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Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
h ps://doi.o g/10.1186/s13023-024-03219-5 O phane Jou nal o Ra e
Diseases
*Co espondence:
Simon A Jones
[email p o ec ed]
1Uni o Diagnosis and T ea men o Congeni al Me abolic Diseases,
Depa men o Neona ology, San iago de Compos ela Uni e si y Clinical
Hospi al, San iago de Compos ela, Spain
2Cen o de In es igación Biomédica en Red de En e medades Ra as
(CIBERER), Eu opean Re e ence Ne wo k o He edi a y Me abolic
Diso de s (Me abERN), IDIS-Heal h Resea ch Ins i u e o San iago de
Compos ela, San iago de Compos ela Uni e si y Clinical Hospi al,
San iago de Compos ela, Spain
3Willink Biochemical Gene ics Uni , S Ma y’s Hospi al, Manches e
Uni e si y Founda ion T us , Uni e si y o Manches e ,
Manches e ZIP M13 9WL, UK
4School o Biological Sciences, Facu ly o Biology, Medicine and Heal h,
The Uni e si y o Manches e , Manches e , UK
5Di ision o Pedia ic Me abolism a C uces Uni e si y Hospi al, Cen o
de In es igación Biomédica en Red de En e medades Ra as (CIBERER),
Eu opean Re e ence Ne wo k o He edi a y Me abolic Diso de s
(Me abERN), Bioc uces-Bizkaia Heal h Resea ch Ins i u e, Uni e si y o he
Basque Coun y (UPV/EHU), Ba akaldo, Spain
6Fundación Española pa a el Es udio y Te apéu ica de la En e medad de
Gauche y o as lisosomales (FEETEG), Za agoza, Spain
Abs ac
Backg ound Sebelipase al a (Kanuma®) is app o ed o pa ien s wi h Wolman disease (WD) a a dosage o 3–5mg/
kg once weekly. Su i al a es in he second o wo clinical ials was g ea e , despi e ec ui ing mo e se e ely ill
pa ien s, p obably ela ed o highe ini ial and maximal doses. We aimed o e alua e he e ec i e pha macokine ics
and pha macodynamics o Sebelipase al a when adminis e ed o pa ien s wi h se e e WD a 5mg/kg wice weekly,
an in ensi e egimen which was no assessed in he ials.
Me hods We ec ui ed 3 pa ien s ecei ing Sebelipase al a 5mg/kg wice weekly. We measu ed LAL ac i i y in
leukocy es and plasma oxys e ol concen a ion in wo pa ien s and LAL ac i i y in ib oblas s in one pa ien . Clinical
ollow up was also assessed.
Resul s Analyses o LAL ac i i y and oxys e ols demons a e ha he e is sho -li ed enzyme ac i i y pos -dosing
which is associa ed wi h he elease o s o ed lipids. Clinical da a demons a e ha 5mg/kg wice weekly dosing is
well ole a ed and e ec i e.
Conclusion 5mg/kg wice weekly dosing wi h Sebelipase al a escues se e ely ill in an s wi h WD by inc easing
subs a e clea ance. The e is biologically ele an lipid accumula ion in he ‘ ough’ pe iods be o e he nex dosing,
e en wi h his in ensi e egimen.
Twice weekly dosing wi h Sebelipase al a
(Kanuma®) escues se e ely ill in an s
wi h Wolman disease
Ma ía JosédeCas o1,2, Simon AJones3,4* , Ja ie de lasHe as5, PaulaSánchez-Pin os1,2, Ma ía LCouce1,2,
C is óbalColón1,2, PabloC ujei as1,2, Ma íaUnce a5, Hea he Chu ch3, Ka h ynB ammeie 3, Wu HoiYee3,
JamesCoope 3, Lau aLópez de F u os6, I eneSe ano-Gonzalo6, Ma ía JoséCamba1,2, Fiona J.Whi e3,
Vic o iaHolmes3 and A unabhaGhosh3,4
Page 2 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
In oduc ion
Lysosomal acid lipase de iciency (LAL-D) is a a e inhe -
i ed au osomal ecessi e me abolic disease wi h an es i-
ma ed p e alence o 0,2 pe 10,000 indi iduals in Eu ope
[1, 2]. LAL-D is caused by pa hogenic a ian s in he
LIPA gene (MIM*613,497), which encodes an essen ial
enzyme in he me abolism and deg ada ion o choles e yl
es e s and iglyce ides (EC:3.1.1.13) [3, 4]. Absence o
dec eased le els o LAL leads o he accumula ion o he
a o emen ioned subs a es mainly in he li e , spleen, and
small in es ines [5, 6].
Wolman disease (WD) is he mos se e e o m o
LAL-D and is cha ac e ized by ea ly onse and apid
p og ession. Clinical mani es a ions include ailu e o
h i e, omi ing, dia hoea, hepa osplenomegaly [7] and
calci ica ion o he ad enal glands [8]. Ano he common
ini ial p esen a ion is wi h a seconda y hemophagocy ic
synd ome [9–11]. Wi hou ea men , in an s wi h WD
do no su i e beyond 6 mon hs o age [12]. Diagno-
sis is based on clinical symp oms, measu emen o LAL
enzyme ac i i y [13], and molecula gene ic con i ma ion
[14].
