Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/43—Enzymes; Proenzymes; Derivatives thereof
  • A61K38/46—Hydrolases (3)
  • A61K38/465—Hydrolases (3) acting on ester bonds (3.1), e.g. lipases, ribonucleases
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/13—Amines
  • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline
  • A61K31/137—Arylalkylamines, e.g. amphetamine, epinephrine, salbutamol, ephedrine or methadone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/43—Enzymes; Proenzymes; Derivatives thereof
  • A61K38/46—Hydrolases (3)
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Y—ENZYMES
  • C12Y301/00—Hydrolases acting on ester bonds (3.1)
  • C12Y301/03—Phosphoric monoester hydrolases (3.1.3)
  • C12Y301/03001—Alkaline phosphatase (3.1.3.1)

Definitions

• Enzyme replacement therapy has been successfully implemented to treat subjects with deficiencies in alkaline phosphatase (AP) activity.
• therapies are useful for treating bone mineralization defects associated with deficient AP activity.
• factors regulate bone formation and resorption including, for example, serum calcium and phosphate concentrations, and circulating parathyroid hormone (PTH).
• FGF23 for example, is a hormone that contributes to the regulation of calcium and phosphate homeostasis- promoting renal phosphate excretion and reducing circulating levels of active vitamin D (diminishing intestinal absorption of calcium).
• ERT treatment that leads to normalized bone formation can potentially have an effect on the production of modulators (e.g., hormones such as, for example, parathyroid hormone (PTH), or vitamin D) that regulate or are regulated by bone mineralization factors (e.g., serum calcium and phosphate).
• modulators e.g., hormones such as, for example, parathyroid hormone (PTH), or vitamin D
• PTH parathyroid hormone
• vitamin D e.g., vitamin D
• bone mineralization factors e.g., serum calcium and phosphate
• PTH also referred to as "parathormone” or “parathyrin,” is secreted by the parathyroid gland as an 84-amino acid polypeptide (9.4 kDa). PTH acts to increase the concentration of calcium (Ca 2+ ) in the blood by acting upon the parathyroid hormone 1 receptor (high levels of the parathyroid hormone 1 receptor are present in bone and kidney) and the parathyroid hormone 2 receptor (high levels of the parathyroid hormone 2 receptor are present in the central nervous system, pancreas, testes, and placenta).
• PTH enhances the release of calcium from the large reservoir contained in the bones by affecting bone resorption by modulation of expression of key genes that regulate bone resorption and formation.
• Bone resorption is the normal degradation of bone by osteoclasts, which are indirectly stimulated by PTH. Since osteoclasts do not have a receptor for PTH, PTH's effect is indirect, through stimulation of osteoblasts, the cells responsible for creating bone.
• PTH increases osteoblast expression of the receptor activator of nuclear factor kappa-B ligand (RANKL) and inhibits the expression of osteoprotegerin (OPG).
• OPG binds to RANKL and blocks it from interacting with RA K, a receptor for RA KL.
• the binding of RANKL to RANK stimulates fusion of osteoclasts into multinucleated osteoclasts, ultimately leading to bone resorption.
• the downregulation of OPG expression thus promotes bone resorption by osteoclasts.
• PTH production (synthesis of PTH) is stimulated with high serum levels of phosphates (often present in late stages of chronic kidney disease) by direct effect of serum phosphates on PTH synthesis in the parathyroid gland by promoting the stability of PTH.
• PTH negatively impacts retention of phosphates in kidneys (promoting loss through urine) affecting homeostasis of phosphates and calcium.
• the importance of this signaling pathway in the renal response to PTH is highlighted by the renal resistance to PTH associated with deficiency of PTH receptor G protein subunit (Gsaipha) deficiency in patients with pseudohypoparathyroidism.
• PTH also enhances the uptake of phosphate from the intestine and bones into the blood.
• PTH secretion of PTH is controlled chiefly by serum Ca 2+ through negative feedback, increased levels of calcium reduce PTH secretion, while diminished levels increase PTH secretion.
• Calcium-sensing receptors located on parathyroid cells are activated when Ca 2+ is elevated.
