Exploring New Treatment Advances for Acid sphingomyelinase Deficiency

In this slide deck, explore new treatment advances for acid sphingomyelinase deficiency (ASMD) in adults with Neal Weinreb, Voluntary Associate Professor for Human Genetics at the University of Miami, Miller School of Medicine. Learn about diagnosis, counseling points, and the recent approval of the first acid sphingomyelinase (ASM) enzyme replacement therapy, which presents the first opportunity to address the pathology underlying this condition.

STATEMENT OF NEED

Acid sphingomyelinase deficiency (ASMD) is a rare, hereditary lysosomal storage disease with multisystemic manifestations, including splenomegaly, hepatomegaly, interstitial lung disease, dyslipidemia, bone marrow and lymph node involvement, and sometimes neurological and peripheral nerve involvement. While the most severe form of ASMD, infantile neurovisceral ASMD, results in death in early childhood, chronic forms of ASMD have more prolonged survival but are associated with substantial morbidity and reduced life expectancy. Outcomes for adults with chronic ASMD are affected by diagnostic delays that in turn delay monitoring and management of ASMD manifestations (Wasserstein et al, 2019). Furthermore, while treatment of ASMD has until now been solely supportive in nature, an acid sphingomyelinase (ASM) enzyme replacement therapy has recently been approved, presenting the first opportunity to address the pathology underlying this condition (US Food & Drug Administration, 2022). This activity chaired by Dr. Neal Weinreb, Voluntary Associate Professor for Human Genetics at the University of Miami Miller School of Medicine, will provide expert perspectives on current challenges and new opportunities in the management of ASMD in adults.

TARGET AUDIENCE

Metabolic disease specialists, medical geneticists, pulmonologists, hepatologists, gastroenterologists, neurologists, hematologists, primary care physicians, nurse practitioners, physician assistants, nurses, pharmacists, and other health care professionals involved in the treatment of patients with acid sphingomyelinase deficiency (ASMD).

LEARNING OBJECTIVES

Upon completion of this activity, participants should be able to
Assess the clinical presentation and diagnostic workup of chronic ASMD in adults
Evaluate the mechanism of action, efficacy, and safety of ASM enzyme replacement therapy for chronic ASMD in adults as elucidated by recent clinical trials
Monitor and manage the multisystemic manifestations of ASMD
Counsel patients on supportive services for patients with ASMD, including social services, genetic counseling, family counseling, and patient/caregiver support groups

1. Exploring New Treatment Advances for Acid Sphingomyelinase Deficiency in Adults Neal Weinreb, MD, FACP Voluntary Associate Professor of Human Genetics University of Miami Miller School of Medicine

2. Disclosures A dvisory board/panel: Avrobio , Pfizer, Sanofi, Takeda Speaker’s bureau: Sanofi C onsultant: Pfizer, Sanofi i3 Health has mitigated all relevant financial relationships

3. Learning Objectives ASMD = acid sphingomyelinase deficiency; ASM = acid sphingomyelinase. Assess the clinical presentation and diagnostic workup of chronic ASMD in adults Evaluate the mechanism of action, efficacy, and safety of ASM enzyme replacement therapy for chronic ASMD in adults as elucidated by recent clinical trials Monitor and manage the multisystemic manifestations of ASMD Counsel patients on supportive services for patients with ASMD, including social services, genetic counseling, family counseling, and patient/caregiver support groups

4. Acid Sphingomyelinase Deficiency ASMD, historically known as Niemann-Pick disease (NPD) Types A, A/B and B, is a rare, autosomal recessive disorder caused by a deficiency of acid sphingomyelinase resulting from mutations in the SMPD1 gene Sphingomyelins and other secondary lipid substrates such as cholesterol accumulate in cells of the mononuclear phagocytic system and in other cells such as hepatocytes Organs affected: liver, spleen, hematopoietic marrow, lungs, nervous system, and skeletal system Estimated worldwide incidence is 0.4 to 0.6 in 100,000 newborns Current numbers are likely underestimated Panethnic Specific types of ASMD are more prevalent in certain ethnic groups, eg, ASMD Type A (NPD A) in persons of Ashkenazi Jewish descent Males and females equally affected SMPD1 = sphingomyelin phosphodiesterase 1. McGovern, Dionisi-Vici et al, 2017; McGovern, Avetisyan et al, 2017; McGovern et al, 2008; Schuchman, 2007; McGovern et al, 2013; Villarubia et al, 2015.

