RELATED APPLICATION

This application claims the benefit of U.S. Provisional Application No. 62/908,784, filed October 1, 2019, which is incorporated herein by reference in its entirety. TECHNICAL FIELD

The present disclosure relates to novel trehalose compositions, processes for making the compositions, and the use of the compositions in therapy. More particularly, it relates to trehalose compositions useful in the treatment and/or amelioration of symptoms of mucopolysaccharidoses.

BACKGROUND

The mucopolysaccharidoses (MPSs) are a group of inherited lysosomal storage disorders (LDSs) that are characterized by abnormalities in multiple organ systems and reduced life expectancy. The MPSs are heterogeneous, progressive disorders where subjects typically appear normal at birth, but during early childhood they experience the onset of clinical disease, including skeletal, joint, airway and cardiac symptoms, and hearing, vision, and cognitive impairment. MPSs are caused by deficiency in the activity of a single, specific lysosomal enzyme required for glycosaminoglycan (GAG) degradation. See Muenzer, et ah, Rheumatology , Volume 50, Suppl. Issue No. 5, pp. v4- vl2 (2011). Glycosaminoglycans, with the exception of hyaluronic acid, are the degradation products of proteoglycans in the extracellular matrix. The proteoglycans are proteolytic cleaved, giving rise to GAGs, which enter the lysosome for intracellular digestion. There are four different pathways of lysosomal degradation of GAGs, depending on the molecule to be degraded: dermatan sulfate, heparan sulfate, keratan sulfate, and chondroitin sulfate. The stepwise degradation of glycosaminoglycans requires ten different enzymes. Deficiencies of each one of these enzymes have been reported and result in seven different MPSs, all of them sharing a series of clinical features to varying degrees. See Couthino, et al., Biochem. Res. Inti. , Volume 2012, Article ID 471325, pp. 1-16.

Current treatment options for MPSs include hematopoietic stem cell transplant (HSCT) and enzyme replacement therapy (ERT). However, HSCT is invasive and expensive, and ERT is also expensive, and provides an uneven distribution of enzyme, leaving certain areas such as the bones, lungs, and brain untreated. Both of these treatments also require access to advanced medical care facilities. Thus, there is a need for MPS treatments that efficacious and less invasive.

SUMMARY Provided herein are methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants. Also provided herein are methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.5; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants. Also provided herein are methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Also provided herein are methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Also provided herein are methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising (a) determining that the subject has a lysosomal enzyme deficiency; and (b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Also provided herein are methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising (a) determining that the subject has a lysosomal enzyme deficiency; and (b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Also provided herein are methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising (a) determining that the subject has a lysosomal enzyme deficiency; and (b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Also provided herein are methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising (a) determining that the subject has a lysosomal enzyme deficiency; and (b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Methods and materials are described herein for use in the present invention; other, suitable methods and materials known in the art can also be used. The materials, methods, and examples are illustrative only and not intended to be limiting. All publications, patent applications, patents, sequences, database entries, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control.

Other features and advantages of the invention will be apparent from the following detailed description and figures, and from the claims.

DESCRIPTION OF DRAWINGS

FIG. 1 illustrates the different known MPSs, the gene and protein associated with each MPS, and the saccharide compound(s) that aggregates due to the dysregulation of the MPS-associated gene and/or MPS -associated protein.

DETAILED DESCRIPTION

Definitions

As used herein, the terms “treat” or “treatment,” refer to therapeutic measures. Beneficial or desired clinical results include, but are not limited to, stabilized (i.e., not worsening) state of disease, delay or slowing of disease progression, and remission (whether partial or total), whether detectable or undetectable. “Treatment” can also mean prolonging survival as compared to expected survival if not receiving treatment. In some embodiments, treatment includes alleviation of one or more symptoms of a disease, as defined herein. As used herein, “alleviate” or “alleviation,” refer to reduction, in whole or in part, of symptoms associated with a disease or disorder or condition, diminishment of the extent of disease, and amelioration or palliation of the disease state (e.g., one or more symptoms of the disease).

