Treatment of patients with classic fabry disease

Abstract

This invention provides a method for treating classic Fabry disease in patients. Some methods include administering the patient approximately 123 mg of free base equivalent migastrol to reduce glomerular trisphingosamine, stabilize renal function, reduce left ventricular mass, reduce plasma glomerular trisphingosamine, and / or treat gastrointestinal symptoms.

Description

Technical Field

[0001] The principles and embodiments of the present invention generally relate to the use of pharmacologically protective proteins for the treatment of lysate storage diseases, and particularly the use of migalastat for the treatment of Fabry disease. Prior Technology

[0002] Fabry disease is a progressive, X-linked, congenital disorder of glucose sheath lipid metabolism caused by a deficiency of the lysosomal enzyme α-galactosidase A (α-Gal A) as a result of a mutation in the α-Gal A gene (GLA). Despite being an X-linked disorder, females may present with varying degrees of clinical manifestations. Fabry disease is a rare condition with an estimated incidence between 1 in 40,000 males and 1 in 117,000 in the general population. Furthermore, there are variants of Fabry disease with later-onset phenotypes that may be below the diagnostic criteria because they do not present with typical signs and symptoms. This situation, along with newborn screening for Fabry disease, suggests that the actual incidence of Fabry disease may be higher than currently estimated.

[0003] Without treatment, Fabry's disease reduces life expectancy, typically leading to death around age 40 or 50 due to vascular disease affecting the kidneys, heart, and / or central nervous system. Enzyme deficiency results in the intracellular accumulation of the substrate globular triacetin (GL-3) in the endothelium and visceral tissues throughout the body. Progressive renal function decline and the development of azotemia due to glycosphingolipid deposition usually occur between the ages of 30 and 50, but can occur as early as age 20. Kidney damage has been observed in both hemizygous (male) and heterozygous (female) patients.

[0004] Heart disease caused by Fabry disease occurs in most men and many women. Early cardiac findings include left ventricular enlargement, valvular involvement, and conduction abnormalities. Mitral regurgitation is the most common valvular injury typically present in children or adolescents. Cerebrovascular manifestations primarily arise from multifocal small vessel involvement and may include thrombosis, transient ischemic attacks, basilar artery ischemia and aneurysms, seizures, hemiplegia, hemiparesis, aphasia, labyrinthine disorders, or cerebral hemorrhage. The average age of onset of cerebrovascular manifestations is 33.8 years. Personality changes and psychotic behaviors may appear with age.

[0005] The currently approved treatment for Fabry disease is enzyme replacement therapy (“ERT”). Two alpha-Gal A products are currently available for the treatment of Fabry disease: alpha-agalsidase (Replagal®, Shire Human Genetic Therapies) and beta-agalsidase (Fabrazyme®, Sanofi Genzyme Corporation). Both forms of ERT are designed to compensate for insufficient alpha-Gal A activity in patients by administering a recombinant form of the enzyme intravenously. While ERT is effective in many cases, this treatment has limitations. For example, neither of these alpha-Gal A products has been shown to adequately reduce the risk of stroke, the myocardium responds slowly to treatment, and the elimination of GL-3 from some cell types in the kidneys is limited.

[0006] In addition, patients with the classic Fabry phenotype tend to have lower baseline α-Gal A activity, multi-organ system involvement, and more severe disease presentation at baseline.

[0007] Therefore, there is still a need for treatments for Fabry disease, especially for patients with classic Fabry disease. Summary of the Invention

[0008] Several aspects of this invention relate to the use of migastricostat for the treatment of patients with classic Fabry disease. This treatment may include lowering renal GL-3, stabilizing renal function, reducing left ventricular mass (LVM), lowering plasma spherical trisphingosine (hemolytic-Gb3), and / or treating gastrointestinal symptoms.

[0009] One aspect of the invention relates to a method for reducing renal GL-3 in a patient with classic Fabry disease, the method comprising administering an effective amount of migasstat or a salt thereof to the patient at a frequency of once every other day to reduce the patient's renal GL-3. In one or more embodiments, the effective amount is about 100 mg to about 150 mg free base equivalent (FBE).

[0010] In one or more embodiments, the patient has elevated renal interstitial capillary GL-3 levels prior to the initiation of administration of migastrol or its salts.

[0011] In one or more embodiments, reducing renal GL-3 includes reducing the GL-3 contents of each renal interstitial capillary.

[0012] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups, which consist of: p.Ile253Th (I253T), p.Pro259Arg (P259R), p.Gly183Asp (G183D), p.Leu243Phe (L243F), p.Cys174Arg (C174R), p.Asp55Val / Gln57Leu (D55V / Q57L), p.Gly144Val (G144V), p.Arg328Gln (R301Q), p.Gly373Ser (G373S), p.Asp322Glu (D322E), p.Gly325Arg G325R, and p.Tyr216Cys (Y216C).

[0013] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0014] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0015] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0016] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0017] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0018] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0019] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0020] In one or more embodiments, the patient is an ERT-naïve patient.

[0021] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in an average reduction of at least about 0.5 in GL-3 contents per renal interstitial capillary after 6 months of administration of migasstat or its salts.

[0022] Another aspect of the invention relates to a method of treating classic Fabry disease in a patient in need, the method comprising administering to the patient an effective amount of migasstat or a salt thereof at a frequency of once every other day. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE. In one or more embodiments, administration of migasstat or a salt thereof reduces the patient's renal GL-3.

[0023] In one or more embodiments, the patient has elevated renal interstitial capillary GL-3 levels prior to the initiation of administration of migastrol or its salts.

[0024] In one or more embodiments, reducing renal GL-3 includes reducing the GL-3 contents of each renal interstitial capillary.

[0025] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0026] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0027] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0028] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0029] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0030] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0031] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0032] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0033] In one or more embodiments, the patient is an ERT-naïve patient.

[0034] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in an average reduction of at least about 0.5 in GL-3 contents per renal interstitial capillary after 6 months of administration of migasstat or its salts.

[0035] Another aspect of the invention relates to a method for stabilizing renal function in a patient with classic Fabry disease, the method comprising administering an effective amount of migastric or a salt thereof to the patient at a frequency of once every other day to stabilize the patient's renal function. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE.

[0036] In one or more embodiments, the patient has kidney damage before starting administration of migasstat or its salts.

[0037] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0038] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0039] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0040] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0041] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0042] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0043] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0044] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0045] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0046] In one or more embodiments, the patient is an ERT-naïve patient.

[0047] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in a mean annualized change in eGFRCKD-EPI greater than -1.0 mL / min / 1.73 m2 after 24 months of administration of migasstat or its salts.

[0048] Another aspect of the invention relates to a method of treating classic Fabry disease in a patient in need, the method comprising administering to the patient an effective amount of migasstat or a salt thereof at a frequency of once every other day. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE. In one or more embodiments, administration of migasstat or a salt thereof stabilizes the patient's renal function.

[0049] In one or more embodiments, the patient has kidney damage before starting administration of migasstat or its salts.

[0050] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0051] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0052] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0053] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0054] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0055] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0056] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0057] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0058] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0059] In one or more embodiments, the patient is an ERT-naïve patient.

[0060] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in a mean annualized change in eGFRCKD-EPI greater than -1.0 mL / min / 1.73 m2 after 24 months of administration of migasstat or its salts.

[0061] Another aspect of the invention relates to a method for reducing LVM in a patient with classic Fabry disease, the method comprising administering an effective amount of migastricostat or a salt thereof to the patient at a frequency of once every other day to reduce the patient's LVM. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE.

[0062] In one or more embodiments, the patient has left ventricular hypertrophy (LVH) before starting administration of migastrol or its salts.

[0063] In one or more embodiments, reducing LVM includes reducing the left ventricular mass index (LVMi).

[0064] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0065] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0066] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0067] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0068] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0069] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0070] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0071] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0072] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0073] In one or more embodiments, the patient is an ERT-naïve patient.

[0074] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in an average reduction of at least about 5 g / m2 in LVMi after 24 months of administration of migasstat or its salts.

[0075] Another aspect of the invention relates to a method of treating classic Fabry disease in a patient in need of it, the method comprising administering to the patient an effective amount of migasstat or a salt thereof at a frequency of once every other day. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE. In one or more embodiments, administration of migasstat or a salt thereof reduces the patient's LVM.

[0076] In one or more embodiments, the patient has LVH before starting administration of migastrol or its salts.

[0077] In one or more implementations, reducing LVM includes reducing LVMi.

[0078] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0079] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0080] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0081] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0082] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0083] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0084] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0085] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0086] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0087] In one or more embodiments, the patient is an ERT-naïve patient.

[0088] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in an average reduction of at least about 5 g / m2 in LVMi after 24 months of administration of migasstat or its salts.

[0089] Another aspect of the invention relates to a method for reducing plasma hemolytic-Gb3 in a patient with classic Fabry disease, the method comprising administering to the patient an effective amount of migastricostat or a salt thereof at a frequency of once every other day to reduce plasma hemolytic-Gb3. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE.

[0090] In one or more embodiments, the patient has elevated plasma hemolytic-Gb3 levels before administration of migasstat or its salts is initiated.

[0091] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0092] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0093] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0094] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0095] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0096] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0097] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0098] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0099] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0100] In one or more embodiments, the patient is an ERT-naïve patient.

[0101] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in an average reduction of at least about 15 nmol / L in plasma hemolyzed Gb3 after 24 months of administration of migasstat or its salts.

[0102] Another aspect of the invention relates to a method of treating classic Fabry disease in a patient in need of it, the method comprising administering to the patient an effective amount of migasstat or a salt thereof at a frequency of once every other day. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE. In one or more embodiments, administration of migasstat or a salt thereof reduces the patient's plasma hemolytic-Gb3.

[0103] In one or more embodiments, the patient has elevated plasma hemolytic-Gb3 levels before administration of migasstat or its salts is initiated.

[0104] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0105] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0106] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0107] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0108] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0109] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0110] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0111] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0112] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0113] In one or more embodiments, the patient is an ERT-naïve patient.

[0114] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in an average reduction of at least about 15 nmol / L in plasma hemolyzed Gb3 after 24 months of administration of migasstat or its salts.

[0115] Another aspect of the invention relates to a method for treating gastrointestinal symptoms in a patient suffering from classic Fabry disease, the method comprising administering the patient a formulation containing an effective amount of migastric or a salt thereof on a every other day for the treatment of gastrointestinal symptoms. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE.

[0116] In one or more embodiments, the patient suffers from diarrhea before mitral administration of migasstat or its salts.

[0117] In one or more embodiments, treating one or more gastrointestinal symptoms in a patient includes relieving diarrhea symptoms.

[0118] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0119] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0120] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0121] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0122] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0123] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0124] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0125] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0126] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0127] In one or more embodiments, the patient is an ERT-naïve patient.

[0128] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease resulted in a mean reduction of at least about 0.5 on the Gastrointestinal Symptoms Rating Scale for Diarrhea (GSRS-D) after 24 months of administration of migasstat or its salts.

[0129] Another aspect of the invention relates to a method of treating classic Fabry's disease in a patient in need, the method comprising administering to the patient an effective amount of migasstat or a salt thereof at a frequency of once every other day. In one or more embodiments, the effective amount is about 100 mg to about 150 mg of FBE. In one or more embodiments, migasstat or a salt thereof is administered to treat one or more gastrointestinal symptoms in the patient.

[0130] In one or more embodiments, the patient suffers from diarrhea before mitral administration of migasstat or its salts.

[0131] In one or more embodiments, treating one or more gastrointestinal symptoms in a patient includes relieving diarrhea symptoms.

[0132] In one or more embodiments, the patient has a mutation in α-Gal A selected from the following groups: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, R301Q, G373S, D322E, G325R, and Y216C.

[0133] In one or more embodiments, migastrol or its salts enhance α-Gal A activity.

[0134] In one or more embodiments, the effective amount is about 123 mg of FBE.

[0135] In one or more embodiments, the effective amount is about 123 mg of migastart free base.

[0136] In one or more embodiments, the salt of migastrol is migastrol hydrochloride.

[0137] In one or more embodiments, the effective amount is about 150 mg of migastart hydrochloride.

[0138] In one or more embodiments, migasstat or its salts are in an oral dosage form. In one or more embodiments, the oral dosage form includes tablets, capsules, or solutions.

[0139] In one or more embodiments, migastrol or its salts are administered for at least 6 months.

[0140] In one or more embodiments, migastine or its salts are administered for at least 24 months.

[0141] In one or more embodiments, the patient is an ERT-naïve patient.

