Gene Therapy for Spastic Paraplegia

Age: < 18

Sex: Male

Trial Phase: Phase 1

Sponsor: The Hospital for Sick Children

Must not be taking: Immune suppressants

Disqualifiers: Bleeding disorder, Active infection, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 2 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 9

Duration: Single dose

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to test a new gene therapy called MELPIDA for a rare genetic condition known as SPG50. The goal is to determine if MELPIDA is safe and tolerable for children under five with specific mutations in the AP4M1 gene, which cause neurological issues. MELPIDA is administered through a lumbar puncture, injecting the treatment directly into the spinal fluid. Children with confirmed SPG50, who exhibit neurological symptoms and whose parents can provide consent, may be suitable candidates for this trial. As a Phase 1 trial, this research focuses on understanding how MELPIDA works in people, offering participants the opportunity to be among the first to receive this new treatment.

Will I have to stop taking my current medications?

The trial protocol does not specify if you need to stop taking your current medications, but it mentions that any chronic drug treatment that creates unnecessary risks for gene transfer may be a concern. It's best to discuss your current medications with the trial team.

Is there any evidence suggesting that this treatment is likely to be safe for humans?

Research has shown that MELPIDA, a gene therapy, underwent testing in early animal studies. These studies suggest that MELPIDA is safe when administered directly into the spinal fluid. The dose used in these animal studies matches the one planned for the current trial.

Although MELPIDA will be tested in humans for the first time, early results are promising. They indicate that the treatment is safe, as no serious side effects appeared in earlier tests. This gives researchers confidence that the treatment will likely be well-tolerated in people. However, human responses can vary, so this trial will focus closely on safety. ^{1 2 3 4 5}

Why do researchers think this study treatment might be promising?

Unlike the standard treatments for spastic paraplegia, which mainly focus on managing symptoms through physical therapy and medications like muscle relaxants, MELPIDA is unique because it directly targets the genetic cause of the condition. Researchers are excited about MELPIDA because it involves a gene therapy approach, delivering therapeutic genes directly into the spinal fluid via a single intrathecal infusion. This method has the potential to address the root cause of spastic paraplegia at the molecular level, offering hope for long-term improvement rather than just temporary symptom relief.

What evidence suggests that MELPIDA might be an effective treatment for spastic paraplegia?

Research shows that MELPIDA, the investigational gene therapy for hereditary spastic paraplegia type 50 (SPG50), has shown promising results in early studies. These studies indicate that the treatment is safe and may help reduce muscle stiffness. The therapy uses a virus to deliver a healthy version of the AP4M1 gene into the spinal fluid, aiming to fix the genetic issue causing SPG50. In one case, a patient experienced stable muscle stiffness after receiving the therapy. While these early findings are encouraging, more research is needed to fully understand the therapy's effectiveness in people. ^{2 3 6 7 8}

Are You a Good Fit for This Trial?

This trial is for children under 5 with SPG50, a genetic disorder affecting movement. They must have specific mutations in the AP4M1 gene and be able to follow study procedures. Kids can't join if they've had other recent treatments, are on certain drugs, or have conditions that make the study's procedures risky.

Inclusion Criteria

Parent/legal guardian willing to provide written informed consent for their child prior to participation in the study

I have SPG50, confirmed by a DNA test showing specific mutations in the AP4M1 gene.

Subject able to comply with all protocol requirements and procedures

Exclusion Criteria

I cannot undergo certain procedures required in this study.

I haven't taken any experimental drugs in the last 30 days and don't plan to during the study.

I am allergic or cannot take MELPIDA or its components.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

1 visit (in-person)

Treatment

Single intrathecal infusion of MELPIDA administered through a lumbar puncture

Single dose

1 visit (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment

5 years

Multiple visits on Days 7, 30, 60, 90, 180, 270, 360, 540, 720, then annually for 3 years

What Are the Treatments Tested in This Trial?

Interventions

• MELPIDA

Trial Overview The trial tests MELPIDA, a gene therapy delivered directly into spinal fluid to treat SPG50. It's an initial safety test involving one dose and monitoring over five years with several follow-up visits after dosing.

How Is the Trial Designed?

