FINAL PROGRAM AND ABSTRACT BOOK

2nd Dietitians workshop on PKURome, Italy - March 22, 2012

General information

VenueThe workshop takes place at the:Rome Marriott Park Hotel

Via Colonnello Tommaso Masala, 5400148 Rome, Italy

LanguageThe official language of the workshop is English.

Scientific secretariatSerono Symposia International FoundationSalita di San Nicola da Tolentino, 1/b00187 Rome, Italy

Junior Project Manager: Simona GaudiosiTel.: +39-06-420 413 308Fax: +39-06-420 413 677E-mail: simona.gaudiosi@seronosymposia.org

Serono Symposia International Foundation is a Swiss Foundation with headquarters in 14, rue du Rhône, 1204 Geneva, Switzerland

Organizing secretariatMeridiano Congress InternationalVia Mentana, 2/B - 00185 Rome, ItalyCongress coordinator: Sara GuglielminiTel.: +39 (0)6 88595 211 - Fax: +39 (0)6 88595 234E-mail: s.guglielmini@meridiano.it

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2nd Dietitians workshop on PKU

Serono Symposia International Foundation workshop on:

2nd Dietitians workshop on PKURome, Italy - March 22, 2012

Aim of the workshopDietary restriction of phenylalanine is the mainstay of treatment of phenylketonuria (PKU). Other treatment options (i.e. BH4) usedas an alternative treatment or in combination with diet therapy are also important. Aim of this workshop is to share practice, latestresearch and developments in the dietary management of PKU patients.

Learning objectives• Examine the management of PKU, particularly concerning issues of supplementation and assessment of nutritional status.

• Explore developments, latest research and progress surrounding diet therapy.

• Consider the many issues and challenges of dietary treatment and appraise different management strategies.

• Consider patient education and motivation.

Target audienceDietitians and nutritionists and any health professional interested in the dietary and nutritional management of PKU.

AccreditationSerono Symposia International Foundation (www.seronosymposia.org) is accredited by the European Accreditation Council forContinuing Medical Education (EACCME®) to provide the following CME activity for medical specialists. The EACCME is an institutionof the European Union of Medical Specialists (UEMS), www.uems.net

The conference “2nd Dietitians workshop on PKU” (March 22, 2012 - Rome, Italy) is designated for a maximum of 6 (six) hours ofEuropean CME credits (ECMEC). Each medical specialist should claim only those credits that he/she actually spent in theeducational activity. EACCME® credits are recognized by the American Medical Association (AMA) towards the Physician'sRecognition Award (PRA). To convert EACCME® credit to AMA PRA category 1 credit, please contact the AMA.

Accreditamento ECM per partecipanti italianiSSIF SRL (Società Scientifica di Formazione Internazionale) provider Scientifico No. 13753 ha sottoposto, secondo la prassi indicatadal Ministero della Salute, la richiesta di accreditamento del congresso “2nd Dietitians workshop on PKU” (23-24 marzo - Roma,Italia), n. riferimento provider 13753, n. riferimento evento 12000636 - Medico Chirurgo e n. riferimento 12000637 - Dietista, allaCommissione Nazionale per la Formazione Continua che provvederà a comunicare i crediti formativi concessi per l’evento.

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All Serono Symposia International Foundation programs are organized solely to promote the exchange and dissemination of scientific and medical information. No formsof promotional activities are permitted. There may be presentations discussing investigational uses of various products. These views are the responsibility of the namedspeakers, and do not represent an endorsement or recommendation on the part of Serono Symposia International Foundation. This program is made possible thanks tothe unrestricted Educational grants received from: Centre d’Esclerosi Multiple de Catalunya, ComtecMed, Congrex Sweden, Congrex Switzerland, Cryo-Save, Datanalysis,Esaote, European Society of Endocrinology, Fondazione Humanitas, Fundación IVI, ISFP International Society for Fertility Preservation, ISMH International Society of Men’sHealth, K.I.T.E., Merck Serono, Sanofi-Aventis, University of Catania, Vall d'Hebron University Hospital.

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Learning effectiveness project

The world of CME is changing with many different live and online formats, and Serono Symposia International Foundation(SSIF) is continually trying to improve its CME activities.

With your participation in a structured series of evaluations, SSIF can provide cutting-edge learning activities designed to giveyou the greatest value from the time you invest.

SSIF is running the learning effectiveness project for this meeting.

You will be involved in three main steps:

• During the conference: you will be asked to complete a questionnaire at the beginning and at the end of the workshop toassess the program in various domains.

• Post-event: three weeks after the event we will email you a short questionnaire which will give you the opportunity to tellus how much of what you learned has had an affect on your know-how and daily practice.

• Follow-up: three-months after the event, we will contact you with the final questionnaire.

We will collate and analyse your responses and use the results to improve and develop our ongoing programs.

Of course, we commit to maintaining the confidentiality of the information you provide and we will inform you about the resultsof the process regarding the activity that you attended.

Thank you very much for participating in this project!

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Scientific organizerAnita MacDonald

Dietetic DepartmentThe Children’s HospitalBirmingham, UK

Scientific committeeKirsten Ahring

PKU DepartmentThe Kennedy CentreBagsvaerd, Denmark

Amaya Bélanger-Quintana

Unidad de EnfermedadesMetabólicasServicio de PediatríaHospital Ramon y CajalMadrid, Spain

Katharina Dokoupil

Department of Metabolismand NutritionDr. von Hauner Children's HospitalUniversity of MunichMunich, Germany

Hulya Gokmen-Ozel

Faculty of Health SciencesDepartment of Nutritionand DieteticsHacettepe UniversityAnkara, Turkey

Anna Maria Lammardo

Department of PediatricsSan Paolo HospitalUniversity of MilanMilan, Italy

Anita MacDonald

Dietetic DepartmentThe Children’s HospitalBirmingham, UK

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Kristina Motzfeldt

Department of PediatricsWomen and Children’s divisionSection for specialized medicineand unit for newborn screeningOslo University Hospital,Rikshospitale

