WO2014120900A1

WO2014120900A1 - Enhanced therapeutic regimens for treating fabry disease

Info

Publication number: WO2014120900A1
Application number: PCT/US2014/013803
Authority: WO
Inventors: Robert J. Desnick
Original assignee: Icahn School Of Medicine At Mount Sinai
Priority date: 2013-01-31
Filing date: 2014-01-30
Publication date: 2014-08-07

Abstract

Presented herein are methods for treating Fabry disease involving enhanced alpha- galactosidase A ("alpha-Gal A") enzyme replacement therapy. In certain embodiments, the methods involve the administration of escalating doses of alpha-Gal A. In a specific embodiment, the methods for treating Fabry disease involve the escalation of the dose of alpha-galactosidase A enzyme administered to a patient with Fabry disease to prevent renal dysfunction, cardiac dysfunction, Fabry cardiac pathology and/or cerebral dysfunction. In another embodiment, the methods for treating Fabry disease involve combination therapies to enhance the efficacy of the dose of alpha-galactosidase A enzyme administered to a patient with Fabry disease to prevent renal dysfunction, cardiac dysfunction, Fabry cardiac pathology, and/or cerebral dysfunction.

Description

ENHANCED THERAPEUTIC REGIMENS FOR TREATING FABRY DISEASE

[0001] This application claims priority to U.S. Provisional Application Serial No.

61/759,366, filed January 31, 2013, which is incorporated herein by reference in its entirety.

1. INTRODUCTION

[0002] Presented herein are methods for treating Fabry disease involving increasing doses in classic patients and later-onset patients as a means of enhanced alpha-galactosidase A enzyme replacement therapy. In a specific embodiment, the methods for treating Fabry disease described herein involve the escalation of the dose of alpha-galactosidase A enzyme administered to a patient with Fabry disease to prevent renal dysfunction, cardiac

dysfunction, Fabry cardiac pathology and/or cerebral dysfunction. In another embodiment, the methods for treating Fabry disease described herein involve combination therapies to enhance the efficacy of the dose of alpha-galactosidase A enzyme administered to a patient with Fabry disease to prevent Fabry renal pathology, renal dysfunction, cardiac dysfunction, Fabry cardiac pathology, and/or cerebral dysfunction.

2. BACKGROUND

[0003] Fabry disease ("FD") is an X-linked inborn error of glycosphingolipid catabolism resulting from the deficient activity of the lysosomal exoglycohydrolase, human a- galactosidase A (EC 3.2.1.22; human a-Gal A; human alpha-Gal A) (Desnick et al., alpha- Galactosidase A deficiency: Fabry disease. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The Metabolic and Molecular Bases of Inherited Disease (8th ed.). McGraw-Hill, New York, USA: 2001; 3733-3774; Eng and Desnick, alpha-Galactosidase A deficiency: Fabry disease. In: D Valle ea, editor. In Scriver's The Online Metabolic and Molecular Basis of Inherited Disease (OMBBID). McGraw-Hill Companies, Inc.; 2010). The enzymatic defect causes the progressive accumulation of globotriaosylceramide (GL-3) and related

glycosphingolipids with terminal a-linked galactosyl moieties in the plasma and in tissue lysosomes throughout the body. In classically affected males who have little, if any, a-Gal A activity, onset of disease manifestations occurs in childhood or adolescence and is characterized by severe acroparesthesias, angiokeratoma, corneal and lenticular opacities, and hypohidrosis. With advancing age, the progressive glycosphingolipid deposition, particularly in vascular endothelial lysosomes, leads to vascular disease of the heart, kidneys, and brain, resulting in early demise, typically in the fourth or fifth decade of life. In contrast to the classic phenotype, later-onset patients have been identified which have residual a-Gal A activity. These patients typically present with cardiac and/or renal disease and lack the major classical manifestations, including angiokeratoma, acroparesthesias, hypohidrosis and ocular abnormalities (Elleder M, Bradova V, Smid F. et al. Cardiocyte storage and hypertrophy as a sole manifestation of Fabry disease. Report on a case simulating hypertrophic non-obstructive cardiomyopathy. Virchows Arch A Pathol Anat Histopathol. 1990;417:449-455; Nakao S, Kodama C, Takenaka T. et al. Fabry disease: Detection of undiagnosed hemodialysis patients and identification of a "renal variant" phenotype. Kidney Int. 2003;64:801-807; Nakao S, Takenaka T, Maeda M. et al. An atypical variant of Fabry disease in men with left ventricular hypertrophy. N Engl J Med. 1995;333:288-293; von Scheldt W, Eng CM, Fitzmaurice TF. et al. An atypical variant of Fabry disease with manifestations confined to the myocardium. N EnglJMed. 1991;324:395-399).

[0004] Treatment of FD patients with recombinant human alpha-galactosidase A

("rhaGalA") was approved in 2001 by the European Medicines Agency ("EMA") for two preparations of rhaGalA, Replagal (agalsidase alpha) and Fabrazyme (agalsidase beta), and in 2003 by the FDA for Fabrazyme only at doses of 0.2 mg/kg every other week ("EOW") for Replagal and at 1.0 mg/kg EOW for Fabrazyme. Studies have shown that both preparations are similar, although Fabrazyme has more mannose-6-phosphate and higher sialylation per molecule (Lee K, Jin X, Zhang K, Copertino L, Andrews L, et al. 2003. A Biochemical and Pharmacological Comparison of Enzyme Replacement Therapies for the Glyco lipid Storage Disorder Fabry Disease. Glycobiology. 13:305-313; Sakuraba H, Murata-Ohsawa M, Kawashima I, Tajima Y, Kotani M, et al. 2006. Comparison of the effects of agalsidase alfa and agalsidase beta on cultured human Fabry fibroblasts and Fabry mice. J. Hum. Genet. 51 : 180- 188), which is evidenced when the same dose of each is administered to the mouse model of FD.

[0005] For Fabrazyme a Phase 1/2 open-label clinical trial evaluated doses of 0.3, 1.0 and 3.0 mg/kg EOW (Eng CM, Banikazemi M, Gordon R, Goldman M, Phelps R, et al. 2001. A phase 1/2 clinical trial of enzyme replacement in Fabry disease: Pharmacokinetic, substrate clearance, and safety studies. Am. J. Hum. Genet. 68:711-722). The dose of 1 mg/kg EOW was chosen for randomized, double-blind, placebo-controlled phase 3 and 4 trials (Eng CM, Guffon N, Wilcox WR, Germain DP, Lee P, et al. 2001. Safety and efficacy of recombinant human a-galactosidase A replacement therapy in Fabry disease. N. Eng. J. Med. 345:9-16; Banikazemi M, Bultas J, Waldek S, Wilcox WR, Whitley CB, McDonald M, Finkel R, et al. Agalsidase-beta therapy for advanced Fabry disease: a randomized trial. Ann Intern Med. 2007;146:77-86). These clinical trials identified the ability of rhaGalA to clear the vascular endothelium (and other cells) in the kidney, heart, and skin. They did not clear the long-lived (and therefore longer accumulating) podocytes in the kidney or cardiomyocytes in the heart (Germain DP, Waldek S, Banikazemi M, Bushinsky DA, Charrow J, Desnick RJ, Lee P, et al. Sustained, long-term renal stabilization after 54 months of agalsidase beta therapy in patients with Fabry disease. J Am Soc Nephrol. 2007;18: 1547-1557). Podocytes are key in the retention of proteins in the body, and preventing proteinuria which is harmful (toxic) to renal function. Cardiomyocytes are essential for normal heart function and structure, and accumulation in these cells, particularly in the ventricles, leads to left ventricular hypertrophy (LVH), hypertrophic cardiomyopathy (HCM), and may ultimately lead to ventricular dysfunction, ventricular tachycardia, and heart failure.

[0006] Recent studies of young (7-33years old, mostly <18 yrs) classic males who had renal biopsies at baseline and then 5 years after treatment with 0.2 mg/kg EOW or 1 mg/kg EOW revealed that clearance of renal endothelial and mesangial cells occurred at both doses, but that podocyte GL-3 clearance only occurred at 1 mg/kg (Tondel C, Bostad, L, Hirth, A, and Svarstad E. Renal biopsy findings in children and adolescents with Fabry disease and minimal albuminuria. Am J Kidney Dis. 2008; 51 : 767-776). In fact, there was almost complete clearance of the accumulated podocyte GL-3 in a male who started treatment at age 7 years, again emphasizing the importance of early treatment as did the Fabrazyme Phase 3 and 4 clinical trials. Podocyte clearance in all 12 studied patients was shown to be directly related (statistically significant) with their respective 5 year cumulative dosages (Tondel C, Bostad, L, Hirth, A, and Svarstad E. Renal biopsy findings in children and adolescents with Fabry disease and minimal albuminuria. Am J Kidney Dis. 2008; 51 : 767-776). Of note, none of the seven FD males treated at 0.2 mg/kg cleared little to any podocyte GL-3. Moreover, albuminuria, a functional indicator of podocyte function, was directly correlated with lower cumulative dosages, and was shown to not occur, or to improve or stabilize at the higher cumulative doses. These and related early intervention studies with Fabrazyme and biopsies before and after 5 years of treatment by Mauer at the University of Minnesota further confirm that the podocytes can be totally cleared with early intervention (Najafian B, Svarstad E, Bostad L, Gubler MC, Tondel C, Whitley C, Mauer M. Progressive podocyte injury and globotriaosylceramide (GL-3) accumulation in young patients with Fabry disease. Kidney Int. 2011;79:663-670). Thus, GL-3 clearance of the kidney by enzyme replacement therapy (ERT) requires at least a dose of 1.0 mg/kg and early childhood (particularly 7 years or under) intervention for optimal treatment. [0007] To date, no such studies have evaluated the effect of dose and cumulative dose on cardiomyocyte GL-3 clearance. Pre-clinical studies of ERT at doses of 0.3, 1.0, 3.0, and 10.0 mg/kg qod for 8 doses revealed a dose-dependent GL-3 clearance from liver, heart and kidney in the a-Gal A knock out mouse model of Fabry disease (Ioannou YA, Zeidner KM, Gordon RE, Desnick RJ. 2001. Fabry disease: Preclinical studies demonstrate the

effectiveness of a-galactosidase A replacement in enzyme-deficient mice. Am. J. Hum. Genet. 68: 14-25). A Phase 1/2 study that involved cardiac biopsies of patients on 1.0 and 3.0 mg/kg EOW also showed a dose response (Eng CM, Banikazemi M, Gordon R, Goldman M, Phelps R, et al. 2001. A phase 1/2 clinical trial of enzyme replacement in Fabry disease:

Pharmacokinetic, substrate clearance, and safety studies. Am. J. Hum. Genet. 68:711-722). Early studies of ERT in older patients monitored by cardiac non-invasive techniques suggested slight improvement in ventrical wall thickness following 1 to 3 years of 1.0 mg/kg EOW, however the greatest reduction in wall thickness was in the younger patients with milder hypertrophy (Weidemann F, Breunig F, Beer M, Sandstede J, Turschner O, et al. 2003. Improvement of cardiac function during enzyme replacement therapy in patients with Fabry disease: a prospective strain rate imaging study. Circulation. 108: 1299-1301).

However, older patients with advanced disease experiencing significant renal and/or cardiac deterioration (e.g. , patients with chronic kidney disease stage 3 or 4) continued to deteriorate at 1 mg/kg of alpha-Gal A EOW.

3. SUMMARY

[0008] Presented herein are methods for treating Fabry disease involving enhanced alpha- galactosidase A ("alpha-Gal A") enzyme replacement therapy. In certain embodiments, the methods described herein involve the administration of escalating doses of alpha-Gal A. In a specific embodiment, the methods for treating Fabry disease described herein involve the escalation of the dose of alpha-Gal A enzyme administered to a patient with Fabry disease to prevent or reduce evidence of Fabry renal pathology, Fabry cardiac pathology, renal dysfunction, cardiac dysfunction,and/or cerebral dysfunction. In some embodiments, the methods described herein involve the administration of alpha-Gal A in addition to the administration of one, two or more of the following: (1) an immunomodulation therapy, (2) a pharmacological chaperone for alpha-Gal A, (3) a beta-2 agonist, (4) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide

(lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2), globotriaosylceramide (GL-3), lysogloboside (lyso-GL3; otherwise known as globotriaosylsphingosine), globoside (GL-4), and/orlysogloboside (lyso-GL-4), such as, e.g., a glycosylceramide synthase, a galactosyltransferase, a glucosyltransferase, a

lactosylceramide 4-a-galactosyltransferase, a globotriaosylceramide 3-β-Ν- acetylgalactosaminyltransferase, an N-acetylgalactosamine glycosyltransferase, a globoside hydrolase, and/or a globotetraosylceramide synthase, etc., (5) an siR A designed to reduce the glycosyltransferase specific R A, such as, e.g., galactosyltransferase and/or

glucosyltransferase, (6) any other therapy that may reduce and/or prevent substrate accumulation, and/or (7) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation. The methods for treating Fabry disease involve a therapeutic regimen for administering alpha-Gal A that varies depending upon the age, gender, severity of manifestations, and the phenotype subtype (classic or later-onset) of the Fabry disease. The early diagnosis of Fabry disease allows for the selection of the appropriate therapeutic regimen for a particular patient.