Group I: MELPIDA Experimental Treatment 1 Intervention

A single intrathecal infusion of 10 mL at 1E14 vg/mL for a total dose of 1E15 vg (open-label)

MELPIDA is already approved in United States, Canada for the following indications:

Approved in United States as MELPIDA for:

• Spastic Paraplegia Type 50 (SPG50)

Approved in Canada as MELPIDA for:

• Spastic Paraplegia Type 50 (SPG50)

Who Is Running the Clinical Trial?

The Hospital for Sick Children

Lead Sponsor

Trials

724

Recruited

6,969,000+

Published Research Related to This Trial

A study of 107 brain MRI scans from 76 individuals with genetically confirmed AP-4-associated hereditary spastic paraplegia (AP-4-HSP) revealed a distinct imaging signature that includes a thin splenium of the corpus callosum and absent or thin anterior commissure, which can help diagnose the condition with about 99% sensitivity.

The research also found that reduced white matter volume correlates with the severity of motor symptoms, and some patients exhibited polymicrogyria, which is linked to a higher risk of seizures, highlighting the importance of early diagnosis and understanding the role of the AP-4 complex in brain development.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Systematic Analysis of Brain MRI Findings in Adaptor Protein Complex 4-Associated Hereditary Spastic Paraplegia. Ebrahimi-Fakhari, D., Alecu, JE., Ziegler, M., et al.[2022]

AAV9/AP4M1 gene therapy shows promise for treating spastic paraplegia 50 (SPG50) in preclinical studies, with effective phenotypic rescue observed in patient-derived fibroblasts and significant therapeutic benefits in Ap4m1-KO mice when treated early and with higher doses.

The therapy demonstrated an acceptable safety profile in toxicology studies across various species, including nonhuman primates, indicating that it is safe for potential use in human clinical trials for SPG50.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intrathecal AAV9/AP4M1 gene therapy for hereditary spastic paraplegia 50 shows safety and efficacy in preclinical studies. Chen, X., Dong, T., Hu, Y., et al.[2023]

In a mouse model of Charcot-Marie-Tooth disease type 4J (CMT4J), gene therapy using an AAV9 vector to deliver a human FIG4 sequence significantly improved survival, with treated mice living for at least 1 year compared to an average of 5 weeks for untreated mice.

The treatment also resulted in largely normal motor performance and minimal signs of neuropathy, indicating that AAV9-mediated delivery of FIG4 is both safe and effective in restoring function in this model of the disease.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

AAV9-mediated FIG4 delivery prolongs life span in Charcot-Marie-Tooth disease type 4J mouse model. Presa, M., Bailey, RM., Davis, C., et al.[2023]

The study successfully constructed both wild-type and mutant SPAST vectors to investigate hereditary spastic paraplegia, using COS7 cells for transfection and analysis.

Results showed that while wild-type spastin localized in the plasma membrane, the mutant spastin maintained the same localization and neither form co-localized with microtubules or mitochondria, suggesting a specific role for spastin that does not involve these cellular structures.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Construction of wild-type and mutant SPAST vectors for the study of molecular mechanism of hereditary spastic paraplegia]. Yan, YP., Pu, JL., Zhang, BR., et al.[2019]

In a trial involving 12 patients with hereditary spastic paraplegia (HSP), treatment with dalfampridine for 2 weeks led to significant improvements in walking ability, as measured by the Spastic Paraplegia Rating Scale and the Multiple Sclerosis Walking Scale.

The study found no serious adverse events, suggesting that dalfampridine is a safe option for improving mobility in patients with HSP.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Dalfampridine in hereditary spastic paraplegia: a prospective, open study. Béreau, M., Anheim, M., Chanson, JB., et al.[2018]

The study identifies a specific homozygous nonsense variant in the AP4M1 gene (c.1012C>T p.Arg338*) as a cause of AP4 deficiency syndrome, which includes symptoms like hypotonia, spastic paraplegia, and intellectual disability, based on exome sequencing of three patients from consanguineous families in the Middle East.

This variant appears to have a founder effect, suggesting a common ancestor of Turkish origin, as it has been reported in four patients from three other families worldwide, highlighting the genetic link and potential for targeted genetic counseling.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Putative founder effect of Arg338* AP4M1 (SPG50) variant causing severe intellectual disability, epilepsy and spastic paraplegia: Report of three families. Becker, A., Felici, C., Lambert, L., et al.[2023]

AAVrh10, a specific adeno-associated virus serotype, was found to be the most effective for gene delivery in a chronic spinal cord injury mouse model, showing the highest photon count in bioluminescence imaging and greater expression of the reporter protein Venus.

