 1-deoxynojirimycin hydrochloride (30 mg / kg) followed by a bolus intravenous administration of rhGAA (40 mg / kg) 30 minutes later. [Examples]

[0053] Example 1: Dosage plan for Pompe disease treatment using 1-deoxynojirimycin hydrochloride and alglucosidase α One of the objectives of this study is to evaluate the safety, efficacy, and pharmacokinetics of a treatment regimen including co-administration of 1-deoxynojirimycin hydrochloride (also known as AT2220) and alglucosidase α in patients with Pompe disease.

[0054] Another objective of this study is to evaluate the effect of various doses of 1-deoxynojirimycin hydrochloride on GAA activity. This will be assessed by measuring GAA activity and protein levels 3 and / or 7 days after administration, and by measuring GAA activity in the muscle after administration of alglucosidase α alone and alglucosidase α in combination with 1-deoxynojirimycin hydrochloride.

[0055] Prior to initiating alglucosidase α injection, WBC (PBMC) GAA activity and protein levels, as well as anti-rhGAA antibody titers, are measured. GAA enzyme activity is measured in plasma, WBC, and muscle, with and without Con A capture, and protein levels are determined by Western blotting.

[0056] Test design This is a Phase II clinical, single-dose, open-label trial to evaluate the safety and efficacy of co-administration of 1-deoxynojirimycin hydrochloride and alglucosidase α. The trial will be conducted in men and women aged 18–65 years who have been receiving a stable dose of alglucosidase α for at least one month prior to trial enrollment. Approximately 16 participants will be enrolled.

[0057] This study evaluates the safety and efficacy of 1-deoxynojirimycin hydrochloride in escalating doses (50, 100, 250, and 600 mg) administered one hour prior to the initiation of alglucosidase α infusion, in relation to the pharmacokinetics of GAA. Four subjects will be enrolled for each of the four 1-deoxynojirimycin hydrochloride dose levels. Each cohort of four subjects will receive a single intravenous infusion of alglucosidase α alone, and 2–4 weeks later, will receive a single oral dose of 1-deoxynojirimycin hydrochloride administered one hour prior to the initiation of the intravenous infusion of alglucosidase α.

[0058] Dose increases of 1-deoxynojirimycin hydrochloride to the next dose level may be carried out after a review of safety and tolerability data from previous dose level groups. The reviewed safety data include adverse events (including infusion reactions), laboratory tests (including creatine kinase, LDH (LDH-5), alkaline phosphatase, AST, and ALT), Hex4 and 12-lead ECG, physical examinations, muscle strength tests, and vital signs.

[0059] Each participant receives alglucosidase α alone as an intravenous infusion during Period 1, and receives a single dose of 1-deoxynojirimycin hydrochloride one hour before the intravenous infusion of alglucosidase α during Period 2. The dose of alglucosidase α administered in Periods 1 and 2 is the same.

[0060] Each cohort consists of four subjects. Subjects are successively enrolled in one of four administration cohorts of 1-deoxynojirimycin hydrochloride at the following dose levels during period 2.

[0061] Cohort 1: A single 50 mg oral dose of 1-deoxynojirimycin hydrochloride; Cohort 2: Single 100 mg oral dose of 1-deoxynojirimycin hydrochloride; Cohort 3: Single oral dose of 1-deoxynojirimycin hydrochloride at 250 mg; Cohort 4: A single oral dose of 600 mg of 1-deoxynojirimycin hydrochloride.

[0062] During Period 1, the following assessments will be performed on the subject before the next scheduled alglucosidase α infusion: adverse event assessment, concomitant medications, physical examination, body weight, vital signs, 12-lead ECG, clinical laboratory tests (including creatine analysis, LDH (LDH-5), alkaline phosphatase, AST, ALT), Hex4, and muscle strength test.

[0063] On the morning of day 1, the subject's current alglucosidase α dose is administered intravenously using an infusion pump. The infusion rate (any changes in rate during infusion), infusion duration, and the dose of alglucosidase α administered must be the same in periods 1 and 2. Blood samples for pharmacokinetic analysis are collected immediately before the start of alglucosidase α infusion and over the 24 hours following the start of alglucosidase α infusion. Plasma and WBC GAA enzyme activity and plasma anti-rhGAA antibody titer are determined from the collected blood samples at the times summarized in Table 2. A 12-lead ECG is performed at the end of alglucosidase α infusion and immediately after the collection of post-infusion blood samples.

[0064] After collecting the final pharmacokinetic sample, the following evaluations should be performed: adverse event assessment (including infusion reaction), concomitant medications, vital signs, 12-lead ECG, clinical laboratory tests (including creatine kinase, LDH (LDH-5), alkaline phosphatase, AST, and ALT), Hex4, and muscle strength tests.

[0065] On day 7, the following evaluations will be performed on the subjects: adverse event assessment, concomitant medications, physical examination, vital signs, clinical laboratory tests (including creatine kinase, LDH (LDH-5), alkaline phosphatase, AST, and ALT), Hex4, and muscle strength tests. Muscle biopsies will be collected to determine GAA enzyme activity. Blood samples will also be collected for plasma and WBC GAA enzyme level determination.