As used herein, the term “MPS -associated,” refers to nucleic acids (e.g., DNA or RNA) and/or proteins associated with a mucopolysaccharidosis, e.g., having a dysregulation of an MPS-associated gene, an MPS -associated protein, or the expression or activity or level of any of the same, leads to the development of a mucopolysaccharidosis. Non-limiting examples of MPS-associated genes include, for example, IDUA, IDS, SGSH, NAGLU, HGSNAT, GNS, GALNS, GLB1, ARSB, GUSB, and HYALl. Non-limiting examples of MPS-associated proteins include, for example, a-L-iduronidase, iduronate sulfatase, heparan sulfamidase, N-acetylglucosaminidase, heparan-a-glucosaminide N- acetyltransferase, N-acetylglucosamine 6-sulfatase, galactose-6-sulfate sulfatase, b- galactosidase, N-acetylgalactosamine-4-sulfatase, b -glucuronidase, and hyaluronidase.

As used herein, the term “subject” refers to any animal, including mammals such as mice, rats, other rodents, rabbits, dogs, cats, swine, cattle, sheep, horses, primates, and humans. In some embodiments, the subject is a human. In some embodiments, the subject has experienced and/or exhibited at least one symptom of the disease or disorder to be treated and/or alleviated. In some embodiments, the subject has been identified or diagnosed as having an MPS with a dysregulation of an MPS-associated gene, an MPS- associated protein, or activity or level of any of the same (e.g., as determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit). In some embodiments, the subject has a sample that is positive for a dysregulation of an MPS-associated gene, an MPS-associated protein, or activity or level of any of the same (e.g., as determined using a regulatory agency-approved assay or kit). In some embodiments, the subject is suspected of having an MPS. In some embodiments, the subject has a clinical record indicating that the subject has a sample that has a dysregulation of an MPS-associated gene, an MPS- associated protein, or activity or level of any of the same (and optionally the clinical record indicates that the subject should be treated with any of the compositions provided herein). In some embodiments, the subject is a pediatric subject. The term “pediatric subject” as used herein refers to a subject under the age of 21 years at the time of diagnosis or treatment. The term “pediatric” can be further be divided into various subpopulations including: neonates (from birth through the first month of life); infants (1 month up to two years of age); children (two years of age up to 12 years of age); and adolescents (12 years of age through 21 years of age (up to, but not including, the twenty-second birthday)). Berhman RE, Kliegman R, Arvin AM, Nelson WE. Nelson Textbook of Pediatrics, 15th Ed. Philadelphia: W.B. Saunders Company, 1996; Rudolph AM, et al. Rudolph ’s Pediatrics, 21st Ed. New York: McGraw-Hill, 2002; and Avery MD, First LR. Pediatric Medicine, 2nd Ed. Baltimore: Williams & Wilkins; 1994. In some embodiments, a pediatric subject is from birth through the first 28 days of life, from 29 days of age to less than two years of age, from two years of age to less than 12 years of age, or 12 years of age through 21 years of age (up to, but not including, the twenty-second birthday). In some embodiments, a pediatric subject is from birth through the first 28 days of life, from 29 days of age to less than 1 year of age, from one month of age to less than four months of age, from three months of age to less than seven months of age, from six months of age to less than 1 year of age, from 1 year of age to less than 2 years of age, from 2 years of age to less than 3 years of age, from 2 years of age to less than seven years of age, from 3 years of age to less than 5 years of age, from 5 years of age to less than 10 years of age, from 6 years of age to less than 13 years of age, from 10 years of age to less than 15 years of age, or from 15 years of age to less than 21 years of age.

