Treatment of bone abnormalities in patients with acid sphingomyelinase deficiency

Abstract

To provide the use of a human acid sphingomyelinase (e.g., olipudase alfa) in production of drugs for treating abnormal bone conditions in acid sphingomyelinase deficiency patients, such as low bone density, high bone marrow burden, and other skeletal abnormalities presented in acid sphingomyelinase deficiency patients.SOLUTION: The present invention provides the use of a recombinant human acid sphingomyelinase (rhASM) for manufacture of a medicament for reducing accumulation of sphingomyelin in bone marrow cells in a patient in need thereof. Preferably, the bone marrow cells are precursor cells of the mononuclear-macrophage lineage. The rhASM improves a bone condition of a patient indicated by the bone maturation. After the accumulation, the bone maturation improves.SELECTED DRAWING: None

Description

Technical Field

[0001] Cross-Reference to Related Applications This application claims priority based on U.S. Provisional Patent Application No. 62 / 549,732 filed on August 24, 2017, and European Patent Application No. 17306720.8 filed on December 7, 2017. The entire disclosures of these two priority applications are incorporated herein by reference.

[0002] Sequence Listing This application contains a Sequence Listing submitted electronically in ASCII format, the entire content of which is incorporated herein by reference. The ASCII copy, created on August 10, 2018, is named 022548_WO047_SL.txt and is 21,687 bytes in size.

[0003] The present application relates to the use of human acid sphingomyelinase in the treatment of bone abnormalities in patients with acid sphingomyelinase deficiency (ASMD).

Background Art

[0004] Acid sphingomyelinase deficiency (ASMD) is a rare, life-threatening lysosomal storage disorder. It is an autosomal recessive genetic disease caused by mutations in the SMPD1 gene, which encodes the lysosomal enzyme acid sphingomyelinase (ASM) (Non-Patent Document 1). ASMD patients cannot metabolize sphingomyelin, and as a result, sphingomyelin accumulates in lysosomes in multiple organs, causing visceral disease and neurodegeneration in severe cases. ASMD patients show increased levels of cholesterol and other lipids in the spleen, liver, lungs and bone marrow.

[0005] The most severe disease phenotype, infantile visceral ASMD (historically known as Niemann-Pick disease type A or NPD A), is characterized by early onset and acute neurological impairment, resulting in growth retardation, hepatosplenomegaly, and rapidly progressive neurodegeneration. Patients die in infancy (Non-Patent Literature 2). Patients with chronic visceral ASMD (NPD B) and chronic visceral neurodegenerative ASMD (NPD A / B) have varying onset dates, ranging from infancy to adulthood (Non-Patent Literature 3; Non-Patent Literature 4). NPD B patients are usually diagnosed in childhood, typically after the age of two. Most NPD B patients survive into adulthood. NPD A / B patients are classified as an intermediate type, exhibiting neurological symptoms in childhood, which may also manifest as neurodegenerative disease.

[0006] Pathological conditions due to liver, lung, and blood disorders occur in all patients with chronic ASMD, including hepatosplenomegaly, hepatic dysfunction, infiltrative lung disease, and thrombocytopenia (Non-Patent Literature 5; Non-Patent Literature 6). Growth retardation in childhood and bone disorders such as low bone density are also common features of chronic ASMD (Non-Patent Literature 7). Lung and liver diseases are the leading causes of death in these patients (Non-Patent Literature 8; Non-Patent Literature 9). [Prior art documents] [Non-patent literature]

[0007] [Non-Patent Document 1] Schuchman et al., Mol. Genet. Metab. 120(1-2): pp. 27-33 (2017) [Non-Patent Document 2] McGovern et al., Neurology 66(2):228-232 (2006) [Non-Patent Document 3] Wasserstein et al., Pediatrics 114(6):e672-677 (2004) [Non-Patent Document 4] Wasserstein et al., J. Pediatr. 149(4): pp. 554-559 (2006) [Non-Patent Document 5] McGovern et al., Genet. Med. 15(8): pp. 618-623 (2013) [Non-Patent Document 6] McGovern et al., Orphanet J.Rare Dis.12(1):41 ​​(2017) [Non-Patent Document 7] Wasserstein et al., J. Pediatr. 142(4): pp. 424-428 (2003) [Non-Patent Document 8] McGovern et al., Pediatrics 122(2):e341-349 (2008) [Non-Patent Document 9] Cassiman et al., Mol. Genet. Metab. 118(3): pp. 206-213 (2016) [Overview of the project] [Problems that the invention aims to solve]

[0008] Given the high morbidity and mortality rates of ASMD, effective treatments for this genetic disorder remain urgently needed. [Means for solving the problem]

[0009] The present invention provides a method for treating a bone malformation in a patient with acid sphingomyelinase deficiency (ASMD), comprising the steps of: administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient; measuring the patient's bone markers; and comparing the patient's bone markers to the patient's baseline bone markers prior to the administration step, wherein the patient's bone markers improve or do not worsen after administration of multiple doses of rhASM. In some embodiments, the bone marker is bone mineral density (BMD), and BMD improves (e.g., increases) or does not worsen after administration of multiple doses of rhASM. In some embodiments, the bone marker is bone marrow load (BMB), and BMB decreases or does not increase after administration of multiple doses of rhASM. In some embodiments, the bone marker is skeletal growth (e.g., bone maturity and / or length growth), and skeletal growth improves after administration of multiple doses of rhASM. In certain embodiments, the bone malformation is osteopenia or osteoporosis.

[0010] The present invention also provides a method for reducing bone marrow burden (BMB) in patients with acid sphingomyelinase deficiency requiring a reduction in BMB, comprising the steps of determining the patient's BMB and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient to thereby reduce the patient's BMB.

[0011] The present invention also provides a method for improving bone mineral density (BMD) in patients with acid sphingomyelinase deficiency who require improvement of BMD, comprising the steps of determining the patient's BMD and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient to thereby improve the patient's BMD.

[0012] The present invention also provides a method for reducing bone marrow burden (BMB) in patients with acid sphingomyelinase deficiency who require a reduction in BMB, comprising the steps of selecting patients with acid sphingomyelinase deficiency who have not received bisphosphonate therapy, and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patients to thereby reduce the patients' BMB.

[0013] This invention also relates to acid sphingo, which requires improvement (e.g., increase) of bone mineral density (BMD). The present invention also provides a method for improving BMD in patients with myelinase deficiency, comprising the steps of selecting patients with acid sphingomyelinase deficiency who have not received bisphosphonate therapy, and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patients to thereby improve the patients' BMD.

[0014] The present invention also provides a method for improving skeletal development in patients with acid sphingomyelinase deficiency (ASMD) who require improvement in skeletal development (e.g., bone maturity and / or length growth), comprising the steps of: selecting ASMD patients for whom skeletal development is to be improved; and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patients to thereby improve the patients' skeletal development.

[0015] The present invention also provides a method for improving or maintaining the quality of life in patients with acid sphingomyelinase deficiency (ASMD) who require improvement or maintenance of their quality of life, the method comprising the steps of selecting ASMD patients whose quality of life needs improvement, and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patients to thereby improve or maintain their quality of life.

[0016] The present invention also provides a method of treating osteopenia in a patient with acid sphingomyelinase deficiency (ASMD) in need of treatment of osteopenia, comprising the steps of: selecting an ASMD patient in need of treatment of osteopenia; and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient.

[0017] The present invention also provides a method of treating osteoporosis in a patient with acid sphingomyelinase deficiency in need of treatment of osteoporosis, comprising the steps of: selecting an ASMD patient in need of treatment of osteoporosis; and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient.

[0018] In any of the treatment methods described herein, multiple doses may be administered to the patient over a period of from 6 months to 30 months. Accordingly, the effects of the multiple doses of rhASM recited herein are obtained during said period.

[0019] In any of the treatment methods described herein, the patient may, for example, have chronic visceral ASMD (Niemann-Pick disease type B) or chronic neurovisceral ASMD (NPD A / B). The patient may be an adult patient or a pediatric patient.

