Target Research 2014 (3 of 4)

Target Research Issue 3 of 4 2014

Working in partnership How we work with other charities and organisations

Diagnosis and genetic testing Our guide to the tests used to diagnose muscle-wasting conditions

Translarna recommended for conditional approval First drug treating the underlying cause of Duchenne muscular dystrophy Also inside‌ read about all the latest research and clinical trial news from the UK and around the world

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About us

Glossary This glossary is intended to help with some of the scientific and technical terms used in this magazine. Words that are in the glossary are highlighted in italics in the text.

Animal model – a laboratory animal such as a mouse or rat that is useful for medical research because it has specific characteristics that resemble a human disease or disorder.

Molecular patch – a short piece of genetic material (DNA or RNA) which can bind to a specific gene and change how the code is read. Also called an antisense oligonucleotide.

Biomarker – a biological substance found in blood, urine or other parts of the body that can be used as an indicator of health or disease.

A biomarker may be used to help clinicians diagnose a condition and monitor how it is progressing, but can also be used to see how well the body responds to a treatment.

Mouse model – see animal model.

DNA – (deoxyribonucleic acid) is the molecule that contains the genetic instructions for the functioning of all known living organisms.

DNA is divided into segments called genes.

Dystrophin – the protein missing in people with Duchenne muscular dystrophy and reduced in those with Becker muscular dystrophy. Dystrophin is important for maintaining the structure of muscle cells.

Exon – genes are divided into regions called exons and introns. Exons are the sections of DNA that code for the protein and they are interspersed with introns which are also sometimes called ‘junk DNA’.

Exon skipping – a potential therapy currently in clinical trial for Duchenne muscular dystrophy.

It involves ‘molecular patches’ or ‘antisense oligonucleotides’ which mask a portion (exon) of a gene and causes the body to ignore or skip-over that part of the gene. This restores production of the dystrophin protein, albeit with a piece missing in the middle.

Gene – genes are made of DNA and each carries instructions for the production of a specific protein. Genes usually come in pairs, one inherited from each parent. They are passed on from one generation to the next, and are the basic units of inheritance. Any alterations in genes (mutations) can cause inherited disorders.

Inflammation – the body’s reaction to injury or infection. It is a protective attempt by the body to remove whatever is causing the injury or infection (for example a splinter in your finger or a virus in your lungs) as well as initiate the healing process. mdx mouse – a mouse model of Duchenne muscular dystrophy. These mice have a mutation in the dystrophin gene – the gene that is mutated in boys with Duchenne. The muscles of these mice have many features in common with the muscles of boys with Duchenne muscular dystrophy.

Membrane – the barrier between the inside and outside of a cell or between two compartments of a cell. Membranes act like a skin to protect cells and control which substances leave or enter them.

www.muscular-dystrophy.org/research

Mutation – a permanent change in the DNA code that makes up a gene. Depending on where the mutation occurs, and the type of mutation, they can either have no effect or result in genetic diseases such as muscular dystrophy. Mutations can be passed on from generation to generation.

Next generation sequencing – a cutting edge technology that allows researchers to ‘read’ the whole of an individual’s genome. Researchers have recently started to use it for finding new genes and diagnosing genetic conditions more accurately.

Phase 1 clinical trial – a small study designed to assess the safety of a new treatment and how well it’s tolerated, often using healthy volunteers.

Phase 2 clinical trial – a study to test the effectiveness of a treatment on a larger number of patients. Participants are usually divided into groups to receive different doses or a placebo.

Phase 3 clinical trial – a multicentre trial involving a large number of patients aimed at being the definitive assessment of how effective a treatment is prior to applying to the regulatory authorities for approval to make the treatment widely available.

Placebo – an inactive substance designed to resemble the drug being tested. It is used to rule out any benefits a drug might exhibit because the recipients believe they are taking it.

Protein – molecules required for the structure, function, and regulation of the body’s cells, tissues, and organs. Our bodies contain millions of different proteins, each with unique functions.

The instructions for their construction are contained in our genes.

SMN protein (Survival Motor Neuron protein) – produced by the SMN genes and reduced in individuals with spinal muscular atrophy.

This protein is necessary for normal motor neuron function.

Translational research – the application of knowledge gained from scientific medical research in the laboratory to studies in humans.

Utrophin – a very similar protein to dystrophin.

Low levels of utrophin are present in everyone – including people with Duchenne muscular dystrophy – but in insufficient amounts to compensate for the loss of dystrophin.

The Muscular Dystrophy Campaign is the leading UK charity fighting muscle-wasting conditions.

We are dedicated to beating muscular dystrophy and related neuromuscular conditions by finding treatments and cures and to improving the lives of everyone affected by them.

The Muscular Dystrophy Campaign’s medical research programme has an international reputation for excellence, investing more than £1m each year, which includes more than 25 live projects taking place at any one time.

Our information, care and support services, support networks and advocacy programmes support more than 5,000 families across the UK each year. We have awarded more than 6,000 grants totalling more than £6m towards specialist equipment, such as powered wheelchairs.

References and further information Please contact us at research@muscular-dystrophy.org if you would like any further information or a link to the original research article. The articles are written in technical language with no summary in layman’s terms; and some may require a payment before they can be viewed.

Disclaimer While every effort has been made to ensure the information contained within Target Research is accurate, the Muscular Dystrophy Campaign accepts no responsibility or liability where errors or omissions are made. The views expressed in this magazine are not necessarily those of the charity. ISSN 1663-4538

Muscular Dystrophy Campaign, 61A Great Suffolk Street, London SE1 0BU t: 020 7803 2862 e: info@muscular-dystrophy.org w: www.muscular-dystrophy.org Registered Charity No. 205395 and Registered Scottish Charity No. SC039445 Printed on PEFC paper, produced at a mill that is certified with the ISO14001 environmental management standard Enclosed into a bio-degradeable polybag

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Welcome

In this edition we look into the techniques and tools used by clinicians to make a diagnosis – from muscle biopsies to genetic sequencing. A precise diagnosis can help individuals to understand their condition, to make family planning decisions and can help clinicians to provide information on disease progression.

