2-hydroxypropyl beta-cyclodextrins for use in a method of treating niemann-pick disease type c in subjects with infantile onset

Abstract

Provided herein are methods of treatment and medicaments for treating Niemann-Pick Disease Type C (NPC) with hydroxypropyl beta-cyclodextrin (HPBCD), including in subjects with infantile-onset NPC. Provided herein are also methods of preventing NPC in in a human subject in need thereof with HPBCD wherein the human subject is 0-2 or 0-6 years of age or has an age on onset of NPC of 0-2 or 0-6 years. Provided herein are also methods of preventing NPC in in a human subject in need thereof with HPBCD for at least 2 years, at least 4 years, or at least 6 years, wherein the human subject is 0-2 or 0-6 years of age or has an age of onset of 0-2 or 0-6 years.

Description

METHODS OF TREATING NIEMANN-PICK DISEASE TYPE C IN SUBJECTS WITHINFANTILE ONSET CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to US 63 / 676065 filed on 26th July 2024, US 63 / 746180filed on 16th January 2025, and US 63 / 746623 filed on 17th January 2025, the contents of which are hereby incorporated by reference in their entirety. FIELD OF THE INVENTION

[0002] The present invention relates to treating Niemann-Pick Disease Type C (NPC) withhydroxypropyl beta-cyclodextrin (HPBCD), including in subjects with infantile-onset NPC. Thepresent invention also relates to increasing the survival rate of NPC with HPBCD, including insubjects with infantile-onset NPC. The present invention also relates to preventing the onset ofsymptoms of NPC with HPBCD, including in subjects with infantile-onset NPC.BACKGROUND OF THE INVENTION

[0003] Niemann-Pick disease Type C (NPC) is a lysosomal lipid storage disorder caused byautosomal recessive mutations in either the NPC1 or NPC2 gene. Symptoms typically manifest beginning in the perinatal period and progress throughout life. The disorder often includes neurological symptoms, such as cerebellar ataxia, dysarthria, seizures, vertical gaze palsy, motor impairment, dysphagia, psychotic episodes, and progressive dementia, as well as systemic symptoms in other organs, such as the liver, spleen, or lung. NPC has been described as a cellular cholesterol transport defect, although in the brain accumulation of other lipids, such asGM2 and GM3 gangliosides, also occurs. Owing to different clinical presentations and course ofdisease, NPC1 disease is typically categorized as early-infantile onset (< 2 yrs), late-infantile onset (2 to <6 years), juvenile onset (6 to <15 years), and adolescent / adult onset (>15 years).

[0004] Effective treatment of Niemann-Pick Disease Type C (NPC) with hydroxypropyl beta-cyclodextrin (HPBCD) requires chronic intrathecal or intracerebroventricular administrationbeginning in infancy. Parenteral grade compositions of hydroxypropyl beta-cyclodextrins previously used in human patients contain impurities that make them unsuitable for chronic administration directly to the cerebrospinal fluid of infants and children: propylene glycol,which is thought to be ototoxic; beta-cyclodextrin molecules having no hydroxypropyl substitutions, which are known to form precipitates and to have an acute toxicity; and bacterialendotoxin, which is highly inflammatory. In addition, parenteral grade compositions ofhydroxypropyl beta-cyclodextrins used in the past have contained complex mixtures of HPBCDspecies having different degrees of hydroxypropyl substitution. The ratios of these species within the mixture differ widely among the various suppliers, and vary even among batches from a single supplier. More recently, HPBCD compositions have been developed with lower levels of toxins and better-characterized degrees of hydroxypropyl substitutions.

[0005] Yet the degree of disease severity and progression varies widely among NPC patients,with some experiencing disease onset as infants and others as adults. In classic NPC, the age of onset (e.g. neurological symptoms) can be as early as a few months old, although many patientsare diagnosed around 2-4 years, with age of death at 5-15 years. For patients with early onset,rapidly progressing NPC, early drug intervention is necessary. The urgency for intervention is not as acute for others. Accordingly, it is important to identify patients requiring urgent drug intervention, including with HPBC. Given the wide variance in disease severity and onset among NPC patients, there is a need in the art to identify patients who require early intervention with HPCD. SUMMARY OF THE INVENTION

[0006] Provided herein is a method of increasing survival in a subject in need thereof, whereinthe subject has infantile-onset Niemann-Pick Disease Type C (NPC). The method may comprise administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules. Further provided are use of the composition in themanufacture of a medicament for increasing survival in a subject having infantile-onset NPC and the composition for use in increasing survival in a subject having infantile-onset NPC. Thecomposition may be administered pre-symptomatically or post-symptomatically, or may beadministered pre-symptomatically and post-symptomatically. The increase in survival may be incomparison to a population of untreated subjects with infantile-onset NPC.

[0007] The age of onset of infantile-onset NPC in the subject may be 0-6 years. The subject mayhave an age of onset of 0-2 years or 2-6 years. The composition may be administered or be foradministration over a period of at least 1, 2, 3, 4, 5, or 6 years. The increase in survival may be atleast 2.5-fold after 5 years. The subject may have an age of 0-1 years, 0-2 months, or 0-1 month.

[0008] For subjects with infantile-onset NPC, the age of neurological symptom onset may bebetween 0 and 6 years. The composition may be first administered to the subject at any age. Thecomposition may be first administered to the subject between 0 and 6 years, for example pre-symptomatically (e.g. prior to neurological symptom onset) or post-symptomatically (e.g. afterneurological symptom onset). The method preferably comprises multiple administrations of the composition, e.g. over a period of at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 years. The method may comprise a first administration of the composition and then one or moresubsequent administrations across the remaining duration of the subject’s life.

[0009] Provided herein is a method of slowing disease progression in a subject with NPC (suchas infantile-onset NPC), which comprises administering to the subject a composition comprisinga mixture of HPBCD molecules. The subject may have been diagnosed with NPC (such asinfantile-onset NPC) prior to the first administration of the composition. The diagnosis may beobtained by any of the diagnosis methods described elsewhere herein (e.g. based on (1) a verticalsupranuclear gaze palsy and either (A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC intracellular transporter 2 (NPC2) gene; or based on (2) one or more mutations in at least one copy of an NPC1 gene; or a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene).

[0010] The NPC disease progression may be slowed relative to the disease progression in apopulation of untreated subjects and / or relative to the disease progression in the subject prior to the first administration of the composition. The method may slow disease progression in the subject by at least about 30%, at least about 40%, or at least about 50%.

[0011] The NPC disease progression may be measured by the NPC Clinical Severity Scale(NPCCSS), such as the four-domain NPC Clinical Severity Scale (4D-NPCCSS). The NPCdisease progression may be measured by the rate of change in the subject’s NPCCSS score perunit of time, for example, by the rate of change in the subject’s NPCCSS score per one month, per two months, per three months, per four months, per five months, per six months, per seven months, per eight months, per nine months, per 10 months, or per 11 months, or by the rate of change in the subject’s NPCCSS score per year.

[0012] For example, the annual change in the subject’s NPCCSS score following the firstadministration of the composition may be compared with the annual change in the subject’sNPCCSS score before the first administration of the composition. Disease progression has been slowed if the annual change in the subject’s NPCCSS score following the first administration ofthe composition is the same or lower than the annual change in the subject’s NPCCSS scorebefore the first administration of the composition.

[0013] As another example, the subject’s NPCCSS score can be evaluated using a severity scale,wherein the severity scale plots the subject’s NPCCSS score against time, and wherein the slopeof the linear regression line provides the change in “units / time period”, for example the annualchange in “units / year”. The slowing of disease progression may be confirmed by comparing thesubject’s NPCCSS rate of change (units / year) following the first administration of thecomposition with the subject’s NPCCSS rate of change (units / year) before the firstadministration of the composition. Disease progression has been slowed if the subject’s NPCCSSrate of change (units / year) following the first administration of the composition is the same orlower than the subject’s NPCCSS rate of change (units / year) before the first administration of thecomposition. The method may slow disease progression in the subject by at least about -0.40units / year, at least about -0.50 units / year, at least about -0.60 units / year, at least about -0.70 units / year, or at least about -0.80 units / year.

[0014] As another example, the annual change in the subject’s NPCCSS score following the firstadministration of the composition may be compared with the predicted annual change in the subject’s NPCCSS score, wherein the predicted annual change is based on the annual change ofNPCCSS score of an untreated subject or population. Disease progression has been slowed if theannual change in the subject’s NPCCSS score following the first administration of the composition is the same or lower than the predicted annual change.

[0015] As another example, the slowing of disease progression may be confirmed by comparingthe subject’s NPCCSS rate of change (units / year) following the first administration of thecomposition with the subject’s predicted NPCCSS rate of change (units / year), wherein thesubject’s predicted NPCCSS rate of change (units / year) is based on NPCCSS rate of change inunits / year of an untreated subject or population. Disease progression has been slowed if thesubject’s NPCCSS rate of change (units / year) following the first administration of thecomposition is the same or lower than the subject’s predicted NPCCSS rate of change(units / year). The method may slow disease progression in the subject by at least about -0.40units / year, at least about -0.50 units / year, at least about -0.60 units / year, at least about -0.70units / year, or at least about -0.80 units / year.

[0016] The method may slow disease progression in the subject such that the subject has, or isexpected to have, an NPCCSS score that is lower than the NPCCSS score that they would havehad if they had remained untreated. For example, the subject has, or is expected to have, an NPCCSS score after one year of treatment, or two years of treatment, or three years of treatment that is lower than the NPCCSS score that they would have had at that time if they had remaineduntreated. For example, the NPCCSS score may be about 2.0 points lower, about 2.1 pointslower, about 2.2 points lower, about 2.3 points lower, about 2.4 points lower, about 2.5 pointslower, about 2.6 points lower, about 2.7 points lower, about 2.8 points lower, about 2.9 points lower, or about 3.0 points lower.

[0017] Provided herein is a method of increasing cholesterol release by neuronal cells in asubject in need thereof. The method may comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Further provided are use of the composition in themanufacture of a medicament for increasing cholesterol release by neuronal cells in the subjectand the composition for increasing cholesterol release by neuronal cells in the subject. The increase may be relative to an amount of cholesterol release measured in the subject before the composition is first administered to the subject.

[0018] The subject may have infantile-onset NPC. The age of onset of infantile-onset NPC in thesubject may be 0-6 years. The cholesterol release may be measured by measuring 24- hydroxycholesterol levels. The increase may be at least 10, 15, 20, or 25% The increase may be measured at about 10, 20, 30, 40, or 52 weeks after the composition is first administered to the subject.

[0019] Provided herein is a method of decreasing neuronal cell death in a subject in need thereof.The method may comprise administering to the subject a composition comprising a mixture of HPBCD molecules. The increase may be relative to an amount of neuronal cell death measured in the subject before the composition is first administered to the subject. Further provided are use of the composition in the manufacture of a medicament for decreasing neuronal cell death in the subject and the composition for decreasing neuronal cell death in the subject.

[0020] The subject may have infantile-onset NPC. The age onset of infantile-onset NPC in thesubject may be 0-6 years. The neuronal cell death may be measured by measuring Fatty acid- binding protein 3 or Calbindin D levels. The decrease may be at least 25, 30, 35, 40, 45, 50, 55, or 60%. The decrease may be measured at about 10, 20, 30, 40, or 52 weeks after the composition is first administered to the subject.

[0021] Provided herein is a method of preventing the onset of NPC in a human subject in needthereof. The method may comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Further provided herein are use of the composition of a medicament for preventing the onset of NPC in the human subject and the composition for preventing the onset of NPC in the human subject. The human subject may have (a) an age of 0 to 18 years; and, (b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or moremutations in at least one copy of an NPC1 gene. The subject may have an age of 0 to 1 years, 0to 2 years, 0 to 3 years, 0 to four years, 0 to five years, or 0 to 6 years. The subject may have an age of 6 to 18 years.

[0022] Provided herein is a method of increasing the survival rate of a human subject in needthereof with NPC, which may comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Further provided herein is use of the composition in the manufacture of a medicament for increasing the survival rate of the human subject and the composition for use in increasing the survival rate of the human subject. The subject may have (a) an age of 0 to 18 years; and, (b) a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene. Administering the composition to the subject over a period of at least 3 years, 4, years, 5 years, or 6 years may provide anestimated survival rate of at least 95%, and the subject may be a member of a combined infantilepopulation. The patient may be on administration of the composition described herein for his orher entire life which may be beyond 6 years of age.

[0023] Provided herein is a method of treating NPC in a human subject in need thereof, whichmay comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Further provided are use of the composition in the manufacture of a medicament for treating NPC in the subject and the composition for use in treating NPC in the subject. Thesubject may have an age of 6 to 18 years and a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene.

[0024] The diagnosis of NPC may comprise the presence of at least two mutations in at least onecopy of an NPC1. The diagnosis of NPC may further comprise a positive filipin test and at least one mutation in at least one copy of an NPC1 gene. Each mutation may be pathogenic. Each mutation may be a null mutation. The subject may have at least one copy of an E4 variant of an ApoE gene (ApoE E4).

[0025] Provided herein is a method of treating NPC in a human subject in need thereof, whichmay comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Also provided are use of the composition in the manufacture of a medicament for treating NPC and the composition for treating NPC. The subject may have an age of 6 to 18 years; and a diagnosis of NPC based on a vertical supranuclear gaze palsy and either (A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC intracellular transporter 2 (NPC2) gene.

[0026] Each mutation may be pathogenic. Each mutation may be a null mutation. The subjectmay have a score of 1-4 in at least two domains of an NPC Clinical Severity Scale (NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS. The subject may have a total score of at least 10 on the NPCCSS.

[0027] Provided herein is a method of treating NPC in a human subject in need thereof, whichmay comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Also provided are use of the composition in the manufacture of a medicament, and the composition, for treating NPC in the human subject. The subject may have (a) an age of 6 to18 years; (b) a diagnosis of NPC based on one of the following sets of traits: (i) a first mutationin each of both copies of a NPC intracellular transporter 1 (NPC1) gene, or a first mutation in a first copy of an NPC1 gene and a second mutation in a second copy of an NPC1 gene; (ii) a positive filipin test and at least one pathogenic mutation in at least one copy of an NPC1 gene; and (iii) vertical supranuclear gaze palsy and either (A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with Niemann-Pick disease, and no mutation in an NPC intracellular transporter 2 (NPC2) gene; (c) a score of 1-4 in at least two domains of an NPC Clinical Severity Scale (NPCCSS) selected from the group consisting ofambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS; and, (d) a total score of at least 10 on the NPCCSS.

[0028] The subject may not have, as assessed from the NPCCSS, an ambulation domain score of5, a swallowing domain score of 5, a fine motor skills domain score of 5, or a cognition domainscore of 5. Each mutation may be pathogenic. Each mutation may be a null mutation. The subjectmay have at least one copy of ApoE E4.

[0029] In the methods, uses, and compositions disclosed herein, the filipin staining maycomprise obtaining skin fibroblasts from the subject, culturing the fibroblasts in a medium deprived of cholesterol, incubating the fibroblasts in low-density lipoprotein cholesterol-enrichedmedium for at least 24 hours, fixing the fibroblasts, and staining the fibroblasts with filipin. Inthe methods, uses, and compositions disclosed herein, the oxysterol level consistent with NPC may comprise one or more of a level of cholestane-3β,5α,6β-triol greater than 0.070 nmol / mL, a level of 7-ketocholesterol greater than 0.100 nmol / mL, and a level of lyso-sphingomyelin greater than 0.100 nmol / mL, as measured in a plasma sample from the subject.

[0030] Provided herein is a method of treating, or preventing or slowing progression of NPC in ahuman subject in need thereof, which may comprise administering to the subject a composition comprising a mixture of HPBCD molecules. Also provided are use of the composition in themanufacture of a medicament, and the composition, for treating, or preventing or slowingprogression of NPC. The subject may have at least one pathogenic mutation in at least one copyof an NPC1 gene. The subject may be no older than 6 years of age. The subject may haveinfantile-onset NPC. For subjects with infantile-onset NPC, the age of neurological symptomonset may be between 0 and 6 years. The composition may be first administered to the subject atany age. The composition may be first administered pre-symptomatically (e.g. prior toneurological symptom onset) or post-symptomatically (e.g. after neurological symptom onset).The method preferably comprises multiple administrations of the composition, e.g. over a period of at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 years. The method may comprise a first administration of the composition and then multiple subsequent administrations for the remaining duration of the subject’s life. The subject may be 2-6 years of age or 2-4 years of age. Each pathogenic mutation may be a null mutation. The subject may have at least one copy of ApoE E4.

[0031] Provided herein is a method of prognosing progression of NPC in a human subject, whichmay comprise identifying at least one pathogenic mutation in at least one copy of an NPC1 gene in the subject. The presence of at least one pathogenic mutation may be indicative of more rapid progression of NPC in the subject as compared to a population of humans who do not carry the pathogenic mutation. Each pathogenic mutation may be a null mutation. The method may further comprise identifying whether the subject has at least one copy of ApoE E4. The presence of ApoE E4 in the subject may be indicative of more rapid progression of NPC in the subject as compared to a population of humans who carry each pathogenic mutation but do not carry a copy of ApoE E4. The method may further comprise administering a composition comprising a mixture of HPBCD molecules to the subject based the prognosis of progression of NPC for the subject.

[0032] Provided herein is a method of treating NPC in a subject in need thereof, which maycomprise administering to the subject a composition comprising a mixture of HPBCD molecules. Also provided herein a use of the composition in the manufacture of a medicament, and thecomposition, for treating NPC in the subject. The subject may have received a first dose of amixture of HPBCD molecules. The composition may comprise a second dose of a mixture of HPBCD molecules. The second dose may be different from the first dose. The second dose may be higher than the first dose if the subject is determined to have at least one pathogenic mutation in at least one copy of an NPC1 gene. The second dose may be lower than the first dose if the subject is determined not to have a pathogenic mutation in at least one copy of an NPC1 gene. The second dose may be higher than the first dose if the subject further has at least one copy of ApoE E4.

[0033] Provided herein is a method of treating NPC in a subject in need thereof, which maycomprise administering a composition comprising a mixture of HPBCD molecules to the subject. Also provided are use of the composition in the manufacture of a medicament, and the composition, for treating NPC in the subject. The composition may be administered intrathecally or be for intrathecal administration if the subject is determined to have at least one pathogenic mutation in at least one copy of an NPC1 gene. The composition may be administered intravenously or be for intravenous administration if the subject is determined not to have a pathogenic mutation in at least one copy of an NPC1 gene. The composition may beadministered intrathecally or be for intrathecal administration if the subject further has at least one copy of ApoE E4.

[0034] In the methods, uses, and compositions disclosed herein, each mutation in each NPC1gene may be relative to one or more wild-type NPC1 genes from one or more reference human genomes. Each mutation in each NPC1 gene may be in an open reading frame of the respective NPC1 gene. Each mutation in each NPC1 gene may result in a change in an amino acid sequence of a NPC1 protein encoded by the NPC1 gene. The change may be one or more of an amino acid substitution, a deletion, a frameshift, a premature stop, and a lack of NPC1 protein production. Each mutation may be a null mutation, and the change may be a frameshift or a premature stop.

[0035] In the methods, uses, and compositions disclosed herein, each mutation in each NPC1gene may be associated with early- or late-infantile onset of at least one NPC symptom. EachNPC1 mutation may be independently selected from R1186H, I1061T, a frameshift at K142,T1205K, S734I, A1054T, or a premature stop at R1059, deletion of promoter and exon 1, c.385delT, D944N, A1035V, c.1757delA, c.2746_2748delAAT, L380F, R958 stop, C63 frameshift causing premature stop at position 75 in shifted reading frame, C63 frameshift causing premature stop at position 75 in shifted reading frame, T1205R, IVS21-2del ATGC, IVS21-2del ATGC, G1195V, P433L, IVS14+1G>A, T1205 frameshift, T1036M, D501Y, I601F frameshift causing premature stop at position 13 in shifted reading frame, N140K frameshift causing premature stop at position 30 in shifted reading frame, D611G, R726T, P1245R frameshift causing premature stop at position 12 in shifted reading frame, V744S frameshift causing premature stop at position 27 in shifted reading frame, P1245R frameshift causing premature stop at position 12 in shifted reading frame, R518Q, c.2795dupA, R1186H, T1036M, C1168Y, c.3578_3591 + 9del, R934Q, G993E frameshift causing premature stop at position 4 in shifted reading frame, IVS23+1G>A, A605C frameshift causing premature stop at position 2 in shifted reading frame, A1187R frameshift causing premature stop at position 54 in shifted reading frame, Y276H, P733S frameshift causing premature stop at position 10 in shifted reading frame, c.319delc, nucleotide +5 at intron 18, F703S, S813 stop, Q928P, L1003R, W942C, I962 to F966 deletion, A1035V, C177Y, V959E, c.955+1G>A, C645 stop, F1079S, C976 frameshift, M1127I frameshift causing premature stop at position 131 in shifted frame, K142R frameshift causing premature stop at position 27 in shifted frame, R958 stop, c.2245+1G>A, Q991R frameshift, duplication / multiple copies of exons 10 and 11, C1011 stop, IVS23+1G>A, S151F frameshiftcausing premature stop at position 18 in shifted frame, C976F frameshift causing premature stop at position 6 in shifted frame, C914S, L472P, c.3478-6T>A, A321G frameshift causing premature stop at position 16 in shifted frame, F284L frameshift causing premature stop at position 26 of shifted frame, Q991R frameshift, R607 stop, C31W frameshift causing premature stop at position 26 in shifted fame, c.464-2A>C, N1156S, T1205N frameshift causing premature stop at position 53 in shifted frame, R934 stop, R958 stop, P691S, F760 deletion, Q119V frameshift causing premature stop at position 8 in shifted frame, H1016L, I1061T, P1007A, R958Q, F284L frameshift causing premature stop at position 26 in shifted frame, deletion of promoter and exons 1-10, Q92R, C119 stop, E1089K, N701K causing premature stop at position 13 in shifted frame, R404Q, 237S, Q775P, and A1132P. The subject may carry at least one mutation in a first copy of the NPC1 gene and at least one mutation in a second copy of the NPC1 gene. The mutation in the first and second copies of the NPC1 gene may comprise a combination in Table 1.

[0036] In the methods, uses, and compositions disclosed herein, each mutation in NPC1 may beassociated with late-infantile or juvenile onset of at least one NPC symptom. Each mutation may be independently selected from I1061T, a premature stop at R1059, F1087L, P1007A, T1205R, R518Q, T1036M, I1061T, S954L, R518Q, E391G, R518Q, P1007A, R518Q, A165V, R1186H, P474L, Y276H, D944N, P733S frame shift causing a premature stop at position 9 in shifted frame, S954L, A1132P, C1168Y, R404Q, V1378A, IVS23+1G>A, V697A, and A1035V. The subject may carry at least one mutation in a first copy of the NPC1 gene and at least one mutation in a second copy of the NPC1 gene. The mutation in the first and second copies of the NPC1 gene comprise a combination in Table 2.

[0037] Provided herein is a method of preventing or treating onset of infantile-onset NPC in asubject in need thereof, which may comprise administering pre-symptomatically or post-symptomatically, or pre-symptomatically and post-symptomatically to the subject a compositioncomprising a mixture of HPBCD molecules. Also provided are use of the composition in the manufacture of a medicament, and the composition, for preventing or treating onset of infantile- onset NPC in the subject. The composition may be administered pre-symptomatically and post- symptomatically or be for pre-symptomatic and post-symptomatic administration. The age ofonset of infantile-onset NPC in the subject may be 0-6 years. The subject may be or may havebeen diagnosed via genetic testing.