Sebelipase al a (Kanuma®, Kanuma™) has been
app o ed since 2015 as a long- e m enzyme eplacemen
he apy (ERT) o pa ien s diagnosed wi h LAL-D [15–
17]. Sebelipase al a binds o he mannose 6-phospha e
ecep o and he mac ophage mannose ecep o and is
subsequen ly in e nalized in o he lysosome, ca alysing
he hyd olysis o choles e yl es e s and iglyce ides [18].
The e icacy, sa e y and pha macokine ics o Sebelipase
al a in pa ien s wi h WD we e e alua ed in wo pi o al
mul icen e phase II/III s udies: LAL-CL03 (VITAL) [19]
and LAL-CL08[20]. The VITAL s udy included 9 pa ien s
who p esen ed wi h g ow h e a da ion, se e e hepa o-
splenomegaly and apidly p og essi e li e disease be o e
he age o 6 mon hs. All pa ien s ecei ed weekly in a-
enous (IV) in usions o Sebelipase al a a a s a ing dose
o 0.35mg/kg (8 pa ien s) o 0.20mg/kg (1 pa ien ) o
a leas 2 in usions, ollowed by a weekly dose o 1mg/
kg o 3 mg/kg based on clinical esponse. LAL-CL08
included 10 pa ien s wi h WD which appea ed o ha e
mo e se e e disease a baseline. Sebelipase al a ea men
was s a ed a a highe dose, and as e dose escala ion
was pe mi ed. All pa icipan s s a ed ea men wi h
weekly Sebelipase al a in usions a a dose o 1mg/kg and
hey could be conside ed o a dose inc ease o 3mg/kg
and up o 5mg/kg. No ably, su i al was be e o e all
in he LAL-CL08 s udy, wi h Kaplan-Meie es ima es o
su i al being 67% ( o 12 mon hs) and 56% ( o 4 yea s) in
VITAL, compa ed o 90% ( o 12 mon hs) and 80% ( o 3
yea s) in CL08. This inc eased su i al in he CL08 s udy
compa ed o VITAL may be ela ed o he highe ini ial
and maximal doses o ERT, wi h as e dose escala ion
[20] .
Following hese pi o al ials, Sebelipase al a ecei ed
ma ke ing au ho isa ion a a licensed dose o 3 mg /
kg weekly o WD. Recen ly, he da a shee has been
upda ed o ecommend he adminis a ion o highe
doses (5 mg/kg weekly) when a subop imal clinical
esponse is obse ed.
This a icle pos ula es ha pa ien s wi h mo e ad anced
o apidly p og essing WD may bene i om in ensi ica-
ion o he ERT egimen. We ca ied ou in i o and in
i o pha macodynamic e alua ions in h ee pa ien s
wi h WD and mul iple o gan ailu e who we e escued
wi h an in ensi e egimen o ERT wi h Sebelipase al a
a 5mg/kg wice weekly, desc ibing sa e y, e icacy, and
clinical ollow up.
Ma e ials and me hods
W i en consen o publica ion o pa ien da a was
ob ained om he amilies o all indi iduals included.
Demog aphic in o ma ion and clinical da a was collec ed
om medical eco ds, and haema ological and biochemi-
cal da a was ob ained om hospi al labo a o y eco ds.
LAL enzyme ac i i y
LAL ac i i y was measu ed in mixed leucocy es in
pa ien s 1 and 2 using he a i icial subs a e 4-me hy-
lumbelli e yl-palmi a e (NBS Biologicals, UK) based on
he p e iously published p o ocol [21,22]. This assay has
also been used o measu e LAL ac i i y in cul u ed skin
ib oblas s as pa o a pulse-chase expe imen wi h Sebe-
lipase al a in pa ien 3.
Molecula gene ic diagnosis
In pa ien s 1, 2 and 3 molecula gene ic analysis was
pe o med by Sange sequencing. All exons and in on-
bounda ies, as well as 3’ and 5’-UTR egion o LIPA gene
we e ampli ied by homemade design PCR. P oduc s we e
sequenced by capilla y elec opho esis using a SeqS udio
analyse (Applied Biosys ems), and esul s we e com-
pa ed wi h he GeneBank da abase’s e e ence sequence
(NG_008194.1).
Plasma oxys e ols
In pa ien s 1 and 2, se ial measu emen s o plasma oxys-
e ol concen a ions we e used as a su oga e disease bio-
ma ke . 7-ke ocholes e ol (7-KC) was quan i ied by liquid
ch oma og aphy and coupled andem mass spec ome y
as p e iously epo ed [23–25].
Cell cul u e
Cul u ed skin ib oblas s om pa ien 3 we e used as an
in- i o model o enzyme up ake and clea ance. Cells
a e ou inely cul u ed in comple e Minimum Essen ial
Medium (MEM), 10% FCS, 5 mM glu amine, non-essen-
ial amino acids (Gibco, UK) in 5% ca bon dioxide.