We also have an article on ataluren (or Translarna as it is now known). In May, the European Medicines Agency announced that it would recommend that the drug should be given conditional approval for Duchenne muscular dystrophy. This decision could bring the first-ever treatment targeting an underlying genetic cause of Duchenne muscular dystrophy to the market as early as 2015.

Finally, we feature the work we are doing in partnership with other organisations and charities. From the Duchenne Forum, to SMA Reach, to the Chief Scientists Office in Scotland, we work with a number of groups from across Europe to support research into muscular dystrophies and related neuromuscular conditions. In this article we show off some of the exciting results of this work.

I do hope you enjoy this edition of Target Research.

Neil Bennett Editor, Target Research t: 020 7803 4813 e: research@muscular-dystrophy.org tw: @ResearchMDC

Contents 4

Reaching a diagnosis A guide to the tools and techniques used by clinicians to identify a condition

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Research news The latest news stories from around the world

10 Clinical trial round-up

Latest results from clinical trials 12 The importance of partnerships

We showcase the work we do with other organisations

Cover photo: AlexRaths/istock

14 Translarna (ataluren) recommended for conditional approval by EMA

Your questions answered 15 Research is needed as much as ever

Dr Marita Pohlschmidt, Director of Research Follow us on: www.facebook.com/musculardystrophycampaign Follow us on: www.twitter.com/TargetMD leading the way forward

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Diagnosis and genetic testing: a family guide A precise genetic diagnosis is vital for individuals and families affected by a muscular dystrophy or related neuromuscular condition. Identification of the condition allows clinicians to provide appropriate care and support and can help families to plan for the future and understand how the condition will progress. In this article we look at the tests clinicians do to reach a genetic diagnosis in people with a neuromuscular condition.

www.muscular-dystrophy.org/research

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F

or most people affected by a muscle-wasting condition, the pathway to diagnosis starts with a visit to their General Practitioner. Maybe somebody notices that their child falls over more than his or her friends, or an adult finds they can no longer walk very far without tiring. The GP may carry out some initial tests to explain the symptoms, but since these conditions are often difficult to diagnose, the individual will usually be referred to a specialist – typically a neurologist with a specialist interest in neuromuscular conditions – for further investigation and diagnosis. The specialist will use a range of tools and tests to reach a clinical diagnosis that best explains the symptoms and test results, and this will be used as the basis for genetic testing. This article investigates some of the more common diagnostic tests and looks in more detail at genetic testing.

Blood tests Individual or family notices symptoms

visit GP examination

People with a suspected neuromuscular condition are likely to be asked to provide blood for a creatine kinase test. Creatine kinase protein is normally found in muscle, but can leak into the blood following muscle damage. The test measures the level of creatine kinase in the blood and clinicians can use this as a measure of muscle damage.

Although elevated levels of creatine kinase in the blood point toward muscle damage, the test is not specific for damage caused by neuromuscular conditions.

A particularly hard session in the gym can also lead to increased levels, and so the test result cannot provide a diagnosis by itself.

Magnetic Resonance Imaging Magnetic Resonance Imaging (or MRI) is a non-invasive technique that can produce images of the inside of our bodies (see Target Research Issue 4 of 4, 2012 for a detailed explanation). Unlike an X-ray which only shows our bones, MRI images can show the structure of different types of tissue such as muscle, fat, and bone. An MRI scan can highlight which muscles are affected by a condition and can help a surgeon choose the most suitable muscle on which to perform a biopsy.

medical history blood tests

refer to specialist examination medical history blood tests MRI scan muscle biopsy muscle/nerve function tests genetic tests

precise diagnosis

Muscle biopsy A muscle biopsy is a small piece of muscle removed through a small cut or hollow needle, usually from the leg or arm. The tissue sample enables clinicians to examine the muscle structure in detail under a microscope (see the picture on page 4 for an example of a muscle biopsy viewed under the microscope). Using dyes to stain specific proteins (or types of cells in the muscles), a clinician can also identify proteins that are missing from the muscle. In some cases this may provide a diagnosis – for example, the lack of dystrophin in Duchenne muscular dystrophy – but in other conditions, where several genes may play a role in the biological pathway that produces the protein, genetic testing will be required to identify the precise cause of the condition.

Functional test of muscles and nerves Other tests like nerve conduction studies or electromyography (EMG) are also used by clinicians to examine electrical activity in nerves and muscles. By comparing the results at rest and when the muscles are contracting, clinicians can pinpoint the location of underlying problems – either in the muscles themselves, or in the nerves carrying signals to the muscles.

advice on family planning

best standards of care

advice on prognosis leading the way forward

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Types of mutations

Functional gene Deletion Mutated gene part of the gene (orange) has been deleted

Types of mutations Functional gene Insertion Mutated gene an additional piece of DNA (yellow) has been inserted into the gene

Functional gene Duplication Mutated gene a piece of the gene (orange) has replicated

Functional gene

Genetic testing In the past a diagnosis was often based just on clinical symptoms, but the availability of genetic testing means individuals with a muscular dystrophy or related neuromuscular condition can now be given a more precise diagnosis.

Genetic tests are usually performed on a blood sample. Clinicians use the clinical diagnosis to identify the gene most likely to cause the condition. Sometimes this is relatively straightforward – maybe the symptoms are very specific, or biochemical tests on a muscle biopsy identify a missing protein. With only one gene to test, finding the mutation is easier; testing will initially look for the most common mutations (for example, deletions for Duchenne muscular dystrophy) and gradually working towards rarer mutations (for example, duplications, insertions and point mutations). www.muscular-dystrophy.org/research

Sometimes, choosing which gene to test is more difficult. For example, the symptoms Pointbe mutation of limb girdle muscular dystrophy can hard to distinguish from other conditions like Becker muscular dystrophy. In other cases, a condition can be caused by mutations Mutated gene in any one of several, or even tens of genes. In these cases the clinician chooses the a single letter in the DNA code of the gene (yellow) is changed gene most likely to cause the condition observed and tests it first. If no mutation is found, the next likely gene will be checked, and so on. In this case a diagnosis can take months, depending on how many genes need to be tested. Occasionally, if a genetic test is not available through the diagnostic service, samples are sent to research laboratories, where the DNA is then analysed as part of ongoing research projects.

