Effect of Pioglitazone Administered to Patients With Adrenomyeloneuropathy
Effect of Pioglitazone Administered to Patients With Adrenomyeloneuropathy
X-linked adrenoleukodystrophy is a rare, demyelinating and neurodegenerative disorder, due to
 loss of function of a fatty acid transporter, the peroxisomal ABCD1 protein. Its more
 frequent phenotype, the adrenomyeloneuropathy in adults, is characterized by axonal
 degeneration in spinal cord, spastic paraparesis and a disabling peripheral neuropathy.
 Actually, there is no efficient treatment for the disease. The work of the researchers in the
 last twelve years dissecting the physiopathological basis of the disorder has uncovered an
 involvement of the early oxidative stress in the neurodegenerative cascade and mitocondrial
 depletion. In a preclinical trial they have observed that pioglitazone, a PPARγ/PGC-1α axis
 metabolic activator with immunomodulatory, anti-inflammatory and antioxidant response
 regulator properties, efficiently reverse the clinical symptoms and the axonal degeneration
 in the mouse model for the disease and normalize stress and mitochondrial depletion
 biomarkers.

 The researchers will test the effectiveness of the drug in terms of motor function and
 correction of oxidative damage markers in proteins and DNA and inflammation markers in an
 open trial. Fifteen-twenty patients will be included and clinically explored and assessed in
 the HU of Bellvitge and the HU of Donostia using clinical scales for spasticity, evoked
 potentials, electroneurinograms and cranial RMN. The information will be collected in a data
 base that will be of great value to improve the present attention and the future follow-up of
 the patients and to facilitate their inclusion in therapeutic randomized, double blind,
 against placebo, multicentric and international clinical trials.
Proof of concept for this trial is provided by the results of biochemical, neuropathological
 and motor effects of pioglitazone in two mouse models of AMN. Pioglitazone was given orally
 (9 mg/kg/day) for two months in both models.

 The Abcd1-null mouse model already shows at 3,5 months biochemical signs oxidative stress
 that increase with time and are then associated with energy homeostasis alterations, although
 first clinical signs of AMN-i.e. axonopathy and locomotor impairment-appear at 20 months. In
 these mice, there are mitochondrial anomalies, decreased levels of PGC-1α which is a master
 regulator of mitochondrial biogenesis, and decreased levels and activity of SIRT1α, which
 activates PGC-1α.

 The Abcd1-null mouse can be considered as a "AMN-like" model, because of the absence of
 demyelinating lesions in brain and spinal cord, the presence of non-inflammatory
 ''dying-back'' axonopathy in peripheral nerves and spinal cord and its late-onset motor
 deficits that all are hallmarks of AMN in X-ALD patients. This model was used to assess the
 efficacy of pioglitazone on several biochemical markers in the spinal cord of Abcd1-null mice
 (N=12), using comparisons with placebo-¬treated Abcd1-null mice (N=12) or wild-type mice
 (N=12).

 In Abcd1-null mice treated with pioglitazone at 10,5 months of age and studied at 12 months
 (1,5 months following the beginning of the ongoing treatment), mitochondrial anomalies were
 corrected to the level of wild type control mice. Indeed, mitochondrial DNA and protein
 (including PGC-1α, NRF1 and TFAM) levels were corrected; as well as mitochondrial metabolism,
 as assessed by pyruvate kinase activity, ATP and NAD+ concentrations. Pioglitazone had no
 effect on SIRT1 expression (mRNA and protein levels). However, pioglitazone significantly
 lowered the carbonylation of SIRT1 protein, which presumably accounts for the observed rescue
 of SIRT1 activity.

 In these mice treated with pioglitazone, oxidative lesions in the spinal cord were reversed.
 Studied oxidative stress biomarkers included markers of oxidative lesions to proteins (GSA,
 AASA), lipids (MDAL) and carbohydrates (CEL). Additionally, the activity and concentration
 level of antioxidant enzymes GPX1, which were increased in untreated Abcd1-null mice, but not
 SOD2, was normalized to the level of wild type mice.