[0038] In the methods, compositions, and uses disclosed herein, the mixture of HPBC moleculesmay comprise less than 0.05% unsubstituted beta-cyclodextrin (“DS-0”) and less than 0.05% beta-cyclodextrin substituted with one hydroxypropyl group (“DS-1”). The mixture of HPBCDmolecules may have an average degree of substitution of 6.02-7.98. The composition comprisinga mixture of HPCD molecules may be administered intravenously or be for intravenous injection.The composition may have an osmolality of 291.21 mOsm / kg ± 5, 10, or 15%. The composition may have an osmolality of 288.35 mOsm / kg ± 5, 10, or 15%.

[0039] In the methods, uses, and compositions disclosed herein, measuring a biomarker in asubject may mean measuring the biomarker in a sample obtained from the subject. In one example, the sample is a blood sample, which may be a plasma or serum sample. The sample may be a cerebrospinal fluid sample.

[0040] It will be appreciated that each of the features, methods, uses, compositions,embodiments and claims that are presented herein may be combined as appropriate. BRIEF DESCRIPTION OF THE DRAWINGS

[0041] FIG. 1A-C show Kaplan Meier plots of matched overall survival in HPBCD composition(VTS-270)-treated subjects versus pooled cohorts for subjects with NPC having ages of onset of0-6 years (FIG. 1A), 0-2 years (early infantile; FIG. 1B), and 2-6 years (late infantile; FIG. 1C).

[0042] FIG. 2A-C show matched overall survival Kaplan Meier analyses of VTS-270-treatedpatients in combined infantile NPC populations by individual external controls (EC) based ondata from published studies by Freihuber (Orphanet J Rare Dis, 18, 204 (2023)) and Vanier(Orphanet J Rare Dis, 5, 162010 (2010)) (FIG. 2A), NIH Study 06-CH0186 (NIH) (FIG. 2B),and Yale University Open Data Access (NPC Registry AC-056C501) (YODA) (FIG. 2C).

[0043] FIG. 3A-C show matched overall survival Kaplan Meier analyses of VTS-270-treatedpatients in early infantile NPC populations by individual EC based on data from publishedstudies by Freihuber 2023 (FIG.3A), NIH (FIG.3B), and YODA (FIG. 3C).

[0044] FIG. 4A-C show matched overall survival Kaplan Meier analyses of VTS-270-treatedpatients in late infantile NPC populations by individual EC based on data from published studiesby Vanier 2010 (FIG.4A), NIH (FIG. 4B), and YODA (FIG.4C).

[0045] FIG. 5 shows matched overall survival Kaplan Meier analyses with genetics in VTS-270-treated patients versus a pooled cohort in early infantile NPC populations based on data fromFreihuber 2023 and NIH (n of VTS-270 treated patients with match=13; p<0.0001 adjustedLogrank test; HR (95% CI): 0.041 (0.005, 0.328)).

[0046] FIG. 6A-C show changes in 24-hydroxycholesterol (FIG. 6A), fatty acid binding protein3 (FABP3) (FIG. 6B), and Calbindin D (FIG. 6C) levels from baseline measured in HPBCD(VTS-270)-treated patients at time 0 (pre-treatment) and at about 13, 26, 39, and 52 weeks of treatment.

[0047] FIG. 7 discusses the mechanism of action in NPC with VTS-270 / adrabetadex.

[0048] FIG. 8 explains that NPC is a heterogeneous, progressive, terminal neurodegenerativedisease with varying age of onset & speed or progression.

[0049] FIG. 9 confirms that biomarkers over 52 weeks demonstrate adrabetadex increases CNScholesterol trafficking and reduces neuronal cell death & neurodegeneration.

[0050] FIG. 10 shows the predicted change in NPCCSS in a combined cohort of early and lateinfantile-onset NPC subjects from 0 to 3 years who have received treatment with VTS-270 / adrabetadex. DETAILED DESCRIPTION

[0051] The age of onset and progression rate of NPC is influenced by genetic background,particularly by alleles of the NPC Intracellular Cholesterol Transporter 1 (NPC1) gene, withadditional modification by alleles of the apolipoprotein E gene. The inventors had the insight thatpatients who require earlier treatment of NPC1 with HPBCD or higher doses of HPBCD can beidentified by determining their NPC1 and ApoE genotypes. The inventors have also created atreatment paradigm wherein, surprisingly, HPBCD compositions increase survival in patients with infantile-onset (0-6 years of age) NPC, not only overall but also for both early-infantile (0-2 years of age) and late-infantile (2-6 years of age) NPC. The inventors have further created a treatment paradigm wherein HPBCD increases cholesterol release in neuronal cells and decreases neuronal cell death in NPC patients. The methods described herein advantageously lead to a slowing of the progression of the disease.1. Definitions.

[0052] The terminology used herein is for the purpose of describing particular embodiments onlyand is not intended to be limiting. As used in the specification and the appended claims, thesingular forms “a,” “an” and “the” include plural referents unless the context clearly dictates otherwise.

[0053] For recitation of numeric ranges herein, each intervening number there between with thesame degree of precision is explicitly contemplated. For example, for the range of 6-9, the numbers 7 and 8 are contemplated in addition to 6 and 9, and for the range 6.0-7.0, the numbers 6.0, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6,9, and 7.0 are explicitly contemplated.

[0054] For the avoidance of doubt, references to methods of treatment herein should beunderstood as also disclosing the composition, mixture of HPBCD molecules and / or compoundsfor use in said methods of treatment.2. HPBCD

[0055] Provided herein is a composition comprising HPBCD, which may be a pharmaceuticalcomposition. The compositions described herein may be used in any of the methods and uses described herein. The present disclosure provides a pharmaceutical composition comprising, as apharmaceutically active ingredient, a mixture of beta-cyclodextrin molecules substituted at oneor more hydroxyl positions by hydroxypropyl groups, the mixture optionally includingunsubstituted beta-cyclodextrin molecules. The composition comprising HPBCD may be asdescribed in U.S. Patent No. 9,675,634, the contents of which are incorporated herein byreference. In one example, the HPBCD composition may be VTS-270 (adrabetadex; PubChemCID 138059665).

[0056] The pharmaceutically active ingredient is a mixture of beta-cyclodextrin moleculessubstituted at one or more hydroxyl positions by hydroxypropyl groups, the mixture optionallyincluding unsubstituted beta-cyclodextrin molecules. The term “pharmaceutically activeingredient” is used synonymously with “active pharmaceutical ingredient” in this disclosure.

[0057] As used herein, “substituted at one or more hydroxyl positions by hydroxypropyl groups”refers to replacement of the hydrogen of one or more hydroxyl groups of a beta-cyclodextrin molecule with a hydroxypropyl group or a hydroxypropyl oligomer. For instance,“substituted at one or more hydroxyl positions by hydroxypropyl groups” can refer to aninsertion of one or more CH2CH(CH3)O- substituents within one or more O-H bonds on a beta-cyclodextrin molecule resulting in one or more ether linkages.

[0058] As used herein, the “degree of substitution” or “DS” refers to the total number ofhydroxypropyl groups substituted directly or indirectly on a beta-cyclodextrin molecule. Forexample, a beta-cyclodextrin molecule containing glucose units, each of which is substitutedwith one hydroxypropyl group, has a DS=7. In another example, a beta-cyclodextrin molecule inwhich only one of the seven glucose units is substituted with a hydroxypropyl group, and thathydroxypropyl group is itself substituted with another hydroxypropyl group (e.g., a beta-cyclodextrin with a single occurrence of HP that comprises two hydroxypropyl groups), has aDS=2.

[0059] As used herein, the “average number of hydroxypropyl groups per beta-cyclodextrin,”also known as an “average degree of substitution,” “average DS,” or “DSa,” refers to the total number of hydroxypropyl groups in a population of beta-cyclodextrins divided by the numberof beta-cyclodextrin molecules. In an illustrative example, an equal parts mixture of beta-cyclodextrins containing glucose units that are each substituted with one hydroxypropyl group and beta-cyclodextrins containing glucose units that are each substituted with two hydroxypropyl groups has a DSa=10.5 (average of equal parts beta-cyclodextrins with DS=7 and DS=14). In another illustrative example, a mixture of 33.3% beta-cyclodextrins in which only one of the seven glucose units is substituted with a hydroxypropyl group (i.e., DS=1) and 66.7% beta- cyclodextrins containing glucose units that are each substituted with one hydroxypropyl group (i.e., DS=7) has a DSa=5.0.

[0060] The DSa is determined by multiplying the MS by 7. As used herein, DSa is usedsynonymously with “degree of substitution” as that term is defined in the USP Hydroxypropyl Betadex monograph.

[0061] In some embodiments, the beta-cyclodextrins in the mixture consist of glucose units ofthe structure:wherein R1, R2, and R3, independently for each occurrence, are –H or –HP, wherein HP comprises one or more hydroxypropyl groups.

[0062] In some embodiments, HP comprises one hydroxypropyl group. In some embodiments,HP consists essentially of one hydroxypropyl group. In some embodiments, HP consists of one hydroxypropyl group.

[0063] In some embodiments, the average number of occurrences of HP per beta-cyclodextrin isabout 3 to about 7, e.g., about 3 to about 6, about 3 to about 5, about 3 to about 4, about 4 to about 7, about 4 to about 6, about 4 to about 5, about 5 to about 7, about 5 to about 6, or about 6 to about 7.

[0064] In some embodiments, the total occurrences of R3 = HP are greater than the totaloccurrences of either R1= HP or R2= HP. In certain embodiments, the total occurrences of R3= HP are greater than the total combined occurrences of R1= HP and R2= HP.

[0065] In some embodiments, at least about 5%, e.g., at least about 10%, at least about 15%, atleast about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, or at least about 45% of total occurrences of R1and R2combined are HP.

[0066] In some embodiments, not more than about 95%, e.g., not more than about 90%, notmore than about 85%, not more than about 80%, not more than about 75%, not more than about 70%, not more than about 65%, not more than about 60%, not more than about 55%, or not more than about 50% of total occurrences of R1and R2combined are HP.

[0067] In some embodiments, the percentage of R1 and R2 combined that are HP ranges fromabout 5% to about 95%, such as about 10% to about 95%, about 15% to about 95%, about 20% to about 95%, about 25% to about 95%, about 30% to about 95%, about 35% to about 95%, about 40% to about 95%, about 45% to about 95%, about 50% to about 95%, about 55% to about 95%, about 60% to about 95%, about 65% to about 95%, about 70% to about 95%, about 75% to about 95%, about 80% to about 95%, about 85% to about 95%, about 90% to about 95%; such as from about 5% to about 90%, about 10% to about 90%, about 15% to about 90%, about 20% to about 90%, about 25% to about 90%, about 30% to about 90%, about 35% to about 90%, about 40% to about 90%, about 45% to about 90%, about 50% to about 90%, about 55% to about 90%, about 60% to about 90%, about 65% to about 90%, about 70% to about 90%, about 75% to about 90%, about 80% to about 90%, about 85% to about 90%; such as from about 5% to about 85%, about 10% to about 85%, about 15% to about 85%, about 20% to about 85%, about 25% to about 85%, about 30% to about 85%, about 35% to about 85%, about 40% to about 85%, about 45% to about 85%, about 50% to about 85%, about 55% to about 85%, about 60% to about 85%, about 65% to about 85%, about 70% to about 85%, about 75% to about 85%, about 80% to about 85%; such as from about 5% to about 80%, about 10% to about 80%, about 15% to about 80%, about 20% to about 80%, about 25% to about 80%, about 30% to about 80%, about 35% to about 80%,about 40% to about 80%, about 45% to about 80%, about 50% to about 80%, about 55% to about 80%, about 60% to about 80%, about 65% to about 80%, about 70% to about 80%, about 75% to about 80%; such as from about 5% to about 75%, about 10% to about 75%, about 15% to about 75%, about 20% to about 75%, about 25% to about 75%, about 30% to about 75%, about 35% to about 75%, about 40% to about 75%, about 45% to about 75%, about 50% to about 75%, about 55% to about 75%, about 60% to about 75%, about 65% to about 75%, about 70% to about 75%; such as from about 5% to about 70%, about 10% to about 70%, about 15% to about 70%, about 20% to about 70%, about 25% to about 70%, about 30% to about 70%, about 35% to about 70%, about 40% to about 70%, about 45% to about 70%, about 50% to about 70%, about 55% to about 70%, about 60% to about 70%, about 65% to about 70%; such as from about 5% to about 65%, about 10% to about 65%, about 15% to about 65%, about 20% to about 65%, about 25% to about 65%, about 30% to about 65%, about 35% to about 65%, about 40% to about 65%, about 45% to about 65%, about 50% to about 65%, about 55% to about 65%, about 60% to about 65%; such as from about 5% to about 60%, about 10% to about 60%, about 15% to about 60%, about 20% to about 60%, about 25% to about 60%, about 30% to about 60%, about 35% to about 60%, about 40% to about 60%, about 45% to about 60%, about 50% to about 60%, about 55% to about 60%; such as from about 5% to about 55%, about 10% to about 55%, about 15% to about 55%, about 20% to about 55%, about 25% to about 55%, about 30% to about 55%, about 35% to about 55%, about 40% to about 55%, about 45% to about 55%, about 50% to about 55%; such as from about 5% to about 50%, about 10% to about 50%, about 15% to about 50%, about 20% to about 50%, about 25% to about 50%, about 30% to about 50%, about 35% to about 50%, about 40% to about 50%, about 45% to about 50%; such as from about 5% to about 45%, about 10% to about 45%, about 15% to about 45%, about 20% to about 45%, about 25% to about 45%, about 30% to about 45%, about 35% to about 45%, about 40% to about 45%; such as from about 5% to about 40%, about 10% to about 40%, about 15% to about 40%, about 20% to about 40%, about 25% to about 40%, about 30% to about 40%, about 35% to about 40%; such as from about 5% to about 35%, about 10% to about 35%, about 15% to about 35%, about 20% to about 35%, about 25% to about 35%, about 30% to about 35%; such as from about 5% to about 30%, about 10% to about 30%, about 15% to about 30%, about 20% to about 30%, about 25% to about 30%; such as from about 5% to about 25%, about 10% to about 25%, about 15% to about 25%, about 20% to about 25%;such as from about 5% to about 20%, about 10% to about 20%, about 15% to about 20%; such as from about 5% to about 15%, about 10% to about 15%; or about 5% to about 10%.

[0068] In some embodiments, at least about 5%, e.g., at least about 10%, at least about 15%, atleast about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, or at least about 50% of occurrences of R3are HP.

[0069] In some embodiments, not more than about 95%, e.g., not more than about 90%, notmore than about 85%, not more than about 80%, not more than about 75%, not more than about 70%, not more than about 65%, not more than about 60%, or not more than about 55% of occurrences of R3are HP.

[0070] In some embodiments, the percentage of occurrence of R3 that are HP ranges from about20% to about 90%, e.g., about 25% to about 90%, about 30% to about 90%, about 35% to about 90%, about 40% to about 90%, about 45% to about 90%, about 50% to about 90%, about 55% to about 90%, about 60% to about 90%, about 65% to about 90%, about 70% to about 90%, about 75% to about 90%, about 80% to about 90%, about 85% to about 90%, about 20% to about 85%, about 25% to about 85%, about 30% to about 85%, about 35% to about 85%, about 40% to about 85%, about 45% to about 85%, about 50% to about 85%, about 55% to about 85%, about 60% to about 85%, about 65% to about 85%, about 70% to about 85%, about 75% to about 85%, about 80% to about 85%, about 20% to about 80%, about 25% to about 80%, about 30% to about 80%, about 35% to about 80%, about 40% to about 80%, about 45% to about 80%, about 50% to about 80%, about 55% to about 80%, about 60% to about 80%, about 65% to about 80%, about 70% to about 80%, about 75% to about 80%, about 20% to about 75%, about 25% to about 75%, about 30% to about 75%, about 35% to about 75%, about 40% to about 75%, about 45% to about 75%, about 50% to about 75%, about 55% to about 75%, about 60% to about 75%, about 65% to about 75%, about 70% to about 75%, about 20% to about 70%, about 25% to about 70%, about 30% to about 70%, about 35% to about 70%, about 40% to about 70%, about 45% to about 70%, about 50% to about 70%, about 55% to about 70%, about 60% to about 70%, about 65% to about 70%, about 20% to about 65%, about 25% to about 65%, about 30% to about 65%, about 35% to about 65%, about 40% to about 65%, about 45% to about 65%, about 50% to about 65%, about 55% to about 65%, about 60% to about 65%, about 20% to about 60%, about 25% to about 60%, about 30% to about 60%, about 35% to about 60%, about 40% to about 60%, about 45% to about 60%, about 50% to about 60%, about 55% to about 60%, about 20% to about 55%, about 25% to about55%, about 30% to about 55%, about 35% to about 55%, about 40% to about 55%, about 45% to about 55%, about 50% to about 55%, about 20% to about 50%, about 25% to about 50%, about 30% to about 50%, about 35% to about 50%, about 40% to about 50%, about 45% to about 50%, about 20% to about 45%, about 25% to about 45%, about 30% to about 45%, about 35% to about 45%, about 40% to about 45%, about 5% to about 40%, about 10% to about 40%, about 15% to about 40%, about 20% to about 40%, about 25% to about 40%, about 30% to about 40%, about 35% to about 40%, about 20% to about 35%, about 25% to about 35%, about 30% to about 35%, about 20% to about 30%, about 25% to about 30%, or about 20% to about 25%.

[0071] In some embodiments, at least about 70%, e.g., at least about 75%, at least about 80%, atleast about 85%, at least about 90%, or at least about 95%, of the beta-cyclodextrins collectivelyhave an average number of occurrences of HP per beta-cyclodextrin of about 4 to about 7, e.g.,about 4 to about 6, about 4 to about 5, about 5 to about 7, about 5 to about 6, or about 6 to about 7.

[0072] In some embodiments, the percentage of beta-cyclodextrins that collectively have anaverage number of occurrences of HP per beta-cyclodextrin of about 4 to about 7, e.g., about 4 toabout 6, about 4 to about 5, about 5 to about 7, about 5 to about 6, or about 6 to about 7, ranges from about 50% to about 99%, such as about 55% to about 99%, about 60% to about 99%, about 65% to about 99%, about 70% to about 99%, about 75% to about 99%, about 80% to about 99%, about 85% to about 99%, about 90% to about 99%, about 95% to about 99%; such as from about 50% to about 97%, such as about 55% to about 97%, about 60% to about 97%, about 65% to about 97%, about 70% to about 97%, about 75% to about 97%, about 80% to about 97%, about 85% to about 97%, about 90% to about 97%, about 95% to about 97%; such as from about 50% to about 95%, about 55% to about 95%, about 60% to about 95%, about 65% to about 95%, about 70% to about 95%, about 75% to about 95%, about 80% to about 95%, about 85% to about 95%, about 90% to about 95%; such as from about 50% to about 90%, about 55% to about 90%, about 60% to about 90%, about 65% to about 90%, about 70% to about 90%, about 75% to about 90%, about 80% to about 90%, about 85% to about 90%; such as from about 50% to about 85%, about 55% to about 85%, about 60% to about 85%, about 65% to about 85%, about 70% to about 85%, about 75% to about 85%, about 80% to about 85%; such as from about 50% to about 80%, about 55% to about 80%, about 60% to about 80%, about 65% to about 80%, about 70% to about 80%, about 75% to about 80%; such as from about 50% to about 75%, about 55% to about 75%,about 60% to about 75%, about 65% to about 75%, about 70% to about 75%; such as from about 50% to about 70%, about 55% to about 70%, about 60% to about 70%, about 65% to about 70%; such as from about 50% to about 65%, about 55% to about 65%, about 60% to about 65%; such as from about 50% to about 60%, about 55% to about 60%; or such as from about 50% to about 55%.

[0073] In certain embodiments, the pharmaceutical compositions of the disclosure comprise, as apharmaceutically active ingredient, a mixture of unsubstituted beta-cyclodextrin moleculesand beta-cyclodextrin molecules substituted at one or more hydroxyl positions by hydroxypropylgroups, wherein the mixture has an average number of hydroxypropyl groups per beta-cyclodextrin molecule (DSa) of about 3 to about 7.

[0074] In some embodiments, the DSa is about 3 to about 5, such as about 3 to about 4. In someembodiments, the DSa is 3.3 ± 0.3, 3.5 ± 0.3, or 3.7 ± 0.3. In other embodiments, the DSa is 3.2 ± 0.2, 3.3 ± 0.2, 3.4 ± 0.2, 3.5 ± 0.2, 3.6 ± 0.2, 3.7 ± 0.2, or 3.8 ± 0.2. In other embodiments, the DSa is 3.1 ± 0.1, 3.2 ± 0.1, 3.3 ± 0.1, 3.4 ± 0.1, 3.5 ± 0.1, 3.6 ± 0.1, 3.7 ± 0.1, 3.8 ± 0.1, or 3.9 ± 0.1.

[0075] In some embodiments, the DSa is about 3.5 to about 5.5, such as about 3.5 to about 4.5. Insome embodiments, the DSais 3.8 ± 0.3, 4.0 ± 0.3, or 4.2 ± 0.3. In other embodiments, the DSais 3.7 ± 0.2, 3.8 ± 0.2, 3.9 ± 0.2, 4.0 ± 0.2, 4.1 ± 0.2, 4.2 ± 0.2, or 4.3 ± 0.2. In other embodiments, the DSais 3.6 ± 0.1, 3.7 ± 0.1, 3.8 ± 0.1, 3.9 ± 0.1, 4.0 ± 0.1, 4.1 ± 0.1, 4.2 ± 0.1, 4.3 ± 0.1, or 4.4 ± 0.1.

[0076] In some embodiments, the DSa is about 4 to about 6, such as about 4 to about 5. In someembodiments, the DSa is 4.3 ± 0.3, 4.5 ± 0.3, or 4.7 ± 0.3. In other embodiments, the DSa is 4.2 ± 0.2, 4.3 ± 0.2, 4.4 ± 0.2, 4.5 ± 0.2, 4.6 ± 0.2, 4.7 ± 0.2, or 4.8 ± 0.2. In other embodiments, the DSais 4.1 ± 0.1, 4.2 ± 0.1, 4.3 ± 0.1, 4.4 ± 0.1, 4.5 ± 0.1, 4.6 ± 0.1, 4.7 ± 0.1, 4.8 ± 0.1, or 4.9 ± 0.1.

[0077] In some embodiments, the DSa is about 4.5 to about 6.5, such as about 4.5 to about 5.5. Insome embodiments, the DSa is 4.8 ± 0.3, 5.0 ± 0.3, or 5.2 ± 0.3. In other embodiments, the DSa is 4.7 ± 0.2, 4.8 ± 0.2, 4.9 ± 0.2, 5.0 ± 0.2, 5.1 ± 0.2, 5.2 ± 0.2, or 5.3 ± 0.2. In other embodiments, the DSais 4.6 ± 0.1, 4.7 ± 0.1, 4.8 ± 0.1, 4.9 ± 0.1, 5.0 ± 0.1, 5.1 ± 0.1, 5.2 ± 0.1, 5.3 ± 0.1, or 5.4 ± 0.1.