[0066] Muscle biopsies, which determine GAA enzyme activity and 1-deoxynojirimycin hydrochloride levels, are also collected on day 3.

[0067] In Period 2, approximately two weeks after the administration of alglucosidase α infusion in Period 1, and before the next scheduled alglucosidase α infusion, the subjects will undergo the following evaluations: adverse event assessment, concomitant medications, physical examination, body weight, vital signs, 12-lead ECG, clinical laboratory tests (including creatine analysis, LDH (LDH-5), alkaline phosphatase, AST, ALT), Hex4, and muscle strength tests.

[0068] On the morning of day 1, administer an oral dose of 1-deoxynojirimycin hydrochloride one hour before the scheduled alglucosidase α infusion. The subjects must fast for at least two hours before and at least two hours after the administration of 1-deoxynojirimycin hydrochloride. The infusion rate (any changes in rate during infusion), infusion duration, and the dose of alglucosidase α administered must be the same in periods 1 and 2.

[0069] Blood samples for pharmacokinetic analysis were collected before administration of 1-deoxynojirimycin hydrochloride, 1 hour after administration of 1-deoxynojirimycin hydrochloride (i.e., immediately before the start of alglucosidase α infusion), and for 24 hours after the start of alglucosidase α infusion. Plasma and WBC GAA enzyme activity, plasma 1-deoxynojirimycin hydrochloride concentration, and plasma anti-rhGAA antibody titer were determined from the collected blood samples at the times summarized in Table 2. A 12-lead ECG was performed at the end of alglucosidase α infusion and immediately after the collection of post-infusion blood samples.

[0070] After collecting the final pharmacokinetic sample, the following evaluations should be performed: adverse event assessment (including infusion reaction), concomitant medications, vital signs, 12-lead ECG, clinical laboratory tests (including creatine kinase, LDH (LDH-5), alkaline phosphatase, AST, and ALT), Hex4, and muscle strength tests.

[0071] On day 7, the following evaluations will be performed on the subjects: adverse event assessment, concomitant medications, physical examination, vital signs, clinical laboratory tests (including creatine kinase, LDH (LDH-5), alkaline phosphatase, AST, ALT), Hex4, and muscle strength tests. Muscle biopsies will be collected to determine GAA enzyme activity and 1-deoxynojirimycin hydrochloride levels. Blood samples will also be collected for plasma and WBC GAA enzyme level determination.

[0072] Muscle biopsies, which determine GAA enzyme activity and 1-deoxynojirimycin hydrochloride levels, are also collected on day 3.

[0073] During follow-up 26-30 days after administration of 1-deoxynojirimycin hydrochloride and alglucosidase α in Period 2, the following evaluations will be performed on the subjects: adverse event assessment, concomitant medications, physical examination, vital signs, 12-lead ECG, clinical laboratory tests (including creatine kinase, LDH (LDH-5), alkaline phosphatase, AST, and ALT), Hex4, muscle strength test, and anti-rhGAA antibody titer.

[0074] Evaluation and sample collection schedule Table 1 shows the evaluation schedule for periods 1 and 2. Table 2 shows the sample collection time and analytes for co-administration of 1-deoxynojirimycin hydrochloride and alglucosidase α.

[0075] TIFF2026143438000002.tif232170

[0076] TIFF2026143438000003.tif175167

[0077] Plasma pharmacokinetics of 1-deoxynojirimycin hydrochloride and GAA The concentration of 1-deoxynojirimycin hydrochloride in blood samples is measured in plasma using an effective LC-MS / MS assay. GAA activity in plasma is determined by an effective assay using 4-MUG, with and without Con A, to measure enzyme activity. GAA protein levels are measured by Western blotting using an anti-human GAA antibody.

[0078] GAA enzyme activity and 1-deoxynojirimycin hydrochloride levels in muscle GAA enzyme activity is tested in muscle biopsy samples. A piece of muscle tissue is removed as shown in Table 1. GAA activity in muscle is determined by an effective assay using 4-MUG, with and without Con A, to measure enzyme activity. GAA protein levels are measured by Western blotting with anti-human GAA antibody. The concentration of 1-deoxynojirimycin hydrochloride in muscle samples collected in period 2 is determined using an effective LC-MS / MS assay.

[0079] WBC(PBMC)GAA activity GAA activity in WBCs in blood samples is determined by an effective assay using 4-MUG to measure enzyme activity with and without Con A. GAA protein levels are measured by Western blotting using anti-human GAA antibody.

[0080] Anti-(Ant)-rhGAA antibody titer Blood samples are collected, and the anti-rhGAA antibody titers in the samples are measured as described in Table 2.

[0081] Safety parameters Safety parameters are evaluated by reviewing physical examination findings, vital signs, ECG changes over a period of time, clinical laboratory tests, Hex4, and changes in adverse events.

