Miglustat formulations comprising nitrosamine for use in the treatment of pompe disease

Abstract

Provided are compositions comprising certain miglustat-related nitrosamine compounds, such as pharmaceutical compositions comprising miglustat and such miglustat-related nitrosamine compounds. Also provided are pharmaceutical compositions comprising miglustat and less than certain levels of such miglustat-related nitrosamine compounds. Also provided are methods of analyzing such miglustat-related nitrosamine compounds.

Description

Docket No.: AT24-003-PCT1NITROSAMINE COMPOUNDS AND METHODS FOR ANALYZING THE SAMETECHNICAL FIELD

[0001] The present disclosure relates to compositions comprising certain nitrosamine compounds and methods for analyzing the same.BACKGROUND

[0002] Pompe disease (also known as glycogen storage disease type II (GSD-II) or acid maltase deficiency disease) is an inherited lysosomal storage disease that results from a deficiency in acid a-glucosidase (GAA) activity. A person having Pompe disease lacks or has reduced levels of GAA, the enzyme which breaks down glycogen to glucose, a main energy source for muscles. This enzyme deficiency causes excess glycogen accumulation in the lysosomes, which are intra-cellular organelles containing enzymes that ordinarily break down glycogen and other cellular debris or waste products. Glycogen accumulation in certain tissues of a subject having Pompe disease, especially muscles, impairs the ability of cells to function normally. In Pompe disease, glycogen is not properly metabolized and progressively accumulates in the lysosomes, especially in skeletal muscle cells and, in the infantile-onset form of the disease, in cardiac muscle cells. The accumulation of glycogen damages the muscle and nerve cells as well as those in other affected tissues.

[0003] There exists a need for miglustat formulations such as those that can be used for the treatment of Pompe disease.SUMMARY

[0004] Provided are compositions relating to one or more compounds comprising an N-nitrosated tertiary amine.Docket No.: AT24-003-PCT2

[0005] In some embodiments, the compound has a structure of either (A) or (B) from the following:(A) (B) or a salt or solvate thereof.

[0006] In some embodiments, a composition comprises one or more compounds of either (A) or (B).

[0007] In some embodiments, the composition comprises at least 0.0001 , 0.0002, 0.0003, 0.0004, 0.0005, 0.0006, 0.0007, 0.0008, 0.0009, 0.001 , 0.002, 0.003, 0.004, 0.005, 0.006, 0.007, 0.008, 0.009, 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, or 0.1 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.0001 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.001 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.01 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.1 ppb of the one or more compounds comprising a structure of either (A) or (B).

[0008] In some embodiments, the composition comprises less than 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.1 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, 2, 2.1 , 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8 2.9, 3, 3.1 ,Docket No.: AT24-003-PCT33.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4, 4.1 , 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 5, 5.1 ,5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 6, 6.1 , 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7, 7.5, 8, 8.5, 9, 9.5, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 83.1 , 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 160, 170, 180, 190, 200,250, or 500 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 100 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 69 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 6.9 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 2.3 ppb of the one or more compounds comprising a structure of either (A) or (B).

[0009] In some embodiments, the composition further comprises at least 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30, 35, or 40 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 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, 1 , 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30, 35, or 40 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 20 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 19 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 18 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 17 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 16 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 15 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 10 ng of the oneDocket No.: AT24-003-PCT4 or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 5 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 1 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 0.6 ng of the one or more compounds comprising a structure of either (A) or (B).

[0010] In some embodiments, the composition further comprises miglustat and / or L-ido miglustat. In some embodiments, the composition comprises miglustat. In some embodiments, the composition comprises L-ido miglustat. In some embodiments, the composition comprises about 10, 15, 20, 25, 30, 35, 40, 45, or 50% by weight miglustat. In some embodiments, the composition comprises about 20% to about 40% by weight miglustat. In some embodiments, the composition comprises about 30% to about 35% by weight miglustat. In some embodiments, the composition comprises about 20% to about weight miglustat. In some embodiments, the composition comprises about 30% by weight miglustat. In some embodiments, the composition comprises about 35% by weight miglustat. In some embodiments, the composition comprises about 40% by weight miglustat. In some embodiments, the composition comprises miglustat and the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises miglustat and has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0011] In some embodiments, the composition further comprises a source of nitrate and / or nitrite. In some embodiments, the composition comprises miglustat, a source of nitrate and / or nitrite, and the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises miglustat, a source of nitrate and / or nitrite, and also has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0012] In some embodiments, the composition further comprises microcrystalline cellulose. In some embodiments, the composition comprises about 10, 15, 20, 25,Docket No.: AT24-003-PCT530, 35, 40, 45, 50, 55, 60, 65, or 70% by weight microcrystalline cellulose. In some embodiments, the composition comprises about 40% to about 60% by weight microcrystalline cellulose. In some embodiments, the composition comprises about 45% to about 55% by weight microcrystalline cellulose. In some embodiments, the composition comprises about 40% by weight microcrystalline cellulose. In some embodiments, the composition comprises about 45% by weight microcrystalline cellulose. In some embodiments, the composition comprises about 55% by weight microcrystalline cellulose. In some embodiments, the composition comprises about 60% by weight microcrystalline cellulose. In some embodiments, the microcrystalline cellulose includes nitrate and / or nitrite. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises miglustat and microcrystalline cellulose, and also has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0013] In some embodiments, the composition further comprises starch. In some embodiments, the composition comprises starch in the form of pregelatinized starch. In some embodiments, the composition comprises about 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, or 40% by weight starch. In some embodiments, the composition comprises about 5% to about 25% by weight starch. In some embodiments, the composition comprises about 10% to about 20% by weight starch. In some embodiments, the composition comprises about 5% by weight starch. In some embodiments, the composition comprises about 10% by weight starch. In some embodiments, the composition comprises about 20% by weight starch. In some embodiments, the composition comprises about 25% by weight starch. In some embodiments, the starch includes nitrate and / or nitrite. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises miglustat and starch, and also has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0014] In some embodiments, the composition further comprises sucralose. In some embodiments, the composition comprises sucralose in the form of powder. In someDocket No.: AT24-003-PCT6 embodiments, the composition comprises about 0.1 , 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10% by weight sucralose. In some embodiments, the composition comprises about 0.1 % to about 5% by weight sucralose. In some embodiments, the composition comprises about 0.2% to about 1 % by weight sucralose. In some embodiments, the composition comprises about 0.1 % by weight sucralose. In some embodiments, the composition comprises about 0.2% by weight sucralose. In some embodiments, the composition comprises about 1 % by weight sucralose. In some embodiments, the composition comprises about 5% by weight sucralose. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0015] In some embodiments, the composition further comprises magnesium stearate. In some embodiments, the composition comprises about 0.1 , 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10% by weight magnesium stearate. In some embodiments, the composition comprises about 0.1 % to about 5% by weight magnesium stearate. In some embodiments, the composition comprises about 0.2% to about 1 % by weight magnesium stearate. In some embodiments, the composition comprises about 0.1 % by weight magnesium stearate. In some embodiments, the composition comprises about 0.2% by weight magnesium stearate. In some embodiments, the composition comprises about 1 % by weight magnesium stearate. In some embodiments, the composition comprises about 5% by weight magnesium stearate. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0016] In some embodiments, the composition further comprises colloidal silicon dioxide. In some embodiments, the composition comprises colloidal silicon dioxide in addition to magnesium stearate. In some embodiments, the composition alternatively comprises colloidal silicon dioxide rather than magnesium stearate. In some embodiments, the composition comprises about 0.1 , 0.2, 0.3, 0.4, 0.5, 0.6,Docket No.: AT24-003-PCT70.7, 0.8, 0.9, 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10% by weight colloidal silicon dioxide. In some embodiments, the composition comprises about 0.1 % to about 5% by weight colloidal silicon dioxide. In some embodiments, the composition comprises about 0.2% to about 1 % by weight colloidal silicon dioxide. In some embodiments, the composition comprises about 0.1 % by weight colloidal silicon dioxide. In some embodiments, the composition comprises about 0.2% by weight colloidal silicon dioxide. In some embodiments, the composition comprises about 1 % by weight colloidal silicon dioxide. In some embodiments, the composition comprises about 5% by weight colloidal silicon dioxide. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0017] In some embodiments, the composition further comprises about 20% to about 40% by weight miglustat, about 40% to about 60% by weight microcrystalline cellulose, about 5% to about 25% by weight starch, about 0.1 % to about 5% by weight sucralose, about 0.1 % to about 5% by weight magnesium stearate, and / or about 0.1 % to about 5% by weight colloidal silicon dioxide. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0018] In some embodiments, the composition comprises about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 60, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900 or 1 ,000 mg of miglustat. miglustat. In some embodiments, the composition comprises about 260 mg miglustat. In some embodiments, the composition comprises about 195 mg miglustat. In some embodiments, the composition comprises about 130 mg miglustat. In some embodiments, the composition comprises about 65 mg miglustat. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less thanDocket No.: AT24-003-PCT a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0019] In some embodiments, the composition further comprises about 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 150, 200, 250, 300, 350, 400, 450 or 500 mg microcrystalline cellulose. In some embodiments, the composition comprises about 400 mg microcrystalline cellulose. In some embodiments, the composition comprises about 300 mg microcrystalline cellulose. In some embodiments, the composition comprises about 200 mg microcrystalline cellulose. In some embodiments, the composition comprises about 100 mg microcrystalline cellulose. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0020] In some embodiments, the composition further comprises about 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 150, or 140 mg starch. In some embodiments the composition comprises about 135 mg starch.In some embodiments, the composition comprises about 130.4 mg starch. In some embodiments, the composition comprises about 100 mg starch. In some embodiments, the composition comprises about 97.8 mg starch. In some embodiments, the composition comprises about 70 mg starch. In some embodiments, the composition comprises about 65.2 mg starch. In some embodiments, the composition comprises about 35 mg starch. In some embodiments, the composition comprises about 32.6 mg starch. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0021] In some embodiments, the composition comprises about 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 mg sucralose. In some embodiments, the composition comprises about 4 mg sucralose. In some embodiments, the composition comprises about 3 mg sucralose.Docket No.: AT24-003-PCT9In some embodiments, the composition comprises about 2 mg sucralose. In some embodiments, the composition comprises about 1 mg sucralose. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0022] In some embodiments, the composition comprises about 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 mg magnesium stearate. In some embodiments, the composition comprises about 4 mg magnesium stearate. In some embodiments, the composition comprises about 3 mg magnesium stearate. In some embodiments, the composition comprises about 2 mg magnesium stearate. In some embodiments, the composition comprises about 1 mg magnesium stearate. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0023] In some embodiments, the composition comprises about 0.1 , 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1 .0, 1 .1 , 1 .2, 1 .3, 1 .4, 1 .5, 1 .6, 1 .7, 1 .8, 1 .9, 2.0, 2.1 , 2.2, 2.3, 2.4, or 2.5 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 2 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 1.6 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 1 .5 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 1.2 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 1 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 0.8 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 0.5 mg colloidal silicon dioxide. In some embodiments, the composition comprises about 0.4 mg colloidal silicon dioxide. In some embodiments, the composition comprises colloidal silicon dioxide in addition to magnesium stearate. In some embodiments, the composition alternatively comprises colloidal silicon dioxide rather than magnesium stearate. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, theDocket No.: AT24-003-PCT10 composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0024] In some embodiments, the composition comprises about 260 mg miglustat, about 400 mg microcrystalline cellulose, about 130.4 mg pregelatinized starch, about 4 mg sucralose powder, about 4 mg magnesium stearate, and about 1 .6 mg colloidal silicon dioxide. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0025] In some embodiments, the composition comprises about 195 mg miglustat, about 300 mg microcrystalline cellulose, about 97.8 mg pregelatinized starch, about 3 mg sucralose powder, about 3 mg magnesium stearate, and about 1 .2 mg colloidal silicon dioxide. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0026] In some embodiments, the composition comprises about 130 mg miglustat, about 200 mg microcrystalline cellulose, about 65.2 mg pregelatinized starch, about 2 mg sucralose powder, about 2 mg magnesium stearate, and about 0.8 mg colloidal silicon dioxide. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0027] In some embodiments, the composition comprises about 65 mg miglustat, about 100 mg microcrystalline cellulose, about 32.6 mg pregelatinized starch, about 1 mg sucralose powder, about 1 mg magnesium stearate, and about 0.4 mg colloidal silicon dioxide. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).Docket No.: AT24-003-PCT11

[0028] In some embodiments, the composition is provided in an oral liquid. In some embodiments, the oral liquid comprises a solution, a dispersion, or a suspension. In some embodiments, the oral liquid is provided for oral administration. In some embodiments, the composition is provided in a hard gelatin capsule. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0029] In some embodiments, the composition comprises about 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.1 , 0.12, 0.13, 0.14, 0.15, 0.16, 0.18, 0.19, 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, 1 , 1.1 , 1.2, 1 .3, 1 .4, 1 .5, 1 .6, 1 .7, 1 .8, 1 .9, 2, 2.1 , 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.1 , 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7.0 10, 50, 80, 83, 83.1 84, 85, 100, 150, 200, 250, 300, 350, 400, 450, 500 ppb of the one or more compounds. In some embodiments, the composition comprises between 2.3 ppb and 6.9 ppb of the one or more compounds. In some embodiments the composition comprises no more than 6.9 ppb of the one or more compounds. In some embodiments, the composition comprises no less than 2.3 ppb of the one or more compounds. In some embodiments, the composition comprises between 0.06 ppb and 0.18 ppb of the one or more compounds. In some embodiments the composition comprises no more than 0.18 ppb of the one or more compounds. In some embodiments, the composition comprises no less than 0.06 ppb of the one or more compounds. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B).

[0030] In one or more embodiments, the composition is administered to a patient in need thereof. In some embodiments, the patient has Pompe disease. In some embodiments, the administration of the composition to a patient in need thereof is for a method of treating Pompe disease. In some embodiments, the composition administered to the patient comprises miglustat. In some embodiments, the composition administered to the patient comprises miglustat at about 10, 20, 30, 35, 40, 45, 50, 55, 60, 65, 70, or 75 mg miglustat. In some embodiments, theDocket No.: AT24-003-PCT12 composition comprises miglustat at 65 mg. In some embodiments, the composition comprises the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0031] In one or more embodiments, a method for preparing the compound for the treatment of Pompe disease in a patient in need thereof comprises oxidative cleavage of an alkyl group attached to a nitrogen atom on miglustat or L-ido miglustat. In some embodiments the method comprises oxidative cleavage of an alkyl group attached to a nitrogen atom on miglustat. In some embodiments the method comprises oxidative cleavage of an alkyl group attached to a nitrogen atom on L-ido miglustat. In some embodiments, the method comprises oxidative cleavage and a reaction of the nitrogen atom with a nitrosating agent. In some embodiments the nitrosating agent comprises one or more of nitrite and / or nitrous acid. In some embodiments the nitrosating agent has the formula of N2O3. In some embodiments the nitrosating agent has the formula of N2O. In some embodiments the method happens all at once. In some embodiments the method is sequential. In some embodiments the method comprises oxidative cleavage of an alkyl group attached to a nitrogen atom on miglustat or L-ido miglustat prior to reacting the nitrogen atom with a nitrosating agent. In some embodiments this method occurs as one, two, three, four, five, or six step process. In some embodiments, the method occurs as a four-step process. In some embodiments, the method occurs as a five-step process.

[0032] In some embodiments, the process occurs under stress conditions. In some embodiments the stress condition comprises an acidic pH. In some embodiments the pH is about 2.0, 2.1 , 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3.0, 3.1 , 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4.0. In some embodiments the pH is about 2.5. In some embodiments the pH is about 3.4. In some embodiments the pH is about 2.5 to about 3.4. In some embodiments, the stress conditions comprise a pKA of less than 5. In some embodiments the pKA is at least 1.0, 1.5, 2.0. 2.5, 3.0, 3.1 , 3.2, 3.3, 3.31 , 3.32, 3.33, 3.34, 3.35, 3.36, 3.37, 3.38, 3.39, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4.0. In some embodiments the pKA is 3.37. In some embodiments the entire process occurs under stress conditions. In some embodiments the first step of the process occursDocket No.: AT24-003-PCT13 under stress conditions. In some embodiments the second step of the process occurs under stress conditions. In some embodiments the third step of the process occurs under stress conditions. In some embodiments the fourth step of the process occurs under stress conditions. In some embodiments the fifth step of the process occurs under stress conditions.

[0033] Also provided is a method for detecting and / or quantifying the amount of the one or more compounds comprising a structure of either (A) or (B) in a composition. In one or more embodiments, the method is used to detect and / or quantify the amount of the one or more compounds comprising a structure of either (A) or (B) in a composition comprising miglustat, such as in miglustat capsules. In one or more embodiments, the capsules are prepared under stress conditions. In one or more embodiments, the detection and / or quantification is based on comparison of the combined nitrosamine peak to (2R,3R,4R,5S)-2-(hydroxymethyl)-1 -nitroso-3,4,5- piperidinetriol spiked into acidified water (pH 3.5) in the range of 0.0865-160 ng / mL. In some embodiments, the limit of detection is 0.0865 ng / mL and / or the lower limit of quantification is 0.173 ng / mL.

[0034] In some embodiments, the subject is an enzyme replacement therapy (ERT)- experienced subject.

[0035] In some embodiments, the ERT-experienced subject had been previously treated with alglucosidase alfa. In some embodiments, the ERT-experienced subject had been previously treated with alglucosidase alfa for from about 2 years to about 6 years. In some embodiments, the ERT-experienced subject had been previously treated with alglucosidase alfa for at least about 7 years. In some embodiments, the ERT-experienced subject is non-ambulatory. In some embodiments, the ERT-experienced subject is ambulatory.

[0036] In some embodiments, the subject is an ERT-naive subject.

[0037] In some embodiments, the is administered a population of recombinant human acid a-glucosidase (rhGAA) molecules, concurrently or sequentially with an enzyme stabilizer; wherein the enzyme stabilizer is miglustat; wherein each rhGAA moleculeDocket No.: AT24-003-PCT14 comprises seven potential N-glycosylation sites; wherein 40%-60% of the N-glycans on the rhGAA molecules are complex type N-glycans; wherein the rhGAA molecules comprise at least 0.5 mol bis-mannose-6-phosphate (bis-M6P) per mol of rhGAA at the first potential N-glycosylation site as determined using liquid chromatography tandem mass spectrometry (LC-MS / MS).

[0038] In some embodiments, the population of rhGAA molecules is administered at a dose of 5 mg / kg to 20 mg / kg, optionally 20 mg / kg.

[0039] In some embodiments, the population of rhGAA molecules is administered biweekly. In some embodiments, the population of rhGAA molecules is administered intravenously.

[0040] In some embodiments, the enzyme stabilizer is miglustat or a pharmaceutically acceptable salt thereof, wherein further optionally the miglustat or pharmaceutically acceptable salt thereof is administered orally. In some embodiments, the miglustat or pharmaceutically acceptable salt thereof is administered at a dose of 195 mg or 260 mg.

[0041] In some embodiments, the miglustat or pharmaceutically acceptable salt thereof is administered prior to administration of the population of rhGAA molecules, optionally one hour prior to administration of the population of rhGAA molecules. In some embodiments, the subject fasts for at least two hours before and at least two hours after the administration of miglustat or a pharmaceutically acceptable salt thereof.

[0042] In some embodiments, the rhGAA molecules comprise an amino acid sequence at least 95% identical to SEQ ID NO: 4 or SEQ ID NO: 6.

[0043] In some embodiments, the rhGAA molecules comprise the amino acid sequence of SEQ ID NO: 4 or SEQ ID NO: 6.

[0044] In some embodiments, at least 30% of the rhGAA molecules comprise one or more N-glycan units bearing one mannose-6-phosphate residue (mono-M6P) or bis- M6P, as determined using LC-MS / MS.Docket No.: AT24-003-PCT15

[0045] In some embodiments, the rhGAA molecules comprise on average from 0.5 mol to 7.0 mol of mono-M6P or bis-M6P per mol of rhGAA, as determined using LC- MS / MS.

[0046] In some embodiments, the rhGAA molecules comprise on average from 2.0 to 8.0 mol of sialic acid per mol of rhGAA, as determined using LC-MS / MS.

[0047] In some embodiments, the rhGAA molecules comprise on average from 3.0 to 8.0 mol of sialic acid per mol rhGAA, as determined using LC-MS / MS.

[0048] In some embodiments, the rhGAA molecules comprise greater than 4.0 mol of sialic acid per mol of rhGAA, as determined using LC-MS / MS.

[0049] In some embodiments, the rhGAA molecules comprise on average at least 2.5 mol M6P per mol of rhGAA and at least 4 mol sialic acid per mol of rhGAA, as determined using LC-MS / MS.

[0050] In some embodiments, per mol of rhGAA, the rhGAA molecules comprise on average: (a) 0.4 to 0.6 mol mono-M6P at the second potential N-glycosylation site; (b) 0.4 to 0.6 mol bis-M6P at the fourth potential N-glycosylation site; or (c) 0.3 to 0.4 mol mono-M6P at the fourth potential N-glycosylation site; wherein (a)-(c) are determined using LC-MS / MS.

[0051] In some embodiments, the population of rhGAA molecules comprises, on average, at least 1 .0 mol bis-M6P per mol rhGAA.

[0052] In some embodiments, the population of rhGAA molecules comprises, on average, at least 1 .3 mol bis-M6P per mol rhGAA.

[0053] In some embodiments, at least 3% of the total N-glycans on the population of rhGAA are bis-M6P.

[0054] In some embodiments, at least 17% of the total N-glycans on the population of the rhGAA are bis-M6P.Docket No.: AT24-003-PCT16

[0055] In the embodiments, at least 3% to 25% of the total glycans on the population of the rhGAA are bis-M6P.

[0056] In the embodiments, at least 17% to 25% of the total glycans on the population of the rhGAA are bis-M6P.

[0057] In some embodiments, at least 25% of the total glycans on the population of the rhGAA are bis-M6P.

[0058] In some embodiments, per mol of rhGAA, the rhGAA molecules further comprise 4 mol to 7.3 mol sialic acid; and, per mol of rhGAA, the rhGAA molecules comprise on average: (a) 0.9 to 1 .2 mol sialic acid at the third potential N-glycosylation site; (b) 0.8 to 0.9 mol sialic acid at the fifth potential N-glycosylation site; or (c) 1 .5 to 4.2 mol sialic acid at the sixth potential N-glycosylation site; wherein (a)-(c) are determined using LC-MS / MS.

[0059] In some embodiments, the population of rhGAA molecules is formulated in a pharmaceutical composition further comprising at least one pharmaceutically acceptable buffer, excipient, or carrier.

[0060] In some embodiments, the pharmaceutical composition further comprises at least one buffer selected from the group consisting of a citrate, a phosphate, and a combination thereof, and at least one excipient selected from the group consisting of mannitol, polysorbate 80, and a combination thereof; wherein the pharmaceutical composition has a pH of 5.0 to 7.0.

[0061] In some embodiments, the pharmaceutical composition has a pH of 5.0 to 6.0.

[0062] In some embodiments, the pharmaceutical composition further comprises water, an acidifying agent, an alkalizing agent, or a combination thereof.

