Title: Treatment of Pompe's
United States Patent: 7,351,410
Issued: April 1, 2008
Inventors: van Bree;
Johannes B. M. M. (Nieuw-Vennep, NL), Venneker; Edna H. G. (Saturnushof
15, NL), Meeker; David P. (Concord, MA)
Therapeutic Products Limited Partnership (Cambridge, MA)
Appl. No.: 10/611,598
Filed: June 30, 2003
Executive MBA in Pharmaceutical Management, U. Colorado
The invention provides methods of
treating Pompe's disease using human acid alpha glucosidase. A preferred
treatment regime comprises administering greater than 10 mg/kg body weight
per week to a patient.
Description of the
SUMMARY OF THE CLAIMED
In one aspect, the invention provides methods of treating a patient with
Pompe's disease. Such methods entail administering to the patient a
therapeutically effective amount of human acid alpha glucosidase. The dosage
is preferably at least 10 mg/kg body weight per week. In some methods, the
dosage is at least 60 mg/kg body weight per week or at least 120 mg/kg body
weight per week. In some methods, such dosages are administered on a single
occasion per week and in other methods on three occasions per week. In some
methods, the treatment is containued for ate least 24 weeks. Adminstration
is preferably intravenous. The human acid alpha glucosidase is preferably
obtained in the milk of a nonhuman transgenic mammal, and is preferably
predominatly in a 110 kD form.
The methods can be used for treating patients with infantile, juvenile or
adult Pompe's disease. In some methods of treating infantile Pompe's disease
efficacy is indicated by a patient surviving to be at least one year old.
In some methods, levels of human acid alpha glucosidase are monitored in the
recuouebt patient. Optionally, a second dosage of human acid alpha
glucosidase can be administered if the level of alpha-glucosidase falls
below a threshold value in the patient.
In some emthods, the human alpha glucosidase is administered intravenously
and the rate of administration increases during the period of
administration. In some methods, the rate of administration increases by at
least a factor of ten during the period of administration. In some methods,
the rate of administration increases by at least a factor of ten within a
period of five hours. In some methods, the patient is administered a series
of at least four dosages, each dosage at a higher strength than the previous
dosage. In some methods, the dosages are a first dosage of 0.03-3 mg/kg/hr,
a second dosage of 0.3-12 mg/kg/hr, a third dosage of 1-30 mg/kg/hr and a
fourth dosage of 2-60 mg/kg/hr. In some methods, the dosages are a first
dosage of 0.1-1 mg/kg/hr, a second dosage of 1-4 mg/kg/hr, a third dosage of
3-10 mg/kg/hr and a fourth dosage of 6-20 mg/kg/hr. In some methods, the
dosages are a first dosage of 0.25-4 mg/kg/hr, a second dosage of 0.9-1.4
mg/kg/hr, a third dosage of 3.6-5.7 mg/kg/hr and a fourth dosage of 7.2-11.3
mg/kg/hr. In some methods, the dosages are a first dosage of 0.3 mg/kg/hr, a
second dosage of 1 mg/kg/hr, a third dosage of 4 mg/kg/hr and a fourth
dosage of 12 mg/kg/hr. In some methods, the first, second, third and fourth
dosages are each administered for periods of 15 min to 8 hours.
In some methods, the first, second, third and fourth dosages are
administered for periods of 1 hr, 1 hr, 0.5 hr and 3 hr respectively.
In another aspect, the invention provides a pharmaceutical composition
comprising human acid alpha glucosidase, human serum albumin, and a sugar in
a physiologically acceptable buffer in sterile form. Some such compositions
comprise human acid alpha glucosidase, human serum albumin, and glucose in
sodium phosphate buffer. Some compositions comprise alpha glucosidase,
mannitol and sucrose in an aqueous solution. In some compositions, the sugar
comprises mannitol and sucrose and the concentration of mannitol is 1-3% w/w
of the aqueous solution and the concentration of sucrose is 0.1 to 1% w/w of
the aqueous solution. In some compositions, the concentration of mannitol is
2% w/w and the concentration of sucrose is 0.5% w/w.
The invention further provides a lyophilized composition produced by
lyophilizing a pharmaceutical composition comprising human acid glucosidase,
mannitol and sucrose in aqueous solution. Such a composition can be prepared
by lyophilizing a first composition comprising human acid alpha-glucosidase,
mannitol, sucrose and an aqueous solution to produce a second composition;
and reconstituting the lyophilized composition in saline to produce a third
composition. In some such compositions, the the human acid alpha-glucosidase
is at 5 mg/ml in both the first and third composition, the mannitol is at 2
mg/ml in the first composition, the sucrose is at 0.5 mg/ml in the first
composition, and the saline used in the reconstituting step is 0.9% w/w.
The invention provides transgenic nonhuman mammals secreting a lysosomal
protein into their milk. Secretion is achieved by incorporation of a
transgene encoding a lysosomal protein and regulatory sequences capable of
targeting expression of the gene to the mammary gland. The transgene is
expressed, and the expression product posttranslationally modified within
the mammary gland, and then secreted in milk. The posttranslational
modification can include steps of glycosylation and phosphorylation to
produce a mannose-6 phosphate containing lysosomal protein.
