• 03|10|2020 Estimated prevalence of moderate to severely elevated total homocysteine levels in the United States: A missed opportunity for diagnosis of homocystinuria?

    Demonstrates the large number of tHCY tests conducted in the US where the result is greater than 30. In fact, in all age deciles the percentage of the results greater than 30, which is in the 98% of the frequency distribution, is consistent. Very few of these patients have a diagnosis of HCU. We believe that many of these patients should be further evaluated for HCU.

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  • 03|10|2020 Prevalence, characteristics, and costs of diagnosed homocystinuria, elevated homocysteine, and phenylketonuria in the United States: a retrospective claims-based comparison.

    The implications of this data are that a large number of patients with an ICD-10 code specific to HCU are not being referred to metabolic geneticists.  These patients healthcare costs are similar to a PKU patients and greater than patients with an tHCY>20 and no ICD-10 code.

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  • 10|24|2019 Characteristics Of Patients Participating In A Study Of Homocystinuria Due To Cystathionine Beta-synthase Deficiency

    This interim analysis assessed baseline and longitudinal characteristics, including demographics, medical and family histories, medications, dietary information, ophthalmologic findings, plasma total Hcy (tHcy) and other sulfur metabolites, and laboratory values.

    The interim results demonstrate that despite being seen at centers of excellence and being prescribed a natural protein-restricted diet and/or a Met-free L-amino acid mixture and supplements, many patients have: plasma tHcy values 5 to 40 times the ULN for tHcy, hypermethioninemia (≥600 μM) in 33% of patients (36% pediatric, 33% adult), ocular deficits, signs of inflammation, protein metabolism and/or liver dysfunction.

    These data indicate that current diet and therapeutic interventions are poorly effective and/or that most patients are not able to remain compliant, leading to high tHcy levels, even in patients being frequently monitored at centers of excellence

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  • 10|24|2019 Homocysteine Is Negatively Correlated With Cognition In Homocystinuria Due To Cystathionine Beta-synthase Deficiency

    Study CBS-HCY-NHS-01 is a multicenter (8 sites), international, observational, prospective, natural history study of HCU that enrolled 55 pediatric and adult patients to characterize the clinical course of HCU in patients under current clinical management practices over 3 years.  This interim analysis assessed patients’ Cognitive function at baseline and every 6 months using the age-normalized NIH Toolbox Cognition Battery (NIHCB).   tHcy levels were measured in plasma.

    This study highlights the overall cognitive impairment in many HCU patients.  Patients with lower plasma tHcy levels performed better on measures of executive functioning, extending prior studies showing that controlling tHcy levels is essential for maintaining intellectual functioning within average range.  As expected, lower Met levels, which reflect a better control of sulfur-amino acid metabolism, are associated with better cognition.  The results of this study have practical implications for the management of HCU. Neuropsychological evaluations should be considered an important component of medical care for HCU patients, and assessment of executive functioning (including response inhibition) should be included as part of those evaluations.

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  • 10|24|2019 Skeletal Fragility In A Natural History Study Of Homocystinuria Due To Cystathionine Beta-synthase Deficiency Patients

    Study CBS-HCY-NHS-01 is a multicenter (8 sites), international, observational, prospective, natural history study of HCU that enrolled 55 pediatric (5-17 years of age) and adult (>18 years of age) patients to characterize the clinical course of HCU in patients under current clinical management practices over 3 years.  This interim analysis assessed patient Bone Mineral Density (BMD) at baseline and 1 year at three locations (the hip, lumbar spine, and whole body) by dual-energy X-ray absorptiometry (DXA).

    Results indicate patients with plasma tHcy levels <100 µM had much greater skeletal fragility than those with levels >100 µM. BMD improves with greater total dietary protein intake, as shown by a positive correlation between BMD at all three locations and total dietary protein intake.  This study shows that most HCU patients have skeletal fragility despite a relatively young age. For each patient, BMD results and Z-scores were stable over 12 months. Therefore, BMD and Z-scores assessed by DXA scan be considered a reliable endpoint to assess the efficacy of investigational treatments in future clinical trials in HCU patients. Bone health in this population is correlated with higher total dietary protein intake and higher tHcy levels, suggesting that, by chronically restricting their total protein intake to control their tHcy levels, patients may be increasing their skeletal fragility


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  • 10|24|2019 Claims-Based Analysis of Homocysteine Testing, Elevated Homocysteine Levels, and Homocystinuria Diagnosis in the U.S.

    This study examined the all-cause healthcare costs and resource utilization between HCU and PKU patients using the Administrative claims in the IBM® MarketScan® Commercial and Medicare Supplemental Databases from January 1, 2010 through December 31, 2016.

    HCU patients had higher rates of all-cause healthcare utilization in nearly all components of care captured compared to their PKU counterparts. Additionally, HCU patients incurred higher monthly all-cause medical costs. compared to PKU patients, with more than half of the medical costs for HCU patients attributable to IP admissions.

