Final Report Summary - DEVELOPAKURE (Clinical Development of Nitisinone for Alkaptonuria) Executive Summary:Executive SummaryAKU, also known as Black Bone Disease, is caused by the deficiency of the enzyme homogentisate 1,2-dioxygenase (HGD), leading to the accumulation of a substance called homogentisic acid (HGA). A blackpigment formed from HGA is deposited in body tissues, particularly cartilage, leading to early onset, severearthritis, heart disease and disability. Nitisinone is an enzyme inhibitor that reduces the accumulation of HGAand should prevent or slow the damage from AKU.The DevelopAKUre project was established to improve the understanding of Alkaptonuria, especially inpatients of younger age (AKU) and to develop an orphan designated drug, nitisinone, for the treatment ofpatients with AKU. To this end a group of clinical and basic scientists in addition to clinical trial experts cametogether to carry out the clinical development of nitisinone for AKU.The programme involved a dose-response study (SONIA 1) which for the first time clearly identified that a doseof 8 mg daily was optimal for decreasing homogentisic acid in AKU. An efficacy study (SONIA 2) todemonstrate improved clinical parameters was then undertaken using 10 mg nitisinone. The principal outcomeof sustained decrease in urinary HGA by nitisinone 10 mg was clearly shown. Of the 138 patients recruited tothe SONIA 2 4-year study, 110 completed the clinical phase by 31st January 2019. The results will now berigorously analysed so as to decide whether an application for marketing authorisation is justified by the databy studying the clinical outcomes beyond HGA. A cross-sectional study (SOFIA) in children and young adultswas completed which showed that aspects of AKU disease other than HGA is already present by age 16 years,the youngest age of a participant in SOFIA. This now provides support for the development of a paediatricSOFIA study to further clarify the age when nitisinone therapy is likely to be beneficial.The project was complex and required the co-operation of a large consortium that came together to deliverDevelopAKUre. They include the Royal Liverpool University Hospital as the Coordinator, the AKU Society(UK) and ALCAP (France) patient groups for communications/dissemination and enabling patient recruitment,three SMEs (Nordic Biosciences (Denmark) for biomarker analysis, PSR (Netherlands) for clinical trialcoordination, and previously Cudos (Netherlands) for medical monitoring until the first 36 months, a mid-sizedpharma company Sobi (Swedish Orphan Biovitrum International) supplying the drug and providing regulatoryadvice, three universities (Liverpool, Siena and the Biomedical Research Center of the Slovak Academy ofSciences) for the analysis and interpretation of data, and three clinical trial centres (Liverpool, Hôpital Necker(Paris), National Institute of Rheumatic Diseases (Slovakia)) to recruit sufficient participants.Project Context and Objectives:Summary Description of Project Context and ObjectivesAKU is a serious, multisystem disorder of peak adulthood affecting approximately one in every 250,000 people,although some countries such as Slovakia have a higher prevalence rate of around one in 19,000. Despite SirArchibald Garrod identifying AKU in London in 1902 as the first recognised inborn error of metabolism, littlehas changed for patients. A recent study of 44 patients by our group showed they had received: 76 jointreplacements, 28 ruptures (tendons/ligaments/ muscle), 10 fractures, 4 with renal stones, 4 with prostatic stonesand 7 with aortic valve disease.This morbidity is caused by the inability to fully metabolise tyrosine, resulting in increased HGA, despiteefficient urinary excretion. The high concentrations of HGA become converted to a melanin-like pigment - aprocess termed ochronosis. The pigment is deposited in connective tissues, particularly cartilage, leading toearly onset, severe arthritis, starting at around the age of 30, with few symptoms or signs earlier in life.Visible external ochronosis in ears and eyes begins at around the same time as serious and inevitable painfulspinal disease, which is characterised by disc disease/prolapse (resulting in spinal stenosis, cord compressionand myelopathy), vertebral fractures. Valvular heart disease is common, requiring valve replacement, as arejoint replacements. Aortic valve and aortic root disease appear to be especially common. Often patients andtheir medical advisors do not fully appreciate the burden of disease, which is only detected through systematicassessment.A recent survey by the AKU Society indicated that patients suffered constant pain, difficulty with activities ofdaily living, poor sleep, depression, poor quality of life, unemployment and isolation. Current assumptions arethat ochronosis is irreversible. If true, early treatment is required to modify the disease. Later treatment leads togreater residual disease.Our understanding of AKU is incomplete since we do not know if ochronosis is present at a sub-threshold levelearlier. Early treatment in children and young pre-ochronotic patients would only be justified if evidencesuggested that it