Saturday, May 28, 2011
As a result, HD families face enormous caregiving and financial burdens, ones that neither governmental agencies nor disease organizations yet adequately relieve. (A pending bill in Congress, as described below, could help significantly.)
From the time of my HD-stricken moster's apparent early symptoms in the late 1980s until her death in 2006, I watched her lose the ability to walk, converse, and eat.
Fortunately, my “HD warrior” father could care for her. Ten years her senior, he retired around the time that she began to need full-time care. She mainly sat at home, rode around with him in the car, ate with him at restaurants, and attended Sunday Mass. They did slow walks around the local indoor mall, first with Dad helping support her so that she wouldn’t fall, then with her using a walker, and finally with her in a wheelchair.
At home, Mom started to fall more frequently. Once she broke a wrist. Another time she hit her head on a piece of furniture, opening a gash that required five staples. In August 2005, we agreed to put her in a nursing home.
Until that point, my parents had gotten by financially on their modest retirement savings and Social Security.
They had enough money for several years of care at the nursing home, but the monthly nursing home bills of several thousand dollars began to rapidly deplete their savings. They would have to spend virtually every penny before she could qualify for Medicaid.
Her death cut short the need to seek public assistance. My father lived almost four more years, able to survive on his savings and Social Security.
Worries about the future
Now my family also faces potential financial difficulties.
In 1999, I tested positive for HD. Now, at 51, I have reached my mother’s age of disease onset. I am doing my best – via exercise, meditation, and supplements – to stave off symptoms. Still, when those symptoms inevitably start, I could lose my job, causing a dramatic drop in family income. Frugality has long been the name of the game in our home.
To prepare for the worst, in recent years we have built a Huntington’s disease “war chest” by saving between 15 and 20 percent of our income. Our daughter turns eleven next month, so we’ll also need to tap those funds for her college education.
Once I become symptomatic, we will have to apply for Social Security disability and Medicare benefits.
Inadequate nursing homes
Often I am painfully reminded of my family’s situation and the urgent need for financial and caregiving assistance for our HD families.
Recently, my fellow HD advocate Frances Saldaña of Fountain Valley, CA, unburdened herself to me about her family’s struggles.
Frances’s first husband died of HD, and her three children developed juvenile Huntington’s disease. Her youngest child, Marie, died in late 2009 at the age of 32.
Michael, 38, lives in a care facility in the infamous, crime-plagued Los Angeles neighborhood of Watts, far from Fountain Valley, which is in Orange County.
“It’s the only place that would take him,” Frances told me over the phone after we discussed advocacy for the Huntington’s Disease Parity Act of 2011, a bill in Congress that would make it easier for HD patients to obtain Social Security and Medicare benefits.
In Orange County, all of the care centers she approached refused to take in Michael because of their inability to work with HD patients.
“‘They require too much work, and we don’t have the staff,’” Frances explained, quoting the comments of care administrators about HD patients.
Frances says these facilities are violating the law by refusing to live up to the contracts they sign with the State of California, which prohibit discrimination against patients in facilities that receive Medi-Cal funds (the name for Medicaid in California).
To my knowledge, nobody in the HD community has had the time or expertise to seek redress from the state.
A family drained by HD
I met Frances’s oldest child Margie Hayes when the mother-daughter team advocated for HD stem-cell research at a meeting of the California state stem-cell agency in December 2007. Margie already had noticeable symptoms such as chorea (shaking and trembling), although she could still speak clearly. Everybody in the room was moved by their presentation.
Margie Hayes (right) speaks at California stem-cell meeting in 2007 as mother Frances Saldaña looks on (photo by Gene Veritas).
Now 41, Margie struggles with her worsening symptoms. For more than a year, Frances and other relatives have pooled resources to hire a private caregiver to watch over Margie eight hours per day. Because Margie is not her legal dependent, Frances cannot deduct her contribution on her tax returns.
“Her husband is so drained,” Frances said of Craig Hayes’ attempt to care for his wife at their home. “He doesn’t have the energy to do this anymore. He quit his job in Huntington Beach, which paid a lot more, so he could be close to Margie and the kids.”
Craig comes home at midday to give Margie her medications and feed her lunch.
“Not very many men would put up with this," Frances said. "She gets feisty and has behavioral issues when things don’t go her way."
On one occasion, Craig had to hold Margie to prevent her from running out of the house, Frances told me.
“She’s totally disabled,” Frances continued. “She can’t talk anymore. She’s just mumbling. She can’t walk without anybody holding on to her. She has grimacing on her face. She refused a wheelchair.” The family must chop Margie’s food into small pieces so that she can safely swallow it.
In early April, Margie fell in the bathroom, slicing her skin open on a metal rail. She required 30 external and internal stitches. Yet, according to Frances, the emergency room personnel missed another laceration on the crown of Margie’s head. Only later, when the home caregiver was brushing Margie’s hair, did that cut become apparent. A crust of dried blood had formed, causing it to heal on its own. Luckily, Margie didn’t fracture her skull or have internal bleeding, Frances said.
The battle for Social Security
For years, Frances has championed the cause for improved facilities for HD patients in California, but to little avail. The family again faces the extremely difficult challenge of finding a care facility, this time for Margie.
Despite her advanced HD, Margie has not gotten Social Security disability payments. According to Frances, Craig became too overwhelmed to successfully complete the long and bureaucratic application process. Frances, too, feels overwhelmed and wishes she had more time to devote to the matter. Those funds would help defray the cost of Margie’s care.
She pointed out the need for the Huntington’s Disease Society of America (HDSA) to provide legal services for people in her situation.
After seeing three children devastated by HD, Frances is anxious about her grandchildren, who have not been tested.
“The clock is ticking,” she told me. “These kids are getting older. If they have the mutant protein, we still don’t have a treatment. The research has to move faster.