• G-protein coupled calcium receptors bind extracellular calcium and are found on the surface of a wide variety of cells distributed in the brain, heart, skin, stomach, parafollicular cells ("C ceils”), and other tissues. In the parathyroid gland, high concentrations of extracellular calcium result in activation of the Gq G-protein coupled cascade through the action of phospholipase C.
• PIP2 phosphatidyiinositoi 4,5-bisphosphate
• DAG diacylglyceroi
• PTH calcium-sensitive proteases in the storage granules.
• PTH Upon activation increase the cleavage of PTH (1-84) into carboxyi-terminai fragment, further reducing the amount of intact PTH in storage granules.
• PTH also increases the activity of 1-a-hydroxyiase enzyme, which converts 25-hydroxycholecalciferol to 1 ,25-dihydroxycholecalciferol, the active form of vitamin D in kidneys. Vitamin D decreases transcription of the PTH gene. Vitamin D deficiency (often seen in chronic renal disorders) thus causes increases in PTH production.
• FGF23 is another regulator of parathyroid function, it is secreted by osteocytes or osteoblasts in response to increased oral phosphate intake and other factors. If acts on kidney to reduce expression transporters of phosphates in kidney reducing phosphate retention, in early stages of chronic renal disease, levels of FGF23 are increased to help promote the urinary excretion of phosphates. Elevated FGF23 in chronic renal disorders reduces activity of the Vitamin D 1-a-hydroxylase enzyme and results low production of the active form of vitamin D. In the intestines, absorption of calcium is mediated by an increase in activated vitamin D.
• AP replacement therapy replaces part of a complex pathway, for example, for proper bone formation
• Such tracking may indicate therapeutic efficacy and/or may identify additional therapies that may become necessary as a result of AP replacement therapy.
• Described herein are methods for treating a subject with an alkaline phosphatase deficiency that comprise monitoring one or more analytes to determine additional therapeutic treatments and procedures.
• One aspect of the disclosure is directed to a method of treating a subject with an alkaline phosphatase deficiency, comprising: administering a therapeutically effective amount of an alkaline phosphatase; and monitoring the concentration of one or more bone mineralization analytes, wherein the monitoring the concentration of one or more bone mineralization anaiytes is indicative for at least one additional treatment regimen for the subject.
• the one or more bone mineralization analytes is at least one analyte selected from the group consisting of: vitamin D, Ca 2+ , and parathyroid hormone.
• a non-limiting example for all methods described herein provides that the alkaline phosphatase deficiency is hypophosphatemia.
• the alkaline phosphatase is a tissue non-specific alkaline phosphatase, a placental alkaline phosphatase, an intestinal alkaline phosphatase, an engineered alkaline phosphatase, a fusion protein comprising an alkaline phosphatase moiety, or a chimeric alkaline phosphatase.
• a non-limiting example for ail methods described herein provides that the alkaline phosphatase is asfotase alfa (STRENSIG®) (see, e.g. , U.S. Patent No. 7,763,712; International Pub. No.
• a non-limiting example for ail methods described herein provides that the bone mineralization analyte is Ca 2+ .
• a non-limiting example for ail methods described herein provides that the subject is determined to be hypocalcemia the method further comprising treating the subject with a therapeutically effective amount of calcium gluconate, calcium chloride, calcium arginate, vitamin D or a vitamin D analog or parathyroid hormone or a fragment or analog thereof.
• a non-limiting example for ail methods described herein provides that the subject is determined to be hypercalcemic, the method further comprising treating the subject with a therapeutically effective amount of a calcimimetic, a bisphosphonate, prednisone, intravenous fluids, or a diuretic.
• a non-limiting example for ail methods described herein provides that the calcimimetic is cinacalcet.
• a non-limiting example for all methods described herein provides that the bone mineralization analyte is parathyroid hormone, A non-limiting example for all methods described herein provides that the subject has a statistically significantly low serum
• the method further comprising treating the subject with surgery or by administering a therapeutically effective amount of a calcimimetic, parathyroid hormone or an analog thereof, or a bisphosphonate.
• a calcimimetic is cinacalcet.
• the bone mineralization analyte is vitamin D.
• the method further comprising administering a therapeutically effective amount of vitamin D or an analog thereof.