The phrase “dysregulation of an MPS-associated gene, an MPS-associated protein, or the expression or activity or level of any of the same” refers to a genetic mutation. For example, a mutation in an IDUA gene that results in the expression of a a-L-iduronidase protein that includes a deletion of at least one amino acid as compared to a wild type a-L- iduronidase protein, a mutation in an IDUA gene that results in the expression of a a-L- iduronidase protein with one or more point mutations as compared to a wild type a-L- iduronidase protein, or a mutation in an IDUA gene that results in the expression of a a-L- iduronidase protein with at least one inserted amino acid as compared to a wild type a-L- iduronidase protein. Non-limiting examples of particular an MPS-associated protein point mutations/insertions/deletions are described in Table 1. The term “wild type” describes a nucleic acid (e.g., a particular gene or mRNA, such as IDUA) or protein (e.g., an a-L-iduronidase protein) that is found in a subject that does not have an MPS (and optionally also does not have an increased risk of developing an MPS and/or is not suspected of having an MPS), or is found in a cell or tissue from a subject that does not have an MPS (and optionally also does not have an increased risk of developing an MPS and/or is not suspected of having an MPS).

The phrases “consisting essentially of’ or “consisting of’ exclude any element, step, or ingredient not specified, e.g., excluding materials other than those recited except for impurities ordinarily associated therewith.

The term “regulatory agency” refers to a country's agency for the approval of the medical use of pharmaceutical agents with the country. For example, a non-limiting example of a regulatory agency is the U.S. Food and Drug Administration (FDA).

Methods of Treatment

Some embodiments provide methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.5; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising

(a) determining that the subject has a lysosomal enzyme deficiency; and

(b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising

(a) determining that the subject has a lysosomal enzyme deficiency; and

(b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising

(a) determining that the subject has a lysosomal enzyme deficiency; and

(b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising

(a) determining that the subject has a lysosomal enzyme deficiency; and

(b) administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; the formulation is administered over about 15 minutes to about 150 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants.

Some embodiments provide methods of treating a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 5.0 to 6.0; the formulation contains less than about 0.25 endotoxin units per mL; the formulation has an osmolality of about 300 mOsm/kg to 310 mOsm/kg; the formulation is administered over about 15 minutes to about 60 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 8% (w/v) to about 10% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants. In some embodiments, the mucopolysaccharidosis is selected from: Sanfillippo syndrome A (MPS IIIA), Sanfillippo syndrome B (MPS MB), Sanfillippo syndrome C (MPS IIIC), and Sanfillippo syndrome D (MPS HID). Other embodiments provide methods of alleviating one or more symptoms of a mucopolysaccharidosis in a subject in need thereof, comprising administering intravenously an aqueous pharmaceutical formulation to the subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 5.0 to 6.0; the formulation contains less than about 0.25 endotoxin units per mL; the formulation has an osmolality of about 300 mOsm/kg to 310 mOsm/kg; the formulation is administered over about 15 minutes to about 60 minutes; wherein the substantially purified trehalose is present in the formulation in an amount of about 8% (w/v) to about 10% (w/v); and wherein the substantially purified trehalose contains less than about 0.5% contaminants. In some embodiments, the mucopolysaccharidosis is selected from: Sanfillippo syndrome A (MPS IIIA), Sanfillippo syndrome B (MPS IIIB), Sanfillippo syndrome C (MPS IIIC), and Sanfillippo syndrome D (MPS HID).

In some embodiments, the pH of the formulation is about 4.5 to 7.0. In some embodiments, the pH of the formulation is about 4.5, about 4.8, about 5, about 5.3, about 5.5, about 5.8, about 6, about 6.3, about 6.5, about 6.8, about 7, or any value in between. In some embodiments, the pH of the formulation, is about 4.4 to about 6.6. In other embodiments, the pH of the formulation, is about 4.5 to about 6.5. In still other embodiments, the pH of the formulation is about 5 to about 6. In some embodiments, the pH of the formulation is about 5.5. In some embodiments, the formulation contains less than about 0.75 endotoxin units per mL, e.g., between an undetectable level of endotoxin units per mL, up to about 0.75 endotoxin units per mL, such as about 0.05, about 0.10, about 0.15, about 0.20, about 0.25, about 0.30, about 0.35, about 0.40, about 0.45, about 0.50, about 0.55, about 0.60, about 0.65, or about 0.70 endotoxin units per mL. In some embodiments, the formulation contains than about 0.50 endotoxin units per mL. In other embodiments, the formulation contains than about 0.25 endotoxin units per mL. In still other embodiments, the formulation contains than about 0.20 endotoxin units per mL. In some embodiments, the formulation contains about 0.01 to about 0.15 endotoxin units per mL, or any value in between. In some embodiments, the formulation contains less than about 0.15 endotoxin units per mL. In other embodiments, the formulation contains less than about 0.10 endotoxin units per mL. In still other embodiments, the formulation contains less than about 0.05 endotoxin units per mL. In some embodiments, the formulation contains less than about 0.02 endotoxin units per mL. In other embodiments, the formulation contains less than about 0.01 endotoxin units per mL. In still other embodiments, the formulation contains an undetectable amount of endotoxin units per mL. Methods for detecting endotoxin levels are known in the art, and include, for example, the rabbit pyrogen test (USP <151>), the monocyte activation test, the limulus amoebocyte lysate assay, and HPLC -based methods.