“I gave up on the care being there for my children about four or five years ago. My goal now is to make them comfortable. I hope to God that my grandchildren are not carrying it.”
Losing a home
James Valvano, a 39-year-old Florida patient with early symptoms, has received a doubly harsh dose of HD reality: he lost his business – and now his home. James has produced an important film on HD titled The Faceless Faces of Huntington’s Disease (click here to read more).
“My partner and I lost our home (of 14 years) and have moved in with my parents,” James wrote me a couple weeks ago. “Although something of this magnitude would normally ‘crush’ someone, we have decided to look at this in a positive light.
“Since my diagnosis in 2009, and the fact that I had to let my small business go, financial burdens continued to become overbearing.We will be fine, and I believe there is a reason for everything. I have to apologize for not getting back with you (let alone keeping in touch), however I became overwhelmed by life's curve-balls, and the simple fact that we were struggling to stay afloat."
James has tried to find the bright side. “The saving grace to all of this is the wonderful people within our … community, and my Film Team," he wrote. "I was not willing to let financial hardship destroy what we had worked on for two years ... nor was I going to let the anxiety and depression drown me.”
James Valvano (personal photo)
James receives Social Security disability income and, with the standard two-year waiting period about to expire, will also get Medicare benefits. (The above-mentioned HD Parity Act would eliminate that waiting period.) James’s partner was let go from his job at British Petroleum. For a number of months the couple tried to get by on just $1,000 a month.
“It came down to not having enough money to pay the mortgage, and the mortgage company would not work with us to refinance the house at its current value,” James continued. “We had a lawyer who was keeping them ‘at bay,’ but due to financial (constraints), we were unable to continue to pay him (the lawyer). So, we just decided to pick up and leave.”
Too big a hole to fill
In situations like those faced by Margie and James, HD families often have nowhere to turn.
“Why in this world is there no organization out there to financially set up or give help to HD families?” one woman lamented in an HD discussion group on Facebook.
In an interview on May 19, I put this question to Louise Vetter, the CEO of the Huntington’s Disease Society of America, based in New York City.
“The Board (of Trustees) has actually talked quite a bit about it, because it is something that I’ve heard from the day that I joined,” said Louise, now in her third year at the HDSA helm after nine years working for the American Lung Association. “Certainly the financial impact of HD is unique and particularly devastating.
“Unfortunately, it’s a hole that we just can’t fill, due to our (limited) resources and the overwhelming financial need. How would we choose that somebody’s rent is worth paying and somebody else’s isn’t? It really comes down to that. The board has struggled with this and felt that we cannot be a financial service organization at this time and still meet the other needs of our mission.”
HDSA’s annual budget is approximately $8.5 million, with roughly one quarter going for administration and fundraising and the rest for education, research, and the local Centers of Excellence for Family Services and Research.
The organization continues to rely mainly on affected families for its donations.
“There are a lot of smaller foundations that will provide support in specific communities,” Louise continued in reference to the dire needs of HD families. However, most national health non-profits do not provide such assistance.
May 31: HDSA’s call-in day to Congress
So, for now at least, HD families must depend on public assistance.
Louise pointed out that HDSA staff members can assist family members with questions about government benefits such as Social Security and Medicare. HDSA’s number is 800-345-HDSA (4372).
To help get benefits faster into families’ hands, HDSA and its many volunteer advocates in the field are making a big push to pass the HD Parity Act.
As of May 27, 2011, 67 members of the House of Representatives and four Senators had co-sponsored the Act.
In mid-May, HDSA announced the key support for the bill from Sen. Charles Schumer (D-NY), who is a member of the powerful Senate Committee on Finance and its Subcommittee on Social Security, Pensions, and Family Policy.
On Tuesday, May 31, HDSA is sponsoring a national call-in day. The organization requests that all HD families, friends, and supporters call uncommitted senators and representatives and urge them to co-sponsor the bill.
To learn more, click here. Also watch the interview on the bill that I conducted on May 19 with HDSA advocacy manager Jane Kogan.
The call-in day is the HD community’s S.O.S. to Congress and the country. Families like the Valvanos and the Hayeses need our help. Because their burden is so huge, society needs to lend a hand.
Passage of the HD Parity Act of 2011 would provide a tremendous boost to HD families and the cause in general.
Remember: please call your representative and senators on May 31!
Wednesday, May 25, 2011
For me, it was like holding the most valuable substance in the world. I inherited the HD-causing gene from my mother, who died of the disease in 2006 at the age of 68. At 51, I have now reached the age when HD started destroying my mother’s brain, erasing her personality, and leaving her unable to walk, talk, eat, or care for herself in the most basic way.
HD is 100 percent genetic: unless drug hunters get a treatment on the market in the next few years, I will get symptoms.
As I held what seemed like a magic compound, held in a small, securely capped plastic container, I smiled. A treatment – and maybe even a cure – now seemed more possible than ever. And Alnylam – along with its partners Medtronic and the CHDI Foundation, Inc., the so-called “cure Huntington’s disease initiative – is indeed preparing intensively to start a clinical trial.
A shot of me holding the potential cure (photo by Dr. Mathias Kretschmer of Alnylam).
This was a historic moment. As I stood in the lab at the Alnylam (pronounced “al-NIGH-lam”) facility, I thought of all the years that our community of affected families and treatment-seeking researchers had waited for scientific breakthroughs.
I, the gene-positive HD person, caught a glimpse of a future filled with hope, even as I recognize that hope depends on further scientific breakthroughs and long odds. In the drug industry, 90 percent of clinical trials fail to produce a treatment.
ALN-HTT: white and flaky
“ALN-HTT” is the name Alnylam has given this candidate drug product, which is a solution containing the drug substance, the term scientists use for the active ingredient in drugs. It stands for “Alnylam” and “huntingtin,” the name of both the gene and protein that, when defective, cause HD.
The substance – an “siRNA,” or small interfering RNA molecule – is white and flaky.
