Clinical Trial of the Protein Farnesylation Inhibitors Lonafarnib, Pravastatin, and Zoledronic Acid in Children With Hutchinson-Gilford Progeria Syndrome

Abstract

Background: Hutchinson-Gilford progeria syndrome is an extremely rare, fatal, segmental premature aging syndrome caused by a mutation in LMNA yielding the farnesylated aberrant protein progerin. Without progerin-specific treatment, death occurs at an average age of 14.6 years from an accelerated atherosclerosis. A previous single-arm clinical trial demonstrated that the protein farnesyltransferase inhibitor lonafarnib ameliorates some aspects of cardiovascular and bone disease. This present trial sought to further improve disease by additionally inhibiting progerin prenylation.

Methods: Thirty-seven participants with Hutchinson-Gilford progeria syndrome received pravastatin, zoledronic acid, and lonafarnib. This combination therapy was evaluated, in addition to descriptive comparisons with the prior lonafarnib monotherapy trial.

Results: No participants withdrew because of side effects. Primary outcome success was predefined by improved per-patient rate of weight gain or carotid artery echodensity; 71.0% of participants succeeded (P<0.0001). Key cardiovascular and skeletal secondary variables were predefined. Secondary improvements included increased areal (P=0.001) and volumetric (P<0.001-0.006) bone mineral density and 1.5- to 1.8-fold increases in radial bone structure (P<0.001). Median carotid artery wall echodensity and carotid-femoral pulse wave velocity demonstrated no significant changes. Percentages of participants with carotid (5% to 50%; P=0.001) and femoral (0% to 12%; P=0.13) artery plaques and extraskeletal calcifications (34.4% to 65.6%; P=0.006) increased. Other than increased bone mineral density, no improvement rates exceeded those of the prior lonafarnib monotherapy treatment trial.

Conclusions: Comparisons with lonafarnib monotherapy treatment reveal additional bone mineral density benefit but likely no added cardiovascular benefit with the addition of pravastatin and zoledronic acid.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00879034 and NCT00916747.

Keywords: aging; atherosclerosis; progeria.

Figure 1

Consort Diagram of Trial Inclusion and Testing

Figure 2

Cardiovascular Outcomes Comparing Triple Therapy Whole Cohort, Naive and Non-naive Subgroups with Lonafarnib Monotherapy. All bars show mean (±SE); P-values between adjacent bars: ***=<0.0001,**= <0.001, *=<0.05.; B-baseline, E = end of study, M=lonafarnib monotherapy, T= triple therapy, N-naive participants, N-n=non-naive participants A. Carotid artery echodensity significantly decreased with monotherapy (n=24), but not with triple therapy (n=30) regardless of naive or non-naive entry status. B. PWV: The monotherapy cohort entered the trial with significantly higher PWV, and significantly improved with monotherapy (n=19) (P=0.0025), but not with triple therapy (n=23) (P>0.05) regardless of naive or non-naive entry status.

Figure 2

Cardiovascular Outcomes Comparing Triple Therapy Whole Cohort, Naive and Non-naive Subgroups with Lonafarnib Monotherapy. All bars show mean (±SE); P-values between adjacent bars: ***=<0.0001,**= <0.001, *=<0.05.; B-baseline, E = end of study, M=lonafarnib monotherapy, T= triple therapy, N-naive participants, N-n=non-naive participants A. Carotid artery echodensity significantly decreased with monotherapy (n=24), but not with triple therapy (n=30) regardless of naive or non-naive entry status. B. PWV: The monotherapy cohort entered the trial with significantly higher PWV, and significantly improved with monotherapy (n=19) (P=0.0025), but not with triple therapy (n=23) (P>0.05) regardless of naive or non-naive entry status.

Figure 3

Box plots of a) height-adjusted spine aBMD b) vBMD at the 50%^ile radial site c) bending (EI) rigidity measured at the 50%^ile radial site in the various patient groups. Interquartile ranges (IQR; 75^th and 25^th percentiles) are top and bottom box edges, respectively. Horizontal lines within boxes represent medians. Lower and upper whiskers show the extreme points that fall within Q1-1.5 x IQR and Q3+ 1.5 x IQR. *, **, and NS represent P values <0.05, <0.001, and >0.05, respectively. B-baseline, E = end of study, M=lonafarnib monotherapy, T= triple therapy, N-naive participants, N-n=non-naive participants, C=non-HGPS controls. n for each participant group listed above each box at top of graph.

Figure 3

Box plots of a) height-adjusted spine aBMD b) vBMD at the 50%^ile radial site c) bending (EI) rigidity measured at the 50%^ile radial site in the various patient groups. Interquartile ranges (IQR; 75^th and 25^th percentiles) are top and bottom box edges, respectively. Horizontal lines within boxes represent medians. Lower and upper whiskers show the extreme points that fall within Q1-1.5 x IQR and Q3+ 1.5 x IQR. *, **, and NS represent P values <0.05, <0.001, and >0.05, respectively. B-baseline, E = end of study, M=lonafarnib monotherapy, T= triple therapy, N-naive participants, N-n=non-naive participants, C=non-HGPS controls. n for each participant group listed above each box at top of graph.

Figure 3

Box plots of a) height-adjusted spine aBMD b) vBMD at the 50%^ile radial site c) bending (EI) rigidity measured at the 50%^ile radial site in the various patient groups. Interquartile ranges (IQR; 75^th and 25^th percentiles) are top and bottom box edges, respectively. Horizontal lines within boxes represent medians. Lower and upper whiskers show the extreme points that fall within Q1-1.5 x IQR and Q3+ 1.5 x IQR. *, **, and NS represent P values <0.05, <0.001, and >0.05, respectively. B-baseline, E = end of study, M=lonafarnib monotherapy, T= triple therapy, N-naive participants, N-n=non-naive participants, C=non-HGPS controls. n for each participant group listed above each box at top of graph.