9
N N E E W W S S EFACTS Coordinator: Prof. Massimo Pandolfo EFACTS Patient Registry: Prof. Jörg B. Schulz (Director Registry) Kathrin Fedosov (Patient contact) Department of Neurology RWTH Aachen University Pauwelsstraße 30 52074 Aachen +49-241-80-88253 +49-241-80-82582 [email protected] www.e-facts.eu October 2014 • Issue 4 Imprint: Prof. Dr. Jörg B. Schulz for the EFACTS Consortium (European Friedreich’s Ataxia Consortium for Translational Studies) Director, Dept. of Neurology, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany. The information contained in this newsletter is subject to the EFACTS Liability Disclaimer which can be found at http://www.e- facts.eu/html/liability –Please consult a doctor for medical advice.– Except as otherwise noted this work is licensed under the Creative Commons Attribution-No Derivative Works 3.0 Unported License. Subscribe here to EFACTS NEWS: Please go to the URL below and fill out the online form: http://www.e- facts.eu/html/studies/home/n ewsletter/subscribe Please send us your comments, suggestions and overall feedback: [email protected] Content Page Status of the EFACTS patient registry ___________ 2 Findings and Publications 3 ‘Switching’ the Frataxin gene back ‘on’ in Friedreich’s ataxia 8 The Future of the Registry 9 Meetings & Dates 9 Welcome to the 4 t t h h issue of EFACTS NEWS The EFACTS (European Friedreich’s Ataxia Consortium for Translational Studies) Consortium is approaching the end of its last year of funding within the European Commission’s 7 th framework program and is publishing its fourth and last annual newsletter EFACTS NEWS. In the past four years, we have provided updates on the activities of the network and progress in European Friedreich’s Ataxia research to affected families, health care professionals, the scientific community, and the general public. All issues of EFACTS NEWS will continue to be available on the EFACTS Website. Any comments, suggestions, questions or overall feedback on EFACTS NEWS and the EFACTS network are always welcome at contact@e- facts.eu. In this last issue of EFACTS NEWS, we would like to present another update on the status of the EFACTS patient registry which has begun to see patients at their third annual follow-up visits. Since the recruitment of a “core sample” was completed in the spring of 2013, baseline data analyses have been underway and baseline results will be published shortly. Basic science projects have provided a lot of new important knowledge and short summaries of findings of the past year can be found in this newsletter. Finally, we would like to report on the progress of the nicotinamide trial, present results from the completed nicotinamide dose-escalation trial, and give you an outlook on the future of the EFACTS consortium and registry.

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Page 1: Efacts Newsletter Oct 14

NNEEWWSS

EFACTS Coordinator:

Prof. Massimo Pandolfo

EFACTS Patient Registry:

Prof. Jörg B. Schulz

(Director Registry)

Kathrin Fedosov

(Patient contact)

Department of Neurology

RWTH Aachen University

Pauwelsstraße 30

52074 Aachen

� +49-241-80-88253

� +49-241-80-82582

[email protected]

www.e-facts.eu

October 2014 • Issue 4

Imprint: Prof. Dr. Jörg B. Schulz for

the EFACTS Consortium

(European Friedreich’s Ataxia

Consortium for Translational

Studies) Director, Dept. of

Neurology, RWTH Aachen

University, Pauwelsstraße 30,

52074 Aachen, Germany.

The information contained in this

newsletter is subject to the

EFACTS Liability Disclaimer which

can be found at

http://www.e-

facts.eu/html/liability

–Please consult a doctor for

medical advice.–

Except as otherwise noted this

work is licensed under the

Creative Commons Attribution-No

Derivative Works 3.0 Unported

License.

Subscribe here to EFACTS

NEWS:

Please go to the URL below

and fill out the online form:

http://www.e-

facts.eu/html/studies/home/n

ewsletter/subscribe

Please send us your

comments, suggestions and

overall feedback:

[email protected]

Content Page

Status of the EFACTS patient registry ___________ 2

Findings and Publications 3

‘Switching’ the Frataxin gene back ‘on’ in Friedreich’s ataxia 8

The Future of the Registry 9

Meetings & Dates 9

WWeellccoommee ttoo tthhee 44tthh

iissssuuee ooff EEFFAACCTTSS NNEEWWSS

The EFACTS (European Friedreich’s Ataxia Consortium for Translational

Studies) Consortium is approaching the end of its last year of funding

within the European Commission’s 7th

framework program and is

publishing its fourth and last annual newsletter EFACTS NEWS.