ALN-HTT in the hands of Dr. Muru Murugaiah, an Alnylam principal scientist, in the company's lab (photo by Gene Veritas)
RNA interference (RNAi) was discovered in 1998 by Craig Mello and Andrew Fire in C. elegans, a species of worm. By interfering with the conversion of the genetic code into specific proteins, RNAi controls helps control the expression of genes and prevents problems from occurring in cells.
For their discovery, in 2006 Mello and Fire won the Nobel Prize in Physiology or Medicine.
At the outset, they and other scientists thought RNAi could not occur in mammals or humans.
Then, in the early 2000s, two teams of German scientists discovered that RNAi did indeed exist in cultured human cells (cells outside the body). In a presentation at the Dana Farber Cancer Institute this past January, Alnylam demonstrated that RNAi also exists in humans.
This process is also known as “gene silencing.” RNAi can turn off practically any gene in the body. The discovery of RNAi virtually coincided with the completion of the Genome Project, which identified every gene in the human body.
Immediately, scientists embarked on making siRNAs to turn off harmful genes. Drug discovery companies in Europe and the United States sprung up to explore this breathtaking technology, seen by many as the genesis of a new, very large class of drugs for halting all kinds of disease.
Nobel laureate Phil Sharp started Alnylam in 2002. The company took its name from the middle star in the belt of the constellation Orion. “The star has a luminosity that is 250,000 greater than the sun, representative of the potential strength that RNAi therapeutics could bring to bear in human health,” the company states on its website.
No company has yet put an RNAi drug onto the market, but Alnylam is hoping to be the first. The company has a staff of about 175 and partners with large pharmaceuticals in the search for RNAi remedies. Last year Alnylam ended a five-year partnership with Swiss pharmaceutical giant Novartis, forcing Alnylam to lay off 25 employees, but Novartis continues to pursue drug possibilities using Alnylam experimental treatments. Alnylam has more than $300 million in cash to support its activities.
Alnylam research focuses on a range of diseases and conditions, including liver cancers, respiratory syncytial virus infection (affecting the lungs and breathing passages), ultra-high cholesterol, refractory anemia, and transthyretin-mediated amyloidosis. It also facilitates research on neglected tropical diseases. The company is working on five RNAi products for genetic diseases and aims to have them in advanced stages of clinical development by the end of 2015.
Aiming for a clinical trial
In 2005, Alnylam initiated a major Huntington’s disease research project, aiming not only to address HD but also to develop techniques that might prove useful against other neurological diseases. Because HD is 100 percent genetic, it provides an excellent test for the effectiveness of gene silencing.
Alnylam intends to use ALN-HTT to silence the huntingtin gene so that less huntingtin protein is produced to harm brain cells. If successful, the treatment would save brain cells from dying and slow down and possibly even reverse the course of Huntington’s disease.
Model of how siRNA drugs work: click to enlarge (Alnylam image)
A number of research labs have already demonstrated safety and effectiveness of this approach in transgenic mice that have HD-like symptoms. In preliminary studies, it’s also safe in monkeys.
The next step is a big one. Alnylam, Medtronic, and CHDI are preparing to apply in 2012 to the U.S. Food and Drug Administration (FDA) for permission to conduct a Phase I clinical trial of ALN-HTT in humans. Alnylam hopes to start the trial in a small number of HD patients once the application is accepted.
The goal of Phase I studies in general is to demonstrate safety and tolerability – that the drug does not cause adverse impacts. If successful, Alnylam would then proceed to Phases II and III, which would be designed to demonstrate the effectiveness of the drug.
Entering uncharted territory
This is all uncharted territory for the FDA, doctors, researchers, the biotech industry, and investors. Safety for the test subjects is of the utmost importance – but so is the need to find a treatment for those families facing the horrors of HD.
Getting ALN-HTT into the brain is a major scientific and medical challenge. Because of the blood-brain barrier, which protects the brain against foreign substances, many drugs cannot get into the brain. So a drug like ALN-HTT must be injected directly into the brain.
So, for the first time in history, doctors will attempt to treat a brain condition by implanting a device into the skull in order to inject a siRNA drug.
Doctors have already experimented with deep-brain stimulation by implanting electrodes into the brains of patients with Parkinson’s, epilepsy, dystonia, depression, and even HD, explained Dinah Sah, Ph.D., the head of the Alnylam HD team and Vice President of Research. The procedure has shown some benefit in Parkinson’s, but no known effect yet in HD.
Dr. Dinah Sah, Vice President of Research and the head of the Alnylam HD team (photo by Gene Veritas)
Recently a clinical trial demonstrated improvement in Parkinson’s patients who received gene therapy in which a virus was used to transport the genetic message into brain cells.
Physicians have also injected a cell growth stimulant (growth factor) into the brains of Parkinson’s patients. This last approach is still under study.
Alnylam has partnered with Medtronic, a leading maker of medicinal pumps, to devise a pump to be placed in the HD patients’ abdomens. Doctors will run thin tubing under the skin from the pumps to a nodule at the top of the patients’ heads, and from that point a very fine needle will run into the putamen, one of the regions of the brain most devastated by HD.
For all of this to happen, expert doctors in the procedure will conduct an operation on the clinical trial participants. Doctors will then administer ALN-HTT, which will be dissolved in a special solution, by filling the pump and allowing it to send the drug to the brain according to a schedule and in doses to be determined by the researchers.
This is all just a very brief sketch of the Alnylam project. Soon I will be writing more detailed reports, which will examine how Alnylam and its partners developed ALN-HTT and hope to turn it into a successful drug to treat Huntington’s disease. These reports will also consider the many challenges involved in this quest for an siRNA treatment.