[0082] vital signs, weight and height Body temperature and respiration will be measured during screening and check-in. To monitor safety, body temperature, respiration, seated blood pressure, and heart rate will be measured before administration, approximately 1, 2, 3, 4, and 6 hours after administration of alglucosidase α (period 1) or 1-deoxynojirimycin hydrochloride (period 2), and on the days listed in Table 1. If the timing of vital signs monitoring coincides with blood sampling, blood sampling will take precedence, and vital signs monitoring will be adjusted accordingly.

[0083] ECG monitoring ECG monitoring is performed using a standard 12-lead ECG.

[0084] Clinical laboratory testing Blood samples (hematology, blood biochemistry tests) and urine samples for clinical laboratory testing will be collected according to the schedule in Table 1. Hematological tests include total hemoglobin, hematocrit, red blood cell count, platelet count, and white blood cell count, with differential diagnosis. • Coagulation (screening only) includes INR and aPTT. Blood biochemistry tests include the measurement of AST, ALT, alkaline phosphatase, total bilirubin, creatinine, creatine kinase, urea, glucose, calcium, sodium, potassium, magnesium, total protein, albumin, bicarbonate, LDH (LDH-5), blood urea nitrogen, chloride, and phosphate. • Urinalysis includes microscopic examination of color, appearance, specific gravity, pH, protein, glucose, ketones, blood, leukocyte esterase, nitrite, bilirubin, urobilinogen, and precipitates.

[0085] Urinary tetrasaccharides (Hex4) Urine samples for Hex4 determination are collected at the times shown in Table 1.

[0086] Muscle strength test (manual grip strength meter) Muscle strength tests using a manual grip strength meter will be performed during screening, on days 1 and 7 of each period, and during follow-up. Proximal and distal muscle groups will be evaluated.

[0087] Pharmacokinetic parameters AUC 0-t , AUC 無限大 , C max , t max , k el Non-compartmental pharmacokinetic parameters and half-life are calculated from plasma 1-deoxynojirimycin hydrochloride concentration and plasma rhGAA enzyme levels. Pharmacokinetic parameters are summarized by processing using descriptive statistics. Calculate the AUC after administration of GAA enzyme activity alone or in combination with 1-deoxynojirimycin hydrochloride 0-t , AUC 無限大 ratio. Pharmacokinetic and pharmacodynamic data from subjects receiving Myozyme® and Lumizyme® are analyzed separately.

[0088] Statistical Analysis Descriptive statistics (N, mean, standard deviation and coefficient of variation, standard error, median, minimum and maximum values) are provided where appropriate. The effect of 1-deoxynojirimycin hydrochloride on GAA enzyme activity is assessed by calculating individual (per subject) AUC and C max ratios as follows. TIFF2026143438000004.tif34161

[0089] AUC and C max ratio is expressed as the mean of individual ratios, and also as a 90% confidence interval for the mean. Pharmacokinetic and pharmacodynamic data from subjects receiving Myozyme® and Lumizyme® are analyzed separately. GAA activity in muscle with and without co-administration of 1-deoxynojirimycin hydrochloride is compared. Results are presented in tabular and graphical form where appropriate. All subjects who have been administered the study drug and have sufficient data to generate reliable pharmacokinetic parameters are included in the safety and pharmacokinetic analysis.

[0090] This disclosure should not be limited in scope by the specific embodiments described herein. In fact, various modifications of the application beyond those described herein will become apparent to those skilled in the art from the foregoing description and the accompanying drawings. These modifications shall be included within the scope of the accompanying claims.

[0091] It should be further understood that all values ​​are approximations and are provided for illustrative purposes only.

[0092] Example 2: Dosage scheme for Pompe disease treatment using 1-deoxynojirimycin hydrochloride and alglucosidase α - Cohorts 1 and 2 One of the objectives of this study was to evaluate the safety, efficacy, and pharmacokinetics of a treatment regimen including co-administration of 1-deoxynojirimycin hydrochloride and alglucosidase α in patients with Pompe disease.

[0093] Another objective of this study was to evaluate the effects of various doses of 1-deoxynojirimycin hydrochloride on GAA activity. This was assessed by measuring GAA enzyme activity and protein levels in skeletal muscle on days 3 and / or 7, following a single intravenous infusion of alglucosidase α alone and a pre-administration of a single, escalating oral dose of 1-deoxynojirimycin hydrochloride.

[0094] method This study was conducted essentially according to the method described in Example 1. Cohort 1 included four subjects. Cohort 2 included six subjects. Each subject received alglucosidase α alone as an intravenous infusion during Period 1, and during Period 2, received a single 50 mg dose (Cohort 1) or 100 mg (Cohort 2) of 1-deoxynojirimycin hydrochloride one hour prior to the intravenous infusion of alglucosidase α. The genotypes (where available), including nucleotide and amino acid variations, for each subject are shown below.