In some embodiments, the formulation has an osmolality of about 290 mOsm/kg to 320 mOsm/kg, or any value in between, for example, about 290, about 295, about 300, about 305, about 310, about 315, or about 320 mOsm/kg. In other embodiments, the formulation has an osmolality of about 300 mOsm/kg to about 310 mOsm/kg. In some embodiments, the formulation has an osmolality of about 290 mOsm/kg, about 300 mOsm/kg, about 310 mOsm/kg, or about 320 mOsm/kg. In some embodiments, the formulation is administered over about 15 minutes to about 150 minutes, or any value in between. In some embodiments, the formulation is administered over about 15 minutes to about 90 minutes. In other embodiments, the formulation is administered over about 15 minutes to about 60 minutes. In other embodiments, the formulation is administered over about 15 minutes to about 45 minutes. In some embodiments, the formulation is administered over about 15 minutes to about 30 minutes. In other embodiments, the formulation is administered over about 120 minutes to about 150 minutes. In some embodiments, the formulation is administered over less than about 150 minutes, less than about 120 minutes, less than about 90 minutes, less than about 60 minutes, less than about 45 minutes, or less than about 30 minutes.

In some embodiments, the formulation comprises about 5% (w/v) to about 15% (w/v) substantially purified trehalose, or any value in between, for example, about 5, about 6, about 7, about 8, about 9, about 10, about 11, about 12, about 13, about 14, or about 15% (w/v) substantially purified trehalose. In some embodiments, the formulation comprises about 6% (w/v) to about 12% (w/v) substantially purified trehalose. In other embodiments, the formulation comprises about 7% (w/v) to about 11% (w/v) substantially purified trehalose. In still other embodiments, the formulation comprises about 8% (w/v) to about 10% (w/v) substantially purified trehalose. In some embodiments, the formulation comprises about 9% (w/v) substantially purified trehalose. In other embodiments, the formulation comprises about 10% (w/v) substantially purified trehalose. In still other embodiments, the formulation comprises about 8% (w/v) substantially purified trehalose.

In some embodiments, the substantially purified trehalose contains less than about 0.5% contaminants, e.g., an undetectable level of contaminants by HPLC to about 0.5% contaminants, or any value in between. In some embodiments, the substantially purified trehalose contains about 0.01, about 0.02, about 0.03, about 0.04, about 0.05, about 0.08, about 0.10, about 0.12, about 0.15, about 0.18, about 0.20, about 0.22, about 0.25, about 0.28, about 0.30, about 0.32, about 0.35, about 0.38, about 0.40, about 0.42, about 0.45, about 0.48, or about 0.5% contaminants. In other embodiments, the substantially purified trehalose contains less than about 0.25% contaminants. In still other embodiments, the substantially purified trehalose contains less than about 0.1% contaminants. In some embodiments, the substantially purified trehalose contains less than about 0.08% contaminants. In other embodiments, the substantially purified trehalose contains less than about 0.05% contaminants. In still other embodiments, the substantially purified trehalose contains less than about 0.02% contaminants. In some embodiments, the substantially purified trehalose contains less than about 0.01% contaminants. In some embodiments, the contaminants in the substantially purified trehalose comprise glucose, maltotriose, or a combination thereof. In some embodiments, the formulation contains less than about 0.01% glucose and less than about 0.01% maltotriose.