Remember, too, that Alnylam is not the only project seeking to control HD at its genetic roots. As I have noted in several articles since 2008, Isis Pharmaceuticals, Inc., of Carlsbad, CA, has devised a similar drug candidate to be applied directly in the brain (click here to read more). And Dr. Jan Nolta’s lab at the University of California, Davis, is experimenting with ways to use stem cells to introduce siRNA into the brain. For an overview of HD and gene silencing, see the excellent article by Dr. Jeff Carroll.
Isis and Alnylam operate a joint venture, Regulus Therapeutics, to research microRNAs, an even more recent discovery also involving RNA interference.
HD researchers aren’t banking on any one of these initiatives as the sole solution to HD. Although one of them could indeed turn out to be the “cure,” most researchers speak of the likely need for an HD “cocktail” of drugs that would stop or at least reduce the many harmful effects on the brain caused by HD.
Seeking patient input
To assist with the HD project, last November Alnylam signed an agreement with CHDI, a multi-million-dollar effort backed by an anonymous donor. CHDI is pumping money into the project and lending its expertise in Huntington’s disease.
The crucial CHDI collaboration will reinforce Alnylam’s efforts to design a safe Phase I trial.
To that end, Alnylam is also seeking to learn more about the patients and gene-positive people whom it hopes to benefit.
After watching my keynote speech at CHDI’s Sixth Annual HD Therapeutics Conference in Palm Springs, CA, on February 7, Dr. Sah invited me to give a similar presentation at the company. My May 17 visit inaugurated a new Alnylam initiative to involve patient advocates in order to put a human face on the conditions they seek to alleviate.
During the Q & A after the speech, attended by about 50 people, Alnylam executives and scientists were anxious to hear my opinion about several aspects of clinical trials.
The desire to function normally
One scientist wanted to know what people affected by HD community would consider to be a successful treatment. Obviously we all want a “cure” that completely eliminates the disease, I responded. But short of that, we need something that would at least allow us to continue to function normally. If someone suffered from chorea (the shaking and trembling caused by HD), a good drug would at least prevent that person from also losing the ability to think and speak.
We also need a drug that would prevent HD from erasing an individual’s personality by preventing the behavioral, emotional, and cognitive problems. HD, I said, had stolen my mother’s personhood.
One doctor asked: what if we fail and no treatment results from this experiment?
I responded that I recognized that failure is a part of science. You don’t know if something will work unless you try it, and if it fails, then you know it’s time to proceed to other alternatives.
However, I told the audience that I personally do not think about failure. The project must succeed! At that, many people nodded enthusiastically, and one of the executives said: “We agree with you!”
At that moment, I felt a special bond with everybody in the room. We were all rededicating ourselves to the quest for the cure – although everybody also recognized that failure remained a distinct possibility.
Avoiding hurdles, gaining speed
Afterwards I met with CEO John Maraganore, Ph.D., President and COO Barry Greene, Dr. Sah, Doug Macdonald, Ph.D., of CHDI, and Jules Greenwald, the development director for the Huntington’s Disease Society of America (HDSA). I took the opportunity to interview Maraganore and Greene.
Both stressed the need to prepare an effective Phase I application to the FDA and to convince the agency of the urgency of getting an siRNA treatment to HD patients.
“It’s important for us to have a dialogue, which includes patient advocates, with the FDA and other regulatory agencies, so that they appreciate the significant burden that the disease has on patients and their families,” Greene said.
“I think they know the disease, but they don’t really know the face of the disease,” Dr. Maraganore said.
Much of the upcoming discussion with the FDA will revolve around the question of how fast Phase II and Phase III of the trial can go. If the FDA requires an extremely long efficacy study – from seven to ten years – the costs could become prohibitive and scare off funding sources, like investors, Greene explained. For patients and success, “speed really matters,” he said.
Another crucial question involves determining “endpoints.” In this case, an endpoint would be an observable change in a specific symptom and/or a change in the level of defective protein in the brain cells or some other marker of the drug’s effects (biomarkers).
Measuring huntingtin protein levels would likely prove the quickest endpoint, although it’s not clear if a lower level of huntingtin in humans will diminish symptoms the way it has in mice.
“We … want to have a testing approach that doesn’t create undue hurdles to the point where you actually make it so difficult to prove that something is maximally safe and maximally effective,” said Dr. Maraganore in summarizing the challenges. “So you want to have the right balance.
“The urgency? The need? I think you said it: You have more to lose now than ever,” he continued, referring to my race against time as I await a treatment. “That’s the level of urgency that needs to be put into this equation in terms of how these medicines are developed. That can only be said by a patient."
Hanging out with the scientists
My day at Alnylam was one of the most intense of my entire life. This article doesn’t even scratch the surface of what I experienced.
But Alnylam also planned some relaxation.
I enjoyed hanging out with the scientists at lunch and dinner, and I was impressed by their humanity and openness to new and different perspectives.
I had contemplated removing from my speech a mini-meditation exercise involving a demonstration of deep breathing, and also my discussion of the question of God, HD, and the Jesuit priest-scientist Teilhard de Chardin. But I was glad I didn’t. To my great surprise and joy, Sara Nochur, Ph.D., the Vice President for Regulatory Affairs, had read Teilhard’s works, and her husband had just completed a book on the topic of the link between science and the transcendental and also knew Teilhard’s writings. As we walked back in the rain to the office, Dr. Nochur and I compared notes on meditation and breathing as coping mechanisms.
At dinner Martin Goulet, Ph.D., who handles non-clinical experiments in the Alnylam lab, and I talked about our families. He has a girl about the same age as my HD-free ten-year-old daughter.
Dr. Martin Goulet (right) at work on the Alnylam HD project (photo by Gene Veritas)
Getting out the word on trials and the cause
Over the next few days, I excitedly told other people in the movement that I had held ALN-HTT in my hand. I felt like an apostle spreading news of a religious revelation.
My journey did not end at Alnylam. On May 18 I flew to New York City for meetings with other leaders of the HD movement. That day I visited CHDI headquarters in Manhattan, where communications director Simon Noble, Ph.D., and I discussed at length ways of getting out the word about the need for involvement in upcoming clinical trials.
