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Safety, Tolerability, PK, and Efficacy Evaluation of Repeat Ascending Doses of Olipudase Alfa in Pediatric Patients <18 Years of Age With Acid Sphingomyelinase Deficiency (ASCEND-Peds)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT02292654
Recruitment Status : Completed
First Posted : November 17, 2014
Results First Posted : February 1, 2021
Last Update Posted : February 1, 2021
Sponsor:
Information provided by (Responsible Party):
Sanofi ( Genzyme, a Sanofi Company )

Brief Summary:

Primary Objective:

To evaluate the safety and tolerability of olipudase alfa administered intravenously in pediatric participants every 2 weeks for 64 weeks.

Secondary Objective:

To characterize the pharmacokinetic profile and evaluate the pharmacodynamics and exploratory efficacy of olipudase alfa administered intravenously in pediatric participants every 2 weeks for 64 weeks.


Condition or disease Intervention/treatment Phase
Sphingomyelin Lipidosis Drug: Olipudase alfa Phase 1 Phase 2

Detailed Description:
The maximum study duration per participant was approximately 18 months (screening period: up to 60 days; treatment period: 64 weeks; post-treatment period: up to 37 days, not applicable if participants enrolled in a long-term extension treatment trial).

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 20 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: A Phase 1/2, Multi-Center, Open-Label, Ascending Dose Study to Evaluate the Safety, Tolerability, Pharmacokinetics, Pharmacodynamics and Exploratory Efficacy of Olipudase Alfa in Pediatric Patients Aged <18 Years With Acid Sphingomyelinase Deficiency
Actual Study Start Date : May 1, 2015
Actual Primary Completion Date : December 9, 2019
Actual Study Completion Date : December 9, 2019


Arm Intervention/treatment
Experimental: Olipudase alfa
Participants received intravenous (IV) infusion of olipudase alfa once every 2 weeks (Q2W) for 64 weeks. Each participant underwent a dose escalation according to the following paradigm: 0.03, 0.1, 0.3, 0.3, 0.6, 0.6, 1.0, 2.0, 3.0 milligram per kilogram (mg/kg). Three (3) mg/kg was the target maintenance dose, which was maintained for the remaining duration of 64 treatment weeks.
Drug: Olipudase alfa
Pharmaceutical form: powder for concentrate for solution for infusion Route of administration: intravenous infusion
Other Name: GZ402665




Primary Outcome Measures :
  1. Number of Participants With Treatment-Emergent Adverse Events (TEAEs) [ Time Frame: From Baseline up to End of study (64 weeks) ]
    TEAEs were defined as adverse events (AEs) that occurred or worsened during the on-treatment period (time from the start of investigational medicinal product [IMP]) administration until end of study (i.e. up to 64 weeks).

  2. Number of Participants With Infusion-Associated Reactions (IARs) [ Time Frame: Within up to 24 hours after start of any infusion (during the treatment period i.e. from Baseline up to 64 weeks) ]
    IARs were defined as AEs that occurred during the infusion or within up to 24 hours after the start of infusion and were considered as related or possibly related to the study treatment by the investigator or the sponsor. Protocol-defined IAR: all AEs that were identified as an IAR by the investigator. Events occurring greater than or equal to (>=) 24 hours after the start of an infusion might had been judged an IAR at the discretion of the investigator or sponsor.

  3. Number of Participants With Change in Physical Examination [ Time Frame: Baseline, Week 52 (last complete assessment) ]
    Change from Normal assessment (at Baseline) to Abnormal assessment (at Week 52) was reported. Physical examinations included following observations/measurements: examination of the skin, head, eyes, ears, nose, and throat; lymph nodes; heart, lungs, and abdomen; extremities and joints. Abnormality in physical examinations was based on investigator's discretion.

  4. Number of Participants With Change in Neurological Examination [ Time Frame: Baseline, Week 52 (last assessment) ]
    Change from Normal assessment (at Baseline) to Abnormal assessment (at Week 52) was reported. Neurological examination included: coordination examination, cranial nerve examination, extrapyramidal features, fundoscopy, gait and coordination examination, motor examination, tone peripheral nervous system, reflexes examination, sensory examination, strength examination, mental status.