[0020] In any of the treatment methods described herein, the first two doses or more doses of rhASM may be escalating doses and may be administered in sequentially increasing amounts. In some embodiments, the dose following the escalating doses is a maintenance dose (which may, for example, start from the maximum maintenance dose), and may be administered in an amount equal to or less than the last escalating dose. In certain embodiments, the maximum maintenance dose is the highest dose tolerated by the patient. The initial dose may be, for example, 0.1 mg / kg for either adult or pediatric patients. The maximum maintenance dose may be, for example, in an amount of 0.3 mg / kg to 3 mg / kg (e.g., 1 mg / kg to 3 mg / kg), for example, 1 mg / kg, 2 mg / kg, or 3 mg / kg. The maintenance dose may be, for example, 0.1 mg / kg to 3 mg / kg or 0.3 mg / kg to 3 mg / kg, for example, in an amount of 0.1 mg / kg, 0.2 mg / kg, 0.3 mg / kg, 0.4 mg / kg, 0.5 mg / kg, 0.6 mg / kg, 0.7 mg / kg, 0.8 mg / kg, 0.9 mg / kg, 1 mg / kg, 1.5 mg / kg, 2 mg / kg, 2.5 mg / kg, or 3 mg / kg. In certain embodiments, the escalating doses are administered in the order of 0.1 mg / kg, 0.3 mg / kg, 0.3 mg / kg, 0.6 mg / kg, 0.6 mg / kg, 1.0 mg / kg, 2.0 mg / kg, and 3.0 mg / kg

[0021] In some embodiments, multiple doses in any of the treatment methods described herein are administered at an interval of every two weeks. Administration of multiple doses can be performed, for example, by intravenous injection.

[0022] In any of the treatment methods described herein, rhASM may be olipudase alfa (SEQ ID NO: 2).

[0023] ​The present invention also provides the use of recombinant human ASM (e.g., olipidase alfa) for the manufacture of pharmaceuticals used in any of the treatment methods described herein, and also provides recombinant human ASM (e.g., olipidase alfa) for use in any of the treatment methods described herein.

[0024] The present invention also provides a product (e.g., a kit) containing recombinant human ASM (e.g., olipudase alfa) for use in any of the treatment methods described herein. [Brief explanation of the drawing]

[0025] [Figure 1] Figures 1A to C are graphs summarizing the changes in ceramide (A), lysosphingomyelin (B), and chitotriosidase (C) activity during 30 months of treatment with oripudase alfa. The normal range for plasma ceramide was defined as 1.8–6.5 mg / L. The upper limit of normal for lysosphingomyelin in dried blood spots was defined as <69 μg / L, and the normal level for serum chitotriosidase was defined as ≤181 nmol / hour / mL (Note: Activity has not been corrected for the two heterozygous patients with chitotriosidase nonexpression mutations). [Figure 2]Figures 2A and 2B are graphs summarizing the effects of olipudase alfa on liver and spleen volume (A) and lung disease (B). Figure 2A: Liver and spleen volumes were calculated by integrating cross-sectional magnetic resonance images and are shown as multiples (MN) of normal values. Normal spleen volume (L) was assumed to be 0.2% of body weight, and normal liver volume (L) was assumed to be 2.5% of body weight. Figure 2B: Lung disease. Percentages of predicted DLco, corrected for baseline and treatment hemoglobin (Hb) levels in each patient, were calculated using measured values ​​for male and female patients (Crapo et al., Am. Rev. Respir. Dis. 123(2): pp. 185-189 (1981); Macintyre et al., Eur. Respir. J. 26(4): pp. 720-735 (2005)). Severity: 80% = lower limit of normal; >60%~79% = mild decline; 40%~60% = moderate decline; <40% = severe decline. HRCT evaluation of infiltrative lung disease at baseline and during treatment with oripudase alfa included ground-glass opacities (GGA), interstitial lung disease (ILD), and reticular granular opacities (RD), scored on a 4-point scale. 0 = no interstitial lung disease; 1 = mild (lesion of 1-25% of lung volume); 2 = moderate (lesion of 26-50% of lung volume); 3 = severe (lesion of 51-100% of lung volume). [Figure 3] Figures 3A and 3B are photographs showing the effect of oripudase alfa on bone marrow load. Figure 3A (Femur): Changes in bone marrow load in the coronal plane of the femur of Patient 2 (female, 32 years old at baseline). The hypoechoic signaling of the proximal epiphyseal bone marrow in T1-weighted images (A) and T2-weighted images (B) at screening is compared to the decreased volume and slightly hypoechoic signaling of the diaphysis bone marrow after 30 months of treatment (T1-weighted, C, and T2-weighted, D). Full-length vertical scale bar, 20 cm. Figure 3B (Spine): Bone marrow load in the sagittal plane of the lumbar spine of Patient 2. At screening, diffuse bone marrow infiltration was observed, showing isoechoic signaling of non-disease intervertebral discs on T1-weighted images (A) and hyperechoic signaling of anterior sacral fat on T2-weighted images (B). After 30 months of treatment, bone marrow infiltration remained unchanged (T1-weighted, C), but the anterior sacral fat improved to slightly hyperechoic (T2-weighted, D). Full-length vertical scale bar, 20 cm. [Figure 4]Figures 4A–4D are graphs showing fasting lipid parameters at baseline and during treatment with oripudase alfa (30 months). Mean (SD) pre-infusion fasting levels of total cholesterol (A), triglycerides (B), HDL cholesterol (C), and LDL cholesterol (D) are shown. Normal range for total cholesterol: US <5.18 mmol / L; UK 0–3.9 mmol / L. Normal range for HDL-C: US ​​men >0.777; US women >0.9065 mmol / L; UK >1.2 mmol / L. Normal range for LDL-C: US ​​<3.3411 mmol / L; UK 0–2 mmol / L. Normal range for triglycerides: <1.7 mmol / L. [Modes for carrying out the invention]

[0026] This invention is based on the discovery that ASM enzyme replacement therapy (ERT) alleviates bone abnormalities in ASMD patients, including increasing bone density and reducing bone marrow load. Such improvements are observed in as little as 6 to 30 months of treatment. This discovery was unexpected because it was unclear whether ASM ERT would improve all symptoms of ASMD, including low bone density, and if so, how long it would take for the therapy to achieve symptom improvement. In other lipid storage disorders, ERT alone takes a very long time to improve bone mineral density. For example, in Gaucher disease, another hereditary lipid storage disorder, the patient's response to ERT treatment lags behind the blood and visceral response in GD in terms of bone mineral density (BMD). Studies have shown that it takes 8 years of ERT (imiglucerase) to restore a patient's BMD to normal levels (Wenstrup et al., J Bone Miner Res. 22(1): pp. 119-26 (2007)). This finding is also significant because bisphosphonates interfere with ASM activity, meaning that ASMD patients cannot use bisphosphonates, which are the standard treatment for low BMD, while undergoing ASM ERT.

[0027] Therefore, the present invention provides a method for treating bone abnormalities in ASMD patients by using ASM ERT. ASMD causes the accumulation of sphingomyelin in bone marrow cells, particularly mononuclear macrophage progenitor cells. These cells phagocytose and become trapped in the bone marrow, causing bone marrow infiltration and high bone marrow load (BMB). ASMD patients also often exhibit chronic inflammation, including intraosseous inflammation. Bone disease in ASMD adversely affects bone metabolism and bone structure. Patients present with several symptoms, including growth retardation, stunted growth, delayed maturation, bone pain, and fractures. In fact, ASMD has been shown to affect the skeletal system, with an inverse correlation to the Z-score of lumbar spine bone mineral density (BMD) (Wasserstein et al., J. Inherit. Metab. Dis. 36(1): pp. 123-127 (2013)). As used herein, bone abnormalities or bone diseases mean any bone problems associated with ASMD and their resulting symptoms, such as high bone marrow load, low bone mineral density, osteopenia, osteoporosis, delayed skeletal development (e.g., delayed bone age (maturation) and delayed length growth), increased disability, bone pain, decreased mobility, osteonecrosis, and increased risk of fracture.