Page 3 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
Enzyme challenge - Cells we e pla ed in o T12.5 lasks x
10 and g own o ~ 95% con luence. Each lask (minus one
baseline con ol) was challenged wi h sebelipase alpha a
a concen a ion o 100 ng/ml dilu ed in comple e MEM
(500 ng in 5ml comple e MEM pe T25 lask) and incu-
ba ed o 1h a 37 oC in 5% ca bon dioxide. Following
exposu e, he sebelipase al a condi ioned medium was
emo ed, and esh 5ml comple e medium was eplaced
in o each lask. The cells we e hen ha es ed wi h yp-
sin, washed in iso onic saline, and hen s o ed a -80oC
eady o enzyme analysis a successi e ime poin s: ime
ze o, 1, 2, 4,6 ,24, 48, 72, 96 and 120h pos -sebelipase al a
challenge. Fo a baseline con ol a single lask was ha -
es ed a ime ze o wi hou exposu e o sebelipase al a
as a baseline diagnos ic measu emen o his pa ien cell
line. The ac i i y o LAL wi hin he ha es ed ib oblas s
was hen measu ed using he abo e p o ocol [21].
Resul s
Demog aphics, sa e y and clinical ollow up in se e ely
ill WD pa ien s ecei ing sebelipase al a 5mg/kg wice
weekly
Pa ien 1
Pa ien 1 p esen ed aged 3.5 mon hs wi h e e , pancy o-
penia, hepa osplenomegaly and associa ed hype iglyc-
e idemia (max. alue 1,950 mg/dL), hype e i inemia
(max. alue 11,300 ng/mL) and ansamini is (max. al-
ues AST 177 UI/L, ALT 106 UI/L, GGT 266 UI/L). A
diagnosis o hemophagocy ic lymphohis iocy osis was
made, and she was ini ially ea ed wi h s e oids and
e oposide. Due o poo e olu ion and lack o esponse
o ea men , u he in es iga ions con i med a se e e
pheno ype o WD. LAL enzyma ic ac i i y quan i ied on
DBS was 0.04 nmol/punch/h (no mal ange 0.71–2.38
nmol/punch/h). 7-KC a diagnosis was 2313 ng/mL (no -
mal ange: 2-104 ng/mL). Gene ic es ing iden i ied he
NM_000235.2:c.966 + 2T > G a ian in a homozygous
s a e. This a ian was p e iously desc ibed in a Span-
ish WD coho wi h a le hal ou come [26]. Pa ien 1 was
ans e ed o he paedia ic in ensi e ca e uni due o
espi a o y dis ess, wi h massi e hepa osplenomegaly
eaching he iliac ossa, alongside se e e h ombocy ope-
nia and neu openia. The i s in usion o Sebelipase al a
was adminis e ed one day a e he diagnosis, a a dose
o 3mg/kg. She de e io a ed apidly du ing he ollowing
days, de eloping acu e espi a o y ailu e ha equi ed
in uba ion and mechanical en ila ion, as well as acu e
enal ailu e ha equi ed he ini ia ion o haemodia il-
a ion. A e con i ming adequa e ole ance o he i s
in usion o sebelipase and gi en he acu ely li e- h ea -
ening si ua ion o he pa ien (pulmona y oedema, acu e
enal ailu e, asci es, h ombocy openia wi h ans u-
sion dependence and hype -in lamma o y s a e), i was
decided o inc ease he dose o ERT o 5mg/kg (in used
o e 4h) and adminis e i wice weekly. The pa ien ’s
o e all clinical s a us imp o ed du ing he ollowing
weeks, wi h mechanical en ila ion being discon inued
a e 2.5 weeks, and haemodia il a ion discon inued
a e 3 weeks. A p og essi e imp o emen in he analy i-
cal pa ame e s ela ed o in lamma ion, wi h a ma ked
dec ease in e i in and iglyce ide le els du ing he i s
week o he in ensi ied ERT egimen, as well as esolu-
ion o leukopenia. Hemoglobin le els and pla ele coun s
imp o ed om he second week on, al hough he pa ien
con inued o equi e daily blood p oduc ans usions
du ing he i s mon h o hospi aliza ion, which subse-
quen ly educed in equency and s opped by 2 mon hs.
