the rapidly changing landscape of fragile x · educational approach • classroom modification •...
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The Rapidly Changing Landscape of Fragile X
AUCD Annual Conference
Research Symposium
Elizabeth Berry-Kravis MD PhD Rush University Medical Center
Disclosures: EBK has received funding from Neuropharm LTD, Seaside
Therapeutics , Novartis and Roche Pharmaceuticals to consult on trial
design and conduct clinical trials in FXS
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Features of Fragile X Syndrome
• Physical: large prominent ears, long face, large head, prominent jaw and forehead, midfacial hypoplasia hyperflexible joints, large testis
• Intellectual Disability or LD • Behavior problems: hyperactivity
distractibility, anxiety, perseveration • Autism: 18-36% AD, 43-67% ASD • Seizures – 15% • Strabismus – 30% • Medical: otitis, sinus, MVP, reflux, sleep
apnea, loose stools, allergies
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FXS Treatment in Clinic - Supportive
• Early intervention • Intensive speech therapy • OT with sensory integration • Inclusion in school as much
as possible • Educational curriculum,
environment, teaching style matched to FXS cognitive profile
• Socialization program • Behavior plan • Behavior medications for
ADD/anxiety
• Aggressive tx of otitis – tubes/audiology
• Manage sleep apnea – T&A
• Treat sleep dysregulation – melatonin/medications
• Yearly eye exams – patching, surgery, glasses
• Control seizures • Orthopedics if needed • Monitor for MVP/heart • Genetic counseling • Discuss reproductive
options
Rush FXS Clinic since
1992 > 450 patients
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Seizures in Fragile X Syndrome – Recent and Largest Study National Fragile X Survey
1394 FXS full mutation (1090 M, 304 F)
173 (12%) seizures: 154 (14%) M, 19 (6%) F
Rush FX Clinic – Chart Data
352 FXS full mutation (268 M, 84 F)
46 (13%) seizures, 39 (14.5%) M, 7 (8%) F
Berry-Kravis et al, 2011 AJIDD
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Time of last seizure
0
20
40
60
80
100
120
This
week
2 or 3
weeks
ago
1 to 3
months
ago
3 to 6
months
ago
More
than 6
months
ago
perc
en
tag
e o
f p
op
ula
tio
ns
Age seizure first experienced
0
10
20
30
40
50
60
70
Less than 1
yr
1 to 3 years
old
4 to 10
years old
11 years or
older
Unknown
perc
en
tag
e o
f p
op
ula
tio
n
Males from NationalSurveyMales fromRush FXSClinicFemales fromNational SurveyFemales from RushFXS Clinic
Type of Seizure
0
10
20
30
40
50
Focal or
localized
seizures
Generalized
or distributed
seizures
Both types of
seizures
Unknown
pe
rce
nta
ge
of
po
pu
lati
on
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Effectiveness of Medications
0
20
40
60
80
100
120
Not at all A little Somewhat A lot
perc
en
tag
e o
f p
op
ula
tio
nNumber of Current Seizure Medications
0
10
20
30
40
50
60
70
80
None One Two or more
perc
en
tag
e o
f p
op
ula
tio
n
Males fromNational Survey
Males fromRushFXS Clinic
Females fromNational Survey
Females fromRush FXS Clinic
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Co-Occurring Conditions/Symptoms: Seizure Cohort Vs. Matched No Seizure Cohort
Males Condition Seizures (%) No Seizures (%) N p Attention Problems 88.1 82.1 134 0.18 Hyperactivity 62.9 68.2 132 0.39 Aggressiveness 48.9 34.6 133 0.015 Self-Injury 52.2 43.3 134 0.16 Autism 63.6 41.1 129 0.0002 Anxiety 75.2 57.9 133 0.0038 Depression 12.6 8.7 127 0.30 Developmental Delay 98.5 95.6 135 0.16 Poor Verbal Ability 30.6 18.2 121 0.019 Poor Reading Ability 64.5 66.9 124 0.70 Fair-Poor Thinking 89.5 87.3 134 0.59 Fair-Poor Quality of Life 13.2 13.9 136 0.85 Fair-Poor Overall Health 14.1 6.7 135 0.03
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Conclusions Seizure frequency in FXS: 14-14.5% males, 6-8% females.
Seizure characteristics similar in survey and clinic cohorts, suggests parent data for this is reliable.
Seizures in FXS are often partial onset, present frequently in mid-childhood, and are generally infrequent and easily controlled with minimal AEDs.