[0009] The invention is based, in part, on the inventor's recognition that there are many ways to treat Fabry disease. In a certain embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises an escalating dose of alpha-Gal A administered to a subject. In another embodiment, provided herein is a method for treating Fabry disease comprising a means for reducing substrate, e.g., GL-1, lyso-GL-1, GL-2, lyso-GL-2, GL-3, lyso-GL-3, GL-4, and/or lyso-GL-4, accumulation. In another embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A and another therapy(ies) to a subject, wherein the other therapy(ies) enhances the efficacy of the dose of alpha-Gal A that the subject receives. In a specific embodiment, the alpha-Gal A is administered to a subject in combination with a means of decreasing the substrate, e.g., GL-1, lyso-GL-1, GL-2, lyso-GL-2, GL-3, lyso-GL-3, GL-4, and/or lyso-GL-4, accumulation, such that less enzyme is required for substrate breakdown, which results in a higher effective dose of the alpha-Fal A enzyme. In some embodiments, alpha-Gal A is administered to a subject in combination with one, two or more of the following: (1) an immunomodulation therapy, (2) a pharmacological chaperone for alpha-Gal A, (3) a beta-2 agonist, (4) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide

(lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2),

globotriaosylceramide (GL-3), lysogloboside (lyso-GL3; otherwise known as globotriaosylsphingosine), globoside (GL-4), and/orlysogloboside (lyso-GL-4), such as, e.g., a glycosylceramide synthase, a galactosyltransferase, a glucosyltransferase, a

glucosyltransferase, (6) any other therapy that may reduce and/or prevent substrate accumulation, and/or (7) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation (e.g., an anti-inflammatory agent).

[0010] In a specific embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1 mg/kg of alpha-Gal A every other week; and (b) increasing the dose of alpha-Gal A administered to the subject if there is evidence of renal dysfunction, cardiac dysfunction, cerebral dysfunction, Fabry renal pathology, and/or Fabry cardiac pathology. In certain embodiments, the dose of alpha-Gal A the human subject is receiving is increased

incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg, 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry cardiac pathology, cardiac dysfunction, renal dysfunction, Fabry renal pathology and/or cerebral dysfunction.

[0011] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha galactosidase A once per month beginning when the subject is approximately 1-5 years of age; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject to 1-2 mg/kg every other week when the subject is approximately 5-10 years of age. In certain embodiments, the dose of alpha-Gal A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence Fabry renal pathology and/or Fabry cardiac pathology, evidence cardiac dysfunction and/or renal dysfunction is continuing or progressing, or any evidence of cerebral dysfunction.

[0012] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering recombinant alpha-galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha galactosidase A once per month beginning when the subject is approximately 1-5 years of age, wherein the subject has received immunomodulation therapy prior to the administration of the first dose of recombinant alpha-galactosidase A to the subject; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject to 1-2 mg/kg every other week when the subject is approximately 5-10 years of age. In certain

embodiments, the dose of alpha-Gal A the human subject is receiving is increased

incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry renal pathology, Fabry cardiac pathology, cardiac dysfunction and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction.

[0013] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha galactosidase A once per month beginning when the subject is approximately 1-5 years of age; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject to 1-3 mg/kg every other week upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of renal dysfunction (e.g., a change in glomerular filtration rate, increased micro albuminuria, or increased proteinuria, such as described in Section 4.3, infra.) and/or cardiac dysfunction (e.g., by performing an EKG, MRI, or ECHO, such as described in Section 4.3, infra.). In certain embodiments, the dose of alpha-Gal A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction.

[0014] In another embodiment, provided herein is a method for treating later-onset Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the later-onset phenotype of Fabry disease 1 mg/kg of recombinant human alpha galactosidase A every other week; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject to 2 mg/kg or 3 mg/kg every other week or once per month upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication cardiac dysfunction, renal dysfunction, and/or neurological manifestations (such as described in Section 4.3, infra). In certain embodiments, the dose of alpha-Gal A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry cardiac pathology, Fabry renal pathology, or cardiac dysfunction and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction.

[0015] In another embodiment, provided herein is a method for treating later-onset Fabry disease comprising administering recombinant human alpha-galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the later-onset phenotype of Fabry disease upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction and/or renal dysfunction 1 mg/kg of alpha-Gal A every other week; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject upon the evidence of continued or progressive Fabry cardiac pathology, Fabry renal pathology, renal dysfunction, and/or cardiac dysfunction, and/or any evidence of cerebral dysfunction. In certain embodiments, the dose of alpha-Gal A the human subject is receiving is increased

incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction.

[0016] In another embodiment, provided herein is a method for treating later-onset Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with later-onset phenotype of Fabry disease that has advanced cardiac dysfunction and/or renal dysfunction a dose of 2 mg/kg to 5 mg/kg of alpha-Gal A every other week; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject upon the evidence of significant cardiac and/or renal disease. In certain embodiments, the dose of alpha-Gal A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increases to up to 5 m/kg, 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that significant cardiac or renal disease.

[0017] In another embodiment, provided herein is a method for treating later-onset Fabry disease comprising administering alpha-galactosidase A in a therapeutic regimen, wherein the therapeutic regiment comprises: (a) administering to a human male or heterozygote approximately 15-20 years old with later-onset phenotype of Fabry disease 1 mg/kg of alpha- galactosidase A every month; and (b) increasing the dose schedule of alpha-galactosidase A administered to the subject to 1 mg/kg every other week upon the evidence of Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction.

[0018] In specific embodiments, the alpha-Gal A used in the methods described herein is recombinant human alpha-Gal A, such as agalsidase alpha or agalsidase beta. In specific embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is a human male. In other embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is a female heterozygous for Fabry disease.

3.1 TERMINOLOGY

[0019] As used herein, the terms "patient" and "subject" are used interchangeably to refer to a human subject. In a specific embodiment, the terms "patient" and "subject" are used interchangeably to refer to a human subject diagnosed as having Fabry disease.

[0020] In certain embodiments, the term "prior to" in the context of the administration of an immunomodulation therapy, a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), galabiosylceramide (GL-2), globotriaosylceramide (GL-3), lyso-GL3, globoside (GL-4), and/or lyso-GL-4, or an siRNA designed to reduce the galactosyltransferase specific RNA means that the immunomodulation therapy, the pharmacological chaperone, the beta-2 agonist, the inhibitor, or the siRNA is administered to a subject 10-15 minutes, 15-30 minutes, 30-60 minutes, 1-2 hours, 2-4 hours, 2-6 hours, 4-6 hours, 1-12 hours, 6-12 hours, 12-24 hours, 24-36 hours, 24-48 hours, 36-48 hours, 48-72 hours, 3-5 days, 3-7 days, 5-7 days, 7-10 days, 7-14 days, or 12-14 days before the subject is administered of a dose of alpha-Gal A. In other embodiments, the term "prior to" in the context of the administration of an immunomodulation therapy, a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), galabiosylceramide (GL-2), globotriaosylceramide (GL-3), lyso-GL3, globoside (GL-4) and/or lyso-GL-4, or an siRNA designed to reduce the galactosyltransferase specific RNA means that the immunomodulation therapy, the pharmacological chaperone, the beta-2 agonist, the inhibitor, or the siRNA is administered to a subject 2-3 weeks, 2-4 weeks, or 4-6 weeks before the subject is administered a dose of alpha-Gal A. [0021] In certain embodiments, the term "subsequent to" in the context of the

administration of an immunomodulation therapy, a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), galabiosylceramide (GL-2), globotriaosylceramide (GL-3), lyso-GL3, globoside (GL-4), and/or lyso-GL-4, or an siRNA designed to reduce the galactosyltransferase specific RNA means that the immunomodulation therapy, the pharmacological chaperone, the beta-2 agonist, the inhibitor, or the siRNA is administered to a subject 10-15 minutes, 5-15 minutes, 15-30 minutes, 30-60 minutes, 1-2 hours, 2-4 hours, 2-6 hours, 4-6 hours, 1-12 hours, 6-12 hours, 12-24 hours, 24-36 hours, 24-48 hours, 36-48 hours, 48-72 hours, 3-5 days, 3-7 days, 5-7 days, 7-10 days, 7-14 days, or 12-14 days after the subject is administered of a dose of alpha-Gal A. In other embodiments, the term "subsequent to" in the context of the administration of an immunomodulation therapy, a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), galabiosylceramide (GL-2), globotriaosylceramide (GL-3), lyso-GL3, globoside (GL-4), and/or lysogloboside (lyso-GL-4), or an siRNA designed to reduce the

glucosyltransferase specific RNA means that the immunomodulation therapy, the

pharmacological chaperone, the beta-2 agonist, the inhibitor, or the siRNA is administered to a subject 2-3 weeks, 2-4 weeks, or 4-6 weeks after the subject is administered a dose of alpha-Gal A.

[0022] In a certain embodiment, the term "effective dose" refers to the amount of alpha- Gal A administered to a subject that results in a therapeutic outcome. In certain

embodiments, an increased effective dose does not equal an increased amount (e.g., mg) of alpha-Gal A administered to a subject. In certain embodiments, a combinatorial-therapeutic regimen comprising of: (a) reduction of substrate accumulation; and (b) administering alpha- Gal A, will result in a lower effective dose of enzyme, as a consequence of diminished substrate levels. In another embodiment, the effective dose is achieved by inhibiting an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide (lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2),

globotriaosylceramide (GL-3), lysogloboside (lyso-GL3; otherwise known as

globotriaosylsphingosine), globoside (GL-4), and/or lysogloboside (lyso-GL-4). In certain embodiments, the effectiveness of a dose of alpha-Fal A is assessed by measuring the concentration of plasma GL-3 and/or plasma lyso GL-3. In a specific embodiment, a dose of alpha-Gal A is effective if the plasma concentration of GL-3 and/or lyso GL-3 is reduced. [0023] In certain embodiment, the term "concurrently with" in the context of the administration of an immunomodulation therapy, a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), galabiosylceramide (GL-2), globotriaosylceramide (GL-3), lyso-GL3, globoside (GL-4), and/or lysogloboside (lyso-GL-4) or an siR A designed to reduce the

galactosyltransferase specific R A means that the immunomodulation therapy, the pharmacological chaperone, the beta-2 agonist, the inhibitor, or the siRNA is administered to a subject at the same time, within 1-10 minutes, 5-10 minutes, within 1-5 minutes, or 2-5 minutes of the administration of a dose of alpha-Gal A to the subject.

4. DETAILED DESCRIPTION

[0024] Presented herein are methods for treating Fabry disease involving enhanced alpha- Gal A enzyme replacement therapy. In certain embodiments, the therapeutic regimes described herein involve the administration of escalating doses of recombinant alpha-Gal A. In a specific embodiment, the methods for treating Fabry disease described herein involve the escalation of the dose of alpha-Gal A enzyme administered to a patient with Fabry disease to prevent or reduce evidence of Fabry renal pathology, Fabry cardiac pathology, renal dysfunction, cardiac dysfunction, and/or cerebral dysfunction. In a certain embodiment, the methods for treating Fabry disease described herein involve the administration of another therapy(ies) to increase the effective dose of alpha-Gal A. The methods for treating Fabry disease involve a therapeutic regimen for administering alpha-Gal A that varies depending upon the age, gender, severity of manifestations, the phenotype subtype (classic or later- onset) of the Fabry disease. The early diagnosis of Fabry disease allows for the selection of the appropriate therapeutic regimen for a particular patient.

4.1 ENHANCED THERAPEUTIC REGIMEN

FOR TREATING FABRY DISEASE

[0025] Presented herein are therapeutic regimens for the treatment of Fabry disease involving the administration of escalating doses of alpha-Gal A to patients. In certain embodiments, the therapeutic regimens described herein involve the administration of escalating doses of alpha-Gal A. In some embodiments, the therapeutic regimens described herein involve the administration of alpha-Gal A in addition to the administration of one, two or more of the following: (1) an immunomodulation therapy, (2) a pharmacological chaperone for alpha-Gal A, (3) a beta-2 agonist, (4) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide (lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2), globotriaosylceramide (GL-3), lysogloboside (lyso-GL3), globoside (GL-4), and/or lysogloboside (lyso-GL-4), such as, e.g., a

glycosylceramide synthase, a galactosyltransferase, a lactosylceramide 4-a- galactosyltransferase, a globotriaosylceramide 3-P-N-acetylgalactosaminyltransferase, an N- acetylgalactosamine glycosyltransferase, a globoside hydrolase, and/or a

globotetraosylceramide synthase, etc., (5) an siR A designed to reduce the

glycosylsyltransferase specific R A, such as, e.g., galactosyltransferase and/or

glucosyltransferase, (6) any other therapy that may reduce and/or prevent substrate accumulation, and/or (7) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation and/or inflammation. In specific embodiments, the alpha-Gal A used in the therapeutic regimens described herein is recombinant human alpha-Gal A, such as agalsidase alfa or agalsidase beta. In certain embodiments, the subject administered the alpha-Gal A is and/or has received gene transfer and mutation-corrected induced pluriopotent stem cells (iPS) derived from the subject. In a specific embodiment, the stems cells are engineered to enhance the expression and activity of alpha-Gal A. In specific embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is a human male. In other embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is a female heterozygous for Fabry disease.