was. The SOFIA study was designed to address this issue. To detect the high prevalence ofoccult disease, a systematic assessment system is necessary in clinical studies. An instrument that best reflectsthe burden of disease, the AKUSSI (Alkaptonuria Severity Score Index) will be used as an outcome measure inSONIA 2. The AKUSSI incorporates multiple, clinically meaningful outcomes that can be described in a singlescore. It includes kidney and prostate stones, aortic stenosis, bone fractures, tendon/ligament/muscle ruptures,kyphosis, scoliosis, joint replacements and all other clinical features of AKU. This score is sensitive to allmorbid features of AKU and not any one feature. AKUSSI, a quantitative, multidisciplinary assessment system,changes over time, reflecting changes in disease severity. It will be used in SONIA 2, having been furthervalidated since its original description. Studies of other rare diseases, such as Fabry disease, have used a similarapproach.Several therapeutic approaches have been previously evaluated in AKU patients with little success. Currenttreatments for AKU are palliative and hence do not tackle the intrinsic cause of AKU. These include the use ofascorbic acid, an antioxidant, since the formation of the melanin-like HGA pigment is an oxidative process.Ascorbic acid has no effect on HGA excretion and no credible studies have shown that treatment with vitaminC is clinically effective. We have recently shown that AKU mice, which create their own vitamin Cendogenously, are not protected from ochronosis. Similarly, low protein diets have been ineffective in AKU.Since tyrosine (and therefore HGA) is derived from protein, restricting dietary protein and thereby tyrosine hasbeen a focus of previous treatments. Such an approach requires restricting dietary protein for life, for which isnot easy for patients to comply. Anecdotal reports of efficacy with low protein diet have not been confirmed inany systematic long-term efficacy studies. AKU causes significant musculoskeletal disability with the limitationof activity and consequent impairment of quality of life. Physiotherapy, while not addressing the causative factorof AKU, namely HGA, has been shown to improve the range of joint motion and activity. Physiotherapy isunderused both by the medical profession and patients but can only be palliative at best. Systematic surveillancefor treatable complications of the heart, kidney and prostate after the fourth decade of life is important, but notwidely adopted by physicians due to lack of knowledge. This approach is also palliative at best. Effective paincontrol is crucial, but efforts are often ineffective. Pain can be ameliorated by a wide range of drugs(paracetamol, non-steroidal anti-inflammatory drugs, opioids, anticonvulsants, local anaesthetics andgabapentin) in addition to physical modalities (TENS, acupuncture, physiotherapy and nerve blocks), but formany patients pain is constant, severe and disabling. When liver or kidney transplantation has been conductedin AKU patients, there have been reports of partial or total resolution of AKU. Timely palliative spinal and jointreplacement surgery is critical for the continued functioning of severely affected patients where analgesia fails.Progressive disability often requires the use of physical aids, such as crutches and/or the use of a wheelchair.Nitisinone inhibits 4-hydroxy-phenyl-pyruvate-dioxygenase and decreases the formation of HGA. Since highlevels of HGA in AKU leads to ochronosis, which in turn results in destructive functional consequences,decreasing HGA, by inhibiting an enzyme proximal to HGA, could prevent the progression of disease in AKU.Such an approach with nitisinone is now feasible. Because nitisinone targets and corrects the principal metabolicabnormality causing AKU disease, it should prevent morbidity, if started before the symptomatic phase, andalter progression in those already symptomatic.An in vitro model of ochronosis employing osteosarcoma or chondrocyte cultures growing in mediumcontaining HGA resulted in ochronotic pigment formation in cells and associated matrix in a dose-dependentmanner. These results confirm that HGA concentration is the principal determinant of ochronosis and thatdecreasing the concentration of HGA in vivo should prevent ochronosis.An AKU mouse model (HGD-/-) has demonstrated that nitisinone administration can totally prevent ochronosisin joint cartilage. This AKU mouse is a model of AKU biochemistry and joint pathology which is appropriatefor testing the drug nitisinone. Adding nitisinone at low doses in the drinking water over the lifetime of a of AKU mice resulted in the plasma levels of HGA falling close to zero. Mice on ntisisinone did not developpigmented chondrocytes, compared to the untreated AKU cohort. Electron microscopy of the joint tissues ofhuman AKU patients showed individual collagen fibres that had become decorated with pigment.Nitisinone has been used in Hereditary Tyrosinaemia 1 (HT-1) for more than 20 years at a dose of 1-2 mg/kgbodyweight. An early dose-ranging study in two older women with AKU indicated that the dose required todecrease HGA significantly was up to 