[0142] In one or more embodiments, administration of migasstat or its salts to a group of patients with classic Fabry disease provided a mean reduction of at least about 0.5 in GSRS-D after 24 months of administration of migasstat or its salts. Simple Explanation of the Diagram

[0143] Other features of the invention will become apparent from the following written description and accompanying drawings, wherein:

[0144] [Figures 1A-1E] show the complete DNA sequence of the human wild-type GLA gene (SEQ ID NO: 1);

[0145] [Figure 2] shows the wild-type α-Gal A protein (SEQ ID NO: 2);

[0146] [Figure 3] shows the nucleic acid sequence encoding the wild-type α-Gal A protein (SEQ ID NO: 3); and

[0147] [Figures 4.4A-4E] show measurements of disease severity in classic males and other patient subgroups (non-classical males and females). (A) Mean annualized change in GFR from baseline / month 6 to month 24. (B) Mean change in LVMi from baseline / month 6 to month 24. (C) Mean change in GSRS-D from baseline / month 6 to month 24. (D) Mean change in the mean number of GL-3 inclusions per interstitial capillary from baseline to month 12. Within each subgroup (classical males and other patients), patients were grouped according to treatment allocation (miralstat to migalstat or placebo to migalstat). (E) Mean change in plasma hemolyzed-Gb3 from baseline / month 6 to month 24. In Figures 4A-4E, group a consists of patients who switched from placebo to migastine at month 6, and data b is the mean (SD) number of GL-3 contents in each interstitial capillary at month 6 (i.e., 6 months after placebo treatment). Implementation

[0148] Before describing several exemplary embodiments of the present invention, it should be understood that the present invention is not limited to the details of the construction or process steps listed in the following description. The present invention can have other embodiments and can be implemented or carried out in different ways.

[0149] Different aspects of the present invention relate to dosing regimens for administering pharmacologically protective proteins (such as migastricostat) for the treatment of classic Fabry disease. In one or more embodiments, the migastricostat dosing regimen reduces renal GL-3, stabilizes renal function, reduces LVM, reduces plasma hemolytic-Gb3, and / or treats gastrointestinal symptoms. [definition]

[0150] The terms used in this specification generally have their common meaning in the art, both in the context of the invention and in the specific context in which each term is used. Some terms are discussed below or elsewhere in the specification to provide practitioners with additional guidance on describing the components and methods of the invention and how to make and use them.

[0151] The term "Fabry disease" refers to an X-linked, congenital disorder of glycosphingolipid catabolism caused by a deficiency of lysosomal α-Gal A activity. This defect leads to the accumulation of the substrate globular trisphingosine ("GL-3", also known as Gb3 or ceramide trihexoside) and associated glycosphingolipids in the endothelial lysosomes of the heart, kidneys, skin, and other tissues. Another substrate for this enzyme is plasma globular trisphingosine ("plasma hemolysin-Gb3").

[0152] The term "classic Fabry disease" refers to a patient with multi-organ system involvement. In one or more embodiments, the patient also has <3% residual peripheral blood mononuclear cell (PBMC) α-Gal A activity.

[0153] In different implementations, multi-organ system involvement can be determined at baseline based on medical history. In other implementations, multi-organ system involvement can be determined by identifying patients with cardiac, central nervous system, neuropathic pain, and / or gastrointestinal disorders at baseline, and then further identified as having renal symptoms due to baseline proteinuria > 150 mg / 24 hours or baseline eGFR < 90 mL / min / 1.73 m2.

[0154] A summary of exemplary criteria used to identify classic males in ERT-naïve trials and trials that have undergone ERT is shown in the following chart: ERT initial treatment Having undergone ERT 1 Baseline multi-organ disease (kidney, heart, CNS, neuropathic pain, and GI) based on medical history However, if there is a medical history and if the kidney is not captured, then: Multiple organs (≥ 2 organs) Multiple organs (≥ 2 organs) 2 Baseline urine protein > 150 mg / 24 hours > 150 mg / 24 hours Baseline eGFR < 90 mL / min / 1.73m2 < 90 mL / min / 1.73m2 3 WBC α-gal-A at baseline < 3% WT *NA *Use different standards in trials that undergo ERT because using ERT immediately before conducting the study will affect the WBC α-gal-A value at baseline.

[0155] Therefore, in one set of exemplary criteria for ERT-naïve trials, classic patients have multi-organ involvement at baseline and WBC α-gal-A levels <3% of normal at baseline (i.e., 1 and 3 in the above charts). In another set of exemplary criteria for ERT-naïve trials, classic patients have >150 mg / 24-hour urinary protein at baseline or baseline eGFR <90 mL / min / 1.73 m2, and WBC α-gal-A levels <3% of normal at baseline (i.e., 2 and 3 in the above charts).

[0156] In the exemplary criteria used for trials undergoing ERT, classic patients have multi-organ involvement at baseline, or have proteinuria > 150 mg / 24 hours at baseline or baseline eGFR < 90 mL / min / 1.73 m2 (i.e., 1 or 2 in the above chart).

[0157] A "carrier" is a female who has one X chromosome with a defective GLA gene and another X chromosome with the normal gene, wherein the normal allele on the X chromosome is inactivated in one or more cell types. Carriers are typically diagnosed with Fabry disease.

[0158] "Patient" refers to a subject who has been diagnosed with or is suspected of having a specific disease. Patients can be humans or animals.

[0159] "Fabry patient" refers to an individual who has been diagnosed with or is suspected of having Fabry disease and has an α-Gal A mutation as further defined below. The characteristic markers of Fabry disease can occur in both male hemizygotes and female carriers with the same prevalence, but women are usually less severely affected.

[0160] The term "ERT-naïve patient" refers to a Fabry patient who has never received ERT or has not received ERT for at least 6 months prior to starting migastric therapy.

[0161] Human α-galactosidase A (α-Gal A) is an enzyme encoded by the human GLA gene. The complete DNA sequence of α-Gal A, including introns and exons, is available in GenBank accession number X14448.1 and is shown in SEQ ID NO: 1 and Figures 1A-1E. The human α-Gal A enzyme consists of 429 amino acids and is available in GenBank accession numbers X14448.1 and U78027.1 and is shown in SEQ ID NO: 2 and Figure 2. The nucleic acid sequence including only the coding region (i.e., exon) of SEQ ID NO: 1 is shown in Figure 3 (SEQ ID NO: 3).

[0162] The term "mutant protein" includes proteins with mutations in the gene encoding them, causing the protein to fail to reach a stable conformation under conditions normally found in the endoplasmic reticulum. This failure to reach a stable conformation results in significant degradation of the enzyme instead of its transport to lysosomes. Such mutations are sometimes called "conformation mutants." These mutations include, but are not limited to, missense mutations, as well as small deletions and insertions within frames.

[0163] As used in one embodiment herein, the term "mutant α-Gal A" includes α-Gal A with a mutation in the gene encoding α-Gal A, which causes the enzyme to fail to reach a stable conformation under conditions normally present in the endoplasmic reticulum. This failure to reach a stable conformation results in significant degradation of the enzyme instead of its translocation to lysosomes.

[0164] As used herein, the term "pharmacologically-associated protector protein" ("PC") refers to any molecule, including small molecules, proteins, peptides, nucleic acids, carbohydrates, etc., that specifically binds to a protein and has one or more of the following effects: (i) enhancing the formation of a stable molecular conformation of the protein; (ii) inducing the transport of the protein from the endoplasmic reticulum to another cellular location, preferably the native cellular location, i.e., preventing endoplasmic reticulum-related degradation of the protein; (iii) preventing the aggregation of misfolded proteins; and / or (iv) restoring or enhancing at least some of the wild-type function and / or activity of the protein. A compound specifically binding to, for example, α-Gal A means that it binds to that enzyme and exerts a protector effect on that enzyme, and not on a group of related or unrelated enzymes. More specifically, this term does not refer to endogenous protector proteins such as BiP, or to nonspecific agents such as glycerol, DMSO, or deuterated water that exhibit nonspecific protector activity against different proteins, i.e., chemical protector proteins. In one or more embodiments of the invention, the PC may be a reversible competitive inhibitor.

[0165] A "competitive inhibitor" of an enzyme can be a compound that is structurally similar to the enzyme substrate in terms of chemical structure and molecular geometry, binding to the enzyme at approximately the same site as the substrate. Therefore, the inhibitor competes with the substrate molecule for the same active site, thereby increasing Km. Competitive inhibition is usually reversible if sufficient substrate molecules are available to replace the inhibitor; that is, the competitive inhibitor can bind reversibly. Therefore, the amount of enzyme inhibition depends on the inhibitor concentration, the substrate concentration, and the relative affinities of the inhibitor and substrate to the active site.

[0166] As used herein, the term "specific binding" refers to the interaction between a pharmacologically protected protein and a protein such as α-Gal A, particularly with the amino acid residues of that protein that are directly involved in contacting the pharmacologically protected protein. A pharmacologically protected protein specifically binds to a target protein, such as α-Gal A, to exert a protective effect on that protein rather than a group of related or unrelated proteins. The amino acid residues of the protein interacting with any given pharmacologically protected protein may or may not be within the protein's "active site." Specific binding can be evaluated by routine binding assays or by structural studies (e.g., co-crystallization, NMR, etc.). The active site of α-Gal A is the substrate-binding site.

[0167] “Deficient α-Gal A activity” refers to α-Gal A activity in cells from a patient that is below the normal range, such as the activity in a normal individual who does not have or is not suspected of having Fabry’s disease or any other disease (especially blood disorders) using the same method.

[0168] As used herein, the terms "enhanced α-Gal A activity" or "increased α-Gal A activity" refer to an increase in the amount of α-Gal A in a stable conformation in cells that have contact with a pharmacologically specific protein for α-Gal A, relative to the amount of α-Gal A in cells that have not contacted a pharmacologically specific protein for α-Gal A (preferably the same cell type or the same cells, e.g., at an earlier time). This term also refers to an increase in the transport of α-Gal A to lysosomes in cells that have contact with a pharmacologically specific protein for α-Gal A, relative to the transport of α-Gal A in cells that have not contacted a pharmacologically specific protein for α-Gal A. These terms refer to both wild-type and mutant α-Gal A. In one embodiment, the increase in the amount of α-Gal A in cells is measured by measuring the hydrolysis of artificial substrates in lysates from cells that have been treated with PC. An increase in hydrolysis indicates increased α-Gal A activity.

[0169] The term "α-Gal A activity" refers to the normal physiological function of wild-type α-Gal A in cells. For example, α-Gal A activity includes the hydrolysis of GL-3.

[0170] "Responder" is an individual diagnosed with or suspected of having a cytosolic storage disease such as Fabry's disease who responds to exposure to PCs, and whose cells exhibit sufficiently increased α-Gal A activity and / or symptom relief or enhancement of alternative markers. Non-limiting examples of enhancement of Fabry's alternative markers are hemolytic-Gb3 and those disclosed in U.S. Patent Application Publication No. US 2010 / 0113517.

[0171] Non-limiting examples of enhanced alternative markers in Fabry's disease disclosed in US 2010 / 0113517 include increased levels or activity of α-Gal A in cells (e.g., fibroblasts) and tissues; decreased GL-3 accumulation; decreased plasma concentrations of homocysteine ​​and vascular cell adhesion molecule-1 (VCAM-1); decreased GL-3 accumulation in cardiomyocytes and valvular fibroblasts; decreased plasma hemolysin-Gb3; decreased cardiac hypertrophy (especially in the left ventricle), reduced valvular insufficiency and arrhythmias; reduced proteinuria; decreased urinary concentrations of lipids (e.g., CTH, lactosylceramide, ceramide) and increased urinary concentrations of glucosylceramide and sphingomyelin; absence of cascaded inclusion bodies (zebra bodies) in glomerular epithelial cells; enhanced renal function; reduced hypohidrosis; absence of angiokeratoma; and enhanced hearing abnormalities (e.g., high-frequency sensorineural hearing loss, progressive hearing loss, sudden deafness, or tinnitus). Enhancement of neurological symptoms includes prevention of transient ischemic attacks (TIAs) or strokes; and reduction of neuropathic pain that manifests as paresthesia in the extremities (burning or tingling in the extremities). Another type of clinical marker that can be assessed for Fabry's disease is the prevalence of detrimental cardiovascular manifestations.

[0172] "Elevated renal interstitial capillary GL-3" refers to any detectable level of interstitial capillary GL-3 in the kidneys. Interstitial capillary GL-3 does not accumulate in the kidneys of healthy individuals. Instead, due to decreased kidney function, such as in patients with Fabry's disease, the level of interstitial capillary GL-3 is elevated—detectable by pathological examination during renal biopsy.

[0173] As used herein, the phrase “stabilizing renal function” and similar terms refer to reducing renal function decline and / or restoring renal function. Since renal function is expected to be significantly reduced in untreated Fabry patients, improvements in the rate of renal function decline and / or renal function demonstrate the benefits of migastric therapy as described herein.

