I ve Participated in a Research Study. Now What? Oleg Shchelochkov, MD NIH/Venditti Lab

Natural History To understand the onset of ORGANIC ACIDEMIAS, progression and outcomes for each body system Biomarkers Discovery and validation of biomarkers Drugs Partnering to develop new drug targets and new treatments

Natural History: A Moving Target and the Unknowns

Propionic and Methylmalonic Acidemias Multisystem Disorders METABOLIC INSTABILITY = HIGH MORTALITY Long QT interval Arrhythmias Cardiomyopathy Optic nerve atrophy Intellectual impairment Basal ganglia stroke Hearing loss Hyperammonemia Chronic renal failure Onset Progression Hepatomegaly Fatty liver Osteopenia Bone marrow failure Immunodeficiency Pancreatitis GI dysmotility, G/J tube dependence Outcomes

% o f p a tie n ts in a c o h o rt H is to r ic a l C ro s s -S e c tio n a l M o r ta lity R a te s in P r o p io n ic A c id e m ia 1 0 0 8 0 6 0 4 0 2 0 * * Publications Rousson R et al, 1984 Surtees RA et al, 1992 van der Meer et al, 1996 Essa et al, 1998 Perez-Cerda et al, 2000 Sass et al, 2004 de Baulny et al, 2005 Dionisi-Vici et al, 2006 Touati et al, 2006 Grünert et al, 2012 Pena et al, 2012 Rafique, 2014 0 1 9 8 5 1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 Y e a r o f p u b lic a tio n * Averaged mortality rate

% o f p a tie n ts in a c o h o rt H is to r ic a l C ro s s -S e c tio n a l In te lle c tu a l D is a b ility in P r o p io n ic A c id e m ia 1 0 0 5 0 Intellectual disability % of Patients Publications IQ<60 100% among neonatal onset patients Surtees RA et al, 1992 IQ<75 60% de Baulny, 2005 IQ not specified 40-100% Dionisi-Vici 2006 IQ<70 35% Touati et al 2006 IQ<69 76% Grünert et al 2012 Cognitive deficit 72% Pena et al, 2012 IQ <75 75% Witters et al, 2016 0 1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 Y e a r o f p u b lic a tio n

The MMA and PA Enrollment (July 2018) CD320, 3 TCII, 2 other, 1 undetermined, 6 cblf, 4 cblx, 4 cblg, 4 cble, 1 CMAMMA, 26 MUT, 78 PCCB, 15 PCCA, 13 cblc, 49 cblb, 11 cbla, 15 The MMA Natural History Protocol (n=204) Pending, 1 The PA Natural History Protocol (n=29)

Outside records Pre-admit calls Pre-Admission Clinical Evaluation MMA/PA Team Consults Labs Imaging Nutrition/REE Research Studies Labs/Imaging Biobanking Blood Urine Microbiome Exome/Genome Interim Events Communicatio n with home teams Post-Discharge Follow-up 2-5 Days

High Prevalence of Abnormal Height and Body Weight in PA Patients

Low daily activity levels (overestimation of the activity factor) Dietary nonadherence Discrepant predicted and actual protein and caloric needs Endocrine abnormalities Frequent hospitalizations and intercurrent infections ( sick day diet ) Short Stature with High BMI Toxic effects of propionaterelated metabolites

Z -s c o re W e ig h t, Z -s c o re Growth in PA Patients Slows after Birth 4 P v a lu e = 0.0 0 7 4 n.s. 2 2 0 0-2 - 2-4 B ir th le n g th z - s c o r e H e ig h t z - s c o r e a t th e tim e o f e x a m - 4 B ir th w e ig h z - s c o r e W e ig h t z - s c o r e a t th e tim e o f e x a m

C a lo ric In ta k e, % o f R E E S c h o fie ld E q u a tio n, k c a l/d a y Average Reported Caloric Intake in PA Patients Exceeds Measured REE 2 5 0 R e p o r te d C a lo ric In ta k e a s % o f R E E 2 0 0 0 S c h o fie ld E q u a tio n (p r e d ic te d ) 2 0 0 1 8 0 0 1 5 0 1 6 0 0 1 4 0 0 1 0 0 1 2 0 0 5 0 0 0 1 2 3 4 5 6 7 8 9 1 01 1 1 2 1 31 4 1 5 1 61 7 1 8 1 92 0 1 0 0 0 8 0 0 6 0 0 6 0 0 8 0 0 1 0 0 0 1 2 0 0 1 4 0 0 1 6 0 0 1 8 0 0 2 0 0 0 R E E, k c a l/d a y R 2 = 0.59 P value = 0.0001

P re s c rib e d c o m p le te p ro te in g m /k g /d a y PA Patients Adhere to the Prescribed Complete Protein 2.0 1.5 R 2 = 0.71 P value = 0.0022 1.0 0.5 0.0 0.0 0.5 1.0 1.5 2.0 R e p o rte d C o m p le te p ro te in in ta k e g /k g /d a y

