14 CLINICAL STUDIES

14.1 Bile Acid SynthesisDisorders due to Single Enzyme Defects

The effectiveness of CHOLBAM at dosagesof 10 to 15 mg/kg per day in patients with SEDs was assessed in:

Trial 1: a non-randomized, open-label, single-arm trialin 50 patients over an 18-year period.
Trial 2: an extension trial of 12 new patients along with21 patients who rolled-over from Trial 1 (n=33 total). Efficacy dataare available for 21 months of treatment.
A published case series of 15 patients patients with SEDsand 3 patients with PDs.

Enrollment criteria inTrials 1 and 2 were based on abnormal urinary bile acid by Fast AtomBombardment ionization - Mass Spectrometry (FAB-MS).

Pre- and post-treatment liver biopsies wereperformed in a limited number of patients. Documentation of adherenceto treatment, concomitant medications, and response to treatment wereincomplete during Trial 1. Additional interventions in some patientsincluded supplementation with fat-soluble vitamins, as dictated bythe patient's clinical signs and symptoms.

Trials 1 and 2

On average, patients were 4 years of age at the start of cholic acid treatment (range three weeks to 36 years). The majority of patients were treated for an average of 310 weeks (6 years). Patient ages at the end of treatment ranged from 19 to 36 years.

These trials were carried out over many years, and data are not available on all patients. Thirty-nine patients in Trial 1 and 5 new patients in Trial 2 received at least one dose of CHOLBAM and had sufficient data available to assess baseline liver function and effects of CHOLBAM treatment. A responder analysis was performed to determine the response to treatment with CHOLBAM.

Response to CHOLBAM treatment was assessed by the following laboratory criteria:

ALT or AST values reduced to less than 50 U/L, or baseline levels reduced by 80%;
total bilirubin values reduced to less than or equal to 1 mg/dL; and
no evidence of cholestasis on liver biopsy;

and the following clinical criteria:

body weight increased by 10% or stable at greater than the 50th percentile; and
survival for greater than 3 years on treatment or alive at the end of Trial 2

CHOLBAM responders were defined as patients who either:

met at least two laboratory criteria and were alive at the last follow-up; or
met at least one laboratory criterion, had increased body weight and were alive at the last follow-up.

Overall, 28 of 44 patients (64%) were responders. The breakdown by defect type is as follows:

Table 4: Response to CHOLBAM Treatment by Type of Single Enzyme Defect
Single Enzyme Defect	Responders/Number Treated (%)
* N/A indicates no evaluable patients in the defect subgroup are represented.
3β-HSD	22/37 (59%)
AKR1D1	3/4 (75%)
CTX	2/2 (100%)
AMACR	1/1 (100%)
CYP7A1	N/A*
Smith-Lemli-Opitz	N/A*

Among SED responsive patients, 45% of the responders met the two clinical criteria plus 1 to 3 laboratory criteria and 55% met the weight criteria.

Only six patients had pre- and post-treatment liver biopsies in Trial 1. Where biopsies were available, pre-treatment biopsies showed varying degrees of inflammation, bridging fibrosis, and giant cell formation. Post-treatment biopsies generally showed reduced or absent inflammation and reduced or absent giant cell formation. Fibrosis remained but did not progress.

It is difficult to evaluate long term survival in patients with SEDs since there is little natural history survival data for comparison. Overall, 41 of 62 (67%) patients with SEDs survived greater than 3 years from trial entry. Thirteen of these 41 patients (32%) survived for 10 to 24 years on treatment.

Four patients in Trial 1 underwent liver transplant, including two patients diagnosed with AKR1D1 deficiency, one with 3β-HSD deficiency, and one with CYP7A1 deficiency and two patients in Trial 2, both with AKR1D1.

CHOLBAM’s effects on extrahepatic manifestations of SEDs, such as neurologic symptoms have not been established.

Case Series

A published report of a case series described 15 patients with SEDs; thirteen were diagnosed with 3β-HSD deficiency and two with AKR1D1 deficiency by mass spectrometry and gene sequencing. All patients were treated with cholic acid with a median duration of treatment of 12.4 years (range 5.6 to 15 years). Therapy started at a median age of 3.9 years (range 0.3 to 13.1 years). The mean dose at the start of cholic acid treatment was 13 mg/kg and the mean dose at last follow up was 6 mg/kg. Eight patients were initially treated with oral ursodeoxycholic acid prior to receiving a diagnosis of bile acid synthesis defect, after which they were switched to cholic acid. Initial signs and symptoms included jaundice, hepatosplenomegaly, steatorrhea, or symptoms related to deficiency of a fat-soluble vitamin (K, D or E).