[0174] "Kidney injury" is defined as a patient with an estimated glomerular filtration rate (eGFR) of less than 90 mL / min / 1.73 m². The two most commonly used equations for calculating eGFR from serum creatinine are the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the Modification of Diet in Renal Disease (MDRD) equation, referred to as eGFRCKD-EPI and eGFRMDRD, respectively. Chronic kidney disease severity is classified into six stages: a. (Stage 0) Normal renal function - eGFR > 90 mL / min / 1.73 m2 and no proteinuria; b. (Stage 1) - eGFR above 90 mL / min / 1.73 m2, with evidence of kidney damage; (Stage 2) (mild) - eGFR 60 to 89 mL / min / 1.73 m2, with evidence of kidney damage; c. (Stage 3) (Moderate) - eGFR 30 to 59 mL / min / 1.73 m2; d. (Stage 4) (Severe) -eGFR 15 to 29 mL / min / 1.73 m2; e. (Stage 5) Renal failure - eGFR less than 15 mL / min / 1.73 m2.

[0175] As used in this article, the term “left ventricular hypertrophy” or “LVH” refers to a patient with an LVMi higher than the normal range. Since the normal range for LVMi is 43–95 g / m² for women and 49–115 g / m² for men, female patients with LVH have an LVMi > 95 g / m², and male patients with LVH have an LVMi > 115 g / m².

[0176] "Elevated plasma hemolysin-Gb3" refers to a plasma hemolysin-Gb3 level above the normal range. The normal range for plasma hemolysin-Gb3 can vary depending on the specific assay used to assess plasma hemolysin-Gb3. In one or more embodiments, the normal range for plasma hemolysin-Gb3 is 0.375–1.19 nmol / L, and elevated plasma hemolysin-Gb3 refers to a plasma hemolysin-Gb3 level greater than 1.19 nmol / L.

[0177] The phrase “pharmaceutical acceptable” refers to a molecular entity and composition that is physiologically tolerable and does not typically produce adverse effects when administered to humans. In some embodiments, as used herein, the term “pharmaceutical acceptable” means approved by a federal or state regulatory agency or listed in the United States Pharmacopeia or other generally recognized pharmacopoeia for use in animals and more specifically in humans. The term “carrier” in relation to a drug carrier refers to a diluent, excipient, excipient, or transporter administered with the compound. Such drug carriers can be sterile liquids, such as water and oils. Preferably, water or aqueous saline solutions and aqueous dextran and glycerol solutions are used as carriers, particularly for injectable solutions. Suitable drug carriers are described in the following literature: EW Martin, ed., Remington's Pharmaceutical Sciences, 18th edition, or other editions.

[0178] The term "enzyme replacement therapy" or "ERT" refers to the introduction of a non-natural, purified enzyme into an individual with such enzyme deficiency. The protein administered can be obtained from natural sources or through recombinant expression (as described in more detail below). The term also refers to the introduction of a purified enzyme into an individual who otherwise needs or benefits from the administration of the purified enzyme, such as when the individual suffers from enzyme deficiency. The introduced enzyme can be a purified recombinant enzyme produced in vitro, or a protein purified from isolated tissues or body fluids (such as placenta or animal milk) or from plants.

[0179] The term "ERT-naïve patient" refers to a Fabry patient who has never received ERT or has not received ERT for at least 6 months prior to starting migastric therapy.

[0180] As used herein, the term "isolated" means removing a reference material from its natural environment. Thus, an isolated biological material can be free of cellular components, i.e., components of the cells in which the material is found or produced. In the case of nucleic acid molecules, isolated nucleic acids include PCR products, mRNA bands on gels, cDNA, or restriction fragments. In another embodiment, an isolated nucleic acid is preferably excised from the chromosome on which it is found, and more preferably is no longer linked to non-regulatory non-coding regions, or linked to other genes upstream or downstream of the gene contained by the isolated nucleic acid molecule when found in the chromosome. In yet another embodiment, an isolated nucleic acid lacks one or more introns. Isolated nucleic acids include sequences inserted into plasmids, cosmids, artificial chromosomes, etc. Thus, in one specific embodiment, a recombinant nucleic acid is an isolated nucleic acid. An isolated protein can be bound to other proteins or nucleic acids or both to which it binds in the cell, or to the cell membrane if it is a membrane-bound protein. An isolated organelle, cell, or tissue is removed from its anatomical site in an organism. An isolated material can be, but need not be, purified.

[0181] The terms "about" and "approximately" generally mean an acceptable degree of error of the quantity being measured, given the nature or precision of the measurement. Typically, exemplary degrees of error are within 20% of a given numerical value or numerical range, preferably within 10%, and more preferably within 5%. Alternatively, particularly in biological systems, the terms "about" and "approximately" can mean within one order of magnitude of a given value, preferably within 10-fold or 5-fold, more preferably within 2-fold. Unless otherwise indicated, numerical quantities given herein are approximate, meaning that the terms "about" or "approximately" can be inferred when not explicitly stated. [Fabry] [disease]

[0182] Fabry disease is a rare, progressive, and debilitating X-linked lysosomal storage disorder. Mutations in the GLA gene result in a deficiency of the lysosomal enzyme α-Gal A, which is essential for glycosphingolipid metabolism. From early in life, the reduction in α-Gal A activity leads to the accumulation of glycosphingolipids, including GL-3 and plasma lyso-Gb3, and causes the symptoms and life-limiting sequelae of Fabry disease, including pain, gastrointestinal symptoms, renal failure, cardiomyopathy, cerebrovascular events, and early death. Early initiation of therapy and lifelong treatment offer the opportunity to slow disease progression and extend life expectancy.

[0183] Fabry disease encompasses a wide range of severity and age of onset, although it is traditionally classified into two main phenotypes: "classical" and "late-onset." The classic phenotype has primarily been attributed to earlier-onset men with undetectable to low levels of α-Gal A activity and renal, cardiac, and / or cerebrovascular manifestations. The late-onset phenotype has primarily been attributed to later-onset men with higher residual α-Gal A activity and these disease manifestations. Heterozygous female carriers typically present with the late-onset phenotype, but depending on the pattern of X chromosome inactivation, they may also exhibit the classic phenotype.

[0184] More than 1,000 GLA mutations contributing to Fabry's disease have been identified. Approximately 60% are missense mutations, resulting in the substitution of a single amino acid in the α-Gal A enzyme. Missense GLA mutations typically lead to the production of aberrantly folded and unstable forms of α-Gal A. Normal cellular quality control mechanisms in the endoplasmic reticulum block the transport of these abnormal proteins to lysosomes and target them for premature degradation and elimination. Many missense mutant forms are targets of migastartrate (an α-Gal A-specific pharmacological escort protein).

[0185] Fabry disease presents with a wide range of clinical severity and is broadly correlated with a patient's residual α-Gal A levels. Patients with the classic phenotype experience disease in multiple organs, including the kidneys, heart, and brain, with symptoms typically first appearing in adolescence and progressively worsening until death in the fourth or fifth decade of life. Numerous recent studies have identified a large number of undiagnosed men and women with a range of Fabry disease symptoms that typically first appear in adulthood, such as impaired heart or kidney function and stroke. Individuals with this type of Fabry disease (called late-onset Fabry disease) tend to have higher residual α-Gal A levels compared to those with classic Fabry disease. Individuals with late-onset Fabry disease typically experience disease symptoms for the first time in adulthood and often have symptoms focused on a single organ, such as enlargement of the left ventricle or progressive kidney failure. Furthermore, late-onset Fabry disease can also present as a stroke of unknown cause.

[0186] Fabry patients exhibit progressive kidney damage, and untreated patients show end-stage renal impairment by their fifth decade of life. Defects in α-Gal A activity lead to the accumulation of GL-3 and associated glycosphingolipids in numerous cell types, including renal cells. GL-3 accumulates in podocytes, epithelial cells, and tubular cells in the distal tubules and the loop of Henle. Kidney function impairment can manifest as proteinuria and a decreased glomerular filtration rate.

[0187] Accurate diagnosis is challenging due to the rarity, multi-organ involvement, wide age range of onset, and heterogeneity of Fabry disease. Awareness among healthcare professionals is low, and misdiagnosis is frequent. Once a patient presents with symptoms, and with mutation analysis, the diagnosis of Fabry disease is most often confirmed based on reduced α-Gal A activity in plasma or peripheral white blood cells (WBCs). Diagnosis is even more challenging in women, as enzyme identification in carrier women is less reliable due to random X chromosome inactivation in some cells of the carrier. For example, some definitive carriers (daughters of orthodoxly affected men) have α-Gal A enzyme activity ranging from normal to very low levels. Because carriers have normal α-Gal A enzyme activity in their white blood cells, identifying α-Gal A mutations solely through genetic testing provides accurate carrier identification and / or diagnosis.

[0188] The mutant form of α-Gal A is considered compliant with migalastat, and when the mutant form of α-Gal A is expressed in HEK-293 cells (referred to as the “HEK assay”), it is defined as showing a relative increase of ≥ 1.20-fold (± 10 µM migalastat) and an absolute increase of ≥ 3.0% of wild-type (WT) (± 10 µM migalastat) according to a Good Laboratory Practice (GLP) validated in vitro assay (GLP HEK or Migalastat Amenability Assay). This type of mutation is also referred to herein as the “HEK assay compliant” mutation.

[0189] Previous screening methods have been provided for assessing enzyme enhancement prior to the initiation of treatment. For example, an assay using HEK-293 cells has been used in clinical trials to predict whether a given mutation responds to pharmacologically linked proteins (e.g., migasstat) treatment. In this assay, a cDNA construct was constructed. The corresponding α-Gal A mutant form was transiently expressed in HEK-293 cells. Cells were then incubated with ± migasstat (17 nM to 1 mM) for 4 to 5 days. Subsequently, α-Gal A levels were measured in cell lysates using a synthetic fluorescent substrate (4-MU-α-Gal) or by Western ink dot method. This has been performed against known disease-causing missense or small in-frame insertion / deletion mutations. Mutations previously identified using these methods as responding to PCs (e.g., migasstat) are listed in U.S. Patent No. 8,592,362. [Pharmacological Companion Protein]

[0190] The conjugation of small-molecule inhibitors of LSD-associated enzymes can increase the stability of mutant enzymes and their corresponding wild-type enzymes (see U.S. Patent Nos. 6,274,597; 6,583,158; 6,589,964; 6,599,919; 6,916,829; and 7,141,582, all of which are incorporated herein by reference). In particular, the administration of small-molecule derivatives of glucose and galactose (which are specific, selective, and competitive inhibitors for several target lysosomal enzymes) effectively increases the stability of the enzyme in vitro and thus increases the transport of the enzyme to the lysosome. Therefore, by increasing the amount of enzyme in the lysosome, the hydrolysis of the enzyme substrate is expected to increase. The underlying theory behind this strategy is as follows: because mutant enzyme proteins are unstable in the endoplasmic reticulum (Ishii et al., Biochem. Biophys. Res. Comm. [Biochemical and Biophysical Research Communications] 1996; 220: 812-815), they are delayed and prematurely degraded in the normal transport pathway (endoplasmic reticulum → Golgi apparatus → endosomes → lysosome). Therefore, compounds that bind to and increase the stability of mutant enzymes can act as “guardian proteins” for the enzymes, increasing the amount that can leave the endoplasmic reticulum and move to the lysosomes. Furthermore, since the folding and transport of some wild-type proteins are incomplete, in some cases up to 70% of some wild-type proteins are degraded before reaching their final cellular location, these guardian proteins can be used to stabilize wild-type enzymes and increase the amount of enzymes that can leave the endoplasmic reticulum and be transported to the lysosomes.

[0191] In one or more embodiments, the pharmacologically protective protein comprises migasstat or a salt thereof. As used herein, the compound migasstat, also known as 1-deoxygalactonojirimycin (1-DGJ) or (2R,3S,4R,5S0-2-(hydroxymethyl)piperidine-3,4,5-triol), is a compound having the following chemical formula: as well as Milgastrol free base.

[0192] As discussed below, pharmaceutically acceptable salts of migasstat can also be used in this invention. When using a salt of migasstat, the dosage of the salt is adjusted so that the dose of migasstat received by the patient is equivalent to the dose received when using the free base of migasstat. An example of a pharmaceutically acceptable salt of migasstat is migasstat hydrochloride: Migastartrate hydrochloride.

[0193] The term “mirastat” covers the free base of migasstat or its pharmaceutically acceptable salts (e.g., migasstat hydrochloride as shown above), unless otherwise specified.

[0194] As used herein, the term “free base equivalent” or “FBE” refers to the amount of migasstat present in migasstat or its salts. In other words, the term “FBE” refers to one amount of free migasstat base, or an equivalent amount of free migasstat base provided by a salt of migasstat. For example, due to the weight of the hydrochloride, 150 mg of migasstat hydrochloride provides only the same amount of migasstat as 123 mg of migasstat in its free base form. Other salts have different conversion factors, which depend on the molecular weight of the salt.