5. Lysosomal Hydrolase Deficiencies and Sphingolipid Accumulation GalCer = galactosylceramide; GalCeramidase = galactosyl ceramidase GCS = glucosylceramide synthase; SM = sphingomyelin; ⍺-gal = alpha galactosidase; GSL = glycosphingolipid. Xu et al, 2010. Galactosylceramide Ceramide Sphingomyelin Galcerebroside-3-SO 3 Glucosylceramide (GL-1) Globotriasylceramide (GL-3) Lactosylceramide Gangliosides Downstream GSLs derived from GL-1 3 main classes of sphingolipids X X X X X X GalCer synthase GalCeramidase SM synthase Sphingomyelinase Aryl sulfatase GL-3 synthase α -Gal Sialyl transferases Glycosyl transferases β -hexosamindase β -galactosidase Fabry disease Gangliosidoses, Tay-Sachs, and others ASMD Krabbe Disease Metachromatic leukodystrophy Glucocerebrosidase Gaucher disease GCS

6. Clinical Spectrum of ASMD Photo courtesy of the Pender and Ayik families on NNPDF.org. McGovern, Dionisi-Vici et al, 2017. ASMD Type A NPD Type A ASMD Type A/B Intermediate NPD NPD A/B ASMD Type B NPD Type B Onset Early infancy Infancy to childhood Infancy to adulthood Phenotype Rapidly progressive, severe visceral disease and neurodegeneration; cherry red spot Slowly progressive, variable visceral disease and neurodegeneration that includes developmental delay, intellectual disability, ataxia, and peripheral neuropathy Slowly progressive, variable visceral disease with little or no neurologic involvement Life expectancy Death by age 3 Death from childhood to mid-adulthood Death from childhood to late adulthood MOST SEVERE INTERMEDIATE SEVERITY LEAST SEVERE

7. ASMD is an autosomal recessive disorder ASMD is caused by pathogenic variants in both parental copies of the SMPD1 gene ASMD and Gaucher Disease: Inheritance Wasserstein & Schuchman, 2021. Carrier mother (unaffected) Carrier father (unaffected) Normal gene Gene with pathogenic variants Unaffected child Affected child Carrier child (unaffected) Carrier child (unaffected)

8. Gaucher Disease and ASMD Pathways Lyso = lysolipid; Lyso-GL-1 = g lucosylsphingosine ; AC = acid ceramidase. Xu et al, 2010; Ishibashi et al, 2003; Stirnemann et al, 2017; Villarubia et al, 2015. GL-1 GCS Glucocerebrosidase Sphingomyelin Sphingomyelin synthase Ceramide Acid sphingomyelinase X X AC Lyso-Sphingomyelin AC Lyso-GL-1 Accumulation within the lysosomes of monocyte/macrophage s ystem Gaucher disease ASMD

9. Gaucher Type I ASMD Type A/B and B Splenomegaly Hepatomegaly Hematologic abnormalities Anemia Thrombocytopenia Bone involvement Erlenmeyer flask deformity Osteonecrosis Osteopenia Bone marrow infiltration Pathologic fracture Bone pain Pulmonary involvement Interstitial lung disease Rare Dyslipidemia Low HDL Low total cholesterol Low LDL Normal triglycerides Low HDL High total cholesterol Elevated LDL Elevated triglycerides Liver disease Liver fibrosis Cirrhosis Liver dysfunction (elevated ALT/AST) Infrequent Cardiac disease Coronary artery disease/heart valve disease None to rare ASCVD ASMD Clinical Presentation in Adults HDL = high-density lipoprotein; LDL = low-density lipoprotein; ALT = alanine transaminase; AST = aspartate aminotransferase; ASCVD = atherosclerotic cardiovascular disease. Pastores & Hughes, 2023; Kaplan et al, 2006; Faden et al, 2009; Baris et al, 2014; McGovern, Avetisyan et al, 2017; McGovern, Dionisi-Vici et al, 2017; Charrow et al, 2000; McGovern et al, 2004. Growth retardation Atherogenic lipid profile Pathologic fracture Pulmonary involvement Thrombocytopenia Osteopenia Osteonecrosis Bone marrow infiltration Cherry red macula Bone pain Hepatomegaly Anemia splenomegaly Erlenmeyer flask deformity ASMD & Gaucher Disease ASMD Gaucher Disease

10. Morbidity and Mortality in Chronic ASMD McGovern et al, 2013. 10-year natural history study in 103 patients with ASMD ASMD Type A/B (n=8) and ASMD Type B (n=95) Serious morbidities associated with ASMD in this study included clinically significant hepatic, cardiac, and neurologic diseases Median age at death in 18 patients: 15.5 years (range: 1-72 years) Most common causes of death Pneumonia/respiratory failure (5 patients) Liver failure (3 patients) Bone marrow transplant complications (3 patients) Causes of death in the remaining 7 patients Hemorrhage (post-op bleed, splenic vein tear, subdural hematoma), liver cancer, congestive heart failure, multisystem failure, unknown

11. Establishing the Diagnosis Wasserstein & Schuchman 2021; Pastores & Hughes, 2023; Mistry et al, 2011; McGovern, Dionisi-Vici et al, 2017; Bronstein et al, 2014; McGovern, Avetisyan et al, 2017. Enzyme Activity ASMD : acid s phingomyelinase enzyme assay <10% residual activity Residual activity does not predict clinical outcome Consider ordering in parallel, or if glucocerebrosidase is normal Gaucher disease : glucocerebrosidase enzyme assay Adults: usually 10%-30% of normal Children (severe cases) <10% of normal Residual activity does not predict clinical outcome Genetic Testing (DNA Sequencing) ASMD : SMPD1 gene sequencing 2 pathogenic variants in trans ΔR610 appears to be neuroprotective, common in chronic visceral form in multiple ethnic groups Gaucher disease : GBA gene sequencing 2 pathogenic variants in trans 6 variants account for 97% of all pathogenic variants in patients of Ashkenazi heritage: N370S, R496H, V394L, 84insG, A→1G+IVS2, and L444P N370S is neuroprotective