A. Lysosomal Genes
The invention provides transgenic nonhuman mammals expressing DNA segments
containing any of the more than 30 known genes encoding lysosomal enzymes
and other types of lysosomal proteins, including .alpha.-glucosidase,
.alpha.-L-iduronidase, iduronate-sulfate sulfatase, hexosaminidase A and B,
ganglioside activator protein, arylsulfatase A and B, iduronate sulfatase,
heparan N-sulfatase, galacto-ceramidase, .alpha.-galactosylceramidase A,
sphingomyelinase, .alpha.-fucosidase, .alpha.-mannosidase,
aspartylglycosamine amide hydrolase, acid lipase,
N-acetyl-.alpha.-D-glucosamine-6-sulphate sulfatase, .alpha.- and .beta.-galactosidase,
.beta.-glucuronidase, .beta.-mannosidase, ceramidase, galacto-cere-brosidase,
.alpha.-N-acetylgalactosaminidase, and protective protein and others.
Transgenic mammals expressing allelic, cognate and induced variants of any
of the known lysosomal protein gene sequences are also included. Such
variants usually show substantial sequence identity at the amino acid level
with known lysosomal protein genes. Such variants usually hybridize to a
known gene under stringent conditions or crossreact with antibodies to a
polypeptide encoded by one of the known genes.
DNA clones containing the genomic or cDNA sequences of many of the known
genes encoding lysosomal proteins are available. (Scott et al., Am. J. Hum.
Genet. 47, 802-807 (1990); Wilson et al., PNAS 87, 8531-8535 (1990); Stein
et al., J. Biol. Chem. 264, 1252-1259 (1989); Ginns et al., Biochem. Biophys.
Res. Comm. 123, 574-580 (1984); Hoefsloot et al., EMBO J. 7, 1697-1704
(1988); Hoefsloot et al., Biochem. J. 272, 473-479 (1990); Meyerowitz &
Proia, PNAS 81, 5394-5398 (1984); Scriver et al., supra, part 12, pages
2427-2882 and references cited therein)) Other examples of genomic and cDNA
sequences are available from GenBank. To the extent that additional cloned
sequences of lysosomal genes are required, they may be obtained from genomic
or cDNA libraries (preferably human) using known lysosomal protein DNA
sequences or antibodies to known lysosomal proteins as probes.
B. Conformaion of Lysosomal Proteins
Recombinant lysosomal proteins are preferably processed to have the same or
similar structure as naturally occurring lysosomal proteins. Lysosomal
proteins are glycoproteins that are synthesized on ribosomes bound to the
endoplasmic reticulum (RER). They enter this organelle co-translationally
guided by an N-terminal signal peptide (Ng et al., Current Opinion in Cell
Biology 6, 510-516 (1994)). The N-linked glycosylation process starts in the
RER with the en bloc transfer of the high-mannose oligosaccharide precursor
Glc3Man9GlcNAc2 from a dolichol carrier. Carbohydrate chain modification
starts in the RER and continue in the Golgi apparatus with the removal of
the three outermost glucose residues by glycosidases I and II.
Phosphorylation is a two-step procedure in which first
N-acetyl-gluco-samine-1-phosphate is coupled to select mannose groups by a
lysosomal protein specific transferase, and second, the N-acetyl-gluco-samine
is cleaved by a diesterase (Goldberg et al., Lysosomes: Their Role in
Protein Breakdown (Academic Press Inc., London, 1987), pp. 163-191).
Cleavage exposes mannose 6-phosphate as a recognition marker and ligand for
the mannose 6-phosphate receptor mediating transport of most lysosomal
proteins to the lysosomes (Kornfeld, Biochem. Soc. Trans. 18, 367-374
In addition to carbohydrate chain modification, most lysosomal proteins
undergo proteolytic processing, in which the first event is removal of the
signal peptide. The signal peptide of most lysosomal proteins is cleaved
after translocation by signal peptidase after which the proteins become
soluble. There is suggestive evidence that the signal peptide of acid
.alpha.-glucosidase is cleaved after the enzyme has left the RER, but before
it has entered the lysosome or the secretory pathway (Wisselaar et al., J.
Biol. Chem. 268, 2223-2231 (1993)). The proteolytic processing of acid at-glucosidase
is complex and involves a series of steps in addition to cleavage of the
signal peptide taking place at various subcellular locations. Polypeptides
are cleaved off at both the N and C terminal ends, whereby the specific
catalytic activity is increased. The main species recognized are a 110/100
kD precursor, a 95 kD intermediate and 76 kD and 70 kD mature forms. (Hasilik
et al., J. Biol. Chem. 255, 4937-4945 (1980); Oude Elferink et al., Eur. J.
Biochem. 139, 489-495 (1984); Reuser et al., J. Biol. Chem. 260, 8336-8341
(1985); Hoefsloot et al., EMBO J. 7, 1697-1704 (1988)). The post
translational processing of natural human acid .alpha.-glucosidase and of
recombinant forms of human acid .alpha.-glucosidase as expressed in cultured
mammalian cells like COS cells, BHK cells and CHO cells is similar (Hoefsloot
et al., (1990) supra; Wisselaar et al., (1993) supra.
Authentic processing to generate lysosomal proteins phosphorylated at the 6'
position of the mannose group can be tested by measuring uptake of a
substrate by cells bearing a receptor for mannose 6-phosphate. Correctly
modified substrates are taken up faster than unmodified substrates, and in a
manner whereby uptake of the modified substrate can be competitively
inhibited by addition of mannose 6-phosphate.
