Observational study of spinal muscular atrophy type I and implications for clinical trials
Abstract
Objectives:
Prospective cohort study to characterize the clinical features and course of spinal muscular atrophy type I (SMA-I).
Methods:
Patients were enrolled at 3 study sites and followed for up to 36 months with serial clinical, motor function, laboratory, and electrophysiologic outcome assessments. Intervention was determined by published standard of care guidelines. Palliative care options were offered.
Results:
Thirty-four of 54 eligible subjects with SMA-I (63%) enrolled and 50% of these completed at least 12 months of follow-up. The median age at reaching the combined endpoint of death or requiring at least 16 hours/day of ventilation support was 13.5 months (interquartile range 8.1–22.0 months). Requirement for nutritional support preceded that for ventilation support. The distribution of age at reaching the combined endpoint was similar for subjects with SMA-I who had symptom onset before 3 months and after 3 months of age (p = 0.58). Having 2 SMN2 copies was associated with greater morbidity and mortality than having 3 copies. Baseline electrophysiologic measures indicated substantial motor neuron loss. By comparison, subjects with SMA-II who lost sitting ability (n = 10) had higher motor function, motor unit number estimate and compound motor action potential, longer survival, and later age when feeding or ventilation support was required. The mean rate of decline in The Children's Hospital of Philadelphia Infant Test for Neuromuscular Disorders motor function scale was 1.27 points/year (95% confidence interval 0.21–2.33, p = 0.02).
Conclusions:
Infants with SMA-I can be effectively enrolled and retained in a 12-month natural history study until a majority reach the combined endpoint. These outcome data can be used for clinical trial design.
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REFERENCES
1.
Sugarman EA, Nagan N, Zhu H, et al. Pan-ethnic carrier screening and prenatal diagnosis for spinal muscular atrophy: clinical laboratory analysis of >72,400 specimens. Eur J Hum Genet 2012;20:27–32.
2.
Lefebvre S, Burglen L, Reboullet S, et al. Identification and characterization of a spinal muscular atrophy-determining gene. Cell 1995;80:155–165.
3.
Lorson C, Hahnen E, Androphy E, Wirth B. A single nucleotide in the SMN gene regulates splicing and is responsible for spinal muscular atrophy. Proc Natl Acad Sci USA 1999;96:6307–6311.
4.
Feldkötter M, Schwarzer V, Wirth R, Wienker T, Wirth B. Quantitative analyses of SMN1 and SMN2 based on real-time LightCycler PCR: fast and highly reliable carrier testing and prediction of severity of spinal muscular atrophy. Am J Hum Genet 2002;70:358–368.
5.
Gabanella F, Carissimi C, Usiello A, Pellizzoni L. The activity of the spinal muscular atrophy protein is regulated during development and cellular differentiation. Hum Mol Genet 2005;14:3629–3642.
6.
Zerres K, Rudnik-Schöneborn S. Natural history in proximal spinal muscular atrophy: clinical analysis of 445 patients and suggestions for a modification of existing classifications. Arch Neurol 1995;52:518–523.
7.
Munsat T, Davies K. Spinal muscular atrophy. 32nd ENMC International Workshop. Naarden, The Netherlands, 10–12 March, 1995. Neuromuscul Disord 1996;6:125–127.
8.
Dubowitz V. Very severe spinal muscular atrophy (SMA type 0): an expanding clinical phenotype. Eur J Paediatr Neurol 1999;3:49–51.
9.
Thomas NH, Dubowitz V. The natural history of type I (severe) spinal muscular atrophy. Neuromuscul Disord 1994;4:497–502.
10.
Bertini E, Burghes A, Bushby K, et al. 134th ENMC International Workshop: outcome measures and treatment of spinal muscular atrophy, 11–13 February, 2005, Naarden, The Netherlands. Neuromuscul Disord 2005;15:802–816.
11.
