Friedreich's ataxia (FRDA or FA) is an
autosomal-recessive genetic disease that causes difficulty walking, a loss of coordination in the arms and legs, and
impaired speech that worsens over time. Symptoms generally start between 5 and 20 years of age. Many develop
hypertrophic cardiomyopathy and require a
mobility aid such as a cane, walker, or wheelchair in their teens. As the disease progresses, some affected people lose their sight and hearing. Other complications may include
scoliosis and
diabetes mellitus.
The condition is caused by mutations in the FXN gene on
chromosome 9, which makes a protein called
frataxin. In FRDA, cells produce less frataxin.
Degeneration of
nerve tissue in the
spinal cord causes the
ataxia; particularly affected are the
sensory neurons essential for directing muscle movement of the arms and legs through connections with the
cerebellum. The spinal cord becomes thinner, and nerve cells lose some
myelin sheath.
In February 2023, the first approval of a treatment for FRDA was granted by the
U.S. Food and Drug Administration (
FDA). Approval in the
EU is pending. There are several additional therapies in trial. FRDA shortens life expectancy due to heart disease, but some people can live into their 60s or older.
FRDA affects one in 50,000 people in the
United States and is the most common inherited ataxia. Rates are highest in people of Western European descent. The condition is named after German physician
Nikolaus Friedreich, who first described it in the 1860s.
Symptoms
Symptoms typically start between the ages of 5 and 15, but in late-onset FRDA, they may occur after age 25 years.[1] The symptoms are broad, but consistently involve
gait and limb
ataxia,
dysarthria and loss of lower limb reflexes.[1]
People who have been living with FRDA for a long time may develop other complications. 36.8% experience decreased visual acuity, which may be progressive and could lead to functional blindness.[3] Hearing loss is present in about 10.9% of cases.[3] Some patients report bladder and bowel symptoms.[4] Advanced stages of disease are associated with
supraventriculartachyarrhythmias, most commonly
atrial fibrillation.[1]
The progressive loss of coordination and muscle strength leads to the full-time use of a wheelchair. Most young people diagnosed with FRDA require mobility aids such as a cane, walker, or wheelchair by early 20s.[5]
The disease is progressive, with increasing staggering or stumbling gait and frequent falling. By the third decade, affected people lose the ability to stand or walk without assistance and require a wheelchair for mobility.[6]
Early-onset cases
Non-neurological symptoms such as
scoliosis,
pes cavus, cardiomyopathy and diabetes are more frequent amongst the early-onset cases.[1]
Genetics
FRDA is an autosomal-recessive disorder that affects a gene (FXN) on chromosome 9, which produces an important protein called frataxin.[7]
In 96% of cases, the mutant FXN gene has 90â1,300 GAA
trinucleotide repeat expansions in
intron 1 of both
alleles.[8] This expansion causes
epigenetic changes and formation of
heterochromatin near the repeat.[7] The length of the shorter GAA repeat is correlated with the age of onset and disease severity.[9] The formation of heterochromatin results in reduced
transcription of the gene and low levels of frataxin.[10] People with FDRA might have 5-35% of the frataxin protein compared to healthy individuals.
Heterozygouscarriers of the mutant FXN gene have 50% lower frataxin levels, but this decrease is not enough to cause symptoms.[11]
In about 4% of cases, the disease is caused by a (
missense,
nonsense, or
intronic)
point mutation, with an expansion in one
allele and a
point mutation in the other.[12] A missense point mutation can have milder symptoms.[12] Depending on the point mutation, cells can produce no frataxin, nonfunctional frataxin, or frataxin that is not properly localized to the mitochondria.[13][14]
Pathophysiology
FRDA affects the nervous system, heart, pancreas, and other systems.[15][16]
Degeneration of nerve tissue in the spinal cord causes ataxia.[15] The sensory neurons essential for directing muscle movement of the arms and legs through connections with the cerebellum are particularly affected.[15] The disease primarily affects the spinal cord and
peripheral nerves.
