NeoPhe in the Treatment of Phenylketonuria New Formulation of LNAA

1. NeoPhe in the Treatment of PhenylketonuriaNew Formulation of LNAA 2nd Ukraine Congress On Clinical Genetics October 2005

2. USAReuben Matalon, M.D., Ph.D.Kim MatalonRussiaPeter Novikov DenmarkJytte Bieber NielsenLeah BrammerUkraineElena Grechanina

3. Large Neutral Amino Acids (LNAA) • Phenylalanine (Phe) • Leucine • Tyrosine • Tryptophan • Methionine • Histidine • Isoleucine • Valine • Threonine

4. Transport of LNAA to the Brain Km mmol/L Km app • Phenylalanine (Phe) 0.12 0.45 • Leucine 0.15 0.53 • Tyrosine 0.16 0.58 • Tryptophan 0.19 0.71 • Methionine 0.19 0.77 • Histidine 0.28 1.10 • Isoleucine 0.33 1.30 • Valine 0.63 2.50 • Threonine 0.73 3.00 Pardridge, Inborn Errors of Metabolism in Humans. MTP Press, 1980.

5. Andersen AE, Avinsl • LNAA injected to rat pups • Phenylalanine hydroxylase was ihibited by parachlorophenylalanine • Brain phenylalanine decreased 1976 Arch Neurology 33:684

6. Tyrosine in The Treatment of PKU Lou et al used Tyr 160 mg/kg in treated patients with PKU • Increased attention span • Increased dopamine synthesis 1987 Acta Paediatr Scand 76:560

7. Tyrosine in Treatment of PKU • Pietz et al. used high dose tyrosine in adults with PKU and high blood Phe • No difference in treated group vs placebo 1995 J Pediatr 127:936

8. Tryptophan in Treated PKU • Nielsen et al used tryptophan 4.5 gm/day to treated PKU for 3 weeks • Showed a 3 fold increase in 5-HIAA in CSF despite high blood Phe 1988 Dietary Phenylalanine and Brain Function. Birkhauser

9. LNAA Supplementation in PKU • Dotremont et al. used LNAA and a low protein diet 0.6 gm/kg on 4 patients with PKU • After 1 month subjects found with negative nitrogen balance • Lysine was limiting amino acid 1995 J Inherit Metab Dis 18:127

10. PreKUnil Composition per Tablet • Tyrosine 191 mg • Tryptophan 65 mg • Arginine 35 mg • Leucine 35 mg • Isoleucine 35 mg • Valine 35 mg • Methionine 35 mg • Threonine 35 mg • Lysine 0 mg

11. Km (app) – Km (1 + ∑[aa]/Km] This predicts that, if the plasma level of an LNAA is much less than its value of Km, then that amino acid will not compete effectively for the carrier protein

13. Neo Phe L-Tyrosine 195.0 mg L-Tryptophan 51.0 mg L-Methionine 32.0 mg L-Isolecine 35.0 mg L-Threonine 32.0 mg L-Valine 35.0 mg L-Leucine 130.0 mg L-Histidine 30.0 mg L-Lysine 30.0 mg L-Arginine 30.0 mg

14. LNAA Transport in Intestinal Mucosa Km mmol/L • Phenylalanine 1.0 • Leucine 2.0 • Valine 3.0 • Methionine 5.0 • Histidine 6.0 • Competition effect is not likely to occur in tissue other than brain unless high concentration of amino acids is used Pardridge, Inborn Errors of Metabolism in Humans. MTP Press, 1980.

15. Hidalgo Biochem Biophys. Acta 1008: 5-30a (1990)

16. PKU Mice on NeoPhe Control phe mg/dl NeoPhe

18. Denmark LNAA STUDY

19. Denmark LNAA STUDY

20. Russia LNAA STUDY

21. Russia LNAA Study

22. USA LNAA STUDY

23. USA LNAA STUDY

25. 1200 828 765 624

26. US Blood Phe and TyrNeoPhe Patient K 1 Weekµmol/L (mg)

27. US Blood Phe and TyrNeoPhe Patient G 1 Week

28. NeoPhe 0.5 g/kg in PKU Subjects • 13 subjects • Mean age 26.6 years • 7 males, 6 females • Mean decrease in blood Phe after one week 243 µmol/L • Average decrease in blood Phe 22 %.

29. NeoPhe 1.0 g/kg in PKU Subjects • 7 subjects • Mean age 25.2 years • 5 males, 2 females • Mean decrease in blood Phe after one week 377 µmol/L • Average decrease in blood Phe 25 %.

30. Figure 1. Blood Phe Response to 0.5g/kg NeoPhe in Patients withPKU Paired t-test: p=0.001

31. Figure 2. Blood Phe Response to 1.0 g/kg NeoPhe in Patients withPKU Paired t-test: p=0.006

32. CONCLUSIONS • For the first time mixture of LNAA can lower blood phenylalanine • Using NeoPhe avoids lysine deficiency • Lysine deficiency can lead to negative nitrogen balance and decreased levels of carnitine

33. Acknowledgement Participants in the study Professor Elena Grechanina Kharkiv, Ukraine Professor Peter Novikov Moscow, Russia Dr. Jytte Bieber Nielsen Glostrup, Denmark