Download - Late onset Pompe Disease (LOPD)
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Late onset Pompe Disease
(LOPD)
Nick Davies
Regional Neuromuscular Service
Queen Elizabeth Hospital
Birmingham
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GLYCOGEN
GLUCOSE
PYRUVATE
LACTATE
TCA
cycle
NADH for electron transport chain
Phosphorylase kinase (VIII)
Debrancher (III)
Brancher (IV)
Myophosphorylase (V)
Acid maltase
(II)
Phosphofructokinase (VII)
Aldolase (XII)
Phosphoglycerate kinase (IX)
Phosphoglycerate mutase (X)
Lactate dehydrogenase (XI)
NADH
Pyruvate dehydrogenase
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• limb girdle or myalgia/rhabdo
• elevated CK interictal or not
• neurophysiology - ?mixed
• other systems involved
• respiratory or not
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Pompe disease is a rare AR lysosomal
storage disease (GSDII or acid maltase
disease)
Two groups
– Classic infantile phenotype
– Late onset (often) adult phenotype
(LOPD)
LOPD
– childhood, juvenile and adult onset
forms
– progressive deterioration of truncal,
proximal LLs and respiratory muscles
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Case
61y male
Normal milestones
Odd gait since childhood
Worse in early 30s
In 50s developed slurring of speech
SOB on exertion
No myoglobinuria
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Case
Examination
Cranials normal
NF 4+
Facial fasciculations
Some accessory muscle use
4+ proximal weakness
Trendelenburg gait
Areflexic
CK 694
EMG - myopathic
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Case
pO2 11.2, pCO2 6.8 (2000)
FEV1 2.35, FVC 3.1 (standing)
FEV1 1.05, FVC 1.6 (supine)
NB gas transfer was low
2005 requiring NIPPV
Sister – since been diagnosed
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LE H&E
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LE H&E
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LE PAS
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CB H&E
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CB H&E
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CB Gomori
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CB PAS
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Muscle Biochemistry
Glycolysis Enzymes - normal
Glycogen 6.0 mg/g (0.5 - 10.5)
Acid Maltase (lysosomal) pH 4.0 1.7 nmol/g/min (7.0 -42)
Neutral Maltase (microsomal) pH 6.5 29.8 (3.0 - 26.0)
Lymphocyte Acid Alpha Glucosidase
<0.8mU/U hexosaminidase (3.7 -30.0)
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Case
57y male
2/12 history of lethargy, poor mobility,
poor appetite, stomach cramps, weight loss
Developed confusional state
Admitted but respiratory arrest in ED
Type 2 respiratory failure, ITU, trache
Found to have basal pneumonia and PEs
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Case
On recovery, gave history that 2.5 years
before, had moved to 3 storey house but had
to sleep on ground floor
If he lay flat, he would feel as if he was drowning
Morning headaches and daytime somnolence
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Case
Examination
Cranials – normal
Arms – ShAb 4-/5
Legs – HF 2/5, DF 3/5
CK – normal
DBS positive
Compound het for 2 mutations in GAA
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Chan J et al, Molecular Genetics and Metabolism, 2017
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Diagnosis
CK may be normal to several 1000
EMG may show myotonic discharges
in addition to fibrillation etc
Muscle biopsy light microscopy can be normal
A combination of DBS, lymphocyte levels,
GAA gene analysis and possibly muscle biopsy
may be required to confirm the diagnosis
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A longitudinal study of 16 untreated patients followed
for a mean of 16 years (range 4-29 years) observed
a mean rate of decline in respiratory function of 1.6%
per year and a gradual decline in proximal muscle
strength
• 8 patients (50%) became wheelchair-bound and
3 patients (19%) became ventilator-dependent
during the follow-up period
• 2/3 Pulmonary and muscle function decreased
together
• At an individual level, the rate and extent of
progression varied considerably among patients
van der Beek N et al. Neuromuscul Disord. 2009
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Multicenter, multinational, prospective, observational study of 58 patients with late-onset Pompe disease All patients ambulatory and free of invasive ventilator support at enrollment Statistically significant declines were observed in the 12-month study period Evidence from LOPOS provides natural history data on patients with late-onset Pompe disease and helped to identify endpoints for LOTS
Wokke et al. Muscle Nerve. 2008
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Study of safety and efficacy of alglucosidase alfa in
children and adults with Pompe disease
Randomized, double-blind, placebo-controlled
20 mg/kg alglucosidase alfa or placebo IV
administration biweekly
90 patients enrolled
Age 10-70
Trial period 18 months
Conclusions – in treated group, 6MWT increased by
25.1m, pulmonary function stabilized
Van der Ploeg AT et al NEJM 2010
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Van der Ploeg AT et al NEJM 2010
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Kuperus E et al., Neurology 2017
Prospective cohort study of 102 patients (aged 24-76) over 5 years
6MWT 376m to 416m, FVC increase by 7.3% (first 2-3 years of ERT)
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Cost effectiveness study
Based on observational data of 283 patients
with LOPD begun in 2002
Cost per QALY 1.8 – 3.2 million Euros
Fabry cost per QALY 3.3 million Euros
Spinraza cost per QALY £400,000-600,000
Kanters T et al., Orphanet Journal of Rare Diseases 2017
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Ebbink B et al. Developmental Medicine and Child Neurology, 2018
6y 9y 17y
6y 5y 13y
9y 9y 17y
5y 13y 13y
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New treatments
Augmented ERT
- IGFII tagged-rhGAA (withdrawn)
- Chaperone + rhGAA
- Increase mannose-6-phosphate residues
Substrate reduction therapy (SRT)
Suppression of autophagy
Stimulation of lysosomal exocytosis
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New treatments
Gene therapy
Animal models
AAV Intrathecal – KO mice
Cell lines
Antisense
Gene editing
Human trials
Diaphragm injections
Kohler L et al., Neurotherapeutics 2018
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• 11 patients with adult onset AMD.
• Progressive pattern with adductor magnus, SM early on with later
changes to BFLH, ST and anterior thigh muscles.
• Muscle strength and MRI correlated.
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Conclusions
Late onset Pompe disease should be
considered in anybody with respiratory
symptoms and muscle weakness
Scapular winging, rigid spine,
calf hypertrophy and tongue involvement
can occur or just hyperCKaemia
CK may however be normal
EMG may show myotonic discharges
in addition to fibrillation etc
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Conclusions
Muscle biopsy light microscopy can be normal
A combination of DBS, lymphocyte levels,
GAA gene analysis (and possibly muscle biopsy)
may be required to confirm the diagnosis
ERT made a significant impact on survival in IOPD
but more effective treatment needs to be sought
for it and LOPD
qMRI should prove a useful tool in assessing
innovative therapies
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Thanks to Professor Tracey Willis