30-fold lower than that used in treating HT-1. Another open-label studyat the NIH, which employed nitisinone at 2.1 mg daily, decreased HGA by 95% and increased serum tyrosine11-fold, in 9 AKU adult patients over a 4 month period. The tyrosinaemia did not cause corneal or any othertoxicity when patients received eye and other examinations. Six out of seven patients who received nitisinonefor more than 1 week noted decreased pain in their affected joints. In a third study, a three-year, single-blind,controlled NIH clinical trial of 40 patients, the nitisinone group (2.1 mg/day) showed a sustained decrease inmean urinary HGA from 5.1 g/day to 0.125 g/day. Mean plasma HGA levels fell from 5.74 mg/L to 0.306 mg/Lafter treatment. Urine and plasma HGA decreased by 98% and 95% respectively.These studies by colleagues at the NIH demonstrated that nitisinone is able to consistently decrease HGA. Thehalf-life of serum nitisinone is 52.1 hours. Steady state is achieved after 11 days. Because patients in the studiesdescribed above were switched to a higher nitisinone dose within a week, and possibly higher doses thannecessary, is the reason why the SONIA 1 dose-response study was required. The NIH trial was inconclusivebecause it used only the difference in range of hip motion between placebo and nitisinone groups as the primaryoutcome and did not have sufficient patient numbers (40). Conversely, the SONIA 2 study was designed toinclude a larger cohort and utilized AKUSSI to prove efficacy (WP 3).The DevelopAKUre project was designed with the following aims:1. A Phase 2 dose-response study (SONIA 1: Suitability Of Nitisinone In Alkaptonuria 1) to determine the doseresponsecurve of nitisinone in reducing HGA levels in circulating blood and the inter-patient variability, andprovide guidance on the useful dose range in the treatment of AKU.2. A phase 3 clinical efficacy study (SONIA 2: Suitability Of Nitisinone In Alkaptonuria 2) to evaluate the longtermefficacy and the safety of nitisinone for treating AKU.3. A cross-sectional study (SOFIA: Subclinical Ochronosis Features In Alkaptonuria) to evaluate whether AKUprogresses subclinically prior to the development of overt ochronosis. This study aimed to determine at whatage treatment should begin.4. To provide sufficient data to determine whether a marketing authorisation application could be filed to theEuropean Medicines Agency for use of nitisinone for the treatment of AKU.Project Results:Main S&T Results/ForegroundThe most significant results arising from the project research are summarised below, in as muchdetail that is possible without losing the rights of the consortium to the IPR embedded within thediscoveries.1.3.1 SOFIA StudyThe goal of the SOFIA study was to determine if the AKU progresses sub-clinically by conducting across-sectional study in paediatric and young adult AKU patients without external ochronosis andadults with external ochronosis. The results were used to determine at what age it might be appropriateto begin nitisinone treatment. The SOFIA study concluded that ear ochronosis could be observed atage 20 and could even be present earlier. A paediatric study to investigate this further is currentlyunderway in the UK.• Normal ranges for the metabolic and non-metabolic measures used for AKUNormal non-AKU data have been established for metabolic and non-metabolic measures byrecruiting non-AKU controls such as those for HGA and related metabolic measurements, inaddition to gait analysis.• Ear biopsy outcome establishedOchronosis was identified on thin sections from the age 20, although it is possible it could be presentearlier than 20 years of age. A greater number of patients younger than 20 need to be studied tohave greater confidence of the earliest age when ochronosis begins. An additional study, developedas a result of the outcomes of the SOFIA study, called SOFIA-Paediatric is near to commencementstudying children younger than 16 years of age.• Development of eye ochronotic pigmentation (visual)Visual inspection and grading of ochronotic pigment in the eye demonstrated that pigmentation wasvisibile from the age of 20 years.• Development of ear ochronotic pigmentation (visual)Visual inspection and grading of ochronotic pigment of the surface of the ear in photographsdemonstrated the presence of such pigmentation from the age 30 years, unlike the cartilage biopsieswhich generated visible colour 10 years earlier.Alteration in metabolism with ageingThere was no change in 24-h-urine HGA levels with increasing age and homogentisicaciduria waspresent even in the youngest patients. Serum HGA increased with age but increased levels wereobserved in even the youngest subjects.• Tissue damage evolved with ageThe concentration of tissue damage markers varied with ageing but it was not possible to identifythe precise age at which biomarkers changed, which will require further study of younger patients.Disppointingly, no clear tissue damage biomarker was reliably identified from the SOFIA study.