Learning, reading not associated with seizures but diagnosis of autism is associated with seizures, and aggression, anxiety, and poor verbal skills may also co-occur with seizures.
Seizures and autism may share mechanisms based on defects of synaptic plasticity and glutamatergic signaling due to absence of FMRP in FXS.
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Principles of Seizure Management in FXS
1. start medicines after 2 or more clinical seizures, do
not need to treat abnormal EEG
2. stop 2 years after last seizure
3. single drug regimen, lowest effective dose best
4. dose guide is effectiveness and toxicity
5. Match drug to seizure type, patient characteristics
6. Use drugs with less effect on cognition and
behavior
7. EEG is adjunct for deciding which drug, how much,
and how long
8. more drug is not necessarily more effective
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Intellectual Disability in FXS
• Present with motor (some), language (most), behavior (high functioning)
• Males - average adult IQ about 40 and mental age 5-6y, range severe ID to normal (mosaics)
• IQ scores higher when young, decline with age • Specific cognitive profile • Achievement and Adaptive skills higher
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Fragile X Syndrome
Characteristic cognitive pattern with
prominent executive function deficits
• Strengths
– Receptive vocabulary
– Syntax
– Imitation
– Grammatical
structure
– Visual memory
– Simultaneous
processing
– Experiential learning
• Weaknesses
– Auditory processing
– Sequencing
– Abstraction
– Short-term memory
– Topic maintenance/
"connectedness"
– Mathematics
– Working memory
– Coordination/praxis
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General Components of the
Educational Approach • Early intervention
• Speech therapy - work on fluency, vocab, length
of utterance, pragmatics
• OT/sensory integration therapy – work on fine
motor and writing problems
• Structure/routines
• Schedule/message boards - visual cues
(pictures of normal day events) to help
understand schedule, token boards
• Inclusive program when possible to maximize
imitation of normal behaviors
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General Components of the
Educational Approach • Classroom modification • Environmental - seat away from distraction, quiet
area in room, natural lights, help with initiation
• Instruction - co-operative learning in small groups,
peer tutoring, high teacher-to-student ratio, one-
on-one instruction, indirect instruction
• Curriculum - appropriate task complexity, text
enlargement, high interest/daily life topics
• Behavior management - behavior
modification, calming, medications
• Aide to deliver specialized curriculum, carry
out behavior and socialization interventions
• DO NOT FORCE EYE CONTACT
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FXS Curriculum Matched to
Cognitive Profile • Learning based on visual memory - visual
cues to all instructions
• Use of whole language, logos or picture-
word association rather than phonics for
reading (Edmark)
• Use of computer-assisted writing
• Concrete, hands-on math with visual representation/manipulatives (eg. Touch-Point, number lines)
• Functional life-math: eg. money, time
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Social Interventions in School • Individual socialization therapy
• Group socialization therapy (modeling
social interactions with normal peers)
• Videos of appropriate social behaviors
for behaviors that are problematic
• Social stories
• Peer tutoring
• Circle of Friends
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• Hyperactivity/fidgety (90%) • Short attention span (~100%) • Anxiety (~100%) • Tactile defensiveness (80%) • Eye (gaze) aversion (>90%) • Perseverative speech/thinking
(>80%) • Hand flapping (60%) • Hand biting (50%)-self regulatory • Mood swings • Outbursts/aggression
Behavior Problems in FXS THE BIGGEST PROBLEM
FOR MANY FAMILIES
Behavior in fragile X
out-of-proportion to
cognitive level
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Difficult Behavior in FXS
• Problems communicating – Cannot express what is bothering them
– Only alternative may be aberrant behavior
• Lack of cognitive sophistication about interpreting problem and coming up with a solution
• Social misinterpretation (lack of understanding about when others are teasing etc)
• Poorly modulated emotional state
• Overarousal and hypersensitivity to everything: noises, smells, facial expressions, temperature, flashing visual stimuli, something different in room, routine change, “on the spot”
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Difficult Behavior in FXS • Anxiety
– Aberrant behavior may be only strategy FXS individual has to deal with anxiety
– Anxiety about novel exposures, separation, being unable to do something, not doing it right, other specific phobias, no particular thing
– FXS individual learns what is difficult and becomes increasingly anxious about success and novelty
– Anxiety increases with age; fear learning is enhanced in FXS – fear without threat