  5. Number of Participants With Abnormal Liver Function Laboratory Values at the End of Study [ Time Frame: At End of Study (Week 64) ]
    Abnormal values in alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and alkaline phosphatase were reported.

  6. Number of Participants With Potentially Clinically Significant Vital Sign Abnormalities [ Time Frame: From Baseline up to End of Study (64 weeks) ]
    • Heart Rate (HR) High: >=120 beats per minute (bpm) (adolescents), >=120 bpm (children), >=140 bpm (early children), >=175 bpm (infants) & increase from baseline (IFB) >=20 bpm for all age categories.
    • HR Low: <=50 bpm (adolescents), <=50 bpm (children), <=75 bpm (early children), <=80 bpm (infants) & decrease from baseline (DFB) >=20 bpm for all age categories.
    • Systolic BP (SBP) High: >=119 mmHg (adolescents), 108 mmHg (children), 101 mmHg (in early children), 98 mmHg (infants) & IFB >=20 mmHg for all age categories.
    • SBP Low: <=90 mmHg (adolescents), <= 80mm Hg (children), <=70 mmHg (early children), <=70 mmHg (infants) & DFB >=20 mmHg for all age categories.
    • Diastolic BP (DBP) High:>=78 mmHg (adolescents), >=72 mmHg (children), >=59 mmHg (in early children), >=54 mmHg (infants) & IFB >=10 mmHg for all age categories.
    • DBP Low:<=54 mmHg (adolescents), <=48 mmHg (children), <=34 mmHg (early children), <=34 mmHg (infants) & DFB >=10 mmHg for all age categories.

  7. Number of Participants With Potentially Clinically Significant Electrocardiogram (ECG) Abnormalities [ Time Frame: From Baseline up to End of Study (64 weeks) ]

    Criteria for potentially clinically significant ECG abnormalities:

    • High PR Interval: >=180 milliseconds (ms) in adolescents, 170 ms in children, 160 ms in early children, and 140 ms in infants;
    • High QRS Interval: >=110 ms in adolescents, 100 ms in children, 95 ms in early children and 85 ms in infants;
    • Prolonged QTc Fridericia (QTc F): >450 ms in male adolescents, children, early children and infants or 470 ms in female adolescents,
    • QTc F >500 ms;
    • QTc F increase from baseline >60 ms.

  8. Change From Baseline in Safety Biomarker Level: High Sensitivity C Reactive Protein (hsCRP) at Week 64 [ Time Frame: Baseline, Week 64 (pre-infusion) ]
  9. Change From Baseline in Safety Biomarker: Ceramide Level at Week 64 [ Time Frame: Baseline, Week 64 (pre-infusion) ]
  10. Change From Baseline in Safety Biomarker: Iron at Week 64 [ Time Frame: Baseline, Week 64 (pre-infusion) ]
  11. Change From Baseline in Safety Biomarker: Cardiac Troponin I and Ferritin at Week 64 [ Time Frame: Baseline, Week 64 (pre-infusion) ]
  12. Change From Baseline in Safety Biomarker: Interleukin (IL)-6 and IL-8 at Week 24 [ Time Frame: Baseline, Week 24 (pre-infusion, last assessment) ]
  13. Change From Baseline in Safety Biomarker: Calcitonin at Week 64 [ Time Frame: Baseline, Week 64 (pre-infusion) ]
  14. Doppler Echocardiogram: Absolute Change From Baseline in Left Ventricular Ejection Fraction at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
  15. Number of Participants With Treatment-Emergent Antibody: Treatment-Induced/Treatment-Boosted Anti-drug Antibodies and Neutralizing Antibody (NAb) [ Time Frame: From Baseline up to Week 64 ]
    Serum samples for immunogenicity assessment were analyzed to detect ADA. ADA response were categorized as: treatment emergent antibody i.e. treatment-induced/treatment-boosted response. A participant whose ADA status was positive anytime post-baseline and was negative or missing at baseline was considered to have treatment induced ADA. A participant whose ADA status was positive at baseline (pre-existing ADA) and the ADA titer level anytime post-baseline was significantly higher than that at baseline is considered to have treatment boosted ADA. Positive samples in the ADA assay were further analyzed in the NAb assay as positive NAb inhibition of catalytic activity and positive NAb inhibition of cellular uptake.

