Accelerating clinical trials in Wolfram syndrome: development of efficacy biomarkers and patient relevant outcome measures

Association for Wolfram Syndrome + Eye Hope Foundation + The Snow Foundation logos

1st teleconference meeting report
Tuesday 24 April, 2018

Report written by: Virginie Picard (Association du syndrome de Wolfram)
Report validated by: prof. Timothy Barrett, project coordinator

The first update teleconference meeting on Biomarker project led by professor Tim Barrett took place on Tuesday 24 April, six months after the official beginning of the project. Representatives of the three funding organizations were present: Stephanie Gebel (The Snow Foundation), Nolwen Le Floch & Virginie Picard (Association du syndrome de Wolfram) and Lode Carnel (Eye Hope Foundation). 

The project coordinator, professor Timothy Barrett, presented the progress of the project, with the kind assistance of two members of his consortium: Drs. Dewi Astuti and Anita Slade (University of Birmingham).

As an introduction, professor Barrett recalled that the project is aimed at validating biomarkers relevant to underlying Wolfram syndrome mechanisms and at developing Patient-Reported Outcomes (PROs) to capture the broader experience of the patient and to define patient-relevant clinical trial endpoints for future clinical trials. The ultimate goal of the project is to hasten delivery of treatments to the patient in the clinic and to develop tools allowing to predict within the first 6 months /1 year of a clinical trial whether a candidate medicine has a chance to succeed or not. 

The progress of three workpackages was then presented:

Dr. Anita Slade presented the work she is doing on the development of PROs. She has achieved initial consultations with British patients (adults or adolescents) and parents in order to define what the expected outcomes of a candidate medicine on the patient life and health can be. She has based her research on patients experience as well as on various existing clinical Quality of Life questionnaires that are relevant to Wolfram syndrome and vision loss. She has been able to establish a list of potential PROs that now need to be evaluated for their clinical meaningfulness and usefulness.

Dr. Dewi Astuti next presented her current work on the identification of biomarkers that can be used to evaluate the progress of Wolfram syndrome and more especially the neurodegenerative component of the disease. She has searched for biomarkers that can be preferentially measured in small amounts of blood and that are time and cost-effective. For this, she has made an extensive literature search, looking for candidate biomarkers already used for neurodegenerative diseases. Thanks to this, she has been able to identify 4 new candidate biomarkers that are now being tested for their relevance and sensitivity in cultures of cells depleted of WFS1 gene and in sera of patients with Wolfram syndrome. One of the biomarkers selected seems to be consistently increased in sera of Wolfram patients. Additional assays are ongoing.

Professor Barrett then presented progress being achieved with Euro-WABB, the patient registry for rare diabetes (including Wolfram syndrome). In May 2018, new European standards on data protection will be published, as well as a set of common data elements for all rare disease registries. Moreover, a common consent form for European Reference Networks is now available. The aim of all these new measures is to make all registries interoperable and linked to an EU platform for rare diseases registration. Euro-WABB is currently being modified by Richard Sinnott to comply with these new regulations and requirements. Data from past registry will be transferred to a new, user-friendly database. Hopefully, work will be completed during the summer.

Another project workpackage has not started yet. This workpackage is aimed at validating the first candidate efficacy biomarker p21cip within the frame of the European Phase II clinical trial on candidate drug Valproate. For this, biosamples need to be collected from patients treated and non-treated with the drug. The organization of the clinical trial has faced some delays, but it is now expected to start in Autumn 2018. 

This work will be extensively presented at next international workshop organized by the Association du syndrome de Wolfram that will take place in June in Paris, France. The second update teleconference meeting is due in September 2018. 

/by

Proof of Concept study in Wolfram Mice – Mitochon Pharmaceuticals

Mitochon Pharmaceuticals, Inc., Blue Bell, Pennsylvania, is sponsoring a Proof of Concept (POC) study in Wolfram mice using a mitochondrial target approach to attenuate diabetes, behavioral and functional decline. Mitochon has developed clinical stage (Phase I ready) pharmaceuticals that modulate mitochondrial physiology.  These compounds, MP101 and MP201, have shown merit in animal models of vision loss, hearing loss, movement disorders, trauma, neuromuscular/neurodegenerative and metabolic diseases. Stephanie Gebel recommended Dr. Sulev Koks at the University of Tartu, Estonia, who generated the Wsf1 KO mice to the company.  Dr. Geisler, CSO of Mitochon, said, “I was delighted to hear Dr. Koks outside the box spirit for embracing new ideas and for seeing the possible merits of our approach for Wolfram”.  Dr. Saad Naseer provided Mitochon some guidance to capture critical endpoints as well.

