EA045263B1 - WAYS TO STRENGTHEN AND/OR STABILIZE CARDIAC FUNCTION IN PATIENTS WITH FABRY DISEASE - Google Patents

Description

Cross reference to related applications

This application claims priority to US Provisional Application No. 62/550984, filed August 28, 2017, which is incorporated herein by reference in its entirety.

Field of technology

The principles and embodiments of the present invention generally relate to the use of pharmacological chaperones for the treatment of lysosomal storage diseases, in particular the use of migalastat for the treatment of Fabry disease.

State of the art

Fabry disease is a progressive X-linked inborn error of glycosphingolipid metabolism caused by deficiency of the lysosomal enzyme α-galactosidase A (α-Gal A) resulting from mutations in the α-Gal A (GLA) gene. Although it is an X-linked disorder, women may exhibit varying degrees of clinical manifestations. Fabry disease is a rare disorder with an estimated incidence of 1 in 40,000 men to 1 in 117,000 in the general population. In addition, there are later-onset variants of the Fabry disease phenotype that may be underdiagnosed because they do not have the classic signs and symptoms. This finding and newborn screening for Fabry disease suggest that the actual incidence of Fabry disease may be higher than currently estimated.

If left untreated, life expectancy in patients with Fabry disease is reduced, and death usually occurs in the fourth or fifth decade due to vascular disease affecting the kidneys, heart, and/or central nervous system. Enzyme deficiency results in intracellular accumulation of the substrate globotriaosylceramide (GL-3) in the vascular endothelium and visceral tissues throughout the body. The gradual deterioration of renal function and the development of azotemia, caused by the deposition of glycosphingolipids, usually occur during the third to fifth decade of life, but can occur as early as the second decade. Renal lesions are found in both hemizygous (male) and heterozygous (female) patients.

Heart disease due to Fabry disease occurs in most men and many women. Early cardiac signs include left ventricular dilatation, valvular disease, and conduction abnormalities. Mitral regurgitation is the most common valvular disorder, usually present in childhood or adolescence. Cerebrovascular manifestations arise primarily from multifocal small vessel disease and may include thrombosis, transient ischemic attacks, basilar artery ischemia and aneurysm, seizures, hemiplegia, hemianesthesia, aphasia, labyrinthine dysfunction, or cerebral hemorrhage. The average age of onset of cerebrovascular manifestations is 33.8 years. Personality changes and psychotic behavior may occur with age.

One approved therapy for treating Fabry disease is enzyme replacement therapy (ERT), which usually involves intravenous infusion of a purified form of the corresponding wild-type protein. Two α-Gal A products are currently available for the treatment of Fabry disease: agalsidase alfa (Replagal®, Shire Human Genetic Therapies) and agalsidase beta (Fabrazyme®; Sanofi Genzyme Corporation). Although ERT is effective in a wide range of conditions, the treatment also has limitations. ERT has not been shown to reduce the risk of stroke, the heart muscle responds slowly, and the clearance of GL-3 from some types of kidney cells is limited. Some patients also develop immune reactions to ERT.

Accordingly, there remains a need for therapies to treat Fabry disease, especially to enhance cardiac function.

Summary of the invention

Various aspects of the present invention relate to the treatment of Fabry disease in ERT-naive and ERT-treated patients using migalatat. Such treatment may include enhancing and/or stabilizing cardiac function, such as increasing and/or stabilizing midwall fractional shortening (MWFS).

One aspect of the present invention relates to a method of improving cardiac function in a patient suffering from Fabry disease, the method comprising administering to the patient a preparation containing an effective amount of migalatat or a salt thereof once every two days to improve the patient's cardiac function, wherein said effective amount is from about 100 to about 150 mg free base equivalent (FBE - free base equivalent).

In one or more embodiments, enhancing cardiac function includes enhancing left ventricular systolic function.

In one or more embodiments, the patient has an impairment of the FFS before initiation of administration of migalastat or a salt thereof.

In one or more embodiments, the patient has left ventricular hypertrophy (LVH) before administration of migalastat or a salt thereof is initiated.

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In one or more embodiments, migalastat or a salt thereof enhances the activity of α-Gal A.

In one or more embodiments, the patient is administered about 123 mg of migalastat ESO or a salt thereof every two days.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every two days.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every two days.

In one or more embodiments, said drug comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

In one or more embodiments, migalastat or a salt thereof is administered for at least 12 months.

In one or more embodiments, migalastat or a salt thereof is administered for at least 24 months.

In one or more embodiments, the patient is an ERT-naive patient.

In one or more embodiments, administration of migalastat or a salt thereof provides an average increase in FSFS in a group of ERT-naive patients with impaired FSFS of at least about 1% after 24 months of administration of migalastat or a salt thereof.

In one or more embodiments, the patient is an ERT-treated patient.

Another aspect of the present invention relates to a method of increasing the FWB in a patient suffering from Fabry disease, the method comprising administering to the patient a formulation containing an effective amount of migalatat or a salt thereof, once every two days to increase the FWB of the patient, wherein the effective amount is from about 100 to about 150 mg ESO.

In one or more embodiments, the patient had an impairment of the FFS before initiation of administration of migalastat or a salt thereof.

In one or more embodiments, the patient has LVH before starting administration of migalastat or a salt thereof.

In one or more embodiments, migalastat or a salt thereof enhances the activity of α-Gal A.

In one or more embodiments, the patient is administered about 123 mg of migalastat ESO or a salt thereof every two days.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every two days.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every two days.

In one or more embodiments, said preparation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

In one or more embodiments, migalastat or a salt thereof is administered for at least 12 months.

In one or more embodiments, migalastat or a salt thereof is administered for at least 24 months.

In one or more embodiments, the patient is an ERT-naive patient.

In one or more embodiments, administration of migalastat or a salt thereof provides an average increase in FSFS in a group of ERT-naive patients with impaired FSFS of at least about 1% after 24 months of administration of migalastat or a salt thereof.

In one or more embodiments, the patient is an ERT-treated patient.

Another aspect of the present invention relates to a method of normalizing the FSFS in a patient with Fabry disease and impaired FSFS, the method comprising administering to the patient a preparation containing an effective amount of migalatat or a salt thereof once every two days to normalize the patient's FSFS, wherein the effective amount is from about 100 to about 150 mg ESO.

In one or more embodiments, migalastat or a salt thereof enhances the activity of α-Gal A.

In one or more embodiments, the patient is administered about 123 mg of migalastat ESO or a salt thereof every two days.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every two days.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every two days.

In one or more embodiments, said preparation comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

In one or more embodiments, migalastat or a salt thereof is administered for at least 12 months.

In one or more embodiments, migalastat or a salt thereof is administered for at least 24 months.

In one or more embodiments, the patient is an ERT-naive patient.

In one or more embodiments, administration of migalastat or a salt thereof provides an average increase in FSFS in a group of ERT-naive patients with impaired FSFS of at least about 1% after 24 months of administration of migalastat or a salt thereof.

Another aspect of the present invention relates to a method of stabilizing the HFRS in a patient suffering from Fabry disease, the method comprising administering to the patient a formulation containing an effective amount of migalatat or a salt thereof, once every two days to stabilize the patient's SFRS, wherein the effective amount is from about 100 to about 150 mg ESO.

In one or more embodiments, the patient had an impairment of the FFS before initiation of administration of migalastat or a salt thereof.

In one or more embodiments, the patient has LVH before starting administration of migalastat or a salt thereof.

In one or more embodiments, migalastat or a salt thereof enhances the activity of α-Gal A.

In one or more embodiments, the patient is administered about 123 mg of migalastat ESO or a salt thereof every other day.

In one or more embodiments, the patient is administered about 123 mg of migalastat free base every two days.

In one or more embodiments, the patient is administered about 150 mg of migalastat hydrochloride every two days.

In one or more embodiments, said drug comprises an oral dosage form. In one or more embodiments, the oral dosage form comprises a tablet, capsule, or solution.

In one or more embodiments, migalastat or a salt thereof is administered for at least 12 months.

In one or more embodiments, migalastat or a salt thereof is administered for at least 30 months.

In one or more embodiments, the patient is an ERT-treated patient.

In one or more embodiments, administration of migalastat or a salt thereof provides a mean change in FWB in a group of ERT-treated patients with impaired FWB of greater than about -0.5% after 30 months of administration of migalastat or a salt thereof.

Brief description of drawings

Additional features of the present invention will become apparent from the following written description and the accompanying drawings, in which:

in fig. 1A-E show the complete DNA sequence of the wild-type human GLA gene (SEQ ID NO: 1);

fig. 2 shows wild-type α-Gal A protein (SEQ ID NO: 2) and FIG. 3 shows the nucleic acid sequence encoding the wild type α-Gal A protein (SEQ ID NO: 3).

Detailed description of the invention

Before describing several illustrative embodiments of the invention, it should be understood that the invention is not limited to the design details or process steps set forth in the following description. The present invention is capable of other embodiments and may be practiced or carried out in various ways.

Various aspects of the present invention relate to dosage regimens for the administration of pharmacological chaperones, such as migalatat, for the treatment of Fabry disease. In one or more embodiments, migalastat dosing regimens improve one or more parameters of a patient's heart.

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Definitions

The terms used in this description generally have their ordinary meanings in the art, in the context of this invention and in the particular context in which each term is used. Certain terms are discussed below or elsewhere in the specification in order to provide practitioners with additional guidance in describing the preparations and methods of this invention, as well as their manufacture and use.