Martine Robert

Hôpital Universitaire des EnfantsReine-FabiolaBrussels, Belgium

Júlio César Rocha

Centro de Genética MédicaJacinto de MagalhãesInstituto Nacional de SaúdePorto, Portugal

Margreet van Rijn

Section of Metabolic DiseasesBeatrix Children's HospitalUniversity Medical Center GroningenGroningen, Netherlands

List of speakers and chairmen

Kirsten Ahring

PKU DepartmentThe Kennedy CentreBagsvaerd, Denmark

Amaya Bélanger-Quintana

Unidad de enfermedades metabolicasServicio de PediatriaHospital Ramon y CajalMadrid, Spain

Laurie Bernstein

Inherited Metabolic Diseases (IMD) clinicThe Anschutz Medical CampusUniversity of ColoradoAurora, USA

Annet M. Bosch

Department of PediatricsAcademic Medical Center (AMC) AmsterdamAmsterdam, Netherlands

Katharina Dokoupil

Department of Metabolism and NutritionDr. von Hauner Children's HospitalUniversity of MunichMunich, Germany

François Feillet

Centre de Référence desMaladies Héréditaires du MétabolismeHôpital d’Enfants, CHU BraboisVandoeuvre les Nancy, France

Hulya Gokmen-Ozel

Faculty of Health SciencesDepartment of Nutrition and DieteticsHacettepe UniversityAnkara, Turkey

Shauna Kearney

Department of PsychologyThe Children’s HospitalBirmingham, UK

Anna Maria Lammardo

Department of PediatricsSan Paolo HospitalUniversity of MilanMilan, Italy

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Anita MacDonald

Dietetic DepartmentThe Children’s HospitalBirmingham, UK

Kristina Motzfeldt

Department of PediatricsWomen and Children’s divisionSection for specialized medicineand unit for newborn screeningOslo University Hospital, RikshospitaletOslo, Norway

Júlio César Rocha

Centro de Genética MédicaJacinto de MagalhãesInstituto Nacional de SaúdePorto, Portugal

Friedrich K. Trefz

Medical Centre GammertingenKreiskliniken Reutlingen GmbHGammertingen, Germany

Margreet van Rijn

Section of Metabolic DiseasesBeatrix Children's HospitalUniversity Medical Center GroningenGroningen, Netherlands

Eleanor Weetch

Nutrition and DieteticsNational Society for Phenylketonuria UKand Adult Metabolic DietitianNorthern General Hospital, SheffieldBarnsley, South Yorkshire, UK

Scientific ProgramThursday - March 22, 2012

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08.40 Welcome and introduction

Anita MacDonald (UK)

Chairs: Kirsten Ahring (Denmark)Chairs: Anna Maria Lammardo (Italy)

09.00 L1: Micronutrient intake vs nutritional

biochemistry: does it all add up?

Speaker 1: François Feillet (France) on vitamins

Speaker 2: Anita MacDonald (UK) on minerals

09.50 Roundtable discussion: should we routinely

measure micronutrient markers in all patients with

PKU?

Led by: François Feillet (France)

Led by: Anita MacDonald (UK)

Led by: Júlio César Rocha (Portugal)

10.10 Coffee Break

Chairs: Kristina Motzfeldt (Norway) - Eleanor Weetch (UK)

10.40 Oral presentations: 4 original contributions

OP1: Case Study of R.P.: Managing Levels inToddlers with Diet and SapropterinNicole Pallone (Canada)

OP2: SMS text message reminder service forPhenylketonuria patients to monitorphenylalanine concentrationsSara Boocock (UK)

OP3: Trace Element Status in Adult Patients withPhenylketonuriaSara Boocock (UK)

OP4: A model of comprehension of low Phe diet ina family with PKU childNatalia Usurelu (Republic of Moldova)

Micronutrient status and PKUSession I

Oral presentationsSession II

11.50 Parallel workshops

1. Education and motivation of patients: what

works in PKU?

Laurie Bernstein (USA)

2. Maternal PKU

Eleanor Weetch (UK) Kristina Motzfeldt (Norway)

3. Assessing nutritional status

Júlio César Rocha (Portugal) Hulya Gokmen-Ozel (Turkey)

4. Introducing Sapropterin with diet

Margreet van Rijn (Netherlands) Amaya Bélanger-Quintana (Spain)

12.40 Lunch and rotation of workshop

13.40 Parallel workshops

1. Education and motivation of patients: what

works in PKU?

Laurie Bernstein (USA)

2. Maternal PKU

Eleanor Weetch (UK) Kristina Motzfeldt (Norway)

3. Assessing nutritional status

Júlio César Rocha (Portugal)Hulya Gokmen-Ozel (Turkey)

4. Introducing Sapropterin with diet

Margreet van Rijn (Netherlands) Amaya Bélanger-Quintana (Spain)

Parallel workshopsSession III

14.30 Case studies in PKU

CS1: Dosage of Sapropterin in overweight patients

Katharina Dokoupil (Germany)

CS2: Managing illness with diet and Sapropterin

Hulya Gokman-Ozel (Turkey)

CS3: Managing pregnancy with Sapropterin

Friedrich K. Trefz (Germany)

CS4: Managing a second diagnosis with

Sapropterin

Kirsten Ahring (Denmark)

Comment by expert panel: psychologist, dietitian,

physician

Amaya Bélanger-Quintana (Spain)

Margreet van Rijn (Netherlands)

Shauna Kearney (UK)

15.40 Tea break

Case studiesSession IV

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Chairs: Anita MacDonald (UK) Chairs: Amaya Bélanger-Quintana (Spain)

16.10 L2: Quality of Life vs. strict dietary control? Is one

at the cost of the other?