C. Transgene Design
Transgenes are designed to target expression of a recombinant lysosomal
protein to the mammary gland of a transgenic nonhuman mammal harboring the
transgene. The basic approach entails operably linking an exogenous DNA
segment encoding the protein with a signal sequence, a promoter and an
enhancer. The DNA segment can be genomic, minigene (genomic with one or more
introns omitted), cDNA, a YAC fragment, a chimera of two different lysosomal
protein genes, or a hybrid of any of these. Inclusion of genomic sequences
generally leads to higher levels of expression. Very high levels of
expression might overload the capacity of the mammary gland to perform
posttranslation modifications, and secretion of lysosomal proteins. However,
the data presented below indicate that substantial posttranslational
modification occurs including the formation of mannose 6-phosphate groups,
notwithstanding a high expression level in the mg/ml range. Substantial
modification means that at least about 10, 25, 50, 75 or 90% of secreted
molecules bear at least one mannose 6-phosphate group. Thus, genomic
constructs or hybrid cDNA-genomic constructs are generally preferred.
In genomic constructs, it is not necessary to retain all intronic sequences.
For example, some intronic sequences can be removed to obtain a smaller
transgene facilitating DNA manipulations and subsequent microinjection. See
Archibald et al., WO 90/05188 (incorporated by reference in its entirety for
all purposes). Removal of some introns is also useful in some instances to
reduce expression levels and thereby ensure that posttranslational
modification is substantially complete. In other instances excluding an
intron such as intron one from the genomic sequence of acid .alpha.-glucosidase
leads to a higher expression of the mature enzyme. It is also possible to
delete some or all of noncoding exons. In some transgenes, selected
nucleotides in lysosomal protein encoding sequences are mutated to remove
proteolytic cleavage sites.
Because the intended use of lysosomal proteins produced by transgenic
mammals is usually administration to humans, the species from which the DNA
segment encoding a lysosomal protein sequence is obtained is preferably
human. Analogously if the intended use were in veterinary therapy (e.g., on
a horse, dog or cat), it is preferable that the DNA segment be from the same
The promoter and enhancer are from a gene that is exclusively or at least
preferentially expressed in the mammary gland (i.e., a mammary-gland
specific gene). Preferred genes as a source of promoter and enhancer include
.beta.-casein, .kappa.-casein, .alpha.S1-casein, .alpha.S2-casein, .beta.-lactoglobulin,
whey acid protein, and .alpha.-lactalbumin. The promoter and enhancer are
usually but not always obtained from the same mammary-gland specific gene.
This gene is sometimes but not necessarily from the same species of mammal
as the mammal into which the transgene is to be expressed. Expression
regulation sequences from other species such as those from human genes can
also be used. The signal sequence must be capable of directing the secretion
of the lysosomal protein from the mammary gland. Suitable signal sequences
can be derived from mammalian genes encoding a secreted protein.
Surprisingly, the natural signal sequences of lysosomal proteins are
suitable, notwithstanding that these proteins are normally not secreted but
targeted to an intracellular organelle. In addition to such signal
sequences, preferred sources of signal sequences are the signal sequence
from the same gene as the promoter and enhancer are obtained. Optionally,
additional regulatory sequences are included in the transgene to optimize
expression levels. Such sequences include 5' flanking regions, 5'
transcribed but untranslated regions, intronic sequences, 3' transcribed but
untranslated regions, polyadenylation sites, and 3' flanking regions. Such
sequences are usually obtained either from the mammary-gland specific gene
from which the promoter and enhancer are obtained or from the lysosomal
protein gene being expressed. Inclusion of such sequences produces a genetic
milieu simulating that of an authentic mammary gland specific gene and/or
that of an authentic lysosomal protein gene. This genetic milieu results in
some cases (e.g., bovine .alpha.S1-casein) in higher expression of the
transcribed gene. Alternatively, 3' flanking regions and untranslated
regions are obtained from other heterologous genes such as the .beta.-globin
gene or viral genes. The inclusion of 3' and 5' untranslated regions from a
lysosomal protein gene, or other heterologous gene can also increase the
stability of the transcript.
In some embodiments, about 0.5, 1, 5, 10, 15, 20 or 30 kb of 5' flanking
sequence is included from a mammary specific gene in combination with about
1, 5, 10, 15, 20 or 30 kb or 3' flanking sequence from the lysosomal protein
gene being expressed. If the protein is expressed from a cDNA sequence, it
is advantageous to include an intronic sequence between the promoter and the
coding sequence. The intronic sequence is preferably a hybrid sequence
formed from a 5' portion from an intervening sequence from the first intron
of the mammary gland specific region from which the promoter is obtained and
a 3' portion from an intervening sequence of an IgG intervening sequence or
lysosomal protein gene. See DeBoer et al., WO 91/08216 (incorporated by
reference in its entirety for all purposes).
A preferred transgene for expressing a lysosomal protein comprises a cDNA-genomic
hybrid lysosomal protein gene-linked 5' to a casein promoter and enhancer.
The hybrid gene includes the signal sequence, coding region, and a 3'
flanking region from the lysosomal protein gene. Optionally, the cDNA
segment includes an intronic sequence between the 5' casein and untranslated
region of the gene encoding the lysosomal protein. Of course, corresponding
cDNA and genomic segments can also be fused at other locations within the
gene provided a contiguous protein can be expressed from the resulting
Other preferred transgenes have a genomic lysosomal protein segment linked
5' to casein regulatory sequences. The genomic segment is usually contiguous
from the 5' untranslated region to the 3' flanking region of the gene. Thus,
the genomic segment includes a portion of the lysosomal protein 5'
untranslated sequence, the signal sequence, alternating introns and coding
exons, a 3' untranslated region, and a 3' flanking region. The genomic
segment is linked via the 5' untranslated region to a casein fragment
comprising a promoter and enhancer and usually a 5' untranslated region.