On May 19, I spent most of the day at HDSA. I gave an informal talk to the staff about my situation and advocacy. I also interviewed CEO Louise Vetter, now in her third year at HDSA. In line with the theme of clinical trials, we discussed the HDSA Clinical Trial Ambassador program, which will utilize experienced members of the HD community to promote awareness about the trials and answer potential participants’ concerns.
On May 20, I traveled to Princeton, NJ, to interview scientists from CHDI’s clinical trials division.
The visit began with an informal brainstorming session at the home of Maria Beconi, Ph.D., the director for drug metabolism and pharmacokinetics (how drugs are absorbed, distributed, and excreted from the body).
After we consumed pizza, soft drinks, brownies, and cupcakes, Maria introduced me. I thanked the team for its commitment to HD research and explained that I was tracking the social history of the HD movement and the work of the scientists towards treatments and a cure.
I’ll be writing more about this issue and the CHDI unit in a future article.
In New York I met up twice with my friend and “HD alter ego,” Norman Oder, who edits this blog. We caught up on each other’s lives, and we discussed strategies for broadening the message of the HD cause.
Alnylam: passionate about HD
In 2008, when I first studied the Isis HD project, I fantasized about wearing a drug-injecting pump on my head. That was a somewhat inaccurate fantasy, because the pump would not be located on the head itself, but in the abdomen. Isis plans to use this kind of system. But even if it were located on the head, I would gladly use it – or any other device in any other location, for that matter.
Likewise, I would happily accept the implantation of an ALN-HTT pump in my abdomen. My need to avoid HD far outweighs any potential inconvenience caused by such devices.
I came away from Alnylam energized by its scientists’ seriousness, intelligence, practicality, and commitment to stopping HD. “We are very passionate about this disease and finding a cure for it,” Dr. Maraganore told me at the end of our interview.Dr. John Maraganore (Alnylam photo)
Dr. Maraganore told me that Alnylam will likely call on me again, as well as other patient advocates, to offer advice on the design of the clinical trial and to put a human face on the disease for the FDA.
Holding the cure is not enough
During the Q &A after my speech and the interview with Maraganore and Greene, I had an uneasy sensation in my gut. Alnylam’s scientists wanted not only to learn about my personal struggle against HD: they also wanted me to become involved in the strategizing for a clinical trial. I suddenly felt myself taking on a new, challenging, and immense responsibility in my HD advocacy. Though I have no training in science, I need to increase my knowledge of HD, the research for treatments, and the clinical trial process.
Dr. Maraganore observed that, as a result of Alnylam's new collaboration with CHDI, the company was "smarter about what we need to do" to get ALN-HTT into trials. "By being smarter, we're going to be faster," he added.
I, too, felt a bit smarter after meeting the Alnylam team. And I need to get even smarter as we all move together towards this potentially historic treatment.
Holding the potential cure in my hands is just the beginning. I must do my part to help get that cure into our patients and ultimately into me.
(Note: because Alnylam invited me to speak and visit its facility, the company paid for my round-trip airfare to the East Coast, my hotel in Cambridge, and meals related to the visit. I maintained the right to express my opinion in this and other articles on the HD project. )
Wednesday, May 11, 2011
As one individual commented on this blog last year, our community is "rising and converging."
We have traveled a long road.
Before the founding of the Huntington’s Disease Society of America (HDSA) in 1967, nobody advocated for the well-being of HD patients and their families. Huntington’s disease was shrouded in a combination of stigma and ignorance.
Today four organizations dedicate themselves to the cause: HDSA, the Hereditary Disease Foundation (HDF), the Huntington’s Disease Drug Works program (HDDW), and the CHDI Foundation, Inc., informally known as the “cure Huntington’s disease initiative.” They have brought great hope for treatments and a cure. Britain, Canada, and many other foreign countries also have important HD associations.
HDSA, solidarity, and the Web
Thanks especially to HDSA’s work over the decades, public awareness of this killer disease has increased, although HD is still far from being a household word.
HDSA has also promoted community solidarity, from the very first local support groups of the late 1960s to the organization’s 26th national convention, scheduled for June 24-26 in Minneapolis, MN. In late 1995, after receiving the shocking news that my mother had HD, one of my first phone calls was to the local HDSA chapter. The chapter president compassionately explained the potential implications of my mother’s diagnosis for my own future and invited me to attend the support group.
With the power of scientific knowledge and the reach of the Internet, members of the HD community have strengthened their ties and promoted the cause. People today can learn instantly about the many aspects of Huntington’s disease from numerous informational websites, YouTube, and the portals of the primary HD organizations.
I frequently refer to Stanford University’s Hopes site, the Huntington’s Disease Advocacy Center, and HD Buzz. Communication also takes place through social networking sites and chat rooms. Thousands of people interested in HD belong to Facebook, where they can find support and information.
HDDW even conducted a clinical trial via the Web. I logged in regularly to perform cognitive tests on my computer keyboard. Because I am gene-positive for HD, HDDW founder Dr. LaVonne Goodman reviewed my performance to check for possible signs of symptoms. So far, I remain free of HD’s classic symptoms, although the scientific research indicates that the genetic defect most likely is already damaging my brain.
A chapter and a major stem-cell project
For many in the HD community, the lifeblood of the movement is their local HDSA chapter and support group. HDSA has more than 30 chapters and affiliates around the country, many tied to an HDSA Center of Excellence for Family Services and Research.
On May 6 and 7. I paid an emotion-filled visit to the Northern California Chapter (which includes Sacramento, San Francisco, and the northern part of the state) and observed a critical mass of HD-related activities.
