Preventative treatment of tuberous sclerosis complex with sirolimus: Phase I safety and efficacy results

Abstract

Objective: Tuberous sclerosis complex (TSC) results from overactivity of the mechanistic target of rapamycin (mTOR). Sirolimus and everolimus are mTOR inhibitors that treat most facets of TSC but are understudied in infants. We sought to understand the safety and potential efficacy of preventative sirolimus in infants with TSC.

Methods: We conducted a phase 1 clinical trial of sirolimus, treating five patients until 12 months of age. Enrolled infants had to be younger than 6 months of age with no history of seizures and no clinical indication for sirolimus treatment. Adverse events (AEs), tolerability, and blood concentrations of sirolimus measured by tandem mass spectrometry were tracked through 12 months of age, and clinical outcomes (seizure characteristics and developmental profiles) were tracked through 24 months of age.

Results: There were 92 AEs, with 34 possibly, probably, or definitely related to treatment. Of those, only two were grade 3 (both elevated lipids) and all AEs were resolved by the age of 24 months. During the trial, 94% of blood sirolimus trough levels were in the target range (5-15 ng/mL). Treatment was well tolerated, with less than 8% of doses held because of an AE (241 of 2941). Of the five patients, three developed seizures (but were well controlled on medications) at 24 months of age. Of the five patients, four had normal cognitive development for age. One was diagnosed with possible autism spectrum disorder.

Interpretation: These results suggest that sirolimus is both safe and well tolerated by infants with TSC in the first year of life. Additionally, the preliminary work suggests a favorable efficacy profile compared with previous TSC cohorts not exposed to early sirolimus treatment. Results support sirolimus being studied as preventive treatment in TSC, which is now underway in a prospective phase 2 clinical trial (TSC-STEPS).

Keywords: safety; seizures; sirolimus; tuberous sclerosis complex.

Figure 1.

Predicted versus measured sirolimus blood levels using precision dosing strategy. For each participant, predicted concentration profile for given dose is shown in blue, as the dose was adjusted over time throughout the study (0–12 months). Measured (actual) sirolimus levels in whole blood drawn at study visits are shown as red dots. The precision dosing strategy, which targeted a blood trough level of 10 ng/mL, is shown with the horizontal red line. Accepted range (within target) blood trough levels (between 5 and 15 ng/mL) is shown with horizontal dotted lines.

Figure 2.

Model-informed precision dosing recommendations. For each participant, the dosing recommendation of TAVT-18 (sirolimus) in mg/m² at study start is shown. Circles indicate the dosing recommendation at poststudy start. Blue arrows show when trough blood levels were measured and new dosing recommendations were calculated. In participant 001–003, a dosing recommendation was given based on the model at six months poststudy start (red arrow), but the clinical team decided to reduce the recommended dosing due to AEs (gray shaded area, correlating with reduced levels in Figure 1). D, day; M, month.