[0063] In some embodiments, in the pharmaceutical composition, the population of rhGAA molecules is present at a concentration of 5-50 mg / mL, the at least one buffer is a sodium citrate buffer present at a concentration of 10-100 mM, the at least one excipient is mannitol present at a concentration of 10-50 mg / mL and polysorbate 80 present at a concentration of 0.1 -1 mg / mL, and the pharmaceutical compositionDocket No.: AT24-003-PCT17 further comprises water and optionally comprises an acidifying agent and / or alkalizing agent; wherein the pharmaceutical composition has a pH of 6.0.

[0064] In some embodiments, in the pharmaceutical composition, the population of rhGAA molecules is present at a concentration of 15 mg / mL, the sodium citrate buffer is present at a concentration of 25 mM, the mannitol is present at a concentration of 20 mg / mL, and the polysorbate 80 is present at a concentration of 0.5 mg / mL.

[0065] In some embodiments, the rhGAA is produced from Chinese hamster ovary cells.

[0066] The headings herein are for the convenience of the reader and not intended to be limiting.

[0067] The use of ‘may’ and ‘can’ herein is to describe the various embodiments that are included within the claims, and not to indicate uncertainty about the scope of the claims.BRIEF DESCRIPTION OF THE DRAWINGS

[0068] FIG. 1 shows the structures of miglustat, L-ldo miglustat, N-Nitroso miglustat, and N-Nitroso- L-ldo miglustat.

[0069] FIG. 2 shows a fishbone diagram describing the potential sources of nitrosamines in drug products.

[0070] FIG. 3 shows the general structure of N-Nitrosamines.

[0071] FIG. 4 shows the general formation of Nitrosating species from Nitrites.

[0072] FIG. 5. shows the general pathway for N-nitrosation of tertiary amines from nitrites (e.g., N2O3), illustrating the dealkylation process and the 2:1 stoichiometry.

[0073] FIG. 6 shows the theoretical chemical pathway for NDSRI formation of miglustat API by nitrate.Docket No.: AT24-003-PCT18

[0074] FIG. 7 shows the theoretical chemical pathway for N-nitrosamine formation of L-ido-miglustat with nitrate.

[0075] FIG. 8 shows exemplary forms of NxOy.

[0076] FIG. 9 shows1H-NMR analysis for N-nitroso miglustat.

[0077] FIG. 10 shows13C-NMR analysis for N-nitroso miglustat.

[0078] FIG. 11 shows MS(ESI Positive) analysis for N-nitroso miglustat.

[0079] FIG. 12 shows1H-NMR analysis for N-nitroso L-ido miglustat.

[0080] FIG. 13 shows13C-NMR analysis for N-nitroso L-ido miglustat.

[0081] FIG. 14 shows MS(ESI+ve) analysis for N-nitroso L-ido miglustat.DETAILED DESCRIPTION

[0082] Provided herein are compositions comprising miglustat and / or miglustat-related nitrosamine compounds.

[0083] Nitrosamines, particularly N-nitrosamines, are a class of compounds known for their mutagenic and potential carcinogenic properties in humans, necessitating strict control and monitoring. There exist six “typical” nitrosamines that are monitored either as limit testing or quantitative testing in drug substance or product batches, which include NDMA (N-Nitrosodimethylamine), NDEA (N-Nitrosodiethylamine), NMBA (N-Nitroso-N-methyl-4-aminobutyric Acid), NMPA (N- Nitrosomethylphenylamine), NIPEA (N-Nitrosoisopropylethylamine), NDIPA (N- Nitrosodiisopropylamine). These nitrosamines are small molecule simple dealkylated nitrosamines. The Als for these nitrosamines range from 26.5 to 96 ng / day as outlined in various health authority guidelines. More recently, MeNP (1 - Methyl-4-nitrosopiperazine) and NDBA (N-Nitrosodibutylamine) have been added to the above list of nitrosamines, generating a list of the “Big 8” nitrosamines.

[0084] Recently, nitrites have been identified as potential impurity precursors for nitrosation of amine-containing active pharmaceutical ingredients (APIs). For solidDocket No.: AT24-003-PCT19 oral dosage forms, the nitrite contribution is dominated by the highest percentage excipients in the formulas (e.g., diluents).

[0085] The recent discovery of small-molecule nitrosamine impurities in marketed drugs, starting with N-nitrosodimethylamine (NDMA) in batches of Valsartan in 2018, prompted significant regulatory response in the “Sartans” class. This included drug recalls and rolling out of regulatory guidance to re-evaluate all synthetic and formulation routes for the potential presence of nitrosamine impurities via a comprehensive risk assessment during drug development. Due to the diverse potential routes of formation for nitrosamines, many active pharmaceutical ingredients and impurities are themselves susceptible to be nitrosated, either during the later stages of the synthetic process of the API, during drug product manufacturing, or in the finished and packaged drug product.

[0086] There remains a need to identify nitrosamine compounds that may form between reported nitrite from excipients (e.g., microcrystalline cellulose and / or starch) and a tertiary amine (e.g., miglustat and / or L-ido miglustat).

[0087] N-nitroso compounds can be produced by the acid-catalyzed reaction of nitrite with nitrogen-containing compounds. The chemistry of the N-nitrosation reaction has been extensively investigated. N-nitrosamines have the general structure shown in FIG. 3. N-nitrosamines are known to exist as two conformational isomers (atropisomers) due to restricted rotation about the N-N-bond, and these atropisomers may be resolvable by HPLC and NMR. N-nitrosamines are formed by the reaction of organic nitrogen with a nitrosating compound (e.g., NxOy where x and y can be any number of 0, 1 , 2, 3, 4, 5, 6, 7, 8, or 9, and x and y can be different or the same number). Example forms of NxOyare shown in Fig. 8. A nitrosating agent (e.g., N2O3) can be formed from nitrites, nitrates (via reduction), and compounds containing reactive nitro or nitroso groups. The main nitrosating reagent relevant to pharmaceuticals is believed to be N2O3, formed from nitrous acid which is in turn formed from protonation of nitrites.

[0088] While not wishing to be bound by any particular theory, it is believed that nitrates do not N-nitrosate directly; reduction of nitrites is first required. Such reductionDocket No.: AT24-003-PCT20 processes generally require very high processing temperatures. The rate of N- nitrosation of secondary amines is greatest around pH 3 to pH 3.5, while the rate of N-nitrosation of secondary amides continues to increase at even lower pHs. Secondary amides are often subjected to tests for nitrosatability at both pH 3 and pH 1 .5. For nitrosation to occur, nitrite is first converted to nitrous acid (pKa 3.37) via protonation. The general reaction scheme is shown in FIG. 4. Under acidic conditions (e.g., pH of 4), nitrite is converted to HNO2, and then to N2O3, the nitrosating species. Acidic conditions are therefore favored for formation of the nitrosating species, while alkaline conditions are favored for reaction of the nitrosating species with the amine to be nitrosated. N-nitrosation is generally inhibited or completely prevented by the presence of ascorbic acid.

[0089] Miglustat, also known as N-butyl-1 -deoxynojirimycin or NB-DNJ or (2R,3R,4R,5S)-1 -butyl-2-(hydroxymethyl)piperidine-3,4,5-triol, is a compound having the chemical formula of C10H21 N04 and comprising the structure of:

[0090] The compound L-ldo miglustat, a diastereomeric impurity of miglustat, is a tertiary amine resulting from a process impurity of miglustat. L-ldo miglustat, also known as (2S,3R,4R,5S)-1 -Butyl-2-(hydroxymethyl)-3,4,5-piperidinetriol, is a compound having the chemical formula of C10H21 N04 and comprising the structure ofDocket No.: AT24-003-PCT21

[0091] The formation of capsules containing miglustat for administration into Pompe patients in need thereof, involves a dry mixing process wherein water and acid are not used in the drug product manufacturing process.5

[0092] Capsules comprising miglustat contain excipients such as filler / disintegrant, sweetener, lubricant, and glidant. Table 1 demonstrates that nitrosamine products of miglustat and L-ido miglustat can be formed from a reaction with example excipients, including microcrystalline cellulose (MCC, 50.0% w / w, 100 mg / capsule) and starch (16.3% w / w, 32.6 mg / capsule) due to their trace amounts of nitrite and / or nitrate.10Table 1. Miglustat Capsule ExcipientsDocket No.: AT24-003-PCT22

[0093] As shown in Figure 1 , there is high structural similarity between the N-nitroso miglustat and N-nitroso L-ido-miglustat with the only difference in the stereochemistry of substitution at the a-carbon. Thus, N-nitrosation of theDocket No.: AT24-003-PCT23 diastereomer of miglustat, L-ido miglustat, would lead to a diastereomer of the N- nitroso miglustat. For both nitrosamine products, at least one of the a-carbons is protected from hydroxylation due to the CH2OH substitution at the a-carbon, resulting in a 50% reduction in mutagenicity risk.

[0094] Due to the potential formation of miglustat-related nitrosamine compounds, the present disclosure relates to compositions comprising miglustat and / or such miglustat-related nitrosamine compounds.Definitions

[0095] Technical and scientific terms used herein have the meanings commonly understood by one of ordinary skill in the art to which the present invention pertains, unless otherwise defined. Materials to which reference is made in the following description and examples are obtainable from commercial sources, unless otherwise noted. Certain terms are discussed below, or elsewhere in the specification, to provide additional guidance to the practitioner in describing the compositions and methods of the disclosure and how to make and use them.

[0096] The articles “a” and “an” refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. The term “or” means, and is used interchangeably with, the term “and / or,” unless context clearly indicates otherwise. In this application, the use of the singular includes the plural unless specifically stated otherwise. Furthermore, the use of the term “including,” as well as other forms, such as “includes” and “included,” are not limiting. Any range described herein will be understood to include the endpoints and all values between the endpoints. In the present specification, except where the context requires otherwise due to express language or necessary implication, the word “comprises,” or variations such as “comprising,” is used in an inclusive sense, i.e., to specify the presence of the stated features but not to preclude the presence or addition of further features in various embodiments of the disclosure. It is noted that in this disclosure and particularly in the claims and / or paragraphs, terms such as “comprises,” “comprising,” “consists of,” “consisting of,” “consists essentially of,” and “consisting essentially of” can have the meaning attributed to it in U.S. patent law. It isDocket No.: AT24-003-PCT24 contemplated that features set forth using any of such terms can instead be set forth using another of such terms. For instance, if a feature is set forth using “comprising” language, alternative embodiments setting forth the feature using “consisting of” or “consisting essentially of” language is within the scope of the present disclosure.

[0097] As used herein, the terms “about” and “approximately” are intended to refer to an acceptable degree of error for the quantity measured given the nature or precision of the measurements. For example, the degree of error can be indicated by the number of significant figures provided for the measurement, as is understood in the art, and includes but is not limited to a variation of ±1 in the most precise significant figure reported for the measurement. Typical exemplary degrees of error are within 20 percent (%), preferably within 10%, and more preferably within 5% of a given value or range of values. Numerical quantities given herein are approximate unless stated otherwise, meaning that the term “about” or “approximately” can be inferred when not expressly stated.

[0098] “Pharmaceutical grade” or "Active Pharmaceutical Ingredient (API) grade" as used herein means that a substance (e.g., an API) complies with regulatory requirements (e.g., FDA, EMA, and / or PMDA requirements) for incorporation into a finished drug product, e.g., related to identity, strength, quality, and purity.

[0099] As used herein, the term “Pompe disease” refers to an autosomal recessive LSD characterized by deficient acid alpha glucosidase (GAA) activity which impairs lysosomal glycogen metabolism. The enzyme deficiency leads to lysosomal glycogen accumulation and results in progressive skeletal muscle weakness, reduced cardiac function, respiratory insufficiency, and / or CNS impairment at late stages of disease. Genetic mutations in the GAA gene result in either lower expression or produce mutant forms of the enzyme with altered stability, and / or biological activity ultimately leading to disease, (see generally Hirschhorn R, 1995, Glycogen Storage Disease Type II: Acid a-Glucosidase (Acid Maltase) Deficiency, The Metabolic and Molecular Bases of Inherited Disease, Scriver et aL, eds., McGraw-Hill, New York, 7th ed., pages 2443-2464). The three recognized clinical forms of Pompe Disease (infantile, juvenile, and adult) are correlated with the levelDocket No.: AT24-003-PCT25 of residual a-glucosidase activity (Reuser A J et aL, 1995, Glycogenosis Type II (Acid Maltase Deficiency), Muscle & Nerve Supplement 3, S61 -S69). Infantile Pompe disease (type I or A) is the most common and most severe, characterized by failure to thrive, generalized hypotonic, cardiac hypertrophy, and cardiorespiratory failure within the second year of life. Juvenile Pompe disease (type II or B) is intermediate in severity and is characterized by a predominance of muscular symptoms without cardiomegaly. Juvenile Pompe individuals usually die before reaching 20 years of age due to respiratory failure. Adult Pompe disease (type III or C) often presents as a slowly progressive myopathy in the teenage years or as late as the sixth decade (Felicia K J et aL, 1995, Clinical Variability in Adult-Onset Acid Maltase Deficiency: Report of Affected Sibs and Review of the Literature, Medicine 74, 131 -135). In Pompe disease, it has been shown that a-glucosidase is extensively modified post- translationally by glycosylation, phosphorylation, and proteolytic processing. Conversion of the 110 kilodalton (kDa) precursor to 76 and 70 KDa mature forms by proteolysis in the lysosome is required for optimum glycogen catalysis. The formulations and dosing regimens disclosed in this application may be used to treat, for example, Type I, Type II or Type III Pompe disease.

[0100] Pompe disease is now considered to be a continuous spectrum of phenotypes, with the clinically most severe, rapidly progressive phenotypes being the classic infantile-onset Pompe disease (IOPD) and the less severe, slowly progressive phenotypes being late-onset Pompe disease (LOPD). Symptoms of Pompe disease can first appear at any point in life. The most severe form of IOPD appears in the first 3 months of life. Muscle weakness, heart dysfunction, and respiratory dysfunction characterize IOPD progression, and life expectancy is approximately 2 years. Atypical infantile, juvenile-onset, and non-classic IOPD are a few of the terms used to describe pediatric patients with Pompe disease who do not have the significant and progressive hypertrophic cardiomyopathy that is seen in classic IOPD, and hence their phenotype is more closely comparable to LOPD.

[0101] Late-onset Pompe disease can manifest in childhood or adulthood and does not present with clinically apparent cardiac involvement (Leslie and Bailey, 2017). Late- onset Pompe disease is often referred to as juvenile-onset Pompe disease whenDocket No.: AT24-003-PCT26 occurring in the pediatric subpopulation of the LOPD category. LOPD has a slower rate of progression compared with classic IOPD, with most patients experiencing progressive limb girdle weakness and respiratory failure due to involvement of muscles in the proximal lower and upper limbs, paraspinal muscles, and diaphragm. Clinical manifestations include difficulty walking, climbing stairs, and progressive limitations of motor activities of daily living with progression to a need for ambulatory support followed by wheelchair dependence (Reuser, et al 2001 ). Clinical manifestations of the disease are compounded by respiratory involvement, initially as sleep disordered breathing and orthopnea (shortness of breath in supine position). The progressive nature of Pompe disease generally results in the use of invasive mechanically assisted ventilation. Biochemical abnormalities include increased level of serum creatine kinase (CK), a biomarker of muscle injury, and urinary hexose tetrasaccharide (Hex4), a biomarker of disease substrate (An, et al 2005; Young, et al 2009). Life expectancy for patients with LOPD can range from early childhood to late adulthood, depending on the age of onset, rate of disease progression, the extent of respiratory muscle involvement, and the presence of co morbidities (Hagemans, et al 2004). If untreated, life expectancy in adults with Pompe disease is greatly reduced (Gungor, et al 2011 ).

[0102] As used herein, “ppb” refers to parts per billion. In some embodiments the term refers to ng per g.

[0103] As used herein, the term “pharmaceutically acceptable” is intended to refer to molecular entities and compositions that are physiologically tolerable and do not typically produce untoward reactions when administered to a human. Preferably, as used herein, the term “pharmaceutically acceptable” means approved by a regulatory agency of the federal or a state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans. As used herein, the term “carrier” is intended to refer to a diluent, adjuvant, excipient, or vehicle with which a compound is administered. Suitable pharmaceutical carriers are known in the art and, in at least one embodiment, are described in “Remington's Pharmaceutical Sciences” by E. W. Martin, 18th Edition, or other editions.Docket No.: AT24-003-PCT27

[0104] The term “pharmaceutically acceptable salt” as used herein is intended to mean a salt which is, within the scope of sound medical judgment, suitable for use in contact with the tissues of humans and lower animals without undue toxicity, irritation, allergic response, and the like, commensurate with a reasonable benefit / risk ratio, generally water or oil-soluble or dispersible, and effective for their intended use. The term includes pharmaceutically-acceptable acid addition salts and pharmaceutically-acceptable base addition salts. Lists of suitable salts are found in, for example, S. M. Berge et aL, J. Pharm. Sci., 1977, 66, pp. 1 -19, herein incorporated by reference. The term “pharmaceutically-acceptable acid addition salt” as used herein is intended to mean those salts which retain the biological effectiveness and properties of the free bases and which are not biologically or otherwise undesirable, formed with inorganic acids. The term “pharmaceutically- acceptable base addition salt” as used herein is intended to mean those salts which retain the biological effectiveness and properties of the free acids and which are not biologically or otherwise undesirable, formed with inorganic bases.

[0105] As used herein, the term “buffer” refers to a solution containing a weak acid and its conjugate base or a weak base and its conjugate acid that helps to prevent changes in pH.

[0106] As used herein, the terms “therapeutically effective dose” and “effective amount” are intended to refer to an amount of acid a-glucosidase and / or of miglustat and / or of a two-component therapy thereof, which is sufficient to result in a therapeutic response in a subject.

[0107] The term “GAA” refers to human acid a-glucosidase (GAA) enzyme that catalyzes the hydrolysis of a-1 ,4- and a-1 ,6-glycosidic linkages of lysosomal glycogen as well as to insertional, relational, or substitution variants of the GAA amino acid sequence and fragments of a longer GAA sequence that exert enzymatic activity. Human acid a-glucosidase is encoded by the GAA gene (National Centre for Biotechnology Information (NCBI) Gene ID 2548), which has been mapped to the long arm of chromosome 17 (location 17q25.2-q25.3). An exemplary amino acid sequence of GAA is NP 000143.2, which is incorporated by reference. ThisDocket No.: AT24-003-PCT28 disclosure also encompasses DNA sequences that encode the amino acid sequence of NP 000143.2. More than 500 mutations have currently been identified in the human GAA gene, many of which are associated with Pompe disease. Mutations resulting in misfolding or misprocessing of the acid a-glucosidase enzyme include T 1064C (Leu355Pro) and C2104T (Arg702Cys). In addition, GAA mutations which affect maturation and processing of the enzyme include Leu405Pro and Met519Thr. The conserved hexapeptide WIDMNE at amino acid residues 516-521 is required for activity of the acid a-glucosidase protein. As used herein, the abbreviation “GAA” is intended to refer to human acid a-glucosidase enzyme, while the italicized abbreviation “GAA” is intended to refer to the human gene coding for the human acid a-glucosidase enzyme. The italicized abbreviation “Gaa” is intended to refer to non-human genes coding for non-human acid a-glucosidase enzymes, including but not limited to rat or mouse genes, and the abbreviation “Gaa” is intended to refer to non-human acid a-glucosidase enzymes.

[0108] The term “rhGAA” is intended to refer to the recombinant human acid a- glucosidase enzyme and is used to distinguish synthetic and / or recombinant- produced GAA (e.g., GAA produced from CHO cells or other host cells transformed with DNA encoding GAA) from endogenous GAA. Accordingly, rhGAA does not include endogenous GAA. The term “rhGAA” encompasses a population of individual rhGAA molecules. Characteristics of the population of rhGAA molecules are provided herein. The term “conventional rhGAA product” is intended to refer to products containing alglucosidase alfa, such as LUMIZYME® or MYOZYME®, or avalglucosidase alfa, such as NEXVIAZYME®.

[0109] The term “genetically modified” or “recombinant” refers to cells, such as CHO cells, that express a particular gene product, such as rhGAA, following introduction of a nucleic acid comprising a coding sequence which encodes the gene product, along with regulatory elements that control expression of the coding sequence. Introduction of the nucleic acid may be accomplished by any method known in the art including gene targeting and homologous recombination. As used herein, the term also includes cells that have been engineered to express or overexpress anDocket No.: AT24-003-PCT29 endogenous gene or gene product not normally expressed by such cell, e.g., by gene activation technology.

[0110] As used herein, the term “alglucosidase alfa” is intended to refer to a recombinant human acid a-glucosidase identified as [199-arginine,223- histidine]prepro-a-glucosidase (human); Chemical Abstracts Registry Number 420794-05-0. Alglucosidase alfa is approved for marketing in the United States by Sanofi Genzyme, as the products LUMIZYME® and MYOZYME®.

[0111] As used herein, the term “avalglucosidase alfa” is intended to refer to a recombinant human acid a-glucosidase identified as avalglucosidase alfa-ngpt; Chemical Abstracts Registry Number 1802558-87-7. Avalglucosidase alfa is approved for marketing in the United States by Sanofi Genzyme , as the product NEXVIAZYME®.

[0112] The term “ATB200” is intended to refer to a recombinant human acid a- glucosidase described in International Pat. App. No. PCT / 2015 / 053252, U.S. Pat. No. 10,208,299, and U.S. Pat. No. 10,961 ,522, the disclosures of which are herein incorporated by reference in their entirety. ATB200 is also referred to as “cipaglucosidase alfa.” In some embodiments, “ATB200” refers to a rhGAA with a high content of N-glycans bearing mono-M6P and bis-M6P, which is produced and purified from a GA-ATB200 cell line. Cipaglucosidase alfa is currently marketed under the name POMBILITI™ in the United States and POMBILITI® in the European Union. POMBILITI is currently indicated, in combination with OPFOLDA, for the treatment of adult patients with late-onset Pompe disease. The US Prescribing Information and European Union Summary of Product Characteristics for POMBILITI are hereby incorporated by reference in their entireties.

[0113] As used herein, the term “glycan” is intended to refer to an oligosaccharide covalently bound to an amino acid residue on a protein or polypeptide. As used herein, the term “N- glycan” or “N-linked glycan” is intended to refer to a polysaccharide chain attached to an asparagine residue on a protein or polypeptide through covalent binding to a nitrogen atom of the asparagine residue. In some embodiments, the N-glycan units attached to a rhGAA are determined by liquidDocket No.: AT24-003-PCT30 chromatography-tandem mass spectrometry (LC-MS / MS) utilizing an instrument such as the Thermo Scientific™ Orbitrap Velos Pro™ Mass Spectrometer, Thermo Scientific™ Orbitrap Fusion™ Lumos Tribid™ Mass Spectrometer, or Waters Xevo® G2-XS QTof Mass Spectrometer.

[0114] As used herein, the term “glycan bearing mono-M6P” or “glycan bearing bis- M6P” is intended to refer to an N-glycan unit of the mono-phosphorylated (mono- M6P) or bis-phosphorylated (bis-M6P) as part of all N-glycan types, unless specifically stated to be the high mannose N-glycan type or the hybrid N-glycan class.