On May 6, I spent the day interviewing Jan Nolta, Ph.D., and observing the work of the stem-cell research facility she directs, the Institute for Regenerative Cures, co-funded by the University of California, Davis (UCD), and the California Institute for Regenerative Medicine (CIRM). This 109,000 square-foot facility supports the work of 145 faculty researchers organized into 15 disease teams, including heart disease, blood disorders, HIV, Alzheimer’s, Parkinson’s, Lou Gehrig’s, and Huntington’s.
Dr. Nolta and her HD team have used a well-known type of stem cells, called “mesenchymal stem cells” (MSC), to develop two potential treatments for HD.
Dr. Nolta refers to the MSC as “paramedics” because of the way they congregate around and repair damaged cells. Injected into the brain of an HD patient, the MSC might be able to repair damaged neurons (brain cells) and restore the vital connections between them.
Dr. Nolta at the HD bench at the Institute for Regenerative Cures (photo by Gene Veritas)
Dr. Nolta and her HD team have also reengineered MSC to deliver small interfering RNA molecules directly into cells in order to stop the mutant huntingtin protein from causing damage. She has obtained a patent for this technology, hoping to later negotiate an agreement with a pharmaceutical company that would produce and market an MSC drug. If successful, this approach would stop the cause of HD at its genetic roots.
At the Institute for Regenerative Cures, I felt excited as I took a step into the future of medical treatments. I will provide a detailed report on the HD research efforts in a future article.
A record turnout
With nurse practitioner Teresa Tempkin as my guide, I also toured the HDSA Center of Excellence at the UC Davis Medical Center. I viewed the consultation rooms where Teresa, center director Dr. Vicki Wheelock, and a team of other physicians and healthcare specialists attend to the roughly two hundred HD patients living in the region.
By introducing Dr. Nolta to the HD community, Dr. Wheelock helped make HD research a priority of the Institute for Regenerative Cures.
Dr. Vicki Wheelock, director of the UC Davis Center for Excellence (photo by Gene Veritas).
In the evening, I dined at a Sacramento restaurant with Dr. Wheelock, Teresa, chapter president Judy Roberson, family services chair and former president Les Pue, and other participants in the annual Northern California Chapter convention, held the next day and coinciding with HD Awareness Month.
The chapter’s annual meetings date back to at least 1991. In 2000, the chapter upgraded them to convention status, now held at the UC Davis Medical Center campus. Starting in 2009, the chapter has received financial assistance from Lundbeck, a Denmark-based pharmaceutical firm that markets Xenazine (tetrabenazine), the first-ever FDA-approved drug for chorea, the shaking and trembling that occurs in many HD patients.
This year’s convention attracted a record number of attendees, with 197 official registrants and about eight or more other participants – yet another indication of the rising and convergence of the HD community. People from Lundbeck, Stanford Hopes, and other HD-related initiatives staffed information tables.
The audience at the 2011 HDSA Northern California Chapter convention (photo by Gene Veritas)
HD-free with PGD
The convention featured eight morning workshops divided into two sessions. All were compelling.
The first session I attended, “All About Preimplantation Genetic Diagnosis for HD Families,” was presented by Stacy Brookhyser, the gene-positive, 35-year-old mother of twins free from HD after she and her husband opted for the preimplantation procedure, known as PGD.
“When I started this journey, I was newly married, and at risk,” Stacy told the audience, which included her HD-stricken mother. “I hadn’t tested, and I didn’t know what to expect, but I knew about the at-risk status. I knew that if my husband and I went ahead had children naturally, that my children, of course, would have a chance of inheriting Huntington’s.”
The decisions about her HD test and PGD were “daunting,” Stacy added. During the rest of the presentation she recounted how they researched the various options for starting a family, considered their personal and moral beliefs, and went through the medical procedures necessary in PGD.
You can watch Stacy’s presentation in the video below, and you can learn more about PGD by visiting her website, www.HDFreeWithPGD.com.
I was deeply moved by Stacy’s presentation. Listening to her, I was transported back to the harrowing moments that my wife and I experienced as we pondered our own extremely difficult decision (in late 1999 and early 2000) to have our child tested in the womb. This was before the availability of PGD. Our “miracle baby” tested negative.
I am glad that families today have access to PGD, although it continues to be a highly expensive procedure that is not always covered by insurance. Stacy’s PGD cost $30,000, with insurance picking up most of the cost. However, as she pointed out, that sum pales before the cost to the health system of caring for an individual with HD – not to mention the lost income and suffering experienced by the family.
Emotional and behavioral symptoms
I was anxious to attend the talk by psychiatrist Raheel Khan on “Dealing with Emotional and Behavioral Changes in HD.”
I have read on many occasions that these symptoms often appear first. My mother’s first apparent symptoms, including seemingly inexplicable mood swings and crying, fell into this category.
As a gene-positive individual, I wanted to know what might lie in my not-too-distant future. I want to prepare effectively by learning what to anticipate and how to help my family understand how they might need to assist.
Defining HD as a “classic ‘neuropsychiatric’ disorder,” Dr. Khan outlined the many conditions faced by HD patients, including depression, delirium, loss of interest in daily activities, apathy, anxiety, irritability, and many psychotic symptoms such as hallucinations, delusions, and disorganization.
Dr. Raheel Khan speaks on emotional and behavioral problems in HD (photo by Gene Veritas).
A depressing scenario
Dr. Khan spent a good part of the time on depression, which, he said, occurs in 30 to 50 percent of all HD patients. To paraphrase him, this is a very high percentage. When you have depression, it’s tougher to cope with the underlying disease. This worsens the course of the HD, so this aspect must be treated. Depression is insidious. The person rarely experiences their situation as a symptom. It’s up to the caregiver or family member to point out the changes to the patient.
Indeed, Dr. Khan made it very clear that assistance from family members and caregivers is crucial in dealing with this aspect of HD.
One caregiver in the audience wanted to know how to assist an affected loved one who refused to take psychiatric medication.
One solution is to pose the psychiatric condition as a part of the disease and tell the patient of the need for help, Dr. Khan responded. This, he added, was a very common problem.