[0026] The invention is based, in part, on the inventor's recognition that there are many ways to treat Fabry disease. In a certain embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises an escalating dose of alpha-Gal A administered to a subject. In another embodiment, provided herein is a method for treating Fabry disease comprising a means for reducing substrate, e.g., GL-1, lyso-GL-1, GL-2, lyso-GL-2, GL-3, lyso-GL-3, GL-4, and/or lyso-GL-4, accumulation. In another embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A and another therapy(ies) to a subject, wherein the other therapy(ies) enhances the efficacy of the dose of alpha-Gal A that the subject receivs. In a specific embodiment, the alpha-Gal A is administered to a subject in combination with a a means of decreasing the substrate, e.g., GL- 1, lyso-GL-1, GL-2, lyso-GL-2, GL-3, lyso-GL-3, GL-4, and/or lyso-GL-4, accumulation, such that less enzyme is required for substrate breakdown, which results in a higher effective dose of the alpha-Fal A enzyme. In some embodiments, alpha-Gal A is administered to a subject in combination with one, two or more of the following: (1) an immunomodulation therapy, (2) a pharmacological chaperone for alpha-Gal A, (3) a beta-2 agonist, (4) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1),

lysoglucosylceramide (lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2), globotriaosylceramide (GL-3), lysogloboside (lyso-GL3; otherwise known as globotriaosylsphingosine), globoside (GL-4), and/orlysogloboside (lyso-GL-4), such as, e.g., a glycosylceramide synthase, a galactosyltransferase, a glucosyltransferase, a

glucosyltransferase, (6) any other therapy that may reduce and/or prevent substrate accumulation, and/or (7) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation.

[0027] In certain embodiments, an increased effective dose does not equal an increased amount {e.g., mg) of alpha-Gal A being administered to a subject. In certain embodiments, the administration to a subject of alpha-Gal A and another therapy(ies), such as an agent that reduces substrate accumulation in Fabry patients and/or an agent that inhibits an enzyme involved in the synthesis of GL-1, lyso-GL-1, GL-2, lyso-GL-2, GL-3, lyso-GL-3, GL-4, and/or lyso GL-4, results in a lower dose of alpha-Gal A being effective in treating the patient.

[0028] In one aspect, presented herein are therapeutic regimens directed to the treatment of Fabry disease. In specific embodiments, the therapeutic regimen(s) for treating Fabry disease varies depending upon the mutation in the gene encoding alpha-GalA and its association with the phenotype of Fabry disease. Thus, in a specific embodiment, subjects with a family history of Fabry disease, newborns, and subjects presenting with signs and symptoms of Fabry disease are screened for Fabry disease, and the appropriate therapeutic regimen for treating Fabry disease is selected. In one embodiment, if the subject has a mutation associated with the classic phenotype of Fabry disease, dosing of the subject at 1 mg/kg of alpha-GalA once a month or every other week ("EOW") begins at 1-5 years, 1-4 years, 1-3 years, 2-5 years, or 2-4 years old. In some embodiments, the dose of the alpha- GalA that the subject with the classic phenotype of Fabry disease is receiving is increased and/or the frequency of administration of the dose is increased if there are early signs and/or symptoms of the disease, evidence of Fabry cardiac pathology, evidence of cardiac dysfunction, evidence of renal dysfunction and/or evidence of cerebral dysfunction. See Sections 4.2, infra, for early signs and symptoms of Fabry disease and Section 4.3, infra, for evidence of Fabry cardiac pathology, cardiac dysfunction, Fabry renal pathology, renal dysfunction, and cerebral dysfunction. In other embodiments, the dose of the alpha-GalA that the subject with the classic phenotype of Fabry disease is receiving is increased and/or the frequency of administration of the dose is increased if one or more biomarkers, such as those described in Section 4.2, infra, indicate a need and/or the subject manifests one, two or more signs and/or symptoms of the Fabry disease. In another embodiment, if the subject has a mutation associated with the later-onset phenotype of Fabry disease, the subject is monitored for one or more biomarkers, such as those described in Section 4.2, infra, and/or signs and symptoms of the disease, and dosing is commenced if the one or more biomarker levels indicate a need and/or the subject manifests one, two or more signs and symptoms of the Fabry disease.

[0029] In another embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with Fabry disease a dose of 1 mg/kg of alpha-Gal A EOW; and (b) increasing the dose of alpha-Gal A administered to the subject if there is evidence of Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, and/or cerebral dysfunction. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence of Fabry cardiac pathology, Fabry renal pathology, renal dysfunction, cardiac dysfunction, and/or cerebral dysfunction. Evidence of Fabry cardiac pathology, Fabry renal pathology, renal dysfunction, cardiac dysfunction, and cerebral dysfunction are described in Section 4.3, infra. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment (by, e.g., clinical measurements and biomarkers). In certain embodiments, the subject is monitored at least 1, 2, 3, 4, 5 or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment. In certain embodiments, the subject has Fabry disease of the classic phenotype. In certain embodiments, the subject is a male 4-6, 7- 10, 8-10, or 10-15 years old that has Fabry disease. In other embodiments, the subject has Fabry disease of the later-onset phenotype. In certain embodiments, the subject has Fabry disease of the later-onset phenotype and the subject has begun to experience symptoms and/or pathology (e.g., Fabry cardiac and/or Fabry renal pathology) of the disease. In certain embodiments, the subject is administered an immunomodulation therapy prior to the administration of at least the first dose of alpha-Gal A the subject receives. In some embodiments, the subject is monitored for anti-alpha-Gal A antibodies (e.g., the subject is monitored at least 1, 2, 3, 4, 5 or more times per year from the presence of anti-galactosidase A antibodies). Techniques known to one of skill in the art can be used to measure the concentration of anti-alpha-Gal A antibodies, such as ELISA and radioimmunoassay. In certain embodiments, the subject is administered an immunomodulation therapy when anti- alpha-Gal A antibodies are detected in a biological sample from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha- Gal A being administered. In certain embodiments, the subject is administered an

immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha-Gal A being administered. In some embodiments, the subject is administered an immunomodulation therapy prior to the administration of the first dose of alpha-Gal A the subject receives and prior to other doses of alpha-Gal A when anti-alpha-Gal A antibodies are detected in a biological sample from the subject. To minimize the antibody response to the alpha-Gal A, the alpha-Gal A can be administered by slow infusions.

[0030] In certain embodiments, the therapeutic regimens for treating patients with Fabry disease described herein further include the administration of one, two or more of the following: (1) a pharmacological chaperone for alpha-Gal A, (2) a beta-2 agonist, (3) an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, such as, e.g., a glycosylceramide synthase, and/or a glycosyltransferase, (4) an siR A designed to reduce the glucosyltransferase specific R A, such as, e.g., galactosyltransferase and/or glucosyltransferase, (5) any other therapy that may reduce and/or prevent substrate accumulation, and/or (6) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation. In some embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, an siR A designed to reduce the galactosyltransferase or other glycosyltransferase specific R A, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of the first dose of alpha-Gal A to the subject. In other embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3. GL-4, and/or lyso-GL-4, an siRNA designed to reduce the galactosyltransferase or other glycosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of each dose of alpha-Gal A the subject receives.

[0031] In another aspect, presented herein are therapeutic regimens directed to the treatment of patients with the classic phenotype of Fabry disease. In one embodiment, provided herein is a method for treating classic Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of alpha-Gal A once per month beginning when the subject is approximately 6 months to 1 year, 6 months to 2 years, 1-2 years, 1-4 years, 1-5 years, 2-3 years, 2-4 year, 2-5 years, 3-4 years, or 4-5 years of age, or approximately 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, or 5.5 years of age; and (b) increasing the dose of alpha-Gal A administered to the subject to 1-2 mg/kg EOW when there is an alteration (e.g., an increase) in one or more biomarkers, such as those described in Section 4.2, infra (e.g., GL3 and lysoGL3) and/or the subject exhibits early signs and symptoms of Fabry disease, such as, e.g., neuropathic pain, chronic pain, abdominal pain, and angiokeratomas, hypohidrosis. See Section 4.2, infra, for examples of early signs and symptoms of Fabry disease. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment (e.g., the levels of one or more biomarkers). In certain embodiments, the subject is monitored at least 1, 2, 3, 4, 5 or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment e.g., the levels of one or more biomarkers. In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment (e.g., the levels of one or more biomarkers). In some embodiments, the dose of alpha-Gal A the subject is receiving is changed to an alternating dose of 1 mg/kg and 2 mg/kg every other week, or an alternating dose of 1 mg/kg and 3 mg/kg every other week upon evidence of Fabry cardiac pathology and/or Fabry renal pathology ,and/or the first indication of cardiac dysfunction and/or renal dysfunction. Evidence of Fabry cardiac pathology and Fabry renal pathology is described in Section 4.3, infra. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. The first indication of renal dysfunction comprises one, two, or more of the early signs and symptoms of renal dysfunction described in Section 4.3, infra. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, and/or renal dysfunction is continuing or progressing and/or any evidence of cerebral dysfunction. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in heart cells, such as cardiomyocytes, by, e.g., electron microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glycolipids, such as GL-3, in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of renal dysfunction described in Section 4.3, infra. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In certain embodiments, the subject is administered an immunomodulation therapy prior to the administration of at least the first dose of alpha-Gal A the subject receives. In specific embodiments, the subject is administered an immunomodulation therapy prior to and/or concurrently with at least the first dose of alpha-Gal A the subject receives and then 1-5 days, 1-4 days, 1-3 days, 2 days, 1 day after receiving the first dose of the alpha-GalA. In some embodiments, the subject is monitored for anti-alpha-Gal A antibodies (e.g., the subject is monitored at least 1, 2, 3, 4, 5 or more times per year from the presence of anti-galactosidase A antibodies). Techniques known to one of skill in the art can be used to measure the concentration of anti-alpha-Gal A antibodies, such as ELISA and radioimmunoassay. In certain embodiments, the subject is administered an immunomodulation therapy when anti- alpha-Gal A antibodies are detected in a biological sample from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha- Gal A being administered. In certain embodiments, the subject is administered an

[0032] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of alpha-Gal A once per month beginning when the subject is approximately 6 months to 1 year, 6 months to 2 years, 1-2 years, 1-4 years, 1-5 years, 2-3 years, 2-4 year, 2-5 years, 3-4 years, or 4-5 years of age, or approximately 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, or 5.5 years of age; (b) monitoring the subject regularly for one or more biomarkers, such as those described in Section 4.2, e.g., GL3 and lysoGL3, and/or signs and symptoms of Fabry disease; and (c) increasing the dose of alpha-Gal A administered to the subject to 1-2 mg/kg EOW if the levels of the one or more biomarkers is altered (e.g., increased) and/or when the subject exhibits early signs and symptoms of Fabry disease, such as, e.g., neuropathic pain, chronic pain, abdominal pain, and angiokeratomas, hypohidrosis. See Section 4.2, infra, for examples of early signs and symptoms of Fabry disease. In certain embodiments, the subject is monitored at least 1, 2, 3, 4, 5 or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment (e.g., the levels of one or more biomarkers). In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment (e.g., the levels of one or more biomarkers). In some embodiments, the dose of alpha-Gal A the subject is receiving is changed to an alternating dose of 1 mg/kg and 2 mg/kg every other week, or an alternating dose of 1 mg/kg and 3 mg/kg every other week upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction and/or renal dysfunction. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. The first indication of renal dysfunction comprises one, two, or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac and renal pathology are described in Section 4.3, infra. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology,cardiac dysfunction and/or renal dysfunction is continuing or progressing and/or any evidence of cerebral dysfunction. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of renal dysfunction described in Section 4.3, infra.

Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL-3, in heart cells, such as cardiomyocytes, by, e.g., electron microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL-3, in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In certain embodiments, the subject is administered an immunomodulation therapy prior to the administration of at least the first dose of alpha-Gal A the subject receives. In specific embodiments, the subject is administered an

immunomodulation therapy prior to and/or concurrently with at least the first dose of alpha- Gal A the subject receives and then 1-5 days, 1-4 days, 1-3 days, 2 days, 1 day after receiving the first dose of the alpha-GalA. In some embodiments, the subject is monitored for anti- alpha-Gal A antibodies (e.g., the subject is monitored at least 1 , 2, 3, 4, 5 or more times per year from the presence of anti-galactosidase A antibodies). Techniques known to one of skill in the art can be used to measure the concentration of anti-alpha-Gal A antibodies, such as ELISA and radioimmunoassay. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are detected in a biological sample from the subject. In some embodiments, the subject is administered an

immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha-Gal A being administered. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha-Gal A being administered. In some embodiments, the subject is administered an immunomodulation therapy prior to the administration of the first dose of alpha-Gal A the subject receives and prior to other doses of alpha-Gal A when anti-alpha-Gal A antibodies are detected in a biological sample from the subject. To minimize the antibody response to the alpha-Gal A, the alpha-Gal A can be administered by slow infusions.