[0115] As used herein, the term “enzyme stabilizer” is intended to refer to a molecule that specifically binds to acid a-glucosidase and has one or more of the following effects: enhances the formation of a stable molecular conformation of the protein; enhances proper trafficking of the protein from the endoplasmic reticulum to another cellular location, preferably a native cellular location, so as to prevent endoplasmic reticulum-associated degradation of the protein; prevents aggregation of conformationally unstable or misfolded proteins; restores and / or enhances at least partial wild-type function, stability, and / or activity of the protein; improves the phenotype or function of the cell harboring acid a-glucosidase; and / or stabilizes the acid a-glucosidase in vitro and / or in vivo (e.g., in a patient’s bloodstream). Enzyme stabilizers are also sometimes known as “pharmacological chaperones,” or simply “chaperone”. Thus, an enzyme stabilizer for acid a-glucosidase is a molecule that binds to acid a-glucosidase, resulting in proper folding, trafficking, non-aggregation, and / or activity of acid a-glucosidase. In at least one embodiment, the enzyme stabilizer is miglustat.

[0116] As used herein, the term “enzyme replacement therapy” or “ERT” is intended to refer to the introduction of a non-native, purified enzyme into an individual having a deficiency in such enzyme. The administered protein can be obtained from natural sources or by recombinant expression. The term also refers to the introduction of a purified enzyme in an individual otherwise requiring or benefiting from administration of a purified enzyme. In at least one embodiment, such an individual suffers fromDocket No.: AT24-003-PCT31 enzyme insufficiency. The introduced enzyme may be a purified, recombinant enzyme produced in vitro, or a protein purified from isolated tissue or fluid, such as, for example, placenta or animal milk, or from plants.

[0117] As used herein, the term “two-component therapy” is intended to refer to any therapy wherein two or more individual therapies are administered concurrently or sequentially. In some embodiment, the results of the two-component therapy are enhanced as compared to the effect of each therapy when it is performed individually. Enhancement may include any improvement of the effect of the various therapies that may result in an advantageous result as compared to the results achieved by the therapies when performed alone. Enhanced effect or results can include a synergistic enhancement, wherein the enhanced effect is more than the additive effects of each therapy when performed by itself; an additive enhancement, wherein the enhanced effect is substantially equal to the additive effect of each therapy when performed by itself; or less than additive effect, wherein the enhanced effect is lower than the additive effect of each therapy when performed by itself, but still better than the effect of each therapy when performed by itself. Enhanced effect may be measured by any means known in the art by which treatment efficacy or outcome can be measured.

[0118] As used herein, “significant” refers to statistical significance. The term refers to statistical evidence that there is a difference between two treatment groups. It can be defined as the probability of making a decision to reject the null hypothesis when the null hypothesis is actually true. The decision is often made using a p-value < 0.05 derived from a suitable statistical analysis for the comparison.

[0119] A “subject” or “patient” is preferably a human, though other mammals and nonhuman animals having disorders involving accumulation of glycogen may also be treated. A subject may be a fetus, a neonate, child, juvenile, or an adult with Pompe disease or other glycogen storage or accumulation disorder. One example of an individual being treated is an individual (fetus, neonate, child, juvenile, adolescent, or adult human) having GSD-II (e.g., infantile GSD-II, juvenile GSD-II, or adult-onset GSD-II). The individual can have residual GAA activity, or no measurable activity.Docket No.: AT24-003-PCT32For example, the individual having GSD-II can have GAA activity that is less than about 1 % of normal GAA activity (infantile GSD-II), GAA activity that is about 1 -10% of normal GAA activity (juvenile GSD-II), or GAA activity that is about 10-40% of normal GAA activity (adult GSD-II). In some embodiments, the subject or patient is an “ERT-experienced” or “ERT-switch” patient, referring to a Pompe disease patient who has previously received enzyme replacement therapy. In some embodiments, an “ERT-experienced” or “ERT-switch” patient is a Pompe disease patient who has received or is currently receiving alglucosidase alfa for greater than or equal to 24 months. In some embodiments, an “ERT-experienced” or “ERT-switch” patient is a Pompe disease patient who is declining on currently approved ERT (e.g., MYOZYME® or LUMIZYME®). In some embodiments, the subject is an adult patient (e.g., 18 years of age or older) with a confirmed diagnosis of late onset Pompe disease (acid a-glucosidase (GAA) deficiency), who have previously received enzyme replacement therapy (ERT). In some embodiments, the subject is an adult (e.g., 18 years of age and older) with late-onset Pompe disease (lysosomal acid alpha-glucosidase [GAA] deficiency) weighing > 40 kg whose disease has progressed on enzyme replacement therapy (ERT). In some embodiments, the subject or patient is an “ERT-naive” patient, referring to a Pompe disease patient who has not previously received enzyme replacement therapy. In certain embodiments, the subject or patient is ambulatory (e.g., an ambulatory ERT-switch patient or an ambulatory ERT-naive patient). In certain embodiments, the subject or patient is nonambulatory (e.g., a nonambulatory ERT-switch patient). Ambulatory or nonambulatory status may be determined by a six-minute walk test (6MWT). In some embodiments, an ambulatory patient is a Pompe disease patient who is able to walk at least 200 meters in the 6MWT. In some embodiments, a nonambulatory patient is a Pompe disease patient who is unable to walk unassisted or who is wheelchair bound. In some embodiments, the subject is using effective contraception. In some embodiments, the subject and / or the subject’s partner are using highly effective contraception, such as one that results in a low failure rate (e.g., < 1 % per year) when used consistently and correctly. Examples of highly effective methods of contraception include, but are not limited to: total abstinence; combined (estrogen- and progestogen-containing) hormonal contraceptionDocket No.: AT24-003-PCT33 associated with inhibition of ovulation; oral, intravaginal, transdermal progestogen- only hormonal contraception associated with inhibition of ovulation: oral, injectable, implantable intrauterine device; intrauterine hormone-releasing system; bilateral tubal occlusion; and vasectomy. In some embodiments, the subject is postmenopausal. In some embodiments, the subject is not of child-bearing potential. In some embodiments, the subject is permanently sterile. In some embodiments, the subject is not pregnant. In some embodiments, the subject is not breastfeeding.

[0120] In some embodiments, a patient has a diagnosis of late onset Pompe disease, based on documentation of at least one of the following: (1 ) deficiency of GAA enzyme; and / or (2) gene encoding human acid a-glucosidase (GAA) genotyping. In some embodiments, the patient is 18 years of age or older. In some embodiments, the patient has previously received enzyme replacement therapy (ERT). In some embodiments, the patient is declining on currently approved ERT (e.g., MYOZYME® or LUMIZYME®). In some embodiments, if of reproductive potential, both male and female patients have agreed to use a highly effective method of contraception throughout the duration of the treatment and for up to 90 days after their last dose. In some embodiments, patients who are taking [32-receptor agonists or non- selective [3-blockers (e.g., propranolol, nadolol, carvedilol) maintain a stable dose as appropriate and determined by the treating physician.

[0121] The terms “treat” and “treatment,” as used herein, refer to amelioration of one or more symptoms associated with the disease, delay of the onset of one or more symptoms of the disease, and / or lessening of the severity or frequency of one or more symptoms of the disease. For example, treatment can refer to improvement of cardiac status (e.g., increase of end-diastolic and / or end-systolic volumes, or reduction or amelioration of the progressive cardiomyopathy that is typically found in GSD-II) or of pulmonary function (e.g., increase in crying vital capacity over baseline capacity, and / or normalization of oxygen desaturation during crying); improvement in neurodevelopment and / or motor skills (e.g., increase in AIMS score); reduction of glycogen levels in tissue of the individual affected by the disease; or any combination of these effects. In one preferred embodiment,Docket No.: AT24-003-PCT34 treatment includes improvement of cardiac status, particularly in reduction of GSD- ll-associated cardiomyopathy.

[0122] The terms “improve,” “increase,” and “reduce,” as used herein, indicate values that are relative to a baseline measurement or the corresponding values from a control treatment, such as a measurement in the same individual prior to initiation of the treatment described herein, a measurement in a control individual (or multiple control individuals) in the absence of the treatment described herein, or a measurement after a control treatment. A control individual is an individual afflicted with the same form of GSD-II (either infantile, juvenile, or adult-onset) as the individual being treated, who is about the same age as the individual being treated (to ensure that the stages of the disease in the treated individual and the control individual(s) are comparable). In some embodiments, a control treatment comprises administering alglucosidase alfa and a placebo for an enzyme stabilizer.

[0123] All references, articles, publications, patents, patent publications, and patent applications cited herein are incorporated by reference in their entireties for all purposes. However, mention of any reference, article, publication, patent, patent publication, and patent application cited herein is not, and should not be taken as an acknowledgment or any form of suggestion that they constitute valid prior art or form part of the common general knowledge in any country in the world.

[0124] The section headings used herein are for organizational purposes only and are not to be construed as limiting the subject matter described.RECOMBINANT HUMAN ACID A-GLUCOSIDASE (rhGAA)

[0125] In some embodiments, the recombinant human acid a-glucosidase (rhGAA) is an enzyme having an amino acid sequence as set forth in SEQ ID NO: 1 , SEQ ID NO: 3, SEQ ID NO: 4, SEQ ID NO: 5, or SEQ ID NO: 6. In some embodiments, the rhGAA is encoded by a nucleotide sequence as set forth in SEQ ID NO: 2.Table 2. Nucleotide Sequences and Protein SequencesDocket No.: AT24-003-PCT35Docket No.: AT24-003-PCT36Docket No.: AT24-003-PCT37Docket No.: AT24-003-PCT38

[0126] In some embodiments, the rhGAA has a GAA amino acid sequence as set forth in SEQ ID NO: 1 , as described in U.S. Patent No. 8,592,362 and has GenBank accession number AHE24104.1 (GI:568760974). In some embodiments, the rhGAA has a GAA amino acid sequence as encoded in SEQ ID NO: 2, the mRNA sequenceDocket No.: AT24-003-PCT39 having GenBank accession number Y00839.1 . In some embodiments, the rhGAA has a GAA amino acid sequence as set forth in SEQ ID NO: 3. In some embodiments, the rhGAA has a GAA amino acid sequence as set forth in SEQ ID NO: 4, and has National Center for Biotechnology Information (NCBI) accession number NP_000143.2 or UniProtKB Accession Number P10253.

[0127] In some embodiments, the rhGAA is initially expressed as having the full-length 952 amino acid sequence of wild-type GAA as set forth in SEQ ID NO: 1 or SEQ ID NO: 4, and the rhGAA undergoes intracellular processing that removes a portion of the amino acids, e.g., the first 56 amino acids. Accordingly, the rhGAA that is secreted by the host cell can have a shorter amino acid sequence than the rhGAA that is initially expressed within the cell. In some embodiments, the shorter protein has the amino acid sequence set forth in SEQ ID NO: 5, which only differs from SEQ ID NO: 1 in that the first 56 amino acids of SEQ ID NO: 1 comprising the signal peptide and precursor peptide have been removed, thus resulting in a protein having 896 amino acids. In some embodiments, the shorter protein has the amino acid sequence set forth in SEQ ID NO: 6, which only differs from SEQ ID NO: 4 in that the first 56 amino acids of SEQ ID NO: 4 comprising the signal peptide and precursor peptide have been removed, thus resulting in a protein having 896 amino acids. Other variations in the number of amino acids are also possible, such as having 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, or more deletions, substitutions and / or insertions relative to the amino acid sequence described by SEQ ID NO: 1 , SEQ ID NO: 4, SEQ ID NO: 5, or SEQ ID NO: 6. In some embodiments, the rhGAA product includes a mixture of recombinant human acid a-glucosidase molecules having different amino acid lengths.

[0128] In some embodiments, the rhGAA comprises an amino acid sequence that is at least 80%, 85%, 90%, 95%, 98% or 99% identical to SEQ ID NO: 4 or SEQ ID NO: 6. Various alignment algorithms and / or programs may be used to calculate the identity between two sequences, including FASTA, or BLAST which are available as a partDocket No.: AT24-003-PCT40 of the GCG sequence analysis package (University of Wisconsin, Madison, Wis.), and can be used with, e.g., default setting. For example, polypeptides having at least 80%, 85%, 90%, 95%, 98% or 99% identity to specific polypeptides described herein and preferably exhibiting substantially the same functions, as well as polynucleotide encoding such polypeptides, are contemplated. Unless otherwise indicated a similarity score will be based on use of BLOSUM62. When BLASTP is used, the percent similarity is based on the BLASTP positives score and the percent sequence identity is based on the BLASTP identities score. BLASTP “Identities” shows the number and fraction of total residues in the high scoring sequence pairs which are identical; and BLASTP “Positives” shows the number and fraction of residues for which the alignment scores have positive values, and which are similar to each other. Amino acid sequences having these degrees of identity or similarity or any intermediate degree of identity of similarity to the amino acid sequences disclosed herein are contemplated and encompassed by this disclosure. The polynucleotide sequences of similar polypeptides are deduced using the genetic code and may be obtained by conventional means, in particular by reverse translating its amino acid sequence using the genetic code.

[0129] In some embodiments, the rhGAA undergoes post-translational and / or chemical modifications at one or more amino acid residues in the protein. For example, methionine and tryptophan residues can undergo oxidation. As another example, the N-terminal glutamine in SEQ ID NO: 6 can be further modified to form pyroglutamate. As another example, asparagine residues can undergo deamidation to aspartic acid. As yet another example, aspartic acid residues can undergo isomerization to iso-aspartic acid. As yet another example, unpaired cysteine residues in the protein can form disulfide bonds with free glutathione and / or cysteine. Accordingly, in some embodiments, the enzyme is initially expressed as having an amino acid sequence as set forth in SEQ ID NO: 1 , SEQ ID NO: 3, SEQ ID NO: 4, or SEQ ID NO: 5, or an amino acid sequence encoded by SEQ ID NO: 2, and the enzyme undergoes one or more of these post-translational and / or chemicalDocket No.: AT24-003-PCT41 modifications. Such modifications are also within the scope of the present disclosure.N-LINKED GLYCOSYLATION OF rhGAA

[0130] There are seven potential N-linked glycosylation sites on a single rhGAA molecule. These potential glycosylation sites are at the following positions of SEQ ID NO: 6: N84, N177, N334, N414, N596, N826, and N869. Similarly, for the full- length amino acid sequence of SEQ ID NO: 4, these potential glycosylation sites are at the following positions: N140, N233, N390, N470, N652, N882, and N925. Other variants of rhGAA can have similar glycosylation sites, depending on the location of asparagine residues. Generally, sequences of Asn-X-Ser or Asn-X-Thr in the protein amino acid sequence indicate potential glycosylation sites, with the exception that X cannot be His or Pro.

[0131] The rhGAA molecules described herein may have, on average, 1 , 2, 3, or 4 mannose-6-phosphate (M6P) groups on their N-glycans. For example, only one N- glycan on a rhGAA molecule may bear M6P (mono-phosphorylated or mono-M6P), a single N-glycan may bear two M6P groups (bis-phosphorylated or bis-M6P), or two different N-glycans on the same rhGAA molecule may each bear single M6P groups. In some embodiments, the rhGAA molecules described herein on average have 3-4 mol M6P groups on their N-glycans per mol rhGAA. Recombinant human acid a-glucosidase molecules may also have N-glycans bearing no M6P groups. In another embodiment, on average the rhGAA comprises greater than 2.5 mol M6P per mol rhGAA and greater than 4 mol sialic acid per mol rhGAA. In some embodiments, on average the rhGAA comprises about 3-3.5 mol M6P per mol rhGAA. In some embodiments, on average the rhGAA comprises about 4-5.4 mol sialic acid per mol rhGAA. On average at least about 3, 4, 5, 6, 7, 8, 9, 10%, or 20% of the total N-glycans on the rhGAA may be in the form of a mono-M6P N-glycan, for example, about 6.25% of the total N-glycans may carry a single M6P group and on average, at least about 0.5, 1 , 1.5, 2.0, 2.5, 3.0, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19 or 20% of the total N-glycans on the rhGAA are in the form of a bis-M6P N-glycan and on average less than 25% of total rhGAA contains noDocket No.: AT24-003-PCT42 phosphorylated N-glycan binding to CIMPR. In some embodiments, on average about 10% to about 14% of the total N-glycans on the rhGAA are monophosphorylated. In some embodiments, on average about 3% to 25% of the total N-glycans on the rhGAA are bis-phosphorylated. In some embodiments, on average about 7% to about 25% of the total N-glycans on the rhGAA are bis-phosphorylated. In some embodiments, on average the rhGAA comprises at least about 1 .0, 1 .1 , 1 .2 or 1 .3 mol bis-M6P per mol rhGAA.

[0132] The rhGAA described herein may have on average from 0.5 to 7.0 mol M6P per mol rhGAA or any intermediate value or subrange thereof including 0.5, 1 .0, 1 .5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, or 7.0 mol M6P per mol rhGAA. The rhGAA can be fractionated to provide rhGAA preparations with different average numbers of mono-M6P-bearing or bis-M6P-bearing N-glycans, thus permitting further customization of rhGAA targeting to the lysosomes in target tissues by selecting a particular fraction or by selectively combining different fractions.

[0133] In some embodiments, up to 60% of the N-glycans on the rhGAA may be fully sialylated, for example, up to 10%, 20%, 30%, 40%, 50% or 60% of the N-glycans may be fully sialylated. In some embodiments, no more than 50% of the N-glycans on the rhGAA are fully sialylated. In some embodiments, from 4% to 20% of the total N-glycans are fully sialylated. In other embodiments, no more than 5%, 10%, 20% or 30% of N-glycans on the rhGAA carry sialic acid and a terminal galactose residue (Gal). This range includes all intermediate values and subranges, for example, 7% to 30% of the total N-glycans on the rhGAA can carry sialic acid and terminal galactose. In yet other embodiments, no more than 5%, 10%, 15%, 16%, 17%, 18%, 19%, or 20% of the N-glycans on the rhGAA have a terminal galactose only and do not contain sialic acid. This range includes all intermediate values and subranges, for example, from 8% to 19% of the total N-glycans on the rhGAA in the composition may have terminal galactose only and do not contain sialic acid.

[0134] In some embodiments, 30% to 60%, 35% to 60%, 40% to 60%, 45% to 60%, 50% to 60%, or 55% to 60% of the total N-glycans on the rhGAA are complex type N-glycans; or no more than 1 %, 2%, 3%, 4%, 5%, 6,%, or 7% of the total N-glycansDocket No.: AT24-003-PCT43 on the rhGAA are hybrid-type N-glycans; no more than 5%, 10%, 15%, 20%, 25%, or 30% of the total N-glycans on the rhGAA are high mannose-type N-glycans that are non-phosphorylated; at least 5%, 6%, 7%, 8%, 9%, 10%, 1 1 %, 12%, 13%, 14%, or 15% of the total N-glycans on the rhGAA are mono-phosphorylated high mannose-type N-glycans; and / or at least 1 %, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 1 1 %, 12%, 13%, 14%, 15%, or 20% of the total N-glycans on the rhGAA are bis-phosphorylated high mannose-type N-glycans. These values include all intermediate values and subranges. A rhGAA may meet one or more of the content ranges described above.

[0135] In some embodiments, the rhGAA may bear, on average, 2.0 to 8.0 moles of sialic acid residues per mole of rhGAA. This range includes all intermediate values and subranges thereof, including 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, and 8.0 mol sialic acid residues per mol rhGAA. Without being bound by theory, it is believed that the presence of N-glycan units bearing sialic acid residues may prevent non-productive clearance of the rhGAA by asialoglycoprotein receptors.

[0136] In one or more embodiments, the rhGAA has a certain N-glycosylation profile at certain potential N-glycosylation sites. In some embodiments, the rhGAA has seven potential N-glycosylation sites. In some embodiments, at least 20% of the rhGAA is phosphorylated at the first potential N-glycosylation site (e.g., N84 for SEQ ID NO: 6 and N140 for SEQ ID NO: 4). For example, at least 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA can be phosphorylated at the first potential N-glycosylation site. This phosphorylation can be the result of mono-M6P and / or bis-M6P units. In some embodiments, at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA bears a mono-M6P unit at the first potential N-glycosylation site. In some embodiments, at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA bears a bis-M6P unit at the first potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 1 .4 mol M6P (mono-M6P and bis-M6P) per mol rhGAA at the first potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about at least 0.5 mol bis-M6P perDocket No.: AT24-003-PCT44 mol rhGAA at the first potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.25 mol mono-M6P per mol rhGAA at the first potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.2 mol to about 0.3 mol sialic acid per mol rhGAA at the first potential N-glycosylation site.

[0137] In some embodiments, at least 20% of the rhGAA is phosphorylated at the second potential N-glycosylation site (e.g., N177 for SEQ ID NO: 6 and N223 for SEQ ID NO: 4). For example, at least 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA can be phosphorylated at the second N-glycosylation site. This phosphorylation can be the result of mono- M6P and / or bis-M6P units. In some embodiments, at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA bears a mono-M6P unit at the second N-glycosylation site. In some embodiments, at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA bears a bis-M6P unit at the second N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.5 mol M6P (mono-M6P and bis-M6P) per mol rhGAA at the second potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.4 to about 0.6 mol mono-M6P per mol rhGAA at the second potential N-glycosylation site.

[0138] In one or more embodiments, at least 5% of the rhGAA is phosphorylated at the third potential N-glycosylation site (e.g., N334 for SEQ ID NO: 6 and N390 for SEQ ID NO: 4). In other embodiments, less than 5%, 10%, 15%, 20%, or 25% of the rhGAA is phosphorylated at the third potential N-glycosylation site. For example, the third potential N-glycosylation site can have a mixture of non-phosphorylated high mannose N-glycans, di-, tri-, and tetra-antennary complex N-glycans, and hybrid N-glycans as the major species. In some embodiments, at least 3%, 5%, 8%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50% of the rhGAA is sialylated at the third potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.9 to about 1 .2 mol sialic acid per mol rhGAA at the third potential N-glycosylation site.Docket No.: AT24-003-PCT45

[0139] In some embodiments, at least 20% of the rhGAA is phosphorylated at the fourth potential N-glycosylation site (e.g., N414 for SEQ ID NO: 6 and N470 for SEQ ID NO: 4). For example, at least 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA can be phosphorylated at the fourth potential N-glycosylation site. This phosphorylation can be the result of mono-M6P and / or bis-M6P units. In some embodiments, at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA bears a mono-M6P unit at the fourth potential N-glycosylation site. In some embodiments, at least 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA bears a bis-M6P unit at the fourth potential N-glycosylation site. In some embodiments, at least 3%, 5%, 8%, 10%, 15%, 20%, or 25% of the rhGAA is sialylated at the fourth potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 1 .4 mol M6P (mono-M6P and bis-M6P) per mol rhGAA at the fourth potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.4 to about 0.6 mol bis-M6P per mol rhGAA at the fourth potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.3 to about 0.4 mol mono-M6P per mol rhGAA at the fourth potential N- glycosylation site.

[0140] In some embodiments, at least 5% of the rhGAA is phosphorylated at the fifth potential N-glycosylation site (e.g., N596 for SEQ ID NO: 6 and N692 for SEQ ID NO: 4). In other embodiments, less than 5%, 10%, 15%, 20%, or 25% of the rhGAA is phosphorylated at the fifth potential N-glycosylation site. For example, the fifth potential N-glycosylation site can have fucosylated di-antennary complex N-glycans as the major species. In some embodiments, at least 3%, 5%, 8%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% of the rhGAA is sialylated at the fifth potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.8 to about 0.9 mol sialic acid per mol rhGAA at the fifth potential N-glycosylation site. .