Annet M. Bosch (Netherlands)

16.50 Workshops round up

17.50 Final conclusions

Anita MacDonald (UK)

18.00 End of the Workshop

Quality of lifeSession V

Workshops round upSession VI

Disclosure of faculty relationships

Serono Symposia International Foundation adheres to guidelines of the European Accreditation Council for Continuing MedicalEducation (EACCME) and all other professional organizations, as applicable, which state that programs awarding continuingeducation credits must be balanced, independent, objective, and scientifically rigorous. Investigative and other uses forpharmaceutical agents, medical devices, and other products (other than those uses indicated in approved product labeling/packageinsert for the product) may be presented in the program (which may reflect clinical experience, the professional literature or otherclinical sources known to the presenter). We ask all presenters to provide participants with information about relationships withpharmaceutical or medical equipment companies that may have relevance to their lectures. This policy is not intended to excludefaculty who have relationships with such companies; it is only intended to inform participants of any potential conflicts soparticipants may form their own judgments, based on full disclosure of the facts. Further, all opinions and recommendationspresented during the program and all program-related materials neither imply an endorsement, nor a recommendation, on the partof Serono Symposia International Foundation. All presentations solely represent the independent views of the presenters/authors.

The following faculty provided information regarding significant commercial relationships and/or discussions of investigational ornon-EMEA/FDA approved (off-label) uses of drugs:

Kirsten Ahring Declared no potential conflict of interest

Amaya Bélanger-Quintana Declared to be member of: Merk Serono PKU European Scientific Advisory board, Europeannutritionist expert panel and Kamper advisory board.

Laurie Bernstein Declared receipt of grants and contracts from Biomarin and Nutricia. Declared receipt of honorariaor consultation fees by Applied Nutrition and Nutricia.

Sarah Boocock Declared no potential conflict of interest.

Annet M. Bosch Declared receipt research grant by Danone. Declared to be member of a company advisory board:Merk Serono and Danone.

Katharina Dukoupil Declared receipt of grants and contract from Merck Serono. Declared receipt of honoraria orconsultation fees by Merck Serono.

François Feillet Declared receipt of honoraria or consultation fees by Geuggue, Biomarin, Merk Serono and Nutricia.Declared to be member of Merck Serono and Nutricia advisory boards.

Hulya Gokmen-Ozel Declared receipt of honoraria or consultation fees by: Merck Serono.

Shauna Kearney Declared no potential conflict of interest.

Anna Maria Lammardo Declared no potential conflict of interest.

Anita MacDonald Declared receipt research grants from Nutricia, Vitaflo, Cambrooke Foods and Merck Serono.Declared to receipt of honoraria or consultation fees by Merck Serono and Nutricia.

Kristina Motzfeldt Declared to be member of European Nutritional Expert Panel in PKU Merck Serono. Declaredparticipation in a company sponsored speaker’s bureau sponsored by SHS International.

Nicole Pallone Declared receipt of grants and contract from Biomarin and declared to be member of CanadianPKU and allied disorders Inc.

Júlio César Rocha Declared receipt of honoraria or consultation fees by Merck Serono. Declared to be member of theEuropean Nutritionist Expert Panel on PKU – Merck Serono.

Friedrich K. Trefz Declared receipt of honoraria or consultation fees by Merck Serono.Declared to be member of EPG and KAMPER advisory boards.

Natalia Usurelu Declared receipt of grants and contracts from Association of Rehabilitation of Children with PKU,Association ”ACASA”, CORDAID and Janivo Foundations.

Margreet van Rijn Declared receipt of grants and contracts from Nutricia. Declared receipt of honoraria or consultationfees by Nutricia and Merck Serono.

Eleanor Weetch Declared no potential conflict of interest.

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Abstracts

L1 - “Micronutrient intake vs nutritional biochemistry: does it all add up?” -- Focused on vitamins

Vitamins intake and nutritional status in PKU

Introduction

The nutritional vitamin status results of the vitamin intake and the bioavailability of the vitamin in relation with the dietary referenceintake for age. As animal proteins act as the principal vectors for many micronutrients, there is a risk for vitamins deficiencies inpatients with a low-protein diet. On another hand, the vitamins supplementation of amino acids mixtures used in inborn error ofmetabolism can exceed the daily requirement because sometimes, this supplementation did not take into account the vitamin intakecoming from the natural proteins. Moreover, some patients can use more than one AA mixture every day, which makes thecalculation of the nutritional intake more and more complex.

The multiplication of the amino acids mixtures

During the last 30 years, the number and the quality of the AA mixtures increased constantly. The macronutrients composition ofthese mixture differ importantly from one AA mixture to another. For example, some very concentrated AA mixture do not containany fat in their composition, but they still have the same content of vitamins A, D and E which are fat soluble vitamins. The absorptionand the bioavailability of such vitamins in a no-fat substitute must be decrease compared with those which would be observed witha fat containing substitute. Today the vitamins composition of the AA mixtures is mainly calculated from the daily recommendedintake or from the legal content of micronutrient for medical food which is determined per 100 Kcal (which is a nonsense for the lowcaloric AA mixtures). This shows that the simple evaluation of the vitamin content of the AA mixture is not sufficient to really estimateits nutritional efficiency of the patients.

The necessity of a yearly nutritional follow-up

Consecutively, there is a real need for a yearly nutritional follow-up of these micronutrients to assess the real nutritional status ofour patients. The assessment of the vitamins nutritional status can be based on the recognition of the (rare) clinical signs of deficiencies of thesemicronutrients and/or on the biological measurement of these vitamins. Excesses in vitamin status are usually determined on thebiological assessment. Most often, this biological assessment is based on the analysis of the plasmatic values of vitamins but theseparameters are not always reliable with the real vitamin status. As an example, retinol status must be calculated in conjugation ofplasma RBP and the α-tocopherol status mainly reflects the plasma triglycerides levels. For some other vitamins as thiamin andriboflavin, the single plasmatic value only reflect the recent intake but not the chronic nutritional status of this vitamin. For someother the analysis of some secondary metabolites (pyridoxal phosphate for B6 or methylmalonic acid for B12) are more reliable todetect a vitamin deficiency but their analysis are less available and more expensive than the simple plasmatic dosage of the vitamin.Despite all these imperfections, the vitamins plasmatic analysis are often the only assessment performed in PKU patients.