In the past four years, we have provided updates on the activities of

the network and progress in European Friedreich’s Ataxia research to

affected families, health care professionals, the scientific community,

and the general public. All issues of EFACTS NEWS will continue to be

available on the EFACTS Website.

Any comments, suggestions, questions or overall feedback on EFACTS

NEWS and the EFACTS network are always welcome at contact@e-

facts.eu.

In this last issue of EFACTS NEWS, we would like to present another

update on the status of the EFACTS patient registry which has begun to

see patients at their third annual follow-up visits.

Since the recruitment of a “core sample” was completed in the spring

of 2013, baseline data analyses have been underway and baseline

results will be published shortly. Basic science projects have provided a

lot of new important knowledge and short summaries of findings of the

past year can be found in this newsletter.

Finally, we would like to report on the progress of the nicotinamide

trial, present results from the completed nicotinamide dose-escalation

trial, and give you an outlook on the future of the EFACTS consortium

and registry.

Page 2: Efacts Newsletter Oct 14

SSttaattuuss ooff tthhee EEFFAACCTTSS

PPaattiieenntt RReeggiissttrryy

Registry recruitment and follow-up visits are ongoing!

The 604 patients who were enrolled by 30th

April 2013 were considered the “core

sample” of EFACTS and baseline analyses of collected patient data were based on this

group of patients. Results from these analyses will be published shortly. However, the

Consortium expects that for future treatment trials, a large number of patients will need

to be identified to obtain conclusive results on the effectiveness of tested treatments.

Therefore, the registry remains open for new patients!

Enrolment and retention

In addition to the 604 patients of the “core sample”, who are the largest group of

Friedreich’s ataxia patients ever followed for a minimum of 2 years to collect natural

history data, the registry has accepted 37 new patients since spring 2013. 1-year follow-up assessments on 496 patients of the “core sample” were concluded in

May 2014 and analyses of collected data have begun. By mid-October 2014 341 “core

sample” patients had returned for their 2-year follow-up assessment and 47 patients for

their third annual follow-up assessment.

“Core sample” enrolment and retention by centre

London Milan Madrid Paris Innsbruck Munich Brussels Aachen Tübingen Bonn Marburg

BL 151 138 78 49 41 39 31 30 22 18 7

1YFU 120 130 48 42 34 34 29 19 21 14 5

2YFU 118 92 0 28 33 0 23 16 15 3 3

3YFU 11 0 0 0 16 0 12 8 0 0 0

0

20

40

60

80

100

120

140

160

No. of patients

Participant characteristics at baseline

Male (%)/ female (%) 299 (47)/ 342 (53)

Mean age in years at (range) 34 (6-76)

No. of children (<18 years) 63

THANK YOU FOR YOUR INVESTMENT IN THE REGISTRY,

HELPING US FIND A TREATMENT FOR FRIEDREICH’S ATAXIA!

2 October 2014 • Issue 4

Clinical Study Sites and Contacts

Austria

Prof. Sylvia Boesch

[email protected]

Belgium

Dr. Myriam Raï

[email protected]

France

Paris: Sandra Benaich

[email protected]

Strasbourg: Prof. Mathieu Anheim

[email protected]

Germany

Aachen: Kathrin Fedosov

[email protected]

Bonn: Ilaria Anna Giordano

[email protected]

bonn.de

Marburg: Prof. Katrin Bürk

[email protected]

München: Ivan Karin

[email protected]

Tübingen: Prof. Ludger Schöls

[email protected]

tuebingen.de

Italy

Dr. Caterina Mariotti

[email protected]

United Kingdom

Prof. Paola Giunti

[email protected]

Friedreich’s Ataxia patient

associations in Europe

euro-ATAXIA

www.euro-ataxia.eu

United Kingdom

Ataxia UK

www.ataxia.org.uk

Italy

GoFAR

www.fa-petition.org

France

Association Française de l’Ataxie de

Friedreich

www.afaf.asso.fr

Germany

Deutsche Heredo-Ataxie Gesellschaft

e.V.

www.ataxie.de

Spain

Federación de Ataxias de España

www.fedaes.org

Netherlands

Autosomal Dominant Cerebellar

Ataxia Vereniging Nederland

www.ataxie.nl

Ireland

Ataxia Ireland

www.ataxia.ie

Friedreich’s Ataxia Research

Groups

Ataxia Study Group

www.ataxia-study-group.net

Friedreich’s Ataxia Research Alliance

www.curefa.org

EEFFAACCTTSS NNEEWWSS

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EEFFAACCTTSS NNEEWWSS October 2014 • Issue 4 3

Epigenetic and neurological effects and safety of high-dose nicotinamide in patients with

Friedreich's ataxia: an exploratory, open-label, dose-escalation study.