[0095] TIFF2026143438000005.tif118161

[0096] Results: Cohort 1 Plasma rhGAA activity is increased by co-administration of 1-deoxynojirimycin hydrochloride and acid α-glucosidase compared to acid α-glucosidase alone.

[0097] As shown in Table 3, when acid α-glucosidase was co-administered with 50 mg of 1-deoxynojirimycin hydrochloride (period 2) compared with ERT alone (period 1), a mean 1.5-fold increase in plasma rhGAA activity AUC (area under the curve) was observed. Table 3 also shows the doubling of rhGAA activity between days 7 of periods 1 and 2 for muscle biopsies from cohort 1 subjects.

[0098] TIFF2026143438000006.tif137170

[0099] When α-glucosidase acid and 50 mg 1-deoxynojirimycin hydrochloride were co-administered (period 2) to ERT alone (period 1), the increase in plasma rhGAA activity AUC in individual subjects was 1.2, 1.5, 1.5, and 1.6 times, as shown in Tables 4-7. Tables 4-7 also show the doubling of rhGAA activity in muscle biopsies between days 7 of periods 1 and 2.

[0100] TIFF2026143438000007.tif133170

[0101] TIFF2026143438000008.tif107170

[0102] TIFF2026143438000009.tif130167

[0103] TIFF2026143438000010.tif125167

[0104] Table 8 below shows the cumulative AUC for rhGAA activity in plasma from Cohort 1.

[0105] TIFF2026143438000011.tif128161

[0106] Table 9 shows the total rhGAA protein in a summary of plasma PK obtained by Western blotting (Cohort 1).

[0107] TIFF2026143438000012.tif211161

[0108] TIFF2026143438000013.tif209161

[0109] Results: Cohort 2 Plasma rhGAA activity is increased by co-administration of 1-deoxynojirimycin hydrochloride and acid α-glucosidase compared to acid α-glucosidase alone.

[0110] As shown in Table 10A, when acid α-glucosidase was co-administered with 100 mg of 1-deoxynojirimycin hydrochloride (period 2) compared with ERT alone (period 1), a mean 1.7-fold increase in plasma rhGAA activity AUC (area under the curve) was observed. Table 10A also shows the doubling of rhGAA activity between days 3 and 7 of periods 1 and 2 for muscle biopsies from cohort 2 subjects. Table 10B shows a summary of plasma PK for 1-deoxynojirimycin hydrochloride from period 2 of cohorts 1 and 2. Table 10C shows the total rhGAA protein concentration from cohorts 1 and 2 as measured by Western blotting.

[0111] TIFF2026143438000014.tif224170

[0112] TIFF2026143438000015.tif76161

[0113] TIFF2026143438000016.tif85161

[0114] When ERT was co-administered with 100 mg 1-deoxynojirimycin hydrochloride (period 2) compared to ERT alone (period 1), the increase in plasma rhGAA activity AUC in individual subjects was 1.5, 1.5, 1.6, 1.7, 1.8, and 1.9 times, as shown in Tables 11-16. Tables 11-16 also show the doubling of rhGAA activity in muscle biopsies from cohort 2 subjects between days 3 or 7 of periods 1 and 2.

[0115] TIFF2026143438000017.tif163170

[0116] TIFF2026143438000018.tif154166

[0117] TIFF2026143438000019.tif156161

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[0119] TIFF2026143438000021.tif167165

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[0121] Table 17 below shows the cumulative AUC for rhGAA activity in plasma from cohort 2.

[0122] TIFF2026143438000023.tif191170

[0123] Table 18A shows the rhGAA activity from muscle biopsies taken on days 3 or 7 of periods 1 and 2, as well as from biopsies taken during optional follow-up, for subjects in Cohort 2.

[0124] TIFF2026143438000024.tif99161

[0125] Table 18B shows the 1-DNJ-HCl(AT2220) concentrations of individual muscle samples collected on day 3 or 7 from cohorts 1 and 2.

[0126] TIFF2026143438000025.tif152161

[0127] Summary of Results Single doses of 50 mg and 100 mg 1-DNJ-HCl (AT2220) were found to be safe and well-tolerated in patients with Pompe disease. Only mild transient adverse events (AEs) were reported, none of which were related to AT2220 (representative adverse events are listed below). One serious AE was citalopram-induced QTc prolongation. QTc prolongation was alleviated after citalopram dose reduction. In general, urinary hex4 levels remained unchanged from baseline or showed no consistent trend after single-dose AT2220 (Figure 7). In addition, CPK levels did not change noticeably from baseline in cohorts 1 and 2 (Figure 8).

[0128] Plasma rhGAA activity AUC increased in all patients for both co-administered doses compared to alglucosidase α alone. This increase in AUC was primarily driven by an extension of the plasma half-life due to increased rhGAA activity after Tmax (Table 10A, Figure 2A, and Figure 4). The increased plasma rhGAA activity AUC suggests increased stabilization of rhGAA uptake in relation to tissue distribution.