The cost of the analysis

These analysis are often very costly, and are not always reimbursed by insurances or national social security. Then all vitamins (andminerals) should not be performed in all patients every year. The vitamins without any safe upper levels or which have never beenshown to be deficient in PKU should be skipped of this nutritional follow up (thiamine, riboflavin, pyridoxin, biotin for example). Someothers must be systematically checked as cobalamin, which has been found deficient in many PKU patients, mainly those who areon a vegan like diet and who do not take any (or not enough) vitamins supplements.

Who must beneficiate of the nutritional follow up?

All patients must have a minimal nutritional assessment every year but some patients have an increase risk of nutritional deficiency,mainly due to the deficiency of animal protein in their diet.For example PKU patients are at risk of developing micronutrient deficiency if:

- They fail to adhere to their phe-free amino acids (AA) mixtures (which contain the vitamins supplements).

- They have mild hyperphenylalaninemia, treated with a low protein diet (containing mainly vegetable proteins without amino acidsmixture)

- They are with BH4 and managed to stop their amino acids mixtures in combination with a low-protein diet mainly composed ofvegetable proteins.

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François Feillet

Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital d’Enfants, CHU Brabois, Vandoeuvre les Nancy, France

Folates, an example of vitamin in excess?

The risk of excess which can be deleterious can exist for some vitamins. Most of the AA mixture contain more or less the total dailyrequirement intake for vitamins and minerals. As an example, the folates content of these mixtures goes from 25 μg/10 g of AA to133 μg/10g of AA. But, as these patients can eat vegetables which have a high content in folates (beans, spinach, asparagus, salad,cereals), the recommended daily intake is often surpassed. If the beneficial effect of folates supplementation has been demonstratedin many situation (Neural tube defects prevention for example) we must also keep in mind that the excess of folates has beenincriminated in facilitating colon cancer. An improvement in the folates composition of some AA mixture could be done to avoid theseexcesses which have no interest and which could be deleterious.

Conclusion

The assessment of the vitamins status in patients treated by a low protein diet is very important. A complete screening must be donein some centers to improve the composition of the amino acids mixtures in the future. For the vast majority of patients, the onlyfollow up of the vitamins which can be deficient seems sufficient for the follow up of the patients and less costly for the society.

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Micronutrients in PKU: trace minerals

In PKU optimal nutrient status is challenging when a substantial proportion of nutrient intake is from non-natural sources. Whennutrients are from artificial sources, defining the optimal intake of each nutrient and estimating their bioavailability is particularlytaxing. Results of studies are difficult to interpret when different biomarkers of nutrient status are tested, varying reference targetranges based on dissimilar diets and populations are used, and adherence to diet and protein substitute is commonly undefined.Relatively little is reported about trace mineral status using protein substitutes based on natural protein sources such asglycomacropeptide, the biochemical and clinical impact of any change in micronutrient composition of protein substitutes thatmanufacturers have made over the years and micronutrient status of different age groups. Three trace minerals/ minerals will bediscussed.

Zinc: protein substitute supplemented with micronutrients is the major source of zinc intake in a low phenylalanine diet. Despitegenerous supplementation in protein substitutes, zinc deficiency is still described. Plasma zinc was low in 25% of 468 samples in a73 patients aged 1 to 17 years of age (MacDonald et al. 2011). Patients were mainly compliant with diet therapy. In PKU, the majorsource of zinc is added to the phenylalanine-free protein substitute; and it is probable that its bioavailability of zinc is sub-optimal.The bioavailability of zinc is affected by the copper, calcium and iron content of the diet, all of which compete for absorption. Reliablevalidated measures of zinc status are unavailable. Plasma or serum zinc is the most commonly used markers but do not necessarilyreflect cellular zinc status.

Selenium: In humans, selenium is an essential component of antioxidant enzymes such as glutathionine peroxidase a trace elementthat functions as cofactor to protect membranes and essential proteins from potentially damaging effects of reactive oxygen andlipid peroxides. The content of selenium in foods depends upon the selenium content of the soil where plants or animals are raised.In the earlier years of dietary management, biochemical selenium deficiency was commonly reported mainly because proteinsubstitutes were not supplemented with selenium. The only reported clinical symptom of selenium deficiency in PKU is a dysrythmicventricular tachycardia in a 9-month old infant (Greeves et al. 1990). Long term BH4 therapy has been associated with improved longterm selenium status in PKU patients. Selenium is measured in plasma, serum, and red cells and by estimating tissue glutathionineperoxidase activity.

Iron: Studies either demonstrate no deficiency or poor status. In iron deficient patients, no correlation has been demonstratedbetween iron intake and any index of iron status.

Assessing vitamin and mineral status: Many factors affect blood sample analysis and its interpretation including blood samplequality, sample storage, and interlaboratory variation, and lack of age specific reference ranges. In addition diurnal variation, fastingstatus, acute infections, inflammatory stress may alter results observed.

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References:

1. Greeves LG, Carson DJ, Craig BG, McMaster D Potentially life-threatening cardiac dysrhythmia in a child with selenium deficiency and phenylketonuria. ActaPaediatr Scand, 1990, 79 (1990): 1259-62.

2. MacDonald A, Lee P, Davies P, Daly A, Lilburn M, Gokmen Ozel H, Preece MA, Hendriksz C, Chakrapani A. Long-term compliance with a novel vitamin andmineral supplement in older people with PKU. J Inherit Metab Dis. 31 2008: 718-23. Epub 2008 Oct 22.

L1 - “Micronutrient intake vs nutritional biochemistry: does it all add up?” -- Focused on minerals

Anita MacDonald

Dietetic Department, The Children’s Hospital, Birmingham, UK

CS1 - Dosage of Sapropterin in overweight patients

This is a case report about a male patient with PKU, 36 years old. His body weight is 127 kg and his height 185 cm resulting in a bodymass index (BMI) of 37 kg/m². He is married and has two healthy children. Currently he works as a male nurse.