In some embodiments, the subject is a pediatric subject. In other embodiments, the subject is under 18 years of age. In still other embodiments, the subject is under 12 years of age. In some embodiments, the subject is under 8 years of age. In other embodiments, the subject is under 6 years of age. In still other embodiments, the subject is under 4 years of age. In some embodiments, the subject is under 2 years of age. In other embodiments, the subject is under 1 year of age. In still other embodiments, the subject is under 8 months of age. In some embodiments, the subject is under 4 months of age. In other embodiments, the subject is under 1 month of age. In still other embodiments, the subject is 1 week of age. In some embodiments, the subject is between about 2 years of age and about 6 years of age. In other embodiments, the subject is about 4 years of age to about 6 years of age.

In some embodiments, the subject is in utero and wherein the intravenous administration to the subject comprises intravenous administration to the mother.

Some embodiments described herein further comprise administering enzyme replacement therapy to the subject. In some embodiments, described herein, the subject has previously been administered enzyme replacement therapy. In some embodiments, the enzyme replacement therapy is selected from the group consisting of: Aldurazyme, Elaprase, Agalsidase a, Agalsidase b, Imiglucerase, Taliglucerase a, Velaglucerase a, Alglucerase, Sebelipase a, Laronidase, Idursulfase, Elosulfase a, Galsulfase, Alglucosidase a; and combinations of any of the foregoing.

Some embodiments described herein further comprise administering a substrate reduction therapy to the subject. In some embodiments, described herein, the subject has previously been administered a substrate reduction therapy. In some embodiments, the substrate reduction therapy comprises one or more of miglustat, migalastat, miglitol, eliglustat, genistein, (S)-quinuclidin-3-yl(2-(2-(4-fluorophenyl)thiazol-4-yl)propa n-2- yl)carbamate (GZ 161), quinuclidin-3 -yl(2-(4'-fluoro-[ 1 , 1 '-biphenyl]-3 -yl)propan-2- yl)carbamate, ibiglustat, venglustat, eliglustat; or a combination of any of the foregoing; or a pharmaceutically acceptable salt of any of the foregoing.

In some embodiments, the formulation comprises substantially purified trehalose and a trehalase inhibitor as the sole active ingredients. In some embodiments, the trehalase inhibitor is selected from the group consisting of validimycin A, trehazolin, amygdalin; or a combination of any of the foregoing; or a pharmaceutically acceptable salt of any of the foregoing.

Some embodiments further comprise administering a trehalase inhibitor as a non- fixed combination with the pharmaceutical formulation comprising a single active ingredient consisting essentially of substantially purified trehalose. In some embodiments, the trehalase inhibitor is selected from the group consisting of validimycin A, trehazolin, amygdalin; or a combination of any of the foregoing; or a pharmaceutically acceptable salt of any of the foregoing. In some embodiments, the trehalase inhibitor is administered simultaneously or sequentially in either order with the pharmaceutical formulation comprising a single active ingredient consisting essentially of substantially purified trehalose.

Some embodiments provide a ready to use aqueous pharmaceutical formulation for intravenous administration to a subject, wherein the formulation comprises a single active ingredient consisting essentially of substantially purified trehalose, wherein: the pH of the formulation is about 4.5 to 7.0; the formulation contains less than about 0.75 endotoxin units per mL; the formulation has an osmolality of about 280 mOsm/kg to 330 mOsm/kg; wherein the substantially purified trehalose is present in the formulation in an amount of about 5% (w/v) to about 15% (w/v); wherein the substantially purified trehalose contains less than about 0.5% contaminants; wherein the formulation is disposed within a sealed container; and wherein the formulation is sterile.

In some embodiments, the container includes, but is not limited to, glass vials (for example, flint glass vials), ampoules, plastic flexible containers such as PVC (polyvinyl chloride) containers, VisiV™ plastic containers (Hospira, Inc., Lake Forest, Ill.), and CR3 elastomer copolyester ether containers (Hospira, Inc., Lake Forest, Ill.), CZ resin containers, and polypropylene containers. In some embodiments, the container is BPA- free.