[0028] In some embodiments, the bone abnormalities treated in ASMD patients by the method of the present invention are osteopenia or osteoporosis. In some embodiments, the patient is an adult (e.g., a patient aged 18 years or older, including elderly patients aged 65 years or older). In other embodiments, the patient is a pediatric patient (a patient under 18 years of age, e.g., a newborn to 6 years, 6 to 12 years, or 12 to 18 years). In some embodiments, the patient may have Niemann-Pick disease type A, Niemann-Pick disease type B, or Niemann-Pick disease type A / B. In certain embodiments, the method described herein is used to treat adult patients with chronic visceral ASMD (NPD B). In some embodiments, the method described herein is used to treat pediatric patients with chronic visceral ASMD (NPD B). In other embodiments, the method described herein is used to treat adult and pediatric patients with non-neurological symptoms of ASMD.

[0029] Bone condition assessment The bone condition of the subject can be evaluated by analyzing bone parameters (collectively referred to herein as “bone indicators”) using various methods. Bone indicators include, for example, bone mineral density (BMD), bone marrow load (BMB), bone age, length growth, and the status of certain bone biomarkers. In certain embodiments, bone abnormalities can be evaluated by bone imaging, such as X-ray imaging and magnetic resonance imaging (MRI). For example, bone scans can be taken from the femur and lumbar vertebrae at various time points to evaluate bone mineral density (BMD) and bone marrow load (BMB) as indicators of the patient’s bone condition before, during, and after treatment with the composition of the present invention. In certain embodiments, images are acquired using DXA (dual-energy X-ray absorptiometry) or MRI. In some embodiments, bone scan images can be acquired approximately weekly, every two weeks, every three weeks, every four weeks, every five weeks, every six weeks, monthly, every two months, every three months, every four months, every five months, every six months, every seven months, every eight months, every nine months, every ten months, every eleven months, annually, every two years, every three years, every four years, or every five years, and compared with baseline images acquired before the treatment of the present invention. In certain embodiments, bone scan images may be acquired approximately every six months or annually.

[0030] BMD can be calculated for each patient using the T-score and Z-score. The T-score positions the patient's bone density compared to that of a healthy individual of the same sex. The Z-score positions the patient's bone density compared to that of a healthy individual of the same age, sex, weight, and ethnicity.

[0031] BMB can be evaluated from sequential MRI scans using the BMB scoring system, which is based on the bone marrow signal intensity scoring system and assigns a category score from a possible 8 points for each of the lumbar spine and femur, out of a total score of 16 points (the femoral score is the average score of the left and right femurs). The bone marrow signal intensity scoring system is described, for example, by Hangartner et al., Skeletal Radiol. 37(3): pp. 185-188 (2008); Robertson et al., AJM Am J Roentgenol. 188(6): pp. 1521-1528 (2007); and Maas et al., Radiology 229(2): pp. 554-561 (2003) (all of these contents are incorporated herein by reference).

[0032] In other embodiments, bone biomarkers are analyzed to assess the bone status of the subject. “Bone biomarkers,” as used herein, refer to biomarkers associated with bone formation and bone resorption. For example, bone biomarkers such as serum bone-type alkaline phosphatase (ALP) and C-telopeptide can be analyzed in samples taken from a patient. Bone-type ALP, a marker of active bone formation, and C-telopeptide, an indicator of bone resorption, can be used as indicators of bone status. For example, in Gaucher disease, another lipid storage disorder, serum levels of C-telopeptide are reduced. In some embodiments, bone biomarkers can be analyzed approximately every 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, or 11 months, or every 1 year, 2 years, 3 years, 4 years, or 5 years, and compared to baseline levels obtained before treatment according to the present invention. In certain embodiments, bone biomarkers may be analyzed every 3 months or every 6 months.

[0033] Most children with ASMD exhibit growth retardation. Z-scores for height and weight are often lower in children with ASMD than in children without ASMD. In children with ASMD, bone age (e.g., determined by X-ray of the hand) and length growth are also often lower. Additional bone indicators can be analyzed to assess bone growth or skeletal development. In exemplary embodiments, hand X-rays may be performed to collect images of the patient's hand, fingers, and wrist. Bone age (maturity) can be calculated from the X-rays using the Greulich & Pyle Atlas (1959). Length growth, determined by the Z-score of height, is another bone indicator for assessing growth in pediatric patients.

[0034] Treatment of bone abnormalities using ASM Patients with bone abnormalities, such as those with ASMD, can be treated with ASM ERT. As used herein, “to treat,” “to treat,” and “treatment” mean a method of alleviating, suppressing, or preventing at least one of a biological disorder or condition and / or its associated symptoms, or delaying their onset or worsening (i.e., progression). As used herein, “alleviating” a disease, disorder, or condition means reducing the severity and / or frequency of the symptoms of that disease, disorder, or condition.

[0035] In some embodiments, the ASM used in ASM ERT may be human ASM, for example, recombinant human ASM (rhASM). Recombinant ASM can be produced in prokaryotic or eukaryotic host cells, such as mammalian host cells (e.g., Chinese hamster ovary (CHO) cells), using recombinant technology. In certain embodiments, rhASM is olipudase alpha, which is the glycoform alpha of human ASM (EC-3.1.4.12) produced in CHO cells. Mature olipudase alpha is a 570-amino acid polypeptide that retains the enzymatic and lysosomal targeting activity of the native human protein. The amino acid sequence of olipudase alpha, including its leader sequence (residues 1-57), is shown below, with the leader sequence indicated in italics and bold. The mature olipudase alpha sequence (SEQ ID NO: 2, spanning residues 58-627 of the sequence below) does not have a leader sequence. [ka]

[0036] In some embodiments, the ASM has an amino acid sequence that is 99%, 98%, 97%, 96%, or 95% identical to that of olipidase alpha. For example, the ASM useful in the present invention has the ASM sequence shown in U.S. Patent No. 6,541,218 (the entire disclosure of which is incorporated herein by reference). That sequence is shown below, with the leader sequence shown in bold in italics, but the mature protein does not have this leader sequence. [ka]

[0037] The ASM useful in this invention may also have the same amino acid sequence as the human ASM or its polymorphic variant disclosed in the UNIPROT database as sequence P17405-1. The P17405-1 sequence is shown below, with the leader sequence indicated in bold in italics; however, mature proteins do not have this leader sequence. [ka]

[0038] Proof of concept for olipudase alfa therapy has been demonstrated in ASM-deficient (ASMKO) mouse models (see, e.g., Miranda et al., FASEB 14(13):1988-95 (2000); Dhami et al., Lab.Inves. 81(7):987-99 (2001)). These studies showed that repeated intravenous administration of olipudase to ASMKO mice resulted in a dose-dependent decrease in sphingomyelin in endothelial organs. This decrease in sphingomyelin was also observed in the lungs. These ASMKO studies also showed that olipudase alfa may be toxic when administered at high doses. However, when olipudase alfa was administered to ASMKO mice in multiple low doses followed by a high dose, it did not produce the toxicity observed with a single high dose.

[0039] Olipudase alfa has been used in clinical trials to treat non-neurological ASMD symptoms. Findings in mice led to the initiation of a Phase 1 trial to evaluate the safety and pharmacokinetics of olipudase alfa treatment, in which a single escalating dose of olipudase alfa (0.03, 0.1, 0.3, 0.6, and 1.0 mg / kg) was evaluated in 11 patients (McGovern et al., Genet. Med. 15(8): pp. 618-623 (2013) and WO2011 / 025996; the entirety of these disclosures is incorporated herein by reference). Patients in this trial showed dose-related increases in acute-phase reactants, including ceramide, bilirubin, and high-sensitivity C-reactive protein (hsCRP). Dose-related adverse events, including systemic symptoms consistent with first-dose toxicity (pain, fever, nausea, and vomiting), were also reported.