[0195] Migastrol is a low-molecular-weight imino sugar and an analogue of the GL-3 terminal galactose. In vitro and in vivo pharmacological studies have demonstrated that migastrol acts as a pharmacological escort protein, selectively and reversibly binding with high affinity to the active site of wild-type (WT) α-Gal A and specific mutant forms of α-Gal A, genotypes of which are termed HEK assay compliant mutations. Migastrol binding stabilizes these mutant forms of α-Gal A in the endoplasmic reticulum, facilitating their proper transport to lysosomes, where dissociation of migastrol in lysosomes allows α-Gal A to reduce the levels of GL-3 and other substrates. Approximately 35%–50% of Fabry disease patients have HEK assay compliant mutations; most of these are associated with the classic phenotype of the disease. The list of HEK assay compliant mutations includes at least those listed in Table 1 below. In one or more embodiments, if the double mutation is present on the same chromosome (male and female), the patient is considered HEK-compliant if the double mutation is present in one of the entries in Table 1 (e.g., D55V / Q57L). In some embodiments, if the double mutation is present on different chromosomes (female only), the patient is considered HEK-compliant if either of the individual mutations is present in Table 1. [Table 1] [nucleotide changes] [nucleotide changes] [Protein sequence changes] c.7C>G c.C7G L3V c.8T>C c.T8C L3P c.[11G>T; 620A>C] c.G11T / A620C R4M / Y207S c.37G>A c.G37A A13T c.37G>C c.G37C A13P c.43G>A c.G43A A15T c.44C>G c.C44G A15G c.53T>G c.T53G F18C c.58G>C c.G58C A20P c.59C>A c.C59A A20D c.70T>C or c.70T>A c.T70C or c.T70A W24R c.70T>G c.T70G W24G c.72G>C or c.72G>T c.G72C or c.G72T W24C c.95T>C c.T95C L32P c.97G>T c.G97T D33Y c.98A>G c.A98G D33G c.100A>G c.A100G N34D c.101A>C c.A101C N34T c.101A>G c.A101G N34S c.102T>G or c.102T>A c.T102G or c.T102A N34K c.103G>C or c.103G>A c.G103C or c.G103A G35R c.104G>A c.G104A G35E c.104G>T c.G104T G35V c.107T>C c.T107C L36S c.107T>G c.T107G L36W c.108G>C or c.108G>T c.G108C or c.G108T L36F c.109G>A c.G109A A37T c.110C>T c.C110T A37V c.122C>T c.C122T T41I c.124A>C or c.124A>T c.A124C or c.A124T M42L c.124A>G c.A124G M42V c.125T>A c.T125A M42K c.125T>C c.T125C M42T c.125T>G c.T125G M42R c.126G>A or c.126G>C or c.126G>T c.G126A or c.G126C or c.G126T M42I c.137A>C c.A137C H46P c.142G>C c.G142C E48Q c.152T>A c.T152A M51K c.153G>A or c.153G>T or c.153G>C c.G153A or c.G153T or c.G153C M51I c.157A>G c.A157G N53D c. [157A>C; 158A>T] c.A157C / A158T N53L c.160C>T c.C160T L54F c.161T>C c.T161C L54P c.164A>G c.A164G D55G c.164A>T c.A164T D55V c. [164A>T; 170A>T] c.A164T / A170T D55V / Q57L c.167G>T c.G167T C56F c.167G>A c.G167A C56Y c.170A>T c.A170T Q57L c.175G>A c.G175A E59K c.178C>A c.C178A P60T c.178C>T c.C178T P60S c.179C>T c.C179T P60L c.196G>A c.G196A E66K c.197A>G c.A197G E66G c.207C>A or c.207C>G c.C207A or c.C207G F69L c.214A>G c.A214G M72V c.216G>A or c.216G>T or c.216G>C c.G216A or c.G216T or c.G216C M72I c.218C>T c.C218T A73V c.227T>C c.T227C M76T c.239G>A c.G239A G80D c.247G>A c.G247A D83N c.253G>A c.G253A G85S c.254G>A c.G254A G85D c. [253G>A; 254G>A] c.G253A / G254A G85N c. [253G>A; 254G>T; 255T>G] c.G253A / G254T / T255G G85M c.261G>C or c.261G>T c.G261C or c.G261T E87D c.265C>T c.C265T L89F c.272T>C c.T272C I91T c.288G>A or c.288G>T or c.288G>C c.G288A or c.G288T or c.G288C M96I c.289G>C c.G289C A97P c.290C>T c.C290T A97V c.305C>T c.C305T S102L c.311G>T c.G311T G104V c.316C>T c.C316T L106F c.322G>A c.G322A A108T c.326A>G c.A326G D109G c.334C>G c.C334G R112G c.335G>A c.G335A R112H c.337T>A c.T337A F113I c.337T>C or c.339T>A or c.339T>G c.T337C or c.T339A or c.T339G F113L c.352C>T c.C352T R118C c.361G>A c.G361A A121T c.368A>G c.A368G Y123C c.373C>T c.C373T H125Y c.374A>T c.A374T H125L c.376A>G c.A376G S126G c.383G>A c.G383A G128E c.399T>G c.T399G I133M c.404C>T c.C404T A135V c.408T>A or c.408T>G c.T408A or c.T408G D136E c.416A>G c.A416G N139S c.419A>C c.A419C K140T c.427G>A c.G427A A143T c.431G>A c.G431A G144D c.431G>T c.G431T G144V c.434T>C c.T434C F145S c.436C>T c.C436T P146S c.437C>G c.C437G P146R c.454T>C c.T454C Y152H c.455A>G c.A455G Y152C c.466G>A c.G466A A156T c.467C>T c.C467T A156V c.471G>C or c.471G>T c.G471C or c.G471T Q157H c.484T>G c.T484G W162G c.493G>C c.G493C D165H c.494A>G c.A494G D165G c. [496C>G; 497T>G] c.C496G / T497G L166G c.496C>G c.C496G L166V c.496_497delinsTC c.496_497delinsTC L166S c.499C>G c.C499G L167V c.506T>C c.T506C ​​​​​​​​c.520T>C c.T520C C174R c.520T>G c.T520G C174G c.525C>G or c.525C>A c.C525G or c.C525A D175E c.539T>G c.T539G L180W c.540G>C c.G540C L180F c.548G>C c.G548C G183A c.548G>A c.G548A G183D c.550T>A c.T550A Y184N c.551A>G c.A551G Y184C c.553A>G c.A553G K185E c.559A>G c.A559G M187V c.559_564dup c.559_564dup p.M187_S188dup c.560T>C c.T560C M187T c.561G>T or c.561G>A or c.561G>C c.G561T or c.G561A or c.G561C M187I c.572T>A c.T572A L191Q c.581C>T c.C581T T194I c.584G>T c.G584T G195V c.586A>G c.A586G R196G c.593T>C c.T593C I198T c.595G>A c.G595A V199M c.596T>C c.T596C V199A c.596T>G c.T596G V199G c.599A>G c.A599G Y200C c.602C>T c.C602T S201F c.602C>A c.C602A S201Y c.608A>T c.A608T E203V c.609G>C or c.609G>T c.G609C or c.G609T E203D c.613C>A c.C613A P205T<于 c.613C>T c.C613T P205S c.614C>T c.C614T P205L c.619T>C c.T619C Y207H It should be noted that there seems to be a problem with the tag "<于 " in the original text. It might be a misrepresentation. I've translated it as is for now. If it's incorrect, you may need to correct the original text for a more accurate translation. c.620A>C c.A620C Y207S c.623T>G c.T623G M208R c.628C>T c.C628T P210S c.629C>T c.C629T P210L c.638A>G c.A638G K213R c.638A>T c.A638T K213M c.640C>T c.C640T P214S c.641C>T c.C641T P214L c.643A>G c.A643G N215D c.644A>G c.A644G N215S c.644A>T c.A644T N215I c. [644A>G; 937G>T] c.A644G / G937T N215S / D313Y c.646T>G c.T646G Y216D c.647A>G c.A647G Y216C c.655A>C c.A655C I219L c.656T>A c.T656A I219N c.656T>C c.T656C I219T c.659G>A c.G659A R220Q c.659G>C c.G659C R220P c.662A>C c.A662C Q221P c.671A>C c.A671C N224T c.671A>G<00千1144> c.A671G N224S c.673C>G c.C673G H225D c.683A>G c.A683G N228S c.687T>A or c.687T>G c.T687A or c.T687G F229L c.695T>C c.T695C I232T c.713G>A c.G713A S238N c.716T>C c.T716C I239T c.720G>C or c.720G>T c.G720C or c.G720T K240N c.724A>G c.A724G I242V c.724A>T c.A724T I242F c.725T>A c.T725A I242N c.725T>C c.T725C I242T c.728T>G c.T728G L243W c.729G>C or c.729G>T c.G729C or c.G729T L243F c.730G>A c.G730A D244N c.730G>C c.G730C D244H c.733T>G c.T733G W245G c.740C>G c.C740G S247C c.747C>G or c.747C>A c.C747G or c.C747A N249K c.749A>C c.A749C Q250P c.749A>G c.A749G<​​​​​​​​​​​​​​​​​​​​​​​​​​​ c.G769C A257P c.770C>G c.C770G A257G c.772G>C or c.772G>A c.G772C or c.G772A G258R c.773G>T c.G773T G258V c.776C>G c.C776G P259R c.776C>T c.C776T P259L c.779G>A c.G779A G260E c.779G>C c.G779C G260A c.781G>A c.G781A G261S c.781G>C c.G781C G261R c.781G>T [[ID=;61]] c.G781T G261C c.788A>G c.A788G N263S c.790G>T c.G790T D264Y c.794C>T c.C794T P265L c.800T>C c.T800C M267T c.805G>A c.G805A V269M c.806T>C c.T806C V269A c.809T>C c.T809C I270T c.810T>G c.T810G I270M c.811G>A c.G811A G271S c. [811G>A; 937G>T] c.G811A / G937T G271S / D313Y c.812G>A c.G812A G271D c.823C>G c.C823G L275V c.827G>A c.G827A S276N c.829T>G c.T829G W277G c.831G>T or c.831G>C c.G831T or c.G831C W277C c.832A>T c.A832T N278Y c.835C>G c.C835G Q279E c.838C>A c.C838A Q280K c.840A>T or c.840A>C c.A840T or c.A840C Q280H c.844A>G c.A844G T282A c.845C>T c.C845T T282I c.850A>G c.A850G M284V c.851T>C c.T851C M284T c.860G>T c.G860T W287L c.862G>C c.G862C A288P c.866T>G c.T866G I289S c.868A>C or c.868A>T c.A868C or c.A868T M290L c.869T>C c.T869C M290T c.870G>A or c.870G>C or c.870G>T c.G870A or c.G870C or c.G870T M290I c.871G>A c.G871A A291T c.877C>A c.C877A P293T c.881T>C c.T881C L294S c.884T>G c.T884G F295C c.886A>G c.A886G M296V c.886A>T or c.886A>C c.A886T or c.A886C M296L c.887T>C c.T887C M296T c.888G>A or c.888G>T or c.888G>C c.G888A or c.G888T or c.G888C M296I c.893A>G c.A893G N298S c.897C>G or c.897C>A c.C897G or c.C897A D299E c.898C>T c.C898T L300F c.899T>C c.T899C L300P c.901C>G c.C901G R301G c.902G>C c.G902C R301P c.902G>A c.G902A R301Q c.902G>T c.G902T R301L c.907A>T c.A907T I303F c.908T>A c.T908A I303N c.911G>A c.G911A S304N c.911G>C c.G911C S304T c.919G>A c.G919A A307T c.922A>G c.A922G K308E c.924A>T or c.924A>C c.A924T or c.A924C K308N c.925G>C c.G925C A309P c.926C>T c.C926T A309V c.928C>T c.C928T L310F c.931C>G c.C931G L311V c.935A>G c.A935G Q312R c.936G>T or c.936G>C c.G936T or c.G936C Q312H c.937G>T c.G937T D313Y c. [937G>T; 1232G>A] c.G937T / G1232A D313Y / G411D c.938A>G c.A938G D313G c.946G>A c.G946A V316I c.947T>G c.T947G V316G c.950T>C c.T950C I317T c.955A>T c.A955T I319F c.956T>C c.T956C I319T c.959A>T c.A959T N320I c.962A>G c.A962G Q321R c.962A>T c.A962T Q321L c.963G>C or c.963G>T c.G963C or c.G963T Q321H c.964G>A c.G964A 63> D322N c.964G>C c.G964C D322H c.966C>A or c.966C>G c.C966A or c.C966G D322E c.968C>G c.C968G P323R c.973G>A c.G973A G325S c.973G>C c.G973C G325R c.978G>C or c.978G>T c.G978C or c.G978T K326N c.979C>G c.C979G Q327E c.980A>T c.A980T Q327L c.983G>C c.G983C G328A c.989A>G c.A989G Q330R c.1001G>A c.G1001A G334E c.1010T>C c.T1010C F337S c.1012G>A c.G1012A E338K c.1016T>A c.T1016A V339E c.1027C>A c.C1027A P343T c.1028C>T c.C1028T P343L c.1033T>C c.T1033C S345P c.1046G>C c.G1046C W349S c.1055C>G c.C1055G A352G c.1055C>T c.C1055T A352V c.1061T>A c.T1061A I354K c.1066C>G c.C1066G R356G c.1066C>T c.C1066T R356W c.1067G>A c.G1067A R356Q c.1067G>C c.G1067C R356P c.1072G>C c.G1072C E358Q c.1073A>C c.A1073C E358A c.1073A>G c.A1073G E358G c.1074G>T or c.1074G>C c.G1074T or c.G1074C E358D c.1076T>C c.T1076C I359T c.1078G>A c.G1078A G360S c.1078G>T c.G1078T G360C c.1079G>A c.G1079A G360D c.1082G>A ` c.G1082A G361E c.1082G>C c.G1082C G361A c.1084C>A c.C1084A P362T c.1085C>T c.C1085T P362L c.1087C>T c.C1087T R363C c.1088G>A c.G1088A R363H c.1102G>A c.G1102A A368T c.1117G>A c.G1117A G373S c.1124G>A c.G1124A G375E c.1153A>G c.A1153G T385A c.1168G>A c.G1168A V390M c.1172A>C c.A1172C K391T c.1184G>A c.G1184A G395E c.1184G>C c.G1184C G395A c.1192G>A c.G1192A E398K c.1202_1203insGACTTC c.1202_1203insGACTTC p.T400_S401dup c.1208T>C c.T1208C L403S c.1225C>G c.C1225G P409A c.1225C>T c.C1225T P409S c.1225C>A c.C1225A P409T c.1228A>G c.A1228G T410A c.1229C>T c.C1229T T410I c.1232G>A c.G1232A G411D c.1235C>A c.C1235A T412N c.1253A>G c.A1253G E418G c.1261A>G c.A1261G M421V [Administration, preparation, and administration]

