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Preliminary Communication
April 24, 2018

Association of Lonafarnib Treatment vs No Treatment With Mortality Rate in Patients With Hutchinson-Gilford Progeria Syndrome

Author Affiliations
  • 1Department of Pediatrics, Division of Genetics, Hasbro Children’s Hospital, Providence, Rhode Island
  • 2Warren Alpert Medical School of Brown University, Providence, Rhode Island
  • 3Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 4Department of Mathematics and Statistics, Boston University, Harvard Clinical Research Institute, Boston, Massachusetts
  • 5Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island
  • 6Division of Hematology/Oncology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 7Division of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
JAMA. 2018;319(16):1687-1695. doi:10.1001/jama.2018.3264
Key Points

Question  Is treatment with the protein farnesyltransferase inhibitor lonafarnib associated with a lower mortality rate among children with the rare, fatal premature aging disease Hutchinson-Gilford progeria syndrome?

Findings  In this cohort study of 27 treated patients with Hutchinson-Gilford progeria syndrome compared with a pool of 103 contemporaneous untreated patients, treatment with lonafarnib monotherapy compared with no treatment was associated with a significantly lower mortality rate (3.7% vs 33.3%) after a median of 2.2 years of follow-up.

Meaning  This preliminary study suggests that treatment with lonafarnib may have therapeutic benefit for children with Hutchinson-Gilford progeria syndrome, but the findings are limited by its observational design.

Abstract

Importance  Hutchinson-Gilford progeria syndrome (HGPS) is an extremely rare fatal premature aging disease. There is no approved treatment.

Objective  To evaluate the association of monotherapy using the protein farnesyltransferase inhibitor lonafarnib with mortality rate in children with HGPS.

Design, Setting, and Participants  Cohort study comparing contemporaneous (birth date ≥1991) untreated patients with HGPS matched with treated patients by age, sex, and continent of residency using conditional Cox proportional hazards regression. Treatment cohorts included patients from 2 single-group, single-site clinical trials (ProLon1 [n = 27; completed] and ProLon2 [n = 36; ongoing]). Untreated patients originated from a separate natural history study (n = 103). The cutoff date for patient follow-up was January 1, 2018.

Exposure  Treated patients received oral lonafarnib (150 mg/m2) twice daily. Untreated patients received no clinical trial medications.

Main Outcomes and Measures  The primary outcome was mortality. The primary analysis compared treated patients from the first lonafarnib trial with matched untreated patients. A secondary analysis compared the combined cohorts from both lonafarnib trials with matched untreated patients.

Results  Among untreated and treated patients (n = 258) from 6 continents, 123 (47.7%) were female; 141 (54.7%) had a known genotype, of which 125 (88.7%) were classic (c.1824C>T in LMNA). When identified (n = 73), the primary cause of death was heart failure (79.4%). The median treatment duration was 2.2 years. Median age at start of follow-up was 8.4 (interquartile range [IQR], 4.8-9.5) years in the first trial cohort and 6.5 (IQR, 3.7-9.0) years in the combined cohort. There was 1 death (3.7%) among 27 patients in the first trial group and there were 9 deaths (33.3%) among 27 patients in the matched untreated group. Treatment was associated with a lower mortality rate (hazard ratio, 0.12; 95% CI, 0.01-0.93; P = .04). In the combined cohort, there were 4 deaths (6.3%) among 63 patients in the treated group and 17 deaths (27.0%) among 63 patients in the matched untreated group (hazard ratio, 0.23; 95% CI, 0.06-0.90; P = .04).

Conclusions and Relevance  Among patients with HGPS, lonafarnib monotherapy, compared with no treatment, was associated with a lower mortality rate after 2.2 years of follow-up. Study interpretation is limited by its observational design.

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