[0129] Muscle biopsies were taken from all four patients in Cohort 1 on day 7, and from three patients each from the six patients in Cohort 2 on day 3 or day 7. Three patients from Cohort 2 had an optional day 30 muscle biopsy, which was used as the baseline for those patients. After co-administration of 50 mg AT2220, one patient in Cohort 1 showed a 40% increase in muscle rhGAA activity compared to rhGAA alone, two showed no change, and one showed a 30% decrease in rhGAA activity. After co-administration of 100 mg AT2220, from biopsies taken on day 3, two patients in Cohort 2 showed a 60% and 40% increase in rhGAA activity compared to rhGAA alone, while one showed a 20% decrease. From biopsies taken on day 7, two showed a 60% and 10% increase, and one showed no change in rhGAA activity.

[0130] The pharmacokinetics of plasma AT2220 were nearly linear at this point in the study for both 50 mg and 100 mg doses. Approximately twofold increases in Cmax and AUC were observed with dose (Table 10B, Figure 5). The absorption rate (Tmax) was 2–3 hours, indicating that all bioavailable drug was absorbed early during rhGAA infusion. Muscle AT2220 concentrations from biopsies on day 3 or day 7 were either below or near the lower limit of quantification of 8 ng / g (Table 18B).

[0131] Total plasma rhGAA protein, as determined by Western blotting, followed a similar trend to plasma rhGAA activity in terms of AT2220 dose-related increases (Figure 6, Table 10C).

[0132] conclusion To date, 1-DNJ-HCl has been evaluated as safe and well-tolerated at both 50 mg and 100 mg dose levels.

[0133] Plasma rhGAA activity increased from 20% to 40% and from 50% to 90% after single doses of 50 mg and 100 mg 1-DNJ-HCl, respectively.

[0134] At a 50 mg dose level, one in four patients showed increased rhGAA activity in the muscle; however, at 100 mg 1-DNJ-HCl, four out of six patients showed an increase of up to 60% in rhGAA activity in the muscle.

[0135] Plasma 1-DNJ-HCl has shown nearly linear pharmacokinetics (PK) for two doses evaluated to date.

[0136] Muscle 1-DNJ-HCl concentrations from biopsies on days 3 or 7 were either below or just above the limit of quantification, suggesting that 1-DNJ-HCl may not accumulate after multiple doses administered every 14 days.

[0137] Total plasma rhGAA protein PK followed a similar trend to rhGAA activity PK.

[0138] Adverse events Twenty adverse events (AEs) were reported, one of which was serious. Representative adverse events are shown in Tables 19 and 20. The serious AE that occurred after the screening visit but before administration, a prolongation of the corrected QTc time from 473 to 493 msec, was of moderate severity and considered by the researchers to be unrelated to the study drug. All other AEs were of mild severity, all were considered unrelated to the study drug, and resolved without treatment. Urinary hexose tetrasaccharide A (urinary Hex4) and serum CPK levels for each patient are shown in Figures 7 and 8.

[0139] TIFF2026143438000026.tif250153

[0140] TIFF2026143438000027.tif195161

[0141] Example 3: Dosage scheme for Pompe disease treatment using 1-deoxynojirimycin hydrochloride and alglucosidase α - Cohorts 3 and 4 One of the objectives of this study was to evaluate the safety, efficacy, and pharmacokinetics of a treatment regimen including co-administration of 1-deoxynojirimycin hydrochloride and alglucosidase α in patients with Pompe disease.

[0142] Another objective of this study was to evaluate the effects of various doses of 1-deoxynojirimycin hydrochloride on GAA activity. This was assessed by measuring GAA enzyme activity and protein levels in skeletal muscle on days 3 and / or 7, following a single intravenous infusion of alglucosidase α alone and a pre-administration of a single, escalating oral dose of 1-deoxynojirimycin hydrochloride.

[0143] method This study was conducted essentially according to the method described in Example 1. Cohort 3 included 6 subjects. Cohort 4 included 7 subjects. Each subject received alglucosidase α alone as an intravenous infusion during Period 1, and during Period 2, received a single dose of 250 mg (Cohort 3) or 600 mg (Cohort 4) of 1-deoxynojirimycin hydrochloride one hour before the intravenous infusion of alglucosidase α.

[0144] Results: Cohort 3 Plasma and muscle rhGAA activity is increased by co-administration of 1-deoxynojirimycin hydrochloride and acid α-glucosidase compared to acid α-glucosidase alone.

[0145] As shown in Table 21, when α-glucosidase was co-administered with 250 mg of 1-deoxynojirimycin hydrochloride (period 2) compared with ERT alone (period 1), a mean 2.0-fold increase in plasma rhGAA activity was observed.

[0146] TIFF2026143438000028.tif76161

[0147] Tables 22-35 show the increase in plasma rhGAA activity in cohort 3 subjects when co-administered with acid α-glucosidase and 250 mg 1-deoxynojirimycin hydrochloride (period 2) compared to ERT alone (period 1). These tables also show the increase in rhGAA in muscle tissue after co-administration of acid α-glucosidase and 250 mg 1-deoxynojirimycin hydrochloride (period 2) compared to ERT alone (period 1).