This information can help people to find out about possible clinical trials that may be of interest, and if treatments are licensed in the future, it is likely that knowledge about the mutation type will be needed to identify individuals who could be treated.

Researchers are also working to link the mutations that cause Duchenne muscular dystrophy with the symptoms seen in an individual.

For conditions where the diagnosis is not clear, clinicians will choose the gene that is most likely to cause the symptoms observed and test that gene for mutations.

If the test fails to find a mutation, the clinician chooses the next most likely gene and so on. In some individuals, clinicians will test all the likely genes and fail to identify the mutation causing the condition. Approximately 25 percent of people with congenital muscular dystrophy still do not receive a genetic diagnosis.

Once a mutation that causes a condition is identified, clinicians may offer genetic testing to other family members in case they carry the mutation or are affected themselves. It is important that family members who are offered this testing make an informed choice about whether to have the tests – often people prefer not to know.

However, all individuals should consult a genetic counsellor who will be able to give more information about the tests and what the results might mean.

Why is a gentic diagnosis important?

A precise genetic diagnosis allows clinicians to give their patients better information about how the condition will progress during their lifetime. This can help individuals and families to prepare in advance to manage the condition and to make informed family planning decisions.

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GRANT INFORMATION Project leader: Prof Francesco Muntoni University College, London

Types of mutations

Functional gene

Conditions: Congenital muscular dystrophy, congenital myopathy

Deletion Mutated gene

Duration:

part of the gene (orange) has been deleted

4 years, starting 2012

Total project cost: £118,500 Functional gene Insertion Mutated gene

Official title: Identifying new genes responsible for congenital muscular dystrophies and congenital myopathies.

an additional piece of DNA (yellow) has been inserted into the gene

Functional gene

When conditions with similar symptoms have different care requirements, a precise Many individuals with congenital diagnosis also helps clinicians to understand the healthcare needs of an individual muscular dystrophy and congenital Duplication and to the best possible standard of care. This provision of best standards of care myopathy do not have a genetic Mutated gene also extends to clinical trials and treatments for the underlying genetic cause of a diagnosis. Although numerous gene a piece of the gene (orange) has replicated condition. Trials testing potential drugs are now underway for several conditions and mutations have already been found to participation in these trials is often restricted to individuals with a certain type of cause these conditions, some cases are mutation. For example, exon skipping technology for Duchenne muscular dystrophy not caused by mutations in these genes. is being tested in boys with deletions that are amenable to exon skipping induced by In Professor Francesco Muntoni’s the trial molecular patch. laboratory, researchers are using next Functional gene If these treatments reach the market, then they will only be available to people with generation sequencing to search for Point mutation certain mutations – those who could potentially benefit. For example, ataluren, which new causative genes. Professor Muntoni and his student will examine DNA from has been recommended for conditonal approval, will only be available Mutated to boysgene with around 100 people who have a clinical Duchenne musculara single dystrophy a nonsense mutation (but not deletions, letter in thecaused DNA code ofby the gene (yellow) is changed diagnosis of either congenital myopathy insertions or duplications) since only this group could potentially benefit. or a congenital muscular dystrophy but do not have a mutation in one of the Carrier and predictive testing genes known to cause these conditions.

Because genetic conditions are inherited, the diagnosis of a genetic condition in an Once a gene is identified, the next step individual means their relatives may be at risk of developing the condition. These is to test, in cells grown in the laboratory relatives may want to find out whether they have the mutation that causes the and in animal models, whether the condition and can ask for genetic testing. Sometimes, however, individuals prefer mutations cause these conditions. not to find out in case the results affect their quality of life.

Working as part of an international In some conditions, relatives may also be at risk of being carriers. Following team, the researchers have identified diagnosis of a genetic condition, relatives may be offered genetic testing to confirm three genes that cause the conditions. whether or not they are carriers. While carriers do not usually experience symptoms of Interestingly, the genes all carry the the condition, there is a risk that they will pass the mutated gene on to their children genetic blueprint for proteins that who could either be affected by a condition or be carriers themselves. Although the play a role in the biological pathway level of this risk depends on how the mutated gene is inherited (see Target Research responsible for producing dystroglycan 2 of 4 2014), individuals who know they are carriers can use this information to make protein. The mutations stop the informed family planning decisions. proteins working properly which Importantly, before individuals are offered testing, they will be given counselling in turn stops dystroglycan being from a specially trained genetic counsellor who will describe the test, its possible assembled, which is believed to outcomes, and what impact a positive or negative result may have on somebody’s cause muscle-wasting conditions. life. It is only with this information and informed consent that people can be tested. leading the way forward

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News Research

The research team is always on the look-out for exciting developments in the field of muscular dystrophies and related neuromuscular conditions. Here we bring you the latest research and clinical trial news from around the world.

New mouse model of Ullrich congenital muscular dystrophy developed An international team of researchers has developed a mouse model for Ullrich congenital muscular dystrophy caused by dominant mutations. The mouse model showed signs of progressive muscle damage and muscle weakness and could be used to test future therapeutic approaches of the condition.

The researchers, from Germany and the USA, used genetic engineering techniques to delete part of one copy of a collagen VI gene. This prevented the cells constructing the scaffold of collagen VI that supports muscle cells. The mouse model showed signs of progressive muscle damage and compared to healthy mice demonstrated muscle weakness and tendon problems.

In the muscles, collagen VI functions as a scaffold that holds and supports the muscle cells. The scaffold is built from individual protein units. These first assemble into pairs (called a dimer), then pairs of pairs (called a tetramer), and finally longer chains that form the scaffold that supports the muscle cells. Some mutations in the genes that carry the blueprint for collagen VI mean that cells can produce normal amounts of a protein that is unable to form dimers, tetramers, or chains. These mutations can stop the construction of the scaffold and leave muscle cells lacking support.