• Inflammation and oxidation increased with age but was not significantly higher in AKUpatients than controlsLevels of Amyloid A and protein thiols in serum increased with age, but no differences wereobserved between AKU patients and controls. Disppointingly, no clear inflammatory and oxidationbiomarkers could be reliably identified from the SOFIA study.• Changes in the structure in the spine and joints was found to occur in AKU patients as theyagedAKU led to worsening spine disease (using Pfirmann and SPARCC scores), first observed from theage of 30 years, but no association could be identified between knee (WORMS score) and age upto 45 years, after which there was an association between age and disease severity.• Clinical gait analysis identified pathological changes in AKU changes even from an early agethat varied with ageThe mean values of Movement Deviation Profile (MDP), a score for gait, were significantly higherfor AKU patients than they were for non-AKU controls. Gait deviations in AKU patients could beobserved even in the youngest age group.• Quality of life deteriorated as paitents became olderAn increase in pain was identified in older AKU patients and their general quality of life alsodeclined with age, from the 3rddecade, with no difference between genders.• Severity of symptoms of AKU increased with ageThe severity of the symptoms of AKU increased with age, with no difference between genders, withAKU found in even the youngest group.The data and from this study have been accepted for publication, as follows:• Cox TF et al. BMJ Innovations 2019 in pressSONIA 1 StudyThe goal of this study was to investigate the dose-response of nitisinone in AKU patients. Althoughextensive experiments had been performed in rodents, this information was not available in humans.We successfully established reference ranges that allowed the consortium to later conduct a phase IIIstudy with the most effective dose of nitisinone at its lowest and safest or least toxic concentration.• Normal ranges for HGA and tyrosine establishedThe primary outcome in SONIA was to bring the excretion of HGA into urine over 24-hours into anormal range. To undertake this, a study was conducted in non-AKU control subjects and referencevalues obtained after 24 hours for HGA in urine and serum in addition to serum tyrosine. Noprevious reliable data employing state-of-the-art analytical techniques had been available at the startof the DevelopAKUre project.• Effects on 24 hour excretion of HGA in urine of various doses of nitisinone clarifiedThere has never been a full dose-response study conducted for nitisinone in AKU. The doseassessment in prior studies at the National Institutes of Health was determined in 2 patients only(Phornphutkul C, Introne WJ, Perry MB, et al. Natural History of Alkaptonuria. N Engl J Med2002;347:2111-21). The SONIA 1 study was the first detailed study of the effect of different dosesof nitisinone on metabolic parameters (pharmcaodynamic effect) in AKU.• Acidification of serum stabilised serum HGA for the first time allowing reliable serummeasurementsThere is little data on circulating HGA not only because the metabolite is present is lowconcentrations, but also because it is labile and rapidly altered in vitro, epecially in alkalineenvironments. In these circumstances, HGA rapidly oxidises to benozoquinone acetic acid. In orderto ensure accurate quantification of HGA in urine, collections are routinely acidified. However, nosuch methodologies were available for serum. Thus, an acidification process for human AKU serumsamples was developed, validated and utilized for the first time, allowed reliable serum HGAquantitation in all samples.• Effects of various doses of nitisinone on serum HGAThe effects of various doses of nitisinone on the metabolic parameters (pharmcaodynamic effect)of AKU patients was clarified. Administration of a liquid formulation of nitisinone at doses of 0, 1,2, 4 and 8 mg daily to 5 groups of eight subjects allowed the effect of nitisinone on serum HGA tobe confirmed. The optimal dose was 8 mg, which was the least concentration that reliably (in alleight patients) decreased serum HGA concentrations to the lowest value (>99% reduction).Effect of various doses of nitisinone on serum tyrosineFor the first time it has been demonstrated that all doses of nitisinone increase levels of circulatingtyrosine. A near maximal increase is reached at a 2mg dose with small further increases at 4 and 8mg in AKU patients in normal living environments.• Data on the PK/PD effects of nitisinone generatedData on nitisinone profiles over 24-hours provided information on the absorption, distribution,metabolism and elimination of the drug, described as its pharmacokinetics (PK), in AKU for thefirst time.• Changes in the tyrosine pathway demonstrated in SONIA 1 study using a targeted metabolomicsapproachA targeted metabolomics technique was developed and utilized for the first time in order tocharacterise metabolites such as hydroxyphenyl-pyruvate (HPPA), hydroxyphenyllactate (HPLA),in addition to phenylalanine, tyrosine and HGA, before and after treatment with nitisinone.Analyses of the data clarified the magnitude of changes in levels of metabolites post-nitisinone.