The term Fabry disease refers to an X-linked inborn error of glycosphingolipid catabolism due to a deficiency of lysosomal α-Gal A activity. This defect causes accumulation of the substrate globotriaosylceramide (GL-3, also known as Gb3 or ceramide trihexoside) and associated glycosphingolipids in endothelial lysosomes vessels of the heart, kidneys, skin and other tissues. Another enzyme substrate is plasma globotriaosylsphingosine (plasma lyso-Gb ³ ).

The term atypical Fabry disease refers to patients with predominantly cardiac manifestations of α-Gal A deficiency, namely the progressive accumulation of GL-3 in myocardial cells, resulting in significant enlargement of the heart, especially the left ventricle.

A carrier is a woman who has one X chromosome with a defective α-Gal A gene and one X chromosome with a normal gene, and in whom X chromosome inactivation of the normal allele is present in one or more cell types. The carrier is often diagnosed with Fabry disease.

Patient refers to a subject who has been diagnosed or suspected of having a specific disease. The patient may be human or animal.

A Fabry patient refers to an individual who is diagnosed or suspected of having Fabry disease and who has mutant α-Gal A, as defined below. The characteristic markers of Fabry disease can occur in hemizygous males and female carriers with equal prevalence, although females tend to be less affected.

Human α-galactosidase A (α-Gal A) is an enzyme encoded by the human GLA gene. The complete DNA sequence of α-Gal A, including introns and exons, is available in GenBank under accession number X14448.1 and is shown in FIG. 1A-E (SEQ ID NO: 1). The human α-Gal A enzyme consists of 429 amino acids and is available under GenBank accession numbers X14448.1 and U78027.1 and is demonstrated in FIG. 2 (SEQ ID NO: 2). The nucleic acid sequence, which includes only the coding regions (ie, exons) of SEQ ID NO: 1, is shown in FIG. 3 (SEQ ID NO: 3).

The term mutant protein includes a protein that has a mutation in the gene encoding the protein, resulting in the inability of the protein to achieve a stable conformation under conditions normally found in the endoplasmic reticulum (ER). Failure to achieve a stable conformation results in a significant amount of the enzyme being degraded rather than being transported to the lysosome. This mutation is sometimes called a conformational mutant. Such mutations include, but are not limited to, missense mutations and small in-frame deletions and insertions.

As used herein, in one embodiment, the term α-Gal A mutant includes an α-Gal A that has a mutation in the gene encoding α-Gal A, resulting in the inability of the enzyme to achieve a stable conformation under conditions normally present in the ER. Failure to achieve a stable conformation results in a significant amount of the enzyme being degraded rather than being transported to the lysosome.

As used herein, the term pharmacological chaperone (PC) refers to any molecule, including a small molecule, protein, peptide, nucleic acid, carbohydrate, etc., that specifically binds to a protein and has one or more of the following effects: (i) enhances the formation of a stable molecular conformation of the protein; (ii) induces delivery of protein from the ER to another cellular location, preferably to the native cellular location, i.e., prevents ER-associated protein degradation; (iii) prevents aggregation of misfolded proteins; and/or (iv) restores or enhances at least partial function and/or activity of the wild-type protein. A compound that specifically binds to, for example, α-Gal A means that it binds and has a chaperone effect on an enzyme and not on a general group of related or unrelated enzymes. More specifically, the term does not refer to endogenous chaperones such as BiP, or to nonspecific agents that have demonstrated nonspecific chaperone activity against various proteins, such as glycerol, DMSO or deuterated water, i.e., chemical chaperones. In one or more embodiments of the present invention, PS may be a reversible competitive inhibitor. In one embodiment, PS is migalastat or a salt thereof. In another embodiment, the PS is migalastat free base (eg, 123 mg migalastat free base). In yet another embodiment, the PS is a migalastat salt (eg, 150 mg migalastat HCl).

A competitive enzyme inhibitor can refer to a compound that structurally resembles the chemical structure and molecular geometry of an enzyme substrate to bind the enzyme at approximately the same location as the substrate. Thus, the inhibitor competes for the same active site,

- 4 045263 as the substrate molecule, thereby increasing Km. Competitive inhibition is usually reversible if there are sufficient substrate molecules to displace the inhibitor, i.e., competitive inhibitors can bind reversibly. Therefore, the degree of enzyme inhibition depends on the concentration of the inhibitor, the concentration of the substrate, and the relative affinity of the inhibitor and substrate for the active site.

As used herein, the term specifically binds refers to the interaction of a pharmacological chaperone with a protein, such as α-Gal A, in particular the interaction with amino acid residues of the protein that are directly involved in contact with the pharmacological chaperone. A pharmacological chaperone specifically binds a target protein, such as α-Gal A, to exert its chaperone effect on the protein rather than on a general group of related or unrelated proteins. The amino acid residues of a protein that interact with any pharmacological chaperone may or may not be located in the active site of the protein. Specific binding can be assessed using routine binding assays or structural studies, for example, co-crystallization, NMR and the like. The active site for α-Gal A is the substrate binding site.

α-Gal A deficiency refers to α-Gal A activity in a patient's cells that is below the normal range compared (using the same methods) with activity in normal individuals without or suspected of having Fabry disease or any other disease diseases (especially blood diseases).

As used herein, the terms enhance the activity of α-Gal A or increase the activity of α-Gal A refer to increasing the amount of α-Gal A that assumes a stable conformation in a cell brought into contact with a pharmacological chaperone specific for α-Gal A, relative to amount in a cell (preferably the same cell type or the same cell, for example, at an earlier time) not brought into contact with a pharmacological chaperone specific for α-Gal A. This term also refers to an increase in the transfer of α-Gal A to the lysosome in a cell brought into contact with a pharmacological chaperone specific for α-Gal A, relative to the transfer of α-Gal A not brought into contact with a pharmacological chaperone specific for the specified protein. These terms refer to both the wild type and the α-Gal A mutant. In one embodiment, the increase in the amount of α-Gal A in the cell is measured by measuring the hydrolysis of the artificial substrate in lysates from cells that have been treated with PS. An increase in hydrolysis indicates an increase in α-Gal A activity.

The term α-Gal A activity refers to the normal to physiological function of wild-type α-Gal A in the cell. For example, α-Gal A activity involves hydrolysis of GL-3.

A responder is a person who is diagnosed or suspected of having a lysosomal storage disease (LSD), such as Fabry disease, whose cells exhibit sufficiently increased α-Gal A activity, respectively, and/or a decrease in symptoms or improvement surrogate markers in response to contact with FS.

Non-limiting examples of improvements to surrogate markers for Fabry disease include lyso-GB3 and those disclosed in US Patent Application Publication No. 2010/0113517, which is hereby incorporated by reference in its entirety.

Non-limiting examples of improvements in surrogate markers for Fabry disease disclosed in US Pat. No. 2010/0113517 include increasing α-Gal A levels or activity in cells (eg, fibroblasts) and tissue; decreased accumulation of GL-3; decreased plasma concentrations of homocysteine and vascular cell adhesion molecule-1 (VCAM-1); decreased accumulation of GL-3 in myocardial cells and valve fibrocytes; decrease in plasma lyso-GB ³ ; reduction of cardiac hypertrophy (especially the left ventricle), improvement of valvular insufficiency and arrhythmia; improvement of proteinuria; decreased urinary concentrations of lipids such as STN, lactosylceramide, ceramide, and increased urinary concentrations of glucosylceramide and sphingomyelin; absence of layered inclusion bodies (Zebra bodies) in glomerular epithelial cells; improved renal function; mitigation of hypohidrosis; absence of angiokeratoma; and improvement of hearing disorders such as high-frequency sensorineural hearing loss, progressive hearing loss, sudden deafness or tinnitus. Improvements in neurological symptoms include prevention of transient ischemic attack (TIA) or stroke; and reduction of neuropathic pain manifested as acroparasthesia (burning or tingling in the extremities). Another type of clinical marker that can be assessed for Fabry disease is the prevalence of harmful cardiovascular manifestations.

Midwall fractional shortening (MWFS) is a measure of systolic function that identifies patients with hypertension who have evidence of end organ damage, impaired contractile reserve, and increased mortality.

The term cardiac function refers to the performance of a patient's heart.

For example, one assessment of cardiac function is left ventricular systolic function,

- 5 045263 which relates to the characteristics of the emptying of the left ventricle of the heart. Left ventricular systolic function can be assessed by several methods, including, but not limited to, left ventricular ejection fraction (LVEF), endocardial fractional shortening (EFS), and endocardial fractional shortening (EFS).

As used herein, the phrase, stabilization of cardiac function and similar terms refer to the reduction or reversal of decline in cardiac function and/or restoration of cardiac function. Because significant declines in cardiac function are expected to occur over time in untreated patients with Fabry disease, an increase in the rate of decline in cardiac function and/or an improvement in cardiac function demonstrates the benefit of migalatat therapy as described herein. In various embodiments, stabilizing cardiac function includes stabilizing HFCS. Stabilizing FASB also refers to reducing or stopping the decline of FASB.

The term enhancement of cardiac function refers to a beneficial change in at least one parameter used to assess cardiac function. If a patient's parameter is at the lower end of the normal range or below the normal range for that parameter, then a beneficial change in that parameter is to increase that parameter. For example, an increase in SSFU for a patient with low SSFS is an improvement in this parameter. Likewise, if a patient's parameter is at the upper limit of the normal range or above the normal range for that parameter, then a beneficial change in that parameter is to decrease that parameter. In one aspect, improving cardiac function includes one or more of (i) improving left ventricular function, (ii) improving fractional shortening, (iii) improving ejection fraction, (iv) reducing end-diastolic volume, and (v) normalizing cardiac geometry.

As used herein, the term impaired FSFS refers to a patient with FSFS below the normal range. The normal range for a woman is at least 15%, and the normal range for a man is at least 14%. Thus, the impaired SFFS for a female patient is <15%, and the impaired SFFS for a male patient is <14%.