Three genes are required to produce the collagen VI protein and each cell contains two copies of each gene. In this study, researchers targeted part of one gene that they knew was required to produce collagen VI protein that could successfully be built into a scaffold. The researchers used genetic engineering techniques to delete this part of the gene to prevent cells from building a scaffold of collagen VI. Mice lacking this part of the collagen VI gene had progressive muscle damage and some muscles were smaller in size than those in healthy mice. By eight months of age, the amount of force generated by muscles from the mouse model was reduced compared to muscles from healthy mice. The mouse model also demonstrated signs of damaged to the tendon tissue – also seen in people with collagen VI disorders. However, the differences seen between the mouse model and healthy mice were less severe than the symptoms experienced by people with Ullrich congenital muscular dystrophy.

Animal models can mirror the progression of a condition in people, and the development of animal models is key in the identificaton and testing of potential therapeutic approaches. Recent studies have suggested possible therapeutic approaches that could be developed for Ullrich congenital muscular dystrophy caused by dominant mutations. These studies are currently at a very early stage and having a mouse model will allow researchers to test the potential of these possible therapeutic approaches further. www.muscular-dystrophy.org/research

Researchers develop a new technique to detect microRNAs Researchers in Oxford and California, led by Professor Matthew Wood, have developed a new technique to detect and accurately measure levels of microRNAs in the blood of mdx mice (a mouse model of Duchenne muscular dystrophy). MicroRNAs are being investigated as possible biomarkers for Duchenne muscular dystrophy and finding ways to accurately measure their level is a key first step.

MicroRNAs are very small pieces of RNA (a molecular copy of a gene) used by cells to control which genes are turned on and off. Although techniques that can measure the levels of RNA molecules have been available for some time, measuring levels of the smaller microRNAs is more challenging.

MicroRNAs are often unstable and can be broken down into their component parts if care is not taken in their isolation.

The small size of the molecules means they are also difficult to detect. The newly-developed technique includes steps which increase the length of time a microRNA lasts and carefully optimised systems for detection to overcome some of these challenges.

This research is part of the drive towards identifying biomarkers for Duchenne muscular dystrophy. Although no biomarkers were identified in this study, the researchers have identified techniques that they can use to detect and accurately quantify the levels of microRNA in the blood. This is a key step in the investigation of these molecules as biomarkers.

Often, research papers contain only the information absolutely required for another scientist to repeat an experiment. This paper contains very detailed instructions as well as helpful tips for other scientists who want to carry out the procedure. Importantly, the study has been published in an open-access journal so scientists worldwide have the chance to use the method in their own studies, moving forward research into micro-RNAs more quickly.

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A plant extract – quercetin – has been tested in a mouse model of SMA A research team led by Professor Tom Gillingwater, based at the University of Edinburgh, have identified that a plant extract – quercetin – can reduce the severity of the muscle function defects observed in mouse models of spinal muscular atrophy (SMA). Although the research is at an early stage, this may highlight a biological process that could lead to potential therapies for people with SMA. An international team of researchers, funded in part by the Muscular Dystrophy Campaign and led by Professor Thomas Gillingwater at Edinburgh University, has found that a plant extract called quercetin might have the potential to slow the decline in muscle function in a mouse model of spinal muscular atrophy. While the extract did not affect the lifespan of the mouse model, there was evidence that it slowed decline in muscle function.

Spinal muscular atrophy is caused by mutations in a gene called Smn1, which carries the genetic blueprint for a protein (called survival motor neuron protein 1). This protein is essential for nerve cell survival and function.

The researchers believe that Smn1 protein may also play an important role in the production of other proteins, such as UBA1. UBA1 plays an important role in cells, where it marks out proteins that are no longer needed for disposal. This is a key way in which cells control the levels of many proteins.

When researchers treated a zebrafish model with chemicals that stop UBA1 working properly, or used a zebrafish model with artificially reduced levels of UBA1, they found that the nerve cells did not develop properly and the fish developed motor defects.

Without functional UBA1, a number of proteins could no longer be marked for destruction and the level of one of these proteins (B-catenin) increased significantly. Importantly, researchers found that tissue samples from SMA mouse models and people with SMA had increased levels of B-catenin.

The possible chain of events from lack of Smn1 protein to increased levels of B-catenin and a possible link with nerve cell development suggested to researchers that the levels of B-catenin may play a role in the muscle damage seen in SMA. Initially, zebrafish with reduced levels of UBA1 were treated with quercetin – a plant extract that can inhibit the actions of B-catenin – and the motor defects were reversed. When researchers gave quercetin to a mouse model of SMA the symptoms of the disease and the reduction in muscle function were reduced, but neither the body weight nor lifespan of the mice was increased – possibly because levels of B-catenin are only increased in the nerves and muscles.

The identification of a pathway that could lead to potential therapies in people with SMA is encouraging news. Because quercetin can affect a number of proteins and pathways inside cells, researchers may need to identify different molecules and compounds that specifically target the B-catenin protein. These may have the potential to be developed into a therapeutic approach that could slow the decline in muscle function in people with SMA. However, since this research is at an early stage in animal models, it will be some time before potential treatments based on these results could be tested in a clinical trial.

These findings will increase understanding of SMA and the molecular pathways affected in the condition, and will help researchers to develop therapeutic approaches in the future.

MRI study improves understanding of limb girdle muscular dystrophy type 2I An international study, led by Newcastle University and co-ordinated

by Muscular Dystrophy Campaignfunded researchers Professor Volker Straub and Dr Tracey Willis (now at Oswestry), demonstrated the potential of a specific MRI technique called the Dixon technique, to be more accurate than standard techniques. When tested in people affected by limb girdle muscular dystrophy type 2I, the Dixon imaging technique showed great potential to lead to a more accurate assessment of the progression of the condition and a better way of measuring the benefit of potential treatments in clinical trials.

MRI is a non-invasive technique that scans the body using strong magnetic

fields to produce an image of the anatomy. It can be used to see changes in muscle that are associated with inherited muscle disorders, such as limb girdle muscular dystrophy.

Infiltration of fat into muscle, a marker of muscle degeneration seen in muscle disorders, can be viewed by MRI. This is mostly done using a method called T1-weighting (T1w) to obtain images which are then assessed by a doctor and graded according to the level of fat infiltration seen. Another method is available for measuring fat infiltration that does not rely on human input; the Dixon MRI method.