Libri V, Yandim C, Athanasopoulos S, Loyse N, Natisvili T, Law PP, Chan PK, Mohammad T, Mauri M, Tam KT, Leiper J, Piper S, Ramesh A,

Parkinson MH, Huson L, Giunti P, Festenstein R.

Lancet. 2014 Aug 9;384(9942):504-13. doi: 10.1016/S0140-6736(14)60382-2.

Friedreich's ataxia is a progressive degenerative disorder caused by deficiency of the frataxin protein. Expanded

GAA repeats within intron 1 of the frataxin (FXN) gene lead to its heterochromatinisation and transcriptional

silencing. Preclinical studies have shown that the histone deacetylase inhibitor nicotinamide (vitamin B3) can

remodel the pathological heterochromatin and upregulate expression of FXN. We aimed to assess the epigenetic

and neurological effects and safety of high-dose nicotinamide in patients with Friedreich's ataxia. In this

exploratory, open-label, dose-escalation study in the UK, male and female patients (aged 18 years or older) with

Friedreich's ataxia were given single doses (phase 1) and repeated daily doses of 2-8 g oral nicotinamide for 5 days

(phase 2) and 8 weeks (phase 3). Doses were gradually escalated during phases 1 and 2, with individual maximum

tolerated doses used in phase 3. The primary outcome was the upregulation of frataxin expression. We also

assessed the safety and tolerability of nicotinamide, used chromatin immunoprecipitation to investigate changes

in chromatin structure at the FXN gene locus, and assessed the effect of nicotinamide treatment on clinical scales

for ataxia. This study is registered with ClinicalTrials.gov, number NCT01589809. Nicotinamide was generally well

tolerated; the main adverse event was nausea, which in most cases was mild, dose-related, and resolved

spontaneously or after dose reduction, use of antinausea drugs, or both. Phase 1 showed a dose-response relation

for proportional change in frataxin protein concentration from baseline to 8 h post-dose, which increased with

increasing dose (p=0.0004). Bayesian analysis predicted that 3.8 g would result in a 1.5-times increase and 7.5 g in

a doubling of frataxin protein concentration. Phases 2 and 3 showed that daily dosing at 3.5-6 g resulted in a

sustained and significant (p<0.0001) upregulation of frataxin expression, which was accompanied by a reduction in

heterochromatin modifications at the FXN locus. In the short period of time, clinical measures showed no

significant changes. Nicotinamide was associated with a sustained improvement in frataxin concentrations

towards those seen in asymptomatic carriers during 8 weeks of daily dosing. Further investigation of the long-

term clinical benefits of nicotinamide and its ability to ameliorate frataxin deficiency in Friedreich's ataxia is

warranted.

Model of the nicotinamide molecule, C6H6N2O

Page 4: Efacts Newsletter Oct 14

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Deferiprone in Friedreich's Ataxia: A six-month randomized controlled trial.

Pandolfo M, Arpa J, Delatycki MB, Sang KH, Mariotti C, Munnich A, Sanz-Gallego I, Tai G, Tarnopolsky MA, Taroni F, Spino M, Tricta F.

Ann Neurol. 2014 Aug 11. doi: 10.1002/ana.24248.

We conducted a 6-month randomized, double-blind, placebo-controlled study to assess safety, tolerability, and

efficacy of deferiprone in Friedreich's ataxia. Seventy-two patients were treated with deferiprone 20, 40, or 60

mg/kg/day or placebo, divided into two daily doses. Safety was the primary objective, secondary objectives

included standardized neurological assessments (FARS, ICARS, 9HPT, T25FW, LCLA), general functional status

(ADL), and cardiac assessments. Deferiprone was well tolerated at 20 mg/kg/day, whereas more adverse events

occurred in the 40 mg/kg/day than in the placebo group. The 60mg/kg/day dose was discontinued due to

worsening of ataxia in two patients. One patient on deferiprone 20 mg/kg/day experienced reversible

neutropenia, but none developed agranulocytosis. Deferiprone-treated patients receiving 20 or 40 mg/kg/day

showed a decline in the left ventricular mass index, compared to an increase in the placebo-treated patients.

