1. Fabry disease: results of the enzyme
replacement therapy with agalsidase
beta
C. SPÂNU, C. DRUGAN, C.NIŢĂ, S.SPÂNU, C. CRĂCIUN,
M. RADU,V.TODEA, M. GHERMAN- CĂPRIOARĂ

2. Lysosomal storage disorders and
enzyme replacement therapy (ERT)
Disease Enzyme deficiency ERT available Producer
Gaucher type 1, 3 Acid β-glucosidase Imiglucerase Genzyme Corp.
(Cerezyme®)
Fabry α-Galactosidase A Agalsidase alfa Shire Pharm.
(Replagal®)
Agalsidase beta Genzyme Corp.
(Fabrazyme®)
MPS I α-L Iduronidase Laronidase Genzyme Corp.
(Aldurazyme®)
Pompe Acid α-glucosidase Alglucosidase alfa Genzyme Corp.
(MyozymeTM)
MPS VI Arylsulfatase B Galsulfase BioMarin Pharm.

3. ERT for Fabry Disease: Characteristics of Drugs
Agalsidase alfa Agalsidase beta
(Replagal®) (Fabrazyme®)
Mode of production Gene activated human α-GalA Recombinant human α-GalA
expressed in a continuous human expressed in a continuous CHO cell
cell line line
Structure Homodimer consisting of two Homodimer consisting of two
~50kDa subunits. ~50kDa subunits.
Aa sequence is identical to the Aa sequence is identical to the
endogenous human enzyme endogenous human enzyme
Sialic acid:galactose 0.56 0.88
Mannose-6-phosphate 1.8 ± 0.0 mol/mol protein 3.1 ± 0.1 mol/mol protein
Specific activity 3.4 - 3.9 nmol/kg/h 3.8 nmol/kg/h
Provided as Sterile isotonic solution Lyophilised powder
Recommended dose 0.2 mg/kg bw 1 mg/kg bw

4. Biosynthesis, secretion and recapture
of α-GalA
Endoplasmic reticulum Extracellular secretion of-GalA
•Α-GalA synthesis & glycosylation
•M6PR synthesis
Golgi apparatus
Α-GalA mannose residues phosphorylation
α-GalA
+ M6PR
recapture
from
Endosome extracellular
Cell membrane fluid
α-GalA dissociation from M6PR M6PR
Lysosome
Germain DP, Expert Opin Investig Drug, 2002

5. ERT for Fabry disease : main clinical trials
• Agalsidase α (Replagal)
Schiffmann et al, JAMA, 2001 (randomized placebo-controlled ):
* reduction of neuropathic pain
* stabilization of renal function and improvement of renal histology
after 24 weeks;
• Agalsidase β (Fabrazyme )
Eng et al, N Engl J Med, 2001 (randomized placebo-controlled ):
* resolution of the microvascular endothelial deposits of GL-3 from
kidney, heart and skin after 20 weeks;
* persistence of deposits in podocytes and distal tubular epithelium;
Wilcox et al, Am J Hum Genet, 2004 (open-label extension trial):
*stable renal function at 36 mo in pts with baseline normal GFR;
*progression to renal insufficiency in pts with baseline impaired GFR and
glomerulosclerosis≥ 50%
Benikazemi et al, Ann Intern Med, 2007 (randomized placebo-controlled ):
* slowed progression to renal, cardiac, and cerebrovascular complications and
death in pts with advanced Fabry disease

6. Current Guidelines for ERT in Fabry Disease
Patients
( Eng CM et al, Genet Med, 2006)
Fabry population Guideline for instituting ERT
Adult males (>16y) At time of diagnosis of Fabry disease
Pediatric males At time of development of significant
symptoms or, if asymptomatic, consider
at 10- 13 yr
Females (all ages) Monitor; institute if significant symptoms
or evidence of progression of organ
involvement

7. Patients and methods
• 15 pts, 7 M ( 25 -46 yr) and 8 F ( 8-69 yr), from 3
different families
- 3 pts - index cases, all males
- 12 pts - dx by active family screening
• Routine clinical, laboratory and imagistic exam
• Clinical pedigree analysis
• Plasma and leukocytes α-Gal activity (14 pts)
• DNA analysis ( 11 pts from 2 families)
• Renal biopsy (4 pts, TEM in 2 pts)
• Enzyme replacement therapy ( 7 pts):
agalsidase β ( Fabrazyme® ) 1 mg/Kg biweekly

8. Clinical and biochemical findings in 7 males
and 8 females with Fabry disease
Males Females
Age (yrs) 25-47 8-69
α-Gal activity
plasma ↓↓↓ 7/7 ↓ 4/8
leukocytes ↓↓↓ 7/7 ↓ 3/8
Proteinuria >0.15g/24hr 5/7 (0.8-3.8) 2/6 (0.17-1.3)
↓GFR (ml/min) 7/7 (22.2-89.8) 3/6 (34.3-66.5)
Acroparesthesia 6/7 1/8
Angiokeratomas 4/7 0/8
Edema 3/7 0/8
Hypertension 3/7 3/8
LV hypertrophy 5/7 3/6
Hearing loss 4/7 1/8
Cornea verticillata 4/7 1/6

9. Results of ERT in 7 Fabry disease
patients
• Patients: 5 males (25,40, 43, 46 and 47 yrs of age)
2 females (45 and 69 yrs of age)
(1 pair donor-recipient of renal transplantation)
• Treatment protocol:
agalsidase β (FABRAZYME®) 1 mg/kg biweekly
• Follow-up:
> 36 mo - 3 pts
> 24 mo - 2 pts
< 6 mo - 2 pt (stop, adverse effects- 1pt)

10. Evaluation: baseline and after every 6
months or any event
1. General clinical exam
2. Ophtalmology, neurology, electro and
echocardiography
3. Biochemistry: proteinuria / 24 hr, s.creatinine, GFR
4. Questionaries that evaluated general health:
- brief inventory pain
- mos-36 short-form health survey

11. Baseline and follow-up serum creatinine in 5
Fabry pts treated with agalsidase β
7
6
creatinina serica (mg/dl)
5 MP
4 MI
BA
3
CO
2 CM
1
0
0 luni 6 luni 12 luni 18 luni 24 luni 30 luni 36 luni

12. Baseline and follow-up GFR in 5 Fabry pts
treated with agalsidase β
140
120
100
RFG (ml/min)
80 MP
MI
60
BA
40 CO
CM
20
0
0 luni 6 luni 12 luni 18 luni 24 luni 30 luni 36 luni

13. Baseline and follow-up proteinuria in 5 Fabry
pts treated with agalsidase β
1.2
1
proteinurie (g/24 ore)
0.8 MP
MI
0.6
BA
0.4 CO
CM
0.2
0
0 luni 6 luni 12 luni 18 luni 24 luni 30 luni 36 luni

14. Effects of agalsidase β in 5 Fabry pts
- non-renal manifestations-
• Heart: ↓ LVH
• Nervous system:
- neuropathic pain : improvement in 3/3 pts
- hearing loss: improvement in 2/3 pts
aggravation in 1 pt
• Skin: improvement (1 pt) or disappearance (1 pt) of
angiokeratomas
• Quality of life: improvement of general health status 3/5 pts

15. Regression of angiokeratomas after 3 yr
of treatment with agalsidase beta
(M, 46 yr)

16. Conclusions
• Most of the studied patients have had advanced
disease at the time of ERT initiation
• No major events related to disease or therapy
were noted during treatment period
• Renal and extrarenal manifestations in our Fabry
patients were favorably influenced by ERT with
agalsidase beta
• ERT with agalsidase β is more efficient in early
stages of Fabry disease