– Fight or flight reactions over minimal stimuli – can see visual signs – red ears, increased pulse, sweating, pacing, increased perseveration
• Need behavior plan - figure out antecedents and use behavior/environment modification
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Decision to Use Behavioral Medication
• Individual engaging in dangerous behaviors
• Individual is dysfunctional from behavior
• Individual could accomplish more or be higher functioning if specific behavior is managed – Increase ability to participate
– Able to be in more inclusive setting
• Not necessarily “when all else fails”
• ALWAYS an adjunct to behavioral, environmental measures
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Psychopharmacology in Fragile X Syndrome
• Targets behavior to improve functioning
• Supportive, does not target underlying cognitive problem
• Only one prior controlled trial in FXS (N=15) shows Ritalin effective in 2/3 of boys
• Therapeutic decisions based on target largest problem symptom complex(es) – trial and error
• May need to treat multiple behavioral domains
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FXS - Types of Medications and Indications*
Problem
Behavior Cluster
Medication
Class
Medications
Distractibility/
Hyperactivity
Stimulants Methylphenidate,
Adderall, Provigil
Overarousal/
Hypersensitivity
Alpha-agonists Clonidine, Tenex
Anxiety/OCD/
Perseverative
SSRIs Prosac, Zoloft,
Celexa, Lexapro
Mood Lability Antidepressants,
AEDs, Lithium
Tricyclics, Effexor, Li,
SSRIs, VPA, TPX, CBZ
Aggression/Self
abusive
Atypical
Antipsychotics,
Risperdal, Abilify,
Seroquel, Geodon
*meds may be targeting several clusters
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Percent of Individuals With FXS Taking Medications for Specific Symptoms
Males, N=1064
Females, N=299
0
5
10
15
20
25
30
Two or more
One
From National Survey
Bailey et al. 2011 in press, JDBP
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Percent of Individuals with FXS Using Medication By Symptom and Age
0
10
20
30
40
50
60
Birth to 5 6 to 10 11 to 15 16 to 20 21 to 30 >30
0
5
10
15
20
25
30
35
40
45
Birth to 5 6 to 10 11 to 15 16 to 20 21 to 30 >30
Anxiety
Attention
Hyperactive
Anger
Mood
Sleep
Self-injury
Seizures
Depression
Males
Females
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Medication Use in FXS Males age 5-17
0
10
20
30
40
50
60
70
80
stim
ulan
ts
SSRIs
othe
r an
tidep
ress
ant
alph
a2-a
goni
st
antip
sych
otic
pe
rce
nt
of
tota
l o
n m
ed
ica
tio
n
Chicago (n=57)
Denver (n=126)
Males age 18 and over
0
10
20
30
40
50
60
70
stim
ulan
ts
SSRIs
othe
r an
tidep
ress
ant
alph
a2-a
goni
st
antip
sych
otic
pe
rce
nt
of
tota
l o
n m
ed
ica
tio
n Chicago (n=23)
Denver (n=46)
Berry-Kravis and Potanos, 2004
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Perceived Efficacy of Medications for Individuals with FXS by Symptom
0%10%20%30%40%50%60%70%80%90%
100%
A lot
Somewhat
Little or none
Males Females
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Supportive Psychopharmacology is Helpful in FXS…
Berry-Kravis and Sumis, 2006
…but treating
the underlying
disorder would
be better
Rush Fragile X Clinic
208 trials
136 patients
231 trials
123 patients
100 trials
58 patients
52 trials
52 patients
Attention
Hyperactivity
Anxiety
Mood
Aggression
Irritability
Hyperarousal
Oversensitivity
Successfully Treated
65%
Failed30%
Unknown5%
Abilify Responce (n=64)Abilify in FXS
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Fragile X Syndrome: an Unmet Need • Behavior: attention, hyperactivity, anxiety, sensory
over-responsiveness, aggression, perseveration, rigidity, mood lability/irritability – Currently available medications help, do not fully treat
• Cognition: low IQ, impaired social/executive cognition – No medications to treat this
• Therapy, behavioral, cognitive training help, do not normalize
• Unmet medication needs:
– Improved medications to target specific behaviors
– Medications to target underlying brain disorder directly (behavioral and cognitive treatment)
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Premutation
Normal
FXS
No FMR1
mRNANo FMRP
FMRP
FMRP
CH3 CH3
Synaptic defects
Intellectual compromise
Synaptic defects
Intellectual compromise
Tremor, neurological
disease
Tremor, neurological
disease
FMR1
inclusions
disrupt nuclear processes
transcription
splicing
FMR1 the Fragile X Gene Causes 3 Diseases
10-45 CGGs
55-200 CGGs “Carrier”
FXTAS FXPOI
>200 CGGs (Full mutation)
Fragile X Syndrome
Carrier state passed through many generations before FXS
Simple DNA test to diagnose FXS – measures repeat size
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FMRP Expression and Disability
100
0
Disability
FM
RP
Social anxiety/shyness
Distractibility/hyperactivity
Executive deficits
Spatial perceptual deficits
NVLD
Intellectual Disability
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The Fragile X Mouse (Knockout; K/O)
• Fmr1 gene inactivated
• No active FMRP
• Subtle cognitive problems
• Audiogenic seizures
• Good neurobiological model to answer question: WHAT DOES FMRP DO?