As used herein, the term normalization of HFRS refers to the increase of a patient's HFRS from impaired SFRS to the normal range. Thus, normalizing the SFRS for a female patient increases the SFRS from <15% to at least 15%, and normalizing the SFRS for a male patient increases the SFRS from <14% to at least 14%.

As used herein, the term left ventricular hypertrophy or LVH refers to a patient with a left ventricular mass index (LVMi) above the normal range of 43-95 g/m ² for women and 49-115 g/m ² for men. Thus, LVH refers to LVMi >95 g/ ^m2 for women or >115 g/ ^m2 for men.

A dose that achieves one or more of the above responses is a therapeutically effective dose.

The phrase pharmaceutically acceptable refers to molecular substances and drugs that are physiologically tolerable and do not typically cause adverse reactions when administered to humans. In some embodiments, the term pharmaceutically acceptable as used herein means approved by a regulatory agency of the federal or state government or listed in the United States Pharmacopoeia or other generally accepted pharmacopoeia for use in animals and, in particular, in humans. The term carrier, in relation to a pharmaceutical carrier, refers to the diluent, adjuvant, excipient or vehicle with which the compound is administered. Such pharmaceutical carriers may be sterile liquids such as water and oils. Water or aqueous saline solutions and aqueous solutions of dextrose and glycerol are preferably used as carriers, especially for injection solutions. Suitable pharmaceutical carriers are described in Remington's Pharmaceutical Sciences E.W. Martin, 18th Edition or other publications.

As used herein, the term isolated/isolated means that the specified material is removed from the environment in which it is normally found. Thus, isolated biological material may not contain cellular components, i.e., components of the cells in which the material is found or produced. In the case of nucleic acid molecules, the isolated nucleic acid includes a PCR product, an mRNA band on a gel, a cDNA, or a restriction fragment. In another embodiment, the isolated nucleic acid is preferably excised from the chromosome in which it may be found, and more preferably is no longer attached to non-regulatory, non-coding regions or other genes located upstream or downstream of the gene that is contained in the isolated nucleic acid molecule when detected in the chromosome. In yet another embodiment, the isolated nucleic acid lacks one or more introns. Isolated nucleic acids include sequences inserted into plasmids, cosmids, artificial

- 6 045263 chromosomes and the like. Thus, in a particular embodiment, the recombinant nucleic acid is an isolated nucleic acid. An isolated protein may be associated with other proteins or nucleic acids or both with which it is associated in the cell, or with cell membranes if it is a membrane-bound protein. An isolated organelle, cell, or tissue is removed from the anatomical site in which it is found in the body. The insulated material can be cleaned, but does not have to be.

The term enzyme replacement therapy or ERT refers to the administration of a non-native, purified enzyme to an individual who is deficient in such an enzyme. The protein input can be obtained from natural sources or by recombinant expression (as described in more detail below). The term also refers to the administration of a purified enzyme to an individual who requires or benefits from administration of the purified enzyme, for example, an individual suffering from enzyme deficiency. The introduced enzyme may be a purified recombinant enzyme produced in vitro, or a protein purified from isolated tissue or fluid, such as placenta or animal milk, or from plants.

The term ERT-naive patient refers to a Fabry patient who has never received ERT or has not received ERT for at least 6 months before starting migalatat therapy.

The term ERT-treated patient refers to a Fabry patient who received ERT immediately before starting migalatat therapy. In some embodiments, the ERT patient received at least 12 months of ERT immediately prior to initiation of migalatat therapy.

As used herein, the term free base equivalent or FBE refers to the amount of migalastat present in migalastat or a salt thereof. In other words, the term ESO means either the amount of migalastat free base or the equivalent amount of migalastat free base that is provided by the migalastat salt. For example, due to the weight of the hydrochloride salt, 150 mg of migalastat hydrochloride provides the same amount of migalastat as 123 mg of the free base form of migalastat. Other salts are expected to have different conversion factors depending on the molecular weight of the salt.

The term migalastat encompasses migalastat free base or a pharmaceutically acceptable salt thereof (eg, migalastat HCl) unless otherwise specified.

The terms mutation and variant (eg, as in mutable or variant) refer to a change in the nucleotide sequence of a gene or chromosome. The two terms mentioned herein are generally used together - for example, as in the case of mutation or variant - to refer to a change in the nucleotide sequence specified in the previous sentence. If for any reason only one of the two terms is given, the omitted term should have been included and should be understood as such. In addition, the terms susceptible mutation and susceptible variant refer to a mutation or variant that is treatable with PS therapy, for example, a mutation that is treatable with migalatat. The specific type of susceptible mutation or variant is a HEK assay-sensitive mutation or variant that is a HEK assay-sensitive mutation that is determined to be suitable for migalatat therapy according to the criteria in the in vitro HEK assay described herein and in US Pat. No. 8,592,362, which is incorporated herein by reference in its entirety.

The terms about and approximately usually mean an acceptable degree of error for the quantity being measured, taking into account the nature or accuracy of the measurements. Typical exemplary degrees of error are within 20 percent (%), preferably within 10%, and more preferably within 5% of a target value or range of values. Alternatively, and especially in biological systems, the terms about and approximately can mean values that are within an order of magnitude, preferably 10 or 5 times and more preferably 2 times the target value. Numerical values given herein are approximate unless otherwise stated, which means that the term about or roughly may be inferred unless otherwise indicated.

Fabry disease

Fabry disease is a rare, progressive and devastating X-linked LND. Mutations in the GLA gene lead to deficiency of the lysosomal enzyme α-Gal A, which is necessary for the metabolism of glycosphingolipids. Early in life, decreased α-Gal A activity leads to the accumulation of glycosphingolipids, including GL-3 and lyso-Gb3 in the plasma, and leads to the symptoms and life-limiting consequences of Fabry disease, including pain, gastrointestinal symptoms, renal failure, cardiomyopathy, cerebrovascular phenomena and early mortality. Early initiation of therapy and lifelong treatment make it possible to slow the progression of the disease and increase life expectancy.

Fabry disease includes a spectrum of disease severity and age of onset, although it is traditionally divided into 2 main phenotypes: classic and late onset. The classic phenotype was

- 7 045263 is attributed primarily to men with undetectable low α-Gal A activity and earlier onset of renal, cardiac and/or cerebrovascular manifestations. The late-onset phenotype has been attributed primarily to males with higher residual α-Gal A activity and later onset of these disease features. Heterozygous female carriers usually express a late-onset phenotype, but depending on the pattern of X chromosome inactivation, the classic phenotype may also be expressed.

More than 1000 GLA mutations have been identified to cause Fabry disease. Approximately 60% are missense mutations, resulting in single amino acid substitutions in the α-Gal A enzyme. GLA missense mutations often result in abnormally folded and unstable forms of αGal A, and most are associated with the classical phenotype.

Normal cell quality control mechanisms in the ER block the transit of these abnormal proteins into lysosomes and direct them to premature degradation and elimination. Many missense mutant forms are targets of migalastat, an α-Gal A-specific pharmacological chaperone.

The clinical manifestations of Fabry disease span a wide spectrum of severity and roughly correlate with the patient's residual α-Gal A levels. The majority of patients currently treated are called classic Fabry patients, most of whom are male. These patients experience disease in multiple organs, including the kidneys, heart, and brain, with symptoms first appearing in adolescence and typically progressing in severity until death in the fourth or fifth decade of life. A number of recent studies show that there are a large number of undiagnosed men and women who have a range of symptoms of Fabry disease, such as heart or kidney dysfunction and strokes, which usually first appear in adulthood. People with this type of Fabry disease, called later-onset Fabry disease, tend to have higher residual α-Gal A levels than classic Fabry patients. People with late-onset Fabry disease usually first experience symptoms of the disease in adulthood and often have symptoms of the disease that are concentrated in one organ, such as an enlarged left ventricle or progressive kidney failure. Additionally, later-onset Fabry disease may also present as strokes of unknown cause.

Patients with Fabry disease have progressive renal failure, and untreated patients experience end-stage renal failure by the fifth decade of life. Deficiency of α-Gal A activity results in the accumulation of GL-3 and related glycosphingolipids in many cell types, including kidney cells. GL-3 accumulates in podocytes, epithelial cells and tubular cells of the distal tubule and loop of Henle. Impaired renal function may manifest as proteinuria and decreased glomerular filtration rate.

Because Fabry disease is rare, affects multiple organs, has a wide age range, and is heterogeneous, proper diagnosis is a challenge. Awareness among health professionals is low and misdiagnosis is common. The diagnosis of Fabry disease is most often confirmed by a decrease in α-Gal A activity in plasma or peripheral white blood cells (WBCs) when the patient is symptomatic in combination with mutation analysis. In women, diagnosis is even more difficult because enzymatic identification of female carriers is less reliable due to random inactivation of the X chromosome in some carrier cells. For example, some obligate carriers (daughters of classically affected men) have α-Gal A enzyme activity ranging from normal to very low activity. Because carriers may have normal α-Gal A enzyme activity in their leukocytes, only identification of the α-Gal A mutation by genetic testing provides accurate identification and/or diagnosis of the carrier.

In one or more embodiments, mutant forms of α-Gal A considered amenable to treatment with migalastat are defined as exhibiting a relative increase (+10 μM migalastat) of >1.2-fold and an absolute increase (+10 μM migalastat) of >3.0% wild type (WT) when the mutant form of α-Gal A is expressed in HEK-293 cells (called the HEK assay) in accordance with a GLP-validated in vitro assay (GLP HEK assay or sensitivity to migalastat). Such mutations are also referred to herein as HEK sensitive mutations.