[0033] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of alpha-Gal A once per month beginning when the subject is approximately 1-2 years, 1-4 years, 1-5 years, 2-3 years, 2-4 year, 2-5 years, 3-4 years, or 4-5 years of age, or approximately 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, or 5.5 years of age; and (b) increasing the dose of alpha-Gal A administered to the subject to 1-2 mg/kg EOW when the subject is approximately 7-8 years, 7-9 years, 7-10 years, 8-9 years, 8-10 years or 9-10 years of age, or approximately 6.5 years, 7 years, 7.5 years, 8 years, 8.5 years, 9 years, 9.5 years, 10 years, or 10.5 years of age. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least 1 , 2, 3, 4, 5 or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment. In some embodiments, the dose of alpha-Gal A the subject is receiving is changed to an alternating dose of 1 mg/kg and 2 mg/kg every other week, or an alternating dose of 1 mg/kg and 3 mg/kg every other week upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction and/or renal dysfunction. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. The first indication of renal dysfunction comprises one, two, or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac and Fabry renal pathology are described in Section 4.3, infra. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of renal dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in heart cells, such as cardiomyocytes, by, e.g., electron microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In certain embodiments, the subject is administered an immunomodulation therapy prior to the administration of at least the first dose of alpha-Gal A the subject receives. In some embodiments, the subject is monitored for anti-alpha-Gal A antibodies {e.g., the subject is monitored at least 1, 2, 3, 4, 5 or more times per year from the presence of anti-galactosidase A antibodies). Techniques known to one of skill in the art can be used to measure the concentration of anti-alpha-Gal A antibodies, such as ELISA and radioimmunoassay. In certain embodiments, the subject is administered an

immunomodulation therapy when anti-alpha-Gal A antibodies are detected in a biological sample from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha-Gal A being administered. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha-Gal A being administered. In some embodiments, the subject is administered an immunomodulation therapy prior to the administration of the first dose of alpha-Gal A the subject receives and prior to other doses of alpha-Gal A when anti-alpha-Gal A antibodies are detected in a biological sample from the subject. To minimize the antibody response to the alpha-Gal A, the alpha-Gal A can be administered by slow infusions.

[0034] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of alpha-Gal A once per month beginning when the subject is approximately 1-2 years, 1-4 years, 1-5 years, 2-3 years, 2-4 year, 2-5 years, 3-4 years, or 4-5 years of age, or approximately 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, or 5.5 years of age, wherein the subject has received immunomodulation therapy prior to the administration of the first dose of alpha-Gal A to the subject; and (b) increasing the dose of alpha-Gal A administered to the subject to 1-2 mg/kg every other week when the subject is approximately 7-8 years, 7-9 years, 7-10 years, 8-9 years, 8-10 years or 9-10 years of age, or approximately 6.5 years, 7 years, 7.5 years, 8 years, 8.5 years, 9 years, 9.5 years, 10 years, or 10.5 years of age. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least one, two, three, four, five or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or

responsiveness to treatment. In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment. In some embodiments, the dose of alpha-Gal A the human subject is receiving is changed to an alternating dose of 1 mg/kg and 2 mg/kg every other week, or an alternating dose of 1 mg/kg and 3 mg/kg every other week upon evidence of Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, and/or renal

dysfunction. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra The first indication of renal dysfunction comprises one, two, or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac and Fabry renal pathology are described in Section 4.3, infra. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of renal dysfunctin progressing described in Section 4.3, infra. Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in heart cells, such as cardiomyocytes, by, e.g., electron

microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as, GL3- in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In certain embodiments, the immunomodulation therapy is administered to the subject 30-60 minutes, 2-6 hours, 1-12 hours, 6-12 hours, 12-24 hours, 24-36 hours, 24- 48 hours, 36-48 hours, 48-72 hours, 3-5 days, 3-7 days, 5-7 days, 7-10 days, 7-14 days, or 12- 14 days before the subject is administered the first dose of alpha-Gal A. In other

embodiments, the immunomodulation therapy is administered to the subject 2-3 weeks, 2-4 weeks, or 4-6 weeks before the subject is administered the first dose of alpha-Gal A. In certain embodiments, immunomodulation therapy comprises administering anti-inflammatory agents before or when anti-alpha-Gal A antibodies are detected in a biological sample from the subject. To minimize the antibody response to the alpha-Gal A, the alpha-Gal A can be administered by slow infusions.

[0035] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg alpha-Gal A of once per month beginning when the subject is approximately 1-2 years, 1-4 years, 1-5 years, 2-3 years, 2-4 year, 2-5 years, 3-4 years, or 4-5 years of age, or approximately 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, or 5.5 years of age; and (b) increasing the dose of alpha-Gal A administered to the subject to 1 mg/kg EOW upon the first indication of evidence of Fabry cardiac pathology, Fabry renal pathology, renal dysfunction and/or cardiac dysfunction. The first indication of renal dysfunction comprises one, two or more of the early signs and symptoms of renal dysfunction described in Section 4.3, infra. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology and Fabry renal pathology are described in Section 4.3, infra. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least 1, 2, 3, 4, 5 or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 2 mg/kg, 3 mg/kg, 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, and/or renal dysfunction continues or progresses and/or any evidence cerebral dysfunction.

Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of renal dysfunction progression described in Section 4.3, infra. Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in heart cells, such as cardiomyocytes, by, e.g., electron microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glycolipids, such as GL3, in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In certain embodiments, the subject is administered an immunomodulation therapy prior to the administration of at least the first dose of alpha-Gal A the subject receives. In specific embodiments, the subject is

administered an immunomodulation therapy prior to and/or concurrently with the

administration of at least the first dose of alpha-Gal A the subject receives and 1-5 days, 1-4 days, 1-3 days, 2 days or 1 day after the administration of the dose of alpha-Gal A. In some embodiments, the subject is monitored for anti-alpha-Gal A antibodies (e.g., the subject is monitored at least 1, 2, 3, 4, 5 or more times per year from the presence of anti-galactosidase A antibodies). Techniques known to one of skill in the art can be used to measure the concentration of anti-alpha-Gal A antibodies, such as ELISA and radioimmunoassay. In certain embodiments, the subject is administered an immunomodulation therapy when anti- alpha-Gal A antibodies are detected in a biological sample from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha- Gal A being administered. In certain embodiments, the subject is administered an

[0036] In another embodiment, provided herein is a method for treating classic Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the classic phenotype of Fabry disease a dose of 1 mg/kg of alpha-Gal A every other week beginning when the subject is approximately 2-3 years, 2-4 year, 2-5 years, 3-4 years, or 4-5 years of age, or

approximately 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, 5 years, or 5.5 years of age; and (b) increasing the dose of alpha-Gal A administered to the subject and/or the frequency of administration of the dose if there is evidence of Fabry cardiac pathology, Fabry renal pathology, renal dysfunction, cardiac dysfunction and/or cerebral dysfunction.

Evidence of Fabry renal pathology, Fabry cardiac pathology, renal dysfunction, renal dysfunction, and/or cerebral dysfunction are described herein, in particular, in Section 4.3, infra. In specific embodiments, the subject is monitored regularly prior to and during alpha- Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least 1, 2, 3, 4, 5 or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In some embodiments, the subject is monitored every 3-6 months, 4-6 months, 2-6 months, 3-5 months or 3-7 months for disease progression and/or responsiveness to treatment. In some embodiments, the dose of alpha-Gal A the subject is receiving is changed to an alternating dose of 1 mg/kg and 2 mg/kg every other week, or an alternating dose of 1 mg/kg and 3 mg/kg every other week upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction, and/or renal dysfunction. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. The first indication of renal dysfunction comprises one, two or more of the early signs and symptoms of renal dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology and Fabry renal pathology are described in Section 4.3, infra. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased

incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction is continuing or progressing and/or any evidence of cerebral dysfunction. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of renal dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in heart cells, such as cardiomyocytes, by, e.g., electron microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as, GL3, in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In certain embodiments, the subject is administered an immunomodulation therapy prior to the administration of at least the first dose of alpha-Gal A the subject receives. In specific embodiments, the subject is administered an immunomodulation therapy prior to and/or concurrently with the administration of at least the first dose of alpha-Gal A the subject receives and 1-5 days, 1-4 days, 1-3 days, 2 days or 1 day after the administration of the dose of alpha-Gal A. In some embodiments, the subject is monitored for anti-alpha-Gal A antibodies (e.g., the subject is monitored at least 1, 2, 3, 4, 5 or more times per year from the presence of anti-galactosidase A antibodies). Techniques known to one of skill in the art can be used to measure the concentration of anti-alpha-Gal A antibodies, such as ELISA and radioimmunoassay. In certain embodiments, the subject is administered an immunomodulation therapy when anti- alpha-Gal A antibodies are detected in a biological sample from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha- Gal A being administered. In certain embodiments, the subject is administered an

[0037] In certain embodiments, the therapeutic regimens for treating patients with the classic phenotype of Fabry disease described herein further include the administration of one or more of the following: (1) a pharmacological chaperone for alpha-Gal A, (2) a beta-2 agonist, (3) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide (lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2), globotriaosylceramide (GL-3), lysoglobotriaosylceramide (lyso-GL3), globoside (GL-4), and/or lysogloboside (lyso-GL-4), such as, e.g., a glycosylceramide synthase, a glycosyltransferase and/or glucosyltransferase, (4) an siRNA designed to reduce the glycosyltransferase specific RNA, such as, e.g., galactosyltransferase and/or

glucosyltransferase, (5) any other therapy that may reduce and/or prevent substrate accumulation, and/or (6) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation. In some embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, an siRNA designed to reduce the glycosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of the first dose of alpha-Gal A to the subject. In other embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of , lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, an siRNA designed to reduce the galactosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of each dose of alpha-Gal A the subject receives. In yet other embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, an siRNA designed to reduce the glycosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of at least the administration of the increased dose of 1 mg/kg of alpha-Gal A to the subject every other week.

[0038] In another aspect, presented herein are therapeutic regimens directed to the treatment of patients with the later-onset phenotype of Fabry disease. In one embodiment, described herein is a method for treating later-onset Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the later-onset phenotype of Fabry disease 1 mg/kg of alpha- Gal A every week, every other week, or once per month; and (b) increasing the dose of alpha- Gal A administered to the subject to 2 mg/kg or 3 mg/kg every other week or once per month upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction and/or renal dysfunction. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology and Fabry renal pathology are described in Section 4.3, infra. The first indication of renal dysfunction comprises one, two or more of the early signs and symptoms of renal dysfunction described in Section 4.3, infra. In specific embodiments, the subject with later-onset Fabry disease was diagnosed with the disease as a newborn or before symptoms of the disease began to manifest. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least one, two, three, four, five or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In some embodiments, the subject with Fabry disease of the later-onset phenotype (in specific embodiments, males with later- onset phenotype) is monitored every 1-2 years beginning at about age 10-15 years, 15-20 years, 20-25 years, or 25-30 years and the subject is monitored annually at about age 15-20 years, 20-25 years, 25-30 years, 30-35 or 35-40 years. In certain embodiments, the subject with the later-onset phenotype of Fabry disease is approximately 15-20 years, 20-30 years, 25-30 years, 30-35 years, 35-40 years, or 40-45 years of age when administration of 1 mg/kg of alpha-Gal A every other week or once per month to the subject is initiated. In other embodiments, the subject with the later-onset phenotype of Fabry disease is approximately 15 years, 16 years, 17 years, 18 years, 19 years, 20 years, 21 years, 22 years, 23 years, 24 years, 25 years, 26 years, 27 years, 28 years, 29 years, 30 years, 31 years, 32 years, 33 years, 34 years, 35 years, 36 years, 37 years, 38 years, 39 years or 40 years of age when administration of 1 mg/kg of alpha-Gal A every other week or once per month to the subject is initiated. In some embodiments, the administration of 1 mg/kg of alpha-Gal A every other week or once per month to the subject with later-onset phenotype Fabry disease begins when certain biochemical, biomarker and/or clinical features are detected. In a specific embodiment, the administration of 1 mg/kg of alpha-Gal A every other week or once per month to the subject with later-onset phenotype Fabry disease begins when elevated levels of GL-3, elevated levels of lysoGL-3, elevated levels of sphingosine-1 -phosphate, and/or elevated levels of cytokines (e.g., cytokines involved in inflammation, such as, e.g., TNF-alpha) are detected in a biological sample (e.g., plasma or urine) from the subject. In certain embodiments, the administration of 1 mg/kg of alpha-Gal A every other week or once per month to the subject with later-onset phenotype Fabry disease begins when the subject displays early signs and symptoms of Fabry disease, such as those provided in Section 4.2, infra. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction is continuing or progressing. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of Fabry renal pathology continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of Fabry renal pathology described in Section 4.3, infra. Evidence of Fabry cardiac pathology continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of Fabry cardiac pathology described in Section 4.3, infra. In certain embodiments, the subject is monitored for anti-alpha-Gal A antibodies. For example, the subject may be monitored at least 1, 2, 3, 4, 5 or more times per year for the presence of anti-alpha-Gal A antibodies. In some embodiments, the subject is administered an immunomodulation therapy when anti- alpha-Gal A antibodies are detected in a biological sample {e.g., plasma or blood sample) from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha-Gal A being administered. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha-Gal A being administered. Techniques known to one of skill in the art can be used to measure anti-alpha galactosidase A antibody concentrations, such as ELISAs and radioimmunoassays. In specific embodiments, the immunomodulation therapy is

administered prior to the administration of alpha-Gal A.

