Friedreich's ataxia
Friedreich's ataxia | |
---|---|
Other names | Spinocerebellar ataxia, FRDA, FA |
diabetes mellitus | |
Usual onset | 5–20 years |
Duration | Long-term |
Causes | Genetic |
Diagnostic method | Medical history and physical examination |
Treatment | None |
Prognosis | Shortened life expectancy |
Frequency | 1 in 50,000 (United States) |
Friedreich's ataxia (FRDA or FA) is an
The condition is caused by mutations in the FXN gene on
In February 2023, the first approval of a treatment for FRDA was granted by the
is pending. There are several additional therapies in trial. FRDA shortens life expectancy due to heart disease, but some people can live into their 60s or older.FRDA affects one in 50,000 people in the United States and is the most common inherited ataxia. Rates are highest in people of Western European descent. The condition is named after German physician Nikolaus Friedreich, who first described it in the 1860s.
Symptoms
Symptoms typically start between the ages of 5 and 15, but in late-onset FRDA, they may occur after age 25 years.[1] The symptoms are broad, but consistently involve gait and limb ataxia, dysarthria and loss of lower limb reflexes.[1]
Classical symptoms
There is some variability in symptom frequency, onset and progression. All individuals with FRDA develop
Other symptoms
People who have been living with FRDA for a long time may develop other complications. 36.8% experience decreased visual acuity, which may be progressive and could lead to functional blindness.
Other later stage symptoms can include,
The progressive loss of coordination and muscle strength leads to the full-time use of a wheelchair. Most young people diagnosed with FRDA require mobility aids such as a cane, walker, or wheelchair by early 20s.[5] The disease is progressive, with increasing staggering or stumbling gait and frequent falling. By the third decade, affected people lose the ability to stand or walk without assistance and require a wheelchair for mobility.[6]
Early-onset cases
Non-neurological symptoms such as scoliosis, pes cavus, cardiomyopathy and diabetes are more frequent amongst the early-onset cases.[1]
Genetics
FRDA is an autosomal-recessive disorder that affects a gene (FXN) on chromosome 9, which produces an important protein called frataxin.[7]
In 96% of cases, the mutant FXN gene has 90–1,300 GAA
In about 4% of cases, the disease is caused by a (
Pathophysiology
FRDA affects the nervous system, heart, pancreas, and other systems.[15][16]
Degeneration of nerve tissue in the spinal cord causes ataxia.
The spinal cord becomes thinner and nerve cells lose some
Structures in the brain are also affected by FRDA, notably the dentate nucleus of the cerebellum.[16] The heart often develops some fibrosis, and over time, develops left-ventricle hypertrophy and dilatation of the left ventricle.[16]
Frataxin
The exact role of frataxin remains unclear.[17] Frataxin assists iron-sulfur protein synthesis in the electron transport chain to generate adenosine triphosphate, the energy molecule necessary to carry out metabolic functions in cells. It also regulates iron transfer in the mitochondria by providing a proper amount of reactive oxygen species (ROS) to maintain normal processes.[18] One result of frataxin deficiency is mitochondrial iron overload, which damages many proteins due to effects on cellular metabolism.[19]
Without frataxin, the energy in the mitochondria falls, and excess iron creates extra ROS, leading to further cell damage.[18] Low frataxin levels lead to insufficient biosynthesis of iron–sulfur clusters that are required for mitochondrial electron transport and assembly of functional aconitase and iron dysmetabolism of the entire cell.[19]
Diagnosis
Balance difficulty, loss of proprioception, an
Other diagnoses might include Charcot-Marie-Tooth types 1 and 2, ataxia with vitamin E deficiency, ataxia-oculomotor apraxia types 1 and 2, and other early-onset ataxias.[23]
Management of Symptoms
Physicians and patients can reference the clinical management guidelines for Friedreich ataxia.[24] These Guidelines are intended to assist qualified healthcare professionals in making informed treatment decisions about the care of individuals with Friedreich ataxia.[25]
Therapeutics
Omaveloxolone received FDA approval under the brand name Skyclarys for the treatment of Friedreich's ataxia in February 2023.[26] Approval in the EU is pending.[27]
Rehabilitation
Physical therapists play a critical role in educating on correct posture, muscle use, and the identification and avoidance of features that aggravate spasticities such as tight clothing, poorly adjusted wheelchairs, pain, and infection.[28]
Physical therapy typically includes intensive motor coordination, balance, and stabilization training to preserve gains.[29] Low-intensity strengthening exercises are incorporated to maintain functional use of the upper and lower extremities.[29] Stretching and muscle relaxation exercises can be prescribed to help manage spasticity and prevent deformities.[29] Other physical therapy goals include increased transfer and locomotion independence, muscle strengthening, increased physical resilience, "safe fall" strategy, learning to use mobility aids, learning how to reduce the body's energy expenditure, and developing specific breathing patterns.[29] Speech therapy can improve voice quality.[30]