  16. Number of Participants With Abnormalities in Liver Ultrasound Doppler at Week 52 [ Time Frame: Week 52 (last assessment) ]
    Evidence of portal hypertension was assessed by portal vein direction from liver ultrasound doppler.


Secondary Outcome Measures :
  1. Pharmacokinetic (PK) Parameter: Plasma Concentration of Olipudase Alfa at the End of Infusion (Ceoi) [ Time Frame: At the end of infusion of the first 3.0 mg/kg dose and at Week 52 ]
    Ceoi was defined as the plasma concentration at the end of infusion (EOI). Data collected for child and Infant/child age groups at 0-30 min from end of infusion was considered at end of infusion.

  2. Pharmacokinetic Parameter: Maximum Observed Plasma Concentration (Cmax) of Olipudase Alfa [ Time Frame: Adolescent: at pre-infusion, EOI, 2 h, 6 h, 24 h, 48 h & 72 h (at first 3.0 mg/kg dose) or 96 h (at Week 52) post EOI; Child & infant/early child: pre-infusion, 0-30 min, 2-4 h, 6-12 h, 24-36 h, and 84-96 h post EOI at the first 3.0 mg/kg dose & Week 52 ]
    Cmax: maximum plasma concentration observed.

  3. Pharmacokinetic Parameter: AUC0-last, AUC(0-tau) of Olipudase Alfa [ Time Frame: Adolescent: at pre-infusion, EOI, 2 h, 6 h, 24 h, 48 h & 72 h (at first 3.0 mg/kg dose) or 96 h (at Week 52) post EOI; Child & infant/early child: pre-infusion, 0-30 min, 2-4 h, 6-12 h, 24-36 h, and 84-96 h post EOI at the first 3.0 mg/kg dose & Week 52 ]

    AUClast: Area under the plasma concentration versus time curve calculated using the trapezoidal method from time zero to the time of last measured concentration.

    AUC(0-tau): area under the plot of the drug concentration versus the time curve from time "0" to the end of the dosing interval (tau), where dosing interval was 2 weeks.


  4. Pharmacokinetic Parameter: Terminal Half-Life of Olipudase Alfa [ Time Frame: Adolescent: at pre-infusion, EOI, 2 h, 6 h, 24 h, 48 h & 72 h (at first 3.0 mg/kg dose) or 96 h (at Week 52) post EOI; Child & infant/early child: pre-infusion, 0-30 min, 2-4 h, 6-12 h, 24-36 h, and 84-96 h post EOI at the first 3.0 mg/kg dose & Week 52 ]
    Half-life is the time measured for the plasma concentration of drug to decrease by one half.

  5. Pharmacokinetic Parameter: Total Body Clearance (CL) of Olipudase Alfa [ Time Frame: Adolescent: at pre-infusion, EOI, 2 h, 6 h, 24 h, 48 h & 72 h (at first 3.0 mg/kg dose) or 96 h (at Week 52) post EOI; Child & infant/early child: pre-infusion, 0-30 min, 2-4 h, 6-12 h, 24-36 h, and 84-96 h post EOI at the first 3.0 mg/kg dose & Week 52 ]
    Drug clearance is a quantitative measure of the rate at which a drug substance is removed from the blood. Total body clearance of a drug from the plasma calculated using equations below: CL = Dose / AUC after the first dose.

  6. Pharmacokinetic Parameter: Volume of Distribution at Steady State (Vss) of Olipudase Alfa [ Time Frame: Adolescent: at pre-infusion, EOI, 2 h, 6 h, 24 h, 48 h & 72 h (at first 3.0 mg/kg dose) or 96 h (at Week 52) post EOI; Child & infant/early child: pre-infusion, 0-30 min, 2-4 h, 6-12 h, 24-36 h, and 84-96 h post EOI at the first 3.0 mg/kg dose & Week 52 ]
    Volume of distribution is defined as the theoretical volume in which the total amount of drug would need to be uniformly distributed to produce the desired plasma concentration of a drug.