[0039] In another embodiment, described herein is a method for treating later-onset Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with the later-onset phenotype of Fabry disease upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction and/or renal dysfunction 1 mg/kg of alpha- Gal A EOW; and (b) increasing the dose of alpha-Gal A administered to the subject upon the evidence of continued or progressive Fabry cardiac pathology, Fabry renal pathology, renal dysfunction and/or cardiac dysfunction and/or any evidence of cerebral dysfunction. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction is continuing or progressing, and/or any evidence of cerebral dysfunction. The first indication of cardiac dysfunction comprises one, two or more of the early signs and symptoms of cardiac dysfunction described in Section 4.3, infra. The first indication of renal dysfunction comprises one, two or more of the early signs and symptoms of renal dysfunction described in Section 4.3, infra. Evidence of Fabry cardiac pathology and Fabry renal pathology are described in Section 4.3, infra. Evidence of cardiac dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of cardiac dysfunction described in Section 4.3, infra. Evidence of renal dysfunction continuing or progressing comprises one, two or more of the signs and symptoms of the continuance or progression of renal dysfunction described in Section 4.3, infra.

Evidence of Fabry cardiac pathology continuing or progressing comprises detecting increasing accumulation of glyco lipids, such as GL3, in heart cells, such as cardiomyocytes, by, e.g., electron microscopy over time. Evidence of Fabry renal pathology continuing or progressing comprises detecting increasing accumulation of glycolipids, such as, GL3- in renal cells, such as podocytes, by, e.g., electron microscopy over time. Evidence of cerebral dysfunction comprises one, two or more of the signs and symptoms of cerebral dysfunction described in Section 4.3, infra. In specific embodiments, the subject with later-onset Fabry disease was diagnosed with the disease as a newborn or before symptoms of the disease began to manifest. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or

responsiveness to treatment. In certain embodiments, the subject is monitored at least one, two, three, four, five or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In some embodiments, the subject with Fabry disease of the later-onset phenotype (in specific embodiments, males with later-onset phenotype) is monitored every 1-2 years beginning at about age 10-15 years, 15-20 years, 20-25 years, or 25-30 years and the subject is monitored annually at about age 15-20 years, 20-25 years, 25-30 years, 30-35 or 35-40 years. In certain embodiments, the subject with the later-onset phenotype of Fabry disease is approximately 15-20 years, 20-30 years, 25-30 years, 30-35 years, 35-40 years, or 40-45 years of age when administration of 1 mg/kg of alpha-Gal A EOW to the subject is initiated. In other embodiments, the subject with the later-onset phenotype of Fabry disease is approximately 15 years, 16 years, 17 years, 18 years, 19 years, 20 years, 21 years, 22 years, 23 years, 24 years, 25 years, 26 years, 27 years, 28 years, 29 years, 30 years, 31 years, 32 years, 33 years, 34 years, 35 years, 36 years, 37 years, 38 years, 39 years or 40 years of age when administration of 1 mg/kg of alpha-Gal A EOW to the subject is initiated. In certain embodiments, the subject is monitored for anti-alpha-Gal A antibodies. For example, the subject may be monitored at least 1 , 2, 3, 4, 5 or more times per year for the presence of anti-alpha-Gal A antibodies. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are detected in a biological sample (e.g. , plasma, blood, or biopsy sample) from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha-Gal A being administered. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha-Gal A being administered. Techniques known to one of skill in the art can be used to measure anti-alpha galactosidase A antibody concentrations, such as ELISAs and radioimmunoassays.

[0040] In another embodiment, described herein is a method for treating later-onset Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with later-onset phenotype of Fabry disease that has advanced cardiac dysfunction and/or renal dysfunction a dose of 2 mg/kg to 5 mg/kg, 2 mg/kg to 4 mg/kg, or 2 mg/kg, 3 mg/kg, 4 mg/kg or 5 mg/kg of alpha- Gal A EOW; and (b) increasing the dose of alpha-Gal A administered to the subject upon the evidence of significant cardiac and/or renal disease (e.g., significant hypertrophy, arrthymia, chronic kidney disease (such as, e.g., stage 3 or 4 chronic kidney disease), renal failure, decreased glomerular filtration rate, and/or proteinuria). In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 1 1 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is evidence of significant cardiac and/or renal disease. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least one, two, three, four, five or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In specific embodiments, the subject with the later-onset phenotype of Fabry disease was only diagnosed with Fabry disease when symptoms of cardiac and/or renal dysfunction were detected. In certain embodiments, the subject with the later-onset phenotype of Fabry disease is approximately 25-30 years, 30-35 years, 35-40 years, or 40-45 years of age when administration of 2 mg/kg to 5 mg/kg, 2 mg/kg to 4 mg/kg, or 2 mg/kg, 3 mg/kg, 4 mg/kg or 5 mg/kg of alpha-Gal A EOW to the subject is initiated. In other embodiments, the subject with the later-onset phenotype of Fabry disease is approximately 15 years, 16 years, 17 years, 18 years, 19 years, 20 years, 21 years, 22 years, 23 years, 24 years, 25 years, 26 years, 27 years, 28 years, 29 years, 30 years, 31 years, 32 years, 33 years, 34 years, 35 years, 36 years, 37 years, 38 years, 39 years or 40 years of age when administration of 2 mg/kg to 5 mg/kg, 2 mg/kg to 4 mg/kg, or 2 mg/kg, 3 mg/kg, 4 mg/kg or 5 mg/kg of alpha-Gal A EOW to the subject is initiated. In certain embodiments, the subject is monitored for anti-alpha-Gal A antibodies. For example, the subject may be monitored at least 1, 2, 3, 4, 5 or more times per year for the presence of anti- alpha-Gal A antibodies. In some embodiments, the subject is administered an

immunomodulation therapy when anti-alpha-Gal A antibodies are detected in a biological sample (e.g., plasma, blood, or biopsy sample) from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha-Gal A being administered. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha-Gal A being administered.

[0041] In another embodiment, described herein is a method for treating later-onset Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) monitoring a subject that has a mutation associated with the later-onset phenotype of Fabray disease subject regularly (e.g., at least one, two, three, four, five or more times per year) for one or more biomarkers, such as described in Section 4.2, infra, and e.g., GL3, lysoGL3, GL-4, or lyso-GL-4; (b) administering a dose of 1 mg/kg of alpha-GalA once per month to the subject if the one or more biomarkers, such as GL3, lysoGL3 GL-4, or lyso-GL-4, are altered (e.g., elevated) relative to levels of the one or more biomarkers in a healthy patient(s) without Fabry disease; and (c) maintaining the dose of 1 mg/kg of alpha-GalA once per month if the levels of the one or more biomarkers, such as GL3, lysoGL3, GL-4, or lyso-GL-4, are within the range found in a healthy patient(s) without Fabry disease, and increasing the dose of alpha-Gal A administered to the subject and/or frequency of administration of the dose of alpha-Gal A to the subject if the levels of the one or more biomarkers has not improved after a certain period of time (e.g., 3, 4, 5, 6, 7, 8, 9 or more doses of alpha-GalA) or is worse relative the levels of the one or more biomarkers found in a healthy patient(s) without Fabry disease. In specific embodiments, the one or more biomarkers are GL3, lysoGL3, GL-4, and/or lyso-GL-4 and the dose and/or frequency of administration of the alpha-GalA is increased if the GL3 and/or lysoGL3 are increased relative to the levels of GL3, lysoGL3, GL-4, and/or lyso-GL-4 found in a healthy patient(s) without Fabry disease. In certain embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 1 mg/kg, 2 mg/kg, 3 mg/kg, 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 1 1 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is increase in one or more biomarkers, such as GL3, lysoGL3, GL-4, or lyso-GL-4. In certain embodiments, the subject with the mutation associated with the later-onset phenotype of Fabry disease is monitored for the levels of one or more biomarkers beginning at the age of 5-10 years, 8-10 years, 8-12 years, 10-15 years or 15-20 years old. In specific embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or

responsiveness to treatment. In certain embodiments, the subject is monitored at least one, two, three, four, five or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored for anti-alpha-Gal A antibodies. For example, the subject may be monitored at least 1 , 2, 3, 4, 5 or more times per year for the presence of anti- alpha-Gal A antibodies. In some embodiments, the subject is administered an

[0042] In another embodiment, described herein is a method for treating later-onset Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a subject with later-onset phenotype of Fabry disease a dose of 1 mg/kg of alpha-Gal A once per month; (b) monitoring the subject regularly (e.g., prior to or during alpha-Gal A enzyme replacement, or at least one, two, three, four, five or more times per year) for one or more biomarkers, such as described in Section 4.2, infra, and e.g., GL3, lysoGL3, GL-4, or lyso-GL-4; and (c) increasing the dose of alpha- Gal A administered to the subject and/or frequency of administration of the dose of alpha-Gal A to the subject if the levels of the one or more biomarkers increases. In certain

embodiments, the dose of alpha-Gal A the subject is receiving is increased incrementally in 0.5 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, or 2.5 mg/kg increments, or 0.5 to 1 mg/kg, 0.75 to 1 mg/kg, or 1 mg/kg to 2 mg/kg increments to up to 1 mg/kg, 2 mg/kg, 3 mg/kg, 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg or 20 mg/kg every other week if there is increase in one or more biomarkers, such as GL3 or lysoGL3. In specific

embodiments, the subject is monitored regularly prior to and during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored at least one, two, three, four, five or more times per year prior to and/or during alpha-Gal A enzyme replacement therapy for disease progression and/or responsiveness to treatment. In certain embodiments, the subject is monitored for anti-alpha-Gal A antibodies. For example, the subject may be monitored at least 1, 2, 3, 4, 5 or more times per year for the presence of anti-alpha-Gal A antibodies. In some

embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are detected in a biological sample (e.g., plasma, blood, or biopsy sample) from the subject. In some embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of any of the enzymatic activity of the alpha-Gal A being administered. In certain embodiments, the subject is administered an immunomodulation therapy when anti-alpha-Gal A antibodies are at titer that results in the loss of 10% to 50%, 10% to 25%, 10% to 20%, 10% to 15%, or 25% to 50%, or 10%, 15%, 20%, 30%, 35%, 40%, 45%, 50% or more of the enzymatic activity of the alpha- Gal A being administered. [0043] In certain embodiments, the therapeutic regimens for treating patients with the later-onset phenotype of Fabry disease described herein further include the administration of one, two or more of the following: (1) a pharmacological chaperone for alpha-Gal A, (2) a beta-2 agonist, (3) an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, such as, e.g., a glycosylceramide synthase, and/or a glycosyltransferase , (4) an siR A designed to reduce the

glycosyltransferase specific RNA, such as, e.g., galactosyltransferase, (5) any other therapy that may reduce and/or prevent substrate accumulation, and/or (6) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation. In some embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL- 1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso GL-4, an siRNA designed to reduce the glycosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha- Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of the first dose of alpha-Gal A to the subject. In other embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, an siRNA designed to reduce the glycosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of each dose of alpha-Gal A the subject receives. In yet other embodiments, the therapeutic regimen comprises administering a pharmacological chaperone for alpha-Gal A, a beta-2 agonist, an inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, an siRNA designed to reduce the galactosyltransferase specific RNA, a therapy that reduces and/or prevents substrate accumulation, or a therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of at least the administration of the increased dose of 2 mg/kg or 3 mg/kg of alpha-Gal A to the subject every other week.

[0044] In another aspect, provided herein are therapeutic regimens for treating Fabry disease comprising the administration of alpha-Gal A in combination with another therapy. In certain embodiments, the other therapy enhances the activity of the alpha-Gal A and/or reduces the dose of alpha-Gal A needed to effectively treat Fabry disease. In a specific embodiment, provided herein is a method for treating Fabry disease comprising administering alpha-Gal A in a therapeutic regimen, wherein the therapeutic regimen comprises

administering to a subject with Fabry disease alpha-Gal A in combination with one, two, three or more of the following: (1) an immunomodulation therapy, (2) a pharmacological chaperone for alpha-Gal A, (3) a beta-2 agonist, (4) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide (lysoGL-1), galabiosylceramide (GL-2), lysogalabiosylceramide (lysoGL-2), globotriaosylceramide (GL-3), lysogloboside (lyso-GL3), globoside (GL-4), and/orlysogloboside (lyso-GL-4), such as, e.g., a

glycosylceramide synthase, a galactosyltransferase, a lactosylceramide 4-a- galactosyltransferase, a globotriaosylceramide 3-P-N-acetylgalactosaminyltransferase, an N- acetylgalactosamine glycosyltransferase, a globoside hydrolase, a globotetraosylceramide synthase, and/or glucosyltransferase, etc., (5) an siR A designed to reduce

glycosyltransferase specific R A, such as, e.g., a specific glucosyltransferaseand/or galactosyltransferase, (6) any other therapy that may reduce and/or prevent substrate accumulation, and/or (7) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation, cardiac hypertrophy and/or inflammation. In certain embodiments, the therapeutic regimen for treating Fabry disease comprises administering to a subject with Fabry disease recombinant human alpha-Gal A {e.g., agalsidase alfa or agalsidase beta or a biosimilar) at the currently approved doses or a lower dose in combination with one, two, three or more of the following: (1) an immunomodulation therapy, (2) a pharmacological chaperone for alpha-Gal A, (3) a beta-2 agonist, (4) an inhibitor of an enzyme involved in the synthesis of glucosylceramide (GL-1), lysoglucosylceramide (lysoGL-1), galabiosylceramide (GL-2),

lysogalabiosylceramide (lysoGL-2), globotriaosylceramide (GL-3), lysogloboside (lyso-GL3; otherwise known as globotriaosylsphingosine), globoside (GL-4), and/or lysogloboside (lyso- GL-4), such as, e.g., a glycosylceramide synthase, a galactosyltransferase, a lactosylceramide 4-a-galactosyltransferase, a globotriaosylceramide 3-P-N-acetylgalactosaminyltransferase, an N-acetylgalactosamine glycosyltransferase, a globoside hydrolase, a globotetraosylceramide synthase, and/or glucosyltransferase, etc., (5) an siRNA designed to reduce a

glycosyltransferase specific RNA, such as, e.g., a galactosyltransferase and/or

glucosyltransferase, (6) any other therapy that may reduce and/or prevent substrate accumulation, and/or (7) any other therapy that prevents and/or reduces any secondary effect of alpha-Gal A enzyme deficiency, such as, e.g., smooth muscle proliferation and/or inflammation. In some embodiments, the immunomodulation therapy, pharmacological chaperone for alpha-Gal A, beta-2 agonist, the inhibitor of an enzyme involved in the synthesis of GL-1 , lysoGL-1 , GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, the siRNA designed to reduce a glycosyltransferase specific RNA, the therapy that reduces and/or prevents substrate accumulation, or the therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of the first dose of alpha-Gal A to the subject. In other embodiments, the immunomodulation therapy, pharmacological chaperone for alpha-Gal A, beta-2 agonist, the inhibitor of an enzyme involved in the synthesis of GL-1 , lysoGL-1 , GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4, the siRNA designed to reduce a glycosyltransferase specific RNA, the therapy that reduces and/or prevents substrate accumulation, or the therapy that prevents or reduces any secondary effect of alpha-Gal A enzyme deficiency prior to, concurrently with and/or subsequent to the administration of each dose of alpha-Gal A the subject receives.