Patients receiving 20 mg/kg/day of deferiprone had no significant change in FARS, similar to the placebo-treated

patients, while those receiving 40 mg/kg/day had worsening in FARS and ICARS scores. The lack of deterioration in

the placebo arm impaired the ability to detect any potential protective effect of deferiprone. However, subgroup

analyses in patients with less severe disease suggested a benefit of deferiprone 20 mg/kg/day on ICARS, FARS,

kinetic function and 9HPT. This study demonstrated an acceptable safety profile of deferiprone at 20 mg/kg/day

for the treatment of patients with FRDA. Subgroup analyses raise the possibility that, in patients with less severe

disease, deferiprone 20 mg/kg/day may reduce disease progression, while higher doses appear to worsen ataxia.

MutLα heterodimers modify the molecular phenotype of

Friedreich ataxia.

Ezzatizadeh V, Sandi C, Sandi M, Anjomani-Virmouni S, Al-Mahdawi S, Pook MA.

PLoS One. 2014 Jun 27;9(6):e100523. doi: 10.1371/journal.pone.0100523.

LAY ABSTRACT

Previous studies of FRDA cell and mouse models have revealed a role for

certain proteins that usually repair damaged DNA, called mismatch repair

proteins, in GAA repeat instability: MSH2, MSH3 and MSH6 promote GAA

repeat expansions, while PMS2 inhibits GAA repeat expansions. These

effects may play important roles in FRDA disease progression. By studying

FRDA mouse models, we have now investigated the potential role of

another mismatch repair protein, MLH1, in GAA repeat instability. We

find that MLH1 promotes GAA repeat expansions. However, we also find

that loss of MLH1 and PMS2 can also reduce frataxin expression levels.

Therefore, both PMS2 and MLH1 have now been shown to modify the

molecular phenotype of FRDA. We propose that upregulation of MLH1 or

PMS2 could be potential FRDA therapeutic approaches to increase

frataxin expression.

Page 5: Efacts Newsletter Oct 14

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Prevention and reversal of severe mitochondrial cardiomyopathy by gene therapy in a mouse

model of Friedreich's ataxia.

Perdomini M, Belbellaa B, Monassier L, Reutenauer L, Messaddeq N, Cartier N, Crystal RG, Aubourg P, Puccio H.

Nat Med. 2014 May;20(5):542-7. doi: 10.1038/nm.3510.

Cardiac failure is the most common cause of mortality in Friedreich's ataxia (FRDA), a mitochondrial disease

characterized by neurodegeneration, hypertrophic cardiomyopathy and diabetes. FRDA is caused by reduced

levels of frataxin (FXN), an essential mitochondrial protein involved in the biosynthesis of iron-sulfur (Fe-S)

clusters. Impaired mitochondrial oxidative phosphorylation, bioenergetics imbalance, deficit of Fe-S cluster

enzymes and mitochondrial iron overload occur in the myocardium of individuals with FRDA. No treatment exists

as yet for FRDA cardiomyopathy. A conditional mouse model with complete frataxin deletion in cardiac and

skeletal muscle (Mck-Cre-Fxn(L3/L-) mice) recapitulates most features of FRDA cardiomyopathy, albeit with a

more rapid and severe course. Here we show that adeno-associated virus rh10 vector expressing human FXN

injected intravenously in these mice fully prevented the onset of cardiac disease. Moreover, later administration

of the frataxin-expressing vector, after the onset of heart failure, was able to completely reverse the

cardiomyopathy of these mice at the functional, cellular and molecular levels within a few days. Our results

demonstrate that cardiomyocytes with severe energy failure and ultrastructure disorganization can be rapidly

rescued and remodeled by gene therapy and establish the preclinical proof of concept for the potential of gene

therapy in treating FRDA cardiomyopathy.

hFXN protein expression assessed by immunofluorescence in heart from

35-week-old treated Mck mice using antibody to FXN.