DNA sequence information is available for all of the mammary gland specific
genes listed above, in at least one, and often several organisms. See, e.g.,
Richards et al., J. Biol. Chem. 256, 526-532 (1981) (.alpha.-lactalbumin
rat); Campbell et al., Nucleic Acids Res. 12, 8685-8697 (1984) (rat WAP);
Jones et al., J. Biol. Chem. 260, 7042-7050 (1985)) (rat .beta.-casein);
Yu-Lee & Rosen, J. Biol. Chem. 258, 10794-10804 (1983) (rat
.gamma.-casein)); Hall, Biochem. J. 242, 735-742 (1987) (.alpha.-lactalbumin
human); Stewart, Nucleic Acids Res. 12, 389 (1984) (bovine .alpha.s1 and
.kappa. casein cDNAs); Gorodetsky et al., Gene 66, 87-96 (1988) (bovine
.beta. casein); Alexander et al., Eur. J. Biochem. 178, 395-401 (1988)
(bovine .kappa. casein); Brignon et al., FEBS Lett. 188, 48-55 (1977)
(bovine .alpha.S2 casein); Jamieson et al., Gene 61, 85-90 (1987), Ivanov et
al., Biol. Chem. Hoppe-Seyler 369, 425-429 (1988), Alexander et al., Nucleic
Acids Res. 17, 6739 (1989) (bovine .beta. lactoglobulin); Vilotte et al.,
Biochimie 69, 609-620 (1987) (bovine .alpha.-lactalbumin) (incorporated by
reference in their entirety for all purposes). The structure and function of
the various milk protein genes are reviewed by Mercier & Vilotte, J. Dairy
Sci. 76, 3079-3098 (1993) (incorporated by reference in its entirety for all
purposes). To the extent that additional sequence data might be required,
sequences flanking the regions already obtained could be readily cloned
using the existing sequences as probes. Mammary-gland specific regulatory
sequences from different organisms are likewise obtained by screening
libraries from such organisms using known cognate nucleotide sequences, or
antibodies to cognate proteins as probes.
General strategies and exemplary transgenes employing .alpha.S1-casein
regulatory sequences for targeting the expression of a recombinant protein
to the mammary gland are described in more detail in DeBoer et al., WO
91/08216 and WO 93/25567 (incorporated by reference in their entirety for
all purposes). Examples of transgenes employing regulatory sequences from
other mammary gland specific genes have also been described. See, e.g.,
Simon et al., Bio/Technology 6, 179-183 (1988) and WO88/00239 (1988)
(.beta.-lactoglobulin regulatory sequence for expression in sheep); Rosen,
EP 279,582 and Lee et al., Nucleic Acids Res. 16, 1027-1041 (1988)
(.beta.-casein regulatory sequence for expression in mice); Gordon,
Biotechnology 5, 1183 (1987) (WAP regulatory sequence for expression in
mice); WO 88/01648 (1988) and Eur. J. Biochem. 186, 43-48 (1989) (.alpha.-lactalbumin
regulatory sequence for expression in mice) (incorporated by reference in
their entirety for all purposes).
The expression of lysosomal proteins in the milk from transgenes can be
influenced by co-expression or functional inactivation (i.e., knock-out) of
genes involved in post translational modification and targeting of the
lysosomal proteins. The data in the Examples indicate that surprisingly
mammary glands already express modifying enzymes at sufficient quantities to
obtain assembly and secretion of mannose 6-phosphate containing proteins at
high levels. However, in some transgenic mammals expressing these proteins
at high levels, it is sometimes preferable to supplement endogenous levels
of processing enzymes with additional enzyme resulting from transgene
expression. Such transgenes are constructed employing similar principles to
those discussed above with the processing enzyme coding sequence replacing
the lysosomal protein coding sequence in the transgene. It is not generally
necessary that posttranslational processing enzymes be secreted. Thus, the
secretion signal sequence linked to the lysosomal protein coding sequence is
replaced with a signal sequence that targets the processing enzyme to the
endoplasmic reticulum without secretion. For example, the signal sequences
naturally associated with these enzymes are suitable.
The transgenes described above are introduced into nonhuman mammals. Most
nonhuman mammals, including rodents such as mice and rats, rabbits, ovines
such as sheep and goats, porcines such as pigs, and bovines such as cattle
and buffalo, are suitable. Bovines offer an advantage of large yields of
milk, whereas mice offer advantages of ease of transgenesis and breeding.
Rabbits offer a compromise of these advantages. A rabbit can yield 100 ml
milk per day with a protein content of about 14% (see Buhler et al.,
Biotechnology 8, 140 (1990)) (incorporated by reference in its entirety for
all purposes), and yet can be manipulated and bred using the same principles
and with similar facility as mice. Nonviviparous mammals such as a spiny
anteater or duckbill platypus are typically not employed.