• Renal handling of metabolites clarified in AKU and post-nitisinoneFor the first time, the manner in which metabolites important in AKU (HPPA, HPLA, HGA,tyrosine, phenylalanine) is managed and excreted by the kidney was clarified in AKU patients andfollowing treatment with nitisinone. HGA was excreted by the kidney through glomerular filtrationand net tubular secretion. For the first time local renal production of HGA was demonstrated.Tyrosine and phenylalanine were shown to be mostly reabsorbed. HPPA, similar to HGA, wasexcreted by the kidney through glomerular filtration and net tubular secretion. HPLA, to a lesserextend was also excreted by the kidney through glomerular filtration and net tubular secretion.• Even the largest dose of nitisinone was safe over a 4 week periodAlthough the SONIA 1 study was a short investigation employing nitisinone administration over a4-week period only, it nevertheless revealed no safety issues during this time.• HGA interference in urine creatinine measurement recognized and resolvedInterpretation of urine tissue biomarkers employing urine creatinine ratios was confounded by HGAinterference of the creatininase assay. Re-assay of urine samples for creatinine employing the Jaffereaction eliminated this interference allowing accurate interpretation of biomarkers. As a result,systematic investigation of the interference of HGA on laboratory parameters was evaluated andpublished.profiles of circulating metabolites profiles generatedFor the first time, 24-h profiles of HGA, HPPA, HPLA in serum were generated in addition tophenylalanine and tyrosine. These data will be helpful in understanding and managing tyrosinaemiapost-nitisinone as anecdotal evidence from clinical observations indicate that tyrosinaemia effectsmay have a circadian rhythm.• 24-hour profiles of tissue damage biomarkers generated in AKUData from this study revealed significant rhythms (>20%) for bone (CTX-1), cartilage (AGNx1)and cardiovascular markers (MIM). These data are helpful in ascertaining the optimal time to obtainsamples in clinical practice.• Status of inflammatory markers pre- and post-nitisinone clarifiedDespite the speculation that there was likely little difference in levels of inflammatory markers inAKU patients before or after treatment with nitisinone, these data were generated for the first timeand their status established.• Genetic analysis data obtainedNovel mutations were discovered during genetic analyses (HGD mutations) conducted on samplesfrom SONIA 1, SOFIA and SONIA 2 studies. These data have been published and the HGDdatabase updated. This additional information will facilitate potential gene therapies that could beconsidered for AKU in the future.• Non-targeted metabolomic data developedA comprehensive strategy for carrying out urine metabolomics in an iconic metabolic disease wasdeveloped and published. This can be considered as state-of-the-art in high-resolution analysis inAKU.• Changes to 5HIAA and metanephrines levels established after nitisinone treatment3-methoxytyramine concentrations increased following nitisinone therapy. Conversely,normetadrenaline and 5-hydroxyindole acetic acid concentrations decreased. The SONIA 1 studyfor the first time demonstrated that catecholamine and serotonin metabolism is modified bytreatment with nitisinone.• Dose of nitisinone to be used in a phase III trial (SONIA 2) identifiedA 10mg capsule was chosen as the dose for the 4-year phase III SONIA 2 study as it matched theliquid formulation used in the SONIA 1 study, which decreased HGA in urine by >99% in all 8patients treated in this study.data and discoveries from this study were published, or are in the process of being published, inten manuscripts, as follows:• Curtis SL et al. Clin Biochem. 2014;47:640-7. PMID: 24373924• Hughes AT et al. J Chromatogr B Analyt Technol Biomed Life Sci. 2014;963:106-12. PMID:24952314• Hughes AT et al. Ann Clin Biochem. 2015;52(5):597-605. PMID: 25628464• Olsson B et al. JIMD Rep. 2015;24:21-7. PMID: 25772318• Genovese F et al. JIMD Rep. 2015;24:29-37. PMID: 25786641• Davison AS et al. Clin Chem Lab Med. 2015;53:e81-3. PMID: 25252754• Ranganath LR et al. Ann Rheum Dis. 2016;75:362-7. PMID: 25475116• Davison AS et al. JIMD Rep. 2018;41:1-10. PMID: 29147990• Norman BP et al. Clin Chem 2019;65:530-539. PMID: 30782595• Milan AM et al. Scientific Reports (under review)1.3.2 SONIA 2 studyThe main goal of the SONIA 2 study was to carry out a phase III 4-year efficacy and safety study in138 AKU patients, half on nitisinone and half in a no-treatment arm, to obtain data so that anapplication could be made to the European Medicines Agency for approval for marketing authorisationof nitisinone 10 mg in AKU, dependant on the final results of the trial.The SONIA 2 study only completed its clinical phase in January 2019, several days before the officialend date of the project. The data are currently being cleaned with the database likely to be lockedimminently. Thus, the main conclusions from this study cannot be known until statistical analysis cantake place in the future. The only results available are those from the interim analysis at month 12.