This serotype demonstrated favorable targeting of key cell types in the spinal cord, including neurons, astrocytes, and oligodendrocytes, suggesting its potential as a safe and effective tool for gene therapy in chronic spinal cord injuries.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The adeno-associated virus rh10 vector is an effective gene transfer system for chronic spinal cord injury. Hoshino, Y., Nishide, K., Nagoshi, N., et al.[2021]

AAV-mediated AP4M1 gene replacement therapy shows promise in preclinical studies for treating spastic paraplegia 50 (SPG50), demonstrating the ability to partially rescue functional defects in cellular and mouse models.

The therapy exhibited acceptable safety profiles in both rodent and monkey models, paving the way for potential clinical trials and representing a significant advancement in the search for effective treatments for SPG50.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Paving a way to treat spastic paraplegia 50. Brent, JR., Deng, HX.[2023]

Current treatments for hereditary spastic paraplegias (HSPs) mainly focus on alleviating symptoms but often fall short, highlighting the need for new therapeutic approaches.

Promising treatment targets for HSPs include oxidative stress and microtubule dynamics, with various clinical measures identified to assess treatment efficacy, such as the Spastic Paraplegia Rating Scale and gait velocity.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Clinical Trial Designs and Measures in Hereditary Spastic Paraplegias. Trummer, B., Haubenberger, D., Blackstone, C.[2020]

Intrathecal delivery of AAV6 or AAV9 vectors was found to be more effective than intraparenchymal injections for gene therapy targeting motor neurons, achieving broader distribution across the spinal cord in adult mice.

Using the cytomegalovirus (CMV) promoter with AAV6 or AAV9 vectors resulted in the highest levels of motor neuron transduction, indicating that both vector choice and promoter selection are crucial for effective gene therapy in motor neuron diseases.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of adeno-associated viral vector serotypes for spinal cord and motor neuron gene delivery. Snyder, BR., Gray, SJ., Quach, ET., et al.[2011]

Citations

1. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/36951961/

Intrathecal AAV9/AP4M1 gene therapy for hereditary spastic ... Intrathecal AAV9/AP4M1 gene therapy for hereditary spastic paraplegia 50 shows safety and efficacy in preclinical studies. J Clin Invest. 2023 ...

2. nature.com nature.com/articles/s41591-024-03078-4

AAV gene therapy for hereditary spastic paraplegia type 50 The primary outcome was safety, and secondary efficacy measures were related to spasticity. AAV9-AP4M1 was administered at 1 × 1015 vector ...

3. clinicaltrials.gov clinicaltrials.gov/study/NCT06692712

NCT06692712 | Phase 3, Open-label Study to Assess the ... This clinical study is a pivotal open-label phase 3 study designed to assess safety and efficacy of MELPIDA in individuals with SPG50. Official Title.

4. clinicaltrials.gov clinicaltrials.gov/study/NCT05518188

Melpida: Recombinant Adeno-associated Virus (serotype 9 ... MELPIDA is a gene therapy product being developed for the treatment of Spastic Paraplegia Type 50 (SPG50), which is one of a group of four genetic disorders.

5. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC12265280/

a case study of Elpida therapeutics and Melpida - PMC Within a year of Michael's gene therapy, he exhibited stabilization of spasticity, one of the efficacy outcomes for the trial, as measured by ...

6. jci.org jci.org/articles/view/164575

Intrathecal AAV9/AP4M1 gene therapy for hereditary ... AAV9/AP4M1 gene therapy for hereditary spastic paraplegia 50 shows safety and efficacy in preclinical studies

7. clinicaltrials.gov clinicaltrials.gov/study/NCT06069687

Study Details | NCT06069687 | Administration of MELPIDA ... The primary outcome will be the determination of the safety and tolerability of MELPIDA in patients with SPG50, based on development of toxicity. The secondary ...

8. clinicaltrial.be clinicaltrial.be/en/details/459188

Phase 3, Open-label Study to Assess the Efficacy and Safe... This clinical study is a pivotal open-label phase 3 study designed to assess safety and efficacy of MELPIDA in individuals with SPG50.