12. SMPD1 Gene, cDNA, and Translated ASM Protein cDNA = copy deoxyribonucleic acid. Breiden & Sandhoff, 2021. The gene SMPD1 of the ASM has been mapped to the chromosomal region 11p15.4 Mature human ASM domains: Signal peptide Amino acids 1–46 Sap-domain Amino acids 89–165 Proline-rich domain Amino acids 166–198 Catalytic metallophosphatase domain Amino acids 199–461 C-terminal domain Amino acids 462–62 N-glycosylation sites and disulfide bridges

13. SMPD1 Gene Sequencing McGovern, Dionisi-Vici et al, 2017; Zampieri et al, 2016. Gene sequencing analysis revealed known mutations of the SMPD1 gene for the chronic visceral ASMD phenotype1: Homozygous c.1829_1831delGCC (p.ΔR610) p. Δ R610 is the most frequently reported mutation worldwide, and is associated with an attenuated chronic visceral ASMD phenotype p.Q294K and p.W393G Chronic Neurovisceral ASMD Infantile Neurovisceral ASMD Homo- or heteroallelic p.ΔR610, p.P323A, and p.P330R (neuroprotective) Chronic Visceral ASMD Known genotype/phenotype correlations, eg: Unknown genotype/phenotype correlations: Clinical assessment to determine phenotype SMPD1 gene sequencing Homoallelic for p.R498L, p.L304P and p.P333sfs*52 (Ashkenazi founder mutations)

14. Algorithm for the Laboratory Diagnosis of ASMD DBS = dried blood spots; VUS = variants of uncertain significance. Geberhiwot et al, 2023. Clinical Suspicion ASM Activity Leukocytes (DBS) NP Biomarkers Plasma (DBS) SMPD1 Sequencing Borderline Normal Deficient Abnormal profile Normal Biallelic pathogenic variants 1 pathogenic variant and/or VUS or no variants Genetic Counseling Not ASMD => Assess biomarkers if not done and/or genetic tests ASMD Confirmed Assay ASM if not done before => If not done, assess ASM activity And biomarkers If ASM deficient, discuss more refined genetic tests ASMD Confirmed => add genetic tests

15. Case Study Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. The patient stated that his overall health had always been good He did not mention any physical impairments, although he rarely participated in sports or outdoor activities He completed a university education at 23 years of age and has been able to perform his job duties without limitations A 31-year-old male presented to his primary care physician with a swollen and tender abdomen and excessive bruising on his right leg

16. Case Study (cont.) RR = respiratory rate; SpO 2 = oxygen saturation; BP = blood pressure; BMI = body-mass index. Johns Hopkins Medicine, 2023; ACS, 2020. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. Clinical Examination at Presentation: Age 31 Years A 31-year-old male presented to his primary care physician with a swollen and tender abdomen and excessive bruising on his right leg Temperature: 99.1 F (37.3C), orally (average normal 98.0 F-98.6 F [36.6C-37C]) RR: 22 breaths per minute (normal RR adults at rest: 16-20 breaths per min) SpO 2 (RA, rest) 95% (normal young adult 95%-98%) BP: 110/68 mm Hg (normal BP in adults: 120/80 mm Hg) Pulse: 80 beats per min (normal pulse in adults: 50-80 beats per minute) Vital signs: Physical examination: Height: 170.4 cm (67.1 in) Weight: 64.4 kg (142 lbs) BMI : 22.2 (normal: 18.5-24.9) Cranial nerve examination: normal findings

17. Clinical Examination: Testing and Imaging: Case Study (cont.) EOM = extraocular movement; LUQ = left upper quadrant; EKG = electrocardiography; FVC = forced vital capacity; FEV 1 = forced expiratory volume in 1 second; DL CO = diffusing capacity for carbon monoxide. Chow et al, 2016. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. Clinical Examination at Presentation: Age 31 Years Respiratory : FVC: 133% (normal: >80%) FEV 1 : 118% (normal: >80%) DL CO : 107% predicted, no diffusion dysfunction Abdominal Ultrasonography : Marked hepatosplenomegaly Spleen craniocaudal length: 18.7 cm Normal spleen size in adults: ~11 cm 70% larger than normal E yes : No EOM abnormalities Cardiovascular : EKG: normal findings Echocardiography: normal findings Abdomen : Enlarged liver Tender LUQ A 31-year-old male presented to his primary care physician with a swollen and tender abdomen and excessive bruising on his right leg