[0078] In some embodiments, the DSa is about 5 to about 7, such as about 5 to about 6. In someembodiments, the DSa is 5.3 ± 0.3, 5.5 ± 0.3, or 5.7 ± 0.3. In other embodiments, the DSa is 5.2 ± 0.2, 5.3 ± 0.2, 5.4 ± 0.2, 5.5 ± 0.2, 5.6 ± 0.2, 5.7 ± 0.2, or 5.8 ± 0.2. In other embodiments, the DSa is 5.1 ± 0.1, 5.2 ± 0.1, 5.3 ± 0.1, 5.4 ± 0.1, 5.5 ± 0.1, 5.6 ± 0.1, 5.7 ± 0.1, 5.8 ± 0.1, or 5.9 ± 0.1.

[0079] In some embodiments, the DSa is about 5.5 to about 6.5. In some embodiments, the DSais 5.8 ± 0.3, 6.0 ± 0.3, or 6.2 ± 0.3. In other embodiments, the DSa is 5.7 ± 0.2, 5.8 ± 0.2, 5.9 ± 0.2, 6.0 ± 0.2, 6.1 ± 0.2, 6.2 ± 0.2, or 6.3 ± 0.2. In other embodiments, the DSais 5.6 ± 0.1, 5.7 ± 0.1, 5.8 ± 0.1, 5.9 ± 0.1, 6.0 ± 0.1, 6.1 ± 0.1, 6.2 ± 0.1, 6.3 ± 0.1, or 6.4 ± 0.1.

[0080] In some embodiments, the DSa is about 6 to about 7. In some embodiments, the DSa is6.3 ± 0.3, 6.5 ± 0.3, or 6.7 ± 0.3. In other embodiments, the DSais 6.2 ± 0.2, 6.3 ± 0.2, 6.4 ± 0.2, 6.5 ± 0.2, 6.6 ± 0.2, 6.7 ± 0.2, or 6.8 ± 0.2. In other embodiments, the DSa is 6.1 ± 0.1, 6.2 ± 0.1, 6.3 ± 0.1, 6.4 ± 0.1, 6.5 ± 0.1, 6.6 ± 0.1, 6.7 ± 0.1, 6.8 ± 0.1, or 6.9 ± 0.1.

[0081] In some embodiments, the DSa is about 4.1 ± 15%, about 4.2 ± 15%, about 4.3 ± 15%,about 4.4 ± 15%, or about 4.5 ± 15%, such as about 4.1 ± 10%, about 4.2 ± 10%, about 4.3 ± 10%, about 4.4 ± 10%, or about 4.5 ± 10%, such as about 4.1 ± 5%, about 4.2 ± 5%, about 4.3 ± 5%, about 4.4 ± 5%, or about 4.5 ± 5%. For example, in certain embodiments, the DSais about 4.31 ± 10%, about 4.32 ± 10%, about 4.33 ± 10%, about 4.34 ± 10%, about 4.35 ± 10%, about 4.36 ± 10%, or about 4.37 ± 10%, such as about 4.31 ± 5%, about 4.32 ± 5%, about 4.33 ± 5%, about 4.34 ± 5%, about 4.35 ± 5%, about 4.36 ± 5%, or about 4.37 ± 5%. In particular embodiments, the DSa is about 4.34 ± 10%, such as about 4.34 ± 5%.

[0082] In some embodiments, the DSa is about 4.3 ± 15%, about 4.4 ± 15%, about 4.5 ± 15%,about 4.6 ± 15%, or about 4.7 ± 15%, such as about 4.3 ± 10%, about 4.4 ± 10%, about 4.5 ± 10%, about 4.6 ± 10%, or about 4.7 ± 10%, such as about 4.3 ± 5%, about 4.4 ± 5%, about 4.5 ± 5%, about 4.6 ± 5%, or about 4.7 ± 5%. For example, in certain embodiments, the DSa is about 4.47 ± 10%, about 4.48 ± 10%, about 4.49 ± 10%, about 4.50 ± 10%, about 4.51 ± 10%, about 4.52 ± 10%, or about 4.53 ± 10%, such as about 4.47 ± 5%, about 4.48 ± 5%, about 4.49 ± 5%, about 4.50 ± 5%, about 4.51 ± 5%, about 4.52 ± 5%, or about 4.53 ± 5%. In particular embodiments, the DSais about 4.50 ± 10%, such as about 4.50 ± 5%.

[0083] In some embodiments, the DSa is about 6.1 ± 15%, about 6.2 ± 15%, about 6.3 ± 15%,about 6.4 ± 15%, or about 6.5 ± 15%, such as about 6.1 ± 10%, about 6.2 ± 10%, about 6.3 ±10%, about 6.4 ± 10%, or about 6.5 ± 10%, such as about 6.1 ± 5%, about 6.2 ± 5%, about 6.3 ± 5%, about 6.4 ± 5%, or about 6.5 ± 5%. For example, in certain embodiments, the DSa is about 6.34 ± 10%, about 6.35 ± 10%, about 6.36 ± 10%, about 6.37 ± 10%, about 6.38 ± 10%, about 6.39 ± 10%, or about 6.40 ± 10%, such as about 6.34 ± 5%, about 6.35 ± 5%, about 6.36 ± 5%, about 6.37 ± 5%, about 6.38 ± 5%, about 6.39 ± 5%, or about 6.40 ± 5%. In particular embodiments, the DSa is about 6.37 ± 10%, such as about 6.37 ± 5%.

[0084] In some embodiments, the DSa is about 6.3 ± 15%, about 6.4 ± 15%, about 6.5 ± 15%,about 6.6 ± 15%, or about 6.7 ± 15%, such as about 6.3 ± 10%, about 6.4 ± 10%, about 6.5 ± 10%, about 6.6 ± 10%, or about 6.7 ± 10%, such as about 6.3 ± 5%, about 6.4 ± 5%, about 6.5 ± 5%, about 6.6 ± 5%, or about 6.7 ± 5%. For example, in certain embodiments, the DSais about 6.50 ± 10%, about 6.51 ± 10%, about 6.52 ± 10%, about 6.53 ± 10%, about 6.54 ± 10%, about 6.55 ± 10%, or about 6.56 ± 10%, such as about 6.50 ± 5%, about 6.51 ± 5%, about 6.52 ± 5%, about 6.53 ± 5%, about 6.54 ± 5%, about 6.55 ± 5%, or about 6.56 ± 5%. In particular embodiments, the DSa is about 6.53 ± 10%, such as about 6.53 ± 5%.

[0085] The distribution of the degree of substitution within a mixture of unsubstituted beta-cyclodextrin molecules and beta-cyclodextrin molecules substituted at one or more hydroxylpositions by hydroxypropyl groups can vary. For example, an equal parts mixture of beta- cyclodextrins containing glucose units each of which is substituted with one hydroxypropyl group and beta-cyclodextrins containing glucose units each of which is substituted with two hydroxypropyl groups has a DSa=10.5 (average of equal parts beta-cyclodextrins with DS=7 and DS=14). Although DSa=10.5, in this example there are no beta-cyclodextrins having DS=10 or DS=11 within the mixture. In other cases, the majority of beta-cyclodextrins within the mixture of beta-cyclodextrins have DS that are close to the DSa.

[0086] In some embodiments of the disclosure, at least about 50%, e.g., at least about 55%,about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%,or about 97%, of the beta-cyclodextrins within the mixture have a DS within DSa ± Xσ, whereinσ is the standard deviation, and X is 1, 2, or 3. For example, in some embodiments, at least about50%, e.g., at least about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about85%, about 90%, about 95%, or about 97%, of the beta-cyclodextrins within the mixture have aDS within DSa± 1σ. In some embodiments, at least 70% of the beta-cyclodextrins have a DSwithin DSa ± 1σ. In some embodiments, at least 90% of the beta-cyclodextrins have a DS withinDSa± 1σ. In some embodiments, at least 95% of the beta-cyclodextrins have a DS within DSa± 1σ.

[0087] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, of the beta-cyclodextrins within the mixture have a DS within DSa ± 2σ. In some embodiments, at least 70% of the beta-cyclodextrins have a DS within DSa ± 2σ. In some embodiments, at least 90% of the beta-cyclodextrins have a DS within DSa ± 2σ. In some embodiments, at least 95% of the beta-cyclodextrins have a DS within DSa± 2σ.

[0088] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, of the beta-cyclodextrins within the mixture have a DS within DSa± 3σ. In some embodiments, at least 70% of the beta-cyclodextrins have a DS within DSa ± 3σ. In some embodiments, at least 90% of the beta-cyclodextrins have a DS within DSa ± 3σ. In some embodiments, at least 95% of the beta-cyclodextrins have a DS within DSa ± 3σ.

[0089] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 1. In some embodiments, at least 70% of the beta-cyclodextrins have a DS within DSa ± 1. In some embodiments, at least 90% of the beta- cyclodextrins have a DS within DSa± 1. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 1.

[0090] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.8. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa± 0.8. In some embodiments, at least 90% of the beta- cyclodextrins have a DS within DSa ± 0.8. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 0.8.

[0091] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.6. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa± 0.6. In some embodiments, at least 90% of the beta-cyclodextrins have a DS within DSa± 0.6. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 0.6.

[0092] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.5. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa ± 0.5. In some embodiments, at least 90% of the beta- cyclodextrins have a DS within DSa ± 0.5. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa± 0.5.

[0093] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.4. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa ± 0.4. In some embodiments, at least 90% of the beta- cyclodextrins have a DS within DSa ± 0.4. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 0.4.

[0094] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.3. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa ± 0.3. In some embodiments, at least 90% of the beta- cyclodextrins have a DS within DSa± 0.3. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 0.3.

[0095] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.2. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa± 0.2. In some embodiments, at least 90% of the beta- cyclodextrins have a DS within DSa ± 0.2. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 0.2.

[0096] In some embodiments, at least about 50%, e.g., at least about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, ofthe beta-cyclodextrins have a DS within DSa ± 0.1. In some embodiments, at least 70% of thebeta-cyclodextrins have a DS within DSa± 0.1. In some embodiments, at least 90% of the beta-cyclodextrins have a DS within DSa± 0.1. In some embodiments, at least 95% of the beta- cyclodextrins have a DS within DSa ± 0.1.

[0097] In some embodiments, the MS ranges from 0.40 to 0.80, such as 0.41 to 0.79, 0.42 to0.78, 0.43 to 0.77, 0.44 to 0.76, 0.45 to 0.75, 0.46 to 0.74, 0.47 to 0.73, 0.48 to 0.72, 0.49 to 0.71, 0.50 to 0.70, 0.51 to 0.69, 0.52 to 0.68, 0.53 to 0.67, 0.54 to 0.66, 0.55 to 0.65, 0.56 to 0.64, 0.57 to 0.63, 0.58 to 0.62, or 0.59 to 0.61.

[0098] In certain embodiments, the MS is about 0.40, about 0.41, about 0.42, about 0.43, about0.44, about 0.45, about 0.46, about 0.47, about 0.48, about 0.49, about 0.50, about 0.51, about 0.52, about 0.53, about 0.54, about 0.55, about 0.56, about 0.57, about 0.58, about 0.59, about 0.60, about 0.61, about 0.62, about 0.63, about 0.64, about 0.65, about 0.66, about 0.67, about 0.68, about 0.69, about 0.70, about 0.71, about 0.72, about 0.73, about 0.74, about 0.75, about 0.76, about 0.77, about 0.78, about 0.79, or about 0.80.

[0099] In certain embodiments, the MS is about 0.571 – 0.686 (DSa about 4.0 to about 4.8). Insome of these embodiments, the MS is in the range of about 0.58 to about 0.68. In currentlypreferred embodiments, the MS is in the range of 0.58 – 0.68.

[0100] In various embodiments, the MS is at least about 0.55. In certain embodiments,the MS is at least about 0.56, 0.57, 0.58, 0.59, or 0.60. In certain embodiments, the MS is no more than about 0.70. In specific embodiments, the MS is no more than about 0.69, 0.68, 0.67, 0.66, or 0.65.

[0101] Hydroxypropyl groups may be bonded to the beta-cyclodextrins as monomers, ormay themselves be sequentially bonded to one or more additional hydroxypropyl groups to formhydroxypropyl oligomers which are then bonded to the beta-cyclodextrins. In some embodiments, the hydroxypropyl groups are substituted at the hydroxyl positions of the beta- cyclodextrins as hydroxypropyl chains of the structure —[CH2CH(CH3)O]nH, wherein n≧1 andthe average number of hydroxypropyl chains per beta-cyclodextrin is about 3 to about 7, e.g.,about 3 to about 6, about 3 to about 5, about 3 to about 4, about 4 to about 7, about 4 to about 6, about 4 to about 5, about 5 to about 7, about 5 to about 6, or about 6 to about 7. In some embodiments, n is 1, 2, 3 or 4.

[0102] In one illustrative example, a hydroxypropyl chain of the structure-CH2CH(CH3)OH includes one hydroxypropyl group in the hydroxypropyl chain (i.e., n = 1). Inanother illustrative example a hydroxypropyl chain of the structure -[CH2CH(CH3)O]3H includes three hydroxypropyl groups in the hydroxypropyl chain (i.e., n = 3).

[0103] In certain embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is 3.3±0.3, 3.4±0.3, 3.6±0.3, or 3.8±0.3. In other embodiments, the average numberof hydroxypropyl chains per beta-cyclodextrin is 4.0±0.3, 4.2±0.3, 4.4±0.3, 4.6±0.3, or 4.8±0.3.In other embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is5.0±0.3, 5.2±0.3, 5.4±0.3, 5.6±0.3, or 5.8±0.3. And in other embodiments, the average number ofhydroxypropyl chains per beta-cyclodextrin is 6.0±0.3, 6.2±0.3, 6.4±0.3, 6.6±0.3, or 6.7±0.3.

[0104] In some embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is 3.2±0.2, 3.3±0.2, 3.4±0.2, 3.5±0.2, 3.6±0.2, 3.7±0.2, or 3.8±0.2. In otherembodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is 4.0±0.2,4.1±0.2, 4.2±0.2, 4.3±0.2, 4.4±0.2, 4.5±0.2, 4.6±0.2, 4.7±0.2, or 4.8±0.2. In other embodiments,the average number of hydroxypropyl chains per beta-cyclodextrin is 5.0±0.2, 5.1±0.2, 5.2±0.2,5.3±0.2, 5.4±0.2, 5.5±0.2, 5.6±0.2, 5.7±0.2, or 5.8±0.2. And in other embodiments, the averagenumber of hydroxypropyl chains per beta-cyclodextrin is 6.0±0.2, 6.1±0.2, 6.2±0.2, 6.3±0.2,6.4±0.2, 6.5±0.2, 6.6±0.2, 6.7±0.2, or 6.8±0.2.

[0105] In some embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is 3.1±0.1, 3.2±0.1, 3.3±0.1, 3.4±0.1, 3.5±0.1, 3.6±0.1, 3.7±0.1, 3.8±0.1, or 3.9±0.1.In other embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is4.0±0.1, 4.1±0.1, 4.2±0.1, 4.3±0.1, 4.4±0.1, 4.5±0.1, 4.6±0.1, 4.7±0.1, 4.8±0.1, or 4.9±0.1. Inother embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is5.0±0.1, 5.1±0.1, 5.2±0.1, 5.3±0.1, 5.4±0.1, 5.5±0.1, 5.6±0.1, 5.7±0.1, 5.8±0.1, or 5.9±0.1. Andin other embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is6.0±0.1, 6.1±0.1, 6.2±0.1, 6.3±0.1, 6.4±0.1, 6.5±0.1, 6.6±0.1, 6.7±0.1, 6.8±0.1, or 6.9±0.1.

[0106] In some embodiments, at least about 50%, e.g., about 55%, about 60%, about65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, or about 97%, of the hydroxypropyl chains have n = 1. In some embodiments, at least 70% of the hydroxypropyl chains have n = 1. In some embodiments, at least 90% of the hydroxypropyl chains have n = 1.

[0107] In some embodiments, percentage of the hydroxypropyl chains that have n = 1ranges from about 50% to about 99%, such as about 55% to about 99%, about 60% to about 99%, about 65% to about 99%, about 70% to about 99%, about 75% to about 99%, about 80% toabout 99%, about 85% to about 99%, about 90% to about 99%, about 95% to about 99%; such as from about 50% to about 97%, such as about 55% to about 97%, about 60% to about 97%, about 65% to about 97%, about 70% to about 97%, about 75% to about 97%, about 80% to about 97%, about 85% to about 97%, about 90% to about 97%, about 95% to about 97%; such as from about 50% to about 95%, about 55% to about 95%, about 60% to about 95%, about 65% to about 95%, about 70% to about 95%, about 75% to about 95%, about 80% to about 95%, about 85% to about 95%, about 90% to about 95%; such as from about 50% to about 90%, about 55% to about 90%, about 60% to about 90%, about 65% to about 90%, about 70% to about 90%, about 75% to about 90%, about 80% to about 90%, about 85% to about 90%; such as from about 50% to about 85%, about 55% to about 85%, about 60% to about 85%, about 65% to about 85%, about 70% to about 85%, about 75% to about 85%, about 80% to about 85%; such as from about 50% to about 80%, about 55% to about 80%, about 60% to about 80%, about 65% to about 80%, about 70% to about 80%, about 75% to about 80%; such as from about 50% to about 75%, about 55% to about 75%, about 60% to about 75%, about 65% to about 75%, about 70% to about 75%; such as from about 50% to about 70%, about 55% to about 70%, about 60% to about 70%, about 65% to about 70%; such as from about 50% to about 65%, about 55% to about 65%, about 60% to about 65%; such as from about 50% to about 60%, about 55% to about 60%; or such as from about 50% to about 55%.

[0108] In some embodiments, less than about 50%, such as about 45%, about 40%, about35%, about 30%, about 25%, about 20%, about 15%, about 10%, about 5%, or about 3%, of the hydroxypropyl chains have n = 2. In some embodiments, less than 30% of the hydroxypropyl chains have n = 2. In some embodiments, less than 10% of the hydroxypropyl chains have n = 2.

[0109] In some embodiments, the percentage of the hydroxypropyl chains that have n = 2ranges from about 5% to about 50%, such as about 10% to about 50%, about 15% to about 50%, about 20% to about 50%, about 25% to about 50%, about 30% to about 50%, about 35% to about 50%, about 40% to about 50%, about 45% to about 50%; such as from about 5% to about 45%, about 10% to about 45%, about 15% to about 45%, about 20% to about 45%, about 25% to about 45%, about 30% to about 45%, about 35% to about 45%, about 40% to about 45%; such as from about 5% to about 40%, about 10% to about 40%, about 15% to about 40%, about 20% to about 40%, about 25% to about 40%, about 30% to about 40%, about 35% to about 40%; such as from about 5% to about 35%, about 10% to about 35%, about 15% to about 35%, about 20% to about35%, about 25% to about 35%, about 30% to about 35%; such as from about 5% to about 30%, about 10% to about 30%, about 15% to about 30%, about 20% to about 30%, about 25% to about 30%; such as from about 5% to about 25%, about 10% to about 25%, about 15% to about 25%, about 20% to about 25%; such as from about 5% to about 20%, about 10% to about 20%, about 15% to about 20%; such as from about 5% to about 15%, about 10% to about 15%; or about 5% to about 10%.

[0110] In some embodiments, less than about 50%, such as about 45%, about 40%, about35%, about 30%, about 25%, about 20%, about 15%, about 10%, about 5%, or about 3%, of the hydroxypropyl chains have n > 2. In some embodiments, less than 10% of the hydroxypropyl chains have n > 2.

[0111] In some embodiments, the percentage of the hydroxypropyl chains that have n > 2ranges from about 5% to about 50%, such as about 10% to about 50%, about 15% to about 50%, about 20% to about 50%, about 25% to about 50%, about 30% to about 50%, about 35% to about 50%, about 40% to about 50%, about 45% to about 50%; such as from about 5% to about 45%, about 10% to about 45%, about 15% to about 45%, about 20% to about 45%, about 25% to about 45%, about 30% to about 45%, about 35% to about 45%, about 40% to about 45%; such as from about 5% to about 40%, about 10% to about 40%, about 15% to about 40%, about 20% to about 40%, about 25% to about 40%, about 30% to about 40%, about 35% to about 40%; such as from about 5% to about 35%, about 10% to about 35%, about 15% to about 35%, about 20% to about 35%, about 25% to about 35%, about 30% to about 35%; such as from about 5% to about 30%, about 10% to about 30%, about 15% to about 30%, about 20% to about 30%, about 25% to about 30%; such as from about 5% to about 25%, about 10% to about 25%, about 15% to about 25%, about 20% to about 25%; such as from about 5% to about 20%, about 10% to about 20%, about 15% to about 20%; such as from about 5% to about 15%, about 10% to about 15%; or such as from about 5% to about 10%.

[0112] In some embodiments, the average number of hydroxypropyl chains per beta-cyclodextrin is about 4 to about 6. In some embodiments, at least about 60%, such as at leastabout 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, or at least about 97%, of the beta-cyclodextrins collectivelyhave an average number of hydroxypropyl chains per beta-cyclodextrin of about 4 to about 6. Insome embodiments, the percentage of the beta-cyclodextrins that collectively have an averagenumber of hydroxypropyl chains per beta-cyclodextrin of about 4 to about 6 ranges from about60% to about 97%, such as about 65% to about 97%, about 70% to about 97%, about 75% to about 97%, about 80% to about 97%, about 85% to about 97%, about 90% to about 97%; such as from about 60% to about 95%, about 65% to about 95%, about 70% to about 95%, about 75% to about 95%, about 80% to about 95%, about 85% to about 95%, about 90% to about 95%; such as from about 60% to about 90%, about 65% to about 90%, about 70% to about 90%, about 75% to about 90%, about 80% to about 90%, about 85% to about 90%; such as from about 60% to about 85%, about 65% to about 85%, about 70% to about 85%, about 75% to about 85%, about 80% to about 85%; such as from about 60% to about 80%, about 65% to about 80%, about 70% to about 80%, about 75% to about 80%; such as from about 60% to about 75%, about 65% to about 75%, about 70% to about 75%; such as from about 60% to about 70%, about 65% to about 70%; or such as from about 60% to about 65%.

[0113] In typical embodiments, the pharmaceutically active ingredient contains less thanabout 2%, such as less than about 1.5%, less than about 1.4%, less than about 1.3%, less than about 1.2%, less than about 1.1%, less than about 1.0%, less than about 0.9%, less than about 0.8%, less than about 0.7%, less than about 0.6%, less than about 0.5%, less than about 0.4%, less than about 0.3%, less than about 0.2%, less than about 0.1%, less than about 0.09%, less than about 0.08%, less than about 0.07%, less than about 0.06%, or less than about 0.05%unsubstituted beta-cyclodextrin (“DS-0”; “BCD”), as determined by peak height of anelectrospray MS spectrum.

[0114] In typical embodiments, no more than (“NMT”) 1% of the beta-cyclodextrin mixture is unsubstituted with a hydroxypropyl group (BCD), as determined by peakheight of an electrospray MS spectrum.

[0115] In various embodiments, the composition comprises no more than about 0.01%BCD, no more than about 0.02% BCD, no more than about 0.03% BCD, no more than about0.04% BCD, or no more than about 0.05% BCD of the beta-cyclodextrin mixture.