Rega ding lysosomal disease bioma ke s, du ing he
i s week CCL18/PARC and ChT dec eased (35 ng/mL
and 138 nmol/mL/h espec i ely), bu 7-KC was s ill is-
ing (2944 ng/mL). Th ee weeks a e he diagnosis, 7-KC
began o dec ease (398 ng/mL). Du ing he i s 15 days
o admission and due o he clinical ins abili y o he
pa ien , she was main ained wi h o al pa en e al nu i-
ion wi hou lipids. Subsequen ly, en e al nu i ion was
s a ed wi h a p o ein hyd olysa e and lac ose ee modu-
la o mula (ca bohyd a e in ake: 18mg/kg/min, p o ein
in ake: 4g/kg/day and lipid in ake: 1.0–1.5g/kg/day, wi h
a o al calo ic in ake o 120 o 140 Kcal/day). Weigh
was s a ic du ing he i s wo mon hs o admission, bu
imp o ed he ea e (5kg a 4 mon hs o age – co e-
sponding o pe cen ile 10 – on he i s day o admission,
and 7kg a 6 mon hs o age – co esponding o pe cen ile
35 - p io o discha ge). Finally, a clinically meaning ul
dec ease in he size o he li e and spleen was obse ed.
Pa ien 1 emains well on 5mg/kg once weekly ERT,
s epped down a e 3 mon hs, which was well ole a ed,
wi h no anaphylaxis o ad e se eac ions
Pa ien 2
The pa ien , a ull- e m male newbo n wi h no mal bi h
weigh (3.23kg), p esen ed wi h omi ing and abdomi-
nal dis ension om he i s days o li e, and was admi -
ed in hospi al a 6 weeks o age due o ailu e o h i e.
He was pale, and abdominal dis ension wi h spleno-
megaly and cachexia we e e iden , wi h a body weigh o
3.52kg, below he 3 d pe cen ile. Labo a o y in es iga-
ions showed HDL < 5mg/dL, aised ansaminases (AST:
225 IU/L, ALT: 237 IU/L, GGT: 157 IU/L), high e i in
(1072 ng/mL), and low a soluble i amins (25-OH- i a-
min D: 13 ng/mL, i amin A: 0.08mg/L and i amin E:
1.3mg/L). Blood ilm examina ion e ealed acuola ed
lymphocy es and 7-KC le els we e inc eased (906 ng/
mL; no mal ange 2 o 103.6). LAL-D diagnosis was con-
i med a e he de e mina ion o LAL enzyme ac i i y
in DBS (0.02 nmol/punch/h) and gene ic es ing, which
e ealed he NM_000235.2:c.966 + 2T > G a ian in a
homozygous s a e. The pa ien s a ed en e al modula
Page 4 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
eeds con aining glucose polyme , medium-chain a and
an amino acid mix u e a 1 mon h and 23 days o age,
and a day la e ERT wi h Sebelipase a 5mg/kg/week was
s a ed. Due o he in es inal damage, he e was a malab-
so p ion wo sening wi h a weigh loss o 250g in 24h,
and TPN was s a ed. A ha momen , he decision was
made o inc ease Sebelipase dosage up o 5mg/kg/ wice
a week. This wice a week in usion egimen was main-
ained o 4 weeks. A 3 mon hs o age TPN was s opped,
and he pa ien was discha ged home eigh days la e . A
he ime o w i ing, he pa ien is almos 5 mon hs, wi h a
body weigh o 6.75kg (p25).
Pa ien 3
Pa ien 3 p esen ed a he age o 2.5 mon hs wi h a ypi-
cal his o y o WD, including omi ing and loose s ools
since bi h, hepa osplenomegaly and asci es, wi h lipid
s o age in Kup e cells on li e biopsy. The diagno-
sis was con i med by bo h enzyme analysis (leukocy e
acid es e ase ac i i y 32 nmol/mg/h , e e ence ange
35 − 2,000 nmol/mg/h) and molecula gene ics, which
iden i ied a homozygous whole gene dele ion o LIPA,
p e iously epo ed in a se ies o pa ien s wi h WD o
Sou h Asian backg ound [27]. Enzyme eplacemen
he apy wi h sebelipase al a a an ini ial dose o 5mg/kg
weekly was commenced a 3 mon hs o age, and he was
changed om a high ene gy eed wi h signi ican a con-
en (6.3g o al a /kg/d, 60% MCT) o a - ee o al pa -
en e al nu i ion. A baseline, he had hypoalbuminaemia
(26g/L), mildly ele a ed iglyce ides (2.7 mmol/L) and
C- eac i e p o ein (32mg/L). He was anemic (hemoglo-
bin 76g/L), bu wi hou h ombocy openia o leukope-
nia. T ansaminases and e i in we e no mal. Plasma
oxys e ols (choles ane-3β, 5α, 6β- iol) a baseline we e
ele a ed a 107 ng/ml ( e e ence ange 10–37 ng/ml).
Du ing he i s 2–3 weeks on ERT, a hype -in lamma o y
pic u e became appa en , wi h pe sis en ly aised CRP,
in e mi en e e wi hou posi i e blood cul u es, and
a equi emen o epea ed blood ans usions. Abdomi-
nal dis ension and asci es ma kedly inc eased, associa ed
wi h apid weigh gain and achypnoea, and his pe sis ed
despi e ea men wi h luid es ic ion and diu e ics
( u osemide and spi onolac one). Due o ongoing espi-
a o y dis ess, he was admi ed o he paedia ic in en-
si e ca e uni a e 5 weeks on ERT, and commenced
non-in asi e en ila o y suppo . The e was a modes
imp o emen in achypnoea ollowing needle aspi a-
ion o asci ic luid, bu his was no sus ained. Gi en he
hype in lamma o y pic u e, asci es and espi a o y dis-
ess, he equency o enzyme eplacemen he apy was
inc eased ( o 5mg/kg wice weekly). Following his, he
made a good eco e y and was s epped down om in en-
si e ca e a e one week. The e was clinical and adio-
logical imp o emen in asci es wi h only a ace o ee
luid obse able on ul asound a e 6 mon hs on ERT.