[0045] In certain embodiments, the immunomodulation therapy used in accordance with the methods described herein comprises any therapy known to one of skill in the art that will modulate the immune system to reduce the antibody response generated following the administration of a foreign protein. In a specific embodiments, the immunomodulation therapy used in accordance with the methods described herein comprises one, two, three or more of the following: methotrexate, an anti-CD20 antibody (e.g., ritixumab), anti-CD4 antibody, plasmapheresis, cyclophosphamide, bortezomib (Velcade®, Millenium

Pharmaceuticals, Inc.), rapamycin and/or gamma globulin. The dose and the route of administration of the immunomodulation therapy will vary depending upon the type of therapy. In a specific embodiment, the immunomodulation therapy used in accordance with the methods described herein comprises bortezomib (Velcade) in combination with rituximab, methotrexate, and intravenous immunoglobulin. In certain embodiments, bortezomib (Velcade) is only used when other immunomodulation therapies are not effective.

[0046] In certain embodiments, the pharmacological chaperone for alpha-Gal A used in accordance with the methods described herein is any pharmacological chaperone for alpha- Gal A known to one skilled in the art. In some embodiments, the pharmacological chaperone for alpha-galactosidase is 2,5-dideoxy-2,5-imino-D-mannitol, 2,4-diepz-a-homonojirimycin, 5-O-a-D-galactopyranosyl-a-homonojirimycin, 1 -deoxygalactonojirimycin, 4-epi-fagomine, calystegine A₃, calystegine B₂, or calystegine B₃. In certain embodiments, the dose of the pharmacological chaperone administered to the subject is between 0.5 and 1000 mg/kg of body weight, 0.5 and 100 mg/kg of body weight, 1 and 50 mg/kg of body weight, 1 and 25 mg/kg of body weight, or 1 and 10 mg/kg of body weight. See, e.g., International Publication Nos. WO 1999/062517 and WO2010/015816, and U.S. Patent No. 6,274,597, which are incorporated herein by reference in their entirety, for examples of pharmacological chaperones for alpha-Gal A and doses for pharmacological chaperones. In a specific embodiment, the pharmacological chaperone for alpha-Gal A used in accordance with the methods described herein is AT 1001 (GR181413A, 1-deoxygalactonojirimycin, migalastat hydrochloride). See, e.g., International Publication No. WO 2012/125402, which in incorporated herein by reference in its entirety, for information regarding 1- deoxygalactonojirimycin, migalastat hydrochloride and the administration of 1- deoxygalactonojirimycin, migalastat hydrochloride in combination with alpha-Gal A enzyme replacement therapy to a subject with Fabry disease, including dosing information, the frequency of administration and the route of administration. In a specific embodiment, a dose of 50 mg to 600 mg, 100 mg to 600 mg, 150 mg to 600 mg, 50 mg to 500 mg, 100 mg to 500 mg, 150 mg to 500 mg, 50 mg to 450 mg, 100 mg to 450 mg, 150 to 450 mg, 50 mg to 400 mg, 100 mg to 400 mg, 150 mg to 400 mg, 50 mg to 300 mg, 100 mg to 300 mg, 150 to 300 mg, 50 mg to 200 mg, or 100 mg to 200 mg of 1-deoxygalactonojirimycin, migalastat hydrochloride is administered prior to, concurrently with and/or subsequent to the

administration of a dose of alpha-Gal A. In another specific embodiment, a dose of 50 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 350 mg, 400 mg, 450 mg, 500 mg, 550 mg, or 600 mg of 1-deoxygalactonojirimycin, migalastat hydrochloride is administered prior to, concurrently with and/or subsequent to the administration of a dose of alpha-Gal A. In a specific embodiment, the 1-deoxygalactonojirimycin, migalastata hydrochloride is administered to the subject orally. In certain embodiments, a pharmacological chaperone is administered to subjects with Fabry disease of the later-onset phenotype. In other embodiments, a pharmacological chaperone is administered to subjects with Fabry disease of the classic and/or later-onset phenotype.

[0047] In certain embodiments, the beta-2 agonist used in accordance with the methods described herein is any beta-2 agonist known to one skilled in the art to enhance cation- independent mannose-6-phosphate receptor. In a specific embodiment, the beta-2 agonist is clenbuterol. In other embodiments, the beta-2 agonist is formoterol, salmeterol, or albuterol. In certain embodiments, the dose of beta-2 agonist used will vary depending upon the beta-2 agonist selected. In some embodiments, the beta-2 agonist is administered at a dose of 1 to 100 micrograms/kg, 5 to 75 micrograms/kg, 10 to 50 micrograms/kg, 25 to 50 micrograms/kg, 5 to 25 micrograms/kg, or 1 to 10 micrograms/kg. The route of the beta-2 agonist will also vary with the beta-2 agonist selected. In certain embodiments, the beta-2 agonist is administered orally, by inhalation, intramuscularly or intravenously.

[0048] In certain embodiments, the inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4, and/or lyso-GL-4 is a

glycosylceramide synthase inhibitor. In a specific embodiment, the glycosylceramide synthase inhibitor is eliglustat tartrate ((1 R, 2i?)-octanonic acid [2-(2', 3'-dihydro- benzol[ 1 ,4] dioxin-6-yl)-2-hydroxyl- 1 -pyrrolidin- 1 -ylmethyl-ethyl]-amide-L-tartaric acid salt). In certain embodiments, eliglustat tartrate is administered to a subject at a dose of 25- 500 mg per day, 50-400 mg per day, 50-300 mg per day, 50-200 mg per day, or 25-100 mg per day. See, e.g., Lukina et al, 2010, Blood 116: 893-899 for information regarding eliglustat tartrate. In some embodiments, the inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, lyso-GL3, GL-4 and/or lyso-GL-4 is a glycosyltransferase inhibitor. In other embodiments, the inhibitor of an enzyme involved in the synthesis of GL-1, lysoGL-1, GL-2, lysoGL-2, GL-3, and/or lyso-GL3 is a

galactosyltransferase inhibitor, or GL-4 is a N-acteyl-galactosiminyltransferase.

[0049] In certain embodiments, the siRNA designed to reduce the glycosyltransferase specific RNA, such as, e.g. , galactosyltransferase and/or glucosyltransferase RNA, is administered at a dose of 0.01 mg/kg to 10 mg/kg of a subject's body weight. The frequency of administration of the siRNA will vary depending upon the durability of the effect. In certain embodiments, the siRNA is administered to the subject every 1-2 weeks, every 1-4 weeks, or every 2-4 weeks. In some embodiments, the siRNA designed to reduce the galactosyltransferase specific RNA is directed/targeted to the liver, kidney, heart, and/bone marrow of a subject.

[0050] In certain embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is and/or has received gene transfer and mutation-corrected induced pluriopotent stem cells (iPS) derived from the subject. In a specific embodiment, the stems cells are engineered to enhance the expression and activity of alpha-Gal A. In specific embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is a human male. In other embodiments, the subject administered alpha-Gal A in accordance with the methods described herein is a female heterozygous for Fabry disease.

[0051] In certain embodiments, the therapy that prevents and/or reduces inflammation is any therapy known to one of skill in the art to modulate the inflammatory response in a subject. In a specific embodiment, the therapy that prevents and/or reduces inflammation comprises one, two or more of the following: a Toll-like receptor inhibitor (such as, e.g., a Toll-like receptor 4 inhibitor), a TNF-alpha inhibitor (e.g., Remicade®), and/or Petosan polysulfate. In a specific embodiment, the therapy that prevents and/or reduces inflammation comprises Remicade® or Petocan polysulfate. In certain embodiments, the therapy is an antiinflammatory agent that reduces TNF-alpha and/or inflammatory cytokines, such as IL-6. The dose, frequency of administration and route of administration of the therapy will vary depending upon the modulator of inflammation selected.

4.2 METHODS FOR DIAGNOSING FABRY DISEASE

[0052] Any technique known to one of skill in the art for diagnosing Fabry disease can be used in accordance with the methods described herein. Early detection of Fabry disease is advantageous in preventing complications due to the accumulation of globtriaosylceramide (GL-3) and related alpha-galactosyl compounds, including renal and cardiac complications. The early detection of Fabry disease enables the subject to be monitored routinely for progression of the disease and for enzyme replacement therapy with alpha-Gal A to begin early. In a specific embodiment, subjects with a family history of Fabry disease, newborns, and subjects presenting with signs and symptoms of Fabry disease are screened for Fabry disease.

[0053] Early signs and symptoms of Fabry disease include: neuropathic pain {e.g., episodic crises characterized by agonizing burning pain originating the extremities and radiating inwards to the limbs and other parts of the body; and chronic pain characterized by burning and tingling paraesthesias called acroparesthesias), abdominal pain, heat intolerance, tinnitus, postprandial ischemic symptoms including bloating and pain, angiokeratomas, hypohidrosis, and the characteristic corneal and lenticular opacities. The enzymatic activity of alpha-Gal A in a biological sample {e.g., plasma sample, leukocyte sample or dried blood spot) obtained from subjects can be used to biochemically diagnose Fabry disease, particularly in males. The enzymatic activity of alpha-Gal A can be assessed using techniques known to one of skill in the art. Little or no alpha-Gal A activity in a biological sample {e.g., plasma sample, leukocyte sample or dried blood spot) from a male subject can be used to confirm the diagnosis of Fabry disease.

[0054] In certain embodiments, the enzymatic activity of alpha-GalA is measured and responsiveness to a pharmacologoical chaperone, such as 1-deoxygalactonojirimycin is assessed by, e.g., Western blot assay and in patient's T-lymphocytes. This type of analysis provides a functional characterization of alpha-GalA mutations. See, e.g., Lukas et al., 2013, PLOS Genetics 9(8): el003632 for a description of this type of analysis.

[0055] In addition to assessing the enzymatic activity of alpha-Gal A, genotyping can be done on a biological sample from a subject. In female heterozygotes, the enzymatic activity of alpha-Gal A may fall within the normal range so genotyping should be conducted.

Leukocytes or a dried blood spot from a subject may be used for genotyping. Any technique known to one of skill in the art may be used to genotype. For example, genotyping can be done by direct sequencing of exons and adjacent flanking regions, and by multiplex ligation- dependent probe amplification (MLPA) for crytic alpha-Gal A mutations. The genotype of a subject can be compared to known genotypes, such as those available in The Human Gene Mutation Database, to identify whether a subject has Fabry disease of the classic phenotype or the later-onset phenotype.

[0056] In certain embodiments, Fabry disease is diagnosed preimplantation without abortion. In other embodiments, Fabry disease is diagnosed prenatally by measuring the enzymatic activity of alpha-Gal A in direct and/or cultured chorionic villi at about 10 weeks of pregnancy or in cultured amniotic cells at about 14 weeks of pregnancy, or by an alpha- Gal- A- family specific mutation(s).

[0057] In certain embodiments, the concentration of a biomarker in a biological sample from a subject is used to diagnose Fabry disease. In some embodiments, the concentration of a biomarker in a biological sample from a subject is used to assess progression of Fabry disease and/or responsiveness to alpha-Gal A enzyme replacement therapy. GL-3 levels in the plasma and urine of males with Fabry disease are usually elevated relative to healthy subjects. Females with Fabry disease may or may not have elevated GL-3 levels in their plasma and urine. In a specific embodiment, plasma and/or urinary GL-3 levels are measured to diagnose Fabry disease. In certain embodiments, the plasma and/or urinary GL-3 levels are measured to diagnose Fabry disease of the classic phenotype and/or later-onset phenotype. In some embodiments, the plasma and/or urinary GL-3 levels are measured to assess progression of Fabry disease and/or responsiveness to alpha-Gal A enzyme

replacement therapy. For example, an increase in plasma and/or urinary GL-3 levels for a subject relative to plasma and/or urinary GL-3 levels at an earlier point in time for the subject may indicate that the subject's Fabry disease is progressing and/or that the dose alpha-Gal A enzyme that the subject is receiving is not high enough. Techniques known to one of skill in the art can be used to measure GL-3 and levels. For example, routine glycolipid analysis procedures by gas-liquid chromatography, tandem MS, stable isotope ultraperformance liquid chromatography-tandem mass spectrometry, atmospheric pressure photoionization mass spectrometry (APPI-MS) can be used to measure GL-3 levels.