[0100] In typical embodiments, less than 4% of the beta-cyclodextrin mixture is beta-cyclodextrin substituted with just one hydroxypropyl group (“DS-1”), as determined by peakheight of an electrospray MS spectrum.

[0101] In various embodiments, less than 3.9%, less than 3.8%, less than 3.7%, less than 3.6%,or less than 3.5% of the beta-cyclodextrin mixture is DS-1. In certain embodiments, thepharmaceutically active ingredient comprises less than 3.5%, 3.4%, 3.3%, 3.2%, 3.1%, or 3.0% DS-1. In particular embodiments, the pharmaceutically active ingredient comprises less than 2.9%, 2.8%, 2.7%, 2.6%, 2.5%, 2.4%, 2.3%, 2.2%, 2.1%, or 2.0% DS-1. In some embodiments,the mixture of beta-cyclodextrin molecules comprises less than 1.9%, 1.8%, 1.7%, 1.6%, 1.5%,1.4%, 1.3%, 1.2%, 1.1%, or 1.0% DS-1. In presently preferred embodiments, the pharmaceutically active ingredient comprises less than 0.9%, 0.8%, 0.7%, 0.6%, 0.5%, 0.4%, 0.3%, 0.2% or 0.1% DS-1, even less than about 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03% DS-1. In certain preferred embodiments, the composition comprises less than 0.03%, even as low as 0.02% DS-1.

[0102] In various embodiments, the beta-cyclodextrin mixture has a low percentage of beta-cyclodextrin substituted with two hydroxypropyl groups (“DS-2”), as determined by peak heightof an electrospray MS spectrum.

[0103] In various embodiments, less than 3.9%, less than 3.8%, less than 3.7%, less than 3.6%,or less than 35% of the beta-cyclodextrin mixture is DS-2. In certain embodiments, thepharmaceutically active ingredient comprises less than 3.5%, 3.4%, 3.3%, 3.2%, 3.1%, or 3.0% DS-2. In particular embodiments, the pharmaceutically active ingredient comprises less than 2.9%, 2.8%, 2.7%, 2.6%, 2.5%, 2.4%, 2.3%, 2.2%, 2.1%, or 2.0% DS-2. In some embodiments,the mixture of beta-cyclodextrin molecules comprises less than 1.9%, 1.8%, 1.7%, 1.6%, 1.5%,1.4%, 1.3%, 1.2%, 1.1%, or 1.0% DS-2. In presently preferred embodiments, the pharmaceutically active ingredient comprises less than 0.9%, 0.8%, 0.7%, 0.6%, 0.5%, 0.4%, 0.3%, 0.2% or 0.1% DS-2, even less than about 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03% DS-2. In certain preferred embodiments, the composition comprises less than 0.03%, even as low as 0.02% DS-2.

[0104] In typical embodiments, the mixture comprises at least 10% beta-cyclodextrin moleculeshaving three hydroxypropyl substitutions (“DS-3”) as a percentage of the total mixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, at least 11%, at least 12%, at least 13%, at least 14%, at least 15%, at least 16%, at least 17%, at least 18%, at least 19%, at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, or at least25% of the beta-cyclodextrin mixture is DS-3.

[0105] In typical embodiments, the mixture comprises at least 20% beta-cyclodextrin moleculeshaving four hydroxypropyl substitutions (“DS-4”) as a percentage of the total mixture, asdetermined by peak height of an electrospray MS spectrum. In various embodiments, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34%, or at least35% of the beta-cyclodextrin mixture is DS-4.

[0106] In typical embodiments, the mixture comprises at least 15% beta-cyclodextrin moleculeshaving five hydroxypropyl substitutions (“DS-5”) as a percentage of the total mixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, at least 16%, at least 17%, at least 18%, at least 19%, at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, or at least30% of the beta-cyclodextrin mixture is DS-5.

[0107] In typical embodiments, the mixture comprises at least 5% beta-cyclodextrin moleculeshaving six hydroxypropyl substitutions (“DS-6”) as a percentage of the total mixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, at least 6%, at least 7%, at least 8%, at least 9%, at least 10%, at least 11%, at least 12%, at least 13%, at least 14%, at least 15%, at least 16%, at least 17%, at least 18%, at least 19%, or at least 20% ofthe beta-cyclodextrin mixture is DS-6.

[0108] In typical embodiments, less than 10% of the beta-cyclodextrin mixture is beta-cyclodextrin substituted with seven hydroxypropyl groups (“DS-7”) as a percentage of the totalmixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, less than 9%, less than 8%, less than 7%, less than 6%, less than 5%, less than 4%, less than 3%,less than 2%, or less than 1% of the beta-cyclodextrin mixture is DS-7.

[0109] In typical embodiments, the beta-cyclodextrin mixture comprises less than 2% of beta-cyclodextrin substituted with eight hydroxypropyl groups (“DS-8”) as a percentage of the totalmixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, less than 1.5%, less than 1.4%, less than 1.3%, less than 1.2%, less than 1.1%, less than 1%, less than 0.9%, less than 0.8%, less than 0.7%, less than 0.6%, less than 0.5%, less than 0.4%, less than 0.3%, less than 0.2%, less than 0.1%, less than 0.09%, less than 0.08%, less than 0.07%, less than 0.06%, less than 0.05%, less than 0.04%, less than 0.03%, less than 0.02%, or less than0.01% of beta-cyclodextrin is DS-8.

[0110] In typical embodiments, no more than 1% of the beta-cyclodextrin mixture is beta-cyclodextrin substituted with nine hydroxypropyl groups (“DS-9”) as a percentage of the totalmixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, no more than 0.9%, no more than 0.8%, no more than 0.7%, no more than 0.6%, no more than 0.5%, no more than 0.4%, no more than 0.3%, no more than 0.2%, no more than 0.1%, no more than 0.09%, no more than 0.08%, no more than 0.07%, no more than 0.06%, no more than 0.05%, no more than 0.04%, no more than 0.03%, no more than 0.02%, or no more than 0.01%of beta-cyclodextrin is DS-9.

[0111] In typical embodiments, no more than 1% of the beta-cyclodextrin mixture is beta-cyclodextrin substituted with ten hydroxypropyl groups (“DS-10”) as a percentage of the totalmixture, as determined by peak height of an electrospray MS spectrum. In various embodiments, no more than 0.9%, no more than 0.8%, no more than 0.7%, no more than 0.6%, no more than 0.5%, no more than 0.4%, no more than 0.3%, no more than 0.2%, no more than 0.1%, no more than 0.09%, no more than 0.08%, no more than 0.07%, no more than 0.06%, no more than 0.05%, no more than 0.04%, no more than 0.03%, no more than 0.02%, or no more than 0.01%of beta-cyclodextrin is DS-10.

[0112] In various embodiments, the beta-cyclodextrin mixture contains at least 75% of DS-3,DS-4, DS-5, and DS-6, collectively, as a percentage of the entire mixture. In certain embodiments, at least 76%, at least 77%, at least 78%, at least 79%, at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, atleast 96%, at least 97%, or at least 98% of beta-cyclodextrin in the mixture is DS-3, DS-4, DS-5,and DS-6, collectively.

[0113] In various embodiments, the beta-cyclodextrin mixture comprises DS-3, DS-4, DS-5, andDS-6, collectively, as a percentage of the entire mixture in the range from about 75% to about 98%, such as about 76% to about 97%, about 77% to about 96%, about 78% to about 95%, about 79% to about 94%, about 80% to about 93%, about 81% to about 92%, about 82% to about 91%, about 83% to about 90%, about 84% to about 89%, about 85% to about 88%, or about 86% to about 87%.

[0114] In typical embodiments, the beta-cyclodextrin mixture comprises at least 25% of DS-5and DS-6, collectively, as a percentage of the entire mixture. In certain embodiments, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34%, at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least47%, at least 48%, at least 49%, or at least 50% of beta-cyclodextrin in the mixture is DS-5 andDS-6, collectively.

[0115] In various embodiments, the beta-cyclodextrin mixture comprises DS-5 and DS-6,collectively, as a percentage of the entire mixture in the range from about 25% to about 50%, such as about 26% to about 49%, about 27% to about 48%, about 28% to about 47%, about 29% to about 46%, about 30% to about 45%, about 31% to about 44%, about 32% to about 43%, about 33% to about 42%, about 34% to about 41%, about 35% to about 40%, about 36% to about 39%, or about 37% to about 38%.

[0116] In various embodiments, the beta-cyclodextrin species with the greatest prevalence as apercentage of the entire mixture is DS-4.

[0117] In one example, the mixture of HPBCD molecules comprises less than 0.05%unsubstituted beta-cyclodextrin (“DS-0”) and less than 0.05% beta-cyclodextrin substituted withone hydroxypropyl group (“DS-1”). The composition may comprise an average degree ofsubstitution of 6.02 – 7.98. The composition is suitable for intrathecal, intravenous, oral, orintracerebroventricular administration to a patient in need thereof. The composition may have apH of 6.0-7.9. The true density of the composition may be about 1.096-1.098 g / cm3. The osmolality of the composition may be about 635-695 mOs / kg.

[0118] In certain embodiments, the present disclosure describes a pharmaceutical compositionwherein the sole pharmaceutically active ingredient is obtained by purifying one or moreHPBCD products selected from KLEPTOSE® HBP, KLEPTOSE® HP, TRAPPSOL® Cyclo,and CAVASOL® W7 HP Pharma.

[0119] KLEPTOSE® HBP and KLEPTOSE® HP are HPBCD products available from RoquettePharma, Lestrem, France. KLEPTOSE® HBP is a parenteral grade endotoxin-controlled composition of HPBCDs with a DSa of about 4.3. KLEPTOSE® HP is an endotoxin-controlled composition of HPBCDs with a higher DSa than KLEPTOSE® HBP. TRAPPSOL® Cyclo is a parenteral grade of hydroxypropyl beta cyclodextrin with a DSa of about 6.37, and is available in a powdered or sterile liquid form from Sphingo Biotechnology, Inc., a division of CTD Holdings, Inc., Alachua, Fla., USA. CAVASOL® W7 HP Pharma is a pharmaceutical gradehydroxypropyl-beta-cyclodextrin with a DSa from about 4.1 to about 5.1, e.g., a DSa of about 4.5,available from Wacker Chemie AG, Munchen, Germany.

[0120] In some embodiments, the pharmaceutical composition purified from TRAPPSOL®Cyclo (CTD) comprises a mixture of beta-cyclodextrin molecules substituted at one or morehydroxyl positions by hydroxypropyl groups, the mixture optionally includingunsubstituted beta-cyclodextrin molecules, and a diluent that is pharmaceutically acceptable forintrathecal, intracerebroventricular, or intravenous administration. The composition comprises nomore than (“NMT”) 5 EU of endotoxins per gram of beta-cyclodextrin mixture, no more than0.5% propylene glycol, as measured by the HPLC method set forth in the USP Hydroxypropyl Betadex monograph, and no more than 1 ppm propylene oxide, determined according to the USP Hydroxypropyl Betadex monograph.

[0121] In some embodiments, the pharmaceutical composition purified from TRAPPSOL®Cyclo (CTD) comprises NMT 1.5 EU of endotoxins per gram of beta-cyclodextrin mixture. Insome embodiments, the composition comprises no more than 0.01% propylene glycol, as measured by the HPLC method set forth in the USP Hydroxypropyl Betadex monograph.

[0122] In certain embodiments, the pharmaceutically active ingredient purified fromTRAPPSOL® Cyclo (CTD) comprises less than 5%, such as less than 4.5%, less than 4%, less than 3.5%, less than 3%, less than 2.5%, less than 2%, less than 1.5%, less than 1%, less than0.5%, or less than 0.1% unsubstituted beta-cyclodextrin (“DS-0”), beta-cyclodextrin substitutedwith one hydroxypropyl group (“DS-1”), and beta-cyclodextrin substituted with twohydroxypropyl groups (“DS-2”), collectively, as determined by peak heights of an electrospray MS spectrum.

[0123] In certain embodiments, the pharmaceutically active ingredient purified fromTRAPPSOL® Cyclo (CTD) comprises at least 50%, such as at least 55%, at least 60%, at least65%, at least 70%, at least 75%, at least 80%, at least 85%, or at least 90% beta-cyclodextrin substituted with five hydroxypropyl groups (“DS-5”), beta-cyclodextrin substitutedwith six hydroxypropyl groups (′DS-6″), and beta-cyclodextrin substituted with sevenhydroxypropyl groups (′DS-7″), collectively, as determined by peak heights of an electrospray MS spectrum.

[0124] In certain embodiments, the pharmaceutically active ingredient purified fromTRAPPSOL® Cyclo (CTD) comprises less than 5%, such as less than 4.5%, less than 4%, less than 3.5%, less than 3%, less than 2.5%, less than 2%, less than 1.5%, less than 1%, less than0.5%, or less than 0.1% beta-cyclodextrin substituted with nine hydroxypropyl groups (“DS-9”)and beta-cyclodextrin substituted with ten hydroxypropyl groups (“DS-10”), collectively, asdetermined by peak heights of an electrospray MS spectrum.

[0125] In certain embodiments, purifying one or more HPBCD products selected fromKLEPTOSE® HBP, KLEPTOSE® HP, TRAPPSOL® Cyclo, and CAVASOL® W7 HP Pharma comprises one or more of complex formation, precipitation, and adsorption chromatography. In some embodiments, the purification comprises one method, e.g., adsorption chromatography. In some embodiments, the purification comprises two or more methods, e.g., precipitation in combination with adsorption chromatography. In cases where the purification comprises two or more methods used in combination, the methods can be combined in any order to purify aHPBCD product. In an illustrative example, KLEPTOSE® HBP or TRAPPSOL® Cyclo canfirst be subjected to adsorption chromatography, then one or more selected fractions from the chromatographic step can be subjected to solvent precipitation from a precipitation solvent system to effect further purification. In an alternative example, KLEPTOSE® HBP can first be subjected to solvent precipitation from a precipitation solvent system, then the precipitate can be subjected to adsorption chromatography to effect further purification.

[0126] In some embodiments, the purification of one or more HPBCD products, e.g.,KLEPTOSE® HBP or TRAPPSOL® Cyclo, results in an increase in DSadue to removal of unsubstituted (DS=0) and / or monosubstituted (DS=1) beta-cyclodextrins. In an illustrative example, a commercial sample of KLEPTOSE® HBP having DSa=4.34 contains 0.6% unsubstituted beta-cyclodextrins (DS=0) and 3.68% monosubstituted beta-cyclodextrins (DS=1). The DSa after removal of the DS=0 and DS=1 species can be calculated using the following equations: x(0)+y(1)+z(DSa)=4.34 x+y+z=1 wherein x=fraction of unsubstituted beta-cyclodextrins; y=fraction of monosubstituted beta- cyclodextrins; z=fraction of beta-cyclodextrins with DS≧2. In this instance, the DSa of the resulting sample after removal of beta-cyclodextrins having DS=0 and DS=1 is 4.5.

[0127] Accordingly, in certain embodiments the present disclosure provides a method forpurifying one or more HPBCD products selected from KLEPTOSE® HBP, KLEPTOSE® HP,TRAPPSOL® Cyclo, and CAVASOL® W7 HP Pharma, particularly KLEPTOSE® HBP orTRAPPSOL® Cyclo, wherein the purification method reduces in the product the amount of propylene glycol or propylene glycol oligomers (e.g., by solvent precipitation) and / or the amountof unsubstituted beta-cyclodextrin (DS=0) and / or the amount of monosubstituted beta-cyclodextrin (DS=1) (e.g., by adsorption chromatography). In certain of such embodiments,wherein the amount of unsubstituted beta-cyclodextrin (DS=0) and / or the amount ofmonosubstituted beta-cyclodextrin (DS=1) in the product is reduced, the purified productexhibits an increased DSa. Hence, in certain embodiments the present disclosure provides amethod for increasing the DSa of one or more HPBCD products selected from KLEPTOSE®HBP, KLEPTOSE® HP, TRAPPSOL® Cyclo, and CAVASOL® W7 HP Pharma, particularly KLEPTOSE® HBP or TRAPPSOL® Cyclo, the method comprising reducing the amount ofunsubstituted beta-cyclodextrin (DS=0) and / or monosubstituted beta-cyclodextrin (DS=1) in theproduct, for example, according one or more purification steps described herein, such as adsorption chromatography.

[0128] Although KLEPTOSE® HBP, KLEPTOSE® HP, TRAPPSOL® Cyclo, andCAVASOL® W7 HP Pharma each have a reported DSa, as discussed above, DSa is an averagemeasure, and therefore each of these HPBCD products is comprised of HPBCDs with varyingDS values. In some embodiments, the pharmaceutically active ingredient described herein isobtained by isolating from one or more of these products one or more HPBCD fractions with aDSadescribed herein.

[0129] In some embodiments, the pharmaceutical composition contains less than about 10 IU,such as less than about 6, about 5, about 4, about 3, about 2, about 1.5, about 1.2, about 1 IU, about 0.8 IU, about 0.6 IU, about 0.5 IU, about 0.4 IU, about 0.3 IU, about 0.2 IU, about 0.1 IU, about 0.07 IU, or about 0.05 IU endotoxin per gram of pharmaceutically active ingredient. In some embodiments, the pharmaceutical composition contains a level of bacterial endotoxin in a range of from about 0.05 IU to about 10 IU, e.g., about 0.05 IU to about 6 IU, about 0.05 IU to about 5 IU, about 0.05 IU to about 4 IU, about 0.05 IU to about 3 IU, about 0.05 IU to about 2 IU, about 0.05 IU to about 1.5 IU, about 0.05 IU to about 1.2 IU, about 0.05 IU to about 1 IU, about 0.05 IU to about 0.8 IU, about 0.05 IU to about 0.6 IU, about 0.05 IU to about 0.5 IU, about 0.05 IU to about 0.4 IU, about 0.05 IU to about 0.3 IU, about 0.05 IU to about 0.2 IU, orabout 0.05 IU to about 0.1 IU endotoxin per gram of the beta-cyclodextrin mixture.

[0130] In certain embodiments, the pharmaceutical composition comprises no more than(“NMT”) 5 EU / g beta-cyclodextrin mixture, NMT 4 EU / g beta-cyclodextrin mixture, NMT 3EU / g beta-cyclodextrin mixture, or no more than 2 EU / g beta-cyclodextrin mixture. In preferredembodiments, the pharmaceutical composition comprises NMT 1.5 EU / g beta-cyclodextrin mixture. In certain embodiments, the pharmaceutical composition comprises NMT1.4 EU / g beta-cyclodextrin mixture, NMT 1.3 EU / g beta-cyclodextrin mixture, NMT 1.2EU / g beta-cyclodextrin mixture, NMT 1.1 EU / g beta-cyclodextrin mixture, or NMT 1.0EU / g beta-cyclodextrin mixture.

[0131] Pharmaceutical compositions comprising mixtures of HPBCDs may contain impuritiesarising from the synthesis of hydroxypropyl beta-cyclodextrins. Such impurities may include unreacted starting materials such as unsubstituted beta-cyclodextrins and propylene oxide, and reaction by-products such as propylene glycol and propylene glycol oligomers. In certain embodiments, the pharmaceutical compositions described herein exhibit reduced levels of one or more of such impurities.

[0132] In some embodiments, the pharmaceutically active ingredient comprises less than about1%, such as less than about 0.9%, 0.8%, 0.7%, 0.6%, or 0.5%, propylene glycol, determined according to the USP Hydroxypropyl Betadex monograph. In various embodiments, the pharmaceutically active ingredient comprises less than about 0.4%, 0.3%, 0.2% or 0.1%propylene glycol, determined according to the USP Hydroxypropyl Betadex monograph. Incertain embodiments, the pharmaceutical composition comprises less than about 0.09%, 0.08%, 0.07%, or less than about 0.05% propylene glycol, determined according to the USP Hydroxypropyl Betadex monograph. In currently preferred embodiments, the pharmaceutically active ingredient comprises no more than 0.5% propylene glycol, determined according to the USP Hydroxypropyl Betadex monograph.

[0133] In some embodiments, the pharmaceutically active ingredient comprises from about0.05% to about 1% propylene glycol, such as about 0.05% to about 0.8%, about 0.05% to about 0.6%, about 0.05% to about 0.5%, about 0.05% to about 0.4%, about 0.05% to about 0.3%, about 0.05% to about 0.2%, about 0.05% to about 0.1%, about 0.05% to about 0.07%, about 0.07% to about 1%, about 0.07% to about 0.8%, about 0.07% to about 0.6%, about 0.07% to about 0.5%, about 0.07% to about 0.4%, about 0.07% to about 0.3%, about 0.07% to about 0.2%, about 0.07% to about 0.1%, about 0.1% to about 1%, about 0.1% to about 0.8%, about 0.1% to about0.6%, about 0.1% to about 0.5%, about 0.1% to about 0.4%, about 0.1% to about 0.3%, about 0.1% to about 0.2%, about 0.2% to about 1%, about 0.2% to about 0.8%, about 0.2% to about 0.6%, about 0.2% to about 0.5%, about 0.2% to about 0.4%, about 0.2% to about 0.3%, about 0.3% to about 1%, about 0.3% to about 0.8%, about 0.3% to about 0.6%, about 0.3% to about 0.5%, about 0.3% to about 0.4%, about 0.4% to about 1%, about 0.4% to about 0.8%, about 0.4% to about 0.6%, about 0.4% to about 0.5%, about 0.5% to about 1%, about 0.5% to about 0.8%, about 0.5% to about 0.6%, about 0.6% to about 1%, about 0.6% to about 0.8%, or about0.8% to about 1.0%, determined according to the USP Hydroxypropyl Betadex monograph.

[0134] In some embodiments, the pharmaceutically active ingredient comprises less than about0.01% propylene glycol monomers, determined according to the USP Hydroxypropyl Betadexmonograph. In some embodiments, the pharmaceutically active ingredient comprises less thanabout 0.2% propylene glycol dimers, determined according to the USP Hydroxypropyl Betadexmonograph. In some embodiments, the pharmaceutically active ingredient comprises less thanabout 0.2% propylene glycol trimers, determined according to the USP Hydroxypropyl Betadexmonograph.

[0135] In some embodiments, the pharmaceutically active ingredient contains less than about 1ppm, such as less than about 0.8 ppm, less than about 0.6 ppm, less than about 0.5 ppm, less than about 0.4 ppm, less than about 0.3 ppm, less than about 0.2 ppm, less than about 0.1 ppm, less than about 0.07 ppm, or less than about 0.05 ppm, propylene oxide, determined according to the USP Hydroxypropyl Betadex monograph. For example, the pharmaceutically active ingredient can have about 1, about 0.8, about 0.6, about 0.5, about 0.4, about 0.3, about 0.2, about 0.1, about 0.07, or about 0.05 ppm propylene oxide, determined according to the USP Hydroxypropyl Betadex monograph.