By his poin , weigh gain had s abilised, achypnoea and
e e had esol ed, he was no longe ans usion depen-
den , and he had es ablished en e al eeding wi h an
amino acid based, high ca bohyd a e, minimal a (0.8g
LCT o essen ial a y acids) modula eed. O ganomeg-
aly imp o ed, wi h 6cm hepa omegaly and no palpable
splenomegaly. Plasma oxys e ols educed o below he
uppe limi o no mal wi hin one mon h o s a ing wice
weekly ERT, and emain wi hin he e e ence ange. An i-
sebelipase an ibody i es peaked a a mode a e i e o
1:16384 (7 weeks a e commencing ERT), and ha e since
emained s able. O e all, his clinical condi ion is as ly
imp o ed and he was discha ged home a e a o al inpa-
ien s ay o 6 mon hs. A e 2 mon hs he was s epped
down o once weekly sebelipase a 5mg/kg.
E ec i e pha macokine ics in pa ien s 1 and 2
We ca ied ou se ial de e mina ions o LAL ac i i y
in leukocy es and quan i ica ion o plasma oxys e ols
(7-KC), o explo e he pha macokine ics and pha maco-
dynamics o his in ensi e egimen. Six ime poin s we e
included: p e-in usion be o e he i s o wo weekly doses
o sebelipase al a (0h); 24h a e he i s weekly dose o
Sebelipase al a (24h); 72h a e he i s weekly dose o
Sebelipase al a (72h); 96h a e he i s weekly dose o
sebelipase al a, which coincides wi h he p e-in usion
ime poin o he second weekly dose o sebelipase al a
(96h); 120h a e he i s weekly dose o sebelipase al a
which coincides wi h 24h a e he second weekly dose
o sebelipase al a (120h); and 144h a e he i s weekly
dose o sebelipase al a which coincides wi h 48h a e
he second weekly dose o sebelipase al a (144h). Resul s
co esponding o pa ien 1 a e displayed in Fig.1. I mus
be no ed ha due o wo sening anaemia, he olume o
blood ob ained a he 144h ime poin was only su icien
o analyse 7-KC concen a ions. Resul s a e displayed in
Fig.1 o pa ien 1 and Fig.2 o pa ien 2.
As shown in Fig.1, he baseline le el o LAL ac i i y
was abno mally low (15 nmol/mg/h; no mal ange: 258–
1141 nmol/mg/h), simila o le els obse ed in un ea ed
WD pa ien s. Twen y- ou hou s a e he i s wice
weekly dose o Sebelipase al a, a apid inc ease in LAL
ac i i y was obse ed up o 40 nmol/mg/hou , co e-
sponding o an inc ease o 133% o he basal ac i i y. Sub-
sequen ly, a apid dec ease in LAL ac i i y was obse ed,
eaching baseline alues wi hin 72h a e . Simila ly, 24h
a e he second weekly dose o sebelipase al a, he e is
e idence o a apid ise in LAL ac i i y up o 50 nmol/
mg/h.
In pa allel, wo peaks o 7-KC in plasma (498 ng/mL
and 300 ng/mL) a e obse ed a 24h a e he i s and
he second wice weekly doses o Sebelipase al a espec-
i ely, and p og essi ely dec easing be ween in usions,
Page 5 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
showing a double clea ance o subs a e. Baseline 7-KC
concen a ion p io o he i s wice weekly dose o Sebe-
lipase al a was 400 ng/mL (no mal ange: 2–104 ng/mL)
and ell o 225 ng/mL p io o he second weekly dose
o Sebelipase al a. Howe e , despi e he a o emen ioned
double clea ance mechanism, oxys e ol le els in plasma
emain signi ican ly high wi h alues compa ible wi h
he diagnosis o WD and did no no malize, e en a e
ecei ing he in ensi e egimen o ERT o 1.5 mon hs.
As shown in Fig.2, he baseline le el o LAL ac i -
i y was abno mally low (9.20 nmol/mg/h; no mal ange:
258–1141 nmol/mg/h). Twen y- ou hou s a e he i s
wice weekly dose o Sebelipase al a, a apid inc ease in
LAL ac i i y was obse ed, up o 28 nmol/mg/hou . Sub-
sequen ly, a apid dec ease in LAL ac i i y was obse ed.
Simila ly, 24h a e he second weekly dose o sebelipase
al a, he e is e idence o a apid ise in LAL ac i i y up o
20.8 nmol/mg/h.
