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  • lorsque la demande peut être examinée par le public;
  • lorsque le brevet est émis (délivrance).
(12) Demande de brevet: (11) CA 2920272
(54) Titre français: COMPOSITIONS THERAPEUTIQUES RENFERMANT DE LA PHENAZINE-3-ONE ET DES DERIVES DE PHENOTHIAZINE-3-ONE ET LEURS UTILISATIONS EN VUE DE TRAITER ET PREVENIR LES MALADIES ET TROUBLES MITOCHONDRIAUX
(54) Titre anglais: THERAPEUTIC COMPOSITIONS INCLUDING PHENAZINE-3-ONE AND PHENOTHIAZINE-3-ONE DERIVATIVES AND USES THEREOF TO TREAT AND PREVENT MITOCHONDRIAL DISEASES AND CONDITIONS
(51) Classification internationale des brevets (CIB):
  • A61K 31/5415 (2006.01)
  • A61K 31/498 (2006.01)
  • A61P 3/00 (2006.01)
(72) Inventeurs :
  • WILSON, D. TRAVIS (Etats-Unis d'Amérique)
(73) Titulaires :
  • STEALTH BIOTHERAPEUTICS CORP (Non disponible)
(71) Demandeurs :
  • STEALTH BIOTHERAPEUTICS CORP (Cayman Islands)
(74) Agent: OSLER, HOSKIN & HARCOURT LLP
(74) Co-agent:
(45) Délivré:
(22) Date de dépôt: 2016-02-09
(41) Mise à la disponibilité du public: 2016-08-13
(30) Licence disponible: S.O.
(30) Langue des documents déposés: Anglais

(30) Données de priorité de la demande:
Numéro de la demande Pays / territoire Date
62/115,955 Etats-Unis d'Amérique 2015-02-13

Abrégé anglais


Disclosed herein are methods and compositions related to the treatment and/or
amelioration of diseases and conditions comprising administration of phenazine-
3-one
and/or phenothiazine-3-one derivatives and/or analogues, or pharmaceutically
acceptable salts thereof. In particular, the present technology relates to
administering
an effective amount of phenazine-3-one and/or phenothiazine-3-one derivatives
to a
subject in need thereof to prevent or treat a disease or medical condition,
reduce risk
factors associated with a disease or medical condition, and/or reducing the
severity of
a medical disease or condition.


Note : Les revendications sont présentées dans la langue officielle dans laquelle elles ont été soumises.

CLAIMS
What is claimed is:
1. A method for treating or preventing a mitochondrial disease or disorder
in a
subject in need thereof, comprising administering to the subject a
therapeutically effective amount of a phenazine-3-one or phenothiazine-3-one
derivative or a pharmaceutically acceptable salt thereof, in combination with
one or more additional therapeutic agents selected from the group consisting
of: vitamins, cofactors, antibiotics, hormones, antineoplastic agents,
steroids,
immunomodulators, dermatologic drugs, antithrombotic, antianemic, and
cardiovascular agents.
2. The method of claim 1, wherein the mitochondrial disease or disorder is
selected from the group consisting of Alexander disease, Alpers Syndrome,
Alpha-ketoglutarate dehydrogenase (AKDGH) deficiency, ALS-FTD,
Sideroblastic anemia with spinocerebellar ataxia, Pyridoxine-refractory
sideroblastic anemia, GRACILE Syndrome, Björnstad Syndrome, Leigh
Syndrome, mitochondrial complex III deficiency nuclear type 1 (MC3DN1),
combined oxidative phosphorylation deficiency 18 (COXPD18), Thiamine-
responsive megaloblastic anemia syndrome (TRMA), Pearson Syndrome,
HAM Syndrome, Ataxia, Cataract, and Diabetes Syndrome, MELAS/MERRF
Overlap Syndrome, combined oxidative phosphorylation deficiency-14
(COXPD14), Infantile cerebellar-retinal degeneration (ICRD), Charlevoix-
Saguenay spastic ataxia, Primary coenzyme Q10 deficiency-1 (COQ10D1),
ataxia oculomotor apraxia type 1 (AOA1), Autosomal recessive
spinocerebellar ataxia-9/ coenzyme Q10 deficiency-4 (COQ10D4), Ataxia,
Pyramidal Syndrome, and Cytochrome Oxidase Deficiency, Friedreich's
ataxia, Infantile onset spinocerebellar ataxia (IOSCA)/ Mitochondrial DNA
Depletion Syndrome-7, Leukoencephalopathy with brainstem and spinal cord
involvement and lactate elevation (LBSL), Autosomal recessive spastic ataxia-
3 (SPAX3), MIRAS, SANDO, mitochondrial spinocerebellar ataxia and
epilepsy (MSCAE), spastic ataxia with optic atrophy (SPAX4), progressive
external ophthalmoplegia with mitochondrial DNA deletions autosomal
dominant type 5 (PEOA5), mitochondrial complex III deficiency nuclear type
236

2 (MC3DN2), episodic encephalopathy due to thiamine pyrophosphokinase
deficiency/Thiamine Metabolism Dysfunction Syndrome-5 (THMD5),
Spinocerebellar ataxia-28 (SCA28), autosomal dominant cerebellar ataxia,
deafness, and narcolepsy (ADCA-DN), Dominant Optic Atrophy (DOA),
cerebellar ataxia, areflexia, pes cavus, optic atrophy, and sensorineural
hearing
loss (CAPOS) Syndrome, spinocerebellar ataxia 7 (SCA7), Barth Syndrome,
Biotinidase deficiency, gyrate atrophy, Syndromic Dominant Optic Atrophy
and Deafness (Syndromic DOAD), Dominant Optic Atrophy plus (DOAplus),
Leber's hereditary optic neuropathy (LHON), Wolfram Syndrome-1 (WFS1),
Wolfram Syndrome-2 (WFS2), Age-related macular degeneration (ARMD),
Brunner Syndrome, Left ventricular noncompaction-1 (LVNC1), histiocytoid
cardiomyopathy, Familial Myalgia Syndrome, Parkinsonism, Fatal infantile
cardioencephalomyopathy due to cytochrome c oxidase (COX) deficiency-1
(CEMCOX1), Sengers Syndrome, Cardiofaciocutaneous Syndrome-1 (CFC1),
Mitochondrial trifunctional protein (MTP) deficiency, infantile
encephalocardiomyopathy with cytochrome c oxidase deficiency,
cardiomyopathy + encephalomyopathy, mitochondrial phosphate carrier
deficiency, infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX) deficiency (CEMCOX2), .beta.-Hydroxyisobutyryl CoA Deacylase
(HIBCH) deficiency, ECHS1) deficiency, Maternal Inheritance Leigh
Syndrome (MILS), dilated cardiomyopathy with ataxia (DCMA),
Mitochondrial DNA Depletion Syndrome-12 (MTDPS12), cardiomyopathy
due to mitochondrial tRNA deficiencies, mitochondrial complex V (ATP
synthase) deficiency nuclear type 1 (MC5DN1), combined oxidative
phosphorylation deficiency-8 (COXPD8), progressive leukoencephalopathy
with ovarian failure (LKENP), combined oxidative phosphorylation
deficiency-10 (COXPD10), combined oxidative phosphorylation deficiency-
16 (COXPD16), combined oxidative phosphorylation deficiency-17
(COXPD17), combined oxidative phosphorylation deficiency-5 (COXPD5),
combined oxidative phosphorylation deficiency-9 (COXPD9), carnitine
acetyltransferase (CRAT) deficiency, carnitine palmitoyltransferase I (CPT I)
deficiency, myopathic carnitine deficiency, primary systemic carnitine
deficiency (CDSP), carnitine palmitoyltransferase H (CPT II) deficiency,
carnitine-acylcarnitine translocase deficiency (CACTD), cartilage-hair
237


hypoplasia, cerebrotendinous xanthomatosis (CTX), congenital adrenal
hyperplasia (CAH), megaconial type congenital muscular dystrophy, cerebral
creatine deficiency syndrome-3 (CCDS3), maternal nonsyndromic deafness,
maternal nonsyndromic deafness, autosomal dominant deafness-64
(DFNA64), Mohr-Tranebjaerg Syndrome, Jensen Syndrome, MEGDEL,
reticular dysgenesis, primary coenzyme Q10 deficiency-6 (COQ10D6),
CAGSSS, diabetes, Dimethylglycine dehydrogenase deficiency (DMGDHD),
Multiple Mitochondrial Dysfunctions Syndrome-1 (MMDS1), Multiple
Mitochondrial Dysfunctions Syndrome-2 (MMDS2), Multiple Mitochondrial
Dysfunctions Syndrome-3 (MMDS3), childhood leukoencephalopathy
associated with mitochondrial Complex II deficiency, encephalopathies
associated with mitochondrial Complex I deficiency, encephalopathies
associated with mitochondrial Complex III deficiency, encephalopathies
associated with mitochondrial Complex IV deficiency, encephalopathies
associated with mitochondrial Complex V deficiency, hyperammonemia due
to carbonic anhydrase VA deficiency (CA5AD), early infantile epileptic
encephalopathy-3 (ElEE3), 2,4-Dienoyl-CoA reductase deficiency (DECRD),
infection-induced acute encephalopathy-3 (IIAE3), ethylmalonic
encephalopathy (EE), hypomyelinating leukodystrophy (HLD4), exocrine
pancreatic insufficiency, dyserythropoietic anemia and calvarial hyperostosis,

Glutaric aciduria type 1 (GA-1), glycine encephalopathy (GCE), hepatic
failure, 2-hydroxyglutaric aciduria, 3-hydroxyacyl-CoA dehydrogenase
deficiency, familial hyperinsulinemic hypoglycemia (FHH), hypercalcemia
infantile, hyperornithinemia-hyperammonemia-homocitrullinuria (HHH)
Syndrome, Immunodeficiency with hyper-IgM type 5 (HIGM5), Inclusion
Body Myositis (IBM), polymyositis with mitochondrial pathology, IM-Mito,
granulomatous myopathies with anti-mitochondrial antibodies, necrotizing
myopathy with pipestem capillaries, myopathy with deficient chondroitin
sulfate C in skeletal muscle connective tissue, benign acute childhood
myositis, idiopathic orbital myositis, masticator myopathy, hemophagocytic
lymphohistiocytosis, infection-associated myositis, Facioscapulohumeral
dystrophy (FSH), familial idiopathic inflammatory myopathy, Schmidt
Syndrome (Diabetes mellitus, Addison disease, Myxedema), TNF receptor-
associated Periodic Syndrome (TRAPS), focal myositis, autoimmune fasciitis,

238

Spanish toxic oil-associated fasciitis, Eosinophilic fasciitis, Macrophagic
myofasciitis, Graft-vs-host disease fasciitis, Eosinophilia-myalgia Syndrome,
perimyositis, isovaleric acidemia (IVA), Kearnes-Sayre Syndrome (KSS), 2-
oxoadipic aciduria, 2-aminoadipic aciduria, Limb-girdle Muscular Dystrophy
Syndromes, leukodystrophy, Maple syrup urine disease (MSUD), 3-
Methylcrotonyl-CoA carboxylase (MCC), Methylmalonic aciduria (MMA),
Miller Syndrome, Mitochondrial DNA Depletion Syndrome-2 (MTDPS2),
spinal muscular atrophy syndrome, rigid spine syndrome, severe myopathy
with motor regression, Mitochondrial DNA Depletion Syndrome-3, MELAS
Syndrome, camptocormia, MNGIE, MNGIM Syndrome, Menkes Disease,
Occipital Horn Syndrome, X-linked distal spinal muscular atrophy-3
(SMAX3), methemoglobinemia, MERRF, progressive external
ophthalmoplegia with myoclonus, deafness and diabetes (DD), multiple
symmetric lipomatosis, Myopathy with Episodic high Creatine Kinase
(MIMECK), Epilepsia Partialis Continua, malignant hyperthermia syndromes,
glycogen metabolic disorders, fatty acid oxidation and lipid metabolism
disorders, medication-, drug- or toxin-induced myoglobinuria, mitochondrial
disorder-associated myoglobinuria, hypokalemic myopathy and
rhabdomyolysis, muscle trauma-associated myoglobinuria, ischemia-induced
myoglobinuria, infection-induced myoglobinuria, immune myopathies
associated with myoglobinuria, Myopathy, lactic acidosis, and sideroblastic
anemia (MLASA), infantile mitochondrial myopathy due to reversible COX
deficiency (MMIT), Myopathy, Exercise intolerance, Encephalopathy and
Lactic acidemia Syndrome, myoglobinuria and exercise intolerance syndrome,
exercise intolerance, proximal weakness myoglobinuria syndrome,
encephalopathy and seizures syndrome, septo-optic dysplasia, exercise
intolerance mild weakness, myopathy exercise intolerance, growth or CNS
disorder, maternally-inherited mitochondrial myopathies, myopathy with lactic
acidosis, myopathy with rhabdomyolysis, Myopathy with cataract and
combined respiratory chain deficiency, myopathy with abnormal
mitochondrial translation, Fatigue Syndrome, myopathy with extrapyramidal
movement disorders (MPXPS), glutaric aciduria II (MADD), primary CoQ10
deficiency-1 (COQ10D1), primary CoQ10 deficiency-2 (COQ10D2), primary
CoQ10 deficiency-3 (COQ10D3), primary CoQ10 deficiency-5 (COQ10D5),
239


secondary CoQ10 deficiency, autosomal dominant mitochondrial myopathy,
myopathy with focal depletion of mitochondria, mitochondrial DNA breakage
syndrome (PEO + Myopathy), lipid type mitochondrial myopathy, multiple
symmetric lipomatosis (MSL), N-acetylglutamate synthase (NAGS)
deficiency, Nephronophthisis (NPHP), ornithine transcarbamylase (OTC)
deficiency, neoplasms, NARP Syndrome, paroxysmal nonkinesigenic
dyskinesia (PNKD), sporadic PEO, maternally-inherited PEO, autosomal
dominant progressive external ophthalmoplegia with mitochondrial DNA
deletions-3 (PEOA3), autosomal dominant progressive external
ophthalmoplegia with mitochondrial DNA deletions-2 (PEOA2), autosomal
dominant progressive external ophthalmoplegia with mitochondrial DNA
deletions-1 (PEOA1), PEO+ demyelinating neuropathy, PEO +
hypogonadism, autosomal dominant progressive external ophthalmoplegia
with mitochondrial DNA deletions-4 (PEOA4), distal myopathy, cachexia &
PEO, autosomal dominant progressive external ophthalmoplegia-6 (PEOA6),
PEO + Myopathy and Parkinsonism, autosomal recessive progressive external
ophthalmoplegia (PEOB), Mitochondrial DNA Depletion Syndrome-11
(MTDPS11), PEO with cardiomyopathy, PEPCK deficiency, Perrault
Syndromes (PRLTS), propionic acidemia (PA), pyruvate carboxylase
deficiency, pyruvate dehydrogenase E1-alpha deficiency (PDHAD), pyruvate
dehydrogenase E1-beta deficiency (PDHBD), dihydrolipoamide
dehydrogenase (DLD) deficiency, pyruvate dehydrogenase phosphatase
deficiency, pyruvate dehydrogenase E3-binding protein deficiency (PDHXD),
mitochondrial pyruvate carrier deficiency (MPYCD), Schwartz-Jampel
Syndrome type 1 (SJS1), selenium deficiency, short-chain acyl-CoA
dehydrogenase (SCAD) deficiency, succinyl CoA:3-oxacid CoA transferase
(SCOT) deficiency, Stuve-Wiedemann Syndrome (STWS), thrombocytopenia
(THC), Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD),
Vitamin D-dependent rickets type 1A (VDDR1A), Wilson's disease,
Zellweger Syndrome (PBD3A), arsenic trioxide myopathy, myopathy and
neuropathy resulting from nucleoside analogues, germanium myopathy,
Parkinsonism and mitochondrial Complex I neurotoxicity due to
trichloroethylene, valproate-induced hepatic failure, neurodegeneration with
brain iron accumulation-4 (NBIA4), Complex I deficiency, Complex II

240


deficiency, Complex III deficiency, Complex IV deficiency, Complex V
deficiency, Cytochrome c oxidase (COX) deficiency, combined complex I, II,
IV, ~ V deficiency, combined complex I, II, and III deficiency, combined
oxidative phosphorylation deficiency-1 (COXPD1), combined oxidative
phosphorylation deficiency-2 (COXPD2), combined oxidative
phosphorylation deficiency-3 (COXPD3), combined oxidative
phosphorylation deficiency-4 (COXPD4), combined oxidative
phosphorylation deficiency-6 (COXPD6), combined oxidative
phosphorylation deficiency-7 (COXPD7), combined oxidative
phosphorylation deficiency-9 (COXPD9), combined oxidative
phosphorylation deficiency-11 (COXPD11), combined oxidative
phosphorylation deficiency-12 (COXPD12), combined oxidative
phosphorylation deficiency-13 (COXPD13), combined oxidative
phosphorylation deficiency-15 (COXPD15), combined oxidative
phosphorylation deficiency-16 (COXPD16), combined oxidative
phosphorylation deficiency-19 (COXPD19), combined oxidative
phosphorylation deficiency-20 (COXPD20), combined oxidative
phosphorylation deficiency-21 (COXPD21), fumarase deficiency, HMG-CoA
synthase-2 deficiency, hyperuricemia, pulmonary hypertension, renal failure,
and alkalosis (HUPRA) Syndrome, syndromic microphthalmia-7,
pontocerebellar hypoplasia type 6 (PCH6), Mitochondria1 DNA Depletion
Syndrome-9 (MTDPS9P), and Sudden infant death Syndrome (SIDS).
3. The method of any one of claims 1-2, wherein the phenazine-3-one or
phenothiazine-3-one derivative, in combination with one or more additional
therapeutic agents, is administered daily for one, two, three, four or five
weeks.
4. The method of any one of claims 1-3, wherein the phenazine-3-one or
phenothiazine-3-one derivative, in combination with one or more additional
therapeutic agents, is administered daily for 6 weeks or more.
5. The method of claim 1, wherein the subject displays abnormal levels of
one or
more energy biomarkers compared to a normal control subject.

241


6. The method of claim 5, wherein the energy biomarker is selected from the

group consisting of lactic acid (lactate) levels; pyruvic acid (pyruvate)
levels;
lactate/pyruvate ratios; total, reduced or oxidized glutathione levels; total,

reduced or oxidized cysteine levels; reduced/oxidized glutathione ratios;
reduced/oxidized cysteine ratios; phosphocreatine levels; NADH
(NADH+H30) or NADPH (NADPH+H30) levels; NAD or NADP levels; ATP
levels; reduced coenzyme Q (CoQred) levels; oxidized coenzyme Q (CoQox)
levels; total coenzyme Q (CoQtot) levels; oxidized cytochrome C levels;
reduced cytochrome C levels; oxidized cytochrome C/reduced cytochrome C
ratio; acetoacetate levels; beta-hydroxy butyrate levels; acetoacetate/ beta-
hydroxy butyrate ratio; 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels; levels
of reactive oxygen species; oxygen consumption (VO2), carbon dioxide output
(VCO2), and respiratory quotient (VCO2/VO2).
7. The method of any one of claims 1-6, wherein the subject is human.
8. The method of any one of claims 1-7, wherein the phenazine-3-one or
phenothiazine-3-one derivative is administered orally, intranasally,
intrathecally, intraocularly, intradermally, transmucosally,
iontophoretically,
topically, systemically, intravenously, subcutaneously, intraperitoneally, or
intramuscularly.
9. The method of claim 1, wherein the symptoms of the mitochondrial disease
or
disorder comprises one or more of poor growth, loss of muscle coordination,
muscle weakness, neurological deficit, seizures, autism, autistic spectrum,
autistic-like features, learning disabilities, heart disease, liver disease,
kidney
disease, gastrointestinal disorders, severe constipation, diabetes, increased
risk
of infection, thyroid dysfunction, adrenal dysfunction, autonomic dysfunction,

confusion, disorientation, memory loss, failure to thrive, poor coordination,
sensory (vision, hearing) problems, reduced mental functions, hypotonia,
disease of the organ, dementia, respiratory problems, hypoglycemia, apnea,
lactic acidosis, seizures, swallowing difficulties, developmental delays,
movement disorders (dystonia, muscle spasms, tremors, chorea), stroke, and
brain atrophy.

242


10. The method of any one of claims 1-8, comprising separately,
sequentially or
simultaneously administering the additional therapeutic agent to the subject.
11. A method for modulating the expression of one or more energy biomarkers
in
a mammalian subject in need thereof, the method comprising: administering to
the subject a therapeutically effective amount of a phenazine-3-one or
phenothiazine-3-one derivative or a pharmaceutically acceptable salt thereof,
in combination with one or more additional therapeutic agents selected from
the group consisting of: vitamins, cofactors, antibiotics, hormones,
antineoplastic agents, steroids, immunomodulators, dermatologic drugs,
antithrombotic, antianemic, and cardiovascular agents.
12. The method of claim 11, wherein the energy biomarker is selected from
the
group consisting of lactic acid (lactate) levels; pyruvic acid (pyruvate)
levels;
lactate/pyruvate ratios; total, reduced or oxidized glutathione levels; total,

reduced or oxidized cysteine levels; reduced/oxidized glutathione ratios;
reduced/oxidized cysteine ratios; phosphocreatine levels; NADH
(NADH+H30) or NADPH (NADPH+H30 ) levels; NAD or NADP levels; ATP
levels; reduced coenzyme Q (CoQred) levels; oxidized coenzyme Q (CoQox)
levels; total coenzyme Q (CoQtot) levels; oxidized cytochrome C levels;
reduced cytochrome C levels; oxidized cytochrome C/reduced cytochrome C
ratio; acetoacetate levels; beta-hydroxy butyrate levels; acetoacetate/ beta-
hydroxy butyrate ratio; 8-hydroxy-2'-deoxyguanosine (8-OHdG) levels; levels
of reactive oxygen species; oxygen consumption (VO2), carbon dioxide output
(VCO2), and respiratory quotient (VCO2/VO2).
13. The method of any one of claims 11-12, wherein the phenazine-3-one or
phenothiazine-3-one derivative, in combination with one or more additional
therapeutic agents, is administered daily for one, two, three, four or five
weeks.
14. The method of any one of claims 11-13, wherein the phenazine-3-one or
phenothiazine-3-one derivative, in combination with one or more additional
therapeutic agents, is administered daily for 6 weeks or more.

243


15. The method of any one of claims 11-14, wherein the subject has been
diagnosed as having, is suspected of having, or is at risk of having a
mitochondrial disease or disorder.
16. The method of claim 15, wherein symptoms of the mitochondrial disease
or
disorder comprises one or more of poor growth, loss of muscle coordination,
muscle weakness, neurological deficit, seizures, autism, autistic spectrum,
autistic-like features, learning disabilities, heart disease, liver disease,
kidney
disease, gastrointestinal disorders, severe constipation, diabetes, increased
risk
of infection, thyroid dysfunction, adrenal dysfunction, autonomic dysfunction,

confusion, disorientation, memory loss, failure to thrive, poor coordination,
sensory (vision, hearing) problems, reduced mental functions, hypotonia,
disease of the organ, dementia, respiratory problems, hypoglycemia, apnea,
lactic acidosis, seizures, swallowing difficulties, developmental delays,
movement disorders (dystonia, muscle spasms, tremors, chorea), stroke, and
brain atrophy. .
17. The method of any one of claims 11-16, wherein the subject is human.
18. The method of any one of claims 11-17, wherein the phenazine-3-one or
phenothiazine-3-one derivative is administered orally, intranasally,
intrathecally, intraocularly, intradermally, transmucosally,
iontophoretically,
topically, systemically, intravenously, subcutaneously, intraperitoneally, or
intramuscularly.
19. The method of any one of claims 11-18, wherein the additional
therapeutic
agent is administered sequentially or simultaneously to the subject.

244

Note : Les descriptions sont présentées dans la langue officielle dans laquelle elles ont été soumises.

CA 02920272 2016-02-09
THERAPEUTIC COMPOSITIONS INCLUDING PHENAZINE-3-
ONE AND PHENOTHIAZINE-3-ONE DERIVATIVES AND USES
THEREOF TO TREAT AND PREVENT MITOCHONDRIAL
DISEASES AND CONDITIONS
TECHNICAL FIELD
[0001] Disclosed herein are methods and compositions related to the treatment
and/or amelioration of diseases and conditions comprising administration of
phenazine-3-one and/or phenothiazine-3-one derivatives, analogues, or
pharmaceutically acceptable salts thereof.
BACKGROUND
[0002] The following description is provided to assist the understanding of
the
reader. None of the information provided or references cited is admitted to be
prior
art to the present technology.
[0003] Mitochondria are sometimes described as cellular "power plants" because

among other things, mitochondria are responsible for creating more than 90% of
the
energy needed by the body to sustain life and support growth. Mitochondria are

organelles found in almost every cell in the body. In addition to making
energy,
mitochondria are also deeply involved in a variety of other activities, such
as making
steroid hormones and manufacturing the building blocks of DNA. Mitochondrial
failure causes cell injury that leads to cell death.
[0004] Mitochondrial diseases are nearly as common as childhood cancer.
Approximately one in 4,000 children born in the United States every year will
develop a mitochondrial disorder by age 10. In adults, many diseases of aging
have
been found to have defects of mitochondrial function. These include, but are
not
limited to, type 2 diabetes, Parkinson's disease, Alzheimer's disease, and
cancer. In
addition, select drugs can injure the mitochondria.
[0005] There are multiple forms of mitochondrial disease. Mitochondrial
disease
can manifest as a chronic, genetic disorder that occurs when the mitochondria
of the
cell fails to produce enough energy for cell or organ function. Indeed, for
many
patients, mitochondrial disease is an inherited condition that runs in
families (genetic).
1

CA 02920272 2016-02-09
Mitochondrial disease is inherited in a number of different ways. There is
autosomal
inheritance, mtDNA inheritance as well as a combination thereof. For example,
mutations of genes encoding Complex I ¨ Complex V can contribute to
mitochondrial
disease in humans. An uncertain percentage of patients acquire symptoms due to

other factors, including mitochondrial toxins.
[0006] Mitochondrial disease presents very differently from individual to
individual. There is presently no cure for mitochondrial-based disease.
Treatment is
generally palliative to improve disease symptoms.
SUMMARY
[0007] In one aspect, the present disclosure provides a method for treating or

preventing a mitochondrial disease or disorder in a subject in need thereof,
comprising administering to the subject a therapeutically effective amount of
a
phenazine-3-one or phenothiazine-3-one derivative or a pharmaceutically
acceptable
salt thereof. In some embodiments, the phenazine-3-one or phenothiazine-3-one
derivative is selected from:
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(6) (7) (8)
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(9) (10)
2

CA 02920272 2016-02-09
B/30 NY N
=-..õ,..
. '...,õõ
(11) (12) (13)
N= 0 N
14:3C S 0. S 0,
(
(14) 15)
FJC N.....,
0 Mc-IN
all N
sõloos
0. F 4C, N
010 -Ai
S 0.
(16) (17) (18)
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(19) (20)
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0 min NIPP--- s 0 0
(21) (22) (23)
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(
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=-=,,,,
Iill 1101 NI. II ' Si 0 W S 0 F S
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(26) (27) (28)
OCII,I OCII.3
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el =-.......
41 .
0 S 0 NicAti
(29) (30)
3

CA 02920272 2016-02-09
*
0
HO
(31)
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(32)
ocII3
0013, and
SO
(33)
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=(35)
F3C S 0
4

CA 02920272 2016-02-09
(36)
8 0,
; and
*(37)
!tele2N S 0..
[0008] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0009] In some embodiments of the method, the mitochondrial disease or
disorder is
selected from the group consisting of Alexander disease, Alpers Syndrome,
Alpha-
ketoglutarate dehydrogenase (AKDGH) deficiency, ALS-FTD, Sideroblastic anemia
with spinocerebellar ataxia, Pyridoxine-refractory sideroblastic anemia,
GRACILE
Syndrome, Bjornstad Syndrome, Leigh Syndrome, mitochondrial complex III
deficiency nuclear type 1 (MC3DN1), combined oxidative phosphorylation
deficiency
18 (COXPD18), Thiamine-responsive megaloblastic anemia syndrome (TRMA),
Pearson Syndrome, HAM Syndrome, Ataxia, Cataract, and Diabetes Syndrome,
MELAS/MERRF Overlap Syndrome, combined oxidative phosphorylation
deficiency-14 (COXPD14), Infantile cerebellar-retinal degeneration (ICRD),
Charlevoix-Saguenay spastic ataxia, Primary coenzyme Q10 deficiency-1
(C0Q10D1), ataxia oculomotor apraxia type 1 (A0A1), Autosomal recessive
spinocerebellar ataxia-9/ coenzyme Q10 deficiency-4 (C0Q10D4), Ataxia,
Pyramidal
Syndrome, and Cytochrome Oxidase Deficiency, Friedreich's ataxia, Infantile
onset
spinocerebellar ataxia (IOSCA)/ Mitochondrial DNA Depletion Syndrome-7,
leukoencephalopathy with brainstem and spinal cord involvement and lactate
elevation (LBSL), Autosomal recessive spastic ataxia-3 (SPAX3), MIRAS, SANDO,
mitochondrial spinocerebellar ataxia and epilepsy (MSCAE), spastic ataxia with
optic
atrophy (SPAX4), progressive external ophthalmoplegia with mitochondrial DNA
deletions autosomal dominant type 5 (PEOA5), mitochondrial complex III
deficiency
nuclear type 2 (MC3DN2), episodic encephalopathy due to thiamine
pyrophosphokinase deficiency/Thiamine Metabolism Dysfunction Syndrome-5
(THMD5), Spinocerebellar ataxia-28 (SCA28), autosomal dominant cerebellar
ataxia,

CA 02920272 2016-02-09
deafness, and narcolepsy (ADCA-DN), Dominant Optic Atrophy (DOA), cerebellar
ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss
(CAPOS)
Syndrome, spinocerebellar ataxia 7 (SCA7), Barth Syndrome, Biotinidase
deficiency,
gyrate atrophy, Syndromic Dominant Optic Atrophy and Deafness (Syndromic
DOAD), Dominant Optic Atrophy plus (D0Aplus), Leber's hereditary optic
neuropathy (LHON), Wolfram Syndrome-1 (WFS1), Wolfram Syndrome-2 (WFS2),
Age-related macular degeneration (ARMD), Brunner Syndrome, Left ventricular
noncompaction-1 (LVNC1), histiocytoid cardiomyopathy, Familial Myalgia
Syndrome, Parkinsonism, Fatal infantile cardioencephalomyopathy due to
cytochrome c oxidase (COX) deficiency-1 (CEMCOX1), Sengers Syndrome,
Cardiofaciocutaneous Syndrome-1 (CFC1), Mitochondrial trifunctional protein
(MTP) deficiency, infantile encephalocardiomyopathy with cytochrome c oxidase
deficiency, cardiomyopathy + encephalomyopathy, mitochondrial phosphate
carrier
deficiency, infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX)
deficiency (CEMCOX2), P-Hydroxyisobutyryl CoA Deacylase (HIBCH) deficiency,
ECHS1) deficiency, Maternal Inheritance Leigh Syndrome (MILS), dilated
cardiomyopathy with ataxia (DCMA), Mitochondrial DNA Depletion Syndrome-12
(MTDPS12), cardiomyopathy due to mitochondrial tRNA deficiencies,
mitochondrial
complex V (ATP synthase) deficiency nuclear type 1 (MC5DN1), combined
oxidative
phosphorylation deficiency-8 (COXPD8), progressive leukoencephalopathy with
ovarian failure (LKENP), combined oxidative phosphorylation deficiency-10
(COXPD10), combined oxidative phosphorylation deficiency-16 (COXPD16),
combined oxidative phosphorylation deficiency-17 (COXPD17), combined oxidative

phosphorylation deficiency-5 (COXPD5), combined oxidative phosphorylation
deficiency-9 (COXPD9), carnitine acetyltransferase (CRAT) deficiency,
carnitine
palmitoyltransferase I (CPT I) deficiency, myopathic carnitine deficiency,
primary
systemic carnitine deficiency (CDSP), carnitine palmitoyltransferase II (CPT
II)
deficiency, carnitine-acylcarnitine translocase deficiency (CACTD), cartilage-
hair
hypoplasia, cerebrotendinous xanthomatosis (CTX), congenital adrenal
hyperplasia
(CAH), megaconial type congenital muscular dystrophy, cerebral creatine
deficiency
syndrome-3 (CCDS3), maternal nonsyndromic deafness, maternal nonsyndromic
deafness, autosomal dominant deafness-64 (DFNA64), Mohr-Tranebjaerg Syndrome,
Jensen Syndrome, MEGDEL, reticular dysgenesis, primary coenzyme Q10
deficiency-6 (C0Q10D6), CAGSSS, diabetes, Dimethylglycine dehydrogenase
6

CA 02920272 2016-02-09
deficiency (DMGDHD), Multiple Mitochondrial Dysfunctions Syndrome-1
(MMDS1), Multiple Mitochondrial Dysfunctions Syndrome-2 (MMDS2), Multiple
Mitochondrial Dysfunctions Syndrome-3 (MMDS3), childhood leukoencephalopathy
associated with mitochondrial Complex II deficiency, encephalopathies
associated
with mitochondrial Complex I deficiency, encephalopathies associated with
mitochondrial Complex III deficiency, encephalopathies associated with
mitochondrial Complex IV deficiency, encephalopathies associated with
mitochondrial Complex V deficiency, hyperammonemia due to carbonic anhydrase
VA deficiency (CA5AD), early infantile epileptic encephalopathy-3 (EIEE3), 2,4-

Dienoyl-CoA reductase deficiency (DECRD), infection-induced acute
encephalopathy-3 (IIAE3), ethylmalonic encephalopathy (EE), hypomyelinating
leukodystrophy (HLD4), exocrine pancreatic insufficiency, dyserythropoietic
anemia
and calvarial hyperostosis, Glutaric aciduria type 1 (GA-1), glycine
encephalopathy
(GCE), hepatic failure, 2-hydroxyglutaric aciduria, 3-hydroxyacyl-CoA
dehydrogenase deficiency, familial hyperinsulinemic hypoglycemia (FHH),
hypercalcemia infantile, hyperornithinemia-hyperammonemia-homocitrullinuria
(HHH) Syndrome, Immunodeficiency with hyper-IgM type 5 (HIGM5), Inclusion
Body Myositis (IBM), polymyositis with mitochondrial pathology, IM-Mito,
granulomatous myopathies with anti-mitochondrial antibodies, necrotizing
myopathy
with pipestem capillaries, myopathy with deficient chondroitin sulfate C in
skeletal
muscle connective tissue, benign acute childhood myositis, idiopathic orbital
myositis, masticator myopathy, hemophagocytic lymphohistiocytosis, infection-
associated myositis, Facioscapulohumeral dystrophy (FSH), familial idiopathic
inflammatory myopathy, Schmidt Syndrome (Diabetes mellitus, Addison disease,
Myxedema), TNF receptor-associated Periodic Syndrome (TRAPS), focal myositis,
autoimmune fasciitis, Spanish toxic oil-associated fasciitis, Eosinophilic
fasciitis,
Macrophagic myofasciitis, Graft-vs-host disease fasciitis, Eosinophilia-
myalgia
Syndrome, perimyositis, isovaleric acidemia (IVA), Kearnes-Sayre Syndrome
(KSS),
2-oxoadipic aciduria, 2-aminoadipic aciduria, Limb-girdle Muscular Dystrophy
Syndromes, leukodystrophy, Maple syrup urine disease (MSUD), 3-Methylcrotonyl-
CoA carboxylase (MCC), Methylmalonic aciduria (MMA), Miller Syndrome,
Mitochondrial DNA Depletion Syndrome-2 (MTDPS2), spinal muscular atrophy
syndrome, rigid spine syndrome, severe myopathy with motor regression,
Mitochondrial DNA Depletion Syndrome-3, MELAS Syndrome, camptocormia,
7

CA 02920272 2016-02-09
MNGIE, MNGIM Syndrome, Menkes Disease, Occipital Horn Syndrome, X-linked
distal spinal muscular atrophy-3 (SMAX3), methemoglobinemia, MERRF,
progressive external ophthalmoplegia with myoclonus, deafness and diabetes
(DD),
multiple symmetric lipomatosis, Myopathy with Episodic high Creatine Kinase
(MIMECK), Epilepsia Partialis Continua, malignant hyperthermia syndromes,
glycogen metabolic disorders, fatty acid oxidation and lipid metabolism
disorders,
medication-, drug- or toxin-induced myoglobinuria, mitochondrial disorder-
associated
myoglobinuria, hypokalemic myopathy and rhabdomyolysis, muscle trauma-
associated myoglobinuria, ischemia-induced myoglobinuria, infection-induced
myoglobinuria, immune myopathies associated with myoglobinuria, Myopathy,
lactic
acidosis, and sideroblastic anemia (MLASA), infantile mitochondrial myopathy
due
to reversible COX deficiency (MMIT), Myopathy, Exercise intolerance,
Encephalopathy and Lactic acidemia Syndrome, myoglobinuria and exercise
intolerance syndrome, exercise intolerance, proximal weakness myoglobinuria
syndrome, encephalopathy and seizures syndrome, septo-optic dysplasia,
exercise
intolerance mild weakness, myopathy exercise intolerance, growth or CNS
disorder, maternally-inherited mitochondrial myopathies, myopathy with lactic
acidosis, myopathy with rhabdomyolysis, Myopathy with cataract and combined
respiratory chain deficiency, myopathy with abnormal mitochondrial
translation,
Fatigue Syndrome, myopathy with extrapyramidal movement disorders (MPXPS),
glutaric aciduria II (MADD), primary CoQ10 deficiency-1 (C0Q10D1), primary
C0Q10 deficiency-2 (C0Q10D2), primary CoQ10 deficiency-3 (C0Q10D3), primary
CoQ10 deficiency-5 (C0Q10D5), secondary C0Q10 deficiency, autosomal dominant
mitochondrial myopathy, myopathy with focal depletion of mitochondria,
mitochondrial DNA breakage syndrome (PEO + Myopathy), lipid type mitochondrial

myopathy, multiple symmetric lipomatosis (MSL), N-acetylglutamate synthase
(NAGS) deficiency, Nephronophthisis (NPHP), ornithine transcarbamylase (OTC)
deficiency, neoplasms, NARP Syndrome, paroxysmal nonkinesigenic dyskinesia
(PNKD), sporadic PEO, maternally-inherited PEO, autosomal dominant progressive

external ophthalmoplegia with mitochondrial DNA deletions-3 (PEOA3), autosomal

dominant progressive external ophthalmoplegia with mitochondrial DNA deletions-
2
(PEOA2), autosomal dominant progressive external ophthalmoplegia with
mitochondrial DNA deletions-1 (PEOA1), PEO+ demyelinating neuropathy, PEO +
hypogonadism, autosomal dominant progressive external ophthalmoplegia with
8

CA 02920272 2016-02-09
mitochondrial DNA deletions-4 (PEOA4), distal myopathy, cachexia & PEO,
autosomal dominant progressive external ophthalmoplegia-6 (PEOA6), PEO +
Myopathy and Parkinsonism, autosomal recessive progressive external
ophthalmoplegia (PEOB), Mitochondrial DNA Depletion Syndrome-11 (MTDPS11),
PEO with cardiomyopathy, PEPCK deficiency, Perrault Syndromes (PRLTS),
propionic acidemia (PA), pyruvate carboxylase deficiency, pyruvate
dehydrogenase
El-alpha deficiency (PDHAD), pyruvate dehydrogenase El-beta deficiency
(PDHBD), dihydrolipoamide dehydrogenase (DLD) deficiency, pyruvate
dehydrogenase phosphatase deficiency, pyruvate dehydrogenase E3-binding
protein
deficiency (PDHXD), mitochondrial pyruvate carrier deficiency (MPYCD),
Schwartz-Jampel Syndrome type 1 (SJS1), selenium deficiency, short-chain acyl-
CoA
dehydrogenase (SCAD) deficiency, succinyl CoA:3-oxacid CoA transferase (SCOT)
deficiency, Stuve-Wiedemann Syndrome (STWS), thrombocytopenia (THC), Very
long-chain acyl-CoA dehydrogenase deficiency (VLCADD), Vitamin D-dependent
rickets type lA (VDDR1A), Wilson's disease, Zellweger Syndrome (PBD3A),
arsenic trioxide myopathy, myopathy and neuropathy resulting from nucleoside
analogues, germanium myopathy, Parkinsonism and mitochondrial Complex I
neurotoxicity due to trichloroethylene, valproate-induced hepatic failure,
neurodegeneration with brain iron accumulation-4 (NBIA4), Complex I
deficiency,
Complex II deficiency, Complex III deficiency, Complex IV deficiency, Complex
V
deficiency, Cytochrome c oxidase (COX) deficiency, combined complex I, II, IV,
V
deficiency, combined complex I, II, and III deficiency, combined oxidative
phosphorylation deficiency-1 (COXPD1), combined oxidative phosphorylation
deficiency-2 (COXPD2), combined oxidative phosphorylation deficiency-3
(COXPD3), combined oxidative phosphorylation deficiency-4 (COXPD4), combined
oxidative phosphorylation deficiency-6 (COXPD6), combined oxidative
phosphorylation deficiency-7 (COXPD7), combined oxidative phosphorylation
deficiency-9 (COXPD9), combined oxidative phosphorylation deficiency-11
(COXPD11), combined oxidative phosphorylation deficiency-12 (COXPD12),
combined oxidative phosphorylation deficiency-13 (COXPD13), combined oxidative

phosphorylation deficiency-15 (COXPD15), combined oxidative phosphorylation
deficiency-16 (COXPD16), combined oxidative phosphorylation deficiency-19
(COXPD19), combined oxidative phosphorylation deficiency-20 (COXPD20),
combined oxidative phosphorylation deficiency-21 (COXPD21), fumarase
deficiency,
9

CA 02920272 2016-02-09
HMG-CoA synthase-2 deficiency, hyperuricemia, pulmonary hypertension, renal
failure, and alkalosis (HUPRA) Syndrome, syndromic microphthalmia-7,
pontocerebellar hypoplasia type 6 (PCH6), Mitochondrial DNA Depletion Syndrome-

9 (MTDPS9P), and Sudden infant death Syndrome (SIDS).
[0010] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
one,
two, three, four, or five times per day. In some embodiments of the method,
the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
more
than five times per day.
[0011] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
every
day, every other day, every third day, every fourth day, every fifth day, or
every sixth
day. In some embodiments of the method, the phenazine-3-one or phenothiazine-3-

one derivative composition is administered weekly, bi-weekly, tri-weekly, or
monthly.
[0012] In some embodiments, the phenazine-3-one or phenothiazine-3-one
derivative composition is administered for a period of one, two, three, four,
or five
weeks. In some embodiments, the phenazine-3-one or phenothiazine-3-one
derivative
is administered for six weeks or more. In some embodiments, the phenazine-3-
one or
phenothiazine-3-one derivative is administered for twelve weeks or more. In
some
embodiments, the phenazine-3-one or phenothiazine-3-one derivative is
administered
for a period of less than one year. In some embodiments, the phenazine-3-one
or
phenothiazine-3-one derivative is administered for a period of more than one
year.
[0013] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative is administered daily for
one, two,
three, four or five weeks. In some embodiments of the method, the phenazine-3-
one
or phenothiazine-3-one derivative is administered daily for less than 6 weeks.
In
some embodiments of the method, the phenazine-3-one or phenothiazine-3-one
derivative is administered daily for 6 weeks or more. In other embodiments of
the
method, the phenazine-3-one or phenothiazine-3-one derivative is administered
daily
for 12 weeks or more.

CA 02920272 2016-02-09
[0014] In some embodiments of the method, the subject displays abnormal levels
of
one or more energy biomarkers compared to a normal control subject. In some
embodiments, the energy biomarker is selected from the group consisting of
lactic
acid (lactate) levels; pyruvic acid (pyruvate) levels; lactate/pyruvate
ratios; total,
reduced or oxidized glutathione levels; reduced/oxidized glutathione ratios;
total,
reduced or oxidized cysteine levels; reduced/oxidized cysteine ratios;
phosphocreatine
levels; NADH (NADH+H30) or NADPH (NADPH+H30 ) levels; NAD or NADP
levels; ATP levels; reduced coenzyme Q (CoQred) levels; oxidized coenzyme Q
(CoQox) levels; total coenzyme Q (CoQtot) levels; oxidized cytochrome C
levels;
reduced cytochrome C levels; oxidized cytochrome C/reduced cytochrome C ratio;

acetoacetate levels; beta-hydroxy butyrate levels; acetoacetate/ beta-hydroxy
butyrate
ratio; 8-hydroxy-2'-deoxyguanosine (8-0HdG) levels; levels of reactive oxygen
species; oxygen consumption (V02), carbon dioxide output (VCO2), and
respiratory
quotient (VCO2NO2). In some embodiments of the method, the lactate levels of
one
or more of whole blood, plasma, cerebrospinal fluid, or cerebral ventricular
fluid are
abnormal compared to a normal control subject. In some embodiments of the
method,
the pyruvate levels of one or more of whole blood, plasma, cerebrospinal
fluid, or
cerebral ventricular fluid are abnormal compared to a normal control subject.
In some
embodiments of the method, the lactate/pyruvate ratios of one or more of whole

blood, plasma, cerebrospinal fluid, or cerebral ventricular fluid are abnormal

compared to a normal control subject. In some embodiments of the method, the
total,
reduced or oxidized glutathione levels of one or more of whole blood, plasma,
lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid are abnormal
compared
to a normal control subject. In some embodiments of the method, the total,
reduced or
oxidized cysteine levels of one or more of whole blood, plasma, lymphocytes,
cerebrospinal fluid, or cerebral ventricular fluid are abnormal compared to a
normal
control subject. In some embodiments of the method, the reduced/oxidized
glutathione ratios of one or more of whole blood, plasma, lymphocytes,
cerebrospinal
fluid, or cerebral ventricular fluid are abnormal compared to a normal control
subject.
In some embodiments of the method, the reduced or oxidized cysteine ratios of
one or
more of whole blood, plasma, lymphocytes, cerebrospinal fluid, or cerebral
ventricular fluid are abnormal compared to a normal control subject.
11

CA 02920272 2016-02-09
[0015] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative is administered orally,
intranasally, intrathecally, intraocularly, intradermally, transmucosally,
iontophoretically, topically, systemically, intravenously, subcutaneously,
intraperitoneally, or intramuscularly. In some embodiments of the method, the
subject is human.
[0016] Additionally or alternatively, in some embodiments of the method, the
symptoms of the mitochondrial disease or disorder comprises one or more of
poor
growth, loss of muscle coordination, muscle weakness, neurological deficit,
seizures,
autism, autistic spectrum, autistic-like features, learning disabilities,
heart disease,
liver disease, kidney disease, gastrointestinal disorders, severe
constipation, diabetes,
increased risk of infection, thyroid dysfunction, adrenal dysfunction,
autonomic
dysfunction, confusion, disorientation, memory loss, failure to thrive, poor
coordination, sensory (vision, hearing) problems, reduced mental functions,
hypotonia, disease of the organ, dementia, respiratory problems, hypoglycemia,

apnea, lactic acidosis, seizures, swallowing difficulties, developmental
delays,
movement disorders (dystonia, muscle spasms, tremors, chorea), stroke, and
brain
atrophy.
[0017] Additionally or alternatively, in some embodiments, the method further
comprises separately, sequentially or simultaneously administering an
additional
therapeutic agent to the subject. In certain embodiments, the additional
therapeutic
agent is selected from the group consisting of: vitamins, cofactors,
antibiotics,
hormones, antineoplastic agents, steroids, immunomodulators, dermatologic
drugs,
antithrombotic, antianemic, and cardiovascular agents.
[0018] In another aspect, the present disclosure provides a method for
modulating
the expression of one or more energy biomarkers in a mammalian subject in need

thereof, the method comprising: administering to the subject a therapeutically

effective amount of a phenazine-3-one or phenothiazine-3-one derivative or a
pharmaceutically acceptable salt thereof.
[0019] In some embodiments of the method, the energy biomarker is selected
from
the group consisting of lactic acid (lactate) levels; pyruvic acid (pyruvate)
levels;
12

CA 02920272 2016-02-09
lactate/pyruvate ratios; total, reduced or oxidized glutathione levels;
reduced/oxidized
glutathione ratios; total, reduced or oxidized cysteine levels;
reduced/oxidized
cysteine ratios; phosphocreatine levels; NADH (NADH+H30) or NADPH
(NADPH+H30 ) levels; NAD or NADP levels; ATP levels; reduced coenzyme Q
(CoQred) levels; oxidized coenzyme Q (CoQox) levels; total coenzyme Q (CoQtot)

levels; oxidized cytochrome C levels; reduced cytochrome C levels; oxidized
cytochrome C/reduced cytochrome C ratio; acetoacetate levels; beta-hydroxy
butyrate
levels; acetoacetate/ beta-hydroxy butyrate ratio; 8-hydroxy-2'-deoxyguanosine
(8-
OHdG) levels; levels of reactive oxygen species; oxygen consumption (V02),
carbon
dioxide output (VCO2), and respiratory quotient (VCO2NO2). In some
embodiments of the method, the lactate levels of one or more of whole blood,
plasma,
cerebrospinal fluid, or cerebral ventricular fluid are abnormal compared to a
normal
control subject. In some embodiments of the method, the pyruvate levels of one
or
more of whole blood, plasma, cerebrospinal fluid, or cerebral ventricular
fluid are
abnormal compared to a normal control subject. In some embodiments of the
method,
the lactate/pyruvate ratios of one or more of whole blood, plasma,
cerebrospinal fluid,
or cerebral ventricular fluid are abnormal compared to a normal control
subject. In
some embodiments of the method, the total, reduced or oxidized glutathione
levels of
one or more of whole blood, plasma, lymphocytes, cerebrospinal fluid, or
cerebral
ventricular fluid are abnormal compared to a normal control subject. In some
embodiments of the method, the total, reduced or oxidized cysteine levels of
one or
more of whole blood, plasma, lymphocytes, cerebrospinal fluid, or cerebral
ventricular fluid are abnormal compared to a normal control subject. In some
embodiments of the method, the reduced/oxidized glutathione ratios of one or
more of
whole blood, plasma, lymphocytes, cerebrospinal fluid, or cerebral ventricular
fluid
are abnormal compared to a normal control subject. In some embodiments of the
method, the reduced or oxidized cysteine ratios of one or more of whole blood,

plasma, lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid are
abnormal
compared to a normal control subject.
[0020] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
one,
two, three, four, or five times per day. In some embodiments of the method,
the
13

CA 02920272 2016-02-09
phenazine-3-one or phenothiazine-3-one derivative composition is administered
more
than five times per day.
[0021] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
every
day, every other day, every third day, every fourth day, every fifth day, or
every sixth
day. In some embodiments of the method, the phenazine-3-one or phenothiazine-3-

one derivative composition is administered weekly, bi-weekly, tri-weekly, or
monthly.
[0022] In some embodiments, the phenazine-3-one or phenothiazine-3-one
derivative composition is administered for a period of one, two, three, four,
or five
weeks. In some embodiments, the phenazine-3-one or phenothiazine-3-one
derivative
is administered for six weeks or more. In some embodiments, the phenazine-3-
one or
phenothiazine-3-one derivative is administered for twelve weeks or more. In
some
embodiments, the phenazine-3-one or phenothiazine-3-one derivative is
administered
for a period of less than one year. In some embodiments, the phenazine-3-one
or
phenothiazine-3-one derivative is administered for a period of more than one
year.
[0023] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative is administered daily for
one, two,
three, four or five weeks. In some embodiments of the method, the phenazine-3-
one
or phenothiazine-3-one derivative is administered daily for less than 6 weeks.
In
some embodiments of the method, the phenazine-3-one or phenothiazine-3-one
derivative is administered daily for 6 weeks or more. In other embodiments of
the
method, the phenazine-3-one or phenothiazine-3-one derivative is administered
daily
for 12 weeks or more.
[0024] In some embodiments of the method, the subject has been diagnosed as
having, is suspected of having, or is at risk of having a mitochondrial
disease or
disorder. In a further embodiment of the method, the subject is human.
[0025] In some embodiments of the method, the symptoms of the mitochondrial
disease or disorder comprises one or more of poor growth, loss of muscle
coordination, muscle weakness, neurological deficit, seizures, autism,
autistic
spectrum, autistic-like features, learning disabilities, heart disease, liver
disease,
14

CA 02920272 2016-02-09
kidney disease, gastrointestinal disorders, severe constipation, diabetes,
increased risk
of infection, thyroid dysfunction, adrenal dysfunction, autonomic dysfunction,

confusion, disorientation, memory loss, failure to thrive, poor coordination,
sensory
(vision, hearing) problems, reduced mental functions, hypotonia, disease of
the organ,
dementia, respiratory problems, hypoglycemia, apnea, lactic acidosis,
seizures,
swallowing difficulties, developmental delays, movement disorders (dystonia,
muscle
spasms, tremors, chorea), stroke, and brain atrophy.
[0026] In some embodiments of the method, the phenazine-3-one or phenothiazine-

3-one derivative is administered orally, intranasally, intrathecally,
intraocularly,
intradermally, transmucosally, iontophoretically, topically, systemically,
intravenously, subcutaneously, intraperitoneally, or intramuscularly.
[0027] Additionally or alternatively, in some embodiments, the method further
comprises separately, sequentially or simultaneously administering an
additional
therapeutic agent to the subject. In certain embodiments of the method, the
additional
therapeutic agent is selected from the group consisting of: vitamins,
cofactors,
antibiotics, hormones, antineoplastic agents, steroids, immunomodulators,
dermatologic drugs, antithrombotic, antianemic, and cardiovascular agents.
[0028] In another aspect, the present technology provides methods for
treating,
ameliorating or preventing the disruption of mitochondrial oxidative
phosphorylation
in a subject in need thereof, by administering phenazine-3-one and/or
phenothiazine-
3-one derivatives as disclosed herein, the method comprising administering to
the
subject a therapeutically effective amount of a phenazine-3-one or
phenothiazine-3-
one derivative or a pharmaceutically acceptable salt thereof, thereby
preventing,
ameliorating, or treating mitochondrial oxidative phosphorylation, and/or
signs or
symptoms thereof. In one embodiment, the method further comprises the step
administering one or more additional therapeutic agents to the subject.
[0029] In some embodiments of the method, the subject is suffering from or is
at
increased risk of a disruption of mitochondrial oxidative phosphorylation. In
some
embodiments, the subject is suffering from or is at increased risk of a
disease or
conditions characterized by a genetic mutation which affects mitochondrial
function.

CA 02920272 2016-02-09
BRIEF DESCRIPTION OF THE DRAWINGS
[0030] Figure 1 shows the effect that various dysfunctions can have on energy
biomarkers as well as biochemical events that occur within the body. It also
indicates
the physical effect (such as a disease symptom or other effect of the
dysfunction)
typically associated with a given dysfunction. It should be noted that any of
the
energy biomarkers listed in the table, in addition to energy biomarkers
enumerated
elsewhere, can also be modulated, enhanced, or normalized by the phenazine-3-
one
and phenothiazine-3-one derivatives of the present technology. RQ=respiratory
quotient; BMR=basal metabolic rate; HR (C0)=heart rate (cardiac output);
T=body
temperature (preferably measured as core temperature); AT=anaerobic threshold;

pH=blood pH (venous and/or arterial).
DETAILED DESCRIPTION
[0031] It is to be appreciated that certain aspects, modes, embodiments,
variations
and features of the present technology are described below in various levels
of detail
in order to provide a substantial understanding of the present technology. The

definitions of certain terms as used in this specification are provided below.
Unless
defined otherwise, all technical and scientific terms used herein generally
have the
same meaning as commonly understood by one of ordinary skill in the art to
which
the present technology belongs.
[0032] All numerical designations, e.g., pH, temperature, time, concentration
and
molecular weight, including ranges, are approximations which are varied (+) or
(-) by
increments of 1.0 or 0.1, as appropriate, or alternatively by a variation of
+/- 10%, or
alternatively 5% or alternatively 2%. It is to be understood, although not
always
explicitly stated, that all numerical designations are preceded by the term
"about".
[0033] As used in this specification and the appended claims, the singular
forms
"a", "an" and "the" include plural referents unless the content clearly
dictates
otherwise. For example, reference to "a cell" includes a combination of two or
more
cells, and the like.
[0034] As used herein, the term "about" encompasses the range of experimental
error that may occur in a measurement and will be clear to the skilled
artisan.
Reference to "about" a value or parameter herein includes (and describes)
variations
16

CA 02920272 2016-02-09
that are directed to that value or parameter per se. For example, a
description
referring to "about X" includes description of "X".
[0035] As used herein, the "administration" of an agent, drug, or compound to
a
subject includes any route of introducing or delivering to a subject a
compound to
perform its intended function. Administration can be carried out by any
suitable
route, including orally, intranasally, intrathecally, parenterally
(intravenously,
intramuscularly, intraperitoneally, or subcutaneously), intraocularly,
intradermally,
transmucosally, iontophoretically, or topically. Administration includes self-
administration and the administration by another.
[0036] As used herein, the term "amino acid" includes naturally-occurring
amino
acids and synthetic amino acids, as well as amino acid analogs and amino acid
mimetics that function in a manner similar to the naturally-occurring amino
acids.
Naturally-occurring amino acids are those encoded by the genetic code, as well
as
those amino acids that are later modified, e.g., hydroxyproline, y-
carboxyglutamate,
and 0-phosphoserine. Amino acid analogs refers to compounds that have the same

basic chemical structure as a naturally-occurring amino acid, i.e., an a-
carbon that is
bound to a hydrogen, a carboxyl group, an amino group, and an R group, e.g.,
homoserine, norleucine, methionine sulfoxide, methionine methyl sulfonium.
Such
analogs have modified R groups (e.g., norleucine) or modified peptide
backbones, but
retain the same basic chemical structure as a naturally-occurring amino acid.
Amino
acid mimetics refers to chemical compounds that have a structure that is
different
from the general chemical structure of an amino acid, but that functions in a
manner
similar to a naturally-occurring amino acid. Amino acids can be referred to
herein by
either their commonly known three letter symbols or by the one-letter symbols
recommended by the IUPAC-IUB Biochemical Nomenclature Commission.
[0037] The term "aryl" is intended to embrace an aromatic cyclic hydrocarbon
group of from 6 to 10 carbon atoms having a single ring (e.g., phenyl) or
multiple
condensed (fused) rings (e.g., naphthyl).
[0038] "(C1-C4) alkyl" is intended to embrace a saturated linear, branched, or
cyclic
hydrocarbon, or any combination thereof, of 1 to 4 carbon atoms. Non-limiting
examples of "(Ci-C4) alkyl" include methyl, ethyl, n-propyl, isopropyl,
cyclopropyl,
17

CA 02920272 2016-02-09
n-butyl, isobutyl, sec-butyl, t-butyl, cyclobutyl, cyclopropyl-methyl, and
methyl-
cyclopropyl. The point of attachment of the (C i-C4) alkyl group to the
remainder of
the molecule can be at any chemically possible location on the (C1-C4) alkyl
group.
[0039] "(Ci-C12) alkyl" is intended to embrace a saturated linear, branched,
or cyclic
hydrocarbon, or any combination thereof, of 1 to 12 carbon atoms. Non-limiting

examples of "(Ci-C12) alkyl" include methyl, ethyl, n-propyl, isopropyl,
cyclopropyl,
n-butyl, isobutyl, sec-butyl, t-butyl, cyclobutyl, cyclopropyl-methyl, methyl-
cyclopropyl, pentyl, cyclopentyl, hexyl, cyclohexyl, heptyl, octyl, nonyl,
decyl,
undecyl, and dodecyl. The point of attachment of the (Ci-C12) alkyl group to
the
remainder of the molecule can be at any chemically possible location on the
(Ci-C12)
alkyl group.
[0040] "(C2-Ci2)-alkenyl" is intended to embrace an unsaturated linear,
branched, or
cyclic group, or any combination thereof, having 2 to 12 carbon atoms. All
double
bonds may be independently either (E) or (Z) geometry, as well as arbitrary
mixtures
thereof. Examples of alkenyl groups include, but are not limited to ¨CH2-
CH=CH¨
CH3; and ¨CH2-CH2-cyclohexenyl, where the ethyl group can be attached to the
cyclohexenyl moiety at any available carbon valence.
[0041] "(C2-Ci2)-alkynyl" is intended to embrace an unsaturated linear,
branched, or
cyclic group, or any combination thereof, having 2 to 12 carbon atoms, which
contain
at least one triple bond.
[0042] "(Ci-C4) haloalkyl" is intended to embrace any CI-Ca alkyl substituent
having at least one halogen substituent; the halogen can be attached via any
valence
on the C1-C4 alkyl group. Some examples of Ci-C4 haloalkyl are ¨CF3, ¨CC13, ¨
CHF2, ¨CHC12, ¨CHBr2, ¨CH2F, ¨CH2C1, or ¨CF2CF3.
[0043] "(Ci-C12) haloalkyl" is intended to embrace any Cl-C12 alkyl
substituent
having at least one halogen substituent; the halogen can be attached via any
valence
on the C1-C12 alkyl group. Some examples of C 1-C 12 haloalkyl are ¨CF3,
¨CC13, ¨
CHF2, ¨CHC12, ¨CHBr2, ¨CH2F, ¨CH2C1, or ¨CF2CF3.
[0044] As used herein, a "control" is an alternative sample used in an
experiment for
comparison purpose. A control can be "positive" or "negative." For example,
where
18

CA 02920272 2016-02-09
the purpose of the experiment is to determine a correlation of the efficacy of
a
therapeutic agent for the treatment for a particular type of disease, a
positive control
(a compound or composition known to exhibit the desired therapeutic effect)
and a
negative control (a subject or a sample that does not receive the therapy or
receives a
placebo) are typically employed.
[0045] As used herein, the term "effective amount" refers to a quantity
sufficient to
achieve a desired therapeutic and/or prophylactic effect, e.g., an amount
which results
in the prevention of, or amelioration of a disease or medical condition
described
herein or one or more symptoms associated with a disease or medical condition
described herein. In the context of therapeutic or prophylactic applications,
the
amount of a composition administered to the subject will depend on the type
and
severity of the disease and on the characteristics of the individual, such as
general
health, age, sex, body weight and tolerance to drugs. It will also depend on
the
degree, severity and type of disease. The skilled artisan will be able to
determine
appropriate dosages depending on these and other factors. The compositions can
also
be administered in combination with one or more additional therapeutic
compounds.
In some embodiments, an effective amount of a compound is an amount of the
compound sufficient to modulate, normalize, or enhance one or more energy
biomarkers (where modulation, normalization, and enhancement are defined
herein).
In the methods described herein, the compositions of the present technology
may be
administered to a subject having one or more signs or symptoms of a disease or

medical condition described herein. For example, a "therapeutically effective
amount" of the phenazine-3-one and/or phenothiazine-3-one derivatives is meant

levels at which the physiological effects of a particular disease or medical
condition
are, at a minimum, ameliorated. A therapeutically effective amount can be
given in
one or more administrations. By way of example only, in some embodiments, the
disease or medical condition is a mitochondrial disease or disorder. In some
embodiments, signs, symptoms or complications of a mitochondrial disease or
disorder include, but are not limited to: poor growth, loss of muscle
coordination,
muscle weakness, neurological deficit, seizures, autism, autistic spectrum,
autistic-
like features, learning disabilities, heart disease, liver disease, kidney
disease,
gastrointestinal disorders, severe constipation, diabetes, increased risk of
infection,
thyroid dysfunction, adrenal dysfunction, autonomic dysfunction, confusion,
19

CA 02920272 2016-02-09
disorientation, memory loss, failure to thrive, poor coordination, sensory
(vision,
hearing) problems, reduced mental functions, hypotonia, disease of the organ,
dementia, respiratory problems, hypoglycemia, apnea, lactic acidosis,
seizures,
swallowing difficulties, developmental delays, movement disorders (dystonia,
muscle
spasms, tremors, chorea), stroke, brain atrophy, or any other sign or symptom
of a
mitochondrial disease state disclosed herein. In other embodiments of the
method, the
disease or medical condition is selected from the group consisting of
vitiligo,
porphyria, Alport Syndrome, and IPF.
[0046] As used herein, the terms "enhancement" of, or to "enhance," energy
biomarkers means to improve the level of one or more energy biomarkers in a
direction that results in a beneficial or desired physiological outcome in a
subject
(compared to the values observed in a normal control subject, or the value in
the
subject prior to treatment with a composition or compound). For example, in a
situation where significant energy demands are placed on a subject, it may be
desirable to increase the level of ATP in that subject to a level above the
ATP level
observed in a normal control subject. Enhancement can also be of beneficial
effect in
a subject suffering from a disease or pathology such as a mitochondrial
disease, in
that normalizing an energy biomarker may not achieve the optimum outcome for
the
subject; in such cases, enhancement of one or more energy biomarkers can be
beneficial, for example, higher-than-normal levels of ATP, or lower-than
normal
levels of lactic acid (lactate) can be beneficial to such a subject.
[0047] As used herein, "expression" refers to the process by which
polynucleotides
are transcribed into mRNA and/or the process by which the transcribed mRNA is
subsequently being translated into peptides, polypeptides, or proteins. If the

polynucleotide is derived from genomic DNA, expression may include splicing of
the
mRNA in an eukaryotic cell. The expression level of a gene may be determined
by
measuring the amount of mRNA or protein in a cell or tissue sample. In one
aspect,
the expression level of a gene from one sample may be directly compared to the

expression level of that gene from a control or reference sample. In another
aspect,
the expression level of a gene from one sample may be directly compared to the

expression level of that gene from the same sample following administration of
a
phenazine-3-one or phenothiazine-3-one derivative.