[0196] In one or more embodiments, migasstat or a salt thereof is administered to a Fabry patient at a frequency of once every other day (also referred to as “QOD”). In different embodiments, the dosages described herein involve migasstat hydrochloride or an equivalent dose of migasstat or a salt thereof that is not a hydrochloride. In some embodiments, these dosages involve the free base of migasstat. In alternative embodiments, these dosages involve a salt of migasstat. In further embodiments, the salt of migasstat is migasstat hydrochloride. The administration of migasstat or a salt of migasstat is referred to herein as “mirastat therapy”.

[0197] The effective amount of migasstat or its salts can be in the range of about 100 mg FBE to about 150 mg FBE. Exemplary doses include about 100 mg FBE, about 105 mg FBE, about 110 mg FBE, about 115 mg FBE, about 120 mg FBE, about 123 mg FBE, about 125 mg FBE, about 130 mg FBE, about 135 mg FBE, about 140 mg FBE, about 145 mg FBE, or about 150 mg FBE.

[0198] Again, it should be noted that 150 mg of migasstat hydrochloride is equivalent to 123 mg of migasstat in its free base form. Therefore, in one or more embodiments, this dose is 150 mg of migasstat hydrochloride or an equivalent dose of migasstat or a salt thereof that is not a hydrochloride, administered every other day. As mentioned above, this dose is referred to as 123 mg of migasstat in FBE. In another embodiment, the dose is 150 mg of migasstat hydrochloride administered every other day. In still other embodiments, the dose is 123 mg of migasstat free base administered every other day.

[0199] In different embodiments, the effective amount is about 122 mg, about 128 mg, about 134 mg, about 140 mg, about 146 mg, about 150 mg, about 152 mg, about 159 mg, about 165 mg, about 171 mg, about 177 mg, or about 183 mg of migastart hydrochloride.

[0200] Therefore, in various implementations, migasstat therapy includes administering 123 mg of FBE every other day, such as 150 mg of migasstat hydrochloride every other day.

[0201] Milgastrol or its salts may be administered for a period of time. In one or more embodiments, mildgastrol or its salts are administered for at least 28 days, such as at least 30, 60, or 90 days, or at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30, or 36 months, or at least 1, 2, 3, 4, or 5 years. In various embodiments, mildgastrol therapy is long-term mildgastrol therapy, lasting at least 6 months, such as at least 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30, or 36 months, or at least 1, 2, 3, 4, or 5 years.

[0202] Migastrol or its salts according to the invention may be administered in the form of a formulation suitable for any route of administration, but preferably in an oral dosage form (such as tablets, capsules, or solutions). As an example, the patient is given capsules orally, each capsule containing 150 mg of migastrol hydrochloride or an equivalent dose of migastrol or a salt other than hydrochloride.

[0203] In some embodiments, PC (e.g., migasstat or its salts) is administered orally. In one or more embodiments, PC (e.g., migasstat or its salts) is administered by injection. PC may be accompanied by a pharmaceutically acceptable carrier, depending on the method of administration.

[0204] In one embodiment of the invention, PC (e.g., migasstat or its salts) is administered as a monotherapy and may be in a form suitable for any route of administration, including, for example, oral administration in tablet or capsule or liquid form, in a sterile aqueous solution for injection, or in the form of a dried lyophilized powder (added to the formulation of the alternative enzyme during or immediately after remodeling to prevent enzyme aggregation in vitro prior to administration).

[0205] When formulating PCs (e.g., migasstat or its salts) for oral administration, these tablets or capsules can be prepared by conventional means using pharmaceutically acceptable excipients such as binders (e.g., pregelatinized corn starch, polyvinylpyrrolidone, or hydroxypropyl methylcellulose); fillers (e.g., lactose, microcrystalline cellulose, or calcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talc, or silica); disintegrants (e.g., potato starch or sodium carboxyacetic acid starch); or wetting agents (e.g., sodium lauryl sulfate). Tablets can be coated using methods well known in the art. Liquid formulations for oral administration can be in the form of, for example, solutions, syrups, or suspensions, or they can be present as dry products (formulated with water or other suitable carriers prior to use). Such liquid formulations can be prepared using conventional methods with pharmaceutically acceptable additives such as suspending agents (e.g., sorbitol syrup, cellulose derivatives, or hydrogenated edible fats); emulsifiers (e.g., lecithin or gum arabic); non-aqueous carriers (e.g., almond oil, oily esters, ethanol, or fractionated vegetable oils); and preservatives (e.g., methylparaben, propylparaben, or sorbic acid). Where appropriate, the formulation may also contain buffer salts, flavoring agents, coloring agents, and sweeteners. Oral formulations can be appropriately formulated to allow for the controlled release of the active companion protein compound.

[0206] Pharmaceutical formulations suitable for parenteral / injection use of PCs (e.g., migasstat or its salts) typically comprise sterile aqueous solutions (in the case of water solubility), or dispersions, as well as sterile powders for the ad hoc preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and must have a degree of flowability sufficient for easy injection. It must be stable under production and storage conditions and must be preserved against microbial contamination (e.g., bacteria and fungi). The carrier can be a solvent or dispersion medium comprising, for example, water, ethanol, polyols (e.g., glycerol, propylene glycol, and polyethylene glycol). Diols, etc.), their suitable mixtures, and vegetable oils. Proper flowability can be maintained, for example, by using a coating (e.g., lecithin), by maintaining the desired particle size in the dispersed state, and by using surfactants. Prevention of microbial activity can be achieved through various antibacterial and antifungal agents (e.g., parabens, chlorobutanol, phenol, benzyl alcohol, sorbic acid, etc.). In many cases, isotonic agents such as sugars or sodium chloride would be appropriate. Extended absorption of injectable compositions can be achieved by using compositions containing delayed-absorption agents (e.g., aluminum monostearate and gelatin).

[0207] As needed, sterile injectable solutions can be prepared by incorporating purified enzymes (if available) and PC (e.g., migasstat or its salts) in the required amounts into a suitable solvent containing the various other components listed above (as needed), followed by filtration or final sterilization. Typically, dispersions are prepared by incorporating various sterilized active ingredients into a sterile carrier containing a base dispersion medium and any other desired components from those listed above. In the case of sterile powders used to prepare sterile injectable solutions, preferred methods of preparation include vacuum drying and freeze-drying techniques, which produce a powder from the preceding sterile filtered solution containing the active ingredient plus any other desired components.

[0208] The formulation may contain excipients. Pharmaceutically acceptable excipients that can be included in the formulation are buffers such as citrate buffer, phosphate buffer, acetate buffer, and bicarbonate buffer; amino acids; urea; alcohols; ascorbic acid; phospholipids; proteins such as serum albumin, collagen, and gelatin; salts such as EDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrrolidone; sugars such as dextran, mannitol, sorbitol, and glycerol; propylene glycol and polyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol; glycine or other amino acids; and lipids. Buffer systems used with these formulations include citrate; acetate; bicarbonate; and phosphate buffers. Phosphate buffer is a preferred embodiment.

[0209] The companion protein compound can be administered orally or parenterally, including intravenously, subcutaneously, intra-arterially, intraperitoneally, intraocularly, intramuscularly, buccally, rectally, vaginally, intraorbitally, intracerebrally, intradermally, intracranially, intraspinally, intracardiac, intrathecally, intrasheathally, intracisionally, intracapsularly, intrapulmonaryly, intranasally, via mucosa, via skin, or by inhalation.

[0210] The parenteral formulation of the companion protein compound can be administered by bolus injection of a periodic injectable formulation, or by intravenous or intraperitoneal administration from a bolus, which can be external (e.g., an intravenous bag) or internal (e.g., a bioerosible implant).

[0211] The embodiments relating to the formulation and administration of the pharmaceutical can be combined with any other embodiments of the invention, such as methods of treating patients with classic Fabry disease, methods of treating ERT-naïve patients with classic Fabry disease, methods of reducing renal GL-3, methods of stabilizing renal function, methods of reducing LVM or LVMi, methods of reducing plasma hemolytic-Gb3 and / or methods of treating gastrointestinal symptoms (e.g., diarrhea), methods of enhancing α-Gal A in patients diagnosed with or suspected of having Fabry disease, the use of pharmacologically protected proteins of α-Gal A in the manufacture of medicaments for treating patients diagnosed with Fabry disease, or embodiments of pharmacologically protected proteins of α-Gal A for treating patients diagnosed with Fabry disease, together with embodiments relating to compliance mutations, PCs, and appropriate dosages thereof.

[0212] In one or more embodiments, PC (e.g., migasstat or a salt thereof) is administered in combination with ERT. By infusion, ERT increases the amount of protein by exogenously introducing a wild-type enzyme or an enzyme with biological function. This therapy has been developed for many genetic diseases, including lysosomal storage diseases such as those cited above (e.g., Fabry disease). After infusion, the exogenous enzyme is expected to be absorbed by tissues via non-specific or receptor-specific mechanisms. Generally, absorption efficiency is low, and the circulation time of exogenous proteins is short. Furthermore, exogenous proteins are unstable and undergo rapid intracellular degradation, and adverse immune responses may occur with subsequent treatment. In one or more embodiments, the companion protein is administered simultaneously with a replacement enzyme (e.g., a replacement for α-Gal A). In some embodiments, the companion protein is co-formulated with a replacement enzyme (e.g., a replacement for α-Gal A).

[0213] In one or more embodiments, a patient is switched from ERT to migastric therapy. In some embodiments, a patient receiving ERT is identified, the patient's ERT is interrupted, and the patient begins migastric therapy. Migastric therapy can be performed according to any of the methods described herein. [kidney] [GL-3]

[0214] The dosing regimen described herein reduces renal GL-3 (e.g., GL-3 contents in each renal interstitial capillary) in patients with Fabry's disease. Since untreated Fabry's patients typically exhibit an increase in renal GL-3 over time, both a reduction and stabilization of renal GL-3 indicate benefit from migastrict therapy. As further detailed in the examples below, a phase 3 study found that migastrict therapy reduced renal GL-3 in ERT-naïve patients with classic Fabry's disease. Therefore, migastrict therapy can be used to treat patients with classic Fabry's disease by reducing and / or stabilizing renal GL-3.

[0215] Compared to the same patient not treated with migasstat, migasstat can reduce the increase in renal GL-3 in patients with classic Fabry's disease. In one or more embodiments, migasstat provides a change in GL-3 contents in each renal interstitial capillary that is less than (i.e., more negative than) 0, such as less than about -0.1, -0.2, -0.3, -0.4, -0.5, -0.6, -0.7, -0.8, -0.9, or -1. Alternatively, in one or more embodiments, migasstat provides a reduction in GL-3 contents in each renal interstitial capillary that is greater than 0, such as a reduction of at least about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, or 1.