E ec i e pha macokine ics in ib oblas s (pa ien 3)
Se ial LAL ac i i y was measu ed in cul u ed ib oblas s
ob ained om a his o ical WD pa ien as pa o a pulse-
chase expe imen . Addi ion o Sebelipase showed a sig-
ni ican peak abo e physiological ange ini ially bu his
had dec eased o almos baseline alues by 48–72h pos
in usion. Fib oblas s p obably ake up lysosomal enzymes
ia he M-6P ecep o whe eas mac ophages p edomi-
nan ly use he mannose ecep o . Impo an ly, bo h cell
ypes in i o and in i o consis en ly show a ela i ely
sho in acellula hal li e.
Fig. 3 Pa ien 3 ib oblas clea ance o Sebelipase. Black a ows deno e
he ime o Sebelipase addi ion. The solid black line shows he ac i i y o
he same pa ien ib oblas be o e he ea men
Fig. 2 Pa ien 2LAL ac i i y le els and 7-KC concen a ion a e 1.5 mon h ecei ing sebelipase a a dose o 5mg/kg wice weekly
Fig. 1 Pa ien 1 LAL ac i i y le els and 7-KC concen a ion a e 1.5 mon h ecei ing sebelipase a a dose o 5mg/kg wice weekly
Page 6 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
Discussion
WD is a a e, p og essi e in an ile onse disease caused
by insu icien LAL ac i i y and leading o dea h wi h a
median age o 3.5 mon hs [12]. The disease hallma ks
include li e ailu e, hepa osplenomegaly, s ea o hea
and malabso p ion, and ad enal calci ica ion due o
ex ensi e s o age o choles e yl es e s and iglyce ides
in he lysosomes o Kup e cells, hepa ocy es and mac-
ophages [28]. Sebelipase al a is licensed o long- e m
ea men o in an s wi h WD a e ecei ing ma ke ing
au ho iza ion om he Food and D ug Adminis a ion
and he Eu opean Medicine Agency in 2015, ollowing an
accele a ed assessmen due o unme medical need [29].
Due o he e y low incidence o WD, he numbe o
pa icipan s in he pi o al clinical ials o sebelipase al a
was necessa ily small. The collec ion o long- e m e i-
cacy da a is he e o e manda o y. In he clinical ials
VITAL (N = 9) and CL08 (N = 10), signi ican imp o e-
men s we e obse ed o a numbe o disease pa ame e s
and he e was an imp o emen in su i al o in an s wi h
WD. This su i al bene i appea ed o be e en g ea e in
he second clinical ial, CL08, which allowed o highe
s a ing doses, as e dose escala ion, and highe maximal
doses, as compa ed o he VITAL s udy [20].
Dose-dependen esponses o ecombinan human
LAL ha e been demons a ed in a mouse model o
LAL-D. Howe e , he LIPA-/- mouse is no an ideal
model o WD as i esembles he la e onse pheno-
ype mo e closely [30, 31]. I also does no demons a e
he in lamma o y disease seen so equen ly in in an s.
Two compa a i e p eclinical s udies wi h ecombinan
human LAL in LIPA-/- mice [32] we e conduc ed wi h
lowe doses (0.8 and 3.2 mg/kg weekly), beginning a
16 weeks (s udy 1) and wi h highe dose (10mg/kg) in
ea ly (8 weeks), middle (16 weeks) and la e (24 weeks)
disease s age (s udy 2). Sys emic e alua ion o he dosage
and ea men ini ia ion age on lipids, o gan size, body
weigh and li e span in LIPA-/- mice e ealed ha ea -
men s a ed a ea ly o middle disease s ages esul ed in
g ea e e ec s han la e s age ini ia ions, and su i al
was also dose dependen (in s udy 1 ERT ex ended he
li e span by 52 days wi h 0.8mg/kg e sus 94 days wi h
3.2 mg/kg). Also, he highe dose o ERT (10 mg/kg)
gi en weekly was able o p e en disease p og ession and
e en e e sal o ad anced disease. These s udies e ealed
some issues ha emain ele an o he dosing o ERT o
pa ien s wi h WD, especially hose mo e se e ely a ec ed
wi h ad anced disease. This includes he po en ial need
o dose a ia ion depending upon disease s age, and
aises he possibili y o e e sal o disease mani es a ions
wi h highe dosing, e en in la e s age disease.
Highe doses han 5mg/kg weekly we e no es ed in
he clinical ials due o a p io assump ion ha he op i-
mal dose would be be ween 1 and 3mg/kg weekly (o
no e he licensed dose o la e onse LAL-D is 1mg/kg
al e na e weekly). Mo e han once weekly dosing was no
es ed in ei he he p e-clinical model o human ials.
Howe e , he e a e p e ious da a om h ee o he p e-
clinical s udies employing ecombinan human LAL p o-
duced in di e en sys ems. In hese s udies, using a 3-day
in e al o adminis a ion, he au ho s showed no mal-
iza ion o hepa ic colo , dec eases in hepa ic choles e ol
and iglyce ides con en s, and diminished oamy mac o-
phages in li e , spleen and in es inal illi in a dose depen-
den manne [33–35]. They also demons a ed ha he
hal -li e o he ecombinan enzyme was 14h and 32h in
li e and spleen, espec i ely [33].