The concept is that endoplasmic reticulum (ER) stress associated with Wolfram Syndrome has a strong detrimental effect on the mitochondria and thus cellular survival. In addition, the abundance of oxidative stress in Wolfram through reactive oxygen species (ROS) production via the mitochondria further creates a hostile environment for cells.  Unlike anti-oxidants that attempt to mop up ROSs once they are made, Mitochon’s compounds, MP101/MP201, abolish overt ROS production in the mitochondria, which is a much better starting point, and reduce the burden of mitochondrial calcium overload due to ER stress.  Together, these targeted approaches have been shown to prevent cell death.  Dr. Geisler says “There are many diseases, such as Alzheimer’s, Parkinson, Huntington, epilepsy, Wolfram, Multiple Sclerosis, etc., that have both ER and oxidative stress issues.  Our therapies work by helping the mitochondria to cope with the deleterious effects of ER stress.”

With ER stress, the mitochondria get overburdened with calcium coming from the endoplasmic reticulum.  One of the main roles of the mitochondria, besides making energy (ATP), is to store calcium and to keep the cytosol calcium free.  The calcium storage capacity of the mitochondria is tremendous, but there is a threshold.  When that threshold is exceeded, the mitochondria will self-destruct and leak out all of the calcium into the cytoplasm.  The neighboring mitochondria are obligated to take it up, but are already near their threshold, so they self-destruct.  Eventually, this cascades into the death of cells such as neurons or myotubes (muscle cell).  Reducing ER stress is a great approach, but lowering calcium overload at the mitochondria is critical.  Since Mitochon’s compounds (MP101 and MP201) simultaneously abolish ROS production and reduce calcium overload, their targeted effects should lower the burden on mitochondria and preserve cellular health in diseases that exhibit these types of stressors.  This has already been shown in models of Huntington’s disease, traumatic brain injury (TBI), and Duchenne Muscular Dystrophy DMD) and the plan is to provide evidence that this approach is useful in Wolfram Syndrome.

Dr. Geisler says, “in a nutshell, we plan to run both compounds (MP101 and MP201) in the Wfs1KO mouse starting at 2-mths of age when diabetes starts to appear.  They will be orally dosed once per day for 4-mths until 6-mths of age.  An oral glucose tolerance test (OGTT) will be performed each month to monitor changes in glucose flux.  At the end of the study, behavior will be monitored for balance and gait.  Finally, the pancreas will be removed to examine islet morphology (diameter and number), the liver will be used to measure steatosis, histology on the eyes for retinal ganglion cell (RGC) survival and the optic nerve for demyelination.  We expect the study to start in July 2018 and complete in early 2019.  We don’t know for sure if it will work, but it seems reasonable!  We already have data on preventing hearing loss, vision loss, diabetes, neuroprotection, neuromuscular protection, and calcium overload, so Wolfram looks like a plausible target.”

About Mitochon Pharmaceuticals

Mitochon was founded in 2014 by experienced Pharma executives with the mission to develop treatments for insidious diseases through the modulation of mitochondrial physiology, with applications to neurodegeneration (Huntington’s, Parkinson’s, MS) neuromuscular (Duchenne) and developmental (Wolfram Syndrome) diseases.  Mitochon’s lead programs, MP101 and MP201, specifically harnesses the power of the mitochondria to provide broad neural protection. These compounds elicit mild increases in energy expenditure that result in strengthening cellular survival – similar to the positive effects seen with fasting and exercise.  These compounds also induce an important neurotrophin, Brain Derived Neurotrophic Factor (BDNF), involved in cognition and neural growth. Mitochon is supported by Ben Franklin Technology Partners Southeastern PA, an initiative of the Pennsylvania Department of Community and Economic Development funded by the Ben Franklin Technology Development Authority. Additional Information:  www.mitochonpharma.com

For background information, please see [1-5]