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What Does FMRP Do?
FMRP is in dendrites and regulates
proteins translation in dendritic spines
– needs to be regulated precisely for
synaptic maturation and connectivity
Both FXS Mouse and Human Brains:
Dendritic spines are abnormal in FXS with
immature long spines
FMRP regulates maturation of brain
synapses
McKinney et al, AJMG, 2005
Picture courtesy of Gary Bassell
Dendritic spine
FMRP
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AMPA AMPA
AMPA
ribosome
mGluR1/5
Glu
FMRP
FMRP
Normal
Mature connection
LTD AMPA
AMPA AMPA
ribosome
mGluR1/5
glu
Fragile X
Immature connection
(too weak)
Excessive LTD – due to
mGluR system overactivity
mGluR Theory of Fragile X: The Basic Concept
Dendrite
Aberrant dendritic translation and
synaptic plasticity in FXS
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Treatments aimed
at many of these
targets reverse
phenotypes in the
fmr1 K/O mouse
FMRP mechanism
Targets for
FXS treatment
based on
mechanism
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mGluR Theory Hat
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Equation for Fragile X Research to Lead to Treatment
FMR1
Find Gene
+ Missing Protein
Mouse model +
=
FMRP
Knowledge of brain cell mechanisms abnormal in FXS
Targeted treatment
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Mechanism 1A: mGluR5 Blockers in FXS Models Reverse Phenotypes at all Ages
• Audiogenic seizures • Epileptiform bursts • Open field behavior • Dendritic spine shape • AMPA receptor internalization • Excessive LTD • Excessive protein synthesis • Behavioral phenotypes
Bauschwitz, 2006
Wong et al. 2006
Phenotypes in the fmr1 K/O mouse also all reversed by crossing fmr1 K/O to mGluR5 heterozygous mutant (half the mGluR5 receptors)
Many phenotypes in the FXS fly (eg. courtship and odor-shock memory) reversed by mGluR5 blockers
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AMPA Receptor Rescue by MPEP
Control
FMRP Internal
GluR1
Surface
GluR1
siRNA to block
FMRP translation
siRNA and MPEP
GluR1 =
AMPA
receptors
that drive
strength of
neural
connections
Nakamoto et al. 2007
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But Mouse is not Man… WE CAN “CURE” THE FXS MOUSE
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human
mouse Human brain a lot more wiring time but cautious optimism for treatment – amount of reversal possible at given age in human unclear
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13 years, 5 years in trials
9 drugs to get 1
$$$$$$$
FXS 2002 FXS 2011
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Lack of Models for Trials in FXS • Before 2002 lack of significant moderate/large clinical
trial experience in FXS with any “standard” drug
• No defined measure of behavioral improvement
• No “gold standard” outcome measure
• No template from any developmental disability about measuring cognitive outcomes when attempting to treat underlying disorder
Basic science has targets but mismatch in trial design/outcome measure development
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Issues for Each FXS Trial
• Type of design – how long placebo period?
• Dosing – same as when no disorder?