Pha macokine ics (PK) o enzyme eplacemen he a-
pies a e adi ionally e alua ed as plasma le els. These
le els howe e a e a ely in o ma i e o dosing deci-
sions as lysosomal enzymes a e usually only ac i e a
lysosomal pH. Mo e use ul in o ma ion may be gained
om unde s anding he in acellula PK o e ime and
ollowing an in a enous in usion. While his can be
challenging in LSDs wi h mul i-o gan s o age, in WD
he mac ophage is he main s o age cell. Using a mixed
leukocy e p epa a ion pe mi s accu a e unde s anding
o ac i e enzyme in he ele an cell ype in his disease.
We ha e e med his he ‘e ec i e PK’. Ou LAL ac i i y
da a, bo h in leukocy es and ib oblas s, suppo he idea
ha he e is sho -li ed enzyme ac i i y pos -dose, sug-
ges ing ha sebelipase al a is p esen in cells o only 2–3
days pos -adminis a ion. When combined wi h plasma
oxys e ol le els, i is shown ha he inc ease in LAL
ac i i y a e wice weekly ERT adminis a ion is biologi-
cally impo an , as i is associa ed wi h a empo a y ise
in oxys e ol, p esumably ela ed o elease o p e iously
s o ed lipids and pa ially oxidised choles e ol, exe ing a
u he clea ance o subs a e. Impo an ly, he ac ha
oxys e ol le els we e pe sis en ly high in pa ien 1, wi h-
ou no maliza ion e en a e 1.5 mon hs o wice weekly
sebelipase, shows ha he e is s ill biologically ele an
lipid s o age in he ‘ ough’ pe iods be o e he nex dos-
ing. This may sugges ha e en wi h wice weekly in u-
sions, no s eady s a e is uly achie ed. Co espondingly,
samples aken in e mi en ly in pa ien 3 o e he cou se
o se e al weeks, showed highe leukocy e LAL ac i i y
in all in e -in usion samples compa ed o all p e-in usion
‘ ough’ samples (supplemen al Fig.1). This may be o
special in e es in he mos se e ely ill pa ien s p esen -
ing in ex emis, wi h a po en ial o inc eased chance o
su i al by co ec ing he pa hophysiology o he dis-
ease mo e quickly and a oiding he apid p og ession o
mul i-o gan ailu e.
While he su i al bene i o sebelipase al a was clea
om he wo clinical ials, e en in he second ial some
in an s died. This was ecognised o be o en hose in an s
p esen ing in la e s ages o disease, wi h signi ican
Page 7 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
in lamma ion and mo e se e e end o gan damage. Indi-
iduals desc ibed in his epo had a se e ely comp o-
mised clinical s a us, consis en wi h a mo e ad anced
s age o WD. Due o hei li e- h ea ening condi ion and
he hypo hesis ha highe doses o sebelipase may lead o
be e ou comes, he medical eams decided o adminis-
e in ensi e high dose wice weekly ea men . This was
associa ed wi h p og essi e imp o emen in clinical s a-
us and ul ima ely led o he escue and su i al o he
h ee pa ien s included in his coho , and wi hou any
se e e ad e se e en s ela ed o he inc eased dosage.
One possible conce n o he adminis a ion o his
in ensi e egimen o sebelipase al a wice weekly would
be he inc eased isk o hype sensi i i y eac ions. Ne -
e heless, all pa ien s we e success ully main ained on
wice weekly in usions as long as was clinically indi-
ca ed, despi e occasional in usion eac ions as p e iously
epo ed, hus con i ming he accep able sa e y p o ile
o his he apeu ic s a egy. This is especially ele an
when dealing wi h uns able pa ien s wi h an ad anced
s age o WD, in whom he isk o decompensa ion may
be inc eased.
We acknowledge limi a ions o his s udy including he
small sample size, he lack o a head- o-head compa ison
and no blinding. Howe e , gi en he a i y and le hali y
o WD, li le is known abou an op imal ERT dosing and
he pos -licensing en i onmen does no allow o a o -
mal clinical ial e alua ion.
Ou PK app oach in his pape di e s om he ypi-
cal model. Howe e , we belie e i may o e ad an ages
in lysosomal s o age diso de s when he d ug is ypi-
cally only ac i e once in acellula . P elimina y wo k in
ou labo a o y sugges s o he ecombinan enzymes (e.g.
la onidase) a e much mo e pe sis en in leukocy es and
each a s eady s a e wi h weekly dosing (unpublished
obse a ions). This clea ly does no occu wi h Sebelipase
and his in o ma ion is c i ical o dosing decisions in he
mos ex eme cases. The concep o ‘e ec i e pha maco-
kine ics’ may be ele an o a numbe o o he ERTs in
his a ea.