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    Marcia Sellos-Moura, Frank Glavin, David Lapidus, Patrick T. Horn, Kristin Evans, Carolyn R. Lew, Debra E. Irwin

    Homocystinuria (HCU) may be underdiagnosed at birth due to inadequately sensitive newborn screening. This study estimated the prevalence of diagnosed HCU in the United States (U.S.) population across age groups, compared with that of diagnosed phenylketonuria (PKU) in similar age groups.

    As expected, the highest proportion of diagnosed PKU was observed in the youngest age group (ages 0–11 years), likely due to infants being diagnosed through mandatory newborn screening. Conversely, the proportion of diagnosed HCU cases in the younger age group was approximately ten times smaller, implying that HCU patients are not diagnosed primarily at birth or during early childhood. This suggests that current newborn screening tests fail to capture the vast majority of HCU cases, with patients diagnosed at later ages, even into adulthood, when they present with symptoms or comorbid conditions indicative of HCU.

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  • 11|12|2018 Claims-based Analysys of Homocystine Testing, Homocystine Levels >30 µmoles/L and Homocystinuria Diagnosis in the US

    Marcia Sellos-Moura, Frank Glavin, David Lapidus, Patrick T. Horn, Kristin Evans, Liisa Palmer

    Approximately 1 in 200,000–335,000 people worldwide have homocystinuria (HCU) but it may be underdiagnosed. We examined incidence and prevalence of homocysteine (tHcy) testing and the frequency of tHcy levels >30 µmoles/L.

    This study is one of the first to estimate the prevalence of tHcy levels in the range of classical HCU in the U.S. Of patients having many symptoms associated with classical HCU, few were diagnosed with a sulfur metabolism disorder. Such patients warrant further evaluation for etiology of their hyperhomocysteinemia, including screening for classical HCU.

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  • 09|30|2018 Cognitive functioning in patients entering a study of homocystinuria due to cystathionine beta-synthase deficiency (HCU)

    HCU is an inherited disorder of methionine metabolism, leading to abnormal accumulation of homocysteine and its metabolites. Developmental delay and intellectual disability are common among poorly controlled individuals, but early detection and consistent biochemical correction may result in improved intellectual functioning. Study CBS-HCY-NHS-01 is a prospective observational study of the natural history of patients with HCU on current therapy.

    Ongoing data collection will allow for investigation of biochemical markers and neuropsychological functioning over time.

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  • 09|29|2018 Baseline bone mineral density (BMD) of patients in an ongoing study of homocystinuria due to cystathionine beta-synthase deficiency (HCU)

    HCU is a disorder of methionine metabolism, leading to accumulation of homocysteine. Skeletal abnormalities including osteoporosis are common in poorly-controlled patients, but onset may be delayed or prevented with consistent biochemical control. CBS-HCY­ NHS-01 is an observational study of the natural history of patients with HCU on current therapy.
    Our ongoing study will be able to shed a light on the status and clinical course of BMD in pediatric and adult patients with HCU.

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  • 09|28|2018 Characteristics of patients entering a study of homocystinuria due to cystathionine beta-synthase deficiency (HCU)

    HCU is the major genetic disorder of sulfur metabolism, with abnormalities in the visual, skeletal, vascular and central nervous systems. Elevated plasma levels of total homocysteine (tHcy) are implicated in the pathophysiology. Study CBS-HCY-NHS-01 is a comprehensive,longitudinal, natural history study in the US, UK and Ireland documenting the clinical course of patients with HCU on current therapy. Data will allow for the development of standardized clinical outcome parameters and inform statistical analyses for future interventional studies.

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  • 12|22|2017 Enzyme replacement therapy ameliorates multiple symptoms of murine homocystinuria

    Tomas Majtan, Wendell Jones Jr., Jakub Krijt, Insun Park, Warren D. Kruger, Viktor Kožich, Steven Bassnett, Erez M. Bublil, Jan P. Kraus

    Classical homocystinuria (HCU) is the most common inherited disorder of sulfur amino acid metabolism caused by deficiency in cystathionine beta-synthase (CBS) activity and characterized by severe elevation of homocysteine in blood and tissues. Treatment with dietary methionine restriction is not optimal and poor compliance leads to serious complications. We developed an enzyme replacement therapy (ERT) and studied its efficacy in a severe form of HCU in mouse (the I278T model). Treatment was initiated before or after the onset of clinical symptoms in an effort to prevent or reverse the phenotype. ERT substantially reduced and sustained plasma homocysteine concentration at around 100 μM and normalized plasma cysteine for up to 9 months of treatment. Biochemical balance was also restored in the liver, kidney and brain. Furthermore, ERT corrected liver glucose and lipid metabolism. The treatment prevented or reversed facial alopecia, fragile and lean phenotype and low bone mass. In addition, structurally defective ciliary zonules in the eyes of I278T mice contained low density and/or broken fibers, while administration of ERT from birth partially rescued the ocular phenotype. In conclusion, ERT maintained an improved metabolic pattern and ameliorated many of the clinical complications in the I278T mouse model of HCU

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  • 10|16|2017 Enzyme replacement therapy prevents loss of bone and fat mass in murine homocystinuria