Devices
Well-fitted
As progression of ataxia continues, assistive devices such as a cane, walker, or wheelchair may be required for mobility and independence. A standing frame can help reduce the secondary complications of prolonged use of a wheelchair.[31][32]
Managing Cardiac Involvement
Cardiac abnormalities can be controlled with
Surgical Intervention
Surgery may correct deformities caused by abnormal muscle tone. Titanium screws and rods inserted in the spine help prevent or slow the progression of scoliosis. Surgery to lengthen the
Omaveloxolone was approved for medical use in the United States in February 2023.[33]
Prognosis
The disease evolves differently in different people.[31] In general, those diagnosed at a younger age or with longer GAA triplet expansions tend to have more severe symptoms.[5]
Congestive heart failure and
Epidemiology
FRDA affects Indo-European populations. It is rare in East Asians, sub-Saharan Africans, and Native Americans. FRDA is the most prevalent inherited ataxia, affecting approximately 1 in 40,000 with European descent.[15] Males and females are affected equally. The estimated carrier prevalence is 1:100.[5] A 1990–1996 study of Europeans calculated the incidence rate was 2.8:100,000.[35] The prevalence rate of FRDA in Japan is 1:1,000,000.[36]
FRDA follows the same pattern as haplogroup R1b. Haplogroup R1b is the most frequently occurring paternal lineage in Western Europe. FRDA and Haplogroup R1b are more common in northern Spain, Ireland, and France, rare in Russia and Scandinavia, and follow a gradient through central and eastern Europe. A population carrying the disease went through a population bottleneck in the Franco-Cantabrian region during the last ice age.[37]
History
The condition is named after the 1860s German
Frantz Fanon wrote his medical thesis on FRDA, in 1951.[43]
A 1984 Canadian study traced 40 cases to one common ancestral couple arriving in New France in 1634.[44]
FRDA was first linked to a GAA repeat expansion on chromosome 9 in 1996.[45]
Research
Currently there is no cure for Friedreich's ataxia, and treatment development is currently directed toward slowing, stopping, or reversing disease progression. In 2019,
There are several additional therapies in trial. Patients can enroll in a registry to make clinical trial recruiting easier. The Friedreich's Ataxia Global Patient Registry is the only worldwide registry of Friedreich's ataxia patients to characterize the symptoms and establish the rate of disease progression.[52] The Friedreich's Ataxia App is the only global community app which enables novel forms of research.[53]
As of May 2021, research continues along the following paths.
Improve mitochondrial function and reduce oxidative stress
- PTC-743 (formerly EPI-743) is being developed by PTC Therapeutics. PTC-743 is a para-benzoquinone and targets the NAD(P)H dehydrogenase (quinone 1) (NQO1) enzyme to increase the biosynthesis of glutathione.[54]
Modulation of frataxin controlled metabolic pathways
- Dimethyl fumarate has been shown to increase frataxin levels in FRDA cells, mouse models, and humans. DMF showed an 85% increase in frataxin expression over 3 months in multiple sclerosis .[56]
Frataxin replacements or stabilizers
- EPO mimetics are orally available peptide imitations of erythropoietin. They are small molecules erythropoietin receptor agonists designed to activate the tissue-protective erythropoietin receptor.[57][58]
- Etravirine, an antiviral drug used to treat HIV, was found in a drug repositioning screening to increase frataxin levels in peripheral cells.[59] Fratagene Therapeutics is developing a small molecule called RNF126 to inhibit an enzyme which degrades frataxin.[60]
Increase frataxin gene expression
- Resveratrol might improve mitochondrial function.[61]
- Nicotinamide (vitamin B3) was found effective in preclinical FRDA models and well tolerated.[11]
- An ncRNA) could be responsible for directing the localized epigeneticsilencing of the FXN gene.
- fibroblasts.[62]
- CRISPR Therapeutics received a grant from the Friedreich's Ataxia Research Alliance to investigate gene editing as a potential treatment for the disease in 2017.[63]
Society and culture
The Cake Eaters is a 2007 independent drama film that stars Kristen Stewart as a young woman with FRDA.[64]
The Ataxian is a documentary that tells the story of Kyle Bryant, an athlete with FRDA who completes a long-distance bike race in an adaptive "trike" to raise money for research.[65]
Dynah Haubert spoke at the 2016 Democratic National Convention about supporting Americans with disabilities.[66]
Geraint Williams in an athlete affected by FRDA who is known for scaling Mount Kilimanjaro in an adaptive wheelchair.[67]
Shobhika Kalra is an activist with FRDA who helped build over 1000 wheelchair ramps across the United Arab Emirates in 2018 to try to make Dubai fully wheelchair-friendly by 2020.[68]
Butterflies Still Fly is a 2023 film, based on a true story, directed by Joseph Nenci. Italo is a light-hearted journalist, darkened by a personal drama that distracts him from work. He encounters with Giorgia, a young girl suffering from Friedreich's Ataxia, who will change his life.
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