In some embodiments, the container is selected form the group consisting of a glass container or a plastic container. In some embodiments, the container is a glass container. In other embodiments, the container is a plastic container. In some embodiments, the formulation is formulated as a total volume of 10 mL to 100 mL, or any value in between. In some embodiments, the formulation is formulated as a total volume selected from the group consisting of 10 mL, 20 mL, 30 mL, or 40 mL. In other embodiments, the formulation is formulated as a total volume of 10 mL. In still other embodiments, the formulation is formulated as a total volume of 20 mL. In some embodiments, the formulation is formulated as a total volume of 30 mL. In other embodiments, the formulation is formulated as a total volume of 40 mL.

In some embodiments, the plastic container is flexible. In some embodiments, the plastic container comprises a copolymer of ethylene and vinyl acetate. In other embodiments, the plastic container comprises a copolymer of an ethylene-propylene and a styrene-ethylene butylene-styrene (SEBS). In some embodiments, the plastic container comprises polypropylene. In some embodiments, the plastic container comprises single or multiple layers of polypropylene. In some embodiments, the plastic container is a film bag. In some embodiments, the plastic container further comprises an injection port and a tube port. In some embodiments, the formulation has been sterilized in moist steam. In other embodiments, the formulation has been aseptically sterilized.

In some embodiments, the formulations described herein are disposed in a container that can maintain the sterility of, or prevent the contamination of the formulation. In some embodiments, the container is a sealed container. In some embodiments, the formulation is disposed in a container, and formulated as a single use dosage. In other embodiments, the formulation is disposed in a container, and formulated as a multiple use dosage.

Accordingly, provided herein are methods for treating a subject diagnosed with (or identified as having) an that include administering to the subject a trehalose formulation as described herein Also provided herein are methods for treating a subject identified or diagnosed as having an MPS that include administering to the subject a formulation as described herein. In some embodiments, the subject that has been identified or diagnosed as having an MPS through the use of a regulatory agency-approved, e.g., FDA-approved test or assay for identifying dysregulation of a particular an MPS -associated gene or an MPS -associated protein, or activity or level same, in a subject or a sample from the subject or by performing any of the non-limiting examples of assays described herein. In some embodiments, the test or assay is provided as a kit. In other embodiments, the subject has been identified or diagnosed as having an MPS by measuring the levels of an aggregation product in a bodily fluid such as blood or urine.

Also provided are methods for treating an MPS in a subject in need thereof, the method comprising: (a) detecting a dysregulation of an MPS-associated gene and/or MPS- associated protein in the subject; and (b) administering to the subject a formulation as described herein. In some embodiments, the subject is determined to have an MPS through the use of a regulatory agency-approved, e.g., FDA-approved test or assay for identifying dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, in a subject or in a sample from the subject or by performing any of the non-limiting examples of assays described herein. In some embodiments, the test or assay is provided as a kit

Also provided are methods of treating a subject that include performing an assay on a sample obtained from the subject to determine whether the subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, and administering (e.g., specifically or selectively administering) a trehalose formulation as described herein to the subject determined to have a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same. Some embodiments of these methods further include administering to the subject another therapy such as enzyme replacement therapy or substrate reduction therapy, as described herein. In some embodiments, the subject is a subject suspected of having an MPS, a subject presenting with one or more symptoms of an MPS, or a subject having an elevated risk of developing an MPS. In some embodiments, the assay is a regulatory agency-approved assay, e.g., FDA-approved kit.