[0216] In one or more embodiments, after 6 months of administration of migasstat or its salts, migasstat therapy provides a mean reduction of at least about 0.1 in GL-3 contents of each renal interstitial capillary in a cohort of patients with classic Fabry's disease. In different embodiments, after 6 months of administration of migasstat or its salts, the mean reduction in this group of patients with classic Fabry's disease is at least about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, or 0.8, such as about 0.8. In different embodiments, the patients with classic Fabry's disease are ERT-naïve. [Kidney function]

[0217] The dosing regimen described herein can stabilize and / or enhance renal function (e.g., eGFR) in patients with Fabry's disease. Since untreated Fabry's patients typically exhibit renal function decline over time, both enhancement and maintenance of renal function indicate a benefit of migastrict therapy. As further detailed in the examples below, a phase 3 study found that migastrict therapy stabilized renal function in ERT-naïve patients with classic Fabry's disease. Therefore, migastrict therapy can be used to treat patients with classic Fabry's disease by increasing and / or stabilizing renal function.

[0218] Compared to the same patients not treated with migasstat, migasstat can prevent or reduce the decline in renal function in patients with classic Fabry's disease, and / or can increase their renal function. In one or more embodiments, migasstat provides patients with an annual variation in eGFRCKD-EPI greater than (i.e., corrected to) -5.0 mL / min / 1.73 m² / year, such as greater than -4.5, -4.0, -3.5, -3.0, -2.5, -2.0, -1.5, -1.0, -0.9, -0.8, -0.7, -0.6, -0.5, -0.4, -0.3, -0.2, -0.1, or even greater than 0 mL / min / 1.73 m² / year. In one or more embodiments, migasstat therapy provides patients with an annual change in mGFR iohexol greater than -5.0 mL / min / 1.73 m² / year, such as greater than -4.5, -4.0, -3.5, -3.0, -2.5, -2.0, -1.5, -1.0, -0.9, -0.8, -0.7, -0.6, -0.5, -0.4, -0.3, -0.2, -0.1, or even greater than 0 mL / min / 1.73 m² / year. Therefore, migasstat therapy can reduce or even improve the decline in renal function in patients. These annual rates of change can be measured over specific time periods (e.g., more than 6 months, 12 months, 18 months, 24 months, 30 months, or 36 months).

[0219] In one or more embodiments, after 24 months of administration of migasstat or its salts, migasstat therapy provided a mean annual change in eGFRCKD-EPI greater than -5.0 mL / min / 1.73 m² / year in a cohort of patients with classic Fabry’s disease, such as greater than -4.5, -4.0, -3.5, -3.0, -2.5, -2.0, -1.5, -1.0, -0.9, -0.8, -0.7, -0.6, -0.5, -0.4, -0.3, -0.2, -0.1 or even greater than 0 mL / min / 1.73 m² / year. In one or more embodiments, after 24 months of administration of migasstat or its salts, migasstat therapy provided a mean annual change in mGFR of iohexol greater than -5.0 mL / min / 1.73 m² / year in a cohort of patients with classic Fabry's disease, such as greater than -4.5, -4.0, -3.5, -3.0, -2.5, -2.0, -1.5, -1.0, -0.9, -0.8, -0.7, -0.6, -0.5, -0.4, -0.3, -0.2, -0.1, or even greater than 0 mL / min / 1.73 m² / year. In various embodiments, patients with classic Fabry's disease were ERT-naïve. [Left ventricular mass]

[0220] The dosing regimen described in this article can improve LVM or LVMi in patients with Fabry's disease. The natural history of LVMi and cardiac hypertrophy in untreated Fabry's patients (regardless of phenotype) (Patel, O'Mahony et al. 2015) is an increasing LVMi between +4.07 and +8.0 g / m² / year (Kampmann, Linhart et al. 2008; Wyatt, Henley et al. 2012; Germain, Weidemann et al. 2013). Since untreated Fabry's patients typically exhibit an increase in LVMi over time, both a decrease and maintenance of LVMi indicate a benefit of migastrict therapy. As further detailed in the examples below, a phase 3 study found that migastrict therapy reduced LVMi in ERT-naïve patients with classic Fabry's disease. Therefore, migastrict therapy can be used to treat patients with classic Fabry's disease, including those with LVH, by reducing LVM and / or LVMi.

[0221] Compared to the same patient who was not treated with migastric therapy, migastric therapy can reduce the increase in LVM or LVMi in patients with classic Fabry's disease. In one or more embodiments, migastric therapy provides the patient with a change in LVMi less than (i.e., more negative than) 0 g / m2, for example less than or equal to about -0.5, -1, -1.5, -2, -2.5, -3, -3.5, -4, -4.5, -5, -5.5, -6, -7, -8, -9, -10, -11, -12, -13, -14, -15, -16, -17, -18, -19, or -20 g / m2. In other words, in one or more embodiments, migasstat therapy provides a reduction of LVMi greater than 0 g / m2, such as a reduction of at least about 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 or 20 g / m2.

[0222] In one or more embodiments, after 24 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 1 g / m² in LVMi in a classic Fabry's disease group. In different embodiments, after 24 months of administration of migasstat or its salts, the mean reduction in this classic Fabry's disease group was at least about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, or 17 g / m², such as about 16.7 g / m². In different embodiments, the classic Fabry's disease patients were ERT-naïve. [Plasma hemolysis] [-Gb, 3, ]

[0223] The dosing regimen described in this article reduces plasma hemolytic-Gb3 in patients with Fabry's disease. Since untreated Fabry's patients typically exhibit an increase in plasma hemolytic-Gb3 over time, both a reduction and maintenance of plasma hemolytic-Gb3 indicate the benefit of migastrict therapy. As further described in the examples below, a phase 3 study found that migastrict therapy reduced plasma hemolytic-Gb3 in ERT-naïve patients with classic Fabry's disease. Therefore, migastrict therapy can be used to treat patients with classic Fabry's disease by reducing and / or stabilizing plasma hemolytic-Gb3.

[0224] Compared to the same patient not treated with migastrict therapy, migastrict therapy can reduce the increase in plasma hemolytic-Gb3 in patients with classic Fabry's disease. In one or more embodiments, migastrict therapy provides a change in plasma hemolytic-Gb3 less than (i.e., more negative than) 0 nmol / L, such as less than about -5, -10, -15, -20, -25, -30, -35, or -40 nmol / L. Alternatively, in one or more embodiments, migastrict therapy provides a reduction in plasma hemolytic-Gb3 greater than 0 nmol / L, such as a reduction of at least about 5, 10, 15, 20, 25, 30, 35, or 40 nmol / L.

[0225] In one or more embodiments, after 24 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 5 nmol / L in plasma hemolyzed-Gb3 in a cohort of patients with classic Fabry's disease. In different embodiments, after 6 months of administration of migasstat or its salts, the mean reduction in this group of patients with classic Fabry's disease was at least about 5, 10, 15, 20, 25, 30, 35, or 40 nmol / L, such as about 36 nmol / L. In different embodiments, the patients with classic Fabry's disease were ERT-naïve. [Gastrointestinal symptoms]

[0226] The dosing regimen described in this article can treat gastrointestinal symptoms (e.g., diarrhea) in patients with Fabry's disease. As further described in the following examples, a phase 3 study found that migastrict therapy reduced diarrhea symptoms in ERT-naïve patients with classic Fabry's disease. Therefore, migastrict therapy can be used to treat patients with classic Fabry's disease by relieving gastrointestinal symptoms (e.g., diarrhea).

[0227] Compared to the same patient who was not treated with migastric therapy, migastric therapy can reduce GSRS-D in patients with classic Fabry's disease. In one or more embodiments, migastric therapy provides a change in GSRS-D in the patient that is less than (i.e., more negative than) 0, such as less than about -0.1, -0.2, -0.3, -0.4, -0.5, -0.6, -0.7, -0.8, -0.9, -1, -1.1, -1.2, -1.3, -1.4, -1.5, -1.6, -1.7, -1.8, -1.9, or -2. In other words, in one or more embodiments, migasstat therapy provides a reduction greater than 0 in the GL-3 contents of each renal interstitial capillary, such as a reduction of at least about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, or 2.

[0228] In one or more embodiments, after 6 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 0.1 in GSRS-D in a cohort of patients with classic Fabry's disease. In various embodiments, after 6 months of administration of migasstat or its salts, the mean reduction in this cohort of patients with classic Fabry's disease was at least about 0.1, 0.15, 0.2, 0.25, 0.3, 0.35, or 0.4, such as about 0.4. In various embodiments, the patients with classic Fabry's disease were ERT-naïve.

[0229] In one or more embodiments, after 24 months of administration of migasstat or its salts, migasstat therapy provided a mean reduction of at least about 0.1 in GSRS-D in a cohort of patients with classic Fabry's disease. In various embodiments, after 24 months of administration of migasstat or its salts, the mean reduction in this group of patients with classic Fabry's disease was at least about 0.1, 0.15, 0.2, 0.25, 0.3, 0.35, 0.4, 0.45, 0.5, 0.55, 0.6, 0.65, 0.7, 0.75, 0.8, 0.85, 0.9, 0.95, or 1, such as about 0.9. In various embodiments, the patients with classic Fabry's disease were ERT-naïve. [Example]

[0230] The following examples will provide a better understanding of the components and methods of the present invention, which are intended to illustrate rather than limit the scope of the invention. Various changes and modifications to the disclosed embodiments will be apparent to those skilled in the art, and such changes and modifications can be made without departing from the spirit of the invention and the scope of the appended claims, including but not limited to those relating to the methods, formulations, and / or processes of the invention. [Example] [1] [:] [For treatment with migasstat hydrochloride] [Fabry] [Dosage regimen for patients with this condition]

[0231] This case describes a phase 3 study of migastric therapy in ERT-naïve patients with Fabry disease, including those with classic Fabry disease.

[0232] [, Patients were selected. Eligible patients are 16-74 years old and have genetically confirmed Fabry disease; have never received ERT or have not received ERT for ≥ 6 months; have a GLA mutation that produces a mutant protein that will respond to migastricostat, based on the HEK assay used at enrollment; have an eGFR > 30 ml / min / 1.73 m2 and urinary GL-3 ≥ 4 times the upper limit of normal.

[0233] [, Research design. Following eligibility-baseline assessment (2 months), patients were randomized to Phase 1—a double-blind administration of 150 mg migasstat hydrochloride or placebo every other day for 6 months. All patients completing Phase 1 were eligible to receive unblinded migasstat in Phase 2 (months 6–12) and an additional year thereafter (months 13–24). The primary objective was to compare the effects of migasstat on renal GL-3 levels, as assessed by histological scoring of the number of contents in interstitial capillaries, relative to placebo, after 6 months of treatment. Secondary objectives of Phase 1 were to compare the effects of migasstat on urinary GL-3 levels, renal function, 24-hour urinary protein, and safety and tolerability relative to placebo. A third objective was to assess cardiac function, patient-reported outcomes, exploratory renal analysis, and leukocyte α-Gal A activity. Study completers were eligible to participate in an unblinded extension study for up to 5 years.

[0234] [, Kidney histological evaluation. Each patient underwent a baseline renal biopsy, which was repeated at 6 and 12 months. The number of GL-3 contents in each renal interstitial capillary at baseline and at 6 and 12 months was quantitatively assessed in 300 capillaries by three separate pathologists (unaware of treatment and visits). All values ​​from each individual biopsy were averaged at a given time prior to statistical analysis.

[0235] The same three pathologists (unaware of the treatment / visits) quantitatively assessed changes in GL-3 in podocytes, endothelial cells, and mesangial cells, as well as glomerular sclerosis.

[0236] [, Globular triacetin and globular triacetin. Plasma hemolysin-Gb3 and 24-hour urinary GL-3 were analyzed by liquid chromatography-mass spectrometry using a novel and stable isotope-labeled internal standard 13C6-hemolysin-Gb3 (lower limit: 0.200 ng / mL, 0.254 nmol / L).

[0237] [, Kidney function assessment. The annual rate of change (mL / min / 1.73 m2 / year) was calculated using the Chronic Kidney Disease Epidemiology Collaboration-eGFRCKD-EPI and measured iohexol clearance rate - mGFR iohexol.

[0238] [, Echocardiography. , ] Parameters such as LVMi, left posterior wall thickness, diastolic blood pressure, interventricular septal thickness, and diastolic blood pressure are assessed through blinded, centralized evaluation.

[0239] [, Patient-reported results. Patient-reported outcomes were assessed using the Gastrointestinal Symptom Rating Scale (GSRS), the Short Form-36v2™, and the Brief-Pain-Inventory-Pain-Severity Component of the Brief Pain Inventory.

[0240] [, Safety analysis and adverse events.Randomized patients receiving ≥1 dose were included in the safety analysis, which included vital signs, physical examination, electrocardiogram, clinical laboratory results, and adverse events.

[0241] [, Renal interstitial capillaries , ] [, GL-3 , ] [, Statistical analysis of the substrate. The primary Phase 1 (6-month) endpoint (ITT population with baseline biopsy, n = 64) was the proportion of patients in the migastric and placebo groups with a ≥ 50% reduction in GL-3 contents in each renal interstitial capillary. Two additional Phase 1 endpoints were assessed (modified ITT population: randomized patients with paired baseline and 6-month biopsy; n = 60): the percentage change in GL-3 contents in each renal interstitial capillary, and the percentage of interstitial capillaries without GL-3 contents.