Previous screening methods have been provided to evaluate enzyme enhancement prior to treatment. For example, an assay using HEK-293 cells has been used in clinical trials to predict whether a given mutation will respond to a pharmacological chaperone (eg, migalatat). In this assay, cDNA constructs are generated. The corresponding mutant forms of α-Gal A are transiently expressed in HEK-293 cells. The cells are then incubated ± migalastat (17 nM to 1 mM) for 4-5 days. α-Gal A levels are then measured in cell lysates using

- 8 045263 synthetic fluorogenic substrate (4-MU-a-Gal) or Western blotting. This was done for known disease-causing missense mutations or small in-frame insertions/deletions. Mutations that have previously been identified as sensitive to PS (eg, migalastat) using these methods are listed in US Pat. No. 8,592,362.

Pharmacological chaperones

Binding of small molecule inhibitors of enzymes associated with LBN can increase the stability of both the mutant enzyme and the corresponding wild-type enzyme (see US Pat. No. 6274597; 6583158; 6589964; 6599919; 6916829 and 7141582, all of which are incorporated herein by reference). In particular, the administration of low molecular weight derivatives of glucose and galactose, which are specific selective competitive inhibitors for several target lysosomal enzymes, effectively increased the stability of enzymes in cells in vitro and thus increased the delivery of enzymes to lysosomes. Thus, it is expected that as the amount of enzyme in the lysosome increases, the hydrolysis of enzyme substrates will increase. The original theory behind this strategy was that because the mutant enzyme protein is unstable in the ER (Ishii et al., Biochem. Biophys. Res. Comm. 1996;220:812-815), the enzyme protein is retained in the normal transport pathway (ER ^ Golgi apparatus ^ endosomes ^ lysosome) and degrades prematurely. Therefore, a compound that binds to and increases the stability of the mutant enzyme can serve as a chaperone for the enzyme and increase the amount that can exit the ER and translocate to lysosomes. Additionally, since the folding and trafficking of some wild-type proteins is incomplete, with up to 70% of some wild-type proteins being degraded in some cases before reaching their final cellular location, chaperones can be used to stabilize wild-type enzymes and increase the amount of enzyme that can leave ER and enter lysosomes.

In one or more embodiments, the pharmacological chaperone includes migalastat or a salt thereof. The compound migalastat, also known as 1-deoxygalactonojirimycin (1-DGJ) or (2R,3S,4R,5S)-2-(hydroxymethyl)piperdine-3,4,5-triol, is a compound having the following chemical formula:

Migalastat free base

As discussed herein, pharmaceutically acceptable salts of migalastat can also be used in this invention. When migalastat salt is used, the dosage of the salt will be adjusted so that the dose of migalastat received by the patient is equivalent to the amount that would have been received if migalastat free base had been used. One example of a pharmaceutically acceptable salt of migalastat is migalastat HCl:

Migalastat is a low molecular weight iminosugar and is a terminal galactose GL-3 analogue. In vitro and in vivo pharmacological studies have demonstrated that migalatat acts as a pharmacological chaperone, selectively and reversibly binding, with high affinity, to the active site of wild-type α-Gal A and specific mutant forms of α-Gal A, genotypes termed sensitive by the HEK assay. mutations. Binding of migalastat stabilizes these mutant forms of α-Gal A in the endoplasmic reticulum, facilitating their proper transport into lysosomes, while dissociation of migalastat allows α-Gal A to reduce the levels of GL-3 and other substrates. Approximately 30-50% of patients with Fabry disease have HEK-sensitive mutations; most of which are associated with the classic disease phenotype.

Suitable mutations for HEK analysis include at least those mutations that are listed in the Pharmacological Reference Table (eg, those listed on the US or international product labels for a migalastat product such as GALAFOLD®). As used herein, a pharmacological reference table refers to any publicly available written or electronic record included either on the product label in the product packaging

- 9 045263 migalastat (eg, GALAFOLD®), or on a website accessible to healthcare providers, it demonstrates whether a particular mutation or variant responds to FS therapy with migalastat (eg, GALAFOLD®), and is not necessarily limited to written records, presented in tabular form. Thus, in one embodiment of the present invention, a pharmacological reference Table refers to any repository of information that includes one or more sensitive mutations or variants. An illustrative pharmacological reference table for HEK-sensitive mutations can be found in the summary of product characteristics and/or prescribing information for GALAFOLD® in the various countries in which GALAFOLD® is approved for use or on a website such as www.galafoldamenabilitytable.com or www.fabrygenevariantsearch.com, each of which is hereby incorporated by reference in its entirety.

An illustrative pharmacological reference table for assayable HEK mutations is presented in Table. 1 below. In one or more embodiments, if a double mutation is present on the same chromosome (male and female), that patient is considered eligible for HEK analysis if the double mutation is present in one entry in the table. 1 (eg D55V/Q57L). In some embodiments, if the double mutation is present on different chromosomes (females only), the patient is considered eligible for HEK analysis if Table 1 one of the individual mutations is present.

Table 1

Nucleotide substitution Nucleotide substitution Sequence and protein changes C.7OG c.C7G L3V p.8T>S c.T8C L3P c.[HG>T; 620A>C] C.G11T/A620C R4M/Y207S c.37G>A C.G37A A13T c.37G>C C.G37C A13P c.43G>A C.G43A A15T C.44OG C.C44G A15G c.53T>G C.T53G F18C c.58G>C C.G58C A20P C.59OA C.C59A A20D c.70T>C or c.70T>A C.T70C or C.T70A W24R c.70T>G C.T70G W24G c.72G>C or c.72G>T C.G72C or C.G72T W24C c.95T>C S.T95S L32P c.97G>C C.G97C D33H c.97G>T C.G97T D33Y c.98A>G C.A98G D33G c,100A>G c.AlOOG N34D c.101A>C c.AIOIC N34T c,101A>G c.AlOIG N34S c,102T>G or c,102T>A C.T102G or C.T102A N34K c. 103G>C or c. 103G>A C.G103C or C.G103A G35R c,104G>A C.G104A G35E c,104G>C C.G104C G35A c,104G>T C.G104T G35V c,107T>C S.T107S L36S c,107T>G C.T107G L36W c. 108G>C or c. 108G>T C.G108C or C.G108T L36F c,109G>A C.G109A A37T c.HOOT s.SPOT A37V C.122OT S.S122T T41I With. 124A>C or c. 124A>T S.A124S or S.A124T M42L c,124A>G C.A124G M42V c,125T>A S.T125A M42K c,125T>C S.T125S M42T c,125T>G C.T125G M42R c. 126G>A or c. 126G>C or c. 126G>T C.G126A or C.G126C or C.G126T M42I c,137A>C S.A137S N46R c,142G>C C.G142C E48Q c,152T>A S.T152A M51K c. 153G>A or c. 153G>T or 153О>С C.G153A or C.G153T or C.G153C M51I c,157A>G C.A157G N53D c.[157A>C; 158A>T] S.A157S/A158T N53L C.160OT S.S160T L54F p.161T>S S.T161S L54P c,164A>G C.A164G D55G c,164A>T S.A164T D55V c.[164A>T; 17OA>T1 S.A164T/A170T D55V/Q57L

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c,167G>T C.G167T C56F c,167G>A C.G167A C56Y p.170A>T C.A170T Q57L c,175G>A C.G175A E59K c.178C>A C.C178A Р60Т c.178C>T C.C178T P60S C.179OT C.C179T P60L c,196G>A C.G196A E66K c,197A>G C.A197G E66G c.207C>A or C.207OG C.C207A or C.C207G F69L c.214A>G C.A214G M72V c.216G>A or c.216G>T or c.216G>C C.G216A or C.G216T or C.G216C M72I c.218C>T C.C218T A73V c.227T>C C.T227C M76T c.239G>A C.G239A G80D c.247G>A C.G247A D83N c.253G>A C.G253A G85S c.254G>A C.G254A G85D c.[253G>A; 254G>A] C.G253A/G254A G85N c.[253G>A; 254G>T; 255T>G] C.G253A/G254T/T255G G85M c.261G>C or is.26Yu>T C.G261C or C.G261T E87D c.263A>C S.A263S Y88S C.265OT S.S265T L89F c.272T>C S.T272S I91T c.288G>A or c.288G>T or c.288G>C C.G288A or C.G288T or C.G288C M96I c.289G>C C.G289C A97R C.290OT S.S290T A97V C.305OT S.S305T S102L c.311G>T C.G311T G104V C.316OT S.S316T L106F c.322G>A C.G322A A108T c.326A>G C.A326G D109G C.334OG C.C334G R112G c.335G>A C.G335A R112H c.337T>A S.T337A F113I c.337T>C or c.339T>A or c.339T>G S.T337S or S.T339A or C.T339G F113L C.352OT c.361G>A c.368A>G C.373OT c.374A>T c.376A>G c.383G>A c.399T>G C.404OT c.408T>A or c.408T>G c.416A>G c.419A>C c.427G>A c.431G>A c.431G>T c.434T>C C.436OT C.437OG c.454T>C c.455A>G c.466G>A C.467OT c.471G>C oris.47Yu>T c.484T>G c.493G>C c.494A>G c.[496OG; 497T>G1 C.496OG c.496 497delinsTC C.499OG c.506T>C c.511G>A c.520T>C S.S352T C.G361A C.A368G C.C373T C.A374T C.A376G C.G383A C.T399G C.C404T C.T408A or C.T408G C.A416G C.A419C C.G427A C.G431A C.G431T C.T434S C.C436T C.C437G S.T454S C.A455G C.G466A S.S467T C.G471C or C.G471T C.T484G C.G493C C.A494G C.C496G/T497G C.C496G p.496 497delinsTC C.C499G S.T506S C.G511A S.T520S R118C А121Т Y123C H125Y H125L S126G G128E PZZM A135V D136E N139S K140T A143T G144D G144V F145S P146S P146R Y152H Y152C A156T A156V Q157H W162G D165H D165G L166G L166V L166S L167V F169S G171S C174R c.520T>G C.T520G C174G C.525OG or C.525OA C.C525G or C.C525A D175E c.539T>G C.T539G L180W c.540G>C C.G540C L180F c.548G>C C.G548C G183A c.548G>A C.G548A G183D c.550T>A S.T550A Y184N