Also provided are trehalose formulations for use in treating an MPS in a subject identified or diagnosed as having an MPS through a step of performing an assay (e.g., an in vitro assay) on a sample obtained from the subject to determine whether the subject has a dysregulation of an MPS -associated gene, an MPS -associated protein, or expression or activity or level of any of the same, where the presence of a dysregulation of an MPS- associated gene, an MPS-associated protein, or expression or activity or level of any of the same, identifies that the subject has an MPS. Also provided is the use of the trehalose formulations described herein for the manufacture of a medicament for treating an MPS in a subject identified or diagnosed as having an MPS through a step of performing an assay on a sample obtained from the subject to determine whether the subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same where the presence of dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, identifies that the subject has an MPS. Some embodiments of any of the methods or uses described herein further include recording in the subject’s clinical record (e.g., a computer readable medium) that the subject is determined to have a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, through the performance of the assay, should be administered a the trehalose formulations described herein. In some embodiments, the assay is a regulatory agency-approved assay, e.g., FDA- approved kit.

Also provided is a the trehalose formulations described herein for use in the treatment of an MPS in a subject in need thereof or a subject identified or diagnosed as having an MPS. Also provided is the use of the trehalose formulations described herein for the manufacture of a medicament for treating an MPS in a subject identified or diagnosed as having an MPS. In some embodiments, a subject is identified or diagnosed as having an MPS through the use of a regulatory agency-approved, e.g., FDA-approved, kit for identifying dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, in a subject or a sample from the subject. Also provided herein are methods for treating a pediatric subject diagnosed with (or identified as having) an MPS that include administering to the pediatric subject a the trehalose formulations described herein. Also provided herein are methods for treating a pediatric subject identified or diagnosed as having an MPS that include administering to the pediatric subject a the trehalose formulations described herein. In some embodiments, the pediatric subject that has been identified or diagnosed as having an MPS through the use of a regulatory agency-approved, e.g ., FDA-approved test or assay for identifying dysregulation of an MPS-associated gene, an MPS -associated protein, or expression or activity or level of any of the same, in a pediatric subject or a sample from the pediatric subject or by performing any of the non-limiting examples of assays described herein. In some embodiments, the test or assay is provided as a kit.

Also provided are methods for treating a lysosomal storage disorder in a pediatric subject in need thereof, the method comprising: (a) determining if the lysosomal storage disorder in the pediatric subject is an MPS; and (b) if the lysosomal storage disorder is determined to be an MPS, administering to the pediatric subject a the trehalose formulations described herein. Some embodiments of these methods further include administering to the subject another therapy such as enzyme replacement therapy or substrate reduction therapy. In some embodiments, the subject was previously treated with an enzyme replacement therapy (e.g., Aldurazyme, Elaprase, Agalsidase a, Agalsidase b, Imiglucerase, Taliglucerase a, Velaglucerase a, Alglucerase, Sebelipase a, Laronidase, Idursulfase, Elosulfase a, Galsulfase, Alglucosidase a) and/or a substrate reduction therapy (e.g., miglustat, migalastat, miglitol, eliglustat, genistein, (S)-quinuclidin-3-yl(2-(2-(4- fluorophenyl)thiazol-4-yl)propan-2-yl)carbamate (GZ161), quinuclidin-3-yl(2-(4'-fluoro- [l,l'-biphenyl]-3-yl)propan-2-yl)carbamate, ibiglustat, venglustat, eliglustat; or a combination of any of the foregoing; or a pharmaceutically acceptable salt of any of the foregoing).

In some embodiments, the pediatric subject is determined to have an MPS through the use of a regulatory agency-approved, e.g. , FDA-approved test or assay for identifying dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, in a pediatric subject or a sample from the pediatric subject or by performing any of the non-limiting examples of assays described herein. In some embodiments, the test or assay is provided as a kit.