In some methods of transgenesis, transgenes are introduced into the
pronuclei of fertilized oocytes. For some animals, such as mice and rabbits,
fertilization is performed in vivo and fertilized ova are surgically
removed. In other animals, particularly bovines, it is preferable to remove
ova from live or slaughterhouse animals and fertilize the ova in vitro. See
DeBoer et al., WO 91/08216. In vitro fertilization permits a transgene to be
introduced into substantially synchronous cells at an optimal phase of the
cell cycle for integration (not later than S-phase). Transgenes are usually
introduced by microinjection. See U.S. Pat. No. 4,873,292. Fertilized
oocytes are then cultured in vitro until a pre-implantation embryo is
obtained containing about 16-150 cells. The 16-32 cell stage of an embryo is
described as a morula. Pre-implantation embryos containing more than 32
cells are termed blastocysts. These embryos show the development of a
blastocoele cavity, typically at the 64 cell stage. Methods for culturing
fertilized oocytes to the pre-implantation stage are described by Gordon et
al., Methods Enzymol. 101, 414 (1984); Hogan et al., Manipulation of the
Mouse Embryo: A Laboratory Manual, C.S.H.L. N.Y. (1986) (mouse embryo); and
Hammer et al., Nature 315, 680 (1985) (rabbit and porcine embryos); Gandolfi
et al. J. Reprod. Fert. 81, 23-28 (1987); Rexroad et al., J. Anim. Sci. 66,
947-953 (1988) (ovine embryos) and Eyestone et al. J. Reprod. Fert. 85,
715-720 (1989); Camous et al., J. Reprod. Fert. 72, 779-785 (1984); and
Heyman et al. Theriogenology 27, 5968 (1987) (bovine embryos) (incorporated
by reference in their entirety for all purposes). Sometimes pre-implantation
embryos are stored frozen for a period pending implantation.
Pre-implantation embryos are transferred to the oviduct of a pseudopregnant
female resulting in the birth of a transgenic or chimeric animal depending
upon the stage of development when the transgene is integrated. Chimeric
mammals can be bred to form true germline transgenic animals.
Alternatively, transgenes can be introduced into embryonic stem cells (ES).
These cells are obtained from preimplantation embryos cultured in vitro.
Bradley et al., Nature 309, 255-258 (1984) (incorporated by reference in its
entirety for all purposes). Transgenes can be introduced into such cells by
electroporation or microinjection. Transformed ES cells are combined with
blastocysts from a non-human animal. The ES cells colonize the embryo and in
some embryos form the germline of the resulting chimeric animal. See
Jaenisch, Science, 240, 1468-1474 (1988) (incorporated by reference in its
entirety for all purposes). Alternatively, ES cells can be used as a source
of nuclei for transplantation into an enucleated fertilized oocyte giving
rise to a transgenic mammal.
For production of transgenic animals containing two or more transgenes, the
transgenes can be introduced simultaneously using the same procedure as for
a single transgene. Alternatively, the transgenes can be initially
introduced into separate animals and then combined into the same genome by
breeding the animals. Alternatively, a first transgenic animal is produced
containing one of the transgenes. A second transgene is then introduced into
fertilized ova or embryonic stem cells from that animal. In some
embodiments, transgenes whose length would otherwise exceed about 50 kb, are
constructed as overlapping fragments. Such overlapping fragments are
introduced into a fertilized oocyte or embryonic stem cell simultaneously
and undergo homologous recombination in vivo. See Kay et al., WO 92/03917
(incorporated by reference in its entirety for all purposes).
E. Characteristics of Transgenic Mammals
Transgenic mammals of the invention incorporate at least one transgene in
their genome as described above. The transgene targets expression of a DNA
segment encoding a lysosomal protein at least predominantly to the mammary
gland. Surprisingly, the mammary glands are capable of expressing proteins
required for authentic posttranslation processing including steps of
oligosaccharide addition and phosphorylation. Processing by enzymes in the
mammary gland results in phosphorylation of the 6' position of mannose
Lysosomal proteins can be secreted at high levels of at least 10, 50, 100,
500, 1000, 2000, 5000 or 10,000 .mu.g/ml. Surprisingly, the transgenic
mammals of the invention exhibit substantially normal health. Secondary
expression of lysosomal proteins in tissues other than the mammary gland
does not occur to an extent sufficient to cause deleterious effects.
Moreover, exogenous lysosomal protein produced in the mammary gland is
secreted with sufficient efficiency that no significant problem is presented
by deposits clogging the secretory apparatus.
The age at which transgenic mammals can begin producing milk, of course,
varies with the nature of the animal. For transgenic bovines, the age is
about two-and-a-half years naturally or six months with hormonal
stimulation, whereas for transgenic mice the age is about 5-6 weeks. Of
course, only the female members of a species are useful for producing milk.
However, transgenic males are also of value for breeding female descendants.
The sperm from transgenic males can be stored frozen for subsequent in vitro
fertilization and generation of female offspring.
F. Recovery of Proteins from Milk
Transgenic adult female mammals produce milk containing high concentrations
of exogenous lysosomal protein. The protein can be purified from milk, if
desired, by virtue of its distinguishing physical and chemical properties,
and standard purification procedures such as precipitation, ion exchange,
molecular exclusion or affinity chromatography. See generally Scopes,
Protein Purification (Springer-Verlag, N.Y., 1982).
Purification of human acid .alpha.-glucosidase from milk can be carried out
by defatting of the transgenic milk by centrifugation and removal of the
fat, followed by removal of caseins by high speed centrifugation followed by
dead-end filtration (i.e., dead-end filtration by using successively
declining filter sizes) or cross-flow filtration, or; removal of caseins
directly by cross-flow filtration. Human acid .alpha.-glucosidase is
purified by chromatography, including Q Sepharose FF (or other
anion-exchange matrix), hydrophobic interaction chromatography (HIC),
metal-chelating Sepharose, or lectins coupled to Sepharose (or other
Q Sepharose Fast Flow chromatography may be used to purify human acid
.alpha.-glucosidase present in filtered whey or whey fraction as follows: a
Q Sepharose Fast Flow (QFF; Pharmacia) chromatography (Pharmacia XK-50
column, 15 cm bed height; 250 cm/hr flow rate) the column was equilibrated
in 20 mM sodiumphosphate buffer, pH 7.0 (buffer A); the S/D-incubated whey
fraction (about 500 to 600 ml) is loaded and the column is washed with 4-6
column volumes (cv) of buffer A (20 mM sodium phosphate buffer, pH 7.0). The
human acid .alpha.-glucosidase fraction is eluted from the Q FF column with
2-3 cv buffer A, containing 100 mM NaCl.