• Safety assessments – can’t always report AEs
• Age of subjects – younger might respond better
• Formulation – can’t always swallow pills
• Gender/mosaics – better higher or lower function
• Other medications – allow or not; pure signal vs improvement over available treatment
• Efficacy outcome measures – strong placebo effects; not well developed for FXS
• Distance and travel for rare disease
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Mechanism 3: AMPA Activators
• Mouse – increase BDNF, reverse hippocampus LTP (connection strengthening) deficits
• Human - Phase II Double-blind, placebo-controlled Ampakine CX516 (Cortex Pharmaceuticals) trial at RUSH/MIND, 49 participants
– Drug too weak, only improved those on antipsychotics
– Good safety, 94% completion rate (shows individuals with FXS can do intensive trial)
• Waiting for a better ampakine
Berry-Kravis et al. 2006
Berry-Kravis et al. JCAP 2006
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Mechanism 2: Block Specific Overactive
Protein
• Minocycline – blocks MMP9, overactive in FXS mouse
• Mouse – reverse dendrite spine shape and behaviors
• Observational study with patient report– improved some obsessive and mood symptoms (Hagerman)
• Open-label 8 week study: 20 patients age 13-32, improved behavior on ABC, CGI, VAS (Paribello)
• Double blind placebo-controlled study ongoing at MIND (Hagerman) – age 5 and up
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Mechanism 4: Other Systems Impacting
mGluR Pathway
• Arbaclofen (Seaside) - GABA-B agonist, decrease glutamate release – less mGluR5 activation – Mouse/fly – reverse audiogenic seizures and other
phenotypes, GABA system abnormal – Placebo-controlled crossover trial with 4 weeks of treatment
each arm – 63 subjects (Seaside – 12 sites) – Good safety/side effect profile – Efficacy best in irritable/autistic/socially-impaired patients – Extension in progress, further trials planned for 2011
Other: mGluR2/3 agonists, ganaxolone (GABA-A), acamprosate (GABA activator, glu blocker?), donazepil (cholinergic)
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Mechanism 4 : Correct Connectivity Through Systems Effect: R-baclofen – Decrease Excessive Glutamatergic Transmission
Pre-synaptic Post -synaptic
Proteins FMRP Proteins
GABA-B
STX209
Model Courtesy of Seaside Therapeutics
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CGI-I (Improvement) Results in Arbaclofen trial (Seaside) “Responders”
35% vs. 18% p = 0.11 44% vs. 6%
(p < 0.05) Per Protocol
N=52 Autism
N=18
58% vs. 19% p < 0.01
Low Social
N=27
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Efficacy scores: “Lower sociability” subgroup
STX209 n=27
(mean ± SD)
Placebo n=27
(mean ± SD)
p-value
CGI-I 2.7 ± 1.1 3.5 ± 1.2 < 0.01
CGI-S -1.0 ± 1.1 -0.3 ± 0.9 = 0.01
Treatment preference (clinician) 63% 19% < 0.01
Treatment preference (parent) 67% 19% = 0.001
ABC-Social Withdrawal -4.3 ± 6.3 -0.4 ± 7.1 < 0.05
Vineland Socialization domain (raw score)
14.2 ± 19.0 4.6 ± 10.8 < 0.05
Responders (CGI-I =1 or 2, and ABC-SW improvement ≥ 25%)
42% 7% < 0.01
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Mechanism 1B (Inside Cell): Block Excessive Signaling in mGluR-
Activated Translational Pathway
• Not receptor-specific, cover all receptors activating pathway, more off-target effects on cellular metabolism
• Lithium – blocks PI and GSK3ß in signaling pathway
– Mouse/fly – behavior/spines phenotypes reversed
– open label 2 month trial, 15 patients
• behavior, adaptive, ERK biomarker, 1 cognitive task better
• Other pathway targets
– PAK inhibitors (Afraxis), PI3K blockers, GSK3ß blockers
Berry-Kravis et al, JDBP 2008
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Average Scores on ABC-C Subtests for Subjects with
FXS During treatment with Lithium, n=11
16
11.7
19.8
61.3
12.6
4.14.6 4.2
76.7
34.7
3.8
8.45.8
12.98.6 8
38.4
0
10
20
30
40
50
60
70
Irritability SD
8.4
Lethargy SD
6.6
Stereotypy SD
4.5
Hyperactivity SD
7.6
Inappropriate
Speech SD 2.7
Total SD 21.6
Av
era
ge
AB
C-C
sc
ore
Baseline 2 Month 1 Year
Open-Label Lithium Trial in FXS 13/15 better at 2 mo, little toxicity
-44
-13
27
-18
-19
1
-22-20
-5
-25-15
-67
-2
-58
-8 -7
-80
-60
-40
-20
0
20
40
Group Mean
Change
Individual
Change
ABC Total (range 0-174)
13 improved, p=0.005
0
34
-1
3
7
-2
4
8
4
15
-4
-2
0
2
4
6
8
10
12
14
16
Group MeanChange