[0141] In some embodiments, at least 5% of the rhGAA is phosphorylated at the sixth N-glycosylation site (e.g., N826 for SEQ ID NO: 6 and N882 for SEQ ID NO: 4). InDocket No.: AT24-003-PCT46 other embodiments, less than 5%, 10%, 15%, 20% or 25% of the rhGAA is phosphorylated at the sixth N-glycosylation site. For example, the sixth N- glycosylation site can have a mixture of di-, tri-, and tetra-antennary complex N- glycans as the major species. In some embodiments, at least 3%, 5%, 8%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95% of the rhGAA is sialylated at the sixth N-glycosylation site. In some embodiments, the rhGAA comprises on average about 1 .5 to about 4.2 mol sialic acid per mol rhGAA at the sixth potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.9 mol acetylated sialic acid per mol rhGAA at the sixth potential N-glycosylation site. In some embodiments, the rhGAA comprises an average of at least 0.05 mol glycan species with poly-N- Acetyl-D-lactosamine (poly-LacNAc) residues per mol rhGAA at the sixth potential N-glycosylation site. In some embodiments, over 10% of the rhGAA comprises a glycan bearing a poly-LacNAc residue at the sixth potential N-glycosylation site.

[0142] In some embodiments, at least 5% of the rhGAA is phosphorylated at the seventh potential N-glycosylation site (e.g., N869 for SEQ ID NO: 6 and N925 for SEQ ID NO: 4). In other embodiments, less than 5%, 10%, 15%, 20%, or 25% of the rhGAA is phosphorylated at the seventh potential N-glycosylation site. In some embodiments, less than 40%, 45%, 50%, 55%, 60%, or 65% of the rhGAA has any N-glycan at the seventh potential N-glycosylation site. In some embodiments, at least 30%, 35%, or 40% of the rhGAA has an N-glycan at the seventh potential N- glycosylation site. In some embodiments, the rhGAA comprises on average at least 0.5 mol sialic acid per mol rhGAA at the seventh potential N-glycosylation site. In some embodiments, the rhGAA comprises on average at least 0.8 mol sialic acid per mol rhGAA at the seventh potential N-glycosylation site. In some embodiments, the rhGAA comprises on average about 0.86 mol sialic acid per mol rhGAA at the seventh potential N-glycosylation site. In some embodiments, the rhGAA comprises an average of at least 0.3 mol glycan species bearing poly-LacNAc residues per mol rhGAA at the seventh potential N-glycosylation site. In some embodiments, nearly half of the rhGAA comprises a glycan bearing a poly-LacNAc residue at the seventh potential N-glycosylation site. In at least one embodiment, all N-glycans identified at the seventh potential N-glycosylation site are complex N-glycans.Docket No.: AT24-003-PCT47

[0143] In some embodiments, the rhGAA comprises on average 3-4 mol M6P residues per mol rhGAA and about 4 to about 7.3 mol sialic acid per mol rhGAA. In some embodiments, the rhGAA further comprises on average at least about 0.5 mol bisMS P per mol rhGAA at the first potential N-glycosylation site, about 0.4 to about 0.6 mol mono-M6P per mol rhGAA at the second potential N-glycosylation site, about 0.9 to about 1 .2 mol sialic acid per mol rhGAA at the third potential N-glycosylation site, about 0.4 to about 0.6 mol bis-M6P per mol rhGAA at the fourth potential N- glycosylation site, about 0.3 to about 0.4 mol mono-M6P per mol rhGAA at the fourth potential N-glycosylation site, about 0.8 to about 0.9 mol sialic acid per mol rhGAA at the fifth potential N-glycosylation site, and about 1 .5 to about 4.2 mol sialic acid per mol rhGAA at the sixth potential N-glycosylation site. In some embodiments, the rhGAA further comprises on average at least 0.5 mol sialic acid per mol rhGAA at the seventh potential N-glycosylation site. In some embodiments, the rhGAA comprises on average at least 0.8 mol sialic acid per mol rhGAA at the seventh potential N-glycosylation site. In at least one embodiment, the rhGAA further comprises on average about 0.86 mol sialic acid per mol rhGAA at the seventh potential N-glycosylation site.

[0144] Methods of making rhGAA are disclosed in International Pat. App. No. PCT / 2015 / 053252, U.S. Pat. No. 10,208,299, and U.S. Pat. No. 10,961 ,522, the entire disclosures of which are incorporated herein by reference.

[0145] Once inside the lysosome, rhGAA can enzymatically degrade accumulated glycogen. However, conventional rhGAA products have low total levels of mono- M6P- and bis-M6P bearing N-glycans and, thus, target muscle cells poorly, resulting in inferior delivery of rhGAA to the lysosomes. The majority of rhGAA molecules in these conventional products do not have phosphorylated N-glycans, thereby lacking affinity for the CIMPR. Non-phosphorylated high mannose N-glycans can also be cleared by the mannose receptor, which results in non-productive clearance of the ERT. In contrast, a rhGAA described herein may contains a higher amount of mono- M6P- and bis-M6P bearing N-glycans, leading to productive uptake of rhGAA into specific tissues such as muscle.Docket No.: AT24-003-PCT48PHARMACEUTICAL COMPOSITIONS

[0146] In various embodiments, a pharmaceutical composition comprising the rhGAA described herein, either alone or in combination with other therapeutic agents, and / or a pharmaceutically acceptable carrier, is provided.

[0147] In one or more embodiments, a pharmaceutical composition described herein comprises a pharmaceutically acceptable salt.

[0148] In some embodiments, the pharmaceutically acceptable salt used herein is a pharmaceutically-acceptable acid addition salt. The pharmaceutically-acceptable acid addition salt may include, but is not limited to, hydrochloric acid, hydrobromic acid, sulfuric acid, sulfamic acid, nitric acid, phosphoric acid, and the like, and organic acids including but not limited to acetic acid, trifluoroacetic acid, adipic acid, ascorbic acid, aspartic acid, benzenesulfonic acid, benzoic acid, butyric acid, camphoric acid, camphorsulfonic acid, cinnamic acid, citric acid, digluconic acid, ethanesulfonic acid, glutamic acid, glycolic acid, glycerophosphoric acid, hemisulfic acid, hexanoic acid, formic acid, fumaric acid, 2-hydroxyethanesulfonic acid (isethionic acid), lactic acid, hydroxymaleic acid, malic acid, malonic acid, mandelic acid, mesitylenesulfonic acid, methanesulfonic acid, naphthalenesulfonic acid, nicotinic acid, 2-naphthalenesulfonic acid, oxalic acid, pamoic acid, pectinic acid, phenylacetic acid, 3-phenylpropionic acid, pivalic acid, propionic acid, pyruvic acid, salicylic acid, stearic acid, succinic acid, sulfanilic acid, tartaric acid, p- toluenesulfonic acid, undecanoic acid, and the like.

[0149] In some embodiments, the pharmaceutically acceptable salt used herein is a pharmaceutically-acceptable base addition salt. The pharmaceutically-acceptable base addition salt may include, but is not limited to, ammonia or the hydroxide, carbonate, or bicarbonate of ammonium or a metal cation such as sodium, potassium, lithium, calcium, magnesium, iron, zinc, copper, manganese, aluminum, and the like. Salts derived from pharmaceutically-acceptable organic nontoxic bases include, but are not limited to, salts of primary, secondary, and tertiary amines, quaternary amine compounds, substituted amines including naturally occurring substituted amines, cyclic amines and basic ion-exchange resins, such asDocket No.: AT24-003-PCT49 methylamine, dimethylamine, trimethylamine, ethylamine, diethylamine, triethylamine, isopropylamine, tripropylamine, tributylamine, ethanolamine, diethanolamine, 2-dimethylaminoethanol, 2-diethylaminoethanol, dicyclohexylamine, lysine, arginine, histidine, caffeine, hydrabamine, choline, betaine, ethylenediamine, glucosamine, methylglucamine, theobromine, purines, piperazine, piperidine, N-ethylpiperidine, tetramethylammonium compounds, tetraethylammonium compounds, pyridine, N,N-dimethylaniline, N-methylpiperidine, N-methylmorpholine, dicyclohexylamine, dibenzylamine, N,N- dibenzylphenethylamine, 1 -ephenamine, N,N’- dibenzylethylenediamine, polyamine resins, and the like.

[0150] In some embodiments, the rhGAA or a pharmaceutically acceptable salt thereof may be formulated as a pharmaceutical composition adapted for intravenous administration. In some embodiments, the pharmaceutical composition is a solution in sterile isotonic aqueous buffer. Where necessary, the composition may also include a solubilizing agent and a local anesthetic to ease pain at the site of the injection. The ingredients of the pharmaceutical composition may be supplied either separately or mixed together in unit dosage form, for example, as a dry lyophilized powder or water free concentrate in a hermetically sealed container such as an ampule or sachet indicating the quantity of active agent. Where the composition is to be administered by infusion, it may be dispensed with an infusion bottle containing sterile pharmaceutical grade water, saline or dextrose / water. In some embodiments, the infusion may occur at a hospital or clinic. In some embodiments, the infusion may occur outside the hospital or clinic setting, for example, at a subject’s residence. Where the composition is administered by injection, an ampule of sterile water for injection or saline may be provided so that the ingredients may be mixed prior to administration.

[0151] In some embodiments, the rhGAA or a pharmaceutically acceptable salt thereof is administered every 2 weeks as an IV infusion lasting about 4 hours. In some embodiments, the total volume of infusion is determined by the patient’s body weight. Infusion rate can be lowered and infusion duration increased if patient experiences an IAR.Docket No.: AT24-003-PCT50

[0152] In some embodiments, the initial infusion rate is 1 mg / kg / hour. In some embodiments, the infusion rate is gradually increased by 2 mg / kg / hour every 30 minutes if there are no signs of infusion-associated reactions (lARs) until a maximum rate of 7 mg / kg / hour is reached; then, the infusion rate is maintained at 7 mg / kg / hour until the infusion is complete. In some embodiments, the approximate total infusion duration is 4 hours.

[0153] Infusions should be administered in a step-wise manner using an infusion pump. Infusion rates can be increased from initial rate every 30 minutes + / - 5 minutes until the maximum rate is reached as shown in Table 3A-3C below based on patient weight.Table 3A: Recommended Infusion Volumes and Rates for 20 mq / kq DoseTable 3B: Recommended Infusion Volumes and Rates for 25 mq / kq DoseDocket No.: AT24-003-PCT51Table 3C: Recommended Infusion Volumes and Rates for 30 mq / kq Dose

[0154] The most serious tolerability issue with the rhGAA or a pharmaceutically acceptable salt thereof is the occurrence of infusion-associated reactions (lARs), which, in some instances can include life-threatening anaphylaxis or other severe allergic responses. In some embodiments, prior to administration of the rhGAA or a pharmaceutically acceptable salt thereof, pretreatments with antihistamines, antipyretics, and / or corticosteroids are administered. If pretreatment was used with previous enzyme replacement therapy (ERT), prior to administration of the rhGAA or a pharmaceutically acceptable salt thereof, pretreatments with antihistamines, antipyretics, and / or corticosteroids are administered.

[0155] In some embodiments, the rhGAA or a pharmaceutically acceptable salt thereof may be formulated for oral administration. Orally administrable compositions mayDocket No.: AT24-003-PCT52 be formulated in a form of tablets, capsules, ovules, elixirs, solutions or suspensions, gels, syrups, mouth washes, or a dry powder for reconstitution with water or other suitable vehicle before use, optionally with flavoring and coloring agents for immediate-, delayed-, modified-, sustained-, pulsed-, or controlled-release applications. Solid compositions such as tablets, capsules, lozenges, pastilles, pills, boluses, powder, pastes, granules, bullets, dragees, or premix preparations can also be used. Solid and liquid compositions for oral use may be prepared according to methods well known in the art. Such compositions can also contain one or more pharmaceutically acceptable carriers and excipients which can be in solid or liquid form. Tablets or capsules can be prepared by conventional means with pharmaceutically acceptable excipients, including but not limited to binding agents, fillers, lubricants, disintegrants, or wetting agents. Suitable pharmaceutically acceptable excipients are known in the art and include but are not limited to pregelatinized starch, polyvinylpyrrolidone, povidone, hydroxypropyl methylcellulose (HPMC), hydroxypropyl ethylcellulose (HPEC), hydroxypropyl cellulose (HPC), sucrose, gelatin, acacia, lactose, microcrystalline cellulose, calcium hydrogen phosphate, magnesium stearate, stearic acid, glyceryl behenate, talc, silica, corn, potato or tapioca starch, sodium starch glycolate, sodium lauryl sulfate, sodium citrate, calcium carbonate, dibasic calcium phosphate, glycine croscarmellose sodium, and complex silicates. Tablets can be coated by methods well known in the art.

[0156] In some embodiments, a pharmaceutical composition described herein may be formulated according to U.S. Pat. No. 10,512,676 and U.S. Provisional Application No. 62 / 506,574, both incorporated herein by reference in their entirety. For instance, in some embodiments, the pH of a pharmaceutical composition described herein is from about 5.0 to about 7.0 or about 5.0 to about 6.0. In some embodiments, the pH ranges from about 5.5 to about 6.0. In some embodiments, the pH of the pharmaceutical composition is 6.0. In some embodiments, the pH may be adjusted to a target pH by using pH adjusters (e.g., alkalizing agents and acidifying agents) such as sodium hydroxide and / or hydrochloric acid.Docket No.: AT24-003-PCT53

[0157] The pharmaceutical composition described herein may comprise a buffer system such as a citrate system, a phosphate system, and / or a combination thereof. The citrate and / or phosphate may be a sodium citrate or sodium phosphate. Other salts include potassium and ammonium salts. In one or more embodiments, the buffer comprises a citrate. In further embodiments, the buffer comprises sodium citrate (e.g., a mixture of sodium citrate dehydrate and citric acid monohydrate). In one or more embodiments, buffer solutions comprising a citrate may comprise sodium citrate and citric acid. In some embodiments, both a citrate and phosphate buffer are present.

[0158] In some embodiments, a pharmaceutical composition described herein comprises at least one excipient. The excipient may function as a tonicity agent, bulking agent, and / or stabilizer. Tonicity agents are components which help to ensure the formulation has an osmotic pressure similar to or the same as human blood. Bulking agents are ingredients which add mass to the formulations (e.g., lyophilized) and provide an adequate structure to the cake. Stabilizers are compounds that can prevent or minimize the aggregate formation at the hydrophobic air-water interfacial surfaces. One excipient may function as a tonicity agent and bulking agent at the same time. For instance, mannitol may function as a tonicity agent and also provide benefits as a bulking agent.

[0159] Examples of tonicity agents include sodium chloride, mannitol, sucrose, and trehalose. In some embodiments, the tonicity agent comprises mannitol. In some embodiments, the total amount of tonicity agent(s) ranges in an amount of from about 10 mg / mL to about 50 mg / mL. In further embodiments, the total amount of tonicity agent(s) ranges in an amount of from about 10, 1 1 , 12, 13, 14, or 15 mg / mL to about 16, 20, 25, 30, 35, 40, 45, or 50 mg / mL.

[0160] In some embodiments, the excipient comprises a stabilizer. In some embodiments, the stabilizer is a surfactant. In some embodiments, the stabilizer is polysorbate 80. In one or more embodiments, the total amount of stabilizer ranges from about 0.1 mg / mL to about 1 .0 mg / mL. In further embodiments, the total amount of stabilizer ranges from about 0.1 , 0.2, 0.3, 0.4, or 0.5 mg / mL to about 0.5, 0.6, 0.7,Docket No.: AT24-003-PCT540.8, 0.9, or 1 .0 mg / mL. In yet further embodiments, the total amount of stabilizer is about 0.1 , 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, or 1 .0 mg / mL.

[0161] In some embodiments, the pharmaceutical composition comprises one or more of the following excipients: sodium citrate dihydrate, citric acid monohydrate, mannitol or polysorbate-80.

[0162] In some embodiments, a pharmaceutical composition comprises (a) a rhGAA (e.g., ATB200 or cipaglucosidase alfa), (b) at least one buffer selected from the group consisting of a citrate, a phosphate, and a combination thereof, and (c) at least one excipient selected from the group consisting of mannitol, polysorbate 80, and a combination thereof, and has a pH of (i) from about 5.0 to about 6.0, or (ii) from about 5.0 to about 7.0. In some embodiments, the composition further comprises water. In some embodiments, the composition may further comprise an acidifying agent and / or alkalizing agent.

[0163] In some embodiments, the pharmaceutical composition comprises (a) a rhGAA (e.g., ATB200 or cipaglucosidase alfa) at a concentration of about 5-50 mg / mL, about 5-30 mg / mL, or about 15 mg / mL, (b) sodium citrate buffer at a concentration of about 10-100 mM or about 25 mM, (c) mannitol at a concentration of about 10-50 mg / mL, or about 20 mg / mL, (d) polysorbate 80, present at a concentration of about 0.1 -1 mg / mL, about 0.2-0.5 mg / mL, or about 0.5 mg / mL, and (e) water, and has a pH of about 6.0. In at least one embodiment, the pharmaceutical composition comprises (a) 15 mg / mL rhGAA (e.g., ATB200 or cipaglucosidase alfa) (b) 25 mM sodium citrate buffer, (c) 20 mg / mL mannitol (d) 0.5 mg / mL polysorbate 80, and (e) water, and has a pH of about 6.0. In some embodiments, the composition may further comprise an acidifying agent and / or alkalizing agent.

[0164] In some embodiments, the pharmaceutical composition comprising rhGAA (e.g., ATB200 or cipaglucosidase alfa) is diluted prior to administration to a subject in need thereof. In some embodiments, the pharmaceutical composition described herein may undergo lyophilization (freeze-drying) process to provide a cake or powder. Accordingly, in some embodiments, the pharmaceutical composition described herein pertains to a rhGAA composition after lyophilization. The lyophilized mixtureDocket No.: AT24-003-PCT55 may comprise the rhGAA described herein (e.g., ATB200 or cipaglucosidase alfa), buffer selected from the group consisting of a citrate, a phosphate, and combinations thereof, and at least one excipient selected from the group consisting of trehalose, mannitol, polysorbate 80, and a combination thereof. In some embodiments, other ingredients (e.g., other excipients) may be added to the lyophilized mixture. The pharmaceutical composition comprising the lyophilized formulation may be provided in vial, which then can be stored, transported, reconstituted and / or administered to a patient.

[0165] In some embodiments, the pharmaceutical composition comprising a rhGAA (e.g., ATB200 or cipaglucosidase alfa) as described herein is a lyophilized powder in glass vials. In some embodiments, each vial may contain about 105 mg of lyophilized rhGAA (e.g., ATB200 or cipaglucosidase alfa). The powder may be reconstituted in sterile water and then followed by dilution with 0.9% sodium chloride prior to administration by IV infusion. In some embodiments, after reconstitution, the concentrate obtained contains 15 mg of rhGAA (e.g., ATB200 or cipaglucosidase alfa) per mL. In some embodiments, after reconstitution with 72 mL of diluent, the vial contains a usable volume of 7.0 mL of concentrate containing 15 mg / mL of rhGAA (e.g., ATB200 or cipaglucosidase alfa). In some embodiments, the diluent is sterile water and / or 0.9% sodium chloride. In some embodiments, each vial may include an overfill to make up for fluid loss during preparation. In some embodiments, the instant disclosure provides a vial (e.g., a glass vial) containing 105 mg lyophilized rhGAA (e.g., ATB200 or cipaglucosidase alfa) composition comprising rhGAA (e.g., ATB200 or cipaglucosidase alfa), sodium citrate dihydrate, citric acid monohydrate, mannitol, polysorbate 80, wherein the amount / concentration of each ingredient may be selected from those described herein.

[0166] In some embodiments, the number of vials to be reconstituted are based on patient’s body weight and the fact that each vial contains 105 mg of rhGAA (e.g., ATB200 or cipaglucosidase alfa). Accordingly, in some embodiments, patient dose (mg) = Subject weight (kg) x dose (mg / kg); and Number of vials required = patientDocket No.: AT24-003-PCT56 dose (in mg) / 105 (mg per vial). In some embodiments, if the number of vials includes a fraction, round up to the next whole number.

[0167] For example, in a 65 kg patient dosed at 20 mg / kg: Patient dose (mg) = 65 kg X 20 mg / kg = 1300 mg total dose; Number of vials required = 1300 / 105 mg per vial = 12.381 rounded up to 13 vials for the purpose of dispensation. The patient dose is 20 mg / kg, therefore the full volume of the first 12 vials will be extracted bu’ the 13thvial will have 2.7 ml extracted and added to the infusion bag.

[0168] For example, in a 40 kg patient dosed at 25 mg / kg: Patient dose (mg) = 40 kg X 25 mg / kg = 1000 mg total dose; Number of vials required = 1000 / 105 mg per vial = 9.524 rounded up to 10 vials for the purpose of dispensation. The patient dose is 25 mg / kg, therefore the full volume of the first 9 vials will be extracted but the 10th vial will have 3.7 ml extracted and added to the infusion bag.

[0169] For example, in a 20 kg patient dosed at 30 mg / kg: Patient dose (mg) = 20 kg X 30 mg / kg = 600 mg total dose; Number of vials required = 600 / 105 mg per vial = 5.714 rounded up to 6 vials for the purpose of dispensation. The patient dose is 30 mg / kg, therefore the full volume of the first 5 vials will be extracted but the 6th vial will have 5.0 ml extracted and added to the infusion bag.

[0170] For example, in a 10 kg patient dosed at 30 mg / kg: Patient dose (mg) = 10 kg X 30 mg / kg = 300 mg total dose; Number of vials required = 300 / 105 mg per vial = 2.857 rounded up to 3 vials for the purpose of dispensation. The patient dose is 30 mg / kg, therefore the full volume of the first 2 vials will be extracted but the 3rd vial will have 6.0 mL extracted and added to the infusion bag.

[0171] In some embodiments, the method of reconstitution comprises or consists essentially of the follow processes: (1 ) reconstitute each vial by slowly injecting 7.2 mL of Sterile Water for Injection, to the inside wall of each vial and not directly onto the lyophilized cake; (2) roll each vial gently, do not invert, swirl, or shake; (3) dilute an amount of reconstituted rhGAA based on the patient’s body weight in 0.9% Sodium Chloride for Injection, immediately after reconstitution to the total infusion volume for 20 mg / kg dose based on patient weight; (4) prior to adding theDocket No.: AT24-003-PCT57 reconstituted rhGAA, remove air and total amount equal to reconstituted volume 0.9% Sodium Chloride for Injection bag; (5) slowly withdraw the reconstituted solution from each vial avoiding foaming in the syringe; (6) slowly add the reconstituted cipaglucosidase alfa solution directly into the 0.9% Sodium Chloride for Injection bag (do not add directly into the airspace that may remain within the infusion bag) avoiding foaming in the infusion bag (Alternatively, product dilution can be accomplished using an appropriately sized empty infusion bag to add the required volume of 0.9% Sodium Chloride for Injection and the reconstituted rhGAA based on patient weight.. It is recommended to use pre-filled 0.9% Sodium Chloride for Injection bag); (7) gently invert or massage the infusion bag to mix; and (8) cover the infusion bag and tubing to protect the medication from light. After reconstitution, each vial will yield a concentration of 15mg / mL. The total extractable dose per vial is 105 mg per 7 mL.