Prevalence of Endocrine Abnormalities in the PA Cohort Parameter Prevalence Low plasma IGF1 2/19 Blood TSH in the 4-10 mciu/ml range (subclinical hypothyroidism) 7/21* Elevated PTH 3/19** * This number includes 5 patients who had blood TSH in the 4-10 mciu/ml range and two patients had normal TSH, but treated with levothyroxine. A total of 3/21 patients in the NIH PA cohort were treated with levothyroxine. ** 3 patients with elevated PTH accompanying chronic kidney disease

H t, z -s c o r e 4 2 P la s m a P r o p io n y lc a r n itin e v s H e ig h t Z -s c o re P v a lu e = 0.0 0 8 R 2 = 0.2 3 2 8 0 5 0 1 0 0-2 - 4 C 3, P la s m a

Growth in Propionic Acidemia Patients Parental Heights G-tube Total Protein Intake Growth Medical Foods The severity of PA mutations Growth Diet Sick day Renal Disease Heart Disease

Opportunities for Collaboration Emergency and Acute Care Care under 2 years of Age Newborn Screening and the Initial Presentation

Biomarkers

Biomarkers and Drug Development Biomarker is any measurable outcome associated with the studied disease No FDA-approved biomarkers - MMA and PA

Discovery and Validation of Surrogate Endpoints for Organic Acidemias Residual Enzyme Activity? Healthcare Utilization Propionic and Methylmalonic Acidemias Plasma MC or MMA? Plasma C3? Other Biomarkers? Growth Survival Neurocognitive Development Associations Not cause and effect Surrogate Endpoints (FDA) True Clinical Outcome (FDA)

Discovery and Validation of Surrogate Endpoints for Organic Acidemias Residual Enzyme Activity? Healthcare Utilization Propionic and Methylmalonic Acidemias Plasma MC or MMA? Plasma C3? Growth Survival Liver Transplantation Other Biomarkers? Surrogate Endpoints (FDA) Neurocognitive Development True Clinical Outcome (FDA)

Discovery and Validation of Surrogate Endpoints for Organic Acidemias Residual Enzyme Activity? Healthcare Utilization Plasma MC or MMA? Growth Propionic and Methylmalonic Acidemias Diet Change Plasma C3? Other Biomarkers? Survival Neurocognitive Development Surrogate Endpoints (FDA) True Clinical Outcome (FDA)

Discovery and Validation of Surrogate Endpoints for Organic Acidemias Residual Enzyme Activity? Healthcare Utilization Plasma MC or MMA? Growth Propionic and Methylmalonic Acidemias Development of Drugs Plasma C3? Other Biomarkers? Survival Neurocognitive Development Surrogate Endpoints (FDA) True Clinical Outcome (FDA)

Hospital Records MMA-PA Database Patient-Reported Outcomes Quality of Life Scales Intelligence Tools REDCap Email-based Surveys

Discovery and Validation of Surrogate Endpoints ~500 Parameters Collection of Clinical, Laboratory, Biochemical, Genomic and Research Parameters ~300 Parameters Hypothesis-Driven and Agnostic Surveys of Parameters Correlating with Clinically-Relevant Outcomes ~25 Parameters Cross-Over Replication of Identified Correlations in MMA/PA Sets Review of Patients Charts 3 Endpoints Evaluation of Surrogate Endpoints in Mouse Models of MMA/PA 1-2 FDA Acceptance Pathways (IND/NDA Development, Biomarker Qualification, Scientific Consensus Pathways)

F S IQ F S IQ F S IQ Evaluation of Biomarkers in the Real-Life Cohort (PA) 1 5 0 1 5 0 1 5 0 1 0 0 1 0 0 1 0 0 5 0 5 0 5 0 0 0 1 0 2 0 3 0 4 0 R e s e a rc h P a r a m e te r # 1 0 0 2 0 4 0 6 0 8 0 1 0 0 L a b o r a to r y P a r a m e te r # 3 0 0 5 0 0 0 0 1 0 0 0 0 0 1 5 0 0 0 0 2 0 0 0 0 0 2 5 0 0 0 0 L a b o r a to r y P a r a m e te r # 2 R2=0.58, P value = 0.0009 R2=0.51, P value = 0.0017 R2=0.12, P value = 0.19

Frequency Hospital Records MMA-PA Database High ALT or AST in a Cobalamin C Patient? 70 Abnormal Range 56 42 28 14 Intelligence Tools 0-35 -20-5 10 25 40 55 70 85 100 115 130 145 160 Observation Value

Collaborations

Acknowledgements Families, Patients, and Referring Teams Venditti Lab Charles P. Venditti, MD, PhD Irini Manoli, MD, PhD Jennifer Sloan, PhD, MA, CGC Carol Van Ryzin, ARNP Susan Ferry, RN Alexandra (Ally) Pass Jack Gagne NIH Clinical Center Jennifer Myles, RD Megan Schoenfeld, RD National Institute of Mental Health Audrey Thurm, PhD Joseph Snow, PhD NIDDK Kong Chen, PhD Brooks Leither Laura Fletcher Jeffrey Kopp, MD CNMC Andrea Gropman, MD NHGRI (The Caregiver Study) Laura Koehly, PhD Dawn Lea, PhD Jennifer Cleary Lena Eskin

Questions