• Significant reduction of urinary HGA was maintained after one year of treatment withnitisinoneAs agreed with the EMA, an interim analysis of data at 12 months concluded that AKU patientsgiven nitisinone for a year maintinaed a significant reduction in 24-h-urine HGA levels of 99.7%that of control patient values.Potential ImpactThe observations from DevelopAKUre project, although definitive results of the 4-year study are notyet known, already showed that over 12 months, nitisinone at a dose tolerable over that period canreduce urine HGA levels by 99.7%. From our knowledge of the aetiology of the disease, this stronglysuggests that nitisinone could have a dramatice impact on the progression of AKU.Thus, if the final 4 year results of the SONIA 2 study replicate those of the interim results, we can beconfident that it will have a significant impact on the ongoing care of established AKU patients.Furthermore, if the study, from the AKUSSI results, finds that nitisinone improves the mobility andreduces the impact of AKU on patients over the longer-term, the project will have positive implicationsfor healthier ageing and enhanced independent living for AKU patients in the future, even those thatcurrently have significant disability.Successful results as described earlier in sections 1.2 and 1.3 would allow much younger patients, forexample those just starting adulthood, who have no apparent symptoms of the disease, to receivetreatment to modify serum HGA levels and so would be unlikely to suffer the classical ssymptoms ofAKU. Although not a cure, this would represent a considerable change to the quality of life of allyoung individuals with AKU. Although patients with AKU probably have a normal life span, theysuffer a long decline with manifestations of multisystemic arthropathy, often combined withdepression and loss of employment. Patients often require multiple joint replacements and sufferruptures of tendons, ligaments and muscle, bone fractures, renal stones, prostatic stones and aorticvalve disease.By treating the disease early and probably before morbid features evolve, the economic cost of theAKU disease burden should be reduced considerably. A recent (unpublished) study estimated that atypical AKU patient costs approximately €140,000/year in the UK (uprated for inflation). Ifextrapolated to the estimated AKU population in Europe, using normal population statistics, aconservative estimate of the total cost of AKU, including indirect costs (i.e. lost wages and production),but excluding estimates of loss of quality of life, is €235 million per year. This estimate ignoressignificant individually unquantifiable costs incurred related to drug therapy (specifically painmanagement), health care devices and psychological distress which were found to occur across themajority of patients who have been interviewed.The longer a patient has lived with significant complications from AKU, the longer and more costlythe recovery from necessary surgery. Our research (unpublished) indicates that AKU patients whohave a first or second surgery generally require less than three days’ recovery in hospital. Those whohave lived with significant symptoms for longer and are having their third or more surgery can requiremore than a week to recover in hospital, including several days in special or intensive care. It istherefore clear that social, psychological, healthcare and family/individual costs for AKU are extremlyhigh. There are also significant costs for carers who are often crucial in providing support for disabledand isolated patients. If successful, the DevelopAKUre would have a dramatic effect on AKU patients.If translated around the world, the results would represent healthcare cost savings in the order of >€1Bwith a concomitant improvement of the health and quality of life of thousands of AKU patients.The AKU Society has been a key strategic partner in the dissemination of the project and its results. Adissemination plan was created and successfully implemented. The key features of the plan were:• Targeting scientific publications• Speaking at conferencesIn addition to scientific conferences, project participants have spoken at conferences aimed atindustry, patient representatives, healthcare professionals, governmental organisations, etc.• Linking with IRDiRC and other networksNick Sireau (AKUS) was a member of the IRDiRC working group on drug repurposing, providingadvice from DevelopAKUre. We publicised how DevelopAKUre contributes to the IRDiRC’s goalof 200 new therapies by 2020. AKUS were also represented on the council for RD-Connect, anintegrated platform connecting databases, registries, biobanks and clinical bioinformatics for raredisease research.• Communicating to family doctors and hospital specialistsClinicians were kept informed about the process of the trial either by subscription to the AKUSociety e-newsletter, the DevelopAKUre.eu website or directly via a patient letter written by thechief investigator. This letter was designed to educate clinicians about the trial and nitisinone. Staffmembers and partners attended numerous medical conferences on various related disciplines andrare diseases more generally. AKU clinicians and researchers were invited to all AKU workshopsto discuss the project and the illness in length.Communicating to Ministries of HealthVarious governmental figures in the UK and its devolved nations have discussed DevelopAKUreand its progress. The consortium has met with representatives from the EMA (European MedicinesAgency) and plans to use the MOCA network (Mechanism of Coordinated Access to OrphanMedical Products) to understand the next steps for reimbursement if licensing is achieved.