[0040] A Phase 1b trial to evaluate the safety and tolerability of olipudase alfa over a 26-week treatment period was conducted in five adult patients (this entire content is incorporated herein by reference, Wasserstein et al., Mol. Genet. Metab. 116). (1-2): pp. 88-97 (2015). Patients in this study received oripudase alfa via a dose escalation regimen, starting with an initial dose of 0.1 mg / kg and gradually increasing every two weeks until reaching the target dose of 3.0 mg / kg. This study demonstrated that this dose escalation regimen was well-tolerated without serious or severe adverse events and gradually reduced sphingomyelin and its degradation products. Dose reduction refers to the removal of sphingomyelin accumulated in the patient's internal organs by ASMD. Improvements observed in patients included decreased spleen and liver volume, reduced interstitial lung disease scores, improved lung function, and decreased serum chitotriosidase, CCL18, ACE, and other disease biomarkers. The inventors have now found that these patients, when treated and monitored for 30 months in long-term safety and efficacy evaluations, exhibited a sustained safety profile and continuous improvements in clinically relevant parameters, including spleen and liver volume, lung disease score, lipid profile, and ASM biomarkers. The inventors also unexpectedly found that the patients showed significant improvements in both bone mineral density (BMD) and bone marrow load (BMB). These data indicate that ASM ERT can alleviate or prevent the worsening of bone malformations in patients with osteopenia and osteoporosis.

[0041] Dosage and route of ASM administration The pharmaceutical compositions containing ASM described herein are administered in a therapeutically effective dose for the treatment of the condition in question (e.g., bone abnormalities associated with ASMD), i.e., in the dosage and duration necessary to achieve the desired outcome. The therapeutically effective dose may vary depending on factors such as the specific condition being treated, the patient's age, sex, and weight, and whether enzyme replacement therapy is administered as a standalone treatment or in combination with one or more additional treatments. "Therapeutally effective dose" means the amount of the therapeutic agent administered that reduces, to some extent, one or more symptoms of the disorder or condition being treated, or prevents their exacerbation. The ASM compositions may be administered by intravenous injection.

[0042] In some embodiments, efficacy is indicated as an improvement in the bone mineral density T-score (e.g., T-score of the spine and / or femur). In certain embodiments, the T-score improves by at least 0.5 points. In some embodiments, efficacy is indicated as an improvement in the bone mineral density Z-score (e.g., Z-score of the spine and / or femur). In certain embodiments, the Z-score improves by at least 0.1 points. In some embodiments, efficacy is indicated as improvement, non-exacerbation, or delayed progression of bone diseases such as osteopenia or osteoporosis. In some embodiments, efficacy is indicated by improvement in skeletal development, such as length growth or bone age (maturity). In certain embodiments, improvement in skeletal development is determined by comparison with data obtained from studies of pediatric patients (Wasserstein et al., J Pediatr 142(4):424-428 (2003)). In other embodiments, improvement in skeletal development is determined by comparison with the growth curve of each patient before ASM therapy.

[0043] In some embodiments, the method of the present invention includes a dose-escalation protocol in which increasing doses of ASM (e.g., rhASM such as olipudase alfa) are administered over an appropriate period of time to gradually reduce the amount of sphingomyelin accumulated up to that point and to minimize toxic side effects caused by sphingomyelin degradation products. For example, the treatment may involve administering one or more initial non-toxic low doses of ASM to the patient to reduce the amount of sphingomyelin accumulated in the patient. Each escalation dose may be spaced one, two, or three weeks apart from the previous dose. In certain embodiments, escalation doses are administered at two-week intervals. As used herein, “non-toxic dose” and similar terms mean: (i) a moderate or severe clinical symptom that interferes with normal daily functioning and requires additional monitoring, intervention, or treatment, or an abnormal clinical laboratory value or treatment outcome that requires further monitoring, treatment, or intervention. The degree of related adverse events (e.g., Clinical Data Interchange Standards Consortium Study Data Tabulation Model standard terminology) See v.3.1.1); (ii) total bilirubin levels greater than 1.5 mg / dL, greater than 2 mg / dL, greater than 3 mg / dL, or greater than 4 mg / dL that persist for more than one week, more than two weeks, or more than three weeks after administration of a certain dose of rhASM; (iii) plasma ceramide concentrations greater than 8.2 μg / dL, greater than 9 μg / dL, greater than 10 μg / dL, greater than 15 μg / dL, greater than 20 μg / dL, greater than 30 μg / dL, greater than 40 μg / dL, greater than 50 μg / dL, greater than 60 μg / dL, greater than 70 μg / dL, or greater than 80 μg / dL 24 hours, 36 hours, 48 ​​hours, or 72 hours after administration of that dose of ASM; or (iv) doses of ASM administered to an ASMD patient without causing one, two, three, or all of the acute phase responses / reactions. The "non-toxic dose" of an ASM may vary depending, for example, on the stability of the enzyme used, its activity, and / or the route of administration of that enzyme. For example, the dose of a modified ASM enzyme with enhanced activity may be less than the dose of an unmodified ASM. Those skilled in the art can adjust the dose of the enzyme administered based on the enzyme's stability, activity, and / or the route of administration.

[0044] After a certain period, the dose of ASM may be escalated until the patient reaches the highest therapeutically effective dose tolerable by the patient. Once this dose is identified, the patient can be treated with this as a maintenance dose. Alternatively, the maintenance dose may be reduced from the highest escalation dose if the patient's ASMD condition stabilizes after the dose escalation regimen. The maintenance dose may be administered to the patient every week, every two weeks, every three weeks, or every four weeks. In a particular embodiment, the maintenance dose is administered every two weeks.

[0045] As used herein, the term “maintenance dose” means the amount of ASM described herein administered to an ASMD patient to maintain a desired therapeutic effect, for example, improvement or non-exacerbation of one or more bone malformations, for example, the bone malformations described herein.In certain embodiments, the maintenance dose is the desired therapeutic effect: (i) reduction of spleen volume as assessed by techniques known in the art, e.g., MRI; (ii) reduction of hepatic sphingomyelin levels as assessed by techniques known in the art, e.g., biochemical analysis and / or histomorphometric analysis of liver samples; (iii) improvement of exercise capacity as assessed by techniques known in the art, e.g., maximal workload by bicycle ergometry including percentage of predicted maximum workload, maximum oxygen consumption, and carbon dioxide production; (iv) improvement of exercise capacity as assessed by techniques known in the art, e.g., American Thoracic (v) Improvement of lung function as assessed by techniques described in Society, Am. Rev. Respir. Dis. 144: pp. 1202-1218 (1991), e.g., diffusion capacity (DLco), a percentage of predicted forced vital capacity (FVC) as measured by spirometry, e.g., forced expiratory volume in one second (FEV1) as determined by spirometry, e.g., forced expiratory volume in one second (FEV1), and total lung volume; (v) Reduction of bronchoalveolar lavage (BAL) sphingomyelin; (vi) Reduction of liver volume as assessed by techniques known in the art, e.g., MRI; (vii) Improvement of lung appearance as assessed by techniques known in the art, e.g., high-resolution computed tomography (CT) scans or chest X-rays; (viii) E.g., tandem mass spectrometry (ix) Decreased sphingomyelin or lysosphingomyelin concentrations in the liver, skin, plasma, and dried blood spots (DBS) as determined by; (x) Decreased or improved severity of ASMD and / or related symptoms; (x) Reduced duration of ASMD-related symptoms; (xi) Prevention of relapses of ASMD-related symptoms; (xii) Reduced hospitalizations in the subject; (vi) Shorter length of hospital stay; (xiii) Increased survival time in the subject; (xiv) Reduced mortality; (xv) Reduced hospitalization rate; (xvi) Reduced number of ASMD-related symptoms; (xvii) Increased asymptomatic survival time for ASMD patients; (xviii) Improved neurological function (e.g., psychomotor function, social responsiveness, etc.); (xix) E.g., by BAL cell count and profile. (xx) Improvement in lung clearance as measured by (xx) a decrease in serum levels of chitotriosidase; (xxi) a decrease in serum levels of chemokine (cc) motif ligand 18 (CCL18); (xxii) improvement in lipid profile (e.g., HDL, LDL, cholesterol, triglycerides, and total cholesterol:HDL ratio); (xxiii) improvement in bone status abnormalities; and (xxiv) for example, questionnaires, e.g., Brief Fatigue Inventory (BFI) (Mendoza et al., Cancer 85(5): pp. 1186-1196 (1999)), Brief Pain Questionnaire (BFI) Maintain one, two, three, four, or more improvements in quality of life (QOL) as assessed by the Inventory-Short Form (BPI-SF) (Cleeland C., Acta Paediatr. Suppl. 91(439): pp. 43-47 (2002)), the Pediatric Quality of Life (PedsQL) Questionnaire (Varmi et al., Medical Care 39(8): pp. 800-812 (2001)), or the PedsQL Multidimensional Fatigue Scale (Varmi et al., J Rheumatol 31(12): pp. 2494-2500 (2004)). In certain embodiments, the maximum maintenance dose is the highest or maximum dose tolerated by the patient.