Of the 8 patients who received ursodeoxycholic acid initially, the six with 3β-HSD deficiency demonstrated mild clinical improvement. Following treatment with cholic acid, all patients experienced resolution of their pre-existing jaundice and steatorrhea, and all but one experienced resolution of hepatosplenomegaly. Weight and height improved, and sexual maturation progressed normally in all patients. Liver biopsies were performed in 14 patients after at least 5 years of cholic acid treatment and all showed resolution of cholestasis. In one patient with 3β-HSD deficiency, biliary bile acid analysis while on cholic acid therapy showed enrichment of the bile with cholic acid.

14.2 Peroxisomal Disordersincluding Zellweger Spectrum Disorders

The effectiveness of CHOLBAM at a dosageof 10 to 15 mg/kg per day in patients with PDs including Zellwegerspectrum disorders was assessed in patients in the same trials describedin section 14.1.

Trial 1 treated 29 patients with PDs over an 18‑year period.
Trial 2 treated 2 new patients along with 10 patients whorolled over from Trial 1 (n=12 total). Efficacy data are availablefrom Trial 2 for 21 months of treatment.
Additional efficacy data were obtained from published casereports of 3 patients.

Enrollment criteria inTrials 1 and 2 were based on abnormal urinary bile acids analysisby FAB-MS and a neurologic exam. Most patients received concomitantDHA (docosahexaenoic acid) and Vitamins A, D, E, and K. Documentationof adherence to treatment, concomitant medications, and response totreatment were incomplete during Trial 1.

Trials 1 and 2

The majority of patients (80%, 25/31) were less than 2 years of age at the start of CHOLBAM treatment (range 3 weeks to 10 years). The majority of patients were treated for an average of 254 weeks (4.8 years).

Sufficient data were available to assess baseline liver function and effects of CHOLBAM treatment in 23 patients in Trial 1 and in one new patient in Trial 2. A responder analysis was performed in the patients who had received at least one dose of CHOLBAM and had sufficient data available to assess baseline liver impairment.

Response to CHOLBAM treatment was assessed by the following laboratory criteria:

ALT or AST values reduced to less than 50 U/L, or baseline levels reduced by 80%;
total bilirubin values reduced to less than or equal to 1 mg/dL; and
no evidence of cholestasis on liver biopsy;

and the following clinical criteria:

body weight increased by 10% or stable at greater than the 50th percentile; and
survival for greater than 3 years on treatment or alive at the end of Trial 2

CHOLBAM responders were defined as patients who either:

met at least two laboratory criteria and were alive at the last follow-up; or
met at least one laboratory criterion, had increased body weight and were alive at the last follow-up.

Overall, 11 of 24 patients (46%) were responders. The breakdown by disorder is as follows:

Table 5: Response to CHOLBAM Treatment by Type of Peroxisomal Disorders including Zellweger Spectrum Disorders
Peroxisomal Disorder	Responders/Number Treated (%)
Neonatal Adrenoleukodystropyhy	3/6 (50%)
Generalized Peroxisomal Disorder	1/1 (100%)
Refsum Disease	3/4 (75%)
Zellweger Syndrome	3/8 (38%)
Peroxisomal Disorder, Type Unknown	1/5 (20%)

Among responsive patients with PDs, 38% of the responders met the two clinical criteria plus 1 to 3 laboratory criteria and 63% met the weight criteria. There were no PD patients that underwent liver transplant.

No evidence of improvement in survival over that seen in historical controls could be demonstrated from the data presented. Overall, 13 of 31 patients (42%) survived greater than 3 years from the time of trial entry. Eight of these 13 patients (62%) survived 10 to 17 years on treatment.

Nine patients had both pre- and post-treatment liver biopsies. One patient showed improvement in histology, while the majority of patients remained unchanged. Two patients demonstrated worsening histology, which was consistent with a worsening of other liver laboratory parameters (bilirubin, serum transaminase values).

CHOLBAM’s effects on extrahepatic manifestations of PDs including Zellweger spectrum disorders, such as neurologic symptoms have not been established.

One patient, who did not have cholestasis on pre-treatment liver biopsy, developed cholestasis on treatment with CHOLBAM and subsequently died.

Case Reports

In case reports from the literature, a 6-month-old patient with Zellweger syndrome treated with a combination of cholic and chenodeoxycholic acids experienced normalization of serum transaminases and bilirubin, improvement in liver histology, reduced serum and urinary atypical bile acid intermediates, and improvement in steatorrhea and growth. Two patients with Zellweger syndrome treated with oral bile acids showed decreased serum transaminases.