• Communicating to AKU sufferersThe AKU Society has been in regular contact with AKU sufferers, using online communicationstools, social media etc., to keep patients updated and supported. We translated and edited patientinformation as much as possible and have redesigned the developAKure.eu website so that it wasfar easier to use and automatically and accurately translated information into the viewer's nativelanguage. It also hosted an innovative tool that increases the accessibility of the website throughread-aloud technology and other various ways to make the website as accessible as possible.• Audio-visual workThroughout the trial, SONIA 2 patients were interviewed and recorded to highlight the patientcentricity of the trial and to highlight participants’ experiences. AKUS produced webinars on theSONIA 1 and SONIA 2 trials which are available in video format.The Univerisity of Liverpool produced a video for the EC explaining the research element of thestudy in detail. AKUS was featured on national UK TV (BBC Two) Incredible Medicine: DrWeston's Casebook, which highlighted Nick Sireau’s story, the AKUS and DevelopAKUre.• Media workThe AKUS maintained one-on-one contact with interested journalists. AKUS produced anddistributed several press releases about DevelopAKUre. The DevelopAKUre project has beenfeatured on local radio and TV. AKUS worked with partners to get press releases translated anddistributed locally. AKUS and the AKU research have also been featured in national media andnumerous online magazines.• Online comminutionsAKUS maintains regular online communications on the following platforms:‒ The DevelopAKUre microsite – www.developakure.eu‒ The AKU Society website – www.akusociety.org‒ Facebook – www.facebook.com/AKUSociety‒ Twitter – www.twitter.com/AKUSociety‒ LinkedIn – https://www.linkedin.com/company/aku-society/‒ YouTube – https://www.youtube.com/user/findAKUre‒ PatientsLikeMe – http://www.patientslikeme.com/join/aku‒ RareConnect - https://www.rareconnect.org/en/community/alkaptonuria-akuExcepting scientific publications, a full list of dissemination events of the project, numberingapproximately 250 separate activities, is provided in Deliverable 12.3 the Dissemination Report.Potential Impact:Exploitable Foreground and Plans for ExploitationNotwithstanding the standard rules of collaborative projects funded by the EC FrameworkProgrammes, as set out in Articles 26 – 29 of Annex II to the Grant Agreement, the Consortium agreedthat all parties to the Grant Agreement granted Sobi an exclusive, royalty-free and assignable license,with the right to sublicense, right under any Foreground to research, develop, manufacture, promote,market, distribute and sell any nitisinone product to AKU patients.To demonstrate the commitment to this strategy, Sobi have applied for a patent regarding the resultsof the SONIA 1 study, which defines the dosing of nitisinone. At the end of the project, the final resultsof the SONIA 2 study are not yet known, and these will define the ultimate direction of the commercialstrategy. If successful, Sobi intends to apply for marketing authorisation, in which case the commercialexploitation plan, as set out below, will apply.2.2.1 Commercial exploitation planThe aim of this exploitation strategy is to create a new state-of-the-art by providing nitisinone as alicensed treatment to AKU patients in the EU and worldwide. A license to use nitisinone as thetreatment for AKU will result in a new commercial venture for Sobi, which will contribute to theobjectives of the IRDiRC to obtain 200 new treatments for rare diseases by 2020. Sobi will exploit thislicense to generate revenue for the company, helping create jobs and brand value. This is summarisedbelow.EU market sizeCurrent estimates are that AKU affects one in every 250,000 people, apart from in Slovakia where itaffects one in every 19,000. This indicates that the market size should be around 2,275 patients, basedon an EU population of 502M in 2011 (Eurostat), and a Slovakian population of 5.44m in 2010. AKUSknows of 450 AKU patients in the EU, so there are still many unidentified patients, which the newAKU societies set up in Germany, the Netherlands and Belgium will identify with support from theAKU Society as the principal group. AKUS has launched a new online community for AKU patientsin the EU and worldwide via its website that includes a patient identification campaign. The AKUSocieties identify on average 30-50 new AKU patients in the EU each year. This number will mostlikely increase significantly if nitisinone is approved, as doctors refer patients for treatmentMarket exclusivity in the EUAccording to the EU orphan drug legislation of 2000, nitisinone will be granted market exclusivity forAKU within the EU for 10 years if marketing authorisation is