[0136] In some embodiments, the pharmaceutically active ingredient has an amount of propyleneoxide in a range of from about 0.05 to about 1 ppm, such as about 0.05 to about 0.8, about 0.05 to about 0.6, about 0.05 to about 0.5, about 0.05 to about 0.4, about 0.05 to about 0.3, about 0.05 to about 0.2, about 0.05 to about 0.1, about 0.1 to about 1, about 0.1 to about 0.8, about 0.1 to about 0.6, about 0.1 to about 0.5, about 0.1 to about 0.4, about 0.1 to about 0.3, about 0.1 to about 0.2, about 0.2 to about 1, about 0.2 to about 0.8, about 0.2 to about 0.6, about 0.2 to about 0.5, about 0.2 to about 0.4, about 0.2 to about 0.3, about 0.3 to about 1, about 0.3 to about 0.8, about 0.3 to about 0.6, about 0.3 to about 0.5, about 0.3 to about 0.4, about 0.4 to about 1, about0.4 to about 0.8, about 0.4 to about 0.6, about 0.4 to about 0.5, about 0.5 to about 1, about 0.5 to about 0.8, about 0.5 to about 0.6, about 0.6 to about 1, about 0.6 to about 0.8, or about 0.8 to about 1 ppm, determined according to the USP Hydroxypropyl Betadex monograph.

[0137] HPBCD compositions comprising a pharmaceutically active ingredient of the disclosureand, optionally, one or more additional therapeutic agents, such as the combination therapeutic agents described in Section 6.3.3., are provided herein.

[0138] In certain embodiments, the pharmaceutical composition comprises about 100 mg toabout 2000 mg, such as about 100 to about 1800, about 100 to about 1600, about 100 to about 1500, about 100 to about 1200, about 100 to about 1000, about 100 to about 800, about 100 to about 600, about 100 to about 500, about 100 to about 400, about 100 to about 300, about 100 to about 200, about 200 to about 2000, about 200 to about 1800, about 200 to about 1600, about 200 to about 1500, about 200 to about 1200, about 200 to about 1000, about 200 to about 800, about 200 to about 600, about 200 to about 500, about 200 to about 400, about 200 to about 300, about 300 to about 2000, about 300 to about 1800, about 300 to about 1600, about 300 to about 1500, about 300 to about 1200, about 300 to about 1000, about 300 to about 800, about 300 to about 600, about 300 to about 500, about 300 to about 400, about 400 to about 2000, about 400 to about 1800, about 400 to about 1600, about 400 to about 1500, about 400 to about 1200, about 400 to about 1000, about 400 to about 800, about 400 to about 600, about 400 to about 500, about 500 to about 2000, about 500 to about 1800, about 500 to about 1600, about 500 to about 1500, about 500 to about 1200, about 500 to about 1000, about 500 to about 800, about 500 to about 600, about 600 to about 2000, about 600 to about 1800, about 600 to about 1600, about 600 to about 1500, about 600 to about 1200, about 600 to about 1000, about 600 to about 800, about 800 to about 2000, about 800 to about 1800, about 800 to about 1600, about 800 to about 1500, about 800 to about 1200, or about 800 to about 1000 mg of the pharmaceutically active ingredient. For example, the pharmaceutical composition can comprise about 100, about 200, about 300, about 400, about 500, about 600, about 800, about 1000, about 1200, about 1400, about 1500, about 1600, about 1800, or about 2000 mg of the pharmaceutically active ingredient.

[0139] In some embodiments, the pharmaceutical composition for administration, for example, apharmaceutical composition suitable for intrathecal administration, has a concentration of about 10 mg / mL to about 200 mg / mL, such as about 10 to about 180, about 10 to about 150, about 10 to about 120, about 10 to about 100, about 10 to about 80, about 10 to about 60, about 10 toabout 50, about 10 to about 40, about 10 to about 30, about 10 to about 20, about 20 to about 200, about 20 to about 180, about 20 to about 150, about 20 to about 120, about 20 to about 100, about 20 to about 80, about 20 to about 60, about 20 to about 50, about 20 to about 40, about 20 to about 30, about 30 to about 200, about 30 to about 180, about 30 to about 150, about 30 to about 120, about 30 to about 100, about 30 to about 80, about 30 to about 60, about 30 to about 50, about 30 to about 40, about 40 to about 200, about 40 to about 180, about 40 to about 150, about 40 to about 120, about 40 to about 100, about 40 to about 80, about 40 to about 60, about 40 to about 50, about 50 to about 200, about 50 to about 180, about 50 to about 150, about 50 to about 120, about 50 to about 100, about 50 to about 80, about 50 to about 60, about 60 to about 200, about 60 to about 180, about 60 to about 150, about 60 to about 120, about 60 to about 100, about 60 to about 80, about 80 to about 200, about 80 to about 180, about 80 to about 150, about 80 to about 120, about 80 to about 100, about 100 to about 200, about 100 to about 180, about 100 to about 150, about 100 to about 120, about 120 to about 200, about 120 to about 180, about 120 to about 150, about 150 to about 200, about 150 to about 180, or about 180 to about 200 mg / mL of the pharmaceutically active ingredient. For example, the pharmaceutical composition can have a concentration of about 10, about 20, about 30, about 40, about 50, about 60, about 70, about 80, about 90, about 100, about 110, about 120, about 130, about 140, about 150, about 160, about 170, about 180, about 190, or about 200 mg / mL of the pharmaceutically active ingredient. In certain embodiments, the pharmaceutical composition for intrathecal administration has a concentration of about 200 mg / mL of the pharmaceutically active ingredient.

[0140] In certain embodiments, the pharmaceutical compositions described herein exhibit a lowlevel of ototoxicity when administered to an animal. In some embodiments, the pharmaceutical composition exhibits a lower ototoxicity than TRAPPSOL® Cyclo. The ototoxicity can be assessed in vitro by toxicity in a House Ear Institute-organ of Corti 1 (HEI-OC1) cell or in vivo by a brainstem auditory evoked response (BAER) test in an animal, such as a mouse, a rat, a cat, a dog, a monkey, a chimpanzee, or a human. See, for example, Leigh-Paffenroth, E. et al. “Objective Measures of Ototoxicity,” Sept.2005, vol. 9, No.1, pages 10-16, in Perspectives on Hearing and Hearing Disorders: Research and Diagnostics, Special Interest Division 6 of the American Speech-Language-Hearing Association, incorporated herein by reference in its entirety.

[0141] In some embodiments, the pharmaceutical composition, e.g., a pharmaceuticalcomposition suitable for intrathecal administration, has an osmolality in a range of from about 300 to about 450 mOsm / kg, e.g., about 300 to about 400, about 300 to about 350, about 350 to about 450, or about 350 to about 400 mOsm / kg. In some embodiments, the composition has an osmolality of about 300, about 320, about 350, about 380, about 400, about 420, or about 450 mOsm / kg.

[0142] In some embodiments, the compositions described herein are suitable for intravenous orintrathecal injection to a human subject in need thereof and have a mean osmolality of 291.21mOsm / kg ± 15%, ± 10%, or ± 5%. In some embodiments, the compositions described hereinsuitable for intravenous injection to a human subject in need thereof and have a mean osmolalityof 286.67 mOsm / kg with a standard deviation of ≤ 10.00, ≤ 9.50, ≤ 9.00, ≤ 8.50, ≤ 8.00, ≤ 7.50,≤ 7.00, ≤ 6.50, ≤ 6.00, ≤ 5.50, ≤ 5.00. In some embodiments, the compositions described hereinare suitable for intravenous or intrathecal injection to a human subject in need thereof and have amean osmolality of 286.67 mOsm / kg ± 15%, ± 10%, or ± 5%. In some embodiments, thecompositions described herein suitable for intravenous or intrathecal injection and have a meanosmolality of 286.67 mOsm / kg with a standard deviation of ≤ 10.00, ≤ 9.50, ≤ 9.00, ≤ 8.50, ≤8.00, ≤ 7.50, ≤ 7.00, ≤ 6.50, ≤ 6.00, ≤ 5.50, ≤ 5.00. In some embodiments, the compositions described herein are stable and suitable for intravenous injection for up to 36 months aftermanufacture and have a mean osmolality of 288.35 mOsm / kg ± 15%, ± 10%, or ± 5%. In someembodiments, the compositions described herein suitable for intravenous injection and have amean osmolality of 286.67 mOsm / kg with a standard deviation of ≤ 15.00, ≤ 14.50, ≤ 14.00, ≤13.50, ≤ 13.00, ≤ 12.50, ≤ 12.00, ≤ 11.50, ≤ 11.00, ≤ 10.50, ≤ 10.00, ≤ 9.50, ≤ 9.00, ≤ 8.50, ≤ 8.00, ≤ 7.50, ≤ 7.00, ≤ 6.50, ≤ 6.00, ≤ 5.50, ≤ 5.00. In some embodiments, the human subject in need thereof is a pediatric patient. In some embodiments, the pediatric patient is a toddler, infantor newborn (e.g., 0-6 years of age). In some embodiments, the pediatric patient is less than 6months old, less than 3 months old, less than 2 months old, less than 1 month old, less than 3 weeks old, less than 2 weeks old, or less than 1 week old. In some embodiments, the pediatricpatient is diagnosed after birth, at birth, or before birth (e.g., via genetic testing of the humansubject or via genetic testing of one or more family member(s) of the human subject).

[0143] Suitable diluents for pharmaceutical compositions as described herein, e.g.,pharmaceutical compositions suitable for intravenous, intrathecal, or intracerebroventricularadministration, include isotonic saline solutions. Compositions, such as pharmaceutical composition suitable for intrathecal administration, may also be diluted with Elliotts B® solution (buffered intrathecal electrolyte / dextrose injection from Lukare Medical, LLC, Scotch Plains, New Jersey, USA).

[0144] In some embodiments, the pharmaceutical composition for injection is made bydissolving the Active Pharmaceutical Ingredient (the mixture of beta-cyclodextrin molecules) in water, adding sodium chloride to 0.9% w / v, and adjusting pH to 6.0-8.0 as necessary with 0.01N sodium hydroxide. The pharmaceutical composition is then sterile filtered into vials and autoclaved. The product is stable and can be stored at 15-25ºC.

[0145] The compositions will usually be supplied as part of a sterile, pharmaceuticalcomposition that will normally include a pharmaceutically acceptable carrier. This composition can be in any suitable form (depending upon the desired method of administration). For example, the pharmaceutical composition can be formulated as an aqueous solution and administered by intrathecal injection or intrathecal infusion.

[0146] In some embodiments, pharmaceutical compositions comprise unit dose forms thatcontain an amount of a pharmaceutically active ingredient of the disclosure per dose. Such a unit can contain for example but without limitation about 5 mg to about 5 g, for example 5 mg to about 4 g, 5 mg to about 3 g, 5 mg to about 2 g, 5 mg to about 1 g, about 50 mg to about 5 g, about 50 mg to about 4 g, about 50 mg to about 3 g, about 50 mg to about 2 g, about 50 mg to about 1 g, about 200 mg to about 5 g, about 200 mg to about 4 g, about 200 mg to about 3 g, about 200 mg to about 2 g, about 200 mg to about 1 g, about 400 mg to about 5 g, about 400 mg to about 4 g, about 400 mg to about 3 g, about 400 mg to about 2 g, about 400 mg to about 1 g, about 500 mg to about 5 g, about 500 mg to about 4 g, about 500 mg to about 3 g, about 500 mg to about 2 g, about 500 mg to about 1 g, about 600 mg to about 5 g, about 600 mg to about 4 g, about 600 mg to about 3 g, about 600 mg to about 2 g, about 600 mg to about 1 g, about 800 mg to about 5 g, about 800 mg to about 4 g, about 800 mg to about 3 g, about 800 mg to about 2 g, about 800 mg to about 1 g, about 1 g to about 5 g, about 1 g to about 4 g, about 1 g to about 3 g, about 1 g to about 2 g, about 1200 mg to about 5 g, about 1200 mg to about 4 g, about 1200 mg to about 3 g, about 1200 mg to about 2 g, about 1400 mg to about 5 g, about 1400 mg to about 4 g, about 1400 mg to about 3 g, about 1400 mg to about 2 g, about 1600 mg to about 5 g, about 1600 mg to about 4 g, about 1600 mg to about 3 g, about 1600 mg to about 2 g, about 1800 mgto about 5 g, about 1800 mg to about 4 g, about 1800 mg to about 3 g, or about 1800 mg to about 2 g of the pharmaceutically active ingredient. Certain embodiments include unit doses that contain about 900 mg, about 1200 mg, and about 1800 mg of the pharmaceutically active ingredient.

[0147] In certain embodiments, the unit dose can contain between about 200 mg and about 900mg of the pharmaceutically active ingredient of the disclosure, such as about 200 mg, about 250 mg, about 300 mg, about 350 mg, about 400 mg, about 450 mg, about 500 mg, about 550 mg, about 600 mg, about 650 mg, about700 mg, about 750 mg, about 800 mg, about 850 mg, or about 900 mg of the pharmaceutically active ingredient. In certain embodiments, the unit dose may be adjusted based on patient mass and / or weight.

[0148] Pharmaceutical compositions of the HPBCD mixtures of the disclosure can be preparedfor storage as lyophilized formulations or aqueous solutions by mixing the pharmaceutically active ingredient having the desired degree of purity with optional pharmaceutically-acceptable carriers, excipients or stabilizers typically employed in the art (all of which are referred to herein as “carriers”), i.e., buffering agents, stabilizing agents, preservatives, isotonifiers, non-ionic detergents, antioxidants, and other miscellaneous additives. See, Remington’s Pharmaceutical Sciences, 16th edition (Osol, ed.1980).

[0149] In some embodiments, buffering agents are used to help to maintain the pH in the rangethat approximates physiological conditions from about 2 mM to about 50 mM, such as about 2 to about 40, about 2 to about 30, about 2 to about 20, about 2 to about 10, about 10 to about 50, about 10 to about 40, about 10 to about 30, about 10 to about 20, about 20 to about 50, about 20 to about 40, about 20 to about 30, or about 40 to about 50 mM. For example, one or more buffering agents can be present at a concentration of about 2, about 5, about 10, about 15, about 20, about 25, about 30, about 35, about 40, about 45, or about 50 mM. Suitable buffering agents for use with the present disclosure include both organic and inorganic acids and salts thereof, such as citrate buffers (e.g., monosodium citrate-disodium citrate mixture, citric acid-trisodium citrate mixture, citric acid-monosodium citrate mixture, etc.), succinate buffers (e.g., succinic acid-monosodium succinate mixture, succinic acid-sodium hydroxide mixture, succinic acid- disodium succinate mixture, etc.), tartrate buffers (e.g., tartaric acid-sodium tartrate mixture, tartaric acid-potassium tartrate mixture, tartaric acid-sodium hydroxide mixture, etc.), fumarate buffers (e.g., fumaric acid-monosodium fumarate mixture, fumaric acid-disodium fumaratemixture, monosodium fumarate-disodium fumarate mixture, etc.), gluconate buffers (e.g., gluconic acid-sodium glyconate mixture, gluconic acid-sodium hydroxide mixture, gluconic acid-potassium glyuconate mixture, etc.), oxalate buffer (e.g., oxalic acid-sodium oxalate mixture, oxalic acid-sodium hydroxide mixture, oxalic acid-potassium oxalate mixture, etc.), lactate buffers (e.g., lactic acid-sodium lactate mixture, lactic acid-sodium hydroxide mixture, lactic acid-potassium lactate mixture, etc.) and acetate buffers (e.g., acetic acid-sodium acetate mixture, acetic acid-sodium hydroxide mixture, etc.). Additionally, phosphate buffers, histidine buffers and trimethylamine salts such as Tris can be used.

[0150] In some embodiments, preservatives are added to retard microbial growth, in amountsranging from 0.01%-1% (w / v), such as 0.1%-1%, 0.2%-1%, 0.3%-1%, 0.5%-1%, 0.01%-0.5%, 0.02%-0.5%, 0.05%-0.5%, 0.1%-0.5%, 0.2%-0.5%, or 0.05%-0.2% (w / v). For example, a preservative in an amount of about 0.02%, about 0.05%, about 0.1%, about 0.2%, about 0.5%, about 0.8% (w / v) can be added. Suitable preservatives for use with the present disclosure include phenol, benzyl alcohol, meta-cresol, methyl paraben, propyl paraben, octadecyldimethylbenzyl ammonium chloride, benzalconium halides (e.g., chloride, bromide, and iodide), hexamethonium chloride, and alkyl parabens such as methyl or propyl paraben, catechol, resorcinol, cyclohexanol, and 3-pentanol.

[0151] In some embodiments, isotonifiers sometimes known as “stabilizers” are added to ensureisotonicity of liquid compositions of the present disclosure and include polyhydric sugar alcohols, for example trihydric or higher sugar alcohols, such as glycerin, erythritol, arabitol, xylitol, sorbitol and mannitol. Stabilizers refer to a broad category of excipients which can range in function from a bulking agent to an additive which solubilizes the therapeutic agent or helps to prevent denaturation or adherence to the container wall. Typical stabilizers can be polyhydric sugar alcohols (enumerated above); amino acids such as arginine, lysine, glycine, glutamine, asparagine, histidine, alanine, ornithine, L-leucine, 2-phenylalanine, glutamic acid, threonine, etc., organic sugars or sugar alcohols, such as lactose, trehalose, stachyose, mannitol, sorbitol, xylitol, ribitol, myoinisitol, galactitol, glycerol and the like, including cyclitols such as inositol; polyethylene glycol; amino acid polymers; sulfur containing reducing agents, such as urea, glutathione, thioctic acid, sodium thioglycolate, thioglycerol, α-monothioglycerol and sodium thio sulfate; low molecular weight polypeptides (e.g., peptides of 10 residues or fewer); proteins such as human serum albumin, bovine serum albumin, gelatin or immunoglobulins; hydrophylicpolymers, such as polyvinylpyrrolidone monosaccharides, such as xylose, mannose, fructose, glucose; disaccharides such as lactose, maltose, sucrose and trisaccacharides such as raffinose; and polysaccharides such as dextran. In some embodiments, stabilizers are present in the range from 0.1 to 10,000 weights per part of weight of pharmaceutically active ingredient, such as 0.1 to 1,000, 0.2 to 2,000, 0.5 to 5,000, 1 to 10,000, or 1 to 1,000 weights per part of weight of pharmaceutically active ingredient. For example, stabilizers can be present in about 0.2, about 0.5, about 1, about 5, about 10, about 20, about 50, about 100, about 200, about 500, about 1,000, about 2,000, about 5,000, or about 8,000 weights per part of weight of pharmaceutically active ingredient.

[0152] In some embodiments, ionic surfactants are added to help solubilize the therapeutic agentas well as to protect the active ingredient against agitation-induced aggregation. In some embodiments, non-ionic surfactants or detergents (also known as “wetting agents”) are added to help solubilize the therapeutic agent as well as to protect the active ingredient against agitation- induced aggregation. Suitable non-ionic surfactants include polysorbates (20, 80, etc.), polyoxamers (184, 188 etc.), Pluronic polyols, polyoxyethylene sorbitan monoethers (TWEEN®-20, TWEEN®-80, etc.). In some embodiments, non-ionic surfactants are present in a range of from about 0.05 mg / mL to about 1.0 mg / mL, such as about 0.05 mg / mL to about 0.2 mg / mL, about 0.07 mg / mL to about 0.2 mg / mL, about 0.1 mg / mL to about 0.3 mg / mL, or about 0.1 mg / mL to about 0.5 mg / mL. For instance, non-ionic surfactants can be present in about 0.05, about 0.07, about 0.08, about 0.1, about 0.2, about 0.3, about 0.4, about 0.5, about 0.6, about 0.8, or about 1.0 mg / mL.

[0153] Additional miscellaneous excipients include bulking agents (e.g., starch), chelatingagents (e.g., EDTA), antioxidants (e.g., ascorbic acid, methionine, vitamin E), and cosolvents.

[0154] In some embodiments, the pharmaceutical composition herein also contains acombination of therapeutic agents, e.g., a second therapeutic agent in addition to the pharmaceutically active ingredient of the disclosure (the mixture of beta-cyclodextrins described herein). Examples of suitable combination therapeutic agents are provided in Section 6.3.3. below.

[0155] In some embodiments, the pharmaceutical compositions described herein solubilize lipidsin an aqueous medium. The aqueous medium can be, for example, distilled water or deionized water, or can be an aqueous environment, e.g., blood, cerebrospinal fluid, or lymphatic fluid, inthe body of a subject. The solubilizing ability of the compositions can be typically measured by UV transmission properties of the solution, e.g., as monitored by UV spectrometry or by HPLC, with a decrease in transmission correlating with formation of a suspension within the solution. In some embodiments, the lipids that are solubilized comprise unesterified or esterified cholesterol; cholesterol metabolites, e.g., 7-ketocholesterol, 7α-hydroxycholesterol, 24S-hydroxycholesterol, 25-hydroxycholesterol, 27-hydroxycholesterol, and cholestane-3β,5α,6β-triol; sphingolipids; glycolipids; ceramides; gangliosides, e.g., GM2 ((2S,3R,4E)-3-Hydroxy-2- (octadecanoylamino)octadec-4-en-1-yl 2-acetamido-2-deoxy-β-D-galactopyranosyl-(1→4)-[5- acetamido-3,5-dideoxy-D-glycero-α-D-galacto-non-2-ulopyranonosyl-(2→3)]-β-D-galactopyranosyl-(1→4)-β-D-glucopyranoside) or GM3 (monosialodihexosylganglioside); orany combination thereof.

[0156] As used herein, a weight per volume (“weight / volume” or “w / v”) solution refers to theweight of a solute dissolved in a volume of water. In an illustrative example, a 10% (w / v) solution of hydroxypropyl beta-cyclodextrins has 1 g of the solute in 10 mL of the aqueous solution. In another example, a 20% (w / v) solution of hydroxypropyl beta-cyclodextrins has 200 mg of the solute in 1 mL of the aqueous solution.

[0157] In some embodiments, 1 mL of a 20% (w / v) solution of the pharmaceutically activeingredient described herein solubilizes at least 2 mg, such as at least 3 mg, at least 4 mg, at least 5 mg, at least 6 mg, at least 7 mg, at least 8 mg, or at least 10 mg, of unesterified cholesterol in distilled water at room temperature when measured, e.g., by UV spectrometry, after about 24 hours. In some embodiments, about 200 mg of the pharmaceutically active ingredient solubilizes at least 2 mg, such as at least 3 mg, at least 4 mg, at least 5 mg, at least 6 mg, at least 7 mg, atleast 8 mg, or at least 10 mg of unesterified cholesterol in distilled water at room temperaturewhen measured after about 24 hours.3. Methods of treating NPC

[0158] Provided herein is a method of treating NPC in a subject in need thereof, which maycomprise administering an HPBCD composition disclosed herein. Further provided are use of the HPBCD composition in the manufacture of a medicament for treating NPC in a subject and the HPBCD composition for use in treating NPC in a subject. The subject may have one or more characteristics described herein.

[0159] As used herein, a “subject” is a human. The subject may be a pediatric patient or an adultpatient. Pediatric human patients include pediatric patients with disease characterized at early- infantile onset (less than 2 years of age), late-infantile onset (2 to less than 6 years of age),infantile onset (less than 6 years of age), juvenile onset (6 to less than 15 years of age) andadolescent onset (15 years of age or greater). The subject may be 6 to 18 years of age. Thesubject may be no older than 6 years of age. The subject may be 2-6 years of age or 2-4 years ofage. The NPC may be spontaneous.

