Migalastat

Key takeaways

Migalastat belongs to science; place it in that map before memorising details.
Learn the definition first, then one example that makes the definition concrete.
Connect Migalastat to a quantity you can measure, compute or draw — that is where exam questions come from.
Reproduce the core statement of Migalastat from memory before moving on to harder problems.

Reference excerpt

Migalastat, sold under the brand name Galafold, is a medication used for the treatment of Fabry disease, a rare genetic disorder. Migalastat is an alpha-galactosidase A (alpha-Gal A) pharmacological chaperone. It was developed by Amicus Therapeutics. The most common adverse drug reactions include headache, nasal and throat irritation (nasopharyngitis), urinary tract infection, nausea, and fever (pyrexia). Migalastat was authorized for medical use in the European Union in May 2016, and approved for medical use in the United States in August 2018. The US Food and Drug Administration considers it to be a first-in-class medication.

Medical uses In the EU, migalastat is indicated for the long-term treatment of people aged 16 years of age and older with a confirmed diagnosis of Fabry disease (alpha-galactosidase A deficiency) and who have an amenable mutation. In the US, migalastat is indicated for the treatment of adults with a confirmed diagnosis of Fabry disease and an amenable galactosidase alpha gene (GLA) variant based on in vitro assay data. An "amenable" mutation is one that leads to misfolding of the enzyme, but otherwise would not significantly impair its function. Based on an in vitro test, Amicus Therapeutics has published a list of 269 amenable and nearly 600 non-amenable mutations. About 35 to 50% of people with Fabry have an amenable mutation.

Adverse effects The most common adverse drug reactions include headache, nasal and throat irritation (nasopharyngitis), urinary tract infection, nausea, and fever (pyrexia). The most common side effect in clinical trials was headache (in about 10% of people who take it). Less common side effects (between 1 and 10% of people) included unspecific symptoms such as dizziness, fatigue, and nausea, but also depression. Possible rare side effects could not be assessed because of the low number of subjects in the clinical trials in which adverse effects were measured.

Interactions When combined with intravenous agalsidase alfa or beta, which are recombinant versions of the enzyme α-GalA, migalastat increases tissue concentrations of functional α-GalA compared to agalsidase given alone up to fivefold.Migalastat is not intended to be combined with agalsidase. Migalastat does not inhibit or induce cytochrome P450 liver enzymes or transporter proteins and is therefore expected to have a low potential for interactions with other drugs.

Pharmacology

Mechanism of action Fabry disease is a genetic disorder caused by various mutations of the enzyme α-GalA, which is responsible for breaking down the sphingolipid globotriaosylceramide (Gb3), among other glycolipids and glycoproteins. Some of these mutations result in misfolding of α-GalA, which subsequently fails protein quality control in the endoplasmic reticulum and is decomposed. Lack of functional α-GalA leads to accumulation of Gb3 in blood vessels and other tissues, with a wide range of symptoms including kidney, heart, and skin problems. Migalastat is a potent, orally available inhibitor of α-GalA (IC50: 4 μM). When binding to faulty α-GalA, it shifts the folding behaviour towards the proper conformation, resulting in a functional enzyme provided the mutation is amenable. Molecules with this type of mechanism are called pharmacological chaperones. When the enzyme reaches its destination, the lysosome, migalastat dissociates because of the low pH and the relative abundance of Gb3 and other substrates, leaving α-GalA free to fulfill its function. Depending on the mutation, the EC50 is between 0.8 μM and over 1 mM in cellular models.

Pharmacokinetics Migalastat is almost completely absorbed from the gut; taking the drug together with food decreases its absorption by about 40%. Total bioavailability is about 75% when taken without food. The substance is not bound to blood plasma proteins. Only a small fraction of a migalastat dose is metabolized, mainly to three dehydrogenated O-glucuronides (4% of the dose) and a number of unspecified metabolites (10%). The drug is mainly eliminated via the urine (77%) and to a smaller extent via the faeces (20%). Practically all of the metabolites are excreted in the urine. Elimination half-life is three to five hours after a single dose.

Chemistry

Migalastat is used in form of the hydrochloride, which is a white crystalline solid and is soluble in water. The molecule has four asymmetric carbon atoms with the same stereochemistry as the sugar D-galactose, but is missing the first hydroxyl group. It has a nitrogen atom in the ring instead of an oxygen, which makes it an iminosugar.

