Lipid Storage Disorders Treatment & Management
- Author: Lynne Ierardi-Curto, MD, PhD; Chief Editor: Luis O Rohena, MD more...
Except for Gaucher and Fabry disease, treatment options are limited in patients with lipid storage disorders. Primarily, treatment is directed at symptomatic relief. No specific treatment is available for either form of GM1 gangliosidosis, Tay-Sachs disease, Sandhoff disease, fucosidosis, Krabbe disease or Schindler disease. These disorders pursue a relentless course, leading to death.
When possible, patients with Gaucher disease should be managed by a multidisciplinary team at a comprehensive Gaucher Center. Enzyme replacement therapy with recombinant beta-glucocerebrosidase (Cerezyme, Genzyme, Cambridge, Mass; VPRIV, Shire, Cambridge, Mass) is available for the treatment of symptomatic patients with Gaucher disease type 1.
Regular intravenous infusions of recombinant enzyme have been shown to clear the stored substrate GL1, and thus reverse hematologic and liver/spleen involvement. Although skeletal disease is slower to respond, early treatment may be efficacious in normalizing linear growth and bone morphology in affected children.
Although enzyme replacement does not alter the neurologic progression of patients with Gaucher disease types 2 and 3, it has been used in selected patients as a palliative measure, particularly in patients with severe visceral involvement. Individuals with severe visceral symptoms due to Gaucher disease type 3 often benefit from bone marrow transplantation. In some individuals, a combination approach using both enzyme replacement therapy and bone marrow transplant has been used. However, the use of bone marrow transplant is limited due to the associated morbidity and mortality.
Glucosylceramide synthase inhibitors include miglustat (Zavesca) and eliglustat (Cerdelga). Miglustat was approved in 2003 as monotherapy for treatment of adults with mild-to-moderate type 1 Gaucher disease for whom enzyme replacement therapy is not a therapeutic option.
Eliglustat was approved in August 2014 as first-line treatment for the long-term treatment of adults with Gaucher disease type 1. The dose of eliglustat is determined by establishing the patient’s CYP2D6 phenotype (ie, extensive metabolizers [EM], intermediate metabolizers [IM], or poor metabolizers [PM]).
Approval was based on efficacy data from 2 positive phase 3 studies involving 199 patients. One study involved patients new to therapy (trial 1), and the other involved patients switching from approved enzyme replacement therapies (trial 2). Efficacy data from 4 years of the Cerdelga phase 2 study also contributed to the approval. Improvements in study participants were observed in spleen size, platelet levels, hemoglobin levels, and liver volume, and noninferiority to enzyme replacement therapy (imiglucerase) was established in trial 2.
Studies are currently underway to investigate the use of miglustat for the treatment of infantile-onset GM2 gangliosidosis and childhood Niemann-Pick type C.
Until recently, treatment for Fabry disease has been nonspecific and limited to supportive care. These measures included the use of phenytoin and carbamazepine, which have been shown to decrease the frequency and severity of the chronic acroparesthesias and the periodic crises of excruciating pain. Renal transplantation and long-term hemodialysis also have become life-saving procedures for patients with renal failure.
Enzyme replacement therapy with recombinant alpha-galactosidase A (Replagal, TKT Corporation, Cambridge, Mass; Fabrazyme, Genzyme Corporation, Cambridge, Mass) is available. Fabrazyme is the only ERT for Fabry disease approved by the FDA. Data from clinical trials show a decrease in GL-3 levels following enzyme replacement therapy, reversal in lipid tissue storage, and stabilized or improved renal and cardiac function. Subjective reduction or relief from neuropathic pain has been documented, in addition to a decrease in the long-term use of neuropathic pain medication.
Recent advances in recombinant enzyme replacement, bone marrow transplantation, gene transfer, substrate reduction, and chaperone-mediated therapy provide great hope in potentially treating other lipid storage disorders.
Patients thought to have a lipidosis should have an evaluation with a clinical geneticist.
Neurologic consultation also is indicated.
Patients with Fabry disease should have a cardiac evaluation.
Patients with Gaucher disease type 1 and sphingomyelinase deficiency (NPD type B) should have pulmonary consultations.
No specific dietary manipulations have an effect on the disease course. In particular, restriction of lipids is of no benefit.
Patients with sphingomyelinase deficiency (NPD) have elevated total cholesterol, although effects of dietary restriction of cholesterol have not been demonstrated.
Gaucher disease and patients with sphingomyelinase deficiency (NPD types A and B) with organomegaly should avoid contact sports and seek immediate medical attention for trauma. If their platelet counts drop precipitously secondary to hypersplenism, they are at risk for both splenic rupture and intracranial bleeding.
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