[0160] Provided herein is a method of increasing survival of a subject with infantile-onset NPC,which may comprise administering an HPBCD composition disclosed herein to the subject. Further provided are use of the HPBCD composition in the manufacture of a medicament for increasing survival of a subject with infantile-onset NPC and the HPBCD composition for use inincreasing survival of a subject with infantile-onset NPC. The HPBCD composition mayincrease the likelihood of survival of the subject by at least 1.5, 2, 2.5, or 2.7 times after 5 years as compared to a population of untreated subjects with infantile-onset NPC. The HPBCD composition may increase the likelihood of survival of the subject for at least 1 year, at least 2 years, at least 3 years, at least 4 years, at least 5 years, at least 6 years, at least 7 years, at least 8 years, at least 9 years, or at least 10 years as compared to a population of untreated subjects with infantile-onset NPC.

[0161] The HPBCD composition may also prevent or decrease the onset of NPC symptoms forthe subject for at least 1 year, at least 2 years, at least 3 years, at least 4 years, at least 5 years, at least 6 years, at least 7 years, at least 8 years, at least 9 years, or at least 10 years as compared to a population of untreated subjects with infantile-onset NPC. This improvement in preventing the onset of NPC symptoms for the subject is also a surprising and unexpected result.

[0162] Provided herein is a method of increasing cholesterol release by neuronal cells in asubject with infantile-onset NPC, which may comprise administering an HPBCD composition disclosed herein to the subject. Further provided are use of the HPBCD composition in themanufacture of a medicament for increasing cholesterol release by neuronal cells in a subjectwith infantile-onset NPC and the HPBCD composition for use in increasing cholesterol release by neuronal cells in a subject with infantile-onset NPC. The cholesterol release may be indicatedby an increase in 24-hydroxycholesterol (24-OHC) levels in the subject after being administeredthe HPBCD composition as compared to 24-OHC levels measured in the subject beforereceiving the HPBCD composition. The increase may be at least 10, 15, 20, or 25%. Theincrease may be at about 10, 20, 30, 40 or 52 weeks after the start of administering the HPBCD composition.

[0163] Provided herein is a method of decreasing death of neuronal cells and neurodegenerationin a subject with infantile-onset NPC, which may comprise administering an HPBCD composition disclosed herein to the subject. Further provided are use of the HPBCD compositionin the manufacture of a medicament for decreasing death of neuronal cells andneurodegeneration in a subject with infantile-onset NPC and the HPBCD composition for use indecreasing death of neuronal cells and neurodegeneration in a subject with infantile-onset NPC.The neuronal cell death may be indicated by a decrease in one or more of Fatty acid-binding protein 3 (FABP3) and Calbindin D levels in the subject after being administered the HPBCD composition as compared to FABP3 and Calbindin D levels, respectively, measured in thesubject before receiving the HPBCD composition. The decrease may be at least 25, 30, 35, 40,45, 50, 55, or 60%. The decrease may be at about 10, 20, 30, 40 or 52 weeks after the start ofadministering the HPBCD composition.

[0164] Provided herein is a method of improving or stabilizing symptoms of NPC in a subjectwith infantile-onset NPC, which may comprise administering an HPBCD composition disclosed herein to the subject. Further provided are use of the HPBCD composition in the manufacture of a medicament for improving or stabilizing symptoms of NPC in a subject with infantile-onset NPC and the HPBCD composition for use in improving or stabilizing symptoms of NPC in a subject with infantile-onset NPC.

[0165] Provided herein are characteristics of subjects who are to be treated with an HPBCDcomposition, which may at one or more of a dose and mode of administration disclosed herein. The characteristics may comprise one or more molecular markers. The one or more molecular markers may comprise at least one allele of at least one copy of one or more genes of the subject.The allele may comprise a pathogenic mutation. In one example, the gene is NPC1. The genemay be ApoE.

[0166] The subject may carry in a genome one or more mutations in at least one copy of anNPC1 gene. The subject may carry at least two mutations in at least one copy of the NPC1 gene.The subject may carry a first mutation in each of both copies of the NPC1 gene (i.e., may behomozygous mutant), or may carry a first mutation in a first copy of the NPC1 gene and asecond mutation in a second copy of the NPC1 gene (i.e., may be heterozygous mutant). One ormore of the mutations may be a pathogenic mutation. The pathogenic mutation may be a loss offunction mutation or may be a null mutation. The mutation may be in a promoter or may be in anopen reading frame. The mutation may comprise an insertion, a deletion, a frameshift, orpremature stop. In one example, the NPC1 gene comprises NCBI Reference SequenceNM_000271.3, NM_000271.4, or NM_000271.4. The mutation may be described using standard mutation nomenclature in molecular diagnostics. The mutation may be located at a positionwithin the nucleotide sequence of the reference sequence (designated by c.#### where #### isthe nucleic acid position) or at a position within the NPC1 protein encoded by the referencesequence (designated by p.#### wherein #### is the amino acid position). Standard mutationnomenclature in molecular diagnostics is known in the art, such as that described in Ogino (JMol Diagn, Vol. 9, No.1, pp.1-6 (2007)).

[0167] The null mutation may comprise a frame shift at H1029, a frameshift at D721, apremature stop at R348, or M1T. The mutation may be associated with pre-adolescent development of NPC, and may comprise a frameshift at L1248, T1250K, R1186H, F1087L, a premature stop at R1077, I1061T, a premature stop at R1059, a premature stop at Q921, S734I, P691L, R615C, an insertion at 518 causing a premature stop, R404Q, a deletion of S230 and V231, or a frameshift at K142.

[0168] The subject may carry one or more mutations associated with early or late infantile onset.Each mutation may comprise R1186H, I1061T, a frameshift at K142, T1205K, S734I, A1054T, or a premature stop at R1059, deletion of promoter and exon 1, c.385delT, D944N, A1035V, c.1757delA, c.2746_2748delAAT, L380F, R958 stop, C63 frameshift causing premature stop at position 75 in shifted reading frame, C63 frameshift causing premature stop at position 75 in shifted reading frame, T1205R, IVS21-2del ATGC, IVS21-2del ATGC, G1195V, P433L, IVS14+1G>A, T1205 frameshift, T1036M, D501Y, I601F frameshift causing premature stop at position 13 in shifted reading frame, N140K frameshift causing premature stop at position 30 in shifted reading frame, D611G, R726T, P1245R frameshift causing premature stop at position 12 in shifted reading frame, V744S frameshift causing premature stop at position 27 in shifted reading frame, P1245R frameshift causing premature stop at position 12 in shifted reading frame, R518Q, c.2795dupA, R1186H, T1036M, C1168Y, c.3578_3591 + 9del, R934Q, G993E frameshift causing premature stop at position 4 in shifted reading frame, IVS23+1G>A, A605Cframeshift causing premature stop at position 2 in shifted reading frame, A1187R frameshift causing premature stop at position 54 in shifted reading frame, Y276H, P733S frameshift causing premature stop at position 10 in shifted reading frame, c.319delc, nucleotide +5 at intron 18, F703S, S813 stop, Q928P, L1003R, W942C, I962 to F966 deletion, A1035V, C177Y, V959E, c.955+1G>A, C645 stop, F1079S, C976 frameshift, M1127I frameshift causing premature stop at position 131 in shifted frame, K142R frameshift causing premature stop at position 27 in shifted frame, R958 stop, c.2245+1G>A, Q991R frameshift, duplication / multiple copies of exons 10 and 11, C1011 stop, IVS23+1G>A, S151F frameshift causing premature stop at position 18 in shifted frame, C976F frameshift causing premature stop at position 6 in shifted frame, C914S, L472P, c.3478-6T>A, A321G frameshift causing premature stop at position 16 in shifted frame, F284L frameshift causing premature stop at position 26 of shifted frame, Q991R frameshift, R607 stop, C31W frameshift causing premature stop at position 26 in shifted fame, c.464-2A>C, N1156S, T1205N frameshift causing premature stop at position 53 in shifted frame, R934 stop, R958 stop, P691S, F760 deletion, Q119V frameshift causing premature stop at position 8 in shifted frame, H1016L, I1061T, P1007A, R958Q, F284L frameshift causing premature stop at position 26 in shifted frame, deletion of promoter and exons 1-10, Q92R, C119 stop, E1089K, N701K causing premature stop at position 13 in shifted frame, R404Q, 237S, Q775P, or A1132P. The mutations may comprise one of the following combinations ofmutations in the subject’s two copies of NPC1. Table 1 Genotypes associated with early or late infantile onset

[0169] The subject may carry one or more mutations associated with late infantile or juvenileonset. Each mutation may comprise I1061T, a premature stop at R1059, F1087L, P1007A,T1205R, R518Q, T1036M, I1061T, S954L, R518Q, E391G, R518Q, P1007A, R518Q, A165V, R1186H, P474L, Y276H, D944N, P733S frame shift causing a premature stop at position 9 in shifted frame, S954L, A1132P, C1168Y, R404Q, V1378A, IVS23+1G>A, V697A, or A1035V. The mutations may comprise one of the following combinations of mutations in the subject’s two copies of NPC1. Table 2 Genotypes associated with late infantile or juvenile onset

[0170] The subject may carry one or more mutations associated with severe NPC. Each mutationmay comprise a premature stop at R348 or M1T. The mutations may comprise one of thefollowing combinations of mutations in the subject’s two copies of NPC1. Table 3 Genotypes associated with severe NPC

[0171] The subject may carry one or more mutations associated with intermediate onset of NPC.Each mutation may comprise a frameshift at L1248, G992R, a frameshift at H1029, S954L, adeletion at G992, G992W, S954L, or an insertion at position 61. The mutations may compriseone of the following combinations of mutations in the subject’s two copies of NPC1. Table 4 Genotypes associated with intermediate onset

[0172] The subject may carry a variant of an ApoE gene that modifies one or more of NPC1mutations. The ApoE variant may be indicative of more rapid progression of NPC in a subject carrying one or more pathogenic mutations in one or more copies of the NPC1 gene, as compared to a populations of humans who carry the same one or more pathogenic mutations but who do not carry a copy of the ApoE variant. In one example, the variant is ApoE E4. In oneexample, the subject carries a I1061T mutation in one copy of NPC1, a R1059 premature stop in a second copy of NPC1, and is homozygous for ApoE E4.

[0173] If the subject carries one or more mutations in at least one copy of an NPC1 gene that areassociated with early or late infantile onset of NPC, juvenile onset, intermediate onset, or severeNPC, then the subject may be administered an increased dose of HPBCD as compared to a subject who does not carry the one or more mutations. The subject may have received a first dose of a mixture of HPBCD molecules described herein. The subject may be administered a seconddose of a mixture of HPBCD molecules. The second dose may be different from the first dose.The second dose may be higher than the first dose if the subject is determined to have at leastone pathogenic mutation in at least one copy of the NPC1 gene. The second dose may be lowerthan the first dose if the subject is determined not to have a pathogenic mutation in at least onecopy of the NPC1 gene. If the subject is determined to have at least one copy of ApoE E4, thenthe second dose may be higher than the first dose.

[0174] If the subject carries one or more mutations in at least one copy of an NPC1 gene that areassociated with early or late infantile onset of NPC, juvenile onset, intermediate onset or severeNPC, then the subject may be administered HPBCD intrathecally.

[0175] The subject may have a positive filipin test. The filipin staining may have comprisedobtaining skin fibroblasts from the subject, culturing the fibroblasts in a medium deprived ofcholesterol, incubating the fibroblasts in low-density lipoprotein cholesterol-enriched medium for at least 24 hours, fixing the fibroblasts, and staining the fibroblasts with filipin.

[0176] The subject may have an oxysterol level that is consistent with NPC. The oxysterol levelconsistent with NPC may comprise one or more of a level of cholestane-3β,5α,6β-triol greaterthan 0.070 nmol / mL, a level of 7-ketocholesterol greater than 0.100 nmol / mL, and a level of lyso-sphingomyelin greater than 0.100 nmol / mL, as measured in a plasma sample from the subject.

[0177] The subject may not carry a mutation in a NPC2 gene. The subject may have a score of 1-4 in at least two domains of an NPC Clinical Severity Scale (NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing. The subject may have an NPC severity score of 0-3 on a cognition domain of the NPCCSS. The subject may have a totalscore of at least 10 on the NPCCSS. The subject may not have an ambulation score of 5, aswallowing domain score of 5, a fine motor skills domain score of 5, or a cognition domain score of 5, as assessed by the NPCCSS.

[0178] The subject may have vertical gaze palsy. In one example, the subject is positive forfilipin and carries at least one mutation in at least one copy of an NPC1 gene. In anotherexample, the subject has vertical supranuclear gaze palsy; and either: one mutation in one copy of the NPC1 gene; or a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC2 gene.

[0179] The terms “treat”, “treating” or “treatment” refer to administration of a pharmaceuticalcomposition described herein so as to modulate beneficially a level of one or more lipidbiomarkers or therapeutic effects as described herein compared to a baseline level. An exemplarytreatment phase involves a repeat administration of a pharmaceutical composition described herein where the score of one or more domains of the NPC Severity Scale as defined herein reduced compared to a prior baseline value.

[0180] In some embodiments, the method comprises administering about 200 mg to about 3000mg, such as about 200 to about 2800, about 200 to about 2600, about 200 to about 2500, about 200 to about 2400, about 200 to about 2200, about 200 to about 2000, about 200 to about 1800, about 200 to about 1600, about 200 to about 1500, about 200 to about 1200, about 200 to about1100, about 200 to about 1000, about 200 to about 800, about 200 to about 700, about 200 to about 600, about 200 to about 500, about 200 to about 400, about 200 to about 300; about 300 to about 3000, about 300 to about 2800, about 300 to about 2600, about 300 to about 2500, about 300 to about 2400, about 300 to about 2200, about 300 to about 2000, about 300 to about 1800, about 300 to about 1600, about 300 to about 1500, about 300 to about 1200, about 300 to about 1100, about 300 to about 1000, about 300 to about 800, about 300 to about 700, about 300 to about 600, about 300 to about 500, about 300 to about 400; such as from about 400 to about 3000, about 400 to about 2800, about 400 to about 2600, about 400 to about 2500, about 400 to about 2400, about 400 to about 2200, about 400 to about 2000, about 400 to about 1800, about 400 to about 1600, about 400 to about 1500, about 400 to about 1200, about 400 to about 1100, about 400 to about 1000, about 400 to about 800, about 400 to about 700, about 400 to about 600, about 400 to about 500; such as from about 500 to about 3000, about 500 to about 2800, about 500 to about 2600, about 500 to about 2500, about 500 to about 2400, about 500 to about 2200, about 500 to about 2000, about 500 to about 1800, about 500 to about 1600, about 500 to about 1500, about 500 to about 1200, about 500 to about 1100, about 500 to about 1000, about 500 to about 800, about 500 to about 700, about 500 to about 600; such as from about 600 to about 3000, about 600 to about 2800, about 600 to about 2600, about 600 to about 2500, about 600 to about 2400, about 600 to about 2200, about 600 to about 2000, about 600 to about 1800, about 600 to about 1600, about 600 to about 1500, about 600 to about 1200, about 600 to about 1100, about 600 to about 1000, about 600 to about 800, about 600 to about 700; such as from about 700 to about 3000, about 700 to about 2800, about 700 to about 2600, about 700 to about 2500, about 700 to about 2400, about 700 to about 2200, about 700 to about 2000, about 700 to about 1800, about 700 to about 1600, about 700 to about 1500, about 700 to about 1200, about 700 to about 1100, about 700 to about 1000, about 700 to about 800; such as from about 800 to about 3000, about 800 to about 2800, about 800 to about 2600, about 800 to about 2500, about 800 to about 2400, about 800 to about 2200, about 800 to about 2000, about 800 to about 1800, about 800 to about 1600, about 800 to about 1500, about 800 to about 1200, about 800 to about 1100, about 800 to about 1000; such as from about 1000 to about 3000, about 1000 to about 2800, about 1000 to about 2600, about 1000 to about 2500, about 1000 to about 2400, about 1000 to about 2200, about 1000 to about 2000, about 1000 to about 1800, about 1000 to about 1600, about 1000 to about 1500, about 1000 to about 1200, about 1000 to about 1100; such asfrom about 1100 to about 3000, about 1100 to about 2800, about 1100 to about 2600, about 1100 to about 2500, about 1100 to about 2400, about 1100 to about 2200, about 1100 to about 2000, about 1100 to about 1800, about 1100 to about 1600, about 1100 to about 1500, about 1100 to about 1200; such as from about 1200 to about 3000, about 1200 to about 2800, about 1200 to about 2600, about 1200 to about 2500, about 1200 to about 2400, about 1200 to about 2200, about 1200 to about 2000, about 1200 to about 1800, about 1200 to about 1600, about 1200 to about 1500; such as from about 1500 to about 3000, about 1500 to about 2800, about 1500 to about 2600, about 1500 to about 2500, about 1500 to about 2400, about 1500 to about 2200, about 1500 to about 2000, about 1500 to about 1800, about 1500 to about 1600; such as from about 1600 to about 3000, about 1600 to about 2800, about 1600 to about 2600, about 1600 to about 2500, about 1600 to about 2400, about 1600 to about 2200, about 1600 to about 2000, about 1600 to about 1800; such as from about 1800 to about 3000, about 1800 to about 2800, about 1800 to about 2600, about 1800 to about 2500, about 1800 to about 2400, about 1800 to about 2200, about 1800 to about 2000; such as from about 2000 to about 3000, about 2000 to about 2800, about 2000 to about 2600, about 2000 to about 2500, about 2000 to about 2400, about 2000 to about 2200; such as from about 2200 to about 3000, about 2200 to about 2800, about 2200 to about 2600, about 2200 to about 2500, about 2200 to about 2400; such as from about 2400 to about 3000, about 2400 to about 2800, about 2400 to about 2600, about 2400 to about 2500; such as from about 2500 to about 3000, about 2500 to about 2800, about 2500 to about 2600; such as from about 2600 to about 3000, about 2600 to about 2800; or about 2800 to about 3000 mg, of the pharmaceutically active ingredient to the subject per administration.

[0181] In some embodiments, the dosage schedule consists of administration once every week,once every two weeks, once every three weeks, once a month, once every two months, or once every three months. For example, the method can comprise administering about 200, about 300, about 400, about 500, about 600, about 700, about 800, about 900, about 1000, about 1200, about 1400, about 1500, about 1600, about 1800, about 2000, about 2200, about 2400, about 2500, or about 3000 mg of the pharmaceutically active ingredient to the subject per administration.

[0182] In some embodiments, the administering occurs in a single dose per administration. Inother embodiments, the pharmaceutical composition is administered in divided doses, with the overall dose divided into two doses, three doses, or even four doses, per administration, e.g., over a week, two weeks, a month, two months, etc., specifically over two weeks. The compositionmay also be administered continuously, or in any effective range or value therein depending on the condition being treated, the route of administration and the age, weight and condition of the subject.

[0183] In some embodiments, the pharmaceutical compositions of the disclosure are suitable forintrathecal or intracerebroventricular administration. In certain embodiments, intrathecal administration of the pharmaceutical composition is through an intrathecal port. In certain of these embodiments, the port is a CELSITE® port (B. Braun Medical, France). In certain embodiments, the intrathecal administration comprises administering as an intrathecal slow bolus (1-2 minute, depending on the volume administered) lumbar puncture injection (maximum rate of administration = 4.5 mL / minute). In certain embodiments, the techniques of lumbar puncture include use of a non-cutting needle, such as a Whiteacre or Sprotte needle, insertion parallel to dural fibers, and replacing stylet prior to needle removal. In certain embodiments, prior to injection, a volume of CSF fluid equal to the volume to be administered is removed.

[0184] In another illustrative example, intracerebroventricular administration can be through anOmmaya reservoir.

[0185] For treatment of NPC described herein, an effective dose of the pharmaceutically activeingredient, the HPBCD mixture, can range from about 0.001 to about 1000 mg / kg, such as about0.1 to about 1000, about 1 to about 1000, about 10 to about 1000, about 20 to about 1000, about 50 to about 1000, about 100 to about 1000, about 200 to about 1000, about 300 to about 1000, about 400 to about 1000, about 500 to about 1000, about 600 to about 1000, about 800 to about 1000; such as from about 0.1 to about 800, about 1 to about 800, about 10 to about 800, about 20 to about 800, about 50 to about 800, about 100 to about 800, about 200 to about 800, about 300 to about 800, about 400 to about 800, about 500 to about 800, about 600 to about 800; such as from about 0.1 to about 600, about 1 to about 600, about 10 to about 600, about 20 to about 600, about 50 to about 600, about 100 to about 600, about 200 to about 600, about 300 to about 600, about 400 to about 600, about 500 to about 600; such as from about 0.1 to about 500, about 1 to about 500, about 10 to about 500, about 20 to about 500, about 50 to about 500, about 100 to about 500, about 200 to about 500, about 300 to about 500, about 400 to about 500; such as from about 0.1 to about 400, about 1 to about 400, about 10 to about 400, about 20 to about 400, about 50 to about 400, about 100 to about 400, about 200 to about 400, about 300 to about 400; such as from about 0.1 to about 300, about 1 to about 300, about 10 to about 300, about 20 to about 300,about 50 to about 300, about 100 to about 300, about 200 to about 300; such as from about 0.1 to about 200, about 1 to about 200, about 10 to about 200, about 20 to about 200, about 50 to about 200, about 100 to about 200; such as from about 0.1 to about 100, about 1 to about 100, about 10 to about 100, about 20 to about 100, about 50 to about 100; such as from about 0.1 to about 50, about 1 to about 50, about 10 to about 50, about 20 to about 50; such as from about 0.1 to about 20, about 1 to about 20, about 10 to about 20; such as from about 0.1 to about 10, about 1 to about 10; or about 0.1 to about 1 mg / kg.

[0186] In some embodiments, the method comprises a treatment phase wherein theadministering occurs every week, every two weeks, every three weeks, or every month, in order to reduce symptoms of NPC.

[0187] In some embodiments, the method comprises a maintenance phase wherein theadministering occurs every three weeks, every month, every two months, or every three months, in order to maintain a steady state of the disease.

[0188] In some embodiments, the pharmaceutical composition is administered as a bolus,followed by a continuous maintenance dose.

[0189] In certain embodiments, the pharmaceutical composition is administered monthly throughintrathecal or intracerebroventricular administration. In certain embodiments, the pharmaceutical composition is administered continuously through intrathecal or intracerebroventricular administration.

[0190] In some embodiments, the method comprises a treatment phase wherein 900 mg of thepharmaceutically active ingredient is administered to the patient as initial doses and a maintenance phase wherein less than 900 mg of the pharmaceutically active ingredient is administered every other week by intrathecal administration.

[0191] In some embodiments, the method comprises administering the pharmaceutically activeingredient using multiple routes of administration. In certain embodiments, the method comprises administering the pharmaceutically active ingredient (i) intrathecally or by intracerebroventricular administration, and (ii) intravenously. These embodiments usefully allow reduction of cholesterol accumulation in both the central nervous system and peripheral organs.

[0192] In some embodiments, the intravenous administration comprises administering about 200mg / kg to about 4000 mg / kg of the beta-cyclodextrin mixture by intravenous infusion over 6 to 8hours to the patient. In some embodiments, the intravenous administration comprisesadministering about 500 mg / kg to about 4000 mg / kg of the beta-cyclodextrin mixture byintravenous infusion over 6 to 8 hours to the patient.