  1. Feissner, R.F., et al., Crosstalk signaling between mitochondrial Ca2+ and ROS. Front Biosci (Landmark Ed), 2009. 14: p. 1197-218.
  2. Geisler, J.G., et al., DNP, mitochondrial uncoupling, and neuroprotection: A little dab’ll do ya. Alzheimers Dement, 2017. 13(5): p. 582-591.
  3. Geisler, J.G., Targeting energy expenditure via fuel switching and beyond. Diabetologia, 2011. 54(2): p. 237-44.
  4. Wu, B., et al., 2,4 DNP Improves Motor Function, Preserves Medium Spiny Neuronal Identity, and Reduces Oxidative Stress in a Mouse Model of Huntington’s disease. Experimental Neurology, 2017. 293(Mar 28): p. 83-90.
  5. Khan, R.S., et al., Mitochondrial Uncoupler Prodrug of 2,4-Dinitrophenol, MP201, Prevents Neuronal Damage and Preserves Vision in Experimental Optic Neuritis. Oxid Med Cell Longev, 2017. 2017: p. 7180632.
/by

May 2018 Update from Dr. Urano

Fumihiko “Fumi” Urano, MDDear Friends,

First of all, I would like to express my gratitude to you for coming to see me today. Thank you so much for following my mission & vision and being the kindest person. I think about patients with Wolfram syndrome and their families and friends every morning. That’s one of the first things I do every day at 4:30 am. I would like to support, help, and save them. I would like to know their challenges and help them overcome these challenges. Three things are always on my mind: 1. Improve Clinical Care, 2. Raise Awareness, and 3. Provide a Cure. We are clearly making progress in #1 and #2. How about #3? Is it possible? If so, how long?

Here is my answer. “We are making progress. We are this close.”

This close = my head size. I have all the strategies and ideas for developing cutting-edge treatments for Wolfram syndrome in my head. My challenge is to realize these ideas. There are technical roadblocks for developing gene therapy. There are regulatory issues to bring new drugs from bench (lab) to bedside (patients). There are financial constraints. These are not so easy to overcome, but these are much smaller challenges than those our patients have been experiencing. I would like to articulate my strategies again. There are three steps. Step 1: Drug Therapy for halting progression. Step 2: Regenerative therapy for protecting and regrow remaining eye and brain cells. Step 3: Gene therapy for replacing pathogenic genes. To achieve these goals and accelerate our progress, I have started creating three new animal models (mice and rats) carrying human Wolfram gene mutations. They are humanized Wolfram mice and rats. I plan to use these animals to test gene therapy and regenerative therapy.

In addition, I have been developing “genetic testing” for screening Wolfram syndrome and Wolfram-related diseases. I believe that Wolfram syndrome is an underdiagnosed disease. Using a single tube of blood, I would like to provide an accurate diagnosis. An accurate diagnosis serves as a basis for targeted therapy. An accurate diagnosis provides a sense of relief. 

As always, please feel free to contact me with any questions or concerns (urano@wustl.edu). I would like to know what you think and how you feel. Thank you again for your support. Our potential is limitless. We have superpower to overcome this challenge.

With passion, hope, and gratitude,

Fumi Urano

/by

Wolfram Research Clinic Update – May 2018 – Tamara Hershey, PhD

 Washington-University-Wolfram-Study-group Washington-University-School-of-MedicineWashington University School of Medicine

Wolfram Research Clinic Update- Tamara Hershey, PhD

The main activity in our lab right now is the furious planning process for the 2018 Wolfram Research Clinic! However, we also have some other progress to report. First, in the past month, we have submitted two new papers on Wolfram Syndrome for review, both based on data from previous research clinics. One of the papers is on the very important topic of urological symptoms. The paper reports on the common urological issues in Wolfram Syndrome, possible explanations for these issues and makes some recommendations for interventions. The second paper is on sleep, using the overnight sleep apnea monitoring data collected during the last few years of the research clinic. This paper describes the high rate of obstructive apnea that we observed and discusses the potential importance of detecting and treating this symptom. A third paper is almost ready to be submitted; this one is on hearing impairment and how it changes over time in Wolfram Syndrome. Once these papers are peer reviewed and approved for publication we will certainly share them with all who are interested.
Second, Dr. Marshall and I are planning our trip to Paris for the International Wolfram meeting. I will be presenting on change in brain structures over time in Wolfram Syndrome, again using our Wolfram research clinic data. We are excited to learn from our Wolfram Syndrome research colleagues and see what progress the entire field has made since we last convened.
Finally, we have been talking with The Snow Foundation about submitting a grant to the NIH to fund a family/scientific conference on Wolfram Syndrome. The idea would be to bring in researchers and clinicians with relevant expertise on Wolfram Syndrome and present the latest information to other researchers, clinicians and families. As we start planning for this, we will be interested in hearing what families might be interested in learning at such a conference.
Thank you all for your interest and support.