CA 02920272 2016-02-09
[0048] "Halogen" or "halo" designates fluoro, chloro, bromo, and iodo.
[0049] The term "isomers" or "stereoisomers" relates to compounds that have
identical molecular formulae but that differ in the arrangement of their atoms
in space.
Stereoisomers that are not mirror images of one another are termed
"diastereoisomers"
and stereoisomers that are non-superimposable mirror images are termed
"enantiomers", or sometimes optical isomers. A carbon atom bonded to four non-
identical substituents is termed a "chiral center". Certain compounds of the
present
technology have one or more chiral centers and therefore may exist as either
individual stereoisomers or as a mixture of stereoisomers. The present
technology
includes all possible stereoisomers as individual stereoisomers or as a
mixture of
stereoisomers.
[0050] As used herein, the term "mitochondrial disease or disorder" refers to
any
disease or disorder that results from the perturbation of any
biological/physiological
process in the mitochondria. Non-limiting examples of mitochondrial disease
include
but are not limited to Alexander disease, Alpers Syndrome, Alpha-ketoglutarate

dehydrogenase (AKDGH) deficiency, ALS-FTD, Sideroblastic anemia with
spinocerebellar ataxia, Pyridoxine-refractory sideroblastic anemia, GRACILE
Syndrome, Bjornstad Syndrome, Leigh Syndrome, mitochondrial complex III
deficiency nuclear type 1 (MC3DN1), combined oxidative phosphorylation
deficiency
18 (COXPD18), Thiamine-responsive megaloblastic anemia syndrome (TRMA),
Pearson Syndrome, HAM Syndrome, Ataxia, Cataract, and Diabetes Syndrome,
MELAS/MERRF Overlap Syndrome, combined oxidative phosphorylation
deficiency-14 (COXPD14), Infantile cerebellar-retinal degeneration (ICRD),
Charlevoix-Saguenay spastic ataxia, Primary coenzyme Q10 deficiency-1
(C0Q10D1), ataxia oculomotor apraxia type 1 (A0A1), Autosomal recessive
spinocerebellar ataxia-9/ coenzyme Q10 deficiency-4 (C0Q10D4), Ataxia,
Pyramidal
Syndrome, and Cytochrome Oxidase Deficiency, Friedreich's ataxia, Infantile
onset
spinocerebellar ataxia (IOSCA)/ Mitochondrial DNA Depletion Syndrome-7,
Leukoencephalopathy with brainstem and spinal cord involvement and lactate
elevation (LBSL), Autosomal recessive spastic ataxia-3 (SPAX3), MIRAS, SANDO,
mitochondrial spinocerebellar ataxia and epilepsy (MSCAE), spastic ataxia with
optic
atrophy (SPAX4), progressive external ophthalmoplegia with mitochondrial DNA
21

CA 02920272 2016-02-09
deletions autosomal dominant type 5 (PEOA5), mitochondrial complex III
deficiency
nuclear type 2 (MC3DN2), episodic encephalopathy due to thiamine
pyrophosphokinase deficiency/Thiamine Metabolism Dysfunction Syndrome-5
(THMD5), Spinocerebellar ataxia-28 (SCA28), autosomal dominant cerebellar
ataxia,
deafness, and narcolepsy (ADCA-DN), Dominant Optic Atrophy (DOA), cerebellar
ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss
(CAPOS)
Syndrome, spinocerebellar ataxia 7 (SCA7), Barth Syndrome, Biotinidase
deficiency,
gyrate atrophy, Syndromic Dominant Optic Atrophy and Deafness (Syndromic
DOAD), Dominant Optic Atrophy plus (D0Aplus), Leber's hereditary optic
neuropathy (LHON), Wolfram Syndrome-1 (WFS1), Wolfram Syndrome-2 (WFS2),
Age-related macular degeneration (ARMD), Brunner Syndrome, Left ventricular
noncompaction-1 (LVNC1), histiocytoid cardiomyopathy, Familial Myalgia
Syndrome, Parkinsonism, Fatal infantile cardioencephalomyopathy due to
cytochrome c oxidase (COX) deficiency-1 (CEMCOX1), Sengers Syndrome,
Cardiofaciocutaneous Syndrome-1 (CFC1), Mitochondrial trifunctional protein
(MTP) deficiency, infantile encephalocardiomyopathy with cytochrome c oxidase
deficiency, cardiomyopathy + encephalomyopathy, mitochondrial phosphate
carrier
deficiency, infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX)
deficiency (CEMCOX2), P-Hydroxyisobutyryl CoA Deacylase (HIBCH) deficiency,
ECHS1) deficiency, Maternal Inheritance Leigh Syndrome (MILS), dilated
cardiomyopathy with ataxia (DCMA), Mitochondrial DNA Depletion Syndrome-12
(MTDPS12), cardiomyopathy due to mitochondrial tRNA deficiencies,
mitochondrial
complex V (ATP synthase) deficiency nuclear type 1 (MC5DN1), combined
oxidative
phosphorylation deficiency-8 (COXPD8), progressive leukoencephalopathy with
ovarian failure (LKENP), combined oxidative phosphorylation deficiency-10
(COXPD10), combined oxidative phosphorylation deficiency-16 (COXPD16),
combined oxidative phosphorylation deficiency-17 (COXPD17), combined oxidative

phosphorylation deficiency-5 (COXPD5), combined oxidative phosphorylation
deficiency-9 (COXPD9), carnitine acetyltransferase (CRAT) deficiency,
carnitine
palmitoyltransferase I (CPT I) deficiency, myopathic carnitine deficiency,
primary
systemic carnitine deficiency (CDSP), carnitine palmitoyltransferase II (CPT
II)
deficiency, carnitine-acylcarnitine translocase deficiency (CACTD), cartilage-
hair
hypoplasia, cerebrotendinous xanthomatosis (CTX), congenital adrenal
hyperplasia
(CAH), megaconial type congenital muscular dystrophy, cerebral creatine
deficiency
22

CA 02920272 2016-02-09
syndrome-3 (CCDS3), maternal nonsyndromic deafness, maternal nonsyndromic
deafness, autosomal dominant deafness-64 (DFNA64), Mohr-Tranebjaerg Syndrome,
Jensen Syndrome, MEGDEL, reticular dysgenesis, primary coenzyme Q10
deficiency-6 (C0Q10D6), CAGS SS, diabetes, Dimethylglycine dehydrogenase
deficiency (DMGDHD), Multiple Mitochondrial Dysfunctions Syndrome-1
(MMDS1), Multiple Mitochondrial Dysfunctions Syndrome-2 (MMDS2), Multiple
Mitochondrial Dysfunctions Syndrome-3 (MMDS3), childhood leukoencephalopathy
associated with mitochondrial Complex II deficiency, encephalopathies
associated
with mitochondrial Complex I deficiency, encephalopathies associated with
mitochondrial Complex III deficiency, encephalopathies associated with
mitochondrial Complex IV deficiency, encephalopathies associated with
mitochondrial Complex V deficiency, hyperammonemia due to carbonic anhydrase
VA deficiency (CA5AD), early infantile epileptic encephalopathy-3 (EIEE3), 2,4-

Dienoyl-CoA reductase deficiency (DECRD), infection-induced acute
encephalopathy-3 (IIAE3), ethylmalonic encephalopathy (EE), hypomyelinating
leukodystrophy (HLD4), exocrine pancreatic insufficiency, dyserythropoietic
anemia
and calvarial hyperostosis, Glutaric aciduria type 1 (GA-1), glycine
encephalopathy
(GCE), hepatic failure, 2-hydroxyglutaric aciduria, 3-hydroxyacyl-CoA
dehydrogenase deficiency, familial hyperinsulinemic hypoglycemia (FHH),
hypercalcemia infantile, hyperornithinemia-hyperammonemia-homocitrullinuria
(HHH) Syndrome, Immunodeficiency with hyper-IgM type 5 (HIGM5), Inclusion
Body Myositis (IBM), polymyositis with mitochondrial pathology, IM-Mito,
granulomatous myopathies with anti-mitochondrial antibodies, necrotizing
myopathy
with pipestem capillaries, myopathy with deficient chondroitin sulfate C in
skeletal
muscle connective tissue, benign acute childhood myositis, idiopathic orbital
myositis, masticator myopathy, hemophagocytic lymphohistiocytosis, infection-
associated myositis, Facioscapulohumeral dystrophy (FSH), familial idiopathic
inflammatory myopathy, Schmidt Syndrome (Diabetes mellitus, Addison disease,
Myxedema), TNF receptor-associated Periodic Syndrome (TRAPS), focal myositis,
autoimmune fasciitis, Spanish toxic oil-associated fasciitis, Eosinophilic
fasciitis,
Macrophagic myofasciitis, Graft-vs-host disease fasciitis, Eosinophilia-
myalgia
Syndrome, perimyositis, isovaleric acidemia (IVA), Kearnes-Sayre Syndrome
(KSS),
2-oxoadipic aciduria, 2-aminoadipic aciduria, Limb-girdle Muscular Dystrophy
Syndromes, leukodystrophy, Maple syrup urine disease (MSUD), 3-Methylcrotonyl-
23

CA 02920272 2016-02-09
CoA carboxylase (MCC), Methylmalonic aciduria (MMA), Miller Syndrome,
Mitochondrial DNA Depletion Syndrome-2 (MTDPS2), spinal muscular atrophy
syndrome, rigid spine syndrome, severe myopathy with motor regression,
Mitochondrial DNA Depletion Syndrome-3, MELAS Syndrome, camptocormia,
MNGIE, MNGIM Syndrome, Menkes Disease, Occipital Horn Syndrome, X-linked
distal spinal muscular atrophy-3 (SMAX3), methemoglobinemia, MERRF,
progressive external ophthalmoplegia with myoclonus, deafness and diabetes
(DD),
multiple symmetric lipomatosis, Myopathy with Episodic high Creatine Kinase
(MIMECK), Epilepsia Partialis Continua, malignant hyperthermia syndromes,
glycogen metabolic disorders, fatty acid oxidation and lipid metabolism
disorders,
medication-, drug- or toxin-induced myoglobinuria, mitochondrial disorder-
associated
myoglobinuria, hypokalemic myopathy and rhabdomyolysis, muscle trauma-
associated myoglobinuria, ischemia-induced myoglobinuria, infection-induced
myoglobinuria, immune myopathies associated with myoglobinuria, Myopathy,
lactic
acidosis, and sideroblastic anemia (MLASA), infantile mitochondrial myopathy
due
to reversible COX deficiency (MMIT), Myopathy, Exercise intolerance,
Encephalopathy and Lactic acidemia Syndrome, myoglobinuria and exercise
intolerance syndrome, exercise intolerance, proximal weakness myoglobinuria
syndrome, encephalopathy and seizures syndrome, septo-optic dysplasia,
exercise
intolerance mild weakness, myopathy exercise intolerance, growth or CNS
disorder, maternally-inherited mitochondrial myopathies, myopathy with lactic
acidosis, myopathy with rhabdomyolysis, Myopathy with cataract and combined
respiratory chain deficiency, myopathy with abnormal mitochondrial
translation,
Fatigue Syndrome, myopathy with extrapyramidal movement disorders (MPXPS),
glutaric aciduria II (MADD), primary C0Q10 deficiency-1 (C0Q1 OD 1), primary
CoQ10 deficiency-2 (C0Q10D2), primary CoQ10 deficiency-3 (C0Q10D3), primary
CoQ10 deficiency-5 (C0Q10D5), secondary CoQ10 deficiency, autosomal dominant
mitochondrial myopathy, myopathy with focal depletion of mitochondria,
mitochondrial DNA breakage syndrome (PEO + Myopathy), lipid type mitochondrial

myopathy, multiple symmetric lipomatosis (MSL), N-acetylglutamate synthase
(NAGS) deficiency, Nephronophthisis (NPHP), ornithine transcarbamylase (OTC)
deficiency, neoplasms, NARP Syndrome, paroxysmal nonkinesigenic dyskinesia
(PNKD), sporadic PEO, maternally-inherited PEO, autosomal dominant progressive

external ophthalmoplegia with mitochondrial DNA deletions-3 (PEOA3), autosomal
24

CA 02920272 2016-02-09
dominant progressive external ophthalmoplegia with mitochondrial DNA deletions-
2
(PEOA2), autosomal dominant progressive external ophthalmoplegia with
mitochondrial DNA deletions-1 (PEOA1), PEO+ demyelinating neuropathy, PEO +
hypogonadism, autosomal dominant progressive external ophthalmoplegia with
mitochondrial DNA deletions-4 (PEOA4), distal myopathy, cachexia & PEO,
autosomal dominant progressive external ophthalmoplegia-6 (PEOA6), PEO +
Myopathy and Parkinsonism, autosomal recessive progressive external
ophthalmoplegia (PEOB), Mitochondrial DNA Depletion Syndrome-11 (MTDPS11),
PEO with cardiomyopathy, PEPCK deficiency, Perrault Syndromes (PRLTS),
propionic acidemia (PA), pyruvate carboxylase deficiency, pyruvate
dehydrogenase
El-alpha deficiency (PDHAD), pyruvate dehydrogenase El-beta deficiency
(PDHBD), dihydrolipoamide dehydrogenase (DLD) deficiency, pyruvate
dehydrogenase phosphatase deficiency, pyruvate dehydrogenase E3-binding
protein
deficiency (PDHXD), mitochondrial pyruvate carrier deficiency (MPYCD),
Schwartz-Jampel Syndrome type 1 (SJS 1), selenium deficiency, short-chain acyl-
CoA
dehydrogenase (SCAD) deficiency, succinyl CoA:3-oxacid CoA transferase (SCOT)
deficiency, Stuve-Wiedemann Syndrome (STWS), thrombocytopenia (THC), Very
long-chain acyl-CoA dehydrogenase deficiency (VLCADD), Vitamin D-dependent
rickets type lA (VDDR1A), Wilson's disease, Zellweger Syndrome (PBD3A),
arsenic trioxide myopathy, myopathy and neuropathy resulting from nucleoside
analogues, germanium myopathy, Parkinsonism and mitochondrial Complex I
neurotoxicity due to trichloroethylene, valproate-induced hepatic failure,
neurodegeneration with brain iron accumulation-4 (NBIA4), Complex I
deficiency,
Complex H deficiency, Complex HI deficiency, Complex IV deficiency, Complex V
deficiency, Cytochrome c oxidase (COX) deficiency, combined complex I, II, IV,
V
deficiency, combined complex I, II, and III deficiency, combined oxidative
phosphorylation deficiency-1 (COXPD1), combined oxidative phosphorylation
deficiency-2 (COXPD2), combined oxidative phosphorylation deficiency-3
(COXPD3), combined oxidative phosphorylation deficiency-4 (COXPD4), combined
oxidative phosphorylation deficiency-6 (COXPD6), combined oxidative
phosphorylation deficiency-7 (COXPD7), combined oxidative phosphorylation
deficiency-9 (COXPD9), combined oxidative phosphorylation deficiency-11
(COXPD11), combined oxidative phosphorylation deficiency-12 (COXPD12),
combined oxidative phosphorylation deficiency-13 (COXPD13), combined oxidative

CA 02920272 2016-02-09
phosphorylation deficiency-15 (COXPD15), combined oxidative phosphorylation
deficiency-16 (COXPD16), combined oxidative phosphorylation deficiency-19
(COXPD19), combined oxidative phosphorylation deficiency-20 (COXPD20),
combined oxidative phosphorylation deficiency-21 (COXPD21), fumarase
deficiency,
HMG-CoA synthase-2 deficiency, hyperuricemia, pulmonary hypertension, renal
failure, and alkalosis (HUPRA) Syndrome, syndromic microphthalmia-7,
pontocerebellar hypoplasia type 6 (PCH6), Mitochondrial DNA Depletion Syndrome-

9 (MTDPS9P), and Sudden infant death Syndrome (SIDS).
[0051] As used herein, the "modulation" of, or to "modulate," an energy
biomarker
means to change the level of the energy biomarker towards a desired value, or
to
change the level of the energy biomarker in a desired direction (e.g.,
increase or
decrease). Modulation can include, but is not limited to, normalization and
enhancement as defined herein.
[0052] As used herein, the terms "normalization" of, or to "normalize," an
energy
biomarker is defined as changing the level of the energy biomarker from a
pathological value towards a normal value, where the normal value of the
energy
biomarker can be 1) the level of the energy biomarker in a healthy person or
subject,
or 2) a level of the energy biomarker that alleviates one or more undesirable
symptoms in the person or subject. That is, to normalize an energy biomarker
which
is depressed in a disease state means to increase the level of the energy
biomarker
towards the normal (healthy) value or towards a value which alleviates an
undesirable
symptom; to normalize an energy biomarker which is elevated in a disease state

means to decrease the level of the energy biomarker towards the normal
(healthy)
value or towards a value which alleviates an undesirable symptom.
[0053] As used herein, the terms "polypeptide," "peptide," and "protein" are
used
interchangeably herein to mean a polymer comprising two or more amino acids
joined
to each other by peptide bonds or modified peptide bonds, i.e., peptide
isosteres.
Polypeptide refers to both short chains, commonly referred to as peptides,
glycopeptides or oligomers, and to longer chains, generally referred to as
proteins.
Polypeptides may contain amino acids other than the 20 gene-encoded amino
acids.
Polypeptides include amino acid sequences modified either by natural
processes, such
26

CA 02920272 2016-02-09
as post-translational processing, or by chemical modification techniques that
are well
known in the art.
[0054] As used herein, "prevention" or "preventing" of a disease or medical
condition refers to a compound that, in a statistical sample, reduces the
occurrence of
the disease or medical condition in the treated sample relative to an
untreated control
sample, or delays the onset of one or more symptoms of the disease or medical
condition relative to the untreated control sample.
[0055] As used herein, the term "simultaneous" therapeutic use refers to the
administration of at least two active ingredients by the same route and at the
same
time or at substantially the same time.
[0056] As used herein, the term "separate" therapeutic use refers to an
administration of at least two active ingredients at the same time or at
substantially the
same time by different routes.
[0057] As used herein, the term "sequential" therapeutic use refers to
administration
of at least two active ingredients at different times, the administration
route being
identical or different. More particularly, sequential use refers to the whole
administration of one of the active ingredients before administration of the
other or
others commences. It is thus possible to administer one of the active
ingredients over
several minutes, hours, or days before administering the other active
ingredient or
ingredients. There is no simultaneous treatment in this case.
[0058] The term "solvate" as used herein means a compound wherein molecules of

a suitable solvent are incorporated in the crystal lattice. A suitable solvent
is
physiologically tolerable at the dosage administered. Examples of suitable
solvents
are ethanol, water and the like. When water is the solvent, the molecule is
referred to
as a "hydrate." The formation of solvates will vary depending on the compound
and
the solvent.
[0059] As used herein, the terms "subject," "individual," or "patient" can be
an
individual organism, a vertebrate, a mammal, or a human.
27

CA 02920272 2016-02-09
[0060] As used herein, a "synergistic therapeutic effect" refers to a greater-
than-
additive therapeutic effect which is produced by a combination of at least two
agents,
and which exceeds that which would otherwise result from the individual
administration of the agents. For example, lower doses of one or more agents
may be
used in treating a disease or disorder, resulting in increased therapeutic
efficacy and
decreased side-effects.
[0061] "Treating" or "treatment" as used herein covers the treatment of a
disease or
medical condition described herein, in a subject, such as a human, and
includes: (i)
inhibiting a disease or disorder, i.e., arresting its development; (ii)
relieving a disease
or disorder, i.e., causing regression of the disorder; (iii) slowing
progression of the
disorder; and/or (iv) inhibiting, relieving, or slowing progression of one or
more
symptoms of the disease or medical condition.
[0062] It is also to be appreciated that the various modes of treatment or
prevention
of medical diseases and conditions as described are intended to mean
"substantial,"
which includes total but also less than total treatment or prevention, and
wherein some
biologically or medically relevant result is achieved. The treatment may be a
continuous prolonged treatment for a chronic disease or a single, or few time
administrations for the treatment of an acute condition.
Phenazine-3-one and Phenothiazine-3-one Derivatives
[0063] In one aspect, the present disclosure provides a compound of Formula
(I):
R7 RI
R6 011 R2
R5 R 0
R4 (I)
[0064] wherein: RI and R2 are independently selected from the group consisting
of:
¨H, ¨Ci-C4 alkyl, ¨0¨Ci-C4 alkyl, and ¨C1-C4 haloalkyl, and R3 is selected
from the group consisting of: ¨H, ¨C1-C12 alkyl, ¨0¨Ci-C12 alkyl, and ¨C1-C12
haloalkyl; or RI and R, are both ¨CH3 or Ri and R2 are both ¨OCH3, and R3 is
selected from the group consisting of:
28

CA 02920272 2016-02-09
HC OH
113C OH
=
,= =
, = and

[0065] n is 0, 1, 2, 3, or 4;
[0066] R4, R5, R6, and R7 are independently selected from the group consisting
of:
¨H, ¨Ci-C12 alkyl, ¨C2-C12 alkenyl, ¨C1-C12 haloalkyl, ¨0¨CI-Cu alkyl, ¨
0¨C1-C12 haloalkyl, ¨C6-C10 aryl, ¨0¨C6-C10 aryl, ¨C1-C6 alkyl-C6-C10 aryl, ¨
0¨C1-C6 alkyl-C6-Cio aryl, ¨N¨(R8)(R9),
and
[0067] with the proviso that at least two of R4, R5, R6, and R7 are
independently
selected from the group consisting of: ¨H and ¨CH3; R8 and R9 are
independently
¨H or ¨Ci-C12 alkyl; m is 0, 1, 2, or 3; and Rii is NH or S; or a
stereoisomer,
mixture of stereoisomers, solvate, hydrate, or pharmaceutically acceptable
salt
thereof.
[0068] In some embodiments, one of RI, R2, and R3 is not ¨H. In some
embodiments, two of R1, R2, and R3 are not ¨H. In some embodiments, RI, R2,
and
29

CA 02920272 2016-02-09
R3 are not ¨H. In some embodiments, one of R1, R2, and R3 is ¨CH3. In some
embodiments, two of RI, R2, and R3 are ¨CH3. In some embodiments, RI, R2, and
R3 are ¨CH3. In some embodiments, two of R1, R2, and R3 are ¨CH3 and one of
RI,
R2, and R3 is ¨H. In some embodiments, R1 and R3 are ¨CH3, and R2 is ¨H. In
some embodiments, R1 and R2 are ¨CH3.
[0069] In some embodiments, RI and R2 are ¨OCH3. In some embodiments, R1
and R2 are ¨OCH3, and R3 is ¨CH3. In some embodiments, R1 and R2 are ¨CH3,
and R3 is -n-Cl-C12 alkyl. In some embodiments, R1 and R2 are ¨OCH3, and R3 is
-
n-Cl-C12 alkyl. In some embodiments, RI and R2 are ¨CH3, and R3 is selected
from
the group consisting of:
HC OH
H3C OH
,
r
6
=
=5 And
[0070] In some embodiments, R1 and R2 are ¨CH3, and R3 is
H3C OH
[0071] In some embodiments, R1 and R2 are ¨CH3, and R3 is
HC OH

CA 02920272 2016-02-09
[0072] In some embodiments, Ri and R2 are ¨CH3, and wherein R3 is
tr
[0073] In some embodiments, R1 and R2 are ¨OCH3, and wherein R3 is selected
from the group consisting of:
li3C Oil
H3c OH
8 *
e"?
1 9
47.
Pr
.#1e1 "V and
n =
[0074] In some embodiments, R1 and R2 are ¨OCH3, and R3 is
113C OH
[0075] In some embodiments, RI and R2 are ¨OCH3, and R3 is
MC OH
[0076] In some embodiments, R1 and R2 are ¨OCH3, and R3 is
31

CA 02920272 2016-02-09
val =
[0077] In some embodiments, Ri and R2 are independently ¨H or ¨CI-Ca alkyl.
In some embodiments, R1, R2, and R3 are ¨H. In some embodiments, including any

of the foregoing embodiments, n is 0. In some embodiments, including any of
the
foregoing embodiments, n is 1. In some embodiments, including any of the
foregoing
embodiments, n is 2. In some embodiments, including any of the foregoing
embodiments, n is 3. In some embodiments, including any of the foregoing
embodiments, n is 4.
[0078] In some embodiments, including any of the foregoing embodiments, two of

R4, R5, R6, and R7 are ¨H. In some embodiments, including any of the foregoing

embodiments, three of Ra, Rs, R6, and R7 are ¨H. In some embodiments,
including
any of the foregoing embodiments, Ra, R5, R6, and R7 are ¨H. In some
embodiments, including any of the foregoing embodiments, at least one of R4,
R5, R6,
and R7 is independently selected from the group consisting of: ¨CI-Cu alkyl,
¨Ci-
C12 haloalkyl, ¨0¨Ci-C12 alkyl, ¨0¨Ci-C6 alkyl-C6-Cio aryl, ¨N¨(R8)(R9), and
=
[0079] In some embodiments, including any of the foregoing embodiments, at
least
one of Ra, R5, R6, and R7 is independently selected from the group consisting
of: ¨
CI-C6 alkyl, ¨0¨C1-C6 alkyl, ¨N¨(R8)(R9) wherein R8 and R9 are independently
¨H or ¨CI-Ca alkyl, ¨CF3, ¨0-benzyl, and
cs540
[0080] wherein m is 1 or 2.
[0081] In some embodiments, including any of the foregoing embodiments, three
of
R4, R5, R6, and R7 are ¨H, and the other is ¨N(CH3)2. In some embodiments,
including any of the foregoing embodiments, three of Ra, R5, R6, and R7 are
¨H, and
the other is ¨0-benzyl. In some embodiments, including any of the foregoing
32

CA 02920272 2016-02-09
embodiments, three of R4, R5, R6, and R7 are ¨H, and the other is ¨0¨CH3. In
some embodiments, including any of the foregoing embodiments, three of R4, R5,
R6,
and R7 are ¨H, and the other is ¨0-n-C2-05 alkyl. In some embodiments,
including
any of the foregoing embodiments, three of Itt, R5, R6, and R7 are ¨H, and the
other
is ¨CF3. In some embodiments, including any of the foregoing embodiments,
three
of R4, R5, R6, and R7 are ¨H, and the other is
cs540
11 =
[0082] wherein m is 1 or 2.
[0083] In some embodiments, including any of the foregoing embodiments, three
of
R.4, R5, R6, and R7 are ¨H, and the other is ¨CH3. In some embodiments,
including
any of the foregoing embodiments, m is 0. In some embodiments, including any
of
the foregoing embodiments, m is 1. In some embodiments, including any of the
foregoing embodiments, m is 2. In some embodiments, including any of the
foregoing embodiments, m is 3. In some embodiments, including any of the
foregoing embodiments, the compound has the formula:
a 'S....,
Ri2
0,
[0084] wherein R12 is selected from the group consisting of: ¨C1-C6 alkyl, ¨0¨
C1-C6 alkyl, ¨N(CH3)2, ¨CF3, ¨0-benzyl, and
[0085] wherein m is 1 or 2, or a stereoisomer, mixture of stereoisomers,
solvate,
hydrate, or pharmaceutically acceptable salt thereof. In some embodiments,
including
any of the foregoing embodiments, the compound has the formula:
33

CA 02920272 2016-02-09
R-12--fr
0,
[0086] wherein R12 is selected from the group consisting of: ¨Cl-C6 alkyl, ¨0¨
Ci-C6 alkyl, ¨N(CH3)2, ¨CF3, ¨0-benzyl, and
,
[0087] wherein m is 1 or 2, or a stereoisomer, mixture of stereoisomers,
solvate,
hydrate, or pharmaceutically acceptable salt thereof. In some embodiments,
including
any of the foregoing embodiments, the compound has the formula:
OCH
N OCH3,
R
12
Rj 0
[0088] wherein R12 is selected from the group consisting of: ¨Ci-C6 alkyl, ¨0¨
C1-C6 alkyl, ¨N(CH3)2, ¨CF3, ¨0-benzyl, and
/0
[0089] wherein m is 1 or 2, or a stereoisomer, mixture of stereoisomers,
solvate,
hydrate, or pharmaceutically acceptable salt thereof. In some embodiments,
including
any of the foregoing embodiments, the compound has the formula:
RI
1
N R2,
R)2 __
RIE 0
11µ;
[0090] wherein RI and R2 are ¨CH3, or R1 and R2 are ¨OCH3, and wherein R3 is:
34

CA 02920272 2016-02-09
H3C OH
or
[0091] wherein n is 1 or 2, or a stereoisomer, mixture of stereoisomers,
solvate,
hydrate, or pharmaceutically acceptable salt thereof. In some embodiments,
including
any of the foregoing embodiments, R11 is S. In some embodiments, including any
of
the foregoing embodiments, R11 is NH. In some embodiments, including any of
the
foregoing embodiments, the compound is not:
Me2N S 0,
[0092] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0093] In some embodiments, including any of the foregoing embodiments, the
compound is selected from the group consisting of:
4 F=Cb01 õoso 401
õdi
(1) S 0 Boo S 0, SI 111 I I I I
I P 0,
(2) (3)
0 N"
0, 0,
(5)
(4)
MeiN
11101
0. 5 0 ]-3(.= s 0
(6) (7) (8)
õ010
40 gip (X
0, and S
(9) (10)

CA 02920272 2016-02-09
[0094] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0095] In some embodiments, including any of the foregoing embodiments, the
compound is selected from the group consisting of:
Bn0 Nill N 113C \ ..õ.õ 411 .
.....õ0,...,
O. Bt10 1111111P1 0, S 'PP' O.
(11) (12) (13)
N 0 N
,,....
0 SI
õ,,, , () :4 0,
(14) (15)
be \ vwc N N
.....õ.
0, S o, F= S0,
(16) (17) (18)
4 N N
101 ,,,,,. illi
......õ õ...., .....õ
o s killop 0. and Nte2N 0,
(19) (20)
[0096] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0097] In some embodiments, including any of the foregoing embodiments, the
compound is selected from the group consisting of:
(xlt, ocH, oen,
Bilo Ali \ ()en, \ oat,. 113C Ns......
(X'113,
=,.,..
OP 0
gip s'Illi 0 no 0 s' 0
(21) (22) (23)
36

CA 02920272 2016-02-09
(X'113OCII
0 03
00b,
FtIC
(
(24) 25)
oca3 ouL 0013
FIC N Oefb, Nle2N N Mb.
410 OCF1A,
('
(26) (27) (28)
cub
OCTIj
1110
C)CtIj, and
0
0
101
(29) (30)
[0098] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0099] In some embodiments, including any of the foregoing embodiments, the
compound is selected from the group consisting of:
*
0
HOE
(31)
\.
()
(32)
37

CA 02920272 2016-02-09
OCHI
N OCH3. and
0
(33)
(34)
HO
[0100] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof. In some embodiments, including any
of the
foregoing embodiments, the compound is:
or (35)
F3C
4110 (36)
0,
[0101] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0102] In some embodiments, including any of the foregoing embodiments, the
compound is:
38

CA 02920272 2016-02-09
4110 (37)
Me2N S 0,
[0103] or a stereoisomer, mixture of stereoisomers, solvate, hydrate, or
pharmaceutically acceptable salt thereof.
[0104] In some embodiments, including any of the foregoing embodiments, the
compound has an EC50 of less than about 1 micromolar. In some embodiments,
including any of the foregoing embodiments, the compound has an EC50 of less
than
about 500 nM. In some embodiments, including any of the foregoing embodiments,

the compound has an EC50 of less than about 250 nM. The compound of the
present
technology can be any individual compound of Formula I, or a stereoisomer,
mixture
of stereoisomers, solvate, hydrate, or pharmaceutically acceptable salt
thereof.
Compositions comprising combinations of compounds of the present technology
are
also contemplated.
[0105] In another aspect, the present disclosure provides a pharmaceutical
formulation comprising a compound as described herein, and a pharmaceutically
acceptable excipient.
[0106] While the compounds described herein can occur and can be used as the
neutral (non-salt) compound, the description is intended to embrace all salts
of the
compounds described herein, as well as methods of using such salts of the
compounds. In one embodiment, the salts of the compounds comprise
pharmaceutically acceptable salts. Pharmaceutically acceptable salts are those
salts
which can be administered as drugs or pharmaceuticals to humans and/or animals
and
which, upon administration, retain at least some of the biological activity of
the free
compound (neutral compound or non-salt compound). The desired salt of a basic
compound may be prepared by methods known to those of skill in the art by
treating
the compound with an acid. Examples of inorganic acids include, but are not
limited
to, hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, and
phosphoric
acid. Examples of organic acids include, but are not limited to, formic acid,
acetic
acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, maleic acid,
malonic
acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid,
cinnamic acid,
39

CA 02920272 2016-02-09
mandelic acid, sulfonic acids, and salicylic acid. Salts of basic compounds
with
amino acids, such as aspartate salts and glutamate salts, can also be
prepared. The
desired salt of an acidic compound can be prepared by methods known to those
of
skill in the art by treating the compound with a base. Examples of inorganic
salts of
acid compounds include, but are not limited to, alkali metal and alkaline
earth salts,
such as sodium salts, potassium salts, magnesium salts, and calcium salts;
ammonium
salts; and aluminum salts. Examples of organic salts of acid compounds
include, but
are not limited to, procaine, dibenzylamine, N-ethylpiperidine, N,N-
dibenzylethylenediamine, and triethylamine salts. Salts of acidic compounds
with
amino acids, such as lysine salts, can also be prepared.
[0107] The present technology also includes, if chemically possible, all
stereoisomers of the compounds, including diastereomers and enantiomers. The
present technology also includes mixtures of possible stereoisomers in any
ratio,
including, but not limited to, racemic mixtures. Unless stereochemistry is
explicitly
indicated in a structure, the structure is intended to embrace all possible
stereoisomers
of the compound depicted. If stereochemistry is explicitly indicated for one
portion or
portions of a molecule, but not for another portion or portions of a molecule,
the
structure is intended to embrace all possible stereoisomers for the portion or
portions
where stereochemistry is not explicitly indicated.
[0108] The compounds can be administered in prodrug form. Prodrugs are
derivatives of the compounds, which are themselves relatively inactive but
which
convert into the active compound when introduced into the subject in which
they are
used by a chemical or biological process in vivo, such as an enzymatic
conversion.
Suitable prodrug formulations include, but are not limited to, esters of
compounds of
the present technology. Further discussion of suitable prodrugs is provided in
H.
Bundgaard, Design of Prodrugs, New York: Elsevier, 1985; in R. Silverman, The
Organic Chemistry of Drug Design and Drug Action, Boston: Elsevier, 2004; in
R. L.
Juliano (ed.), Biological Approaches to the Controlled Delivery of Drugs
(Annals of
the New York Academy of Sciences, v. 507), New York: New York Academy of
Sciences, 1987; and in E. B. Roche (ed.), Design of Biopharmaceutical
Properties
Through Prodrugs and Analogs (Symposium sponsored by Medicinal Chemistry

CA 02920272 2016-02-09
Section, APhA Academy of Pharmaceutical Sciences, November 1976 national
meeting, Orlando, Fla.), Washington: The Academy, 1977.
[0109] The description of compounds herein also includes all isotopologues,
for
example, partially deuterated or perdeuterated analogs of all compounds
herein.
[0110] Metabolites of the compounds are also embraced by the present
technology.
[0111] The compounds useful in the methods of the present disclosure (e.g.,
phenazine-3-one or phenothiazine-3-one derivatives, or analogues, or
pharmaceutically acceptable salts thereof) may be synthesized by any method
known
in the art. Methods for synthesizing the phenazine-3-one or phenothiazine-3-
one
derivatives of the present technology are described in US 2014/0275045.
Mitochondrial Diseases
[0112] Mitochondrial dysfunction plays a role both in the pathogenesis of late-
onset
neurodegenerative disorders, including Parkinson disease (PD), Huntington
disease
(HD), Alzheimer disease (AD), and amyotrophic lateral sclerosis (ALS), and in
the
pathogenesis of aging.
[0113] Mitochondrial diseases are a clinically heterogeneous group of
disorders that
arise as a result of dysfunction of the mitochondrial respiratory chain. The
mitochondrial respiratory chain is the only metabolic pathway in the cell that
is under
the dual control of the mitochondrial genome (mtDNA) and the nuclear genome
(nDNA). While some mitochondrial disorders only affect a single organ (e.g.,
the eye
in Leber hereditary optic neuropathy [LHON]), many involve multiple organ
systems
and often present with prominent neurologic and myopathic features.
Mitochondrial
disorders may present at any age.
[0114] Mutations in mtDNA can be divided into those that impair mitochondrial
protein synthesis in toto and those that affect any one of the 13 respiratory
chain
subunits encoded by mtDNA.
[0115] (i) Heteroplasmy and threshold effect. Each cell contains hundreds or
thousands of mtDNA copies, which, at cell division, distribute randomly among
daughter cells. In normal tissues, all mtDNA molecules are identical
(homoplasmy).
41

CA 02920272 2016-02-09
Deleterious mutations of mtDNA usually affect some but not all mtDNAs within a

cell, a tissue, or an individual (heteroplasmy). The clinical expression of a
pathogenic
mtDNA mutation is largely determined by the relative proportion of normal and
mutant mtDNA genomes in different tissues. A minimum critical number of mutant

mtDNAs is required to cause mitochondrial dysfunction in a particular organ or
tissue
(threshold effect).
[0116] (ii) Mitotic segregation. At cell division, the proportion of mutant
mtDNAs
in daughter cells may shift and the phenotype may change accordingly. This
phenomenon, called mitotic segregation, explains how certain patients with
mtDNA-
related disorders may actually manifest different mitochondrial diseases at
different
stages of their lives.
[0117] (iii) Maternal inheritance. At fertilization, all mtDNA derives from
the
oocyte. Therefore, the mode of transmission of mtDNA and of mtDNA point
mutations (single deletions of mtDNA are usually sporadic events) differs from

Mendelian inheritance. A mother carrying a mtDNA point mutation will pass it
on to
all her children (males as well as females), but only her daughters will
transmit it to
their progeny. A disease expressed in both sexes but with no evidence of
paternal
transmission is strongly suggestive of a mtDNA point mutation.
[0118] Many individuals with a mutation of mtDNA display a cluster of clinical

features that fall into a discrete clinical syndrome, such as the Kearns-Sayre
syndrome
(KSS), chronic progressive external ophthalmoplegia, mitochondrial
encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS),
myoclonic epilepsy with ragged-red fibers (MERRF), neurogenic weakness with
ataxia and retinitis pigmentosa (NARP), or Leigh syndrome (LS). However,
considerable clinical variability exists and many individuals do not fit
neatly into one
particular category, which is well-illustrated by the overlapping spectrum of
disease
phenotypes (including mitochondrial recessive ataxia syndrome (MIRAS)
resulting
from mutation of the nuclear gene POLG, which has emerged as a major cause of
mitochondrial disease.
[0119] Disorders due to mutations in nDNA are more abundant not only because
most respiratory chain subunits are nucleus-encoded but also because correct
42

CA 02920272 2016-02-09
assembly and functioning of the respiratory chain require numerous steps, all
of
which are under the control of nDNA. These steps (and related diseases)
include: (i)
synthesis of assembly proteins; (ii) intergenomic signaling; (iii)
mitochondrial
importation of nDNA-encoded proteins; (iv) synthesis of inner mitochondrial
membrane phospholipids; (v) mitochondrial motility and fission.
[0120] Common clinical features of mitochondrial disease ¨ whether involving a

mitochondrial or nuclear gene ¨ include ptosis, external ophthalmoplegia,
proximal
myopathy and exercise intolerance, cardiomyopathy, sensorineural deafness,
optic
atrophy, pigmentary retinopathy, and diabetes mellitus. Common central nervous

system findings are fluctuating encephalopathy, seizures, dementia, migraine,
stroke-
like episodes, ataxia, and spasticity. A high incidence of mid- and late
pregnancy loss
is a common occurrence that often goes unrecognized.
[0121] Mitochondrial myopathies are characterized by excessive proliferation
of
normal- or abnormal-looking mitochondria in the muscle of patients with
weakness or
exercise intolerance. These abnormal fibers are referred to as "ragged red
fibers"
because the areas of mitochondrial accumulation appear purplish when contacted
with
the modified Gomori trichrome stain. Many patients with ragged red fibers
often
exhibit encephalomyopathy. However, the absence of ragged red fibers in a
biopsy
does not exclude a mitochondrial etiology.
[0122] Diagnosis. In some subjects, the clinical picture is characteristic of
a
specific mitochondrial disorder (e.g., LHON, NARP, or maternally inherited
Leigh
Syndrome), and the diagnosis can be confirmed by identification of a mtDNA
mutation on molecular genetic testing of DNA extracted from a blood sample. In

many individuals, such is not the case, and a more structured approach is
needed,
including family history, blood and/or CSF lactate concentration,
neuroimaging,
cardiac evaluation, and molecular genetic testing for a mtDNA or nuclear gene
mutation. Approaches to molecular genetic testing of a proband to consider are
serial
testing of single genes, multi-gene panel testing (simultaneous testing of
multiple
genes), and/or genomic testing (e.g., sequencing of the entire mitochondrial
genome
exome or exome sequencing to identify mutation of a nuclear gene). In many
individuals in whom molecular genetic testing does not yield or confirm a
diagnosis,
43

CA 02920272 2016-02-09
further investigation of suspected mitochondrial disease can involve a range
of
different clinical tests, including muscle biopsy for respiratory chain
function.
[0123] A brief nonexhaustive summary of the various mitochondrial diseases or
disorders is provided below.
Alexander Disease
[0124] In decreasing order of frequency, 3 forms of Alexander disease are
recognized, based on age of onset: infantile, juvenile, and adult. Younger
patients
typically present with seizures, megalencephaly, developmental delay, and
spasticity.
In older patients, bulbar or pseudobulbar symptoms predominate, frequently
accompanied by spasticity. The disease is progressive, with most patients
dying
within 10 years of onset. Imaging studies of the brain typically show cerebral
white
matter abnormalities, preferentially affecting the frontal region. All 3 forms
have
been shown to be caused by autosomal dominant mutations in the GFAP (Glial
fibrillary acidic protein) gene. Some patients with Alexander disease also
exhibit
mutations in NADH-Ubiquinone Oxidoreductase Flavoprotein 1 (NDUFV1).
[0125] Histologically, Alexander disease is characterized by Rosenthal fibers,

homogeneous eosinophilic masses which form elongated tapered rods up to 30
microns in length, which are scattered throughout the cortex and white matter
and are
most numerous in the subpial, perivascular and subependymal regions. These
fibers
are located in astrocytes, cells that are closely related to blood vessels.
Demyelination
is present, usually as a prominent feature. A few cases have had
hydrocephalus.
Rosenthal fibers are commonly found in astrocytomas, optic nerve gliomas and
states
of chronic reactive gliosis, but they are especially conspicuous in Alexander
disease. Rosenthal fibers found in this situation are typically the result of
degenerative changes in the cytoplasm and cytoplasmic processes of astrocytic
glial
cell.
Alpers-Huttenlocher Disease (Alpers)
[0126] Mitochondrial DNA Depletion Syndrome-4A, also known as Alpers
Syndrome, is an autosomal recessive disorder caused by mutations in POLG.
Alpers
is characterized by a clinical triad of psychomotor retardation, intractable
epilepsy,
and liver failure in infants and young children. Pathologic findings include
neuronal
44

CA 02920272 2016-02-09
loss in the cerebral gray matter with reactive astrocytosis and liver
cirrhosis. The
disorder is progressive and often leads to death from hepatic failure or
status
epilepticus before age 3 years. Symptoms include anoxic encephalopathy, fever,

developmental delay, epilepsy, impaired central visual function, ataxia,
sensory loss,
neuronal loss, progressive liver failure, acute liver dysfunction precipitated
by
valproic acid, cirrhosis, hypotonia, dementia, vomiting, paralysis, stupor,
jaundiced
liver with fibrosis, inflammation and bile duct proliferation, and increased
CSF
protein and lactate.
[0127] Some affected individuals may show mild intermittent 3-methylglutaconic

aciduria and defects in mitochondrial oxidative phosphorylation. Subjects with

Alpers typically exhibit perturbations in pyruvate metabolism and NADH
oxidation.
For example, a subset of patients with mtDNA depletion and Alpers Syndrome
show
a global reduction in respiratory chain complex I, II/III, and IV activity and
deficiency
of mitochondrial DNA polymerase gamma activity. Neuropathologic changes
characteristic of Alpers Syndrome, namely laminar cortical necrosis, may also
be seen
in some patients with combined oxidative phosphorylation deficiency-14
(COXPD14)
due to a mutation in the FARS2 gene.
Alpha-ketoglutarate Dehydrogenase Deficiency
[0128] Alpha-ketoglutarate dehydrogenase (AKDGH) deficiency is a disease of
the
tricarboxylic acid cycle (TCA cycle) that affects mitochondria metabolism.
Alpha-
ketoglutarate dehydrogenase is an enzyme of the TCA cycle that catalyzes the
oxidation of alpha-ketoglutarate to succinyl CoA. Alpha-ketoglutarate
dehydrogenase
is one of 3 alpha-ketoacid dehydrogenases, the others being pyruvate
dehydrogenase
and branched-chain ketoacid dehydrogenase. The alpha-ketoglutarate
dehydrogenase
complex is a multi-enzyme complex consisting of three protein subunits:
oxoglutarate
dehydrogenase, also known as alpha-ketoglutarate dehydrogenase or Elk;
dihydrolipoyl succinyltransferase, also known as DLST or E2k; and
dihydrolipoyl
dehydrogenase, also known as DLD or E3. AKDGH deficiency is associated with
DLD deficiency, which is caused by a mutation in the DLD gene. AKDGH
deficiency is characterized by encephalopathy and hyperlactatemia resulting in
death
in early childhood.

CA 02920272 2016-02-09
Frontotemporal Dementia and/or Amyotrophic Lateral Sclerosis (ALS-FTD)
[0129] ALS-FTD is an autosomal dominant late-onset (between 49 to 65 years)
neurodegenerative disorder comprising frontotemporal dementia, cerebellar
ataxia,
myopathy, and motor neuron disease consistent with amyotrophic lateral
sclerosis,
caused by disruptions in the CHCHD10 gene. Clinical manifestations include
progressive bulbar dysfunction, dementia, sensorineural deafness, extensor
plantar
responses, dysphagia, dysarthria, myopathy, and a frontal lobe syndrome.
Muscle
biopsies usually show ragged red fibers, cytochrome C oxidase (COX)-negative
fibers, and mitochondrial DNA deletions; many patients also have combined
mitochondrial respiratory chain deficiencies and fragmented mitochondrial
networks
in fibroblasts, all suggestive of mitochondrial dysfunction. Other features
include
signs of Parkinsonism, including akinesia and rigidity, sensorineural
hypoacusis, and
fatigue. Overexpression of the mutant CHCHD10 protein in HeLa cells results in

fragmentation of the mitochondrial network as well as major ultrastructural
abnormalities, thereby implicating a role for dysfunctional mitochondria in
the
pathogenesis of late-onset frontotemporal dementia with motor neuron disease.
Anemia
1. Sideroblastic Anemia with Spinocerebellar Ataxia
[0130] Sideroblastic anemia with spinocerebellar ataxia is caused by mutations
in
the ATP-binding cassette 7 (ABCB7) transporter, which mediates ATP-dependent
transfer of solutes. ABCB7 is an inner mitochondrial membrane protein that
contains
2 transmembrane domains that form a membranous pore and 2 cytosolic ATP-
binding
domains, which couple ATP binding to solute movement. Affected males exhibit a

moderate hypochromic microcytic anemia with ring sideroblasts on bone marrow
examination and raised free erythrocyte protoporphyrin levels and no excessive

parenchymal iron storage in adulthood. Neurologic features include non-
progressive
ataxia or incoordination (age of onset at 1 year), accompanied by long motor
tract
signs (hyperactive deep tendon reflexes, positive Babinski sign, clonus) in
young
affected males. Heterozygous females may exhibit mild anemia, but not ataxia.
46

CA 02920272 2016-02-09
2. Sideroblastic Anemia, Pyridoxine-refractory
[0131] Pyridoxine-refractory sideroblastic anemia is an autosomal recessive
disorder caused by a homozygous or compound heterozygous mutation in the
SLC25A38 gene. In addition, a homozygous mutation in the GLRX5 gene has been
identified in some patients with late-onset autosomal recessive pyridoxine-
refractory
sideroblastic anemia. Clinical features include severe microcytic hypochromic
anemia, hepatosplenomegaly, jaundice, iron overload, and cirrhosis. Patients
typically exhibit moderate erythroid expansion in the bone marrow, and
increased iron
staining both in erythroblasts and macrophages, with 28% ringed sideroblasts.
In
some cases, patients may show low levels of 6-amino1evulinic acid synthase in
erythroblasts.
3. Growth Retardation, Amino aciduria, Cholestasis, Iron overload, Lactic
acidosis, Early death (GRACILE) Syndrome
[0132] GRACILE Syndrome, an autosomal recessive disorder usually observed in
Finnish and Turkish populations, is caused by disruptions in the BCSIL gene
which is
required for the expression of functional ubiquinol-cytochrome-c reductase
(bcl)
complex. Loss of BCSIL function results in tubulopathy, encephalopathy, and
liver
failure due to complex III deficiency. Clinical features include severe
intrauterine
growth retardation, fulminant lactic acidosis during the first days of life,
Fanconi-type
amino aciduria, spasticity, increased tendon reflexes, and abnormalities in
iron
metabolism, including liver hemosiderosis. Affected infants fail to thrive,
and die
neonatally or in early infancy. Other BCS1L disorders include Bjornstad
Syndrome,
Leigh Syndrome and mitochondrial complex III deficiency, nuclear type 1
(MC3DN1).
4. Anemia and Mitochondriopathy (COXPD18)
[0133] Anemia and mitochondriopathy, or combined oxidative phosphorylation
deficiency 18 (COXPD18) is an autosomal recessive disorder caused by a
homozygous or compound heterozygous mutation in the SFXN4. COXPD18 is
characterized by intrauterine growth retardation, intellectual disability,
dysmetria,
tremor, muscular atrophy, hypotonia, visual impairment, speech delay, delayed
motor
skills, and lactic acidosis associated with decreased mitochondrial
respiratory chain
activity. Affected patients may also show hematologic abnormalities, mainly
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macrocytic anemia and hypersegmented neutrophils, and increased blood lactate
and
ammonia levels.
5. Thiamine-responsive Megaloblastic Anemia
[0134] Thiamine-responsive Megaloblastic Anemia Syndrome (TRMA), also
known as Thiamine Metabolism Dysfunction Syndrome-1 (THMD1), can be caused
by a homozygous mutation in the SLC19A2 gene, which encodes a thiamine
transporter protein. Thiamine-responsive Megaloblastic Anemia Syndrome
comprises megaloblastic anemia, diabetes mellitus, amino aciduria, and
sensorineural
deafness. Onset is typically between infancy and adolescence, but all of the
cardinal
findings are often not present initially. The anemia, and sometimes the
diabetes,
improves with high doses of thiamine. Other more variable features include
optic
atrophy, congenital heart defects, short stature, and stroke.
6. Pearson Syndrome
[0135] Pearson Syndrome is caused by a deletion in mitochondrial DNA and is
characterized by sideroblastic anemia and exocrine pancreas dysfunction. With
Pearson Syndrome, the bone marrow fails to produce white blood cells called
neutrophils. The syndrome also leads to anemia, low platelet count, and
aplastic
anemia. Pearson Syndrome causes the exocrine pancreas to not function properly

because of scarring and atrophy. Individuals with this condition have
difficulty
absorbing nutrients from their diet which leads to malabsorption. Infants with
this
condition generally do not grow or gain weight
[0136] Other clinical features are failure to thrive, pancytopenic crises,
pancreatic
fibrosis with insulin-dependent diabetes and exocrine pancreatic
deficiency, muscle and neurologic impairment, malabsorption, steatorrhea,
metabolic
and lactic acidosis, and early death. The few patients who survive into
adulthood
often develop symptoms of Kearns-Sayre Syndrome.
Ataxia
[0137] Ataxia is defined as the presence of abnormal, uncoordinated movements.

Defects affecting either the mitochondrial or nuclear genomes can cause
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mitochondrial dysfunction, resulting in mitochondrial ataxia. Ataxia
associated with
mtDNA defects typically manifests as part of a multisystem, multisyndrome
disorder.
Maternally Inherited Ataxias
1. HAM Syndrome
[0138] HAM (Hearing loss, Ataxia, Myoclonus) is a maternally-inherited
syndrome
characterized by a combination of sensorineural hearing loss, ataxia, and
myoclonus
observed in a large kindred from Sicily. Hearing loss is the most prevalent
and
sometimes the only symptom found in family members. HAM Syndrome is
associated with the presence of a C7472 insertion mutation in mtDNA regions
encompassing the tRNA genes. This particular insertion is found in the MT-TS1
gene
(nucleotides 7445-7516), which encodes the mitochondrial tRNA for serine
(UCN).
The insertion adds a seventh cytosine to a six-cytosine run that is part of
the
mitochondrial tRNASer(UCN) gene. Conformational analyses demonstrate that this

mutation likely alters the clover leaf secondary structure of tRNASer/(UCN).
2. Ataxia, Cataract, and Diabetes Syndrome and MELAS/MERRF Overlap
Syndrome
[0139] Mutations in the mitochondrial MT-TS2 gene (nucleotides 12207-12265),
which encodes the mitochondrial tRNA for serine (AGY) are associated with the
development of maternally-inherited cerebellar ataxia, cataract, and diabetes
mellitus.
In particular, these phenotypes are associated with a C-to-A transversion at
position
12258. It is thought that this mutation alters a highly conserved basepair in
the
acceptor stem of the tRNA(Ser) molecule, which would affect aminoacylation of
the
tRNA thereby altering the function of the tRNA for serine and reducing the
accuracy
of mitochondrial translation.
[0140] Other mutations in the same gene cause MELAS/MERRF Overlap
Syndrome. One such mutation is a heteroplasmic 12207G-A transition in the MT-
TS2 gene. Upon examination, skeletal muscle biopsies revealed ragged red
fibers,
significant pleomorphic mitochondrial proliferation, and complex I deficiency.
The
12207G-A mutation occurs in a region involved in the formation of the acceptor
stem
of the tRNA molecule. Individuals with MELAS/MERRF Overlap Syndrome
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CA 02920272 2016-02-09
experience a combination of the signs and symptoms of both disorders as
described
above.
3. Cytochrome c Oxidase Deficiency
[0141] Cytochrome c oxidase (COX) deficiency is a mitochondrial disorder
caused
by a lack of COX. Cytochrome c oxidase, also known as complex IV, is the
terminal
enzyme of the mitochondrial respiratory chain located within the mitochondrial
inner
membrane. Complex IV is composed of 13 polypeptides. Subunits I, II, and III
(MTC01, MTCO2, and MTC03) are encoded by mtDNA, while subunits IV, Va, Vb,
VIa, VIb, VIc, Vila, VIIb, VIIc, and VIII are nuclear encoded. Because COX is
encoded by both nuclear and mitochondrial genes, COX deficiency can be
inherited in
either an autosomal recessive or maternal pattern. A G-to-A transition at
nucleotide
6480 of the MTC01 gene, which encodes cytochrome c oxidase subunit I, is
associated with sensorineural hearing loss, ataxia, myoclonic epilepsy, and
mental
retardation. The signs and symptoms of COX deficiency typically manifest
before
two years of age, but can appear later in mildly affected individuals.
[0142] Another form of cytochrome c oxidase deficiency results from mutations
in
the MTCO2 gene, which encodes cytochrome c oxidase subunit II. A T-to-C
transition at nucleotide 7587 of the MT-0O2 gene is associated with ataxia,
distal
weakness, retinopathy, and optic atrophy.
Recessive ataxia syndromes
1. Infantile Cerebellar-retinal Degeneration
[0143] Infantile cerebellar-retinal degeneration (ICRD), also known as
mitochondrial aconitase deficiency, is associated with a Ser112Arg mutation in
the
nuclear ACO2 gene, which encodes mitochondrial aconitase. Aconitase catalyzes
the
isomerization of citrate to isocitrate via cis-aconitate in the second step of
the TCA
cycle. ICRD is a severe autosomal recessive neurodegenerative disorder
characterized by onset between two and six months of age of truncal hypotonia,

athetosis, seizures, and ophthalmologic abnormalities, including optic atrophy
and
retinal degeneration. Individuals with ICRD exhibit profound psychomotor
retardation and progressive cerebral and cerebellar degeneration.

CA 02920272 2016-02-09
2. Charlevoix-Saguenay Spastic Ataxia
[0144] Charlevoix-Saguenay spastic ataxia, also known as autosomal recessive
spastic ataxia of Charlevoix-Saguenay (ARSACS), is caused by a homozygous or
compound heterozygous mutation in the SACS gene encoding the sacsin protein.
Research suggests that sacsin may interact with the heat shock protein 70
(Hsp70)
chaperone machinery, which plays an important role in protein folding and the
cellular response to aggregation-prone mutant proteins associated with
neurodegenerative diseases. Mutations in the SACS gene lead to the production
of
unstable sacsin protein that fails to function normally. ARSACS is a complex
neurodegenerative disorder characterized by the progressive degeneration of
the
cerebellum and spinal cord and early childhood onset of cerebellar ataxia,
pyramidal
tract signs, peripheral neuropathy, retinal changes, and, in some cases,
cognitive
decline.
3. Primary Coenzyme 010 Deficiency-1
[0145] Primary coenzyme Q10 deficiency-1 (C0Q10D1) is an autosomal recessive
disorder caused by a homozygous or compound heterozygous mutation in the COQ2
gene, which encodes COQ2, or parahydroxybenzoic-polyprenyltransferase. COQ2
catalyzes one of the final reactions in the biosynthesis of CoQ10, the
prenylation of
parahydroxybenzoate with an all-trans polyprenyl group. Coenzyme Q10 (CoQ10),
or ubiquinone, functions as an electron carrier critical for electron transfer
by the
mitochondrial inner membrane respiratory chain, and is a lipid-soluble
antioxidant.
Primary C0Q10 deficiency-1 disorder is associated with five major phenotypes,
including: an encephalomyopathic form with seizures and ataxia; a multisystem
infantile form with encephalopathy, cardiomyopathy and renal failure; a
predominantly cerebellar form with ataxia and cerebellar atrophy; Leigh
Syndrome
with grown retardation; and an isolated myopathic form.
4. Ataxia with Oculomotor Apraxia Type 1
[0146] Ataxia with oculomotor apraxia (AOA) comprises a group of autosomal
recessive disorders characterized by ataxia, oculomotor apraxia, and
choreoathetosis.
AOA includes ataxia telangiectasia (AT), ataxia telangiectasia like disorder
(ATLD),
ataxia oculomotor apraxia type 1 (A0A1), and ataxia oculomotor apraxia type 2
(A0A2). A0A1, also known as ataxia, early-onset, with oculomotor apraxia and
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hypoalbumineria, is characterized by early-onset cerebellar ataxia, oculomotor

apraxia, hypoalbumineria, hypercholesterolemia, and late axonal sensorimotor
neuropathy. A0A1 is caused by mutations in the APTX gene, which encodes
aprataxin, a member of the histidine triad (HIT) superfamily, members of which
have
nucleotide-binding and diadenosine polyphosphate hydrolase activities.
Aprataxin is
a DNA-binding protein involved in single-strand DNA break repair, double-
strand
DNA break repair, and base excision repair. Mutations in APTX result in the
production of an unstable aprataxin protein that is quickly degraded in the
cell.
Nonfunctional aprataxin leads to an accumulation of breaks in DNA,
particularly in
the neurocytes of the cerebellum where DNA repair is critical.
5. Autosomal Recessive Spinocerebellar Ataxia-9
[0147] Autosomal recessive spinocerebellar ataxia-9 (SCAR9), also known as
coenzyme Q10 deficiency-4 (C0Q10D4), is an autosomal recessive disorder caused

by homozygous or compound heterozygous mutations in the COQ8 gene. SCAR9 is
characterized by childhood-onset of cerebellar ataxia and exercise
intolerance.
Patients manifest gait ataxia, cerebellar atrophy with slow progression.
Additional
features include variable seizures, mild mental impairment, brisk tendon
reflexes, and
Hoffmann sign.
6. Ataxia, Pyramidal Syndrome, and Cytochrome Oxidase Deficiency
[0148] A homozygous missense mutation in COX20, also known as FAM36A,
causes impaired cytochrome c oxidase assembly and is associated with ataxia
and
muscle hyptonia. Additional clinical symptoms include oligohydramnios and
growth
retardation during pregnancy, low birth weight, delayed speech development,
pyramidal signs, short stature, mildly elevated serum and cerebrospinal fluid
lactate
levels, and myocyte complex IV deficiency. The mutation has been identified as
a
homozygous c.154A-C transversion in exon 2 of the COX20 gene, resulting in a
T52P
substitution at a highly conserved residue at the interface between the inner-
membrane embedded region and the predicted mitochondrial matrix-localized loop

fragment. The COX2 gene encodes cytochrome c oxidase protein 20, which plays a

role in the assembly of mitochondrial complex W and interacts with cytochrome
c
oxidase subunit II.
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7. Friedreich's Ataxia
[0149] Friedreich's ataxia is an autosomal recessive neurodegenerative
disorder
caused by a mutation in the FXN gene, which encodes frataxin. Frataxin is a
nuclear-
encoded mitochondrial iron chaperone that is localized to the inner
mitochondrial
membrane and involved in iron-sulfur biogenesis and heme biosynthesis. The
most
common molecular abnormality is a GAA trinucleotide repeat expansion in intron
1
of the FXN gene. Whereas normal individual have 5 to 30 GAA repeat expansions,

individuals affected with Friedreich's ataxia have from 70 to more than 1,000
GAA
triplets.
[0150] Friedreich's ataxia is characterized by progressive gait and limb
ataxia with
associated limb muscle weakness, absent lower limb reflexes, extensor plantar
responses, dysarthria, and decreased vibratory sense and proprioception. Other

features include visual defects, scoliosis, pes cavus, and cardiomyopathy.
Onset
typically occurs in the first or second decade. Affected individuals who
develop
Friedreich's ataxia between ages 26 and 39 are considered to have late-onset
Friedreich's ataxia (LOFA). When the signs and symptoms begin after age 40 the

condition is called very late-onset Friedreich's ataxia (VLOFA). LOFA and
VLOFA
usually progress more slowly than typical Friedreich's ataxia.
8. Infantile Onset Spinocerebellar Ataxia
[0151] Infantile onset spinocerebellar ataxia (IOSCA), also known as
Mitochondrial
DNA Depletion Syndrome-7, is an autosomal recessive severe neurodegenerative
disorder caused by a homozygous or compound heterozygous mutation in the
nuclear-
encoded C100RF2 gene, which encodes the twinkle and twinky proteins. Twinkle
is
a mitochondrial protein involved in mtDNA metabolism. The C100RF2 gene
mutations that cause IOSCA interfere with the function of twinkle resulting in

mtDNA depletion. IOSCA is associated with the following C100RF2 mutations:
P83S/R463W; Y508C/A318T; Y508C/R29X; T4511/T4511; c.1460C-T
(T487I)/c.1485-1G-A; and 1472C-T.
[0152] IOSCA is characterized by hypotonia, ataxia, ophthalmoplegia, hearing
loss,
seizures, sensory axonal neuropathy, reduced mental capacity, and mtDNA
depletion
in the brain and liver. Individuals affected with IOSCA often develop
autonomic
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CA 02920272 2016-02-09
nervous system disorders and experience excessive sweating, incontinence, and
constipation.
9. Leukoencephalopathy with Brain Stem and Spinal Cord Involvement and
Lactate Elevation
[0153] Leukoencephalopathy with brainstem and spinal cord involvement and
lactate elevation (LBSL) is an autosomal recessive disorder that can be caused
by
homozygous or compound heterozygous mutations in the gene encoding
mitochondrial aspartyl-tRNA synthetase (DARS2). The mutation results in
reduced
aspartyl-tRNA synthetase activity.
[0154] LBSL is defined by a highly characteristic constellation of
abnormalities
observed by magnetic resonance imaging and spectroscopy. These include a
pattern
of inhomogeneous cerebral white matter abnormalities, selective involvement of

brainstem and spinal tracts, and increased lactate in the abnormal white
matter.
Affected individuals develop slowly progressive cerebellar ataxia, spasticity,
and
dorsal column dysfunction, sometimes with a mild cognitive deficit or decline.
Onset
typically occurs between three and fifteen years of age.
10. Autosomal Recessive Spastic Ataxia-3
[0155] Autosomal recessive spastic ataxia-3 (SPAX3), also known as autosomal
recessive spastic ataxia with leukoencephalopathy (ARSAL), is caused by
homozygous or compound heterozygous complex genomic rearrangements involving
the MARS2 gene, which encodes mitochondrial methionyl-tRNA synthetase
(mtMetRS), a protein localized to the mitochondrial matrix. The protein shares
a high
degree of identity with methionyl-tRNA synthetases from other mammals.
Mutations
in MARS2 result in reduced protein levels. Some affected individuals have a
heterozygous 268-bp deletion in the MARS2 gene, resulting in a frameshift and
premature termination (c.681de1268bpfs236Ter). Other affected individuals have

duplications of the MARS2 gene.
[0156] SPAX3 is a progressive disease characterized by ataxia, dysarthria,
horizontal nystagmus, spasticity, hyperreflexia, urinary urgency, scoliosis,
dystonia,
cognitive impairment, optic atrophy, cataract, hearing loss, cerebellar
atrophy, cortical
atrophy, leukoencephalopathy, and complex I deficiency. The disease usually
manifests between birth and fifty-nine years of age.
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11. MIRAS and SANDO
[0157] Mitochondrial recessive ataxia syndrome (MIRAS) and sensory ataxia
neuropathy dysarthria and ophthalmoplegia (SANDO) are disorders that fall
under a
group of conditions known as the ataxia neuropathy spectrum. Ataxia neuropathy

spectrum is caused by mutations in the POLG gene, and, rarely, the C100RF2
gene.
The POLG gene encodes DNA polymerase gamma, which functions in the replication

of mitochondrial DNA. The POLG protein is composed of a C-terminal polymerase
domain and an amino-terminal exonuclease domain. The exonuclease domain
increases the fidelity of mitochondrial DNA replication by conferring a
proofreading
activity to the enzyme.
[0158] MIRAS is associated with W748S and E1143G cis, and homozygous W748S
or A467T POLG1 mutations. Clinical symptoms of MIRAS include ataxia,
polyneuropathy, reduced muscle strength, cramps, epilepsy, cognitive
impairment,
athetosis, tremor, obesity, eye movement disorders, cerebellar atrophy, white
matter
changes, muscle denervation, and, rarely, mitochondrial alterations. MIRAS
onset
typically occurs between five and thirty-eight years of age.
[0159] SANDO is commonly associated with a compound heterozygous or
homozygous A467T mutation. Other mutations associated with SANDO include
N468D, G517V, G737R, R1138C, and E1143G missense mutations. SANDO is a
progressive disease characterized by neuropathy causing sensory loss, variable

alterations in strength, ataxia, absent or reduced tendon reflexes, ptosis,
ophthalmoplegia, dysarthria, facial weakness, myoclonic epilepsy, and
depression.
Additional features include elevated serum and cerebrospinal fluid lactate
levels,
spinocerebellar and dorsal column tract degeneration, thalamic lesions,
cerebellar
atrophy or white matter changes, multiple mtDNA deletions, ragged red fibers,
loss of
myelinated and unmyelinated axons, posterior column atrophy, dorsal root
ganglia
neuron loss, reduced mtDNA number in affected neurons, and reduced activity of

mitochondrial complexes I and IV.
12. Mitochondrial Spinocerebellar Ataxia and Epilepsy
[0160] Mitochondrial spinocerebellar ataxia and epilepsy (MSCAE) is a disorder

comprising spinocerebellar ataxia, peripheral neuropathy, and epilepsy. Onset
typically occurs during second and third decades and can be with ataxia or
epilepsy,