For PKU treatment the patient followed a vegetarian diet with no Amino Acid Supplements and a calculated mean daily Phe-intakeof 2500 mg. At this, his blood Phe-levels ranged between 8.2- 11.5 (mean 9.6 mg/dl). Because he complained about increasingconcentration disabilities, Sapropterin was considered as a treatment option. Molecular genetic analysis revealed an unclear BH4-responsive Genotype (N167I/ G272X). However, previous testing for BH4-responsiveness resulted in a Phe-reduction of ≥ 30 %.Hence, treatment with Sapropterin was tried starting with concentrations of 4.7 mg/kg up to 7 mg/kg.

Conclusions

The patient benefits from Sapropterin therapy: A dosage of 7 mg/kg body weight resulted in a relevant (50%) and significant (P <0.001) decrease of blood-Phe levels, and a better neurological outcome without eating a strict low Phe diet. There is no need for AAsupplements and for special low protein food. As consequence of this, outside eating remains easy and comfortable.

Sapropterin dosage is not easy to establish in obese patients with PKU. We suggest to start with a lower dose and then to adapt itstep by step according to the patient's individual needs.

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Katharina Dokoupil

Department of Metabolism and Nutrition, Dr. von Hauner Children's Hospital, University of Munich, Munich, Germany

Table: Phe-levels (from daily collected blood samples) before and under Sapropterin (Phe-intake: 2500 mg/d)

Blood Phe level(mg/dl)

Blood Phe level(μmol/l)

Pre Phase (15.07. - 02.08.2010)

mean 9.6 577.3

range 8.2 - 11.5 492-690

Beginning with Sapropterin 600 mg/d (4,7 mg/kg) (07.08. - 23.08.2010)

mean 6,6 396,9

range 5.1 - 9.0 306 - 540

Increased dose of Sapropterin 900 mg/d (7 mg/kg)(25.08. - 12.10.2010)

mean 4.8 290.1

range 2.9 - 6.6 174 - 396

CS2 - Managing illness with diet and Sapropterin

This case report was aimed to show the effect of BH4 on blood phenylalanine (Phe) level in illness. BS is a 5 years and 2 months oldgirl living in Turkey. There is no consanguinity between parents. She was 2 months old when she was diagnosed with the newbornscreening. Her blood Phe level was 26.6 mg/dL. There was no mutation analysis.

BH4 was given 20 mg/kg/day and blood phe level decreased from 32.92 mg/dl to 16.04 mg/dl at the 48th hour of the test (48%). Shewas BH4 responsive. Daily phe intake was increased 10 mg/kg on a weekly basis after BH4 treatment started and blood phe checkedevery week. Drug was administrated once a day in the morning before breakfast. There was no any concurrent medication.

Her daily Phe intake was 20 mg/kg, daily total protein intake was 1.5 g/kg and daily protein intake from protein substitute was 15.1g. She was on low protein foods, vegetables and fruits and did not use normal bread, rice, pasta and animal foods before BH4

treatment. Her energy intake was around 1300 kcal/day. Her daily Phe intake increased ~ 3 fold to 65 mg/kg with BH4. She was on100 ml milk or yoghurt, 1/2 egg, 25 g meat, normal bread, rice, pasta, fruits and vegetables after BH4 treatment. Her median bloodphe level was 5.39 mg/dL (2.99 to 14.5 mg/dL) when she was on BH4. During the first 11 week of the treatment all blood phe levelswere within normal ranges (median= 4.75 mg/dL). From 12nd week of the treatment blood phe increased to median 7.59 mg/dL.Since she had frequent fewer, urinary tract infection and her blood Phe level increased to between 12 and 14 mg/dL for several times,BH4 was stopped. She was not on free diet and needed 7 g protein from protein substitute before BH4 was stopped.

Her weight-for-age Z-scores (WAZ), height-for-age Z-score (HAZ) and weight-for-height Z-score (WHZ) were 0.35, -0.54 and 1.03respectively before BH4 treatment. Her WAZ and WHZ scores increased to 0.59 and 1.32 respectively (p>0.05). HAZ score (-0.56) didnot change just before BH4 was stopped.

Biochemical nutritional status, cognitive functioning, executive functioning, mood, quality of life was not measured when she was onBH4.

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Hulya Gokman-Ozel

Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey

References:

1 - Chappel SC, Howles C 1991 Reevaluation of the roles of luteinizing hormone and follicle-stimulating hormone in the ovulatory process. Human Reproduction6 1206-1212.

2 - Filicori M, Cognigni GE, Pocognoli P et al. 2003 Current concepts and novel applications of LH activity in ovarian stimulation. Trends in Endocrinology andMetabolism 14, 267-273.

CS3 - Managing pregnancy with Sapropterin

Even evidence based recommendations for pre- and post conceptional phenylalanine (phe) restricted dietary treatment inphenylketonuria (PKU) pregnancies are widely accepted. However, overall treatment success for the MPKU offspring isunsatisfactory. Clinical experiences show that the reasons for are multi factorial. One of these may be the burden of the diet requiringmuch self discipline and organization skills to manage every day life. A better treatment to facilitate control of blood phe between100 and 240 μmol/l (in some countries up to 360 μmol/l) is highly desirable. Sapropterin in tetrahydrobiopterin (BH4) responsivewomen may be an alternative or supportive treatment in those cases where dietary treatment alone is not possible or not optimal.So far there are only single cases published (Koch, et al. 1,Trefz and Blau 2). In our experience indication for using sapropterin beforeconception and during pregnancy are primarily women with hyperphenylalaninemia (HPA) who never had a phe restricted diet beforebecause a diet was not indicated in early childhood. As (mild) HPA may be defined according to blood phe levels between 120 and600 μmol/l, the question comes up when to treat. Blood phe levels <360 μmol/l may be of none or very little risk for fetal outcome(Levy and Waisbren 3). Levels from 360-480 μmol/l are a “gray zone” for MPKU risk management, blood phe levels above 480 μmol/are far beyond the upper treatment target and should be treated.