Tamara Hershey, PhD
Professor, Psychiatry & Radiology Departments
Lab Chief, Neuroimaging Labs (NIL) @ MIR
Co-Director, Neuroscience PhD Program, DBBS
Washington University School of Medicine
Email: tammy@wustl.edu

Need Help? For questions or requests regarding the Wolfram Syndrome Research Clinic please contact the WFS Research Clinic Coord., Samantha Ranck, MSW at 314.362.6514 or rancks@npg.wustl.edu 

/by

Paint Party Fundraiser

Paint Party Fundraiser

 

Paint Party Fundraiser in honor of Joe Mirra, Jr. is Friday, July 13 at Hubcap, 128 Center Street, Wallingford at 6pm.

 

Please contact Christine Mirra for more information jemirra@comcast.net or to donate  visit www.thesnowfoundation.org/donate

/by

Derby de Mayo 2018

Read more
/by
,

Prof Tim Barrett Clinical Trial Update-Birmingham, England

Rebecca Storey and Shazia Ahmed, our senior and junior trials coordinators respectively, have been busy writing all the regulatory documents needed for the trial to go ahead. These were submitted to the Health Regulatory Authority in early January. The ethics committee met in early February. This was in Glasgow, but we were allowed to join by telephone conference. the committee was very sympathetic and had only minor requests. Rebecca and I are writing the response, which has to be back with them by Wed. We cannot get complete regulatory sign-off until we have evidence that the study medicine is stable outside it’s manufacturer’s packaging.

Regarding the study medicine, we have been in weekly contact with the pharmacy manufacturing unit at Guy’s and Thomas’s Hospital in London. They have outsourced the testing of the medicine to a commercial contract company, Butterworth’s. So, the problem is that the study medicine comes in foil blister packs. The manufacturer only guarantees the quality of the tablets while they are in their own packaging. For the clinical trial, Guy’s and Thomas’s Pharmacy have to take the tablets out of the manufacturer’s packaging and put them into white polypropylene containers, so that they can be masked (blinded) with the placebo tablets. Unfortunately, these study tablets absorb moisture from the atmosphere when taken out of their foil packaging, which in theory may affect the stability of the active component. Guy’s and Thomas’s hospital have been trying to test some tablets that they have kept in typical study bottles; but without success. They then outsourced this job to Butterworth’s, who found a non-standard method to measure drug stability. However, when they tried to convert this to an approved method, they could not get the measurements to work. This is turning into a major headache, and is the reason the study has been held up. We are having a telephone conference on Monday with the pharmacy team to get an update and plan what we do next.

We have appointed a new study team member, Heather Rose, who will look after the MRI scans for the trial, and do the measurements to see if the study drug is slowing down the brain changes. She is getting the scanners set up in Birmingham for both children and adults to take part.

Rebecca has been in touch with the international sites, in Almeria, Montpellier, Paris and Lodz, to start getting them set up.

Finally, I have been asked to speak with the French families in Paris on March 17th to explain to them where the trial is at.

/by
,

Dr. Urano’s April Update

Dear Friends,Fumihiko “Fumi” Urano, MD

Thank you so much for “coming to see me” today. It is always my pleasure and privilege to see you and talk to you. I feel your support and encouragement, and I am grateful for everything you have done for me, the Snow Foundation, patients, and their families and friends. Just reading this blog is helping me because I can feel your support, which makes me feel stronger and committed.

I would like to share my ideas on how to provide a cure for Wolfram with you today as our first clinical trial is ongoing and we are making steady progress in the development of new drugs, regenerative therapy, and gene therapy. I have been thinking and presenting my strategy for therapeutic development of Wolfram syndrome, CURE4WOLFRAM, since 2002. My current version, 4.0, is the following.