18. Case Study (cont.) a Routine blood work for work physical. Abnormal values prompted annual follow-up. TG = triglycerides. Pagana et al, 2014; Lopez-Jimenez, 2015; Thein et al, 2017. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. Laboratory Test (Normal Value) Value: Age 30 years a Value: Age 31 years ALT (4-36 U/L) 24 21 AST (≤35 U/L) 37 29 Hemoglobin (14-18 g/dL) 12.9 12.5 Leukocytes (5,000-10,000 mm 3 ) 4,100 3,800 Platelets (150,000-400,000 mm 3 ) 102,000 73,000 TG (40-160 mg/dL) 172 194 Cholesterol (<200 mg/dL) 223 236 HDL-C (>45 mg/dL) 36 32 LDL-C (<130 mg/dL) 194 202 LDL/HDL ratio (<3.5:1) 5.4 6.3 Chitotriosidase (20.0 to 267.1 mU/mL) ND 1,995 Relevant Laboratory Results

19. Despite normal lung function test results, unenhanced transverse CT revealed mild interlobular septal thickening in the mid-lung zone Radiologic findings and lung function tests may not always correlate in patients with chronic visceral ASMD Case Study (cont.) CT = computed tomography. Mendelson et al, 2006. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. CT of Thorax

20. Interstitial lung disease Thrombocytopenia Atherogenic dyslipidemia Hepatosplenomegaly (Characteristic but not pathognomonic findings for ASMD B) Case Study (cont.) Wasserstein & Schuchman, 2021. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. Summary of Patient’s Signs and Symptoms Adult

21. Case Study (cont.) Beutler & Saven, 1990. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. The following diseases/conditions were ruled out: Pulmonary diseases Pulmonary edema, cystic fibrosis Diabetes mellitus Normal fasting blood sugar and hemoglobin A1c (HbA1c) test results Leukemia/lymphoma Bone marrow biopsy revealed presence of classic foamy macrophages. (Bone marrow biopsy could have been avoided had ASMD been previously considered) Gaucher disease Normal glucocerebrosidase enzyme activity Differential Diagnosis

22. Case Study (cont.) McGovern, Dionisi-Vici et al, 2017; Wasserstein & Schuchman, 2021. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. ASM enzyme testing showed reduced ASM enzyme activity in leukocytes: 0.7553 nmol/mg/17 h (normal range: 8.8-30.62 nmol/mg/17 h) Residual enzyme activity: 4.51% of normal levels ASM Active Enzyme Testing When a patient presents with signs and symptoms and clinical test results indicative of ASMD, ASM enzyme testing is the next step in the diagnostic process Simultaneous testing of glucocerebrosidase activity to rule out Gaucher disease is recommended Testing can be performed using dried blood spots, leukocytes, peripheral blood lymphocytes, and cultured skin fibroblasts Residual ASM enzyme activity of <10% of normal levels suggests ASMD

23. Case Study (cont.) A diagnosis of chronic visceral ASMD was made based on clinical presentation and laboratory results: Family history of ASMD (retrospective!) Reduction of ASM enzyme activity in leukocytes dyslipidemia Elevation of chitotriosidase levels Hepatosplenomegaly Intralobular interstitial thickening in the mid-lung Lung involvement is common in chronic visceral ASMD1 Gene sequencing revealed known mutations of the SMPD1 gene: ΔR610 McGovern et al, 2013; Mendelson et al, 2006. Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. Diagnosis: Chronic Visceral ASMD Although patients with chronic visceral ASMD can live into adulthood, many die before reaching their 20s. Throughout their lifetime, they may also experience ongoing health concerns involving lung disease and thrombocytopenia (characterized by bruising and bleeding)

24. Case Study (cont.) Case courtesy of Dr. Eugen Mengel and modified by Dr. Neal Weinreb. At 32 years of age, the patient continues to have no neurologic signs, as would be expected, and no growth impairment or skeletal involvement He continues to be in good general health, experiencing 2 intermittent, mild lung infections over the past year He subjectively reports no physical impairment and continues to work without limitations He has refrained (due to splenomegaly) from participating in activities that put him at risk of bruising and bleeding, such as contact sports The patient continues to be under surveillance for:  Changes in his activity levels, bleeding, shortness of breath, abdominal pain, neurologic function, laboratory parameters, pulmonary function, and worsening of interstitial lung disease Patient Outcome: Chronic Visceral ASMD

25. ASMD Impact and Burden: Patient and Caregiver Perspective Pokrzywinski et al, 2021. Most common disease manifestations: Respiratory (n=26, 89.7%) Abdominal (n=25, 86.2%) Musculoskeletal symptoms (n=23, 79.3%) Excessive bleeding or bruising (n=20, 69%) Fatigue (n=20, 69%) Gastrointestinal symptoms (n=18, 62.1%) Headache (n=15, 51.7%) Dermatologic (skin tightness, rashes, and warts) Little is known about how ASMD symptoms affect the lives of patients and their caregivers 17 adult patients (mean age 38.7 years) and 3 caregivers 12 pediatric/adolescent patients with ASMD (mean age 10.5 years) and 12 caregivers Negative impact on patients: Physical function (n=23, 79.3%) Self-esteem (n=18, 62.1%) Emotions (n=16, 55.2%) Social function and relationships (n=16, 55.2%) Personal care (n=9, 31%)