• FIG. 1 shows the mean results for serum PTH (Intact pmoi/L) over time by disease onset
• FIG. 2 shows mean laboratory test results over time for phosphate (mmol/L). The time axis refers to length of treatment with asfotase alfa in weeks. Bars at each timepoint represent 95% confidence intervals.
• FIG. 3 shows mean laboratory test results over time for 25-hydroxyvitamin D (mmol/L).
• the time axis refers to length of treatment with asfotase alfa in weeks. Bars at each time point represent 95% confidence intervals.
• FIG. 4 shows mean results for calcium (mmol/L) over time by disease onset and overall safety set.
• the time axis refers to length of treatment with asfotase alfa in weeks. Bars at each timepoint represent 95% confidence intervals.
• FIG. 5 shows calcium (top panel) and PTH levels (lower panel) with reference ranges for a single patient during treatment with asfotase.
• FIG. 6 shows the mean results for serum PTH (Intact, pmo!/L) over time through week 312 by disease onset (HPP phenotype) and overall safety set.
• the time axis shows length of treatment with asfotase alfa in weeks, "intact” indicates full length PTH (not the PTH fragment). Bars at each timepoint represent 95% confidence intervals.
• FIG. 7 shows mean laboratory test results over time through week 312 for phosphate (mmol/L).
• the time axis refers to length of treatment with asfotase alfa in weeks. Bars at each timepoint represent 95% confidence intervals.
• FIG. 8 shows mean laboratory test results over time through week 3 2 for 25
• hydroxyvitamin D (mmol/L).
• the time axis refers to length of treatment with asfotase alfa in weeks. Bars at each time point represent 95% confidence intervals.
• FIG. 9 shows mean results for calcium (mmol/L) over time through week 312 by disease onset and overall safety set.
• the time axis refers to length of treatment with asfotase alfa in weeks. Bars at each timepoint represent 95% confidence intervals.
• FIG. 10 shows the patient values for calcium (mmol/L) and PTH (pmol/L) as a function of treatment week for the patient of FIG. 5.
• Vertical lines mark the start and end of 3 mg/kg/week dosing and the start of 6 mg/kg/week dosing.
• FIG. 1 1 shows the amino acid sequence of asfotase alfa monomer (SEQ ID NO: 1). Asfotase alfa exists as a dimer with inter-subunit disulfide bonds. DETAI LED DESCRI PTION
• Described herein are materials and methods for monitoring and further treating subjects who are in need of treatment with an alkaline phosphatase or who are being treated with an alkaline phosphatase.
• Particular analytes can lead to additional treatments, for example, for hypocalcemia,
• the materials and methods described herein relate to monitoring and further treating subjects who are in need of alkaline phosphatase (AP) replacement therapy or who are undergoing AP replacement therapy.
• AP alkaline phosphatase
• the terms "individual,” “subject,” “host,” and “patient” are used interchangeably and refer to any subject for whom diagnosis, treatment, or therapy is desired, particularly humans. Other subjects may include cattle, dogs, cats, guinea pigs, rabbits, rats, mice, horses and the like.
• APs are responsible for dephosphorylating a variety of enzymes, and at least one isoform is substantially involved in bone mineralization and formation.
• TNAP tissue non-specific AP
• APs in humans- intestinal (ALPI), placental (ALPP) and tissue non-specific (TNAP; sometimes referred to as liver/bone/kidney AP or ALPL) in addition to germiine AP.
• TNAP is a membrane-anchored AP that is active extraceilulariy. Defects in TNAP result in, for example, elevated blood and/or urine levels of three phosphocompound substrates: inorganic pyrophosphate (PPi), phosphoethanolamine (PEA) and pyridoxal-5'-phosphate (PLP) (Whyte, M. , Endocr. Rev. , 15:439-81 , 1994).
• TNAP is primarily responsible for regulating serum PPi levels (major inhibitor of hydroxyapatite crystal deposition in the bone matrix), and, therefore, is important for bone formation and mineralization.
• Genetic defects in TNAP lead to diseases, conditions, or disorders associated with low or decreased bone mineralization symptoms, e.g. , hypophosphatasia (HPP).