CA 02920272 2016-02-09
but all patients with MSCAE will develop ataxia if they survive, while only
approximately 80% will develop epilepsy. Other clinical features include
migraine,
myoclonus or myoclonic seizures, high T2 signal in the thalamus, occipital
cortex,
and cerebellum, cerebellar atrophy, enlarged olives, stroke-like lesions,
mtDNA
depletion in neurons, and progressively reduced complex I. Several POLG1
mutations are associated with this disorder, the most common being the c.1399G-
A
that gives p.A467T, the c.2243G-C giving the p.W748S, and the Gln497His
mutation.
13. Spastic Ataxia with Optic Atrophy
[0161] Spastic ataxia with optic atrophy (SPAX4) is a slowly progressive
autosomal
recessive neurodegenerative disease characterized by cerebellar ataxia,
spastic
paraparesis, dysarthria, and optic atrophy. SPAX4 is associated with mutations

affecting the MTPAP gene, resulting in a defect of mitochondrial mRNA
maturation.
One particular mutation is a homozygous N478D missense mutation. The MTPAP
gene encodes a polymerase that is a member of the DNA polymerase type-B-like
family. The enzyme synthesizes the 3' poly(A) tail of mitochondrial
transcripts and
plays a role in replication-dependent histone mRNA degradation. Affected
individuals exhibit decreased poly(A) tail length of mitochondrial transcripts

including those for COX1 and RNA14.
14. Mitochondrial Complex I Deficiency
[0162] Mitochondrial complex I deficiency (MT-C1D) is a disorder of the
mitochondrial respiratory chain associated with mutations in the NUBPL gene.
The
NUBPL gene encodes a member of the Mrp/NBP35 ATP-binding proteins family.
The encoded protein is required for the assembly of complex I (NADH
dehydrogenase), located in the mitochondrial inner membrane. MT-C1D is
characterized by a wide variety of clinical manifestations ranging from lethal
neonatal
disease to adult-onset neurodegenerative disorders including macrocephaly with

progressive leukodystrophy, non-specific encephalopathy, cardiomyopathy,
myopathy, liver disease, Leigh Syndrome, LHON, and some forms of Parkinson's
disease.
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15. Progressive External Ophthalmoplegia with Mitochondrial DNA Deletions
Autosomal Dominant Type 5
[0163] Progressive external ophthalmoplegia with mitochondrial DNA deletions
autosomal dominant type 5 (PEOA5) can be either an autosomal dominant or
recessive disorder caused by mutations in the nuclear-encoded RRM2B gene.
Recessive inheritance of PEOA5 is associated with homozygous or compound
heterozygous missense variations in the RRM2B gene. PEOA5 is characterized by
progressive weakness of ocular muscles and levator muscle of the upper eyelid.
In a
minority of cases, it is associated with skeletal myopathy, which
predominantly
involves axial or proximal muscles and which causes abnormal fatigability.
Ragged
red fibers and atrophy are found on muscle biopsy. Additional symptoms may
include cataracts, hearing loss, sensory axonal neuropathy, ataxia,
depression,
hypogonadism, and Parkinsonism.
16. Mitochondrial Complex III Deficiency Nuclear Type 2
[0164] Mitochondrial complex III deficiency nuclear type 2 (MC3DN2) is an
autosomal recessive severe neurodegenerative disorder caused by a homozygous
or
compound heterozygous mutation in the nuclear-encoded TTC19 gene. The TTC19
gene encodes tetratricopeptide repeat protein 19, a subunit of mitochondrial
respiratory chain complex III, which transfers electrons from coenzyme Q to
cytochrome c. This electron transfer contributes to the extrusion of protons
across the
inner mitochondrial membrane and contributes to the mitochondrial
electrochemical
potential. Mutations in the TTC19 gene include Leu219X and G1n173X nonsense
mutations.
[0165] MC3DN2 presents in childhood, but may show later onset, even in
adulthood. Affected individuals have motor disability, with ataxia, apraxia,
dystonia,
and dysarthria, associated with necrotic lesions throughout the brain. Most
patients
also have cognitive impairment and axonal neuropathy and become severely
disabled
later in life. The disorder may present clinically as spinocerebellar ataxia
or Leigh
Syndrome, or with psychiatric disturbances. Complex III deficiency is observed
on
muscle biopsy.
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17. Episodic Encephalopathy due to Thiamine Pyrophosphokinase Deficiency
[0166] Episodic encephalopathy due to thiamine pyrophosphokinase deficiency,
also known as Thiamine Metabolism Dysfunction Syndrome-5 (THMD5), is an
autosomal recessive thiamine metabolism disorder caused by a homozygous or
compound heterozygous mutation in the TPK1 gene. The TPK1 gene encodes
thiamine pyrophosphokinase (TPK), an enzyme involved in the regulation of
thiamine
metabolism. TPK catalyzes the conversion of thiamine, a form of vitamin Bl, to

thiamine pyrophosphate (TPP). Thymine pyrophosphate is an active cofactor for
enzymes involved in glycolysis and energy production, including transketolase,

pyruvate dehydrogenase, and alpha-ketoglutarate dehydrogenase.
[0167] Onset of episodic encephalopathy due to thiamine pyrophosphokinase
deficiency typically occurs between one and four years of age. Affected
individuals
present with a highly variable phenotype characterized by progressive
neurologic
dysfunction manifested as ataxia, dystonia, spasticity, inability to walk,
mildly
delayed developments, and increased serum and cerebrospinal fluid lactate
levels.
Other clinical features include exacerbated encephalopathy during an
infection,
hypotonia, microcephaly, epilepsy, and ophthalmoplegia.
Dominant Ataxia Syndromes
1. Spinocerebellar Ataxia-28
[0168] Spinocerebellar ataxia-28 (SCA28) is an autosomal dominant disorder
caused by heterozygous mutation in the AFG3L2 gene. The AFG3L2 gene encodes
the AFG3-like protein 2 (AFG3L2), an ATP-dependent protease localized to the
mitochondrial inner membrane where it forms the catalytic subunit of the m-AAA

protease, which degrades misfolded proteins and regulates ribosome assembly.
Mutations associated with SCA28 include the following missense mutations:
N432T;
S674L; E691K; A694E; R702Q; and Y689H. SCA28 is characterized by cerebellar
ataxia, dysarthria, nystagmus, ophthalmoparesis, ptosis, slow saccades,
hyperreflexia
in legs, extensor plantar response, leg and arm spasticity, myoclonic
epilepsy, and
cerebellar atrophy.
2. Autosomal Dominant Cerebellar Ataxia, Deafness, and Narcolepsy
[0169] Autosomal dominant cerebellar ataxia, deafness, and narcolepsy (ADCA-
DN) is caused by heterozygous mutation in the DNMT1 gene. The DNMT1 gene
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encodes DNA (cytosine-5)-methyltransferases (DNMTs), such as DNMT1, which
maintain patterns of methylated cytosine residues in the mammalian genome.
Methylation patterns are responsible for the repression of parasitic sequence
elements
and the expression status of genes subject to genomic imprinting and X
inactivation.
Faithful maintenance of methylation patterns is required for normal mammalian
development, and aberrant methylation patterns are associated with certain
human
tumors and developmental abnormalities. Mutations of DNMT1 associated with the

development of ADCA-DN include the following missense mutations: Ala570Val;
Cys596Arg; and Va1606Phe.
[0170] ADCA-DN is characterized by adult onset of progressive cerebellar
ataxia,
narcolepsy/cataplexy, sensorineural deafness, and dementia. More variable
features
include optic atrophy, sensory neuropathy, psychosis, and depression.
Increased lipid
levels are observed on muscle biopsy.
3. Optic Atrophy-1
[0171] Optic atrophy-1 (OPA1) is an autosomal dominant optic atrophy caused by

heterozygous mutation in the OPA1 gene encoding a dynamin-like 120 kDa GTPase
that localizes to the inner mitochondrial membrane where it regulates cellular

processes including the stability of the mitochondrial network, mitochondrial
bioenergetics output, and the sequestration of pro-apoptotic cytochrome c
oxidase
molecules within the mitochondrial cristae spaces. OPA1 directly interacts
with
subunits of complexes I, II, and III, and an apoptosis inducing factor. Over
100
different OPA1 mutations have been identified, most of which are localized in
the
GTPase domain of the OPA1 protein. OPA1 mutations can cause oxidative
phosphorylation defects at the level of complex I, impairment in mitochondrial
ATP
synthesis driven by complex I substrates, fibroblasts which are more prone to
death,
and abnormal mitochondrial morphology.
[0172] OPA1 is characterized by an insidious onset of visual impairment in
early
childhood with moderate to severe loss of visual acuity, temporal optic disc
pallor,
color vision deficits, and centrocecal scotoma of variable density. Some
patients with
mutations in the OPA1 gene may also develop extraocular neurologic features,
such
as deafness, progressive external ophthalmoplegia, muscle cramps,
hyperreflexia, and
ataxia.
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Variable Ataxia Syndromes
1. CAPOS Syndrome
[0173] Cerebellar ataxia, areflexia, pes cavus, optic atrophy, and
sensorineural
hearing loss (CAPOS) syndrome is a neurologic disorder associated with
heterozygous mutation in the ATP1A3 gene. The ATP1A3 gene encodes a Na+/K+
ATPase subunit a3, which forms a catalytic component of the active enzyme that

catalyzes the hydrolysis of ATP coupled with the exchange of sodium and
potassium
ions across the plasma membrane.
[0174] CAPOS is characterized by early-childhood onset of recurrent episodes
of
acute ataxic encephalopathy associated with febrile illnesses. These acute
episodes
tend to decrease with time, but the neurologic sequelae are permanent and
progressive, resulting in gait and limb ataxia and areflexia. Affected
individuals also
develop progressive visual impairment due to optic atrophy and sensorineural
hearing
loss beginning in childhood. More variable features include abnormal eye
movements, pes cavus, and dysphagia.
2. Spinocerebellar Ataxia 7
[0175] Spinocerebellar ataxia 7 (SCA7) is caused by an expanded trinucleotide
repeat in the gene encoding ataxin-7 (ATXN7). The ATXN7 gene encodes ataxin 7,
a
transcription factor that appears to be critically important for chromatin
remodeling at
the level of histone acetylation and deubiquitination. SCA7 is a
neurodegenerative
disorder characterized by adult onset of progressive ataxia associated with
pigmental
macular dystrophy. Associated neurologic signs, such as ophthalmoplegia,
pyramidal
or extrapyramidal signs, deep sensory loss, or dementia, are also variable.
Barth Syndrome
[0176] Barth Syndrome is a heritable disorder of phospholipid metabolism
characterized by dilated cardiomyopathy (DCM), skeletal myopathy, neutropenia,

growth delay and organic aciduria. The prevalence of Barth Syndrome is
estimated at
1/454,000 live births, with an estimated incidence ranging from 1/400,000 to
1/140,000 depending on geographic location. Barth Syndrome is an X-linked
disorder, and so disproportionately affects male patients.

CA 02920272 2016-02-09
[0177] Barth Syndrome is caused by mutations in the TAZ gene (tafazzin).
Defective TAZ1 function results in abnormal remodeling of cardiolipin and
compromises mitochondrial structure and respiratory chain function. TAZ1 is
expressed at high levels in cardiac and skeletal muscle and is involved in the

maintenance of the inner membrane of mitochondria. TAZ1 is involved in
maintaining levels of cardiolipin, which is essential for energy production in
the
mitochondria.
[0178] Clinical presentation of Barth Syndrome is highly variable. Most
subjects
develop DCM during the first decade of life, and typically during the first
year of life,
which may be accompanied by endocardial fibroelastosis (EFE) and/or left
ventricular
noncompaction (LVNC). The manifestations of Barth Syndrome may begin in utero,

causing cardiac failure, fetal hydrops and miscarriage or stillbirth during
the 2nd/3rd
trimester of pregnancy. Ventricular arrhythmia, especially during adolescence,
can
lead to sudden cardiac death. There is a significant risk of stroke. Skeletal
(mostly
proximal) myopathy causes delayed motor milestones, hypotonia, severe lethargy
or
exercise intolerance. There is a tendency to hypoglycemia during the neonatal
period.
Ninety percent of patients show mild to severe intermittent or persistent
neutropenia
with a risk of septicemia, severe bacterial sepsis, mouth ulcers and painful
gums.
Lactic acidosis and mild anemia may occur. Affected boys usually show delayed
puberty and growth delay that is observed until the late teens or early
twenties, when a
substantial growth spurt often occurs. Patients may also present severe
difficulties
with adequate food intake. Episodic diarrhea is common. Many patients have a
similar facial appearance with chubby cheeks, deep-set eyes and prominent
ears.
Skewed X chromosome inactivation is common in female carriers.
Biotinidase Deficiency
[0179] Biotinidase deficiency is an autosomal recessive metabolic disorder
associated with mutations in the BTD gene. In biotinidase deficiency, biotin
is not
released from proteins in the diet during digestion or from normal protein
turnover in
the cell. Biotinidase deficiency is associated with mutations in the BTD gene.
Biotin,
also called vitamin B7, is an important water-soluble nutrient that aids in
the
metabolism of fats, carbohydrates, and proteins. Biotin deficiency can result
in
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behavioral disorders, lack of coordination, learning disabilities and
seizures. Biotin
supplementation can alleviate and sometimes totally arrest such symptoms
Blindness
1. Gyrate Atrophy
[0180] Gyrate atrophy of the choroid and retina is caused by a homozygous or
compound heterozygous mutation in the OAT gene and is usually observed in
Finnish
families. Gyrate atrophy of the choroid and retina due to deficiency of
ornithine
aminotransferase typically begins in late childhood and is clinically
characterized by a
triad of progressive chorioretinal degeneration, early cataract formation, and
type II
muscle fiber atrophy. Characteristic chorioretinal atrophy with progressive
constriction of the visual fields leads to blindness at the latest during the
sixth decade
of life. Clinical symptoms include night-blindness, weakness, glutei atrophy,
scapular
winging, type 2 muscular atrophy, tubular aggregation, mental retardation,
hyperornithinemia, and white matter lesions.
2. Dominant Optic Atrophy
[0181] Dominant optic atrophy (DOA), also known as Kjer's optic neuropathy, is
an
autosomally inherited neuro-ophthalmic disease characterized by a bilateral
degeneration of the optic nerves, causing insidious visual loss, typically
starting
during the first decade of life. The disease affects primarily the retinal
ganglion cells
(RGC) and their axons forming the optic nerve, which transfer the visual
information
from the photoreceptors to the lateral geniculus in the brain. Vision loss in
DOA is
due to optic nerve fiber loss from mitochondria dysfunction. DOA patients
usually
suffer of moderate visual loss, associated with central or paracentral visual
field
deficits and color vision defects. The severity of the disease is highly
variable, the
visual acuity ranging from normal to legal blindness. An ophthalmic
examination of a
subject with DOA presents isolated optic disc pallor or atrophy, related to
the RGC
death. About 20% of DOA patients harbor extraocular multi-systemic features,
including neurosensory hearing loss, or less commonly chronic progressive
external
ophthalmoplegia, myopathy, peripheral neuropathy, multiple sclerosis-like
illness,
spastic paraplegia or cataracts.
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[0182] Two genes (OPA1, OPA3), which encode inner mitochondrial membrane
proteins, and three loci (OPA4, OPA5, OPA8) are known to cause DOA. All OPA
genes identified encode mitochondrial proteins embedded in the inner membrane
and
are ubiquitously expressed. OPA1 mutations affect mitochondrial fusion, energy

metabolism, control of apoptosis, calcium clearance and maintenance of
mitochondrial genome integrity. OPA3 mutations only affect the energy
metabolism
and the control of apoptosis. OPA1 is the major gene responsible for DOA.
[0183] In most cases, DOA presents as a non-syndromic, bilateral optic
neuropathy.
Although DOA is usually diagnosed in school-aged children complaining of
reading
problems, the condition can manifest later, during adult life. On fundus
examination,
the optic disk typically presents a bilateral and symmetrical pallor of its
temporal side
with the loss of RGC fibers entering the optic nerve. The optic nerve rim is
atrophic
and a temporal grey crescent is often present. Optic disc excavation may also
be
present. Optical Coherence Tomography (OCT) discloses the reduction of the
thickness of the peripapillary retinal nerve fiber layer in all four
quadrants, but does
not disclose alteration of other retinal layers. The visual field typically
shows a
cecocentral scotoma, and less frequently a central or paracentral scotoma,
while
peripheral visual field remains normal. Importantly, there is a specific
tritanopia, i.e.,
a blue-yellow axis of color confusion, which, when found, is strongly
indicative of
DOA. The pupillary reflex and circadian rhythms are not affected, suggesting
that the
melanopsin RGC are spared during the course of the disease.
[0184] In Syndromic Dominant Optic Atrophy and Deafness (Syndromic DOAD)
and Dominant Optic Atrophy plus (D0Aplus) patients experience full penetrance
and
usually more severe visual deficits. DOAD and DOAplus with extra-
ophthalmological abnormalities represent up to 20% of DOA patients with an
OPA1
mutation. The most common extra-ocular sign in DOA is sensorineural hearing
loss,
but other associated findings may occur later during life (e.g., myopathy and
peripheral neuropathy), suggesting that there is a continuum of clinical
presentations
ranging from a mild "pure DOA" affecting only the optic nerve to a severe and
multi-
systemic presentations. Sensorineural hearing loss associated to DOA may range

from severe and congenital to subclinical with intra- and inter- familial
variations, and
mostly segregate with the OPA1 R445H (c.1334G>A) mutation. In general,
auditory
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CA 02920272 2016-02-09
brain stem responses, which reflect the integrity of the auditory pathway from
the
auditory nerve to the inferior colliculus, are absent, but both ears show
normal evoked
otoacoustic emissions, reflecting the functionality of presynaptic elements
and in
particular that of the outer hair cells.
3. LHON
[0185] Leber's hereditary optic neuropathy (LHON) is a maternally inherited
blinding disease with variable penetrance. LHON is usually due to one of three

pathogenic mitochondrial DNA (mtDNA) point mutations. These mutations are at
nucleotide positions 11778 G to A, 3460 G to A and 14484 T to C, respectively
in the
MTND4, MTND1 and MTND6 subunit genes of complex I of the oxidative
phosphorylation chain in mitochondria. Reduced efficiency of ATP synthesis and

increased oxidative stress are believed to sensitize the retinal ganglion
cells to
apoptosis.
[0186] Leber's hereditary optic neuropathy (LHON) is characterized by severe
visual loss, which usually does not manifest until young adulthood. Maternal
transmission is due to a mitochondrial DNA (mtDNA) mutation affecting
nucleotide
positions (nps) 11778/ND4, 14484/ ND6, or 3460/ND1. These three mutations,
affecting respiratory complex I, account for about 95% of LHON cases. Patients

inherit multicopy mtDNA entirely from the mother (via the oocyte). The
mitochondria may carry only wild-type or only LHON mutant mtDNA
(homoplasmy), or a mixture of mutant and wild-type mtDNA (heteroplasmy). Only
high loads of mutant heteroplasmy or, most frequently, homoplasmic mutant
mtDNA
in the target tissue put the subject at risk for blindness from LHON. Except
for
patients carrying the 14484/ND6 mutation (who present with a more benign
disease
course), most patients remain legally blind. Typically, a subject in his
second or third
decade of life will present with abrupt and profound loss of vision in one
eye,
followed weeks to months later by similar loss of vision in the other eye.
LHON may
occur later in life and affects both men and women. Environmental factors may
trigger the visual loss but do not fully explain why only certain individuals
within a
family become symptomatic. Additional symptoms include disc microangiopathy,
pseudo disc edema, vascular tortuosity, optic atrophy, cardiac conduction
defects,
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CA 02920272 2016-02-09
spastic paraparesis, sexual and urinary disturbances, Sudden Infant Death
Syndrome,
abnormal visual evoked potentials, spastic dystonia and encephalopathy.
[0187] Disruptions in ND4 can also lead to spastic paraparesis which is
associated
with leg stiffness, abnormal visual evoked potentials and sexual and urinary
disturbances.
4. Wolfram Syndrome 1
[0188] Wolfram Syndrome-1 (WFS1) is a rare and severe autosomal recessive
neurodegenerative disease caused by homozygous or compound heterozygous
mutations in the wolframin gene. Wolframin encodes an endoglycosidase H-
sensitive
glycoprotein that is expressed in the heart, brain, pancreas, liver, kidney,
skeletal
muscle, hippocampus CA 1, amygdaloid areas, olfactory tubercle and allocortex.

WFS1 is characterized by diabetes mellitus, optic atrophy, diabetes insipidus,
and
deafness (DIDMOAD). Additional clinical features may include renal
abnormalities,
ataxia, Nystagmus, polyneuropathy, central respiratory failure, myoclonus,
seizures,
organic brain syndrome, dementia or mental retardation, urinary tract atony,
orthostatic hypotension, gastroparesis, and diverse psychiatric illnesses. The
minimal
diagnostic criteria for Wolfram Syndrome are optic atrophy and diabetes
mellitus of
juvenile onset. Hearing impairment in Wolfram Syndrome is typically
progressive
and mainly affects the higher frequencies, but a small fraction of affected
individuals
have congenital deafness.
[0189] Autosomal dominant mutations in the WFS1 gene have been found to cause
low-frequency nonsyndromic deafness as well as a Wolfram Syndrome-like
phenotype in which affected individuals have hearing impairment with diabetes
mellitus and/or optic atrophy.
[0190] Some cases of Wolfram Syndrome of early-onset diabetes mellitus, optic
atrophy, and deafness may have their basis in a mitochondrial mutation, such
as a 7.6-
kb heteroplasmic deletion of mtDNA extending from nucleotide 6466 to
nucleotide
14134, inclusive. Some patients exhibit mild hyperlactatemia or morphologic
and
biochemical abnormalities of the mitochondria. A high percentage of DIDMOAD
patients harbor so-called secondary LHON mutations, and both DIDMOAD and
LHON patients are concentrated in 2 different mitochondrial haplotypes defined
by

CA 02920272 2016-02-09
sets of polymorphisms in ND and tRNA genes. Thus, the different clinical
features of
the mitochondrial disease groups investigated correspond to different clusters
of
mtDNA variants, which might act as predisposing haplotypes, increasing the
risk for
the given disease.
5. Wolfram Syndrome 2
[0191] Wolfram Syndrome-2 (WFS2) is an autosomal recessive neurodegenerative
disorder caused by homozygous mutations in the CISD2 (ERIS) gene, which
encodes
CDGSH iron sulfur domain protein 2. CISD2 is an endoplasmic reticulum-
localized
zinc finger protein that is expressed in pancreas, brain and other tissues.
WFS2 is
characterized by diabetes mellitus, mild diabetes insipidus, high frequency
sensorineural hearing loss, optic atrophy or neuropathy, urinary tract
dilatation, and
defective platelet aggregation resulting in peptic ulcer bleeding.
6. Age-related Macular Degeneration
[0192] Age-related macular degeneration (ARMD) is a common complex disorder
that affects the central region of the retina and is the leading cause of
blindness in
Caucasian Americans over 65 years of age. Susceptibility to ARMD is associated

with mutations in the ARMS2 gene, which encodes a deduced 107-amino acid
protein
with nine predicted phosphorylation sites and a molecular mass of 12 kD. The
ARMS2 protein is localized to the mitochondrial outer membrane.
Brunner Syndrome
[0193] Brunner Syndrome is a form of X-linked non-dysmorphic mild mental
retardation. Two monoamine oxidase isoenzymes, monoamine oxidase A (MAOA)
and monoamine oxidase B (MAOB), are closely linked in opposite orientation on
the
X chromosome and are expressed in the outer mitochondrial membrane. MAOA and
MAOB oxidize neurotransmitters and dietary amines, the regulation of which is
important to the maintenance of normal mental states. MAOA prefers the
monoamines serotonin, norepinephrine, and dopamine as substrates, while MAOB
prefers phenylethylamine. Brunner Syndrome is caused by an MAOA deficiency,
which results in an accumulation of serotonin, dopamine, and epinephrine, in
the
brain. Mutations in the MAOA gene have been associated with aggressive,
violent,
impulsive, autistic, and antisocial behaviors.
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CA 02920272 2016-02-09
Cardiomyopathy
1. Left Ventricular Noncompaction
[0194] Left ventricular noncompaction-1 (LVNC1) is caused by a heterozygous
mutation in the alpha-dystrobrevin gene and is characterized by numerous
prominent
trabeculations and deep intertrabecular recesses in hypertrophied and
hypokinetic
segments of the left ventricle.
[0195] The developing myocardium gradually condenses, and the large spaces
within the trabecular meshwork flatten or disappear. Isolated noncompaction of

ventricular myocardium, sometimes called spongy myocardium or persisting
myocardial sinusoids, represents an arrest in endomyocardial morphogenesis,
and is
characterized by numerous, excessively prominent trabeculations and deep
intertrabecular recesses. LVNC may occur in isolation or in association with
congenital heart disease. Distinctive morphologic features can be recognized
on 2-
dimensional echocardiography. Clinical manifestations of the disorder included

depressed left ventricular systolic function, ventricular arrhythmias,
systemic
embolization, and distinctive facial dysmorphism.
[0196] The clinical presentation of left ventricular noncompaction is highly
variable, ranging from asymptomatic to severe heart failure and sudden death.
Higher
occurrence of familial cases, facial dysmorphism, and congenital arrhythmias
such as
Wolff-Parkinson-White Syndrome are observed in children, whereas secondary
arrhythmias, such as atrial fibrillation, are more common in adults. The mode
of
inheritance is predominantly autosomal dominant, and sarcomere protein
mutations
are more common in adults.
2. Infantile Histiocytoid Cardiomyopathy
[0197] Histiocytoid cardiomyopathy goes by various names, including infantile
xanthomatous cardiomyopathy, focal lipid cardiomyopathy, oncocytic
cardiomyopathy, infantile cardiomyopathy with histiocytoid change, and foamy
myocardial transformation of infancy. The disorder is caused by mutations in
the
gene encoding mitochondrial cytochrome b (MTCYB) and is a rare but distinctive

entity of infancy and childhood characterized by the presence of
characteristic pale
granular foamy histiocyte-like cells within the myocardium. It usually affects
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CA 02920272 2016-02-09
children younger than 2 years of age, with a clear predominance of females
over
males. Infants present with dysrhythmia or cardiac arrest, and the clinical
course is
usually fulminant, sometimes simulating Sudden Infant Death Syndrome. Clinical

features include high frequency of anomalies involving the nervous system and
eyes
and of oncocytic cells in various glands. Because of the large number of
mitochondria present in the histiocytoid cells, they resemble oncocytes. Other

disorders involving MTCYB mutations include exercise intolerance, myopathy,
LHON, Familial Myalgia Syndrome, colorectal cancer, encephalomyopathy,
Parkinsonism, and susceptibility to obesity.
3. Cardioencephalomyopathy with Cytochrome c Oxidase Deficiency
(CEMCOX1)
[0198] Fatal infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX) deficiency-1 (CEMCOX1) can be caused by a compound heterozygous
mutation in the SCO2 gene, a COX assembly gene on chromosome 22q13. Another
form of fatal infantile cardioencephalomyopathy due to COX deficiency, CEMCOX2

is caused by mutations in the COX15 gene on chromosome 10q24. Age of onset for

infantile cardioencephalomyopathy is usually within the first 3 months of
infancy and
is equally prevalent between males and females. Infants usually die at 6
months.
[0199] Infants with COX deficiency caused by a mutation in the SCO2 gene
present
with a fatal infantile cardioencephalomyopathy characterized by hypertrophic
cardiomyopathy, lactic acidosis, and gliosis. Heart and skeletal muscle show
reductions in COX activity, whereas liver and fibroblasts show mild COX
deficiencies. Patients show a severe reduction of the mitochondrial-encoded
COX I
and II subunits, whereas the nuclear-encoded COX subunits IV and Va are
present but
reduced in intensity. Clinical features include hypotonia, limb spasticity,
muscle
atrophy or denervation, respiratory difficulties, increased blood and CSF
lactate,
hypertrophic cardiomyopathy, seizures, psychomotor retardation, Leigh-like
Syndrome, neutropenia, ptosis, gliosis, ophthalmoplegia, encephalopathy, and
severely reduced COX activity.
4. Sengers Syndrome: Cardiomyopathy, Hypertrophic & Cataracts
[0200] Sengers Syndrome, also known as cardiomyopathic mitochondrial DNA
depletion syndrome-10 (MTDPS10), is caused by a homozygous or compound
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CA 02920272 2016-02-09
heterozygous mutation in the AGK gene. Sengers Syndrome is an autosomal
recessive mitochondrial disorder characterized by congenital cataracts,
hypertrophic
cardiomyopathy, skeletal myopathy, exercise intolerance, and lactic acidosis.
Mental
development is normal, but affected individuals may die early from
cardiomyopathy.
Skeletal muscle biopsies of affected individuals show severe mtDNA depletion.
[0201] While several pieces of evidence pointed indirectly to the involvement
of
oxygen free radicals in the etiology of cardiomyopathy with cataracts, direct
evidence
showed that complex I deficiency is associated with an excessive production of

hydroxyl radicals and lipid peroxidation. Patients with isolated
NADH:ubiquinone
oxidoreductase deficiency (or complex I deficiency) most commonly present with

fatal neonatal lactic acidosis or with Leigh disease. Although the clinical
features of
Sengers Syndrome suggest a mitochondrial disorder, no abnormalities are found
on
routine mitochondrial biochemical diagnostics, viz., the determination of
pyruvate
oxidation rates and enzyme measurements. Protein content of mitochondrial ANT
1 is
strongly reduced in the muscle tissues of affected patients with Sengers
Syndrome.
Additional clinical phenotypes for cardiomyopathy with cataracts include
hepatopathy, tubulopathy, hypotonia, and mild developmental delay.
5. Cardiofaciocutaneous Syndrome 1 (CFC1)
[0202] Cardiofaciocutaneous Syndrome-1 (CFC1), caused by disruptions in the
BRAF gene, is a multiple congenital anomaly disorder characterized by a
distinctive
facial appearance, heart defects, and mental retardation. The heart defects
include
pulmonic stenosis, atrial septal defect, and hypertrophic cardiomyopathy. Some

patients have ectodermal abnormalities such as sparse and friable hair,
hyperkeratotic
skin lesions, and a generalized ichthyosis-like condition. Typical facial
characteristics
include high forehead with bitemporal constriction, hypoplastic supraorbital
ridges,
downslanting palpebral fissures, a depressed nasal bridge, and posteriorly
angulated
ears with prominent helices. Most cases occur sporadically, but autosomal
dominant
transmission has been rarely reported.
[0203] Disruptions in BRAF gene function may impact the TCA cycle and
oxidative metabolism. Clinical features include atopic dermatitis, ichthyosis,

hyperkeratosis (extensor surfaces), keratosis pilaris, multiple palmar
creases, multiple
lentigines, sparse hair growth, optic nerve dysplasia, increased tendon
reflexes,
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CA 02920272 2016-02-09
extensor plantar response, increased sensitivity to light touch, mental
retardation,
seizures, cortical atrophy, hypoplasia, ptosis, strabismus, oculomotor
apraxia,
nystagmus, hypertelorism, exophthalmos, prominent philtrum, micrognathia,
macrocephaly, joint hyperextensibility, osteopenia, clinodactyly, pectus
excavatum or
carinatum, short stature, GI dysmotility, splenomegaly, enlarged mitochondria,

increased frequency of 2C fibers, reduced C0Q10, ventriculomegaly,
hypsarrhythmia;
and focal epileptiform discharges.
6. Trifunctional Protein Deficiency
[0204] Mitochondrial trifunctional protein (MTP) deficiency can be caused by
mutations in the genes encoding either the alpha (HADHA) or beta (HADHB)
subunits of the mitochondrial trifunctional protein. The mitochondrial
trifunctional
protein, composed of 4 alpha and 4 beta subunits, catalyzes 3 steps in
mitochondrial
beta-oxidation of fatty acids: long-chain 3-hydroxyacyl-CoA dehydrogenase
(LCHAD), long-chain enoyl-CoA hydratase, and long-chain thiolase activities.
Trifunctional protein deficiency is characterized by decreased activity of all
3
enzymes. Clinically, classic trifunctional protein deficiency can be
classified into 3
main clinical phenotypes: neonatal onset of a severe, lethal condition
resulting in
sudden unexplained infant death (SIDS), infantile onset of a hepatic Reye-like

syndrome, and late-adolescent onset of primarily a skeletal myopathy.
[0205] Some patients with MTP deficiency show a protracted progressive course
associated with myopathy, recurrent rhabdomyolysis, and sensorimotor axonal
neuropathy. These patients tend to survive into adolescence and adulthood.
Clinical
features include cardiomyopathy, myopathy, liver dysfunction, encephalopathy,
Sudden Infant Death Syndrome, and axonal neuropathy. Variant syndromes
comprising MTP mutations include hepatic with recurrent Hypoketotic
hypoglycemia,
later-onset axonal sensory neuropathy episodic myoglobinuria, and early-
onset
axonal sensory neuropathy.
7. Encephalocardiomyopathy with Cytochrome c Oxidase Deficiency
[0206] Mutations in the nuclear gene C120RF62 have been associated with fatal
infantile encephalocardiomyopathy with cytochrome c oxidase deficiency.
C120RF62 is a membrane-associated protein that localizes to the mitochondria
and
promotes COX I assembly & coupling with assembly of nascent subunits into COX

CA 02920272 2016-02-09
holoenzyme complex. Clinical symptoms include reduced COX activity, neonatal
lactic acidosis, oligoamnios, septum-lucidum cysts, hypotelorism,
microphthalmia,
ogival palate, single palmar crease, hypertrophic cardiomyopathy,
hepatomegaly,
renal hypoplasia, adrenal hyperplasia, brain hypertrophy, white-matter
myelination,
and cavities in parieto-occipital region, brainstem, and cerebellum.
8. Cardiomyopathy + Encephalopathy
[0207] Mutations in NADH-Ubiquinone oxidoreductase Fe-S Protein 2 (NDUFS2)
have been associated with cardiomyopathy + encephalomyopathy. NDUFS2 is a
component of complex I and plays a role in protein transport. The age of onset
for the
disorder is from birth to 7 months. Infants usually die before 2 to 3 years of
age.
Clinical symptoms include axial hypotonia, failure to thrive, hypertrophic
cardiomyopathy, limb hyperreflexia, optic atrophy, nystagmus, progressive
encephalopathy, sleep apnea, high lactate levels in CSF & blood, hypodensities
in
basal ganglia; generalized brain atrophy, and reduced complex I activity.
9. Mitochondrial Phosphate Carrier Deficiency
[0208] Mitochondrial phosphate carrier deficiency can be caused by disruptions
in
SLC25A3, which encodes a mitochondrial solute carrier. SLC25A3 aids in the
import
of inorganic phosphate into mitochondrial matrix and functions in ATP
synthesis.
Mitochondrial phosphate carrier deficiency is characterized by progressive
hypertrophic cardiomyopathy, respiratory failure, hypotonia, high serum
lactate, lipid
accumulation in type I muscle fibers, abnormal mitochondrial network,
defective ATP
synthesis and reduced mitochondrial phosphate carrier activity. Some infants
die in
the 1st year, whereas those that survive to adulthood exhibit exercise
intolerance and
proximal weakness.
10. Fatal infantile Cardioencephalomyopathy, due to Cytochrome c Oxidase
Deficiency 2 (CEMCOX2)
[0209] Fatal infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX) deficiency (CEMCOX2) can be caused by a compound heterozygous mutation
in the COX15 gene. Shortly after birth, patients present with seizures,
hypotonia, and
lactic acidosis. Other clinical symptoms include midface hypoplasia,
biventricular
hypertrophic cardiomyopathy and reduced Complex IV activity. Patients usually
die
within 1 month of life.
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11. Leigh Syndrome
[0210] Leigh Syndrome mutations have been identified in both nuclear- and
mitochondrial-encoded genes involved in energy metabolism, including
mitochondrial
respiratory chain complexes I, II, III, IV, and V, which are involved in
oxidative
phosphorylation and the generation of ATP, and components of the pyruvate
dehydrogenase complex.
[0211] Mutations in complex I genes include mitochondrial-encoded MTND2,
MTND3, MTND5, and MTND6, the nuclear-encoded NDUFS1, NDUFS3, NDUFS4,
NDUFS7, NDUFS8, NDUFA2, NDUFA9, NDUFA10, NDUFA12, NDUFAF6,
FOXRED1, COXPD15 and C200RF7, and the complex I assembly factor
NDUFAF2. A mutation in the MTFMT gene, which is involved in mitochondrial
translation, has also been reported with complex I deficiency.
[0212] Leigh Syndrome is also associated with mutations in complex I
(C80RF38),
complex II (the flavoprotein subunit A (SDHA)); complex III (BCS1L); complex
IV
(MTC03, COX10, COX15, 5CO2, SURF1, TAC01, and PET100); complex V
(MTATP6); mitochondrial tRNA proteins (MTTV, MTTS2, MTTK, MTTW, and
MTTL1); components of the pyruvate dehydrogenase complex (e.g., DLD and
PDHA1); the LRPPRC gene; and coenzyme Q10.
[0213] Leigh Syndrome is an early-onset progressive neurodegenerative disorder

with a characteristic neuropathology consisting of focal, bilateral lesions in
one or
more areas of the central nervous system, including the brainstem, thalamus,
basal
ganglia, cerebellum, and spinal cord. Age of onset is around 1 year and
patients
usually die within 2 years of onset. The lesions are areas of demyelination,
gliosis,
necrosis, spongiosis, or capillary proliferation. Clinical features also
include
hypotonia, ataxia, vomiting, choreoathetosis, hyperventilation,
encephalopathy, loss
verbal milestones, motor spasticity, abnormal breathing rhythm, hearing loss,
nystagmus, dystonia, visual loss, ophthalmoparesis, optic atrophy, peripheral
neuropathy, intercurrent infection, cog-wheel rigidity, distal renal tubular
acidosis,
limb athetosis, seizures, carbohydrate intolerance, COX deficiency in muscle,
lactic
acidosis with hypoglycemia, kyphoscoliosis, short stature, brisk tendon
reflexes,
obesity, and high lactate levels in CSF. Clinical symptoms depend on which
areas of
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CA 02920272 2016-02-09
the central nervous system are involved. The most common underlying cause is a

defect in oxidative phosphorylation.
[0214] Mutations in NDUFV2, MTND2, MTND5, and MTND6 can result in Leigh
Syndrome due to mitochondrial complex I deficiency. Clinical symptoms include
reduced Complex I activity, hypertrophic cardiomyopathy, developmental delay,
cerebral atrophy, hypoplasia of the corpus callosum, acidosis, seizures, coma,

cardiovascular arrest, demyelinization of corticospinal tracts, subacute
necrotizing
encephalomyelopathy, progressive encephalopathy, respiratory failure, exercise

intolerance, weakness, mitochondrial proliferation in muscle, motor
retardation,
hypotonia, deafness, dystonia, pyramidal features, brainstem events with
oculomotor
palsies, strabismus & recurrent apnea, lactic acidemia, and basal ganglia
lesions.
[0215] Mutations in MTC03 can result in Leigh Syndrome that usually presents
at 4
years of age. Clinical symptoms include spastic paraparesis with
ophthalmoplegia,
high serum lactic acid, Leigh-like lesions in putamen, and reduced COX
activity in
muscle. Mutations also found in MTC03 cause LHON, Myopathy with exercise
intolerance, rhabdomyolysis, episodic encephalopathy, and nonarteritic
ischemic optic
neuropathy (NAION)-Myoclonic epilepsy.
[0216] Mutations in 3-hydroxyisobutyryl-CoA hydrolase (HIBCH) results in f3-
Hydroxyisobutyryl CoA Deacylase (HIBCH) deficiency, a Leigh-like Syndrome that

usually manifests at neonatal to 6 months of age. Symptoms include hypotonia,
regression, poor feeding, dystonia, ataxia, seizures, dysmorphic facies,
vertebral
anomalies, tetralogy of fallot, progressive or acute encephalopathy,
respiratory chain
deficiencies, high CSF lactate, basal ganglia abnormalities, brain agenesis
and
accumulation of metabolites (e.g., methacrylyl-CoA, acryloyl-CoA, hydroxy-C4-
carnitine).
[0217] Mutations in enoyl-CoA hydratase, short-chain, 1 (ECHS1) results in
Short
chain enoyl-CoA hydratase (ECHS1) deficiency, a Leigh-like Syndrome that
presents
at the neonatal stage. ECHS1 catalyzes the second step in mitochondrial fatty
acid (3-
oxidation. Clinical symptoms include hypotonia, respiratory insufficiency or
apnea,
bradycardia, developmental delay, high serum lactate, white matter atrophy,
and
accumulation of metabolites (e.g., methacrylyl-CoA, acryloyl-CoA).
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CA 02920272 2016-02-09
[0218] Mutations in ATP synthase 6 (MTATP6) result in Maternal Inheritance
Leigh Syndrome (MILS). Clinical symptoms include hypotonia, developmental
delay, peripheral neuropathy, seizures, retinitis pigmentosa or optic atrophy,
ataxia,
respiratory failure, bilateral striatal necrosis, hereditary spastic
paraparesis,
myelopathy, limb spasticity, weakness, and sensory loss or pain.
12. Dilated Cardiomyopathy with Ataxia (DCMA)
[0219] 3-methylglutaconic aciduria type V (MGCA5), also called dilated
cardiomyopathy with ataxia (DCMA), is caused by a homozygous mutation in the
DNAJC19 gene on chromosome 3q26. DNAJC19 encodes a DNAJ domain-
containing protein that is localized to the inner mitochondrial membrane (TIM)
and
may be involved in molecular chaperone systems of Hsp70/Hsp40 type.
Mitochondrial import inner membrane translocase subunit TIIM14 may also act as
a
co-chaperone that stimulates the ATP-dependent activity.
[0220] DCMA is an autosomal recessive disorder characterized by the onset of
dilated or noncompaction cardiomyopathy in infancy or early childhood.
Clinical
symptoms include cardiomyopathy, long Q-T syndrome, cerebellar ataxia, delayed

psychomotor development, optic atrophy, mental retardation, seizures,
testicular
dysgenesis, cryptorchidism to severe perineal hypospadias, growth retardation,

microcytic anemia, mild muscle weakness, mildly elevated hepatic enzymes and
increased urinary excretion of 3-methylglutaconic acid.
13. Mitochondrial DNA Depletion Syndrome 12 (Cardiomyopathic type)
[0221] Mitochondrial DNA Depletion Syndrome-12 (MTDPS12) is caused by
homozygous mutations in the Adenine nucleotide translocator 1 (ANTI) gene.
Heterozygous mutations in the ANT 1 gene cause autosomal dominant progressive
external ophthalmoplegia-2 (PEOA2).
[0222] Mitochondrial DNA Depletion Syndrome-12 is an autosomal recessive
mitochondrial disorder characterized by childhood onset of slowly progressive
hypertrophic cardiomyopathy and generalized skeletal myopathy resulting in
exercise
intolerance and, in some patients, muscle weakness, pain and atrophy. Skeletal

muscle biopsy shows ragged red fibers, mtDNA depletion, and accumulation of
abnormal mitochondria. Clinical symptoms include headache episodes, nausea,
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CA 02920272 2016-02-09
vomiting, moderately high levels of creatine kinase in serum, ankle
contractures,
lactic acidosis, hyperalaninemia, SDH-positive muscle fibers, multiple mtDNA
deletions or depletions, abnormal mitochondria containing paracrystalline
inclusions,
high citrate synthase levels, partial reductions in complexes I, III, IV and
V,
cardiomyocyte degeneration, subendocardial interstitial fibrosis, and
arteriolar smooth
muscle hypertrophy.
14. Cardiomyopathy due to Mitochondrial tRNA Deficiencies
[0223] Mutations in mtRNA Ile (MTTI) can result in fatal infantile onset
cardiomyopathy. Clinical features of other mtRNA Ile syndromes include cardiac

dilation and hypertrophy, short stature, deafness, some MELAS symptoms, death
due
to cardiac failure, low mitochondrial oxidative enzymes, familial progressive
necrotizing encephalopathy, impaired glucose tolerance, hyperlipidemia,
hyperuricemia, progressive myoclonus epilepsy, ragged red fibers, spastic
paraparesis,
ataxia; PEO; mental retardation, diabetes mellitus, hypomagnesemia,
hypokalemia,
hypertension, hypercholesterolemia, increased prevalence of migraine headache,
and
rhabdomyolysis.
[0224] Mutations in mtRNA Lys can result in neonatal hypertrophic
cardiomyopathy, diabetes, MERRF, high lactate and pyruvate levels in serum and

infantile death.
[0225] Mutations in mtRNA Leu (MTTL1) can result in hypertrophic
cardiomyopathy Barth-like Syndrome, diabetes, dilated cardiomyopathy,
MERRF/KSS, MELAS, MERRF-like with diabetes, optic neuropathy & retinopathy,
left ventricular noncompaction, Wolff-Parkinson-White conduction defects,
Sudden
Infant death Syndrome, riboflavin sensitive myopathy, rhabdomyolysis, fatigue,
PEO,
and the like. Age of onset typically occurs between 24 to 40 years.
[0226] Mutations in mtRNA Leu (MTTL2) can result in adult onset
cardiomyopathy, myopathy, sideroblastic anemia, PEO, and encephalomyopathy.
[0227] Mutations in mtRNA His can result in adult onset dilated or
hypertrophic
cardiomyopathy, pigmentary retinopathy and sensorineural deafness.

CA 02920272 2016-02-09
[0228] Mutations in mtRNA Gly can result in exercise intolerance,
nonobstructive
hypertrophic cardiomyopathy (onset age: neonatal to childhood), Complex IV &
Complexes II + III deficiencies and sudden death.
15. Cardiomyopathy: Mitochondrial ATP synthase (Complex V) Defects
[0229] Mutations in ATP synthase Fl complex assembly factor-2 (ATP 12), which
is required for Complex V biogenesis, can result in mitochondrial complex V
(ATP
synthase) deficiency nuclear type 1 (MC5DN1). The disorder manifests at birth
and
subjects exhibit low APGAR scores and birth weight. Biochemically, the
patients
show a generalized decrease in the content of ATP synthase complex which is
less
than 30% of normal as well as high plasma lactate levels. Most cases present
with
neonatal-onset hypotonia, lactic acidosis, hepatomegaly, hyperammonemia,
hypertrophic cardiomyopathy, facial dysmorphism, microcephaly, psychomotor and

mental retardation, and 3-methylglutaconic aciduria. Many patients die within
a few
months or years.
[0230] Mutations in mitochondrial ATP synthase 8 (MT-ATP8), a component of
Complex V, can also result in apical hypertrophic cardiomyopathy and
neuropathy.
The disorder manifests during infancy and is associated with delayed motor
development, gait and balance disorder, dysarthric speech, extensor plantar
response,
reduced tendon response, mild external ophthalmoplegia, exercise intolerance,
shortness of breath (dyspnea) during exercise, angina and apical left
ventricular
hypertrophy, neuropathy, reduced Complex V activity & assembly, high lactate
levels
in CSF and abnormal nerve conduction velocity in legs.
16. Mitochondrial Complex IV Deficiency
[0231] Complex IV (cytochrome c oxidase) is the terminal enzyme of the
respiratory chain and consists of 13 polypeptide subunits, 3 of which are
encoded by
mitochondrial DNA. The 3 mitochondrial encoded proteins in the cytochrome
oxidase complex are the actual catalytic subunits that carry out the electron
transport
function.
[0232] Cytochrome c oxidase deficiency can be caused by mutations in several
nuclear-encoded and mitochondrial-encoded genes. Mutations associated with the

disorder have been identified in several mitochondrial COX genes, MTC01,
MTCO2,
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CA 02920272 2016-02-09
MTC03, as well as in mitochondrial tRNA (ser) (MTTS1) and tRNA (leu) (MTTL1).
Mutations in nuclear genes include those in COX10, COX6B1, SC01, FASTI(D2,
C20RF64 (COA5), COA6, C120RF62 (COX14), COX20, and APOPT1. COX
deficiency caused by mutations in SCO2 and COX15 have been found to be
associated with fatal infantile cardioencephalomyopathy. Cytochrome c oxidase
deficiency associated with Leigh Syndrome may be caused by mutations in the
SURF1 gene, COX15 gene, TAC01 gene, or PET100 gene. Cytochrome c oxidase
deficiency associated with the French Canadian type of Leigh Syndrome (LSFC)
is
caused by mutations in the LRPPRC gene. Most isolated COX deficiencies are
inherited as autosomal recessive disorders caused by mutations in nuclear-
encoded
genes; mutations in the mtDNA-encoded COX subunit genes are relatively rare.
[0233] Clinical features associated with the disruption of COA5 function
include
hypertrophic restrictive cardiomyopathy, accumulation of lipid droplets in
muscle,
reduced Complex IV activity, and mitochondrial proliferation in muscle. Age of

onset occurs in less than 1 month or in utero.
[0234] Clinical features associated with the disruption of COA6 function
include
hypertrophic cardiomyopathy, reduced complexes I & IV in cardiac tissue, and
multiple respiratory chain defects. Age of onset occurs in less than 1 year.
17. Combined Oxidative Phosphorvlation Deficiency 8 (COXPD8)
[0235] Combined oxidative phosphorylation deficiency-8 (COXPD8) is caused by a

homozygous or compound heterozygous mutation in the Alanyl-tRNA Synthetase 2
(AARS2) gene, which encodes an amino acid tRNA synthetase.
[0236] COXPD8 is an autosomal recessive disorder due to dysfunction of the
mitochondrial respiratory chain. The main clinical manifestation is a lethal
infantile
hypertrophic cardiomyopathy, but there may also be subtle skeletal muscle and
brain
involvement. Biochemical studies show combined respiratory chain complex
deficiencies in complexes I, III, and IV in cardiac muscle, skeletal muscle,
and brain.
The liver is not affected. Muscle cells are positive for both COX & SDH.
[0237] A variant AARS2 syndrome is progressive leukoencephalopathy with
ovarian failure (LKENP), an autosomal recessive neurodegenerative disorder
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CA 02920272 2016-02-09
characterized by loss of motor and cognitive skills, usually with onset in
young
adulthood. Some patients may have a history of delayed motor development or
learning difficulties in early childhood. Neurologic decline is severe,
usually
resulting in gait difficulties, ataxia, spasticity, and cognitive decline and
dementia.
Most patients lose speech and become wheelchair-bound or bedridden. Brain MRI
shows progressive white matter signal abnormalities in the deep white matter.
Affected females develop premature ovarian failure. Clinical features of LKENP

include COX deficiency, ataxia, cerebellar atrophy, spasticity, cognitive
decline,
delayed development, ovarian failure during the 3rd to 5th decade, loss of
motor
skills, speech & cognition by 5th decade, and abnormal cerebral white matter.
18. Combined Oxidative Phosphorylation Deficiency 10 (COXPD10)
[0238] Combined oxidative phosphorylation deficiency-10 (COXPD10) is caused
by homozygous or compound heterozygous mutations in the mitochondrial
translation
optimization 1 homolog (MT01) gene. MT01 is a mitochondrial-tRNA modifier that

is normally expressed in tissues with high metabolic rate, such as skeletal
muscle,
liver, and heart. COXPD10 is an autosomal recessive disorder resulting in
variable
defects of mitochondrial oxidative respiration. Affected individuals present
in
infancy with hypertrophic cardiomyopathy and lactic acidosis. The severity is
variable, but can be fatal in the most severe cases. Additional clinical
symptoms
include oligohydramnios, hypotonia, psychomotor delay, spasticity, seizures,
dystonia, hypoglycemia, metabolic acidosis, high serum lactate and reduced
Complex
I & IV activity.
[0239] Loss of MT01 function can also result in encephalomyopathy, which
usually
manifests at 3 months of age. Symptoms include seizures, infantile spasms,
delayed
motor & cognitive development, axial hypotonia, chorio-athetoid movements, COX

negative muscle fibers, and Complex IV deficiency.
19. Combined Oxidative Phosphorylation Deficiency 16 (COXPD16)
[0240] Combined oxidative phosphorylation deficiency-16 (COXPD16) is caused
by homozygous mutations in the MRPL44 gene. MRPL44 encodes a structural
subunit of mitochondrial large (39S) ribosomal subunit and plays role in the
assembly
and stability of the 39S subunit. Age of onset is usually at 3 to 6 months.
Clinical
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CA 02920272 2016-02-09
features include hypertrophic cardiomyopathy, steatosis, high levels of liver
transaminases, high serum lactate, reduced COX staining in muscle, and reduced

Complex I and IV activity.
[0241] Other mitochondrial ribosomal subunit disorders include disruptions in
MRPS16 and MRPS22, which encode components of the small ribosomal subunit.
Symptoms include early death and severe lactic acidosis. Alternatively,
disruptions in
MRPL3, which encodes a component of the large ribosomal subunit, results in
cardiomyopathy and mental retardation.
20. Combined Oxidative Phosphorylation Deficiency 17 (COXPD17)
[0242] Combined oxidative phosphorylation deficiency-17 (COXPD17) is caused
by homozygous or compound heterozygous mutations in the ELAC2 gene, which
encodes a zinc phosphodiesterase protein with tRNA processing endonuclease
activity. The protein also interacts with PTCD1 and is ubiquitously expressed.

Combined oxidative phosphorylation deficiency-17 is an autosomal recessive
disorder
of mitochondrial dysfunction characterized by onset of severe hypertrophic
cardiomyopathy in the first year of life. Other features include hypotonia,
poor
growth, microcephaly, lactic acidosis, delayed psychomotor development,
impaired
central hearing, high alanine and glutamine levels, abnormal mitochondrial
cristae,
reduced Complex I and IV activity and failure to thrive. The disorder may be
fatal in
early childhood.
21. Combined Oxidative Phosphorylation Deficiency 5 (COXPD5)
[0243] Mutations in MRPS22 can result in combined oxidative phosphorylation
deficiency-5 (COXPD5). Patients show reduced activities of mitochondrial
respiratory chain complexes I, III, and IV, marked and generalized defect in
mitochondrial translation, microcephaly, dilated cardiomyopathy, dysmorphic
features, hypotonia, metabolic acidosis, transient seizures, poor growth, lack
of
development, and spastic tetraplegia.
[0244] Mutations in NDUFAll can result in mitochondrial complex I deficiency.
Symptoms include fatal infantile metabolic acidosis, encephalocardiomyopathy
with
brain atrophy, no motor development, and hypertrophic cardiomyopathy.
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CA 02920272 2016-02-09
22. Combined Oxidative Phosphorylation Deficiency 9 (COXPD9)
[0245] Combined oxidative phosphorylation deficiency-9 (COXPD9) is caused by
compound heterozygous mutations in the MRPL3 gene. Patients present with
failure
to thrive, poor feeding, hypertrophic cardiomyopathy, hepatomegaly,
psychomotor
retardation, mental retardation, increased plasma lactate and alanine,
abnormal liver
enzymes, and decrease in activity of mitochondrial respiratory complexes I,
III, IV,
and V, with a mild decrease in complex II.
Carnitine Disorders
[0246] Carnitine (beta-hydroxy-gamma-trimethylaminobutyric acid) is an
essential
cofactor for transport of long chain fatty acids across mitochondrial
membranes,
permitting beta-oxidation. Carnitine in body fluids is derived from the diet
or
biosynthesis and is actively transported into muscle. Two biochemically and
clinically distinct disorders cause low concentrations of carnitine in
skeletal muscle.
Systemic carnitine deficiency shows low carnitine in the liver and/or plasma.
In
muscle carnitine deficiency, lipid storage myopathy occurs with low muscle
carnitine
but normal liver and serum carnitine.
[0247] The age of onset for carnitine deficiency, myopathic form occurs during

childhood ¨early adulthood. Symptoms include weakness, cardiomyopathy, and
congestive heart failure.
1. Carnitine Acetyltransferase Deficiency
[0248] Carnitine acetyltransferase (CRAT) deficiency is an autosomal recessive

disorder characterized by ataxia, oculomotor palsy, hypotonia, poor
respiration,
failure to thrive, and altered consciousness. CRAT functions in the
maintenance of
normal fatty acid metabolism by catalyzing the transfer of acyl groups from
acyl-CoA
thioester to carnitine. CRAT controls the ratio of acyl-CoA/CoA in
mitochondria,
peroxisomes, and endoplasmic reticulum. CRAT deficiency has been shown to be
associated with deletions of mitochondrial DNA, mainly the ND4-ND4L region, in

muscle. Other regions of the mitochondrial genome also showed deletions of
varying
size and extent, suggesting multiple deletions of the mitochondrial DNA.

CA 02920272 2016-02-09
2. Carnitine Palmitoyltransferase I Deficiency
[0249] Carnitine palmitoyltransferase I (CPT I) deficiency is an autosomal
recessive
metabolic disorder that affects the mitochondrial oxidation of long-chain
fatty acids in
the liver and kidneys and is characterized by recurrent episodes of fasting-
induced
hypoketotic hypoglycemia and an elevated risk of liver failure. During
metabolic
crisis, blood tests reveal hypoglycemia, elevated levels of plasma carnitine
and liver
transaminases, and mild hyperammonemia. Urine tests may show unusually low
levels of ketones, and medium-chain dicarboxylic aciduria. CPT I deficiency is

associated with mutations in the CPT 1 A gene, which encodes carnitine
palmitoyltransferase IA. The carnitine palmitoyltransferase enzyme system
comprising CPT I and CPT II, in combination with acyl-CoA synthetase and
carnitine/acylcarnitine translocase, provides the mechanism by which long-
chain fatty
acids are transferred from the cytosol to the mitochondrial matrix. The CPT I
isozymes, CPT1A and CPT1B are located in the mitochondrial outer membrane,
whereas CPT II is located in the inner mitochondrial membrane.
3. Myopathic Carnitine Deficiency
[0250] Myopathic carnitine deficiency is a progressive autosomal recessive
disorder
characterized by lipid storage myopathy with low muscle carnitine but normal
liver
and serum carnitine. Clinical features include symmetric, proximal weakness in
the
face and tongue, cardiomyopathy, congestive heart failure, moderately elevated
serum
creatine kinase levels.
4. Primary Systemic Carnitine Deficiency
[0251] Primary systemic carnitine deficiency (CDSP) is an autosomal recessive
disorder of fatty acid oxidation caused by a homozygous or compound
heterozygous
mutation in the 5LC22A5 gene. The SLC22A5 gene encodes solute carrier family
22
member 5 protein, which functions as a sodium-ion dependent, high affinity
carnitine
transporter involved in the active cellular uptake of carnitine. Mutations in
the
SLC22A5 gene result in a defective carnitine transporter, which is expressed
in
muscle, heart, kidney, and fibroblasts. This results in impaired fatty acid
oxidation in
skeletal and heart muscle. In addition, renal wasting of carnitine results in
low serum
levels and diminished hepatic uptake of carnitine by passive diffusion, which
impairs
ketogenesis. If diagnosed early, all clinical manifestations of the disorder
can be
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CA 02920272 2016-02-09
completely reversed by supplementation of carnitine. However, if left
untreated,
patients will develop lethal heart failure.
5. Carnitine Palmitoyltransferase II Deficiency
[0252] Carnitine palmitoyltransferase II (CPT II) deficiency is an autosomal
recessive disorder and is the most common inherited disorder of mitochondrial
long-
chain fatty acid oxidation and is associated with mutations in the CPT2 gene.
The
CPT2 gene encodes carnitine palmitoyltransferase 2 an enzyme that is essential
for
fatty acid oxidation. Over 70 different mutations in the CPT2 gene have been
identified. CPT2 mutations lead to a reduction in the activity of carnitine
palmitoyltransferase 2. There are three main types of CPT II deficiency: a
lethal
neonatal form, a severe infantile hepatocardiomuscular form, and a myopathic
form.
[0253] The lethal neonatal form becomes apparent soon after birth. Infants
with this
form of CPT II deficiency develop respiratory failure, seizures, liver
failure,
cardiomyopathy, and arrhythmia. Affected infants also exhibit hypoketotic
hypoglycemia and structurally abnormal brain and kidneys. Infants with the
lethal
neonatal form of CPT II deficiency typically survive for only a few days to a
few
months.
[0254] The severe infantile hepatocardiomuscular form of CPT II deficiency
affects
the liver, heart, and muscles. Signs and symptoms usually appear within the
first year
of life. This form involves recurring episodes of hypoketotic hypoglycemia,
seizures,
hepatomegaly, cardiomyopathy, and arrhythmia. Problems related to this form of

CPT II deficiency can be triggered by periods of fasting or by illnesses such
as viral
infections. Individuals with the severe infantile hepatocardiomuscular form of
CPT II
deficiency are at risk for liver failure, nervous system damage, coma, and
sudden
death.
[0255] The myopathic form is the least severe type of CPT II deficiency. This
form
is characterized by recurrent episodes of myalgia and rhabdomyolysis. The
destruction of muscle tissue results in myoglobinuria. Myoglobin can also
damage
the kidneys, in some cases leading to life-threatening kidney failure.
Episodes of
myalgia and rhabdomyolysis may be triggered by exercise, stress, exposure to
extreme temperatures, infections, or fasting. The first episode usually occurs
during
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CA 02920272 2016-02-09
childhood or adolescence. Most people with the myopathic form of CPT II
deficiency
have no signs or symptoms of the disorder between episodes.
6. Carnitine-acylcarnitine Translocase Deficiency
[0256] Carnitine-acylcarnitine translocase deficiency (CACTD) is an autosomal
recessive metabolic disorder of long-chain fatty acid oxidation caused by a
homozygous or compound heterozygous mutation in the SLC25A20 gene. The
SLC25A20 gene encodes carnitine-acylcarnitine translocase (CACT), one of the
components of the carnitine cycle that mediates the transport of
acylcarnitines of
different length across the mitochondrial inner membrane from the cytosol to
the
mitochondrial matrix for their oxidation by the mitochondrial fatty acid-
oxidation
pathway.
[0257] Individuals with CACTD exhibit hypoketotic hypoglycemia under fasting
conditions, hyperammonemia, elevated serum creatine kinase and transaminases,
dicarboxylic aciduria, very low free carnitine, and abnormal acylcarnitine
profile with
marked elevation of the long-chain acylcarnitines. Additional features include

neurologic abnormalities, cardiomyopathy and arrhythmias, skeletal muscle
damage,
and liver dysfunction. Most patients become symptomatic in the neonatal period
with
a rapidly progressive deterioration and a high mortality rate. However,
presentations
at a later age with a milder phenotype have been reported.
Cartilage-hair Hy_poplasia
[0258] Cartilage-hair hypoplasia, a form of short-limbed dwarfism due to
skeletal
dysplasia, is caused by mutations in the RMRP gene. RMRP encodes an RNA with
endoribonuclease activity that cleaves mitochondrial RNA complementary to
light
chain of displacement loop. Clinical symptoms include short stature, joint
hyperextensibility, metaphyseal dysplasia, hypoplastic sparse hair, neuronal
dysplasia,
megacolon, malabsorption, increased risk of lymphoma & skin neoplasm,
susceptibility to chickenpox, lymphopenia, neutropenia, and hypoplastic
macrocytic
anemia.
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CA 02920272 2016-02-09
Cerebrotendinous Xanthomatosis
[0259] Cerebrotendinous xanthomatosis (CTX), also known as Van Bogaer-
Scherer-Epstein disease, is an autosomal recessive lipid-storage disorder
caused by
the deficient activity of mitochondrial sterol 27-hydroxylase (CYP27A1). CTX
is
associated with mutations in the CYP27A1 gene, which encodes sterol 27-
hydroxylase. CTX is characterized by the formation of xanthomatous lesions in
many
tissues, particularly in the brain, eye lens, and tendons resulting in
progressive
neurologic dysfunction, premature atherosclerosis, and cataracts. Cholestanol,
the 5-
alpha-dihydro derivative of cholesterol, is enriched relative to cholesterol
in all
tissues. A diagnosis of CTX is typically made by demonstrating that
cholestanol is
present in abnormal amounts in the serum and tendon in suspected affected
individuals.
Congenital Adrenal Hyperplasia
[0260] Congenital adrenal hyperplasia (CAH) comprises a group of monogenic
autosomal recessive disorders caused by an enzyme deficiency in steroid
biosynthesis.
All of the adrenal hyperplasia syndromes are examples of mixed hypo- and
hyperadrenocorticism. CAH is associated with 11-beta-hydroxylase deficiency
caused by a mutation in the CYP11B1 gene. The CYP11B1 gene encodes 11-beta-
hydroxylase, which functions primarily in the mitochondria in the zona
fasciculata of
the adrenal cortex to convert 11-deoxycortisol to cortisol and 11-
deoxycorticosterone
to corticosterone. CAH due to 11-beta-hydroxylase deficiency results in
androgen
excess, virilization, and hypertension. The defect causes decreased cortisol
and
corticosterone synthesis in the zona fasciculata of the adrenal gland,
resulting in the
accumulation of 11-deoxycortisol and 11-deoxycorticosterone.
Congenital Muscular Dystrophy with Mitochondrial Structural Abnormalities
fMegaconial) (MDCMC)
[0261] Megaconial type congenital muscular dystrophy is caused by homozygous
or
compound heterozygous mutations in the choline kinase beta (CHKB) gene. This
form of autosomal recessive congenital muscular dystrophy is characterized by
early-
onset muscle wasting and mental retardation. Some patients develop fatal
cardiomyopathy. Muscle biopsy shows peculiar enlarged mitochondria that are
prevalent toward the periphery of the fibers but are sparse in the center.
Additional
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CA 02920272 2016-02-09
clinical symptoms include hypotonia, progressive weakness, delayed walking,
small
head circumference, elevated creatine kinase, muscle necrosis, and increased
endomysial connective tissue.
Cerebral Creatine Deficiency Syndrome-3
[0262] Cerebral creatine deficiency syndromes (CCDS) comprise a group of
inborn
errors of creatine metabolism and include the X-linked creatine transporter
(SLC6A8)
deficiency (CCDS1) and the two autosomal recessive creatine biosynthesis
disorders,
guanidinoacetate methyltransferase (GAMT) deficiency (CCDS2) and L-
arginine:glycine amidinotransferase (AGAT or GATM) deficiency (CCDS3).
Cerebral creatine deficiency syndrome-3 (CCDS3) is associated with the
following
AGAT mutations: Ala97ValfsX11; Trp149X; Arg169X; Tyr203Ser; and
Met371AsnfsX6. AGAT is localized to the mitochondrial intermembrane space.
[0263] These disorders are characterized by developmental delay/regression,
mental
retardation, severe depressive and cognitive speech disturbances, seizures,
and
depletion of creatine/phosphocreatine levels in the brain. Additional
manifestations
include muscular hypotonia and movement disorder (mainly extrapyramidal). The
characteristic biochemical hallmark of all CCDS is cerebral creatine
deficiency as
detected by proton magnetic resonance spectroscopy (H-MRS). Increased levels
of
guanidinoacetate in body fluids are indicative of GAMT deficiency, whereas
reduced
guanidinoacetate levels are indicative of AGAT deficiency. An elevated urinary

creatine/creatinine ratio is associated with SLC6A8 deficiency.
Deafness
1. Maternal Nonsyndromic Deafness
[0264] Mutations in mitochondrial DNA (mtDNA) have been found to be associated

with nonsyndromic sensorineural hearing loss. Mitochondrially inherited
nonsyndromic sensorineural deafness can be caused by mutations in any 1 of
several
mitochondrial genes, including MTRNR1, MTTS1, MTC01, MTTH, MTND1, and
MTTI. Matrilineal relatives within and among families carrying certain
pathogenic
mitochondrial mutations exhibit a wide range of penetrance, severity, and age
of onset
of hearing loss, indicating that the mitochondrial mutations by themselves are
not
sufficient to produce a deafness phenotype. Modifier factors, such as nuclear
and