In this study, various selected muscles from the legs of 38 people with limb girdle muscular dystrophy type 2I (19 men and 19 women) and eight

healthy individuals were scanned using MRI to obtain T1w and Dixon MRI measurements. The two methods were compared for their ability to measure fat infiltration into the muscle.

Both methods were able to measure fat infiltration into muscles, although the Dixon MRI method was more reliable, more objective and better able to measure small changes in an individual’s muscle structure than the grading method.

The findings from the Dixon MRI analyses showed some striking differences in the pattern of fat infiltration between men and women in several of the muscles examined. For example, in men the inside thigh muscle was affected more severely and earlier than the outside and this was not seen leading the way forward

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Continued from page 9

MRI study improves understanding of limb girdle muscular dystrophy type 2I in women. Differences such as these could mean that men experience slightly different symptoms from women, and interestingly this has been reported in another limb girdle muscular dystrophy, type 2L. Additionally, the Dixon MRI fat fraction measurements of many muscles were found to correlate with results of other tests, for example those measuring knee strength, the ability to climb stairs and distances walked in six minutes. The six-minute walk test is a widely accepted method for measuring improvements in function in clinical trials for people with muscular dystrophy.

This research shows that Dixon MRI can be used to measure fat infiltration in the leg muscles of people with limb girdle muscular dystrophy type 2I. The method is more accurate and objective than the currently used grading system, which is based on T1w MRI scans. There are many potential implications for this that could be of benefit for patients; Dixon MRI could be useful for diagnosis, for measuring the progression of the condition over time, and for monitoring outcomes in clinical trials. It offers the benefit over currently used outcome measures for trials (such as muscle biopsies and six-minute walk test) of being non-invasive and not requiring patient participation.

This research also increases our understanding of limb girdle muscular dystrophy type 2I, particularly how it presents itself in men and women.

This information could be useful in the clinic, for example in aiding diagnosis and understanding how the condition progresses over time (natural history).

Limb girdle muscular dystrophy type 2I varies greatly in severity, onset and other symptoms between individuals, so having a way of accurately monitoring the progression in an individual is extremely useful. www.muscular-dystrophy.org/research

Research news

in brief Prosensa give update on Duchenne clinical trials Prosensa, the Dutch biotech company which developed drisapersen, has released a press release giving an update about the current status of the programme.

Drisapersen is a molecular patch to skip exon 51 of the dystrophin gene which showed encouraging results in boys with Duchenne muscular dystrophy. However, last year a phase 3 trial organised by Prosensa and GSK failed to show that drisapersen was effective in boys with Duchenne muscular dystrophy and boys who were taking part in ongoing trials of the potential drug stopped receiving the drug while the results were analysed in detail.

We have been working closely with Prosensa to keep our families and supporters up-to-date with the latest news from the drisapersen programme. Recently, the company sent a letter to patient organisations which explains that after extensive data analysis and discussion with families they plan to restart dosing (giving the potential drug to participants) in the trials in North America and Europe.

The company has also announced that they are in discussions with the Food and Drug Administration (FDA, the drug regulator in the USA) and the European Medicines Agency (EMA, the drug regulator in Europe) about possible routes for drisapersen to reach the market. We will watch out for more news on this and will update you as soon as possible.

Testing viagra and cialis in boys with Duchenne muscular dystrophy Researchers in the USA have reported the results of a small-scale, early-stage clinical trial of tadalafil (cialis) and sildenafil (viagra) in boys with Duchenne muscular dystrophy. The two drugs are widely used to treat erectile dysfunction in men and one of their side effects is known to be an increased flow of blood to the muscles. Clinicians believe this may slow muscle wasting in Duchenne muscular dystrophy and this study tested whether the two drugs had the potential to improve blood flow in boys with the condition.

During the trial, 10 boys with Duchenne muscular dystrophy received a single dose of a drug and blood flow in the muscles of the arm was measured. The researchers found that the single dose was able to increase blood flow to the muscles but it is not yet known whether this has any effect on the progression of the condition.

The study therefore provides a proof of concept for using these drugs in boys with Duchenne muscular dystrophy. However, the boys received only a single dose of the drug and side-effects were observed in all the boys in the trial. It is therefore important to stress that the safety and effectiveness of long-term use of the drugs will not be known until further trials have been completed. Eli Lilly is currently recruiting boys with Duchenne muscular dystrophy to participate in a large phase 3 trial of tadalafil which aims to investigate the safety and effectiveness of tadalafil in detail.

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Santhera announces initial results of Catena/ Raxone for Duchenne Santhera, a Swiss pharmaceutical company, has released preliminary results of their phase 3 trial of a potential drug called catena/raxone (also known as idebenone) in boys with Duchenne muscular dystrophy.

The trial compared the effectiveness of the potential drug with a placebo – an inactive form of the drug – in boys and young men aged 10-18. Researchers used a test called “Peak Expiratory Flow” to measure the strength and function of the breathing muscles and found that catena/raxone could slow the decline in respiratory function (or breathing ability). Importantly, the drug was safe and well-tolerated.

The results are encouraging – suggesting that catena/raxone may be useful to prolong breathing boys with Duchenne muscular dystrophy. However, these results represent only part of the trial – where the participants were not taking steroids.

The phase 3 trial also includes participants who have also been taking steroids during the trial and we look forward to seeing the full results of the trial being published in a peer-reviewed journal where they can be properly assessed.

Hello from Target MD

Summit plc, an Oxford-based biotech company has announced preliminary results of their Phase 1b trial of SMT C1100. The potential drug was developed in Professor Kay Davies’ laboratory and can increase levels of utrophin in cells grown in the laboratory and in mdx mice (an animal model of Duchenne muscular dystrophy).

This is the first trial to test SMT C1100 in boys with Duchenne muscular dystrophy.

When I travelled to Northern Ireland to meet some of our supporters for this Northern Ireland-focused edition, the strong sense of community was so present among the families affected by musclewasting conditions. The Northern Ireland network was started by a family who knew the importance of peer support and shared experience. There are about 2,000 people in Northern Ireland who are affected by muscular dystrophy and related neuromuscular conditions.