• HPP hypophosphatasia
• HPP Hypophosphatasia
• APL thai encodes TNAP
• HPP is an ultra-rare genetic disorder whereby TNAP activity is either absent or barely detectable in affected patients. While differences in patterns of inheritance and mutations cause variability in age at symptom onset and disease severity, ail HPP patients share the same primary pathophysiological defect, the failure to mineralize bone matrix (resulting in rickets or osteomalacia) due to lack of TNAP.
• This primary defect in infants and children, alone or in combination with associated metabolic disturbances can lead to deformity of bones, impaired growth, and decreased motor performance.
• This primary pathophysiological mechanism can rapidly lead to progressive damage to multiple vital organs, seizures due to a CNS deficiency in functional vitamin B6, and developmental delays. Subjects with HPP, left untreated, can develop, for example, hypercalcemia, and hyperphosphatemia.
• HPP HPP
• perinatal onset in utero and at birth
• infantile onset post-natal to 6 months of age
• juvenile also described as childhood, onset from 6 months to 18 years
• adult onset after 18 years of age
• Other milder forms of the disease including benign perinatal HPP and odontohypophosphatasia, have also been described.
• Hypercalcemia and hypercalciuria are also common, and nephrocalcinosis with renal compromise may occur. Weakness and delayed motor development are also common complications of infantile-onset HPP and seizures may occur secondary to vitamin B6 deficiency in the central nervous system.
• Rachitic deformities including, for example, beading of the costochondral junctions, either bowed legs or knock-knees, and enlargement of the wrists, knees, and ankles from flared metaphyses, are common, and often result in short stature. Walking is frequently delayed, and a nonprogressive myopathy characterized by limb weakness, especially of the proximal muscles of the lower extremities, has also been described (Seshia, S. et a!., Arch. Dis. Child. , 65: 130-1 , 1990).
• Nephrocalcinosis may develop in juvenile-onset HPP as well.
• Radiographs often reveal the presence of osteopenia and chondrocaicinosis.
• deposition of calcium pyrophosphate dehydrate occurs, leading to PPi arthropathy.
• adult HPP has been described as 'mild', manifestations of the disease in adults can be severe and debilitating, often requiring multiple surgeries and the use of supportive devices to perform activities of daily living.
• ERT AP enzyme replacement therapy
• HPP AP enzyme replacement therapy
• ERT replaces an enzyme in subjects in whom that particular enzyme is deficient or absent. ERT does not affect the underlying genetic defect, but increases the concentration of enzyme in which ihe patient is deficient.
• the copy of the enzyme to be replaced can be a copy of the endogenous enzyme, an isoform of the enzyme, an orfhoiog of the enzyme, a chimeric version of the enzyme, a fusion protein with the relevant active site of the enzyme or an otherwise engineered version of the enzyme.
• ERT can be accomplished, for example, by providing the enzyme itself or by causing the enzyme to be expressed in particular tissues or cells of the subject (e.g., through gene therapy methods, mRNA methods, transcriptional or transiationai activation methods, etc.).
• Asfotase alfa or STRENSIG ⁇ is a dimeric fusion protein that comprises two monomers with a TNAP phosphatase domain fused to an Fc chain and a bone tag to target the molecule to bone.
• the APs described herein can be, for example, intact native proteins, modified proteins or fusion proteins. Fusion proteins can comprise, for example, sequences to stabilize the protein, increase residence time in a patient, and/or target the fusion protein to a particular tissue, e.g., bone. Fusion proteins, for example, can comprise Fc domains or albumin moieties.
• Bone tags are typically negatively charged regions, e.g., poiy-aspartate or
• po!y-giutamate sequences e.g., between about 5 to about 50, between about 10 to about 25, between about 67 to about 30, about 5, about 10, about 15, about 20, about 25, about 30, about 35, about 40, about 45, about 50 or more aspartates, glutamates, or other negatively charged amino acids (natural or non-naturally occurring).
• treatment of a subject with AP-ERT can result in, for example, hypocalcemia, hyperparathyroidism, hypophosphatemia, vitamin D deficiency, and/or symptoms or side effects thereof.
• Such situations can occur, for example, in cases where the mineral defect is profound and availability of calcium and phosphorous for formation of hydroxyapatite is not adequate (e.g., not enough supplementation in food, not enough utilization of the minerals available in the food or profound loss through urine).