1. Stop Progression

ER Calcium Stabilizers
One of the common molecular pathways altered in patients with Wolfram syndrome and diabetes patients is imbalanced cellular calcium homeostasis. More specifically, endoplasmic reticulum (ER) calcium levels are lower in patients with Wolfram syndrome, leading to cell dysfunction and death. To overcome this challenge, we are currently testing if an ER calcium stabilizer, dantrolene sodium, can delay the progression of Wolfram syndrome. Dantrolene sodium is a FDA-approved drug for the treatment of muscle spasticity and high fever induced by anesthesia. We previously reported that dantrolene sodium stabilizes ER calcium levels and prevents cell death in cell and mouse models of Wolfram syndrome. We are currently conducting a clinical trial of dantrolene sodium in adult and pediatric patients with Wolfram syndrome. In collaboration with NIH/NCATS, we are also developing novel ER calcium stabilizers (i.e., second generation dantrolene) for the treatment of Wolfram syndrome.

Molecular Prosthetics
Another common issue in patients with Wolfram syndrome is ER stress caused by the expression of mutant Wolfram protein produced in patients’ cells. To resolve this issue, we have been developing molecular prosthetics that can optimize the structure of mutant Wolfram protein together with NIH/NCATS and Amylyx, a biotech company in Cambridge, MA.

2. Protect and Regrow Remaining Tissue

Our second step towards a cure for Wolfram syndrome is to protect and regrow remaining tissue using regenerative therapy. We have discovered a naturally produced molecule in our body that can activate the proliferation of damaged beta cells and brain cells. Expression levels of this molecule, MANF, are usually low in our body. We are developing a method to enhance the activity of MANF using a pill that can mimic the functions of MANF and gene therapy (i.e., produce safe virus expressing MANF).

3. Replace Pathogenic Genes

Towards a cure for Wolfram syndrome, a genetic condition, we need to target the root cause of the disease, which is the loss of function of Wolfram syndrome gene, WFS1. Using CRISPR/CAS9 technology, we are attempting to replace a pathogenic Wolfram gene (WFS1 gene) with a healthy Wolfram gene. We are also trying to introduce safe virus expressing normal WFS1 gene into patients’ cells.

Thank you so much for being with me today. Good things happen to people who do good things. I am always hopeful.

With grace and gratitude,
Fumi Urano

/1 Comment/by

The British Journal of Occupational Therapy

“Understanding activity participation among individuals with Wolfram Syndrome”

2018 has brought another publication from the Wolfram Research Group! This article, titled “Understanding activity participation among individuals with Wolfram Syndrome”, was recently accepted to the British Journal of Occupational Therapy.

We wanted to learn more about the use of Occupational Therapy (OT) services in people with Wolfram Syndrome (WFS), and how participation in daily activities could be affected due to WFS symptoms. Participation in daily activities means being able to do the things we want and need to do, which leads to more independence and improved quality of life. Knowing the activities that are most important to those with WFS can help us develop better and more patient-focused interventions and services.

We asked research clinic participants questions about 1) their use of OT services in the past and present, 2) which daily activities were most difficult for them to accomplish, how important these activities are to them and how satisfied they were with their performance and ability to do the activity, and 3) which WFS symptoms affected these daily activities.

Overall, we found that only 22% of participants have ever used OT services. These services were most often for fine motor coordination and low vision. In addition, we found that daily activities identified as important were self-care (personal care, mobility), productive (household management, going to school or work), and leisure (recreation and social) activities.

Overall, we found that people reported reduced participation in daily activities when compared to a non- WFS group. In addition, participation was more restricted over time as WFS neurological symptoms progressed. Adults had more difficulty with activities that were related to social activities and getting out in the community and children/teenagers had more difficulty with activities related to playing and school. Participation in daily activities was most restricted due to walking/balance problems and loss of vision.

These findings raise awareness of the impact of WFS symptoms on daily life and point to neurologic and vision symptoms as being the most limiting aspects of WFS. OT professionals can provide self-management techniques and strategies for low vision or balance issues. These approaches may be of help to those not already using OT services.

 

For more information, look for this publication in the near future: Bumpus E, Hershey T, Doty T, Ranck S, Gronski M, Urano F, & Foster E. Understanding activity participation among individuals with Wolfram Syndrome. British Journal of Occupational Therapy. (In Press).

/by