“People still call me a shrink all the time,” he said, noting the stigma that still exists for psychiatric care. Unfortunately, he added, a person can’t be forced to see a psychiatrist. The psychiatric problems should be raised during a regular checkup, and the attending doctor should pointed out that he or she is the one visiting the patient, not the patient visiting the physician, Dr. Khan explained.
Just hearing about such a plethora of potential psychiatric symptoms – and writing about them again now – leaves me depressed. What if I suffer from some combination of these symptoms? What if I resist medication? I do not want to be a burden on my family. As sad and difficult as the task is, I must prepare my family for this scenario.
Connecting to HD people
With multiple emotions flowing after hearing Stacy and Dr. Khan, I wanted to end the threat of HD for my family and for everybody at the convention. Over lunch, I sat with three HD people and their families.
At the start of the afternoon session I watched chapter representatives present HD patient Cheri Harries with the Joseph P. Roberson Foundation’s “HD Person of the Year” award for her commitment to the chapter and her exemplary perseverance against the disease. She is the wife of chapter board member Terry Harries.
Accompanied by husband and board member Terry, Cheri Harries approaches podium to receive "HD Person of the Year" award (photo by Gene Veritas).
In our fight I felt connected to all of these individuals – and I wanted to do my part to win it.
‘It’s time to conquer HD!’
I got my chance to contribute as one of two featured speakers in the afternoon session, held in the main auditorium of the UC Davis MIND Institute. (MIND stands for “Medical Investigation of Neurodevelopmental Disorders,” such as autism.)
I titled my speech “A Gene-Positive Activist Copes with the Threat of Huntington’s Disease (Fighting Back).” As in my big coming-out keynote address at CHDI’s 6th Annual HD Therapeutics Conference on February 7, I once again took off the mask of Gene Veritas to reveal my true self to the audience.
I spoke extemporaneously about my mother’s downfall, my father’s caregiving as an “HD warrior,” my advocacy for the cause, and, finally, pointers on effective activism.
I felt deeply connected to the standing-room-only audience. Many HD people and their families looked on, and people responded with great passion and enthusiasm. When I announced that our daughter had tested negative, the audience applauded. They applauded again when I recalled how I had removed the mask for the first time at the CHDI conference. Afterwards John, a shaking HD man in his 60s, hugged me several times like a long-lost brother.
You can watch my speech in the video below.
“And so what are we, as we take off our masks and become this new community?” I asked at the end of my speech. “We are a community rising and converging. We’re rising up for the first time. We’re fighting against discrimination. We’re getting tested. We’re advocating for bills. We’re doing new and wonderful things as we rise in this community. And as we rise, we are all converging together on the final point. And what is that final point?
“It’s time to conquer Huntington’s disease!”
Stopping the culprit
Doug Macdonald, Ph.D., CHDI’s director of drug discovery, closed the conference with a presentation titled “Huntingtin Suppression: An Exciting New Therapy Being Developed at CHDI.
Dr. Macdonald explained the efforts to reduce the actions of the defective huntingtin gene and its resultant, harmful protein, the culprit in HD.
Dr. Macdonald brought hope: Isis Pharmaceuticals, Inc., of Carlsbad, CA, and Alnylam Pharmaceuticals of Cambridge, MA, are both preparing to test potential huntingtin suppression drugs in humans within the next couple years.
Like Dr. Nolta’s approach, the Isis and Alnylam drugs would represent a revolutionary advance in the treatment of HD by attacking the genetic roots of the disease. Currently these approaches come the closest to a “cure,” although HD patients most likely would have to take such drugs their entire lives.
You can watch Dr. Macdonald’s presentation in the video below.
I came away deeply inspired by the HD movement in Northern California and reenergized in my advocacy. The annual conventions provide a fine model for other chapters and disease organizations, as does the powerful convergence of efforts by the Center of Excellence, stem-cell researchers, the HDSA chapter, Lundbeck, and the HD community.
I also felt gratitude for Lundbeck’s sponsoring of this event and the many other HD-related activities it has supported in recent years.
I’m looking forward to my next step: a speech at Alnylam on May 17 and interviews with the scientists on its HD team.
Inching towards our goal
At the end of the day, as we chewed the fat about HD matters and shared a bit of our life stories, Les Pue graciously drove me into San Francisco. There I met up with my wife and our child. Turning 11 next month, our daughter had crossed the Golden Gate Bridge earlier in the day for her Girl Scout “bridging ceremony,” which symbolizes a new level of commitment to the organization.
I was thrilled to see my family after such an intense weekend. Sitting with my wife at a restaurant on Fisherman’s Wharf, I thoroughly enjoyed eating clam chowder in a sourdough bread bowl and sipping a tall glass of Stella Artois draft beer.
The battle was not yet won, but I felt our community had inched a bit closer to our final goal.
Monday, May 02, 2011
And most of us will probably remember exactly what we were doing when word came of 9/11 mastermind Osama Bin Laden’s killing on May 1, 2011.
I was checking HD-related e-mail. “No bearing on HD… Thank God Osama Bin Laden is DEAD,” read a message from a member of the Facebook discussion group called “HD Family.”
I immediately jumped to CNN.com to confirm the report. I shouted the news to my wife in another room, where she was getting our 10-year-old daughter ready for bed.
“What a relief!” my wife and I told each other as I rushed to put the TV on CNN.
Riveted to the screen, we watched President Barack Obama’s announcement.
I could feel the two of us being transported back nearly a decade, when we spent so many evenings in that same room anxiously watching the television and worrying what other atrocities Bin Laden might perpetrate upon the nation.
A cause hampered
In fact, Bin Laden did have an enormous – if not always direct – bearing on many facets of American life – including the cause to eliminate Huntington’s disease.