• Treatment of one or more of these effects can lead to "overcorrection" of the effect, and, therefore, require additional treatment to reverse the overcorrection.
• monitoring of calcium, PTH, phosphate and vitamin D therefore, can improve the treatment of a subject in need of or being treated with AP-ERT.
• Described herein are also materials and methods for identifying subjects who, prior to or at the time of treatment, for example, AP-ERT, need to undergo treatment to normalize one or more metabolites associated with bone mineralization (e.g., PTH, Ca 2 ⁇ , vitamin D, and/or phosphate).
• AP-ERT a subject in need of AP-ERT, for example, who is hypocalcemic prior to AP-ERT treatment, would benefit from having normalized calcium levels prior to AP-ERT treatment.
• Routine urinalysis and serum hematology and chemistries can be obtained before, during and after treatment using AP-ERT (e.g., treatment with asfotase alfa).
• Calcium and phosphate metabolism should be monitored periodically with measurements of serum calcium, phosphate and PTH levels and urinary calcium excretion. Dietary intake of calcium should be adjusted according to PTH levels and urinary calcium levels (ionized and adjusted for other markers, e.g., creatinine or albumin).
• hypomineralization e.g., with HPP rickets or osteomalacia
• hypocalcemia-induced seizures can be useful for those patients whose calcium levels are statistically significantly low or high.
• an "engineered” moiecuie is one that can be isolated from natural sources, synthesized and/or modified chemically. If the engineered moiecuie is a biological molecule, an engineered molecule can be one that is mutagenized, fused to a second molecule, e.g., forming a fusion protein, attached to a specific functional moiety, e.g. , a targeting domain, purification domain, active site, etc, humanized, or made into a chimeric protein by switching particular domains with other proteins or isoforms.
• the engineering is the process of modifying the moiecuie in a particular manner to achieve a desirable result.
• fusion protein refers to an engineered protein that comprises residues of moieties from two or more different proteins. Fusion genes, which can be used to generate fusion proteins, are created through the joining of two or more coding sequences that code for separate proteins. Translation of a fusion gene results in a single or multiple polypeptides with functional properties derived from each of the original proteins. Recombinant fusion proteins are created by recombinant DNA technology.
• chimeric proteins are proteins that comprise moieties from at least two distinct proteins.
• the term refers to hybrid proteins made of polypeptides having different functions or physicochemical patterns.
• the subjects described herein have an AP activity defect.
• a defect can arise, for example, due to a genetic anomaly (e.g., a mutation) that causes the AP enzyme to not be produced or to be produced in an inactive form.
• a genetic anomaly e.g., a mutation
• AP defects that lead to bone mineralization defects, e.g., HPP.
• ERT-AP treatment for a bone mineralization disease, disorder, condition or symptoms thereof, e.g., HPP
• analytes that are indicative of the need for additional treatments or a need to alter the current treatment regimen, e.g., alter the dosage and/or frequency of dosage
• Treatment refers to the administration of a therapeutic agent or the performance of medical procedures with respect to a patient or subject, for any of prophylaxis (prevention), cure, or reduction of the symptoms of the disease, disorder, condition, or symptoms from which the subject suffers.
• Combination therapy can be achieved by administering two or more agents, each of which is formulated and administered separately, or by administering two or more agents in a single formulation.
• One active ingredient can be, for example, useful for treating, for example, a disease, disorder, condition or symptoms associated with a TNAP defect, e.g.,
• hypophosphatasemia or symptoms associated with treatment by the active agent ("side effects").
• side effects Other combinations are also encompassed by combination therapy.
• two or more agents can be formulated together and administered in conjunction with a separate formulation containing a third agent. While the two or more agents in the combination therapy can be administered simultaneously, they need not be.
• administration of a first agent (or combination of agents) can precede administration of a second agent (or combination of agents) by minutes, hours, days or weeks.
• the two or more agents can be
• a “therapeutically effective dosage” or “therapeutically effective amount” results in a decrease in severity of disease, disorder, condition or symptoms thereof (e.g., associated with aberrant AP activity, e.g., HPP), an increase in frequency and duration of disease symptom-free periods, or a prevention of impairment or disability due to the disease affliction.