[0058] Lysoglobotriaosylceramide (lysoGL3; otherwise known as

globotriaosylsphingosine) levels in the plasma and urine of males with Fabry disease are elevated relative to healthy subjects. Females with Fabry disease may or may not have elevated lysoGL-3 levels in their plasma and urine. In a specific embodiment, plasma and/or urinary lysoGL-3 levels are measured to diagnose Fabry disease. In certain embodiments, the plasma and/or urinary lysoGL-3 levels are measured to diagnose Fabry disease of the classic phenotype. In some embodiments, the plasma and/or urinary lysoGL-3 levels are measured to assess progression of Fabry disease and/or responsiveness to alpha-Gal A enzyme replacement therapy. For example, an increase in plasma and/or urinary lysoGL-3 levels for a subject relative to plasma and/or urinary lysoGL-3 levels at an earlier point in time for the subject may indicate that the subject's Fabry disease is progressing and/or that the dose alpha-Gal A enzyme that the subject is receiving is not high enough. Techniques known to one of skill in the art can be used to measure lysoGL-3 levels. For example, routine gly co lipid analysis procedures by gas-liquid chromatography, tandem MS, stable isotope ultraperformance liquid chromatography-tandem mass spectrometry, atmospheric pressure photoionization mass spectrometry (APPI-MS) can be used to measure lysoGL-3 levels. See, e.g., Aerts et ah, 2008, PNAS USA 109: 2812-2817 for assays to measure glycosphingolipids and in particular, lysoGL3.

[0059] TNF-alpha, certain other cytokines {e.g., inflammatory cytokines) and/or sphingosine-1 -phosphate levels are elevated in the plasma of subjects with Fabry disease. In a specific embodiment, plasma levels of TNF-alpha, cytokine and/or sphingosine-1 - phosphate levels are measured to diagnose Fabry disease. In certain embodiments, the plasma TNF-alpha, cytokine and/or sphingosine-1 -phosphate levels are measured to diagnose Fabry disease of the classic phenotype. In some embodiments, the plasma TNF-alpha, cytokine and/or sphinogsine-1 -phosphate levels are measured to assess progression of Fabry disease and/or responsiveness to alpha-Gal A enzyme replacement therapy. For example, an increase in plasma TNF-alpha, cytokine and/or sphinogsine-1 -phosphate levels for a subject relative to plasma sphinogsine-1 -phosphate levels at an earlier point in time for the subject may indicate that the subject's Fabry disease is progressing and/or that the dose alpha-Gal A enzyme that the subject is receiving is not high enough. Techniques known to one of skill in the art can be used to measure TNF-alpha, cytokines and sphingosine-1 -phosphate levels. For example, liquid chromatography-tandem mass spectrometry can be used to measure sphingosine-1 -phosphate levels.

[0060] Efforts are focused on identifying Fabry disease biomarkers that can serve as indicators of the severity, progression and effectiveness of treatment. Assessment of these biomarkers are included herein.

4.3 METHODS FOR DETECTING CARDIAC

AND RENAL DYSFUNCTION

[0061] In certain embodiments, subjects diagnosed with Fabry disease are monitored at least 1 , 2, 3, 4, 5 or more times per year for disease progression and/or responsiveness to alpha-Gal A enzyme replacement therapy. In specific embodiments, subjects diagnosed with Fabry disease are monitored for one, two or more of the following: renal involvement, cardiac involvement, neurologic involvement (including assessment of neuropathic pain, brain white matter lesions by MRI, etc.), ocular manifestations, respiratory involvement, and gastrointestinal involvement. Renal involvement can be assessed by one, two or more of the following: serum creatinine, albumin excretion, cy statin C, glomerular filtration rate

("GFR"), total protein, urinary sodium excretion, morning spot for urinary protein/creatinine ratio, urinary GL-3 and urinary lysoGL-3. Cardiac involvement can be assessed by one, two or more of the following: the presence palpitations, angina, blood pressure, ECG (e.g., echocardiography 2-D with Doppler or speckle tracking echocardiography), Holier monitoring, cardiac MRI (e.g., strain-encoded cardiac MRI), and coronary angiography. Neurologic involvement can be assessed by one, two or more of the following: the presence of acroparethesias, fatigue, fever, heat and cold tolerance, and stroke-related symptoms, neurologic examination (e.g., questionnaires such as Brief Pain Inventory), brain MRI, positron tomography (PET), trans-cranial Doppler, proton MR spectroscopy, magnetic resonance angiography, cholesterol levels (e.g., total cholesterol, LDL and HDL), triglyceride levels, Lpa levels, and total plasma homocysteine levels. Ocular manifestations can be assessed by slit-lamp examination, direct ophthalmoscopy, and other ophthalmological exams. Respiratory involvement can be assessed by one, two or more of the following:

exertional dyspnea, exercise intolerance, wheezing, coughing and spirometry.

Gastrointestinal involvement can be assessed by the presence of postprandial abdominal pain, bloating, diarrhea, nausea, vomiting, and difficulty gaining weight, and endoscopic evaluations. [0062] Early signs and symptoms of renal dysfunction include microabluminuira, proteinuria, hyperfiltration, increased urinary GL-3 secretion. As renal dysfunction continues or progresses, proteinuria worsens, isothenuira accompanied by alterations in tubular reabsorption, secretion and excretion develop, reduced GFR develops, azotemia develops, fibrosis develops, sclerosis develops, and tubular atrophy progresses.

[0063] Early signs and symptoms of cardiac dysfunction include impaired heart rate variability, arrhythmias, ECG abnormalities, left ventricular hypertrophy (detected by, e.g., left ventricular mass and left venticular wall thickness), reduction in left venticular function, and valvular insufficiency. In certain embodiments, elevated levels of N-terminal pro-brain natriuretic peptide and/or troponin IC in a biological sample (e.g., serum) from a subject diagnosed with Fabry disease indicate cardiac dysfunction. As cardiac dysfunction continues or progresses, left venticular hypertrophy increases, left venticular function decreases, right ventricular hypertrophy develops, and fibrosis develops.

[0064] Signs and symptoms of cerebral dysfunction include headaches (ranging from mild to severe), vertigo/dizziness, white matter lesions, transient ischemic attacks, strokes (e.g. , mini-strokes or larger strokes) and vascular dementia.

[0065] Techniques known to one skilled in the art can be used to assess evidence of Fabry cardiac pathology and/or Fabry renal pathology. Evidence of Fabry cardiac pathology can be assessed by increased glyco lipids, such as GL3, accumulation in heart cells, such as cardiomyocytes, by, e.g., electron microscopy. In a specific embodiment, a cardiac biopsy is obtained from a patient and the accumulation of glyco lipids, such as GL-3, in heart cells, such as cardiomyocytes, is assessed and/or structural and/or morphological changes are observed in the heart tissue. Evidence of Fabry renal pathology can be assessed by increased glyco lipids, such as GL3, in renal cells, such as podocytes, by, e.g., electron microscopy. In a specific embodiment, a renal biopsy is obtained from a patient and the accumulation of glyco lipids, such as GL3, in renal cells, such as podocytes, by e.g., electron microscopy, is assessed and/or structural and/or morphological changes are observed in the renal tissue.

4.4 ALPHA-GAL AC TO SID ASE A ENZYME

[0066] Alpha-galactosidase A refers to any form the alpha-Gal A enzyme that retains the ability to hydrolyze the terminal alpha-galactosyl residue from glycolipids and glycoproteins, such as glycosphingolipids as assessed by techniques known to one of skill in the art, such as those described in U.S. Patent No. 5,580,757 and International Publication No. WO

1994/012628, which are incorporated herein by reference in their entirety.

[0067] In a specific embodiment, the alpha-Gal A enzyme is a human alpha-Gal A. In another specific embodiment, the human alpha-Gal A enzyme has the amino acid sequence found at UniProtKB/Swiss-Prot. Accession No. P06280.

[0068] In one embodiment, the alpha-Gal A is a modified form of human alpha-Gal A that has increased affinity for a natural receptor of human alpha-Gal A relative to unmodified human alpha-Gal A. In a specific embodiment, the alpha-Gal A is conjugated to an oligosaccharide, such as described in U.S. Patent No. 7,001,994 and International Patent Application Publication No. WO 2010/075010 (which are incorporated herein by reference in their entirety), to increase the targeting the enzyme for its natural receptor. In another embodiment, the alpha-Gal A is a modified form of human alpha-Gal A that binds to an alternative receptor (e.g., intercellular adhesion molecule (ICAM) -1 which may increase targeting to organs, or the sortilin receptor in the kidney) than the natural receptor for alpha- Gal A. In an embodiment, the alpha-Gal A is a modified form of human alpha-Gal A that has increased stability relative to unmodified human alpha-Gal A.

[0069] In some embodiments, the alpha-Gal A is conjugated or fused, directly or indirectly, to a targeting moiety, such as insulin-like growth factor (IGF)-I, IGF-II, leptin, granulocyte colony stimulating factor (G-CSF), or a humanized antibody that binds to human insulin receptor (HIR). See, e.g., U.S. Patent Application Publication No. 2009/0029467 and U.S. Patent No. 7,560,424 (which is incorporated herein by reference in its entirety) for a discussion of the use of IGF-I as a targeting moiety for lysosomal storage enzymes, and U.S. Patent No. 7,396,811 (which is incorporated herein by reference by reference in its entirety) for a discussion of the use of IGF-II as a targeting moiety for lysosomal storage enzymes. The targeting moieties IGF-I and IGF-II can facilitate targeting the alpha-Gal A enzyme to the lysosome. For a discussion of the use of hormones, such as G-CSF and leptin as targeting moieties see, e.g., International Patent Application Publication No. WO 2007/091250 and U.S. Patent Application Publication No. 2010/0183577, which are incorporated herein by reference herein by reference in their entirety.

[0070] The alpha-Gal A enzyme can be produced by any method known in the art, including but not limited to recombinant DNA methods, cDNA cloning (see, e.g., U.S. Patent No. 5,580,757 and International Publication No. 1994/012628, which are incorporated herein by reference in their entirety for cDNA clones of human alpha-Gal A), genomic cloning, gene activation (see, e.g., U.S. Patent No. 5,641,670, which is incorporated herein by reference in its entirety for gene activation techniques), or selected cell lines (e.g., mammalian) that produce high levels of the alpha-Gal A enzyme. Alpha-Gal A as well as methods for producing alpha-Gal A are described, e.g., in U.S. Patent Nos. 5,580,757, 5,658,567 and 7,011,831, and International Publication No. WO 1994/012628; each of which is

incorporated herein by reference in its entirety.

[0071] In a specific embodiment, the alpha-Gal A is a recombinantly produced alpha-Gal A (e.g., a recombinantly produced human alpha-Gal A). Cell expression systems which possess the cellular machinery and elements for the proper processing, i.e., signal cleavage, glycosylation, phosphorylation and protein sorting are preferred. For example, mammalian cell expression systems are preferred for the expression of biologically active enzymes that are properly folded and processed; when administered in humans such expression products should exhibit proper tissue targeting and no adverse immunological reaction.

[0072] In some embodiments, the alpha-Gal A (e.g., human alpha-Gal A) is produced by overexpression of alpha-Gal A cDNA in avian cells, e.g., chicken or duck cells, including avian eggs, such as embryonated eggs. In certain embodiments, the alpha-Gal A (e.g., human alpha-Gal A) is produced by overexpression of alpha-Gal A cDNA in mammalian cells. In a specific embodiment, the human alpha-Gal A is produced by overexpression of human alpha- Gal A cDNA in Chinese hamster ovary (CHO) cells. In another specific embodiment, the mammalian cells are human cells. Examples of human cells that may be used to

recombinantly express alpha-Gal A (e.g. , human alpha-Gal A) include, but are not limited to Crucell Per.C6 cells, HT 1080 cells, HeLa cells, HEK 293 cells, HEK 293T cells, WI38 cells, HuT292 cells, LF 1043 (HEL) cells, MRC-5 cells, TMK-1 cells, BT483 cells, Hs578T cells, HTB2 cells, HTB3 cells, HTB4 cells, BT 20 cells, T47D cells. CRL7030 cells, HsS78Bst cells, 721 cells, A2780 cells, A172 cells., A253 cells, COR-L23/R23 cells, COV-434 cells, DU145 cells, DuCaP cells, EM2 cells, Saos-2 cells, U373 cells, WM39 cells, L132 cells, A- 5489 cells, G-293 cells, G-401 cells, CAKI-1 cells, RD cells, and YAR cells. Other exemplary human cells that may be used to express alpha-Gal A include those human cell lines listed in the Immuno Polymorphism Database of the European Molecular Biology Laboratory, and the database of the U.S. National Institutes of Health, as well as those commercially available form, for example, the American Type Culture Collection, Manassas, Virginia, and Lifeline Cell Technology, Walkersville, Maryland. When using human cell lines for production, recombinant human alpha-Gal A can be produced using cDNAs, gDNAs for human alpha-Gal A or by gene activation techniques such as those described in U.S. Patent No. 5,641,670 which is incorporated by reference herein in its entirety. [0073] Examples of other mammalian cells that may be used to produce alpha-Gal A (e.g., human alpha-Gal A) include, but are not limited to, Vera cells, VERY cells, BHK cells, COS cells, MDCK cells, or 3T3 cells. In certain embodiments, myeloma cells are used to produce alpha-Gal A (e.g., human alpha-Gal A). Non-limiting examples of myeloma cells include NSO cells, 45.6 TGI .7 cells, AF-2 clone 9B5 cells, AF-2 clone 9B5 cells, J558L cells, MOPC 315 cells, MPC-11 cells, NCI-H929 cells, NP cells, NSO/1 cells, P3 NS1 Ag4 cells, P3/NSl/l-Ag4-l cells, P3U1 cells, P3X63Ag8 cells, P3X63Ag8.653 cells, P3X63Ag8U. l cells, RPMI 8226 cells, Sp20-Agl4 cells, U266B1 cells, X63AG8.653 cells, Y3.Ag.l .2.3 cells, and YO cells.

