2. Advances in Mitochondrial Disease
Darius J. Adams, M.D.
Genetics and Metabolism

3. Diagnostics and Therapeutics

5. Mitochondrial Function
genes involved in mitochondrial function
Combination of:
Nuclear DNA
Mitochondrial DNA
37 genes
Reference:

6. Diagnostics Critical to potential future therapies
Nuclear Gene discovery
Autosomal recessive mitochondrial genes
Autosomal dominant mitochondrial genes
X-linked

7. Next Generation Genomic Sequencing
Can analyze the coding regions 20,000 genes with one blood test
The targeted panels are based on clinical findings
Mito panels now with over 1,200 genes

8. Goals of Treatment Slow or arrest progression of symptoms
Increase mitochondrial ATP production
Support electron transfer
Inhibit free radicals
Stabilize OXPHOS complexes
Avoid drugs capable of affecting the respiratory complexes

9. Current Cofactor Treatment of Mitochondrial Disorders
L-Carnitine
Coenzyme Q10/Ubiqinone/CytoQ
L-Arginine
Alpha Lipoic Acid
Dietary manipulation (low carbohydrate diet)
Creatine (high energy phosphate bond)
Vit. C up to 4g/day
Vit. E 10 U/Kg/day
Vit. B1 (PDH), B2(CI&II), Nicotinamide/Niacin
Vit. B6, B12 and Biotin
Vit. K Menadione and Phylloquinone
Exercise

11. Experimental Cofactor Treatment of Mitochondrial disorders
Idebenone 90 mg/day similar to CoQ10 (experimental)
Succinate 6 g/day in MELAS and Complex I deficiency
Uridine (support general enzyme function)
Dichloroacetate (found to be harmful)
Organ transplantation
Physical therapy

12. Medications That Impact Mitochondria
AZT (Inhibitor to gamma polymerase)
Fialuridine antiviral agent for Treatment of Hepatitis B
Valproate, aspirin due to (effect on FAO or CoA sequestration)
Nucleoside analogues: didanosine, zalcitabine
Lamivudine and famciclovir are permitted
Gentamicin and Tetracyclines

13. Gene Therapy

14. Gene Therapy Challenges and Successes
Targeting gene insertion
Successfully inserting plasmids
Immune reactions
Use of Adeno-associated viral (AAV) vectors minimizes immune response
Differential tissue targeting
AAV vectors can target specific tissues like brain and liver

15. Gene Therapy
Success demonstrated in individuals with severe combined immunodeficiency (SCID)
Exploring direct injection vs. IV infusion of gene therapy
Advances in DNA diagnostics for mitochondrial disease allowing of possible gene correction

16. Lysosome

17. Active Trials in Gene Therapy
University of North Carolina, Dr. Steven Gray and Thomas Jefferson, Dr. David Wenger
Using AAV9 to transfer corrective gene for Krabbe disease (lysosomal storage disorder)
Discovered that may need a combination of a bone marrow transplant, intrathecal gene therapy and blood gene therapy

18. Going Forward
Now that we are able to obtain more precise diagnostics, targeting specific mutations associated with mitochondrial disorders can be explored
Start to prepare for human phase I trials

19. Personalized Treatment
It is likely, given the variety of mutations, gene therapy treatment will need to be customized to the individual
Will need specific replacement gene and to be placed in the transport vector

20. Model Vector Cassette
ITR RBE sequence
Transgene - ssDNA
Rep 68/78 mRNA
Promoter
PolyA
Rep 68/78 mRNA needed to integrate into chromosome 19 region that is devoid of active genes for permanent correction

21. Model of Gene Correction

22. Plasmids

23. How Do We Get There?
Likely will need proof of concept to be done at Academic Medical Centers
BioTech will likely be needed for clinical trial work as this will require vast resources to prove safety and efficacy
However, making advances on multiple fronts

24. Conclusion
Advancing our diagnostic abilities will allow for the implementation of targeted therapies
Nutritional and cofactor interventions continue to be refined
Genetic therapeutics are now much closer with advances in vector technology