5 October 2014 • Issue 4

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October 2014 • Issue 4 EEFFAACCTTSS NNEEWWSS

FFiinnddiinnggss aanndd PPuubblliiccaattiioonnss

To read about all previous and new EFACTS publications, please continue to visit www.e-facts.eu

6

Mitochondrial dysfunction induced by frataxin deficiency is associated with cellular senescence

and abnormal calcium metabolism.

Bolinches-Amorós A, Mollá B, Pla-Martín D, Palau F, González-Cabo P.

Front Cell Neurosci. 2014 May 13;8:124. doi: 10.3389/fncel.2014.00124. eCollection 2014.

LAY ABSTRACT

Frataxin deficiency is the cause of Friedreich ataxia (FRDA), a neurodegenerative and systemic disorder that has the

dorsal root ganglia (DRG) as a major target neural tissue. In this manuscript we are addressing new knowledge on the

effect of frataxin depletion on mitochondria and cells, and how modifications in the mitochondrion may affect different

cellular processes. We have investigated the mitochondrial and cellular consequences of frataxin deficiency in a

neuron-like model based on FXN gene silencing in the human neuroblastoma cell line SH-SY5Y. Frataxin silencing

provoked slow cell growth associated with cellular senescence. Cellular senescence should be considered as a

contributing factor for the incomplete neurodevelopment as suggested by necropsy studies. In an attempt to

understand such cellular senescence and its relationship with the disease neuropathology, we focused not only on the

characterization of bioenergetics and redox status of the cell model but also on other mitochondrial functions that

have been associated with neurodegeneration that have not received enough attention in FRDA pathogenesis

(mitochondrial dynamics and calcium homeostasis). We show that the reduction of frataxin induces mitochondrial

dysfunction due to a bioenergetic deficit and reduced Ca2+ uptake capacity of the mitochondria that were associated

with both oxidative and endoplasmic reticulum (ER) stresses. The ER stress is a cellular response from conditions that

interfere with the correct function of the ER, such as changes of the Ca2+ homeostasis. In addition, the depletion of

frataxin does not cause cell death but increased autophagy, an intracellular degradation system, which may have a

protective effect against cellular insults such as oxidative stress. However, under conditions of prolonged stress signals,

ER stress induces apoptosis. We propose that the manipulation of mitochondrial Ca2+ homeostasis, ER stress, and

cellular senescence should be explored as a potential therapeutic strategy for the treatment of FRDA patients. Quantification of the mitochondrial dynamic process in SH-SY5Y (human neuroblastoma cells). The

representative mitochondrial network shows increased fusion morphology in frataxin-deficient cells. © 2014 Bolinches-Amorós, Mollá, Pla-Martín, Palau and González-Cabo.

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7EEFFAACCTTSS NNEEWWSS October 2014 • Issue 4

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For a more comprehensive understanding of Friedreich’s ataxia, past research findings and opinions on needed future

research studies please also see these review articles, which have been published by EFACTS investigators in the past year:

Epigenetic-based therapies for Friedreich ataxia. Sandi C, Sandi M, Anjomani Virmouni S, Al-Mahdawi S, Pook MA.

Front Genet. 2014 Jun 3;5:165. doi: 10.3389/fgene.2014.00165. eCollection 2014.

Friedreich ataxia (FRDA) is a lethal autosomal recessive neurodegenerative disorder caused primarily by a homozygous GAA

repeat expansion mutation within the first intron of the FXN gene, leading to inhibition of FXN transcription and thus reduced

frataxin protein expression. Recent studies have shown that epigenetic marks, comprising chemical modifications of DNA and

histones, are associated with FXN gene silencing. Such epigenetic marks can be reversed, making them suitable targets for

epigenetic-based therapy. Furthermore, since FRDA is caused by insufficient, but functional, frataxin protein, epigenetic-based

transcriptional re-activation of the FXN gene is an attractive therapeutic option. In this review we summarize our current

understanding of the epigenetic basis of FXN gene silencing and we discuss current epigenetic-based FRDA therapeutic

strategies.

Dysregulation of cellular iron metabolism in Friedreich ataxia: from primary iron-sulfur cluster

deficit to mitochondrial iron accumulation. Martelli A, Puccio H.

Front Pharmacol. 2014 Jun 3;5:130. doi: 10.3389/fphar.2014.00130. eCollection 2014.