[0242] Efficacy analyses of GL-3 inclusions and other pre-specified endpoints in each renal interstitial capillary during phase 2 (months 6–12) and the unblinded extension (months 12–24) were based on a modified therapeutic intent (mITT) population of randomized patients with mutant α-Gal A enzymes that were deemed suitable for migastric treatment by validation assays; n = 50).

[0243] For all outcomes except GL-3 inclusions in each renal interstitial capillary, data from patients within the phenotypic subgroup were aggregated, regardless of the treatment allocation during the first six months (mirastat or placebo). [, result , ] [, , ]

[0244] Baseline characteristics. Sixty-seven patients (16–74 years old; 64% female) with the potentially responsive mutant α-Gal A were randomly assigned to the ITT population. Table 2 provides the baseline characteristics of 50 patients in the ITT population with appropriate α-Gal A mutants. There were no statistically significant differences in baseline parameters. [Table 2]: [Baseline Characteristics] [parameter] [Treatment Group] [Migastrostat Hydrochloride] [(] [N=28] [)] [Placebo to Milgastal Hydrochloride] [(] [N=22] [)] [total] [(] [N=50] [)] [Age (years) ()] [n] [)] 28 twenty two 50 Mean ± SD 41.5±13 45.1±8.0 43.1±11 median 37.0 45.5 45.0 [weight(] [kg] [)(] [n] [)] 28 twenty two 50 Mean ± SD 72.6±15.35 76.1±16.52 74.1±15.81 median 72.3 74.0 72.8 [Fabry] [Number of years since diagnosis of [Disease Name]] [n] [)] 28 twenty one 49 Mean ± SD 5.6±6.89 7.3±8.80 6.3±7.73 median 4.1 4.1 4.1 [Previously accepted] [ERT] (Before baseline) [> 6] Number of patients (in [months]) [%] [)] 4 (14.3%) 7 (31.8%) 11 (22.0%) [Use in baseline] [ACEi / ARB / Ri] yes(%) 9 (32.1%) 12 (54.5%) 21 (42.0%) no(%) 19 (67.9%) 10 (45.5%) 29 (58.0%) [Proteinuria] [> 150 mg / 24 h] [(] [%] [)] 17 (60.7%) 18 (81.8%) 35 (70.0%) [Proteinuria] [> 300 mg / 24 h] [(] [%] [)] 8 (28.6%) 11 (50.0%) 19 (38.0%) [Proteinuria] [> 1000 mg / 24 h] [(] [%] [)] 3 (10.7%) 3 (13.6%) 6 (12.0%) [mGFR] [, 碘海醇 , ] [(] [mL / min / 1.73 m, 2 , ] [)(] [n] [)] 27 twenty one 48 Mean ± SD 79.95±30.9 83.12±22.8 81.34±27.5 Median 84.90 82.20 83.40 [eGFR, CKD-EPI , ] [(] [mL / min / 1.73 m, 2 , ] [)] 28 twenty two 50 Mean ± SD 94.4±27.0 90.6±17.1 92.7±23.0 Median 96.6 93.5 94.0 [Hemolysis] [-Gb, 3, ] [(] [n] [)] 18 13 31 Average (nmol / L) ± SD 47.3±62 41.9±39 45.0±53

[0245] Published reports of one or more clinical phenotypes associated with genotypes of patients with suitable mutations (n ​​= 50) showed that 30 (60%) had mutations associated with the classic Fabry disease phenotype, one (2%) had mutations associated with the non-classical phenotype, three (6%) had mutations associated with both phenotypes, and 16 (32%) were unclassified. Of the 16 men, 14 (87%) had residual WBC α-Gal A activity < 3%; of the 31 men and 29 (94%) women, 29 had elevated plasma hemolytic Gb3; and of the 50 men and 47 (94%) women, 47 had multi-organ system disease.

[0246] Based on multi-organ system involvement and PBMC α-Gal A activity <3% of normal, male patients were identified as having classic Fabry disease. Classic male patients (n = 14) had more severe Fabry disease presentation at baseline compared with other patients (i.e., male and female patients with non-classical phenotypes; n = 36) (Figs. 4A-4E). Classic male patients had lower mean (standard deviation [SD]) baseline eGFRCKD-EPI (87.8 [8.98] vs. 95.3 [3.37] mL / min / 1.73 m2) and mGFR iohexol (78.6 [6.90] vs. 88.2 [3.95] mL / min / 1.73 m2) and higher LVMi (114.3 [7.31] vs. 88.2 [5.90] g / m2). The mutations in the classic male subgroup are: p.Ile253Thr (n = 2), p.Pro259Arg (n = 2), p.Gly183Asp, p.Leu243Phe, p.Cys174Arg, p.Asp55Val / Gln57Leu, p.Gly144Val, p.Arg301Gln, p.Gly373Ser, p.Asp322Glu, p.Gly325Arg, and p.Tyr216Cys (n = 1 each).

[0247] [, In vitro activity. Table 3 below provides the baseline PBMC α-Gal A activity and the effect of migastyl on α-Gal A activity measured according to HEK assay. [Table 3]: [Migassah] [α-Gal A] [Effect on activity] [At baseline] [, a , ] [In a position] [PBMC] [China Measurement] [exist] [HEK-293] [Measured in cell lysates] [α-Gal A] [Mutant Form] [-] [Migastrostat] [-] [Migastrostat] [+] [Migastrostat] [exist] [10 µM] [Absolute increase at the location()] [%WT] [)] [exist] [10 µM] [Location] [α-Gal A] [Activity (multiple times above baseline)] [Amino acid changes] [nucleotide changes] [α-Gal A] [active] [(] [nmol / mg / hr] [)] [%WT] [α-Gal A] [active(] [nmol / mg / hr] [)] [%WT] [α-Gal A] [active(] [nmol / mg / hr] [)] [, † , ] [%WT] [, In accordance with the classic phenotype , ] [, b , ] [ , Found in standard patients , ] [ , GLA , ] [ , mutation , ] [ , , ] p.Asp55Val / Gln57Leu c.164 A>T; c.170 A>T BLQ 0.0 BLD N / A 2526 ± 287* 8.0 ± 0.5 8.0 NC p.Gly144Val c.431 G>T 0.05 0.2 253 ± 21 0.8 ± 0.1 2924 ± 335* 9.2 ± 1.2 8.4 11.58 p.Cys174Arg c.520 T>C 0.28 1.3 4671 ± 270 14.3 ± 0.6 16505 ± 393* 51.6 ± 2.0 37.4 3.53 p.Gly183Asp c.548 G>A 0.04 0.2 207 ± 15 0.7 ± 0.1 6074 ± 212* 19.1 ± 1.0 18.4 29.31 p.Tyr216Cys c.647 A>G BLQ 0.0 673 ± 38 2.0 ± 0.1 7003 ± 305* 20.7 ± 0.8 18.7 10.40 p.Leu243Phe c.729 G>C 0.19 0.9 2694 ± 117 7.9 ± 0.3 14370 ± 618* 42.3 ± 1.4 34.4 5.33 p.Ile253Thr c.758 T>C 0.63 / 0.58 2.9 / 2.6 11287 ± 506 38.9 ± 3.0 23417 ± 1077* 80.2 ± 5.9 41.3 2.07 p.Pro259Arg c.776 C>G 0.44 / 0.6 2.0 / 2.7 6681 ± 364 23.3 ± 2.3 17645 ± 515* 60.3 ± 3.8 37.0 2.64 p.Arg301Gln c.902 G>A 0.42 1.9 1914 ± 52 5.5 ± 0.2 15547 ± 353* 44.5 ± 1.0 39.0 8.12 p.Asp322Glu c.966 C>A 0.2 0.9 2398 ± 141 6.7 ± 0.2 9554 ± 667* 26.8 ± 1.3 20.0 3.98 p.Gly325Arg c.973G>C 0.07 0.3 909 ± 31 2.6 ± 0.1 9244 ± 417* 26.6 ± 1.4 24.0 10.17 p.Gly373Ser c.1117 G>A 0.29 1.3 1544 ± 69 4.8 ± 0.3 5128 ± 288* 15.7 ± 0.8 10.9 3.32 GLA mutations found in men who do not conform to the classic phenotype. p.Asp33Gly c.98 A>G 1.42 6.5 9913 ± 600 29.3 ± 1.8 24033 ± 865* 70.6 ± 2.4 41.3 2.42 p.Ala156Thr c.466 G>A 9.05 41.1 907 ± 31 2.8 ± 0.1 7034 ± 289* 21.9 ± 0.9 19.1 7.75 p.Asp244Asn c.730 G>A 13.17 59.8 10317 ± 386 30.9 ± 1.6 16321 ± 402* 48.7 ± 1.7 17.8 1.58 p.Arg356Trp c.1066 C>T 1.22 5.5 3526 ± 240 11.0 ± 0.7 15570 ± 830* 49.1 ± 2.6 38.1 4.42 GLA mutations found in female patients p.Leu36Trp c.107 T>G -- -- 241 ± 19 0.7 ± 0.1 5182 ± 463* 16.6 ± 2.1 15.9 21.49 p.Gly85Asp c.254 G>A -- -- 888 ± 38 2.7 ± 0.1 4534 ± 135* 14.3 ± 0.9 11.6 5.10 p.Arg112His c.335 G>A -- -- 845 ± 39 2.6 ± 0.1 5583 ± 215* 17.4± 0.8 14.8 6.61 p.Met187Ile c.561 G>A -- -- 1775 ± 57 5.1 ± 0.2 10824 ± 555* 30.7 ± 1.1 25.6 6.10 p.Pro205Thr c.613 C>A -- -- 4802 ± 230 14.4 ± 0.9 16371 ± 647* 48.8 ± 2.2 34.4 3.41 p.Gly258Arg c.772 G>C -- -- 9558 ± 348 32.6 ± 2.1 22630 ± 801* 78.1 ± 5.8 45.5 2.37 p.Leu300Pro c.899 T>C -- -- 1277 ± 38 3.7 ± 0.1 13219 ± 412* 37.9 ± 1.2 34.2 10.35 p.Pro293Thr c.877 C>A -- -- 229 ± 20 0.7 ± 0.1 4488 ± 327* 13.3 ± 1.1 12.7 19.60 p.Phe 295Cys c.884 T>G -- -- 1196 ± 38 3.4 ± 0.1 5051 ± 190* 14.5 ± 0.6 11.1 4.22 p.Gly271Ser;Asp313Tyr c.811 G>A;c.937 G>T -- -- BLD N / A 877 ± 18* 3.0 ± 0.2 3.0 NC p.Ile317Thr c.950 T>C -- -- 2298 ± 338 6.5 ± 0.6 7812 ± 530* 23.6 ± 1.0 17.0 3.40 p.Asp264Tyr c.790 G>T -- -- 143 ± 13 0.5 ± 0.0 1842 ± 100* 6.2 ± 0.3 5.7 12.89 p.Gly260Ala c.779 G>C -- -- 2221 ± 142 7.5 ± 0.6 10749 ± 403* 37.4 ± 3.1 29.9 4.84 p.Met284Thr c.851 T>C -- -- 606 ± 40 1.7 ± 0.1 5050 ± 268* 14.3 ± 0.6 12.6 8.33 p.Gly183Asp c.548 G>A -- -- 207 ± 15 0.7 ± 0.1 6074 ± 212* 19.1 ± 1.0 18.4 29.31 p.Arg301Gln c.902 G>A -- -- 1914 ± 52 5.5 ± 0.2 15547 ± 353* 44.5 ± 1.0 39.0 8.12 p.Ile253Thr c.758 T>C -- -- 11287 ± 506 38.9 ± 3.0 23417 ± 1077* 80.2 ± 5.9 41.3 2.07 p.Asp322Glu c.966 C>A -- -- 2398 ± 141 6.7 ± 0.2 9554 ± 667* 26.8 ± 1.3 20.0 3.98 p.Ile270Thr c.809 T>C -- -- 1846 ± 119 6.3 ± 0.5 12416 ± 377* 42.8 ± 3.0 36.5 6.73 p.Gly325Arg c.973G>C -- -- 909 ± 31 2.6 ± 0.1 9244 ± 417* 26.6 ± 1.4 24.0 10.17 p.Tyr216Cys c.647 A>G -- -- 673 ± 38 2.0 ± 0.1 7003 ± 305* 20.7 ± 0.8 18.7 10.40 p.Pro259Arg c.776 C>G -- -- 6681 ± 364 23.3 ± 2.3 17645 ± 515* 60.3 ± 3.8 37.0 2.64 p.Met284Thr c.851 T>C -- -- 606 ± 40 1.7 ± 0.1 5050 ± 268* 14.3 ± 0.6 12.6 8.33 p.Gly258Arg c.772 G>C -- -- 9558 ± 348 32.6 ± 2.1 22630 ± 801* 78.1 ± 5.8 45.5 2.37 BLD = below the detection limit (< 142 nmol / mg / hr); PBMC = peripheral blood mononuclear cells; SEM = standard error of mean; WT = wild type. Data are presented as mean ± SEM: Mutant α-Gal A activity is expressed as the percentage of α-Gal A activity measured in WT cell lysates that were not incubated with migastrol (-migastrol) in parallel. The absolute increase at 10 µM (%WT) = the percentage of wild-type α-Gal A activity to 10 µM migastrol (+mirgastrol) minus the baseline percentage of wild-type α-Gal A activity (-mirgastrol). α-Gal A activity at 10 µM (a multiple of baseline) = α-Gal A activity in cell lysates transfected with a mutant containing 10 µM migastine / α-Gal A activity in cell lysates transfected with a mutant not containing migastine. The one-tailed Mann-Whitney U nonparametric test was used to determine the statistically significant difference in α-Gal A activity between the absence of migastricostat (n = 20) and 10 uM migastricostat (n = 20): *p < 0.001. An asterisk indicates the α-Gal A mutant form, which showed a statistically significant increase in α-Gal A activity after incubation with 10 uM migastricostat. “BLD” indicates that the average α-Gal A activity (average n = 20) is below the limit of detection (< 142 nmol / mg / hr; this value is equal to 3 * standard deviation of pcDNA activity in nmol / mg / hr after vector subtraction of 128 samples determined in ten method validation experiments). This only displays PBMC data for male patients. The criteria for the classic phenotype are: male, PBMC α-Gal A activity <3% of normal, and multiple organ diseases.