[0148] TIFF2026143438000029.tif24349

[0149] TIFF2026143438000030.tif24347

[0150] TIFF2026143438000031.tif24348

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[0155] TIFF2026143438000036.tif220138

[0156] TIFF2026143438000037.tif246127

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[0160] TIFF2026143438000041.tif174162

[0161] TIFF2026143438000042.tif172133

[0162] Results: Cohort 4 Plasma and muscle rhGAA activity is increased by co-administration of 1-deoxynojirimycin hydrochloride and acid α-glucosidase compared to acid α-glucosidase alone.

[0163] Tables 36-38 show the increase in plasma rhGAA activity in cohort 4 subjects when co-administered with acid α-glucosidase and 600 mg of 1-deoxynojirimycin hydrochloride (period 2) compared to ERT alone (period 1). These tables also show the increase in rhGAA in muscle tissue after co-administration of acid α-glucosidase and 600 mg of 1-deoxynojirimycin hydrochloride (period 2) compared to ERT alone (period 1).

[0164] TIFF2026143438000043.tif246159

[0165] TIFF2026143438000044.tif243107

[0166] TIFF2026143438000045.tif234157

[0167] Summary of Results In individuals with Pompe disease, a deficiency in the GAA enzyme leads to glycogen accumulation in diseased tissues (primarily muscle). Preclinical data (Khanna et al. PLoS ONE (2012) 7(7):e40776.doi:10.1371 / journal.pone.0040776) showed that the combination of AT2220 and ERT increased rhGAA enzyme activity, reduced glycogen accumulation, and potentially mitigated ERT-related immunogenicity in a mouse model of Pompe disease. In the study described in Examples 1-3, co-administration of AT2220 to Pompe patients increased rhGAA enzyme activity and improved rhGAA enzyme uptake into muscle tissue compared to ERT alone.

[0168] The studies described in Examples 1-3 were Phase 2, open-label, multicenter trials to evaluate the safety and pharmacokinetic effects of four increasing oral doses of AT2220 (50 mg (Cohort 1), 100 mg (Cohort 2), 250 mg (Cohort 3), or 600 mg (Cohort 4)) co-administered with ERT (Myozyme® / Lumizyme®) compared to ERT alone in men and women with Pompe disease. The trials enrolled male and female patients who had been on a stable dose and dosing schedule of ERT for at least 3 months. All patients received regularly scheduled ERT infusions. One hour before the start of the next ERT infusion, patients received a single oral dose of AT2220. Plasma rhGAA activity and protein levels were assessed during each infusion. Each patient underwent muscle biopsy 3 or 7 days after each infusion to measure GAA enzyme activity in chaperone-containing and chaperone-free tissues, and to measure the level of AT2220 in muscle.

[0169] Safety: The monodose of AT2220 co-administered with ERT was well-tolerated, and no drug-related adverse events were reported. In addition, AT2220 was eliminated from muscle to near-undetectable levels by day 7 in all four cohorts.

[0170] Recombinant human GAA (rhGAA) enzyme activity in plasma: Plasma pharmacokinetics (PK) were measured during and after each infusion, and for 24 hours. Plasma rhGAA activity increased in all 23 patients (100%) after co-administration, and the increase was dose-related. These data suggest that co-administration increases the amount of stabilized, properly folded, and active rhGAA enzyme useful for tissue uptake. Table 39 and Figure 21 show a schematic of rhGAA enzyme activity in plasma area under the curve (AUC) for cohorts 1-4 described in Examples 1-3.

[0171] TIFF2026143438000046.tif68161

[0172] Enzyme activity in muscle: Muscle biopsies were taken, and the uptake of GAA enzyme into muscle tissue was measured for patients with and without AT2220. In Cohort 1, all four patients had muscle biopsies on day 7. In Cohorts 2-4, half of the patients had muscle biopsies taken on day 3, and the other half had them taken on day 7.

[0173] In Cohort 1, no consistent change in GAA enzyme activity was observed on day 7. In Cohorts 2, 3, and 4, the results showed that a larger amount of enzyme was taken up into muscle tissue after co-administration of AT2220 compared to ERT alone. This effect was most pronounced with the maximum (600 mg) dose of AT2220. Table 40 and Figure 22 show a schematic of muscle GAA enzyme activity on day 3 for Cohorts 2-4 described in Examples 1-3.

[0174] TIFF2026143438000047.tif68161

[0175] On day 3, in patients with evaluable biopsies, muscle GAA enzyme activity after co-administration compared to ERT alone increased by the following percentages: 25% in cohort 2 (n=3), 7% in cohort 3 (n=3), and 133% in cohort 4 (n=2). On day 7, muscle GAA enzyme activity was lower than on day 3, as expected based on the cellular half-life of the enzyme. However, in patients with evaluable biopsies, the following increases persisted after co-administration compared to ERT alone: ​​20% in cohort 2 (n=3), 40% in cohort 3 (n=2), and 20% in cohort 4 (n=3).