CA 02920272 2016-02-09
mitochondrial genes, or environmental factors, such as exposure to
aminoglycosides,
appear to modulate the phenotypic manifestations.
2. Maternal Syndromic Deafness
[0265] Mitochondrially inherited syndromic sensorineural deafness can be
caused
by mutations in any 1 of several mitochondrial genes (including MTTL1, MTTS1,
MTTS2, MTTL, MTTK, MTTQ), large (> 1 kb) heteroplasmic deletions, or large (>
1
kb) heteroplasmic partial duplications.
3. Sporadic Syndromic Deafness
[0266] Sporadic syndromic deafness can be caused by single large mtDNA
deletion
or mutations in MTC01. Clinical symptoms associated with MTC01-induced
syndromic deafness include cataracts, progressive sensorineural deafness,
myopathy,
ataxia, myoclonic epilepsy, visual loss, optic atrophy, reduced COX activity,
cerebellar atrophy, and bilateral small symmetrical nodular hyperintensities.
Mutations in MTC01 can result in sideroblastic anemia, exercise intolerance
and
LHON.
4. Autosomal Dominant Deafness-64 (DFNA64)
[0267] Autosomal dominant deafness-64 (DFNA64) is caused by heterozygous
mutations in the DIABLO gene. The age at onset ranges between 12 and 30 years
(average age of 22). The severity of hearing impairment ranges from severe to
moderate to mild and correlates with age. High frequency tinnitus was reported
in
73% of affected individuals at the onset of hearing loss.
5. Deafness-Dystonia-Dementia Syndromes
[0268] Mohr-Tranebjaerg Syndrome and Jensen Syndrome have been found to be
caused by mutations in the TIMM8A (DDP) gene, which aid in the importation of
metabolite transporters from cytoplasm to mitochondrial inner membrane.
Clinical
symptoms of Mohr-Tranebjaerg Syndrome (Deafness-dystonia Syndrome) include
progressive sensory-neural hearing loss, myopia, reduced visual acuity,
constricted
visual fields, retinal change, dystonia, mental deficiency, and cortical
blindness.
Clinical symptoms of Jensen Syndrome include blindness, optic atrophy,
sensorineural hearing loss, dementia, CNS calcifications, and muscle wasting.
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CA 02920272 2016-02-09
[0269] Mutations in the chaperonin HSP60 also impact mitochondrial protein
importation and may lead to hereditary spastic paraplegia.
6. Dystonia, Deafness with Leigh-like Syndrome (MEGDEL)
[0270] 3-methylglutaconic aciduria with deafness, encephalopathy, and Leigh-
like
Syndrome (MEGDEL) is an autosomal recessive disorder characterized by
childhood
onset of delayed psychomotor development or psychomotor regression,
sensorineural
deafness, spasticity or dystonia, and increased excretion of 3-
methylglutaconic acid.
MEGDEL is caused by homozygous or compound heterozygous mutations in the
SERAC I gene, which plays a role in phospholipid exchange and intracellular
cholesterol trafficking. Brain imaging of affected subjects shows cerebral and

cerebellar atrophy as well as lesions in the basal ganglia reminiscent of
Leigh
Syndrome. Clinical symptoms include hypotonia, encephalopathy (Leigh-like
Syndrome), mental retardation, sensorineural deafness, spasticity, dystonia,
hepatopathy, increased serum lactate and alanine, hyperammonemia, 3-
Methylglutaconic aciduria, high transaminases, coagulopathy, high serum a-
fetoprotein, mitochondrial oxidative phosphorylation defects, abnormal
mitochondria,
abnormal phosphatidylglycerol and cardiolipin profiles in fibroblasts, and
abnormal
accumulation of unesterified cholesterol within cells.
7. Reticular Dysgenesis
[0271] Reticular dysgenesis is one of the rarest and most severe forms of
combined
immunodeficiency and is caused by a homozygous or compound heterozygous
mutation in the mitochondrial adenylate kinase-2 gene (AK2). Reticular
dysgenesis is
characterized by bilateral sensorineural deafness, congenital agranulocytosis,

lymphopenia, and lymphoid and thymic hypoplasia with absent cellular and
humoral
immunity functions.
8. Steroid-resistant Nephrotic Syndrome & Sensorineural Hearing Loss
(C0Q10D6)
[0272] Primary coenzyme Q10 deficiency-6 (C0Q10D6) is an autosomal recessive
disorder characterized by onset in infancy of severe progressive nephrotic
syndrome
resulting in end-stage renal failure and sensorineural deafness. COQ10D6 is
caused
by homozygous or compound heterozygous mutations in the COQ6 gene. Renal
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CA 02920272 2016-02-09
biopsy usually shows focal segmental glomerulosclerosis (FSGS). Clinical
features
include bilateral sensorineural deafness and steroid-resistant nephrotic
syndrome.
9. Cataracts, Growth hormone Deficiency, Sensory Neuropathy, Sensorineural
Hearing Loss, Skeletal Dysplasia (CAGSSS)
[0273] Mutations in isoleucyl-tRNA synthetase 2 (IARS2), an aminoacyl-tRNA
synthetase, results in CAGSSS. Clinical symptoms include sensorineural
deafness,
cataracts, skeletal dysplasia, facial dysmorphism, short stature, hip
disorders,
scoliosis, cervical stenosis, C2-odontoid hypoplasia, spondylo-epiphyseal
dysplasia,
sensory loss polyneuropathy, growth hormone deficiency, and pituitary
adenohypophysis atrophy. Alternate IARS2 syndromes include Leigh Syndrome.
Diabetes
[0274] Diabetes may arise as a result of mutations in MTTL, MTTK, MTTE,
MTTS2, mitochondrial elongation factor G2 (GFM2), single large mtDNA
deletions,
and large scale mtDNA tandem duplications. Diabetes is usually observed in
patients
affected with Kearns-Sayre Syndrome, Wolfram Syndrome, Friedreich's ataxia and

Metabolic Syndrome in obesity.
Dimethylglycine Dehydrogenase Deficiency
[0275] Dimethylglycine dehydrogenase deficiency (DMGDHD) is an autosomal
recessive glycine metabolism disorder characterized by chronic muscle fatigue,

elevated serum levels of creatine kinase, and a fishlike body odor. DMGDHD is
also
characterized by an increase of N,N-dimethylglycine (DMG) in serum and urine.
DMGDHD is associated with mutations in the DMGDH gene, which encodes
dimethylglycine dehydrogenase (DMGDH), a mitochondrial matrix flavoprotein
that
catalyzes the oxidative demethylation of dimethylglycine to form sarcosine.
DMGDH has been identified as a monomer in the mitochondrial matrix where it
uses
flavin adenine dinucleotide and folate as cofactors.
Encephalopathies
1. Multiple Mitochondrial Encephalopathy
[0276] Multiple mitochondrial encephalopathies can result from Multiple
Mitochondrial Dysfunctions Syndrome-1 (MMDS1), Multiple Mitochondrial
Dysfunctions Syndrome-2 (MMDS2), and Multiple Mitochondrial Dysfunctions
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Syndrome-3 (MMDS3). Multiple mitochondrial dysfunctions syndrome is a severe
autosomal recessive disorder of systemic energy metabolism, resulting in
weakness,
respiratory failure, lack of neurologic development, lactic acidosis, and
early death.
MMDS1 be caused by a homozygous or compound heterozygous mutation in the
NFUl gene. MMDS2 can be caused by homozygous mutation in the BOLA3 gene.
MMDS3 can be caused by homozygous mutation in the IBA57 gene.
2. Encephalopathies Associated with Mitochondrial Complex I Deficiency
[0277] Encephalopathy can arise as a result of mitochondrial Complex I
deficiencies. Complex I deficiencies leading to encephalopathy are associated
with
mutations in the following genes: NDUFA1, NDUFA 1 1, C60RF66, VARS2,
NDUFA12L, NDUFS1, NDUFV1, NUBPL, and NDUFV2.
3. Childhood Leukoencephalopathy and Complex II Deficiency
[0278] Childhood leukoencephalopathy associated with mitochondrial Complex II
deficiency can be caused by mutations in the SDHAF1 gene, which encodes
succinate
dehydrogenase complex assembly factor 1.
4. Encephalopathies Associated with Mitochondrial Complex III Deficiency
[0279] Encephalopathy can arise as a result of mitochondrial Complex III
deficiencies. Complex III deficiencies leading to encephalopathy are
associated with
mutations in the following genes: UQCRQ, UQCC2, LYRM7, and UQCRC2.
5. Encephalopathies Associated with Mitochondrial Complex IV Deficiency
[0280] Encephalopathies associated with mitochondrial Complex IV deficiency
include encephalocardiomyopathies due to mutations in the MT01 gene and/or
C120RF62 genes, encephalomyopathies due to mutations in the FASTI(D2 and/or
AIFM1 genes, and neonatal hepatoencephalopathy due to mutations in the SCO1
gene.
6. Encephalopathies Associated with Mitochondrial Complex V Deficiency
[0281] Encephalopathies associated with mitochondrial Complex V deficiency
include neonatal encephalopathy, which is caused by mutation in the ATP5A1
gene,
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and neonatal encephalocardiomyopathy, which is caused by mutation in the
TMEM70
gene.
7. Hyperammonemia due to Carbonic Anhydrase VA Deficiency
[0282] Hyperammonemia due to carbonic anhydrase VA deficiency (CA5AD) is
caused by homozygous mutation in the CASA gene. The disorder is characterized
clinically by acute onset of encephalopathy in infancy or early childhood.
Biochemical evaluation shows multiple metabolic abnormalities, including
metabolic
acidosis and respiratory alkalosis. Other abnormalities include hypoglycemia,
increased serum lactate and alanine, and evidence of impaired provision of
bicarbonate to essential mitochondrial enzymes. Apart from episodic acute
events in
early childhood, the disorder showed a relatively benign course.
8. Early Infantile Epileptic Encephalopathy-3
[0283] Early infantile epileptic encephalopathy-3 (E1EE3) is caused by
homozygous
mutation in the SLC25A22 gene. DEE3 is characterized by onset during the first

months of life of erratic refractory seizures, usually myoclonic. The
prognosis is
poor, and most children with the condition either die within 1 to 2 years
after birth or
survive in a persistent vegetative state. The EEG pattern often shows a
suppression-
burst pattern with high-voltage bursts of slow waves mixed with multifocal
spikes
alternating with isoelectric suppression phases.
9. 2,4-Dienoyl-00A Reductase Deficiency
[0284] 2,4-Dienoyl-CoA reductase deficiency (DECRD) is caused by a
homozygous mutation in the NADK2 gene. DECR deficiency is a rare autosomal
recessive inborn error of metabolism resulting in mitochondrial dysfunction.
Affected
individuals have a severe encephalopathy with neurologic and metabolic
dysfunction
beginning in early infancy. Laboratory studies show decreased activity of the
mitochondrial NADP(H)-dependent enzymes DECR1 and AASS, resulting in
increased C10:2-carnitine levels and hyperlysinemia.

CA 02920272 2016-02-09
10. Infection-induced Acute Encephalopathy-3
[0285] Infection-induced acute encephalopathy-3 (IIAE3), also known as acute
necrotizing encephalopathy, is caused by heterozygous mutation in the RANBP2
gene. Affected individuals typically present with IIAE3 following febrile
illness.
11. Ethylmalonic Encephalopathy
[0286] Ethylmalonic encephalopathy (EE) is caused by a homozygous or compound
heterozygous mutation in the ETHE1 gene, which encodes a mitochondrial matrix
protein. Ethylmalonic encephalopathy is an autosomal recessive severe
metabolic
disorder of infancy affecting the brain, gastrointestinal tract, and
peripheral vessels.
The disorder is characterized by neurodevelopmental delay and regression,
prominent
pyramidal and extrapyramidal signs, recurrent petechiae, orthostatic
acrocyanosis, and
chronic diarrhea. Brain MRI shows necrotic lesions in deep gray matter
structures.
Death usually occurs in the first decade of life.
12. Hypomyelinating Leukodystrophy
[0287] Hypomyelinating leukodystrophy (HLD4), also known as mitochondrial
Hsp60 chaperonopathy, is caused by mutation in the HSPD1 gene. Affected
individuals experience a form of severe hypomyelinating leukoencephalopathy.
Age
of onset typically occurs between birth and three month. The disorder is
characterized
by hypotonia, nystagmus, and psychomotor developmental delay, followed by
appearance of prominent spasticity, developmental arrest, and regression.
Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia and Calyarial
Hy_perostosis
[0288] Exocrine pancreatic insufficiency, dyserythropoietic anemia and
calyarial
hyperostosis is caused by mutations in cytochrome c oxidase, Subunit IV,
Isoform 2
(C0X4I2). Clinical features include exocrine pancreatic insufficiency,
steatorrhea,
malabsorption of lipid-soluble vitamins, calvarial hyperostosis, delayed bone
age,
osteopenia and dyserythropoietic, megaloblastic anemia.
Glutaric Aciduria Type 1
[0289] Glutaric aciduria type 1 (GA-1), also known as glutaric acidemia, is an

autosomal recessive disorder characterized by episodes of severe brain
dysfunction,
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spasticity, hypotonia, dystonia, seizures, and developmental delays. GA-1 is
associated with mutations in the GCDH gene causing a deficiency of glutaryl-
CoA
dehydrogenase (GCDH) and leading to an accumulation of glutaric and 3-
hydroxyglutaric acids and secondary carnitine deficiency. Elevated urine C5DC
serves as a marker for the detection of GA-1.
[0290] GCDH is an acyl dehydrogenase that catalyzes the oxidative
decarboxylation
of glutaryl-CoA to crotonyl-CoA and CO2 in the degradative pathway of L-
lysine, L-
hydroxylysine, and L-tryptophan metabolism. The enzyme exists as a
homotetramer
of 45-kD subunits in the mitochondrial matrix. Deficiencies in GCDH lead to an

accumulation of L-lysine, L-hydroxylysine, L-tryptophan, and their
metabolites.
Glycine Encephalopathy
[0291] Glycine encephalopathy (GCE), also known as nonketotic hyperglycinemia
(NKH), is an inborn error of glycine metabolism caused by a deficiency of the
glycine
cleavage system. GCE is characterized by abnormally high levels of glycine
leading
to a progressive lethargy, feeding difficulties, hypotonia, dystonia, and
respiratory
distress. The enzyme system for cleavage of glycine, which is confined to the
mitochondria, is composed of four protein components: P protein (a pyridoxal
phosphate-dependent glycine decarboxylase), H protein (a lipoic acid-
containing
protein), T protein (a tetrahydrofolate-requiring enzyme), and L protein (a
lipoamide
dehydrogenase). GCE may be caused by a defect in the H, P, or T proteins.
Hepatic Failure
[0292] Acute infantile liver failure is caused by mutations in tRNA 5-
methylaminomethy1-2-thiouridylate methyltransferase (TRMU), which encodes a
mitochondria-specific tRNA-modifying enzyme. Age of onset for this disorder is

usually between 1 to 4 months and is characterized by hepatic failure,
irritability, poor
feeding, and vomiting. Clinical features include jaundiced sclerae, distended
abdomen, hepatomegaly, lethargy, coagulopathy, low albumin, direct
hyperbilirubinemia, metabolic acidosis, hyperlactatemia, high a-fetoprotein,
high
phenylalanine, tyrosine, methionine, glutamine and alanine in plasma, high
lactate,
phenylalanine and tyrosine metabolites, ketotic dicarboxylic and 3-
hydroxydicarboxylic aciduria, and reduced Complex I, III and IV activity.
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[0293] Hepatic failure with hyperlactatemia is caused by mutations in DGUOK,
POLG, and MPV17.
2-Hydroxyglutaric Aciduria
[0294] 2-Hydroxyglutaric aciduria is an autosomal recessive neurometabolic
disorder characterized by developmental delay, epilepsy, hypotonia, and
dysmorphic
features. Mutations in the D2HGDH gene, encoding D-2-hydroxyglutarate
dehydrogenase (D2HGDH) are associated with D-2-hydroxyglutaric aciduria (D-2-
HGA) type I. D2HGDH is a mitochondrial enzyme belonging to the FAD-binding
oxidoreductase/transferase type 4 family that is active in liver, kidney,
heart, and
brain where it converts D-2-hydroxyglutarate (D-2-HG) to 2-ketoglutarate.
Mutations
in the IlDH2 gene, encoding isocitrate dehydrogenase 2 (IDH2) are associated
with D-
2-HGA type II. IDH2 is a mitochondrial NADP-dependent isocitrate dehydrogenase

that catalyzes oxidative decarboxylation of isocitrate to alpha-ketoglutarate,
producing NADPH.
[0295] Another form of 2-hydroxyglutaric aciduria, L-2-hydroxyglutaric
aciduria
(L-2-HGA) is associated with mutations in the L2HGDH gene, encoding L-2-
hydroxyglutarate dehydrogenase, an FAD-dependent mitochondrial enzyme that
oxidizes L-2-hydroxyglutarate to alpha-ketoglutarate. L-2-HGA particularly
affects
the cerebellum, resulting in balance and muscle coordination abnormalities.
Clinical
manifestations of infantile onset L-2-HGA include ataxia, mental retardation,
macrocephaly, a potential increased risk of brain neoplasm, leukodystrophy,
and the
presence of L-2-hydroxyglutaric acid in the urine and cerebrospinal fluid.
Adult-
onset L-2-HGA is associated with a c.959delA mutation and causes movement
disorder, tremor, and saccades.
[0296] Combined D,L-2-hydroxyglutaric aciduria (D,L-2HGA) is characterized by
neonatal-onset encephalopathy with severe muscular weakness, intractable
seizures,
respiratory distress, and lack of psychomotor development leading to early
death.
3-Hydroxyacyl-CoA Dehydrogenase Deficiency
[0297] 3-Hydroxyacyl-CoA dehydrogenase deficiency, also known as HADH
deficiency, is an autosomal recessive metabolic disorder, resulting from
mutations in
the HADH gene. The 3-Hydroxyacyl-CoA dehydrogenase protein functions in the
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CA 02920272 2016-02-09
mitochondrial matrix to catalyze the oxidation of straight-chain 3-hydroxyacyl-
CoAs
as part of the beta-oxidation pathway. Human HADH encodes a deduced 314-amino
acid protein comprising a 12-residue mitochondrial import signal peptide and a
302-
residue HADH protein with a calculated molecular mass of 34.3 lc.D. 3-
Hydroxyacyl-
CoA dehydrogenase has a preference for medium chain substrates, whereas short
chain 3-hydroxyacyl-CoA dehydrogenase (SCADH) acts on a variety of substrates,

including steroids, cholic acids, and fatty acids with a preference for short
chain
methyl-branched acyl-CoAs. Mutations in HADH cause one form of familial
hyperinsulinemic hypoglycemia (FHH). FHH is the most common cause of
persistent
hypoglycemia in infancy.
Hypercalcemia Infantile
[0298] Hypercalcemia infantile is an autosomal recessive disorder
characterized by
severe hypercalcemia, failure to thrive, vomiting, dehydration, and
nephrocalcinosis.
Hypercalcemia infantile is associated with homozygous or compound heterozygous

mutations in the CYP24A1 gene. 24-Hydroxylase (CYP24A1) is a mitochondrial
enzyme found mainly in the kidney, bone and intestine, and is likely present
in all
cells that express the vitamin D receptor. CYP24A1 is a 514-amino acid protein
with
a complex structure of a helices and 13 strands. It interacts with the
mitochondrial
membrane, adrenodoxin, heme, and vitamin D molecules. Disruption of this
structure
impairs the function of the enzyme. Tight control of the vitamin D system
requires
inactivation of its active compound 1,25-dihydroxyvitamin D3 (1,25(OH)2D3)
through 24-hydroxylation by means of the CYP24A1 enzyme and degradation to
calcitroic acid.
Hyperornithinemia-hyperammonemia-homocitrullinuria (HHH) Syndrome
[0299] HHH Syndrome is an autosomal recessive early onset (infancy to 18
years)
disorder caused by mutations in the 5LC25A15 gene, which encodes the
mitochondrial ornithine transporter. Patients with HHH exhibit partial
impairment of
uptake of ornithine by mitochondria. Symptoms include mental retardation and
myoclonic seizures associated with hyperornithinemia, hyperammonemia, and
homocitrullinemia, progressive spastic paraparesis, protein intolerance,
stuporous
episodes, cerebellar ataxia, muscular weakness in both legs, myoclonus,
lethargy,
dysmetria, dysdiadochokinesis, scanning speech, learning difficulties,
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CA 02920272 2016-02-09
buccofaciolingual dyspraxia, episodic vomiting, retinal depigmentation, and
chorioretinal thinning.
Immunodeficiency with Hyper-IgM Type 5
[0300] Immunodeficiency with hyper-IgM type 5 (HIGM5) is an autosomal
recessive disorder caused by homozygous or compound heterozygous mutations in
the
gene encoding uracil-DNA glycosylase (UNG). HIGM5 is characterized by
defective
normal or elevated serum IgM concentrations in the presence of diminished or
absent
IgG, IgA, and IgE concentrations, indicating a defect in the class-switch
recombination (CSR) process. UNG removes uracil in DNA resulting from
deamination of cytosine or replicative incorporation of dUMP instead of dTMP,
thereby suppressing GC-to-AT transition mutations. The UNG gene encodes two
isoforms that are individually targeted to the mitochondria and nucleus. The
mitochondrial isoform is referred to as UNG1, UDG1, or UDG1M, and the nuclear
isoform is referred to as UNG2, UDG1A, or UDG1N. HIGM5 is associated with
mutations in the UNG gene. Patients with HIGM5 typically experience recurrent
bacterial infections and often exhibit lymphoid hyperplasia.
Inflammatory Myopathies
1. Inclusion Body Myositis (IBM)
[0301] IBM or Inflammatory Myopathy with Vacuoles, Aggregates and
Mitochondrial Pathology (IM-VAMP) is a sporadic progressive condition that
typically manifests in 9 out of 106 individuals at > 50 years of age. Clinical
features
include proximal and distal weakness, dysphagia, Inflammatory myopathy with
Mitochondrial pathology (PM-Mito), respiratory failure, aspiration, cachexia,
muscle
atrophy, diminished tendon reflexes, polyneuropathy, inflammation, muscle
fiber
hypertrophy, rimmed vacuoles with granular material & filaments (0-Amyloid,
Desmin; Ubiquitin; Transglutaminases 1 & 2), aggregates (stain for SMI-31
antibody,
LC-3, 13-amyloid, VCP, ubiquitin, aB-crystallin), COX deficient and SDH +
muscle
fibers, multiple mtDNA deletions, cricopharyngeus dysfunction, fatty
infiltration,
elevated transglutaminase activity, MHC I upregulation in muscle fibers, and
increased frequency of non-organ specific autoantibodies.

CA 02920272 2016-02-09
[0302] Variant syndromes include autosomal dominant IBM and polymyositis with
mitochondrial pathology.
2. Inflammatory Myopathy + Mitochondrial Pathology in Muscle (IM-Mito)
[0303] The age of onset for IM-Mito ranges from 43 to 71 years. Disease
progression is slower than IBM. Symptoms include proximal and distal weakness,

elevated serum creatine kinase, COX-negative and SDH-positive muscle fibers,
endomysial inflammation, focal invasion of muscle fibers by inflammatory
cells,
multiple mtDNA deletions, and LC-3 and/or aB-crystallin aggregates in muscle
fibers.
3. Granulomatous Myopathies with Anti-mitochondrial Antibodies
[0304] Granulomatous myopathies with anti-mitochondrial antibodies account for

11% of inflammatory myopathies in Tokyo and typically manifests between 33 to
72
years of age. Clinical features include primary biliary cirrhosis, cardiac
arrhythmias,
muscle weakness, atrophy, respiratory defects, skin rash, elevated anti-
mitochondrial
autoantibodies, high serum creatine kinase, elevated alkaline phosphatase,
endomysial
fibrosis, necrosis and regeneration, inflammation, granulomas and MHC I
upregulation in muscle fibers.
[0305] Other inflammatory myopathies include, but are not limited to,
necrotizing
myopathy with pipestem capillaries, myopathy with deficient chondroitin
sulfate C in
skeletal muscle connective tissue, benign acute childhood myositis, idiopathic
orbital
myositis, masticator myopathy, hemophagocytic lymphohistiocytosis, infection-
associated myositis, Facioscapulohumeral dystrophy (FSH), Limb-Girdle
dystrophy,
familial idiopathic inflammatory myopathy, Schmidt Syndrome (Diabetes
mellitus,
Addison disease, Myxedema), TNF receptor-associated Periodic Syndrome (TRAPS),

focal myositis, autoimmune fasciitis, Spanish toxic oil-associated fasciitis,
Eosinophilic fasciitis, Macrophagic myofasciitis, Graft-vs-host disease
fasciitis,
Eosinophilia-myalgia Syndrome, and perimyositis.
Isovaleric Acidemia
[0306] Isovaleric acidemia (IVA), also known as isovaleric aciduria, is an
autosomal recessive inborn error of leucine metabolism caused by a deficiency
of the
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mitochondrial enzyme isovaleryl-CoA dehydrogenase (IVD) resulting in the
accumulation of derivatives of isovaleryl-CoA such as isovaleric acid, which
is toxic
to the central nervous system. There are two forms of IVA. The acute neonatal
form
leads to pernicious vomiting, massive metabolic acidosis, and rapid death. The

chronic form results in periodic attacks of severe ketoacidosis with
asymptomatic
intervening periods. Symptoms of IVA include convulsions, lethargy,
dehydration,
moderate hepatomegaly, depressed platelets and leukocytes, and a distinctive
odor
resembling that of sweaty feet.
Kearns-Sayre Syndrome
[0307] Kearnes-Sayre Syndrome (KSS), also known as oculocranisomatic disorder
or oculocraniosomatic neuromuscular disorder with ragged red fibers, is a
mitochondrial myopathy that is caused by various mitochondrial deletions.
Single
large mtDNA deletions (2 to 8 kb) account for 80% of KSS mutations. The mtDNA
deletions that cause KSS result in the impairment of oxidative phosphorylation
and a
decrease in cellular energy production. In most instances, KSS arises from
sporadic
somatic mutations occurring after conception. Rarely, the mutation is
transmitted
through maternal inheritance.
[0308] Clinical features include progressive external ophthalmoplegia,
pigmentary
degeneration of retina (retinitis pigmentosa), heart block, mitochondrial
myopathy,
limitation or absence of movement in all fields of gaze, ptosis, dysphagia,
weight loss,
weakness, occasional fatigue or pain on exertion, sensory-motor
polyneuropathy,
stroke, reduced respiratory drive, hearing loss, ataxia, dementia, or impaired
intellect,
spasticity, growth hormone deficiency, increased tendon reflexes,
endocrinopathies,
glucose intolerance, hypothyroidism, hypoparathyroidism, short stature, ragged
red
fibers, variation in muscle fiber size, lactic acidosis, high CSF protein, low
5-
methyltetrahydrofolate (5-MTHF) in CSF, high homovanillic acid (HVA) in CSF,
abnormal choroid plexus function, basal ganglia calcifications, cerebral and
cerebellar
atrophy, and status spongiosis in gray and white matter.
[0309] Another variant syndrome related to KSS, or other disorders having a
single
large mtDNA deletion include 2-oxoadipic aciduria and 2-aminoadipic aciduria.
Affected patients exhibit episodes of ketosis and acidosis, and may experience
coma.
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Limb-girdle Muscular Dystrophy (LGMD) Syndromes
[0310] LGMD1 is an autosomal dominant disorder characterized by adult onset of

proximal muscle weakness, beginning in the hip girdle region and later
progressing to
the shoulder girdle region. Distal muscle weakness may occur later. Autosomal
dominant limb-girdle muscular dystrophy (LGMD) type 1A is caused by a
heterozygous mutation in the gene encoding myotilin (TTID). Other forms of
autosomal dominant LGMD include LGMD1B, caused by mutations in the LMNA
gene; LGMD1C, caused by mutations in the CAV3 gene; LGMD1E, caused by
mutations in the DNAJB6 gene; LGMD1F, caused by mutations in the TNP03 gene;
LGMD1G, which maps to chromosome 4q21; and LGMD1H, which maps to
chromosome 3p25-p23. The symbol LGMD1D was formerly used for a disorder later
found to be the same as desmin-related myopathy.
[0311] Autosomal recessive forms of LGMD include LGMD2A, caused by
mutations in Calpain-3; LGMD2B, caused by mutations in Dysferlin; LGMD2C,
caused by mutations in y-Sarcoglycan; LGMD2D, caused by mutations in a-
Sarcoglycan; LGMD2E, caused by mutations in P-Sarcoglycan; LGMD2F, caused by
mutations in S-Sarcoglycan; LGMD2G, caused by mutations in Telethonin;
LGMD2H, caused by mutations in TR11v132; LGMD2I (MDDGC5), caused by
mutations in FKRP; LGMD2J, caused by mutations in Titin; LGMD2K (MDDGC1),
caused by mutations in POMT1; LGMD2L, caused by mutations in AN05;
LGMD2M (MDDGC4), caused by mutations in Fukutin; LGMD2N (MDDGC2),
caused by mutations in POMT2; LGMD20 (MDDGC3), caused by mutations in
POMGnTl; LGMD2P (MDDGC9), caused by mutations in DAG1; LGMD2Q,
caused by mutations in Plectin if; LGMD2R, caused by mutations in Desmin; and
LGMD2S, caused by mutations in TRAPPC11.
Leukodystrophy
[0312] Mutations in COX6B1, which encodes a Complex IV structural subunit, can

result in mitochondrial complex IV deficiency. Symptoms include muscle
weakness,
pain, unsteady gait, visual loss, progressive neurological deterioration,
cognitive
decline, leukodystrophic brain changes, seizures, ataxia, increased serum and
CSF
lactate and decreased COX activity in muscle.
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[0313] Mutations in Apoptogenic protein 1 (APOPT1), which mediates
mitochondria-induced cell death in vascular smooth muscle cells, can result in

cavitating leukodystrophy. This disorder typically manifests between the ages
of 2 to
years. Additional clinical features include spastic tetraparesis, ataxia,
sensory-
motor polyneuropathy, reduced cognition, reduced COX staining, large
mitochondria
with osmophilic inclusions, and reduced Complex IV activity.
[0314] Mutations in SDHB can result in leukodystrophy, which usually presents
at 1
year of age. Clinical features include loss of motor skills, leukodystrophy in
deep
white matter and corpus callosum, and reduced Complex II activity.
[0315] Leukodystrophy may arise as a result of large mtDNA deletions. Clinical

features include progressive ataxia, bulbar palsy, white-matter lesions in
occipital to
parietal lobes, and high CSF lactate.
Maple Syrup Urine Disease
[0316] Maple syrup urine disease (MSUD) can be caused by homozygous or
compound heterozygous mutations in at least 3 genes: BCKDHA, BCKDHB, and
DBT. These genes encode 2 of the catalytic components of the branched-chain
alpha-
keto acid dehydrogenase complex (BCKDC), which catalyzes the catabolism of the

branched-chain amino acids, leucine, isoleucine, and valine. Maple syrup urine

disease caused by a mutation in the El-alpha subunit gene is referred to as
MSUD
type IA; that caused by a mutation in the El-beta subunit gene as type TB; and
that
caused by defect in the E2 subunit gene as type II. Mutations in the third
component,
E3 (DLD), on chromosome 7q31, cause an overlapping but more severe phenotype
known as dihydrolipoamide dehydrogenase deficiency (DLDD). DLD deficiency is
sometimes referred to as MSUD3.
[0317] Clinical features of maple syrup urine disease include mental and
physical
retardation, neuropathy, ataxia, dystonia, athetosis, dysarthria, weakness,
ophthalmoplegia, hearing loss, drowsiness, seizures, feeding problems, reduced

tendon reflexes, sensory loss/pain, endoneurial edema, high lactic acid, and a
maple
syrup odor to the urine. The keto acids of the branched-chain amino acids are
present
in the urine, resulting from a block in oxidative decarboxylation. There are 5
clinical
subtypes of MSUD: the 'classic' neonatal severe form, an 'intermediate' form,
an
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'intermittent' form, a 'thiamine-responsive' form, and an 'E3-deficient with
lactic
acidosis' form. All of these subtypes can be caused by mutations in any of the
4 genes
mentioned above, except for the E3-deficient form, which is caused only by a
mutation in the E3 gene.
3-Methylcrotonyl-00A Carboxylase Deficiency
[0318] 3-Methylcrotonyl-CoA carboxylase (MCC), deficiency also known as 3-
methylcrotonylglycinuria, is an autosomal recessive disorder of leucine
catabolism
with a variable phenotype, ranging from neonatal onset with severe
neurological
involvement to asymptomatic adults. Common symptoms include feeding
difficulties, recurrent episodes of vomiting and diarrhea, lethargy, and
hypotonia.
MCC is a heteromeric biotin-dependent mitochondrial enzyme composed of alpha
subunits and smaller beta subunits, encoded by MCC1 and MCC2, respectively.
MCC is essential for the catabolism of leucine.
Methylmalonic Aciduria
[0319] Methylmalonic aciduria (MMA), also known as methylmalonyl-CoA
epimerase deficiency, is an autosomal recessive disorder characterized by
progressive
encephalopathy, dehydration, developmental delays, failure to thrive,
lethargy,
seizures, and vomiting. MMA is caused by mutations in the MUT, MMAA, MMAB,
MMADHC, and MCEE genes. The long-term effects of MMA depend on which gene
is mutated and the severity of the mutation.
[0320] Mutations in the MUT gene cause a deficiency of methylmalonyl-CoA
mutase (MUT), which is a vitamin B12-dependent mitochondrial enzyme that
catalyzes the isomerization of methylmalonyl-CoA to succinyl-CoA. Mutations in
the
MUT gene lead to a toxic accumulation of methylmalonic acid in the blood. The
proteins encoded by the MMAA, MMAB, and MMADHC genes are required for the
proper function of MUT. Mutations affecting these genes can impair the
activity of
MUT, leading to methylmalonic aciduria. Mutations in the MCEE gene, which
encodes methylmalonyl CoA epimerase, lead to a mild form of methylmalonic
aciduria.

CA 02920272 2016-02-09
Miller Syndrome
[0321] Miller Syndrome, also known as postaxial acrofacial dystosis, is an
autosomal recessive disorder characterized by severe micrognathia, cleft lip
and/or
palate, hypoplasia or aplasia of the postaxial elements of the limbs, coloboma
of the
eyelids, and supernumerary nipples. Miller Syndrome is associated with
mutations in
the DHODH gene encoding dihydroorotate (DHO) dehydrogenase. Dihydroorotate
dehydrogenase catalyzes the fourth enzymatic step in de novo pyrimidine
biosynthesis. DHO dehydrogenase is a monofunctional protein located on the
outer
surface of the inner mitochondrial membrane.
mtDNA Depletion Syndrome-2 (MTDPS2)
[0322] Mitochondrial DNA Depletion Syndrome-2 (MTDPS2) is an autosomal
recessive disorder characterized primarily by childhood onset of muscle
weakness
associated with depletion of mtDNA in skeletal muscle. MTDPS2 is caused by
homozygous or compound heterozygous mutations in the nuclear-encoded
mitochondrial thymidine kinase gene (TK2). There is wide clinical variability;
some
patients have onset in infancy and show a rapidly progressive course with
early death
due to respiratory failure, whereas others have later onset of a slowly
progressive
myopathy.
[0323] Clinical features include gait impairment, hypotonia, weakness,
respiratory
failure, paralysis, gynecomastia, myopathy, chronic partial denervation, mtDNA

depletion, reduced Complex I, III, IV and V activity, and elevated plasma
lactate.
[0324] Variant TK2 syndromes include spinal muscular atrophy syndrome, rigid
spine syndrome, and severe myopathy with motor regression.
Mitochondrial DNA Depletion Syndrome-3 (MTSPS3)
[0325] Mitochondrial DNA Depletion Syndrome-3, also known as hepatocerebral
syndrome, is an autosomal recessive disorder caused by homozygous or compound
heterozygous mutations in the nuclear-encoded DGUOK gene. MTSPS3 is
characterized by onset in infancy of progressive liver failure and neurologic
abnormalities, hypoglycemia, and increased lactate in body fluids. Affected
tissues
show both decreased activity of the mtDNA-encoded respiratory chain complexes
(I,
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CA 02920272 2016-02-09
III, IV, and V) and mtDNA depletion. Clinical symptoms include weakness,
hypotonia, lactic acidosis, elevated serum creatine kinase, renal dysfunction,
and
ragged red fibers.
Mitochondrial Encephalopathy Lactic Acidosis Stroke (MELAS)
[0326] MELAS Syndrome, comprising mitochondrial myopathy, encephalopathy,
lactic acidosis, and stroke-like episodes, is a genetically heterogeneous
mitochondrial
disorder with a variable clinical phenotype. MELAS Syndrome can be caused by
mutations in several genes, including POLG, MTTL1, MTTQ, MTTH, MTTK,
MTTF, MTTC, MTTS1, MTTV, MTTQ, MTND1, MTND3, MTND5, MTND6,
MTCOI, cytochrome b, and MTTS2, with mutations in MTTL1 accounting for the
majority of MELAS cases. In particular, it is estimated that approximately 80%
of
MELAS patients have an A3243G point mutation in the MTTL1 gene. The disorder
is accompanied by features of central nervous system involvement, including
seizures,
hemiparesis, hemianopsia, cortical blindness, and episodic vomiting. Primary
causes
of death are cardiopulmonary failure, status epilepticus, and pulmonary
disease.
[0327] Clinical symptoms include distal arthrogryposis, headache and vomiting,

sensorineural hearing loss, seizures, loss of consciousness, dementia, mental
retardation, focal events (strokes), cortical visual defects, hemiplegia,
neuronal
hyperexcitability, basal ganglia calcifications, weakness, exercise
intolerance, ptosis,
external ophthalmoplegia, gait disorder, paresthesias and numbness, reduced
tendon
reflexes, sensory neuropathy, chorea, Parkinsonism, ataxia, pigmentary
retinopathy,
macular dystrophy, optic atrophy, visual field defects, hypertelorism,
hypertrophic
cardiomyopathy, left ventricular noncompaction, conduction defects (such as
Wolff-
Parkinson-White), hypertension, short stature, maternally inherited diabetes
(MIDD),
pancreatitis, constipation, diarrhea, intestinal pseudoobstruction (ileus),
nausea,
dysphagia, abdominal pain, epigastralgia, sialoadenitis focal segmental
glomerulosclerosis, renal cysts, tubular dysfunction, nephrotic syndrome,
multihormonal hypopituitarism, Hashimoto thyroiditis, goiter,
Hypoparathyroidism,
Addison's disease, ovarian failure, miscarriage, lipoma, Atopic dermatitis,
local
melanoderma, asymmetric vascular dilatation, lactic acidosis, white matter
lesions,
respiratory chain dysfunction, ragged red fibers, cortical atrophy, focal
necrosis,
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CA 02920272 2016-02-09
Purkinje dendrite cactus formations with increased mitochondria, and
mitochondrial
capillary angiopathy.
[0328] Other MTTF disorders include myoglobinuria, MERRF, camptocormia,
seizures, and ataxia.
Mvopathy and External Ophthalmoplegia; Neuropathy; Gastro-Intestinal;
Encephalopathy (MNGIE)
[0329] Mitochondrial DNA Depletion Syndrome-1 (MTDPS1), which manifests as
a neurogastrointestinal encephalopathy (MNGIE), is caused by homozygous or
compound heterozygous mutations in the nuclear-encoded thymidine phosphorylase

gene (TYMP). TYMP catalyzes phosphorolysis of thymidine to thymine and
deoxyribose 1-phosphate, and plays a role in homeostasis of cellular
nucleotide pools.
Mitochondrial DNA Depletion Syndrome-1 (MTDPS1) is an autosomal recessive
progressive multisystem disorder clinically characterized by onset between the
second
and fifth decades of life of ptosis, progressive external ophthalmoplegia
(PEO), retinal
degeneration, optic atrophy, gastrointestinal dysmotility (often
pseudoobstruction,
gastroparesis, obstipation, malabsorption, diarrhea, abdominal pain & cramps,
nausea
& vomiting), borborygmi, early satiety, cachexia, thin body habitus, short
stature,
diffuse leukoencephalopathy, myopathy (proximal weakness, exercise
intolerance),
peripheral neuropathy (sensory loss/pain/ataxia, weakness, tendon reflexes
absent,
axonal loss, demyelination), hearing loss, cognitive impairment or dementia,
seizures,
headaches, and mitochondrial dysfunction. Mitochondrial DNA abnormalities can
include depletion, deletion, and point mutations. MNGIE usually presents at <
20
years of age. Additional symptoms include incomplete right bundle branch block

(cardiac defect), diabetes or glucose intolerance, amylase increase, exocrine
insufficiency, neoplasms, lactic acidosis, elevated plasma thymidine levels,
elevated
plasma deoxyuridine & deoxythymidine levels, tetany, cardiac arrhythmia, high
CSF
protein, brain atrophy, mitochondrial changes in muscle fibers and neurogenic
changes.
[0330] Partial loss of thymidine phosphorylase activity can result in a
variant
MNGIE disorder that manifests around the 5th decade of life. Clinical symptoms

include ophthalmoplegia, ptosis, gastrointestinal features, and axon loss with
or
without demyelination.
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CA 02920272 2016-02-09
[0331] Mitochondrial DNA Depletion Syndrome-4B (MTDPS4B), which manifests
as a neurogastrointestinal encephalopathy (MNGIE), is caused by compound
heterozygous mutations in the nuclear-encoded POLG gene. Mitochondrial DNA
Depletion Syndrome-4B is an autosomal recessive progressive multisystem
disorder
clinically characterized by chronic gastrointestinal dysmotility and
pseudoobstruction,
cachexia, progressive external ophthalmoplegia (PEO), axonal sensory ataxic
neuropathy, and muscle weakness.
[0332] Another MNGIE variant is MNGIM Syndrome without encephalopathy,
which is not associated with mutations in thymidine phosphorylase or dNT-2.
Clinical features include gastrointestinal malabsorption, diarrhea,
borborygmi,
abdominal pain, GI pseudo-obstruction, weight loss, ophthalmoplegia, ptosis,
weakness, cachexia, polyneuropathy (pain, gait disorder, sensory ataxia,
axonal loss),
high CSF protein, ragged red fibers, and reduced Complex I¨IV activities.
[0333] Mutations in MTTW can manifest as a neurogastrointestinal
encephalopathy
(MNGIE). Patients present at 1 year of age with recurrent vomiting and failure
to
thrive. Leg discomfort, cognitive regression, seizures, muscle wasting, and
incontinence manifest later during childhood. Other features include
sensorineural
deafness, ptosis, ophthalmoplegia, pigmentary retinopathy, constricted visual
fields,
short stature, feeding difficulties with constipation, colitis and diarrhea,
high lactate
levels in blood and CSF, brain atrophy, and periventricular white matter
changes.
Muscle biopsies show COX-negative fibers and low activity of Complexes I and
IV.
[0334] Mutations in MTTV can manifest as a neurogastrointestinal
encephalopathy
(MNGIE). Age of onset is usually during early childhood. Clinical symptoms
include cachexia, headache, gastrointestinal motility problems (Ileus,
Abdominal
pain; Megacolon), hearing loss, developmental delay, high serum lactate, COX-
negative fibers and low activity of complexes I and IV. Disruption of MTTV
function
can also lead to Ataxia, Seizures & Hearing loss, and Learning difficulties,
Hemiplegia & Movement disorder.
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CA 02920272 2016-02-09
Menkes Disease, Occipital Horn Syndrome and X-linked Distal Spinal Muscular
Atrophy-3
[0335] Menkes disease is an X-linked recessive disorder characterized by
generalized copper deficiency and is caused by mutations in the ATP7A gene.
Menkes disease usually manifests at birth and its clinical features result
from the
dysfunction of several copper-dependent enzymes. Clinical symptoms include
seizures, pili torti, bladder diverticula, skin laxity, occipital exostoses,
chronic
diarrhea, acute onset of severe intra-abdominal bleeding, hemorrhagic shock,
multiple
fractures, hypoglycemia, hypothermia, feeding difficulties, hair with an
abnormal
texture, low serum copper and ceruloplasmin levels, subdural hematomas, high
arched
palate, wormian bones in the lambdoid suture of the occipital region,
developmental
delay, and speech loss.
[0336] Occipital Horn Syndrome (OHS) is caused by mutations in the gene
encoding Cu(2 )-transporting ATPase, alpha polypeptide (ATP7A). Occipital Horn

Syndrome is a rare connective tissue disorder characterized by hyperelastic
and
bruisable skin, hernias, bladder diverticula, hyperextensible joints,
varicosities, and
multiple skeletal abnormalities. The disorder is sometimes accompanied by mild

neurologic impairment, and bony abnormalities of the occiput are a common
feature,
giving rise to the name. Clinical features include severe congenital cutis
laxa,
extremely loose skin, with truncal folds and sagging facial skin, pectus
excavatum,
craniotabes, stridor, sparse coarse hair, fragmented elastin fibers, and low
serum
copper.
[0337] X-linked distal spinal muscular atrophy-3 (SMAX3) is caused by
mutations
in the copper transport gene ATP7A and is characterized by spinal muscular
atrophy
affecting both the upper and lower limbs. Onset ranges from 1 to 10 years of
age.
Clinical symptoms include foot deformity (pes cavus or pes varus), gait
instability,
distal motor weakness and atrophy.
Methemoglobinemia
[0338] Methemoglobinemia is an autosomal recessive disorder characterized by
decreased oxygen carrying capacity of the blood, resulting in cyanosis and
hypoxia.
Methemoglobinemia is associated with mutations in the CYB5R3 gene, which
encodes cytochrome b5 reductase-3, an enzyme localized to the mitochondrial
outer
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CA 02920272 2016-02-09
membrane where it catalyzes the transfer of reducing equivalents from NADH to
cytochrome b5. There are two types of methemoglobin reductase deficiency. In
type
I, the defect affects the soluble isoform of CYB5R3, which is expressed in
erythrocytes and functions to reduce methemoglobin to hemoglobin. In type II,
the
defect affects both soluble and microsomal isoforms of the enzyme, which play
a role
in physiologic processes including cholesterol biosynthesis and fatty acid
elongation
and desaturation. Type II methemoglobinemia is associated with mental
deficiency
and other neurologic symptoms.
Myoclonic Epilepsy Ragged Red Fibers (MERRF)
[0339] MERRF Syndrome represents a maternally-inherited myopathy that can be
produced by mutations in more than 1 mitochondrial gene, e.g., MTTK, MTTL1,
MTTH, MTTS1, MTTS2, MTTF etc. Features of the MERRF Syndrome have also
been associated with mutations in the MTND5 gene.
[0340] Clinical features include myoclonus, epilepsy, cardiomyopathy, ataxia,
gait
disorder, dementia, optic atrophy, distal sensory loss, hearing loss,
weakness, muscle
pain, cramps, fatigue, short stature, lipomata, ragged red fibers, vacuoles in
small
fibers, and reduced Complex I, III and IV activity.
[0341] Other MTTK syndromes include cardiomyopathy, progressive external
ophthalmoplegia with myoclonus, deafness and diabetes (DD), multiple symmetric

lipomatosis, Leigh Syndrome, MELAS, MNGIE, Myopathy with Episodic high
Creatine Kinase (MIMECK), Parkinson syndrome neuropathy and myopathy.
Clinical features of MIMECK include weakness, dysphagia, and episodic
myalgias.
[0342] Other MTTS1 disorders include MELAS, Epilepsia Partialis Continua, HAM
Syndrome, myopathy , encephalopathy with cytochrome c oxidase deficiency,
Myoclonus, epilepsy, cerebellar ataxia & progressive hearing loss, exercise
intolerance, keratoderma, palmoplantar, with deafness, and sensorineural
hearing loss.
[0343] Mutations in MTTP can also result in myoclonic epilepsy, myopathy,
sensorineural deafness, cerebellar ataxia, and pigmentary retinopathy.
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CA 02920272 2016-02-09
Myoglobinuria
[0344] Myoglobinuria can arise as a result of malignant hyperthermia
syndromes,
glycogen metabolic disorders, fatty acid oxidation and lipid metabolism
disorders,
mitochondrial disorders, certain drugs and toxins, hypokalemic myopathy and
rhabdomyolysis, muscle trauma, ischemia, infections, or immune myopathy. Other

disorders associated with occasional myoglobinuria include Brody myopathy,
cylindrical spiral (myofilamentous) myopathy, familial recurrent
rhabdomyolysis,
fingerprint body disease, G6PDH deficiency, hypokalemic periodic paralysis,
Marinesco-Sjogren Syndrome, myoadenylate deaminase deficiency, myotonias,
multicore disease, Native American Myopathy, Schwartz-Jampel Syndrome
(chondrodystrophic myotonia), sickle cell anemia, and several muscular
dystrophies
including Duchenne and Becker muscular dystrophy, Miyoshi myopathy,
sacroglycanopathies, limb-girdle muscular dystrophy-dystroglycanopathy type
C5,
and limb-girdle muscular dystrophy-2L.
1. Malignant Hyperthermia Syndromes
[0345] Malignant hyperthermia syndromes leading to myoglobinuria can include
central core disease, King-Denborough Syndrome, also known as malignant
hyperthermia susceptibility 1 (MHS1), malignant hyperthermia susceptibility 2
(MHS2) malignant hyperthermia susceptibility 3 (MHS3), malignant hyperthermia
susceptibility 4 (MHS4), malignant hyperthermia susceptibility 5 (MHS5),
malignant
hyperthermia susceptibility 6 (MHS6), and other disorders associated with
malignant
hyperthermia susceptibility, including Duchenne and Becker muscular
dystrophies,
myotonic dystrophy, myotonia congenital, Schwartz-Jampel Syndrome, and
Satoyoshi
Syndrome.
2. Glycogen Metabolic Disorders
[0346] Glycogen metabolic disorders leading to myoglobinuria can include
McArdle disease, also known as glycogen storage disease type V (GSD5), Tarui
disease, also known as glycogen storage disease VII (GSD7), and other
glycogenoses,
including aldolase A deficiency, also known as glycogen storage disease XII
(GSD12), lactate dehydrogenase A deficiency, also known as glycogen storage
disease XI (GSD11), phosphoglycerate kinase-1 deficiency, phosphoglycerate
mutase
deficiency, also known as glycogen storage disease X (GSD10), phosphorylase
kinase
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CA 02920272 2016-02-09
deficiency of liver and muscle, also known as glycogen storage disease IXb
(GSD9B),
Forbes disease, also known as glycogen storage disease III (GSD3) or glycogen
debrancher deficiency, and P-enolase deficiency, also known as glycogen
storage
disease XIII (GSD13).
3. Fatty Acid Oxidation and Lipid Metabolism Disorders
[0347] Fatty acid oxidation and lipid metabolism disorders leading to
myoglobinuria can include carnitine palmitoyltransferase II (CPT II)
deficiency,
acyl-CoA dehydrogenase deficiencies, a-methylacyl-CoA racemase (AMACR)
deficiency, electron transfer flavoprotein disorders, ketoacyl CoA thiolase
deficiency,
recurrent acute myoglobinuria, also known as recurrent rhabdomyolysis in
childhood,
and trifunctional enzyme deficiency, also known as long chain 3-hydroxyacyl-
coenzyme A dehydrogenase deficiency (LCHAD) deficiency.
[0348] Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency is a
rare autosomal recessive condition that prevents the body from converting
certain fats
to energy, particularly during periods without food (fasting). Mutations in
the
HADHA gene cause LCHAD deficiency. Signs and symptoms of LCHAD
deficiency typically appear during infancy or early childhood and can include
feeding
difficulties, lack of energy (lethargy), low blood sugar (hypoglycemia), weak
muscle
tone (hypotonia), liver problems, and abnormalities in the light-sensitive
tissue at the
back of the eye (retina). Later in childhood, people with this condition may
experience muscle pain, breakdown of muscle tissue, and a loss of sensation in
their
arms and legs (peripheral neuropathy). Individuals with LCHAD deficiency are
also
at risk for serious heart problems, breathing difficulties, coma, and sudden
death.
Problems related to LCHAD deficiency can be triggered by periods of fasting or
by
illnesses such as viral infections.
[0349] Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency is an
autosomal recessive condition caused by mutations in the ACADM gene. Signs and

symptoms of MCAD deficiency typically appear during infancy or early childhood

and can include vomiting, lack of energy (lethargy), and low blood sugar
(hypoglycemia). In rare cases, symptoms of this disorder first appear during
adulthood. People with MCAD deficiency are at risk for serious complications
such
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CA 02920272 2016-02-09
as seizures, breathing difficulties, liver problems, brain damage, coma, and
sudden
death.
[0350] Long-chain acyl-CoA dehydrogenase (LCAD) deficiency is caused by
mutations in the ACADL gene. Subjects with LCAD can present with SIDS,
hypoglycemia, hepatomegaly, myopathy, Reye syndrome, and cardiomyopathy. The
plasma acylcarnitine profile exhibits elevated long chain acyl-carnitine
esters. Urine
organic acids typically show elevations of dicarboxylic acids.
4. Mitochondrial Disorders
[0351] Mitochondrial disorders leading to myoglobinuria can include cytochrome
c
oxidase (COX) deficiencies, cytochrome b deficiency, mitochondrial myopathies,

including coenzyme Q10 deficiency, myopathy with lactic acidosis, also known
as
Swedish type myopathy with exercise intolerance, dihydrolipoamide
dehydrogenase
(DLD) deficiency, mutations in the DGUOK gene, which encodes mitochondrial
deoxyguanosine kinase, and iron-sulfur complex disorders, including those
associated
with mutations in one or more of the following genes: ISCU, FDX1L, NFUl,
BOLA3, NUBPL, 1BA57, LYRM4, and LYRM7.
5. Medication-, Drug- or Toxin-induced Mvoglobinuria
[0352] Certain medications such as amiodarone, arsenic trioxide, emetine, s-
amino
caproic acid, lipid lowering agents such as clofibrate and statins, isoniazid,

lamotrigrine, antipsychotics, nicotinic acid, pentamidine, propofol, proton
pump
inhibitors, selective serotonin reuptake inhibitors, irinotican, temazepam,
valproate,
vasopressin, and zidovudine are associated with the development of
myoglobinuria.
Drugs and toxins associated with the development of myoglobinuria include
cocaine,
heroin, snake venom, insect venom, blowpipe dart poison, and drugs and toxins
that
produce muscle overactivity, including amphetamines, hemlock, loxpapine, LSD,
mercuric chloride, phencyclidine, strychnine, tetanus toxin, and terbutaline.
The
ingestion of certain toxins including ethanol, monensin, chromium picolinate,
methylenedioxypyrovalerone, mephedrone, phencyclidine, and those present in
Buffalo fish, burbot, mushrooms (Amanita phalloides, Trichloma equestre),
kidney
beans, and peanut oil may also cause myoglobinuria.
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[0353] Other drugs and toxins associated with the development of myoglobinuria

include acetaminophen, amoxapine, anticholinergics, azathioprine, baclofen,
barbiturates, benzodiazepines, butyrophenones, caffeine, chloral hydrate,
chlorpromazine, colchicine, corticosteroids, daptomycin, diphenhydramine,
doxylamine, ephedra, fenfluramine, glutethimide, hydroxyzine, ketamine,
lysergic
acid diethylamide, methanol, minocycline, morphine, phencyclidine,
phenothiazines,
phentermine phenytoin, quinolones, salicylate, serotonin antagonists,
succinylcholine,
sunitinib sympathomimetics, theophylline, trimethoprim-sulfamethoxazole, and
vincristine.
6. Hypokalemic Myopathy and Rhabdomyolysis
[0354] Hypokalemic myopathy and rhabdomyolysis can be of a pharmacologic or
toxic origin. Hypokalemic myopathy and rhabdomyolysis having a pharmacologic
origin is associated with diuretics and laxatives, such as thiazides,
amphotericin,
lithium, gossypol, methylxanthines, and laxative abuse. Toxins associated with
the
development of hypokalemic myopathy and rhabdomyolysis include glycyrrhizic
acid, glycyrrhetinic acid, barium, ethanol, cottonseed oil, and volatile
substances, such
as toluene.
7. Muscle trauma
[0355] Muscle trauma leading to myoglobinuria can be acute, such as that
associated with physical trauma, or chronic, such as that associated with
alcohol,
opiates, and sedatives. Muscle trauma can also be caused by overactivity due
to
exercise, drugs and toxins producing muscle overactivity, hyperthermia, or
seizures.
Muscle trauma can also be caused by compartment syndromes and temperature
alterations associated with heat stroke, malignant hyperthermia, neuroleptic
malignant
syndrome, burns, or hypothermia.
8. Ischemia
[0356] Ischemia leading to myoglobinuria can be caused by vascular occlusion,
hemangioma steal syndrome, sickle cell trait, cocaine, calciphylaxis,
compartment
syndrome, carbon monoxide exposure, or cyanide poisoning.
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CA 02920272 2016-02-09
9. Infections
[0357] Infections associated with myoglobinuria include viral infections such
as
influenza A and B, coxsackie virus, herpes, adenovirus, and HIV-1; bacterial
infections including Streptococci, Salmonella, Staphylococci, typhoid fever,
Legionella, Clostridia, and E. coli; Mediterranean tick typhus; tick-borne
infections
such as ehrlichiosis, anaplasmosis, baesiosis, Lyme disease, and Rocky
Mountain
spotted fever; and hyperthermia-related infections.
10. Immune myopathy
[0358] Immune myopathies associated with myoglobinuria include polymyositis
and dermatomyositis.
Myopathy, Lactic Acidosis and Sideroblastic Anemia (MLASA)
[0359] Myopathy, lactic acidosis, and sideroblastic anemia (MLASA) is a rare
autosomal recessive oxidative phosphorylation disorder specific to skeletal
muscle
and bone marrow. Myopathy, lactic acidosis, and sideroblastic anemia-1
(MLASA1)
can be caused by homozygous mutations in the PUS1, which converts uridine into

pseudouridine after the nucleotide has been incorporated into RNA.
Pseudouridine
may have a functional role in tRNAs and may assist in the peptidyl transfer
reaction
of rRNAs. MLASA1 usually presents in children and teens and is characterized
by
progressive weakness, exercise intolerance, fatigue, nausea and vomiting,
ptosis, short
stature, sideroblastic anemia, lactic acidosis and reduced mitochondrial
oxidative
enzyme activities.
[0360] Myopathy, lactic acidosis, and sideroblastic anemia-2 (MLASA2) is an
autosomal recessive disorder of the mitochondrial respiratory chain that is
caused by
homozygous mutations in the aminoacyl-tRNA synthetase gene YARS2. The
disorder shows marked phenotypic variability: some patients have a severe
multisystem disorder from infancy, including cardiomyopathy and respiratory
insufficiency resulting in early death, whereas others present in the second
or third
decade of life with sideroblastic anemia and mild muscle weakness. Additional
clinical features include dysphagia, weakness, exercise intolerance, short
stature, high
serum lactate, reduced COX activity, and reduced Complex I, III and IV
activity.
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CA 02920272 2016-02-09
Infantile Mitochondrial Myopathy due to Reversible COX Deficiency (MMIT)
[0361] Infantile mitochondrial myopathy due to reversible COX deficiency is a
rare
mitochondrial disorder characterized by onset in infancy of severe hypotonia
and
generalized muscle weakness associated with lactic acidosis, but is
distinguished from
other mitochondrial disorders in that affected individuals recover
spontaneously after
1 year of age. MMIT is caused by mutations in the MTTE gene, which is encoded
by
the mitochondrial genome.
[0362] Clinical features include muscle weakness, hypotonia, respiratory
failure,
dysphagia, ophthalmoplegia, macroglossia, neuropathy, seizures,
encephalopathy,
hepatomegaly, pneumonia, lactic acidosis, delayed myelination, high serum
creatine
kinase, ragged red fibers, reduced COX activity, reduced Complex I activity,
increased lipid or glycogen in muscle fibers, muscle degeneration,
inflammation, lipid
droplets in fibers, and mtDNA reduction.
[0363] Variant MTTE syndromes include mitochondrial myopathy with diabetes
mellitus, diabetes-deafness syndrome, LHON, Mitochondrial myopathy with
respiratory failure, MELAS/LHON/DEAF, progressive encephalopathy,
encephalomyopathy with retinopathy, leukoencephalopathy and exercise
intolerance.
[0364] Additionally, certain MTTE mutations can lead to at least one or more
symptoms such as myopathy, ataxia, lactic acidosis, high serum creatine
kinase,
SDH+ & COX negative muscle fibers, reduced Complexes I, III & IV activity,
retinopathy, severe myopathy with respiratory failure, ptosis, PEO, pigmentary

retinopathy, migraines, life-long exercise intolerance and leukodystrophy.
Specific Sporadic Mitochondrial Myopathy Syndromes
1. Myopathy, Exercise Intolerance, Encephalopathy, Lactic acidemia
[0365] Cytochrome c oxidase subunit III (COIII or MTC03) is 1 of 3
mitochondrial
DNA (mtDNA) encoded subunits (MTC01, MTCO2, MTC03) of respiratory
Complex IV. Complex IV is located within the mitochondrial inner membrane and
is
the third and final enzyme of the electron transport chain of mitochondrial
oxidative
phosphorylation. It collects electrons from ferrocytochrome c (reduced
cytochrome c)
and transfers then to oxygen to give water. The energy released is to
transport protons
across the mitochondrial inner membrane. Complex IV is composed of 13
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CA 02920272 2016-02-09
polypeptides. Subunits I, II, and III (MTC01, MTCO2, MTC03) are encoded by the

mtDNA while subunits VI, Va, Vb, VIa, VIb, Vic, Vila, VIIb, VIIc, and VIII are

nuclear encoded. Subunits VIa, VIIa, and VIII have systemic as well as heart
muscle
isoforms.
[0366] Mutations in MTC03 can result in Myopathy, Exercise intolerance,
Encephalopathy, Lactic acidemia Syndrome, which usually manifests between 4 to
20
years of age. Clinical symptoms include weakness, myalgia, fatigue,
myoglobinuria,
encephalopathy, migraine, spastic paraparesis, mental retardation,
ophthalmoplegia,
high serum lactate, COX deficiency, SDH positive muscle fibers, and lipid
accumulation in type I fibers.
[0367] Mutations in MTC03 can also result in isolated myopathy (characterized
by
weakness, COX deficiency, persistent ragged red fibers), myoglobinuria,
maternally
inherited myopathies, MELAS-like disorder, Leigh-like disorder, and
nonarteritic
ischemic optic neuropathy (NAION)-Myoclonic epilepsy.
2. Myoglobinuria & Exercise Intolerance
[0368] Mutations in MTC01 can result in Myoglobinuria and exercise
intolerance,
which usually manifests at childhood. Clinical symptoms include exercise
intolerance, myoglobinuria, COX deficiency, and defects in Complex I & III.
Other
MTC01 syndromes include acquired sideroblastic anemia; Deafness, Ataxia,
Blindness, Myopathy; epilepsy partialis continua; motor neuron disease; LHON;
Myopathy, Cardiomyopathy, Stroke; MELAS-like Syndrome.
3. Exercise Intolerance, Proximal Weakness Myoglobinuria
[0369] Cytochrome b (MTCYB) is the only mitochondrial DNA (mtDNA) encoded
subunit of respiratory Complex III (ubiquinol:ferrocytochrome c
oxidoreductase, or
cytochrome bcl, complex). Complex III is located within the mitochondrial
inner
membrane and is the second enzyme in the electron transport chain of
mitochondrial
oxidative phosphorylation. It catalyzes the transfer of electrons from
ubiquinol
(reduced Coenzyme Q10) to cytochrome c and utilizes the energy to translocate
protons from inside the mitochondrial inner membrane to outside.
[0370] Disruption of MTCYB function can result in exercise intolerance,
proximal
weakness myoglobinuria syndrome, which manifests during childhood. Symptoms
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include sensation of cramps, myalgias or fatigue, weakness, myoglobinuria,
septo-
optic dysplasia, retardation, encephalopathy, seizures, high serum lactate,
myopathy,
deficient Complex III activity, and ragged red fibers.
[0371] Mutations in MTCYB can lead to Encephalopathy & Seizures Syndrome,
which usually presents at 9 to 13 years of age. Clinical features include
exercise
intolerance, lactic acidosis, encephalopathy, poor balance, seizures, visual
hallucinations, depression, emotional lability, and ragged red fibers.
[0372] Other variant disorders caused by mutations in MTCYB include septo-
optic
dysplasia (characterized by mental retardation, delayed walking, exercise
intolerance,
retinitis pigmentosa, optic atrophy, hypertrophic cardiomyopathy, Wolff-
Parkinson-
White, lactic acidosis, and cerebellar hypoplasia), Familial Myalgia Syndrome,

