Osteonecrosis in Gaucher disease in the era of multiple therapies: Biomarker set for risk stratification from a tertiary referral center

  1. Mohsen Basiri
  2. Mohammad E Ghaffari
  3. Jiapeng Ruan
  4. Vagishwari Murugesan
  5. Nathaniel Kleytman
  6. Glenn Belinsky
  7. Amir Akhavan
  8. Andrew Lischuk
  9. Lilu Guo
  10. Katherine Klinger
  11. Pramod K Mistry

  • Curated by eLife

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    eLife assessment

    This study presents valuable findings on the risk factors of avascular osteonecrosis in patients with Gaucher disease. The evidence supporting the claims of the authors is convincing. The work will interest clinicians who treat patients with inborn errors of metabolism.

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Abstract

A salutary effect of treatments for Gaucher disease (GD) has been a reduction in the incidence of avascular osteonecrosis (AVN). However, there are reports of AVN in patients receiving enzyme replacement therapy (ERT) , and it is not known whether it is related to individual treatments, GBA genotypes, phenotypes, biomarkers of residual disease activity, or anti-drug antibodies. Prompted by development of AVN in several patients receiving ERT, we aimed to delineate the determinants of AVN in patients receiving ERT or eliglustat substrate reduction therapy (SRT) during 20 years in a tertiary referral center.

Methods:

Longitudinal follow-ups of 155 GD patients between 2001 and 2021 were analyzed for episodes of AVN on therapy, type of therapy, GBA1 genotype, spleen status, biomarkers, and other disease indicators. We applied mixed-effects logistic model to delineate the independent correlates of AVN while receiving treatment.

Results:

The patients received cumulative 1382 years of treatment. There were 16 episodes of AVN in 14 patients, with two episodes, each occurring in two patients. Heteroallelic p.Asn409Ser GD1 patients were 10 times (95% CI, 1.5–67.2) more likely than p.Asn409Ser homozygous patients to develop osteonecrosis during treatment. History of AVN prior to treatment initiation was associated with 4.8-fold increased risk of AVN on treatment (95% CI, 1.5–15.2). The risk of AVN among patients receiving velaglucerase ERT was 4.68 times higher compared to patients receiving imiglucerase ERT (95% CI, 1.67–13). No patient receiving eliglustat SRT suffered AVN. There was a significant correlation between GlcSph levels and AVN. Together, these biomarkers reliably predicted risk of AVN during therapy (ROC AUC 0.894, p<0.001).

Conclusions:

There is a low, but significant risk of AVN in GD in the era of ERT/SRT. We found that increased risk of AVN was related to GBA genotype, history of AVN prior to treatment initiation, residual serum GlcSph level, and the type of ERT. No patient receiving SRT developed AVN. These findings exemplify a new approach to biomarker applications in a rare inborn error of metabolism to evaluate clinical outcomes in comprehensively followed patients and will aid identification of GD patients at higher risk of AVN who will benefit from closer monitoring and treatment optimization.

Funding:

LSD Training Fellowship from Sanofi to MB.

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  1. Version published to 10.7554/elife.87537 on eLife
  2. eLife

    eLife assessment

    This study presents valuable findings on the risk factors of avascular osteonecrosis in patients with Gaucher disease. The evidence supporting the claims of the authors is convincing. The work will interest clinicians who treat patients with inborn errors of metabolism.

  3. eLife

    Reviewer #1 (Public Review):

    This study presents a valuable finding for the incidence of bone avascular necrosis (AVN) in patients with Gaucher's Disease (GD) for twenty years. Furthermore, the evidence supporting the claims of the authors is solid.

    The study's significant limitations relate to small numbers of patients, with only 155 GD patients analyzed. While the study period is excellent for incidence detection at 20 years, the overall number limits the strength of the analysis for cofactors. For example, there is an analysis for linkage to the type of therapy, the GBA1 genotype, spleen status, biomarkers, and other disease indicators. However, substantial numbers that would dictate changes to a preferential enzyme are not convincing. Moreover, the authors described 16 episodes of AVN in 14 patients, again making generalization difficult. Finally, there was a focus on Serum GlcSph levels, and the authors attempted to correlate levels according to probabilities for AVN occurrence while on treatment.

    Overall, however, this is one of the best longitudinal studies for the incidence of AVN in GD patients, and the work will be of interest to medical biologists and professionals treating GD patients.

  4. eLife

    Reviewer #2 (Public Review):

    Gaucher disease is a rare genetic disorder that is commonly treated by either administration of a functional enzyme or reduction of the substrate. Some patients receiving enzyme replacement therapy develop avascular osteonecrosis (AVN), but the risk factors were not known. In this study, a cohort of 155 patients was followed longitudinally for two decades, and their risk of developing AVN was analyzed. The data convincingly shows that patients with heterozygous N409S mutation, a past history of AVN, receiving velaglucerase therapy, or with higher serum glucosylsphingosine levels have a higher risk of AVN. These findings will provide a means to identify Gaucher disease patients at higher risk of AVN and to provide them with an optimal treatment. In addition, the study establishes that it is prudent to achieve a low glucoylspingosine level as a therapeutic goal in Gaucher patients with risk of AVN.

  5. Version published to 10.1101/2023.03.21.23287476v1 on medRxiv