The Q FF Sepharose human acid .alpha.-glucosidase containing fraction can be
further purified using Phenyl Sepharose High Performance chromatography. For
example, 1 vol. of 1 M ammonium sulphate is added to the Q FF Sepharose
human acid .alpha.-glucosidase eluate while stirring continuously. Phenyl HP
(Pharmacia) column chromatography (Pharmacia XK-50 column, 15 cm bed height;
150 cm/hr flow rate) is then done at room temperature by equilibrating the
column in 0.5 M ammonium sulphate, 50 mM sodiumphosphate buffer pH 6.0
(buffer C), loading the 0.5 M ammoniumsulphate-incubated human acid .alpha.-glucosidase
eluate (from Q FF Sepharose), washing the column with 2-4 cv of buffer C,
and eluting the human acid .alpha.-glucosidase was eluted from the Phenyl HP
column with 3-5 cv buffer D (50 mM sodiumphosphate buffer at pH 6.0).
Alternative methods and additional methods for further purifying human acid
.alpha.-glucosidase will be apparent to those of skill. For example, see
United Kingdom patent application 998 07464.4 (incorporated by reference in
its entirety for all purposes).
G. Uses of Recombinant Lysosomal Proteins
The recombinant lysosomal proteins produced according to the invention find
use in enzyme replacement therapeutic procedures. A patient having a genetic
or other deficiency resulting in an insufficiency of functional lysosomal
enzyme can be treated by administering exogenous enzyme to the patient.
Patients in need of such treatment can be identified from symptoms (e.g.,
Hurler's syndrome symptoms include Dwarfism, corneal clouding,
hepatosplenomegaly, valvular lesions, coronary artery lesions, skeletal
deformities, joint stiffness and progressive mental retardation).
Alternatively, or additionally, patients can be diagnosed from biochemical
analysis of a tissue sample to reveal excessive accumulation of a
characteristic metabolite processed by a particular lysosomal enzyme or by
enzyme assay using an artificial or natural substrate to reveal deficiency
of a particular lysosomal enzyme activity. For most diseases, diagnosis can
be made by measuring the particular enzyme deficiency or by DNA analysis
before occurrence of symptoms or excessive accumulation of metabolites (Scriver
et al., supra, chapters on lysosomal storage disorders). All of the
lysosomal storage diseases are hereditary. Thus, in offspring from families
known to have members suffering from lysosomal diseases, it is sometimes
advisable to commence prophylactic treatment even before a definitive
diagnosis can be made.
In some methods, lysosomal enzymes are administered in purified form
together with a pharmaceutical carrier as a pharmaceutical composition. The
preferred form depends on the intended mode of administration and
therapeutic application. The pharmaceutical carrier can be any compatible,
nontoxic substance suitable to deliver the polypeptides to the patient.
Sterile water, alcohol, fats, waxes, and inert solids may be used as the
carrier. Pharmaceutically-acceptable adjuvants, buffering agents, dispersing
agents, and the like, may also be incorporated into the pharmaceutical
The concentration of the enzyme in the pharmaceutical composition can vary
widely, i.e., from less than about 0.1% by weight, usually being at least
about 1% by weight to as much as 20% by weight or more.
For oral administration, the active ingredient can be administered in solid
dosage forms, such as capsules, tablets, and powders, or in liquid dosage
forms, such as elixirs, syrups, and suspensions. Active component(s) can be
encapsulated in gelatin capsules together with inactive ingredients and
powdered carriers, such as glucose, lactose, sucrose, mannitol, starch,
cellulose or cellulose derivatives, magnesium stearate, stearic acid, sodium
saccharin, talcum, magnesium carbonate and the like. Examples of additional
inactive ingredients that may be added to provide desirable color, taste,
stability, buffering capacity, dispersion or other known desirable features
are red iron oxide, silica gel, sodium lauryl sulfate, titanium dioxide,
edible white ink and the like. Similar diluents can be used to make
compressed tablets. Both tablets and capsules can be manufactured as
sustained release products to provide for continuous release of medication
over a period of hours. Compressed tablets can be sugar coated or film
coated to mask any unpleasant taste and protect the tablet from the
atmosphere, or enteric-coated for selective disintegration in the
gastrointestinal tract. Liquid dosage forms for oral administration can
contain coloring and flavoring to increase patient acceptance.
A typical composition for intravenous infusion could be made up to contain
100 to 500 ml of sterile 0.9% NaCl or 5% glucose optionally supplemented
with a 20% albumin solution and 100 to 500 mg of an enzyme. A typical
pharmaceutical compositions for intramuscular injection would be made up to
contain, for example, 1 ml of sterile buffered water and 1 to 10 mg of the
purified alpha glucosidase of the present invention. Methods for preparing
parenterally administrable compositions are well known in the art and
described in more detail in various sources, including, for example,
Remington's Pharmaceutical Science (15th ed., Mack Publishing, Easton, Pa.,
1980) (incorporated by reference in its entirety for all purposes).
AGLU can be formulated in 10 mM sodium phosphate buffer pH 7.0. Small
amounts of ammonium sulphate are optionally present (<10 mM). The enzyme is
typically kept frozen at about -70.degree. C., and thawed before use.