Oskoui M, Levy G, Garland C, et al. The changing natural history of spinal muscular atrophy type 1. Neurology 2007;69:1931–1936.
12.
Kaufmann P, McDermott MP, Darras BT, et al. Observational study of spinal muscular atrophy type 2 and 3: functional outcomes over 1 year. Arch Neurol 2011;68:779–786.
13.
Kaufmann P, McDermott MP, Darras BT, et al. Prospective cohort study of spinal muscular atrophy types 2 and 3. Neurology 2012;79:1889–1897.
14.
Wang C, Finkel R, Bertini E, et al. Consensus statement for standard of care in spinal muscular atrophy. J Child Neurol 2007;22:1027–1049.
15.
Glanzman A, Mazzone E, Main M, et al. The Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND): test development and reliability. Neuromuscul Disord 2010;20:155–161.
16.
Glanzman AM, O'Hagen JM, McDermott MP, et al. Validation of the Expanded Hammersmith Functional Motor Scale in spinal muscular atrophy type II and III. J Child Neurol 2011;26:1499–1507.
17.
Swoboda KJ, Prior TW, Scott CB, et al. Natural history of denervation in SMA: relation to age, SMN2 copy number, and function. Ann Neurol 2005;57:704–712.
18.
Lemoine TJ, Swoboda KJ, Bratton SL, Holubkov R, Mundorff M, Srivastava R. Spinal muscular atrophy type 1: are proactive respiratory interventions associated with longer survival? Pediatr Crit Care Med 2012;13:e161–e165.
19.
Rudnik-Schoneborn S, Lutzenrath S, Borkowska J, Karwanska A, Hausmanowa-Petrusewicz I, Zerres K. Analysis of creatine kinase activity in 504 patients with proximal spinal muscular atrophy types I–III from the point of view of progression and severity. Eur Neurol 1998;39:154–162.
20.
Crawford TO, Sladky JT, Hurko O, Besner-Johnston A, Kelley RI. Abnormal fatty acid metabolism in childhood spinal muscular atrophy. Ann Neurol 1999;45:337–343.
21.
Bowerman M, Swoboda KJ, Michalski JP, et al. Glucose metabolism and pancreatic defects in spinal muscular atrophy. Ann Neurol 2012;72:256–268.
Information & Authors
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© 2014 American Academy of Neurology.
Publication History
Received: July 10, 2013
Accepted: May 23, 2014
Published online: July 30, 2014
Published in print: August 26, 2014
Disclosure
R. Finkel served as a Data and Safety Monitoring Board (DSMB) member for a trial sponsored by Sarepta Therapeutics and now serves on a DSMB for an scAAV9 gene therapy clinical trial at Nationwide Children's Hospital, serves on advisory boards for DuchenneConnect, Families of SMA, SMA-REACH, PTC Therapeutics, Inc., Isis Pharmaceuticals, Inc; has received honoraria from Novartis and Roche, has received travel expenses for lectures not funded by industry; serves on the editorial board of Neuromuscular Disorders and Journal of Neuromuscular Disorders; receives research support from Isis Pharmaceuticals, Inc., PTC Therapeutics, Inc. (PTC124-016 study, site PI), Santhera Pharmaceuticals (DELOS Study in Duchenne MD, site PI), the NIH (5R21-NS058926 [PI], U54 AR0526446-03 [Co-I], 1U54 NS065712-01 [Co-I]), RO1-AR056973 [Co-I]), the SMA Foundation (PNCR network for SMA, site PI), the Muscular Dystrophy Association, Genzyme Corporation, and the Charcot-Marie-Tooth Association; and his spouse serves on the editorial board of Arthritis Research and Therapy, holds and has received license fees for numerous patents related to T-cell activation and HIV, and receives research support from the Gates Foundation, Merck Serono, and the NIH in the field of T-cell activation, HIV, and genomics of juvenile arthritis. M. McDermott serves as a DSMB member for trials sponsored by Isis Pharmaceuticals, Biogen Idec, Inc., The ALS Association/FDA, and the Muscular Dystrophy Association. He serves on the editorial board for Movement Disorders and has been a consultant for the New York State Department of Health, Teva Pharmaceutical Industries, Ltd., Synosia, Inc., Smith & Nephew, Inc., Impax Pharmaceuticals, Bioness, Inc., and Asubio Pharmaceuticals, Inc. He receives research support from the Michael J. Fox Foundation, Spinal Muscular Atrophy Foundation, Muscular Dystrophy Association, American Dental Association, the FDA, and NIH. P. Kaufmann reports no disclosures relevant to the manuscript. B. Darras has received publishing royalties from UpToDate