[0193] In typical embodiments, the pharmaceutical composition comprises about 200 mg / mL ofthe beta-cyclodextrin mixture. In certain other embodiments, the pharmaceutical compositioncomprises about 250 mg / mL of the beta-cyclodextrin mixture. In some embodiments, thepharmaceutical composition is administered once every three days, once every week, once every two weeks, once every three weeks, once every month, once every two months, or once every three months. In certain embodiments, intravenous administration is started shortly after birth. In certain other embodiments, intravenous administration is started after intrathecal (or intracerebroventricular) administration is initiated. In some embodiments, the liver volume, the spleen volume, and / or liver enzyme activity of the patient are monitored to determine the efficacy of the treatment, and for adjustment of dosage schedule.

[0194] Described below are combination therapy methods in which the HPBCD pharmaceuticalcompositions of the disclosure can optionally be utilized. In some embodiments, the combination methods of the disclosure involve the administration of at least two agents to a subject, the firstof which is the HPBCD mixture described herein (for example, in a pharmaceutical compositiondescribed herein), and the additional agent(s) is a combination therapeutic agent. TheHPBCD mixture and the combination therapeutic agent(s) can be administered simultaneously(e.g., in a pharmaceutical composition as described herein), sequentially, or separately.

[0195] The combination therapy methods of the present disclosure can result in a greater thanadditive effect, i.e., a synergistic effect, for example, providing therapeutic benefits greater thanthe expected sum of the benefit from the HPBCD mixture and the combination therapeutic agentwhen each is administered individually.

[0196] In some embodiments, the HPBCD mixture and the combination therapeutic agent areadministered concurrently, either simultaneously or successively. As used herein, theHPBCD mixture and the combination therapeutic agent are said to be administered successivelyif they are administered to the subject on the same day, for example, during the same subject visit. Successive administration can occur 1, 2, 3, 4, 5, 6, 7, or 8 hours apart. In contrast, theHPBCD mixture and the combination therapeutic agent are said to be administered separately ifthey are administered to the subject on different days, for example, the HPBCD mixture and thecombination therapeutic agent can be administered at a 1-day, 2-day or 3-day, 1-week, 2-week or monthly intervals. In the methods of the present disclosure, administration of theHPBCD mixture can precede or follow administration of the combination therapeutic agent.

[0197] As a non-limiting example, the HPBCD mixture and the combination therapeutic agentcan be administered concurrently for a period of time, followed by a second period of time inwhich the administration of the HPBCD mixture and the combination therapeutic agent isalternated.

[0198] Because of the potentially synergistic effects of administering the HPBCD mixture andthe combination therapeutic agent, such agents can be administered as a therapeutically effective combination in amounts that are not therapeutically effective if one or both of the agents were administered alone.

[0199] In certain embodiments, the combination therapeutic agent is a vitamin E or a derivativethereof, an enzyme replacement therapy, a steroid, a glucosyl transferase enzyme inhibitor, a histone deacetylase (HDAC) inhibitor, or a molecular chaperone activator.

[0200] Vitamin E or vitamin E derivatives include but are not limited to alpha-tocopherol, delta-tocopherol, and tocopherol derivatives. In some embodiments, vitamin E derivatives include esterified tocopherols, e.g., tocopheryl acetate, and chemically related tocopherol derivatives such as those described in PCT Publication No. WO 2014 / 078573, incorporated herein by reference in its entirety.

[0201] Enzyme replacement therapies include but are not limited to agalsidase beta(Fabrazyme®), imiglucerase (CEREZYME®), verlaglucerase alfa (VPRIVTM), taliglucerase (ELELYSOTM), alglucosidase alfa (MYOZYME® or LUMIZYME®), laronidase (ALDURAZYME®), idursulfase intravenous (ELAPRASE®), and galsulfase (NAGLAZYMETM).

[0202] Steroids include but are not limited to neurosteroids, such as allopregnanolone andganaxolone.

[0203] Glucosyl transferase enzyme inhibitors include but are not limited to glucoceramidesynthase inhibitors, such as miglustat (ZAVESCA®).

[0204] HDAC inhibitors include but are not limited to vironostat, romidepsin, trichostatin A,valproate, butyrate, trapoxins, and apicidin.

[0205] The molecular chaperone activators include but are not limited to arimoclomol.

[0206] The present invention has multiple aspects, illustrated by the following non-limitingexamples. Example 1 An HPBCD Composition Increases Survival of Subjects with Infantile-Onset NPC

[0207] A study of NPC in patients with infantile-onset NPC was conducted. The patients had anage of onset of 0-6 years. Patients received treatment with an HPBCD composition disclosedherein (VTS-270; adrabetadex) or a control. There were 47 treated patients with a match. Thetreated patients were 2.75 times more likely to be alive after 5 years than untreated patients (91% vs. 33%). The difference was statistically significant (p<0.0001, adjusted Logrank test) and the hazard ratio (95% CI) was 0.109 (0.045, 0262), as measured by adjusted Cox regression analyses. Kaplan Meier plots of overall survival for patients with an age of onset of 0-6 years areshown in FIG. 1A. Kaplan Meier plots of overall survival with ages of onset of 0-2 years (HR(95% CI): 0.085 (0.024, 0.298)) and 2-6 years (HR (95% CI): 0.094 (0.021, 0.415)) are shown in FIG. 1B-C.

[0208] Additional Kaplan Meier survival analyses were performed on combined infantile- (FIG.2A-C), early infantile- (FIG. 3A-C), and late infantile-NPC (FIG. 4A-C) populations for VTS-270-treated patients versus external controls, and for VTS-270-treated patients versus a pooled cohort in early infantile populations (FIG.5), all based on data from various studies. The results demonstrate that an HPBCD composition increases survival of patients with infantile-onset NPC. Example 2 Effects of an HPBCD Composition on Biomarkers

[0209] Biomarkers in VTS-270-treated patients were measured at time 0 (pre-treatment) and atapproximately weeks 13, 26, 39, and 52 after treatment. The biomarkers included 24-hydroxycholesterol (24-OHC), a marker of cholesterol mobilization; and fatty acid bindingprotein 3 (FABP3) and Calbindin D, which are markers of neuronal cell death and neurodegeneration. Compared to pre-treatment levels, 24-OHC levels in treated patientsincreased more than 20% over the 52-week period (FIG. 2A). Compared to pre-treatment levels,FAPB3 levels decreased by about 60% (FIG. 2B) and Calbindin D levels decreased (FIG. 2C) intreated patients over the 52-week period. Thus, treatment with a HPBCD composition increasescholesterol release by neuronal cells and decreases neuronal cell death and neurodegeneration in patients with infantile-onset NPC.

[0210] Treated patients’ symptoms were evaluated using patient narratives (n=16). As shown inthe table below, 14 of the patients showed improvement, one exhibited stable symptoms, and one declined. Table 5

[0211] These results indicate that an HPBCD composition can improve or stabilize thesymptoms of a patient with infantile-onset NPC. This stands in contrast to most therapies forneurodegenerative diseases, which generally slow decline of symptoms, as opposed to reverse or improve them. Example 3 Stability of HPBCD Formulations

[0212] The stabilities of HPBCD formulation (VTS-270) were measured. The stability of a10 mL intrathecal (IT) formulation of a 200 mg / mL HPBCD composition, stored in vials (Type 1clear glass vial capped with butyl rubber; coated with a FLUROTEC® film, aluminum seal with flip-off cap), was tested at 15-25°C (excursions permitted between 15-30°C). The release andstability specifications for this formulation were as follows.Table 6

[0213] The stability of a 50 mL intravenous (IV) formulation of an HPBCD composition, storedin vials (Type 1 clear glass vials capped with butyl rubber; B-42 coated with a FLUROTEC® film, aluminum seal with flip-off cap), was tested at 15-25°C (excursions permitted between 15-30°C). The release and stability specifications for this formulation were as follows.Table 7

[0214] The release and stability data for the IV and IT formulations were as follows.Table 8Example 4 A HPBCD Composition Slows Disease Progression in Subjects with Infantile-Onset NPC

[0200] A comparison of subjects’ pre- and post-treatment change in disease progression wasperformed. This analysis is compelling because it avoids cross-subject heterogeneity andvariability. 132 subjects (80 of which were treated patients) were included in the model. Thetreated patients received adrabetadex.

[0201] A model was developed for assessing disease progression that incorporates data fromuntreated subjects, pre-treatment data for patients treated with the HPBCD composition, and post-treatment data for patients treated with the HPBCD composition. The model accounts forthe age of assessment and the age of onset.

[0202] The results are presented in Table 9 below and in FIG. 10. As shown, the rate of changein 4D-NPCCSS (i.e. the 4-domain severity scale) surprisingly decreased from 1.49 to 0.69 units / year after treatment was initiated, representing a 0.80 unit reduction (P < 0.0001). Thus, the treatment of the invention provided a > 50% decrease in disease progression for infantile-onsetNPC. The sensitivity analyses were consistent with the primary results. The average post- treatment follow-up period was 3 years. Table 9

[0203] As shown in FIG. 10, adrabetadex substantially attenuates (>50%) the rate of 4D-NPCCSS decline. The post-treatment rate of change (solid line) is markedly flatter than the projected untreated trajectory (dotted line) following treatment initiation (vertical dotted line). Thus, three years after starting treatment (average post-treatment follow-up time), a patient isexpected to have a 4D-NPCCSS score that is at least 1 point (such as at about 2 points, such asabout 2.4 points) lower than if they had remained untreated. Thus, the treatment provides amethod of slowing disease progression in a subject with NPC (such as infantile-onset NPC). EMBODIMENTSThe invention includes the following numbered embodiments:1. A method of increasing survival of a subject in need thereof having infantile-onsetNiemann-Pick Disease Type C (NPC), comprising administering pre-symptomatically and post-symptomatically to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the age of onset of infantile-onset NPC in the subject is 0-6 years, and wherein the increase in survival is in comparison to a population of untreated subjects with infantile-onset NPC. 2. The method of embodiment 1, wherein the subject has an age of onset of 0-2years. 3. The method of embodiment 1, wherein the subject has an age of onset of 2-6years. 4. The method of embodiment 1, wherein the composition is administered to thesubject over a period of at least 1 year, 2 years, 3 years, 4, years, 5 years, or 6 years. 5. The method of embodiment 1, wherein increase in survival is at least 2.5-foldafter 5 years. 6. The method of embodiment 1, wherein the subject is 0-1 years of age.7. The method of embodiment 6, wherein the subject is 0-2 months of age.8. A method of increasing cholesterol release by neuronal cells in a subject in needthereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the increase is relative to anamount of cholesterol release measured in the subject before the composition is first administered to the subject. 9. The method of embodiment 8, wherein the subject has infantile-onset NPC,wherein the age of onset of infantile-onset NPC in the subject is 0-6 years. 10. The method of embodiment 8, wherein the cholesterol release is measured bymeasuring 24-hydroxycholesterol levels in the subject.11. The method of embodiment 8, wherein the increase is at least 10, 15, 20, or 25%.12. The method of embodiment 8, wherein the increase is measured at about 10, 20,30, 40, or 52 weeks after the composition is first administered to the subject. 13. A method of decreasing neuronal cell death in a subject in need thereof,comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the increase is relative to an amount of neuronal cell death measured in the subject before the composition is first administered to the subject. 14. The method of embodiment 13, wherein the subject has infantile-onset NPC, andwherein the age of onset of infantile-onset NPC in the subject is 0-6 years. 15. The method of embodiment 13, wherein the neuronal cell death is measured bymeasuring Fatty acid-binding protein 3 (FABP3) or Calbindin D levels in the subject. 16. The method of embodiment 13, wherein the decrease is at least 25, 30, 35, 40, 45,50, 55, or 60%. 17. The method of embodiment 13, wherein the decrease is measured at about 10, 20,30, 40 or 52 weeks after the composition is first administered to the subject. 18. A method of preventing the onset of Niemann-Pick Disease Type C (NPC) in ahuman subject in need thereof, comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the subject has:(a) an age of 0 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene. 19. The method of embodiment 18, wherein the subject has an age of 0 to 1 years, 0to 2 years, 0 to 3 years, 0 to four years, 0 to five years, or 0 to 6 years. 20. The method of embodiment 18, wherein the subject has an age of 6 to 18 years.21. A method of increasing the survival rate of a human subject in need thereof withNiemann-Pick Disease Type C (NPC), comprising administering to the subject a compositioncomprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 0 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene; (c) wherein administering to the subject over a period of at least 3 years, 4, years, 5 years, or 6 years provides an estimated survival rate of at least 95%, when the subject is a member of a combined infantile population. 22. A method of treating Niemann-Pick Disease Type C (NPC) in a human subject inneed thereof, comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the subject has:(a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene. 23. The method of any one of embodiments 18-22, wherein the diagnosis of NPCcomprises the presence of at least two mutations in at least one copy of an NPC1 gene. 24. The method of embodiment 23, wherein the diagnosis of NPC further comprises apositive filipin test and at least one mutation in at least one copy of an NPC1 gene. 25. The method of embodiment 23, wherein each mutation is pathogenic.26. The method of embodiment 23, wherein each mutation is a null mutation.27. The method of embodiment 23, wherein the subject has at least one copy of an E4variant of an ApoE gene (ApoE E4). 28. A method of treating Niemann-Pick Disease Type C (NPC) in a human subject inneed thereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on a vertical supranuclear gaze palsy and either(A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC intracellular transporter 2 (NPC2) gene. 29. The method of embodiment 28, wherein each mutation is pathogenic.30. The method of embodiment 29, wherein each mutation is a null mutation.31. The method of any one of embodiments 28-30, wherein the subject has a score of 1-4in at least two domains of an NPC Clinical Severity Scale (NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS.32. The method of embodiment 31, wherein the subject has total score of at least 10 onthe NPCCSS.33. A method of treating Niemann-Pick Disease Type C (NPC) in a human subject inneed thereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 6 to 18 years;(b) a diagnosis of NPC based on one of the following sets of traits:(i) a first mutation in each of both copies of a NPC intracellulartransporter 1 (NPC1) gene, or a first mutation in a first copy of an NPC1 gene and a second mutation in a second copy of an NPC1 gene; (ii) a positive filipin test and at least one pathogenic mutation in atleast one copy of an NPC1 gene; and (iii) vertical supranuclear gaze palsy and either (A) one mutation in onecopy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with Niemann-Pick disease, and no mutation in an NPC intracellular transporter 2 (NPC2) gene; (c) a score of 1-4 in at least two domains of an NPC Clinical Severity Scale(NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS; and, (d) a total score of at least 10 on the NPCCSS.34. The method of embodiment 33, wherein the subject does not have, as assessed fromthe NPCCSS, an ambulation domain score of 5, a swallowing domain score of 5, a fine motor skills domain score of 5, or a cognition domain score of 5.35. The method of embodiment 33, wherein each mutation is pathogenic.36. The method of embodiment 35, wherein each mutation is a null mutation.37. The method of embodiment 33, wherein the subject has at least one copy of ApoE E4.38. The method of any one of embodiments 28-37, wherein the filipin staining comprisesobtaining skin fibroblasts from the subject, culturing the fibroblasts in a medium deprived ofcholesterol, incubating the fibroblasts in low-density lipoprotein cholesterol-enriched medium for at least 24 hours, fixing the fibroblasts, and staining the fibroblasts with filipin. 39. The method of any one of embodiments 28-38, wherein the oxysterol level consistentwith NPC comprises one or more of a level of cholestane-3β,5α,6β-triol greater than 0.070nmol / mL, a level of 7-ketocholesterol greater than 0.100 nmol / mL, and a level of lyso- sphingomyelin greater than 0.100 nmol / mL, as measured in a plasma sample from the subject. 40. A method of treating, or preventing or slowing progression of, Niemann-Pick DiseaseType C (NPC) in a human subject in need thereof, comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has at least one pathogenic mutation in at least one copy of an NPC1 gene, and wherein the subject is no older than 6 years of age. 41. The method of embodiment 40, wherein the subject is 2-6 years of age.42. The method of embodiment 41, wherein the subject is 2-4 years of age.43. The method of embodiment 40, wherein each pathogenic mutation is a null mutation.44. The method of embodiment 40, wherein the subject has at least one copy of ApoE E4.45. A method of prognosing progression of Niemann-Pick Disease Type C (NPC) in ahuman subject, comprising identifying at least one pathogenic mutation in at least one copy of an NPC1 gene in the subject, wherein the presence of at least one pathogenic mutation is indicative of more rapid progression of NPC in the subject as compared to a population of humans who do not carry the pathogenic mutation.46. The method of embodiment 45, wherein each pathogenic mutation is a null mutation.47. The method of embodiment 45, further comprising identifying whether the subjecthas at least one copy of ApoE E4, wherein the presence of ApoE E4 in the subject is indicative of more rapid progression of NPC in the subject as compared to a population of humans who carry each pathogenic mutation but do not carry a copy of ApoE E4. 48. A method of treating NPC in a subject in need thereof, comprising administering acomposition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules to the subject, wherein the subject has received a first dose of a mixture of HPBCD molecules, wherein the composition comprises a second dose of a mixture of HPBCD molecules, wherein the second dose is different from the first dose, wherein the second dose is higher than the firstdose if the subject is determined to have at least one pathogenic mutation in at least one copy ofan NPC1 gene, and wherein the second dose is lower than the first dose if the subject isdetermined not to have a pathogenic mutation in at least one copy of an NPC1 gene.49. The method of embodiment 48, wherein the second dose is higher than the first doseif the subject further has at least one copy of ApoE E4. 50. A method of treating NPC in a subject in need thereof, comprising administering acomposition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules to the subject, wherein the composition is administered intrathecally if the subject is determined tohave at least one pathogenic mutation in at least one copy of an NPC1 gene, and wherein thecomposition is administered intravenously if the subject is determined not to have a pathogenicmutation in at least one copy of an NPC1 gene. 51. The method of embodiment 50, wherein the composition is administered intrathecallyif the subject further has at least one copy of ApoE E4. 52. The method of any one of embodiments 18-51, wherein each mutation in each NPC1gene is relative to one or more wild-type NPC1 genes from one or more reference human genomes.53. The method of embodiment 52, wherein each mutation in each NPC1 gene is in anopen reading frame of the NPC1 gene. 54. The method of embodiment 53, wherein each mutation in each NPC1 gene results ina change in an amino acid sequence of a NPC1 protein encoded by the NPC1 gene, wherein the change is one or more of an amino acid substitution, a deletion, a frameshift, a premature stop,and a lack of NPC1 protein production.55. The method of embodiment 54, wherein each mutation is a null mutation, andwherein the change is a frameshift or a premature stop. 56. The method of embodiment 52, wherein each mutation in each NPC1 gene isassociated with early or late infantile onset of at least one NPC symptom. 57. The method of embodiment 56, wherein each NPC1 mutation is independentlyselected from R1186H, I1061T, a frameshift at K142, T1205K, S734I, A1054T, or a premature stop at R1059, deletion of promoter and exon 1, c.385delT, D944N, A1035V, c.1757delA, c.2746_2748delAAT, L380F, R958 stop, C63 frameshift causing premature stop at position 75 in shifted reading frame, C63 frameshift causing premature stop at position 75 in shifted reading frame, T1205R, IVS21-2del ATGC, IVS21-2del ATGC, G1195V, P433L, IVS14+1G>A, T1205 frameshift, T1036M, D501Y, I601F frameshift causing premature stop at position 13 in shifted reading frame, N140K frameshift causing premature stop at position 30 in shifted reading frame, D611G, R726T, P1245R frameshift causing premature stop at position 12 in shifted reading frame, V744S frameshift causing premature stop at position 27 in shifted reading frame, P1245R frameshift causing premature stop at position 12 in shifted reading frame, R518Q, c.2795dupA, R1186H, T1036M, C1168Y, c.3578_3591 + 9del, R934Q, G993E frameshift causing premature stop at position 4 in shifted reading frame, IVS23+1G>A, A605C frameshift causing premature stop at position 2 in shifted reading frame, A1187R frameshift causing premature stop at position 54 in shifted reading frame, Y276H, P733S frameshift causing premature stop at position 10 in shifted reading frame, c.319delc, nucleotide +5 at intron 18, F703S, S813 stop, Q928P, L1003R, W942C, I962 to F966 deletion, A1035V, C177Y, V959E, c.955+1G>A, C645 stop, F1079S, C976 frameshift, M1127I frameshift causing premature stop at position 131 in shifted frame, K142R frameshift causing premature stop at position 27 in shifted frame, R958 stop,c.2245+1G>A, Q991R frameshift, duplication / multiple copies of exons 10 and 11, C1011 stop, IVS23+1G>A, S151F frameshift causing premature stop at position 18 in shifted frame, C976F frameshift causing premature stop at position 6 in shifted frame, C914S, L472P, c.3478-6T>A, A321G frameshift causing premature stop at position 16 in shifted frame, F284L frameshift causing premature stop at position 26 of shifted frame, Q991R frameshift, R607 stop, C31W frameshift causing premature stop at position 26 in shifted fame, c.464-2A>C, N1156S, T1205N frameshift causing premature stop at position 53 in shifted frame, R934 stop, R958 stop, P691S, F760 deletion, Q119V frameshift causing premature stop at position 8 in shifted frame, H1016L, I1061T, P1007A, R958Q, F284L frameshift causing premature stop at position 26 in shifted frame, deletion of promoter and exons 1-10, Q92R, C119 stop, E1089K, N701K causing premature stop at position 13 in shifted frame, R404Q, 237S, Q775P, and A1132P. 58. The method of embodiment 57, wherein the subject carries at least one mutation in afirst copy of the NPC1 gene and at least one mutation in a second copy of the NPC1 gene, wherein the mutation in the first and second copies of the NPC1 gene comprise a combination in Table 1. 59. The method of embodiment 52, wherein each mutation in NPC1 is associated withlate infantile or juvenile onset of at least one NPC symptom. 60. The method of embodiment 59, wherein each mutation is independently selected fromI1061T, a premature stop at R1059, F1087L, P1007A, T1205R, R518Q, T1036M, I1061T, S954L, R518Q, E391G, R518Q, P1007A, R518Q, A165V, R1186H, P474L, Y276H, D944N, P733S frame shift causing a premature stop at position 9 in shifted frame, S954L, A1132P, C1168Y, R404Q, V1378A, IVS23+1G>A, V697A, and A1035V. 61. The method of embodiment 60, the subject carries at least one mutation in a first copyof the NPC1 gene and at least one mutation in a second copy of the NPC1 gene, wherein the mutation in the first and second copies of the NPC1 gene comprise a combination in Table 2. 62. The method of any one of embodiments 1-61, wherein the mixture of HPBCDmolecules comprises less than 0.05% unsubstituted beta-cyclodextrin (“DS-0”) and less than0.05% beta-cyclodextrin substituted with one hydroxypropyl group (“DS-1”), and has an averagedegree of substitution of 6.02-7.98. 63. A method of preventing or treating onset of infantile-onset Niemann-Pick DiseaseType C (NPC) in a subject in need thereof, comprising administering pre-symptomatically andpost-symptomatically to the subject a composition comprising a mixture of 2-hydroxypropylbeta-cyclodextrin (HPBCD) molecules, wherein the age of onset of infantile-onset NPC in the subject is 0-6 years. 64. The method of embodiment 63, wherein the subject is diagnosed via genetictesting. 65. The method of embodiment 63, wherein the administering comprises intravenousinjection to the subject, and wherein the composition has an osmolality of 291.21 mOsm / kg ±15%, ± 10%, or ± 5%. 66. The method of embodiment 63, wherein the administering comprises intravenousinjection to the subject, and wherein the composition has an osmolality of 288.35 mOsm / kg ±15%, ± 10%, or ± 5%. 67. The method of embodiment 63, wherein the subject has an age of onset of 0-2years. 68. The method of embodiment 63, wherein the subject has an age of onset of 2-6years. 69. The method of embodiment 63, wherein the composition is administered to thesubject over a period of at least 6 months, 1 year, 2 years, 3 years, 4, years, 5 years, or 6 years.70. The method of embodiment 63, wherein the subject is 0-1 years of age.71. The method of embodiment 63, wherein the subject is 0-2 months of age.72. The method of embodiment 63, wherein the subject is 0-1 months of age.73. A method of increasing the probability survival of a subject in need thereofhaving infantile-onset Niemann-Pick Disease Type C (NPC), comprising administering pre-symptomatically and post-symptomatically to the subject a composition comprising a mixture of2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the age of onset of infantile- onset NPC in the subject is 0-6 years, wherein the increase in survival is in comparison to a population of external control patients with infantile-onset NPC, wherein the composition is to be administered over at least a 5-year period, and wherein the probability of survival of the subject after the 5-year period is 90%. 74. The method of embodiment 73, wherein over a period of at least 5 years theexternal control patients were administered miglustat and were not treated with the composition. 75. The method of embodiment 74, wherein over the period of at least 5 years at least50% of the external control patients received standard of care treatment for infantile-onset NPC.76. The method of embodiment 74, wherein the probability of survival of the externalcontrol patients after the period of at least 5 years is 40% 77. The method of embodiment 73, further comprising administering miglustat to thesubject during at least a portion of the 5-year period. 78. The method of embodiment 73, wherein the subject has an age of onset of 0-2years. 79. The method of embodiment 73, wherein the subject has an age of onset of 2-6years. 80. The method of embodiment 73, wherein the composition is administered to thesubject over a period of at least 6 months, 1 year, 2 years, 3 years, 4, years, 5 years, or 6 years.81. The method of embodiment 73, wherein the subject is 0-1 years of age.82. The method of embodiment 73, wherein the subject is 0-2 months of age.83. The method of embodiment 63, wherein the subject is 0-1 months of age.The method of embodiment 73, wherein the subject has:(a) an age of 0 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene.The method of embodiment 73, wherein the subject has:(a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene.The method of embodiment 73, wherein the subject has:(a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on a vertical supranuclear gaze palsy and either(A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC intracellular transporter 2 (NPC2) gene.The method of embodiment 73, wherein the subject has:(a) an age of 6 to 18 years;(b) a diagnosis of NPC based on one of the following sets of traits:(i) a first mutation in each of both copies of a NPC intracellulartransporter 1 (NPC1) gene, or a first mutation in a first copy of an NPC1 gene and a second mutation in a second copy of an NPC1 gene;(ii) a positive filipin test and at least one pathogenic mutation in atleast one copy of an NPC1 gene; and (iii) vertical supranuclear gaze palsy and either (A) one mutation in onecopy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with Niemann-Pick disease, and no mutation in an NPC intracellular transporter 2 (NPC2) gene;(c) a score of 1-4 in at least two domains of an NPC Clinical Severity Scale(NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS; and,(d) a total score of at least 10 on the NPCCSS.