  7. Pharmacokinetic Parameter: Time to Reach Cmax (Tmax) of Olipudase Alfa [ Time Frame: Adolescent: at pre-infusion, EOI, 2 h, 6 h, 24 h, 48 h & 72 h (at first 3.0 mg/kg dose) or 96 h (at Week 52) post EOI; Child & infant/early child: pre-infusion, 0-30 min, 2-4 h, 6-12 h, 24-36 h, and 84-96 h post EOI at the first 3.0 mg/kg dose & Week 52 ]
    tmax: time to reach maximum plasma concentration observed.

  8. Percent Change From Baseline in Spleen Volume and Liver Volume at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
    Spleen and liver volumes was assessed by abdominal magnetic resonance imaging (MRI).

  9. Change From Baseline in Interstitial Lung Disease Score Measured Using High Resolution Computed Tomography (HRCT) at Week 52 For Both Lungs [ Time Frame: Baseline, Week 52 (last assessment) ]
    Pulmonary imaging of chest using HRCT was obtained to quantitate the degree of possible infiltrative lung disease. Lung fields were assessed by a central reader & scored subjectively for the degree of interstitial lung disease on a scale ranges from 0 =normal, 1 =mild, 2=moderate and 3 =severe, where higher scores indicate more severity.

  10. Change From Baseline in Height Z-Scores at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
    Z-score for height of participants was evaluated. Height Z-Score, i.e., the height-for-age Z Score, is the number of standard deviations of the actual height of a child from the median height of the children of the corresponding age and sex as determined from the standard sample. A height Z-score of 0 is equal to the median and is considered normal. Negative numbers indicate values lower than the median and positive numbers indicate values higher than the median. For analysis, mean Z-score was calculated and an increase of mean height Z-score from baseline indicates an improvement on growth.

  11. Percent Change From Baseline in Percent Predicted Hemoglobin-Adjusted Diffusing Capacity of Carbon Monoxide (DLco) at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
    Percent predicted Hemoglobin-adjusted DLco was calculated as: 100*Adjusted DLco/Predicted DLco in unit of mL CO/min/mmHg where, adjusted DLco = Observed DLco (in mL CO/min/mmHg) divided by Hemoglobin-adjusted factor. Per planned analysis, pulmonary function testing (PFT) was to be performed only on participants >=5 years of age therefore, data for participants in "age cohort: infant/early child" were not collected.

  12. Change From Baseline in Difference Between Actual Age and Bone Age of Participants at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
    Hand X-ray was performed on participant's left hand, fingers and wrist to assess bone age of participants. At each visit (Baseline and Week 52), difference between the bone age and actual age at that visit was calculated. Difference in age in months was calculated as bone age in months minus real age at time of assessment (in months) at specified time points. In this outcome measure change from baseline at Week 52 in the difference between actual age and bone age (in months) is reported.

  13. Change From Baseline in Cycle Ergometry: Maximum Workload at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
    Cardiopulmonary status was assessed using a stationary one-wheeled cycle used as an ergometer to measure a person's work output under controlled conditions. Participants were asked to ride the cycle at increasing workload levels until they could no longer proceed. The workload at which participant stopped and cannot proceed was considered as maximum workload (in watt). As per the planned analysis, this assessment was not to be performed on participants that were <=6 years of age or <120 cm in height on day 1/week 0, therefore infant/early child cohort was not evaluable.