IndividualChange
RBANS List Learning (range 0-40)
8 of 10 improved, p= 0.028
CX516 placebo change: 0.0
Also significant improvement
in CGI, VAS, and Vineland
Personal Daily Living Skills
and Maladaptive Behavior
1 yr
Sustained improvement in
9/11 treated for 1 year
Berry-Kravis et al, JDBP 2008
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Lithium Study Biomarker - ERK
Activation in Lymphocytes
ERK phosphorylation
slower in K/O and FXS
Berry-Kravis et al, JDBP 2008
2
2.5
3
3.5
4
4.5
5
5.5
6
T1/2
Max A
cti
vati
on
(M
in)
N=11
Baseline mean: 4.87 min
2 Month Treatment mean:
4.11 min (p=0.007)
(about 1 min is difference
FXS and control)
1 Year Treatment mean:
3.56 min (P=0.00006)
2 mo
1 yr
baseline
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Mechanism 1A (Outside Cell): mGluR5 Negative Modulators
• Receptor specific – correct one activation route but not all, less off target effects
• Fenobam (Neuropharm) – Rush/MIND - single dose in 12 patients, safe/PPI improved
• STX107 (Seaside) - In Phase I, FXS trials 2011 • AFQ056 (Novartis) – Phase II, placebo-controlled 28 day
(30 M >18) trial in Europe, multinational phase III trial with USA sites 160 adults, 160 age 12-17 – recruiting now and has 2 year extension
• RO4917523 (Roche) – Phase II placebo-controlled 6 week (68 M & F >18) trial in USA, phase III trial about to begin
Berry-Kravis et al. JMG 2009
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RUSH and UC Davis (Neuropharm
and FRAXA) safety trial of 1 dose (50-
150 mg), 12 adult FXS (6M, 6F),age
18-38, IQ 36-85
PPI improved 20% in 6/12
subjects (control test-retest
group 2/13, p=0.03)
Positive behavioral
changes in 9/12 subjects
No fenobam-related AEs
Erratic PK
Berry-Kravis et al. JMG 2009
Trials of mGluR5 Blockers in FXS: Fenobam
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AFQ056 mgluR5 blocker
most effective in subgroup
of fully methylated
subjects in small
exploratory trial –
methylation status may
define treatment response
to targeted treatments
Full Partial
Full Partial
Jacquemont et
al. presented at
ASHG meeting
2010
Trials of mGluR5 Blockers in FXS: AFQ056 - Results of First Multiple-Dose Trial
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Outcome Measures in FXS –
A Problem
RBANS List Learning
0
5
10
15
20
25
30
0 2 4 6 8 10 12
Mental Age
Sco
re
RBANS List Learning N = 28
7% refusals (N = 3), ICC = 0.7
Mental Age cut-off > 3
•First clinical trials – CX516 (2002-4), lithium (2005-6) -
many outcome measures found not to be not useful in FXS
•Some reliable and reproducible – mostly behavior forms
But none of these covers spectrum of behaviors
characteristic of FXS well
Need FXS-specific empirically validated behavioral
outcome measure
•Profiles for many cognitive tests piloted
many have problems with floor
effects, motivation issues,
developmental issues, repeatability,
not clear if important things
measured, how change sensitive
Berry-Kravis et al. JADD 2008
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What We Need to Know to Have a Usable Measure for FXS Trials
• Feasibility – Age range – Functional range – Floor and ceilings – Distribution
• Reproducibility – Test-retest – Time frame for retest – Learning effects
• Validity – Abnormal in condition – Targeted to disease
phenotype as assessed in other ways
– Measure something important for quality of life/function
• Intervention responsiveness – Drugs – Behavioral – Placebo effect – Time of treatment
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Objective Novel Phenotype-Based Outcome Measures
• More scientifically based, translate from models • Tap into specific features of underlying disorder
• Unclear if predict better function in life • Not likely useful for FDA approval
PPI – sensory
overresponsiveness
4. Flexibility: The
dragon’s house
KiTAP – executive function, attention
6 Measures- feasible,
min ceiling/basal,
reproducible in test-retest,
correlate with behavior ratings
Test-retest
ICC=0.88
PROS
CONS
Hessl et al AJMG (2008)
KiTAP
PPI
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Eye Tracking
Fear Faces
0
1
2
3
4
5
6
Eyes Nose Mouth Other
Area of Interest
Me
an #
Fix
atio
ns
Controls
FXS
Happy Faces
0
10
20
30
40
50
60
Eyes Nose Mouth Other
Area of Interest
Me
an P
rop
ort
ion
Lo
oki
ng
Tim
e
Controls
FXS
Time looking at eyes
P<0.001 all face types