Friedreich ataxia (FRDA) is the most common recessive ataxia in the Caucasian population and is characterized by a mixed

spinocerebellar and sensory ataxia frequently associating cardiomyopathy. The disease results from decreased expression of the

FXN gene coding for the mitochondrial protein frataxin. Early histological and biochemical study of the pathophysiology in

patients’ samples revealed that dysregulation of iron metabolism is a key feature of the disease, mainly characterized by

mitochondrial iron accumulation and by decreased activity of iron-sulfur cluster enzymes. In the recent past years, considerable

progress in understanding the function of frataxin has been provided through cellular and biochemical approaches, pointing to

the primary role of frataxin in iron-sulfur cluster biogenesis. However, why and how the impact of frataxin deficiency on this

essential biosynthetic pathway leads to mitochondrial iron accumulation is still poorly understood. Herein, we review data on

both the primary function of frataxin and the nature of the iron metabolism dysregulation in FRDA. To date, the

pathophysiological implication of the mitochondrial iron overload in FRDA remains to be clarified.

Chronochemistry in neurodegeneration. Pastore A, Adinolfi S.

Front Mol Neurosci. 2014 Mar 31;7:20. doi: 10.3389/fnmol.2014.00020. eCollection 2014.

The problem of distinguishing causes from effects is not a trivial one, as illustrated by the science fiction writer Isaac Asimov in a

novel dedicated to an imaginary compound with surprising "chronochemistry" properties. The problem is particularly important

when trying to establish the etiology of diseases. Here, we discuss how the problem reflects on our understanding of disease

using two specific examples: Alzheimer's disease (AD) and Friedreich's ataxia (FRDA). We show how the fibrillar aggregates

observed in AD were first denied any interest, then to assume a central focus, and to finally recess to be considered the dead-

end point of the aggregation pathway. This current view is that the soluble aggregates formed along the aggregation pathway

rather than the mature amyloid fiber are the causes of disease. Similarly, we illustrate how the identification of causes and

effects have been important in the study of FRDA. This disease has alternatively been considered as the consequence of

oxidative stress, iron precipitation or reduction of iron-sulfur cluster protein context. We illustrate how new tools have recently

been established which allow us to follow the development of the disease. We hope that this review may inspire similar studies

in other scientific disciplines.

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Epigenetic therapy for Friedreich's ataxia. Soragni E, Miao W, Iudicello M, Jacoby D, Demercanti S, Clerico M, Longo F, Piga A, Ku S, Campau E, Du J, Penalver P, Rai M, Madara JC,

Nazor K, O'Connor M, Maximov A, Loring JF, Pandolfo M, Durelli L, Gottesfeld JM, Rusche JR.

Ann Neurol. 2014 Aug 27. doi: 10.1002/ana.24260. [Epub ahead of print]

Objective: To investigate whether a histone deacetylase inhibitor (HDACi) would be effective in an in vitro model for the

neurodegenerative disease Friedreich's ataxia (FRDA) and to evaluate safety and surrogate markers of efficacy in a phase I

clinical trial in patients. Methods: We used a human FRDA neuronal cell model, derived from patient induced pluripotent

stem cells, to determine the efficacy of a 2-aminobenzamide HDACi (109) as a modulator of FXN gene expression and

chromatin histone modifications. FRDA patients were dosed in four cohorts, ranging from 30 mg/day to 240 mg/day of the

formulated drug product of HDACi 109, RG2833. Patients were monitored for adverse effects as well as for increases in FXN

mRNA, frataxin protein, and chromatin modification in blood cells. Results: In the neuronal cell model, HDACi 109/RG2833

increases FXN mRNA levels and frataxin protein, with concomitant changes in the epigenetic state of the gene. Chromatin

signatures indicate that histone H3 lysine 9 is a key residue for gene silencing through methylation and reactivation through

acetylation, mediated by the HDACi. Drug treatment in FRDA patients demonstrated increases in FXN mRNA and H3 lysine 9

acetylation in peripheral blood mononuclear cells. No safety issues were encountered. Interpretation: Drug exposure

inducing epigenetic changes in neurons in vitro is comparable to the exposure required in patients to see epigenetic changes

in circulating lymphoid cells and increases in gene expression. These findings provide a proof of concept for the development

of an epigenetic therapy for this fatal neurological disease. © 2014 American Neurological Association.