We report on a women with mild HPA who never was treated during childhood but was at risk for MPKU. In the first pregnancy wetried to introduce dietary treatment but even the mother was very cooperative to manage the diet she did not tolerate it. As acomplication hyperemesis gravidarum occurred and admission to hospital care was necessary. The outcome of the offspring wasperfect. Because of these complications together with potential risk of blood phe levels >360 μmol/l the mother decided not to haveanother child. However, after sapropterin became available also as a treatment in MPKU, the mother accepted to use sapropterin.In a planned pregnancy we started before conception with 100 mg and 200 mg respectively of sapropterin per day (ca. 3 mg/kg BWper day). Blood phe control was in the desired range with a tendency to decrease in the 3rd trimester. Emesis occurred again in earlypregnancy. The baby was perfect (3945 grs, 54 cm, HC 35 cm).

Other indications for using sapropterin are: 1st post conceptional start of treatment to get blood phe levels in the therapeutic rangeas fast as possible, 2nd pregnancy complications as emesis gravidarum, 3rd supportive treatment if the diet is not feasible or bloodphe control is not optimal. So far general recommendations for sapropterin dosages cannot e given. Experiences from ourpregnancy as well from dietary treatment show that in the 1st trimester the dosage must be higher (e.g. 800-1200 mg/day) accordingto 10-15 mg7kg BW per day and may be reduced in the 2nd or 3rd trimester according to blood phe levels, which should be monitored3-4 times per week.

Even there is no evidence for a teratogenic effect of BH4 safety of this treatment must be documented in every single case. ThereforeI strictly recommend to join the International KAMPER register to document course and outcome of every PKU pregnancy treatedwith sapropterin (https://www.kamperstudy.com/). So far three pregnancies are enrolled and we hope with your cooperation for morewomen approving their participation in the register.

15

Friedrich K. Trefz

Medical Centre Gammertingen, Kreiskliniken Reutlingen GmbH, Gammertingen, Germany

References:

1. Koch, R., Moseley, K. & Guttler, F. Tetrahydrobiopterin and maternal PKU. Mol Genet Metab 86 Suppl 1, S139-41 (2005).

2. Trefz, F.K. & Blau, N. Potential role of tetrahydrobiopterin in the treatment of maternal phenylketonuria. Pediatrics 112, 1566-9 (2003).

3. Levy, H.L. & Waisbren, S.E. Effects of untreated maternal phenylketonuria and hyperphenylalaninemia on the fetus. N Engl J Med 309, 1269-74 (1983).

CS4 - Managing a second diagnosis with Sapropterin

Introduction: Since Denmark only recently has started up BH4 treatment, it has so far only been introduced to patients during aproject in 2005. Twelve phenyl keton uria (PKU) patients participated, six males and six females age 8-29 years of age. During thestudy, protein intake was increased to 1g/kg and the patients were supplemented with respectively with 20, 10, and 5 mg BH4/kg/dayfor 1 week on each dose, starting with 20 mg/kg. Blood phenylalanine (Phe) was measured four times a week. A positive responsewas defined as a decline in blood Phe>30%. This case is from this project.

Patient case: Twelve-year old girl was enrolled in the project. She is homozygous for the mutation Y414C and has mild PKU. Shewas diagnosed with insulin depended diabetes mellitus (IDDM) when she was three years old. She has a younger sister with PKU.

Results: The patient responded well to BH4. Average phe levels were as follows:

1) 551 μmol/l with 1g protein/kg during the screening period,

2) 136 μmol/l with 20 mg/kg BH4, 3) 211μmol/l with 10 mg/kg BH4 and 403 μmol/l with 5 mg/kg BH4. The patient’s maximum phelevel on diet with 1 g protein/kg was below 600 μmol/l.

An unexpected and interesting observation was some stabilization and lowering in blood sugar, especially during the week of 20mg/kg of BH4. It was uncertain, if this was coincidence, was related to the changing in diet or there was a real effect of BH4.

Conclusion at the end of the BH4 study: the patient had mild PKU and could probably eat a free diet supplemented with 5 mg BH4/kgand still keep phe levels within range. However, her IDDM was not well regulated. Since PKU diet and diabetes diet is contradictory,the patient was recommended to mainly follow a diabetes diet. To determine the effect of BH4 on blood sugar, further investigationwas necessary. Afterwards, the Kennedy Centre asked the Ethics Committee for extended permission to treat the patient further to investigate theeffect of BH4 at consumption on insulin and blood sugar level. The patient had started on a new type of insulin and blood sugar wasfluctuating. Phe levels were 500-600 μmol/l. The patient started a new 4 weeks trial period with 20 mg BH4/kg and wrote downinsulin and blood sugar. However, the final conclusion was that BH4 did not affect blood sugar level and the consumption of insulin.

16

Kirsten Ahring

PKU Department, The Kennedy Centre, Bagsvaerd, Denmark

L2 - Quality of Life vs. strict dietary control? Is one at the cost of the other?

Phenylketonuria (PKU; MIM 261600) is an autosomal recessive disorder of phenylalanine metabolism caused by a deficiency of theenzyme phenylalanine hydroxylase which, if untreated, results in severe intellectual disability and neurological sequelae. Since the1960s, these complications can be prevented by detection through newborn screening followed by dietary treatment consisting of arestriction of Phe intake by a protein-restricted diet and supplementation of all amino acids but Phe. Adherence to the very strictdiet and maintenance of Phe levels within the advised ranges is highly demanding and poses a burden on the patients and theirfamilies. It may be expected that this therapy has a negative effect on patients' quality of life.

Health related quality of life (HRQoL) is a subjective measure of an individual’s satisfaction or happiness with domains of life thataffect health or are affected by health. Studies evaluating the HRQoL of patients with PKU do not demonstrate an absolute negativeeffect of having PKU on the HRQoL of the patients (1-5) . However, many patients feel that these normal HRQoL results do not dojustice to the efforts they make to obtain an as normal as possible life.