The trial tested different doses of the potential drug in 12 boys (aged between five and eleven) with the condition. Four boys each received a lower dose twice each day, a higher dose twice each day, or a higher dose three times each day. Preliminary results show that all doses of the potential drug were safe and that it was well-tolerated in all individuals. However, the levels of SMT C1100 that reached the bloodstream (or plasma) varied between trial participants – with higher levels in two boys but lower levels in 10. Researchers believe this may be owing to difference in diets between boys, with a possibility that low-fat diets may reduce uptake of the potential drug.

Encouragingly, the researchers noted that levels of creatine kinase in the serum were reduced in boys during the trial. This might suggest that muscle damage was reduced in boys with Duchenne muscular dystrophy receiving SMT C1100, but further trials will be required to confirm this and to test the effectiveness of the potential drug.

Stories of young and older stalwart supporters of the charity fill the pages – you’ll meet the family-orientated Chair of the All Party Group on Muscular Dystrophy, as well as the Chair and Secretary of the Northern Ireland Council.

Gerry and Geraldine McCollum share their story of how they continue to campaign and fundraise for the charity, in honour and in memory of their beloved son, Christopher.

Summit announces encouraging trial results of SMT C1100

Duchenne trials pushing ahead – Sarepta plans marketing application for eteplirsen US-based Sarepta Therapeutics has announced the results of recent discussions with the Food and Drug Administration (FDA; the drug regulator in the USA). Last October the FDA said that it had concerns that the results of Sarepta’s phase 2b clinical trial of eteplirsen – a molecular patch for exon 51 of the dystrophin gene – may not be sufficient to support an application to licence the potential drug.

Although the FDA still has these concerns, the regulator has now informed the company what additional information and data would be required to make an application possible.

Sarepta now plans to submit a marketing application for eteplirsen by the end of the year and is hopeful it may be considered for the FDA’s accelerated approval scheme.

This scheme can be used by the FDA to bring potential drugs to the market faster – when the drug is designed to treat a serious condition with no treatment options and has shown evidence of safety and effectiveness in early clinical trials. Even if accelerated approval were granted, Sarepta Therapeutics would be required to conduct further clinical trials to confirm the results of the current trial. However, if accelerated approval were granted, the trial(s) could take place at the same time that eteplirsen was being made widely available.

As always, there is our regular news roundup with more evidence of our campaigning, advocacy and fundraising successes across the UK. The Wheelchair Football Association update this time comes from recent powerchair football convert, Niamh O’Reilly, and our #TeamOrange calendar of events offers you plenty of opportunities to get involved.

Ruth Martin Editor, Target MD t: 020 7803 4836 e: r.martin@muscular-dystrophy.org tw: @RuthWriter Target MD is also available to read online: www.bit.ly/wTnEsn leading the way forward

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All together now One of the eight strategic goals in our new research strategy is our commitment to building partnerships with other funding agencies and patient organisations to combine resources to fund vital research that falls within one or more of the priority areas set out in this research strategy. In this article we look at some of our most successful partnerships to date.

European Neuromuscular Centre The European Neuromuscular Centre (ENMC) is an international organisation that supports research for neuromuscular conditions and strives to facilitate communication among scientists and clinicians working in the field. The ENMC funds and organises workshops, and in the past these have included workshops on spinal muscular atrophy, Duchenne muscular dystrophy, congenital muscular dystrophy and many others.

The ENMC is funded by a group of patient and healthcare associations and pharmaceutical industries from around Europe, including the Muscular Dystrophy Campaign, and our Director of Research, Dr Marita Pohlschmidt, is the current chair of the ENMC oversight committee.

The ENMC arranges approximately eight workshops on neuromuscular conditions each year. The workshops aim to encourage and facilitate collaborative research. For example, diagnostic criteria for a number of muscular dystrophies and related neuromuscular conditions (based on the symptoms and laboratory test results) were established at the workshops.

Other workshops have focused on on locating, isolating, and characterising genes for specific disorders and on developing standards of care documents. Collaborative groups greatly welcome support, input and guidance in these areas.

The workshops are chosen on the basis of scientific merit.

Applicants base their requests on a set of grant criteria and each application is objectively assessed by the ENMC Research Committee. This ensures that applications are assessed objectively by internationally recognised experts in the field.

To date, approximately 200 workshops on a variety of neuromuscular disorders have taken place and over 125 publications directly related to these workshops have been published. The workshops have been attended by over www.muscular-dystrophy.org/research

1,600 participants from around the world and through their participation, their colleagues have directly benefited from the deliberations and results.

Treat-NMD TREAT-NMD is a network for researchers and cinicians in the neuromuscular field.

The network provides an infrastructure to ensure that promising potential treatments reach patients as quickly as possible. Treat-NMD was launched in 2007 and has been instrumental in the development of tools that the biotech and pharmaceutcal industries, clinicians and researchers need to bring novel therapeutic approaches from the laboratory, through pre-clinical development, into the clinic.

Recent years have seen great progress in the development of potential treatments for neuromuscular conditions and an increase in the number of trials taking place for people with muscular dystrophies or related neuromuscular conditions.

However, translational research has faced a number of challenges: n for people with a condition, the translational of promising laboratory results into clinical trials has seemed like a slow process, while the lack of standardised care guidelines has prevented some from receiving optimal care n for the biomedical industry, identifying clinicians and clinical trial centres that could set up and take part in clinical trials and also identifying participants for these clinical trials has been a significant challenge n for clinicians and researchers, lack of clinical outcome measures that could be used to monitor the progression of a condition and to measure the effectiveness of potential treatments.

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TREAT-NMD is working to address all these challenges.

The Muscular Dystrophy Campaign has worked closely with the organisation to develop registries for people with facioscapulohumeral muscular dystrophy and myotonic dystrophy. We have also worked together to establish best pratice guidelines for care for people with muscular dystrophies and related neuromuscular conditions. These standards of care have now been published for Duchenne muscular dystrophy and congenital muscular dystrophy, and documents for other conditions are being developed.