26. ASMD Impact and Burden: Patient and Caregiver Perspective (cont.) Pokrzywinski et al, 2021. “ I have lost sleep because I was in pain and especially because not just the liver, but just general abdominal pain... it’s just—it’s uncomfortable. As much as I don’t like the pain, it’s just uncomfortable. That’s why I can’t sleep” “Bones…especially when I was a kid, I had really, really bad bone pain, and I still get it it… .I know it’s bone, I know it’s not muscular” “He feels that he looks like a bit of a wimp because he can’t do contact sports, can’t carry his bag, you know, there are a lot of things he can’t do, so he’s very self-conscious of that” “She was bullied when she started high school. I don’t know if it’s a girl thing or generally because she’s quite short” Little is known about how ASMD symptoms affect the lives of patients and their caregivers 17 adult patients (mean age 38.7 years) and 3 caregivers 12 pediatric/adolescent patients with ASMD (mean age 10.5 years) and 12 caregivers Negative impact on caregivers Emotional well-being (n=12, 80%) Social function (n=4, 26.7%) Relationships (n=6, 40%) Financial security (n=7, 46.7%) Physical toll of providing care; need for lifestyle changes Responsibility for making medical decisions

27. Summary LSD = lysosomal storage disorders. Mistry et al, 2011; McGovern, Avetisyan et al, 2017. Gaucher disease and ASMD are inherited diseases caused by lysosomal enzyme deficiencies. Progressive accumulation of glucosylceramide and sphingomyelin respectively within the monocyte/macrophage system may cause debilitating hematologic, visceral, and skeletal manifestations. In ASMD, functionally significant excesses of sphingomyelin can be found in many cell types Signs and symptoms may be non-specific, resulting in delayed diagnosis or misdiagnosis. Because patients often present with thrombocytopenia and splenomegaly, they are frequently referred to hematologists for evaluation and diagnosis Both diseases can be diagnosed with a blood test that measures enzyme activity. Testing is widely available from various commercial laboratories Diagnostic delay can lead to irreversible complications that impact quality of life and longevity. Hematologists should always consider a diagnosis of Gaucher disease when consulting on patients with otherwise unexplained blood cytopenias and hepatosplenomegaly, and test for ASMD if testing for Gaucher is negative. Parallel testing for both LSDs may sometimes be reasonable

28. Treatment of ASMD B and A/B Xu et al, 2010; Ishibashi et al, 2003; Villarrubia et al, 2015. Sphingomyelin Sphingomyelin synthase Ceramide Acid sphingomyelinase X ASMD Lyso-Sphingomyelin Accumulation within the lysosomes of monocyte/macrophage s ystem AC Olipudase Alfa

29. Acid Sphingomyelinase Is a Promiscuous Phospholipase C PC = phosphatidylcholine. Breiden & Sandhoff, 2021. ASM is mostly thought to hydrolyze sphingomyelin to ceramide >20 different phospholipids are cleaved by ASM in vitro, including phospholipids like growth factor ceramide-1-phosphate and lysosomal lysolipid bis(monoacylglycero)phosphate ASM is important to several major cellular functions involved in regulating an increasing number of metabolic disorders The extent to which infused and endocytosed ASM participates in these additional ASM functions requires further study and is a possible concern when evaluating overall treatment efficacy and safety

30. Topology of ASM Processing NPC = Niemann-Pick disease protein C Type 2. Breiden & Sandhoff, 2021. Pro-ASM matures to the active forms in the endolysosomal compartment If L-ASM cannot interact with the intraendolysosomal luminal vesicles, the enzyme is degraded by cathepsins (inactivated ASM) This process leads to higher levels of sphingomyelin Disturbed membrane homeostasis Inactivation of other sphingolipid hydrolases and NPC2 Blocked cholesterol egress and accumulation Lysosome membrane permeabilization (LMP), which triggers autophagy and cell death by apoptosis and apoptosis-like pathways Pro-ASM is generated from pre-pro-ASM within the Golgi, mannose-6-phosphorylated, and transferred by mannose-6-phosphate receptor–mediated vesicles to the endolysosomal compartments (L-ASM) or, alternatively, secreted (S-ASM)

31. Autophagy-Lysosomal Pathway Dysfunction LOF = loss of function; MPS = mucopolysaccharidoses. Monaco & Fraldi, 2020. Protein Aggregation Generates a Vicious Cycle in LSDs LOF mutations in lysosomal hydrolases or in proteins involved in lysosomal function Lysosomal degradation flaw and primary storage Autophagy impairment Amyloid protein aggregation α -synuclein, tau, A β Neurodegeneration Impairment of lysosomal enzyme trafficking (as in Gaucher disease) Alteration of lysosomal distribution impairment of the autophagosome clearance (as in MPSs) Other mechanisms

32. Cellular Pathogenesis of GD and ASMD B GD = Gaucher disease. Roh et al, 2022; Canonico et al, 2016. The pathophysiological processes in GD that are interactive, variably stimulated or suppressed, and potentially either adaptive or deleterious, leading to several downstream complications associated with oxidative stress and inflammation Defective ASMase and lysosomal storage could lead to a reduced ability of lysosomes to fuse with autophagosomes. This in turn could result in a partial block of autophagy maturation and defective degradation, accompanied by accumulation of autophagic vacuoles, peroxidized lipid droplets and aberrant mitochondria (autophagic stress)