Relaxation of the strict diet may well improve the quality of life of the patients.. However, in children this would have a detrimentaleffect on the cognitive abilities of the patients. Dietary relaxation for adults might be considered safe on the basis of the observationthat discontinuation of the diet does not cause a major decrease in IQ in adults (6) However, executive function deficits, associatedwith concurrent high phenylalanine levels, have been observed in both children and adults (7,8) Furthermore, a placebo controlleddouble blind study demonstrated a clear association between high blood Phe levels and poor mood (9).

While relaxation of the diet may have a positive effect on the quality of life of the patients by granting them more freedom in theirlives , the resulting high Phe levels have a significant direct negative effect on mood and neuropsychological performance in adultpatients with PKU. Patients should be educated that potential advantages of going off diet should be balanced against a negativeinfluence on mood, in addition to the consequences of attention failures. A Phe restricted “diet for life” might be an advisable optionfor many.

17

Annet M. Bosch

Department of Pediatrics, Academic Medical Center (AMC) Amsterdam, Amsterdam, Netherlands

References:

1. Weglage J, Funders B, Wilken B, Schubert D, Schmidt E, Burgard P, Ulrich K.(1992) Psychological and social findings in adolescents with phenylketonuria. EurJ Pediatr;151(7):522-5.

2. Landolt MA, Nuoffer JM, Steinmann B, Superti-Furga A (2002) Quality of life and psychologic adjustment in children and adolescents with early treatedphenylketonuria can be normal. J Pediatr. 2002 May;140(5):516-21.

3. Bosch AM, Tybout W, van Spronsen FJ, de Valk HW, Wijburg FA, Grootenhuis MA (2007) The course of life and quality of life of early and continuously treatedDutch patients with phenylketonuria. J Inherit Metab Dis. 2007 Feb;30(1):29-34.

4. Simon E, Schwarz M, Roos J, Dragano N, Geraedts M, Siegrist J, Kamp G, Wendel U (2008) Evaluation of quality of life and description of the sociodemographicstate in adolescent and young adult patients with phenylketonuria (PKU). Health Qual Life Outcomes. Mar 26;6:25.

5. Mütze U, Roth A, Weigel JF, Beblo S, Baerwald CG, Bührdel P, Kiess W (2011)Transition of young adults with phenylketonuria from pediatric to adult care. JInherit Metab Dis. Feb 9.

6. Burgard P (2000) Development of intelligence in early treated phenylketonuria. Eur J Pediatr 159:S74–S79

7. Huijbregts SC, De Sonneville LM, Licht R, Van Spronsen FJ,Sergeant JA (2002) Short-term dietary interventions in children and adolescents with treatedphenylketonuria: effects on neuropsychological outcome of a well-controlled population. J Inherit Metab Dis 25:419–430

8. Schmidt E, Rupp A, Burgard P, Pietz J, Weglage J, de Sonneville L (1994) Sustained attention in adult phenylketonuria: the influence of the concurrentphenylalanine-blood-level. J Clin Exp Neuropsychol 16:681–688

9. ten Hoedt AE, de Sonneville LM, Francois B, ter Horst NM, Janssen MC, Rubio-Gozalbo ME, Wijburg FA, Hollak CE, Bosch AM (2011) High phenylalanine levelsdirectly affect mood and sustained attention in adults with phenylketonuria: a randomised, double-blind, placebo-controlled, crossover trial. J Inherit Metab Dis.2011 Feb;34(1):165-71.

OralPresentations

OP1 - Case Study of R.P.: Managing Levels in Toddlers with Dietand Sapropterin

The mainstay of PKU treatment is a phe-restricted diet; however, new studies show that the diet alone may not prevent significantproblems in some PKU individuals including poor mylenation of the brain, white matter anomalies and lower bone density, evenwhen good metabolic control is maintained. Compounding the issue, diet compliance is a very real problem.

Advances in PKU treatments are being introduced and studied around the world. Parents of PKU babies are assured of “good”outcomes but are looking for access to sapropterin and hopeful for future treatments such as Peg-Pal. Patient Pallone’s parentsweighed the pros and cons of entering their child in a research trial, and chose to buck the “guinea pig” stereotype.

At birth a BH4 load resulted in a drop in her blood-phe level. Patient Pallone at 20 months had phe levels that were stable butoccasionally fell outside the clinical target (120-360 μmol/L). She was enrolled in the PKU-015 study in Vancouver, BC andsapropterin has lowered her blood-phe levels so that they are consistently between 120-240 μmol/L while at the same time doublingher daily phe tolerance.

A significant concern of her parents was how to manage the increased phe tolerance without normalizing her diet – a potentialdisaster given the current lack of government funding and the high price of sapropterin. The Pallone’s have managed to increasePatient’s natural protein yet eliminate the possibility of needing to cut out foods at the end of the study, if funding for sapropterin isstill not available.

19

Nicole Pallone

BC Children’s Hospital, Vancouver, Canada

References:

1 - Chappel SC, Howles C 1991 Reevaluation of the roles of luteinizing hormone and follicle-stimulating hormone in the ovulatory process. Human Reproduction6 1206-1212.

2 - Filicori M, Cognigni GE, Pocognoli P et al. 2003 Current concepts and novel applications of LH activity in ovarian stimulation. Trends in Endocrinology andMetabolism 14, 267-273.

The graph shows patient’s response to a BH4 load done at BC Children’s Hospital, Vancouver, BC, Canada on day 4 of her life, beforethe low-phe diet was implemented.

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OP2 - SMS text message reminder service for Phenylketonuriapatients to monitor phenylalanine concentrations

Background

It is advocated that adults with Phenylketonuria (PKU) monitor their own blood phenylalanine concentrations monthly (MRC 1993).The aim of this service development project was to improve adherence with blood taking by sending a monthly reminder SMS textmessage.

Methods

A monthly SMS text message reminder was set up via the hospital data base. All adult PKU patients (aged 16y and over) from onePKU centre were sent an invitation letter to join this project. An automatic monthly text message was sent reminding each patientto take a blood spot sample. The number of blood spot samples sent one year before and one year after the message service startedwas audited.