Exercise intolerance, LHON, colon cancer, LVNC, MELAS, Parkinsonism, obesity,
and Migraine, Epilepsy, Polyneuropathy, Stroke-like episodes.
4. Exercise Intolerance Mild Weakness
[0373] Mutations in several mitochondrial genes such as MTTW, Cytochrome
b (Complex III), MTND1 (Complex I), MTND2 (Complex I), and MTND4 (Complex
I) can cause exercise intolerance with or without mild weakness, which
manifests at
childhood. Additional clinical features include dyspnea, tachycardia, high
serum
lactate, and ragged red fibers.
5. Mvopathy Exercise Intolerance, Growth or CNS disorder
[0374] Mutations in MTTM can result in Myopathy with or without Exercise
intolerance, Growth or CNS disorders, which usually manifests at 10 to 56
years of
age. Clinical symptoms include myopathy, proximal and distal weakness,
exercise
intolerance, muscle atrophy, ptosis, reduced tendon reflexes, growth
retardation,
mental retardation, lactic acidosis, high serum Creatine Kinase, ragged red
fibers,
COX deficiency, muscular dystrophy, cortical atrophy, and myelomalacia. Other
variant MTTM syndromes include Exercise intolerance, Autoimmune
polyendocrinopathy and Lactic acidosis.
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6. Myopathy with Episodic High Creatine Kinase (M1MECK)
[0375] Mutations in MTTK can result in Myopathy with Episodic high Creatine
Kinase (MIMECK), which usually manifests between the ages of 15 to 69 years.
Clinical features include weakness, dysphagia, myalgias, and episodic high
serum
Creatine Kinase.
Maternally-Inherited Mitochondrial Myopathies
[0376] Maternally-inherited mitochondrial myopathies can be caused by
mutations
in Cytochrome c Oxidase, Subunit II (COX II or MTCO2). Myopathy usually
manifests in children and teens. Clinical features include weakness, fatigue
and
exercise intolerance, rhabdomyolysis, ataxia, retinopathy, optic atrophy,
reduction in
COX activity, lipid in type I fibers, cataracts, hearing loss, cardiac
arrhythmia,
depression, short stature, lactic acidosis, elevated serum or CSF lactate and
mitochondrial proliferation.
[0377] Mutations in MTTS1 can cause Myopathy, Deafness & CNS disorders that
usually manifest at 8 years of age. Clinical features include weakness or
contractures,
fatigue, sensorineural deafness, ataxia, cognitive impairment, optic atrophy,
axonal
sensory neuropathy, high serum and CSF lactate, mitochondrial proliferation,
COX-
fibers, and reduced Complex I & IV activity.
[0378] Mutations in MTTW can cause Myopathy, Ptosis & Dysphonia, which
usually manifests at 50 years of age. Clinical features include ptosis,
weakness,
fatigue, SDH+ and COX negative muscle fibers, and cytochrome c oxidase
reduction.
[0379] Mutations in MTTE can cause Myopathy, Diabetes & CNS disorders, which
usually manifest in teens or adults. Clinical features include fatigue,
weakness,
orbicularis oculi, respiratory failure, FSH dystrophy, fatigue, diabetes,
polyneuropathy, cerebellar ataxia, nystagmus, congenital encephalopathy,
endomysial
fibrosis, mitochondrial proliferation, COX negative muscle fibers, reduced
Complex I
& IV activity, and focal COX reductions in cardiac muscle.
Autosomal Recessive Mitochondrial Myopathies
1. Myopathy with Lactic Acidosis
[0380] Myopathy with lactic acidosis, also known as Swedish type myopathy with

exercise intolerance, is caused by homozygous or compound heterozygous
mutations
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in the ISCU gene, encoding the iron-sulfur cluster scaffold protein, on
chromosome
12q24. Hereditary myopathy with lactic acidosis is an autosomal recessive
muscular
disorder characterized by childhood onset of exercise intolerance with muscle
tenderness, cramping, dyspnea, and palpitations. Clinical features include
fatigue,
shortness of breath, tachycardia, weakness, lactic acidosis, rhabdomyolysis,
muscle
swelling, myalgias, cardiac hypertrophy, SDH deficiency, abnormality of muscle

mitochondrial iron-sulfur cluster-containing proteins, high serum lactate,
reduced
COX expression, and mitochondrial inclusions. Disruption of ISCU function can
also
result in Myopathy with Myoglobinuria.
[0381] Iron-sulfur cluster disorders can also arise as a result of mutations
in
FDX1L, Glutaredoxin 5, NFU', BOLA3, NUBPL, 1BA57, LYRM4 and LYRM7.
2. Myopathy + Rhabdomyolvsis
[0382] Myopathy with rhabdomyolysis is caused by mutations in Ferredoxin 1-
like
protein (FDX1L), which plays a role in Fe-S cluster biogenesis. Clinical
symptoms
include weakness, dyspnea, myoglobinuria, fatigue, reduced Complex I, II &
III activities, reduced aconitase activity, high citrate synthase, high
lactate, 3-methyl
glutaconic acid, ketones & Krebs cycle metabolites.
3. Myopathy + Cataracts & Combined Respiratory Chain Defects
[0383] Myopathy with cataract and combined respiratory chain deficiency can be

caused by mutations in the GFER gene, which plays a role in the
mitochondrial disulfide relay system. Clinical features include reduced
Complex I, II,
and IV activity, accumulation of multiple mtDNA deletions, cataracts,
hypotonia,
developmental delay, muscle smallness, reduced tendon reflexes, sensorineural
hearing loss, SDH+ and COX negative muscle fibers, high serum lactate, low
serum
ferritin, and high serum amylase.
4. Myopathy with Abnormal Mitochondrial Translation
[0384] Myopathy with abnormal mitochondrial translation is an autosomal
disorder
that manifests during childhood. Clinical symptoms include weakness,
fatiguability,
hypotonia, ptosis, ophthalmoplegia, short stature, sideroblastic anemia,
mitochondrial
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proliferation in muscle fibers, reduced COX activity, reduced Complex I, II,
III and
IV activity, and mitochondrial translation defects.
5. Fatigue & Exercise Intolerance
[0385] Fatigue Syndrome is caused by homozygous or compound heterozygous
mutations in the ACAD9 gene, which encodes a protein that catalyzes the
initial rate-
limiting step in 13-oxidation of fatty acyl-CoA. ACAD9 deficiency is an
autosomal
recessive multisystemic disorder characterized by infantile onset of acute
metabolic
acidosis, hypertrophic cardiomyopathy, and muscle weakness associated with a
deficiency of mitochondrial complex I activity in muscle, liver, and
fibroblasts.
Clinical features include exercise intolerance, urge to vomit, sense of mental

slowness, reduced Complex I activity, high serum lactate. Episodic hepatic
dysfunction is also present in some variants of the syndrome.
6. Myopathy with Extrapyramidal Movement Disorders (MPXPS)
[0386] Myopathy with extrapyramidal signs is an autosomal recessive disorder
characterized by early childhood onset of proximal muscle weakness and
learning
disabilities. While the muscle weakness is static, most patients develop
progressive
extrapyramidal signs that may become disabling. Myopathy with extrapyramidal
signs (MPXPS) is caused by homozygous mutations in the MICU I gene, which
plays
a role in mitochondrial Ca2+ uptake. Clinical features include chorea, tremor,

dystonia, orofacial dyskinesia, ataxia, microcephaly, ophthalmoplegia, ptosis,
optic
atrophy, and peripheral neuropathy.
7. Glutaric aciduria II (MADD)
[0387] MADD, also known as glutaric acidemia II or glutaric aciduria II, can
be
caused by mutations in at least 3 different genes: ETFA, ETFB, and ETFDH.
These
genes are all involved in electron transfer in the mitochondrial respiratory
chain. The
disorders resulting from defects in these 3 genes are referred to as glutaric
acidemia
IIA, IIB, and TIC, respectively, although there appears to be no difference in
the
clinical phenotypes.
[0388] Glutaric aciduria II (GA II) is an autosomal recessively inherited
disorder of
fatty acid, amino acid, and choline metabolism. It differs from GA Tin that
multiple
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acyl-CoA dehydrogenase deficiencies result in large excretion not only of
glutaric
acid, but also of lactic, ethylmalonic, butyric, isobutyric, 2-methyl-butyric,
and
isovaleric acids. GA II results from deficiency of any 1 of 3 molecules: the
alpha
(ETFA) and beta (ETFB) subunits of electron transfer flavoprotein, and
electron
transfer flavoprotein dehydrogenase (ETFDH).
[0389] The heterogeneous clinical features of patients with MADD fall into 3
classes: a neonatal-onset form with congenital anomalies (type I), a neonatal-
onset
form without congenital anomalies (type II), and a late-onset form (type III).
The
neonatal-onset forms are usually fatal and are characterized by severe
nonketotic
hypoglycemia, metabolic acidosis, multisystem involvement, and excretion of
large
amounts of fatty acid- and amino acid-derived metabolites. Symptoms and age at

presentation of late-onset MADD are highly variable and characterized by
recurrent
episodes of lethargy, vomiting, hypoglycemia, metabolic acidosis, and
hepatomegaly
often preceded by metabolic stress. Muscle involvement in the form of pain,
weakness, and lipid storage myopathy also occurs. The organic aciduria in
patients
with the late-onset form of MADD is often intermittent and only evident during

periods of illness or catabolic stress.
8. Coenzyme 010 Deficiency
[0390] Primary CoQ10 deficiency is a rare, clinically heterogeneous autosomal
recessive disorder caused by mutation in any of the genes encoding proteins
directly
involved in the synthesis of coenzyme Q. Coenzyme Q10 (C0Q10), or ubiquinone,
is
a mobile lipophilic electron carrier critical for electron transfer by the
mitochondrial
inner membrane respiratory chain.
[0391] The disorder has been associated with 5 major phenotypes, but the
molecular
basis has not been determined in most patients with the disorder and there are
no clear
genotype/phenotype correlations. The phenotypes include an encephalomyopathic
form with seizures and ataxia; a multisystem infantile form with
encephalopathy,
cardiomyopathy and renal failure; a predominantly cerebellar form with ataxia
and
cerebellar atrophy; Leigh Syndrome with growth retardation; and an isolated
myopathic form.
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[0392] Autosomal recessive forms of the disorder include COQ10D1, caused by
mutations in COQ2; COQ10D2, caused by mutations in the PDSS1 gene; COQ10D3,
caused by mutations in the PDSS2 gene; COQ10D4, caused by mutations in the
COQ8 gene (ADCK3); COQ10D5, caused by mutations in the COQ9 gene; and
COQ10D6, caused by mutations in the COQ6 gene.
[0393] Secondary CoQ10 deficiency has been reported in association with
glutaric
aciduria type IIC (MADD), caused by mutation in the ETFDH gene, and with
ataxia-
oculomotor apraxia syndrome-1 (A0A1), caused by mutation in the APTX gene.
Autosomal Dominant Mitochondrial Myopathy
[0394] Dominant mutations in coiled-coil-helix-coiled-coil-helix domain-
containing
protein 10 (CHCHD10) can lead to mitochondrial myopathy with exercise
intolerance, which usually manifests within the first decade of life. Clinical
features
include exercise intolerance, weakness in legs, arms, and face, restrictive
deficits in
pulmonary function, short stature, high serum lactate, high serum pyruvate,
ragged
red fibers, reduced cytochrome c oxidase (Complex W) activity, and reduced
succinate cytochrome c reductase (Complex II & III) activity.
[0395] Other examples of autosomal dominant mitochondrial myopathies include
myopathy with focal depletion of mitochondria, mitochondrial DNA breakage
syndrome (PEO + Myopathy), LGMD1H, and lipid type mitochondrial myopathy.
Multiple Symmetric Lipomatosis (Madelung Syndrome)
[0396] Multiple symmetric lipomatosis (MSL) is a rare disorder characterized
by
the growth of uncapsulated masses of adipose tissue. It is associated with
high
ethanol intake and may be complicated by somatic and autonomic neuropathy and
by
the infiltration of the adipose tissue at the mediastinal level. MSL can arise
as a result
of an autosomal dominant, mitochondrial, or sporadic mutation. Clinical
features
include multiple lipomas in the nape of the neck, supraclavicular and deltoid
regions,
full body lipomas, polyneuropathy, hyperuricemia, high triglycerides (VLDL,
chylomicrons), high HDL, and ragged red fibers.
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N-acetylglutamate Synthase Deficiency
[0397] N-acetylglutamate synthase (NAGS) deficiency is an inborn error of
metabolism affecting ammonia detoxification in the urea cycle. N-
acetylglutamate
synthase is a mitochondrial enzyme that catalyzes the formation of N-
acetylglutamate
(NAG). NAG is an essential allosteric activator of carbamoylphosphate synthase
1
(CPS1), the first and rate-limiting enzyme in the urea cycle. Most NAGS genes
contain a C-terminus transferase domain in which the catalytic activity
resides and an
N-terminus kinase domain where arginine binds. Because CPS1 is inactive
without
NAG, the urea cycle function can be severely affected resulting in fatal
hyperammonemia in neonatal patients or at any later stage in life. Clinical
manifestations of NAGS deficiency include poor feeding, vomiting, altered
levels of
consciousness, seizures, and coma.
Neoplasms
[0398] Mutations in certain nuclear encoded mitochondrial genes can give rise
to
neoplasms, such as paraganglionoma, leiomyomatosis, renal cell cancer, and B-
cell
lymphoma. Paragangliomas, also referred to as 'glomus body tumors,' are tumors

derived from paraganglia located throughout the body. Nonchromaffin types
primarily serve as chemoreceptors (hence, the tumor name 'chemodectomas') and
are
located in the head and neck region (i.e., carotid body, jugular, vagal, and
tympanic
regions), whereas chromaffin types have endocrine activity, conventionally
referred to
as 'pheochromocytomas,' and are usually located below the head and neck (i.e.,

adrenal medulla and pre- and paravertebral thoracoabdominal regions). PGL can
manifest as nonchromaffin head and neck tumors only, adrenal and/or
extraadrenal
pheochromocytomas only, or a combination of the 2 types of tumors.
[0399] Familial paragangliomas-1 (PGL1) is caused by mutations in the SDHD
gene, which encodes the small subunit of cytochrome B in succinate-ubiquinone
oxidoreductase. PGL1 manifests as benign vascularized tumors in the head and
neck.
[0400] Hereditary paragangliomas-2 (PGL2) is caused by mutations in the SDHAF2

gene, which encodes a protein necessary for flavination of SDHA. PGL1
manifests as
tumors in the head and neck, and especially the carotid body.
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[0401] Hereditary paragangliomas-3 (PGL3) is caused by heterozygous mutations
in
the SDHC gene, which encodes subunit C of the succinate dehydrogenase complex.

PGL3 manifests as benign vascularized tumors in the head and neck.
[0402] Familial paragangliomas-4 (PGL4) is caused by heterozygous mutations in

the SDHB gene, which encodes the iron sulfur subunit of succinate
dehydrogenase.
Clinical features include susceptibility to pheochromocytoma and
paraganglioma, and
Cowden-like Syndrome (CWD2).
[0403] Paragangliomas-5 (PGL5) can be caused by heterozygous mutations in the
SDHA gene. Clinical features include hypertension and hyperadrenergic
symptoms,
such as dizziness, tachycardia, and sweating. Patients exhibit high
concentrations of
urinary normetanephrine, norepinephrine, and chromogranin A. Perturbations in
SDHA can also lead to cardiomyopathy and mitochondrial respiratory chain
complex
2 deficiency.
[0404] BCL2 is an integral inner mitochondrial membrane protein of relative
molecular mass 25,000. Overexpression of BCL2 blocks the apoptotic death of a
pro-
B-Iymphocyte cell line, and can result in B-cell lymphoma. Thus, BCL2 is
unique
among proto-oncogenes, being localized in mitochondria and interfering with
programmed cell death independent of promoting cell division.
[0405] Heterozygous mutations in the fumarate hydratase gene can cause
hereditary
leiomyomatosis and renal cell cancer.
[0406] Susceptibility to the development of neuroblastoma-1 (NBLST1) and
isolated pheochromocytoma is associated with mutations in the KIF1B gene,
which
encodes kinesin family member 1B. This protein is a member of the kinesin
family of
proteins that are essential for intracellular transport, including the
transport of
mitochondria. NBLST1 is common neoplasm of early childhood arising from
embryonic cells that form the primitive neural crest and give rise to the
adrenal
medulla and the sympathetic nervous system. Pheochromocytoma is caused by a
catecholamine-producing tumor of chromaffin tissue of the adrenal medulla or
sympathetic paraganglia. The cardinal symptom, reflecting the increased
secretion of
epinephrine and norepinephrine, is hypertension, which may be persistent or
intermittent.
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Nephronophthisis
[0407] Nephronophthisis (NPHP), also known as nephronophthisis-like
nephropathy 1, is an autosomal recessive cystic kidney disease characterized
by the
onset of end-stage renal failure in the first three decades of life. Features
of NPHP
include irregular tubular basement membrane, tubular cyst formation, and
interstitial
cell infiltration with fibrosis. The disorder is also frequently associated
with
extrarenal manifestations including liver fibrosis, retinal degeneration, and
central
nervous system abnormalities. Mutations in ten causative genes (NPHP1-NPHP9
and
NPHP11), whose products localize to the primary cilia-centrosome complex, have

been identified and are linked to the development of NPHP. In addition,
homozygous
frameshift and splice-site mutations in the X-prolyl aminopeptidase 3
(XPNPEP3)
gene have been identified and are associated with the development of a
nephronophthisis-like nephropathy. In contrast to all known NPHP proteins,
XPNPEP3 localizes to mitochondria of renal cells. XPNPEP3 belongs to a family
of
X-pro-aminopeptidases that utilize a metal cofactor and remove the N-terminal
amino
acid from peptides with a proline residue in the penultimate position.
Neuropathy; Ataxia; Retinitis Pigmentosa (NARP)
[0408] NARP Syndrome is caused by mutations in the gene encoding subunit 6 of
mitochondrial H(+)-ATPase (MTATP6) and usually presents at childhood (2nd
decade) or adult stage. The MT-ATP6 protein forms one subunit of complex V
(ATP
synthase), which is responsible for the last step in ATP production. Mutations
in MT-
ATP6 alter the structure or function of ATP synthase, reducing the ability of
mitochondria to produce ATP. Most individuals with NARP have a specific point
mutation at nucleotide 8993, with a T8993G mutation causing more severe
symptoms
than a T8993C mutation. Some cases involve a G8989C point mutation.
[0409] Clinical features include sensory neuropathy, proximal and distal
weakness,
reduced tendon reflexes, retinitis pigmentosa, reduced night vision, Bull's
eye
maculopathy, pigment in posterior pole & mid-periphery, small retinal scars,
vascular
narrowing, central and paracentral scotomas, gait disorder, dysarthria,
dementia,
seizures, Tonic-clonic seizures, developmental delay, pyramidal signs,
dystonia,
hearing loss, cardiac hypertrophy, denervation, cerebral atrophy, cortical
cerebellar
atrophy, focal cystic necrosis, and rod or cone dysfunction.
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[0410] Disruption of MTATP6 function can result in Distal Hereditary Motor
Neuropathy (dHMN), which usually presents during the 1st or 2nd decade of
life.
Clinical features include gait disorder, weakness, sensory loss, brisk tendon
reflexes,
extensor plantar reflex, pes cavus, Kyphoscoliosis, motor axon loss, sensory
axon
loss, and reduced Complex V activity.
Ornithine Transcarbamylase Deficiency
[0411] Ornithine transcarbamylase (OTC) deficiency is an X-linked inborn error
of
metabolism of the urea cycle that causes hyperammonemia. Ornithine
carbamoyltransferase is a nuclear-encoded mitochondrial matrix enzyme that
catalyzes the second step of the urea cycle in mammals. OTC deficiency is
associated
with mutations in the OTC gene. OTC is the most common urea cycle defect and
is
characterized by the triad of hyperammonemia, encephalopathy, and respiratory
alkalosis.
Paroxysmal Nonkinesigenic Dyskinesia
[0412] Paroxysmal nonkinesigenic dyskinesia (PNKD) is an autosomal dominant
movement disorder characterized by sudden attacks of dystonia, chorea, and
athetosis.
PNKD is associated with mutations in the myofibrillogenesis regulator-1 gene
(MR1).
MR1 is transcribed into three alternatively spliced isoforms: long (MR-1L);
medium
(MR-1M); and small (MR-1S). The MR-1L and MR-1M isoforms are mitochondrial
proteins imported into the organelle by a 39-amino acid, N-terminal
mitochondrial
targeting sequence (MTS).
Progressive External Ophthalmoplegia (PEO)
[0413] PEO is a slowly progressive disorder associated with slow eye movement
speed, limited gaze in all directions, ptosis, and extraocular muscle
pathology. PEO
may arise sporadically or as a consequence of autosomal dominant, autosomal
recessive, or maternal inheritance.
1. Sporadic PEO
[0414] Syndromes with severe ophthalmoplegia include Kearns-Sayre, PEO +
Proximal myopathy, and PEO.
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[0415] Chronic PEO is caused by a single large mtDNA deletion and usually
manifests at > 20 years of age. Symptoms include ophthalmoplegia, and heart
block
in some patients.
[0416] PEO with sensory ataxic neuropathy usually manifests between 10 to 31
years of age. Clinical features include sensory loss, gait disorder, distal
motor
weakness, absent tendon reflexes, external ophthalmoplegia, ptosis,
dysarthria, facial
weakness, myopathy, and ragged red muscle fibers.
[0417] Mutations in MTTQ can result in PEO that presents at 5 years of age.
Clinical symptoms include weakness, ptosis, dysphonia, dysphagia,
ophthalmoplegia,
reduced tendon reflexes, ragged red fibers, COX negative muscle fibers and
impairment in mitochondrial protein synthesis.
[0418] Mutations in MTTA can result in PEO that presents in the 6th decade of
life.
Clinical symptoms include ptosis, weakness, decreased eye movements,
dysphagia,
COX negative muscle fibers, mitochondrial proliferation, and partial defect of

Complex I.
[0419] Mutations in MTTL can result in PEO that presents in the 5th decade of
life.
Clinical symptoms include ptosis, migraines, decreased eye movements, exercise

intolerance, short stature, COX negative, ragged red muscle fibers, and
partial defects
of Complex I & IV.
[0420] Mutations in MTTY can result in PEO that presents in the 4th decade of
life.
Clinical symptoms include ptosis, exercise intolerance, ophthalmoplegia,
myopathy,
COX negative muscle fibers with increased SDH staining, and partial defect of
Complex I & IV. Other MTTY syndromes include exercise intolerance
with Complex III deficiency, and focal segmental glomerulosclerosis and
dilated
cardiomyopathy.
2. Maternally-inherited PEO
[0421] Maternal PEO is caused by mtDNA point mutations in MTTL, MTTN,
MTTQ, MTTA, and MTTK.
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3. Autosomal Dominant PEO
[0422] Autosomal dominant progressive external ophthalmoplegia (adPEO) with
mitochondrial DNA (mtDNA) deletions-3 (PEOA3) is caused by heterozygous
mutations in the nuclear-encoded twinkle gene (C100RF2), which binds to the 13-

subunit of polymerase-y (POLO). Progressive external ophthalmoplegia is
characterized by multiple mitochondrial DNA deletions in skeletal muscle. The
most
common clinical features include adult onset of weakness of the external eye
muscles
and exercise intolerance. Patients with C100RF2-linked adPEO may have other
clinical features including proximal muscle weakness, muscle pain, cramps,
respiratory failure, ataxia, peripheral neuropathy, cardiomyopathy, cataracts,

depression, ptosis, dysarthria, dysphagia, dysphonia, hearing loss, memory
loss,
Parkinsonism, avoidant personality traits, SDH+ COX negative muscle fibers,
ragged
red fibers, ketoacidosis, cortical atrophy or white matter lesions, and
endocrine
abnormalities. Variant syndromes involving Twinkle mutations include Infantile

Onset Spinocerebellar Ataxia (IOSCA), SANDO, MTDPS7, PEO + Dementia, PEO +
Parkinson, and Perrault.
[0423] Autosomal dominant progressive external ophthalmoplegia (adPEO) with
mitochondrial DNA (mtDNA) deletions-2 (PEOA2) is caused by heterozygous
mutations in the nuclear-encoded ANT 1 gene (SLC25A4), which usually manifests
at
20 to 35 years of age. Clinical symptoms include ophthalmoplegia, ptosis,
dysphagia,
dysphonia, face, proximal, and respiratory weakness, cataracts, sensorineural
hypoacusia, goiter, dementia, Bipolar affective disorder, high serum lactic
acid, and
multiple mtDNA deletions. Over-expression of ANT 1 is also observed in FSH
dystrophy muscle.
[0424] PEOA2 can also be caused by heterozygous mutations in the nuclear-
encoded twinkle gene (ClOORF2). The most common mutation is an Ala359Thr
missense mutation, the homozygous version producing more severe effects than
the
heterozygous version. In addition, adPEO is characterized by multiple
mitochondrial
DNA deletions in skeletal muscle. A severe CNS phenotype with polyneuropathy
is
associated with a 39-bp deletion. In general, the mutations tend to cluster in
regions
of the protein involved in subunit interactions (amino acids 303-508). The
twinkle
protein is involved in mtDNA metabolism and could function as an adenine
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CA 02920272 2016-02-09
nucleotide-dependent DNA helicase. The function of the twinkle protein is
believed
to be critical for lifetime maintenance of mtDNA integrity. The most common
clinical features of adPEO include adult onset of weakness of the external eye

muscles and exercise intolerance. Patients with ClOORF2-linked adPEO may have
other clinical features including proximal muscle weakness, ataxia, peripheral

neuropathy, cardiomyopathy, cataracts, depression, and endocrine
abnormalities.
[0425] Autosomal dominant progressive external ophthalmoplegia (adPEO) with
mitochondrial DNA (mtDNA) deletions-1 (PEOA1) is caused by mutations in the
nuclear-encoded DNA polymerase-gamma gene (POLG). Autosomal recessive PEO
(PEOB) is also caused by mutations in the POLG gene. PEO1 manifests at 16 to
39
years of age. Clinical features include PEO, muscle weakness, exercise
intolerance,
sensory loss, absent tendon reflexes, poorly formed 2 sexual characteristics,
early
menopause, testicular atrophy, Parkinsonism, proximal weakness & wasting,
dysphagia, dysphonia, facial diplegia, abnormal gait, depression,
extrapyramidal
syndrome, ragged red fibers, COX negative and SDH + fibers, and proximal
myopathy. Other clinical syndromes associated with dominant POLG mutations
include PEO+ Demyelinating neuropathy, PEO + Distal myopathy, Sensory
neuropathy, PEO & Tremor, and PEO + Hypogonadism. Clinical syndromes
associated with recessive POLG mutations include Alpers-Huttenlocher
Syndrome (AHS), Childhood myocerebrohepatopathy spectrum (MCHS), Myoclonic
epilepsy, Myopathy, Sensory ataxia (MEMSA), SANDO, MIRAS, MNGIE and
Parkinsons.
[0426] PEO+ Demyelinating neuropathy manifests at the second decade of life
and
is characterized by weakness, sensory loss, absent tendon reflexes, PEO with
ptosis,
dysphonia, dysphagia, nerve pathology, ragged red fibers, COX negative fibers,
and
reduced Complex I, III & IV activity.
[0427] Mitochondrial Recessive Ataxia Syndrome (MIRAS) usually manifests
between the ages of 5 to 38 years. Clinical symptoms include balance disorder,

epilepsy, dysarthria, nystagmus, reduced tendon reflexes, pain, sensory
neuropathy,
cramps, cognitive impairment, athetosis, tremor, obesity, and eye movement
disorders.
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[0428] PEO + Hypogonadism is characterized by delayed sexual maturation,
primary amenorrhea, early menopause, testicular atrophy, cataracts, cerebellar
ataxia,
tremor, Parkinsonism, depression, mental retardation, polyneuropathy, PEO,
dysarthria, dysphonia, proximal weakness, rhabdomyolysis, hypoacusis, Pes
cavus,
ragged red fibers, and cytochrome c oxidase negative muscle fibers.
[0429] Distal myopathy, Cachexia & PEO is caused by dominant or sporadic
mutations in POLG1 and usually manifests between the third and fourth decade
of
life. Clinical features include weakness, dysarthria, dysphagia, cachexia,
ptosis,
ophthalmoplegia, cataracts, and ragged red & COX negative muscle fibers.
[0430] Autosomal dominant progressive external ophthalmoplegia (adPEO) with
mitochondrial DNA (mtDNA) deletions-4 (PEOA4) is caused by heterozygous
mutations in the nuclear-encoded DNA polymerase gamma-2 gene (POLG2).
Progressive external ophthalmoplegia-4 is an autosomal dominant form of
mitochondrial disease that variably affects skeletal muscle, the nervous
system, the
liver, and the gastrointestinal tract. Age of onset ranges from infancy to
adulthood.
The phenotype ranges from relatively mild, with adult-onset skeletal muscle
weakness
and weakness of the external eye muscles, to severe, with a multisystem
disorder
characterized by delayed psychomotor development, lactic acidosis,
constipation, and
liver involvement. Clinical features include ptosis, external ophthalmoplegia,

exercise intolerance, pain, weakness, seizures, hypotonia, impaired glucose
tolerance,
high lactate, cerebellar atrophy, cardiac conduction defect, and abnormal
mitochondrial morphology.
[0431] Autosomal dominant progressive external ophthalmoplegia-6 (PEOA6) is
caused by heterozygous mutations in the DNA2 gene. PEOA6 is characterized by
muscle weakness, mainly affecting the lower limbs, external ophthalmoplegia,
exercise intolerance, and mitochondrial DNA (mtDNA) deletions on muscle
biopsy.
Clinical features include hypotonia, myalgia, exertional dyspnea, ptosis or
ophthalmoplegia, lordosis, and muscular atrophy. Symptoms may appear in
childhood or adulthood and show slow progression.
[0432] In some embodiments, dominant POLG mutations may lead to sensory
neuropathy, tremor and PEO.
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4. Autosomal Recessive PEO
[0433] PEO + Myopathy & Parkinsonism is an adult onset autosomal recessive
disorder. Clinical features include extrapyramidal signs (e.g., akinesia,
rigidity, rest
tremor), ptosis, ophthalmoplegia, proximal & facial weakness, occasional
distal leg
weakness, hearing loss, SDH + and COX negative muscle fibers, reduced complex
III
activity, and multiple mtDNA deletions.
[0434] Autosomal recessive progressive external ophthalmoplegia (PEOB) is
caused by homozygous or compound heterozygous mutations in the nuclear-encoded

DNA polymerase-gamma gene (POLG). Recessive mutations in the POLG gene can
also cause sensory ataxic neuropathy, dysarthria, and ophthalmoparesis
(SANDO),
which shows overlapping features. Autosomal recessive PEO is usually more
severe
than autosomal dominant PEO.
[0435] SANDO usually manifests between the ages of 16 to 38 years and is
characterized by exercise intolerance, ptosis, and paresthesias. Clinical
symptoms
include sensory loss, ataxic gait, pseudoathetosis, small fiber modality loss,
weakness,
reduced tendon reflexes, ptosis, ophthalmoplegia, dysarthria, myoclonic
epilepsy,
depression, high CSF and serum lactate, degeneration of spinocerebellar and
dorsal
column tracts, thalamic lesions, cerebellar atrophy or White matter lesions,
ragged red
fibers, loss of myelinated & unmyelinated axons, and reduced activity of
Complex I
& IV.
[0436] Mitochondrial DNA Depletion Syndrome-11 (MTDPS11) can be caused by
homozygous mutations in the MGME1 gene. Mitochondrial DNA Depletion
Syndrome-11 is an autosomal recessive mitochondrial disorder characterized by
onset
in childhood or adulthood of progressive external ophthalmoplegia (PEO),
ptosis,
muscle weakness and atrophy, exercise intolerance, dysphonia, dysphagia, and
respiratory insufficiency due to muscle weakness. More variable features
include
spinal deformity, emaciation, and cardiac abnormalities. Skeletal muscle
biopsies
show deletion and depletion of mitochondrial DNA (mtDNA) with variable defects
in
respiratory chain enzyme activities. Additional features include scapular
winging,
mental retardation, memory deficits, nausea, flatulence, abdominal fullness,
diarrhea,
loss of appetite, SDH+ & COX negative fibers, Complex I or I + IV
deficiencies, and
cerebellar atrophy.
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[0437] PEO with cardiomyopathy is caused by recessive mutations in POLG and
usually manifests at childhood. Clinical features include PEO, cardiomyopathy,

proximal weakness, multiple mtDNA deletions, and ragged red fibers.
[0438] An additional POLG syndrome is Parkinsonism without external
ophthalmoplegia. Clinical feature include Parkinsonism or Dystonia, weakness,
high
serum lactate, COX negative muscle fibers, polyneuropathy, and cerebral and
cerebellar atrophy.
[0439] Ataxia with sensory neuropathy is a variant POLG syndrome that is not
associated with ophthalmoplegia.
PEPCK Deficiency
[0440] PEPCK deficiency is an autosomal recessive disorder of carbohydrate
metabolism. A deficiency of the enzyme phosphoenolpyruvate carboxykinase
(PEPCK), which is a key enzyme in gluconeogenesis, causes acidemia. PEPCK
converts oxaloacetate into phosphoenolpyruvate and carbon dioxide. PEPCK
deficiency is characterized by hypoglycemia, hypotonia, hepatomegaly, liver
impairment, and failure to thrive. In humans, there are two forms of PEPCK
deficiency: cytosolic and mitochondrial. Both forms result from an inherited
deficiency in the enzyme PEPCK. Cytosolic PEPCK is encoded by PCK1 and the
mitochondrial enzyme is encoded by PCK2. PCK2 encodes a deduced 640-amino
acid polypeptide that shares 70% homology with cytosolic PCK.
Perrault Syndromes
[0441] Perrault Syndrome (PRLTS) is a sex-influenced, autosomal recessive
disorder characterized by sensorineural deafness in both males and females and

premature ovarian failure (POF) secondary to ovarian dysgenesis in females.
Some
patients also have neurologic manifestations, including mild mental
retardation and
cerebellar and peripheral nervous system involvement. Perrault Syndrome is
classified into type I, which is static and without neurologic disease, and
type II,
which is with progressive neurologic disease.
[0442] Perrault Syndrome-1 (PRLTS1) is caused by compound heterozygous
mutations in the HSD17B4 gene, which encodes a D-bifunctional protein (DBP).
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[0443] Perrault Syndrome-2 (PRLTS2) is caused by compound heterozygous
mutations in the mitochondrial histidyl-tRNA synthetase, HARS2. Affected
females
have primary amenorrhea, streak gonads, and infertility, whereas affected
males show
normal pubertal development and are fertile
[0444] Perrault Syndrome-3 (PRLTS3) is caused by homozygous or compound
heterozygous mutations in the CLPP gene, an endopeptidase component of a
mitochondrial ATP-dependent proteolytic complex required for protein
degradation in
the mitochondria.
[0445] Perrault Syndrome-4 (PRLTS4) is caused by homozygous or compound
heterozygous mutations in the LARS2 gene.
[0446] Mutations in the Twinkle gene can also lead to Perrault Syndrome. In
addition to sensorineural deafness and female hypogonadism, patients exhibit
symptoms such as nystagmus, gait disorder, epilepsy, polyneuropathy,
ophthalmoplegia, increased serum lactate, and muscle atrophy.
Propionic Acidemia
[0447] Propionic acidemia (PA) is caused by a deficiency of propionyl-CoA
carboxylase (PCC), a biotin-dependent carboxylase located in the mitochondrial
inner
membrane space. PCC catalyzes the conversion of propionyl-CoA to methylmalonyl-

CoA, which eventually enters the TCA cycle as succinyl-CoA. Propionyl-CoA is
common to the pathway for degradation of some amino acids (isoleucine, valine,

threonine, and methionine), odd-chain fatty acids, and cholesterol. Gut
bacteria (i.e.,
Propionibacterium sp.) are also an important source of propionate metabolized
through PCC. PCC is a heterododecamer (a6I36) composed of six a-subunits
encoded
by PCCA and six 13-subunits encoded by PCCB. Biallelic mutation of either PCCA
or
PCCB results in PA.
[0448] Patients with PA exhibit episodic vomiting, lethargy, ketosis,
neutropenia,
periodic thrombocytopenia, hypogammaglobulinemia, developmental retardation,
and
intolerance to protein. Chemical features include hyperglycinemia and
hyperglycinuria.
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Pyruvate Disorders
[0449] Pyruvate dehydrogenase complex (PDHC) is a nuclear-encoded
mitochondrial matrix multienzyme complex composed of multiple copies of 3
enzymes: El, Dihydrolipoyl transacetylase (DLAT), and Dihydrolipoyl
dehydrogenase (DLD). PDHC catalyzes the irreversible conversion of pyruvate
into
acetyl-CoA. Pyruvate disorders may arise as a consequence of perturbations in
PDHA 1, PDHB, PDHX, PDK3, PDP1, DLAT, DLD, NFUl, BOLA3, Lipoic acid
synthase (LIAS), TPK1, Pyruvate carboxylase and Pyruvate transporter.
1. Pyruvate Carboxylase Deficiency
[0450] Pyruvate carboxylase converts pyruvate & CO2 to oxaloacetate and plays
a
role in gluconeogenesis. Pyruvate carboxylase deficiency is caused by
mutations in
the pyruvate carboxylase gene and is categorized into 3 phenotypic subgroups:
Type
A, Type B and Type C. Type A patients have lactic acidemia and psychomotor
retardation, whereas Type B patients have a more complex biochemical phenotype

with increased serum lactate, ammonia, citrulline, and lysine, as well as an
intracellular redox disturbance in which the cytosolic compartment is more
reduced
and the mitochondrial compartment is more oxidized. Type B patients have
decreased survival compared to group A, and usually do not survive beyond 3
months
of age. Type C is relatively benign. Clinical features include hypotonia,
delayed
neurologic development, ataxia, chronic lactic acidemia, developmental delay,
seizures, lactic acidosis, increased lactate:pyruvate & acetoacetate:3-
hydroxybutyrate
ratios, and episodic metabolic acidosis.
2. Pyruvate Dehydrogenase El-a Deficiency (PDHAD)
[0451] Pyruvate dehydrogenase El-alpha deficiency (PDHAD) is caused by
mutations in the gene encoding the El-alpha polypeptide (PDHA1) of the
pyruvate
dehydrogenase (PDH) complex. Genetic defects in the pyruvate dehydrogenase
complex are one of the most common causes of primary lactic acidosis in
children.
Most cases are caused by mutation in the El-alpha subunit gene on the X
chromosome. X-linked PDH deficiency is one of the few X-linked diseases in
which
a high proportion of heterozygous females manifest severe symptoms. Clinical
features of PDHAD include seizures, hyperventilation, episodic cerebellar
ataxia,
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chorioathetosis, lactic acidosis, carbohydrate intolerance, high serum pyruvic
acid,
and high serum alanine.
[0452] Variant syndromes associated with Pyruvate dehydrogenase El-alpha
deficiency are also common and are characterized by hypotonia, lethargy,
seizures,
dystonia, psychomotor retardation, Leigh-like lesions and hyperlactataemia.
3. Pyruvate Dehydrogenase El-f3 Deficiency (PDHBD)
[0453] Pyruvate dehydrogenase El-beta deficiency (PDHBD) is caused by
homozygous mutations in the PDHB gene, and typically presents at the infant
stage.
Clinical symptoms include hypotonia, respiratory insufficiency, lactic
acidosis, corpus
callosum agenesis, and reduced PDH activity.
4. Dihydrolipoamide Dehydrogenase (DLD) Deficiency
[0454] The DLD gene encodes dihydrolipoamide dehydrogenase (EC 1.8.1.4), a
flavoprotein component known as E3 that is common to the 3 alpha-ketoacid
dehydrogenase multienzyme complexes, namely, pyruvate dehydrogenase complex,
the alpha-ketoglutarate dehydrogenase complex (KGDC), and the branched-chain
alpha-keto acid dehydrogenase complex (BCKDC). The enzyme is a functional
homodimer of the DLD protein and catalyzes the oxidative regeneration of a
lipoic
acid cofactor covalently bound to E2 (DBT) yielding NADH. The DLD enzyme is
also a component, referred to as the L protein, of the mitochondrial glycine
cleavage
system (GCS). Clinical symptoms include vomiting and abdominal pain, stroke-
like
episodes, hypothermia, motor retardation, myoglobinuria, exertional fatigue,
lactic
acidosis, hypoglycemia, and high pyruvate, lactate, a-ketoglutarate, and
branched-
chain amino acids.
5. Pyruvate Dehydrogenase Phosphatase Deficiency (PDHPD)
[0455] Pyruvate dehydrogenase phosphatase deficiency can be caused by
mutations
in the PDP1 gene. Clinical features include hypotonia, developmental delay,
seizures,
lactic acidosis, and posterior white matter pathology.
6. Pyruvate Dehydrogenase E3-binding Protein Deficiency (PDHXD)
[0456] Pyruvate dehydrogenase E3-binding protein deficiency is caused by
homozygous or compound heterozygous mutations in the PDHX gene. Clinical
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features include hypotonia, psychomotor retardation, Leigh Syndrome, optic
atrophy,
diplegia, dysarthria, lactic acidosis, putaminal lesions, and hemolytic
anemia.
7. Mitochondrial Pyruvate Carrier Deficiency (MPYCD)
[0457] Mitochondrial pyruvate carrier deficiency (MPYCD) is an autosomal
recessive metabolic disorder characterized by delayed psychomotor development
and
lactic acidosis with a normal lactate/pyruvate ratio resulting from impaired
mitochondrial pyruvate oxidation. MPYCD is caused by homozygous mutations in
the BRP44L gene and usually manifests at birth or childhood. Clinical features

include hypotonia, psychomotor retardation, peripheral neuropathy, dysmorphic
features (face, single palmar fold, wide spaced nipples), hepatomegaly,
metabolic
acidosis, hyperlactacidemia, and periventricular cysts.
Schwartz-Jampel Syndrome Type 1 (SJS1)
[0458] Schwartz-Jampel Syndrome type 1 (SJS1) is caused by mutations in the
gene
encoding perlecan (HSPG2), a heparan sulfate proteoglycan. Perlecan is a major

component of basement membranes & interstitial matrix in cartilage and
functions as
a coreceptor for FGF2.
[0459] Schwartz-Jampel Syndrome type 1A occurs during childhood (usually < 3
years). Clinical features include respiratory difficulties, impaired
swallowing,
polyhydramnios, absent stomach bubble, short femurs, skeletal contractures,
muscle
stiffness, reduced tendon reflexes, muscle hypertrophy, malignant
hyperthermia,
mental retardation, bone dysplasia, micrognathia, platyspondyly, cleft
vertebrae,
reduced height, kyphoscoliosis, myopia, cataracts, blepharophimosis, medial
displacement of outer canthi, hirsutism, small testes, microstomia, jaw muscle

rigidity. SJS Type 1B occurs at birth and is associated with more severe bone
dysplasia. Silverman-Handmaker type of dyssegmental dysplasia (DDSH) refers to

an allelic disorder with a more severe phenotype.
Selenium Deficiency
[0460] Selenium deficiency results in reduced glutathione peroxidase activity,

oxidative damage, reduced levels of selenoproteins and increased toxicity of
drugs &
toxins (e.g., nitrofurantoin, paraquat). Clinical features include myopathy,
cardiomyopathy, selenoprotein disorders (congenital muscular dystrophy with
rigid
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spine, hyperthyroxinemia), nail and hair loss, gastroenteritis, dermatitis,
malabsorption, muscle pain, high serum creatine kinase, low vitamin E levels,
and
enlarged mitochondria.
Short-chain Acyl-CoA Dehydrogenase deficiency
[0461] Short-chain acyl-CoA dehydrogenase (SCAD) deficiency is an autosomal
recessive metabolic disorder of mitochondrial fatty acid beta-oxidation. The
disorder
is associated with mutations in the ACADS gene encoding short-chain acyl-CoA
dehydrogenase. Two clinical phenotypes of SCAD deficiency have been
identified.
One form of the disorder is an infantile onset characterized by acute
acidosis,
myopathy, failure to thrive, developmental delay, and seizures. The other form
is
observed in middle-aged patients who exhibit chronic myopathy,
ophthalmoplegia,
ptosis, and scoliosis.
Succinyl CoA:3-oxacid CoA Transferase Deficiency
[0462] Succinyl CoA:3-oxacid CoA transferase (SCOT) deficiency is an inborn
error of ketone body metabolism associated with mutations in the OXCT1 gene.
SCOT is a key mitochondrial enzyme in the metabolism of ketone bodies in
various
organs. Deficiency of SCOT activity inhibits peripheral ketone body
utilization and
causes episodes of severe ketoacidosis. Ketones are molecules produced in the
liver
during the breakdown of fats and are the major vectors of energy transfer from
the
liver to extrahepatic tissues. As the first step of ketone body utilization,
SCOT
catalyzes the reversible transfer of CoA from succinyl-CoA to acetoacetate.
Stuve-Wiedemann Syndrome (STWS)
[0463] Stuve-Wiedemann Syndrome (STWS), also known as neonatal Schwartz-
Jampel Syndrome type 2 (SJS2), is caused by a mutation in the leukemia
inhibitory
factor receptor gene (LIFR).
[0464] Stuve-Wiedemann Syndrome (STWS) is an autosomal recessive disorder
characterized by bowing of the long bones and other skeletal anomalies,
episodic
hyperthermia, and respiratory and feeding distress usually resulting in early
death.
Age of onset is typically at birth. Clinical features include hypotonia,
respiratory &
feeding difficulties, hyperthermic episodes, high mortality in infancy, joint
contractures, bent bone dysplasia, bowing of lower limbs, internal cortical
thickening,
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wide metaphyses, camptodactyly, spontaneous fractures, short stature,
malignant
hyperthermia, temperature instability, loss of corneal reflex, smooth tongue,
reduced
tendon reflexes, and reduced Complex I and IV activity.
Thrombocytopenia
[0465] Thrombocytopenia (THC) is characterized by a decrease in platelet
count,
resulting in the potential for increased bleeding and a decreased clotting
ability.
Although inherited forms of this syndrome are relatively rare, a number of
genes
underlying thrombocytopenia have been identified. One form of autosomal
dominant
nonsyndromic thrombocytopenia is caused by a mutation in the CYCS gene
encoding
cytochrome c. Cytochrome c is located in the mitochondria of all aerobic cells
and is
involved in the electron transport chain that functions in oxidative
phosphorylation.
Mutations in the CYCS gene have been shown to increase the apoptotic activity
of
cytochrome c in individuals with autosomal dominant nonsyndromic
thrombocytopenia.
Very Long-chain Acyl-CoA Dehydrogenase Deficiency
[0466] Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is a
disorder of fatty acid oxidation associated with the accumulation of fatty
acids and
decreases in cell energy metabolism due to enzyme defects in the fatty acid
metabolic
pathway. VLCADD is caused by homozygous or compound heterozygous mutations
in the ACADVL gene that encodes very long-chain acyl-CoA dehydrogenase. Very
long-chain acyl-CoA dehydrogenase (VLCAD) is unique among the acyl-CoA
dehydrogenases in its size, structure, and intramitochondrial distribution.
Whereas
other acyl-CoA dehydrogenases are homotetramers of a 43- to 45-kD subunit,
VLCAD has been shown to be a 154-kD homodimer of a 70-kD subunit. VLCAD
has been found to be loosely bound to the mitochondrial inner membrane and
required
detergent for stabilization. By contrast, the other three acyl-CoA
dehydrogenases are
readily extractable without detergent, indicating that they are located in the

mitochondrial matrix.
[0467] VLCAD deficiency is classified into three forms: a severe early-onset
with a
high incidence of cardiomyopathy and high mortality; an intermediate form with

childhood onset, usually with hypoketotic hypoglycemia and a more favorable
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CA 02920272 2016-02-09
outcome; and an adult-onset, myopathic form with isolated skeletal muscle
involvement, rhabdomyolysis, and myoglobinuria after exercise or fasting.
Vitamin D-dependent Rickets Type 1A
[0468] Vitamin D-dependent rickets type lA (VDDR1A) is an autosomal recessive
disorder characterized by hypocalcemia, secondary hyperparathyroidism, and
early
onset severe rickets. The disorder is caused by a mutation in the CYP27B1 gene

encoding the enzyme 25-hydroxyvitamin D3-1-alpha-hydroxylase, which is
localized
to the mitochondrial inner membrane. 25-hydroxyvitamin D3-1-alpha-hydroxylase
is
expressed in the renal proximal tubule where it catalyzes the hydroxylation of
25-
hydroxyvitamin D3 into 1-alpha,25-dihydroxyvitamin D3 (1,25(OH)2D3, or
calcitrol).
The active metabolite 1,25(OH)2D3 binds and activates the nuclear vitamin D
receptor (VDR) and regulates physiologic events such as calcium homeostasis
and
cellular differentiation and proliferation.
Wilson's Disease
[0469] Wilson's disease is caused by homozygous or compound heterozygous
mutations in the ATP7B gene. Wilson's disease is an autosomal recessive
disorder
characterized by dramatic build-up of intracellular hepatic copper with
subsequent
hepatic and neurologic abnormalities. In Wilson disease, the basal ganglia and
liver
undergo changes that express themselves in neurologic manifestations and signs
of
cirrhosis, respectively. Markedly reduced levels of cytochrome oxidase
activity and
low ceruloplasmin serum levels are observed in affected individuals.
Ceruloplasmin
functions in enzymatic transfer of copper to copper-containing enzymes such as

cytochrome oxidase.
[0470] There are at least 3 forms of Wilson disease. In a rare 'atypical
form,' the
heterozygotes show about 50% of the normal level of ceruloplasmin. In the 2
typical
forms, the Slavic and the juvenile type, heterozygotes have normal
ceruloplasmin
levels, although they can be identified by decreased reappearance of
radioactive
copper into serum and ceruloplasmin. The Slavic type has a late age of onset
and is
predominantly a neurologic disease. The juvenile type, which occurs in Western

Europeans and several other ethnic groups, has onset before age 16 years and
is
frequently a hepatic disease.
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[0471] The Kayser-Fleischer ring is a deep copper-colored ring at the
periphery of
the cornea which is frequently found in Wilson disease and is thought to
represent
copper deposits. Additional clinical symptoms include azure lunulae of the
fingernails, hypercalciuria, nephrocalcinosis, renal stones, nephrolithiasis,
chondrocalcinosis, osteoarthritis, hemolytic anemia, leukoencephalopathy,
neuropathy, respiratory chain defects, myocardial abnormalities, intermittent
paresthesia and weakness in both hands and feet.
Peroxisome Biogenesis Disorder 3A (PBD3A): Zellweger Syndrome
[0472] Zellweger Syndrome (PBD3A) is caused by homozygous or compound
heterozygous mutations in the PEX12 gene on chromosome 17. The peroxisomal
biogenesis disorder (PBD) Zellweger Syndrome (ZS) is an autosomal recessive
multiple congenital anomaly syndrome resulting from disordered peroxisome
biogenesis. Affected children present in the newborn period with profound
hypotonia, seizures, and inability to feed. Characteristic craniofacial
anomalies, eye
abnormalities, neuronal migration defects, hepatomegaly, and chondrodysplasia
punctata are present. Children with this condition do not show any significant

development and usually die in the first year of life. Brain MRIs of affected
subjects
show reduced white matter and hypoplasia in corpus callosum.
[0473] Another form of peroxisome biogenesis disorder (PBD8B) is caused by
homozygous mutations in the PEX16 gene. Mutations in PEX16 also cause
Zellweger Syndrome. The age of onset usually occurs between 1 to 2 years.
Clinical
symptoms are progressive and include spasticity, dysarthria, dysphagia,
ataxia,
abnormal gait, delayed walking, optic atrophy, cataracts, constipation, and
neuropathy.
[0474] The overlapping phenotypes of neonatal adrenoleukodystrophy (NALD) and
infantile Refsum disease (IRD) represent the milder manifestations of the
Zellweger
Syndrome spectrum (ZSS) of peroxisome biogenesis disorders. The clinical
course of
patients with the NALD and IRD presentation is variable and may include
developmental delay, hypotonia, liver dysfunction, sensorineural hearing loss,
retinal
dystrophy, and visual impairment. Children with the NALD presentation may
reach
their teens, and those with the IRD presentation may reach adulthood.
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Mitochondrial Disorders Associated with Drugs and Toxins
1. Arsenic Trioxide Myopathy
[0475] Arsenic trioxide (ATO) has a proven therapeutic efficacy in acute
promyelocytic leukemia (APL). However, APL patient who have undergone ATO
treatment may develop a delayed, severe, and partially reversible
mitochondrial
myopathy. Affected individuals may present with the inability to walk,
myopathy
with cytoplasmic lipid droplets, decreased mitochondrial respiratory chain
complex
activity, multiple mtDNA deletions, and elevated muscle arsenic content.
2. Myopathy and Neuropathy Resulting from Nucleoside Analogues
[0476] Nucleoside analogues are molecules that function as nucleosides in DNA
or
RNA replication. These analogs include a range of antiviral products used in
the
prevention of viral replication. Various nucleoside analogues including
azidothymidine (AZT), clevudine, telbivudine, and fialuridine are associated
with the
development myopathies and neuropathies.
3. Germanium Myopathy
[0477] Germanium can have a toxic effect on skeletal muscle leading to
myopathy
and polyneuropathy. Pathological examinations of skeletal muscle from
individuals
affected by germanium intoxication exhibit vacuolar myopathy with lipid
excess,
increased acid phosphatase activity, decreased cytochrome oxidase activity,
and
mitochondrial abnormalities.
4. Parkinsonism and Mitochondrial Complex I Neurotoxicity due to
Trichloroethylene
[0478] Long-term exposure to trichloroethylene is associated with Parkinsonism
and
mitochondrial Complex I neurotoxicity. Neurotoxic actions of trichloroethylene

include selective Complex 1 impairment in the midbrain with concomitant
striatonigral fiber degeneration and loss of dopamine neurons.
5. Valproate-induced Hepatic Failure
[0479] Valproate is an anticonvulsant that is administered to control certain
types of
seizures in the treatment of epilepsy. There is an increased risk of Valproate-
induced
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liver failure in patients with hereditary neurometabolic syndromes caused by
mutations of the mitochondrial DNA polymerase y (POLG) gene.
Other Mitochondrial Syndromes Characterized by Infantile and Childhood Onset
1. Neurodegeneration with Brain Iron Accumulation
[0480] Neurodegeneration with brain iron accumulation-4 (NBIA4) is an
autosomal
recessive neurodegenerative disorder caused by a homozygous or compound
heterozygous mutation in the C190RF12 gene. Neurodegeneration with brain iron
accumulation-1 (NBIA1), also known as Hallervorden-Spatz disease, is caused by
a
homozygous or compound heterozygous mutation in the pantothenate kinase-2
gene,
PANK2.
2. Primary Coenzyme 010 Deficiency-3
[0481] Primary coenzyme Q10 deficiency-3 (C0Q10D3) is a fatal
encephalomyopathic form of coenzyme Q10 deficiency with nephrotic syndrome
that
can be caused by compound heterozygous mutation in the PDSS2 gene, which
encodes a subunit of decaprenyl diphosphate synthase, the first enzyme of the
CoQ10
biosynthetic pathway.
3. Combined Mitochondrial Complex Deficiencies
[0482] Combined complex deficiencies include combined complex I, II, IV, V
deficiency, combined complex I, II, and III deficiency, combined oxidative
phosphorylation deficiency-1 (COXPD1), combined oxidative phosphorylation
deficiency-2 (COXPD2), combined oxidative phosphorylation deficiency-3
(COXPD3), combined oxidative phosphorylation deficiency-4 (COXPD4), combined
oxidative phosphorylation deficiency-5 (COXPD5), combined oxidative
phosphorylation deficiency-6 (COXPD6), combined oxidative phosphorylation
deficiency-7 (COXPD7), combined oxidative phosphorylation deficiency-8
(COXPD8), combined oxidative phosphorylation deficiency-9 (COXPD9), combined
oxidative phosphorylation deficiency-10 (COXPD10), combined oxidative
phosphorylation deficiency-11 (COXPD11), combined oxidative phosphorylation
deficiency-12 (COXPD12), combined oxidative phosphorylation deficiency-13
(COXPD13), combined oxidative phosphorylation deficiency-14 (COXPD14),
combined oxidative phosphorylation deficiency-15 (COXPD15), combined oxidative
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phosphorylation deficiency-16 (COXPD16), combined oxidative phosphorylation
deficiency-17 (COXPD17), combined oxidative phosphorylation deficiency-18
(COXPD18), combined oxidative phosphorylation deficiency-19 (COXPD19),
combined oxidative phosphorylation deficiency-20 (COXPD20), combined oxidative

phosphorylation deficiency-21 (COXPD21), mitochondrial DNA depletion myopathy
(MTDPS2), and Multiple Mitochondrial Dysfunctions Syndrome (MMDS).
4. Complex I Deficiency
[0483] Mitochondrial Complex I (NADH-ubiquinone reductase) deficiency is
associated with several disorders including cardiomyopathy due to mutations in
the
NDUFS2 gene, fatal multisystemic complex I deficiency due to mutations in the
NDUFS4 gene, and lethal infantile mitochondrial disease due to mutations in
the
NDUFS6, C200RF7, NDUFAF3, and/or NDUFB2 genes.
5. Complex II Deficiency
[0484] Mitochondrial Complex II (succinate dehydrogenase-CoQ oxoreductase)
deficiency is associated with disorders including Leigh Syndrome due to
mutations in
the SDHA gene, infantile leukoencephalopathy due to SDHAF1 mutations, iron-
sulfur disorders, paragangliomas and pheochromocytomas due to mutations in the

SDHAF2, SDHB, SDHC, and SDHD genes.
6. Complex III Deficiency
[0485] Mitochondrial Complex III (cytochrome reductase) deficiency is
associated
with disorders including insulin-responsive hyperglycemia and encephalopathy
due to
mutations in the CYC1 gene and hypoglycemia due to mutations in the UQCRB
gene.
7. Complex IV Deficiency
[0486] Complex IV (cytochrome oxidase) deficiency is associated with disorders

including developmental delay and multisystem disorders due to mutations in
CEP89,
hepatic failure due to mutations in SC01, leukodystrophies due to mutations in

COX6B1 and/or APOPT1, and spastic ataxia due to mutations in COX10.
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8. Complex V Deficiency
[0487] Complex V (ATP synthase) deficiency is associated with disorders
including
apical hypertrophic cardiomyopathy due to mutations in MT-ATP8, dysmorphic
cerebrooculofacioskeletal features due to mutations in ATPAF2, and mental
retardation, polyneuropathy, and episodic lactic acidosis due to mutations in
TTP5E.
9. Fumarase Deficiency
[0488] Fumarase deficiency, also known as fumaric aciduria, is caused by a
homozygous or compound heterozygous mutation in the fumarate hydratase gene
(FH). Fumarase deficiency is a severe autosomal recessive metabolic disorder
characterized by early-onset hypotonia, profound psychomotor retardation, and
brain
abnormalities, such as agenesis of the corpus callosum, gyral defects, and
ventriculomegaly. Many patients show neonatal distress, metabolic acidosis,
and/or
encephalopathy.
10. 3-Hydroxy-3-methylglutaryl-00A Synthase-2 Deficiency
[0489] Mitochondrial HMG-CoA synthase-2 deficiency is caused by mutation in
the
gene encoding mitochondrial HMG-CoA synthase-2 (HMGCS2). Mitochondrial
HMG-CoA synthase deficiency is an inherited metabolic disorder caused by a
defect
in the enzyme that regulates the formation of ketone bodies. Patients present
with
hypoketotic hypoglycemia, encephalopathy, and hepatomegaly, usually
precipitated
by an intercurrent infection or prolonged fasting.
11. Hyperuricemia, Pulmonary Hypertension, Renal Failure, and Alkalosis
Syndrome
[0490] Hyperuricemia, pulmonary hypertension, renal failure, and alkalosis
(HUPRA) Syndrome is caused by homozygous mutation in the SARS2 gene, which
encodes mitochondrial seryl-tRNA synthetase. HUPRA Syndrome is a severe
autosomal recessive multisystem disorder characterized by onset in infancy of
progressive renal failure leading to electrolyte imbalances, metabolic
alkalosis,
pulmonary hypertension, hypotonia, and delayed development. Affected
individuals
are born prematurely.
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12. Linear Skin Lesions
[0491] Linear skin lesions are associated with syndromic microphthalmia-7
(MCOPS7) and reticulolinear aplasia cutis congenita with microcephaly, facial
dysmorphism, and other congenital anomalies (APLCC).
[0492] Syndromic microphthalmia-7 is caused by mutation in the HCCS gene. The
microphthalmia with linear skin defects syndrome (MLS) is an X-linked dominant

disorder characterized by unilateral or bilateral microphthalmia and linear
skin
defects¨which are limited to the face and neck, consisting of areas of
aplastic skin
that heal with age to form hyperpigmented areas¨in affected females and in
utero
lethality for males. A similar form of congenital linear skin defects, also
limited to
the face and neck and associated with microcephaly, is APLCC, which can be
Caused
by mutation in the COX7B gene.
13. Pontocerebellar Hypoplasia Type 6
[0493] Pontocerebellar hypoplasia (PCH) is a heterogeneous group of disorders
characterized by an abnormally small cerebellum and brainstem and associated
with
severe developmental delay. Pontocerebellar hypoplasia type 6 (PCH6) is caused
by
a homozygous or compound heterozygous mutation in the gene encoding
mitochondrial arginyl-tRNA synthetase (RARS2).
14. Pyruyate Dehydrogenase Complex Disorders
[0494] Pyruvate dehydrogenase complex (PDHC) disorders are a common cause of
lactic acidosis and encephalopathy in children. PDHC disorders are associated
with
mutations in the following genes: PDHA 1, PDHB, PDHX, PDP1, DLD, DLAT,
LIAS, and TPK1.
15. Mitochondrial DNA Depletion Syndrome-9
[0495] Mitochondrial DNA Depletion Syndrome-9 (MTDPS9P), also known as
severe neonatal lactic acidosis with mtDNA depletion, is caused by a
homozygous or
compound heterozygous mutation in the alpha subunit of the succinate-CoA
ligase
gene (SUCLG1). MTDPS9P is a severe autosomal recessive disorder characterized
by infantile onset of hypotonia, lactic acidosis, severe psychomotor
retardation,
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CA 02920272 2016-02-09
progressive neurologic deterioration, and excretion of methylmalonic acid.
Some
patients with MTDPS9 die in early infancy.
16. Sudden Infant Death Syndrome
[0496] Sudden infant death Syndrome (SIDS) is associated with mutations
identified in MTTL1, which encodes mitochondrial leucine transfer RNA 1,
MTND2,
which encodes NADH dehydrogenase subunit 1, and HADHB, which encodes the
beta subunit of the mitochondrial trifunctional protein.
[0497] In one aspect, the present disclosure provides a method of treating,
ameliorating or preventing a mitochondrial disease or disorder or signs and
symptoms
thereof, comprising administering a therapeutically effective amount of a
composition
comprising phenazine-3-one and/or phenothiazine-3-one derivatives, analogues,
or
pharmaceutically acceptable salts thereof. In some embodiments of the method,
the
mitochondrial disease or disorder is selected from the group consisting of
Alexander
disease, Alpers Syndrome, Alpha-ketoglutarate dehydrogenase (AKDGH)
deficiency,
ALS-FTD, Sideroblastic anemia with spinocerebellar ataxia, Pyridoxine-
refractory
sideroblastic anemia, GRACILE Syndrome, Bjornstad Syndrome, Leigh Syndrome,
mitochondrial complex III deficiency nuclear type 1 (MC3DN1), combined
oxidative
phosphorylation deficiency 18 (COXPD18), Thiamine-responsive megaloblastic
anemia syndrome (TRMA), Pearson Syndrome, HAM Syndrome, Ataxia, Cataract,
and Diabetes Syndrome, MELAS/MERRF Overlap Syndrome, combined oxidative
phosphorylation deficiency-14 (COXPD14), Infantile cerebellar-retinal
degeneration
(ICRD), Charlevoix-Saguenay spastic ataxia, Primary coenzyme Q10 deficiency-1
(C0Q10D1), ataxia oculomotor apraxia type 1 (A0A1), Autosomal recessive
spinocerebellar ataxia-9/ coenzyme Q10 deficiency-4 (C0Q10D4), Ataxia,
Pyramidal
Syndrome, and Cytochrome Oxidase Deficiency, Friedreich's ataxia, Infantile
onset
spinocerebellar ataxia (IOSCA)/ Mitochondrial DNA Depletion Syndrome-7,
Leukoencephalopathy with brainstem and spinal cord involvement and lactate
elevation (LBSL), Autosomal recessive spastic ataxia-3 (SPAX3), MIRAS, SANDO,
mitochondrial spinocerebellar ataxia and epilepsy (MSCAE), spastic ataxia with
optic
atrophy (SPAX4), progressive external ophthalmoplegia with mitochondrial DNA
deletions autosomal dominant type 5 (PEOA5), mitochondrial complex III
deficiency
nuclear type 2 (MC3DN2), episodic encephalopathy due to thiamine
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pyrophosphokinase deficiency/Thiamine Metabolism Dysfunction Syndrome-5
(THMD5), Spinocerebellar ataxia-28 (SCA28), autosomal dominant cerebellar
ataxia,
deafness, and narcolepsy (ADCA-DN), Dominant Optic Atrophy (DOA), cerebellar
ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss
(CAPOS)
Syndrome, spinocerebellar ataxia 7 (SCA7), Barth Syndrome, Biotinidase
deficiency,
gyrate atrophy, Syndromic Dominant Optic Atrophy and Deafness (Syndromic
DOAD), Dominant Optic Atrophy plus (D0Aplus), Leber's hereditary optic
neuropathy (LHON), Wolfram Syndrome-1 (WFS1), Wolfram Syndrome-2 (WFS2),
Age-related macular degeneration (ARMD), Brunner Syndrome, Left ventricular
noncompaction-1 (LVNC1), histiocytoid cardiomyopathy, Familial Myalgia
Syndrome, Parkinsonism, Fatal infantile cardioencephalomyopathy due to
cytochrome c oxidase (COX) deficiency-1 (CEMCOX1), Sengers Syndrome,
Cardiofaciocutaneous Syndrome-1 (CFC1), Mitochondrial trifunctional protein
(MTP) deficiency, infantile encephalocardiomyopathy with cytochrome c oxidase
deficiency, cardiomyopathy + encephalomyopathy, mitochondrial phosphate
carrier
deficiency, infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX)
deficiency (CEMCOX2),13-Hydroxyisobutyryl CoA Deacylase (HIBCH) deficiency,
ECHS1) deficiency, Maternal Inheritance Leigh Syndrome (MILS), dilated
cardiomyopathy with ataxia (DCMA), Mitochondrial DNA Depletion Syndrome-12
(MTDPS12), cardiomyopathy due to mitochondrial tRNA deficiencies,
mitochondrial
complex V (ATP synthase) deficiency nuclear type 1 (MC5DN1), combined
oxidative
phosphorylation deficiency-8 (COXPD8), progressive leukoencephalopathy with
ovarian failure (LKENP), combined oxidative phosphorylation deficiency-10
(COXPD10), combined oxidative phosphorylation deficiency-16 (COXPD16),
combined oxidative phosphorylation deficiency-17 (COXPD17), combined oxidative

phosphorylation deficiency-5 (COXPD5), combined oxidative phosphorylation
deficiency-9 (COXPD9), carnitine acetyltransferase (CRAT) deficiency,
carnitine
palmitoyltransferase I (CPT I) deficiency, myopathic carnitine deficiency,
primary
systemic carnitine deficiency (CDSP), carnitine palmitoyltransferase II (CPT
II)
deficiency, carnitine-acylcarnitine translocase deficiency (CACTD), cartilage-
hair
hypoplasia, cerebrotendinous xanthomatosis (CTX), congenital adrenal
hyperplasia
(CAH), megaconial type congenital muscular dystrophy, cerebral creatine
deficiency
syndrome-3 (CCDS3), maternal nonsyndromic deafness, maternal nonsyndromic
deafness, autosomal dominant deafness-64 (DFNA64), Mohr-Tranebjaerg Syndrome,
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CA 02920272 2016-02-09
Jensen Syndrome, MEGDEL, reticular dysgenesis, primary coenzyme Q10
deficiency-6 (C0Q10D6), CAGSSS, diabetes, Dimethylglycine dehydrogenase
deficiency (DMGDHD), Multiple Mitochondrial Dysfunctions Syndrome-1
(MMDS1), Multiple Mitochondrial Dysfunctions Syndrome-2 (MMDS2), Multiple
Mitochondrial Dysfunctions Syndrome-3 (MMDS3), childhood leukoencephalopathy
associated with mitochondrial Complex II deficiency, encephalopathies
associated
with mitochondrial Complex I deficiency, encephalopathies associated with
mitochondrial Complex III deficiency, encephalopathies associated with
mitochondrial Complex IV deficiency, encephalopathies associated with
mitochondrial Complex V deficiency, hyperammonemia due to carbonic anhydrase
VA deficiency (CA5AD), early infantile epileptic encephalopathy-3 (EIEE3), 2,4-