Claims

CLAIMS What is claimed is:

1. A method of increasing survival of a subject in need thereof having infantile-onsetNiemann-Pick Disease Type C (NPC), comprising administering pre-symptomatically and / orpost-symptomatically to the subject a composition comprising a mixture of 2-hydroxypropylbeta-cyclodextrin (HPBCD) molecules, wherein the age of onset of infantile-onset NPC in the subject is 0-6 years, and wherein the increase in survival is in comparison to a population of untreated subjects with infantile-onset NPC.

2. The method of claim 1, wherein the subject has an age of onset of 0-2 years.

3. The method of claim 1, wherein the subject has an age of onset of 2-6 years.

4. The method of any of claims 1-3, wherein the composition is administered to thesubject over a period of at least 1 year, 2 years, 3 years, 4, years, 5 years, or 6 years.

5. The method of any of claims 1-4, wherein increase in survival is at least 2.5-foldafter 5 years.

6. The method of any of claims 1, 2, 4 or 5, wherein the subject is 0-1 years of age.

7. The method of any of claims 1, 2 or 4-6, wherein the subject is 0-2 months of age.

8. A method of increasing cholesterol release by neuronal cells in a subject in needthereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the increase is relative to an amount of cholesterol release measured in the subject before the composition is first administered to the subject.

9. The method of claim 8, wherein the subject has infantile-onset NPC, wherein theage of onset of infantile-onset NPC in the subject is 0-6 years.

10. The method of claim 8 or 9, wherein the cholesterol release is measured bymeasuring 24-hydroxycholesterol levels in the subject.

11. The method of any of claims 8-10, wherein the increase is at least 10, 15, 20, or25%.

12. The method of any of claims 8-11, wherein the increase is measured at about 10,20, 30, 40, or 52 weeks after the composition is first administered to the subject.

13. A method of decreasing neuronal cell death in a subject in need thereof,comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the increase is relative to an amount of neuronal cell death measured in the subject before the composition is first administered to the subject.

14. The method of claim 13, wherein the subject has infantile-onset NPC, andwherein the age of onset of infantile-onset NPC in the subject is 0-6 years.

15. The method of claim 13 or 14, wherein the neuronal cell death is measured bymeasuring Fatty acid-binding protein 3 (FABP3) or Calbindin D levels in the subject.

16. The method of any of claims 13-15, wherein the decrease is at least 25, 30, 35, 40,45, 50, 55, or 60%.

17. The method of any of claims 13-16, wherein the decrease is measured at about 10,20, 30, 40 or 52 weeks after the composition is first administered to the subject.

18. A method of preventing the onset of Niemann-Pick Disease Type C (NPC) in ahuman subject in need thereof, comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 0 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or,a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene.

19. The method of claim 18, wherein the subject has an age of 0 to 1 years, 0 to 2years, 0 to 3 years, 0 to four years, 0 to five years, or 0 to 6 years.

20. The method of claim 18, wherein the subject has an age of 6 to 18 years.

21. A method of increasing the survival rate of a human subject in need thereof withNiemann-Pick Disease Type C (NPC), comprising administering to the subject a compositioncomprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 0 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene; (c) wherein administering to the subject over a period of at least 3 years, 4, years, 5 years, or 6 years provides an estimated survival rate of at least 95%, when the subject is a member of a combined infantile population.

22. A method of treating Niemann-Pick Disease Type C (NPC) in a human subject inneed thereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene.

23. The method of any one of claims 18-22, wherein the diagnosis of NPC comprises thepresence of at least two mutations in at least one copy of an NPC1 gene.

24. The method of claim 23, wherein the diagnosis of NPC further comprises a positivefilipin test and at least one mutation in at least one copy of an NPC1 gene.

25. The method of claim 23 or 24, wherein each mutation is pathogenic.

26. The method of any of claims 23-25, wherein each mutation is a null mutation.

27. The method of any of claims 23-26, wherein the subject has at least one copy of anE4 variant of an ApoE gene (ApoE E4).

28. A method of treating Niemann-Pick Disease Type C (NPC) in a human subject inneed thereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has: (a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on a vertical supranuclear gaze palsy and either(A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC intracellular transporter 2 (NPC2) gene.

29. The method of claim 28, wherein each mutation is pathogenic.

30. The method of claim 28 or 29, wherein each mutation is a null mutation.

31. The method of any one of claims 28-30, wherein the subject has a score of 1-4 in atleast two domains of an NPC Clinical Severity Scale (NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS.

32. The method of claim 31, wherein the subject has total score of at least 10 on theNPCCSS.

33. A method of treating Niemann-Pick Disease Type C (NPC) in a human subject inneed thereof, comprising administering to the subject a composition comprising a mixture of 2- hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has:(a) an age of 6 to 18 years;(b) a diagnosis of NPC based on one of the following sets of traits:(i) a first mutation in each of both copies of a NPC intracellulartransporter 1 (NPC1) gene, or a first mutation in a first copy of an NPC1 gene and a second mutation in a second copy of an NPC1 gene; (ii) a positive filipin test and at least one pathogenic mutation in atleast one copy of an NPC1 gene; and (iii) vertical supranuclear gaze palsy and either (A) one mutation in onecopy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with Niemann-Pick disease, and no mutation in an NPC intracellular transporter 2 (NPC2) gene; (c) a score of 1-4 in at least two domains of an NPC Clinical Severity Scale(NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS; and, (d) a total score of at least 10 on the NPCCSS.

34. The method of claim 33, wherein the subject does not have, as assessed from theNPCCSS, an ambulation domain score of 5, a swallowing domain score of 5, a fine motor skills domain score of 5, or a cognition domain score of 5.

35. The method of claims 33 or 34, wherein each mutation is pathogenic.

36. The method of any of claims 33-35, wherein each mutation is a null mutation.

37. The method of any of claims 33-36, wherein the subject has at least one copy ofApoE E4.

38. The method of any one of claims 28-37, wherein the filipin staining comprisesobtaining skin fibroblasts from the subject, culturing the fibroblasts in a medium deprived ofcholesterol, incubating the fibroblasts in low-density lipoprotein cholesterol-enriched medium for at least 24 hours, fixing the fibroblasts, and staining the fibroblasts with filipin.

39. The method of any one of claims 28-38, wherein the oxysterol level consistent withNPC comprises one or more of a level of cholestane-3β,5α,6β-triol greater than 0.070 nmol / mL,a level of 7-ketocholesterol greater than 0.100 nmol / mL, and a level of lyso-sphingomyelin greater than 0.100 nmol / mL, as measured in a plasma sample from the subject.

40. A method of treating, or preventing or slowing progression of, Niemann-Pick DiseaseType C (NPC) in a human subject in need thereof, comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has at least one pathogenic mutation in at least one copy of an NPC1 gene, and wherein the subject is no older than 6 years of age.

41. The method of claim 40, wherein the method slows progression of NPC.

42. The method of claim 40 or 41, wherein the subject is 2-6 years of age, such as 2-4years of age.

43. The method of any of claims 40-42, wherein each pathogenic mutation is a nullmutation.

44. The method of any of claims 40-43, wherein the subject has at least one copy ofApoE E4.

45. A method of prognosing progression of Niemann-Pick Disease Type C (NPC) in ahuman subject, comprising identifying at least one pathogenic mutation in at least one copy of an NPC1 gene in the subject, wherein the presence of at least one pathogenic mutation is indicative of more rapid progression of NPC in the subject as compared to a population of humans who do not carry the pathogenic mutation, and optionally administering a composition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules to the subject.

46. The method of claim 45, wherein each pathogenic mutation is a null mutation.

47. The method of claim 45 or 46, further comprising identifying whether the subject hasat least one copy of ApoE E4, wherein the presence of ApoE E4 in the subject is indicative of more rapid progression of NPC in the subject as compared to a population of humans who carry each pathogenic mutation but do not carry a copy of ApoE E4.

48. A method of treating NPC in a subject in need thereof, comprising administering acomposition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules to the subject, wherein the subject has received a first dose of a mixture of HPBCD molecules, wherein the composition comprises a second dose of a mixture of HPBCD molecules, wherein the second dose is different from the first dose, wherein the second dose is higher than the first dose if the subject is determined to have at least one pathogenic mutation in at least one copy of an NPC1 gene, and wherein the second dose is lower than the first dose if the subject is determined not to have a pathogenic mutation in at least one copy of an NPC1 gene.

49. The method of claim 48, wherein the second dose is higher than the first dose if thesubject further has at least one copy of ApoE E4.

50. A method of treating NPC in a subject in need thereof, comprising administering acomposition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules to the subject, wherein the composition is administered intrathecally if the subject is determined to have at least one pathogenic mutation in at least one copy of an NPC1 gene, and wherein the composition is administered intravenously if the subject is determined not to have a pathogenic mutation in at least one copy of an NPC1 gene.

51. The method of claim 50, wherein the composition is administered intrathecally if thesubject further has at least one copy of ApoE E4.

52. The method of any one of claims 18-51, wherein each mutation in each NPC1 gene isrelative to one or more wild-type NPC1 genes from one or more reference human genomes.

53. The method of claim 52, wherein each mutation in each NPC1 gene is in an openreading frame of the NPC1 gene.

54. The method of claim 53, wherein each mutation in each NPC1 gene results in achange in an amino acid sequence of a NPC1 protein encoded by the NPC1 gene, wherein the change is one or more of an amino acid substitution, a deletion, a frameshift, a premature stop, and a lack of NPC1 protein production.

55. The method of claims 53 or 54, wherein each mutation is a null mutation, andwherein the change is a frameshift or a premature stop.

56. The method of claim 52, wherein each mutation in each NPC1 gene is associated withearly or late infantile onset of at least one NPC symptom.

57. The method of claim 56, wherein each NPC1 mutation is independently selected fromR1186H, I1061T, a frameshift at K142, T1205K, S734I, A1054T, or a premature stop at R1059, deletion of promoter and exon 1, c.385delT, D944N, A1035V, c.1757delA, c.2746_2748delAAT, L380F, R958 stop, C63 frameshift causing premature stop at position 75 in shifted reading frame, C63 frameshift causing premature stop at position 75 in shifted reading frame, T1205R, IVS21-2del ATGC, IVS21-2del ATGC, G1195V, P433L, IVS14+1G>A, T1205 frameshift, T1036M, D501Y, I601F frameshift causing premature stop at position 13 in shifted reading frame, N140K frameshift causing premature stop at position 30 in shifted reading frame, D611G, R726T, P1245R frameshift causing premature stop at position 12 in shifted reading frame, V744S frameshift causing premature stop at position 27 in shifted reading frame, P1245R frameshift causing premature stop at position 12 in shifted reading frame, R518Q, c.2795dupA, R1186H, T1036M, C1168Y, c.3578_3591 + 9del, R934Q, G993E frameshift causing premature stop at position 4 in shifted reading frame, IVS23+1G>A, A605C frameshift causing premature stop at position 2 in shifted reading frame, A1187R frameshift causing premature stop at position 54 in shifted reading frame, Y276H, P733S frameshift causing premature stop at position 10 in shifted reading frame, c.319delc, nucleotide +5 at intron 18, F703S, S813 stop, Q928P, L1003R, W942C, I962 to F966 deletion, A1035V, C177Y, V959E, c.955+1G>A, C645 stop, F1079S, C976 frameshift, M1127I frameshift causing premature stop at position 131 in shifted frame, K142R frameshift causing premature stop at position 27 in shifted frame, R958 stop, c.2245+1G>A, Q991R frameshift, duplication / multiple copies of exons 10 and 11, C1011 stop, IVS23+1G>A, S151F frameshift causing premature stop at position 18 in shifted frame, C976Fframeshift causing premature stop at position 6 in shifted frame, C914S, L472P, c.3478-6T>A, A321G frameshift causing premature stop at position 16 in shifted frame, F284L frameshift causing premature stop at position 26 of shifted frame, Q991R frameshift, R607 stop, C31W frameshift causing premature stop at position 26 in shifted fame, c.464-2A>C, N1156S, T1205N frameshift causing premature stop at position 53 in shifted frame, R934 stop, R958 stop, P691S, F760 deletion, Q119V frameshift causing premature stop at position 8 in shifted frame, H1016L, I1061T, P1007A, R958Q, F284L frameshift causing premature stop at position 26 in shifted frame, deletion of promoter and exons 1-10, Q92R, C119 stop, E1089K, N701K causing premature stop at position 13 in shifted frame, R404Q, 237S, Q775P, and A1132P.

58. The method of claim 57, wherein the subject carries at least one mutation in a firstcopy of the NPC1 gene and at least one mutation in a second copy of the NPC1 gene, wherein the mutation in the first and second copies of the NPC1 gene comprise a combination in Table 1.

59. The method of claim 52, wherein each mutation in each NPC1 gene is associated withlate infantile or juvenile onset of at least one NPC symptom.

60. The method of claim 59, wherein each mutation is independently selected fromI1061T, a premature stop at R1059, F1087L, P1007A, T1205R, R518Q, T1036M, I1061T, S954L, R518Q, E391G, R518Q, P1007A, R518Q, A165V, R1186H, P474L, Y276H, D944N, P733S frame shift causing a premature stop at position 9 in shifted frame, S954L, A1132P, C1168Y, R404Q, V1378A, IVS23+1G>A, V697A, and A1035V.

61. The method of claim 60, wherein the subject carries at least one mutation in a firstcopy of the NPC1 gene and at least one mutation in a second copy of the NPC1 gene, wherein the mutation in the first and second copies of the NPC1 gene comprise a combination in Table 2.

62. The method of any one of claims 1-61, wherein the mixture of HPBCD moleculescomprises less than 0.05% unsubstituted beta-cyclodextrin (“DS-0”) and less than 0.05% beta-cyclodextrin substituted with one hydroxypropyl group (“DS-1”), and has an average degree ofsubstitution of 6.02-7.98.

63. A method of preventing or treating onset of infantile-onset Niemann-Pick DiseaseType C (NPC) in a subject in need thereof, comprising administering pre-symptomatically andpost-symptomatically to the subject a composition comprising a mixture of 2-hydroxypropylbeta-cyclodextrin (HPBCD) molecules, wherein the age of onset of infantile-onset NPC in the subject is 0-6 years.

64. The method of claim 63, wherein the subject is diagnosed via genetic testing.

65. The method of claim 63 or 64, wherein the administering comprises intravenousinjection to the subject, and wherein the composition has an osmolality of 291.21 mOsm / kg ±15%, ± 10%, or ± 5%.

66. The method of claim 63 or 64, wherein the administering comprises intravenousinjection to the subject, and wherein the composition has an osmolality of 288.35 mOsm / kg ±15%, ± 10%, or ± 5%.

67. The method of any of claims 63-66, wherein the subject has an age of onset of 0-2years.

68. The method of any of claims 63-66, wherein the subject has an age of onset of 2-6years.

69. The method of any of claims 63-68, wherein the composition is administered tothe subject over a period of at least 6 months, 1 year, 2 years, 3 years, 4, years, 5 years, or 6years.

70. The method of any of claims 63-67 or 69, wherein the subject is 0-1 years of age.

71. The method of any of claims 63-67, 69 or 70, wherein the subject is 0-2 months ofage.

72. The method of any of claims 63-67 or 69-71, wherein the subject is 0-1 months ofage.

73. A method of increasing the probability survival of a subject in need thereofhaving infantile-onset Niemann-Pick Disease Type C (NPC), comprising administering pre-symptomatically and post-symptomatically to the subject a composition comprising a mixture of2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules, wherein the age of onset of infantile- onset NPC in the subject is 0-6 years, wherein the increase in survival is in comparison to a population of external control patients with infantile-onset NPC, wherein the composition is to be administered over at least a 5-year period, and wherein the probability of survival of the subject after the 5-year period is 90%.

74. The method of claim 73, wherein over a period of at least 5 years the externalcontrol patients were administered miglustat and were not treated with the composition.

75. The method of claim 73 or 74, wherein over the period of at least 5 years at least50% of the external control patients received standard of care treatment for infantile-onset NPC.

76. The method of claims 73, 74 or 75, wherein the probability of survival of theexternal control patients after the period of at least 5 years is 40% 77. The method of claim 73, further comprising administering miglustat to the subjectduring at least a portion of the 5-year period.

78. The method of any of claims 73-77, wherein the subject has an age of onset of 0-2years.

79. The method of any of claims 73-77, wherein the subject has an age of onset of 2-6years.

80. The method of any of claims 73-79, wherein the composition is administered tothe subject over a period of at least 6 months, 1 year, 2 years, 3 years, 4, years, 5 years, or 6years.

81. The method of any of claims 73-78 or 80, wherein the subject is 0-1 years of age.

82. The method of any of claims 73-78, 80 or 81, wherein the subject is 0-2 months ofage.

83. The method of any of claims 73-78 or 80-82, wherein the subject is 0-1 months ofage.

84. The method of any of claims 73-83, wherein the subject has:(a) an age of 0 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene; or, a sibling or family member with a diagnosis of NPC based on one or more mutations in at least one copy of an NPC1 gene.

85. The method of any of claims 73-83 wherein the subject has:(a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on one or more mutations in at least one copy ofan NPC1 gene.

86. The method of any of claims 73-83, wherein the subject has:(a) an age of 6 to 18 years; and,(b) a diagnosis of NPC based on a vertical supranuclear gaze palsy and either(A) one mutation in one copy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with NPC, and no mutation in an NPC intracellular transporter 2 (NPC2) gene.

87. The method of any of claims 73-83, wherein the subject has:(a) an age of 6 to 18 years;(b) a diagnosis of NPC based on one of the following sets of traits:(i) a first mutation in each of both copies of a NPC intracellulartransporter 1 (NPC1) gene, or a first mutation in a first copy of anNPC1 gene and a second mutation in a second copy of an NPC1 gene; (ii) a positive filipin test and at least one pathogenic mutation in atleast one copy of an NPC1 gene; and (iii) vertical supranuclear gaze palsy and either (A) one mutation in onecopy of an NPC1 gene; or (B) a positive filipin test or an oxysterol level consistent with Niemann-Pick disease, and no mutation in an NPC intracellular transporter 2 (NPC2) gene; (c) a score of 1-4 in at least two domains of an NPC Clinical Severity Scale(NPCCSS) selected from the group consisting of ambulation, fine motor skills, speech, and swallowing, and an NPC severity score of 0-3 on a cognition domain of the NPCCSS; and, (d) a total score of at least 10 on the NPCCSS.

88. A method of slowing disease progression in a subject with Niemann-Pick DiseaseType C (NPC) , comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl beta-cyclodextrin (HPBCD) molecules.

89. The method of claim 88, wherein the NPC is infantile-onset NPC.

90. The method of claim 88 or 89, wherein the subject has been diagnosed withinfantile-onset NPC prior to the first administration of the composition.

91. The method of any of claims 88-90, wherein the NPC disease progression isslowed relative to the disease progression in a population of untreated subjects.

92. The method of any of claims 88-91, wherein the NPC disease progression isslowed relative to the disease progression in the subject prior to the first administration of the composition.

93. The method of any of claims 88-92, wherein the NPC disease progression ismeasured using the NPC Clinical Severity Scale (NPCCSS).

94. The method of claim 93, wherein the NPC disease progression is slowed by atleast about -0.40 units / year, at least about -0.50 units / year, at least about -0.60 units / year, at least about -0.70 units / year, or at least about -0.80 units / year.

95. The method of any of claims 88-94, wherein the NPC disease progression isslowed by at least about 30%, at least about 40% or at least about 50%.

96. A method of treating, or preventing or slowing progression of, Niemann-Pick DiseaseType C (NPC) in a human subject in need thereof, comprising administering to the subject a composition comprising a mixture of 2-hydroxypropyl-beta-cyclodextrin (HPBCD) molecules, wherein the subject has at least one pathogenic mutation in at least one copy of an NPC1 gene.

97. The method of claim 96, wherein the subject has infantile-onset Niemann-PickDisease.

98. The method of claim 96 or 97, wherein the composition is first administered to thesubject between 0 and 6 years of age.

99. The method of any of claims 96-98, wherein the method slows progression of NPC.

100. The method of any of claims 96-99, wherein each pathogenic mutation is a nullmutation.

101. The method of any of claims 96-100, wherein the subject has at least one copy ofApoE E4.

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