[0172] In some embodiments, only the exact amount of reconstituted rhGAA based on the patient’s body weight is diluted. In some embodiments, for partial withdrawal of the reconstituted vial, amounts are rounded up or down to 1 decimal place. In some embodiments, the infusion bag is not shaken to mix or a pneumatic tube used to transport the infusion bag. In some embodiments, the reconstituted and diluted solutions may contain particles in the form of thin white strands or translucent fibers after initial preparation and increase over time.

[0173] The present disclosure also provides a pharmaceutical composition comprising an enzyme stabilizer. In some embodiments, the enzyme stabilizer is miglustat or a pharmaceutically acceptable salt thereof. In another embodiment, the enzyme stabilizer is duvoglustat or a pharmaceutically acceptable salt thereof.

[0174] In some embodiments, a rhGAA described herein is formulated in one pharmaceutical composition, while an enzyme stabilizer such as miglustat is formulated in another pharmaceutical composition. In some embodiments, the pharmaceutical composition comprising miglustat is based on a formulation available commercially as ZAVESCA® (Actelion Pharmaceuticals). In some embodiments, the pharmaceutical composition comprising miglustat comprisesDocket No.: AT24-003-PCT58 microcrystalline cellulose, pregelatinized starch, Emprove® sucralose powder, magnesium stearate, and / or colloidal silicon dioxide. In some embodiments, the pharmaceutical composition is a hard gelatin capsule for oral administration, comprising about 65 mg of miglustat, microcrystalline cellulose, pregelatinized starch, Emprove® sucralose powder, magnesium stearate, and / or colloidal silicon dioxide. In some embodiments, the pharmaceutical composition is a hard gelatin capsule for oral administration, comprising about 65 mg of miglustat, microcrystalline cellulose, pregelatinized starch, Emprove® sucralose powder, magnesium stearate, and / or colloidal silicon dioxide.

[0175] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising 1.0-10.0%, 1.5-8%, 2.0-5.0%, 2.0-6.5%, 2-7% 2.5-5.0%, 2.5-6.5%, 2.5-7%, 3.0-5.0%, 3-6.5%, 3-7%, 3.5-5.0%, 3.5-6%, 3.5-7%, 4.0-5.0%, 4- 6.5%, 4-7%, 4.5-5.0%, 4.5-6%, 4.5-7% 2.0-4.5%, 2.5-4.5%, 3.0-4.5%, 3.5-4.5%, 4.0-4.5%, 2.0-4.0%, 2.5-4.0%, 3.0-4.0%, or 3.5-4.0% miglustat by weight. In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising less than or equal to about 5% miglustat by weight. In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising 1 to 200 mg / mL, such as 10 to 100 mg / mL, 10 to 50 mg / mL or 20 to 60 mg / mL. Exemplary miglustat concentrations include about 5 mg / mL, 10 mg / mL, 15 mg / mL, 20 mg / mL, 30 mg / mL, 40 mg / mL, 50 mg / mL, 60 mg / mL, 70 mg / mL, 80 mg / mL, 90 mg / mL or 100 mg / mL.

[0176] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a buffer system such as a citrate system, a phosphate system, or a combination thereof. The citrate and / or phosphate may be a sodium salt (e.g., sodium citrate or sodium phosphate). Other salts include potassium and ammonium salts. In one or more embodiments, the buffer comprises a citrate. In further embodiments, the buffer comprises sodium citrate (e.g., a mixture of sodium citrate dihydrate and citric acid monohydrate). In one or more embodiments, buffer solutions comprising a citrate may comprise sodium citrate and citric acid. In some embodiments, both a citrate and phosphate buffer are present.Docket No.: AT24-003-PCT59

[0177] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a thickener or thickening agent. In some embodiments, the thickener is selected from hydroxypropyl methylcellulose (HPMC), hydroxypropyl ethylcellulose (HPEC), hydroxypropyl cellulose (HPC), gelatin, or microcrystalline cellulose. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.5-5%, 1 .0-3.0% or 1 .0-2.0% of a thickener by weight. In some embodiments, the thickener is hydroxypropyl methylcellulose (HPMC).

[0178] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a sweetener. In some embodiments, the sweetener is selected from sucrose or sucralose. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.1 -1 %, 0.1 -0.5%, 0.1 -0.3% or 0.15-0.25% sweetener by weight. In some embodiments, the sweetener is sucralose.

[0179] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a preservative. In some embodiments, the preservative is potassium sorbate. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.1 -1 %, 0.1 -0.5%, 0.1 -0.3% or 0.15-0.25% preservative by weight.

[0180] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a flavoring agent. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.1 - 0.5%, 0.1 -0.3% or 0.15-0.25% of a flavoring agent by weight.

[0181] In some embodiments, the balance of the oral solution comprising miglustat is water. In some embodiments, the water comprises greater than or equal to 80%, 90%, 91 %, 92%, 93%, 94% or 95% water.

[0182] In some embodiments, the pH of the oral solution comprising miglustat is adjusted with a strong acid (e.g., hydrochloric acid) and / or a strong base (e.g., sodium hydroxide). In some embodiments, the pH of the oral solution comprisingDocket No.: AT24-003-PCT60 miglustat is adjusted to 5.0 + / - 0.5. Stated differently, in some embodiments, the pH of the oral solution comprising miglustat is in a range of 4.5-5.5, 4.7-5.3, 4.9-5.1 , or is about 5.0.

[0183] In some embodiments, an oral solution comprising miglustat is an oral solution comprising 1.0-10.0%, 2.0-5.0%, 2.5-5.0%, 3.0-5.0%, 3.5-5.0%, 4.0-5.0%, 4.5- 5.0%, 2.0-4.5%, 2.5-4.5%, 3.0-4.5%, 3.5-4.5%, 4.0-4.5%, 2.0-4.0%, 2.5-4.0%, 3.0- 4.0%, or 3.5-4.0% miglustat by weight. In some embodiments an oral solution comprises less than or equal to about 4% miglustat by weight.

[0184] In some embodiments, an oral solution comprising miglustat is an oral solution comprising 1 to 200 mg / mL, such as 10 to 100 mg / mL, 10 to 50 mg / mL or 20 to 60 mg / mL. Exemplary miglustat concentrations include about 5 mg / mL, 10 mg / mL, 15 mg / mL, 20 mg / mL, 30 mg / mL, 40 mg / mL, 50 mg / mL, 60 mg / mL, 70 mg / mL, 80 mg / mL, 90 mg / mL or 100 mg / mL.

[0185] In some embodiments, an oral solution comprising miglustat contains a buffering agent. In some embodiments the buffering agent is sodium citrate. In some embodiments, an oral solution comprising miglustat is an oral solution comprising, 0.5-1 %, 0.5-0.55%, 0.55-0.6%, 0.6-0.65%, 0.65-0.7%, 0.7-0.8%, 0.8-0.85%, 0.85- 0.9%, or 0.9-0.95%. of sodium citrate by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.65% sodium citrate by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.84% sodium citrate by weight. In some embodiments an oral solution comprises a sodium citrate concentration of 0.1 to 100 mg / mL, such as 0.5 to 50 mg / mL, 1 to 20 mg / mL or 5 to 15 mg / mL. Exemplary sodium citrate concentrations include 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / ml, 7 mg / mL, 8 mg / mL, 9 mg / mL, 10 mg / mL, 1 1 mg / mL, 12 mg / mL, 13 mg / mL, 14 mg / mL,15 mg / mL, 20 mg / mL, 25 mg / mL, 30 mg / mL, 35 mg / mL, 40 mg / mL or 50 mg / mL,

[0186] In some embodiments, an oral solution comprising miglustat contains a buffering agent. In some embodiments the buffering agent is citric acid. In some embodiments an oral solution comprising miglustat is an oral solution comprising 0.1 -0.5%, 0.1 -Docket No.: AT24-003-PCT610.2%, 0.2-0.3%, 0.25-0.3%, 0.3-0.35%, 0.35-0.4%, 0.4-0.5%, of citric acid by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.27% citric acid by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.35% citric acid by weight. In some embodiments an oral solution comprises a citric acid concentration of 0.1 to 100 mg / mL, such as 0.5 to 50 mg / mL, 1 to 20 mg / mL or 5 to 15 mg / mL. Exemplary citric acid concentrations include 0.5 mg / mL, 1 mg / mL, 1.5 mg / mL, 2 mg / mL, 2.5 mg / mL, 3 mg / mL, 3.5 mg / mL, 4 mg / mL, 4.5 mg / mL, 5 mg / mL, 6 mg / ml, 7 mg / mL, 8 mg / mL, 9 mg / mL, 10 mg / mL,15 mg / mL, 20 mg / mL, 25 mg / mL, 30 mg / mL, 35 mg / mL, 40 mg / mL or 50 mg / mL,

[0187] In some embodiments, an oral solution comprising miglustat contains a thickening agent. In some embodiments the thickening agent is hypromellose. In some embodiments an oral solution comprising miglustat is an oral solution comprising the thickening agent at 1 -10 mg / mL, 10-20 mg / mL, 1 -5 mg / mL, 10 mg / mL, 1 1 mg / mL, 12 mg / mL, 13 mg / mL, 14 mg / mL, 15 mg / mL, 16 mg / mL, 17 mg / mL, 18 mg / mL, 19 mg / mL, or 20 mg / mL. In some embodiments the oral solution comprises the thickening agent at less than, greater than, or equal to about 15 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 1 -5%, 1.5-2%, 1 -1.5%, 1 -2%, 2.5-3%, 3.5-4%, 4.5-5%, or 5.5- 6% of the thickening agent by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 1.5% thickening agent by weight.

[0188] In some embodiments, an oral solution comprising miglustat contains a sweetener. In some embodiments, the sweetener is sucralose. In some embodiments, an oral solution comprising miglustat is an oral solution comprising the sweetener at 1 -5 mg / mL, 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / mL, 7 mg / mL, 8 mg / mL, 9 mg / mL, or 10 mg / mL. In some embodiments the oral solution comprises the sweetener at less than, greater than, or equal to about 2 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 0.1 -0.2%, 0.15-0.2%, 0.1 -0.5%, 0.1 -0.25%, 0.15-0.25%, 0.2- 0.25%, 0.25-0.3%, 0.25-0.35%, 0.3-0.4%, 0.4-0.5% of the sweetener by weight. InDocket No.: AT24-003-PCT62 some embodiments, an oral solution comprises less than, greater than, or equal to about 0.2% sweetener by weight.

[0189] In some embodiments, an oral solution comprising miglustat contains a preservative. In some embodiments, the preservative is potassium sorbate. In some embodiments, an oral solution comprising miglustat is an oral solution comprising the preservative at 1 -5 mg / mL, 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / mL, 7 mg / mL, 8 mg / mL, 9 mg / mL, or 10 mg / mL. In some embodiments the oral solution comprises the preservative at less than, greater than, or equal to about 2 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 0.1 -0.2%, 0.15-0.2%, 0.1 -0.5%, 0.1 -0.25%, 0.15-0.25%, 0.2- 0.25%, 0.25-0.3%, 0.25-0.35%, 0.3-0.4%, 0.4-0.5% of the preservative by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 0.2% preservative by weight.

[0190] In some embodiments, an oral solution comprising miglustat contains a flavor. In some embodiments, the flavor is mixed berry. In some embodiments, an oral solution comprising miglustat is an oral solution comprising the flavor at 1 -5 mg / mL, 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / mL, 7 mg / mL, 8 mg / mL, 9 mg / mL, or 10 mg / mL. In some embodiments the oral solution comprises the flavor at less than, greater than, or equal to about 2 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 0.1 -0.2%, 0.15-0.2%, 0.1 -0.5%, 0.1 -0.25%, 0.15-0.25%, 0.2-0.25%, 0.25-0.3%, 0.25-0.35%, 0.3-0.4%, 0.4-0.5% of the flavor by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 0.2% flavor by weight.

[0191] Several exemplary pharmaceutical compositions comprising miglustat in an oral solution are provided below.Docket No.: AT24-003-PCT63METHODS OF TREATMENTA. Treatment of Diseases

[0192] The US Prescribing Information and European Union Summary of Product Characteristics for OPFOLDA and POMBILITI are hereby incorporated by reference in their entireties. International patent application numbers WO / 2023 / 215865, WO 2024 / 119070 and WO / 2024 / 119091 are also hereby incorporated by reference in their entireties.

[0193] Another aspect of the disclosure pertains to a method of treatment of a disease or disorder related to glycogen storage dysregulation by administering the rhGAA or pharmaceutical composition described herein. In some embodiments, the disease is Pompe disease (also known as acid maltase deficiency (AMD) and glycogen storage disease type II (GSD II)). In some embodiments, the rhGAA is ATB200 or cipaglucosidase alfa. In some embodiments, the pharmaceutical composition comprises rhGAA (e.g., ATB200 or cipaglucosidase alfa). Also provided herein are uses of rhGAA (e.g., ATB200 or cipaglucosidase alfa) to treat Pompe disease. InDocket No.: AT24-003-PCT64 various embodiments, a composition comprising miglustat is administered to a patient for the treatment of Pompe disease. Such composition comprising miglustat may be administered in combination with rhGAA. In some embodiments, the composition comprising miglustat further comprises one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0194] In some embodiments, the subject treated by the methods disclosed herein is a pediatric patient. In some embodiments, the subject may have an age from 0 to 18 years of age or any intermediate value or subrange thereof including 0, 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 or 12 months of age or 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17 or 18 years of age. In some embodiments, the subject is older than 18 years of age.

[0195] In some embodiments, the subject treated by the methods disclosed herein is an ERT-experienced patient. For instance, the subject treated by the methods disclosed herein is an adult patient 18 years of age or older with a confirmed diagnosis of late onset Pompe disease (acid a-glucosidase (GAA) deficiency), who have previously received enzyme replacement therapy (ERT). In some embodiments, the ERT-experienced patient is currently receiving an approved ERT (e.g., MYOZYME® or LUMIZYME®). In some embodiments, the ERT-experienced patient is declining on their current treatment. In some embodiments, the methods disclosed herein are begun approximately 2 weeks after the last ERT dose. In some embodiments, the subject treated by the methods disclosed herein is an ERT-naive patient.

[0196] In some embodiments, the patient may be expected to be seen again every 3 months to ensure the clinical benefit provided to the patient and thus continue the treatment. This visit frequency may be required until the medicinal product is commercially available. In some embodiments, a patient's response to treatment is regularly assessed based on an assessment of the main clinical and laboratory parameters of the disease. In some embodiments, an rhGAA as described herein (such as cipaglucosidase alfa) and miglustat are administered every two weeks. InDocket No.: AT24-003-PCT65 some embodiments, a dosage of rhGAA such as cipaglucosidase alfa is about 20 mg / kg, about 25 mg / kg, or about 30 mg / kg of body weight given as a 4-hour infusion. In some embodiments, if the infusion is delayed, it should not be started more than 3 hours after oral administration of miglustat. In some embodiments, for patients weighing 50 kg or more, four 65 mg capsules (260 mg total) In some embodiments, a dosage of rhGAA, such as cipaglucosidase alfa is about 30 mg / kg of body weight given as a 4-hour infusion. In some embodiments, if the infusion is delayed, it should not be started more than 3 hours after oral administration of miglustat.

[0197] In some of the above embodiments, for patients weighing between 40 and 50 kg, a dosage of three 65 mg capsules (195 mg total) is administered. In some of the above embodiments, rhGAA (such as cipaglucosidase alfa) is administered via infusion every two weeks.

[0198] In some embodiments, subjects receive capsules of miglustat (or liquid dispersion prepared from miglustat capsule) approximately 1 hour (i.e., 1 hour ± 10 minutes) prior to cipaglucosidase alfa infusion. The number of capsules, amount of water to be used and amount of dispersion to be dosed are summarized in the table below. For example, for subjects who receives 260 mg or 195 mg of miglustat, 4 capsules or 3 capsules of miglustat will be administered orally, respectively.

[0199] In some of the above embodiments, for patients weighing between 40 and 50 kg, a dosage of three 65 mg capsules (195 mg total) of miglustat are administered. In some of the above embodiments, rhGAA (such as cipaglucosidase alfa) is administered via infusion every two weeks.

[0200] In some embodiments, if the subject cannot swallow the miglustat capsules, the capsule can be opened, and the contents transferred into water. In some embodiments, subjects receive a liquid dispersion administration prepared from miglustat capsule approximately 1 hour (i.e., 1 hour ± 10 minutes) prior to cipaglucosidase alfa infusion. The number of capsules, the amount of water to be used, and the amount of dispersion to be dosed are summarized in the table below. For example, for subjects who receive 260 mg of miglustat, 20 mL of water will be used to disperse 4 capsules of miglustat and will be given 20 mL.Docket No.: AT24-003-PCT66

[0201] In some embodiments, the miglustat is administered as an oral solution as described herein. As described above, exemplary oral solutions may comprise miglustat with one or more excipients such as a preservative, a buffering agent, a thickener (or a thickening agent), a sweetener, a flavor, and / or a vehicle. In some embodiments, the oral solution comprises miglustat and one or more of sodium citrate, citric acid, hypromellose, sucralose, potassium sorbate, flavoring and / or water.

[0202] The rhGAA or pharmaceutical composition described herein is administered by an appropriate route. In one embodiment, the rhGAA or pharmaceutical composition is administered intravenously. In some embodiments, the rhGAA or pharmaceutical composition is administered intravenously using an infusion pump. In some embodiments, when administered intravenously, the infusion bag and tubing are covered to protect from light. In other embodiments, the rhGAA or pharmaceutical composition is administered by direct administration to a target tissue, such as to heart or skeletal muscle (e.g., intramuscular), or nervous system (e.g., direct injection into the brain; intraventricularly; intrathecally). In some embodiments, the rhGAA or pharmaceutical composition is administered orally. More than one route can be used concurrently, if desired.

[0203] In some embodiments, subjects receive capsules of miglustat (or liquid dispersion prepared from miglustat capsule) approximately 1 hour (i.e., 1 hour ± 10 minutes) prior to cipaglucosidase alfa infusion. The number of capsules, amount of water to be used and amount of dispersion to be dosed are summarized in the table below. For example, for subjects who receives 260 mg or 195 mg of miglustat, 4 capsules or 3 capsules of miglustat will be administered orally, respectively. In some embodiments, if the subject cannot swallow the miglustat capsules, the capsule can be opened, and the contents transferred into water.Table 4: Number of Capsules and Amount of Water to be Used to Prepare the DispersionDocket No.: AT24-003-PCT67

[0204] In some embodiments, rhGAA (such as cipaglucosidase alfa) is administered via infusion every two weeks.

[0205] In some embodiments, the therapeutic effects of the rhGAA or pharmaceutical composition may be assessed based on one or more of the following criteria: (1 ) cardiac status (e.g., increase of end-diastolic and / or end-systolic volumes, or reduction, amelioration or prevention of the progressive cardiomyopathy that is typically found in GSD-II), (2) pulmonary function (e.g., increase in crying vital capacity over baseline capacity, and / or normalization of oxygen desaturation during crying), (3) neurodevelopment and / or motor skills / function (e.g., increase in AIMS score), (4) reduction of glycogen levels in tissue of the individual affected by the disease, (5) muscle strength; and / or (6) quality of life.

[0206] In some embodiments, the therapeutic effects of the rhGAA or pharmaceutical composition may be assessed across measures of motor function, muscle strength, pulmonary function, patient reported outcomes (PROs) and biomarkers. In some embodiments, the therapeutic effects of the rhGAA or pharmaceutical composition described herein may be measured by the 6-minute walk test (6MWT), % predicted 6MWD, 10-meter walk test (10MWT), GSGC, 4 stair climb, Gowers’, chair test, and Timed Up and Go (TUG). Treatment with the rhGAA or pharmaceutical composition described herein may also result in improved pulmonary function tests (PFTs) as measured by FVC (e.g., sitting, supine), slow vital capacity (SVC), maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), and sniff nasal inspiratory pressure (SNIP), as well as improvements in muscle strength in all tested body parts of both ambulatory and non-ambulatory subjects, as measured by MMTs (e.g., lower MMT, upper MMT, overall MMT) and quantitative muscle testing (QMT).Docket No.: AT24-003-PCT68

[0207] In some embodiments, the treatment effects of the pharmaceutical compositions of the present application, such as those set forth herein are durable and maintained through 12, 24, 36, 48 or >48 months of treatment. In some embodiments, the treatment effects of the pharmaceutical compositions, including such as, improvements in motor function (e.g., as measured by 6MWD, GSGC, 10 m walk, 4 stair climb, Gowers’, Chair test, TUG), pulmonary or respiratory function or improved or stabilized PFTs (e.g., as measured by % predicted FVC (sitting and supine), SVC, MIP, MEP, and SNIP), biomarker levels (e.g., serum CK and urine Hex4), stable or improved muscle strength in all tested body parts (e.g., as measured by MMT (lower, upper, overall), QMT), and / or patient-reported outcomes (PROs, including the PROMIS-Physical Function Short Form [SF] 20a and PROMIS- Fatigue SF 8a) are sustained up to or through 24, 36, or 48 months of treatment.