Number fixations to eyes
P<0.001 all face types
Validity
Feasibility – Age 5 and up
– Most FXS kids/adults can do
Reproducibility
Intervention response No data
????? but placebo effect unlikely
Proportion LT Eyes
Control α = 0.684
FXS α = 0.935
0
10
20
30
40
50
60
0 10 20 30 40 50 60
Visit 1
Vis
it 2
Controls
FXS
Clearly abnormal Phenotype: eye aversion ??? no functional correlate yet
1-2 week
retest, 16
FXS, 20
controls
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APP and Ab Metabolites
Pilot in 10 FXS non-mosaic
full mutation males and 8
similar aged control males
*p<0.004 Malter, Westmark, Berry-Kravis,
unpublished data
0
5
10
15
20
25
30
35
control fragile X
% MMP-9 active in plasma
Biomarkers for FXS Trials
Ethell, Berry-Kravis,
unpublished
N=7 N=9
Matrix Metalloproteinase – 9
(MMP-9)
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Pupillometry
Feasibility – Age 5 and up
– Most FXS kids/adults can do
ICC 0.74 Happy ICC 0.58 Fear
Reproducibility
16 FXS, 20 controls, 1-2 week retest Validity
Happy Fear
Clearly abnormal in FXS, phenotype: social anxiety
No functional correlate yet????
Intervention response Unknown??? Placebo effect unlikely
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Conclusions of NIH Study Group on
FXS Outcome Measures • Adaptive/maladaptive behavior forms – ABC : 5 subscales cover
many behaviors in FXS but not all - very reproducible in FXS (ICC=0.8-0.9), somewhat sensitive to change in lithium minocycline, arbaclofen, AFQ056 studies, factor structure not right for FXS – need re-factoring (done by 5 site collaboration)
• Anxiety – PARS, feasible and valid? (Hessl and B-K validating) • Executive/inhibition – KiTAP, ? • Social cognition - Eye tracker, ? • Memory – RBANS, ?, Working memory - ? • Learning - ? • Language – coded conversation session (length of utterance
perseveration, verbal fluency) – (B-K/Abbeduto validating) • Motor – stereotypies, motor learning, coordination, hyperkinesis?
(Tartaglia validate coord measures, EBK/Hall stereotypies) • Biomarkers (PPI, ERK, APP, others?), fMRI? • Need FXS-specific scale covering entire phenotype (Hessl)
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Re-Factored ABC for FXS • Project based on recommendations from 2008-2009
NIH FXS Outcome Measure Meetings (led by Hessl) • ABC factor structure not felt right for FXS – re-
evaluated based on over 600 ABC ratings entered into NDAR from 5 sites, refactored scale using two independent methods of factor analysis (same result)
• Items eliminated and moved, social withdrawal, SIB questions regrouped, 6 factors emerged, in review
• May show improvements in FXS behavior areas better • Evidence: Seaside study – Social Withdrawal subscale
on new FXS ABC - sigt improvement across entire per protocol group…. Emphasize need to validate measure in disorder being studied
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Conclusions From PARS Study • PARS is feasible with FXS families (N=49, 33 M, 16 F) • PARS has good range of scores in FXS and mean scores
and standard deviations similar at first and second administration
• Scores may be higher in younger individuals • High IRR and cross site reliability (43 Rush, 6 UC Davis) • Good reproducibility for both 5- and 7-item scale – ICC
for number items endorsed and severity scores all >0.72 • Good correlation with both clinician and parent-report
of anxiety (ADAMS) – all p<0.01 • ABC correlations – anxiety manifests more as irritibilility
and hyperactivity in kids, social withdrawal becomes strongest correlate in adults
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Observational Expressive Language Task
• 36 FXS Subjects (all verbal) – 25M 11F – age 5-35 • Video- and audiotape Narrative and Conversation
(picture book story then standardized conversation, 10 min each) - test-retest
• Enter into SALT and measure # utterances, mean length of utterance, # word roots, # intelligible utterances
• Excellent reproducibiility – Most measures ICC>0.9
• Correlate with Vineland – Expressive language score
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The most common movement was rubbing him/herself, followed by (in no particular order): rocking, waving arms, body movement, repetitive movement, yelling, sniffing the body, hand movements, manipulating objects, gazing at objects, and bizarre postures.