 The second mouse model is the double knockouts (DKO) in which both Abcd1 and Abcd2
 transporters are inactivated. The Abcd1-/Abcd2-/-DKO exhibits greater VLCFA accumulation in
 spinal cord (Pujol et al., 2004), higher levels of oxidative damage to proteins, and a more
 severe AMN-¬like pathology, with earlier onset of motor impairment than the single Abcd1-null
 mouse (12 months in the DKO compared to 20 months in Abcd1-null mice). Efficacy of
 pioglitazone at the motor and neuropathologic levels was studied in 17 Abcd1-/Abcd2-/-mice
 comparing them with placebo-treated Abcd1-/Abcd2-/-mice (N=17) and wild-type mice (N=25).

 In Abcd1-/Abcd2-/-mice treated with pioglitazone at 13 months of age and studied at 15 or 17
 months (treatment duration of 2 to 4 months), axonal degeneration was prevented, as shown by
 the normalization to the control level of number of APP or synaptophysin positive axons.

 Also, pioglitazone arrested the progression of locomotor deficits in these mice, as assessed
 by the treadmill test and the bar-cross test. Indeed, the locomotor performances of
 pioglitazone DKO after four months of treatment mice reached the performances of the
 controls.

 Overall, these studies show the efficacy of treatment with pioglitazone in "AMN-like mice
 "and provide a strong rationale for conducting a preliminary open clinical trial with
 pioglitazone in AMN patients.
Inclusion Criteria:

 -  Clinical signs of AMN with at least pyramidal signs in the lower limbs and
 difficulties to run.

 -  Presence of motor deficit according to the EDSS scale

 -  Ability to perform the 2MWT

 -  Normal brain MRI or brain MRI showing abnormalities that can be observed in AMN
 patients without cerebral form of X-ALD with a maximum Loes score of 4

 -  Ejection fraction > 50% at echocardiogram

 -  Normal electrocardiogram

 -  Normal urine cytology

 -  Normal liver function, as assessed by plasma ASAT, ALAT, PAL, γGT, bilirubin measures
 (≤2.5-fold normal values)

 -  Normal kidney function as assessed by plasma urea, creatinin (≤ 2-fold normal values)

 -  Appropriate steroid replacement if adrenal insufficiency is present

 -  Informed consent

 -  Affiliated to the Spanish Public Health System

 Exclusion Criteria:

 -  Gadolinium enhancement on T1 sequence of any abnormal hypersignal of white matter,
 including myelinated pyramidal tracts, visible at brain MRI on FLAIR sequences

 -  Brain MRI abnormalities of the "AMN type" with a Loes score > 4

 -  Any abnormal hypersignal of white matter visible on FLAIR sequences other than of "AMN
 type" and related to X-ALD

 -  Patients taking pioglitazone or another glitazone during the past 6 months

 -  Diabetic patients (type I or II)

 -  Fasting blood glucose > 125 mg/L

 -  Glycosylated hemoglobin > 6%

 -  History of heart failure

 -  Heart failure (NYHA III to IV) or ejection fraction ≤ 50%

 -  History of cardiac disease

 -  [Hemoglobin] < 13g/dl in males, <12 g/dl in women

 -  Absolute neutrophil count (ANC) <1500 cells/mm3

 -  Platelet count <100,000 cells/mm3

 -  Significant peripheral edema (2+ or more on the Assessment Chart for Pitting Edema) of
 the extremities of any etiology

 -  Any evolutive malignancy during the last five years

 -  Prior or current bladder cancer

 -  Smokers (one pack/ day or more for at least 20 years), current or former

 -  Women with history of osteoporosis

 -  Menopaused woman with T-score < -2.5 on osteodensitometry measurement

 -  Any evolutive medical disease other than AMN

 -  Any psychiatric disease

 -  Pregnant or breastfeeding woman

 -  Either no pre-menopaused woman or no menopaused woman not taking any contraceptive
 method

 -  Hereditary intolerance to galatose, or malabsorption of glucose or galactose due the
 presence of monohydrated lactose.

 -  Hypersensibility to the active substance or to galactose (excipient)

 -  Concomitant treatment with cytochrome P450 CYP 2C8 inhibitors (e.g. gemfibrozil) or
 inducers (e.g. rifampicin)

 -  Taking of either vitamin A, E or lipoic acid during the past 3 months

 -  Contraindications for MRI procedure such as subjects with paramagnetic materials in
 the body, such as aneurysm clips, pacemakers, intraocular metal or cochlear implants

 -  Present participation to another therapeutic clinical trial for ALD

 -  Not easily contactable by the investigator in case of emergency or not capable to call
 the investigator

 -  Gross hematuria of unknown origin