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c.551A>G C.A551G Y184C c.553A>G C.A553G K185E c.559A>G C.A559G M187 V c.559 564dup c.559 564dup ρ.Μ187 S188dup c.560T>C C.T560C M187T c.561G>T or is.56Yu>A or c.561G>C C.G561T or C.G561A or C.G561C Μ1871 c.572T>A C.T572A L191Q c.580A>G C.A580G ΤΙ 94 A C.581OT C.C581T ΤΙ 941 c.584G>T C.G584T G195V c.586A>G C.A586G R196G c.593T>C C.T593C Ι198Τ c.595G>A C.G595A V199M c.596T>C C.T596C VI99 A c.596T>G C.T596G V199G c.599A>G C.A599G Y200C C.602OT C.C602T S201F C.602OA C.C602A S201Y c.608A>T C.A608T E203V c.609G>C or c.609G>T C.G609C or C.G609T E203D c.610T>G C.T610G W204G C.613OA C.C613A Ρ205Τ C.613OT C.C613T P205S C.614OT C.C614T P205L c.619T>C C.T619C Υ207Η c.620A>C C.A620C Y207S c.623T>G C.T623G M208R C.628OT C.C628T P210S C.629OT C.C629T P210L c.638A>G C.A638G K213R c.638A>T C.A638T Κ213Μ C.640OT C.C640T P214S C.641OT C.C641T P214L c.643A>G C.A643G N215D c.644A>G C.A644G N215S c.644A>T C.A644T Ν215Ι c.[644A>G; 937G>T] C.A644G/G937T N215S/D313Y c.646T>G C.T646G Y216D c.647A>C C.A647C Y216S

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c.647A>G C.A647G Y216C c.655A>C C.A655C I219L c.656T>A C.T656A I219N c.656T>C C.T656C I219T c.659G>A C.G659A R220Q c.659G>C C.G659C R220P c.662A>C C.A662C Q221P c.671A>C C.A671C N224T c.671A>G C.A671G N224S C.673OG C.C673G H225D c.683A>G C.A683G N228S c.687T>A or c.687T>G C.T687A or C.T687G F229L c.695T>C C.T695C I232T c.713G>A C.G713A S238N c.716T>C C.T716C I239T c.720G>C or c.720G>T C.G720C or C.G720T K240N c.724A>G C.A724G I242V c.724A>T C.A724T I242F c.725T>A C.T725A I242N c.725T>C C.T725C I242T c.728T>G C.T728G L243W c.729G>C or c.729G>T C.G729C or C.G729T L243F c.730G>A C.G730A D244N c.730G>C C.G730C D244H c.733T>G C.T733G W245G C.740OG C.C740G S247C C.747OG or C.747OA C.C747G or C.C747A N249K C.748OA S.S748A Q250K c.749A>C S.A749S Q250P c.749A>G C.A749G Q250R c.750G>C C.G750C Q250H c.758T>C S.T758S I253T c.758T>G C.T758G I253S c.760-762delGTT p.760 762delGTT p.V254del c.769G>C C.G769C A257R C.770OG C.C770G A257G c.772G>C or c.772G>A C.G772C or C.G772A G258R c.773G>T C.G773T G258V C.776OG C.C776G P259R C.776OT S.S776T P259L

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c.779G>A C.G779A G260E c.779G>C C.G779C G260A c.781G>A C.G781A G261S c.781G>C C.G781C G261R c.781G>T C.G781T G261C c.788A>G C.A788G N263S c.790G>T C.G790T D264Y C.794OT C.C794T P265L c.800T>C C.T800C M267T c.805G>A C.G805A V269M c.806T>C C.T806C V269A c.809T>C C.T809C I270T c.810T>G C.T810G I270M c.811G>A C.G811A G271S c.[811G>A; 937G>T] C.G811A/G937T G271S/D313Y c.812G>A C.G812A G271D C.823OG C.C823G L275V c.827G>A C.G827A S276N c.829T>G C.T829G W277G c.831G>T or c.831G>C C.G831T or C.G831C W277C c.832A>T C.A832T N278Y C.835OG C.C835G Q279E C.838OA C.C838A Q280K c.840A>T or c.840A>C C.A840T or C.A840C Q280H c.844A>G C.A844G T282A C.845OT C.C845T T282I c.850A>G C.A850G M284V c.851T>C C.T851C M284T c.860G>T C.G860T W287L c.862G>C C.G862C A288R c.866T>G C.T866G I289S c.868A>C or c.868A>T C.A868C or C.A868T M290L c.869T>C C.T869C M290T c.870G>A or c.870G>C or c.870G>T C.G870A or C.G870C or C.G870T M290I c.871G>A C.G871A A291T C.877OA S.S877A R293T c.881T>C S.T881S L294S c.884T>G C.T884G F295C c.886A>G C.A886G M296V

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p.886A>T or p.886A>S C.A886T or C.A886C M296L p.887T>S C.T887C M296T c.888G>A or c.888G>T or c.888G>C C.G888A or C.G888T or C.G888C M296I c.893A>G C.A893G N298S C.897OG or C.897OA C.C897G or C.C897A D299E S.898OT S.S898T L300F p.899T>S S.T899S L300P C.901OG C.C901G R301G c.902G>C C.G902C R301P c.902G>A C.G902A R301Q c.902G>T C.G902T R301L p.907A>T S.A907T I303F p.908T>A S.T908A I303N c.911G>A C.G911A S304N c.911G>C C.G911C S304T c.919G>A C.G919A A307T c.922A>G C.A922G K308E c.924A>T or c.924A>C S.A924T or S.A924S K308N c.925G>C C.G925C А309Р C.926OT S.S926T A309V C.928OT S.S928T L310F C.931OG C.C931G L311V c.935A>G C.A935G Q312R c.936G>T or c.936G>C C.G936T or C.G936C Q312H c.937G>T C.G937T D313Y c.[937G>T; 1232G>A] C.G937T/G1232A D313Y/G411D c.938A>G C.A938G D313G c.946G>A C.G946A V316I c.947T>G C.T947G V316G c.950T>C S.T950S I317T c.955A>T S.A955T I319F c.956T>C S.T956S I319T c.959A>T S.A959T N320I c.962A>G C.A962G Q321R c.962A>T S.A962T Q321L c.963G>C or c.963G>T C.G963C or C.G963T Q321H c.964G>A C.G964A D322N c.964G>C C.G964C D322H C.966OA or c.966C>G C.C966A or C.C966G D322E

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C.968OG C.C968G P323R c.973G>A C.G973A G325S c.973G>C C.G973C G325R c.978G>C or c.978G>T C.G978C or C.G978T K326N C.979OG C.C979G Q327E p.980A>T C.A980T Q327L c.983G>C C.G983C G328A c.989A>G C.A989G Q330R c,1001G>A C.G1001A G334E p.1010T>S C.T1010C F337S c,1012G>A C.G1012A E338K c,1016T>A C.T1016A V339E C.1027OA C.C1027A P343T C.1028OT C.C1028T P343L c,1033T>C village TYUZZS S345P c,1046G>C C.G1046C W349S C.1055OG C.C1055G A352G C.1055OT C.C1055T A352V c,1061T>A C.T1061A I354K C.1066OG C.C1066G R356G C.1066OT C.C1066T R356W c,1067G>A C.G1067A R356Q c,1067G>C C.G1067C R356P c,1072G>C C.G1072C E358Q c,1073A>C C.A1073C E358A c,1073A>G C.A1073G E358G c,1074G>T or c,1074G>C C.G1074T or C.G1074C E358D c,1076T>C C.T1076C I359T c,1078G>A C.G1078A G360S c,1078G>T C.G1078T G360C c,1079G>A C.G1079A G360D c,1082G>A C.G1082A G361E c,1082G>C C.G1082C G361A C.1084OA C.C1084A P362T C.1085OT C.C1085T P362L C.1087OT C.C1087T R363C c,1088G>A C.G1088A R363H c.H02G>A C.G1102A A368T c.H17G>A C.G1117A G373S c.H24G>A C.G1124A G375E c.H53A>G C.A1153G T385A c.H68G>A C.G1168A V390M c.H72A>C C.A1172C K391T c.H75G>C C.G1175C R392T c.H84G>A C.G1184A G395E c,1184G>C C.G1184C G395A c.H92G>A C.G1192A E398K c.1202 1203insGACTTC c.1202 1203insGACTTC p.T400 S401dup c,1208T>C C.T1208C L403S C.1225OG C.C1225G P409A C.1225OT C.C1225T P409S C.1225OA C.C1225A P409T c,1228A>G C.A1228G T410A C.1229OT C.C1229T T410I c,1232G>A C.G1232A G411D C.1235OA C.C1235A T412N c,1253A>G C.A1253G E418G c,1261A>G C.A1261G M421V

Dosage, drug and administration

In one or more embodiments, migalastat or a salt thereof is administered to a Fabry patient at a once-daily (also referred to as QOD) frequency. In various embodiments, the dosages described herein refer to migalastat hydrochloride or an equivalent dose of migalastat or a salt thereof other than the hydrochloride salt. In some embodiments, these doses are based on migalastat free base. In alternative embodiments, these doses refer to the migalastat salt. In other embodiments, the migalastat salt is migalastat hydrochloride. Administration of migalastat or migalastat salt is referred to herein as migalastat therapy.