33. Olipudase Alfa Placebo-Controlled Clinical Trial: Adults SRS = splenomegaly-related score. Wasserstein et al, 2022. Eligible (n=36) R A N D O M I Z E D 1:1 Olipudase alfa (n=18) Placebo (n=18) Completed 52 weeks (n=18) Completed 52 weeks (n=17) Assessed for eligibility n=62 Withdrawn consent n=2 Failed screening n=24 Patients may have multiple reasons for failing 20 failures to meet inclusion criteria Spleen volume (n=6) DL CO (n=5) SRS (n=6) Informed consent (n=2) Documented ASM deficiency/clinical ASMD diagnosis 5 exclusion criteria met Medical conditions (n=2) Platelet count (n=1) ALT or AST (n=1) Unable to adhere to study requirements (n=1) 1 patient discontinued due to noncompliance

34. Olipudase Alfa: Adult Trial Pulmonary Response HRCT-ILD = high resolution CT–interstitial lung disease; LSmean = least square mean; SE = standard error. Wasserstein et al, 2022.

35. Olipudase Alfa: Adult Trial (cont.) MN = multiples of normal. Wasserstein et al, 2022. Spleen and PLT Responses

36. Olipudase Alfa: Adult Trial (cont.) Wasserstein et al, 2022; Jones et al, 2020. Liver and Plasma Lipid Responses

37. Olipudase Adult T rial (cont.) AE = adverse events; URI = upper respiratory tract infection; Bx = biopsy; TIA = transient ischemic attack. Wasserstein et al, 2022. All patients (n=18/18) experienced ≥AE: olipudase alfa (N AE =242) and placebo (N AE =267) No event led to permanent treatment discontinuation or study withdrawal Most AEs were mild (olipudase: 190/242 [79%]; placebo: 206/270 [76%]) No serious AEs were considered potentially related to the study drug Treatment-related AEs (including infusion-related events): olipudase 12/18; placebo 6/18 The frequency of clinically significant abnormalities in lab findings, vital signs, ECGs, or echocardiograms was similar between treatment groups Safety and Adverse E vents Serious AEs None treatment-related Olipudase: 3 patients (5 events) Bleeding post-liver Bx, cellulitis, viral gastritis, TIA, lower-limb fracture Placebo: 4 patients (11 events) Bleeding post-liver Bx, epistaxis (3), liver abscess, appendicitis, peritonitis, anemia, syncope, hemorrhagic shock, and pleural effusion Most Common AEs Headache Nasopharyngitis Arthralgia URI Cough

38. Olipudase Adult T rial (cont.) LFT = liver function test; DLT = dose-limiting toxicity; IAR = infusion-associated reactions. Wasserstein et al, 2022. Dose-limiting toxicities (LFT abnormalities ranked 1-3 by severity): Olipudase DLT1: 1 patient Placebo DLT2: 4 patients (6 events); DLT3: 1 patient IARs considered manifestations of hypersensitivity: 1 patient in the olipudase group (2 events of erythema and urticaria) 2 placebo patients (2 events of erythema and 1 each of pruritus, erythematous rash, and infusion site urticaria) No reported cases of acute phase reactions of cytokine release syndrome Anti-drug antibodies (ADAs) Baseline: olipudase (n=2/18), placebo (n=4/18); none had a treatment-boosted response Treatment-induced ADAs: olipudase (n=4; 2 transient and 2 persistent low titer); placebo (n=1; transient) No neutralizing Abs that inhibited olipudase cellular uptake Safety and Adverse E vents Serious AEs None treatment-related Olipudase: 3 patients (5 events) Bleeding post-liver Bx, cellulitis, viral gastritis, TIA, lower-limb fracture Placebo: 4 patients (11 events) Bleeding post-liver Bx, epistaxis (3), liver abscess, appendicitis, peritonitis, anemia, syncope, hemorrhagic shock, and pleural effusion Most Common AEs Headache Nasopharyngitis Arthralgia URI Cough