TREAT-NMD was initially established as an EU-funded ‘network of excellence’ with an aim of ‘reshaping the research environment’ in the neuromuscular field. The network has now developed to become a global organisation that brings together leading specialists, patient groups and industry representatives to ensure preparedness for the trials and therapies of the future while promoting best practice today.

Skip-NMD SKIP-NMD is a collaborative group involving 10 partners from the health sector, research, pharmaceutical and other industries. The collaboration was established in 2012 with EU funding of €5,512,424. Over three years, the group aims to develop a potential treatment for Duchenne muscular dystrophy, by designing and testing a novel drug to restore dystrophin production in boys who will benefit from skipping of exon 53 of the dystrophin gene.

SKIP-NMD aims to design and carry out initial tests of a potential drug which will be called SRP-4053. This will be a molecular patch to ‘skip’ exon 53 of the dystrophin gene to restore production of a partially-functional dystrophin protein.

SRP-4053 will only have the potential to treat some boys with Duchenne muscular dystrophy – specifically those whose condition is caused by deletions of exons 52, 45-52, 47-52, 48-52, 49-52 or 50-52.

SRP-4053 will first be tested in cells grown in the laboratory and in animal models of Duchenne muscular dystrophy. If these tests are successful, the potential drug will be tested in a small-scale clinical trial.

The project also aims to develop new outcome measures and biomarkers. Outcome measures are tests (for example how far somebody can walk in six minutes), which help researchers and clinicians to monitor disease progression. Biomarkers are molecules in the body whose level is affected by a condition and which can be easily measured (for example by a blood test). Together, these can be used to measure a potential drug’s effectiveness in clinical trials.

The Muscular Dystrophy Campaign is one of the patient organisations working with the collaborators to ensure that the patients’ voice is represented during the organisation of the trial. We will also be communicating progress of the project to our supporters, so do watch our website for the latest updates.

The Skip-NMD project follows on from Professor Muntoni’s previous work in the MDEX consortium with Sarepta Therapeutics involving another molecular patch designed to skip exon 51 of the dystrophin gene. The potential drug has shown encouraging results in clinical trials where it safely

restored production of a smaller dystrophin protein. However, different antisense oligonucleotides are required to skip different exons and so ultimately a panel of these drugs would be required to ensure as many children as possible can be treated.

Duchenne Forum Last year the Muscular Dystrophy Campaign established the Duchenne Forum, a funding partnership between six UK charities dedicated to beating Duchenne muscular dystrophy.

The collaboration between the Muscular Dystrophy Campaign and Alex’s Wish, the Duchenne Children’s Trust, Duchenne Research Fund, Joining Jack and Harrison’s Fund will accelerate progress in the search for effective treatments and eventually cures. Since 2013 the partnership has been supporting seven pioneering research projects into Duchenne muscular dystrophy, to which it will commit £840,000 over the next four years.

The Duchenne Forum is a great example of effective charity collaboration. By funding together we have been able to make a larger investment to move promising therapies forward with greater speed, avoid duplication and keep costs to a minimum.

The Duchenne Forum is a really positive step forward in charitable funding for Duchenne muscular dystrophy research, and should be encouraging news for the thousands of families who loyally support our six charities in the hope of beating this devastating condition.

SMA-REACH UK Working with the Jennifer Trust (now called SMA Support UK) and the SMA Trust, we established SMA-REACH UK, a new information hub designed to improve healthcare for hundreds of people living with this rare neuromuscular condition and to pave the way for clinical trials into potential treatments The hub will combine and build on information held in Newcastle University’s SMA Patient Registry, (which was funded by the Jennifer Trust and Treat-NMD), and the SMArtNet database (backed by the Jennifer Trust and the Muscular Dystrophy Campaign). It will allow scientists and health professionals to share the results of scientific research, knowledge of clinical practice, symptoms and disease progression and details of patients wishing to take part in clinical trials.

The hub is said to offer an “unprecedented opportunity” to improve and ensure consistency of healthcare for patients with SMA and to simplify the co-ordination of research into potential treatments.

SMA REACH UK will be led by Professor Francesco Muntoni, Director of The Dubowitz Neuromuscular Centre at the UCL Institute of Child Health, in partnership with Great Ormond Street Hospital for Children NHS Foundation Trust and other UK SMA centres. leading the way forward

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EMA recommends conditional approval of ataluren In May, the European Medicines Agency announced that it would recommend that ataluren receive conditional approval to treat Duchenne muscular dystrophy. The next step will be for the European Commission to review this decision. Ataluren has been developed by PTC Therapeutics to overcome a specific change in the DNA called a nonsense mutation which causes 10-15 percent of cases of Duchenne muscular dystrophy. Translarna, as the drug will now be known, will be the first-ever drug to treat an underlying genetic cause of Duchenne muscular dystrophy in children and young people affected, outside of a clinical trial.

In January, the European Medicines Agency (EMA) announced that ataluren (or Translarna as it will now be known) had not been recommended for conditional approval. PTC Therapeutics, the company that developed the drug asked the EMA to re-assess the evidence for Translarna and in May, the EMA announced that it would recommend that the drug should receive conditional approval. This recommendation will now be reviewed by the European Commission which will make the final decision on whether or not to grant a conditional licence.

Being granted conditional approval in the EU would mean that Translarna is placed on the market for one year, with provision for yearly renewal. You can read more about conditional approval in Target Research (Issue 4 of 4, 2013).

PTC will monitor the safety and effectiveness of the treatment while undertaking further trials to provide additional data – for example the phase 3 trial PTC has already started – to confirm the results of the previous trials.

Translarna will be the first-ever drug to treat an underlying genetic cause of Duchenne muscular dystrophy outside of a clinical trial and it has the potential to treat 10 – 15 percent of cases of Duchenne muscular dystrophy. Translarna will only be able to be used in boys over five years of age and who can still walk and only in cases caused by nonsense mutations – when a single letter of the DNA is changed to place a ‘stop signal’ in the middle of the gene. The drug can encourage cells to ignore this stop signal and read all the genetic information.

In boys with Duchenne muscular dystrophy this could restore dystrophin protein production in the muscles.