An effective amount of migalastat or a salt thereof may range from about 100 mg ESO to about 150 mg ESO.

Exemplary doses include about 100 mg ESO, about 105 mg ESO, about 110 mg ESO, about 115 mg ESO, about 120 mg ESO, about 123 mg ESO, about 125 mg ESO, about 130 mg ESO, about 135 mg ESO, about 140 mg ESO, about 145 mg ESO or about 150 mg ESO.

Again, it is noted that 150 mg of migalastat hydrochloride is equivalent to 123 mg of the free base form of migalastat. Thus, in one or more embodiments, the dose is 150 mg of migalastat hydrochloride or an equivalent dose of migalastat, or

- 16 045263 its salt, other than the hydrochloride salt, administered with a frequency of once a day. As stated above, this dose is referred to as 123 mg ESO migalastat. In other embodiments, the dose is 150 mg of migalastat hydrochloride administered at a frequency of once daily. In other embodiments, the dose is 123 mg of migalastat free base administered at a frequency of once daily.

In various embodiments, the effective amount is about 122 mg, about 128 mg, about 134 mg, about 140 mg, about 146 mg, about 150 mg, about 152 mg, about 159 mg, about 165 mg, about 171 mg, about 177 mg or about 183 mg of migalastat hydrochloride.

Accordingly, in various embodiments, migalastat therapy comprises administering 123 mg of ESO at a frequency of once daily, for example, 150 mg of migalastat hydrochloride every other day.

Administration of migalastat or its salt may occur over a period of time. In one or more embodiments, migalatat or a salt thereof is administered for at least 28 days, such as at least 30, 60 or 90 days, or at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30 or 36 months or at least 1, 2, 3, 4 or 5 years. In various embodiments, migalatat therapy is long-term migalatat therapy of at least 6 months, such as at least 6, 7, 8, 9, 10, 11, 12, 16, 20, 24, 30, or 36 months, or at least 1, 2, 3, 4 or 5 years.

Administration of migalastat or a salt thereof in accordance with the present invention may be in a formulation suitable for any route of administration, but is preferably administered in an oral dosage form such as a tablet, capsule or solution. As one example, capsules each containing 150 mg of migalastat hydrochloride or an equivalent dose of migalastat or a non-hydrochloride salt thereof are administered orally to a patient.

In some embodiments, PS (eg, migalastat or a salt thereof) is administered orally. In one or more embodiments, the PS (eg, migalastat or a salt thereof) is administered by injection. PS may be accompanied by a pharmaceutically acceptable carrier, which may depend on the route of administration.

In one or more embodiments, PS (e.g., migalatat or a salt thereof) is administered as monotherapy and may be in a form suitable for any route of administration, including, for example, orally in the form of tablets or capsules or liquid or in a sterile aqueous solution for injections. In other embodiments, PS is provided as a dry lyophilized powder for addition to the replacement enzyme formulation during or immediately after reconstitution to prevent in vitro aggregation of the enzyme prior to administration.

When PS (eg, migalatat or a salt thereof) is formulated for oral administration, tablets or capsules can be prepared by conventional methods with pharmaceutically acceptable excipients such as binders (eg, pregelatinized corn starch, polyvinylpyrrolidone, or hydroxypropyl methylcellulose); fillers (eg lactose, microcrystalline cellulose or calcium hydrogen phosphate); lubricants (for example, magnesium stearate, talc or silicon dioxide); disintegrants (for example, potato starch or sodium starch glycolate); or wetting agents (eg sodium lauryl sulfate). Tablets can be coated by methods well known in the art. Liquid preparations for oral administration may take the form of, for example, solutions, syrups or suspensions, or they may be presented as a dry product for reconstitution with water or other suitable vehicle before use. Such liquid preparations can be prepared by conventional methods with pharmaceutically acceptable additives such as suspending agents (eg sorbitol syrup, cellulose derivatives or hydrogenated edible fats); emulsifying agents (eg lecithin or acacia); non-aqueous vehicles (eg almond oil, oily esters, ethyl alcohol or fractionated vegetable oils); and preservatives (for example, methyl or propyl p-hydroxybenzoates or sorbic acid). The preparations may also contain buffer salts, flavorings, colors and sweeteners, depending on the situation. Oral formulations may be suitably formulated to provide controlled release of the active chaperone compound.

Pharmaceutical preparations of PS (e.g., migalatat or its salts) suitable for parenteral/injection use typically include sterile aqueous solutions (wherein water-soluble) or dispersions and sterile powders for immediate preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and must be fluid to the extent that it can be easily syringed. It must be stable under the conditions of production and storage and must be protected from the contaminating action of microorganisms such as bacteria and fungi. The carrier may be a solvent or dispersion medium containing, for example, water, ethanol, polyol (eg glycerin, propylene glycol and polyethylene glycol and the like), suitable mixtures thereof and vegetable oils. Suitable fluidity can be maintained, for example, by using a coating such as lecithin, by maintaining the required particle size in the case of a dispersion, and by using surfactants. Prevention of the action of microorganisms can be carried out by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, gasoline alcohol, sorbic acid and the like. In many cases it is advisable to include isotonic agents such as sugars or sodium chloride. Prolonged absorption of injectable drugs can be achieved by using absorption retarding agents in the drug, such as aluminum monosterate and gelatin.

Sterile injection solutions are prepared by incorporating the purified enzyme (if available) and PS (e.g., migalastat or its salt) in the required quantity in an appropriate diluent with various other ingredients listed above, as required, followed by filtration or terminal sterilization. Typically, dispersions are prepared by incorporating various sterilized active ingredients into a sterile vehicle that contains the basic dispersion medium and the necessary other ingredients listed above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and freeze-drying, which yield a powder of the active ingredient plus any additional desired ingredient from its pre-sterile-filtered solution.

The drug may contain an excipient. Pharmaceutically acceptable excipients that may be included in the composition are buffers such as nitrate buffer, phosphate buffer, acetate buffer, bicarbonate buffer, amino acids, urea, alcohols, ascorbic acid and phospholipids; proteins such as serum albumin, collagen and gelatin; salts such as EDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrrolidone; sugars such as dextran, mannitol, sorbitol and glycerin; propylene glycol and polyethylene glycol (eg PEG-4000, PEG-6000); glycerol; glycine or other amino acids; and lipids. Buffer systems for use with drugs include citrate; acetate; bicarbonate; and phosphate buffers. A phosphate buffer is a preferred embodiment.

The route of administration of the chaperone compound may be oral or parenteral, including intravenous, subcutaneous, intraarterial, intraperitoneal, ophthalmic, intramuscular, buccal, rectal, vaginal, intraorbital, intracerebral, intradermal, intracranial, intraspinal, intraventricular, intrathecal, intracisternal, intracapsular, intrapulmonary, intranasal, transmucosal, transdermal or through inhalation.

Administration of the above-described parenteral chaperone compound formulations may be an intermittent bolus of drug or may be administered by intravenous or intraperitoneal administration from a reservoir that is external (eg, an intravenous (IV) bag) or internal (eg, a bioerodible implant).

Embodiments relating to pharmaceutical formulations and administration may be combined with any of the other embodiments of the invention, for example, embodiments relating to methods of treating patients with Fabry disease, methods of treating ERT-naïve Fabry patients, methods of treating ERT-treated Fabry patients , methods of improving cardiac function (e.g., left ventricular systolic function), methods of stabilizing cardiac function (e.g., left ventricular systolic function), methods of increasing HFRS, methods of stabilizing HFRS, methods of normalizing HFRS, methods of enhancing α-Gal A in a patient diagnosed with or suspected Fabry disease, the use of a pharmacological chaperone for α-Gal A for the production of a medicament for the treatment of a patient diagnosed with Fabry disease or a pharmacological chaperone for α-Gal A for use in the treatment of a patient diagnosed with Fabry disease, as well as in embodiments related to sensitive mutations, PS and their appropriate doses.

In one or more embodiments, PS (eg, migalastat or a salt thereof) is administered in combination with ERT. ERT increases the amount of protein by exogenously administering a wild-type enzyme or a biologically functional enzyme by infusion. This therapy has been developed for many genetic disorders, including MDD such as Fabry disease, as noted above. Following infusion, the exogenous enzyme is expected to be taken up by tissues through a nonspecific or specific receptor mechanism. In general, the absorption efficiency is not high, and the circulation time of exogenous protein is short. In addition, the exogenous protein is unstable and subject to rapid intracellular degradation, and also has the potential for adverse immunological reactions with subsequent treatment. In one or more embodiments, the chaperone is administered simultaneously with a replacement enzyme (eg, an α-Gal A replacement enzyme). In some embodiments, the chaperone is co-administered with a replacement enzyme (eg, α-Gal A replacement).

In one or more embodiments, the patient is switched from ERT to migalastat therapy. In some embodiments, a patient on ERT is identified, the patient's ERT is discontinued, and the patient begins receiving migalatat therapy. Migala-18 045263 stat therapy can be carried out in accordance with any of the methods described in this document.