History Migalastat was isolated as a fermentation product of the bacterium Streptomyces lydicus (strain PA-5726) in 1988 and called 1-deoxygalactonojirimycin. In 2004, it was designated orphan drug status by the U.S. FDA for the treatment of Fabry disease, as did the European Medicines Agency's CHMP in 2006. The sponsorship for the drug was transferred several times over the following years: from Amicus Therapeutics to Shire Pharmaceuticals in 2008, back to Amicus in 2010, to Glaxo in 2011, and again to Amicus in 2014. Two phase III clinical trials with a total of about 110 subjects were conducted between 2009 and 2015, one double-blind comparing the drug to placebo, and one comparing it to recombinant α-GalA without blinding. Migalastat stabilised heart and kidney function over the 30-months period of these trials. The efficacy of migalastat was demonstrated in a six-month, placebo-controlled clinical trial in 45 adults with Fabry disease. In this trial, participants treated with migalastat over six months had a greater reduction in globotriaosylceramide (GL-3) in blood vessels of the kidneys (as measured in kidney biopsy samples) as compared to participants on placebo. The safety of migalastat was studied in four clinical trials which included a total of 139 participants with Fabry disease. In September 2015, Amicus announced that it would submit a new drug application (NDA) for accelerated approval of migalastat to the FDA by the end of 2015. The CHMP recommended approval in April 2016, but the FDA rejected the application in November for having insufficient data in November 2016. The drug was authorized in the European Union in May 2016. Germany was the first country where migalastat was launched.

Society and culture

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Illustrations

Worked examples

Example 1 — a first encounter with Migalastat

Start with the simplest possible case. Write down what Migalastat claims or describes in one sentence, then invent the smallest concrete situation in which that sentence is true. In science, the smallest case is usually a single object, a single equation or a single measurement. Check that every symbol or term in your sentence has a meaning in that case.

Example 2 — changing one variable

Take the situation from Example 1 and change exactly one quantity: double it, halve it, or set it to zero. Predict what should happen to Migalastat before you calculate. Comparing your prediction with the result is the fastest way to find out whether you understand the idea or only the words.

Example 3 — an exam-style question

Typical questions about Migalastat ask you to (a) state it precisely, (b) apply it to given data, and (c) explain a limitation. Practise writing all three answers in under five minutes; the third part is what separates a full-mark answer from an average one.

Applications of Migalastat

In research: Migalastat appears in science research whenever the underlying quantities have to be modelled precisely. Papers usually cite it as a starting assumption and then explore where it breaks down.
In technology and industry: Engineering practice reuses Migalastat in design rules, simulations and safety margins. Knowing the idea lets you read a specification sheet and understand why the numbers look the way they do.
In the classroom: Migalastat is common in secondary-school and first-year university syllabi. It links to neighbouring topics Hydrolase inhibitors, Iminosugars, Orphan drugs, so understanding it makes those chapters shorter.
In everyday life: Look for Migalastat outside the textbook — in sport, cooking, traffic, electronics or the sky above you. An example you found yourself is remembered far longer than one you were given.

How to study Migalastat in 20 minutes

Read the reference excerpt below once, without taking notes.
Close the page and write down what Migalastat means in your own words.
Compare your version with the excerpt and mark what you missed.
Work through the three examples above with pen and paper.
Explain Migalastat out loud to somebody else — or to Teacher Smith in the lgStudy chat.

Frequently asked questions

What is Migalastat in simple terms?

Migalastat, sold under the brand name Galafold, is a medication used for the treatment of Fabry disease, a rare genetic disorder. Migalastat is an alpha-galactosidase A (alpha-Gal A) pharmacological chaperone.

Why does Migalastat matter?

Because it connects several science ideas at once: it gives you a definition you can apply, a quantity you can calculate, and a way to check whether a result is plausible.

How should I study Migalastat?

Read the excerpt, restate it from memory, then work through the examples and applications listed on this page. The five-step study plan above takes about twenty minutes.

What does this page cover?

It gives you a compact reference excerpt plus original lgStudy explanations, examples, applications and study material on Migalastat.