Dienoyl-CoA reductase deficiency (DECRD), infection-induced acute
encephalopathy-3 (IIAE3), ethylmalonic encephalopathy (EE), hypomyelinating
leukodystrophy (HLD4), exocrine pancreatic insufficiency, dyserythropoietic
anemia
and calvarial hyperostosis, Glutaric aciduria type 1 (GA-1), glycine
encephalopathy
(GCE), hepatic failure, 2-hydroxyglutaric aciduria, 3-hydroxyacyl-CoA
dehydrogenase deficiency, familial hyperinsulinemic hypoglycemia (FHH),
hypercalcemia infantile, hyperornithinemia-hyperammonemia-homocitrullinuria
(HHH) Syndrome, Immunodeficiency with hyper-IgM type 5 (HIGM5), Inclusion
Body Myositis (IBM), polymyositis with mitochondrial pathology, IM-Mito,
granulomatous myopathies with anti-mitochondrial antibodies, necrotizing
myopathy
with pipestem capillaries, myopathy with deficient chondroitin sulfate C in
skeletal
muscle connective tissue, benign acute childhood myositis, idiopathic orbital
myositis, masticator myopathy, hemophagocytic lymphohistiocytosis, infection-
associated myositis, Facioscapulohumeral dystrophy (FSH), familial idiopathic
inflammatory myopathy, Schmidt Syndrome (Diabetes mellitus, Addison disease,
Myxedema), TNF receptor-associated Periodic Syndrome (TRAPS), focal myositis,
autoimmune fasciitis, Spanish toxic oil-associated fasciitis, Eosinophilic
fasciitis,
Macrophagic myofasciitis, Graft-vs-host disease fasciitis, Eosinophilia-
myalgia
Syndrome, perimyositis, isovaleric acidemia (IVA), Kearnes-Sayre Syndrome
(KSS),
2-oxoadipic aciduria, 2-aminoadipic aciduria, Limb-girdle Muscular Dystrophy
Syndromes, leukodystrophy, Maple syrup urine disease (MSUD), 3-Methylcrotonyl-
CoA carboxylase (MCC), Methylmalonic aciduria (MMA), Miller Syndrome,
Mitochondrial DNA Depletion Syndrome-2 (MTDPS2), spinal muscular atrophy
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CA 02920272 2016-02-09
syndrome, rigid spine syndrome, severe myopathy with motor regression,
Mitochondrial DNA Depletion Syndrome-3, MELAS Syndrome, camptocormia,
MNGIE, MNGIM Syndrome, Menkes Disease, Occipital Horn Syndrome, X-linked
distal spinal muscular atrophy-3 (SMAX3), methemoglobinemia, MERRF,
progressive external ophthalmoplegia with myoclonus, deafness and diabetes
(DD),
multiple symmetric lipomatosis, Myopathy with Episodic high Creatine Kinase
(MINIECK), Epilepsia Partialis Continua, malignant hyperthermia syndromes,
glycogen metabolic disorders, fatty acid oxidation and lipid metabolism
disorders,
medication-, drug- or toxin-induced myoglobinuria, mitochondrial disorder-
associated
myoglobinuria, hypokalemic myopathy and rhabdomyolysis, muscle trauma-
associated myoglobinuria, ischemia-induced myoglobinuria, infection-induced
myoglobinuria, immune myopathies associated with myoglobinuria, Myopathy,
lactic
acidosis, and sideroblastic anemia (MLASA), infantile mitochondrial myopathy
due
to reversible COX deficiency (MMIT), Myopathy, Exercise intolerance,
Encephalopathy and Lactic acidemia Syndrome, myoglobinuria and exercise
intolerance syndrome, exercise intolerance, proximal weakness myoglobinuria
syndrome, encephalopathy and seizures syndrome, septo-optic dysplasia,
exercise
intolerance mild weakness, myopathy exercise intolerance, growth or CNS
disorder, maternally-inherited mitochondrial myopathies, myopathy with lactic
acidosis, myopathy with rhabdomyolysis, Myopathy with cataract and combined
respiratory chain deficiency, myopathy with abnormal mitochondrial
translation,
Fatigue Syndrome, myopathy with extrapyramidal movement disorders (MPXPS),
glutaric aciduria II (MADD), primary CoQ10 deficiency-1 (C0Q10D1), primary
CoQ10 deficiency-2 (C0Q10D2), primary CoQ10 deficiency-3 (C0Q10D3), primary
C0Q10 deficiency-5 (C0Q10D5), secondary CoQ10 deficiency, autosomal dominant
mitochondrial myopathy, myopathy with focal depletion of mitochondria,
mitochondrial DNA breakage syndrome (PEO + Myopathy), lipid type mitochondrial

myopathy, multiple symmetric lipomatosis (MSL), N-acetylglutamate synthase
(NAGS) deficiency, Nephronophthisis (NPHP), ornithine transcarbamylase (OTC)
deficiency, neoplasms, NARP Syndrome, paroxysmal nonkinesigenic dyskinesia
(PNKD), sporadic PEO, maternally-inherited PEO, autosomal dominant progressive

external ophthalmoplegia with mitochondrial DNA deletions-3 (PEOA3), autosomal

dominant progressive external ophthalmoplegia with mitochondrial DNA deletions-
2
(PEOA2), autosomal dominant progressive external ophthalmoplegia with
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CA 02920272 2016-02-09
mitochondrial DNA deletions-1 (PEOA1), PEO+ demyelinating neuropathy, PEO +
hypogonadism, autosomal dominant progressive external ophthalmoplegia with
mitochondrial DNA deletions-4 (PEOA4), distal myopathy, cachexia & PEO,
autosomal dominant progressive external ophthalmoplegia-6 (PEOA6), PEO +
Myopathy and Parkinsonism, autosomal recessive progressive external
ophthalmoplegia (PEOB), Mitochondrial DNA Depletion Syndrome-11 (MTDPS11),
PEO with cardiomyopathy, PEPCK deficiency, Perrault Syndromes (PRLTS),
propionic acidemia (PA), pyruvate carboxylase deficiency, pyruvate
dehydrogenase
El-alpha deficiency (PDHAD), pyruvate dehydrogenase El-beta deficiency
(PDHBD), dihydrolipoamide dehydrogenase (DLD) deficiency, pyruvate
dehydrogenase phosphatase deficiency, pyruvate dehydrogenase E3-binding
protein
deficiency (PDHXD), mitochondrial pyruvate carrier deficiency (MPYCD),
Schwartz-Jampel Syndrome type 1 (SJS1), selenium deficiency, short-chain acyl-
CoA
dehydrogenase (SCAD) deficiency, succinyl CoA:3-oxacid CoA transferase (SCOT)
deficiency, Stuve-Wiedemann Syndrome (STWS), thrombocytopenia (THC), Very
long-chain acyl-CoA dehydrogenase deficiency (VLCADD), Vitamin D-dependent
rickets type 1A (VDDR1A), Wilson's disease, Zellweger Syndrome (PBD3A),
arsenic trioxide myopathy, myopathy and neuropathy resulting from nucleoside
analogues, germanium myopathy, Parkinsonism and mitochondrial Complex I
neurotoxicity due to trichloroethylene, valproate-induced hepatic failure,
neurodegeneration with brain iron accumulation-4 (NBIA4), Complex I
deficiency,
Complex II deficiency, Complex III deficiency, Complex IV deficiency, Complex
V
deficiency, Cytochrome c oxidase (COX) deficiency, combined complex I, II, IV,
V
deficiency, combined complex I, II, and III deficiency, combined oxidative
phosphorylation deficiency-1 (COXPD1), combined oxidative phosphorylation
deficiency-2 (COXPD2), combined oxidative phosphorylation deficiency-3
(COXPD3), combined oxidative phosphorylation deficiency-4 (COXPD4), combined
oxidative phosphorylation deficiency-6 (COXPD6), combined oxidative
phosphorylation deficiency-7 (COXPD7), combined oxidative phosphorylation
deficiency-9 (COXPD9), combined oxidative phosphorylation deficiency-11
(COXPD11), combined oxidative phosphorylation deficiency-12 (COXPD12),
combined oxidative phosphorylation deficiency-13 (COXPD13), combined oxidative

phosphorylation deficiency-15 (COXPD15), combined oxidative phosphorylation
deficiency-16 (COXPD16), combined oxidative phosphorylation deficiency-19
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CA 02920272 2016-02-09
(COXPD19), combined oxidative phosphorylation deficiency-20 (COXPD20),
combined oxidative phosphorylation deficiency-21 (COXPD21), fumarase
deficiency,
HMG-CoA synthase-2 deficiency, hyperuricemia, pulmonary hypertension, renal
failure, and alkalosis (HUPRA) Syndrome, syndromic microphthalmia-7,
pontocerebellar hypoplasia type 6 (PCH6), Mitochondrial DNA Depletion Syndrome-

9 (MTDPS9P), and Sudden infant death Syndrome (SIDS).
[0498] In one aspect, the present disclosure provides a method of treating a
disease
or condition characterized by excessive mitochondrial fission, comprising
administering a therapeutically effective amount of a composition comprising
phenazine-3-one and/or phenothiazine-3-one derivatives, analogues, or
pharmaceutically acceptable salts thereof.
[0499] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) are
useful to
regulate mitochondrial fission.
[0500] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful to prevent or treat Leber's Hereditary Optic Neuropathy.
[0501] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful to prevent or treat Friedreich's Ataxia.
[0502] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful to treat one or more signs, symptoms or complications of

Friedreich's Ataxia including mitochondrial iron loading, Complex I and ATP
content
deficiency, and defects in iron-sulfur cluster biosynthesis.
[0503] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful to reduce tumor growth in a subject in need thereof.
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CA 02920272 2016-02-09
Treatment of a Mitochondrial Disease or Disorder
[0504] In some embodiments, the disclosure provides for both prophylactic and
therapeutic methods of treating a subject having or suspected of having a
mitochondrial disease, condition or disorder. For example, in some
embodiments, the
disclosure provides for both prophylactic and therapeutic methods of treating
a
subject having a disruption in oxidative phosphorylation caused by a gene
mutation
e.g., SURF1, POLG etc.
[0505] In some embodiments, the present technology provides methods for the
treatment, amelioration or prevention of a mitochondrial disease, condition or
disorder
in subjects through administration of therapeutically effective amounts of
phenazine-
3-one and/or phenothiazine-3-one derivatives (or analogues, or
pharmaceutically
acceptable salts thereof) of the present technology as disclosed herein to
subjects in
need thereof. In some embodiments of the method, the mitochondrial disease,
condition or disorder is selected from the group consisting of Alexander
disease,
Alpers Syndrome, Alpha-ketoglutarate dehydrogenase (AKDGH) deficiency, ALS-
FTD, Sideroblastic anemia with spinocerebellar ataxia, Pyridoxine-refractory
sideroblastic anemia, GRACILE Syndrome, Bjornstad Syndrome, Leigh Syndrome,
mitochondrial complex III deficiency nuclear type 1 (MC3DN1), combined
oxidative
phosphorylation deficiency 18 (COXPD18), Thiamine-responsive megaloblastic
anemia syndrome (TRMA), Pearson Syndrome, HAM Syndrome, Ataxia, Cataract,
and Diabetes Syndrome, MELAS/MERRF Overlap Syndrome, combined oxidative
phosphorylation deficiency-14 (COXPD14), Infantile cerebellar-retinal
degeneration
(ICRD), Charlevoix-Saguenay spastic ataxia, Primary coenzyme Q10 deficiency-1
(C0Q10D1), ataxia oculomotor apraxia type 1 (A0A1), Autosomal recessive
spinocerebellar ataxia-9/ coenzyme Q10 deficiency-4 (C0Q10D4), Ataxia,
Pyramidal
Syndrome, and Cytochrome Oxidase Deficiency, Friedreich's ataxia, Infantile
onset
spinocerebellar ataxia (IOSCA)/ Mitochondrial DNA Depletion Syndrome-7,
Leukoencephalopathy with brainstem and spinal cord involvement and lactate
elevation (LBSL), Autosomal recessive spastic ataxia-3 (SPAX3), MIRAS, SANDO,
mitochondrial spinocerebellar ataxia and epilepsy (MSCAE), spastic ataxia with
optic
atrophy (SPAX4), progressive external ophthalmoplegia with mitochondrial DNA
deletions autosomal dominant type 5 (PEOA5), mitochondrial complex III
deficiency
nuclear type 2 (MC3DN2), episodic encephalopathy due to thiamine
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CA 02920272 2016-02-09
pyrophosphokinase deficiency/Thiamine Metabolism Dysfunction Syndrome-5
(THMD5), Spinocerebellar ataxia-28 (SCA28), autosomal dominant cerebellar
ataxia,
deafness, and narcolepsy (ADCA-DN), Dominant Optic Atrophy (DOA), cerebellar
ataxia, areflexia, pes cavus, optic atrophy, and sensorineural hearing loss
(CAPOS)
Syndrome, spinocerebellar ataxia 7 (SCA7), Barth Syndrome, Biotinidase
deficiency,
gyrate atrophy, Syndromic Dominant Optic Atrophy and Deafness (Syndromic
DOAD), Dominant Optic Atrophy plus (D0Aplus), Leber's hereditary optic
neuropathy (LHON), Wolfram Syndrome-1 (WFS1), Wolfram Syndrome-2 (WFS2),
Age-related macular degeneration (ARMD), Brunner Syndrome, Left ventricular
noncompaction-1 (LVNC1), histiocytoid cardiomyopathy, Familial Myalgia
Syndrome, Parkinsonism, Fatal infantile cardioencephalomyopathy due to
cytochrome c oxidase (COX) deficiency-1 (CEMCOX1), Sengers Syndrome,
Cardiofaciocutaneous Syndrome-1 (CFC1), Mitochondrial trifunctional protein
(MTP) deficiency, infantile encephalocardiomyopathy with cytochrome c oxidase
deficiency, cardiomyopathy + encephalomyopathy, mitochondrial phosphate
carrier
deficiency, infantile cardioencephalomyopathy due to cytochrome c oxidase
(COX)
deficiency (CEMCOX2),13-Hydroxyisobutyryl CoA Deacylase (HIBCH) deficiency,
ECHS1) deficiency, Maternal Inheritance Leigh Syndrome (MILS), dilated
cardiomyopathy with ataxia (DCMA), Mitochondrial DNA Depletion Syndrome-12
(MTDPS12), cardiomyopathy due to mitochondrial tRNA deficiencies,
mitochondrial
complex V (ATP synthase) deficiency nuclear type 1 (MC5DN1), combined
oxidative
phosphorylation deficiency-8 (COXPD8), progressive leukoencephalopathy with
ovarian failure (LKENP), combined oxidative phosphorylation deficiency-10
(COXPD10), combined oxidative phosphorylation deficiency-16 (COXPD16),
combined oxidative phosphorylation deficiency-17 (COXPD17), combined oxidative

phosphorylation deficiency-5 (COXPD5), combined oxidative phosphorylation
deficiency-9 (COXPD9), carnitine acetyltransferase (CRAT) deficiency,
carnitine
palmitoyltransferase I (CPT I) deficiency, myopathic carnitine deficiency,
primary
systemic carnitine deficiency (CDSP), carnitine palmitoyltransferase II (CPT
II)
deficiency, carnitine-acylcarnitine translocase deficiency (CACTD), cartilage-
hair
hypoplasia, cerebrotendinous xanthomatosis (CTX), congenital adrenal
hyperplasia
(CAH), megaconial type congenital muscular dystrophy, cerebral creatine
deficiency
syndrome-3 (CCDS3), maternal nonsyndromic deafness, maternal nonsyndromic
deafness, autosomal dominant deafness-64 (DFNA64), Mohr-Tranebjaerg Syndrome,
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CA 02920272 2016-02-09
Jensen Syndrome, MEGDEL, reticular dysgenesis, primary coenzyme Q10
deficiency-6 (C0Q10D6), CAGSSS, diabetes, Dimethylglycine dehydrogenase
deficiency (DMGDHD), Multiple Mitochondrial Dysfunctions Syndrome-1
(MMDS1), Multiple Mitochondrial Dysfunctions Syndrome-2 (MMDS2), Multiple
Mitochondrial Dysfunctions Syndrome-3 (MMDS3), childhood leukoencephalopathy
associated with mitochondrial Complex II deficiency, encephalopathies
associated
with mitochondrial Complex I deficiency, encephalopathies associated with
mitochondrial Complex III deficiency, encephalopathies associated with
mitochondrial Complex IV deficiency, encephalopathies associated with
mitochondrial Complex V deficiency, hyperammonemia due to carbonic anhydrase
VA deficiency (CA5AD), early infantile epileptic encephalopathy-3 (EIEE3), 2,4-

Dienoyl-00A reductase deficiency (DECRD), infection-induced acute
encephalopathy-3 (IIAE3), ethylmalonic encephalopathy (EE), hypomyelinating
leukodystrophy (HLD4), exocrine pancreatic insufficiency, dyserythropoietic
anemia
and calvarial hyperostosis, Glutaric aciduria type 1 (GA-1), glycine
encephalopathy
(GCE), hepatic failure, 2-hydroxyglutaric aciduria, 3-hydroxyacyl-CoA
dehydrogenase deficiency, familial hyperinsulinemic hypoglycemia (FHH),
hypercalcemia infantile, hyperornithinemia-hyperammonemia-homocitrullinuria
(HHH) Syndrome, Immunodeficiency with hyper-IgM type 5 (HIGM5), Inclusion
Body Myositis (IBM), polymyositis with mitochondrial pathology, IM-Mito,
granulomatous myopathies with anti-mitochondrial antibodies, necrotizing
myopathy
with pipestem capillaries, myopathy with deficient chondroitin sulfate C in
skeletal
muscle connective tissue, benign acute childhood myositis, idiopathic orbital
myositis, masticator myopathy, hemophagocytic lymphohistiocytosis, infection-
associated myositis, Facioscapulohumeral dystrophy (FSH), familial idiopathic
inflammatory myopathy, Schmidt Syndrome (Diabetes mellitus, Addison disease,
Myxedema), TNF receptor-associated Periodic Syndrome (TRAPS), focal myositis,
autoimmune fasciitis, Spanish toxic oil-associated fasciitis, Eosinophilic
fasciitis,
Macrophagic myofasciitis, Graft-vs-host disease fasciitis, Eosinophilia-
myalgia
Syndrome, perimyositis, isovaleric acidemia (IVA), Kearnes-Sayre Syndrome
(KSS),
2-oxoadipic aciduria, 2-aminoadipic aciduria, Limb-girdle Muscular Dystrophy
Syndromes, leukodystrophy, Maple syrup urine disease (MSUD), 3-Methylcrotonyl-
CoA carboxylase (MCC), Methylmalonic aciduria (MMA), Miller Syndrome,
Mitochondrial DNA Depletion Syndrome-2 (MTDPS2), spinal muscular atrophy
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CA 02920272 2016-02-09
syndrome, rigid spine syndrome, severe myopathy with motor regression,
Mitochondrial DNA Depletion Syndrome-3, MELAS Syndrome, camptocormia,
MNGTE, MNGIM Syndrome, Menkes Disease, Occipital Horn Syndrome, X-linked
distal spinal muscular atrophy-3 (SMAX3), methemoglobinemia, MERRF,
progressive external ophthalmoplegia with myoclonus, deafness and diabetes
(DD),
multiple symmetric lipomatosis, Myopathy with Episodic high Creatine Kinase
(MIMECK), Epilepsia Partialis Continua, malignant hyperthermia syndromes,
glycogen metabolic disorders, fatty acid oxidation and lipid metabolism
disorders,
medication-, drug- or toxin-induced myoglobinuria, mitochondrial disorder-
associated
myoglobinuria, hypokalemic myopathy and rhabdomyolysis, muscle trauma-
associated myoglobinuria, ischemia-induced myoglobinuria, infection-induced
myoglobinuria, immune myopathies associated with myoglobinuria, Myopathy,
lactic
acidosis, and sideroblastic anemia (MLASA), infantile mitochondrial myopathy
due
to reversible COX deficiency (MMIT), Myopathy, Exercise intolerance,
Encephalopathy and Lactic acidemia Syndrome, myoglobinuria and exercise
intolerance syndrome, exercise intolerance, proximal weakness myoglobinuria
syndrome, encephalopathy and seizures syndrome, septo-optic dysplasia,
exercise
intolerance mild weakness, myopathy exercise intolerance, growth or CNS
disorder, maternally-inherited mitochondrial myopathies, myopathy with lactic
acidosis, myopathy with rhabdomyolysis, Myopathy with cataract and combined
respiratory chain deficiency, myopathy with abnormal mitochondrial
translation,
Fatigue Syndrome, myopathy with extrapyramidal movement disorders (MPXPS),
glutaric aciduria II (MADD), primary C0Q10 deficiency-1 (C0Q10D1), primary
CoQ10 deficiency-2 (C0Q10D2), primary CoQ10 deficiency-3 (C0Q10D3), primary
C0Q10 deficiency-5 (C0Q10D5), secondary C0Q10 deficiency, autosomal dominant
mitochondrial myopathy, myopathy with focal depletion of mitochondria,
mitochondrial DNA breakage syndrome (PEO + Myopathy), lipid type mitochondrial

myopathy, multiple symmetric lipomatosis (MSL), N-acetylglutamate synthase
(NAGS) deficiency, Nephronophthisis (NPHP), ornithine transcarbamylase (OTC)
deficiency, neoplasms, NARP Syndrome, paroxysmal nonkinesigenic dyskinesia
(PNI(D), sporadic PEO, maternally-inherited PEO, autosomal dominant
progressive
external ophthalmoplegia with mitochondrial DNA deletions-3 (PEOA3), autosomal

dominant progressive external ophthalmoplegia with mitochondrial DNA deletions-
2
(PEOA2), autosomal dominant progressive external ophthalmoplegia with
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CA 02920272 2016-02-09
mitochondrial DNA deletions-1 (PEOA1), PEO+ demyelinating neuropathy, PEO +
hypogonadism, autosomal dominant progressive external ophthalmoplegia with
mitochondrial DNA deletions-4 (PEOA4), distal myopathy, cachexia & PEO,
autosomal dominant progressive external ophthalmoplegia-6 (PEOA6), PEO +
Myopathy and Parkinsonism, autosomal recessive progressive external
ophthalmoplegia (PEOB), Mitochondrial DNA Depletion Syndrome-11 (MTDPS11),
PEO with cardiomyopathy, PEPCK deficiency, Perrault Syndromes (PRLTS),
propionic acidemia (PA), pyruvate carboxylase deficiency, pyruvate
dehydrogenase
El-alpha deficiency (PDHAD), pyruvate dehydrogenase El-beta deficiency
(PDHBD), dihydrolipoamide dehydrogenase (DLD) deficiency, pyruvate
dehydrogenase phosphatase deficiency, pyruvate dehydrogenase E3-binding
protein
deficiency (PDHXD), mitochondrial pyruvate carrier deficiency (MPYCD),
Schwartz-Jampel Syndrome type 1 (SJS1), selenium deficiency, short-chain acyl-
CoA
dehydrogenase (SCAD) deficiency, succinyl CoA:3-oxacid CoA transferase (SCOT)
deficiency, Stuve-Wiedemann Syndrome (STWS), thrombocytopenia (THC), Very
long-chain acyl-CoA dehydrogenase deficiency (VLCADD), Vitamin D-dependent
rickets type 1A (VDDR1A), Wilson's disease, Zellweger Syndrome (PBD3A),
arsenic trioxide myopathy, myopathy and neuropathy resulting from nucleoside
analogues, germanium myopathy, Parkinsonism and mitochondrial Complex I
neurotoxicity due to trichloroethylene, valproate-induced hepatic failure,
neurodegeneration with brain iron accumulation-4 (NBIA4), Complex I
deficiency,
Complex II deficiency, Complex III deficiency, Complex IV deficiency, Complex
V
deficiency, Cytochrome c oxidase (COX) deficiency, combined complex I, II, IV,
V
deficiency, combined complex I, II, and III deficiency, combined oxidative
phosphorylation deficiency-1 (COXPD1), combined oxidative phosphorylation
deficiency-2 (COXPD2), combined oxidative phosphorylation deficiency-3
(COXPD3), combined oxidative phosphorylation deficiency-4 (COXPD4), combined
oxidative phosphorylation deficiency-6 (COXPD6), combined oxidative
phosphorylation deficiency-7 (COXPD7), combined oxidative phosphorylation
deficiency-9 (COXPD9), combined oxidative phosphorylation deficiency-11
(COXPD11), combined oxidative phosphorylation deficiency-12 (COXPD12),
combined oxidative phosphorylation deficiency-13 (COXPD13), combined oxidative

phosphorylation deficiency-15 (COXPD15), combined oxidative phosphorylation
deficiency-16 (COXPD16), combined oxidative phosphorylation deficiency-19
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CA 02920272 2016-02-09
(COXPD19), combined oxidative phosphorylation deficiency-20 (COXPD20),
combined oxidative phosphorylation deficiency-21 (COXPD21), fumarase
deficiency,
HMG-CoA synthase-2 deficiency, hyperuricemia, pulmonary hypertension, renal
failure, and alkalosis (HUPRA) Syndrome, syndromic microphthalmia-7,
pontocerebellar hypoplasia type 6 (PCH6), Mitochondrial DNA Depletion Syndrome-

9 (MTDPS9P), and Sudden infant death Syndrome (SIDS).
[0506] In some embodiments, the present technology provides methods for the
prevention and/or treatment of mitochondrial disease or disorder in a subject
by
administering an effective amount of phenazine-3-one and/or phenothiazine-3-
one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology to a subject in need thereof to reduce disruption in oxidative
phosphorylation of the subject.
[0507] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in decreasing intracellular ROS (reactive oxygen
species) and
increasing survival in cells of a subject in need thereof, e.g., a subject
suffering from a
disease or condition characterized by mitochondrial dysfunction.
[0508] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in preventing loss of cell viability in subjects
suffering from a
disease or condition characterized by mitochondrial dysfunction.
[0509] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in decreasing the percent of cells showing increased
caspase
activity in a subject in need thereof, e.g., a subject suffering from a
disease or
condition characterized by mitochondrial dysfunction.
[0510] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in reducing the rate of ROS accumulation in a subject in
need
thereof, e.g., a subject suffering from a disease or condition characterized
by
mitochondrial dysfunction.
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[0511] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in inhibiting lipid peroxidation in a subject in need
thereof, e.g.,
a subject suffering from a disease or condition characterized by mitochondrial

dysfunction.
[0512] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in preventing mitochondrial depolarization and ROS
accumulation in a subject in need thereof, e.g., a subject suffering from a
disease or
condition characterized by mitochondrial dysfunction.
[0513] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in preventing apoptosis in a subject in need thereof,
e.g., a
subject suffering from a disease or condition characterized by mitochondrial
dysfunction.
[0514] In one aspect, the present technology provides a method of preventing,
treating or ameliorating a medical disease or condition by administering a
therapeutically effective amount of phenazine-3-one and/or phenothiazine-3-one

derivatives (or analogues, or pharmaceutically acceptable salts thereof) to a
subject in
need thereof. In some embodiments the medical disease or condition is a
mitochondrial disorder. In another aspect, the present technology provides a
method
of modulating one or more energy biomarkers, normalizing one or more energy
biomarkers, or enhancing one or more energy biomarkers by administering a
therapeutically effective amount of phenazine-3-one and/or phenothiazine-3-one

derivatives (or analogues, or pharmaceutically acceptable salts thereof) to a
subject in
need thereof.
Use of Phenazine-3-one and Phenothiazine-3-one Derivatives to Treat IPF,
Alport
Syndrome, Vitiligo, and Porphyria
[0515] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in methods for treating, ameliorating, or reversing
idiopathic
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CA 02920272 2016-02-09
pulmonary fibrosis (IPF). In certain embodiments of the method, 1PF is induced
by
TGF-P signaling. In other embodiments of the method, IPF is induced by
exposure to
bleomycin. In some embodiments of the methods, IPF symptoms or signs include
an
increase in TGF-131-induced epithelial to mesenchymal transition (EMT),
myofibroblast activation, collagen production, and severe progressive fibrosis

including fibrotic foci and honeycombing. In some embodiments, EMT is
characterized by loss of epithelial markers such as E-cadherin, cytoskeletal
reorganization, and transition to a spindle-shaped morphology with the
acquisition of
mesenchymal markers (a-SMA and collagen I). EMT of alveolar epithelial cells
(AECs) has been widely observed in patients with 1FF.
[0516] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in reducing the formation of fibroblast foci and lung
scarring in
the subject, as evidenced by a decrease in collagen content using sircol assay
and
fibrosis scoring.
[0517] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in reducing myofibroblast activation and collagen
production in
the subject, as evidenced by a decrease in a-SMA and collagen I expression.
[0518] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in reducing TGF-131-induced EMT in the subject, as
evidenced
by the persistence of E-cadherin expression and/or decrease in spindle-shaped
morphology. In some embodiments, administration of a therapeutically effective
dose
of phenazine-3-one and/or phenothiazine-3-one derivatives (or analogues, or
pharmaceutically acceptable salts thereof) to a subject in need thereof,
results in a
reduction of TGF-131-induced EMT in the subject, as evidenced by a decrease in
a-
SMA or vimentin expression. In some embodiments, administration of a
therapeutically effective dose of phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) to a
subject in
need thereof, results in a reduction of TGF-131-induced EMT in the subject, as

evidenced by a decrease in cytoskeletal reorganization.
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CA 02920272 2016-02-09
[0519] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in treating or ameliorating melanocyte degeneration in a
subject
in need thereof. In one particular embodiment, phenazine-3-one and/or
phenothiazine-3-one derivatives (or analogues, or pharmaceutically acceptable
salts
thereof) of the present technology are useful in the treatment, amelioration
or
prevention of vitiligo in subjects through administration of therapeutically
effective
amounts of phenazine-3-one and/or phenothiazine-3-one derivatives as disclosed

herein, or pharmaceutically acceptable salts thereof, to subjects in need
thereof.
[0520] Vitiligo is a pigmentation disorder in which melanocytes, the cells
responsible for skin pigmentation, are destroyed. As a result, white patches
appear on
the skin in different parts of the body. Vitiligo lesions can appear anywhere,
but are
most commonly found on the acral areas, mucous membranes (tissues that line
the
inside of the mouth and nose), retina and genitals. Other symptoms include
increased
photosensitivity, decreased contact sensitivity response to
dinitrochlorobenzene, and
premature whitening or graying of hair that grows on areas affected by
vitiligo. Non-
segmental vitiligo (NSV) is associated with some form of symmetry in the
location of
the patches of depigmentation. Classes of NSV include generalized vitiligo,
universal
vitiligo, and focal vitiligo. Generalized vitiligo (GV), the most common
category,
affects approximately 0.5% of the world's population, with an average age of
onset at
about 24 years and occurring with approximately equal frequencies in males and

females. Vitiligo lesions have an infiltrate of inflammatory cells,
particularly
cytotoxic and helper T cells and macrophages. Patients with vitiligo are also
more
likely to have at least one other autoimmune disease including Hashimoto's
thyroiditis, Graves' disease, pernicious anemia, rheumatoid arthritis,
psoriasis, type I
diabetes, Addison's disease, celiac disease, inflammatory bowel disorder, and
systemic lupus erythematosus.
[0521] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in the treatment, amelioration or prevention of
porphyria in a
subject in need thereof. The porphyrias, are metabolic disorders, each
resulting from
the deficiency of a specific enzyme in the heme biosynthetic pathway. These
enzyme
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deficiencies are inherited as autosomal dominant, autosomal recessive, or X-
linked
traits, with the exception of the most common porphyria, porphyria cutanea
tarda,
which usually is sporadic. Porphyrias have been classified as either hepatic
or
erythropoietic depending on the primary site of overproduction and
accumulation of
porphyrin precursors or porphyrins, although some porphyrias have overlapping
features. The hepatic porphyrias are characterized by overproduction and
initial
accumulation of the porphyrin precursors, ALA and PBG, and/or porphyrins
primarily
in the liver, whereas in the erythropoietic porphyrias, overproduction and
initial
accumulation of the pathway intermediates occur primarily in bone marrow
erythroid
cells. The eight major porphyrias can be classified into three groups: (1) the
four
acute hepatic porphyrias, (2) the single hepatic cutaneous porphyria (i.e.,
porphyria
cutanea tarda), and (3) the three erythropoietic cutaneous porphyrias. In
certain
embodiments, the acute hepatic porphyria is acute intermittent porphyria
(AIP),
hereditary coproporphyria (HCP), variegate porphyria (VP) or autosomal
recessive
ALA-dehydratase-deficient porphyria. In some embodiments, the erythropoietic
cutaneous porphyria is congenital erythropoietic porphyria (CEP),
erythropoietic
protoporphyria (EPP) and X-linked porphyria (XLP). Symptoms associated with
porphyria include, but are not limited to, cutaneous lesions, blistering skin
lesions,
hypertrichosis, hyperpigmentation, thickening and/or scarring of the skin,
friability of
the skin, photosensitivity of the skin, lichenification, leathery
pseudovesicles, labial
grooving, nail changes, life threatening acute neurological attacks, abdominal
pain
and cramping, constipation, diarrhea, increased bowel sounds, decreased bowel
sounds, nausea, vomiting, tachycardia, hypertension, headache, mental
symptoms,
extremity pain, neck pain, chest pain, muscle weakness, sensory loss, tremors,

sweating, dysuria, and bladder distension.
[0522] Variegate porphyria (VP) is an autosomal dominant disorder of porphyrin-

heme metabolism characterized by accumulations of the photosensitizing
porphyrins,
protoporphyrin and coproporphyrin, arising from mutations of the gene encoding
the
enzyme protoporphyrinogen oxidase (PPDX). PPDX is an enzyme in the heme
biosynthetic pathway that catalyzes the oxidation of protoporphyrinogen IX to
form
protoporphyrin IX. PPDX is localized to the mitochondrial intermembrane space
and
is found in various tissues, including liver, lymphocytes, and cultured
fibroblasts.
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CA 02920272 2016-02-09
[0523] Manifestations of VP may include cutaneous manifestations, including
photosensitivity, blistering, skin fragility, and postinflammatory
hyperpigmentation.
Acute exacerbations of VP are characterized by the occurrence of neuro-
visceral
attacks that include abdominal pain, the passage of dark urine, and
neuropsychiatric
symptoms such as bulbar paralysis, quadriplegia, motor neuropathy, and
weakness of
the limbs. VP is associated with a heterozygous mutation in the gene for
protoporphyrinogen oxidase (PPDX). The homozygous variant of VP is
characterized
by severe PPDX deficiency, onset of photosensitization by porphyrins in early
childhood, skeletal abnormalities of the hand, short stature, mental
retardation, and
convulsions.
[0524] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives (or analogues, or pharmaceutically acceptable salts thereof) of
the present
technology are useful in the treatment, amelioration or prevention of Alport
Syndrome
in a subject in need thereof. Alport Syndrome is a genetic condition
characterized by
kidney disease, hearing loss, and eye abnormalities and occurs in
approximately 1 in
50,000 newborns. Mutations in the COL4A3, COL4A4, and COL4A5 genes cause
Alport Syndrome. These genes each provide instructions for making one
component
of a protein called type IV collagen. This protein plays an important role in
the
kidneys, specifically in structures called glomeruli. Glomeruli are clusters
of
specialized blood vessels that remove water and waste products from blood and
create
urine. Mutations in these genes result in abnormalities of the type IV
collagen in
glomeruli, which prevents the kidneys from properly filtering the blood and
allows
blood and protein to pass into the urine. Gradual scarring of the kidneys
occurs,
eventually leading to progressive loss of kidney function and end-stage renal
disease
in many people with Alport Syndrome.
[0525] Type IV collagen is also an important component of inner ear
structures,
particularly the organ of Corti, that transform sound waves into nerve
impulses for the
brain. Alterations in type IV collagen often result in abnormal inner ear
function
during late childhood or early adolescence, which can lead to sensorineural
deafness.
In the eye, type IV collagen is important for maintaining the shape of the
lens and the
normal color of the retina. Mutations that disrupt type IV collagen can result
in
misshapen lenses (anterior lenticonus) and an abnormally colored retina.
Significant
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CA 02920272 2016-02-09
hearing loss, eye abnormalities, and progressive kidney disease are more
common in
males with Alport Syndrome than in affected females. Symptoms associated with
Alport Syndrome, including, but not limited to, e.g., hematuria, proteinuria,
cylindruria, leukocyturia, hypertension, edema, microalbuminuria, declining
glomerular filtration rate, fibrosis, Glomerular Basement Membrane (GBM)
ultrastructural abnormalities, nephrotic Syndrome, glomerulonephritis, end-
stage
kidney disease, chronic anemia, macrothrombocytopenia, osteodystrophy,
sensorineural deafness, anterior lenticonus, dot-and-fleck retinopathy,
posterior
polymorphous corneal dystrophy, recurrent corneal erosion, temporal macular
thinning, cataracts, lacrimation, photophobia, vision loss, keratoconus, and
leiomyomatosis.
Therapeutic Methods
[0526] The following discussion is presented by way of example only, and is
not
intended to be limiting.
[0527] One aspect of the present technology includes methods of treating a
mitochondrial disease or disorder in a subject diagnosed as having, suspected
as
having, or at risk of having a mitochondrial disease or disorder. In
therapeutic
applications, compositions or medicaments comprising phenazine-3-one and/or
phenothiazine-3-one derivatives or pharmaceutically acceptable salts thereof,
are
administered to a subject suspected of, or already suffering from such a
disease (such
as, e.g., subjects exhibiting pathological levels of one or more energy
biomarkers such
as, lactic acid (lactate) levels; pyruvic acid (pyruvate) levels; total,
reduced or
oxidized glutathione levels; total, reduced or oxidized cysteine levels;
phosphocreatine levels; NADH (NADH+H30) or NADPH (NADPH+H30 ) levels;
NAD or NADP levels; ATP levels; reduced coenzyme Q (CoQred) levels; oxidized
coenzyme Q (CoQox) levels; total coenzyme Q (CoQtot) levels; oxidized
cytochrome
C levels; reduced cytochrome C levels; acetoacetate levels; beta-hydroxy
butyrate
levels; 8-hydroxy-2'-deoxyguanosine (8-0HdG) levels; and reactive oxygen
species
levels compared to a normal control subject, or alternatively a subject
diagnosed with
a mitochondrial disease or disorder), in an amount sufficient to cure, or at
least
partially arrest, the symptoms of the disease, including its complications and

intermediate pathological phenotypes in development of the disease. In some
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CA 02920272 2016-02-09
embodiments of the method, the lactate levels of one or more of whole blood,
plasma,
cerebrospinal fluid, or cerebral ventricular fluid are abnormal compared to a
normal
control subject. In some embodiments of the method, the pyruvate levels of one
or
more of whole blood, plasma, cerebrospinal fluid, or cerebral ventricular
fluid are
abnormal compared to a normal control subject. In some embodiments of the
method,
the total, reduced or oxidized glutathione levels of one or more of whole
blood,
plasma, lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid are
abnormal
compared to a normal control subject. In some embodiments of the method, the
total,
reduced or oxidized cysteine levels of one or more of whole blood, plasma,
lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid are abnormal
compared
to a normal control subject.
[0528] Subjects suffering from a mitochondrial disease or disorder can be
identified
by any or a combination of diagnostic or prognostic assays known in the art.
For
example, typical symptoms of a mitochondrial disease or disorder include, but
are not
limited to, poor growth, loss of muscle coordination, muscle weakness,
neurological
deficit, seizures, autism, autistic spectrum, autistic-like features, learning
disabilities,
heart disease, liver disease, kidney disease, gastrointestinal disorders,
severe
constipation, diabetes, increased risk of infection, thyroid dysfunction,
adrenal
dysfunction, autonomic dysfunction, confusion, disorientation, memory loss,
failure
to thrive, poor coordination, sensory (vision, hearing) problems, reduced
mental
functions, hypotonia, disease of the organ, dementia, respiratory problems,
hypoglycemia, apnea, lactic acidosis, seizures, swallowing difficulties,
developmental
delays, movement disorders (dystonia, muscle spasms, tremors, chorea), stroke,
brain
atrophy, or any other sign or symptom of a mitochondrial disease state
disclosed
herein.
[0529] In some embodiments, the subject may exhibit pathological levels of one
or
more energy biomarkers such as, lactic acid (lactate) levels; pyruvic acid
(pyruvate)
levels; total, reduced or oxidized glutathione levels; total, reduced or
oxidized
cysteine levels; phosphocreatine levels; NADH (NADH+H30) or NADPH
(NADPH+H30 ) levels; NAD or NADP levels; ATP levels; reduced coenzyme Q
(CoQred) levels; oxidized coenzyme Q (CoQox) levels; total coenzyme Q (CoQtot)

levels; oxidized cytochrome C levels; reduced cytochrome C levels;
acetoacetate
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CA 02920272 2016-02-09
levels; beta-hydroxy butyrate levels; 8-hydroxy-2'-deoxyguanosine (8-0HdG)
levels;
and reactive oxygen species levels compared to a normal control subject, which
is
measureable using techniques known in the art. In some embodiments of the
method,
the lactate levels of one or more of whole blood, plasma, cerebrospinal fluid,
or
cerebral ventricular fluid are abnormal compared to a normal control subject.
In some
embodiments of the method, the pyruvate levels of one or more of whole blood,
plasma, cerebrospinal fluid, or cerebral ventricular fluid are abnormal
compared to a
normal control subject. In some embodiments of the method, the total, reduced
or
oxidized glutathione levels of one or more of whole blood, plasma,
lymphocytes,
cerebrospinal fluid, or cerebral ventricular fluid are abnormal compared to a
normal
control subject. In some embodiments of the method, the total, reduced or
oxidized
cysteine levels of one or more of whole blood, plasma, lymphocytes,
cerebrospinal
fluid, or cerebral ventricular fluid are abnormal compared to a normal control
subject.
[0530] In some embodiments, the subject may exhibit one or more mtDNA or
nuclear DNA mutations in one or more genes described herein that play a
biological/physiological role in the mitochondria (e.g., mitochondrial protein

synthesis, respiratory chain function, intergenomic signaling, mitochondrial
importation of nDNA-encoded proteins, synthesis of inner mitochondrial
membrane
phospholipids, mitochondrial motility and fission, mitophagy etc.). Such
mutations
are detectable using techniques known in the art.
[0531] In some embodiments, administration of phenazine-3-one and/or
phenothiazine-3-one derivatives to subjects suffering from a mitochondrial
disease or
disorder will result in the amelioration or elimination of one or more of the
following
symptoms: poor growth, loss of muscle coordination, muscle weakness,
neurological
deficit, seizures, autism, autistic spectrum, autistic-like features, learning
disabilities,
heart disease, liver disease, kidney disease, gastrointestinal disorders,
severe
constipation, diabetes, increased risk of infection, thyroid dysfunction,
adrenal
dysfunction, autonomic dysfunction, confusion, disorientation, memory loss,
failure
to thrive, poor coordination, sensory (vision, hearing) problems, reduced
mental
functions, hypotonia, disease of the organ, dementia, respiratory problems,
hypoglycemia, apnea, lactic acidosis, seizures, swallowing difficulties,
developmental
delays, movement disorders (dystonia, muscle spasms, tremors, chorea), stroke,
brain
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CA 02920272 2016-02-09
atrophy, or any other sign or symptom of a mitochondrial disease state
disclosed
herein.
[0532] In some embodiments, administration of phenazine-3-one and/or
phenothiazine-3-one derivatives to subjects suffering from a mitochondrial
disease or
disorder will result in the normalization of one or more energy biomarkers
such as,
lactic acid (lactate) levels; pyruvic acid (pyruvate) levels; total, reduced
or oxidized
glutathione levels; total, reduced or oxidized cysteine levels;
phosphocreatine levels;
NADH (NADH+H30) or NADPH (NADPH+H30 ) levels; NAD or NADP levels;
ATP levels; reduced coenzyme Q (CoQred) levels; oxidized coenzyme Q (CoQox)
levels; total coenzyme Q (CoQtot) levels; oxidized cytochrome C levels;
reduced
cytochrome C levels; acetoacetate levels; beta-hydroxy butyrate levels; 8-
hydroxy-2'-
deoxyguanosine (8-0HdG) levels; and reactive oxygen species levels compared to

untreated subjects with a mitochondrial disease or disorder. In some
embodiments of
the method, the lactate levels of one or more of whole blood, plasma,
cerebrospinal
fluid, or cerebral ventricular fluid in a treated subject are normalized
compared to
untreated subjects with a mitochondrial disease or disorder. In some
embodiments of
the method, the pyruvate levels of one or more of whole blood, plasma,
cerebrospinal
fluid, or cerebral ventricular fluid in a treated subject are normalized
compared to
untreated subjects with a mitochondrial disease or disorder. In some
embodiments of
the method, the total, reduced or oxidized glutathione levels of one or more
of whole
blood, plasma, lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid
in a
treated subject are normalized compared to untreated subjects with a
mitochondria'
disease or disorder. In some embodiments of the method, the total, reduced or
oxidized cysteine levels of one or more of whole blood, plasma, lymphocytes,
cerebrospinal fluid, or cerebral ventricular fluid in a treated subject are
normalized
compared to untreated subjects with a mitochondrial disease or disorder.
[0533] One aspect of the present technology includes methods of treating
Alport
Syndrome in a subject diagnosed as having, suspected as having, or at risk of
having
Alport Syndrome. In therapeutic applications, compositions or medicaments
comprising phenazine-3-one and/or phenothiazine-3-one derivatives or
pharmaceutically acceptable salts thereof, are administered to a subject
suspected of,
or already suffering from such a disease (such as, e.g., subjects exhibiting
aberrant
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levels and/or function of one or more of ADAM8, fibronectin, myosin 10, MMP-2,

MMP-9, and podocin compared to a normal control subject, or a subject
diagnosed
with Alport Syndrome), in an amount sufficient to cure, or at least partially
arrest, the
symptoms of the disease, including its complications and intermediate
pathological
phenotypes in development of the disease.
[0534] Subjects suffering from Alport Syndrome can be identified by any or a
combination of diagnostic or prognostic assays known in the art. For example,
typical
symptoms of Alport Syndrome include, but are not limited to, hematuria,
proteinuria,
cylindruria, leukocyturia, hypertension, edema, microalbuminuria, declining
glomerular filtration rate, fibrosis, GBM ultrastructural abnormalities,
nephrotic
syndrome, glomerulonephritis, end-stage kidney disease, chronic anemia,
macrothrombocytopenia, osteodystrophy, sensorineural deafness, anterior
lenticonus,
dot-and-fleck retinopathy, posterior polymorphous corneal dystrophy, recurrent

corneal erosion, temporal macular thinning, cataracts, lacrimation,
photophobia,
vision loss, keratoconus, and leiomyomatosis.
[0535] In some embodiments, the subject may exhibit aberrant levels or
function of
one or more of ADAM8, fibronectin, myosin 10, MMP-2, MMP-9, and podocin
compared to a normal control subject, which is measureable using techniques
known
in the art. In some embodiments, the subject may exhibit one or more mutations
in
COL4A3, COL4A4, and COL4A5, which are involved in the production or assembly
of type IV collagen fibers and are detectable using techniques known in the
art.
[0536] In some embodiments, Alport Syndrome subjects treated with phenazine-3-
one and/or phenothiazine-3-one derivatives will show amelioration or
elimination of
one or more of the following symptoms: hematuria, proteinuria, cylindruria,
leukocyturia, hypertension, edema, microalbuminuria, declining glomerular
filtration
rate, fibrosis, GBM ultrastructural abnormalities, nephrotic syndrome,
glomerulonephritis, end-stage kidney disease, chronic anemia,
macrothrombocytopenia, osteodystrophy, sensorineural deafness, anterior
lenticonus,
dot-and-fleck retinopathy, posterior polymorphous corneal dystrophy, recurrent

corneal erosion, temporal macular thinning, cataracts, lacrimation,
photophobia,
vision loss, keratoconus, and leiomyomatosis. In certain embodiments, Alport
Syndrome subjects treated with phenazine-3-one and/or phenothiazine-3-one
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derivatives will show normalization of one or more of ADAM8, fibronectin,
myosin
10, MMP-2, MMP-9, and podocin urine levels by at least 10% compared to
untreated
Alport Syndrome subjects. In certain embodiments, Alport Syndrome subjects
treated
with phenazine-3-one and/or phenothiazine-3-one derivatives will show MMP-9
expression levels in mesangial cells that are similar to that observed in a
normal
control subject.
[0537] In another aspect, the present technology includes methods of treating
porphyria in a subject diagnosed as having, suspected as having, or at risk of
having
porphyria. In therapeutic applications, compositions or medicaments comprising

phenazine-3-one and/or phenothiazine-3-one derivatives, or pharmaceutically
acceptable salts thereof, are administered to a subject suspected of, or
already
suffering from such a disease, such as, e.g., aberrant levels and/or function
of
enzymes involved in heme biosynthesis compared to a normal control subject or
porphyria, in an amount sufficient to cure, or at least partially arrest, the
symptoms of
the disease, including its complications and intermediate pathological
phenotypes in
development of the disease.
[0538] Subjects suffering from porphyria can be identified by any or a
combination
of diagnostic or prognostic assays known in the art. For example, typical
symptoms
of porphyria include, but are not limited to, cutaneous lesions, blistering
skin lesions,
hypertrichosis, hyperpigmentation, thickening and/or scarring of the skin,
friability of
the skin, photosensitivity of the skin, lichenification, leathery
pseudovesicles, labial
grooving, nail changes, life threatening acute neurological attacks, abdominal
pain
and cramping, constipation, diarrhea, increased bowel sounds, decreased bowel
sounds, nausea, vomiting, tachycardia, hypertension, headache, mental
symptoms,
extremity pain, neck pain, chest pain, muscle weakness, sensory loss, tremors,

sweating, dysuria, and bladder distension.
[0539] In some embodiments, the subject may exhibit aberrant levels or
function of
enzymes required for heme biosynthesis compared to a normal control subject,
which
is measureable using techniques known in the art. In some embodiments, the
subject
may exhibit one or more mutations in genes encoding enzymes required for heme
biosynthesis, which are detectable using techniques known in the art.
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CA 02920272 2016-02-09
[0540] In some embodiments, administration of phenazine-3-one and/or
phenothiazine-3-one derivatives to a subject that is diagnosed as having, is
suspected
of having, or is at risk of having porphyria will result in amelioration or
elimination of
one or more of the following symptoms: cutaneous lesions, blistering skin
lesions,
hypertrichosis, hyperpigmentation, thickening and/or scarring of the skin,
friability of
the skin, photosensitivity of the skin, lichenification, leathery
pseudovesicles, labial
grooving, nail changes, life threatening acute neurological attacks, abdominal
pain
and cramping, constipation, diarrhea, increased bowel sounds, decreased bowel
sounds, nausea, vomiting, tachycardia, hypertension, headache, mental
symptoms,
extremity pain, neck pain, chest pain, muscle weakness, sensory loss, tremors,

sweating, dysuria, and bladder distension. In certain embodiments of the
method,
porphyria subjects treated with the phenazine-3-one and/or phenothiazine-3-one

derivatives will show normalization of the levels and/or function of one or
more
enzymes required for heme biosynthesis compared to untreated porphyria
subjects.
[0541] One aspect of the present technology includes methods of treating
vitiligo in
a subject diagnosed as having, suspected as having, or at risk of having
vitiligo. In
therapeutic applications, compositions or medicaments comprising phenazine-3-
one
and/or phenothiazine-3-one derivatives, or pharmaceutically acceptable salts
thereof,
are administered to a subject suspected of, or already suffering from such a
disease, in
an amount sufficient to cure, or at least partially arrest, the symptoms of
the disease,
including its complications and intermediate pathological phenotypes in
development
of the disease.
[0542] Subjects suffering from vitiligo can be identified by any or a
combination of
diagnostic or prognostic assays known in the art. For example, typical
symptoms of
vitiligo include, but are not limited to, increased photosensitivity,
decreased contact
sensitivity response to dinitrochlorobenzene, depigmentation of the skin,
mucous
membranes (tissues that line the inside of the mouth and nose), retina, or
genitals, and
premature whitening or graying of hair on the scalp, eyelashes, eyebrows or
beard.
[0543] In some embodiments, vitiligo subjects treated with phenazine-3-one
and/or
phenothiazine-3-one derivatives will show amelioration or elimination of one
or more
of the following symptoms: increased photosensitivity, decreased contact
sensitivity
response to dinitrochlorobenzene, depigmentation of the skin, mucous membranes
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CA 02920272 2016-02-09
(tissues that line the inside of the mouth and nose), retina, or genitals, and
premature
whitening or graying of hair on the scalp, eyelashes, eyebrows or beard.
[0544] In some embodiments, administration of phenazine-3-one and/or
phenothiazine-3-one derivatives to a subject that is diagnosed as having, is
suspected
of having, or is at risk of having IPF will result in amelioration or
elimination of one
or more of the following symptoms: increase in TGF-131-induced epithelial to
mesenchymal transition (EMT), myofibroblast activation, collagen production,
lung
scarring, and severe progressive fibrosis including fibrotic foci and
honeycombing.
Prophylactic Methods
[0545] In one aspect, the present technology provides a method for preventing
or
delaying the onset of a mitochondrial disease or disorder in a subject at risk
of having
a mitochondrial disease or disorder. In some embodiments, the subject may
exhibit
one or more mtDNA or nuclear DNA mutations in one or more genes described
herein that play a biological/physiological role in the mitochondria (e.g.,
mitochondrial protein synthesis, respiratory chain function, intergenomic
signaling,
mitochondrial importation of nDNA-encoded proteins, synthesis of inner
mitochondrial membrane phospholipids, mitochondrial motility and fission,
mitophagy etc.).
[0546] Subjects at risk for pathological levels of one or more energy
biomarkers
such as, lactic acid (lactate) levels (in one or more of whole blood, plasma,
cerebrospinal fluid, or cerebral ventricular fluid); pyruvic acid (pyruvate)
levels (in
one or more of whole blood, plasma, cerebrospinal fluid, or cerebral
ventricular
fluid); total, reduced or oxidized glutathione levels (in one or more of whole
blood,
plasma, lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid);
total, reduced
or oxidized cysteine levels (in one or more of whole blood, plasma,
lymphocytes,
cerebrospinal fluid, or cerebral ventricular fluid); phosphocreatine levels;
NADH
(NADH+H30) or NADPH (NADPH+H30 ) levels; NAD or NADP levels; ATP
levels; reduced coenzyme Q (CoQred) levels; oxidized coenzyme Q (CoQox)
levels;
total coenzyme Q (CoQtot) levels; oxidized cytochrome C levels; reduced
cytochrome
C levels; acetoacetate levels; beta-hydroxy butyrate levels; 8-hydroxy-2'-
deoxyguanosine (8-0HdG) levels; and reactive oxygen species levels compared to
a
normal control subject, or alternatively a mitochondrial disease or disorder,
can be
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CA 02920272 2016-02-09
identified by, e.g., any or a combination of diagnostic or prognostic assays
known in
the art.
[0547] In prophylactic applications, pharmaceutical compositions or
medicaments
comprising phenazine-3-one and/or phenothiazine-3-one derivatives or
pharmaceutically acceptable salts thereof, are administered to a subject
susceptible to,
or otherwise at risk of a mitochondrial disease or disorder in an amount
sufficient to
eliminate or reduce the risk, or delay the onset of the disease, including
biochemical,
histologic and/or behavioral symptoms of the disease, its complications and
intermediate pathological phenotypes presenting during development of the
disease.
Administration of prophylactic phenazine-3-one and/or phenothiazine-3-one
derivatives can occur prior to the manifestation of symptoms characteristic of
the
disease or disorder, such that the disease or disorder is prevented or,
alternatively,
delayed in its progression.
[0548] Subjects at risk for pathological levels of one or more energy
biomarkers
compared to a normal control subject, or alternatively a mitochondrial disease
or
disorder include, but are not limited to, subjects harboring mutations in one
or more
genes described herein that play a biological/physiological role in the
mitochondria
(e.g., mitochondrial protein synthesis, respiratory chain function,
intergenomic
signaling, mitochondrial importation of nDNA-encoded proteins, synthesis of
inner
mitochondrial membrane phospholipids, mitochondrial motility and fission,
mitophagy etc.).
[0549] In some embodiments, treatment with the phenazine-3-one and/or
phenothiazine-3-one derivatives will prevent or delay the onset of one or more
of the
following symptoms: poor growth, loss of muscle coordination, muscle weakness,

neurological deficit, seizures, autism, autistic spectrum, autistic-like
features, learning
disabilities, heart disease, liver disease, kidney disease, gastrointestinal
disorders,
severe constipation, diabetes, increased risk of infection, thyroid
dysfunction, adrenal
dysfunction, autonomic dysfunction, confusion, disorientation, memory loss,
failure
to thrive, poor coordination, sensory (vision, hearing) problems, reduced
mental
functions, hypotonia, disease of the organ, dementia, respiratory problems,
hypoglycemia, apnea, lactic acidosis, seizures, swallowing difficulties,
developmental
delays, movement disorders (dystonia, muscle spasms, tremors, chorea), stroke,
brain
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CA 02920272 2016-02-09
atrophy, or any other sign or symptom of a mitochondrial disease state
disclosed
herein.
[0550] In some embodiments, administration of phenazine-3-one and/or
phenothiazine-3-one derivatives in subjects with a mitochondrial disease or
disorder
will cause the levels of one or more energy biomarkers to be similar to that
observed
in a normal control subject. In certain embodiments, the energy biomarker is
selected
from the group consisting of lactic acid (lactate) levels; pyruvic acid
(pyruvate) levels;
total, reduced or oxidized glutathione levels; total, reduced or oxidized
cysteine
levels; phosphocreatine levels; NADH (NADH+H30) or NADPH (NADPH+H30 )
levels; NAD or NADP levels; ATP levels; reduced coenzyme Q (CoQred) levels;
oxidized coenzyme Q (CoQox) levels; total coenzyme Q (CoQtot) levels; oxidized

cytochrome C levels; reduced cytochrome C levels; acetoacetate levels; beta-
hydroxy
butyrate levels; 8-hydroxy-2'-deoxyguanosine (8-0HdG) levels; and reactive
oxygen
species levels. In some embodiments of the method, the lactate levels of one
or more
of whole blood, plasma, cerebrospinal fluid, or cerebral ventricular fluid in
a treated
subject are similar to that observed in a normal control subject. In some
embodiments
of the method, the pyruvate levels of one or more of whole blood, plasma,
cerebrospinal fluid, or cerebral ventricular fluid in a treated subject are
similar to that
observed in a normal control subject. In some embodiments of the method, the
total,
reduced or oxidized glutathione levels of one or more of whole blood, plasma,
lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid in a treated
subject are
similar to that observed in a normal control subject. In some embodiments of
the
method, the total, reduced or oxidized cysteine levels of one or more of whole
blood,
plasma, lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid in a
treated
subject are similar to that observed in a normal control subject.
[0551] In one aspect, the present technology provides a method for preventing
or
delaying the onset of Alport Syndrome or symptoms of Alport Syndrome in a
subject
at risk of having Alport Syndrome. In some embodiments, the subject may
exhibit
one or more mutations in COL4A3, COL4A4, and COL4A5, which are involved in
the production or assembly of type IV collagen fibers.
[0552] Subjects at risk for aberrant levels and/or function of one or more of
ADAM8, fibronectin, myosin 10, MMP-2, MMP-9, and podocin compared to a
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CA 02920272 2016-02-09
normal control subject or Alport Syndrome can be identified by, e.g., any or a

combination of diagnostic or prognostic assays known in the art. In
prophylactic
applications, pharmaceutical compositions or medicaments of phenazine-3-one
and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
are
administered to a subject susceptible to, or otherwise at risk of a disease or
condition
such as e.g., Alport Syndrome, in an amount sufficient to eliminate or reduce
the risk,
or delay the onset of the disease, including biochemical, histologic and/or
behavioral
symptoms of the disease, its complications and intermediate pathological
phenotypes
presenting during development of the disease. Administration of prophylactic
phenazine-3-one and/or phenothiazine-3-one derivatives can occur prior to the
manifestation of symptoms characteristic of the disease or disorder, such that
the
disease or disorder is prevented or, alternatively, delayed in its
progression.
[0553] Subjects at risk for aberrant levels and/or function of one or more of
ADAM8, fibronectin, myosin 10, MMP-2, MMP-9, and podocin compared to a
normal control subject or Alport Syndrome include, but are not limited to,
subjects
harboring mutations in COL4A3, COL4A4, and COL4A5, which are involved in the
synthesis of type IV collagen fibers.
[0554] In some embodiments, treatment with the phenazine-3-one and/or
phenothiazine-3-one derivatives will prevent or delay the onset of one or more
of the
following symptoms: hematuria, proteinuria, cylindruria, leukocyturia,
hypertension,
edema, microalbuminuria, declining glomerular filtration rate, fibrosis, GBM
ultrastructural abnormalities, nephrotic syndrome, glomerulonephritis, end-
stage
kidney disease, chronic anemia, macrothrombocytopenia, osteodystrophy,
sensorineural deafness, anterior lenticonus, dot-and-fleck retinopathy,
posterior
polymorphous corneal dystrophy, recurrent corneal erosion, temporal macular
thinning, cataracts, lacrimation, photophobia, vision loss, keratoconus, and
leiomyomatosis. In certain embodiments, the urine levels of one or more of
ADAM8,
fibronectin, myosin 10, MMP-2, MMP-9, and podocin in Alport Syndrome subjects
treated with the phenazine-3-one and/or phenothiazine-3-one derivatives will
resemble those observed in healthy controls. In certain embodiments, Alport
Syndrome subjects treated with the phenazine-3-one and/or phenothiazine-3-one
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CA 02920272 2016-02-09
derivatives will show MMP-9 expression in mesangial cells that is similar to
that
observed in a normal control subject.
[0555] In one aspect, the present technology provides a method for preventing
or
delaying the onset of porphyria or symptoms of porphyria in a subject at risk
of
having porphyria. In some embodiments, the subject may exhibit one or more
mutations in genes encoding enzymes required for heme biosynthesis.
[0556] Subjects at risk for aberrant levels and/or function of enzymes
involved in
heme biosynthesis compared to a normal control subject or porphyria can be
identified by, e.g., any or a combination of diagnostic or prognostic assays
known in
the art. In prophylactic applications, pharmaceutical compositions or
medicaments of
phenazine-3-one and/or phenothiazine-3-one derivatives, or pharmaceutically
acceptable salts thereof, are administered to a subject susceptible to, or
otherwise at
risk of a disease or condition such as e.g., porphyria, in an amount
sufficient to
eliminate or reduce the risk, or delay the outset of the disease, including
biochemical,
histologic and/or behavioral symptoms of the disease, its complications and
intermediate pathological phenotypes presenting during development of the
disease.
Administration of prophylactic phenazine-3-one and/or phenothiazine-3-one
derivatives can occur prior to the manifestation of symptoms characteristic of
the
disease or disorder, such that the disease or disorder is prevented or,
alternatively,
delayed in its progression.
[0557] Subjects at risk for aberrant levels and/or function of enzymes
involved in
heme biosynthesis compared to a normal control subject, or porphyria include,
but are
not limited to, subjects harboring mutations in one or more genes encoding
enzymes
involved in heme biosynthesis.
[0558] In some embodiments, treatment with the phenazine-3-one and/or
phenothiazine-3-one derivatives will prevent or delay the onset of one or more
of the
following symptoms: cutaneous lesions, blistering skin lesions,
hypertrichosis,
hyperpigmentation, thickening and/or scarring of the skin, friability of the
skin,
photosensitivity of the skin, lichenification, leathery pseudovesicles, labial
grooving,
nail changes, life threatening acute neurological attacks, abdominal pain and
cramping, constipation, diarrhea, increased bowel sounds, decreased bowel
sounds,
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CA 02920272 2016-02-09
nausea, vomiting, tachycardia, hypertension, headache, mental symptoms,
extremity
pain, neck pain, chest pain, muscle weakness, sensory loss, tremors, sweating,

dysuria, and bladder distension. In certain embodiments of the method,
porphyria
subjects treated with the phenazine-3-one and/or phenothiazine-3-one
derivatives will
show normalization of the levels and/or function of one or more enzymes
required for
heme biosynthesis compared to untreated porphyria subjects. In certain
embodiments,
the levels and/or function of one or more enzymes involved in heme
biosynthesis in
porphyria subjects treated with the phenazine-3-one and/or phenothiazine-3-one

derivatives will resemble those observed in healthy controls.
[0559] In one aspect, the present technology provides a method for preventing
or
delaying the onset of vitiligo or symptoms of vitiligo in a subject at risk of
having
vitiligo. In some embodiments, the subject may exhibit one or more mutations
in
NLRP1, TYR, HLA class I, HLA class II, HLA class III, PTPN22, XBP1, IL2RA,
LPP, RERE, FOXP1, TSLP, CCR6, GZMB, UBASH3A, C1QTNF6, and FOXP3.
[0560] In prophylactic applications, pharmaceutical compositions or
medicaments
of phenazine-3-one and/or phenothiazine-3-one derivatives or pharmaceutically
acceptable salts thereof, are administered to a subject susceptible to, or
otherwise at
risk of a disease or condition such as vitiligo, in an amount sufficient to
eliminate or
reduce the risk, or delay the onset of the disease, including biochemical,
histologic
and/or behavioral symptoms of the disease, its complications and intermediate
pathological phenotypes presenting during development of the disease.
Administration of prophylactic phenazine-3-one and/or phenothiazine-3-one
derivatives can occur prior to the manifestation of symptoms characteristic of
the
disease or disorder, such that the disease or disorder is prevented or,
alternatively,
delayed in its progression.
[0561] Subjects at risk for vitiligo include, but are not limited to, subjects
harboring
mutations in NLRP1, TYR, HLA class I, HLA class II, HLA class III, PTPN22,
XBP1, IL2RA, LPP, RERE, FOXP1, TSLP, CCR6, GZMB, UBASH3A, C1QTNF6,
and FOXP3.
[0562] In some embodiments, treatment with the phenazine-3-one and/or
phenothiazine-3-one derivatives will prevent or delay the onset of one or more
of the
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CA 02920272 2016-02-09
following symptoms: increased photosensitivity, decreased contact sensitivity
response to dinitrochlorobenzene, depigmentation of the skin, mucous
membranes,
retina, or genitals, and premature whitening or graying of hair on the scalp,
eyelashes,
eyebrows or beard.
[0563] In some embodiments, treatment with the phenazine-3-one and/or
phenothiazine-3-one derivatives will prevent or delay the onset of one or more
of the
symptoms of 1PF, including but not limited to, an increase in TGF-01-induced
epithelial to mesenchymal transition (EMT), myofibroblast activation, collagen

production, lung scarring, and severe progressive fibrosis including fibrotic
foci and
honeycombing.
[0564] For therapeutic and/or prophylactic applications, a composition
comprising
phenazine-3-one and/or phenothiazine-3-one derivatives, or pharmaceutically
acceptable salts thereof, is administered to the subject. In some embodiments,
the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
one,
two, three, four, or five times per day. In some embodiments, the phenazine-3-
one or
phenothiazine-3-one derivative composition is administered more than five
times per
day. Additionally or alternatively, in some embodiments, the phenazine-3-one
or
phenothiazine-3-one derivative composition is administered every day, every
other
day, every third day, every fourth day, every fifth day, or every sixth day.
In some
embodiments, the phenazine-3-one or phenothiazine-3-one derivative composition
is
administered weekly, bi-weekly, tri-weekly, or monthly. In some embodiments,
the
phenazine-3-one or phenothiazine-3-one derivative composition is administered
for a
period of one, two, three, four, or five weeks. In some embodiments, the
phenazine-
3-one or phenothiazine-3-one derivative is administered for six weeks or more.
In
some embodiments, the phenazine-3-one or phenothiazine-3-one derivative is
administered for twelve weeks or more. In some embodiments, the phenazine-3-
one
or phenothiazine-3-one derivative is administered for a period of less than
one year.
In some embodiments, the phenazine-3-one or phenothiazine-3-one derivative is
administered for a period of more than one year.
[0565] Additionally or alternatively, in some embodiments of the method, the
phenazine-3-one or phenothiazine-3-one derivative is administered daily for
one, two,
three, four or five weeks. In some embodiments of the method, the phenazine-3-
one
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CA 02920272 2016-02-09
or phenothiazine-3-one derivative is administered daily for less than 6 weeks.
In
some embodiments of the method, the phenazine-3-one or phenothiazine-3-one
derivative is administered daily for 6 weeks or more. In other embodiments of
the
method, the phenazine-3-one or phenothiazine-3-one derivative is administered
daily
for 12 weeks or more.
Determination of the Biological Effect of the Phenazine-3-one and
Phenothiazine-3-
one Derivatives of the Present Technology
[0566] In various embodiments, suitable in vitro or in vivo assays are
performed to
determine the effect of a specific phenazine-3-one or phenothiazine-3-one
derivative
of the present technology and whether its administration is indicated for
treatment. In
various embodiments, in vitro assays can be performed with representative
animal
models, to determine if a given phenazine-3-one or phenothiazine-3-one
derivative-
based therapeutic exerts the desired effect in reducing disruption of
mitochondrial
function, such as disruption of OXPHOS, or alternatively treating a medical
disease or
condition, such as vitiligo, Alport Syndrome, porphyria or IPF. Compounds for
use in
therapy can be tested in suitable animal model systems including, but not
limited to
rats, mice, chicken, cows, monkeys, rabbits, and the like, prior to testing in
human
subjects. Similarly, for in vivo testing, any of the animal model system known
in the
art can be used prior to administration to human subjects. In some
embodiments, in
vitro or in vivo testing is directed to the biological function of a phenazine-
3-one or
phenothiazine-3-one derivative, or a pharmaceutically acceptable salt thereof.
[0567] The phenazine-3-one and phenothiazine-3-one derivatives of the present
technology can be tested in vitro for efficacy. One such assay is ability of a

compound to rescue FRDA fibroblasts stressed by addition of L-buthionine-(S,R)-

sulfoximine (BSO), as described in Jauslin et al., Hum. Mol. Genet.
11(24):3055
(2002), Jauslin et al., FASEB J. 17:1972-4 (2003), and International Patent
Application WO 2004/003565. Human dermal fibroblasts from Friedreich's Ataxia
patients have been shown to be hypersensitive to inhibition of the de novo
synthesis of
glutathione (GSH) with L-buthionine-(S,R)-sulfoximine (BSO), a specific
inhibitor of
GSH synthetase (Jauslin et al., Hum. Mol. Genet. 11(24):3055 (2002)). This
specific
BSO-mediated cell death can be prevented by administration of antioxidants or
molecules involved in the antioxidant pathway, such as ct-tocopherol, short
chain
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CA 02920272 2016-02-09
quinones, selenium, or small molecule glutathione peroxidase mimetics.
However,
antioxidants differ in their potency, i.e., the concentration at which they
are able to
rescue BSO-stressed FRDA fibroblasts. With this assay, EC50 concentrations of
the
compounds of the present technology can be determined and compared to known
reference antioxidants. Similar screens can be applied to fibroblasts derived
from
patients diagnosed as having, suspected as having, or at risk of having LHON,
Huntington's Disease, Parkinson's Disease, CoQ10 deficiencies, etc.
[0568] In some embodiments, disruption in oxidative phosphorylation is
determined
by assays well known in the art. By way of example, but not by way of
limitation, a
disruption in oxidative phosphorylation is determined by assays that measures
levels
of coenzyme Q10 (C0Q10). In some embodiments, disruption in oxidative
phosphorylation is determined by assays that measure OXPHOS capacity by the
uncoupling ratio. In some embodiments, disruption in oxidative phosphorylation
is
determined by assays that measure the net routine flux control ratio. In some
embodiments, disruption in oxidative phosphorylation is determined by assays
that
measure leak flux control ratio. In some embodiments, disruption in oxidative
phosphorylation is determined by assays that measure the phosphorylation
respiratory
control ratio.
[0569] Uncoupling ratio (UCR) is an expression of the respiratory reserve
capacity
and indicates the OXPHOS capacity of the cells. In some embodiments, UCR is
defined as Cr u / Cr. Cr u is the maximum rate of oxygen utilization (Oxygen
flux)
produced when mitochondria are chemically uncoupled using FCCP (Carbonyl
cyanide 4-(trifluoromethoxy) phenylhydrazone). FCCP titration must be
performed
since the concentration of FCCP required to produce maximum oxygen utilization

varies among different cell lines. Once the maximum oxygen utilization is
reached,
further increases in FCCP inhibit oxygen utilization by oxidative
phosphorylation. In
some embodiments, Cr represents oxygen utilization by the cells during a
normal
cellular respiration with excess substrates.
[0570] In some embodiments, the Net Routine Flux Control Ratio (Cr! Cr) is the

inverse of the UCR. In some embodiments, this value assesses how close routine

respiration operates to the respiratory capacity of oxidative phosphorylation.
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CA 02920272 2016-02-09
[0571] In some embodiments, the Respiratory Control Ratio (RCR) is defined as
Cru
/ Cr . Cr u is defined above. Cro = Respiration after inhibition of Complex V
(ATP
synthase) by oligomycin. In some embodiments, this ratio allows assessment of
uncoupling and OXPHOS dysfunction.
[0572] In some embodiments, the Leak Flux Control Ratio is determined by Cro /