Cardiac function

The dosage regimens described herein may stabilize and/or enhance cardiac function (eg, left ventricular systolic function) in patients with Fabry disease. Because untreated patients with Fabry disease typically experience worsening cardiac function over time, both improvement and maintenance of cardiac function suggest benefits of migalatat therapy. As described in more detail in the Examples below, phase 3 studies have demonstrated that migalatat therapy increases and/or stabilizes FSFS in both ERT-treated and ERT-naive patients. These phase 3 studies also demonstrated that migalatat therapy normalizes FSFS in some patients with FSFS disorders. Accordingly, migalastat therapy can be used for the treatment of Fabry patients by stabilizing FWB, increasing FWF, and/or normalizing FWB in ERT-naive and/or ERT-treated Fabry patients, including patients with FWB abnormalities.

Migalastat therapy may reverse or reduce the decrease in FSFR and/or increase FSFR for a patient with Fabry disease compared to the same patient without treatment with migalatat therapy. In one or more embodiments, migalastat therapy provides a change in FFS for the patient that is greater than (i.e., more positive than) -2%, such as greater than or equal to about -1.5%, -1.4%, -1. 3%, -1.2%, -1.1%, -1%, -0.9%, -08.0%, -0.7%, -0.6%, -0.5%, - 0.4%, -0.3%, -0.2%, -0.1%, 0%, 0.1%, 0.2%, 0.3%, 0.4%, 0.5% , 0.6%, 0.7%, 0.8%, 0.9%, 1%, 1.1%, 1.2%, 1.3%, 1.4%, 1.5%, 1 .6%, 1.7%, 1.8%, 1.9%, 2%, 2.1%, 2.2%, 2.3%, 2.4% or 2.5%. In one or more Fabry embodiments, the patient is an ERT-treated patient. In one or more Fabry embodiments, the patient is a patient not receiving ERT. In one or more embodiments of Fabry, the patient had an impairment of the FFS prior to initiation of migalatat therapy.

In one or more embodiments, migalastat therapy provides a mean change in FSHR in a group of ERT-naïve patients of at least about 0% after 12 months of administration of migalastat or a salt thereof. In various embodiments, the average increase in the ERT-naïve group after 12 months of administration of migalatat or a salt thereof is at least about 0.05%, about 0.1%, about 0.15%, or about 0.2% . In one or more embodiments, patients who did not receive ERT had impaired FSFS prior to initiation of migalatat therapy.

In one or more embodiments, migalastat therapy provides a mean change in FSHR in a group of ERT-naïve patients of at least about 0% after 24 months of administration of migalastat or a salt thereof. In various embodiments, the average increase in the ERT-naïve group after 12 months of administration of migalatat or a salt thereof is at least about 0.05%, about 0.1%, about 0.15%, about 0.2% , about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1%, about 1, 1%, about 1.2%, about 1.3%, about 1.4% or about 1.5%. In one or more embodiments, patients who did not receive ERT had impaired FSFS prior to initiation of migalatat therapy.

In one or more embodiments, migalastat therapy provides a mean change in FSHR in a group of ERT-naïve patients of at least about 0% after 36 months of administration of migalastat or a salt thereof. In various embodiments, the average increase in the ERT-naïve group after 12 months of administration of migalatat or a salt thereof is at least about 0.05%, about 0.1%, about 0.15%, about 0.2% , about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1%, about 1, 1%, about 1.2%, about 1.3%, about 1.4% or about 1.5%. In one or more embodiments, patients who did not receive ERT had impaired FSFS prior to initiation of migalatat therapy.

In one or more embodiments, migalastat therapy provides a mean change in FSHR in a group of ERT-naïve patients of at least about 0% after 48 months of administration of migalastat or a salt thereof. In various embodiments, the average increase in the ERT-naïve group after 12 months of administration of migalatat or a salt thereof is at least about 0.05%, about 0.1%, about 0.15%, about 0.2% , about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1%, about 1, 1%, about 1.2%, about 1.3%, about 1.4%, about 1.5%, about 1.6% about 1.7%, about 1.8%, about 1.9%, about 2%, about 2.1%, about 2.2%, about 2.3%, about 2.4% or about 2.5%. In one or more embodiments, patients who did not receive ERT had impaired FSFS prior to initiation of migalatat therapy.

In one or more embodiments, migalastat therapy provides a mean change in FSFS in a group of ERT-naïve patients of greater than about -1.5% after 30 months of administration of migalastat or a salt thereof. In various embodiments, the average increase in the ERT-naïve group after 12 months of administration of migalastat or a salt thereof is greater than -1.5%, -1.4%, 1.3%, -1.2%, -1.1% , - 1%, -0.9%, -08.%, -0.7%, -0.6%, -0.5%, -0.4%, -0.3%, -0.2 %, -0.1% or 0%. In one or more embodiments, ERT-treated patients had impaired FSFS before

- 19 045263 initiation of therapy with migalastat.

Examples

Example 1: Dosing regimens for the treatment of ERT-naïve Fabry patients using migalastat hydrochloride

This case study describes a phase 3 study of migalastat therapy in ERT-naïve Fabry patients.

Patient Recruitment

Eligible patients were aged 16–74 years and had genetically confirmed Fabry disease; never received or received ERT for >6 months; had a GLA mutation that resulted in a mutant protein that was sensitive to migalatat, based on the human embryonic kidney -293 (HEK) cell assay used in recruitment; had an eGFR >30ml/min/ ^1.73m2 and had a urine GL-3 >4 times the upper limit of normal.

Study design

After baseline eligibility assessments (2 months), patients were randomized to a 1- to 6-month period of double, uninformed administration of 150 mg migalatat hydrochloride or placebo every other day. All patients who completed stage 1 were eligible to receive open-label migalatat in stage 2 (months 6–12) and for an additional year (months 13–24) thereafter. The primary objective was to compare the effects of migalastat and placebo on renal GL-3 levels as assessed by histological assessment of the number of interstitial capillary inclusions after 6 months of treatment. Secondary objectives of phase 1 were to compare the effects of migalatat with placebo on urinary GL-3 levels, renal function, 24-hour urine protein, and safety and tolerability. Tertiary outcomes were cardiac function, patient-reported outcomes, interim renal analysis, and leukocyte α-Gal A activity. Study completers were eligible to participate in an open-label extension study for up to 5 years.

Evaluation of kidney histology

Each patient underwent an initial kidney biopsy and a repeat kidney biopsy at 6 and 12 months. The number of GL-3 inclusions per renal interstitial capillary per patient at baseline and at 6 and 12 months was quantified in 300 capillaries by 3 independent pathologists blinded to treatment and visit. All values for each individual biopsy at a given time were averaged prior to statistical analysis.

GL-3 changes in podocytes, endothelial cells and mesangial cells and glomerular sclerosis were qualitatively assessed by the same three pathologists who were blinded to treatment/attendance.

Globotriaosylceramide and globotriaosylsphingosine

Plasma lyso-Gb3 and 24-hour urine GL-3 assays were analyzed by liquid chromatography-mass spectroscopy using a new stable isotopically labeled internal standard 13C6-lyso-Gb3 (lower limit of quantitation: 0.200 ng/mL, 0.254 nmol/L ).

Renal function assessment

Annualized rates of change (ml/min _{/1.73 m2/year) were calculated using the Chronic Kidney Disease Epidemiology Collaboration (GFRc KD} ^- _{EP I )} criteria. ) and the measured clearance of iohexol - iGFRuo _r eksol (mGFRуhexol).

Echocardiography

LVMi, left posterior wall thickness, diastolic, interventricular septal thickness, diastolic and other parameters were assessed by uninformed, centralized assessment.

Patient-Reported Outcomes

Patient-reported outcomes were assessed using the Gastrointestinal-Symptoms-Rating-Scale (GSRS), Short Form-36v2TM, and Brief-Pain-Severity. Pain-Inventory-Pain-SeverityComponent).

Safety Analysis and Adverse Events

Randomized patients receiving >1 dose were included in a safety analysis that included vital signs, physical examinations, electrocardiograms, clinical laboratory tests, and adverse events.

Statistical analysis of renal interstitial capillary substrate GL-3

The primary endpoint of Stage 1 (6 months) (ITT population with initial biopsies, n=64) was the proportion of patients in the migalastat and placebo groups with a >50% reduction in GL-3 inclusions per interstitial capillary. Two other Stage 1 measurable parameters were assessed (modified ITT population: randomized patients with paired baseline measurement and 6-month biopsy; n=60): percentage change in GL-3 inclusions per interstitial

- 20 045263 capillary and percentage of interstitial capillaries with no inclusions GL-3.

Efficacy analyzes for GL-3 inclusions per interstitial capillary and other prespecified essential parameters at Stage 2 (months 6-12) and extension with informed administration (months 12-24) were based on the modified intention-to-treat (mITT) population. modified intention to treat, consisting of randomized patients with a mutant α-Gal A enzyme that has been demonstrated to be sensitive to treatment with migalatat using a validated assay; n=50.

results

Initial/initial characteristics.

Sixty-seven patients (16–74 years; 64% women) with potentially sensitive α-Gal A mutant were randomized (NL population). In table Figure 2 shows the baseline characteristics for 50 patients in the NL population with the matching α-Gal A mutant. There were no statistically significant differences in baseline parameters.