The spinal cord becomes thinner and nerve cells lose some
myelin sheath.[15] The diameter of the spinal cord is smaller than that of unaffected individuals mainly due to smaller dorsal root ganglia.[16] The
motor neurons of the spinal cord are affected to a lesser extent than sensory neurons.[15] In peripheral nerves, a loss of large myelinated sensory fibers occurs.[15]
Structures in the brain are also affected by FRDA, notably the dentate nucleus of the cerebellum.[16] The heart often develops some fibrosis, and over time, develops left-ventricle hypertrophy and dilatation of the left ventricle.[16]
Frataxin
The exact role of frataxin remains unclear.[17] Frataxin assists
iron-sulfur protein synthesis in the electron transport chain to generate
adenosine triphosphate, the energy molecule necessary to carry out metabolic functions in cells. It also regulates iron transfer in the mitochondria by providing a proper amount of
reactive oxygen species (ROS) to maintain normal processes.[18] One result of frataxin deficiency is mitochondrial iron overload, which damages many proteins due to effects on cellular metabolism.[19]
Without frataxin, the energy in the mitochondria falls, and excess iron creates extra ROS, leading to further cell damage.[18] Low frataxin levels lead to insufficient biosynthesis of ironâsulfur clusters that are required for mitochondrial electron transport and assembly of functional
aconitase and iron dysmetabolism of the entire cell.[19]
Physicians and patients can reference the clinical management guidelines for Friedreich ataxia.[24] These Guidelines are intended to assist qualified healthcare professionals in making informed treatment decisions about the care of individuals with Friedreich ataxia.[25]
Therapeutics
Omaveloxolone received
FDA approval under the brand name Skyclarys for the treatment of Friedreich's ataxia in February 2023.[26] Approval in the EU is pending.[27]
Rehabilitation
Physical therapists play a critical role in educating on correct posture, muscle use, and the identification and avoidance of features that aggravate spasticities such as tight clothing, poorly adjusted wheelchairs, pain, and infection.[28]
Physical therapy typically includes intensive motor coordination, balance, and stabilization training to preserve gains.[29] Low-intensity strengthening exercises are incorporated to maintain functional use of the upper and lower extremities.[29] Stretching and muscle relaxation exercises can be prescribed to help manage spasticity and prevent deformities.[29] Other physical therapy goals include increased transfer and locomotion independence, muscle strengthening, increased physical resilience, "safe fall" strategy, learning to use mobility aids, learning how to reduce the body's energy expenditure, and developing specific breathing patterns.[29] Speech therapy can improve voice quality.[30]
Devices
Well-fitted
orthoses can promote correct posture, support normal joint alignment, stabilize joints during walking, improve range of motion and gait, reduce
spasticity, and prevent foot deformities and scoliosis.[5]
As progression of ataxia continues,
assistive devices such as a cane, walker, or wheelchair may be required for mobility and independence. A
standing frame can help reduce the secondary complications of prolonged use of a wheelchair.[31][32]
Surgery may correct deformities caused by abnormal muscle tone. Titanium screws and rods inserted in the spine help prevent or slow the progression of scoliosis. Surgery to lengthen the
Achilles tendon can improve independence and mobility to alleviate
equinus deformity.[5] An automated
implantable cardioverter-defibrillator can be implanted after a severe heart failure.[5]
Omaveloxolone was approved for medical use in the United States in February 2023.[33]
Prognosis
The disease evolves differently in different people.[31] In general, those diagnosed at a younger age or with longer GAA triplet expansions tend to have more severe symptoms.[5]
Congestive heart failure and
abnormal heart rhythms are the leading causes of death,[34] but people with fewer symptoms can live into their 60s or older.[22]
Epidemiology
FRDA affects Indo-European populations. It is rare in East Asians, sub-Saharan Africans, and Native Americans. FRDA is the most prevalent inherited ataxia, affecting approximately 1 in 40,000 with European descent.[15] Males and females are affected equally. The estimated carrier prevalence is 1:100.[5] A 1990â1996 study of Europeans calculated the incidence rate was 2.8:100,000.[35] The prevalence rate of FRDA in Japan is 1:1,000,000.[36]
FRDA follows the same pattern as
haplogroup R1b. Haplogroup R1b is the most frequently occurring paternal lineage in Western Europe. FRDA and Haplogroup R1b are more common in northern Spain, Ireland, and France, rare in Russia and Scandinavia, and follow a gradient through central and eastern Europe. A population carrying the disease went through a
population bottleneck in the
Franco-Cantabrian region during the last ice age.[37]
A 1984 Canadian study traced 40 cases to one common ancestral couple arriving in
New France in 1634.[44]
FRDA was first linked to a GAA repeat expansion on chromosome 9 in 1996.[45]
Research
Currently there is no cure for Friedreich's ataxia, and treatment development is currently directed toward slowing, stopping, or reversing disease progression.