Cr. In some embodiments, this parameter is the inverse of RCR and represent
proton
leak with inhibition of ADP phosphorylation by oligomycin.
[0573] In some embodiments, the Phosphorylation Respiratory Control Ratio
(RCRp) is defined as (Cr ¨ CO/ Cr u (or 1/UCR ¨ 1/RCR). In some embodiments,
the
RCRp is an index which expresses phosphorylation-related respiration (Cr- CO
as a
function of respiratory capacity (Cru). In some embodiments, the RCRp remains
constant, if partial uncoupling is fully compensated by an increased routine
respiration
rate and a constant rate of oxidative phosphorylation is maintained. In some
embodiments, if the respiratory capacity declines without effect on the rate
of
oxidative phosphorylation; in some embodiments, the RCRp increases, which
indicates that, a higher proportion of the maximum capacity is activated to
drive ATP
synthesis. In some embodiments, the RCRp declines to zero in either fully
uncoupled
cells or in cells under complete metabolic arrest.
[0574] Accordingly, in some embodiments, therapeutic and/or prophylactic
treatment of subjects having mitochondrial disorder or disease, with phenazine-
3-one
and/or phenothiazine-3-one derivatives as disclosed herein, or a
pharmaceutically
acceptable salt thereof, will reduce the disruption in oxidative
phosphorylation,
thereby ameliorating symptoms of mitochondrial diseases and disorders.
Symptoms
of mitochondrial diseases or disorders include, but are not limited to, poor
growth,
loss of muscle coordination, muscle weakness, neurological deficit, seizures,
autism,
autistic spectrum, autistic-like features, learning disabilities, heart
disease, liver
disease, kidney disease, gastrointestinal disorders, severe constipation,
diabetes,
increased risk of infection, thyroid dysfunction, adrenal dysfunction,
autonomic
dysfunction, confusion, disorientation, memory loss, poor growth, failure to
thrive,
poor coordination, sensory (vision, hearing) problems, reduced mental
functions,
disease of the organ, dementia, respiratory problems, hypoglycemia, apnea,
lactic
acidosis, seizures, swallowing difficulties, developmental delays, movement
disorders
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CA 02920272 2016-02-09
(dystonia, muscle spasms, tremors, chorea), stroke, brain atrophy, or any
other sign or
symptom of a mitochondrial disease state disclosed herein.
[0575] Animal models of various diseases or conditions described herein (e.g.,

vitiligo, Alport Syndrome, IPF, porphyria) may be generated using techniques
known
in the art. Such models may be used to demonstrate the biological effect of
phenazine-3-one or phenothiazine-3-one derivatives of the present technology,
in the
prevention and treatment of conditions arising from disruption of a particular
gene,
and for determining what comprises a therapeutically effective amount of a
phenazine-3-one or phenothiazine-3-one derivative in a given context.
[0576] In some embodiments, melanocyte degeneration is determined by assays
well known in the art. In some embodiments, melanocyte degeneration is
determined
by assays that measure cytotoxicity after epidermal cells are exposed to 100
or
250[IM of 4-tertiary butyl phenol (4-TBP), a common inducer of vitiligo. In
some
embodiments, melanocyte degeneration is determined by assays that measure the
survival rate of epidermal cells that have been exposed to 100 or 250M of 4-
TBP.
[0577] In some embodiments, melanocyte degeneration is determined by assays
that
measure melanocyte antigen-specific T cell accumulation and cytotoxic activity
in
autologous skin explants. For a detailed description of the autologous skin
explant
model, see Van Den Boom et al., Journal of Investigative Dermatology, 129:
2220-
2232 (2009).
[0578] In some embodiments, melanocyte degeneration is determined by assays
that
measure the progressive depigmentation in the pelage of the vitiligo mouse
model
before and two weeks after plucking dorsal hairs. In some embodiments,
melanocyte
degeneration is determined by assays that measure the presence of ocular
pigmentation in vitiligo mice. In some embodiments, melanocyte degeneration is

determined by assays that measure the contact sensitivity of vitiligo mice to
dinitrochlorobenzene. For a detailed description of the vitiligo mouse model,
see
Lerner et al., Journal of Investigative Dermatology, 87(3): 299-304 (1986).
[0579] In some embodiments, melanocyte degeneration is determined by assays
that
measure epidermal depigmentation in an adoptive transfer mouse model of
vitiligo.
In some embodiments, melanocyte degeneration is determined by assays that
measure
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CA 02920272 2016-02-09
tyrosinase RNA expression in an adoptive transfer mouse model of vitiligo. For
a
detailed description of the adoptive transfer mouse model of vitiligo, see
Harris et al.,
Journal of Investigative Dermatology, 132: 1869-1876 (2012).
[0580] Accordingly, in some embodiments, therapeutic and/or prophylactic
treatment of subjects having vitiligo, with phenazine-3-one and/or
phenothiazine-3-
one derivatives as disclosed herein, or pharmaceutically acceptable salts
thereof, will
reduce melanocyte degeneration, thereby ameliorating symptoms of vitiligo.
Symptoms of vitiligo include, but are not limited to, increased
photosensitivity,
decreased contact sensitivity response to dinitrochlorobenzene, depigmentation
of the
skin, mucous membranes, retina, or genitals, and premature whitening or
graying of
hair on the scalp, eyelashes, eyebrows or beard.
[0581] Animal models of Alport Syndrome may be generated using techniques
known in the art, including, for example by generating random or targeted
mutations
in one or more of COL4A3, COL4A4, and COL4A5. For example, murine models of
X-linked Alport Syndrome and autosomal recessive Alport Syndrome have been
generated by targeted disruption of the mouse Col4a5 gene and mouse Co14a3
gene
respectively. See Rheault et al., J Am Soc Nephrol. 15(6):1466-74 (2004);
Cosgrove
et al., Genes Dev. 10(23):2981-92 (1996).
[0582] Accordingly, in some embodiments, therapeutic and/or prophylactic
treatment of subjects having Alport Syndrome, with phenazine-3-one and/or
phenothiazine-3-one derivatives as disclosed herein, or pharmaceutically
acceptable
salts thereof, will ameliorate symptoms of Alport Syndrome. Symptoms of Alport

Syndrome include, but are not limited to, hematuria, proteinuria, cylindruria,

leukocyturia, hypertension, edema, microalbuminuria, declining glomerular
filtration
rate, fibrosis, GBM ultrastructural abnormalities, nephrotic syndrome,
glomerulonephritis, end-stage kidney disease, chronic anemia,
macrothrombocytopenia, osteodystrophy, sensorineural deafness, anterior
lenticonus,
dot-and-fleck retinopathy, posterior polymorphous corneal dystrophy, recurrent

corneal erosion, temporal macular thinning, cataracts, lacrimation,
photophobia,
vision loss, keratoconus, and leiomyomatosis.
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CA 02920272 2016-02-09
[0583] Animals subjected to TGF-131-adenovirus-induced lung fibrosis or
bleomycin-induced lung fibrosis may be used as an in vivo model for IPF.
MacKinnon et al., Am. J. Respir. Crit. Care Med. 185(5):537-46 (2012).
[0584] Accordingly, in some embodiments, therapeutic ancVor prophylactic
treatment of subjects having IPF, with phenazine-3-one and/or phenothiazine-3-
one
derivatives as disclosed herein, or pharmaceutically acceptable salts thereof,
will
ameliorate symptoms of IPF.
[0585] Animal models of porphyria may be generated using techniques known in
the art, including, for example by generating random or targeted mutations in
one or
more genes encoding enzymes involved in heme biosynthesis. For example, a
murine
model of familial porphyria cutanea tarda has been generated by targeted
disruption of
the URO-D gene by homologous recombination.
[0586] Accordingly, in some embodiments, therapeutic and/or prophylactic
treatment of subjects having porphyria, with phenazine-3-one and/or
phenothiazine-3-
one derivatives as disclosed herein, or pharmaceutically acceptable salts
thereof, will
ameliorate symptoms of porphyria. Symptoms of porphyria include, but are not
limited to, cutaneous lesions, blistering skin lesions, hypertrichosis,
hyperpigmentation, thickening and/or scarring of the skin, friability of the
skin,
photosensitivity of the skin, lichenification, leathery pseudovesicles, labial
grooving,
nail changes, acute neurological attacks, abdominal pain and cramping,
constipation,
diarrhea, increased bowel sounds, decreased bowel sounds, nausea, vomiting,
tachycardia, hypertension, headache, mental symptoms, extremity pain, neck
pain,
chest pain, muscle weakness, sensory loss, tremors, sweating, dysuria, and
bladder
distension.
Use of Phenazine-3-one and Phenothiazine-3-one Derivatives of the Present
Technology for Modulation of Energy Biomarkers
[0587] In addition to monitoring energy biomarkers to assess the status of
treatment
or suppression of mitochondrial diseases, the phenazine-3-one and
phenothiazine-3-
one derivatives of the present technology can be used in subjects or patients
to
modulate one or more energy biomarkers. Modulation of energy biomarkers can be

done to normalize energy biomarkers in a subject, or to enhance energy
biomarkers in
a subject.
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CA 02920272 2016-02-09
[0588] Normalization of one or more energy biomarkers is defined as either
restoring the level of one or more such energy biomarkers to normal or near-
normal
levels in a subject whose levels of one or more energy biomarkers show
pathological
differences from normal levels (i.e., levels in a healthy subject), or to
change the
levels of one or more energy biomarkers to alleviate pathological symptoms in
a
subject. Depending on the nature of the energy biomarker, such levels may show

measured values either above or below a normal value. For example, a
pathological
lactate level is typically higher than the lactate level in a normal (i.e.,
healthy) person,
and a decrease in the level may be desirable. A pathological ATP level is
typically
lower than the ATP level in a normal (i.e., healthy) person, and an increase
in the
level of ATP may be desirable. Accordingly, normalization of energy biomarkers
can
involve restoring the level of energy biomarkers to within about at least two
standard
deviations of normal in a subject, or to within about at least one standard
deviation of
normal in a subject, to within about at least one-half standard deviation of
normal, or
to within about at least one-quarter standard deviation of normal.
[0589] When an increase in an energy biomarker level is desired to normalize
the
one or more such energy biomarker, the level of the energy biomarker can be
increased to within about at least two standard deviations of normal in a
subject,
increased to within about at least one standard deviation of normal in a
subject,
increased to within about at least one-half standard deviation of normal, or
increased
to within about at least one-quarter standard deviation of normal, by
administration of
one or more compounds according to the present technology. Alternatively, the
level
of one or more of the energy biomarkers can be increased by about at least 10%
above
the subject's level of the respective one or more energy biomarkers before
administration; by about at least 20% above the subject's level of the
respective one or
more energy biomarkers before administration, by about at least 30% above the
subject's level of the respective one or more energy biomarkers before
administration,
by about at least 40% above the subject's level of the respective one or more
energy
biomarkers before administration, by about at least 50% above the subject's
level of
the respective one or more energy biomarkers before administration, by about
at least
75% above the subject's level of the respective one or more energy biomarkers
before
administration, or by about at least 100% above the subject's level of the
respective
one or more energy biomarkers before administration.
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CA 02920272 2016-02-09
[0590] When a decrease in a level of one or more energy biomarkers is desired
to
normalize the one or more energy biomarkers, the level of the one or more
energy
biomarkers can be decreased to a level within about at least two standard
deviations of
normal in a subject, decreased to within about at least one standard deviation
of
normal in a subject, decreased to within about at least one-half standard
deviation of
normal, or decreased to within about at least one-quarter standard deviation
of normal,
by administration of one or more compounds according to the present
technology.
Alternatively, the level of the one or more energy biomarkers can be decreased
by
about at least 10% below the subject's level of the respective one or more
energy
biomarkers before administration, by about at least 20% below the subject's
level of
the respective one or more energy biomarkers before administration, by about
at least
30% below the subject's level of the respective one or more energy biomarkers
before
administration, by about at least 40% below the subject's level of the
respective one or
more energy biomarkers before administration, by about at least 50% below the
subject's level of the respective one or more energy biomarkers before
administration,
by about at least 75% below the subject's level of the respective one or more
energy
biomarkers before administration, or by about at least 90% below the subject's
level of
the respective one or more energy biomarkers before administration.
[0591] Enhancement of the level of one or more energy biomarkers is defined as

changing the extant levels of one or more energy biomarkers in a subject to a
level
which provides beneficial or desired effects for the subject. For example, a
person
undergoing strenuous effort or prolonged vigorous physical activity, such as
mountain
climbing, could benefit from increased ATP levels or decreased lactate levels.
As
described above, normalization of energy biomarkers may not achieve the
optimum
state for a subject with a mitochondrial disease, and such subjects can also
benefit
from enhancement of energy biomarkers. Examples of subjects who could benefit
from enhanced levels of one or more energy biomarkers include, but are not
limited
to, subjects undergoing strenuous or prolonged physical activity, subjects
with chronic
energy problems, or subjects with chronic respiratory problems. Such subjects
include, but are not limited to, pregnant females, particularly pregnant
females in
labor; neonates, particularly premature neonates; subjects exposed to extreme
environments, such as hot environments (temperatures routinely exceeding about
85-
86 degrees Fahrenheit or about 30 degrees Celsius for about 4 hours daily or
more),
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CA 02920272 2016-02-09
cold environments (temperatures routinely below about 32 degrees Fahrenheit or

about 0 degrees Celsius for about 4 hours daily or more), or environments with
lower-
than-average oxygen content, higher-than-average carbon dioxide content, or
higher-
than-average levels of air pollution (airline travelers, flight attendants,
subjects at
elevated altitudes, subjects living in cities with lower-than average air
quality,
subjects working in enclosed environments where air quality is degraded);
subjects
with lung diseases or lower-than-average lung capacity, such as tubercular
patients,
lung cancer patients, emphysema patients, and cystic fibrosis patients;
subjects
recovering from surgery or illness; elderly subjects, including elderly
subjects
experiencing decreased energy; subjects suffering from chronic fatigue,
including
chronic fatigue syndrome; subjects undergoing acute trauma; subjects in shock;

subjects requiring acute oxygen administration; subjects requiring chronic
oxygen
administration; or other subjects with acute, chronic, or ongoing energy
demands who
can benefit from enhancement of energy biomarkers.
[0592] In another embodiment of the present technology, including any of the
foregoing embodiments, the phenazine-3-one and/or phenothiazine-3-one
derivatives
described herein are administered to subjects suffering from a mitochondrial
disorder
to modulate one or more of various energy biomarkers, including, but not
limited to,
lactic acid (lactate) levels (in one or more of whole blood, plasma,
cerebrospinal fluid,
or cerebral ventricular fluid); pyruvic acid (pyruvate) levels (in one or more
of whole
blood, plasma, cerebrospinal fluid, or cerebral ventricular fluid);
lactate/pyruvate
ratios (in one or more of whole blood, plasma, cerebrospinal fluid, or
cerebral
ventricular fluid); total, reduced or oxidized glutathione levels, or
reduced/oxidized
glutathione ratios (in one or more of whole blood, plasma, lymphocytes,
cerebrospinal
fluid, or cerebral ventricular fluid); total, reduced or oxidized cysteine
levels, or
reduced/oxidized cysteine ratios (in one or more of whole blood, plasma,
lymphocytes, cerebrospinal fluid, or cerebral ventricular fluid);
phosphocreatine
levels; NADH (NADH+H30) or NADPH (NADPH-1-1130 ) levels; NAD or NADP
levels; ATP levels; reduced coenzyme Q (CoQred) levels; oxidized coenzyme Q
(CoQox) levels; total coenzyme Q (CoQtot) levels; oxidized cytochrome C
levels;
reduced cytochrome C levels; oxidized cytochrome C/reduced cytochrome C ratio;

acetoacetate levels; beta-hydroxy butyrate levels; acetoacetate/ beta-hydroxy
butyrate
ratio; 8-hydroxy-2'-deoxyguanosine (8-0HdG) levels; levels of reactive oxygen
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CA 02920272 2016-02-09
species; oxygen consumption (V02), carbon dioxide output (VCO2), respiratory
quotient (VCO2/V02), and to modulate exercise intolerance (or conversely,
modulate
exercise tolerance) and to modulate anaerobic threshold. Energy biomarkers can
be
measured in whole blood, plasma, cerebrospinal fluid, cerebroventricular
fluid,
arterial blood, venous blood, or any other body fluid, body gas, or other
biological
sample useful for such measurement. In one embodiment, the levels are
modulated to
a value within about 2 standard deviations of the value in a healthy subject.
In
another embodiment, the levels are modulated to a value within about 1
standard
deviation of the value in a healthy subject. In another embodiment, the levels
in a
subject are changed by at least about 10% above or below the level in the
subject prior
to modulation. In another embodiment, the levels are changed by at least about
20%
above or below the level in the subject prior to modulation. In another
embodiment,
the levels are changed by at least about 30% above or below the level in the
subject
prior to modulation. In another embodiment, the levels are changed by at least
about
40% above or below the level in the subject prior to modulation. In another
embodiment, the levels are changed by at least about 50% above or below the
level in
the subject prior to modulation. In another embodiment, the levels are changed
by at
least about 75% above or below the level in the subject prior to modulation.
In
another embodiment, the levels are changed by at least about 100% above or at
least
about 90% below the level in the subject prior to modulation.
[0593] Several metabolic biomarkers have already been used to evaluate
efficacy of
C0Q10, and these metabolic biomarkers can be monitored as energy biomarkers
for
use in the methods of the present technology. Pyruvate, a product of the
anaerobic
metabolism of glucose, is removed by reduction to lactic acid in an anaerobic
setting
or by oxidative metabolism, which is dependent on a functional mitochondrial
respiratory chain. Dysfunction of the respiratory chain may lead to inadequate

removal of lactate and pyruvate from the circulation and elevated
lactate/pyruvate
ratios are observed in mitochondrial cytopathies (see Scriver C R, The
Metabolic and
Molecular Bases of Inherited Disease, 7th ed., New York: McGraw-Hill, Health
Professions Division, 1995; and Munnich et al., J. Inherit. Metab. Dis.
15(4):448-55
(1992)). Blood lactate/pyruvate ratio (Chariot et al., Arch. Pathol. Lab. Med.

118(7):695-7 (1994)) is, therefore, widely used as a noninvasive test for
detection of
mitochondrial cytopathies (see again Scriver C R, The Metabolic and Molecular
183

CA 02920272 2016-02-09
Bases of Inherited Disease, 7th ed., New York: McGraw-Hill, Health Professions

Division, 1995; and Munnich et al., J. Inherit. Metab. Dis. 15(4):448-55
(1992)) and
toxic mitochondrial myopathies (Chariot et al., Arthritis Rheum. 37(4):583-6
(1994)).
Changes in the redox state of liver mitochondria can be investigated by
measuring the
arterial ketone body ratio (acetoacetate/3-hydroxybutyrate: AKBR) (Ueda et
al., J.
Cardiol. 29(2):95-102 (1997)). Urinary excretion of 8-hydroxy-2'-
deoxyguanosine
(8-0HdG) often has been used as a biomarker to assess the extent of repair of
ROS-
induced DNA damage in both clinical and occupational settings (Erhola et al.,
FEBS
Lett. 409(2):287-91 (1997); Honda et al., Leuk. Res. 24(6):461-8 (2000);
Pilger etal.,
Free Radic. Res. 35(3):273-80 (2001); Kim et al. Environ Health Perspect
112(6):666-71 (2004)).
[0594] Magnetic resonance spectroscopy (MRS) has been useful in the diagnoses
of
mitochondria' cytopathy by demonstrating elevations in cerebrospinal fluid
(CSF) and
cortical white matter lactate using proton MRS (1H-MRS) (Kaufmann etal.,
Neurology 62(8):1297-302 (2004)). Phosphorous MRS (31P-MRS) has been used to
demonstrate low levels of cortical phosphocreatine (PCr) (Matthews et al.,
Ann.
Neurol. 29(4):435-8 (1991)), and a delay in PCr recovery kinetics following
exercise
in skeletal muscle (Matthews et al., Ann. Neurol. 29(4):435-8 (1991);
Barbiroli et al.,
J. Neurol. 242(7):472-7 (1995); Fabrizi et al., J. Neurol. Sci. 137(1):20-7
(1996)). A
low skeletal muscle PCr has also been confirmed in patients with mitochondrial

cytopathy by direct biochemical measurements.
[0595] Exercise testing is particularly helpful as an evaluation and screening
tool in
mitochondrial myopathies. One of the hallmark characteristics of mitochondrial

myopathies is a reduction in maximal whole body oxygen consumption (V02max)
(Taivassalo et al., Brain 126(Pt 2):413-23 (2003)). Given that VO2max is
determined
by cardiac output (Qc) and peripheral oxygen extraction (arterial-venous total
oxygen
content) difference, some mitochondrial cytopathies affect cardiac function
where
delivery can be altered; however, most mitochondrial myopathies show a
characteristic deficit in peripheral oxygen extraction (A-V02 difference) and
an
enhanced oxygen delivery (hyperkinetic circulation) (Taivassalo et al., Brain
126(Pt
2):413-23 (2003)). This can be demonstrated by a lack of exercise induced
deoxygenation of venous blood with direct AV balance measurements (Taivassalo
et
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CA 02920272 2016-02-09
al., Ann. Neurol. 51(1):38-44 (2002)) and non-invasively by near infrared
spectroscopy (Lynch et al., Muscle Nerve 25(5):664-73 (2002); van Beekvelt et
al.,
Ann. Neurol. 46(4):667-70 (1999)).
[0596] Several of these energy biomarkers are discussed in more detail as
follows.
It should be emphasized that, while certain energy biomarkers are discussed
and
enumerated herein, the present technology is not limited to modulation,
normalization
or enhancement of only these enumerated energy biomarkers.
[0597] Lactic acid (lactate) levels: Mitochondrial dysfunction typically
results in
abnormal levels of lactic acid, as pyruvate levels increase and pyruvate is
converted to
lactate to maintain capacity for glycolysis. Mitochondrial dysfunction can
also result
in abnormal levels of NADH+H30, NADPH+H30, NAD, or NADP, as the reduced
nicotinamide adenine dinucleotides are not efficiently processed by the
respiratory
chain. Lactate levels can be measured by taking samples of appropriate bodily
fluids
such as whole blood, plasma, or cerebrospinal fluid. Using magnetic resonance,

lactate levels can be measured in virtually any volume of the body desired,
such as the
brain.
[0598] Measurement of cerebral lactic acidosis using magnetic resonance in
patients
is described in Kaufmann et al., Neurology 62(8): 1297 (2004). Whole blood,
plasma,
and cerebrospinal fluid lactate levels can be measured by commercially
available
equipment such as the YSI 2300 STAT Plus Glucose & Lactate Analyzer (YSI Life
Sciences, Ohio).
[0599] NAD, NADP, NADH and NADPH levels: Measurement of NAD, NADP,
NADH (NADH+H3 ) or NADPH (NADPH+H3 ) can be measured by a variety of
fluorescent, enzymatic, or electrochemical techniques, e.g., the
electrochemical assay
described in US 2005/0067303.
[0600] Oxygen consumption (v02 or V02), carbon dioxide output (vCO2 or VCO2),
and respiratory quotient (VCO2/V02): v02 is usually measured either while
resting
(resting v02) or at maximal exercise intensity (v02 max). Optimally, both
values will
be measured. However, for severely disabled patients, measurement of v02 max
may
be impractical. Measurement of both forms of v02 is readily accomplished using

standard equipment from a variety of vendors, e.g., Korr Medical Technologies,
Inc.
185

CA 02920272 2016-02-09
(Salt Lake City, Utah). VCO2 can also be readily measured, and the ratio of
VCO2 to
V02 under the same conditions (VCO2/V02, either resting or at maximal exercise

intensity) provides the respiratory quotient (RQ).
[0601] Oxidized Cytochrome C, reduced Cytochrome C, and ratio of oxidized
Cytochrome C to reduced Cytochrome C: Cytochrome C parameters, such as
oxidized
cytochrome C levels (Cyt C0x), reduced cytochrome C levels (Cyt Cred), and the
ratio
of oxidized cytochrome C/reduced cytochrome C ratio (Cyt Cox)/(Cyt Cred), can
be
measured by in vivo near infrared spectroscopy. See, e.g., Rolfe, P., "In vivo
near-
infrared spectroscopy," Annu. Rev. Biomed. Eng. 2:715-54 (2000) and Strangman
et
al., "Non-invasive neuroimaging using near-infrared light" Biol. Psychiatry
52:679-93
(2002).
[0602] Exercise tolerance/Exercise intolerance: Exercise intolerance is
defined as
"the reduced ability to perform activities that involve dynamic movement of
large
skeletal muscles because of symptoms of dyspnea or fatigue" (Pina et al.,
Circulation
107:1210 (2003)). Exercise intolerance is often accompanied by myoglobinuria,
due
to breakdown of muscle tissue and subsequent excretion of muscle myoglobin in
the
urine. Various measures of exercise intolerance can be used, such as time
spent
walking or running on a treadmill before exhaustion, time spent on an exercise
bicycle
(stationary bicycle) before exhaustion, and the like. Treatment with the
compositions
or methods of the present technology can result in about a 10% or greater
improvement in exercise tolerance (for example, about a 10% or greater
increase in
time to exhaustion, e.g., from 10 minutes to 11 minutes), about a 20% or
greater
improvement in exercise tolerance, about a 30% or greater improvement in
exercise
tolerance, about a 40% or greater improvement in exercise tolerance, about a
50% or
greater improvement in exercise tolerance, about a 75% or greater improvement
in
exercise tolerance, or about a 100% or greater improvement in exercise
tolerance.
While exercise tolerance is not, strictly speaking, an energy biomarker, for
the
purposes of the present technology, modulation, normalization, or enhancement
of
energy biomarkers includes modulation, normalization, or enhancement of
exercise
tolerance.
[0603] Similarly, tests for normal and abnormal values of pyruvic acid
(pyruvate)
levels, lactate/pyruvate ratio, ATP levels, anaerobic threshold, reduced
coenzyme Q
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CA 02920272 2016-02-09
(CoQ'd) levels, oxidized coenzyme Q (CoQ") levels, total coenzyme Q (CoQt0t)
levels, oxidized cytochrome C levels, reduced cytochrome C levels, oxidized
cytochrome C/reduced cytochrome C ratio, acetoacetate levels, 13-hydroxy
butyrate
levels, acetoacetate/13-hydroxy butyrate ratio, 8-hydroxy-2'-deoxyguanosine (8-

OHdG) levels, and levels of reactive oxygen species are known in the art and
can be
used to evaluate efficacy of the compositions and methods of the present
technology.
(For the purposes of the present technology, modulation, normalization, or
enhancement of energy biomarkers includes modulation, normalization, or
enhancement of anaerobic threshold.)
[0604] Neuroimaging is indicated in individuals with suspected CNS disease. CT

may show basal ganglia calcification and/or diffuse atrophy. MRI may show
focal
atrophy of the cortex or cerebellum, or high signal change on T2-weighted
images,
particularly in the occipital cortex. There may also be evidence of a
generalized
leukoencephalopathy. Cerebellar atrophy is a prominent feature in children.
[0605] Electroencephalography (EEG) is indicated in individuals with suspected

encephalopathy or seizures. Encephalopathy may be associated with generalized
slow
wave activity on the EEG. Generalized or focal spike and wave discharges may
be
seen in individuals with seizures.
[0606] Peripheral neurophysiologic studies are indicated in individuals with
limb
weakness, sensory symptoms, or areflexia. Electromyography (EMG) is often
normal
but may show myopathic features. Nerve conduction velocity (NCV) may be normal

or may show a predominantly axonal sensorimotor polyneuropathy.
[0607] Magnetic resonance spectroscopy (MRS) and exercise testing (with
measurement of blood concentration of lactate) may be used to detect evidence
of
abnormal mitochondrial function non-invasively.
[0608] Glucose. An elevated concentration of fasting blood glucose may
indicate
diabetes mellitus.
[0609] Cardiac. Both electrocardiography and echocardiography may indicate
cardiac involvement (cardiomyopathy or atrioventricular conduction defects).
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CA 02920272 2016-02-09
[0610] Treatment of a subject afflicted by a mitochondrial disease in
accordance
with the methods of the present technology may result in the inducement of a
reduction or alleviation of symptoms in the subject, e.g., to halt the further

progression of the disorder. Partial or complete suppression of the
mitochondrial
disease can result in a lessening of the severity of one or more of the
symptoms that
the subject would otherwise experience.
[0611] Any one, or any combination of, the energy biomarkers described herein
(e.g., Figure 1) provide conveniently measurable benchmarks by which to gauge
the
effectiveness of treatment or suppressive therapy. Additionally, other energy
biomarkers are known to those skilled in the art and can be monitored to
evaluate the
efficacy of treatment or suppressive therapy.
Modes of Administration and Effective Dosages
[0612] Any method known to those in the art for contacting a cell, organ or
tissue
with a phenazine-3-one or phenothiazine-3-one derivative of the present
technology,
or a pharmaceutically acceptable salt thereof, may be employed. Suitable
methods
include in vitro, ex vivo, or in vivo methods. In vivo methods typically
include the
administration of phenazine-3-one and/or phenothiazine-3-one derivatives, such
as
those described above, to a mammal, suitably a human. When used in vivo for
therapy, the phenazine-3-one and/or phenothiazine-3-one derivatives, or
pharmaceutically acceptable salts thereof, are administered to the subject in
effective
amounts (i.e., amounts that have desired therapeutic effect). The dose and
dosage
regimen will depend upon the degree of the infection in the subject, the
characteristics
of the particular phenazine-3-one or phenothiazine-3-one derivative used,
e.g., its
therapeutic index, the subject, and the subject's history.
[0613] The effective amount may be determined during pre-clinical trials and
clinical trials by methods familiar to physicians and clinicians. An effective
amount
of a phenazine-3-one or phenothiazine-3-one derivative useful in the methods
may be
administered to a mammal in need thereof by any of a number of well-known
methods for administering pharmaceutical compounds. The phenazine-3-one and/or

phenothiazine-3-one derivatives may be administered systemically or locally.
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[0614] The phenazine-3-one or phenothiazine-3-one derivative may be formulated

as a pharmaceutically acceptable salt. The term "pharmaceutically acceptable
salt"
means a salt prepared from a base or an acid which is acceptable for
administration to
a patient, such as a mammal (e.g., salts having acceptable mammalian safety
for a
given dosage regime). However, it is understood that the salts are not
required to be
pharmaceutically acceptable salts, such as salts of intermediate compounds
that are
not intended for administration to a patient. Pharmaceutically acceptable
salts can be
derived from pharmaceutically acceptable inorganic or organic bases and from
pharmaceutically acceptable inorganic or organic acids. In addition, when a
phenazine-3-one or phenothiazine-3-one derivative contains both a basic
moiety, such
as an amine, pyridine or imidazole, and an acidic moiety such as a carboxylic
acid or
tetrazole, zwitterions may be formed and are included within the term "salt"
as used
herein. Salts derived from pharmaceutically acceptable inorganic bases include

ammonium, calcium, copper, ferric, ferrous, lithium, magnesium, manganic,
manganous, potassium, sodium, and zinc salts, and the like. Salts derived from

pharmaceutically acceptable organic bases include salts of primary, secondary
and
tertiary amines, including substituted amines, cyclic amines, naturally-
occurring
amines and the like, such as arginine, betaine, caffeine, choline, N,Ni-
dibenzylethylenediamine, diethylamine, 2-diethylaminoethanol, 2-
dimethylaminoethanol, ethanolamine, ethylenediamine, N-ethylmorpholine, N-
ethylpiperidine, glucamine, glucosamine, histidine, hydrabamine,
isopropylamine,
lysine, methylglucamine, morpholine, piperazine, piperadine, polyamine resins,

procaine, purines, theobromine, triethylamine, trimethylamine, tripropylamine,

tromethamine and the like. Salts derived from pharmaceutically acceptable
inorganic
acids include salts of boric, carbonic, hydrohalic (hydrobromic, hydrochloric,

hydrofluoric or hydroiodic), nitric, phosphoric, sulfamic and sulfuric acids.
Salts
derived from pharmaceutically acceptable organic acids include salts of
aliphatic
hydroxyl acids (e.g., citric, gluconic, glycolic, lactic, lactobionic, malic,
and tartaric
acids), aliphatic monocarboxylic acids (e.g., acetic, butyric, formic,
propionic and
trifluoroacetic acids), amino acids (e.g., aspartic and glutamic acids),
aromatic
carboxylic acids (e.g., benzoic, p-chlorobenzoic, diphenylacetic, gentisic,
hippuric,
and triphenylacetic acids), aromatic hydroxyl acids (e.g., o-hydroxybenzoic, p-

hydroxybenzoic, 1-hydroxynaphthalene-2-carboxylic and 3-hydroxynaphthalene-2-
carboxylic acids), ascorbic, dicarboxylic acids (e.g., fumaric, maleic, oxalic
and
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succinic acids), glucuronic, mandelic, mucic, nicotinic, orotic, pamoic,
pantothenic,
sulfonic acids (e.g., benzenesulfonic, camphosulfonic, edisylic,
ethanesulfonic,
isethionic, methanesulfonic, naphthalenesulfonic, naphthalene-1,5-disulfonic,
naphthalene-2,6-disulfonic and p-toluenesulfonic acids), xinafoic acid, and
the like.
[0615] The phenazine-3-one and/or phenothiazine-3-one derivatives described
herein, or pharmaceutically acceptable salts thereof, can be incorporated into

pharmaceutical compositions for administration, singly or in combination, to a
subject
for the treatment or prevention of a disorder described herein. Such
compositions
typically include the active agent and a pharmaceutically acceptable carrier.
As used
herein the term "pharmaceutically acceptable carrier" includes saline,
solvents,
dispersion media, coatings, antibacterial and antifungal agents, isotonic and
absorption delaying agents, and the like, compatible with pharmaceutical
administration. Supplementary active compounds can also be incorporated into
the
compositions.
[0616] Pharmaceutical compositions are typically formulated to be compatible
with
its intended route of administration. Examples of routes of administration
include
parenteral (e.g., intravenous, intradermal, intraperitoneal or subcutaneous),
oral,
inhalation, intrathecal, transdermal (topical), intraocular, iontophoretic,
and
transmucosal administration. Solutions or suspensions used for parenteral,
intradermal, or subcutaneous application can include the following components:
a
sterile diluent such as water for injection, saline solution, fixed oils,
polyethylene
glycols, glycerine, propylene glycol or other synthetic solvents;
antibacterial agents
such as benzyl alcohol or methyl parabens; antioxidants such as ascorbic acid
or
sodium bisulfite; chelating agents such as ethylenediaminetetraacetic acid;
buffers
such as acetates, citrates or phosphates and agents for the adjustment of
tonicity such
as sodium chloride or dextrose. pH can be adjusted with acids or bases, such
as
hydrochloric acid or sodium hydroxide. The parenteral preparation can be
enclosed in
ampoules, disposable syringes or multiple dose vials made of glass or plastic.
For
convenience of the patient or treating physician, the dosing formulation can
be
provided in a kit containing all necessary equipment (e.g., vials of drug,
vials of
diluent, syringes and needles) for a treatment course (e.g., 7 days of
treatment).
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[0617] Pharmaceutical compositions suitable for injectable use can include
sterile
aqueous solutions (where water soluble) or dispersions and sterile powders for
the
extemporaneous preparation of sterile injectable solutions or dispersion. For
intravenous administration, suitable carriers include physiological saline,
bacteriostatic water, Cremophor ELTM (BASF, Parsippany, N.J.) or phosphate
buffered saline (PBS). In all cases, a composition for parenteral
administration must
be sterile and should be fluid to the extent that easy syringability exists.
It should be
stable under the conditions of manufacture and storage and must be preserved
against
the contaminating action of microorganisms such as bacteria and fungi.
[0618] The phenazine-3-one or phenothiazine-3-one derivative compositions can
include a carrier, which can be a solvent or dispersion medium containing, for

example, water, ethanol, polyol (for example, glycerol, propylene glycol, and
liquid
polyethylene glycol, and the like), and suitable mixtures thereof. The proper
fluidity
can be maintained, for example, by the use of a coating such as lecithin, by
the
maintenance of the required particle size in the case of dispersion and by the
use of
surfactants. Prevention of the action of microorganisms can be achieved by
various
antibacterial and antifungal agents, for example, parabens, chlorobutanol,
phenol,
ascorbic acid, thiomerasol, and the like. Glutathione and other antioxidants
can be
included to prevent oxidation. In some embodiments, the phenazine-3-one or
phenothiazine-3-one derivative compositions include isotonic agents, for
example,
sugars, polyalcohols such as mannitol, sorbitol, or sodium chloride in the
composition. Prolonged absorption of the injectable compositions can be
brought
about by including in the composition an agent that delays absorption, for
example,
aluminum monostearate or gelatin.
[0619] Sterile injectable solutions can be prepared by incorporating the
active
compound in the required amount in an appropriate solvent with one or a
combination
of ingredients enumerated above, as required, followed by filtered
sterilization.
Generally, dispersions are prepared by incorporating the active compound into
a
sterile vehicle, which contains a basic dispersion medium and the required
other
ingredients from those enumerated above. In the case of sterile powders for
the
preparation of sterile injectable solutions, typical methods of preparation
include
vacuum drying and freeze drying, which can yield a powder of the active
ingredient
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CA 02920272 2016-02-09
plus any additional desired ingredient from a previously sterile-filtered
solution
thereof.
[0620] Oral compositions generally include an inert diluent or an edible
carrier. For
the purpose of oral therapeutic administration, the active compound can be
incorporated with excipients and used in the form of tablets, troches, or
capsules, e.g.,
gelatin capsules. Oral compositions can also be prepared using a fluid carrier
for use
as a mouthwash. Pharmaceutically compatible binding agents, and/or adjuvant
materials can be included as part of the composition. The tablets, pills,
capsules,
troches and the like can contain any of the following ingredients, or
compounds of a
similar nature: a binder such as microcrystalline cellulose, gum tragacanth or
gelatin;
an excipient such as starch or lactose, a disintegrating agent such as alginic
acid,
Primogel, or corn starch; a lubricant such as magnesium stearate or Sterotes;
a glidant
such as colloidal silicon dioxide; a sweetening agent such as sucrose or
saccharin; or a
flavoring agent such as peppermint, methyl salicylate, or orange flavoring.
[0621] For administration by inhalation, the compounds can be delivered in the

form of an aerosol spray from a pressurized container or dispenser, which
contains a
suitable propellant, e.g., a gas such as carbon dioxide, or a nebulizer. Such
methods
include those described in U.S. Pat. No. 6,468,798.
[0622] Systemic administration of a therapeutic compound as described herein
can
also be by transmucosal or transdermal means. For transmucosal or transdermal
administration, penetrants appropriate to the barrier to be permeated are used
in the
formulation. Such penetrants are generally known in the art, and include, for
example, for transmucosal administration, detergents, bile salts, and fusidic
acid
derivatives. Transmucosal administration can be accomplished through the use
of
nasal sprays. For transdermal administration, the active compounds are
formulated
into ointments, salves, gels, or creams as generally known in the art. In one
embodiment, transdermal administration may be performed by iontophoresis.
[0623] A therapeutic phenazine-3-one or phenothiazine-3-one derivative can be
formulated in a carrier system. The carrier can be a colloidal system. The
colloidal
system can be a liposome, a phospholipid bilayer vehicle. In one embodiment,
the
therapeutic phenazine-3-one or phenothiazine-3-one derivative is encapsulated
in a
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CA 02920272 2016-02-09
liposome while maintaining its structural integrity. As one skilled in the art
would
appreciate, there are a variety of methods to prepare liposomes. (See
Lichtenberg, et
al., Methods Biochem. Anal., 33:337-462 (1988); Anselem, et al., Liposome
Technology, CRC Press (1993)). Liposomal formulations can delay clearance and
increase cellular uptake (See Reddy, Ann. Pharmacother., 34(7-8):915-923
(2000)).
An active agent can also be loaded into a particle prepared from
pharmaceutically
acceptable ingredients including, but not limited to, soluble, insoluble,
permeable,
impermeable, biodegradable or gastroretentive polymers or liposomes. Such
particles
include, but are not limited to, nanoparticles, biodegradable nanoparticles,
microparticles, biodegradable microparticles, nanospheres, biodegradable
nanospheres, microspheres, biodegradable microspheres, capsules, emulsions,
liposomes, micelles and viral vector systems.
[0624] The carrier can also be a polymer, e.g., a biodegradable, biocompatible

polymer matrix. In one embodiment, the therapeutic phenazine-3-one or
phenothiazine-3-one derivative can be embedded in the polymer matrix, while
maintaining protein integrity. The polymer may be natural, such as
polysaccharides,
or synthetic, such as poly a-hydroxy acids. Examples include carriers made of,
e.g.,
collagen, fibronectin, elastin, cellulose acetate, cellulose nitrate,
polysaccharide,
fibrin, gelatin, and combinations thereof. In one embodiment, the polymer is
poly-
lactic acid (PLA) or copoly lactic/glycolic acid (PGLA). The polymeric
matrices can
be prepared and isolated in a variety of forms and sizes, including
microspheres and
nanospheres. Polymer formulations can lead to prolonged duration of
therapeutic
effect. (See Reddy, Ann. Pharmacother., 34(7-8):915-923 (2000)). A polymer
formulation for human growth hormone (hGH) has been used in clinical trials.
(See
Kozarich and Rich, Chemical Biology, 2:548-552 (1998)).
[0625] Examples of polymer microsphere sustained release formulations are
described in PCT publication WO 99/15154 (Tracy, et al.), U.S. Pat. Nos.
5,674,534
and 5,716,644 (both to Zale, et al.), PCT publication WO 96/40073 (Zale, et
al.), and
PCT publication WO 00/38651 (Shah, et al.). U.S. Pat. Nos. 5,674,534 and
5,716,644
and PCT publication WO 96/40073 describe a polymeric matrix containing
particles
of erythropoietin that are stabilized against aggregation with a salt.
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[0626] In some embodiments, the therapeutic compounds are prepared with
carriers
that will protect the therapeutic compounds against rapid elimination from the
body,
such as a controlled release formulation, including implants and
microencapsulated
delivery systems. Biodegradable, biocompatible polymers can be used, such as
ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen,
polyorthoesters,
and polylactic acid. Such formulations can be prepared using known techniques.
The
materials can also be obtained commercially, e.g., from Alza Corporation and
Nova
Pharmaceuticals, Inc. Liposomal suspensions (including liposomes targeted to
specific cells with monoclonal antibodies to cell-specific antigens) can also
be used as
pharmaceutically acceptable carriers. These can be prepared according to
methods
known to those skilled in the art, for example, as described in U.S. Pat. No.
4,522,811.
[0627] The therapeutic compounds can also be formulated to enhance
intracellular
delivery. For example, liposomal delivery systems are known in the art, see,
e.g.,
Chonn and Cullis, "Recent Advances in Liposome Drug Delivery Systems," Current

Opinion in Biotechnology 6:698-708 (1995); Weiner, "Liposomes for Protein
Delivery: Selecting Manufacture and Development Processes," Immunomethods,
4(3):201-9 (1994); and Gregoriadis, "Engineering Liposomes for Drug Delivery:
Progress and Problems," Trends Biotechnol., 13(12):527-37 (1995). Mizguchi, et
al.,
Cancer Lett., 100:63-69 (1996), describes the use of fusogenic liposomes to
deliver a
protein to cells both in vivo and in vitro.
[0628] Dosage, toxicity and therapeutic efficacy of the therapeutic agents can
be
determined by standard pharmaceutical procedures in cell cultures or
experimental
animals, e.g., for determining the LD50 (the dose lethal to 50% of the
population) and
the ED50 (the dose therapeutically effective in 50% of the population). The
dose
ratio between toxic and therapeutic effects is the therapeutic index and it
can be
expressed as the ratio LD50/ED50. Compounds that exhibit high therapeutic
indices
are preferred. While compounds that exhibit toxic side effects may be used,
care
should be taken to design a delivery system that targets such compounds to the
site of
affected tissue in order to minimize potential damage to uninfected cells and,
thereby,
reduce side effects.
[0629] The data obtained from the cell culture assays and animal studies can
be
used in formulating a range of dosage for use in humans. In some embodiments,
the
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CA 02920272 2016-02-09
dosage of such compounds lies within a range of circulating concentrations
that
include the ED50 with little or no toxicity. The dosage may vary within this
range
depending upon the dosage form employed and the route of administration
utilized.
For any compound used in the methods, the therapeutically effective dose can
be
estimated initially from cell culture assays. A dose can be formulated in
animal
models to achieve a circulating plasma concentration range that includes the
IC50
(i.e., the concentration of the test compound which achieves a half-maximal
inhibition
of symptoms) as determined in cell culture. Such information can be used to
determine useful doses in humans accurately. Levels in plasma may be measured,
for
example, by high performance liquid chromatography.
[0630] Typically, an effective amount of the phenazine-3-one or phenothiazine-
3-
one derivatives, sufficient for achieving a therapeutic or prophylactic
effect, ranges
from about 0.000001 mg per kilogram body weight per day to about 10,000 mg per

kilogram body weight per day. Suitably, the dosage ranges are from about
0.0001 mg
per kilogram body weight per day to about 100 mg per kilogram body weight per
day.
For example dosages can be 1 mg/kg body weight or 10 mg/kg body weight every
day, every two days or every three days or within the range of 1-10 mg/kg
every
week, every two weeks or every three weeks. In one embodiment, a single dosage
of
phenazine-3-one or phenothiazine-3-one derivatives ranges from 0.001-10,000
micrograms per kg body weight. In one embodiment, phenazine-3-one or
phenothiazine-3-one derivative concentrations in a carrier range from 0.2 to
2000
micrograms per delivered milliliter. An exemplary treatment regime entails
administration once per day or once a week. In therapeutic applications, a
relatively
high dosage at relatively short intervals is sometimes required until
progression of the
disease is reduced or terminated, and in certain embodiments, until the
subject shows
partial or complete amelioration of symptoms of disease. Thereafter, the
patient can
be administered a prophylactic regime.
[0631] In some embodiments, a therapeutically effective amount of a phenazine-
3-
one or phenothiazine-3-one derivative may be defined as a concentration of a
phenazine-3-one or phenothiazine-3-one derivative at the target tissue of 10-
12 to 10-6
molar, e.g., approximately 10-7 molar. This concentration may be delivered by
systemic doses of 0.001 to 100 mg/kg or equivalent dose by body surface area.
In
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CA 02920272 2016-02-09
some embodiments, the schedule of doses would be optimized to maintain the
therapeutic concentration at the target tissue, by single daily or weekly
administration,
but also including continuous administration (e.g., parenteral infusion or
transdermal
application).
[0632] The skilled artisan will appreciate that certain factors may influence
the
dosage and timing required to effectively treat a subject, including but not
limited to,
the severity of the disease or disorder, previous treatments, the general
health and/or
age of the subject, and other diseases present. Moreover, treatment of a
subject with a
therapeutically effective amount of the therapeutic compositions described
herein can
include a single treatment or a series of treatments.
[0633] The mammal treated in accordance present methods can be any mammal,
including, for example, farm animals, such as sheep, pigs, cows, and horses;
pet
animals, such as dogs and cats; laboratory animals, such as rats, mice and
rabbits. In
one embodiment, the mammal is a human.
Combination Therapy with Phenazine-3-one and Phenothiazine-3-one Derivatives
and
Other Therapeutic Agents
[0634] In one embodiment, an additional therapeutic agent is administered to a

subject in combination with a phenazine-3-one derivative and/or a
phenothiazine-3-
one derivative of the present technology, such that a synergistic therapeutic
effect is
produced. In one embodiment, the administration of the phenazine-3-one
derivative
and/or phenothiazine-3-one derivative in combination with an additional
therapeutic
agent "primes" the tissue, so that it is more responsive to the therapeutic
effects of one
or more therapeutic agents.
[0635] In any case, the multiple therapeutic agents may be administered in any

order. In some embodiments, the subject is administered multiple therapeutic
agents
simultaneously, separately, or sequentially. If simultaneously, the multiple
therapeutic agents may be provided in a single, unified form, or in multiple
forms (by
way of example only, either as a single pill or as two separate pills). One of
the
therapeutic agents may be given in multiple doses, or both may be given as
multiple
doses. If not simultaneous, the timing between the multiple doses may vary
from
more than zero weeks to less than four weeks. In some embodiments, the
phenazine-
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CA 02920272 2016-02-09
3-one or phenothiazine-3-one derivative, or a pharmaceutically acceptable salt

thereof, is administered prior to or subsequent to additional therapeutic
agent. In
some embodiments, the subject is administered the multiple therapeutic agents
before
the signs, symptoms or complications of a disease or condition are evident. In

addition, the combination methods, compositions and formulations are not to be

limited to the use of only two agents.
[0636] By way of example, but not by way of limitation, the treatment for
mitochondrial diseases or disorders typically involves taking vitamins and
cofactors.
In addition, antibiotics, hormones, antineoplastic agents, steroids,
immunomodulators,
dermatologic drugs, antithrombotic, antianemic, and cardiovascular agents, by
way of
non-limiting example, may also be administered.
[0637] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology are combined with one or more cofactors, vitamins,
iron
chelators, antioxidants, frataxin level modifiers, ACE inhibitors and I3-
blockers. By
way of example, but not by way of limitation, such compounds may include one
or
more of CoQ10, Levocarnitine, riboflavin, acetyl-L-carnitine, thiamine,
nicotinamide,
vitamin E, vitamin C, lipoic acid, selenium, 13-carotene, biotin, folic acid,
calcium,
magnesium, phosphorous, succinate, selenium, creatine, uridine, citratesm
prednisone,
vitamin K, deferoxamine, deferiprone, idebenone, erythropoietin, 1713-
estradiol,
methylene blue, and histone deacetylase inhibitors such as BML-210 and
compound
106.
[0638] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of various anti-oxidant compounds including,
but not
limited to, e.g., parenteral or oral administration of compositions comprising

glycyrrhizin, schisandra, ascorbic acid, L-glutathione, silymarin, lipoic
acid, and D-
alpha-tocopherol (see U.S. Pat. No. 7,078,064, incorporated expressly by
reference
for all purposes).
[0639] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of various anti-oxidant compounds including,
but not
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CA 02920272 2016-02-09
limited to, e.g., parenteral or oral administration of compositions comprising
a water
soluble Vitamin E preparation, mixed carotenoids, or selenium (see U.S. Pat.
No.
6,596,762, incorporated expressly by reference for all purposes).
[0640] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of parenteral or oral administration of
lecithin or
vitamin B complex (see U.S. Pat. Nos. 7,018,652; 6.180,139, incorporated
expressly
by reference for all purposes).
[0641] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of bile salt preparations including, but not
limited to,
e.g., ursodeoxycholic acid, chenodeoxycholic acid of other naturally occurring
or
synthetic bile acids or bile acid salts (see U.S. Pat. No. 6.297,229,
incorporated
expressly by reference for all purposes).
[0642] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a PPAR (peroxisome proliferator-activated
receptor) activity regulators (see U.S. Pat. No. 7,994,353, incorporated
expressly by
reference for all purposes).
[0643] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a benzothiazepine or benzothiepine
compound
represented by the following formula having a thioamide bond and a quaternary
ammonium substituent (see U.S. Pat. No. 7,973.030, incorporated expressly by
reference for all purposes).
[0644] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a mineralocorticoid receptor antagonist,
for
example, but not limited to, spironolactone and eplerenone.
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CA 02920272 2016-02-09
[0645] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a beta-adrenergic antagonist (beta-
blocker), for
example, but not limited to, metoprolol, bisoprolol, carvedilol, atenolol, and

nebivolol.
[0646] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a axacyclopentane derivative that inhibits

stearoyl-coenzyme alpha delta-9 desaturase (see U.S. Pat. No. 7,754,745,
incorporated expressly by reference for all purposes).
[0647] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a acylamide compound having secretagogue
or
inducer activity of adiponectin (see U.S. Pat. No. 7,732,637, incorporated
expressly
herein by reference for all purposes).
[0648] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of quaternary ammonium compounds (see U.S.
Pat.
No. 7,312,208, incorporated expressly by reference for all purposes).
[0649] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of an isoflavone compound (see U.S. Pat. No.
6,592,910, incorporated expressly by reference for all purposes).
[0650] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a macrolide antibiotic (see U.S. Pat. No.
5,760,010, incorporated expressly by reference for all purposes).
[0651] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of carnitine.
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[0652] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a statin, for example, but not limited to,
HMG-
CoA reductase inhibitors such as atorvastatin and simvastatin.
[0653] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of an N-acetyl cysteine.
[0654] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of another galectin inhibitor that may
inhibit a single
galectin protein or multiple galectin proteins, including, but not limited to,
e.g., small
organic inhibitors of galectin, monoclonal antibodies, RNA inhibitors, or
protein
inhibitors.
[0655] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a monoclonal antibody to inhibit lysyl
oxidase or
monoclonal antibody that binds to connective tissue growth factor.
[0656] In another embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of pentraxin proteins, including, but not
limited to,
e.g., recombinant pentraxin-2.
[0657] In another embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of an angiotensin receptor blocker (ARB) or
an
angiotensin-converting enzyme (ACE) inhibitor.
[0658] In another embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a cGMP activating compound.
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CA 02920272 2016-02-09
[0659] In another embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a calcium channel blocker, for example,
but not
limited to, verapamil.
[0660] In another embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a phosphodiesterase 5 inhibitor, for
example, but
not limited to, sildenafil, tadalafil, or vardenafil.
[0661] In some embodiments phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with a
therapeutically effective amount of a diuretic.
[0662] In some embodiments, phenazine-3-one and/or phenothiazine-3-one
derivatives of the present technology can be used in combination with one or
more
additional agents selected from the group consisting of diuretics, ACE
inhibitors,
digoxin (also called digitalis), calcium channel blockers, and beta-blockers.
In some
embodiments, thiazide diuretics, such as hydrochlorothiazide at 25-50 mg/day
or
chlorothiazide at 250-500 mg/day, can be used. However, supplemental potassium

chloride may be needed, since chronic diuresis causes hypokalemis alkalosis.
Typical
doses of ACE inhibitors include captopril at 25-50 mg/day and quinapril at 10
mg/day.
[0663] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology can be used in combination with an adrenergic beta-2

agonist. An "adrenergic beta-2 agonist" refers to adrenergic beta-2 agonists
and
analogues and derivatives thereof, including, for example, natural or
synthetic
functional variants which have adrenergic beta-2 agonist biological activity,
as well as
fragments of an adrenergic beta-2 agonist having adrenergic beta-2 agonist
biological
activity. The term "adrenergic beta-2 agonist biological activity" refers to
activity
that mimics the effects of adrenaline and noradrenaline in a subject and which

improves myocardial contractility in a patient having heart failure. Commonly
known
adrenergic beta-2 agonists include, but are not limited to, e.g., clenbuterol,
albuterol,
formeoterol, levalbuterol, metaproterenol, pirbuterol, salmeterol, and
terbutaline.
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[0664] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology can be used in combination with an adrenergic beta-1

antagonist. Adrenergic beta-1 antagonists and adrenergic beta-1 blockers refer
to
adrenergic beta-1 antagonists and analogues and derivatives thereof,
including, for
example, natural or synthetic functional variants which have adrenergic beta-1

antagonist biological activity, as well as fragments of an adrenergic beta-1
antagonist
having adrenergic beta-1 antagonist biological activity. Adrenergic beta-1
antagonist
biological activity refers to activity that blocks the effects of adrenaline
on beta
receptors. Commonly known adrenergic beta-1 antagonists include, but are not
limited to, acebutolol, atenolol, betaxolol, bisoprolol, esmolol, and
metoprolol.
[0665] Clenbuterol, for example, is available under numerous brand names
including Spiropent (Boehinger Ingelheim), Broncodil (Von Boch I),
Broncoterol (Quimedical PT), Cesbron (Fidelis PT), and Clenbuter (Biomedica

Foscama). Similarly, methods of preparing adrenergic beta-1 antagonists such
as
metoprolol and their analogues and derivatives are well-known in the art.
Metoprolol,
in particular, is commercially available under the brand names Lopressor
(metoprolol tartate) manufactured by Novartis Pharmaceuticals Corporation, One

Health Plaza, East Hanover, N.J. 07936-1080. Generic versions of Lopressor
are
also available from MyIan Laboratories Inc., 1500 Corporate Drive, Suite 400,
Canonsburg, Pa. 15317; and Watson Pharmaceuticals, Inc., 360 Mt. Kemble Ave.
Morristown, N.J. 07962. Metoprolol is also commercially available under the
brand
name Toprol XL , manufactured by Astra Zeneca, LP.
[0666] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology may be combined with one or more additional
therapies for
the prevention or treatment of porphyria. Treatment for acute attacks of
hepatic
porphyria typically comprise, but are not limited to, the use of narcotic
analgesics
(e.g., for abdominal pain), phenothiazines (e.g., for nausea, vomiting,
anxiety, and
restlessness), chloral hydrate (e.g., for insomnia), short-acting
benzodiazepines (e.g.,
for insomnia), carbohydrate loading, intravenous hemin (e.g., lyophilized
hematin,
heme albumin, and heme arginate), allogenic liver transplantation, and liver-
directed
gene therapy. Treatment for porphyria cutanea tarda typically comprises, but
is not
limited to, discontinuing risk factors (e.g., alcohol, estrogens, iron
supplements),
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phlebotomy, and low-dose regimens of chloroquine or hydroxychloroquine.
Treatment for erythropoietic cutaneous porphyrias typically comprise, but is
not
limited to, chronic transfusions (e.g., for anemia), protection from sunlight,
treatment
of complicating bacterial infections, and bone marrow and cord blood
transplantation.
Treatment for EPP and XLP typically comprise, but is not limited to, sunlight
avoidance, oral 13-carotene, administration of an a-melanocyte stimulating
hormone
analog, administration of cholestyramine and other porphyrin absorbents (e.g.,

activated charcoal), plasmapheresis, intravenous hemin, and liver
transplantation.
[0667] In some embodiments, the phenazine-3-one and/or phenothiazine-3-one
derivatives may be combined with one or more narcotic analgesics,
phenothiazines,
chloral hydrate, benzodiazepines, hemin, chloroquine, hydroxychloroquine, 13-
carotene, a-melanocyte stimulating hormone, cholestyramine, or activated
charcoal,
such that a synergistic effect in the prevention or treatment of porphyria
results.
[0668] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology may be combined with one or more additional
therapies for
the prevention or treatment of Alport Syndrome. Treatment for Alport Syndrome
typically comprises, but are not limited to, the use of ACE inhibitors, ARBs,
HMG-
CoA reductase inhibitors, aldosterone inhibitors, aliskiren, calcineurin
inhibitors (e.g.,
cyclosporine A, tacrolimus), endothelin receptor antagonists (e.g.,
sitaxentan,
ambrisentan (LETAIRIS), atrasentan, BQ-123, zibotentan, bosentan (TRACLEER),
macitentan, tezosentan, BQ-788 and A192621), sulodexide, vasopeptidase
inhibitors
(e.g., AVE7688), anti-transforming growth factor-I31 antibody, chemokine
receptor 1
blockers, bone morphogenetic protein-7, PPARy agonists (e.g., rosiglitazone,
pioglitazone, MRL24, Fmoc-L -Leu, SR1664, SR1824, GW0072, MCC555, CLX-
0921, PAT5A, L-764406, nTZDpa, CDDO (2-cyano-3,12-dioxooleana-1,9-dien-28-
oic acid), ragaglitazar, 0-arylmandelic acids, and NSAIDs) and BAY-12-9566.
[0669] In some embodiments, the ACE inhibitors are selected from the group
consisting of captopril, alacepril, lisinopril, imidapril, quinapril,
temocapril, delapril,
benazepril, cilazapril, trandolapril, enalapril, ceronapril, fosinopril,
imadapril,
mobertpril, perindopril, ramipril, spirapril, randolapril and pharmaceutically

acceptable salts of such compounds.
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[0670] In some embodiments, the ARBs are selected from the group consisting of

losartan, candesartan, valsartan, eprosartan, telmisartan, and irbesartan.
[0671] In some embodiments, the HMG-CoA reductase inhibitors (or statins) are
selected from the group consisting of lovastatin (e.g., ADVICOR (niacin
extended-
release/lovastatin) (AbbVie Pharmaceuticals, Chicago, Illinois), ALTOPREVTm
(lovastatin extended-release) (Shiongi, Inc., Atlanta, GA), MEVACOR (Merck,
Whitehouse Station, NJ), atorvastatin (e.g., CADUET (amlodipine and
atorvastatin)
(Pfizer, Morrisville, PA), LIPITOR (Pfizer, Morrisville, PA)), rosuvastatin
and/or
rosuvastatin calcium (e.g., CRESTOR (AstraZeneca, London, England)),
simvastatin
(e.g., JUVISYNC (sitagliptin/simvastatin) (Merck, Whitehouse Station, NJ)),
SIMCOR (niacin extended-release/simvastatin) (AbbVie Pharmaceuticals,
Chicago,
Illinois), VYTORIN (ezetimibe/simvastatin) (Merck, Whitehouse Station, NJ),
and
ZOCOR (Merck, Whitehouse Station, NJ)), fluvastatin and/or fluvastatin sodium

