New therapies in the management of Niemann-Pick type C disease: clinical utility of miglustat

Abstract

Niemann-Pick disease type C (NP-C) is an autosomal recessive disorder characterized by progressive neurological deterioration leading to premature death. The disease is caused by mutations in one of two genes, NPC1 or NPC2, leading to impaired intracellular lipid transport and build-up of lipids in various tissues, particularly the brain. Miglustat (Zavesca(R)), a reversible inhibitor of glycosphingolipid synthesis, has recently been authorized in the European Union, Brazil and South Korea for the treatment of progressive neurological symptoms in adult and pediatric patients, and represents the first specific treatment for NP-C. Here we review current data on the pharmacology, efficacy, safety and tolerability of miglustat in patients with NP-C, based on findings from a prospective clinical trial, preclinical and retrospective studies, and case reports. Findings demonstrated clinically relevant beneficial effects of miglustat on neurological disease progression in adult, juvenile and pediatric patients with NP-C, particularly those diagnosed in late childhood (6-11 years) and in juveniles and adults (12 years and older), compared with those diagnosed in early childhood (younger than 6 years). Miglustat therapy was well-tolerated in all age groups. With the approval of miglustat, treatment of patients with NP-C can now be aimed toward stabilizing neurological disease, which is likely the best attainable therapeutic goal for this disorder.

Keywords: NP-C; Niemann-Pick disease type C; Zavesca®; miglustat.

Figure 1

Change in composite disability score over time for overall NP-C population (n = 57) and by age at diagnosis group (untreated patients). Reproduced with permission from Wraith JE, Guffon N, Rohrbach M, et al. Natural history of Niemann-Pick disease type C in a multicentre observational retrospective cohort study. Mol Genet Metab. 2009;98:250–254. Copyright © 2009 Elsevier.

Figure 2

Annual changes in composite disability scores by age group in NP-C patients treated with miglustat. Reproduced with permission from Pineda M, Wraith JE, Mengel E, et al. Miglustat in patients with Niemann-Pick Type C disease (NP-C): a multicentre observational retrospective cohort study. Mol Genet Metab. 2009;98:243–249. Copyright © 2009 Elsevier. Note: ^aTotal number of patients per age group.

Figure 3

Protocol for initiation of miglustat treatment in NP-C. Reproduced with permission from Wraith JE, Baumgartner MR, Bembi B, et al. Recommendations on the diagnosis and management of Niemann-Pick disease type C. Mol Genet Metab. 2009;98:152–165. Copyright © 2009 Elsevier. Notes: ^aBiochemical and/or molecular-genetic diagnosis, with or without systemic or other clinical signs and symptoms; ^bPatients asymptomatic or with isolated splenomegaly, and with one or more older siblings in whom the time of neurological symptom onset and rate of progression are known.