‘‘SSwwiittcchhiinngg’’ tthhee FFrraattaaxxiinn ggeennee bbaacckk ‘‘oonn’’ iinn FFrriieeddrreeiicchh’’ss aattaaxxiiaa

PPrrooff.. RRiicchhaarrdd FFeesstteennsstteeiinn,, IImmppeerriiaall CCoolllleeggee,, LLoonnddoonn,, UUKK

The Festenstein lab previously demonstrated that GAA-triplet repeats can induce gene silencing in a manner previously

described for the epigenetic phenomenon of position effect variegation (PEV) (Saveliev et al., 2003) which has been

instrumental in the development of the notion of a histone or epigenetic code (Jenuwein and Allis, 2001). This implicated

chromatin modifiers as disease modifiers in Friedreich's ataxia (Chan et al., 2013). In the last newsletter it was reported that

an exploratory clinical study was underway to determine whether the histone deacetylase inhibitor, nicotinamide, could

upregulate the frataxin gene in patients with Friedreich's ataxia. This study revealed upregulation of frataxin in patients using

large doses of nicotinamide which were generally well tolerated (Libri et al., 2014). The results support further investigation

of the safety and clinical efficacy in a larger randomised controlled clinical trial which is being planned. If frataxin can be

safely upregulated in a sustained manner it would be predicted that the treatment may prevent further decline in this

otherwise relentlessly progressive condition. Friedreich's ataxia could be viewed as a prototypic position-effect disease

making it possible that other diseases caused by a similar mechanism would be amenable to similar approach.

References:

Chan, P.K., Torres, R., Yandim, C., Law, P.P., Khadayate, S., Mauri, M., Grosan, C., Chapman-Rothe, N., Giunti, P., Pook, M., et al. (2013).

Heterochromatinization induced by GAA-repeat hyperexpansion in Friedreich's ataxia can be reduced upon HDAC inhibition by vitamin B3. Hum

Mol Genet 22, 2662-2675.

Jenuwein, T., and Allis, C.D. (2001). Translating the histone code. Science 293, 1074-1080.

Libri, V., Yandim, C., Athanasopoulos, S., Loyse, N., Natisvili, T., Law, P.P., Chan, P.K., Mohammad, T., Mauri, M., Tam, K.T., et al. (2014).

Epigenetic and neurological effects and safety of high-dose nicotinamide in patients with Friedreich's ataxia: an exploratory, open-label, dose-

escalation study. Lancet. 2014 Aug 9;384(9942):504-13.

Saveliev, A., Everett, C., Sharpe, T., Webster, Z., and Festenstein, R. (2003). DNA triplet repeats mediate heterochromatin-protein-1-sensitive

variegated gene silencing. Nature 422, 909-913.

Page 9: Efacts Newsletter Oct 14

EEFFAACCTTSS NNEEWWSS October 2014 • Issue 4 9

MMeeeettiinnggss && DDaatteess

Neuroscience 2014

15th

- 19th

November 2014

Washington, DC, USA

International Ataxia Research Conference

25th

– 28th

March 2015

Beaumont Estate, Windsor, UK

International Conference on Rare Diseases and

Orphan Drugs

12th – 17th October 2015

Mexico City, Mexico

28th February 2015:

Rare Disease Day

25th September 2015:

International Ataxia Awareness Day

Attendants of the 4th

annual meeting of the EFACTS

consortium, 27th

– 28th

June 2014,

Centro de Investigación Príncipe Felipe, Valencia, Spain

Photo courtesy of Dr. Michael H. Parkinson ([email protected]).

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Funding of the EFACTS registry by the European Commission will come to an end by April 2015. By

then, we will have a complete 2 year follow-up of all patients which were retained in the database

and a 3rd year investigation by more than 50% of the patients. We have just applied for new funding

through the European Commission’s framework program Horizon 2020. If successful, this funding

will financially secure the patient registry and yearly follow-up investigations for four years. We

consider this to be of importance for successfully planning, designing, and running future clinical

interventional trials, testing e.g. gene therapeutic approaches, HDAC inhibitors or other approaches

for their safety and effectiveness. A decision on our grant application will not be available before

summer or fall 2015. The registry will therefore need to be run without funding starting in May 2015.

Meanwhile, we would welcome short-term financial support from patient associations and the

industry and we would like to strongly encourage patients and investigators to continue yearly

follow-up assessments (without financial compensation until additional funding is secured), thereby

keeping the registry and its value alive.