(e.g., LESCOL , LESCOL XL (fluvastatin extended-release) (Mylan
Pharmaceuticals, Morgantown, WV)), pitavastatin (e.g., LIVALO (Kowa
Pharmaceuticals, Montgomery, AL)), pravastatin and pravastatin sodium (e.g.,
PRAVACHOL (Bristol-Myers Squibb, New York, NY)).
[0672] In some embodiments, the aldosterone inhibitors are selected from the
group
consisting of spironolactone (Aldactone ), eplerenone (Inspral0),
canrenone (canrenoate potassium), prorenone (prorenoate potassium), and
mexrenone (mexrenoate potassium).
[0673] In some embodiments, the phenazine-3-one and/or phenothiazine-3-one
derivatives may be combined with one or more ACE inhibitors, ARBs, HMG-CoA
reductase inhibitors, aldosterone inhibitors, aliskiren, calcineurin
inhibitors (e.g.,
cyclosporine A, tacrolimus), endothelin receptor antagonists (e.g.,
sitaxentan,
ambrisentan (LETAIRIS), atrasentan, BQ-123, zibotentan, bosentan (TRACLEER),
macitentan, tezosentan, BQ-788 and A192621), sulodexide, vasopeptidase
inhibitors
(e.g., AVE7688), anti-transforming growth factor-01 antibody, chemokine
receptor 1
blockers, bone morphogenetic protein-7, PPARy agonists (e.g., rosiglitazone,
pioglitazone, MRL24, Fmoc-L -Leu, SR1664, SR1824, GW0072, MCC555, CLX-
0921, PAT5A, L-764406, nTZDpa, CDDO (2-cyano-3,12-dioxooleana-1,9-dien-28-
oic acid), ragaglitazar, 0-arylmandelic acids, and NSAIDs) and/or BAY-12-9566,
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CA 02920272 2016-02-09
such that a synergistic effect in the prevention or treatment of Alport
Syndrome
results.
[0674] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology may be combined with one or more additional
therapies for
the prevention or treatment of vitiligo. Treatment for vitiligo typically
comprises, but
is not limited to, the use of topical steroid creams, monobenzone,
antibiotics,
vitamins, hormones, immunomodulators, dermatologic drugs, or administering
psoralen photochemotherapy. In some embodiments, the phenazine-3-one and/or
phenothiazine-3-one derivatives may be combined with one or more topical
steroid
creams, monobenzone, antibiotics, vitamins, hormones, immunomodulators,
dermatologic drugs, psoralen photochemotherapy, such that a synergistic effect
in the
prevention or treatment of vitiligo results.
[0675] In one embodiment, phenazine-3-one and/or phenothiazine-3-one
derivatives
of the present technology may be combined with one or more additional
therapies for
the prevention or treatment of 1PF. Additional therapies include, but are not
limited
to, oral corticosteroids, azathioprine, N-acetylcysteine, soluble human TNF
receptor,
interferon-y lb therapy, endothelin receptor antagonists, phosphodiesterase
inhibitors,
tyrosine kinase inhibitors, antifibrotic agents, colchicine, and
anticoagulants.
EXAMPLES
[0676] The present technology is further illustrated by the following
examples,
which should not be construed as limiting in any way.
Example 1 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in the

Treatment of Porphyria
[0677] This Example demonstrates the use of phenazine-3-one and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
in the
treatment of porphyria.
[0678] Subjects suspected of having or diagnosed as having porphyria receive
daily
administrations of a therapeutically effective amount of phenazine-3-one
and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
alone
or in combination with one or more additional agents for the treatment or
prevention
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CA 02920272 2016-02-09
of porphyria. Phenazine-3-one and/or phenothiazine-3-one derivatives and/or
additional agents are administered orally, intranasally, intrathecally,
intraocularly,
intradermally, transmucosally, iontophoretically, topically, systemically,
intravenously, subcutaneously, intraperitoneally, or intramuscularly according
to
methods known in the art. Subjects will be evaluated weekly for the presence
and/or
severity of signs and symptoms associated with porphyria, including, but not
limited
to, e.g., cutaneous lesions, blistering skin lesions, hypertrichosis,
hyperpigmentation,
thickening and/or scarring of the skin, friability of the skin,
photosensitivity of the
skin, lichenification, leathery pseudovesicles, labial grooving, nail changes,
life
threatening acute neurological attacks, abdominal pain and cramping,
constipation,
diarrhea, increased bowel sounds, decreased bowel sounds, nausea, vomiting,
tachycardia, hypertension, headache, mental symptoms, extremity pain, neck
pain,
chest pain, muscle weakness, sensory loss, tremors, sweating, dysuria, and
bladder
distension. Treatments are maintained until such a time as one or more signs
or
symptoms of porphyria are ameliorated or eliminated.
[0679] It is predicted that subjects suspected of having or diagnosed as
having
porphyria and receiving therapeutically effective amounts of phenazine-3-one
and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
will
display reduced severity or elimination of one or more symptoms associated
with
porphyria. It is further expected that administration of phenazine-3-one
and/or
phenothiazine-3-one derivatives in combination with one or more additional
agents
will have synergistic effects in this regard.
[0680] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives, or pharmaceutically acceptable salts thereof, are useful in the
treatment of
porphyria. Accordingly, the phenazine-3-one and/or phenothiazine-3-one
derivatives
are useful in methods comprising administering phenazine-3-one and/or
phenothiazine-3-one derivatives to a subject in need thereof for the treatment
of
porphyria.
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Example 2 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in the

Prevention of Porphyria
[0681] This Example demonstrates the use of phenazine-3-one and/or
phenothiazine-3-one derivatives or pharmaceutically acceptable salts thereof,
in the
prevention of porphyria.
[0682] Subjects at risk of having porphyria receive daily administrations of a

therapeutically effective amount of phenazine-3-one and/or phenothiazine-3-one

derivatives, or pharmaceutically acceptable salts thereof, alone or in
combination with
one or more additional agents for the treatment or prevention of porphyria.
Phenazine-3-one and/or phenothiazine-3-one derivatives and/or additional
agents are
administered orally, intranasally, intrathecally, intraocularly,
intradermally,
transmucosally, iontophoretically, topically, systemically, intravenously,
subcutaneously, intraperitoneally, or intramuscularly according to methods
known in
the art. Subjects will be evaluated weekly for the presence and/or severity of
signs
and symptoms associated with porphyria, including, but not limited to, e.g.,
cutaneous
lesions, blistering skin lesions, hypertrichosis, hyperpigmentation,
thickening and/or
scarring of the skin, friability of the skin, photosensitivity of the skin,
lichenification,
leathery pseudovesicles, labial grooving, nail changes, life threatening acute

neurological attacks, abdominal pain and cramping, constipation, diarrhea,
increased
bowel sounds, decreased bowel sounds, nausea, vomiting, tachycardia,
hypertension,
headache, mental symptoms, extremity pain, neck pain, chest pain, muscle
weakness,
sensory loss, tremors, sweating, dysuria, and bladder distension.
[0683] It is predicted that subjects at risk of having or diagnosed as having
porphyria and receiving therapeutically effective amounts of phenazine-3-one
and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
will
display delayed onset of porphyria, or prevention of onset of porphyria. It is
further
expected that administration of phenazine-3-one and/or phenothiazine-3-one
derivatives in combination with one or more additional agents will have
synergistic
effects in this regard.
[0684] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives or pharmaceutically acceptable salts thereof, are useful in the
prevention
of porphyria. Accordingly, the phenazine-3-one and/or phenothiazine-3-one
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CA 02920272 2016-02-09
derivatives are useful in methods comprising administering phenazine-3-one
and/or
phenothiazine-3-one derivatives to a subject in need thereof for the
prevention of
porphyria.
Example 3 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Treating IPF
[0685] TGF-/3]-adenovirus induced lung fibrosis: TGF-131 adenovirus (Ad-TGF-
131) or control virus (Ad-DL) is prepared and treated as previously described
in Sime
et al., J Clin Invest 100:768-776 (1997). Ad-TGF-131 refers to porcine TGF-131

adenovirus (Ad-TGFP 1223/225), an adenovirus construct containing a mutation
of
cysteine to serine at positions 223 and 225, rendering the expressed TGF-fll
biologically active. This virus expresses active TGF-131 in the lung over a
period of 7
to 14 days and produces extensive and progressive fibrosis in rats and mice.
C57/B6
mice will receive 2 x 108 PFU virus in 50 ilL sterile saline intratracheally
and will be
treated with saline; or phenazine-3-one and/or phenothiazine-3-one
derivatives. Mice
are culled 5 or 14 days post instillation.
[0686] Determination of lung fibrosis and inflammation: Collagen content in
the left
lung is determined by sircol assay as per manufacturer's instructions.
Histological
lung inflammation and fibrosis score is carried out in Masson's trichrome
stained
sections.
[0687] Isolation of murine primary lung fibroblasts and primary type II
alveolar
epithelial cells: Primary cultures of lung fibroblasts are isolated by
collagenase
digestion (0.5 mg/ml for 1 hour at 37 C) of minced lungs and digests passed
through a
100-[tm cell strainer. Cells are cultured in DMEM containing 10% FCS for 4
days
until confluent. Lung fibroblasts are used at passage 2. Lung alveolar
epithelial cells
(AECs) are extracted following the method originally described by Corti et
al., Am J
Respir Cell Mol Biol 14:309-315 (1996). Immunofluorescence is carried out
using
the following primary antibodies: mouse monoclonal anti-a-SMA clone 1A4
(Sigma,
Poole, UK), rabbit anti-mouse collagen 1 and mouse anti-active (ABC)13-catenin

(Millipore).
[0688] Results: It is expected that intratracheal administration of adenoviral
TGF-
131 (Ad-TGF-I31) in saline-treated mice will stimulate the formation of
fibroblast foci,
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whereas mice treated with the Ad-DL control virus will not exhibit pulmonary
fibrosis. Additionally, AECs from saline-treated Ad-TGF-131 mice will show an
increase in u-SMA and collagen-1 expression levels compared to that observed
in
AECs isolated from Ad-DL infected mice. It is also anticipated that Ad-TGF-
131
mice treated with the phenazine-3-one and/or phenothiazine-3-one derivatives
will
show a decrease in lung fibrosis and/or reduced collagen-1 and ct-SMA levels
compared to Ad-TGF-I31 mice treated with saline only.
[0689] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology are useful in treating IPF in mammalian
subjects.
Example 4¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives to
Reduce
Tumor Growth
[0690] This Example will demonstrate use of the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology to reduce the growth
rate of
implanted tumors.
[0691] A standard panel of 12 tumor cell lines will be used for the hollow
fiber
screening of the phenazine-3-one and/or phenothiazine-3-one derivatives. These

include NCI-H23, NCI-H522, MDA-MB-231, MDA-MB-435, SW-620, COLO 205,
LOX, UACC-62, OVCAR-3, OVCAR-5, U251 and SF-295. The cell lines are
cultivated in RPMI-1640 containing 10% FBS and 2 mM glutamine. On the day
preceding hollow fiber preparation, the cells are given a supplementation of
fresh
medium to maintain log phase growth. For fiber preparation, the cells are
harvested
by standard trypsinization technique and resuspended at the desired cell
density (2-10
x 106 cells/mL). The cell suspension is then flushed into 1 mm (internal
diameter)
polyvinylidene fluoride hollow fibers with a molecular weight exclusion of
500,000
Da. The hollow fibers are heat-sealed at 2 cm intervals and the samples
generated
from these seals are placed into tissue culture medium and incubated at 37 in
5% CO2
for 24-48 hours prior to implantation. A total of 3 different tumor lines are
prepared
for each experiment so that each mouse receives 3 intraperitoneal implants (1
of each
tumor line) and 3 subcutaneous implants (1 of each tumor line). On the day of
implantation, samples of each tumor cell line preparation are quantitated for
viable
cell mass by a stable endpoint MTT assay so that the time zero cell mass is
known.
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Mice are treated with vehicle or phenazine-3-one and/or phenothiazine-3-one
derivatives starting on day 3 or 4 following fiber implantation and continuing
daily
for 4 days. Control animals receive the tumor implants and are treated with
only the
empty vehicle. The therapeutic compositions are administered by
intraperitoneal
injection at 2 dose levels. The doses are based on the maximum tolerated dose
(MTD) determined during prior toxicity testing. The fibers are collected from
the
mice on the day following the fourth compound treatment and subjected to the
stable
endpoint MTT assay. The optical density of each implanted tumor sample is
determined spectrophotometrically at 540 nm and the mean of each treatment
group is
calculated. The percent net growth for each cell line in each treatment group
is
calculated and compared to the percent net growth in the vehicle treated
controls. A
50% or greater reduction in percent net growth in the treated samples compared
to the
vehicle control samples is considered a positive result. Each positive result
is given a
score of 2 and all of the scores are totaled for a given phenazine-3-one or
phenothiazine-3-one derivative. The maximum possible score for an agent is 96
(12
cell lines X 2 sites X 2 dose levels X 2 [score]). A compound is considered
for
xenograft testing if it has a combined ip + sc score of 20 or greater, a sc
score of 8 or
greater, or produces cell kill of any cell line at either dose level
evaluated.
[0692] Results: It is expected that vehicle treated controls will show an
increase in
tumor net growth after 4 days. It is also anticipated that treatment with the
phenazine-
3-one and/or phenothiazine-3-one derivatives will result in significantly
reduced
tumor net growth compared to vehicle treated controls.
[0693] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for reducing tumor
growth
in mammalian subjects. The results will show that the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology are generally useful
in
treating a neoplastic disease.
Example 5 ¨ Phenazine-3-one and Phenothiazine-3-one Derivatives Inhibit HUVEC

Cell Migration
[0694] Chemotaxis is an integral part of angiogenesis, and this Example
demonstrates the effect of phenazine-3-one and/or phenothiazine-3-one
derivatives of
the present technology in inhibiting angiogenesis.
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CA 02920272 2016-02-09
[0695] In the first portion of the experimental series, the effect of the
chemoattractant vascular endothelial growth factor (VEGF) on human umbilical
vein
endothelial cells (HUVEC) is quantified. The experiment is carried out in a
transwell
plate, and in preparation therefor, HUVEC cells are grown to approximately 80%

confluency. The cells are suspended in basal media and placed in a transwell
plate on
fibronectin coated membrane inserts at 50,000 cells per insert. Varying
concentrations of VEGF are added to the bottom chamber of the transwell plate,
and
the plates are incubated for 4 hours at 37 C with a 5% CO2 atmosphere.
Following
incubation, the membranes are fixed and stained. Nonmigrated cells are removed
by
mechanical abrasion and cells that migrate through the membrane are counted.
[0696] It is anticipated that VEGF will act as a chemotactic agent that
induces cell
migration, a process that is crucial to angiogenesis. Specifically, it is
expected that
certain VEGF concentrations will produce a strong chemotactic effect.
[0697] In the second portion of the experiment, the effect of phenazine-3-one
and/or
phenothiazine-3-one derivatives in moderating chemotaxis, and hence
angiogenesis,
will be evaluated.
[0698] In this experimental series, HUVEC cells are incubated in a transwell
plate
with 30 ng/ml VEGF, and varying concentrations of the phenazine-3-one and/or
phenothiazine-3-one derivatives, under experimental conditions as described
above.
Group A cells will be incubated with VEGF only (positive control); Group B
cells
will be incubated with VEGF and a phenazine-3-one derivative and/or a
phenothiazine-3-one derivative; Group C will be incubated with VEGF-deficient
growth medium only (negative control).
[0699] It is anticipated that cells incubated with VEGF alone will show an
increase
in cell migration compared to cells incubated with VEGF-deficient growth
medium.
It is also anticipated that the cells treated with phenazine-3-one and/or
phenothiazine-
3-one derivatives will show a decrease in VEGF-mediated cell migration
compared to
the Group A positive control cells.
[0700] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology are useful as potent inhibitors of the
angiogenic
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process, and as such will have utility in the treatment of diseases in which
angiogenesis is a factor.
Example 6 ¨ Therapeutic Effects of Phenazine-3-one and Phenothiazine-3-one
Derivatives on 4-tertiary Butyl Phenol (4-TBP)-induced Cytotoxicity and
Apoptosis
in Melanocytes
[0701] This Example will demonstrate the therapeutic effect of phenazine-3-one

and/or phenothiazine-3-one derivatives on 4-TBP-induced vitiligo.
[0702] Melanocytes are cultured and treated with 4-TBP to induce vitiligo
according to the procedures described in Yang 8z Boissy, Pigment Cell
Research,
12:237-245 (1999). The experimental group of melanocytes is treated with 1-
1011g
of phenazine-3-one and/or phenothiazine-3-one derivatives after exposure to 4-
TBP.
The control melanocyte group is exposed to 4-TBP only.
[0703] It is anticipated that untreated melanocytes will exhibit high levels
of
cytotoxicity and apoptosis following exposure to 4-TBP (Vitiligo control)
compared
to melanocytes that are not exposed to 4-TBP (Normal). However, it is
anticipated
that melanocytes treated with phenazine-3-one and/or phenothiazine-3-one
derivatives
will show cell survival rates that are similar to normal melanocytes that are
not
exposed to 4-TBP and greater than untreated melanocytes following 4-TBP
exposure.
[0704] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology, or pharmaceutically acceptable salts
thereof, are
useful in treating apoptosis and cytotoxicity associated with chemically-
induced
vitiligo. Accordingly, the phenazine-3-one and/or phenothiazine-3-one
derivatives of
the present technology, are useful in treating, or ameliorating melanocyte
degeneration and depigmentation observed in a subject suffering from or
predisposed
to vitiligo.
Example 7 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in the
Treatment of Alport Syndrome in Humans
[0705] This Example demonstrates the use of phenazine-3-one and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
in the
treatment of Alport Syndrome.
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[0706] Subjects suspected of having or diagnosed as having Alport Syndrome
receive daily administrations of 1%, 5% or 10% solution of phenazine-3-one
and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
alone
or in combination with one or more additional agents for the treatment or
prevention
of Alport Syndrome. Phenazine-3-one and/or phenothiazine-3-one derivatives
and/or
additional agents are administered orally, intranasally, intrathecally,
intraocularly,
intradermally, transmucosally, iontophoretically, topically, systemically,
intravenously, subcutaneously, intraperitoneally, or intramuscularly according
to
methods known in the art. Subjects will be evaluated weekly for the presence
and/or
severity of signs and symptoms associated with Alport Syndrome, including, but
not
limited to, e.g., hematuria, proteinuria, cylindruria, leukocyturia,
hypertension, edema,
microalbuminuria, declining glomerular filtration rate, fibrosis, Glomerular
Basement
Membrane (GBM) ultrastructural abnormalities, nephrotic syndrome,
glomerulonephritis, end-stage kidney disease, chronic anemia,
macrothrombocytopenia, osteodystrophy, sensorineural deafness, anterior
lenticonus,
dot-and-fleck retinopathy, posterior polymorphous corneal dystrophy, recurrent

corneal erosion, temporal macular thinning, cataracts, lacrimation,
photophobia,
vision loss, keratoconus, and leiomyomatosis. Treatments are maintained until
such a
time as one or more signs or symptoms of Alport Syndrome are ameliorated or
eliminated.
[0707] It is predicted that subjects suspected of having or diagnosed as
having
Alport Syndrome and receiving therapeutically effective amounts of phenazine-3-
one
and/or phenothiazine-3-one derivatives, or pharmaceutically acceptable salts
thereof,
will display reduced severity or elimination of one or more symptoms
associated with
Alport Syndrome. It is also expected that Alport Syndrome subjects treated
with the
phenazine-3-one and/or phenothiazine-3-one derivatives will show normalization
of
one or more of ADAM8, fibronectin, myosin 10, MMP-2, MMP-9, and podocin urine
levels by at least 10% compared to the untreated Alport Syndrome controls. It
is
further expected that administration of phenazine-3-one and/or phenothiazine-3-
one
derivatives in combination with one or more additional agents will have
synergistic
effects in this regard compared to that observed in subjects treated with the
phenazine-3-one and/or phenothiazine-3-one derivatives or the additional
agents
alone.
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[0708] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives, or pharmaceutically acceptable salts thereof, are useful in the
treatment of
Alport Syndrome. These results will show that phenazine-3-one and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
are
useful in ameliorating one or more of the following symptoms: hematuria,
proteinuria,
cylindruria, leukocyturia, hypertension, edema, microalbuminuria, declining
glomerular filtration rate, fibrosis, GBM ultrastructural abnormalities,
nephrotic
syndrome, glomerulonephritis, end-stage kidney disease, chronic anemia,
macrothrombocytopenia, osteodystrophy, sensorineural deafness, anterior
lenticonus,
dot-and-fleck retinopathy, posterior polymorphous corneal dystrophy, recurrent

corneal erosion, temporal macular thinning, cataracts, lacrimation,
photophobia,
vision loss, keratoconus, and leiomyomatosis. Accordingly, the phenazine-3-one

and/or phenothiazine-3-one derivatives are useful in methods comprising
administering phenazine-3-one and/or phenothiazine-3-one derivatives to a
subject in
need thereof for the treatment of Alport Syndrome.
Example 8 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in the

Prevention of Leber's Hereditary Optic Neuropathy (LHON) in a Mouse Model
[0709] This Example will demonstrate the use of phenazine-3-one and/or
phenothiazine-3-one derivatives in the prevention of Leber's Hereditary Optic
Neuropathy in a mouse model.
[0710] Marine Model. This Example uses the murine model of LHON previously
described by Lin et al., Proc. Natl. Acad. Sci. 109(49):20065-20070 (2012).
The
animals harbor an ND6 P25L mutation. The LT13 cell line corresponds to the ND6

P25L mutant fibroblast line used for mouse embryonic stem cell fusions.
[0711] Mice harboring the ND6 P25L mutation are administered 1-10 [tg of
phenazine-3-one and/or phenothiazine-3-one derivatives, or saline vehicle
(control)
subcutaneously once daily from 0-14 months of age. Various aspects of LHON are

assessed in treatment and control animals at 14 and 24 months of age, with the
ND6
P25L compared to wild-type mice for each parameter measured.
[0712] It is expected that administration of phenazine-3-one and/or
phenothiazine-3-
one derivatives once daily from 0-14 months of age will prevent the onset of,
delay
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the onset of, and/or reduce the severity of the effects of the ND6 P25L
mutation,
thereby preventing LHON in ND6 P25L mutant mice.
[0713] Reduced Retinal Response. The ND6 P25L mice are examined for ocular
function by electroretinogram beginning at 14 months of age. It is expected
that the
animals will show a significant deficit in nearly all parameters examined. The

scotopic B wave of dark-adapted ND6 P25L eyes is expected to be reduced in
amplitude by approximately 25.5% and approximately 33.1% with 0.01 and 1
cd=s/m2
(maximum) stimulations. The scotopic A-wave of ND6 P25L mutant eyes is
expected to show approximately a 23% reduction. The scotopic oscillatory
potentials
(OPs), a high-frequency response derived from multiple retinal cell types, are

expected to show approximately a 20.7% and approximately a 21.7% reduction
with
0.01 and 1 cd- s/m2 stimulations. Photopic B-wave ERG amplitude, measuring
cone
functions, is expected to be decreased approximately 17.7%. There is further
expected a trend toward increased latencies to the A and B waves. Despite the
functional deficit observed in the ERGs, it is expected that the ND6 P25L
mutants
will not exhibit reduced visual responses, as assessed by optokinetic
analysis.
[0714] It is expected that administration of phenazine-3-one and/or
phenothiazine-3-
one derivatives once daily from 0-14 months of age will prevent the onset of,
delay
the onset of, and/or reduce the severity of these effects of the ND6 P25L
mutation,
thereby preventing these aspects of LHON in ND6 P25L mutant mice.
[0715] RGC Axonal Swelling and Preferential Loss of Smallest Fibers. Electron
microscopic analysis of RGC axons is expected to reveal that ND6 P25L mutants
exhibit axonal swelling in the optic nerve. The average axonal diameter is
expected
to be approximately 0.67 [km in wild-type and approximately 0.80 itm in ND6
P25L
mutant 14-month-old mice, and approximately 0.73 Inn in wild-type and
approximately 0.85 iim in ND6 P25L mutant mice at 24 months of age. Fourteen-
month-old ND6 P25L mutant mice are expected to have an increased number of
large
fibers but fewer small axonal fibers (=0.5 [im). The change in axonal
diameters is
expected to be more pronounced in 24-month-old ND6 P25L mice. Hence, ND6
P25L mice are expected to have fewer small and medium axons (Ø8 rim) and
more
swollen axonal fibers with diameters larger than 1 rim. This effect is
expected to be
the most severe in the area of the smallest fibers in the central and temporal
regions of
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the mouse optic nerve, which corresponds to the human temporal region most
affected
in LHON.
[0716] Quantification of the number of axons in the optic nerves is expected
to
reveal no significant difference in the total counts at 14 months of age, and
approximately a 30% reduction at 24 months of age. Thus, the observed shift
toward
larger axons is predicted to be attributable initially (14 months) to swelling
of medium
axons, and later (24 months), to the loss of small axons.
[0717] It is expected that administration of phenazine-3-one and/or
phenothiazine-3-
one derivatives once daily from 0-14 months of age will prevent the onset of,
delay
the onset of, or reduce the severity of these effects in ND6 P25L mutant
animals,
thereby preventing these aspects of LHON.
[0718] Abnormal Mitochondrial Morphology and Proliferation in RGC Axons.
Mitochondria in the optic tracts of the ND6 P25L mutants are expected to be
abnormal and increased in number, consistent with the compensatory
mitochondrial
proliferation observed in LHON patients. The optic tract axons of 14-month-old
ND6
P25L mice are expected to have approximately a 58% increase in mitochondria,
with
24-month-old animals having approximately a 94% increase. The ND6 P25L
mitochondria are expected to appear hollowed with irregular cristae, with
approximately 31.5% more of the ND6 P25L mitochondria being abnormal at 14
months and approximately 56% more at 24 months of age. Axons filled with
abnormal mitochondria are expected to demonstrate marked thinning of the
myelin
sheath.
[0719] It is expected that administration of phenazine-3-one and/or
phenothiazine-3-
one derivatives once daily from 0-14 months of age will prevent the onset of,
delay
the onset of, or reduce the severity of these effects in ND6 P25L mutant
animals,
thereby preventing these aspects of LHON.
[0720] Altered Liver Mitochondria Complex I Activity. The complex I activity
of
the ND6 P25L mice is assayed in liver mitochondria. Results are expected to
demonstrate that rotenone-sensitive NADH:ubiquinone oxidoreductase activity is

decreased by approximately 29%, which is equivalent to the reduction seen in
the
LT13 cell line. It is expected that the decrease in activity will not be
attributable to a
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lower abundance of complex I, as it is expected that the NADH:ferricyanide
oxidoreductase will be unaltered in the ND6 mutant mice. It is further
expected that
the ND6 mutation will cause approximately a 25% decrease in mitochondrial
oxygen
consumption, also seen in the LT13 cell line.
[0721] It is expected that administration of phenazine-3-one and/or
phenothiazine-3-
one derivatives once daily from 0-14 months of age will prevent the onset of,
delay
the onset of, or reduce the severity of these effects in ND6 P25L mutant
animals,
thereby preventing these aspects of LHON.
[0722] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology, are useful for preventing the onset of,
delaying
the onset of, and/or reducing the severity of the symptoms of LHON in a
mammalian
subject. As such, phenazine-3-one and/or phenothiazine-3-one derivatives of
the
present technology are useful in methods for preventing LHON in a mammalian
subject.
Example 9 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Treating Friedreich's Ataxia in in vitro Cell Culture
[0723] This Example will demonstrate the use of phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology in the treatment of
Friedreich's Ataxia in a cell culture model of the disease.
[0724] Cell line model. This Example uses human dermal fibroblasts derived
from
Friedreich's Ataxia patients previously described by Jauslin et al., Hum. Mol.
Genet.
11(24):3055 (2002).
[0725] Fibroblasts from Friedreich's Ataxia (FRDA) patients have been shown to
be
hypersensitive to L-buthionine-(S,R)-sulfoximine (BSO), a specific inhibitor
of GSH
synthetase. Jauslin et al., Hum. Mol. Genet. 11(24):3055 (2002), Jauslin et
al.,
FASEB J. 17:1972-4 (2003), and International Patent Application WO
2004/003565.
The therapeutic efficacy of a compound can be assessed by assaying its ability
to
suppress BSO-mediated cell death in FRDA fibroblasts.
[0726] FRDA fibroblasts and fibroblasts from normal subjects are seeded in
microtiter plates at a density of 4000 cells per 100 ixL in growth medium
consisting of
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CA 02920272 2016-02-09
25% (v/v) M199 EBS and 64% (v/v) MEM EBS without phenol red (Bioconcept,
Allschwil, Switzerland) supplemented with 10% (v/v) fetal calf serum (FAA
Laboratories, Linz, Austria), 100 U/mL penicillin, 100 ag/mL streptomycin (FAA

Laboratories, Linz, Austria), 10 ag/mL insulin (Sigma, Buchs, Switzerland), 10

ng/mL EGF (Sigma, Buchs, Switzerland), 10 ng/mL bFGF (PreproTech, Rocky Hill,
NJ, USA) and 2 mM glutamine (Sigma, Buchs, Switzerland).
[0727] The test samples are supplied in 1.5 ml glass vials. The phenazine-3-
one
and/or phenothiazine-3-one derivatives are diluted with DMSO, ethanol or PBS
to
result in a 5 mM stock solution. Once dissolved, they are stored at ¨20 C.
Reference antioxidants (Idebenone, decylubiquinone, a-tocopherol acetate and
trolox)
are dissolved in DMSO.
[0728] Test samples are screened according to the following protocol:
[0729] A culture with FRDA fibroblasts is started from a 1 ml vial with
approximately 500,000 cells stored in liquid nitrogen. Cells are propagated in
10 cm
cell culture dishes by splitting every third day in a ratio of 1:3 until nine
plates are
available. Once confluent, fibroblasts are harvested. For 54 micro titer
plates (96
well-MTP) a total of 14.3 million cells (passage eight) are re-suspended in
480 ml
medium, corresponding to 100 p,1 medium with 3,000 cells/well. The remaining
cells
are distributed in 10 cm cell culture plates (500,000 cells/plate) for
propagation. The
plates are incubated overnight at 37 C. in an atmosphere with 95% humidity
and 5%
CO2 to allow attachment of the cells to the culture plate.
[0730] MTP medium (243 p1) is added to a well of the microtiter plate. The
phenazine-3-one and/or phenothiazine-3-one derivatives are thawed, and 7.5 1
of a 5
mM stock solution is dissolved in the well containing 243 pl medium, resulting
in a
150 M master solution. Serial dilutions from the master solution are made.
The
period between the single dilution steps is kept as short as possible
(generally less
than 1 second).
[0731] Plates are kept overnight in the cell culture incubator. The next day,
10 til of
a 10 mM BSO solution is added to the wells, resulting in a 1 mM final BSO
concentration. Forty-eight hours later, three plates are examined under a
phase-
contrast microscope to verify that the cells in the 0% control (wells El-Hi)
are clearly
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CA 02920272 2016-02-09
dead. The medium from all plates is discarded, and the remaining liquid is
removed
by gently tapping the plate inversed onto a paper towel.
[0732] 100 IA of PBS containing 1.2 jiM Calcein AM is then added to each well.

The plates are incubated for 50-70 minutes at room temperature. Then, the PBS
is
discarded, and the plate is gently tapped on a paper towel. Fluorescence
intensity is
measured with a Gemini Spectramax XS spectrofluorimeter (Molecular Devices,
Sunnyvale, CA, USA) using excitation and emission wavelengths of 485 and 525
nm,
respectively.
[0733] It is anticipated that untreated FRDA cells will exhibit high levels of
cell
death following exposure to BSO (FRDA Control) as compared to fibroblasts
derived
from normal subjects (Normal). However, it is anticipated that FRDA
fibroblasts
treated with phenazine-3-one and/or phenothiazine-3-one derivatives will show
cell
survival rates that are similar to normal subjects and greater than untreated
FRDA
fibroblasts, following BSO exposure.
[0734] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology are useful in the treatment of
Friedreich's
Ataxia.
Example 10 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Treating Mitochondrial Iron Loading in Friedreich's Ataxia Mouse Model
[0735] This Example will demonstrate the use of phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology in treating
mitochondrial
iron loading in a mouse model of Friedreich's Ataxia.
[0736] Mouse model. This Example uses the muscle creatine kinase (MCK)
conditional frataxin knockout mice described by Puccio et al., Nat. Genet.
27:181-186
(2001). In this model, the tissue-specific Cre transgene under the control of
MCK
promoter results in the conditional deletion of frataxin in only the heart and
skeletal
muscle.
[0737] 8-week-old mutant mice are administered a daily dose of 0.25 mg/kg/day
of
the phenazine-3-one and/or phenothiazine-3-one derivatives, or saline vehicle
only
(control) subcutaneously for two weeks. Total RNA is isolated from hearts of
two 10-
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week-old wild-type mice, two 10-week-old untreated mutant mice and two 10-week-

old treated mutant mice. Total RNA is isolated using TRIzol (Invitrogen).
First-
strand cDNA synthesis and biotin-labeled cRNA are performed and hybridized to
the
mouse Affymetrix GeneChip 430 2Ø A 2-phase strategy is used to identify
differentially expressed genes. First, genome-wide screening is performed
using
Affymetrix GeneChips. Then, low-level analysis is performed with Affymetrix
GeneChip Operating Software 1.3.0, followed by the GC robust multiarray
average
(GCRMA) method for background correction and quantile¨quantile normalization
of
expression. Tukey's method for multiple pairwise comparisons is applied to
acquire
fold-change estimations. Tests for significance are calculated and adjusted
for
multiple comparisons by controlling the false discovery rate at 5%.
[0738] Definitive evidence of differential expression is obtained from RT-PCR
assessment of samples used for the microarray analysis and at least 3 other
independent samples. Principal component analysis is performed by standard
methods. Western blot analysis is performed using antibodies against frataxin
(US
Biological); Tfr 1 (Invitrogen); Fpnl (D. Haile, University of Texas Health
Science
Center); Hmox 1 (AssayDesigns); Sdha, Gapdh, and Iscu 1/2 (Santa Cruz
Biotechnology); Fech (H. Dailey, University of Georgia, Biomedical and Health
Sciences Institute); Hfe2 (S. Parkkila, University of Tampere, Institute of
Medical
Technology); Nfsl, Uros, and Alad (Abnova); Sec1511 (N.C. Andrews, Duke
University); Ftll, Fthl, Ftmt (S. Levi, San Raffaele Institute); and Hifla (BD

Biosciences).
[0739] For heme assays, hearts are exhaustively perfused and washed with PBS
(0.2% heparin at 37 C) to remove blood. After homogenization, heme is
quantified
using the QuantiChrom Heme Assay (BioAssay Systems). Tissue iron is measured
via inductively coupled plasma atomic emission spectrometry.
[0740] It is anticipated that untreated mutant mice will exhibit decreased
expression
of genes involved in heme synthesis, iron¨sulfur cluster assembly, and iron
storage
(FRDA Control) as compared to wild-type mice (Normal). However, it is
anticipated
that mutant mice treated with the phenazine-3-one and/or phenothiazine-3-one
derivatives will show expression levels that are similar to normal subjects
with respect
to genes involved in these three mitochondrial iron utilization pathways.
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CA 02920272 2016-02-09
[0741] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology are useful in treating mitochondrial
iron loading
in a mammalian model of Friedreich's Ataxia.
Example 11 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Treating Complex I and ATP Content Deficiency in Patients Suffering from a
Mitochondrial Disease or Disorder
[0742] This Example will demonstrate the use of phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology in treating complex
I and
ATP content deficiency in patients suffering from a mitochondrial disease or
disorder.
[0743] Patients diagnosed with any mitochondrial disease or disorder described

herein are administered a daily dose of 0.5 mg/kg/day of the phenazine-3-one
and/or
phenothiazine-3-one derivatives; or saline vehicle (control) for six weeks.
[0744] Isolation of Lymphocytes from Peripheral Blood. Blood is diluted with
Hank's solution at a ratio of 1:2 within one hour of extraction and slowly
layered onto
a 15-mL screw-cap tube containing 5 mL Ficolymph (Bharafshan Co. Tehran,
Iran.).
The tubes are centrifuged for 20 minutes at 1000 x g, after which the
lymphocyte-
containing layer is collected into a new centrifuge tube using a sterile
pipette. The
lymphocyte mix is then diluted in 10 mL Hank's solution and centrifuged for 10

minutes at 440xg. The supernatant is discarded, 5 mL of Hank's solution is
added, the
pellet is mixed gently in this buffer, and the mixture is allowed to sit for
about 45
seconds (s). The mixture is gently pipetted and then centrifuged at 230xg for
15
minutes. The supernatant is discarded, and the pellet is suspended in RPMI
1640
medium (Bharashan Co. Tehran, Iran) supplemented with L-glutamine.
[0745] Complex I activity assay. Fresh lymphocyte pellets are homogenized by
sonication in 20 mmol/L potassium phosphate buffer (pH 7.5) for 15s (three
bursts of
5s each) at 30W on ice. The final protein concentration is quantified
according to
Bradford's method. The homogenate, containing 2-4 g/L protein, is kept on ice
and
used for assay the same day. Biochemical studies are carried out on lymphocyte

homogenate of 12 patients and 25 controls. NADH-ferricyanide reductase
activity is
also assayed spectrophotometrically by following the disappearance of oxidized

ferricyanide at 410 nm and 30 C. The assay mixture contained in 1 mL: NADH,
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CA 02920272 2016-02-09
ferricyanide, triethanolamin and phosphate buffer (pH 7.8). The reaction is
started by
the addition of the lymphocyte homogenate.
[0746] Extraction and quantification of intracellular ATP. The lymphocyte
cells
are pelleted in a microcentrifuge tube by centrifugation at 12,000 g for 10
min. The
cellular ATP is then extracted by adding 0.5 mL water and boiling the cell
pellet for 5
min. After vortexing and centrifugation (12,000 g for 5 min at 4 C), 50 lit of
the
supernatant is used for bioluminescence measurement. The standard curve of ATP
is
obtained by serial dilutions of 4 mM ATP solution (0.25, 0.5, 1.0, 2.0, and
4.0). Light
emission is measured with a Sirius tube luminometer, Berthold defection system

(Germany). After calibration against the ATP standard, the ATP content of the
cell
extract is determined.
[0747] It is anticipated that lymphocytes derived from untreated subjects will

exhibit decreased complex I activity and reduced intracellular ATP levels
(mitochondrial disease Control) as compared to controls (Normal). However, it
is
anticipated that subjects treated with the phenazine-3-one and/or
phenothiazine-3-one
derivatives will show complex I activity and ATP levels that are similar to
normal
subjects and greater than untreated subjects suffering from a mitochondrial
disease or
disorder.
[0748] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology are useful in treating complex I and ATP
content
deficiency in patients suffering from a mitochondrial disease or disorder.
Example 12 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Restoring_Aconitase Activity in Cultured Cells Following Deferiprone Exposure
[0749] This Example will demonstrate the use of phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology in restoring
aconitase
activity in cultured cells that have been exposed to deferiprone.
[0750] Deferiprone has been shown to potently impair aconitase activity,
presumably through reduced iron-sulfur cluster biosynthesis. Goncalves et al.,
BMC
Neurology 8:20 (2008).
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CA 02920272 2016-02-09
[0751] Fibroblasts derived from forearm biopsies taken from healthy controls
are
grown under standard conditions in Dulbecco's modified Eagle's medium (DMEM;
Gibco Invitrogen, Cergy Pontoise, France) supplemented with 10% fetal calf
serum,
mg/mL penicillin/streptomycin and 2 mM L-Glutamine (as GlutamaxTM; Gibco
Invitrogen). Final iron content in culture medium will amount to 2-3 IAM. The
medium (4 mL/25 cm2 flask; 3 mL/10 cm2 well) is changed every three days.
[0752] Fibroblasts are administered 1-10 jt g of phenazine-3-one and/or
phenothiazine-3-one derivatives, or empty vehicle (control) for 24 hours
before
addition of deferiprone. Fibroblasts are seeded at 18 x 103 cells/cm2.
Fibroblasts are
then treated with 751.1M deferiprone for 7 days. Aconitase measurement is
spectrophotometrically carried out by following aconitate production from
citrate at
240 nm on the supernatant (800 g x 5 min) of detergent-treated cells (0.2%
lauryl
maltoside). Protein concentration is measured according to Bradford method.
[0753] It is anticipated that untreated fibroblasts will exhibit reduced
aconitase
activity following exposure to deferiprone (Control) as compared to
fibroblasts that
are not exposed to deferiprone (Normal). However, it is anticipated that
concurrent
treatment with phenazine-3-one and/or phenothiazine-3-one derivatives will
show
aconitase activity that is similar to normal subjects and greater than
untreated
fibroblasts following deferiprone exposure.
[0754] These results will show that phenazine-3-one and/or phenothiazine-3-one

derivatives of the present technology are useful in restoring aconitase
activity in
cultured cells that have been exposed to deferiprone.
Example 13 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Reducing Mitochondrial Fission
[0755] This Example will demonstrate use of the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology in the reduction of
mitochondrial fission.
[0756] Cultured human SH-SY5Y neuronal cells are treated with buffer; 5 IIM
CCCP (carbonyl cyanide m-chloro phenyl hydrazone, a mitochondrial uncoupler);
or
5 jtM CCCP and phenazine-3-one and/or phenothiazine-3-one derivatives; for 30
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minutes. The cells are then stained with anti-Tom20 antibody, a mitochondrial
marker, and Hoechst stain. Mitochondrial morphology is analyzed using 63X oil
immersion lens.
[0757] Results ¨ It is expected that control cells treated with CCCP will show

extensive mitochondrial fragmentation as manifested by small, round or dot-
like
staining patterns. It is also anticipated that treatment with the phenazine-3-
one and/or
phenothiazine-3-one derivatives will result in significantly reduced
mitochondrial
fission compared to control cells that are only exposed to CCCP.
[0758] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for reducing
mitochondrial fission in mammalian subjects.
Example 14 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives to
Increase Protein Expression Levels of Fully Assembled Complex I and Complex II
in
Cells Bearing Complex I Mutations
[0759] This Example will demonstrate use of the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology to restore electron
transport
chain function in complex I mutant cells.
[0760] Experimental fibroblast cells are derived from patients with a mutation
in
different Complex I subunits. Control cells are human skin fibroblasts derived
from
healthy controls. Cultured Complex I mutant fibroblasts are incubated with
buffer or
phenazine-3-one and/or phenothiazine-3-one derivatives for up to 72 hours. The
cells
are then harvested by trypsinization and washed twice with ice-cold PBS. The
cell
suspensions are centrifuged for 5 minutes at 4 C and the cell pellets are
snap-frozen
in liquid nitrogen. The cell pellets are subsequently thawed on ice and
resuspended in
100 gl of ice-cold PBS.
[0761] Isolation of OXPHOS complexes: The cell suspension is incubated with
100
[LL (4 mg/mL) digitonin (Sigma, Zwijndrecht, Netherlands) on ice for 10 mm.
Digitonin dissociates membranes that contain cholesterol, thereby dissociating
the cell
membrane and the outer mitochondrial membrane, but not the inner mitochondrial

membrane. Next, 1 mL ice-cold PBS is added to dilute the digitonin, followed
by
224

CA 02920272 2016-02-09
centrifugation (10 min; 15,600xg; 4 C). The resulting pellets contain a cell
fraction
which is enriched for mitoplasts. The supernatant is removed and the pellets
are
resuspended in 1001.IL ice-cold PBS. 1 mL ice-cold PBS is then added and the
suspension is centrifuged again (5 min; 15,600 xg; 4 C), followed by removal
of the
supernatant and resuspension of the pellet in 100 [IL ice-cold PBS. The
supernatant is
removed with a syringe and needle and the pellets containing the mitoplast
fraction
are stored overnight (-20 C).
[0762] The complexes of the OXPHOS system are extracted from the inner
membrane with 0-lauryl maltoside and aminocaproic acid. The pellets are thawed
on
ice and solubilized in 100 [Li, ACBT buffer containing 1.5 M c-aminocaproic
acid
(Serva, Amsterdam, Netherlands) and 75 mM Bis-Tris/HC1 (pH 7.0) (Sigma).
Subsequently 10 tit 20% (w/v) 13-lauryl maltoside (Sigma) is added and the
suspension is left on ice for 10 mm. Next, the suspensions are centrifuged (30
min;
15,600 xg; 4 C) and the supernatants which contain the isolated complexes are

transferred to a clean tube (L.G. Nijtmans et al., Methods 26 (4): 327-334
(2002)).
The protein concentration of the isolated OXPHOS complexes is determined using
a
Biorad Protein Assay (Biorad, Veenendaal, Netherlands). Blue-native PAGE
analysis
of mitoplasts is performed as described in L.G. Nijtmans et al., Methods 26
(4): 327-
334 (2002).
[0763] Complex I or complex II protein detection: To visualize the amount of
complex I or complex II present in the BN-PAGE gels, the proteins are
transferred to
a PVDF membrane (Millipore, Amsterdam, Netherlands) using standard Western
blotting techniques and detected by immunostaining. After the blotting and
prior to
blocking the PVDF membrane with 1:1 PBS-diluted Odyssey blocking buffer (Li-
cor
Biosciences, Cambridge, UK), the PVDF blot is stripped with stripping buffer
for 15
min at 60 C. The stripping buffer consists of PBS, 0.1% Tween-20 (Sigma) and
2%
SDS (Serva). A monoclonal primary antibody against NDUFA9 (39 kDa) (Molecular
probes, Leiden, The Netherlands) is used for detection of Complex I. To detect

Complex II, a monoclonal antibody against the 70 kDa subunit of complex II is
used
(Molecular probes). Both primary antibodies are diluted in PBS, 0.1% Tween-20
and
2.5% Protifar Plus (Nutricia, Cuijk, The Netherlands) and allowed to bind to
the
complex for 4 hours at room temperature or overnight at 4 C. The bound primary
225

CA 02920272 2016-02-09
antibodies are subsequently detected by IRDye 800 CW conjugated anti-Mouse
antibody (Li-cor Biosciences) at a final concentration of 0.1 ug/mL.
[0764] Results: It is expected that untreated Complex I mutant cells will show

reduced protein expression levels of Complex I and Complex II compared to
untreated healthy control cells. It is also anticipated that treatment with
the
phenazine-3-one and/or phenothiazine-3-one derivatives will result in an
increase in
fully assembled complex I and complex II protein levels in Complex I mutant
cells.
[0765] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for elevating
Complex I
and Complex II protein levels in mammalian subjects. The results will show
that the
phenazine-3-one and/or phenothiazine-3-one derivatives of the present
technology are
useful in promoting electron transport chain function generally.
Example 15 ¨ In vivo Effect of Phenazine-3-one and Phenothiazine-3-one
Derivatives
on Grip Strength in Ndufs4 Knockout Mice
[0766] This Example will demonstrate use of the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology to improve grip
strength in
Ndufs4 knockout (Complex I deficient) mice.
[0767] Animals and Treatments: Ndufs4 knockout (KO) and wild-type (WT) mice
are generated by crossing Ndufs4 heterozygote males and females (Kruse SE, et
al.,
2008, Cell Metab 7:312-320). Animals are divided into the following groups:
Vehicle-WT; Vehicle-KO; or Phenazine-3-one and/or Phenothiazine-3-one
Derivative-KO. Animals are tested at 3, 5 and 6 weeks of age. Animals will
receive
either vehicle (control) injections, consisting of sterile water, or
injections consisting
of a phenazine-3-one derivative and/or a phenothiazine-3-one derivative.
Animals are
injected twice a day. Injections begin during week 3 of life, and are
continued daily
until the conclusion of the experiment in week 6.
[0768] Data Analysis: All data are expressed as mean + SEM. Data are analyzed
using a one way ANOVA in SPSS version 20Ø Significant overall effects (i.e.,

genotype, treatment and/or genotype treatment interaction) are further
analyzed using
Fisher's PLSD post-hoc analyses.
226

CA 02920272 2016-02-09
[0769] Grip Strength Paradigm: The grip strength test is designed to measure
muscular strength in rodents. The apparatus consists of a single bar, which
the animal
will grasp by instinct. Once the bar has been grasped, the experimenter gently
retracts
the animal until the animal is forced to release the bar. The amount of force
exerted
by the animal on the bar is measured in Pond (p) (1 p = I gram). The grip
strength
test is repeated 5 times and the average force exerted is used as the
quantitative
readout. All measurements will be corrected for body weight, using the
following
equation:
[0770] Grip Strength Score = ((week X trials 1 + 2 + 3 + 4 +5)/5)/ Average
Body
Weight week X (g) (Week X = week 3, 5 or 6)
[0771] Testing Procedure: On testing days, animals will receive their morning
injection 30 minutes prior to their testing time. After injections, the
animals will be
placed in the testing room for a 30 minute acclimation period.
[0772] Results: It is expected that vehicle KO animals will show remarkably
decreased grip strength compared to wild-type control animals. It is also
anticipated
that chronic treatment with the phenazine-3-one and/or phenothiazine-3-one
derivatives will result in significantly improved grip strength in the
knockout animals
compared to vehicle knockouts.
[0773] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for improving grip

strength in mammalian subjects. The results will show that the phenazine-3-one

and/or phenothiazine-3-one derivatives of the present technology are generally
useful
in treating neuromuscular defects in Complex I deficient subjects.
Example 16 ¨ Phenazine-3-one and Phenothiazine-3-one Derivatives Restore Motor

and Cognitive Function in an in vivo Huntington Disease (HD) Animal Model
[0774] This Example will demonstrate use of the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology to reduce the
neurological
defects associated with HD.
[0775] R6/2 mice, expressing exon 1 of the human HD gene carrying more than
120
CAG repeats, exhibit progressive neurological phenotypes that mimic the
features of
227

CA 02920272 2016-02-09
HD in humans. The mice develop progressive neurological phenotypes gradually
with mild phenotype (e.g., resting tremor) as early as 5 weeks of age and
severe
symptoms (including reduced mobility and seizures) at 9-11 weeks, with many of
the
mice dying by 14 weeks.
[0776] R6/2 HD transgenic mice are treated with an empty vehicle or a
phenazine-
3-one derivative and/or a phenothiazine-3-one derivative using Alzet osmotic
mini-
pumps from age 5 weeks to 13 weeks. These animals will be subjected to a
number
of behavioral assessments to study motor and cognitive function. Rotor-rod and

mobility in an activity chamber are used for assessment of motor function, and
the Y-
maze is used for assessment of working memory.
[0777] Results ¨ It is anticipated that vehicle-treated R6/2 mice will display
major
motor deficits such as a reduced ability to stand on their rear limbs and
increased
periods of immobility compared to wild-type controls. It is further
anticipated that
treatment with the phenazine-3-one and/or phenothiazine-3-one derivatives will

restore motor activity and improve cognitive function (as demonstrated by the
animals' performance in the Y-maze test).
[0778] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for restoring
cognitive and
motor function in mammals suffering from HD. The results will show that the
phenazine-3-one and/or phenothiazine-3-one derivatives of the present
technology are
generally useful in treating symptoms associated with neurodegenerative
diseases.
Example 17 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives to
Suppress Af3-mediated Toxicity in the Brain
[0779] This Example will demonstrate use of the phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology to treat or
ameliorate the
toxic effects of AP accumulation in brain tissue.
[0780] Rats are treated with saline or a phenazine-3-one derivative and/or a
phenothiazine-3-one derivative (0.5-2 molikg body weight, n=12). The
compositions are injected intraperitoneally into the animal 24 hours before
hippocampal slices are obtained to measure long-term potentiation (LTP). Brain
228

CA 02920272 2016-02-09
slices from each group are incubated with AP fragments for 15 min before
evaluating
LTP.
[0781] Results ¨ It is expected that brain slices recovered from saline-
treated
controls will show impaired LTP post AP treatment. It is also anticipated that

treatment with the phenazine-3-one and/or phenothiazine-3-one derivatives will

suppress AP-mediated impairment of LTP.
[0782] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for treating or
ameliorating AP-mediated toxicity in brain tissue. The results will show that
the
phenazine-3-one and/or phenothiazine-3-one derivatives of the present
technology are
generally useful in reducing the synaptic dysfunction and memory loss caused
by A13
accumulation generally.
Example 18 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives to
Delay
Ageing
[0783] This Example will demonstrate use of the methods and compositions of
the
present technology to reduce the frequency and/or severity of age-related
symptoms.
The Example will demonstrate the use of phenazine-3-one and/or phenothiazine-3-

one derivatives of the present technology in delaying ageing.
[0784] Ercc 1-/A progeroid mice are treated with phenazine-3-one and/or
phenothiazine-3-one derivatives (i.p. about 0.5-2 mg/kg) in sunflower oil
carrier three
times per week over an 18-21 week period. Control animals are Erccl-i
progeroid
mice that receive sunflower seed oil according to the same schedule. The
treated and
control mice are monitored twice a week for weight and symptom/sign
development.
Symptoms include dystonia, trembling, kyphosis, ataxia, wasting, priapism,
decreased
activity, incontinence, and vision loss. The rate of deterioration of
intervertebral discs
(an index of degenerative disease of the vertebra) is assessed by measuring
the level
of glycosaminoglycan in the discs in treated and control mice.
[0785] Results ¨ It is expected that treatment with the phenazine-3-one and/or

phenothiazine-3-one derivatives will result in a significant delay in onset of
age-
related degeneration compared to controls treated with vehicle only. It is
also
anticipated that the intervertebral discs of mice treated with the phenazine-3-
one
229

CA 02920272 2016-02-09
and/or phenothiazine-3-one derivatives will contain more glycosaminoglycan
relative
to control mice, indicating inhibition of disc degeneration.
[0786] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for reducing the
frequency
and/or severity of age-related symptoms. The results will show that the
methods and
compositions described herein are useful in delaying ageing generally.
Example 19 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives to
Treat
Mitochondrial Dysfunction
[0787] This Example demonstrates the use of phenazine-3-one and/or
phenothiazine-3-one derivatives, or pharmaceutically acceptable salts thereof,
to treat
different aspects of mitochondrial dysfunction.
[0788] Lymphocytes, fibroblasts or neurons are derived from subjects suspected
of
having or diagnosed as having a mitochondrial disease or disorder. The
isolated cells
are cultured using conventional methods that promote optimal growth of a given
cell
type. The resulting cell cultures are subjected to the following assays:
[0789] Mitochondrial Membrane Potential (dm) Assay: For the determination of
Awm, cells are pre-treated with or without phenazine-3-one and/or
phenothiazine-3-
one derivatives. The cells are treated with 5 mM Dulbecco's modified Eagle's
minimal essential medium (DEM) for 120 minutes, collected by centrifugation at

300xg for 3 minutes and then washed twice with phosphate buffered saline. The
cells
are re-suspended in PBS buffer and incubated at 37 C. in the dark for 15
minutes
with 250 nM TMRM (a cationic dye which accumulates within mitochondria in
accordance with the AymNernst potential). Cells are collected by
centrifugation at
300xg for 3 minutes and then washed twice with phosphate buffered saline. The
samples are analyzed immediately by flow cytometry using 488 nm excitation
laser
and the FL2-H channel. The protonophore FCCP (30 pM) will be used to dissipate

the chemiosmotic proton gradient (Ai_tiff) and serves as a control for loss of
Awm.
The results obtained will be verified in three independent experiments.
[0790] Trypan Blue Cell Viability Assay: This technique is used to assess the
cytoprotective effects of phenazine-3-one and/or phenothiazine-3-one
derivatives in
cultured cells pharmacologically treated to induce cell death by GSH
depletion. DEM
230

CA 02920272 2016-02-09
is used to deplete cellular GSH and induce oxidative stress. The viability of
DEM-
treated cells is determined by their ability to exclude the dye trypan blue.
Viable cells
exclude trypan blue; whereas, non-viable cells take up the dye and stain blue.
Briefly,
cells are seeded at a density of lx106 cells/mL and treated with different
concentrations of phenazine-3-one and/or phenothiazine-3-one derivatives.
Cells are
incubated at 37 C in a humidified atmosphere of 5% CO2 in air for three hours
with 5
mM DEM. Cell viability is determined by staining cells with 0.4% trypan blue
using
a hemocytometer. At least 500 cells are counted for each experimental group.
[0791] Cytochrome c Reduction Assay: The rate of cytochrome c (10 p,M)
reduction
is measured by monitoring the change in absorbance at 550 nm. Briefly the
reaction
is initiated by addition of 100 )1M of phenazine-3-one and/or phenothiazine-3-
one
derivatives to a mixture containing 50 mM phosphate buffer, 0.1 mM EDTA, pH
7.8,
and 10 tiM cytochrome c (Sigma, St. Louis, Mo. USA). For cytochrome c
reduction
by superoxide, xanthine oxidase (0.01 IU/mL) (Sigma, St. Louis, Mo. USA) is
used in
presence of xanthine (50 M).
[0792] Total Cellular ATP Concentration Assay: The reductions of mitochondrial

respiratory chain activity in CoQ10 deficient patients have been reported
(Quinzii G
et al., FASEB J. 22:1874-1885 (2008)). Briefly, lymphocytes (2x105 cell/mL),
are
plated (1 mL in 12-well plates) and treated with phenazine-3-one and/or
phenothiazine-3-one derivatives at final concentrations of 5, 10 p,M, and 25 M
and
incubated at 37 C for 48 hours in a humidified atmosphere containing 5% CO2
in air.
Phenazine-3-one and/or phenothiazine-3-one derivatives are prepared by first
making
20 mM stock solutions in DMSO. Cells are transferred (100 mt) to 96-well
microtiter
black-walled cell culture plates (Costar, Corning, N.Y.). The total
intracellular ATP
level is measured in a luminator (ClarityTM luminescence microplate reader)
with the
ATP Bioluminescence Assay Kit (ViaLight Plus ATP monitoring reagent kit,
Lonza) following the manufacturer's instructions. The standard curve of ATP is

obtained by serial dilution of 1 mM ATP solution. After calibration against
the ATP
standard, the ATP content of the cell extract is determined and normalized for
protein
content in the cell.
[0793] Mitochondrial Bioenergetics Assessment: The use of phenazine-3-one
and/or
phenothiazine-3-one derivatives and methylene blue analogues (positive
control) to
231

CA 02920272 2016-02-09
normalize and restore the respiratory chain activities in cultured cells
derived from
subjects with a mitochondrial disease or disorder are assessed. Lymphocytes
are
cultured under glucose-free media supplemented with galactose for two weeks to

force energy production predominantly through oxidative phosphorylation rather
than
glycolysis. Lymphocytes are cultured in RPMI 1640 medium glucose-free
supplemented with 25 mM galactose, 2 mM glutamine and 1% penicillin-
streptomycin, and 10%, dialyzed fetal bovine serum FBS (<0.5 gg/mL). Briefly,
lymphocytes (2x105 cell/mL), are plated (1 mL in 12-well plates) and treated
with the
phenazine-3-one and/or phenothiazine-3-one derivatives at final concentrations
of 50,
125, 250, 1000, and 5000 nM, and incubated at 37 C for 48 hours in a
humidified
atmosphere containing 5% CO2 in air. Cells are transferred (100 ilL) to 96-
well
microtiter black-walled cell culture plates. The total intracellular ATP level
is
measured in a luminator (ClarityTM luminescence microplate reader) with the
ATP
Bioluminescence Assay Kit (ViaLight -Plus ATP monitoring reagent kit, Lonza)
following the manufacturer's instructions. Carbonyl cyanide-p-trifluormethoxy-
phenylhydrazone (FCCP) and oligomycin are used as controls for inhibition of
ATP
synthesis.
[0794] Results ¨ It is anticipated that cells derived from subjects suspected
of
having or diagnosed as having a mitochondrial disease or disorder will show
one or
more alterations associated with mitochondrial dysfunction such as decreased
cell
viability, loss of mitochondrial membrane potential, decreased cytochrome c
reduction, decreased cellular content of ATP, and reduced efficiency of
oxidative
phosphorylation. It is expected that treatment with phenazine-3-one and/or
phenothiazine-3-one derivatives will reduce the severity or eliminate one or
more of
these alterations associated with mitochondrial dysfunction.
[0795] These results will show that the phenazine-3-one and/or phenothiazine-3-
one
derivatives of the present technology are useful in methods for normalizing
and
restoring mitochondrial bioenergetics generally.
232

CA 02920272 2016-02-09
Example 20 ¨ Use of Phenazine-3-one and Phenothiazine-3-one Derivatives in
Combination with an Additional Therapeutic Agent in Ameliorating Symptoms of a

Mitochondrial Disease or Disorder in Subjects Diagnosed with a Mitochondrial
Disease or Disorder
[0796] This Example will demonstrate the use of phenazine-3-one and/or
phenothiazine-3-one derivatives of the present technology, in combination with
one or
more additional therapeutic agents (e.g., one or more of vitamins, cofactors,
antibiotics, hormones, antineoplastic agents, steroids, immunomodulators,
dermatologic drugs, antithrombotic, antianemic, and cardiovascular agents) to
alleviate or ameliorate one or more symptoms in a subject diagnosed with a
mitochondrial disease. Suitable test subjects diagnosed with a mitochondrial
disease
will exhibit one or more of the following symptoms: poor growth, loss of
muscle
coordination, muscle weakness, neurological deficit, seizures, autism,
autistic
spectrum, autistic-like features, learning disabilities, heart disease, liver
disease,
kidney disease, gastrointestinal disorders, severe constipation, diabetes,
increased risk
of infection, thyroid dysfunction, adrenal dysfunction, autonomic dysfunction,

confusion, disorientation, memory loss, failure to thrive, poor coordination,
sensory
(vision, hearing) problems, reduced mental functions, hypotonia, disease of
the organ,
dementia, respiratory problems, hypoglycemia, apnea, lactic acidosis,
seizures,
swallowing difficulties, developmental delays, movement disorders (dystonia,
muscle
spasms, tremors, chorea), stroke, and brain atrophy.
[0797] Subjects diagnosed with any mitochondrial disease or disorder described

herein and exhibiting one or more of the above symptoms are divided into 4
groups
(N=20) as follows: Group I is administered a daily dose of 0.5 mg/kg/day of
the
phenazine-3-one and/or phenothiazine-3-one derivatives; Group II is
administered a
daily dose of between 0.01-10 mg/k/day of one or more of vitamins, cofactors,
antibiotics, hormones, antineoplastic agents, steroids, immunomodulators,
dermatologic drugs, antithrombotic, antianemic, and cardiovascular agents;
Group III
is administered a combination of a daily dose of 0.5 mg/kg/day of the
phenazine-3-
one and/or phenothiazine-3-one derivatives and a daily dose of between 0.01-10

mg/k/day of one or more of vitamins, cofactors, antibiotics, hormones,
antineoplastic
agents, steroids, immunomodulators, dermatologic drugs, antithrombotic,
antianemic,
and cardiovascular agents; and Group IV is administered saline vehicle
(control).
233

CA 02920272 2016-02-09
Each group will receive therapy for six weeks. At the end of the six-week test
period,
subjects are evaluated for amelioration or attenuation of one or more of the
symptoms
described above.
[0798] It is anticipated that subjects in groups I and II will show an
improvement
(e.g., alleviation, amelioration) in at least one or more of the signs and
symptoms of
the mitochondrial disease or disorder as compared to the control group, Group
IV. It
is anticipated that subjects in Group III will exhibit a synergistic effect
with respect to
the combination therapy, and will exhibit a greater improvement in one or more
signs
or symptoms of the mitochondrial disease or disorder than the subjects of
Group I and
II.
[0799] These results will show that combination therapy, i.e., phenazine-3-one

and/or phenothiazine-3-one derivatives of the present technology in
combination with
one or more additional therapeutic agents, is useful in reducing, alleviating
or
ameliorating one or more of the signs and symptoms associated with a
mitochondrial
disease or disorder.
EQUIVALENTS
[0800] The present technology is not to be limited in terms of the particular
embodiments described in this application, which are intended as single
illustrations
of individual aspects of the present technology. Many modifications and
variations of
the present technology can be made without departing from its spirit and
scope, as
will be apparent to those skilled in the art. Functionally equivalent methods
and
apparatuses within the scope of the present technology, in addition to those
enumerated herein, will be apparent to those skilled in the art from the
foregoing
descriptions. Such modifications and variations are intended to fall within
the scope
of the appended claims. The present technology is to be limited only by the
terms of
the appended claims, along with the full scope of equivalents to which such
claims are
entitled. It is to be understood that the present technology is not limited to
particular
methods, reagents, compounds compositions or biological systems, which can, of

course, vary. It is also to be understood that the terminology used herein is
for the
purpose of describing particular embodiments only, and is not intended to be
limiting.
234

CA 02920272 2016-02-09
[0801] In addition, where features or aspects of the disclosure are described
in terms
of Markush groups, those skilled in the art will recognize that the disclosure
is also
thereby described in terms of any individual member or subgroup of members of
the
Markush group.
[0802] As will be understood by one skilled in the art, for any and all
purposes,
particularly in terms of providing a written description, all ranges disclosed
herein
also encompass any and all possible subranges and combinations of subranges
thereof. Any listed range can be easily recognized as sufficiently describing
and
enabling the same range being broken down into at least equal halves, thirds,
quarters,
fifths, tenths, etc. As a non-limiting example, each range discussed herein
can be
readily broken down into a lower third, middle third and upper third, etc. As
will also
be understood by one skilled in the art all language such as "up to," "at
least,"
"greater than," "less than," and the like, include the number recited and
refer to ranges
which can be subsequently broken down into subranges as discussed above.
Finally,
as will be understood by one skilled in the art, a range includes each
individual
member. Thus, for example, a group having 1-3 cells refers to groups having 1,
2, or
3 cells. Similarly, a group having 1-5 cells refers to groups having 1, 2, 3,
4, or 5
cells, and so forth.
[0803] All patents, patent applications, provisional applications, and
publications
referred to or cited herein are incorporated by reference in their entirety,
including all
figures and tables, to the extent they are not inconsistent with the explicit
teachings of
this specification.
[0804] Other embodiments are set forth within the following claims.
235

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Description du
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Date
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Nombre de pages Taille de l’image (Ko)
Description 2016-02-09 235 12 192
Revendications 2016-02-09 9 461
Dessins 2016-02-09 1 34
Abrégé 2016-02-09 1 15
Page couverture 2016-09-26 1 33
Nouvelle demande 2016-02-09 3 88