and consulting fees from Isis Pharmaceuticals, Quest Diagnostics, Guidepoint Global Consultation, Easton Associates, Clearview Healthcare Partners, and Gerson Lehrman Group. He has received honoraria from the American Academy of Neurology and the Muscular Dystrophy Association. He has received research support from PTC Therapeutics, Isis Pharmaceuticals, NIH/NIAMS 2P01NS-40828-6A11, NIH/National Institute of Neurological Disorders and Stroke (NINDS) 1U10NS077269; NIH/NIAMS 1R01AR060850, SMA Foundation, Muscular Dystrophy Association, and Slaney Family Fund for SMA. He serves on the editorial boards of Neurology and Pediatric Neurology. W. Chung reports no disclosures relevant to the manuscript. D. Sproule receives research funding from PTC Therapeutics, the SMA Foundation, and NINDS-sponsored Neurological Sciences Academic Development Award (K12 NS01698). P. Kang received travel funding from Isis Pharmaceuticals and various nonprofit entities during the study period. He previously served as an occasional consultant for LEK consulting, Gerson Lehrman Group, and Leerink Swann, all commercial consulting firms. He has received honoraria for grant reviews from nonprofit entities and federal government agencies. He previously performed medico-legal consulting for Gross, Minsky & Mogul and currently does so for a federal government agency. He performs EMGs (15% effort). Dr. Kang receives honoraria for serving as an officer of the Massachusetts Medical Society, a nonprofit entity, and has received occasional honoraria from other nonprofit entities. He has received compensation from Oakstone Publishing and Springer, both commercial publishing firms. Dr. Kang receives research support from the NIH and the Muscular Dystrophy Association, and previously received research support from Harvard University and Boston Children's Hospital. His spouse receives research support from the NIH and Boston Children's Hospital, and receives royalties from a gene therapy patent. A. Foley receives research support from the Muscular Dystrophy Campaign (UK). M. Yang and W. Martens report no disclosures relevant to the manuscript. M. Oskoui received research support from the Public Health Agency of Canada, project RT736230, for 2 years and the Spinal Muscular Atrophy Foundation (2004–2007, fellowship). Dr. Oskoui receives research support from SickKids Foundation–CIHR over 3 years. Dr. Oskoui is a Clinician Research Scholar of the Fonds de recherche du Québec–Santé (FRQS). A. Glanzman received funding for travel and training from GlaxoSmithKline, PTC Therapeutics, and Eli Lilly, and receives research support from the SMA Foundation. J. Flickinger reports no disclosures relevant to the manuscript. J. Montes is a consultant for Isis Pharmaceuticals Inc. and is funded in part by Department of Defense grant USAMRAA 09131005. S. Dunaway is funded in part by Department of Defense grant USAMRAA 09131005. J. O'Hagen and J. Quigley report no disclosures relevant to the manuscript. S. Riley received honoraria from the SMA Foundation for speaking at an SMA/Scoliosis conference at the Children's Hospital of Philadelphia. M. Benton, P. Ryan, M. Montgomery, and J. Marra report no disclosures relevant to the manuscript. C. Gooch is a consultant for NeuralStem, a medical advisory board member of the GBS/CIDP Foundation International, and an employee of the FDA. He is an editorial board member of the Journal of Clinical Neuromuscular Disease and Neurology (journal of the American Academy of Neurology). He receives travel funding from the NIH as chair of the DSMB (IVIg in Autonomic Neuropathy). D. De Vivo serves on the scientific advisory boards for Colleen Giblin Foundation, SMA Foundation, Canavan Foundation, Pediatric Neurotransmitter Disease Association, Milestones for Children, Will Foundation, Glut1 Deficiency Foundation, and Isis Pharmaceuticals. He has received compensation as a consultant for Isis Pharmaceuticals and Ultragenyx Pharmaceutical Inc. Dr. De Vivo receives research support from the NIH/NICHD and NINDS, Department of Defense, SMA Foundation, Colleen Giblin Foundation, Milestones for Children, Glut1 Deficiency Foundation, and the Will Foundation. Go to Neurology.org for full disclosures.