[0176] Effect of AT2220 on ERT-related immunogenicity measured ex vivo: Since denatured and aggregated proteins are generally more antigenic than properly folded proteins, AT2220 can mitigate ERT-induced immunogenicity by stabilizing the folded active form of the rhGAA enzyme. A recently published study showed that approximately 40% of administered ERT can be captured by circulating antibodies, and approximately 50% of Pompe patients receiving ERT infusions experience infusion-related reactions (Banati et al., Muscle Nerve. 2011 Nov;44(5):720-6). An initial ex vivo study using T cells derived from the blood of 50 healthy donors showed that the addition of AT2220 could significantly reduce the immunogenicity of Myozyme® and Lumizyme®. This study was replicated using the EpiScreen® assay from Antitope Ltd. with samples from Pompe patients in the studies described in Examples 1-3.

[0177] Example 4: The skeletal muscle distribution and half-life of N-butyl-DNJ (AT2221) are the same as those of 1-DNJ (AT2220). Eight-week-old wild-type C57BL / 6 mice were administered an oral dose of 100 mg / kg of 1-DNJ or N-butyl-DNJ. Plasma and tissue samples were collected at 0.5, 2, 4, 24, 48, 72, 96, 120, 144, and 168 hours after administration, and the presence of the drug was analyzed. The drug concentration in plasma is expressed as ng / ml. The drug concentration in tissue samples is expressed as ng / g.

[0178] As shown in Figure 23, the skeletal muscle distribution and half-life of N-butyl-DNJ (AT2221) are similar to those of 1-DNJ (AT2220). The Cmax of AT2220 was 120 μM. The Cmax of AT2221 was 140 μM.

[0179] Example 5: N-butyl-DNJ (AT2221) and 1-DNJ (AT2220) have similar effects on the pharmacokinetics of rhGAA. Eight-week-old GAAKO mice were administered rhGAA (10 mg / kg IV). Oral AT2220 or AT2221 (100 mg / kg) was administered 30 minutes before GAA (Myozyme) administration; plasma samples were collected before GAA administration and at 0.08, 0.25, 0.50, 0.75, 1, 2, 4, 8, and 24 hours after administration, and enzyme activity was determined.

[0180] As shown in Figure 24, AT2220 and AT2221 increased the circulating half-life of rhGAA by at least approximately twofold. N-butyl-DNJ (AT2221) and 1-DNJ (AT2220) have similar effects on the pharmacokinetics of rhGAA.

[0181] Figure 25 shows Western blots of recombinant GAA in plasma 2, 8, and 24 hours after IV administration of GAA in mice administered rhGAA with or without AT2220 or AT2221.

[0182] Example 6: Co-administration of DNJ or NB-DNJ with rhGAA has a similar effect on glycogen depletion. GAAKO mice at 12 weeks of age were administered 20 mg / kg of iv recombinant human GAA (Myozyme) every other week for 8 weeks. An oral dose of AT2220 or AT2221 (30 mg / kg) was administered 30 minutes before rhGAA (Myozyme). Tissue was collected 21 days after the final dose of rhGAA, and glycogen (GAA substrate) levels were measured.

[0183] As shown in Figure 26, co-administration of DNJ or NB-DNJ with rhGAA has a similar effect on glycogen depletion. n=5-mouse / group; * p<0.05 vs. untreated t-test; #p<0.05 vs. Myozyme single t-test; dotted line indicates wild-type glycogen levels. Cmax approximately 40 μM after administration of 30 mg / kg AT2220 or AT2221; equivalent to approximately 600 mg in humans.

[0184] Patents, patent applications, publications, product descriptions, and protocols are referenced throughout this application, and these disclosures as a whole are incorporated herein by reference for the sole purpose.

Claims

1. A method for treating Pompe disease in a subject, comprising administering approximately 25 mg to approximately 1000 mg of 1-deoxynojirimycin and an effective amount of acid α-glucosidase enzyme replacement therapy to a patient in need thereof.

2. The method according to claim 1, wherein the amount of 1-deoxynojirimycin administered is about 50 mg to about 600 mg.

3. The method according to claim 1, wherein the amount of 1-deoxynojirimycin administered is selected from the group consisting of about 50 mg, about 100 mg, about 250 mg, and about 600 mg.

4. The method according to claim 1, wherein the patient fasts for a period of time starting about 0.5 to about 4 hours before administration of 1-deoxynojirimycin and ending about 0.5 to about 4 hours later.

5. The method according to claim 4, wherein the patient fasts for at least about two hours before administration of 1-deoxynojirimycin and for at least about two hours after the administration.

6. The method according to claim 1, wherein the 1-deoxynojirimycin is administered simultaneously with or approximately 4 hours before the administration of the acid α-glucosidase enzyme replacement therapy.

7. The method according to claim 6, wherein the 1-deoxynojirimycin is administered approximately two hours before the administration of the acid α-glucosidase enzyme replacement therapy.