39. Olipudase Alfa Pediatric Trial Diaz et al, 2021. Biomarker Responses

40. These highlights do not include all the information needed to use olipudase alfa safely and effectively. See full prescribing information for olipudase alfa. ________________________________________________________________________ WARNING: SEVERE HYPERSENSITIVITY REACTIONS See full prescribing information for complete boxed warning. Hypersensitivity Reactions Including Anaphylaxis Appropriate medical support measures, including cardiopulmonary resuscitation equipment, should be readily available. If a severe hypersensitivity reaction occurs, olipudase alfa should be discontinued immediately and appropriate medical treatment should be initiated. _____________________________________________________________________ ——————————— RECENT MAJOR CHANGES ——————————— Dosage and Administration, Preparation Instructions 3/2023 ——————————— INDICATIONS AND USAGE ———————Olipudase alfa is a hydrolytic lysosomal sphingomyelin-specific enzyme indicated for treatment of non–central nervous system manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients. —————————— DOSAGE AND ADMINISTRATION ———————— • Prior to initiating treatment, verify pregnancy status in females of reproductive potential and obtain baseline transaminase levels. • Consider pretreating with antihistamines, antipyretics, and/or corticosteroids. • Adults: Recommended starting dose is 0.1 mg/kg administered as an intravenous infusion. • Pediatrics : Recommended starting dose is 0.03 mg/kg administered as an intravenous infusion. • See Full Prescribing Information for the recommended dose escalation and maintenance dosage, dosage modifications to reduce the risk of adverse reactions, and preparation and administration instructions. ———————WARNINGS AND PRECAUTIONS ————————— • Infusion-Associated Reactions (IARs): If severe IARs occur, discontinue olipudase alfa and initiate appropriate medical treatment. • Elevated Transaminases: Assess ALT and AST within one month prior to initiation of olipudase alfa, within 72 hours prior to any infusion during dose escalation, or prior to the next scheduled olipudase alfa infusion upon resuming treatment following a missed dose. • Pregnancy: Olipudase alfa dosage initiation or escalation, at any time during pregnancy, is not recommended as it may lead to elevated sphingomyelin metabolite levels that may increase the risk of fetal malformations. Advise females of reproductive potential to use effective contraception during treatment and for 14 days after the last dose if olipudase alfa is discontinued. ————————— ADVERSE REACTIONS ——————————— • Most common adverse reactions in adult patients (incidence ≥10%) are headache, cough, diarrhea, hypotension, and ocular hyperemia. • Most common adverse reactions in pediatric patients (incidence ≥20%) are pyrexia, cough, diarrhea, rhinitis, abdominal pain, vomiting, headache, urticaria, nausea, rash, arthralgia, pruritus, fatigue, and pharyngitis. Highlights of Prescribing Information Xenpozyme ® prescribing information, 2023.

41. Summary: Enzyme Replacement Trials for ASMD ERT = enzyme replacement therapy; IV = intravenous. Xenpozyme ® prescribing information, 2023; Wasserstein et al, 2022; Diaz et al, 2021. The pooled safety analysis from 3 clinical trials included a total of 38 olipudase-treated patients (30 adult, 8 pediatric) between 1.5-59 years old receiving IV doses up to 3 mg/kg every 2 weeks. The median exposure duration was 2.5 years (range: 0.4 to 3.7 years) in adult patients and 2.7 years (range: 2.5 to 3.2 years) in pediatric patients In adult patients, improvement in pulmonary function, high-resolution CT lung imaging, spleen and liver volumes, thrombocytopenia, plasma HDL and LDL, ALT, lyso-SM, and chitotriosidase were observed during Year 1 of ERT In children (no ASMD A), major decreases in lyso-SM and chitotriosidase and normalization of liver transaminases occurred by Week 26. Improvements in liver and spleen volumes, DL CO , plasma lipid profiles and height Z-scores, noted at Week 26, continued at Week 52 A and A/B

42. Summary: Enzyme Replacement Trials for ASMD (cont.) CNS = central nervous system. Xenpozyme ® prescribing information, 2023; Wasserstein et al, 2022; Diaz et al, 2021. IARs occurred in approximately 75% of pediatric and 50% of adult olipudase-treated patients in the clinical trials; a severe IAR occurred in 1 (12.5%) of the pediatric patients. There is a “black box” warning re: hypersensitivity reactions Dose escalation protocols are required for adults and children to achieve recommended maximal therapeutic doses (see drug label). Antihistamines, antipyretics, and/or corticosteroids may be given prior to olipudase administration to reduce the risk of IARs; however, IARs may still occur in patients after receiving pretreatment Because olipudase does not cross the blood-brain barrier, it is unlikely that neuronopathic manifestations in children and adults will be either ameliorated or prevented unless, has been suggested for type 3 GD, suppression of systemic inflammatory mediators that may be active in the CNS, may also reduce neuroinflammatory manifestations A and A/B

43. S1P = sphingosine-1-phosphate; GD-1 = Gaucher disease Type 1. Xenpozyme ® prescribing information, 2023. Olipudase is not recommended for use in pregnancy because of potential for fetal malformations on exposure to ceramide or S1P Other than hypersensitivity reactions and increased transaminases, the other reported side effects appear to be minor Information on whether late complications seen in patients with GD-1 such as certain malignancies or Parkinsonism are part of the natural history of ASMD is minimal at this time A and A/B Summary: Enzyme Replacement Trials for ASMD (cont.)

44. Recommended Multidisciplinary Assessment Geberhiwot et al, 2023. Discipline Features of ASMD for Which This Discipline May Be of Assistance For All or As Needed Primary care physician Assist with general medical care; coordinate specialists; provide support for family All Metabolic diseases specialist Diagnosis of ASMD and exclusion of other disorders in the differential diagnosis; ongoing patient assessment for disease progression and response to therapy; coordinate the overall care working with primary care physical All Neurologist Assess the possible neurological manifestation of disease and manage All Hepatologist Periodic assessments of liver derangements; manage impending/existing liver failure As needed Hematologist Assess the risk of bleeding disorder and long-term complications As needed Pulmonologist Assess baseline respiratory functions and periodic assessment for deterioration; manage pulmonary disease and its complications As needed Genetic counselor Inform affected persons and their families regarding nature and implications of ASMD and to facilitate medical and personal decision making; provide counseling for families as to recurrence risk and options for prenatal diagnosis if desired All Lipidologist/cardiologist Manage the mixed dyslipidemia, and perform cardiovascular risk assessment for indicated primary or secondary prevention interventions As needed