[0208] In some embodiments, patients treated with a pharmaceutical composition of the present application achieve greater (e.g., greater clinically meaningful) improvements in motor function (e.g., as measured by 6MWD, GSGC, 10 m walk, 4 stair climb, Gowers’, Chair test, TUG), pulmonary or respiratory function or improved or stabilized PFTs (e.g., as measured by % predicted FVC (sitting and supine), SVC, MIP, MEP, and SNIP), biomarker levels (e.g., serum CK and urine Hex4), stable or improved muscle strength in all tested body parts (e.g., as measured by MMT (lower, upper, overall), QMT), and / or patient-reported outcomes (PROs, including the PROMIS-Physical Function Short Form [SF] 20a and PROMIS-Fatigue SF 8a), than patients treated with a conventional rhGAA product (e.g., MYOZYME®, LUMIZYME® or NEXVIAZYME®). In some embodiments, patients treated with a pharmaceutical composition of the present application show greater (e.g., greater clinically meaningful) improvements in motor function (e.g., as measured by 6MWD), pulmonary or respiratory function (e.g., as measured by FVC), and / or muscle strength (e.g., as measured by MMT) than patients treated with a conventional rhGAA product (e.g., MYOZYME®, LUMIZYME® or NEXVIAZYME®). In some embodiments, such greater improvements are sustained up to or though 12, 24, 36, 48, or >48 months of treatment.Docket No.: AT24-003-PCT69

[0209] In some embodiments, ERT-experienced switch patients treated with a pharmaceutical composition of the present application, such as those patients who are switched from a conventional rhGAA product (e.g., MYOZYME®, LUMIZYME® or NEXVIAZYME®) to a pharmaceutical composition of the present application, show greater (e.g., greater clinically meaningful) improvements in motor function (e.g., as measured by 6MWD, GSGC, 10 m walk, 4 stair climb, Gowers’, Chair test, TUG), pulmonary or respiratory function or improved or stabilized PFTs (e.g., as measured by % predicted FVC (sitting and supine), SVC, MIP, MEP, and SNIP), biomarker levels (e.g., serum CK and urine Hex4), stable or improved muscle strength in all tested body parts (e.g., as measured by MMT (lower, upper, overall), QMT), and / or patient-reported outcomes (PROs, including the PROMIS-Physical Function Short Form [SF] 20a and PROMIS-Fatigue SF 8a), when compared to patients who remain on the conventional rhGAA product. In some embodiments, patients under a conventional rhGAA product (e.g., MYOZYME®, LUMIZYME® or NEXVIAZYME®), who are no longer improving or worsening with such treatment achieve improvements in motor function (e.g., as measured by 6MWD, GSGC, 10 m walk, 4 stair climb, Gowers’, Chair test, TUG), pulmonary or respiratory function or improved or stabilized PFTs (e.g., as measured by % predicted FVC (sitting and supine), SVC, MIP, MEP, and SNIP), biomarker levels (e.g., serum CK and urine Hex4), stable or improved muscle strength in all tested body parts (e.g., as measured by MMT (lower, upper, overall), QMT), and / or patient-reported outcomes (PROs, including the PROMIS-Physical Function Short Form [SF] 20a and PROMIS- Fatigue SF 8a), after switching to a pharmaceutical composition of the present application. In some embodiments, such improvements are sustained up to or through 12, 24, 36, 48, or >48 months.B. Dosages of rhGAA

[0210] The pharmaceutical formulation or reconstituted composition is administered in a therapeutically effective amount (e.g., a dosage amount that, when administered at regular intervals, is sufficient to treat the disease, such as by ameliorating symptoms associated with the disease, delaying the onset of the disease, and / or lessening the severity or frequency of symptoms of the disease). The amount whichDocket No.: AT24-003-PCT70 is therapeutically effective in the treatment of the disease may depend on the nature and extent of the disease's effects, and can be determined by standard clinical techniques. In addition, in vitro or in vivo assays may optionally be employed to help identify optimal dosage ranges. In at least one embodiment, a rhGAA described herein or pharmaceutical composition comprising the rhGAA is administered at a dose of about 1 mg / kg to about 100 mg / kg, such as about 5 mg / kg to about 50 mg / kg, typically about 20 mg / kg to about 40 mg / kg, or about 20 mg / kg to about 30 mg / kg; or such as 5 mg / kg to about 30 mg / kg, typically about 5 mg / kg to about 20 mg / kg. In at least one embodiment, the rhGAA or pharmaceutical composition described herein is administered at a dose of about 5 mg / kg, about 10 mg / kg, about 15 mg / kg, about 20 mg / kg, about 25 mg / kg, about 30 mg / kg, about 35 mg / kg, about 40 mg / kg, about 45 mg / kg, about 50 mg / kg, about 60 mg / kg, about 70 mg / kg, about 80 mg / kg, about 90 mg / kg, or about 100 mg / kg. In some embodiments, the rhGAA is administered at a dose of 5 mg / kg, 10 mg / kg, 20 mg / kg, 25 mg / kg, 30 mg / kg, 35 mg / kg, 40 mg / kg, 50 mg / kg, 75 mg / kg, or 100 mg / kg. In at least one embodiment, the rhGAA or pharmaceutical composition is administered at a dose of about 20, 21 , 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 , 32, 33, 34, 35, 36, 37, 38, 39, or 40 mg / kg. In at least one embodiment, the rhGAA or pharmaceutical composition is administered at a dose of about 30 mg / kg. In at least one embodiment, the rhGAA or pharmaceutical composition is administered at a dose of about 25 mg / kg. In at least one embodiment, the rhGAA or pharmaceutical composition is administered at a dose of about 20 mg / kg.

[0211] In at least one embodiment the dosage of the rhGAA is dependent on the patient’s age. In at least one embodiment, the dosage of the rhGAA is dependent on the patient’s weight. In at least one embodiment, the dosage of the rhGAA is dependent on the patient’s age and weight. In at least one embodiment, the dosage of the rhGAA is provided according to Table 5A-5C below.

[0212] In some embodiments, the rhGAA or pharmaceutical composition is administered concurrently or sequentially with a pharmacological chaperone. In some embodiments, the pharmacological chaperone is miglustat. In at least one embodiment, the miglustat is administered as an oral dose in a range of about 20Docket No.: AT24-003-PCT71 mg to about 260 mg depending on patient age and weight or any intermediate value or subrange thereof including 20, 40, 65, 85, 1 15, 130, 175, 195, or 260 mg. In at least one embodiment, the miglustat is administered as an oral dose of about 260 mg. In at least one embodiment, the miglustat is administered as an oral dose of about 195 mg. The effective dose for a particular individual can be varied (e.g., increased or decreased) over time, depending on the needs of the individual. For example, in times of physical illness or stress, or if anti-acid a-glucosidase antibodies become present or increase, or if disease symptoms worsen, the amount of rhGAA and / or miglustat can be adjusted.

[0213] In some embodiments, the therapeutically effective dose of the rhGAA or pharmaceutical composition described herein is lower than that of conventional rhGAA products. For instance, if the therapeutically effective dose of a conventional rhGAA product is 20 mg / kg, the dose of the rhGAA or pharmaceutical composition described herein required to produce the same as or better therapeutic effects than the conventional rhGAA product may be lower than 20 mg / kg. Therapeutic effects may be assessed based on one or more criteria discussed above (e.g., cardiac status, glycogen level, or biomarker expression). In some embodiments, the therapeutically effective dose of the rhGAA or pharmaceutical composition described herein is at least about 5%, 10%, 15%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more lower than that of conventional rhGAA products.

[0214] In some embodiments, the therapeutic effect of the rhGAA or pharmaceutical composition described herein comprises an improvement and / or stabilization in motor function, an improvement and / or stabilization in muscle strength (upper-body, lower-body, or total-body), an improvement and / or stabilization in pulmonary function, decreased fatigue, reduced levels of at least one biomarker of muscle injury, reduced levels of at least one biomarker of glycogen accumulation, or a combination thereof. In some embodiments, the therapeutic effect of the rhGAA or pharmaceutical composition described herein comprises a reversal of lysosomal pathology in a muscle fiber, a faster and / or more effective reduction in glycogen content in a muscle fiber, an increase in six-minute walk test distance, a decrease in timed up and go test time, a decrease in four-stair climb test time, a decrease inDocket No.: AT24-003-PCT72 ten-meter walk test time, a decrease in gait-stair-gower-chair score, an increase in upper extremity strength, an improvement and / or stabilization in shoulder adduction, an improvement and / or stabilization in shoulder abduction, an improvement and / or stabilization in elbow flexion, an improvement and / or stabilization in elbow extension, an improvement and / or stabilization in upper body strength, an improvement and / or stabilization in lower body strength, an improvement and / or stabilization in total body strength, an improvement in upright (sitting) forced vital capacity, an improvement and / or stabilization in maximum expiratory pressure, an improvement and / or stabilization in maximum inspiratory pressure, a decrease in fatigue severity scale score, a reduction in urine hexose tetrasaccharide levels, a reduction in creatine kinase levels, a reduction in alanine aminotransferase levels, a reduction in asparate aminotransferase levels, or any combination thereof.

[0215] In some embodiments, the rhGAA or pharmaceutical composition described herein achieves desired therapeutic effects faster than conventional rhGAA products when administered at the same dose. Therapeutic effects may be assessed based on one or more criteria discussed above (e.g., cardiac status, glycogen level, or biomarker expression). For instance, if a single dose of a conventional rhGAA product decreases glycogen levels in tissue of a treated individual by 10% in a week, the same degree of reduction may be achieved in less than a week when the same dose of the rhGAA or pharmaceutical composition described herein is administered. In some embodiments, when administered at the same dose, the rhGAA or pharmaceutical composition described herein may achieve desired therapeutic effects at least about 1 .25, 1 .5, 1 .75, 2.0, 3.0, or more faster than conventional rhGAA products.

[0216] In some embodiments, the therapeutically effective amount of rhGAA (or composition or medicament comprising rhGAA) is administered more than once. In some embodiments, the rhGAA or pharmaceutical composition described herein is administered at regular intervals, depending on the nature and extent of the disease's effects, and on an ongoing basis. Administration at a “regular interval,” as used herein, indicates that the therapeutically effective amount is administered periodically (as distinguished from a one-time dose). The interval can be determinedDocket No.: AT24-003-PCT73 by standard clinical techniques. In certain embodiments, rhGAA is administered bimonthly, monthly, bi-weekly, weekly, twice weekly, or daily. In some embodiments, the rhGAA is administered intravenously twice weekly, weekly, or every other week. The administration interval for a single individual need not be a fixed interval, but can be varied over time, depending on the needs of the individual. For example, in times of physical illness or stress, if anti-rhGAA antibodies become present or increase, or if disease symptoms worsen, the interval between doses can be decreased.

[0217] In some embodiments, when used at the same dose, the rhGAA or pharmaceutical composition as described herein may be administered less frequently than conventional rhGAA products and yet capable of producing the same as or better therapeutic effects than conventional rhGAA products. For instance, if a conventional rhGAA product is administered at 20 mg / kg, 30 mg / kg or 40 mg / kg weekly, the rhGAA or pharmaceutical composition as described herein may produce the same as or better therapeutic effects than the conventional rhGAA product when administered at 20 mg / kg, 30 mg / kg, or 40 mg / kg, even though the rhGAA or pharmaceutical composition is administered less frequently, e.g., biweekly or monthly. Also, for instance, if a conventional rhGAA product is administered at 20 mg / kg weekly, the rhGAA or pharmaceutical composition as described herein may produce the same as or better therapeutic effects than the conventional rhGAA product when administered at 20 mg / kg, even though the rhGAA or pharmaceutical composition is administered less frequently, e.g., biweekly or monthly. Therapeutic effects may be assessed based on one or more criterion discussed above (e.g., cardiac status, glycogen level, or biomarker expression). In some embodiments, an interval between two doses of the rhGAA or pharmaceutical composition described herein is longer than that of conventional rhGAA products. In some embodiments, the interval between two doses of the rhGAA or pharmaceutical composition is at least about 1 .25, 1 .5, 1 .75, 2.0, 3.0, or more longer than that of conventional rhGAA products.

[0218] In some embodiments, under the same treatment condition (e.g., the same dose administered at the same interval), the rhGAA or pharmaceutical compositionDocket No.: AT24-003-PCT74 described herein provides therapeutic effects at a degree superior than that provided by conventional rhGAA products. Therapeutic effects may be assessed based on one or more criteria discussed above (e.g., cardiac status, glycogen level, or biomarker expression). For instance, when compared to a conventional rhGAA product administered at 20 mg / kg, 30 mg / kg, or 40 mg / kg weekly, the rhGAA or pharmaceutical composition administered at 20 mg / kg or 30 mg / kg weekly may reduce glycogen levels in tissue of a treated individual at a higher degree. Or, for instance, when compared to a conventional rhGAA product administered at 20 mg / kg weekly, the rhGAA or pharmaceutical composition administered at 20 mg / kg weekly may reduce glycogen levels in tissue of a treated individual at a higher degree. In some embodiments, when administered under the same treatment condition, the rhGAA or pharmaceutical composition described herein provides therapeutic effects that are at least about 1 .25, 1 .5, 1 .75, 2.0, 3.0, or more greater than those of conventional rhGAA products.C. Two-Component Therapy

[0219] In one or more embodiments, the rhGAA or pharmaceutical composition comprising the rhGAA described herein is administered concurrently or sequentially with an enzyme stabilizer. In some embodiments, the enzyme stabilizer is miglustat. In some embodiments, the rhGAA or pharmaceutical composition is administered via a different route as compared to the enzyme stabilizer. For instance, an enzyme stabilizer may be administered orally while the rhGAA or pharmaceutical composition is administered intravenously.

[0220] In some embodiments, a kit is provided containing the rhGAA (or pharmaceutical composition comprising the same) as described herein and the miglustat (or pharmaceutical composition comprising the same) as described herein.

[0221] In some embodiments, the two-component therapy is administered in combination with additional therapies such as gene therapy or substrate reduction therapy. Exemplary gene therapy candidates include those that encode the GAA gene with optional tags such as insulin-like growth factor-ll (IGF2) or variants thereof and / or binding immunoglobulin protein (Bip) or variants thereof. ExemplaryDocket No.: AT24-003-PCT75 substrate reduction therapy strategies include inhibiting glycogen synthesis using small molecules or genetic inhibition. In some embodiments, the two-component therapy comprises ERT or a pharmacological chaperon as the first component of the therapy and gene therapy or substrate reduction therapy as the second component of the therapy. Such substrate reduction therapy includes, for example, small molecule inhibition of glycogenin (GYG) or glycogen synthase (GYS) (e.g., GYS1 small molecule inhibitor currently in human trial NCT05249621 ) or genetic approaches (e.g., antisense oligonucleotide-mediated suppression of muscle GYS1 synthesis).

[0222] In various embodiments, the enzyme stabilizer is miglustat. Without wishing to be bound by any theory, it is believed that when co-administered, miglustat stabilizes rhGAA (e.g., ATB200 or cipaglucosidase alfa) from denaturation in systemic circulation, which enhances the delivery of the active component rhGAA (e.g., ATB200 or cipaglucosidase alfa) to lysosomes.

[0223] In some embodiments, the miglustat is administered at an oral dose of about 10 mg to about 600 mg. In at least one embodiment, the miglustat is administered at an oral dose of about 20 mg to about 300 mg, or at an oral dose of about 20 mg, about 40 mg, about 65 mg, about 85 mg, about 1 15 mg, about 130 mg, about 175 mg, about 195 mg, or about 260 mg. Exemplary oral doses for migalastat also include about 15 mg to about 25 mg, about 30 mg to about 50 mg, about 50 mg to about 80 mg, about 70 mg to about 100 mg, about 100 mg to about 130 mg, about 1 10 mg to about 150 mg, about 150 mg to about 200 mg, about 170 mg to about 220 mg, and about 200 mg to about 300 mg.

[0224] In some embodiments, the miglustat is administered at an oral dose of about 50 mg to about 600 mg. In at least one embodiment, the miglustat is administered at an oral dose of about 200 mg to about 600 mg, or at an oral dose of about 200 mg, about 250 mg, about 300 mg, about 350 mg, about 400 mg, about 450 mg, about 500 mg, about 550 mg, or about 600 mg. In at least one embodiment, the miglustat is administered at an oral dose of about 233 mg to about 500 mg. In at least one embodiment, the miglustat is administered at an oral dose of about 250 to about 270Docket No.: AT24-003-PCT76 mg, or at an oral dose of about 250 mg, about 255 mg, about 260 mg, about 265 mg or about 270 mg. In at least one embodiment, the miglustat is administered as an oral dose of about 260 mg.

[0225] It will be understood by those skilled in the art that an oral dose of miglustat in the range of about 200 mg to 600 mg or any smaller range therewith can be suitable for an adult patient depending on his / her body weight. For instance, for patients having a significantly lower body weight than about 70 kg, including but not limited to infants, children, or underweight adults, a smaller dose may be considered suitable by a physician. Therefore, in at least one embodiment, the miglustat is administered as an oral dose of from about 50 mg to about 200 mg, or as an oral dose of about 50 mg, about 75 mg, about 100 mg, about 125 mg, about 130 mg, about 150 mg, about 175 mg, about 195 mg, about 200 mg, or about 260 mg. In at least one embodiment, the miglustat is administered as an oral dose of from about 65 mg to about 195 mg, as an oral dose of from about 65 mg to about 260 mg, as an oral dose of from about 195 mg to about 260 mg, or as an oral dose of about 65 mg, about 130 mg, about 195 mg, or about 260 mg.

[0226] In at least one embodiment, the dosage of miglustat is dependent on the patient’s age. In at least one embodiment, the dosage of miglustat is dependent on the patient’s weight. In at least one embodiment, the dosage of miglustat is dependent on the patient’s age and weight.

[0227] In some embodiments, the starting dose of rhGAA (e.g., ATB200 or cipaglucosidase alfa) and miglustat may be based on weight (see, for example, Error! Reference source not found.5A). In some embodiments, the miglustat dose may be adjusted and the weight increase or decrease may be confirmed at 2 consecutive infusion visits before the miglustat dose is changed.

[0228] In at least one embodiment, the dosage of rhGAA is provided in the tables below.

[0229] Table 5A; Dosages for rhGAADocket No.: AT24-003-PCT77Table 5B: Dosages for MiqlustatTable 5C: Exemplary rhGAA and Miglustat Dose RegimenaDose administered as three 65 mg capsules or as a 195 mg oral liquid dosage formDocket No.: AT24-003-PCT78bDose administered as four 65 mg capsules or as a 260 mg oral liquid dosage form

[0230] Miglustat exhibited linear pharmacokinetics with plasma area under the concentration-time curve (AUG) and maximum concentration (Cmax) increased approximately proportional with increasing doses from 130 mg (0.5-fold of the recommended dose of 260 mg in patients weighing > 50 kg) to 260 mg. At the recommended 260 mg dose, the mean Cmax was approximately 3 mcg / mL and the mean AUG was approximately 25 mcg*hr / mL. The mean time to reach the maximum concentration ranged from 2 hours to 3 hours.

[0231] In some embodiments, the rhGAA is administered intravenously at a dose described herein, such as a dose of about 5 mg / kg to about 40 mg / kg, or about 15 mg / kg to about 40 mg / kg; and the miglustat is administered orally at a dose described herein, such as a dose of about 10 mg to about 600 mg, or about 15 mg to about 300 mg. In some embodiments, the rhGAA is administered intravenously at a dose described herein, such as a dose of about 15 mg / kg to about 40 mg / kg, or about 25 mg / kg to about 40 mg / kg; and the miglustat is administered orally at a dose described herein, such as a dose of about 15 mg to about 300 mg, or about 15 mg to about 180 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 20 mg / kg to about 30 mg / kg, and the miglustat is administered orally at a dose of about 180 mg to about 220 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 15 mg / kg to about 25 mg / kg and the miglustat is administered orally at a dose of about 240 mg to about 280 mg. wherein the total volume of infusion is determined by the subject’s body weight (e.g., as set forth in Table 5). In some embodiments, the miglustat is administered orally at a dose determined by the age and / or weight of the subject (e.g., as set forth in Table 5B).

[0232] Plasma concentrations of miglustat increased in patients with renal impairment. Accordingly, the apparent clearance of miglustat decreased with decreasing renal function. The available data estimated that the AUCo-24hr of miglustat increased by 21 %, 26%, and 31 % in patients with mild (creatinine clearance based on theDocket No.: AT24-003-PCT79Cockcroft-Gault equation, CLcr 60-89 mL / minute), moderate (CLcr 30-59 mL / minute), and severe (CLcr 15-29 mL / minute) renal impairment, respectively, compared to patients with normal renal function. In some embodiments, the dosage of miglustat in patients with moderate or severe renal impairment is reduced as compared to patients with normal renal function. Exemplary doses for patients with moderate or severe renal impairment are provided in Table 6 below:Table 6: Recommend Miglustat Dosage in Patients with Moderate or Severe Renal Impairment1Renal function classified by creatinine clearance based on the Cockcroft-Gault equation.

[0233] In some embodiments, for patients with mild renal impairment (creatinine clearance based on the Cockcroft-Gault equation, CLcr 60-89 mL / minute), the recommended miglustat dosage is the same as for patients with normal renal function.

[0234] In one or more embodiments, the rhGAA dose is not adjusted for patients with renal impairment.

[0235] Available pharmacodynamic / toxicological data in animals have shown excretion of cipaglucosidase alfa in milk. It is not known whether miglustat is secreted in breast milk. A risk to newborns / breastfed infants cannot be ruled out. The developmental and health benefits of breastfeeding should be considered, as well as the clinical need for the mother to receive co-administration therapy with cipaglucosidase alfaDocket No.: AT24-003-PCT80 and miglustat, and any adverse reactions experienced by the breastfed child potentially related to the co-administration of cipaglucosidase alfa and miglustat or the underlying maternal condition. In some embodiments, breastfeeding is not allowed while taking cipaglucosidase alfa and miglustat.

[0236] There are no clinical data on the effects of co-administration therapy of cipaglucosidase alfa and miglustat on fertility. Preclinical data did not reveal any significant adverse reactions with cipaglucosidase alfa.

[0237] No effect on sperm concentration, motility, or morphology was observed in 7 healthy adult men who received 100 mg of miglustat orally twice daily for 6 weeks. Preclinical data in rats have shown that miglustat negatively affects sperm characteristics (motility and morphology), thereby reducing fertility.

[0238] In some embodiments, the rhGAA is administered intravenously at a dose of about 5 mg / kg to about 20 mg / kg or about 5 mg / kg to about 40 mg / kg; and the miglustat is administered orally at a dose of about 10 mg to about 600 mg or about 50 mg to about 600 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 5 mg / kg to about 20 mg / kg, or about 15 mg / kg to about 40 mg / kg; and the miglustat is administered orally at a dose of about 50 mg to about 200 mg or about 15 mg to about 300 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 5 mg / kg to about 20 miglustat the miglustat is administered orally at a dose of about 200 mg to about 600 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 5 mg / kg to about 20 mg / kg or about 25 mg / kg to about 40 mg / kg; and the miglustat is administered orally at a dose of about 200 mg to about 500 mg or about 15 mg to about 180 mg. In one embodiment, the rhGAA is administered intravenously at a dose of about 20 mg / kg to about 30 mg / kg and the miglustat is administered orally at a dose of about 180 mg to about 220 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 5 mg / kg to about 20 mg / kg, or about 15 mg / kg to about 25 mg / kg; and the miglustat is administered orally at a dose of about 130 mg to about 200 mg or about 140 mg to about 280 mg. In one embodiment, the rhGAA is administered intravenously at a dose of about 20 mg / kgDocket No.: AT24-003-PCT81 and the miglustat is administered orally at a dose of about 195 mg. In some embodiments, the rhGAA is administered intravenously at a dose of about 20 mg / kg and the miglustat is administered orally at a dose of about 260 mg.

[0239] The area under the plasma concentration-time curve (AUG) and maximum plasma concentration (Cmax) of cipaglucosidase alfa following administration with 20 mg / kg of cipaglucosidase alfa in combination with a single oral dose of 260 mg of miglustat in adult patients with LOPD are summarized in Table 7 below:Table 7. Mean (CV%) Pharmacokinetic Parameters of Cipaglucosidase Alfa in ERT-Experienced Adult Patients with LOPD

[0240] In some embodiments, the miglustat and the rhGAA are administered concurrently. For instance, the miglustat may administered within 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1 minute(s) before or after administration of the rhGAA. In some embodiments, the miglustat is administered within 5, 4, 3, 2, or 1 minute(s) before or after administration of the rhGAA.

[0241] In some embodiments, the miglustat and the rhGAA are administered sequentially. In at least one embodiment, the miglustat is administered prior to administration of the rhGAA. In at least one embodiment, the miglustat is administered less than three hours prior to administration of the rhGAA. In at least one embodiment, the miglustat is administered about two hours prior to administration of the rhGAA. In at least one embodiment, the miglustat is administered in a range of 50 minutes to 90 minutes prior to administration of theDocket No.: AT24-003-PCT82 rhGAA. For instance, the miglustat may be administered about 1 .5 hours, about 1 hour, about 50 minutes, about 30 minutes, or about 20 minutes prior to administration of the rhGAA. In at least one embodiment, the miglustat is administered about one hour prior to administration of the rhGAA. In some embodiments, the miglustat is orally administered about one hour prior to administration of the rhGAA.

[0242] In some embodiments, the miglustat is administered after administration of the rhGAA. In at least one embodiment, the miglustat is administered within three hours after administration of the rhGAA. In at least one embodiment, the miglustat is administered within two hours after administration of the rhGAA. For instance, the miglustat may be administered within about 1.5 hours, about 1 hour, about 50 minutes, about 30 minutes, or about 20 minutes after administration of the rhGAA.

