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Therapeutic development and monitoring require demonstration of effects on disease phenotype. However, due to the complexity of measuring clinically-relevant effects in rare multisystem diseases, robust biomarkers are essential. For the mucopolysaccharidoses (MPS), the measurement of glycosaminoglycan levels is relevant as glycosaminoglycan accumulation is the primary event that occurs due to reduced lysosomal enzyme activity. Traditional dye-based assays that measure total glycosaminoglycan levels have a high background, due to a normal, baseline glycosaminoglycan content in unaffected individuals. An assay that selectively detects the disease-specific non-reducing ends of heparan sulfate glycosaminoglycans that remain undegraded due to deficiency of a specific enzyme in the catabolic pathway avoids the normal background, increasing sensitivity and specificity. We evaluated glycosaminoglycan content by dye-based and non-reducing end methods using urine, serum, and cerebrospinal fluid from MPS I human samples before and after treatment with intravenous recombinant human alpha-l-iduronidase. We found that both urine total glycosaminoglycans and serum heparan sulfate derived non-reducing end levels were markedly decreased compared to baseline after 26 weeks and 52 weeks of therapy, with a significantly greater percentage reduction in serum non-reducing end (89.8% at 26 weeks and 81.3% at 52 weeks) compared to urine total glycosaminoglycans (68.3% at 26 weeks and 62.4% at 52 weeks, p

Before the availability of an enzyme replacement therapy (ERT) for mucopolysaccharidosis type II (MPS II), patients were treated by bone marrow transplantation (BMT). However, the effectiveness of BMT for MPS II was equivocal, particularly at addressing the CNS manifestations. To study this further, we subjected a murine model of MPS II to BMT and evaluated the effect at correcting the biochemical and pathological aberrations in the viscera and CNS. Our results indicated that BMT reduced the accumulation of glycosaminoglycans (GAGs) in a variety of visceral organs, but not in the CNS. With the availability of an approved ERT for MPS II, we investigated and compared the relative merits of the two strategies either as a mono or combination therapy. We showed that the combination of BMT and ERT was additive at reducing tissue levels of GAGs in the heart, kidney and lung. Moreover, ERT conferred greater efficacy if the immunological response against the infused recombinant enzyme was low. Finally, we showed that pathologic GAGs might potentially represent a sensitive biomarker to monitor the therapeutic efficacy of therapies for MPS II.

Intrathecal enzyme replacement therapy is an experimental option to treat central nervous system disease due to lysosomal storage. Previous work shows that MPS I dogs receiving enzyme replacement with recombinant human alpha-L-iduronidase into the cisterna magna showed normal brain glycosaminoglycan (GAG) storage after three or four doses. We analyzed MPS I dogs that received intrathecal enzyme in a previous study using an assay that detects only pathologic GAG (pGAG). To quantify pGAG in MPS I, the assay measures only those GAG which display terminal iduronic acid residues on their non-reducing ends. Mean cortical brain pGAG in six untreated MPS I dogs was 60.9 ± 5.93 pmol per mg wet weight, and was 3.83 ± 2.64 in eight normal or unaffected carrier animals (p

Treatment for mucopolysaccharidosis type IIIB (MPS IIIB; Sanfilippo syndrome type B) is hampered because recombinant alpha-N-acetylglucosaminidase (NAGLU) contains little/no mannose 6-phosphate. We developed a fusion protein of insulin-like growth factor 2 (IGF2) and NAGLU (rhNAGLU-IGF2). IGF2 is a natural ligand of the mannose-6phosphate receptor, and thus provides glycosylation-independent lysosomal targeting. Purified rhNAGLU-IGF2 is active in biochemical and cell-based assays (see Abstract: Aoyagi-Scharber, et al.). To evaluate rhNAGLU-IGF2 in vivo, adult (16 wk) MPS IIIB mice were catheterized into the left ventricle and given 4 twice-weekly injections of vehicle or rhNAGLU-IGF2 (100 μg). Mice were harvested 1d, 7d, 14d, and 28d after the last injection (n= 4-8 per group). Vehicle-treated heterozygotes were used as controls. Forebrain NAGLU activity ranged from 100x (1d, p b 0.001), 400x (7d, p = 0.001), 30x (14d, p = 0.9), and 130x fold (28d, p = 0.002) in rhNAGLU-IGF2 treated mice vs. vehicle-treated heterozygotes. Hexosaminidase activity was reduced by 26% (1d), 44% (7d), 51% (14d), and 57% (28d) in rhNAGLU-IGF2 treated vs vehicle-treated MPS IIIB mice (p b 0.001). Brain heparan sulfate was reduced from 228 pmol/ 5 μg brain (in vehicle-treated MPS IIIB) to 79.3 (1d), 24.8 (7d), 20.8 (14d), 17.4 (28d) in rhNAGLU-IGF2-treatedMPS IIIBmice (p b 0.001), vs 10.5 in vehicle-treated heterozygotes. In multiple brain regions, robust neuronal uptake was evident by immunostaining with NAGLU antibody and reduced LAMP1 signal with rhNAGLU-IGF2 treatment. In a separate experiment using 8 week-old mice, secondary accumulations were measured 1d after the last injection. Neuronal accumulations of SCMAS, glypican 5, amyloid beta and P-GSK3 beta in themedial entorhinal cortex and of P-tau in the dentate gyrus were reduced to the control level of these proteins. Accumulation of CD68 in activated microglia in the somatosensory cortex was reduced about half-way to control. In summary, we achieved broad distribution of NAGLU and improvement in neuropathology with short-term intraventricular rhNAGLU-IGF2. Glycosylation-independent lysosomal targeting may permit development of superior therapy for Sanfilippo syndrome type B. Support from NIH/NINDS 1R21NS078314-01A1 and BioMarin Pharmaceutical Inc.

Jillian R. Brown , Roger Lawrence , Kanar Al-Mafraji , William C. Lamanna , James R. Beitel , Geert-Jan Boons , Jeffrey D. Esko , Brett E. Crawford , Zacharon Pharmaceuticals, Inc, San Diego, CA, USA, Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center, University of California, San Diego, USA, Complex Carbohydrate Research Center, University of Georgia, Athens, USA