Types of StereotypiesMeasured in Study
Less common or absent
movements
included: sniffing objects,
spinning the body, rolling
the head, whirling, pacing,
twirling, bouncing, spinning
object, running, finger
movements, clapping,
grimacing, and waving
hands
Videos from Language study, rate 10 min on SBS
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Clinical Validity of SBS Ratings
• ABC-C Total Score and Stereotyped Behavior Scale (SBS) score from first session was correlated with SBS (Pearson 0.3, p=0.01)
• ABC-C Stereotyped Behavior Subscore was strongly correlated with SBS (Pearson 0.4, p=0.0007)
• IQ was strongly negatively correlated with SBS Score (Pearson -0.48, p=0.006)
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Conclusions of Pilot Stereotypy Study
• Very feasible as no demands on patient • Clinician-rated SBS is consistent with parent reported
stereotypic behavior and as expected, stereotypies are more prevalent in FXS individuals with more impaired cognitive function and general behavioral function
• Analysis of SBS reproducibility in progress • Creation and validation of new FXS SBS focused on the
stereotypes seen in FXS (Hall) • Eventually correlate stereotypies with perseverative
language from same audio.videotapes
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FXS Clinical Trial Participation
0
20
40
60
80
100
120
140
160
180
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
Nu
mb
er
of
Sub
ject
s
Year
Folate
Ritalin
L-Acetyl- carnitine
CX516 Mifrepristone
Lithium Fenobam Melatonin VPA AFQ056
Acamprosate Riluzole Arbaclofen Abilify Oxytocin Donezepil Minocycline RO4917523
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Funded by co-
operative agreement
with CDC, AUCD and
IBR (NFXF, NYSPI)
•Facilitate new clinics and standardize care
•Better understand FXS-associated problems
•Allow adequate recruitment for FXS studies
•Facilitate clinical trial network to allow sufficient
recruitment to test new mechanistically based
treatments for FXS for FDA approval
•FXCRC Registry and Database to help achieve
above goals- can join through any FXCRC clinic
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AMPA AMPA
AMPA
ribosome
mGluR
glu
FMRP
FMRP
A SHANK PTEN mTOR PAK CYFIP1
B PSD95, Arc
AMPA
synaptic
proteins
A.Proteins involved in other
forms of autism may be
in signaling cascade for
translational regulation
B.FMRP may regulate
proteins involved in
different forms of autism
C.May be convergence of
glutamate/GABA
pathways involved in
both disorders
C GLU, GABA
Wang, Berry-Kravis, Hagerman;
Neurotherapeutics 2010
Potential Pathway Overlap in Autism
– May Have Treatment Overlap
MR
FXS
Autism
LD
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Acknowledgements/Disclosures • FRAXA Research Foundation
• NIH – NINDS
• Kiwanis Spastic Paralysis Foundation
• National Fragile X Foundation • Collaborators
– Sue Ellen Krause PhD
– Sandy Block MS
– Steve Guter MS
– Ed Cook MD
– Randi Hagerman MD
– Maureen Leehey MD
– Deborah Hall MD PhD
– Paul Hagerman MD PhD
– Chris Goetz MD
– Don Bailey PhD
– Glenn Stebbins PhD
– Pete Van der Klish PhD
– Jim Malter MD PhD
– Cara Westmark PhD
– Nicole Russo PhD
– Iryna Ethell PhD
• Lab Research Associate – Lili Zhou MD
– Victor Kaytser
• Study Co-ordinators – Kristina Potanos
– Dahlia Weinberg
– Rebecca Lara
– Foster Lewin
– Allison Sumis
– Crystal Hervey
– Kristine Urban
– Christina Prescott
– Anna DeSonia
• Students – Ok-Kyung Kim
– Elizabeth Churcinski
– Andrew Knox
– Christina Tran
– Felicia Scaggs
– Emily Doll
– Jessica Yesinsky
• Cortex Pharmaceuticals
• Asuragen
• Clinical Trial Funding – Seaside Therapeutics
– Neuropharm
– Roche
– Novartis
Steve Porges PhD
Mina Johnson PhD
Isabel Boutet PhD
Cary Kogan PhD
Steve Hooper PhD
Ivan Jean Weiler PhD
Bill Greenough PhD
Ning Weng PhD
Mark Bear PhD
Emily Osterweil PhD
David Hessl PhD
Mike Nelson PhD
Faraz Farzin PhD
Christina Gross PhD
Sue Leurgans PhD
Joanna Wuu MS
Joanne O’Keefe PhD
Molly Losh PhD
Jeannie Aschkenasi PhD
FXS Families