8. The method according to claim 6, wherein the 1-deoxynojirimycin is administered about one hour before the administration of the acid α-glucosidase enzyme replacement therapy.

9. The method according to claim 1, wherein the 1-deoxynojirimycin is 1-deoxynojirimycin hydrochloride.

10. The method according to claim 1, wherein the acid α-glucosidase enzyme replacement therapy is rhGAA.

11. The method according to claim 1, wherein the acid α-glucosidase enzyme substitute therapy is alglucosidase α.

12. The method according to claim 1, wherein 1-deoxynojirimycin is administered as an adjunct to the acid α-glucosidase enzyme replacement therapy.

13. The method according to claim 1, wherein the 1-deoxynojirimycin and acid α-glucosidase enzyme replacement therapy are administered as combination therapy.

14. The method according to claim 6, wherein the patient is administered a second dose of 1-deoxynojirimycin between the administration of the acid α-glucosidase enzyme replacement therapy and approximately 4 hours after the administration.

15. The method according to claim 7 or 8, wherein the 1-deoxynojirimycin and acid α-glucosidase enzyme replacement therapy is administered every 1 to 4 weeks.

16. The method according to claim 15, wherein the 1-deoxynojirimycin and acid α-glucosidase enzyme replacement therapy is administered every two weeks.

17. A kit for the treatment of Pompe disease in a subject, comprising approximately 25 mg to approximately 1000 mg of 1-deoxynojirimycin and an effective amount of acid α-glucosidase enzyme replacement therapy.

18. The kit according to claim 17, wherein the amount of 1-deoxynojirimycin is selected from the group consisting of about 50 mg, about 100 mg, about 250 mg, and about 600 mg.

19. A method for treating Pompe disease in a subject, comprising administering approximately 25 mg to approximately 1000 mg of a 1-deoxynojirimycin derivative and an effective amount of acid α-glucosidase enzyme replacement therapy to a patient in need thereof.

20. The method according to claim 19, wherein the amount of the 1-deoxynojirimycin derivative administered is about 50 mg to about 600 mg.

21. The method according to claim 19, wherein the amount of the 1-deoxynojirimycin derivative administered is selected from the group consisting of about 50 mg, about 100 mg, about 250 mg, and about 600 mg.

22. The method according to claim 19, wherein the patient fasts for a period of time starting about 0.5 to about 4 hours before administration of the 1-deoxynojirimycin derivative and ending about 0.5 to about 4 hours later.

23. The method according to claim 22, wherein the patient fasts for at least about two hours before administration of the 1-deoxynojirimycin derivative and for at least about two hours after the administration.

24. The method according to claim 19, wherein the 1-deoxynojirimycin derivative is administered simultaneously with or about 4 hours before the administration of the acid α-glucosidase enzyme replacement therapy.

25. The method according to claim 24, wherein the 1-deoxynojirimycin derivative is administered approximately two hours before the administration of the acid α-glucosidase enzyme replacement therapy.

26. The method according to claim 24, wherein the 1-deoxynojirimycin derivative is administered about one hour before the administration of the acid α-glucosidase enzyme replacement therapy.

27. The method according to claim 19, wherein the 1-deoxynojirimycin derivative is 1-N-butyl-DNJ.

28. The method according to claim 19, wherein the acid α-glucosidase enzyme replacement therapy is rhGAA.

29. The method according to claim 19, wherein the acid α-glucosidase enzyme substitute therapy is alglucosidase α.

30. The method according to claim 19, wherein the 1-deoxynojirimycin derivative is administered as an adjunct to the acid α-glucosidase enzyme replacement therapy.

31. The method according to claim 19, wherein the 1-deoxynojirimycin derivative and the acid α-glucosidase enzyme replacement therapy are administered as combination therapy.

32. The method according to claim 24, wherein the patient is administered a second dose of a 1-deoxynojirimycin derivative between the administration of the acid α-glucosidase enzyme replacement therapy and approximately 4 hours after the administration.

33. The method according to claim 25 or 26, wherein the 1-deoxynojirimycin derivative and acid α-glucosidase enzyme replacement therapy are administered every 1 to 4 weeks.

34. The method according to claim 33, wherein the 1-deoxynojirimycin derivative and acid α-glucosidase enzyme replacement therapy are administered every two weeks.

35. A kit for the treatment of Pompe disease in a subject, comprising approximately 25 mg to approximately 1000 mg of a 1-deoxynojirimycin derivative and an effective amount of acid α-glucosidase enzyme replacement therapy.

36. The kit according to claim 35, wherein the amount of the 1-deoxynojirimycin derivative is selected from the group consisting of about 50 mg, about 100 mg, about 250 mg, and about 600 mg.

37. A method for treating Pompe disease in a subject, comprising administering approximately 25 mg to approximately 1000 mg of 1-deoxynojirimycin or a 1-deoxynojirimycin derivative and an effective amount of acid α-glucosidase enzyme replacement therapy to a patient in need thereof.

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