  14. Physician's Global Assessment of Participant's Progress: Observed Scores at Week 52 [ Time Frame: Week 52 (last assessment) ]
    Physician assessed participant's current clinical status (refers to clinical status at Week 52 in comparison to Baseline) was evaluated by marking 1 of the following 7 categories: • marked improvement, • moderate improvement, • mild improvement, • no change, • mild worsening, • moderate worsening, or • marked worsening. These 7 categories were converted to scores as follows: 3 = marked improvement of daily activities, 2 = moderate improvement of daily activities, 1 = mild improvement of daily activities, 0 = no change, -1 = mild worsening of daily activities, -2 = moderate worsening of daily activities, -3 = marked worsening of daily activities where higher score indicated improvement in daily activities as compared to baseline. In this outcome measure, observed scores of participant's clinical status at Week 52 are reported.

  15. Percent Change From Baseline in Efficacy Biomarkers Level at Week 52 [ Time Frame: Baseline, Week 52 ]
    Efficacy biomarkers included chitotriosidase, chemokine ligand 18 (CCL18), angiotensin-converting enzyme (ACE).

  16. Percent Change From Baseline in Lipid Profile at Week 52 [ Time Frame: Baseline, Week 52 ]
    Lipid profile parameters included low density lipoprotein (LDL)-cholesterol, high density lipoprotein (HDL)-cholesterol and triglycerides.

  17. Percent Change From Baseline in Bone Biomarkers at Week 52 [ Time Frame: Baseline, Week 52 ]
    Bone biomarkers included bone specific alkaline phosphatase, C-Telopeptide.

  18. Change From Baseline in Health Outcome Questionnaires : Pediatric Quality of Life (PedsQL) Generic Core Total Scale Scores at Week 52 [ Time Frame: Baseline, Week 52 (last assessment) ]
    PedsQL includes a child self-report (CS-R) for participants 5 to 18 years and parents' report (PR) of participants 2 to 18 years. CS-R: 23-item PedsQL Generic Core Scales report includes 4 scales, Physical (P), Emotional (E), Social (S), and School Functioning (SF). PR: 21-item PedsQL Generic Core Scales report includes P, E, S, and SF scales. Each item used a 5-point rating scale ( from 0=never to 4=almost always). Items are reverse scored and linearly transformed to a 0 (almost always) -100 (never) scale. Higher score indicates better Health Related Quality of Life (HRQoL). P, E, S and SF summary scores are calculated as mean of respective functioning items. Psychosocial Health Summary Score is calculated as mean of 13 or 15 items (E, S and SF). Generic core total scale score is calculated as the mean of all the 21 or 23 items (P, E, S and SF). All summary/total scores are mean of specific items and they all have values ranges from 0 to 100, where higher score=better HRQoL.

  19. Percent Change From Baseline in Pharmacodynamic Biomarkers: Plasma Sphingomyelin and Lyso-Sphingomyelin Levels at Week 52 [ Time Frame: Baseline, Week 52 (Pre- infusion) ]
    Sphingomyelin and Lyso-sphingomyelin levels were assessed in plasma. Lyso-sphingomyelin is a metabolite of sphingomyelin.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   up to 17 Years   (Child)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion criteria :

  • The participant and/or participant's parent(s)/legal guardian(s) must provide written informed assent/consent prior to any protocol-related procedures being performed.
  • The participant was <18 years of age on the date of informed assent/consent.
  • The participant had documented deficiency of acid sphingomyelinase as measured in peripheral leukocytes, cultured fibroblasts, or lymphocytes.
  • The participant had a spleen volume greater than or equal to (>=) 5 multiples of normal (MN) measured by magnetic resonance imaging (MRI); participants who had partial splenectomy were allowed if the procedure was performed >=1 year before screening and the residual spleen volume was >=5 MN.
  • The participant's height was -1 Z-score or lower.
  • A negative serum pregnancy test in female participants of childbearing potential.
  • Female participants of childbearing potential and male participants must be willing to practice true abstinence in line with their preferred and usual lifestyle or use 2 acceptable effective methods of contraception.