[0074] In some embodiments, a plant cell culture system is used for expression of the alpha-Gal A. See, e.g., U.S. Patent Nos. 5,929,304; 7,504,560; 6,770,799; 6,551,820;

6,136,320; 6,034,298; 5,914,935; 5,612,487; and 5,484,719, U.S. patent application publication Nos. 2009/0208477, 2009/0082548, 2009/0053762, 2008/0038232,

2007/0275014 and 2006/0204487, and Shoji et al, 2008, Vaccine, 26(23):2930-2934, and D'Aoust et al, 2008, J. Plant Biotechnology, 6(9):930-940 (which are incorporated herein by reference in their entirety) for plant cells and methods for the production of proteins utilizing plant cell culture systems. In particular, U.S. patent application Nos. 2009/0208477,

2008/0038232 and 2006/0204487 describe the expression and production of enzymatically active high mannose lysosomal enzymes using transgenic plant root, particularly carrot cells. In a specific embodiment, carrot cells are engineered to express alpha-Gal A. In certain embodiments, algae (e.g., Chlamydomonas reinhardtii) may be engineered to express alpha- Gal A (see, e.g., Rasala et al., 2010, Plant Biotechnology Journal (Published online March 7, 2010, which is incorporated herein by reference in its entirety). In specific embodiments, these cells are only used if they are capable of producing properly folded, glycosylated, and phosphorylated alpha-Gal A.

[0075] In certain embodiments, the carbohydrate chains of the alpha-Gal A enzyme recombinantly expressed are remodeled by sequential treatment with various enzymes, such as neuraminidase, galactosidase and beta N-acetylglucosaminidase. See, e.g., U.S. Patent No. 5,549,892, which is incorporated herein by reference in its entirety, for a methods for remodeling carbohydrate chains of a lysosomal enzyme.

[0076] Uptake of alpha-Gal A, mediated by mannose-6-phosphate (M6P) can be enhanced by modification of alpha-Gal A to produce highly phosphorylated mannose residues and M6P. For example, alpha-Gal A can be modified by recombinant technology to introduce additional mannose-6-phosphate to the alpha-Gal A for enhancing cellular uptake. See, e.g., Matsuoka et al, 2010 Mole. Ther.l8: 1519-1526 which is incorporated herein by reference in its entirety. In other embodiments, alpha-Gal A can be coupled to highly phosphorylated oligosaccharide derivatives containing mannose 6-phosphate (M6P). See, e.g., U.S. Patent No. 7,001,994, U.S Patent Application Publication No. 2010/0173385 and International Publication No. WO2010/075010. In another approach, a yeast culture system can be used for the expression of recombinant alpha-Gal A that contains additional highly phosphorylated mannose-6-phosphate residues. See, e.g., Akeboshi et al, 2009 Glycobiology 19(9): 1002-1009 which is incorporated by reference herein in its entirety.

[0077] Once alpha-Gal A has been produced, it may be isolated or purified by any method known in the art for isolation or purification of a protein, for example, by

chromatography (e.g., ion exchange, high performance liquid chromatography, affinity, particularly by affinity for alpha-Gal A, by Protein A, and sizing column chromatography), centrifugation, differential solubility, or by any other standard technique for the isolation or purification of proteins. Where the alpha-Gal A enzyme is secreted by the cultured cells, alpha-Gal A may be readily recovered from the culture medium.

[0078] The alpha-Gal A enzyme can be formulated for any route of administration (e.g., infusion, subcutaneous, intramuscular, intrathecal, intraventricular, intranasal, inhalation or intradermal). In a specific embodiment, the alpha-galactosidase is administered by infusion. The alpha-Gal A enzyme can be supplied in a lyophilized form that is reconstituted before use with, e.g., sterile saline (e.g., 0.9 % sodium chloride) or sterile water. Alternatively, the alpha-Gal A enzyme can be supplied in an aqueous form. In some embodiments, the alpha- Gal A enzyme is administered to the patient by infusion using, e.g., a syringe pump or an infusion bag with a pump.

[0079] In certain embodiments, alpha-Gal A is administered to a subject in a carrier, such as liposomes or a polycationic carrier. See, e.g., U.S. Patent No. 5,716,614, which is incorporated herein by reference in its entirety, for a carriers that can be used to administered alpha-Gal A. In some embodiments, the alpha-Gal A is administered to a subject in a nanocarrier.

[0080] In specific embodiments, the alpha-Gal A used in the therapeutic regimens described herein is recombinant human alpha-Gal A. In a specific embodiment, the alpha- Gal A used in the therapeutic regimens described herein is agalsidase alfa (Replagal®, Shire). In particular embodiments, the alpha-Gal A used in the therapeutic regimens described herein is agalsidase alfa and it is administered to a subject by the route recommended by the manufacturer. In another specific embodiment, the alpha-Gal A used in the therapeutic regimens described herein is agalsidase beta (Fabrazyme®, Genzyme). In particular embodiments, the alpha-Gal A used in the therapeutic regimens described herein is agalsidase beta and it is administered to a subject by the route recommended by the manufacturer.

[0081] The foregoing is not to be limited in scope by the specific embodiments described herein. Indeed, various modifications of the methods provided herein and their equivalents, in addition to those described herein will become apparent to those skilled in the art from the foregoing description. Such modifications are intended to fall within the scope of the appended claims.

[0082] All references cited herein are incorporated herein by reference in their entirety and for all purposes to the same extent as if each individual publication or patent or patent application was specifically and individually indicated to be incorporated by reference in its entirety for all purposes.

Claims

We Claim:

1. A method for treating Fabry disease comprising administering recombinant human alpha-galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha-galactosidase A every other week from age 5; and (b) increasing the dose of recombinant human alpha-galactosidase A administered to the subject if there is evidence of renal dysfunction, Fabry renal pathology, cardiac dysfunction, Fabry cardiac pathology and/or cerebral dysfunction.

2. A method for treating classic Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha galactosidase A once per month beginning when the subject is approximately 1-5 years of age; and (b) increasing the dose schedule of recombinant human alpha galactosidase A administered to the subject to 1-2 mg/kg every other week when the subject is approximately 6-10 years of age.

3. A method for treating classic Fabry disease comprising administering recombinant alpha-galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha galactosidase A once per month beginning when the subject is approximately 1-5 years of age, wherein the subject has received immunomodulation therapy prior to the administration of the first dose of recombinant alpha- galactosidase A to the subject; and (b) increasing the dose schedule of recombinant human alpha galactosidase A administered to the subject to 1-2 mg/kg every other week when the subject is approximately 6-10 years of age.

4. A method for treating classic Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with the classic phenotype of Fabry disease a dose of 1-2 mg/kg of recombinant human alpha galactosidase A once per month beginning when the subject is approximately 1-5 years of age; and (b) increasing the dose schedule of recombinant human alpha galactosidase A administered to the subject to 1-3 mg/kg every other week upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of renal dysfunction and/or cardiac dysfunction.

5. A method for treating later-onset Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with the later-onset phenotype of Fabry disease 1 mg/kg of recombinant human alpha galactosidase A every other week; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject to 2 mg/kg or 3 mg/kg every other week upon the first indication of renal dysfunction, cardiac dysfunction, and/or neurologic manifestations.

6. A method for treating later-onset Fabry disease comprising administering recombinant human alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with the later-onset phenotype of Fabry disease upon evidence of Fabry cardiac pathology and/or Fabry renal pathology, and/or the first indication of cardiac dysfunction, and/or renal dysfunction 1-3 mg/kg of alpha-Gal A every other week; and (b) increasing the dose of recombinant human alpha galactosidase A administered to the subject upon the evidence of continued or progressive Fabry cardiac pathology, Fabry renal pathology, renal dysfunction and/or cardiac dysfunction, or any evidence of cerebral dysfunction.

7. A method for treating later onset Fabry disease comprising administering recombinant human alpha-galactosidase A in a therapeutic regimen, wherein the therapeutic regimen comprises: (a) administering to a human subject with later-onset phenotype of Fabry disease that has advanced cardiac dysfunction and/or renal dysfunction a dose of 2 mg/kg to 5 mg/kg of alpha-galactosidase A every other week; and (b) increasing the dose of recombinant human alpha glactosidase A administered to the subject upon the evidence of significant cardiac and/or renal disease.

8. A method for treating later-onset Fabry disease comprising administering recombinant alpha galactosidase A in a therapeutic regimen, wherein the therapeutic regiment comprises: (a) administering to a human male approximately 15-20 years old with the later- onset phenotype of Fabry disease 1 mg/kg of alpha-galactosidase A every month; and (b) increasing the dose schedule of alpha-galactosidase A administered to the subject to 1 mg/kg every other week upon evidence of Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction and/or renal dysfunction.

9. The method of claim 1 or 6, wherein the dose of recombinant human alpha- galactosidase A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg, 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that cardiac dysfunction, renal dysfunction, Fabry cardiac pathology, Fabry renal pathology and/or cerebral dysfunction.

10. The method of claim 2, 3, 4, or 8, wherein the dose of recombinant human alpha-galactosidase A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increments to up to 5 mg/kg, 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction or renal dysfunction is continuing or progressing, or any evidence of cerebral dysfunction.

11. The method of claim 7, wherein the dose of recombinant human alpha- galactosidase A the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increases to up to 5 m/kg, 10 mg/kg, 15 mg/kg or 20 mg/kg every other week upon if there is evidence that significant cardiac or renal disease.

12. The method of claim 3, wherein the immunodulation therapy is administered to the human subject prior to increasing the dose of recombinant human alpha-galactosidsase A to 1 mg/kg.

13. The method of any one of claims 1 , 2 or 4-8, wherein an immunomodulation therapy is adminsitered the human subject prior to administering the first dose of recombinant human alpha-galactosidase A to the subject.

14. The method of claim 3, wherein the immunomodulation therapy is

methotrexate.

15. The method of claim 13, wherein the immunomodulation therapy is methotrexate.

16. The method of claim 5, wherein the dose of recombinant human alpha- galactosidase A in the human subject is receiving is increased incrementally in 0.5 to 2 mg/kg increments up to 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg every other week upon evidence of continuing or progressing Fabry cardiac pathology, Fabry renal pathology, cardiac dysfunction, renal dysfunction, and/or neurologic manifestations.

17. The method of claim 3, wherein the immunomodulation therapy is an anti- CD20 monoclonal antibody.

18. The method of claim 13, wherein the immunomodulation therapy is an anti- CD20 monoclonal antibody.

19. The method of claim 3, wherein the immunomodulation therapy comprises a combination of an anti-CD20 monoclonal antibody, methotrexate and gammaglobulin.

20. The method of claim 13, wherein the immunomodulation therapy comprises a combination of an anti-CD20 monoclonal antibody, methotrexate and gammaglobulin.

21. The method of any one of claims 1-8, wherein the therapeutic regimen further comprises administering to the human subject a pharmacological chaperone prior to at least the first dose of recombinant human alpha-galactosidase A.

22. The method of claim 21, wherein the pharmacological chaperone is

GR181321A, 1-deoxygalactonojrimycin, which is migalastat hydrochloride.

23. The method of any one of claims 1-8, wherein the therapeutic regimen further comprises administering to the human subject a beta-2 agonist prior to at least the first dose of recombinant human alpha-galactosidase A.

24. The method of claim 23, wherein the beta-2 agonist is clenbuterol.

25. The method of any one of claims 1-8, wherein the therapeutic regimen further comprises administering a glucosyltransferase inhibitor prior to at least the first dose of recombinant human alpha-galactosidase A and as a co-therapy.

26. The method of any of of claims 1-8, wherein the therapeutic regimen further comprises administering anti-inflammatory agent.

27. The method of claim 26, wherein the anti-inflammatory agent is Remicade® or Petocan polysulfate.

28. The method of any one of claims 1-8, wherein the human subject is a male.

29. The method of any one of claims 1-8, wherein the recombinant human alpha- galactosidase A is agalsidase alfa.

30. The method of any one of claims 1-8, wherein the recombinant human alpha- galactosidase A is agalsidase beta.