[0046] In some embodiments, patients receiving a maintenance dose are monitored every month, every two months, every three months, every four months, every five months, every six months, every seven months, every eight months, every nine months, every ten months, or every eleven months, annually, or every two years for one or more of the following: (i) related adverse events; (ii) total / direct / indirect bilirubin concentration; (iii) plasma ceramide concentration; or (iv) acute phase response. In some embodiments, patients are monitored every three months, every six months, or annually. If a patient exhibits a moderately severe related adverse event, a total bilirubin concentration higher than that of a person without ASMD (e.g., a healthy person), a plasma ceramide concentration higher than that of a person without ASMD (e.g., a healthy person), or an acute phase response, a physician or other healthcare professional may review the dose being administered to the patient and determine whether the dose should be adjusted.

[0047] In a particular embodiment, a method for treating a human patient having ASMD is: (a) a dose-escalation regimen (e.g., aimed at reducing the amount of sphingomyelin substrate accumulated in a human patient) comprising: (i) administering an initial dose (e.g., a non-toxic low dose such as 0.1 mg / kg) of the ASM described herein (e.g., olipudase alfa) to the human patient; (ii) administering successively increasing doses of the ASM to the human patient; and (iii) after each dose of the series, observing, for example, an increase in total bilirubin concentration, an increase in plasma ceramide concentration, production of lysosphingomyelin, chitotriosidase, acute-phase reactants, production of inflammatory mediators, or adverse events (e.g., Clinical Data Interchange Standards Consortium Study Data Tabulation Model standard terminology). (b) A dose-escalation regimen comprising the step of monitoring the patient for one or more adverse side effects, such as those indicated by an adverse event as defined in v.3.1.1; (b) A maintenance regimen comprising the step of administering to the patient a dose less than or equal to the highest dose tolerated by the patient (e.g., less than or equal to 3 mg / kg) as a maintenance dose.

[0048] In a particular embodiment, a method for treating a human patient having ASMD is: (a) a dose-escalation regimen (for example, aimed at reducing the amount of sphingomyelin substrate accumulated in a human patient) comprising: (i) administering an initial dose (for example, a non-toxic low dose such as 0.1 mg / kg) of the ASM described herein (e.g., olipudase alfa) to the human patient; and (ii) the patient having, for example, an increase in total bilirubin concentration, an increase in plasma ceramide concentration, (b) A dose-escalation regimen comprising the step of administering a successively increasing dose of ASM to a human patient if the patient does not exhibit one or more adverse side effects, such as the production of acute-phase reactants, the production of lysosphingomyelin, chitotriosidase, inflammatory mediators, or adverse events (e.g., adverse events as defined in Clinical Data Interchange Standards Consortium Study Data Tabulation Model standard terminology v.3.1.1); (b) a maintenance regimen comprising the step of repeatedly administering a maintenance dose below the highest dose tolerated by the patient (e.g., 3 mg / kg or less). In some embodiments, the patient is monitored for one or more adverse side effects over a period of time following the administration of one dose of ASM (e.g., 6 hours, 12 hours, 16 hours, 24 hours, 48 ​​hours, 72 hours, weekly, or up to the next dose). In certain embodiments, the maintenance dose administered may be adjusted in the course of the patient's treatment. In some embodiments, the highest maintenance dose administered to the patient is the highest dose the patient tolerates.

[0049] In certain embodiments, the initial dose is 0.025–0.275 mg / kg of ASM (e.g., olipudase alfa), for example, 0.03 mg / kg–0.5 mg / kg, 0.01–0.5 mg / kg, or 0.1 mg / kg–1 mg / kg. In certain embodiments, the initial dose is 0.03 mg / kg or 0.1 mg / kg. For example, the initial dose for pediatric patients may be 0.03 mg / kg; the initial dose for adult patients may be 0.1 mg / kg. In some embodiments, the initial dose for pediatric or adult patients may be 0.1 mg / kg.

[0050] In certain embodiments, the patient is administered the same dose of olipudase alfa at least twice before being gradually increased to the next higher dose. In some embodiments, the sequentially increasing dose is administered one, two, three, or four weeks after the previous dose. In some specific embodiments, the sequentially increasing dose is administered two weeks after the previous dose. In certain embodiments, the sequentially increasing dose is 0.05–1.0 mg / kg, 0.1–3.0 mg / kg, or 0.5–2.0 mg / kg more than the previous dose, for example, approximately 0.07 mg / kg, 0.2 mg / kg, 0.3 mg / kg, 0.4 mg / kg, or 1 mg / kg more than the previous dose.

[0051] In some embodiments, the maximum therapeutically effective dose tolerated by the patient is 1 mg / kg to 2.5 mg / kg, 2 mg / kg to 3 mg / kg, or 3 mg / kg to 5 mg / kg. In some embodiments, the maximum therapeutically effective dose tolerated by the patient is 1 mg / kg, 2 mg / kg, 3 mg / kg, 4 mg / kg, or 5 mg / kg. In a particular embodiment, the maximum dose tolerated by the patient is 1 mg / kg to 3 mg / kg, for example, 1 mg / kg to 2.5 mg / kg. In some embodiments, the maximum dose is administered to the human patient as the maximum maintenance dose. In a particular embodiment, the maximum maintenance dose is, for example, 0.3 mg / kg, 0.6 mg / kg, 1 mg / kg, 2 mg / kg, or 3 mg / kg. In a particular embodiment, the maximum maintenance dose is 3 mg / kg. Subsequent maintenance doses may be the same amount as or less than the maximum maintenance dose. In some embodiments, the maintenance dose is 0.3 to 3 mg / kg.

[0052] In some embodiments, the dose escalation regimen may include the step of administering multiple doses of ASM in the following order: for example, 0.1 mg / kg, 0.3 mg / kg, 0.3 mg / kg, 0.6 mg / kg, 0.6 mg / kg, 1.0 mg / kg, 2.0 mg / kg, and 3.0 mg / kg (maximum maintenance dose), with each subsequent dose being administered two weeks after the previous dose. In other embodiments, the dose escalation regimen may include the following steps: for example, 0.03 mg / kg, 0.1 mg / kg, 0.3 mg / kg, 0.3 mg / kg, 0.6 mg / kg, 0.6 mg / kg, 1.0 mg / kg, 2.0 mg / kg, and 3.0 mg / kg (maximum maintenance dose). The process involves administering multiple doses of ASM in the following order, and may include the step of administering each subsequent dose two weeks after the previous dose.

[0053] In certain embodiments, the ASM described in a certain dosage specification is administered to the patient weekly, every two weeks, every three weeks, or every four weeks. In certain embodiments, this dose is administered, for example, by intravenous injection at intervals of two weeks.

[0054] In some embodiments, the method of the present invention involves administering an ASM dose over a period of 6 to 30 months, for example, 6 months or less, 7 months or less, 8 months or less, 9 months or less, 10 months or less, 11 months or less, 12 months or less, 13 months or less, 14 months or less, 15 months or less, 16 months or less, 17 months or less, 18 months or less, 19 months or less, 20 months or less, 21 months or less, 22 months or less, 23 months or less, 24 months or less, 25 months or less, 26 months or less, 27 months or less, 28 months or less, 29 months or less, or 30 months or less, in order to improve the target bone condition. In a particular embodiment, the ASM dose is administered over a period of 30 months or less.

[0055] In further embodiments, the method of the present invention includes, for example, the administration protocol and / or route of administration described in WO2011 / 025996 (the entire disclosure thereof is incorporated herein by reference).