• treatment with AP replacement therapy is more effective or leads to overall improved health or qualify of life, when the treated subject is further monitored for one or more additional analytes, PTH, calcium (Ca 2+ ), phosphate and vitamin D concentrations can each be monitored or individually monitored during AP-ERT, and the specific concentrations are indicative of, for example, efficacy of treatment and/or the need for one or more additional therapeutic regimen(s).
• PTH acts on osteoblasts in bone and tubular ceils within the kidney via G-protein-linked receptors that stimulate adenylate cyclase production of cyclic A P.
• PTH stimulates a process known as osteolysis in which calcium in the minute fluid-filled channels (canaliculi/lacunae) is taken up by syncytial processes of osteocytes and transferred to the external surface of the bone and, hence, into the extracellular fluid. Some hours later, it also stimulates resorption of mineralized bone; a process that releases both Ca 2 ⁇ and phosphate into the extracellular fluid.
• PTH concentration in a sample obtained from a subject is of interest for better treating the subject, as AP-ERT can have an effect on PTH concentration.
• a determination that the treated subject's serum PTH concentration is statistically significantly lower or higher than normal, for example, can lead to revised treatment plans (e.g., combining the AP-ERT plan with one or more therapeutic agents for treating, for example,
• hyperparathyroidism e.g. , with cinacaicet.
• the subject can be treated with higher levels of the AP-ERT, e.g., asfotase aifa, to reduce PTH levels in the case where a patient does not show good response in term of bone mineralization to initial dose.
• sample refers to biological material from a subject.
• samples can be derived from many biological sources, including, for example, single ceils, multiple cells, tissues, tumors, biological fluids, brain extracellular fluid, biological molecules or supernatants or extracts of any of the foregoing. Examples include tissue removed for biopsy, tissue removed during resection, blood, urine, lymph tissue, lymph fluid, cerebrospinal fluid, amniotic fluid, mucous and stool samples.
• the sample used will vary based on the assay format, the detection method and the nature of the tumors, tissues, fluids, ceils or extracts to be assayed. Methods for preparing samples are known in the art and can be readily adapted to obtain a sample that is compatible with the method utilized.
• statistical significance is a statistical term that informs as to the certainty that a difference or relationship exists, e.g., that a sample value id statistically significantly different from a normal or baseline value, it is conferred by finding a low probability of obtaining at least as extreme results given that the null hypothesis is true. It is an integral part of statistical hypothesis testing where it determines whether a null hypothesis can be rejected, in any experiment or observation that involves drawing a sample from a population, there is the possibility that an observed effect would have occurred due to sampling error alone.
• a test for statistical significance involves comparing a test value to some critical value for the statistic.
• the procedure to test for significance is the same- decide on the critical alpha level (i.e., the acceptable error rate), calculate the statistic and compare the statistic to a critical value obtained from a table.
• P-values the probability of obtaining the observed sample results (or a more extreme result) when the null hypothesis is actually true, are often coupled to a significance or alpha (a) level, which is also set ahead of time, usually at about 0.05 (5%).
• a p-value was found to be less than about 0.05, then the result would be considered statistically significant and the null hypothesis would be rejected.
• Other significance levels such as about 0.1 , about 0.075, about 0.025 or about 0.01 can also be used.
• a “statistically significantly low” concentration of an analyte is one that is lower than the normal or baseline situation for a control, e.g., healthy, subject.
• a “statistically significantly high” concentration of an analyte is one that is higher than the normal or baseline concentration of the analyte for a control subject.
• PTH promotes osteoclast function and leads to bone resorption, thereby increasing serum Ca 2+ and phosphate concentrations.
• Low levels of serum Ca 2+ fail to exhibit negative feedback effect on the release or production of PTH from the thyroid, whereas high
• vitamin D increases adsorption of Ca 2+ and phosphate in the intestine, leading to elevated levels of serum Ca 2+ and, therefore, lower bone resorption. Effects of active vitamin D (1 , 25 (OH) 2 D on bone, however, are diverse and can affect formation or resorption.
• hypoparathyroidism is one of the few major hormone deficiency diseases that is often not treated with the missing hormone, hormone replacement therapies are available.