The ecen ly published a icle by Dema e e al. [15]
shows a 100% su i al a e in a coho o i e pa ien s
wi h WD, compa ed o a su i al a e o 55% and 80% in
he LAL-CL03 and LAL-CL08 s udies, espec i ely. The
au ho s a ibu e hese good esul s o he high p opo -
ion o posi i e amily his o y in hei coho (3/5), lead-
ing o an ea ly diagnosis (be ween 0 and 2 mon hs o age)
and be e clinical s a us a ERT ini ia ion. We he e o e
conside ha he e is an unme need o hose pa ien s
who a e diagnosed in mo e ad anced s ages o he dis-
ease wi h p o oundly comp omised clinical s a us, in
which a highe dose inc eased equency egimen may be
o bene i .
Some au ho s ad oca e o mul imodal ea men o
WD [27], including ERT and die a y subs a e educ ion
die (SRD) combined wi h hema opoie ic s em cell ans-
plan a ion (HSCT). ERT and SRD imp o es he HCT
p ocess and HCT likely p o ides be e enzyme deli -
e y o issues and be e long e m ou comes, han hose
achie able wi h ERT alone. The e is a need o a lexible
app oach o dosing and combina ion he apy o gain he
bes ou come o all in an s, e en hose in ex emis. This
is a good example o p ecision medicine, op imising he
dose and mode o he apy o each indi idual pa ien .
While accele a ed app o al o d ugs wi h a d ama ic
pa ien bene i like sebelipase al a a e welcome, clini-
cal ials a e aimed a egula o y app o als a he han
guiding clinical managemen and designing op imal ca e
pa hways. Pos -app o al clinical ials in such a se e e
and ul a-o phan disease a e unlikely and so case se ies
such as his, suppo ed by oppo unis ic pha macokine ic
and dynamic measu es may be he only way o gene a e
u he e idence. While indus y egis ies a e common,
ew ha e gene a ed majo clinically impo an da a [36].
S udies like hese emain an impo an ool o imp o -
ing ou comes bu only i egula o s and eimbu semen
au ho i ies will begin o accep his le el o e idence.
Speci ically o sebelipase al a, we make he case ha a
sho - e m in ensi ica ion o ERT, wi h a dose o 5mg/kg
wice weekly, has he po en ial o escue e en he mos
se e ely unwell WD in an s who o he wise may no ha e
su i ed, and we sugges ha he app o ed label could be
al e ed o e lec his new dosing pa adigm. The bene i s
o accele a ed app o al app oaches om egula o s will
be lessened i he e is no also a p agma ic app oach o
e iew o pos licensing eal wo ld da a.
Conclusions
Pha macokine ics in leukocy es and u he in i o wo k
demons a es ha he in acellula hal -li e o Sebeli-
pase al a (Kanuma®) is e y sho , suppo ing ha wice
weekly dosing (which was no es ed in he clinical ials)
escues he mos unwell child en wi h WD by inc easing
subs a e clea ance.
Acknowledgemen s
To he pa ien s and amilies, he LALD Spanish Socie y (AELALD) and he
MPS Socie y UK. M.J.C., J.H., P.S.P., M.L.C., C.C.M, P.C. and M.J.C a e membe s
o he Eu opean Re e ence Ne wo k o Ra e He edi a y Me abolic Diso de s
(Me abERN) P ojec ID No. 739543. This esea ch was suppo ed by he NIHR
Manches e Biomedical Resea ch Cen e (NIHR203308).
Au ho con ibu ions
M.J.C., S.A.J. and A.G. concei ed he o iginal idea, designed he expe imen ,
looked a e he pa ien s and w o e de manusc ip . J.H, P.S.P, M.L.C, M.J.C,
F.J.W and V.H applied he o iginal idea, looked a e he pa ien s and aided in
in e p e ing he esul s. C.C.M, P.C, M.U, H.C, K.B, W.H.Y, J.C, L.L.F, I.S concei ed
and ca ied ou he expe imen s, aided in in e p e ing he esul s and
designed he igu es. All au ho s p o ided c i ical eedback and helped shape
he esea ch, analysis and manusc ip .
Page 8 o 9Cas o de e al. O phane Jou nal o Ra e Diseases (2024) 19:244
Funding
This esea ch ecei ed no speci ic g an om any unding agency in he public
o comme cial sec o s.
Da a a ailabili y
Da a a chi ing is no manda ed bu da a will be made a ailable on easonable
eques .
Decla a ions
E hics app o al and consen o pa icipa e
No applicable.
Consen o publica ion
In o med consen was ob ained om he pa en s o pa icipa e and o submi
and publish he esul s in he jou nal.
Compe ing in e es s
Ma ía José de Cas o, Simon A Jones, Ja ie de las He as, C is obal Colón and
Fiona J Whi e ha e ecei ed hono a ia and consul ancy ees om Alexion. The
emaining au ho s decla e ha hey ha e no con lic o in e es .
Recei ed: 18 Ap il 2023 / Accep ed: 19 May 2024
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Publishe ’s No e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