[0056] In certain embodiments, dose-escalation regimens used to treat adult or pediatric ASMD patients may be, for example, as shown in the table below:

[0057] [Table 1]

[0058] In further specific embodiments, the dose-escalation regimen used to treat pediatric ASMD patients may be, for example, as shown in the table below:

[0059] [Table 2]

[0060] In some embodiments, the pediatric patient population includes an ASMD adolescent cohort (ages 12 to under 18), an ASMD pediatric cohort (ages 6 to under 12), and an infant / toddler cohort (ages 6 to under 6).

[0061] Products and Kits The present invention also provides products and kits comprising ASM as described herein. In some embodiments, the products and kits are suitable for treating patients as described herein, for example, patients with ASMD. For example, the products and kits may be suitable for treating the bone malformations described herein in patients with ASMD. In some embodiments, the pharmaceutically active ingredients contained in the products and kits are manufactured for administration in the doses described herein and formulated for administration by the methods described herein.

[0062] Unless otherwise specified herein, scientific and technical terms used in connection with the present invention shall have the same meaning as those generally understood by those skilled in the art. Exemplary methods and materials are described herein, but similar or equivalent methods and materials may also be used in the practice and testing of the present invention. In case of any conflict, including definitions, this specification shall prevail. Generally, the nomenclature and techniques used in relation to cell and tissue culture, molecular biology, immunology, microbiology, genetics, analytical chemistry, organic synthesis chemistry, pharmaceutical and pharmaceutical chemistry, and protein and nucleic acid chemistry and hybridization described herein are well known and commonly used in the art. Enzyme reactions and purification methods shall be carried out in accordance with the manufacturer's specifications, as commonly performed in the art, or as described herein. The entire contents of all publications and other references referenced herein are incorporated herein by reference. Numerous documents are cited herein, but these citations do not imply that any of these documents constitute part of the common general knowledge in the art. Furthermore, unless the context requires a different interpretation, singular terms shall include plurals, and plural terms shall include singulars. Throughout this specification and its embodiments, the terms “have” and “comprise,” or variations such as “has,” “having,” “comprises,” or “comprising,” shall include the integer or set of integers presented. However, this should be understood as implying that no other integers or groups of integers are excluded. [Examples]

[0063] To aid in understanding the present invention, examples are provided below. These examples are for illustrative purposes only and should not be construed as limiting the present invention in any way. [Examples]

[0064] Long-term study to evaluate the safety and efficacy of oripudase alfa in patients with ASMD Patient and study design The objective of this study is to obtain information on the safety and efficacy of oripudase alfa in patients with ASMD after long-term administration. This ongoing open-label long-term study (LTS) (NCT02004704; EudraCT number: 2013-000051-40) follows up five adult patients with chronic ASMD who had previously participated in a Phase 1b trial (Wasserstein et al., Mol Genet Metab 116(1-2): pp. 88-97 (2015)). Data were analyzed for all patients after 30 months of treatment. The Institutional Review Board or Ethics Committee at each institution approved the protocol, and all patients submitted written informed consent. The study was conducted in accordance with Good Clinical Practice standards and the principles of the Declaration of Helsinki.

[0065] The eligibility criteria for the Phase 1b trial have already been described. Ibid. Patients who completed the Phase 1b trial with an acceptable safety profile were deemed eligible to continue in the LTS and continued on the same olipudase alfa dose they were receiving at the end of the Phase 1b trial.

[0066] Outcome evaluation items and analysis Safety assessment included a standard series of hematological and chemical tests, as well as continuous adverse event (AE) monitoring, including infusion-associated reactions (IARs), as previously described in McGovern et al., Genet Med 18(1):34-40 (2015) and Wasserstein et al., Mol. Genet. Metab. 116(1-2):88-97 (2015). Plasma ceramides, including sphingomyelin and its degradation products, were evaluated by liquid chromatography-tandem mass spectrometry (LC / MS / MS). Bone status biomarkers also included chitotriosidase (serum) and lysosphingomyelin [dried blood spot (DBS)] as determined by LC / MS / MS. Anti-drug antibody production was assessed as previously described in McGovern et al., 2015, see above, and Wasserstein et al., Mol. Genet. Metab. 116(1-2):88-97 (2015).

[0067] Quantitative assessment of spleen and liver volume was determined from abdominal MRI, and organ volume is expressed as a multiple of normal (MN). The percentage relative to the predicted carbon monoxide pulmonary diffusion capacity (DLco) corrected for hemoglobin was expressed using the standard formula (Crapo and Morris, Am Rev). The calculations were performed using Respir Dis 123(2):pp. 185-189 (1981) and Macintyre et al., Eur Respir J 26(4):pp. 720-735 (2005). Infiltrative lung disease was evaluated by high-resolution computed tomography (HRCT). Ground-glass opacities (GG), interstitial lung disease (ILD), and reticular granular opacities (RND) in lung field HRCT images were subjectively scored from 0 (no disease) to 3 (severe disease), as already described in McGovern et al., 2015, see above, and Wasserstein et al., 2015, see above.

[0068] Fasting plasma lipid profiles, including measurements of total cholesterol (TC), low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), and triglycerides, were measured throughout the study. Non-HDL levels were retrospectively calculated as the difference between total cholesterol levels and HDL-cholesterol levels (Jacobson et al., J. Clin. Lipidol. 9(2): pp. 129-169 (2015)).

[0069] Bone marrow load (BMB) was determined from MRI of the lumbar spine and both femurs, where image quantification indicated the degree of bone marrow infiltration by lipid-loading cells (Robertson et al., AJR.Am.J.Roentgenol.188(6):1521-1528 (2007)). Bone mineral density (BMD) was determined from dual-energy X-ray absorptiometry (DXA) bone scan images of the lumbar spine and both femurs, as well as from T-scores and Z-scores (WHO JAMA 285(6):785-795 (2001)). BMD was evaluated using guidance provided by the International Society for Clinical Densitometry (ISCD 2015).

[0070] Patient-reported outcomes using an 11-point scale from 0 (absent) to 10 (worst) included assessments of impairment in daily activities at baseline and periodically throughout the treatment period, using an effective Brief Fatigue Inventory (BFI) (Mendoza et al., Cancer 85(5): pp. 1186-1196 (1999)); and a Brief Pain Inventory-Science Scale (BPI-SF) questionnaire (Cleeland). C., Acta Paediatr. Suppl. 91(439): pp. 43-47 (2002)).

[0071] statistical method Descriptive statistics for categorical and continuous variables are presented. Changes from baseline and percentage changes from baseline (%) were calculated for organ volume and DLco, and differences were determined using paired t-tests and Wilcoxon-Mann-Whitney tests.

[0072] Patients and exposure All five adult patients (three males and two females, all Caucasian) who completed the Phase 1b trial continued treatment with LTS. At baseline, all patients had splenomegaly (ranging from 7.4 to 16.1 MN), hepatomegaly (ranging from 1.2 to 2.2 MN), impaired gas exchange (ranging from 43 to 80% of predicted DLco), and a pro-atherosclerotic lipid profiles. Patient characteristics have already been published (Wasserstein et al., Mol. Genet. Metab. 116(1-2): pp. 88-97 (2015)), and are summarized in Table 3. The majority of patients (4 / 5) maintained an opidase alfa-targeted dose of 3 mg / kg throughout the 30-month treatment period. In patient 2, due to an adverse event described later, the dose was reduced to 2 mg / kg for 6 months (months 12-18) and then to 1 mg / kg thereafter (month 18-present).

[0073] [Table 3]

[0074] safety During the 30-month treatment period, no deaths, serious or severe events, or discontinuations were observed. All patients experienced at least one adverse event (AE), and almost all of these (826 / 838, 98.5%) were mild in severity. Of the 443 possible treatment-related AEs, 96 (21.7%) were considered to be acute adverse reactions (IARs), including headache, nausea, abdominal pain, arthralgia, musculoskeletal pain, and myalgia. Six moderate AEs considered to be IARs occurred during the Phase 1b trial (first 6 months) and have already been reported (Wasserstein et al., Mol. Genet. Metab. 116(1-2): pp. 88-97 (2015)). In the LTS (long-term study) from 6 to 30 months, five moderate AEs considered to be IARs were abdominal pain, hepatic pain, nausea, muscle cramps, and paresthesia in patient 2. No hypersensitivity reactions, acute phase reactions, or cytokine release syndromes were observed. None of the patients produced IgG antibodies against olivepidase alfa. No clinically significant adverse changes were observed in vital signs, blood, or cardiac safety parameters.