[0243] In some embodiments, the subject fasts for at least two hours before administration of miglustat. In some embodiments, the subject fasts for at least two hours after administration of miglustat. In some embodiments, the subject fasts for at least two hours before and at least two hours after administration of miglustat.

[0244] In some embodiments, the subject fasts for at least two hours before and at least two hours after administration of miglustat, and the miglustat is administered about one hour prior to administration of the rhGAA. In some embodiments, the subject fasts for at least two hours before and at least two hours after administration of miglustat, the miglustat is administered about one hour prior to administration of the rhGAA, and the rhGAA is administered for about 4 hours. In some embodiments, the fasting, miglustat administration and rhGAA administration follows the following dosing timeline:Docket No.: AT24-003-PCT83Take Start Complete miglustat rhGAA rhGAA Typical infusion timeM 4 hoursHoursBegin fasting Stop fasting

[0245] As shown in the dosing timeline above, in some embodiments, the patient begins fasting at time 0, takes miglustat two hours later at time 2 hr, starts rhGAA one hour hour later at time 3 hr, stops fasting one hour later at time 4 hr, and completes the rhGAA infusion three hours later at time 7 hr.

[0246] In some embodiments, the two-component therapy according to this disclosure improves one or more disease symptoms in a subject with Pompe disease compared to (1 ) baseline, or (2) a control treatment comprising administering alglucosidase alfa and a placebo for the enzyme stabilizer. In such control treatment, a placebo was administered in place of the enzyme stabilizer.

[0247] In some embodiments, the subject treated by two-component therapy is an ERT-experienced patient. In some embodiments, the ERT-experienced subject had been previously treated with alglucosidase alfa. In some embodiments, the ERT- experienced subject had been previously treated with alglucosidase alfa for from about 2 years to about 6 years. In some embodiments, the ERT-experienced subject had been previously treated with alglucosidase alfa for at least about 7 years. In some embodiments, the ERT-experienced subject is non-ambulatory. In some embodiments, the ERT-experienced subject is ambulatory. In some embodiments, the subject is an ERT-naive subject.

[0248] In some embodiments, the subject treated by two-component therapy is an ERT-naive patient.D. KitsDocket No.: AT24-003-PCT84

[0249] Another aspect of the disclosure pertains to kits suitable for performing the rhGAA therapy described herein. In one or more embodiments, the kit comprises a container (e.g., vial, tube, bag, etc.) comprising the rhGAA or pharmaceutical composition (either before or after lyophilization) and instructions for reconstitution, dilution and administration. In one or more embodiments, the kit comprises a container (e.g., vial, tube, bag, etc.) comprising an enzyme stabilizer (e.g., miglustat) and a pharmaceutical composition comprising rhGAA (either before or after lyophilization), and instructions for reconstitution, dilution, and administration of rhGAA with the enzyme stabilizer.Miglustat Compositions

[0250] Various embodiments of the present disclosure provide compositions comprising miglustat. Such compositions may also include one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0251] In some embodiments, compositions (e.g., capsules) comprising miglustat may be but are not limited to pharmaceutical compositions. In some embodiments, compositions comprising miglustat comprises 20%-40% by weight miglustat, such as 30-35% by weight miglustat. In some embodiments, a composition comprising miglustat further comprises 40%-60% by weight microcrystalline cellulose, such as 45-55% by weight microcrystalline cellulose. In some embodiments, a composition comprising miglustat further comprises 5%-25% by weight pregelatinized starch, such as 10-20% by weight pregelatinized starch. In some embodiments, a composition comprising miglustat further comprises 0.1 %-5% by weight sucralose, such as 0.2-1 % by weight sucralose. In some embodiments, a composition comprising miglustat further comprises 0.1 %-5% by weight magnesium stearate, such as 0.2-1 % by weight magnesium stearate. In some embodiments, a composition comprising miglustat further comprises 0.1%-5% by weight colloidal silicon dioxide, such as 0.2-1 % by weight colloidal silicon dioxide. In some embodiments, a composition comprising miglustat is provided in a hard gelatinDocket No.: AT24-003-PCT85 capsule for oral administration. In some embodiments, the composition is a hard gelatin capsule for oral administration, comprising about 20%-40% (e.g., 30-35%) by weight of miglustat, 40%-60% (e.g., 45-55%) by weight of microcrystalline cellulose, 5%-25% (e.g., 10-20%) by weight of pregelatinized starch, 0.1 %-5% (e.g., 0.2%-1 %) by weight of sucralose, 0.1 %-5% (e.g., 0.2%-1 %) by weight of magnesium stearate, and / or 0.1 %-5% (e.g., 0.2%-1 %) by weight of colloidal silicon dioxide. In some embodiments, a composition comprising miglustat is provided in an oral liquid dosage form, such as an oral solution, dispersion, or suspension. In some embodiments, the composition is an oral liquid dosage form, comprising about 20%- 40% (e.g., 30-35%) by weight of miglustat, 40%-60% (e.g., 45-55%) by weight of microcrystalline cellulose, 5%-25% (e.g., 10-20%) by weight of pregelatinized starch, 0.1 %-5% (e.g., 0.2%-1 %) by weight of sucralose, 0.1 %-5% (e.g., 0.2%-1 %) by weight of magnesium stearate, and / or 0.1 %-5% (e.g., 0.2%-1%) by weight of colloidal silicon dioxide.

[0252] In some embodiments, the pharmaceutical composition comprising miglustat comprises microcrystalline cellulose, pregelatinized starch, Emprove® sucralose powder, magnesium stearate, and / or colloidal silicon dioxide. In some embodiments, the pharmaceutical composition is a hard gelatin capsule for oral administration, comprising about 65 mg of miglustat, microcrystalline cellulose, pregelatinized starch, Emprove® sucralose powder, magnesium stearate, and / or colloidal silicon dioxide.

[0253] In some embodiments, a pharmaceutical composition comprising miglustat comprises 20%-40% by weight miglustat, such as 30-35% by weight miglustat. In some embodiments, a pharmaceutical composition comprising miglustat further comprises 40%-60% by weight microcrystalline cellulose, such as 45-55% by weight microcrystalline cellulose. In some embodiments, a pharmaceutical composition comprising miglustat further comprises 5%-25% by weight pregelatinized starch, such as 10-20% by weight pregelatinized starch. In some embodiments, a pharmaceutical composition comprising miglustat further comprises 0.1 %-5% by weight sucralose, such as 0.2-1 % by weight sucralose. In some embodiments, a pharmaceutical composition comprising miglustat further comprises 0.1 %-5% byDocket No.: AT24-003-PCT86 weight magnesium stearate, such as 0.2-1% by weight magnesium stearate. In some embodiments, a pharmaceutical composition comprising miglustat further comprises 0.1 %-5% by weight colloidal silicon dioxide, such as 0.2-1 % by weight colloidal silicon dioxide. In some embodiments, a pharmaceutical composition comprising miglustat is provided in a hard gelatin capsule for oral administration. In some embodiments, the pharmaceutical composition is a hard gelatin capsule for oral administration, comprising about 20%-40% (e.g., 30-35%) by weight of miglustat, 40%-60% (e.g., 45-55%) by weight of microcrystalline cellulose, 5%-25% (e.g., 10-20%) by weight of pregelatinized starch, 0.1 %-5% (e.g., 0.2%-1 %) by weight of sucralose, 0.1 %-5% (e.g., 0.2%-1 %) by weight of magnesium stearate, and / or 0.1 %-5% (e.g., 0.2%-1 %) by weight of colloidal silicon dioxide. In some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral liquid dosage form, such as an oral solution, dispersion, or suspension. In some embodiments, the pharmaceutical composition is an oral liquid dosage form, comprising about 20%-40% (e.g., 30-35%) by weight of miglustat, 40%-60% (e.g., 45-55%) by weight of microcrystalline cellulose, 5%-25% (e.g., 10-20%) by weight of pregelatinized starch, 0.1 %-5% (e.g., 0.2%-1 %) by weight of sucralose, 0.1 %-5% (e.g., 0.2%-1 %) by weight of magnesium stearate, and / or 0.1 %-5% (e.g., 0.2%-1 %) by weight of colloidal silicon dioxide.

[0254] In some embodiments, a pharmaceutical composition comprising miglustat comprises about 50 mg to about 100 mg miglustat, such as about 65 mg miglustat. In some embodiments, a pharmaceutical composition comprising miglustat comprises about 50 to about 150 mg microcrystalline cellulose, such as about 75 to about 125 mg microcrystalline cellulose. In some embodiments, a pharmaceutical composition comprising miglustat comprises about 20 to about 50 mg pregelatinized starch, such as about 30 to about 40 mg pregelatinized starch. In some embodiments, a pharmaceutical composition comprising miglustat comprises about 0.1 to about 5 mg sucralose, such as about 0.5 to about 2 mg sucralose. In some embodiments, a pharmaceutical composition comprising miglustat comprises about 0.1 to about 5 mg magnesium stearate, such as about 0.5 to about 2 mg magnesium stearate. In some embodiments, a pharmaceutical composition comprising miglustat comprises about 0.1 to about 5 mg colloidal silicon dioxide, such as about 0.2 mg toDocket No.: AT24-003-PCT87 about 1 mg colloidal silicon dioxide. In some embodiments, a pharmaceutical composition comprising miglustat is provided in a hard gelatin capsule for oral administration. In some embodiments, the pharmaceutical composition is a hard gelatin capsule for oral administration, comprising about 50 to about 100 mg (e.g., 65 mg) of miglustat, about 50 to about 150 mg (e.g., 75 mg to about 125 mg) of microcrystalline cellulose, about 20 to about 50 mg (e.g., 30 mg to about 40 mg) of pregelatinized starch, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of sucralose, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of magnesium stearate, and / or about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of colloidal silicon dioxide. In some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral liquid dosage form, such as an oral solution, dispersion or suspension. In some embodiments, the pharmaceutical composition is an oral liquid dosage form, comprising about 50 to about 100 mg (e.g., 65 mg) of miglustat, about 50 to about 150 mg (e.g., 75 mg to about 125 mg) of microcrystalline cellulose, about 20 to about 50 mg (e.g., 30 mg to about 40 mg) of pregelatinized starch, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of sucralose, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of magnesium stearate, and / or about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of colloidal silicon dioxide.

[0255] In some embodiments, a pharmaceutical composition comprising miglustat is provided in a hard gelatin capsule for oral administration comprising about 65 mg miglustat, about 100 mg microcrystalline cellulose, about 32.6 mg pregelatinized starch, about 1 mg sucralose powder, about 1 mg magnesium stearate, and about 0.4 mg colloidal silicon dioxide.

[0256] In some embodiments, a composition comprising miglustat comprises about 50 to about 100 mg miglustat, such as about 65 mg miglustat. In some embodiments, a composition comprising miglustat comprises about 50 to about 150 mg microcrystalline cellulose, such as about 75 to about 125 mg microcrystalline cellulose. In some embodiments, a composition comprising miglustat comprises about 20 to about 50 mg pregelatinized starch, such as about 30 to about 40 mg pregelatinized starch. In some embodiments, a composition comprising miglustat comprises about 0.1 to about 5 mg sucralose, such as about 0.5 to about 2 mgDocket No.: AT24-003-PCT88 sucralose. In some embodiments, a composition comprising miglustat comprises about 0.1 to about 5 mg magnesium stearate, such as about 0.5 to about 2 mg magnesium stearate. In some embodiments, a composition comprising miglustat comprises about 0.1 to about 5 mg colloidal silicon dioxide, such as about 0.2 mg to about 1 mg colloidal silicon dioxide. In some embodiments, a composition comprising miglustat is provided in a hard gelatin capsule for oral administration. In some embodiments, the composition is a hard gelatin capsule for oral administration, comprising about 50 to about 100 mg (e.g., 65 mg) of miglustat, about 50 to about 150 mg (e.g., 75 mg to about 125 mg) of microcrystalline cellulose, about 20 to about 50 mg (e.g., 30 mg to about 40 mg) of pregelatinized starch, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of sucralose, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of magnesium stearate, and / or about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of colloidal silicon dioxide. In some embodiments, a composition comprising miglustat is provided in an oral liquid dosage form, such as an oral solution, dispersion or suspension. In some embodiments, the composition is an oral liquid dosage form, comprising about 50 to about 100 mg (e.g., 65 mg) of miglustat, about 50 to about 150 mg (e.g., 75 mg to about 125 mg) of microcrystalline cellulose, about 20 to about 50 mg (e.g., 30 mg to about 40 mg) of pregelatinized starch, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of sucralose, about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of magnesium stearate, and / or about 0.1 to about 5 mg (e.g., 0.5 mg to about 2 mg) of colloidal silicon dioxide.

[0257] In some embodiments, a composition comprising miglustat is provided in a hard gelatin capsule for oral administration comprising about 65 mg miglustat, about 100 mg microcrystalline cellulose, about 32.6 mg pregelatinized starch, about 1 mg sucralose powder, about 1 mg magnesium stearate, and about 0.4 mg colloidal silicon dioxide.

[0258] In some embodiments, a composition comprising miglustat is provided in an oral solution, dispersion or suspension, comprising about 65 mg miglustat, about 100 mg microcrystalline cellulose, about 32.6 mg pregelatinized starch, about 1 mg sucralose powder, about 1 mg magnesium stearate, and about 0.4 mg colloidal silicon dioxide.Docket No.: AT24-003-PCT89

[0259] In some embodiments, a composition comprising miglustat is provided in an oral solution dispersion or suspension, comprising about 130 mg miglustat, about 200 mg microcrystalline cellulose, about 65.2 mg pregelatinized starch, about 2 mg sucralose powder, about 2 mg magnesium stearate, and about 0.8 mg colloidal silicon dioxide.

[0260] In some embodiments, a composition comprising miglustat is provided in an oral solution, dispersion or suspension, comprising about 195 mg miglustat, about 300 mg microcrystalline cellulose, about 97.8 mg pregelatinized starch, about 3 mg sucralose powder, about 3 mg magnesium stearate, and about 1.2 mg colloidal silicon dioxide.

[0261] In some embodiments, a composition comprising miglustat is provided in an oral solution, dispersion or suspension, comprising about 260 mg miglustat, about 400 mg microcrystalline cellulose, about 130.4 mg pregelatinized starch, about 4 mg sucralose powder, about 4 mg magnesium stearate, and about 1 .6 mg colloidal silicon dioxide.

[0262] A composition comprising miglustat may have microenvironmental at a pH of about 8. For example, the pH of 1 g of miglustat drug substance in 100 mL of water may be between a pH of 8 and a pH of 10.

[0263] An exemplary composition comprising miglustat (e.g., 65 mg) is provided in Table 2. Miglustat capsules may be packaged into 40 cc, high density polyethylene (HDPE) round bottles closed with child resistant closures with induction sealed liner.Table 8. Composition of Miglustat capsule (e.g., 65 mg).Docket No.: AT24-003-PCT90

[0264] In some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral solution, dispersion or suspension, comprising about 65 mg miglustat, about 100 mg microcrystalline cellulose, about 32.6 mg pregelatinized starch, about 1 mg sucralose powder, about 1 mg magnesium stearate, and about 0.4 mg colloidal silicon dioxide.Docket No.: AT24-003-PCT91

[0265] In some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral solution dispersion or suspension, comprising about 130 mg miglustat, about 200 mg microcrystalline cellulose, about 65.2 mg pregelatinized starch, about 2 mg sucralose powder, about 2 mg magnesium stearate, and about 0.8 mg colloidal silicon dioxide.

[0266] In some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral solution, dispersion or suspension, comprising about 195 mg miglustat, about 300 mg microcrystalline cellulose, about 97.8 mg pregelatinized starch, about 3 mg sucralose powder, about 3 mg magnesium stearate, and about 1 .2 mg colloidal silicon dioxide.

[0267] In some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral solution, dispersion or suspension, comprising about 260 mg miglustat, about 400 mg microcrystalline cellulose, about 130.4 mg pregelatinized starch, about 4 mg sucralose powder, about 4 mg magnesium stearate, and about 1 .6 mg colloidal silicon dioxide.

[0268] In some embodiments, a patient may have difficulty swallowing a hard gelatin capsule. Accordingly, in some embodiments, a pharmaceutical composition comprising miglustat is provided in an oral solution. In some embodiments, the oral solution is flavored.

[0269] In some embodiments, a pharmaceutical composition comprising miglustat is provided as an oral solution comprising one or more excipients. In some embodiments, the pharmaceutical composition comprising miglustat comprises a preservative, a buffering agent, a thickener (or a thickening agent), a sweetener, a flavor, and / or a vehicle.

[0270] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising 1 .0-10.0%, 1 .5-8%, 2.0-5.0%, 2.0-6.5%, 2-7%, 2.5-5.0%, 2.5-6.5%, 2.5-7%, 3.0-5.0%, 3-6.5%, 3-7%, 3.5-5.0%, 3.5-6%, 3.5-7%, 4.0-5.0%, 4- 6.5%, 4-7%, 4.5-5.0%, 4.5-6%, 4.5-7% 2.0-4.5%, 2.5-4.5%, 3.0-4.5%, 3.5-4.5%, 4.0-4.5%, 2.0-4.0%, 2.5-4.0%, 3.0-4.0%, or 3.5-4.0% miglustat by weight. In someDocket No.: AT24-003-PCT92 embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising less than or equal to about 5% miglustat by weight. In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising 1 to 200 mg / mL, such as 10 to 100 mg / mL, 10 to 50 mg / mL or 20 to 60 mg / mL. Exemplary miglustat concentrations include about 5 mg / mL, 10 mg / mL, 15 mg / mL, 20 mg / mL, 30 mg / mL, 40 mg / mL, 50 mg / mL, 60 mg / mL, 70 mg / mL, 80 mg / mL, 90 mg / mL or 100 mg / mL.

[0271] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a buffer system such as a citrate system, a phosphate system, or a combination thereof. The citrate and / or phosphate may be a sodium salt (e.g., sodium citrate or sodium phosphate). Other salts include potassium and ammonium salts. In one or more embodiments, the buffer comprises a citrate. In further embodiments, the buffer comprises sodium citrate (e.g., a mixture of sodium citrate dihydrate and citric acid monohydrate). In one or more embodiments, buffer solutions comprising a citrate may comprise sodium citrate and citric acid. In some embodiments, both a citrate and phosphate buffer are present.

[0272] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a thickener or a thickening agent. In some embodiments, the thickener is selected from hydroxypropyl methylcellulose (HPMC), hydroxypropyl ethylcellulose (HPEC), hydroxypropyl cellulose (HPC), gelatin, or microcrystalline cellulose. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.5-5%, 1 .0-3.0% or 1 .0-2.0% of a thickener by weight. In some embodiments, the thickener is hydroxypropyl methylcellulose (HPMC).

[0273] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a sweetener. In some embodiments, the sweetener is selected from sucrose or sucralose. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.1 -1 %, 0.1 -0.5%, 0.1 -0.3% or 0.15-0.25% sweetener by weight. In some embodiments, the sweetener is sucralose.Docket No.: AT24-003-PCT93

[0274] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a preservative. In some embodiments, the preservative is potassium sorbate. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.1 -1 %, 0.1 -0.5%, 0.1 -0.3% or 0.15-0.25% preservative by weight.

[0275] In some embodiments, a pharmaceutical composition comprising miglustat is an oral solution comprising a flavoring agent. In some embodiments, the pharmaceutical composition comprising miglustat is an oral solution comprising 0.1 - 0.5%, 0.1 -0.3% or 0.15-0.25% of a flavoring agent by weight.

[0276] In some embodiments, the balance of the oral solution comprising miglustat is water. In some embodiments, the water comprises greater than or equal to 80%, 90%, 91 %, 92%, 93%, 94% or 95% water.

[0277] In some embodiments, the pH of the oral solution comprising miglustat is adjusted with a strong acid (e.g., hydrochloric acid) and / or a strong base (e.g., sodium hydroxide). In some embodiments, the pH of the oral solution comprising miglustat is adjusted to 5.0 + / - 0.5. Stated differently, in some embodiments, the pH of the oral solution comprising miglustat is in a range of 4.5-5.5, 4.7-5.3, 4.9-5.1 , or is about 5.0. In some embodiments, the pH of the oral solution comprising miglustat is adjusted to 4.0 + / - 1 .0, such as is in a range of 3-5, 3.5-4.5, 3.7-4.3, 3.9. -4.1 , or is about 4.0. Exemplary values for the pH include 3.0, 3.1 , 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4.0, 4.1 , 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 5.0, 5.1 , 5.2, 5.3, 5.4 or 5.5.

[0278] In some embodiments, an oral solution comprising miglustat is an oral solution comprising 1.0-10.0%, 2.0-5.0%, 2.5-5.0%, 3.0-5.0%, 3.5-5.0%, 4.0-5.0%, 4.5- 5.0%, 2.0-4.5%, 2.5-4.5%, 3.0-4.5%, 3.5-4.5%, 4.0-4.5%, 2.0-4.0%, 2.5-4.0%, 3.0- 4.0%, or 3.5-4.0% miglustat by weight. In some embodiments an oral solution comprises less than or equal to about 4% miglustat by weight.

[0279] In some embodiments, an oral solution comprising miglustat is an oral solution comprising 1 to 200 mg / mL, such as 10 to 100 mg / mL, 10 to 50 mg / mL or 20 to 60 mg / mL. Exemplary miglustat concentrations include about 5 mg / mL, 10 mg / mL, 15Docket No.: AT24-003-PCT94 mg / mL, 20 mg / mL, 30 mg / mL, 40 mg / mL, 50 mg / mL, 60 mg / mL, 70 mg / mL, 80 mg / mL, 90 mg / mL or 100 mg / mL.

[0280] In some embodiments, an oral solution comprising miglustat contains a buffering agent. In some embodiments the buffering agent is sodium citrate. In some embodiments, an oral solution comprising miglustat is an oral solution comprising, 0.5-1 %, 0.5-0.55%, 0.55-0.6%, 0.6-0.65%, 0.65-0.7%, 0.7-0.8%, 0.8-0.85%, 0.85- 0.9%, or 0.9-0.95%. of sodium citrate by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.65% sodium citrate by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.84% sodium citrate by weight. In some embodiments an oral solution comprises a sodium citrate concentration of 0.1 to 100 mg / mL, such as 0.5 to 50 mg / mL, 1 to 20 mg / mL or 5 to 15 mg / mL. Exemplary sodium citrate concentrations include 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / ml, 7 mg / mL, 8 mg / mL, 9 mg / mL, 10 mg / mL, 1 1 mg / mL, 12 mg / mL, 13 mg / mL, 14 mg / mL,15 mg / mL, 20 mg / mL, 25 mg / mL, 30 mg / mL, 35 mg / mL, 40 mg / mL or 50 mg / mL,

[0281] In some embodiments, an oral solution comprising miglustat contains a buffering agent. In some embodiments the buffering agent is citric acid. In some embodiments an oral solution comprising miglustat is an oral solution comprising 0.1 -0.5%, 0.1 -0.2%, 0.2-0.3%, 0.25-0.3%, 0.3-0.35%, 0.35-0.4%, 0.4-0.5%, of citric acid by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.27% citric acid by weight. In some embodiments an oral solution comprises less than, greater than, or equal to about 0.35% citric acid by weight. In some embodiments an oral solution comprises a citric acid concentration of 0.1 to 100 mg / mL, such as 0.5 to 50 mg / mL, 1 to 20 mg / mL or 5 to 15 mg / mL. Exemplary citric acid concentrations include 0.5 mg / mL, 1 mg / mL, 1.5 mg / mL, 2 mg / mL, 2.5 mg / mL, 3 mg / mL, 3.5 mg / mL, 4 mg / mL, 4.5 mg / mL, 5 mg / mL, 6 mg / ml, 7 mg / mL, 8 mg / mL, 9 mg / mL, 10 mg / mL,15 mg / mL, 20 mg / mL, 25 mg / mL, 30 mg / mL, 35 mg / mL, 40 mg / mL or 50 mg / mL.Docket No.: AT24-003-PCT95

[0282] In some embodiments, an oral solution comprising miglustat contains a thickening agent. In some embodiments the thickening agent is Hypromellose. In some embodiments an oral solution comprising miglustat is an oral solution comprising the thickening agent at 1 -10 mg / mL, 10-20 mg / mL, 1 -5 mg / mL, 10 mg / mL, 1 1 mg / mL, 12 mg / mL, 13 mg / mL, 14 mg / mL, 15 mg / mL, 16 mg / mL, 17 mg / mL, 18 mg / mL, 19 mg / mL, or 20 mg / mL. In some embodiments the oral solution comprises the thickening agent at less than, greater than, or equal to about 15 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 1 -5%, 1.5-2%, 1 -1.5%, 1 -2%, 2.5-3%, 3.5-4%, 4.5-5%, or 5.5- 6% of the thickening agent by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 1.5% thickening agent by weight.