Table 2. Baseline characteristics

Parameter Treatment group Total (N=50) Migalastat NS1 (N=28) Placebo for migalastat HC1 (N = 22) Age (years) (p) 28 22 50 Mean ± SD 41.5±13 45.1±8.0 43.1±11 Median 37.0 45.5 45.0 Weight (kg) (p) 28 22 50 Mean ± SD 72.6±15.35 76.1±16.52 74.1±15.81 Median 72.3 74.0 72.8 Number of years since diagnosis of Fabry disease 28 21 49 Mean ± SD 5.6±6.89 7.3±8.80 6.3±7.73 Median 4.1 4.1 4.1 Number of patients previously treated with ERT (> 6 months before baseline measurement) (%) 4 (14.3%) 7(31.8%) 11 (22.0%) Using ACEi/ARB/Ri in Initial Measurement Yes(%) 9(32.1%) 12 (54.5%) 21 (42.0%) No (%) 19 (67.9%) 10 (45.5%) 29 (58.0%) Proteinuria > 150 mg/24h (%) 17 (60.7%) 18(81.8%) 35 (70.0%) Proteinuria > 300 mg/24h (%) 8 (28.6%) 11 (50.0%) 19 (38.0%) Proteinuria > 1000 mg/24h (%) 3 (10.7%) 3 (13.6%) 6 (12.0%) eGFR _iohexol (ml/min/ ^1.73m2 ) 27 21 48 Mean ± SD 79.95±30.9 83.12±22.8 81.34±27.5 Median 84.90 82.20 83.40 RSKFhbp-epi (ml/min/1.73 m ² ) 28 22 50 Mean ± SD 94.4±27.0 90.6±17.1 92.7±23.0 Median 96.6 93.5 94.0 Lyso-Cls (p) 18 13 31 Mean (nmol/l) ± SD 47.3±62 41.9±39 45.0±53

Published reports of clinical phenotype(s) associated with genotypes of patients with matching mutations (n=50) indicate that 30 (60%) had mutations associated with the classic Fabry disease phenotype, one (2%) with a nonclassical phenotype , three (6%) with both phenotypes and 16 (32%) not yet classified. Residual α-Gal A activity in BCC (WBC) <3% was found in 14 of 16 (87%) men; 29 of 31 (94%) men and women had elevated plasma lyso-Gb3 levels, and 47 of 50 (94%) men and women had multi-organ system disease.

Original SSFU. At baseline, 9 patients had impaired FSFS (<15% for women and <14% for men).

Migalastat and cardiac function. This study of ERT-naïve patients demonstrated that migalatat treatment increased FSHR in patients with FSHR impairment present at baseline. Table Figure 3 below demonstrates the change in HFRS from baseline after treatment with migalatat.

- 21 045263

Table 3. Percentage changes from baseline in SFRS over time during migalatat therapy in patients with SFRS abnormalities present at baseline (patients with sensitive mutations)

Average zsh 11.3% Time of change FASB baseline reading = rhenium Month 12 Month 24 Month 36 Month 48 PRPN η 7 8 4 3 8 Average change from baseline 0.1% 1.4% 1.4% 2.4% 1.9% 95% CI -1.2%, - 1.4% -1.3%, 4.0% -1.5%, 4.3% -2.1%, 6.9% -0.8%, 4.5% Any increase 2/7 (29%) 5/8 (63%) 3/4 (75%) 3/3 (100%) 6/8 (75%) Normalization 0 2/8 (25%) 2/4 (50%) 2/3 (67%) 3/8 (38%)

The last observation carried forward (LOCF) analysis is based on the assessment of the last study, including any unplanned or early termination visits; Abnormal FSFS is <15% for women and <14% for men.

As can be seen from table. 3, analysis of PRPN in ERT-naïve patients with impaired FSFS at baseline demonstrated a mean change in FSFS of 1.9% (95% CI - 0.8%, 4.5%; n=8) over 48 months of migalastat therapy . 6/8 (75%) patients experienced an increase in HFRS after treatment with migalatat, with 3/8 (38%) experiencing a normalization of HFRS.

SSFU was also analyzed in patients with LVH at baseline. The change from baseline in SSFU in patients with LVH at baseline is presented in Table. 4 below:

Table 4. Change from baseline in SSFU with migalatat in patients with LVH to at baseline (patients with susceptible mutations)

Start of research Change from Baseline Month 12 Month 24 Month 36 Month 48 PRPN Qty (p) 10 9 9 5 4 10 %, mean (SD) or (95% CI) 12.2 (2.6) 0.2 (-0.8, 1.1) 0.9 (-1.6, 3.4) 0.7 (-2.1, 3.4) 0.6 (-5.7, 6.9) 1.0 (-1.5, 3.5) Any increase - 4/9 (44%) 5/9 (56%) 3/5 (60%) 3/4 (75%) 7/10 (70%) Normalization - 2/9 (22%) 2/9 (22%) 1/5 (20%) 0 2/10 (20%)

The analysis of the PRP is based on the latest study assessment, including any unscheduled or early visits; LVH subgroup: LVMi > 95 g/ ^m2 (women) or > 115 g/ ^m2 (men).

As can be seen from table. 4, PRP analysis of ERT-naïve patients with LVH at baseline demonstrated a mean change in HFRS of 1.0% (95% CI -1.5%, 3.5%; n=10) over 48 months of migalatat therapy. 7/10 (70%) patients had an increase in FSHR after treatment with migalatat, while 2/10 (20%) showed a normalization of FSFS.

Safety and Adverse Events

During Stage 1, treatment-emergent side effects were similar between groups. Adverse events with a higher incidence in patients receiving migalatat compared to placebo were headache (12/34 patients - 35% vs 7/33 patients - 21%) and nasopharyngitis (6/34 patients - 18% vs 2/ 34-6%), The most common side effects for Stage 2 were headache (9/63 patients - 14%) and procedural pain (7/63 patients - 11% - related to renal biopsy), and for the open trial, proteinuria ( 9/57 patients - 16%), headache (6/57 patients - 11%) and bronchitis (6/57 patients - 11%). Most adverse events were mild or moderate in severity. No adverse events led to discontinuation of migalastat.

Six patients experienced serious adverse events in Stage 1 (2: migalatat; 4: placebo), 5 in Stage 2, and 11 in the informed dosing extension. Two serious adverse events that were possibly related to migalatat were assessed by the investigator: fatigue and paresthesia. Both occurred in the same patient between 12-24 months and resolved. There were no isolated serious adverse events reported in >1 patient. Two patients discontinued migalastat due to serious adverse events; both were found to be unrelated to migalastat. No deaths were reported.

Treatment-emergent proteinuria was noted in 9 patients (16%) between 12 and 24 months, and in one case was assessed to be related to migalatat. In 5 patients, 24-month values were in the same range as baseline. Three patients with matching mutations would have

Claims (5)

There was severe initial proteinuria (>1 g/24 h), which increased over 24 months. In 23/28 patients with baseline proteinuria <300 mg/24h, 24-hour urine protein remained stable during migalatat treatment. There was no progression to end-stage renal disease, death due to cardiac problems, or stroke, as demonstrated in Banikazemi et al. There was only one case of transient ischemic attack not associated with migalastat. Analysis of vital signs, physical data, laboratory parameters and ECG parameters did not reveal any clinically significant effect of migalatat. Example 2 Dosing regimens for the treatment of ERT-treated Fabry patients using migalastat hydrochloride This case study describes a phase 3 study of migalastat therapy in ERT-treated Fabry patients. Patient Recruitment Eligible patients were aged 16–74 years and had genetically confirmed Fabry disease; received ERT for >12 months; had a GLA mutation that resulted in a mutant protein that was sensitive to migalastat, based on the human embryonic kidney-293 (HEK) cell assay used at the time of recruitment; had an eGFR >30 ml/min/ ^1.73m2 and had an ERT dose level and regimen that had been stable for at least 3 months. Study design After initial eligibility assessments, 57 patients were randomized to 18 months of migalatat or ERT, followed by 12 months of migalatat. The migalastat dosage regimen was 150 mg migalastat hydrochloride every other day. The primary objective was to compare the effect of migalastat with ERT on renal function as assessed by iohexol _eGFR after 18 months of treatment. Secondary objectives were to compare the effects of migalatat with ERT on: renal function (assessed by eGFR and 24-hour urine protein); cumulative clinical outcome (measured by time to renal, cardiac, cerebrovascular events or death); cardiac function (assessed by echocardiography) and patient-reported outcomes (pain and quality of life). Original SSFU At baseline, impaired FSFS (<15% for women and <14% for men) was reported in 19 (14 migalastat, 5 ERT) patients. results Migalastat and cardiac function. This study of ERT-treated patients demonstrated that migalatat therapy stabilized HFRS in patients with impaired HFRS at baseline. Analysis of LFS in patients with impaired FSFS at baseline demonstrated a mean change from baseline of -0.2% (95% CI -1.3%, 1.0%; n=14) over 30 months of migalatat therapy. Analyzes of the LFS of patients with impaired FSFS at baseline demonstrated a mean change in FSFS of -0.6% (95% CI -2.6%, 1.4%; n=5) over 18 months of treatment with ERT. The embodiments described herein are intended to illustrate these preparations and methods and are not intended to limit the scope of the present invention. It is intended to include various modifications and changes consistent with the description as a whole and which will be apparent to one skilled in the art. The appended claims are not intended to be limited to the specific embodiments set forth in the examples, but are intended to be given the broadest interpretation consistent with the description as a whole. Patents, patent applications, publications, product descriptions, GenBank accession numbers and proceedings are cited in this application, the disclosures of which are incorporated herein by reference in their entirety for all purposes. CLAIM 1. Use of a drug containing an effective amount of migalatat or a salt thereof to increase the mean wall fractional shortening (MFS) in a patient with Fabry disease, wherein the effective amount is 100 to 150 mg free base equivalent (FSE) and the drug is administered to the patient once every two days. 2. Use of the drug according to claim 1, in which the patient had a violation of the FSFU before the start of the administration of migalastat or its salt. 3. Use of a drug according to claim 1 or 2, in which migalastat or its salt enhances the activity of α-galactosidase A. 4. Use of the drug according to any one of claims 1-3, in which the effective amount is 123 mg of ESO. 5. Use of the drug according to any one of claims 1-4, in which the effective amount is 123 -