Alternatively, the enzyme may be stored cold (e.g., at about 4.degree. C. to
8.degree. C.) in solution. In some embodiments, AGLU solutions comprise a
buffer (e.g., sodium phosphate, potassium phosphate or other physiologically
acceptable buffers), a simple carbohydrate (e.g., sucrose, glucose, maltose,
mannitol or the like), proteins (e.g., human serum albumin), and/or
surfactants (e.g., polysorbate 80 (Tween-80), cremophore-EL, cremophore-R,
labrofil, and the like).
AGLU can also be stored in lyophilized form. For lyophilization, AGLU can be
formulated in a solution containing mannitol, and sucrose in a phosphate
buffer. The concentration of sucrose should be sufficient to prevent
aggregation of AGLU on reconstitution. The concentration of mannitol should
be sufficient to significantly reduce the time otherwise needed for
lyophilization. The concentrations of mannitol and sucrose should, however,
be insufficient to cause unacceptable hypertonicity on reconstitution.
Concentrations of mannitol and sucrose of 1-3 mg/ml and 0.1-1.0 mg/ml
respectively are suitable. Preferred concentrations are 2 mg/ml mannitol and
0.5 mg/ml sucrose. AGLU is preferably at 5 mg/ml before lyophilization and
after reconstitution. Saline preferably at 0.9% is a preferred solution for
For AGLU purified from rabbit milk, a small amount of impurities (e.g., up
to about 5%) can be tolerated. Possible impurities may be present in the
form of rabbit whey proteins. Other possible impurities are structural
analogues (e.g., oligomers and aggregates) and truncations of AGLU. Current
batches indicate that the AGLU produced in transgenic rabbits is >95% pure.
The largest impurities are rabbit whey proteins, although on gel
electrophoresis, AGLU bands of differing molecular weights are also seen.
Infusion solutions should be prepared aseptically in a laminar air flow
hood. The appropriate amount of AGLU should be removed from the freezer and
thawed at room temperature. Infusion solutions can be prepared in glass
infusion bottles by mixing the appropriate amount of AGLU finished product
solution with an adequate amount of a solution containing human serum
albumin (HSA) and glucose. The final concentrations can be 1% HSA and 4%
glucose for 25-200 mg doses and 1% HSA and 4% glucose for 400-800 mg doses.
HSA and AGLU can be filtered with a 0.2 .mu.m syringe filter before transfer
into the infusion bottle containing 5% glucose. Alternatively, AGLU can be
reconstituted in saline solution, preferably 0.9% for infusion. Solutions of
AGLU for infusion have been shown to be stable for up to 7 hours at room
temperature. Therefore the AGLU solution is preferably infused within seven
hours of preparation.
The present invention provides effective methods of treating Pompe's
disease. These methods are premised in part on the availability of large
amounts of human acid alpha glucosidase in a form that is catalytically
active and in a form that can be taken up by tissues, particularly, liver,
heart and muscle (e.g., smooth muscle, striated muscle, and cardiac muscle),
of a patient being treated. Such human acid alpha-glucosidase is provided
from e.g., the transgenic animals described in the Examples. The alpha-glucosidase
is preferably predominantly (i.e., >50%) in the precursor form of about
100-110 kD. (The apparent molecular weight or relative mobility of the
100-110 kD precursor may vary somewhat depending on the method of analysis
used, but is typically within the range 95 kD and 120 kD.) Given the
successful results with human acid alpha-glucosidase in the transgenic
animals discussed in the Examples, it is possible that other sources of
human alpha-glucosidase, such as resulting from cellular expression systems,
can also be used. For example, an alternative way to produce human acid
.alpha.-glucosidase is to transfect the acid .alpha.-glucosidase gene into a
stable eukaryotic cell line (e.g., CHO) as a cDNA or genomic construct
operably linked to a suitable promoter. However, it is more laborious to
produce the large amounts of human acid alpha glucosidase needed for
clinical therapy by such an approach.
The pharmaceutical compositions of the present invention are usually
administered intravenously. Intradermal, intramuscular or oral
administration is also possible in some circumstances. The compositions can
be administered for prophylactic treatment of individuals suffering from, or
at risk of, a lysosomal enzyme deficiency disease. For therapeutic
applications, the pharmaceutical compositions are administered to a patient
suffering from established disease in an amount sufficient to reduce the
concentration of accumulated metabolite and/or prevent or arrest further
accumulation of metabolite. For individuals at risk of lysosomal enzyme
deficiency disease, the pharmaceutical compositions are administered
prophylactically in an amount sufficient to either prevent or inhibit
accumulation of metabolite. An amount adequate to accomplish this is defined
as a "therapeutically-" or "prophylactically-effective dose." Such effective
dosages will depend on the severity of the condition and on the general
state of the patient's health.
In the present methods, human acid alpha glucosidase is usually administered
at a dosage of 10 mg/kg patient body weight or more per week to a patient.
Often dosages are greater than 10 mg/kg per week. Dosages regimes can range
from 10 mg/kg per week to at least 1000 mg/kg per week. Typically dosage
regimes are 10 mg/kg per week, 15 mg/kg per week, 20 mg/kg per week, 25
mg/kg per week, 30 mg/kg per week, 35 mg/kg per week, 40 mg/kg week, 45
mg/kg per week, 60 mg/kg week, 80 mg/kg per week and 120 mg/kg per week. In
preferred regimes 10 mg/kg, 15 mg/kg, 20 mg/kg, 30 mg/kg or 40 mg/kg is
administered once, twice or three times weekly. Treatment is typically
continued for at least 4 weeks, sometimes 24 weeks, and sometimes for the
life of the patient. Treatment is preferably administered i.v. Optionally,
levels of human alpha-glucosidase are monitored following treatment (e.g.,
in the plasma or muscle) and a further dosage is administered when detected
levels fall substantially below (e.g., less than 20%) of values in normal
In some methods, human acid alpha glucosidase is administered at an
initially "high" dose (i.e., a "loading dose"), followed by administration
of a lower doses (i.e., a "maintenance dose"). An example of a loading dose
is at least about 40 mg/kg patient body weight 1 to 3 times per week (e.g.,
for 1, 2, or 3 weeks). An example of a maintenance dose is at least about 5
to at least about 10 mg/kg patient body weight per week, or more, such as 20
mg/kg per week, 30 mg/kg per week, 40 mg/kg week.