PTC Therapeutics said: The European Commission will review this positive decision from the CHMP and generally delivers its decision within three months.

We are grateful to the patients, families, advocacy groups and physicians who have supported PTC Therapeutics through many years of research and development of Translarna. It is www.muscular-dystrophy.org/research

important to note that this journey continues through the completion of our Phase 3 Translarna confirmatory trial in nmDMD (ACT DMD), which is a high priority for PTC and the DMD community.

In response to the news, Chief Executive of the Muscular Dystrophy Campaign, Robert Meadowcroft, said: This decision by the EMA is fantastic news. There are more than 200 children and young people in the UK who live with Duchenne muscular dystrophy caused by a ‘nonsense mutation’, for whom Translarna has been designed – 10-15 percent of the total number affected by the condition. Each of them could now have independent access to the drug without needing to be part of a clinical trial.

Encouragingly, extending the numbers of those taking Translarna beyond those on PTC’s final planned clinical trial will also help to further accelerate development of the drug.

We now call for urgent meetings with the National Institute of Health and Clinical Excellence (NICE) and NHS England, to discuss next steps to clear the path for their approval of Translarna and to make sure the drug reaches those for whom it could be effective, without delay.

Professor Volker Stroub at Newcastle University said: This is obviously very encouraging news for all the families and patients that could potentially benefit from treatment with ataluren. So far there is no licenced drug for Duchenne muscular dystrophy and today’s decision is an important milestone for drug development programmes in Duchenne muscular dystrophy.

Dave Anderson MP, Chair of the All Party Parliamentary Group (APPG) for Muscular Dystrophy, commented: The APPG for Muscular Dystrophy conducted a thorough inquiry into access to rare disease drugs last year, with a number of recommendations made to ensure new treatments reach patients without delays.

We called on the government to introduce swiftly an early access to medicines scheme, and today’s decision by the EMA underlines the importance of such an approach.

The APPG for Muscular Dystrophy will do all it can to make sure families with a nonsense mutation of Duchenne muscular dystrophy can access ataluren as soon as possible. We call on NICE and NHS England to work with the Muscular Dystrophy Campaign, together with PTC Therapeutics, to drive the process forward as a matter of urgency.

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Who could Translarna treat?

Translarna (previously known as ataluren) will only be able to treat boys whose Duchenne muscular dystrophy is caused by a nonsense mutation (see below). The drug was specifically developed for this group and will not be of benefit in cases caused by other types of mutation (for example a deletion, insertion, or duplication). The recommended approval for using the drug is based on boys over five years old who can still walk – since this is the group that the drug was tested in and where it showed some benefit.

However, the drug may one day be used to treat boys outside this age range or who can no longer walk. However, it is possible that further trials would be required to show whether the drug is safe and effective in these individuals.

We don’t have any news on this at the moment, but we will keep you updated as we find out more.

mutations are different from deletions, insertions and duplications.

What is a nonsense mutation?

Translarna may have the potential to treat around 200 individuals with Duchenne muscular dystrophy in the UK (of a total of around 2,400). The next step for the drug will be for the European Commission to decide whether or not to grant a conditional licence (which normally takes approximately three months). If this is granted the drug will then need to be assessed by NICE – the organisation responsible for choosing which treatments are offered by the NHS. This is likely to take a further six months.

The Muscular Dystrophy Campaign has already asked for urgent meetings with NICE to find out more about this process.

If you, or your child have Duchenne muscular dystrophy caused by a deletion or duplication in the dystrophin gene, then Translarna will not be beneficial as it was developed only to target nonsense mutations. However, trials of other therapeutic approaches including exon skipping, increasing the levels of utrophin, and testing other drugs to manage and reduce the severity of the symptoms are proceeding and have shown encouraging results.

The DNA of a gene is a series of letters which carry the information required to produce a protein. Mutations can be thought of as spelling mistakes that change the DNA and alter the information it carries.

Different types of mutation can cause a lack of dystrophin in the muscles leading to Duchenne muscular dystrophy. The most common types of mutation are deletions (where part of the gene is deleted), insertions (where an additional piece of DNA is inserted into the gene), duplications (when part of the gene is repeated) and point mutations.

Point mutations occur when a single letter in the DNA code is changed and alters the information needed to produce a protein. The mutation can occur anywhere in a gene and can sometimes lead to a ‘stop signal’ being inserted into the middle of a gene. This stops protein being produced. This type of point mutation is called a nonsense mutation. Nonsense mutations cause 10-15 percent of cases of Duchenne muscular dystrophy. Nonsense

How do I know if my son has a nonsense mutation?

The only way to know for sure is as the result of genetic testing (see page 6).

Genetic testing is usually performed on a small sample of blood. The tests aim to identify the mutation causing the condition in an individual. Different tests are used to identify deletions, insertions and point mutations (when a single letter in the DNA is changed), including DNA sequencing which can read all the information carried in a gene.

If you do not know what type of mutation you or your child has, we recommend you speak to your specialist, your GP, or a genetic counsellor who will be able to advise you further.

What does this mean for me?

Research is needed as much as ever By the time you read this column, I am sure you will have heard about – and maybe even read – the article on these pages about the recommendation of the EMA to grant conditional approval for the first-ever drug that addresses the underlying genetic defect of Duchenne muscular dystrophy.

This was a breakthrough much needed by families affected by this devastating condition that causes muscles to increasingly weaken and waste. Recent setbacks involving other potential treatments have been disappointing for everyone racing against the clock to develop treatments that could protect muscles from further damage. This step forward for Translarna offers much needed hope.

Although this is a significant milestone in the search for treatments for Duchenne muscular dystrophy we must remember that Translarna only has the potential to treat 10-15 percent of those affected; and the search for treatments that will help the other 85-90 percent has to continue.

Therefore, investing into research into Duchenne muscular dystrophy remains a priority of the charity.

And for the time being we still do not know how effective Translarna will be. The view of clinicians and researchers is that a combination of different drugs and treatments might be necessary to stop the progression or even improve the symptoms.

So we should take a deep breath and continue with our fight.

Dr Marita Pohlschmidt Director of Research, Muscular Dystrophy Campaign. leading the way forward

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