[0248] For GLA mutations reported in the literature and associated with the classic phenotype in patients enrolled in this study, the mean absolute increase in α-Gal A activity at 10 µM migastrol was 24.8% of the mean total tachycardia (WT), and the mean activity was 8.2-fold higher than baseline. For all other mutations, the mean absolute increase in α-Gal A activity was 24.5% of the WT, and the mean activity was 6.8-fold higher than baseline.

[0249] [Migalstatin and renal function.] The mean (standard deviation [SD]) annualized rate of change of eGFRCKD-EPI from baseline (or month 6 in patients randomly assigned to placebo) to month 24 was -0.3 (3.76) mL / min / 1.73 m2 (95% CI -2.80, 2.25) in the classic male subgroup and -0.3 (4.47) mL / min / 1.73 m2 (95% CI 1.98, 1.48) in the other patient subgroups (Figure 4A). During this period, the median annualized rate of change was 0.25 mL / min / BSA (min,max: -8.6, 4.3) and 0.33 mL / min / BSA (min,max: -13.8, 7.4) in the classic male and other patients, respectively. The mean (SD) annualized change in mGFR iohexol over the same time period was -3.0 (6.04) mL / min / 1.73 m2 (95% CI -7.65, 1.64) in classic males and -1.0 (6.66) mL / min / 1.73 m2 (95% CI -4.39, 2.33) in other patients. One classic male patient experienced a reduction of -16 mg / mL / 1.73 m2 from month 6 to month 24. The median (range) change in mGFR iohexol from baseline to month 24 was -1.03 mg / mL / 1.73 m2 (min, max: -16.2, 3.0) in classic males and -0.34 mg / mL / 1.73 m2 (min, max: -20.4, 15.8) in other patients.

[0250] The results were similar to those in the overall compliance population in this study, where migastric stabilized the annualized changes in GFR, eGFRCKD-EPI, and mGFR from baseline to 24 months with iohexol of -0.3 (0.66) and -1.5 (1.33) mL / min / 1.73 m2, respectively, in patients with compliance mutations. The use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remained unchanged during the study and therefore did not affect renal function data.

[0251] [Migastrostat and cardiac function.] Migastrostat also resulted in a decrease in LVMi in both subgroups. Notably, baseline LVMi was substantially higher in classic male patients than in other patients (114.3 g / m2 vs. 88.2 g / m2), and seven (50%) classic male patients had LVH at baseline. The mean (SD) change in LVMi from baseline (or month 6) to month 24 was -16.7 (18.64) g / m2 (95% CI -31.1, -2.4) in classic males and -3.2 (18.66) g / m2 (95% CI -12.5, 6.1) in other patients (Figure 4B).

[0252] In contrast, after 24 months of treatment with migastric, the change in LVMi in the overall migastric-treated population in this study was -7.7 g / m2 (95% CI -15.4, -0.01), with a greater reduction in LVH patients (-18.6 g / m2 [95% CI -38.2, 1.0]).

[0253] Furthermore, compared with published data on men with the classic phenotype, the results of this analysis indicate that patients treated with migastrict had better GFR and LVMi outcomes than untreated patients. Studies in untreated men reported annual changes in eGFR (measured using eGFRCKD-EPI or eGFRMDRD) ranging from -2.6 to -12.7 mL / min / 1.73 m² from baseline. For LVMi, studies in untreated men reported annual increases ranging from 4.1 to 8.0 g / m². Moreover, migastrict appears to have a potentially beneficial effect compared to ERT in this patient population. While ERT has been shown to improve LVMi in younger patients (aged 18–29 years), the effects of migastrict have been observed across the entire age spectrum, with data reporting reduced LVMi in 7 / 8 classic male patients (age range 16–61 years; mean 42.4 years).

[0254] [Migalstat and Gastrointestinal Signs and Symptoms.] The mean (SD) GSRS-D score at baseline was 2.4 (1.69) in classic male patients and 2.1 (1.49) in other patients. Eight (57%) classic male patients had diarrhea symptoms at baseline (i.e., GSRS-D score ≥ 1). In classic male patients, treatment with migasstat for six months improved the GSRS-D score (mean [SD] change from baseline -0.3 [1.75]), while patients treated with placebo did have a small increase (0.2 [0.46]). Classic male patients benefited from continued treatment with migasstat or from switching from placebo to migasstat. By 24 months, the mean (SD) change in diarrhea symptoms from baseline (or 6 months) was -0.9 (1.75) (Figure 4C), and 7 of the 8 classic male patients with diarrhea (88%) achieved a minimum clinically important difference (MCID) reduction of 0.33 in the GSRS-D score at baseline. The corresponding changes in other patients were -0.5 (1.01) at month 24. These results are similar to those of the entire compliant patient population in this study, in which patients with compliant mutations treated with migastricostat had mean changes in GSRS-D of -0.3 and -0.5 at months 6 and 24, respectively.

[0255] [Migastrostat and kidney] [GL-3] [。] During the first 6 months of the study, the mean (SD) number of GL-3 inclusions per renal interstitial capillary decreased from baseline in classic men treated with migastric stethoscope (-0.8 [-0.78]) (Figure 4D). Conversely, GL-3 inclusions increased during this period in classic men receiving placebo (mean [SD], 0.3 [0.94]). At month 6 when switching from placebo to migastric stethoscope, in these patients, the mean (SD) of GL-3 inclusions per renal interstitial capillary decreased by -0.7 (0.91) over the next 6 months. These results reflect those reported in this study for the entire compliant patient population, where GL-3 inclusions decreased during 6 months of migastric stethoscope treatment (mean, -0.25) and increased during 6 months of placebo treatment (mean, 0.07). In the entire patient population, a decrease in mean GL-3 contents was observed after switching from placebo to migastric at month 6.

[0256] A decrease in the mean (SD) number of GL-3 contents in each renal interstitial capillary was observed in another patient subgroup, whether from treatment with migastricostat at month 0–6 (-0.1 [0.30]) or from switching from placebo to migastricostat at month 6 (change from month 6–12; -0.1 [0.24]) (Figure 4D). A small decrease was also noted in another patient subgroup treated with placebo at month 0–6 (-0.05 [0.10]), and although the overall decrease was small (likely due to low baseline levels), the change was twice as significant with migastricostat as with placebo.

[0257] [Migastrostat and plasma hemolysis] [-Gb, 3, ] [。]Migalstat was associated with decreased plasma hemolyzed-Gb3 in classic males and other patient subgroups. The decrease in patients with the classic phenotype was more than twice that of other subgroups, likely due to higher baseline levels (99.8 [35.28] vs. 29.3 [48.32] nmol / L) compared to the mean [SD] in other patient subgroups. The mean (SD) change in plasma hemolyzed-Gb3 from baseline (or month 6) to month 24 was -36.04 (34.48) nmol / L (95% CI -67.93, -4.15) for classic males and -16.33 (19.73) nmol / L (95% CI -25.07, -7.58) for other patients (Figure 4E).

[0258] [Safety and Adverse Events.] In Phase 1, treatment-emergent adverse events were similar between groups. The most frequent adverse events in patients receiving miralstat compared to placebo were headache (12 / 34 patients - 35% vs. 7 / 33 patients - 21%) and nasopharyngitis (6 / 34 patients - 18% vs. 2 / 34 patients - 6%). The most frequently reported adverse events in Phase 2 were headache (9 / 63 patients - 14%) and procedural pain (7 / 63 patients - 11%, related to renal biopsy), and the most frequently reported adverse events in the extended unblinded phase were proteinuria (9 / 57 patients - 16%), headache (6 / 57 patients - 11%), and bronchitis (6 / 57 patients - 11%). Most adverse events were mild to moderate in severity. No adverse events led to discontinuation of miralstat.

[0259] Six patients experienced serious adverse events in Phase 1 (2 with miracolic acid; 4 with placebo), five patients experienced serious adverse events in Phase 2, and eleven patients experienced serious adverse events during the unblinded extension period. Two serious adverse events (fatigue and paresthesia) were assessed by respondents as possibly related to miracolic acid. Both occurred in the same patient between months 12 and 24 and have resolved. One patient reported no individual serious adverse events. Two patients discontinued miracolic acid due to serious adverse events; both patients were considered unrelated to miracolic acid. No deaths were reported.

[0260] Nine patients (16%) experienced treatment-induced proteinuria between 12 and 24 months, and one of these cases was determined to be related to migastricostat. In five patients, the 24-month values ​​were within the same range as baseline. Three patients with appropriate mutations had significant baseline proteinuria (>1 g / 24-hr) that increased over 24 months. Of the 28 patients with baseline proteinuria <300 mg / 24-h, 23 had stable 24-hour urinary proteinuria during migastricostat treatment.

[0261] There was no progression to end-stage renal disease, cardiac death, or stroke as defined by Banicazemi et al. One case of transient ischemic attack was determined to be unrelated to migastric.

[0262] Analysis of vital signs, physical examination findings, laboratory and electrocardiogram parameters did not reveal the clinical relevance of migastine.

[0263] The patents and scientific literature cited in this document establish the knowledge available to those skilled in the art. All U.S. patents and published or unpublished U.S. patent applications cited in this document are incorporated herein by reference. All published foreign patents and patent applications cited in this document are incorporated herein by reference. All other published references, documents, manuscripts, and scientific literature cited in this document are incorporated herein by reference.

[0264] Although the invention has been specifically shown and described with reference to its preferred embodiments, those skilled in the art will understand that various changes in form and detail may be made without departing from the scope of the invention as defined in the appended claims.

[0265] none

[0266] Domestic storage information (please note in order of storage institution, date, and number) none

[0267] Overseas storage information (please note in the order of storage country, institution, date, and number) none

Claims

1. A formulation for use in the manufacture of a pharmaceutical agent comprising an effective amount of migasstat or a salt thereof, the pharmaceutical agent being used to reduce globotriaosylceramide (GL-3) in a male patient with classic Fabry disease, wherein the effective amount is 100 mg to 150 mg free base equivalent (FBE), and the patient has a mutation in α-Gal A selected from the group consisting of: I253T, P259R, G183D, L243F, C174R, D55V / Q57L, G144V, G373S, D322E, G325R, and Y216C, and the patient has elevated renal interstitial capillary GL-3 prior to initiation of administration of the migasstat or a salt thereof.

2. The application as described in claim 1, wherein reducing renal GL-3 includes reducing the GL-3 contents of each renal interstitial capillary.

3. The application as described in claim 1 or 2, wherein the migastrol or its salt enhances α-galactosidase A activity.

4. The application as described in claim 1 or 2, wherein the effective amount is 123 mg of FBE.

5. The application as described in claim 1 or 2, wherein the effective amount is 123 mg of migastart free base.

6. The application as described in claim 1 or 2, wherein the migastrol salt is migastrol hydrochloride.

7. The application as described in claim 6, wherein the effective amount is 150 mg of migastart hydrochloride.

8. The application as described in claim 1 or 2, wherein the migastrol or its salt is in an oral dosage form.

9. The application as described in claim 8, wherein the oral dosage form includes tablets, capsules, or solutions.

10. The application as described in claim 1 or 2, wherein the migastrol or its salt is administered for at least 6 months.

11. The application as described in claim 1 or 2, wherein administration of migasstat or its salt to a group of classic Fabry patients resulted in a mean reduction of at least 0.5 in GL-3 contents per renal interstitial capillary after 6 months of administration of migasstat or its salt.

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