In the economic boom of the 1990s, as scientists got their first inklings of possible treatments for HD in the wake of the discovery of the HD gene (1993), the cause started to build substantial momentum under the leadership of the Huntington’s Disease Society of America (HDSA) and the Hereditary Disease Foundation.
Even the tech stock crash of 2000 didn’t seem to threaten the promise of new research.
But Bin Laden’s attacks on the World Trade Center and the Pentagon struck at the heart of our financial and military might. And, as I feared, they diverted the national focus towards security issues and away from philanthropic activities and medical research, both crucial in the fight against HD.
Thus, like many Americans, I took the attacks personally. For the first time that I could remember, I cried for our country.
My worst fears
In June 1999, fewer than two years before 9/11, I had tested positive for HD. In January 2000 our daughter tested negative in the womb. So I was acutely aware of the threat posed by the defective huntingtin gene.
The 9/11 attacks seemed to dash all hope of a quick solution to HD.
I was angry at the Bin Laden terrorists for disrupting our lives and the promise of progress.
I felt especially forlorn about my own gene-positive status, because my mother, who had already been suffering from HD for at least a decade, was rapidly declining and could no longer talk.
As I told a friend at the time, my worst fears had come true: a cataclysmic event threatened to break the back of the nation, perhaps postponing the discovery of a treatment or cure to a date well beyond the start of my inevitable HD symptoms.
But, like the rest of the country, our local HDSA chapter somehow moved ahead, and we proceeded with our plans to raise awareness and funds.
On September 20, 2001, I volunteered at a fundraiser at a small amusement park that brought in $5,000 for HDSA-San Diego. I remember the strange mixture of emotions as I hustled around the park and worried about terrorism.
Exactly one month after 9/11, I attended our chapter’s very first Celebration of Hope Dinner. We raised almost $63,000 – about $10,000 more than our goal.
Generosity and terror
In December 2001, still caught up in the whirlwind of 9/11, I wrote an editorial for our chapter newsletter titled “Generosity and Terror”:
The most immediate concern is about funding. The attacks quickly focused Americans’ sympathies on the plight of the thousands of victims and their families. We mourn these horrible losses and support the efforts to bring the killers to justice.
The attacks also harmed our economy, and the outpouring of sympathy has diverted attention from many other charitable activities.
Government at all levels shifted its focus to dealing with the aftermath of the attacks and protecting the nation against future threats. We are at war. This all means that the government is spending – and will likely continue to spend for years to come – tens of billions of dollars for military defense and national security.
This combination of difficulties could undermine long-term philanthropic giving and reduce the level of activities of many charities and programs that fight disease.
But HDSA-SD supporters have suggested that the reality can and should be otherwise. Within weeks of the attacks they helped us raise tens of thousands of dollars. Other HDSA events went on as planned elsewhere. This is a resounding message that generosity and compassion will overcome the hateful politics of terror. The American spirit is to move ahead, no matter what the odds.
We thank those who have supported us during these difficult moments.
And we urge our leaders to remember that a great nation survives not only with a strong defense, but through the continuation of its programs for the betterment of human life. That includes funding for the National Institutes of Health and other initiatives against disease. In the campaign against terror we must not lose our public soul of domestic concern and generosity by overspending on weapons.
Strong health is our most basic prerequisite for survival as a nation. In the fight to stop disease, the test tube will topple terror, MDs will outlast murderers, and veneration of life will overcome the cynicism of violence.
Ups and downs of philanthropy
American charitable giving slumped from 2001 to 2003, but grew to record levels by 2007.
During the early 2000s downturn, HDSA also took a hit. Previous, ambitious plans for a $20 million annual budget fell by the wayside. Public advocacy languished. And, for a number of reasons, HDSA fell into financial disarray. Only now is financial stability in sight.
Under new leadership, HDSA is seeking to reconfigure itself as a community service organization for HD families. (May is Huntington’s Disease Awareness Month, and I’ll be writing soon on HDSA’s outlook.)
CHDI: a godsend
Meanwhile, in the past six years the CHDI Foundation, Inc. has invested heavily in potential treatments and a cure. Its budget will reach an estimated $100 million this year.
Informally known as the “cure Huntington’s disease initiative,” CHDI has been a godsend for the HD community. It is partnering with biotech companies, the government, and academic labs to speed up the hunt for effective drugs.
Thanks to a wealthy, anonymous donor, CHDI has kept spending at high levels despite the deep recession of 2007-2009, occasioned by a record drop in charitable giving that dwarfed the post-9/11 slump.
Thus, while in the short run Bin Laden’s attacks impacted the HD cause, in the long run the emergence of CHDI trumped terrorism.
In 2001 the 9/11 attacks had caused me to lose much of my hope for an effective treatment or cure. In 2011 I now have a level of hope previously unimaginable – in terms of the organizational and financial commitment to the cure and the research progress.
Unity and ingenuity
In his speech about Bin Laden’s killing, President Obama appealed for a renewal of national unity and reminded Americans that we “can do whatever we set our mind to.”
Listening to the president, I felt proud to be an American and rejoiced in his optimism about our future.
American ingenuity can bring about better care for our HD patients and their families and the treatments that I and tens of thousands of other gene-positive and HD-affected people so desperately need to stave of the devastation of our brains and eventual premature death.
On May 6, I will travel to Sacramento, CA, to interview a team of scientists working on a potential Huntington’s disease stem-cell treatment under the leadership of Dr. Jan Nolta. The next day I will deliver a speech on my experiences as a gene-positive HD activist at the annual convention of HDSA’s Northern California Chapter.
On May 17, I will give a similar speech at Alnylam Pharmaceuticals, which aims in the next year or so to begin Phase I clinical trials for a potentially revolutionary HD treatment.
HDSA, CHDI, Dr. Nolta, Alnylam, and so many other scientists could together change the history of Huntington’s disease and of science and medicine.
It took America ten years to get Bin Laden. With similar determination we can defeat Huntington’s disease in the next ten years.