In 2019,
Reata Pharmaceuticals reported positive results in a phase 2 trial of
RTA 408 (
Omaveloxolone or Omav) to target activation of a transcriptional factor,
Nrf2.[46] Nrf2 is decreased in FRDA cells.[47][48][49][50] In May 2022, the FDA accepted a new drug application for omaveloxolone and granted it priority review.[51] Omaveloxolone received FDA approval under the brand name Skyclarys for the treatment of Friedreich's ataxia in February 2023.[26] Approval in the EU is pending.[27]
There are several additional therapies in trial. Patients can enroll in a registry to make clinical trial recruiting easier. The Friedreich's Ataxia Global Patient Registry is the only worldwide registry of Friedreich's ataxia patients to characterize the symptoms and establish the rate of disease progression.[52] The Friedreich's Ataxia App is the only global community app which enables novel forms of research.[53]
As of May 2021, research continues along the following paths.
Improve mitochondrial function and reduce oxidative stress
Retrotope is advancing
RT001. RT001 is a
deuterated synthetic homologue of ethyl linoleate, an essential
omega-6 polyunsaturated fatty acid which is one of the major components of
lipid membranes, particularly in
mitochondria. Oxidation damage might be reduced if the
polyunsaturated fatty acids in the lipids were made more rigid and less susceptible to oxidation by the replacement of
hydrogen atoms with the heavy hydrogen isotope
deuterium.[55]
Modulation of frataxin controlled metabolic pathways
Dimethyl fumarate has been shown to increase frataxin levels in FRDA cells, mouse models, and humans. DMF showed an 85% increase in frataxin expression over 3 months in
multiple sclerosis .[56]
Frataxin replacements or stabilizers
EPO mimetics are orally available peptide imitations of
erythropoietin. They are small molecules erythropoietin receptor agonists designed to activate the tissue-protective erythropoietin receptor.[57][58]
Etravirine, an antiviral drug used to treat HIV, was found in a
drug repositioning screening to increase frataxin levels in peripheral cells.[59] Fratagene Therapeutics is developing a small molecule called RNF126 to inhibit an enzyme which degrades frataxin.[60]
Nicotinamide (vitamin B3) was found effective in preclinical FRDA models and well tolerated.[11]
An
RNA-based approach might unsilence the FXN gene and increase the expression of frataxin. Non-coding RNA (
ncRNA) could be responsible for directing the localized
epigenetic silencing of the FXN gene.
Lentivirus-mediated delivery of the FXN gene has been shown to increase frataxin expression and prevent DNA damage in human and mouse
fibroblasts.[62]
Your Lie in April is a Japanese
romantic dramamanga series written and illustrated by
Naoshi Arakawa. The story follows a young pianist named KĐžĚsei Arima, who loses the ability to perform the piano after his mother's death, and his experiences after he meets violinist Kaori Miyazono who has an FRDA.