• Bovine PTH has been purified and used as experimental treatment, however utility as a treatment was diminished, mainly because of antibody formation and costs.
• Approval of fully humanized truncated PTH (Teriparatide, PTH (1-34)) and intact parathyroid hormone (Preotact, PTH(1-84)) for treatment of osteoporosis has made the PTH drugs more accessible and thereby made clinical trials with PTH treatment of hypoPT feasible.
• Patients with hypoPT experience an improved quality of life when treated with PTH compared with conventional treatment with 1a-hydroxylated vitamin D metabolites and calcium supplements, although hypoPT is still treated, for example, by supplementing calcium and/or vitamin D.
• PTH Primary hyperparathyroidism results from a hyperfunction of the parathyroid glands. Over secretion of PTH can be due, for example, to a parathyroid adenoma, parathyroid hyperplasia or a parathyroid carcinoma. This disease is often characterized by the presence of kidney stones, hypercalcemia, constipation, peptic ulcers and depression.
• renal osteodystrophy hyperparathyroidism caused by renal failure.
• hyperparathyroidism which eventually leads to hyperplasia of the parathyroid glands and a loss of response to serum calcium levels.
• Quaternary and quintary hyperparathyroidism are rare conditions that may be observed after surgical removal of primary hyperparathyroidism, when it has led to renal damage that now again causes a form of secondary (quaternary) hyperparathyroidism that may itself result in autonomy (quintary) hyperparathyroidism. Additionally, quaternary hyperparathyroidism may ensue from hungry bone syndrome after parathyroidectomy.
• Primary hyperparathyroidism can be treated, for example, by surgery
• hyperparathyroidectomy if treatment, for example, with calcimimetics is unsuccessful.
• Secondary hyperparathyroidism can be treated, for example, by vitamin D supplementation and/or by the use of calcimimetics (e.g., cinacaicet).
• Other forms of hyperparathyroidism are variations of secondary hyperparathyroidism, and treatments involve approaches similar to those used for primary and secondary hyperparathyroidism.
• High plasma calcium stimulates calcitonin secretion, which lowers plasma calcium by inhibiting bone resorption.
• Normal blood calcium level is between about 8.5 to about 10.5 mg/dL (2.12 to
• hypocalcemia or hypercalcemia is characterized by a statistically significantly low or high serum calcium concentration.
• Hypocalcemic subjects typically display a serum calcium concentration of about 2.5 mg/dL or lower (Soreil, M. & Rosen, J., J. Pediatr,, 87:67-70, 1975).
• a hypocalcemic subject for example, can have serum calcium concentration of about 7.0 mg/cIL or lower, about 5,0 mg/dL or lower, about 1.0 mg/dL or lower, or about 0.5 mg/dL or lower.
• hypocalcemia includes hypoparathyroidism, vitamin D deficiency and chronic kidney disease.
• Symptoms of hypocalcemia include, for example, neuromuscular irritability (including tetany as manifested by Chvostek's sign or Trousseau's sign,
• Treatment options include, for example, supplementation of calcium and some form of vitamin D or its analogues, alone or in combination.
• Intravenous calcium gluconate 10% can be administered, or if the hypocalcemia is severe, calcium chloride can be given.
• Other treatments involve multivitamin
• Hypercalcemia is an elevated Ca 2+ level in the blood, which is often indicative of other disease(s). It can be due to excessive skeletal calcium release, increased intestinal calcium absorption or decreased renal calcium excretion. The neuromuscular symptoms of
• hypercalcemia are caused by a negative bathmotropic effect due to the increased interaction of calcium with sodium channels. Since calcium blocks sodium channels and inhibits
• Symptoms of hypercalcemia include, for example, renal or biliary stones, bone mineralization defects and bone pain, abdominal pain, nausea, vomiting, polyuria depression, anxiety, cognitive dysfunction, insomnia, coma, fatigue, anorexia and pancreatitis.
• Hypercalcemia is defined as a serum calcium level greater than about 10.5 mg/dL
• Hypercalcemia can also be classified based on total serum and ionized calcium levels, as follows: Mild: total calcium 10.5-11.9 mg/dL (2.5-3 mmol/L) or ionized calcium
• Hypercalcemia is treated a number of ways, including, for example, using fluids and diuretics for an initial therapy (hydration, increasing salt intake, and forced diuresis).