Results

32 patients with PKU (aged 16y and over) consented to the reminder service. 7 patients were excluded, 25 patients were studied. Atotal of 71 blood spot cards were received in the 12 months before the service started, with an increase of 65% to 117 (p=0.030) bloodspots in the 12 months after the reminder texts service started. The patients were split into 4 groups: a) patients that increased the number of blood spots performed by 2 or more, b) patients thatperformed the same amount, one more or less, c) patients that decreased the number of blood spots by 2 or more, and d) patientsthat performed 0 blood spots before and 0 afterwards.

Conclusions

The SMS text message reminder did increase the amount of blood spot cards sent in for analysis. There was an increase in 20% ofpatients sending in monthly blood spots (10+). The reminder service appeared to help patients who were more adherent with theirdiet therapy at the start of this intervention.

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Boocock S. 1, Robertson L.V. 1, MacDonald A. 2 and Geberhiwot T. 1.1 University Hospital Birmingham NHS Foundation Trust, UK.2 Birmingham Children’s Hospital NHS Foundation Trust, UK

Median phe Phe rangeGroup Patients over 2 years over 2 years

(μmols/l) (μmols/l)

a 11 (44%) 595 260-1055

b 8 (32%) 890 570-1475

c 3 (12%) 700 685-940

d 3 (12%) N/A N/A

Amount ofNumber of patients Number of patients

blood spotssending in blood spots sending in blood spotsbefore the intervention after the intervention

0-3 17 (68%) 13 (52%)

4-6 4 (16%) 3 (12%)

7-9 3 (12%) 3 (12%)

10+ 1 (4%) 6 (24%)

OP3 - Trace Element Status in Adult Patients withPhenylketonuria

Introduction

Little has been reported about the trace element status of adults with Phenylketonuria (PKU). We reviewed the plasma zinc andselenium status of a group of adults with PKU.

Materials and Methods

Non-fasting plasma zinc and selenium concentrations were reviewed for patients with PKU (>16 years) over a 2 year-period. Onezinc/selenium was recorded on each patient. Maternal patients and patients treated with Sapropterin were excluded. The patientswere divided into 3 groups:

1) Patients on dietary treatment with approximately 70% of blood phenylalanine concentrations < 700 μmol/l.

2) Patients on dietary treatment with approximately 70% of blood phenylalanine concentrations > 700μmol/l.

3) Patients not on dietary treatment.The median non-fasting plasma zinc and selenium concentrations and the percentage of results outside the reference ranges(selenium: 0.9-1.7μmol/l and zinc: 11-24μmol/l) were compared.

Results

Forty-nine (of 111) adult patients with PKU had one plasma zinc and selenium concentration measured in the previous 2 years.

Plasma selenium results were more likely to be below the reference range in patients with blood phenylalanine concentrations<700. Over 50% of plasma zinc concentrations fell below reference range in all patients. Patients off diet were more likely to havezinc concentrations below the reference range.

Conclusion

Low plasma zinc and selenium concentrations are common in adult patients with and without dietary treatment. This may beassociated with inadequate zinc and selenium in phenylalanine–free protein substitute, poor adherence with protein substitutes,poor quality diets if off diet or low bioavailability of trace minerals. Further work is needed in adults to assess longitudinal traceelement status, clinical deficiency and any practical solutions in adults with PKU.

21

Boocock S. 1, Robertson L.V. 1, MacDonald A. 2 and Geberhiwot T. 1.1 University Hospital Birmingham NHS Foundation Trust, UK.2 Birmingham Children’s Hospital NHS Foundation Trust, UK

1 49 0.83 71 10.7 55

2 31 0.94 40 10.7 67

3 20 1.04 30 10.1 89

% oftotal patients

Median PlasmaSelenium Concentration

(μmol/l)

Selenium below ref range

(%)

Median PlasmaZinc Concentration

(μmol/l)

Zinc below ref range

(%)

Group(see method)

OP4 - A model of comprehension of low Phe diet in a family withPKU child

1 The National Center of Reproductive Health and Medical Genetics, Chisinau, Republic of Moldova; 2 State University of Medicine and Pharmacy ”N. Testemitsanu” Pediatric Department, Chisinau, Republic of Moldova; 3 State University of Medicine and Pharmacy ”N. Testemitsanu” Biochemical Department, Chisinau, Republic of Moldova; 4 The Institute of Physiology and Sanocreatology of Academy of Science of Moldova, Republic of Moldova.

Dietary restriction of phenylalanine (Phe) is the mainstay of treatment of phenylketonuria(PKU). The low-Phe diet applied to PKUchildren is very complicated and it becomes more difficult within the families with PKU children, when the entire family mustrenounce to the usual lifestyle and accept a new alimentary, behavioral and educational culture.

Methods

We followed the trainings of parents with PKU children (30 families) within the activities of “PKU School” and the furtherencouragement of the family with the support of a multidisciplinary team (doctor, dietitian, psychologist, social worker, lawyer).

Results

We suggest the steps of comprehension of low-Phe diet by a PKU child:

I – 0-9 months, when the parents have a meal separately of their child;

II – 9-15 months – the child is fed before the common meal;

III – 15-24 months – the parents consume the same food as the child and serve it at the same meal;

IV – 24-36 months – the parents and child eat at the same meal different plates.

Thus, the PKU child at 3 years old becomes educated of his diet. The children can go to kindergartens and schools of general profile,respecting their diet after the following model: breakfast and supper are served at home, the dinner and lunch- at the kindergarten.The meals may be prepared by trained parent, improving such the effectiveness of diet control.

Conclusions

In this way, the parents can be involved actively in the labor market. The integration into society begins in the family improving thequality of life of PKU children.

The project “PKU School” was sustained by Association of Rehabilitation of Children with PKU and Association ”ACASA” (Moldova)and financial support of CORDAID and Janivo Foundations (Holland) during 2002-2007.

22

Usurelu, N. 1; Sacara , V. 1; Tsourea, V. 2; Lysyy, L. 3 and Garaeva, S. 4

NOTES

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NOTES

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Improving the patient's life through medical education

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