45. Geberhiwot et al, 2023. Discipline Features of ASMD for Which This Discipline May Be of Assistance For All or As Needed Psychiatrist/clinical psychologist Assess for behavioral disturbances, depression, and manage accordingly As needed Speech and language therapist Assess for dysphagia and aspiration risk; speech and feeding therapy for children with neuronopathic phenotypes As needed Occupational and physical therapists/rehabilitation physician Assess and develop aids and home adjustments as needed for patients with communication and physical challenges As needed Nutritionists Periodic assessments of nutritional status in patients who may be losing weight due to dysphagia or side effects of therapy; gastrostomy tube insertion as indicated As needed Social worker Support of patients and families living with disabilities who require enhanced resources in the community As needed Developmental and behavioral pediatrician Assess for the presence or absence of developmental delays in children; recommend appropriate therapies and educational interventions As needed Recommended Multidisciplinary Assessment (cont.)

46. Management: Clinical Evaluation and Monitoring Geberhiwot et al, 2023. Recommended Assessment Rationale Frequency For All or As Needed Baseline history Establish natural history, systemic involvement, current level of disease severity, and estimate rate of progression At diagnosis All Interval history Establish rate of disease progression; monitor for compliance with and side effects from therapy Every 3-12 months/ each visit As needed Physical examination Document growth parameters, assess for neurological features and organomegaly, assess for fatigue, abdominal pain, and/or bleeding tendency At diagnosis then every 6-12 months/ each visit As needed Nutrition Evaluation of nutritional status and safety of oral intake At diagnosis then each visit As needed Pulmonary assessment Assess recurrent chest infections Assess for shortness of breath At diagnosis then at each visit All Pulmonary function testing including assessment of diffusing capacity in persons old enough to cooperate At diagnosis then annually As needed Chest radiograph and/or high-resolution chest CT to assess extent of interstitial lung disease At diagnosis regardless of age then every 2-4 years All

47. Management: Clinical Evaluation and Monitoring (cont.) Geberhiwot et al, 2023. Recommended Assessment Rationale Frequency For All or As Needed Musculoskeletal assessment Assess for fractures and/or extremity pain At diagnosis then each visit All Neurologic assessment Comprehensive neurologic evaluation At diagnosis then annually As needed Ophthalmology evaluation Presence of cherry-red spots at baseline and document At diagnosis All Cardiac assessment (adult only) EKG, echocardiogram, coronary angiogram as indicated At diagnosis and every 3-5 years As needed Blood investigations Serum chemistries including LFTs, albumin, and clotting factors to evaluate for progression of hepatic dysfunction Complete blood count to evaluate for cytopenia and increased bleeding Measurement of lipid profile At diagnosis then at least annually As needed Imaging studies Radiologic measurements of liver and spleen size as needed At diagnosis and as needed As needed

48. Management: Clinical Evaluation and Monitoring (cont.) Geberhiwot et al, 2023. Recommended assessment Rationale Frequency For All or As Needed Swallowing assessment Swallowing assessment in all patients at risk; document presence of dysphagia and aspiration and response to therapy At diagnoses and then every 6 months in children; in adults, frequency could be reduced to every 12 months if asymptomatic with stable disease As needed Developmental and cognitive assessment Developmental assessment, monitor developmental progress and educational needs (evaluation for early intervention/ special education) At diagnosis then at each visit As needed Document baseline degree of cognitive impairment including motor, adaptive, cognitive and speech/language and monitor response to therapy At diagnosis, every 6 months in children, every 12 months in adults As needed Neuropsychiatric evaluation Document psychiatric manifestations and response to therapy At diagnosis then 6-12 months as indicated As needed Family support and resources Assess need for family support and resources Assess need for community or online resources such as Parent to Parent; social work involvement for parental support Home nursing referral Assess for any change in social, domestic, or school or work-related activities At diagnosis, then each visit As needed

49. International Niemann-Pick Disease Alliance (INPDA) www. inpda.org International Niemann-Pick Disease Registry (INPDR) www. inpdr.org The Niemann-Pick Disease Community

50. International Niemann-Pick Disease Registry Platform A Common Framework and Community Patients Registry Team Health Care Advocates INPDA Health System Administrators Family Caregivers Physicians Other Health Care Providers Regulatory Authorities Role-Based Registry Experience Data In Data Out Site-entered data Patient-reported data Standard reports Regulatory reports Publications Ad hoc reports Online Community

51. Key Takeaways ASMD is a rare lysosomal disease which can present with severe life-limiting neurological manifestations or in a delayed onset presentation in which the manifestations are primarily an enlargement of the spleen and liver, liver dysfunction with cirrhosis, chronic lung disease, and atherosclerotic heart disease ASMD is frequently misdiagnosed or diagnosed only after late symptoms have developed Effective treatment has now been approved which reverses many of the systemic manifestations in patients with type B variant and appears to reduce morbidity and hopefully prolong life expectancy

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