[0075] The levels of the inflammatory markers IL-6, IL-8, and hsCRP were stable at the end of the Phase 1b trial (Wasserstein et al., Mol. Genet. Metab. 116). 1-2):pp. 88-97 (2015) showed that all patients remained stable except for patient 2, who experienced fluctuations in hsCRP (1.10-33.3 mg / mL; normal range 0-5) from 6 to 30 months. Plasma ceramide levels in all patients (Figure 1A) remained within the normal range (1.8-6.5 μg / mL).

[0076] Liver enzyme levels remained within the normal range in all patients until 30 months. At 30 months, patient 4 showed transient increases in ALT (1.4 times normal) and AST (2.9 times normal), but these did not correspond to an adverse event (AE) and subsequently returned to normal levels. Total bilirubin and GGT levels remained at or below baseline levels in all patients. Iron levels fluctuated over time but remained within or near the normal range.

[0077] During the Phase 1b dose escalation, Patient 2 exhibited an IAR (Illegible Arrhythmia), and the dose was repeated at 2 mg / kg (Wasserstein et al., Mol. Genet. Metab. 116(1-2): pp. 88-97 (2015)). This patient subsequently received the target dose of 3 mg / kg during the Phase 1b trial and the first 6 months of the LTS. During this time, the patient reported mild adverse events (AEs) including nausea, headache, fatigue, throbbing, intermittent abdominal pain, and occasional fever (38.3-40.0°C) 7-10 days after most infusions. Episodes lasted approximately 3 days and resolved completely by the next infusion. The dose of olipudase alfa was reduced (2 mg / kg for 6 months, and then 1 mg / kg to date). Reducing the dose did not alter the timing, frequency, or type of reported events.

[0078] efficacy Volume of the spleen and liver Spleen and liver volumes decreased in all patients compared to baseline (Figure 2A). Mean spleen volume decreased from 12.8 MN at baseline to 6.7 MN at 30 months, representing a 47.3% decrease from baseline (p<0.0001). Mean liver volume decreased from 1.7 MN at baseline to 1.07 MN at 30 months, representing a 35.6% decrease from baseline (p=0.006).

[0079] infiltrative lung disease The percentage relative to predicted DLco increased in all patients compared to baseline (Figure 2B), improving from a mean 53.2% (moderate) at baseline to 67.1% (mild) at 30 months. The most significant changes were observed in three patients with the lowest percentage relative to predicted DLco at baseline (<40%, within the severe range). Figure 2B also shows the assessment of invasive lung disease by mean scores for each element at baseline, 6 months, 18 months, and 30 months. This data shows a gradual decrease in all parameters, but GG shadows and RND, in particular, almost completely disappeared.

[0080] Fasting lipid parameters Fasting lipid profiles are shown in Figures 4A-4D. By 30 months, triglycerides decreased by 42.99% (p=0.02), total cholesterol by 12.7% (p=0.04), LDL-C by 22.8% (p=0.007), and HDL-C increased by 137.6% (p=0.01). Non-HDL cholesterol levels (total cholesterol minus HDL-C) were above 3.37 mmol / L (130 mg / dL) in 4 out of 5 patients at baseline (mean 3.91 mmol / L), and below 3.37 mmol / L in all patients at 30 months (mean 2.66 mmol / L).

[0081] Biomarker evaluation During DBS, the mean lysosphingommelinn levels were five times higher than the upper limit of normal (ULN = 69 μg / L) at baseline, but decreased to nearly normal levels and remained stable from month 6 to month 30 (Figure 1B).

[0082] Pre-infusion serum chitotriosidase levels steadily decreased by 72.3% from 735 nmol / hour / mL at baseline to 221 nmol / hour / mL at 30 months (p=0.0007), approaching the upper limit of the normal chitotriosidase range (≤181 nmol / hour / mL) (Figure 1C). Data have not been adjusted for two patients who are heterozygous for a common 24 bp duplication that reduces serum chitotriosidase activity.

[0083] hematology Most patients maintained platelet counts slightly below normal or within the low-normal range. Patient 1 maintained values ​​below low-normal (150 × 10⁹ / L) (57–10ⁿ × 10⁹ / L) throughout the study period. The mean change (increase) in platelet count from baseline fluctuated over time [5.9% (month 27) to 25.7% (month 9)], reaching 20.6% at month 30. Hemoglobin levels remained at similar levels to baseline (mean change from baseline ranged from -6.1% at week 12 to 6.9% at month 24) and were within the normal range in all patients (data not shown).

[0084] bone density At baseline, the mean spinal cord T-score was -1.48 ± 1.14, within the osteopenia range (-1.0 to -2.5), while the Z-score indicated normal BMD (-1.36 ± 1.26), within -1 standard deviation of the low BMD cutoff value (-2.0). Both the T-score and Z-score showed improvement at 30 months (-0.94 ± 1.03 and -0.78 ± 1.11, respectively). Patient 2 (female, 32 years old at baseline) had a baseline spinal cord T-score (-3.06) within the osteoporosis range, but improved to the borderline osteopenia / osteoporosis range at 18 months (-2.48) and 30 months (-2.65). Two patients whose baseline T-scores were within the range for osteopenia (Patient 1, male, 31 years old at baseline, -1.31, and Patient 4, male, 28 years old at baseline, -2.14) showed scores within the normal range at 30 months (-0.76 and -0.82, respectively). Individual longitudinal Z-score results were similar.

[0085] Mean femoral T-scores and Z-scores were within the normal range at baseline (-0.38±1.35 and -0.27±1.46, respectively) and at 30 months (-0.28±1.27 and -0.13±1.4, respectively). Patient 2's baseline femoral T-score was within the osteopenic range (-2.23), and its Z-score indicated low BMD (-2.18); both showed slight improvement at 30 months (-1.89 and -1.82, respectively).

[0086] Bone marrow burden The mean category score of BMB was similar at baseline (6.2±2.5) and 30 months (5.6±1.1). Patient 2 had the highest total BMB score of 10 at baseline, but improved by 3 points at 18 months and 30 months (score 7). T1-weighted and T2-weighted images of the femur and spine of Patient 2 at baseline and after 30 months of oripudase alfa treatment are shown in Figures 3A and 3B. The hypoechoic bone marrow observed at baseline decreased after 30 months of treatment. In the spine, diffuse bone marrow infiltration and hyperechoic signal intensity of anterior sacral fat were observed at baseline, but after 30 months of treatment, the former remained unchanged, while the latter improved.

[0087] Patient-reported outcomes The mean BFI±SD fatigue score was 3.04±2.29 at baseline and 2.44±3.44 at 30 months. The mean BPI±SD pain severity score was 3.45±2.77 at baseline and 2.90±2.70 at 30 months, and the mean BPI±SD pain impairment score was 2.03±1.58 at baseline and 3.29±3.51 at 30 months. Most individual BFI and BPI pain severity scores were in the mild (0-3) or moderate (4-6) range at all time points. The exception was patient 5, whose BPI pain was severe (7-10) at both baseline (6.8) and 30 months (7). BPI pain impairment scores were elevated in Patient 2 (2 at baseline, 8.1 at 30 months) and Patient 3 (1.9 at baseline, 5.3 at 30 months). Patient 2 reported moderate fatigue (5.8) at baseline and severe fatigue (8.3) at 30 months.