    Majtan T, Park I, Bublil EM, Kraus JP
    Skeletal and connective tissue defects are the most striking symptoms in patients suffering from classical homocystinuria (HCU). Here, we determined body composition and bone mass in three mouse models of HCU and assessed whether a long-term administration of enzyme replacement therapy (ERT) corrected the phenotype. The mouse models of HCU were analyzed using dual-energy X-ray absorptiometry and the data were complemented by plasma biochemical profiles. Both the mouse model lacking CBS (KO) and the one expressing human CBS mutant transgene on a mouse CBS null background (I278T) showed marked bone loss and decreased weight mostly due to a lower fat content compared to negative controls. In contrast, the HO mouse expressing the human CBS WT transgene on a mouse CBS null background showed no such phenotype despite similar plasma biochemical profile to the KO and I278T mice. More importantly, administration of ERT rescued bone mass and changes in body composition in the KO mice treated since birth and reversed bone loss and improved fat content in the I278T mice injected after the development of clinical symptoms. Our study suggests that ERT for HCU may represent an effective way of preventing the skeletal problems in patients without a restricted dietary regime. This article is protected by copyright. All rights reserved.

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  • 08|16|2017 Enzyme replacement prevents neonatal death, liver damage, and osteoporosis in murine homocystinuria.

    Majtan T, Hůlková H, Park I, Krijt J, Kožich V, Bublil EM, Kraus JP.
    Classical homocystinuria (HCU) is an inborn error of sulfur amino acid metabolism caused by deficient activity of cystathionine β-synthase (CBS), resulting in an accumulation of homocysteine and a concomitant decrease of cystathionine and cysteine in blood and tissues. In mice, the complete lack of CBS is neonatal lethal. In this study, newborn CBS knockout (KO) mice were treated with recombinant polyethyleneglycolylated human truncated CBS (PEG-CBS). Full survival of the treated KO mice, along with a positive impact on metabolite levels in plasma, liver, brain, and kidneys, was observed. The PEG-CBS treatment prevented an otherwise fatal liver disease characterized by steatosis, death of hepatocytes, and ultrastructural abnormalities of endoplasmic reticulum and mitochondria. Furthermore, treatment of the KO mice for 5 mo maintained the plasma metabolite balance and completely prevented osteoporosis and changes in body composition that characterize both the KO model and human patients. These findings argue that early treatment of patients with HCU with PEG-CBS may prevent clinical symptoms of the disease possibly without the need of dietary protein restriction.-Majtan, T., Hůlková, H., Park, I., Krijt, J., Kožich, V., Bublil, E. M., Kraus, J. P. Enzyme replacement prevents neonatal death, liver damage, and osteoporosis in murine homocystinuria.


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  • 06|12|2017 Engineering and Characterization of an Enzyme Replacement Therapy for Classical Homocystinuria.

    Majtan T, Park I, Carrillo RS, Bublil EM, Kraus JP

    Homocystinuria due to loss of cystathionine beta-synthase (CBS) causes accumulation of homocysteine and depletion of cysteine. Current treatments are suboptimal, and thus the development of an enzyme replacement therapy based on PEGylated human truncated CBS (PEG-CBS) has been initiated. Attenuation of potency was observed, which necessitated a screen of several PEG-CBS conjugates for their efficacy to correct and maintain the plasma metabolite profile of murine homocystinuria after repeated administrations interrupted with washouts. We found that CBS coupling with maleimide PEG inconsistently modified the enzyme. In contrast, the PEG-CBS conjugate with 20 kDa N-hydroxysuccinimide-PEG showed very little loss of potency likely due to a reproducible PEGylation resulting in species modified with five PEGs per subunit on average. We developed assays suitable for monitoring the extent of CBS PEGylation and demonstrated a sustainable partial normalization of homocystinuria upon continuous PEG-CBS administration via osmotic pumps. Taken together, we identified the PEG-CBS conjugate suitable for manufacturing and clinical development.

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  • 06|01|2016 Enzyme replacement with PEGylated cystathionine β-synthase ameliorates homocystinuria in murine model.

    Bublil EM, Majtan T, Park I, Carrillo RS, Hůlková H, Krijt J, Kožich V, Kraus JP

    Homocystinuria, which typically results from cystathionine β-synthase (CBS) deficiency, is the most common defect of sulfur amino acid metabolism. CBS condenses homocysteine and serine to cystathionine that is then converted to cysteine. Individuals with homocystinuria have markedly elevated plasma levels of homocysteine and methionine and reduced concentrations of cystathionine and cysteine. Clinical disease manifestations include thromboembolism and neuropsychiatric, ocular, and skeletal complications. Here, we have shown that administration of PEGylated CBS into the circulation of homocystinuria model mice alters the extra- and intracellular equilibrium of sulfur amino acids, resulting in a decrease of approximately 75% in plasma total homocysteine (tHcy) and normalization of cysteine concentrations. Moreover, the decrease in homocysteine and the normalization of cysteine in PEGylated CBS-treated model mice were accompanied by improvement of histopathological liver symptoms and increased survival. Together, these data suggest that CBS enzyme replacement therapy (ERT) is a promising approach for the treatment of homocystinuria and that ERT for metabolic diseases may not necessitate introduction of the deficient enzyme into its natural intracellular compartment.

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