Exclusion criteria:

  • The participant had received an investigational drug within 30 days before study enrollment.
  • The participant had any of the following medical conditions:
  • An active, serious, intercurrent illness.
  • Active hepatitis B or hepatitis C infection.
  • Infection with human immunodeficiency virus (HIV).
  • Cirrhosis (determined by clinical evaluation).
  • Significant cardiac disease (eg, clinically significant arrhythmia, moderate or severe pulmonary hypertension or valvular dysfunction, or <40 percent (%) left ventricular ejection fraction by echocardiogram).
  • Malignancy diagnosed within the previous 5 years (except basal cell carcinoma).
  • Any other extenuating circumstance that can significantly interfere with study compliance, including all prescribed evaluations and follow-up activities.
  • The participant had acute or rapidly progressive neurological abnormalities.
  • The participant was homozygous for SMPD1 gene mutations R496L, L302P, and fs330 or any combination of these 3 mutations.
  • The participant had a delay of gross motor skills.
  • The participant had a major organ transplant (eg, bone marrow, liver).
  • The participant required use of invasive ventilatory support.
  • The participant required use of noninvasive ventilatory support while awake and for greater than (>)12 hours a day.
  • The participant in the investigator's opinion, was unable to adhere to the requirements of the study.
  • The participant had a platelet count <60 × 10^3/µL (based on the average of 2 screening samples obtained up to 24 hours apart).
  • The participant had alanine aminotransferase or aspartate aminotransferase >250 IU/L or total bilirubin >1.5 mg/dL.
  • The participant had an international normalized ratio (INR) >1.5.
  • The participant was unwilling or unable to abstain from ingesting alcohol the day before through 3 days after each infusion of olipudase alfa during the treatment period. Measuring alcohol concentration in blood was not required.
  • The participant was scheduled during the study for in-patient hospitalization including elective surgery.
  • The participant required medication(s) that may can decrease olipudase alfa activity (eg, fluoxetine, chlorpromazine; tricyclic antidepressants [eg, imipramine, or desipramine]).
  • The participant was breast-feeding.

The above information was not intended to contain all considerations relevant to a participant's potential participation in a clinical trial.


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02292654


Locations
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United States, New York
Investigational Site Number 840001
New York, New York, United States, 10029
Brazil
Investigational Site Number 076001
Porto Alegre, Brazil, 90035 003
France
Investigational Site Number 250002
Bron Cedex, France, 69677
Germany
Investigational Site Number 276001
Mainz, Germany, 55131
Italy
Investigational Site Number 380001
Udine, Italy, 33100
United Kingdom
Investigational Site Number 826001
Manchester, United Kingdom, M13 9WL
Sponsors and Collaborators
Genzyme, a Sanofi Company
Investigators
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Study Director: Clinical Sciences & Operations Sanofi
  Study Documents (Full-Text)

Documents provided by Sanofi ( Genzyme, a Sanofi Company ):
Study Protocol  [PDF] August 21, 2017
Statistical Analysis Plan  [PDF] November 5, 2019

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Responsible Party: Genzyme, a Sanofi Company
ClinicalTrials.gov Identifier: NCT02292654    
Other Study ID Numbers: DFI13803
U1111-1160-6469 ( Other Identifier: UTN )
First Posted: November 17, 2014    Key Record Dates
Results First Posted: February 1, 2021
Last Update Posted: February 1, 2021
Last Verified: January 2021
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Yes
Plan Description: Qualified researchers may request access to participant level data and related study documents including the clinical study report, study protocol with any amendments, blank case report form, statistical analysis plan, and dataset specifications. Participant level data will be anonymized and study documents will be redacted to protect the privacy of trial participants. Further details on Sanofi's data sharing criteria, eligible studies, and process for requesting access can be found at: https://www.clinicalstudydatarequest.com /
Additional relevant MeSH terms:
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Niemann-Pick Disease, Type A
Niemann-Pick Diseases
Niemann-Pick Disease, Type C
Lipidoses
Lipid Metabolism, Inborn Errors
Metabolism, Inborn Errors
Genetic Diseases, Inborn
Lipid Metabolism Disorders
Metabolic Diseases
Sphingolipidoses
Lysosomal Storage Diseases, Nervous System
Brain Diseases, Metabolic, Inborn
Brain Diseases, Metabolic
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Histiocytosis, Non-Langerhans-Cell
Histiocytosis
Lymphatic Diseases
Lysosomal Storage Diseases