successful. This would provide asignificant incentive for Sobi to distribute nitisinone to AKU patients in a sustainable manner.Marketing authorisation EUIf the project is successful and regulatory approval secured, Sobi will take on the legal and regulatoryresponsibilities of being the marketing authorisation holder (MAH): ensuring the quality of the productand that the overall risk/benefit of keeping the product on the market is positive. The estimated timefor review of the Marketing Authorization by EMA is approximately one year, which means nitisinonemay be approved for treatment by late 2020, in time for the IRDiRC deadline of 2020.Exploitation in non EU countriesWe will also, in parallel, and in partnership with the NIH, develop a regulatory strategy for the US.Other territories may also be exploited and will be investigated by Sobi.Distribution and implementationSobi already has a strong distribution network for nitisinone (under the brand name Orfadin®) for HT-1, which it will use as the basis for its distribution of nitisinone for AKU. The overall roll-out periodwill be about a year depending on the future processes within the EU. Patients will be able to accessnitisinone either through their general practitioners or metabolic specialists or, in countries which havethem, through dedicated AKU reference centres. The UK has set up an AKU Reference Centre at theRLUH. France has an AKU programme at HNEM. Slovakia has a National AKU Centre at NIRD.Italy has an AKU reference centre in Tuscany. We have also been involved in setting up referencecentres in the Netherlands and Germany.Pharmacovigilance and registryPatient safety is crucial for the long-term exploitation of the project’s results. Sobi will adhere to allpost marketing safety commitments in accordance with internal Sobi SOPs (Standard OperatingProcedures) fulfilling external regulatory requirements. Sobi will fulfil this information fromhealthcare providers and patients on adverse effects of nitisinone for AKU and to prevent harm.Commercial revenueTreatment will be long-term, thus providing financial incentives for Sobi as the MarketingAuthorisation Holder. Hence, Sobi will finance the launch of the product and the future prospect ofcommercialisation of nitisinone in the treatment of AKU patients.2.2.2 Other exploitation plansAcademic exploitationThe academic centres led on the analysis of patient samples taken during the clinical trials. They havealready published this work in 16 scientific publications, with many more, estimated at approximatelya further 15-20, after the results of the SONIA2 trial are available. Universities will use dedicated pressoffices that will exploit the results of the study in order to gain positive press coverage for theirinstitutions and research teams. This additional brand recognition will increase their chances of raisingfurther funds for research. UniLiv and UniSi also have an active Erasmus agreement that will be furtherexploited for students and teachers exchanges in future.Clinical trial centre exploitationIf the project is successful, the trial centres will prescribe nitisinone to their AKU patients. This willreduce the disease burden and decrease resources spent on AKU patients, such as for jointreplacements. Even if the project fails, the three hospitals will be able to exploit the results of this workas they will have gained deeper understanding of AKU and will use this to develop new care guidelinesfor their patients. It may also be possible for national centres, such as the RLUH, to offer the drug offlabel.SME exploitationNB will use the study data to investigate the use of novel biomarkers for bone degeneration in AKUand extracellular matrix turnover, potentially creating a new commercial venture. NB will use theproject to raise its profile at trade events.Patient organisation exploitationAKUS and ALCAP will use the project results to provide up to date information to AKU patients andfamilies about the disease. If the project is successful, they will use the project results to inform patientsabout nitisinone treatment and the expected benefits. They will publish the results on their websitesand inform patients directly across the EU. Through frequent contact with all patients during the trials,they will continue to build the community of patients, helping them assist each other. They will useknowledge from the project to help other rare disease patient groups work with Horizon 2020 andHorizon Europe programmes, academia and industry to conduct clinical trials.Contract research organisations exploitationThis project will further strengthen PSR’s experience and knowledge in the orphan drug field. Theywill exploit this in their business development and PR.2.2.3 Table B1: Applications for patents, trademarks, registered designsType of IPRights1:ConfidentialClick onYES/NOForeseenembargodatedd/mm/yyyyApplicationreference(s)(e.g. EP123456)Subject or title ofapplicationApplicant (s) (as onthe application)Patent NO N/A WO2015/165972 A1Nitisinone DosingRegimens for theTreatment ofAlkaptonuriaSwedish OrphanBiovitrum InternationalList of Websites:www.DevelopAKUre.eu Related documents final1-periodic-pub-summary.docx