• Diuretic treatments include, for example, furosemide, and they can be given to permit continued large volume intravenous salt and water replacement while minimizing the risk of blood volume overload and pulmonary edema.
• loop diuretics tend to depress renal calcium reabsorption thereby helping to lower blood calcium levels. Caution must be taken to prevent potassium or magnesium depletion.
• Additional therapies include, for example,
• Bisphosphonates are pyrophosphate analogues with high affinity for bone, especially areas of high bone turnover. They are taken up by osteoclasts and inhibit osteoclastic bone resorption.
• Available drugs include, for example, etidronate, tiludronate, IV pamidronate, alendronate, zoledronate, and risedronate.
• Calcitonin blocks bone resorption and also increases urinary calcium excretion by inhibiting renal calcium reabsorption.
• Phosphate therapy can correct the hypophosphatemia in the face of hypercalcemia and lower serum calcium. Calcium mimetics, e.g., cinacalcet, are also used to lower serum calcium concentrations.
• Hypovifaminosis D is a deficiency of vitamin D. It can result from inadequate nutritional intake of vitamin D coupled with inadequate sunlight exposure (in particular sunlight with adequate ultraviolet B rays), disorders that limit vitamin D absorption, and conditions that impair the conversion of vitamin D into active metabolites including certain liver, kidney, and hereditary disorders. Deficiency results in impaired bone mineralization and leads to bone softening diseases including rickets in children and osteomalacia and osteoporosis in adults.
• mean and median PTH levels were notably higher in patients with infantile- and juvenile-onset HPP during the first 12 weeks of treatment compared with later time points, and were likely associated with the bone
• multivitamins, calcium, vitamin D, vitamin A, vitamin K, cinacalcet, pyridoxal phosphate calcium, and/or calcitonin were administered to patients in order to normalize PTH, calcium, and phosphate levels
• FIG. 1 provides the change in serum PTH over time in the clinical studies.
• Vitamin D in some cases was administered as an intramuscular injection or in combination dosages with calcium, vitamin A, and/or vitamin K.
• Caicifrioi, cholecalciferoi, and/or ergocalciferol were also administered as needed.
• Parathyroid Hormone mean and median PTH levels increased with treatment, most notably during the first 12 weeks of treatment with asfotase alfa. This increase was likely due to a physiologic response secondary to increases in the bone mineralization process associated with asfotase alfa treatment.
• the variability in PTH levels noted at Baseline and throughout treatment may be due to factors that affect PTH levels, including, but not limited to: age, body mass index (BMI), serum creatinine levels, serum calcium levels and vitamin D levels.
• BMI body mass index
• mean and median PTH levels were notably higher in patients with infantile- and juvenile-onset HPP during the first 12 weeks of treatment compared with later time points, and were likely associated with the bone mineralization process.
• Mean PTH levels in patients with adult-onset HPP tended to be lower than those observed in the infantile- and juvenile-onset HPP patients through approximately Week 72; there are several variables that can affect PTH levels (Table 1 and FIG. 1).
• Phosphate mean serum phosphate values were variable through Week 24 in patients with infantile-, juvenile- and adult-onset HPP, and then appeared to normalize and stabilize with continued treatment with asfotase alfa. Some decreases in serum phosphate levels appeared to coincide with decreases in serum calcium levels during the first several weeks of treatment, which were likely due to the intense bone mineralization processes occurring early in treatment (Table 1 and FIG. 2).
• Vitamin D changes over time for vitamin D were not clinically meaningful; some of the variability seen in vitamin D results may be reflective of concomitant vitamin D supplements taken by some patients.
• mean vitamin D values were consistently higher in patients with adult-onset HPP than in patients with infantile- or juvenile-onset HPP; however, higher values did decrease slightly over time.
• Mean and median vitamin D values in patients with infantile- and juvenile-onset HPP were relatively consistent over time (Table 1 and FIG. 3). Table 1. Changes from Baseline to Week 24 and last visit for serum Ca , PTH, phosphate and
• Vitamin D pooled safety set overall.

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