The Ataxian is a documentary that tells the story of
Kyle Bryant, an athlete with FRDA who completes a long-distance bike race in an adaptive "trike" to raise money for research.[65]
Geraint Williams in an athlete affected by FRDA who is known for scaling
Mount Kilimanjaro in an adaptive wheelchair.[67]
Shobhika Kalra is an activist with FRDA who helped build over 1000 wheelchair ramps across the
United Arab Emirates in 2018 to try to make
Dubai fully wheelchair-friendly by 2020.[68]
Butterflies Still Fly is a 2023 film, based on a true story, directed by Joseph Nenci. Italo is a light-hearted journalist, darkened by a personal drama that distracts him from work. He encounters with Giorgia, a young girl suffering from Friedreich's Ataxia, who will change his life.
^
abCossĂŠe M, DĂźrr A, Schmitt M, Dahl N, Trouillas P, Allinson P, Kostrzewa M, Nivelon-Chevallier A, Gustavson KH, KohlschĂźtter A, MĂźller U, Mandel JL, Brice A, Koenig M, Cavalcanti F, Tammaro A, De Michele G, Filla A, Cocozza S, Labuda M, Montermini L, Poirier J, Pandolfo M (February 1999). "Friedreich's ataxia: point mutations and clinical presentation of compound heterozygotes". Annals of Neurology. 45 (2): 200â6.
doi:
10.1002/1531-8249(199902)45:2<200::AID-ANA10>3.0.CO;2-U.
PMID9989622.
S2CID24885238.
^Lazaropoulos M, Dong Y, Clark E, Greeley NR, Seyer LA, Brigatti KW, Christie C, Perlman SL, Wilmot GR, Gomez CM, Mathews KD, Yoon G, Zesiewicz T, Hoyle C, Subramony SH, Brocht AF, Farmer JM, Wilson RB, Deutsch EC, Lynch DR (August 2015).
"Frataxin levels in peripheral tissue in Friedreich ataxia". Annals of Clinical and Translational Neurology. 2 (8): 831â42.
doi:
10.1002/acn3.225.
PMC4554444.
PMID26339677.
^Galea CA, Huq A, Lockhart PJ, Tai G, Corben LA, Yiu EM, Gurrin LC, Lynch DR, Gelbard S, Durr A, Pousset F, Parkinson M, Labrum R, Giunti P, Perlman SL, Delatycki MB, Evans-Galea MV (March 2016). "Compound heterozygous FXN mutations and clinical outcome in friedreich ataxia". Annals of Neurology. 79 (3): 485â95.
doi:
10.1002/ana.24595.
PMID26704351.
S2CID26709558.
^
abc"Friedreich's Ataxia Fact Sheet". National Institute of Neurological Disorders and Stroke.
Archived from the original on 26 August 2017. Retrieved 26 August 2017. This article incorporates text from this source, which is in the
public domain.
^Leonardi L, Aceto MG, Marcotulli C, Arcuria G, Serrao M, Pierelli F, Paone P, Filla A, Roca A, Casali C (March 2017). "A wearable proprioceptive stabilizer for rehabilitation of limb and gait ataxia in hereditary cerebellar ataxias: a pilot open-labeled study". Neurological Sciences. 38 (3): 459â463.
doi:
10.1007/s10072-016-2800-x.
PMID28039539.
S2CID27569800.
^Indelicato E, Bosch S (2018). "Emerging therapeutics for the treatment of Friedreich's ataxia". Expert Opinion on Orphan Drugs. 6: 57â67.
doi:
10.1080/21678707.2018.1409109.
S2CID80157839.
^Miller JL, Rai M, Frigon NL, Pandolfo M, Punnonen J, Spencer JR (September 2017). "Erythropoietin and small molecule agonists of the tissue-protective erythropoietin receptor increase FXN expression in neuronal cells in vitro and in Fxn-deficient KIKO mice in vivo". Neuropharmacology. 123: 34â45.
doi:
10.1016/j.neuropharm.2017.05.011.
PMID28504123.
S2CID402724.