Study Funding
This study was sponsored by the SMA Foundation (New York) through funding to the Pediatric Neuromuscular Clinical Research Network. Additional clinical research support was provided through CTSA 1 NIH UL1 RR024134 (The Children's Hospital of Philadelphia), CTSA NIH 1 UL1 RR024156 and the NSADA K12 program (Columbia University), and NIH 1 UL1 RR025755 from the National Center for Research Resources, NIH, to the Harvard Catalyst Clinical & Translational Science Center (Harvard Catalyst).
Authors
Author Contributions
Dr. Finkel's contributions include drafting/revising the manuscript for content, study concept and design, analysis and interpretation of data, acquisition of data, study supervision or coordination, and obtaining funding. Dr. McDermott's contributions include drafting/revising the manuscript for content and analysis or interpretation of data. Dr. Kaufmann's contributions include drafting/revising the manuscript for content, study concept or design, analysis or interpretation of data, acquisition of data, study supervision or coordination, and obtaining funding. Dr. Darras' contributions include drafting/revising the manuscript for content, study concept or design, acquisition of data, study supervision or coordination, and obtaining funding. Dr. Chung's contributions include revising the manuscript for content and data acquisition. Dr. Sproule's contributions include drafting/revising the manuscript for content, study concept or design, analysis, interpretation of data, acquisition of data, and study supervision or coordination. Dr. Kang's contributions include data acquisition and revision of the manuscript for content. Dr. Foley's contributions include review/revision of the manuscript and data acquisition. Dr. Yang's contributions include review/revision of the manuscript and data acquisition. William Martens' contributions include revising the manuscript for content, analysis or interpretation of data, and data acquisition. Dr. Oskoui's contributions include revising the manuscript for content and data acquisition. Allan Glanzman's contributions include review/revision of the manuscript and data acquisition. Jean Flickinger's contributions include drafting/revising the manuscript for content and data acquisition. Jacqueline Montes' contributions include drafting/revising the manuscript for content, study concept or design, analysis or interpretation of data, acquisition of data, and study supervision or coordination. Sally Dunaway's contributions include revising the manuscript for content and data acquisition. Jessica O’Hagen's contributions include revising the manuscript for content, data acquisition, and study supervision or coordination. Janet Quigley's contributions include review/revision of the manuscript and data acquisition. Susan Riley's contributions include review/revision of the manuscript and data acquisition. Maryjane Benton's contributions include review/revision of the manuscript, analysis or interpretation of data, data acquisition, and study supervision or coordination. Patricia Ryan's contributions include revising the manuscript for content and data acquisition. Megan Montgomery's contributions include review/revision of the manuscript for content, data acquisition, and study supervision or coordination. Jonathan Marra's contributions include review/revision of the manuscript and data acquisition. Dr. Gooch's contributions include drafting/revising the manuscript for content, study concept or design, acquisition of data, and study supervision or coordination. Dr. De Vivo's contributions include drafting/revising the manuscript for content, study concept or design, analysis or interpretation of data, acquisition of data, study supervision or coordination, and obtaining funding.
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