[0283] In some embodiments, an oral solution comprising miglustat contains a sweetener. In some embodiments, the sweetener is sucralose. In some embodiments, an oral solution comprising miglustat is an oral solution comprising the sweetener at 1 -5 mg / mL, 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / mL, 7 mg / mL, 8 mg / mL, 9 mg / mL, or 10 mg / mL. In some embodiments the oral solution comprises the sweetener at less than, greater than, or equal to about 2 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 0.1 -0.2%, 0.15-0.2%, 0.1 -0.5%, 0.1 -0.25%, 0.15-0.25%, 0.2- 0.25%, 0.25-0.3%, 0.25-0.35%, 0.3-0.4%, 0.4-0.5% of the sweetener by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 0.2% sweetener by weight.

[0284] In some embodiments, an oral solution comprising miglustat contains a preservative. In some embodiments, the preservative is potassium sorbate. In some embodiments, an oral solution comprising miglustat is an oral solution comprising the preservative at 1 -5 mg / mL, 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / mL, 7 mg / mL, 8 mg / mL, 9 mg / mL, or 10 mg / mL. In some embodiments the oral solution comprises the preservative at less than, greater than, or equal to about 2 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 0.1 -0.2%, 0.15-0.2%, 0.1 -0.5%, 0.1 -0.25%, 0.15-0.25%, 0.2-Docket No.: AT24-003-PCT960.25%, 0.25-0.3%, 0.25-0.35%, 0.3-0.4%, 0.4-0.5% of the preservative by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 0.2% preservative by weight.

[0285] In some embodiments, an oral solution comprising miglustat contains a flavor. In some embodiments, the flavor is mixed berry. In some embodiments, an oral solution comprising miglustat is an oral solution comprising the flavor at 1 -5 mg / mL, 1 mg / mL, 2 mg / mL, 3 mg / mL, 4 mg / mL, 5 mg / mL, 6 mg / mL, 7 mg / mL, 8 mg / mL, 9 mg / mL, or 10 mg / mL. In some embodiments the oral solution comprises the flavor at less than, greater than, or equal to about 2 mg / mL. In some embodiments, an oral solution comprising miglustat is an oral solution comprising 0.1 -0.2%, 0.15-0.2%, 0.1 -0.5%, 0.1 -0.25%, 0.15-0.25%, 0.2-0.25%, 0.25-0.3%, 0.25-0.35%, 0.3-0.4%, 0.4-0.5% of the flavor by weight. In some embodiments, an oral solution comprises less than, greater than, or equal to about 0.2% flavor by weight.

[0286] Several exemplary pharmaceutical compositions comprising miglustat in an oral solution are provided below.Table 9. Exemplary Miglustat Oral SolutionsDocket No.: AT24-003-PCT97Docket No.: AT24-003-PCT98

[0287] Any of the above compositions may comprise the one or more compounds comprising a structure of either (A) or (B). Any of the above compositions may comprise miglustat and also has less than a certain amount of the one or more compounds comprising a structure of either (A) or (B).

[0288] In some embodiments, the composition comprises at least 0.0001 , 0.0002, 0.0003, 0.0004, 0.0005, 0.0006, 0.0007, 0.0008, 0.0009, 0.001 , 0.002, 0.003, 0.004, 0.005, 0.006, 0.007, 0.008, 0.009, 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, or 0.1 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.0001 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.001 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.01 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises greater than 0.1 ppb of the one or more compounds comprising a structure of either (A) or (B).

[0289] In some embodiments, the composition comprises less than 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.1 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, 2, 2.1 , 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8 2.9, 3, 3.1 ,3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4, 4.1 , 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 5, 5.1 ,5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 6, 6.1 , 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7, 7.5, 7.6, 7.7, 7.8, 7.9, 8, 8.5, 9, 9.5, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 83.1 , 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 160, 170, 180, 190, 200,250, or 500 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 100 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 69 ppb of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 6.9 ppb of the one or more compounds comprising a structure of either (A) or (B). In someDocket No.: AT24-003-PCT99 embodiments, the composition comprises less than 2.3 ppb of the one or more compounds comprising a structure of either (A) or (B).

[0290] In some embodiments, the composition further comprises at least 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30, 35, or 40 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 0.01 , 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 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, 1 , 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 30, 35, or 40 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 20 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 19 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 18 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 17 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 16 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 15 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 10 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 5 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 1 ng of the one or more compounds comprising a structure of either (A) or (B). In some embodiments, the composition comprises less than 0.6 ng of the one or more compounds comprising a structure of either (A) or (B).

[0291] Both miglustat and its diastereomeric impurity L-ido miglustat are tertiary amines. Tertiary amines can be converted to nitrosamines in through transformations including but not limited to those shown in FIG. 5. This pathway may includeDocket No.: AT24-003-PCT100 oxidative cleavage of one of the alkyl groups attached to the nitrogen atom to form corresponding secondary amine. The resulting secondary amine can then react with a nitrosating agent (e.g., N2O3) to form N-nitrosamine. The formation of N- nitrosamine does not proceed to 100% conversion of the available nitrite in solid state formulations, but instead plateaus out at a much lower level, typically in the range of < 10% for low drug load products (0.1 % drug load) to < 30% for high drug load products (> 10% drug load). This has been explained as resulting from (a) reduced mobility of the reactants, e.g., the inability of nitrite distributed throughout the excipients in the formulation to translocate to make physical contact (required for reaction to occur) with the amine to be nitrosated, and (b) the instability of the N- nitrosating agent derived from nitrite. Thus, not all the nitrites present in a formulation may be available for the N-nitrosation reaction. Miglustat in miglustat capsules is considered a high drug load product, the prediction for N-nitrosation of the miglustat may be no more than 30% of the available nitrite. L-ido miglustat in miglustat capsules is considered a low drug load product, the prediction for N-nitrosation of the miglustat may be no more than 10% of the available nitrite.

[0292] The nitrosation rates of tertiary amines are four-orders of magnitude slower than for their analogous secondary amines. Moreover, in the solid-state, tertiary amines react at approximately 1000 times slower than the corresponding secondary amines. The stoichiometry for N-nitrosation of tertiary amines was shown to be 2:1 (e.g., 2 molecules of nitrite I nitrous acid per molecule of tertiary amine to yield 1 molecule of N-nitrosated tertiary amine). The significantly slower reaction rate of tertiary amines through the 4-step process is exemplified in FIG. 5. Similarly, the theoretical chemical pathway for N-nitrosation of miglustat and L-ido miglustat by nitrite are presented in FIG. 6 and FIG. 7 respectively. The degradation product, miglustat N- Oxide may form but is controlled to no more than 0.2%. As an N-oxide, miglustat N- Oxide is not subject to N-nitrosation.

[0293] The a-carbon substitution with resulting steric hindrance and substituent on nitrogen in a tertiary amine can further reduce the reaction rate. As shown in Table 10, the relative rates, as calculated from the pseudo 4th-order rate constants for piperidine, 2-methylpiperidine, 2,6-dimethylpiperidine, and 2, 2, 6, 6-Docket No.: AT24-003-PCT101 tetramethylpiperidine, were approximately 100:20:10:1. The reaction rate of N- methylpiperidine is more than 2 orders of magnitude slower than that of 2, 2,6,6- tetramethylpiperidine; therefore, at least 10000 times slower than that of piperidine. The reaction conditions included a ratio of piperidine to nitrite is 1 :1 at pH 4.1 , and 5 2,2,6,6-tetramethylpiperidine and N-methylpiperidine at were at 57°C, all other piperidines were at 27°C. Miglustat and L-ido miglustat are piperidine derivatives with hydroxymethyl (CH2OH) substitution on 1 a-carbon and n-butyl group on the nitrogen. The reaction rate is expected to be much slower than / V-methylpiperidine.10 Table 10: Impact of Steric Effects of a-Carbon and N-substitution on RelativeRates of Nitrosamine Formation.

[0294] For nitrosation to occur, nitrite requires protonation to form nitrous acid (pKa3.37), the precursor of a nitrosating species including but not limited to N2O3. When15 the pH is 7.0, the protonated nitrous acid is at least 4000-fold less than nitrite in solution; when pH is 8.0, the protonated nitrous acid is at least 40000-fold less thanDocket No.: AT24-003-PCT102 nitrite in the solution. This demonstrates that the reaction yield is reduced by at least 4000-fold at a microenvironmental pH of 7.0 and reduced by at least 40000-fold at a micro-environmental pH of 8.0.

[0295] Most quantitative analytical methods for detecting nitrosamines utilize MS / MS in tandem with HPLC or GC, to achieve the desired high sensitivity often in a low parts per billion (ppb) range. Other commonly used techniques include LC-MS / MS based methods, as well as some reported by the nitrosamine scientific community for quantitation of the standard small nitrosamines, (e.g., Thermal Energy Analyzer (TEA) and Supercritical Fluid Chromatography (SFC)). These techniques allow for the simultaneous analysis of multiple nitrosamine compounds, including those regulated by the U.S. Food and Drug Administration (FDA) and the EMA, thus meeting the demand for methods that can quantitate a larger number of nitrosamine compounds effectively. These methods have been employed for quantifying nitrosamines in many pharmaceutical drugs; however, these methods face challenges in achieving the required sensitivity, particularly for complex NDSRIs in drug products.

[0296] In various embodiments, the compound is (2R,3R,4R,5S)-2- (hydroxymethyl)-l - nitroso-3,4,5-piperidinetriol. In miglustat, the compound may be an N-nitroso miglustat and / or an N-nitroso L-ido miglustat. Despite the stereochemistry at the a- hydroxymethyl group, N-nitroso miglustat and N-nitroso L-ido can be otherwise structurally identical, exhibiting very similar physicochemical properties. The one or more compound, (2S,3R,4R,5S)-2- (hydroxymethyl)-l - nitroso-3,4,5-piperidinetriol, in compositions comprising miglustat can be identified as two individual peaks in the chromatographic system wherein the Al limit and corresponding QL is based on individual nitrosamines. In some embodiments, one or more compound, (2S,3R,4R,5S)-2- (hydroxymethyl)-l - nitroso-3,4,5-piperidinetriol can be identified as a combination, represented by a single peak in the chromatographic system wherein the determined Al limit and QL is designated to the combination of nitrosamines.Docket No.: AT24-003-PCT103

[0297] The chromatographic column used for the detection of the one or more compounds of the present disclosure may be one of any used by those skilled in the art. In some embodiments, the chromatographic column is Zorbax SB-CN that is sized at least at 5 pm or 4.6 mm by 150 mm. Exemplary chromatographic column settings are provided herein. In some embodiments, the column temperature is set at least at 10°C, 15°C, 20°C, 25°C, 30°C, 35°C, 36°C, 37°C, 38°C, 39°C, 40°C, 41 °C, 42°C, 43°C, 44°C, 45°C, 46°C, 47°C, 48°C, 49°C, 50°C, 60°C, 70°C, 80°C, or 90°C. In some embodiments, the injection volume for the column is at least 10, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 pL. In some embodiments, the chromatographic column runs for at least 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, or 20 minutes. In some embodiments, the chromatographic autosampler is set at a temperature of at least 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, or 20QC. In some embodiments, the autosampler has two mobile phases, mobile phase A and mobile phase B. In some embodiments, the conditions of mobile phase A are 2mM TEAA in Water. In some embodiments, the conditions of mobile phase B are 0.1% Formic Acid in 80:20 Acetonitrile: Methanol with a needle wash in methanol. In some embodiments, 90:10 Methanol: Acetonitrile mixture was used as diluent. Exemplary HPLC instrument conditions for the chromatography are demonstrated in found in Table 11. In some embodiments, the chromatographic conditions comprise a column switching program wherein the conditions may be found in Table 12.Table 11. HPLC Gradient Table.Docket No.: AT24-003-PCT104Table 12. Mass Spectrometry Parameters.1Adjust as required to achieve adequate sensitivity.

[0298] The Mass Spectrometer used for the detection of the one or compounds of the present disclosure may be one of which is used by one skilled in the art. In some embodiments, the Mass Spectrometer is an Agilent Technologies 1260 Infinity equipped with a quaternary pump and AB SCIEX 5500 Triple Quad Mass Spectrometer. In some embodiments, the ionization mode for the Mass Spectrometer is set for ESI, positive mode. In some embodiments, the source temperature for the Mass Spectrometer is at least 100, 150, 200, 250, 300, 250, 400, 425, 450, 475, 500, 550, 600, 650 or 700°C. In some embodiments the conditions for the Mass Spectrometer employs 1 , 2, 3, 4, 5, or 6 gases. In some embodiments, the gas types may include those known by one skilled in the art, including but not limited to curtain gas, collision gas, and iron source gases. In some embodiments, the curtain gas is 10, 15, 20, 25, 26, 27, 28, 29, 30, 31 , 32, 33, 34, 35, 40, 45, 50, 55, or 60 nitrogen. In some embodiments the collision gas is 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 nitrogen. In some embodiments the Mass Spectrometer comprises 1 , 2, 3, 4, 5, or 6 ion source gases. In some embodiments, the ion source gas may be at least 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, or 60 nitrogen. In someDocket No.: AT24-003-PCT105 embodiments, the ion source gas 1 is 25.0 nitrogen. In some embodiments, the ion source gas 2 is 35.0 nitrogen. In some embodiments, the Mass Spectrometer comprises an entrance potential of 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10. In some embodiments, the Mass Spectrometer employs a multiple reaction monitoring acquisition mode. Exemplary timing parameters can be found in Table 13.Table 13. Column Switching Program(1 ) Note: A=Waste; B=MS. Adjust, as necessary, to ensure peaks of interest are detected.

[0299] In some embodiments, the QL for the combined nitrosamine quantification limit in miglustat (QL) is 6.9 ppb. In some embodiments, the system suitability parameters and criteria establish a validation exercise and are shown in Table 14.Table 14. System SuitabilityDocket No.: AT24-003-PCT106EXAMPLES

[0300] While the following examples describe specific embodiments, it is understood that variations and modifications will occur to those skilled in the art. Accordingly, only such limitations as appear in the claims should be placed on the invention.Example 1 - N-nitroso miglustat Analytical Chemistry Data

[0301] N-nitroso miglustat with the molecular formula C6H12N2O5 has the molecular weight of 192.17. As shown in Figure 9,1H-NMR analysis for N-nitroso miglustat detected a purity of NLT 95% and determined conformity to structure.

[0302] As shown in Figure 10,13C-NMR analysis for N-nitroso miglustat demonstrated conformity to structure.

[0303] As shown in Figure 11 , MS(ESI Positive) analysis for N-nitroso miglustat demonstrated a [M+H]+of 193.00 and conformity to structure. Example 2 - N-nitroso L-ido miglustat Analytical Chemistry Data

[0304] N-nitroso L-ido miglustat with the molecular formula C6H12N2O5 has the molecular weight of 192.17. As shown in Figure 12,1H-NMR analysis for N-nitroso L-ido miglustat detected a purity of NLT 95% and determined conformity to structure.Docket No.: AT24-003-PCT107

[0305] As shown in Figure 13,13C-NMR analysis for N-nitroso L-ido miglustat demonstrated conformity to structure.

[0306] As shown in Figure 14, MS(ESI+ve) analysis for N-nitroso L-ido miglustat demonstrated a [M+H]+of 192.93, [2M+H]+of 385.00, [2M+NH4]+of 401.80 and conformity to structure.Example 3 - ATB200 and Enzyme Stabilizer

[0307] The stability of ATB200 in acidic or neutral pH buffers was evaluated in a thermostability assay using SYPRO Orange, as the fluorescence of the dye increases when proteins denature. As shown in Table 15, the addition of miglustat stabilized ATB200 at pH 7.4 in a concentration-dependent manner, comparable to the stability of ATB200 at pH 5.2, a condition that mimics the acidic environment of the lysosome. As summarized in Table 15, the addition of miglustat increased the melting temperature (Tm) of ATB200 by nearly 10oC. Table 15. Stability of ATB200 with miglustat

Claims

Docket No.: AT24-003-PCT108ClaimsWe Claim:1 . A composition comprising one or more compounds selected from the following:or a salt or solvate thereof.

2. A composition comprising miglustat and one or more compounds selected from the following:Docket No.: AT24-003-PCT109 or a salt or solvate thereof.

3. A composition comprising miglustat and less than 100 ng of one or more compounds selected from the following:or a salt or solvate thereof.

4. A composition comprising miglustat and less than 100 ppb total of one or more compounds selected from the following:(A) (B) or a salt or solvate thereof.Docket No.: AT24-003-PCT1105. The composition of any one of claims 1 -4, wherein the composition comprises greater than 0.001 ppb total of the one or more compounds comprising a structure of either (A) or (B).

6. The composition of any one of claims 1 -5, wherein the composition comprises less than 18 ng total of the one or more compounds comprising a structure of either (A) or (B).

7. The composition of any one of claims 1 -6, wherein the composition further comprises one or more sources of nitrate and / or nitrite.

8. The composition of any one of claims 1 -7, wherein the composition further comprises: (a) about 20% to about 40% by weight miglustat;(b) about 40% to about 60% by weight microcrystalline cellulose;(c) about 5% to about 25% by weight starch;(d) about 0.1 % to about 5% by weight sucralose;(e) about 0.1 % to about 5% by weight magnesium stearate; and / orDocket No.: AT24-003-PCT111(f) about 0.1% to about 5% by weight colloidal silicon dioxide.

9. The composition of any one of claims 1 -8, wherein the composition comprises about 30% to about 35% by weight miglustat.

10. The composition of any one of claims 1 -9, wherein the composition comprises about 45% to about 55% by weight microcrystalline cellulose.11 . The composition of any one of claims 1 -10, wherein the composition comprises about 10% to about 20% by weight starch.

12. The composition of any one of claims 1 -11 , wherein the composition comprises about 0.2% to about 1% by weight sucralose.

13. The composition of any one of claims 1 -12, wherein the composition comprises about 0.2% to about 1% by weight magnesium stearate.

14. The composition of any one of claims 1 -13, wherein the composition comprises about 0.2% to about 1% by weight colloidal silicon dioxide.Docket No.: AT24-003-PCT11215. The composition of any one of claims 1 -14, wherein the composition comprises about 260 mg miglustat, about 400 mg microcrystalline cellulose, about 130.4 mg pregelatinized starch, about 4 mg sucralose powder, about 4 mg magnesium stearate, and about 1 .6 mg colloidal silicon dioxide.

16. The composition of any one of claims 1 -14, wherein the composition comprises about 195 mg miglustat, about 300 mg microcrystalline cellulose, about 97.8 mg pregelatinized starch, about 3 mg sucralose powder, about 3 mg magnesium stearate, and about 1 .2 mg colloidal silicon dioxide.

17. The composition of any one of claims 1 -14, wherein the composition comprises about 130 mg miglustat, about 200 mg microcrystalline cellulose, about 65.2 mg pregelatinized starch, about 2 mg sucralose powder, about 2 mg magnesium stearate, and about 0.8 mg colloidal silicon dioxide.

18. The composition of any one of claims 1 -14, wherein the composition comprises about 65 mg miglustat, about 100 mg microcrystalline cellulose, about 32.6 mg pregelatinized starch, about 1 mg sucralose powder, about 1 mg magnesium stearate, and about 0.4 mg colloidal silicon dioxide.Docket No.: AT24-003-PCT11319. The composition of any one of claims 1 -18, wherein the composition is provided in an oral liquid, such as a solution, dispersion, or suspension, for oral administration.

20. The composition of any one of claims 1 -18, wherein the composition is provided in a hard gelatin capsule.21 . The composition of any one of claims 1 -20, wherein the composition comprises< 400 ppb total of the one or more compounds comprising a structure of either (A) or (B).

22. The composition of any one of claims 1 -20, wherein the composition comprises between 2.3 ppb and 6.9 ppb of the one or more compounds comprising a structure of either (A) or (B).

23. The composition of any one of claims 1 -20, wherein the composition comprises< 6.9 ppb of the one or more compounds comprising a structure of either (A) or (B).

24. The composition of any one of claims 1 -20, wherein the composition comprises > 2.3 ppb of the one or more compounds comprising a structure of either (A) or (B).Docket No.: AT24-003-PCT11425. The composition of any one of claims 1 -20, wherein the composition comprises < 2.3 ppb of the one or more compounds comprising a structure of either (A) or (B).

26. The composition of any one of claims 1 -25, wherein the composition comprises between 0.06 ng / mL and 0.18 ng / mL of the one or more compounds comprising a structure of either (A) or (B).

27. The composition of any one of claims 1 -25, wherein the composition comprises < 0.18 ng / mL of the one or more compounds comprising a structure of either (A) or (B).

28. The composition of any one of claims 1 -25, wherein the composition comprises > 0.06 ng / mL of the one or more compounds comprising a structure of either (A) or (B).

29. A method of treating Pompe disease comprising administering to a patient in need thereof the composition of any one of claims 1 -28.

30. The method of claim 29, wherein the composition comprises miglustat at 65 mg.Docket No.: AT24-003-PCT11531. The method of claim 29 or 30, wherein the composition is administered in combination with a population of recombinant human acid a-glucosidase (rhGAA) molecules.

32. A method for preparing one or more compounds selected from the following:the method comprising:(a) oxidative cleavage of an alkyl group attached to a nitrogen atom on miglustat or L-ido miglustat; and(b) reaction of the nitrogen atom with a nitrosating agent.

33. The method of claim 32, wherein the nitrosating agent comprises nitrite and / or nitrous acid.Docket No.: AT24-003-PCT11634. The method of claim 32 or 33, wherein the nitrosating agent comprises N2O.

35. The method of claim 32 or 33, wherein the nitrosating agent comprises N2O3.

36. The method of any one of claim 32-35, wherein the process occurs under stress conditions.

37. The method of claim 36, wherein the stress condition comprises an acidic pH.

38. The method of claim 36 or 37, wherein the stress condition comprises a pH of about 2.5 to about 3.4.

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