In some methods, a dosage is administered at increasing rate during the
dosage period. Such can be achieved by increasing the rate of flow
intravenous infusion or by using a gradient of increasing concentration of
alpha-glucosidase administered at constant rate. Administration in this
manner reduces the risk of immunogenic reaction. In some dosages, the rate
of administration measured in units of alpha glucosidase per unit time
increases by at least a factor of ten. Typically, the intravenous infusion
occurs over a period of several hours (e.g., 1-10 hours and preferably 2-8
hours, more preferably 3-6 hours), and the rate of infusion is increased at
intervals during the period of administration.
Suitable dosages (all in mg/kg/hr) for infusion at increasing rates are
shown in table 1 (see Original Patent). The first column of the table
indicates periods of time in the dosing schedule. For example, the reference
to 0-1 hr refers to the first hour of the dosing. The fifth column of the
table shows the range of doses than can be used at each time period. The
fourth column shows a narrower included range of preferred dosages. The
third column indicates upper and lower values of dosages administered in an
exemplary clinical trial. The second column shows particularly preferred
dosages, these representing the mean of the range shown in the third column
of table 1.
The methods are effective on patients with both early onset (infantile) and
late onset (juvenile and adult) Pompe's disease. In patients with the
infantile form of Pompe's disease symptoms become apparent within the first
4 months of life. Mostly, poor motor development and failure to thrive are
noticed first. On clinical examination, there is generalized hypotonia with
muscle wasting, increased respiration rate with sternal retractions,
moderate enlargement of the liver, and protrusion of the tongue. Ultrasound
examination of the heart shows a progressive hypertrophic cardiomyopathy,
eventually leading to insufficient cardiac output. The ECG is characterized
by marked left axis deviation, a short PR interval, large QRS complexes,
inverted T waves and ST depression. The disease shows a rapidly progressive
course leading to cardiorespiratory failure within the first year of life.
On histological examination at autopsy lysosomal glycogen storage is
observed in various tissues, and is most pronounced in heart and skeletal
muscle. Treatment with human acid alpha glucosidase in the present methods
results in a prolongation of life of such patients (e.g., greater than 1, 2,
5 years up to a normal lifespan). Treatment can also result in elimination
or reduction of clinical and biochemical characteristics of Pompe's disease
as discussed above. Treatment is administered soon after birth, or
antenatally if the parents are known to bear variant alpha glucosidase
alleles placing their progeny at risk.
Patients with the late onset adult form of Pompe's disease may not
experience symptoms within the first two decades of life. In this clinical
subtype, predominantly skeletal muscles are involved with predilection of
those of the limb girdle, the trunk and the diaphragm. Difficulty in
climbing stairs is often the initial complaint. The respiratory impairment
varies considerably. It can dominate the clinical picture, or it is not
experienced by the patient until late in life. Most such patients die
because of respiratory insufficiency. In patients with the juvenile subtype,
symptoms usually become apparent in the first decade of life. As in adult
Pompe's disease, skeletal muscle weakness is the major problem; cardiomegaly,
hepatomegaly, and macroglossia can be seen, but are rare. In many cases,
nightly ventilatory support is ultimately needed. Pulmonary infections in
combination with wasting of the respiratory muscles are life threatening and
mostly become fatal before the third decade. Treatment with the present
methods prolongs the life of patients with late onset juvenile or adult
Pompe's disease up to a normal life span. Treatment also eliminates or
significantly reduces clinical and biochemical symptoms of disease.
Lysosomal proteins produced in the milk of transgenic animals have a number
of other uses. For example, .alpha.-glucosidase, in common with other
.alpha.-amylases, is an important tool in production of starch, beer and
pharmaceuticals. See. Vihinen & Mantsala, Crit. Rev. Biochem. Mol. Biol. 24,
329-401 (1989) (incorporated by reference in its entirety for all purpose).
Lysosomal proteins are also useful for producing laboratory chemicals or
food products. For example, acid .alpha.-glucosidase degrades 1,4 and 1,6
.alpha.-glucidic bonds and can be used for the degradation of various
carbohydrates containing these bonds, such as maltose, isomaltose, starch
and glycogen, to yield glucose. Acid .alpha.-glucosidase is also useful for
administration to patients with an intestinal maltase or isomaltase
deficiency. Symptoms otherwise resulting from the presence of undigested
maltose are avoided. In such applications, the enzyme can be administered
without prior fractionation from milk, as a food product derived from such
milk (e.g., ice cream or cheese) or as a pharmaceutical composition.
Purified recombinant lysosomal enzymes are also useful for inclusion as
controls in diagnostic kits for assay of unknown quantities of such enzymes
in tissue samples.
Claim 1 of 1 Claim
1. A method of treating a human patient
with Pompe's disease, comprising intravenously administering biweekly to
the patient a therapeutically effective amount of human acid alpha
glucosidase, whereby the concentration of accumulated glycogen in the
patient is reduced and/or further accumulation of glycogen is arrested.
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