[0088] This study demonstrated that 30 days of treatment with olipudase alfa, the first etiology-specific treatment under development for ASMD, was well-tolerated and associated with life-changing, sustained improvement in the clinical endpoints of the related disease. The 30-month safety profile was similar to that of the Phase 1b trial (Wasserstein et al., Mol. Genet. Metab. 116(1-2): pp. 88-97 (2015)). No hypersensitivity reactions occurred, and no anti-drug antibodies were detected. To date, no cytokine release syndrome has been observed in any patient exposed to olipudase alfa. Since IAR is not an immune response, it is thought to be related to the release of bioactive sphingomyelin metabolites, mainly ceramides, which are signaling intermediates for cytokine release, inflammation, and apoptosis (Spiegel et al., Curr. Opin. Cell Biol. 8(2): pp. 159-167 (1996); Gulbins et al., J. Mol. Med. 82(6): pp. 357-363 (2004)). During the first six months of treatment, administration of olipudase alfa induced a transient increase in plasma ceramide levels, which generally peaked 48 hours after infusion (Wasserstein et al., Mol. Genet. Metab. 116(1-2): pp. 88-97 (2015)). Both pre- and post-infusion ceramide levels steadily decreased with each subsequent olipudase alfa infusion, reaching a stable state after 3 months of treatment and remaining stable until 30 months later.

[0089] Clinical improvement persisted over 30 months. Statistically significant improvements in liver and spleen volume (mean reduction rates of 31.2% for liver volume and 39.3% for spleen) were comparable to the response to ERT in other lysosomal storage disorders. In Gaucher disease, the treatment target for spleen volume is a 30-50% reduction within the first year of treatment, and for liver volume, a 20-30% reduction within the first two years of treatment (Pastores et al., Semin Hematol). 41(Supple 5): pp. 4-14 (2004)).

[0090] Patients with chronic visceral or chronic neurovisceral ASMD show worsening of infiltrative lung disease with age (Wasserstein et al., Pediatrics 114(6):e672-677 (2004)). During 30 months of treatment, a 35% increase in lung diffusion capacity from baseline was observed, with significant changes seen in the three patients with the lowest baseline DLCO. The improvement in lung disease scores observed during the first six months of treatment (Wasserstein et al., Mol. Genet. Metab. 116(1-2):88-97 (2015)) continued during the following two years of treatment, and some parameters (e.g., GG shadows and RND) normalized.

[0091] Atherosclerotic lipid profiles typically worsen with age in patients with chronic ASMD (Wasserstein et al., Pediatrics 114(6):e672-677 (2004)), and dyslipidemia may be associated with early coronary artery disease (McGovern et al., J.Pediatr. 145(1):77-81 (2004)). )). At baseline, patients had a mild to moderate risk of cardiovascular disease based on their lipid profiles (Wasserstein et al., Mol. Genet. Metab. 116(1-2): pp. 88-97 (2015)), but their profiles improved during the 30-month treatment period. Non-HDL cholesterol levels are considered a good predictor of cardiovascular risk in many patient populations, with a desirable level being less than 3.37 mmol / L (130 mg / dL) (Jacobson et al., J. Clin. Lipidol. 9(2): pp. 129-169 (2015)). All but one patient had non-HDL levels above 3.37 mmol / L before ERT, but at 30 months, all patients showed improvement in total cholesterol and HDL levels, with non-HDL levels below the 3.37 mmol / L cutoff value.

[0092] Skeletal complications are also a prominent feature of chronic ASMD. Improvement in bone mass denaturation (BMD), particularly in the spine, was observed in some patients, suggesting that opidase alfa has a beneficial effect on BMD in adults with ASMD. In other lipid storage disorders with low BMD, such as Gaucher disease, the bone disease response to ERT alone in adult patients is slow (Wenstrup et al., J. Bone Miner. Res. 22(1): pp. 119-126 (2007)), but combination therapy with ERT to inhibit bone resorption may improve osteopenia (Wenstrup et al., Blood 104(5): pp. 1253-1257 (2004)). However, bisphosphonates may not be suitable for ASMD patients because they inhibit ASM activity (Arenz Cell Physiol. Biochem. 26(1): pp. 1-8 (2010)). None of the patients in the study had received bisphosphonate therapy. The results of this study suggest that olipudase alfa alone may improve osteopenia.

[0093] Other clinical endpoints showed improvement or stability during ERT. Platelet counts and hemoglobin levels remained stable. Moderate levels of BMB were measured at baseline and after 30 months of oripudase alfa treatment, and improvement was observed in some patients. Patients had mild to moderate levels of pain and fatigue at baseline, which remained stable at 30 months in most patients. The worsening of the patient-reported outcome in patient 3 was not related to an AE. Patient 2 reported an AE characterized by influenza-like symptoms, along with worsening fatigue and pain, after 1 year of ERT. This patient had atypical lupus erythematosus, and it is unclear whether this contributed to the fatigue and pain, AE, and fluctuations in inflammatory cytokines. In this patient, reducing the oripudase alfa dose to 1 mg / kg / week did not affect the incidence of AE, fatigue, or pain. This patient continued to experience clinical benefits with a reduced dose of oripudase alfa (12 months of exposure), including reductions in spleen and liver volume, improvement in the percentage of predicted DLco, sustained resolution of invasive HRCT parameters, and stabilization of biomarkers.

[0094] Chitotriosidase, a well-known biomarker for monitoring treatment during ERT in Gaucher disease (Guo et al., J. Inherit. Metab. Dis. 18(6): pp. 717-722 (1995)), and a marker of chronic inflammatory diseases, steadily decreased during oripudase alfa treatment (Boot et al., Clin Chim Acta 411(1-2): pp. 31-36 (2010)). Lysosphingomyelin, a deacylated form of sphingomyelin, decreased during DBS, suggesting its usefulness as a biomarker for monitoring ERT outcomes, as it shows a steady decrease as the patient's sphingomyelin levels stabilize during long-term treatment. Lysosphingomyelin levels were approximately five times higher during DBS in patients with chronic visceral ASMD (Chuang Mol. Genet. Metab. 111(2): pp. 209-211 (2014)).

[0095] This open-label extension trial of olipuidase alfa involved 30 months of olipuidase alfa. The treatment demonstrated good tolerability and clinical effectiveness.

Claims

1. Use of recombinant human acid sphingomyelinase (rhASM) for producing a pharmacopoeia for improving bone mineral density (BMD) by reducing the accumulation of sphingomyelin in bone marrow cells in a patient with acid sphingomyelinase deficiency (ASMD), wherein the patient's BMD is in the range of osteopenia or osteoporosis, the patient requires improvement of BMD, and the rhASM is administered in multiple doses.

2. The use according to claim 1, wherein bone marrow cells are precursor cells of the mononuclear macrophage system.

3. The use according to claim 1 or 2, wherein the patient has Niemann-Pick disease type B.

4. The use according to claim 1 or 2, wherein the patient has Niemann-Pick disease type A / B.

5. The use according to any one of claims 1 to 4, wherein the patient is an adult patient.

6. The use according to any one of claims 1 to 4, wherein the patient is a pediatric patient.

7. The patient is a pediatric patient, and multiple doses of rhASM are administered intravenously, as follows: The first dose of 0.03 mg / kg in week 0, The second dose of 0.1 mg / kg in the second week, The third dose of 0.3 mg / kg in the fourth week, The fourth dose of 0.3 mg / kg in the sixth week, The fifth dose of 0.6 mg / kg in the 8th week, The sixth dose of 0.6 mg / kg in the 10th week, The seventh dose of 1 mg / kg in the 12th week, The 8th dose of 2 mg / kg at week 14, The ninth dose of 3 mg / kg at week 16, and Subsequent maintenance dose of 3 mg / kg every two weeks. The use according to any one of claims 3, 4, and 6, including the use described in claim 6.

8. The patient is an adult, and multiple doses of rhASM are administered intravenously, as follows: The first dose of 0.1 mg / kg in week 0, The second dose of 0.3 mg / kg in the second week, The third dose of 0.3 mg / kg in the fourth week, The fourth dose of 0.6 mg / kg in the sixth week, The fifth dose of 0.6 mg / kg in the 8th week, The sixth dose of 1 mg / kg in the 10th week, The seventh dose of 2 mg / kg at week 12, The 8th dose of 3 mg / kg at week 14, and Subsequent maintenance dose of 3 mg / kg every two weeks. The use according to any one of claims 3 to 5, including the use described in any one of claims 3 to 5.

9. Recombinant human ASM is olipudase alpha, as per any one of claims 1 to 8.

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