Also provided are methods of treating a pediatric subject that include performing an assay on a sample obtained from the pediatric subject to determine whether the pediatric subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, and administering ( e.g ., specifically or selectively administering) a the trehalose formulations described herein to the pediatric subject determined to have a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same. Some embodiments of these methods further include administering to the pediatric subject another therapy such as enzyme replacement therapy or substrate reduction therapy. In some embodiments, the pediatric subject was previously treated with an enzyme replacement therapy (e.g., Aldurazyme, Elaprase, Agalsidase a, Agalsidase b, Imiglucerase, Taliglucerase a, Velaglucerase a, Alglucerase, Sebelipase a, Laronidase, Idursulfase, Elosulfase a, Galsulfase, Alglucosidase a) and/or a substrate reduction therapy (e.g., miglustat, migalastat, miglitol, eliglustat, geni stein, (S)-quinuclidin-3-yl(2-(2-(4- fluorophenyl)thiazol-4-yl)propan-2-yl)carbamate (GZ161), quinuclidin-3-yl(2-(4'-fluoro- [l,l'-biphenyl]-3-yl)propan-2-yl)carbamate, ibiglustat, venglustat, eliglustat; or a combination of any of the foregoing; or a pharmaceutically acceptable salt of any of the foregoing). In some embodiments, the pediatric subject is a pediatric subject suspected of having an MPS, a pediatric subject presenting with one or more symptoms of an MPS, or a pediatric subject having an elevated risk of developing an MPS. In some embodiments, the assay is a regulatory agency-approved assay, e.g., FDA-approved kit. Additional assays are also known in the art.

Also provided is a the trehalose formulations described herein for use in treating an MPS in a pediatric subject identified or diagnosed as having an MPS through a step of performing an assay (e.g, an in vitro assay) on a sample obtained from the pediatric subject to determine whether the pediatric subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, where the presence of a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, identifies that the pediatric subject has an MPS. Also provided is the use of a the trehalose formulations described herein for the manufacture of a medicament for treating an MPS in a pediatric subject identified or diagnosed as having an MPS through a step of performing an assay on a sample obtained from the pediatric subject to determine whether the pediatric subject has a dysregulation of an MPS-associated gene, an MPS -associated protein, or expression or activity or level of any of the same where the presence of dysregulation of an MPS-associated gene, an MPS- associated protein, or expression or activity or level of any of the same, identifies that the pediatric subject has an MPS. Some embodiments of any of the methods or uses described herein further include recording in the pediatric subject’s clinical record ( e.g ., a computer readable medium) that the pediatric subject is determined to have a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, through the performance of the assay, should be administered a the trehalose formulations described herein. In some embodiments, the assay is a regulatory agency- approved assay, e.g., FDA-approved kit.

Also provided is a the trehalose formulations described herein for use in the treatment of an MPS in a pediatric subject in need thereof or a pediatric subject identified or diagnosed as having an MPS. Also provided is the use of a the trehalose formulations described herein for the manufacture of a medicament for treating an MPS in a pediatric subject identified or diagnosed as having an MPS. In some embodiments, a pediatric subject is identified or diagnosed as having an MPS through the use of a regulatory agency- approved, e.g, FDA-approved, kit for identifying dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, in a pediatric subject or a sample from the pediatric subject.

In some embodiments of any of the methods or uses described herein, the subject has been identified or diagnosed as having an MPS with a dysregulation of an MPS- associated gene, an MPS-associated protein, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the subject has a sample that is positive for a dysregulation of an MPS-associated gene, an MPS- associated protein, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the subject can be a subject having a sample that is positive for a dysregulation of an MPS -associated gene, an MPS- associated protein, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the subject can be a subject having a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same. In some embodiments of any of the methods or uses described herein, the subject is suspected of having an MPS (e.g., having one or more mutations in an MPS-associated gene and/or MPS-associated protein, as described herein). In some embodiments, provided herein are methods for treating an MPS in a subject in need of such treatment, the method comprising a) detecting a dysregulation of an MPS-associated gene, an MPS-associated protein, or the expression or activity or level of any of the same in a sample from the subject; and b) administering a the trehalose formulations described herein. In some embodiments, the dysregulation of an MPS- associated gene, an MPS-associated protein, or the expression or activity or level of any of the same includes one or more protein point mutations/insertions/deletions. Non-limiting examples of protein point mutations/insertions/deletions are described in Table 1. In some embodiments, the point mutations/insertions/deletions are selected from the group consisting of those protein mutations described in Table 1. Table 1

The ClinVar database provided by the National Center for Biotechnology Information (NCBI) was used to identify known pathogenic genetic variants as shown in Table 1. See Richards et al. , Genet. Med 17(5):405-24 (2015). As used in herein, “fs” refers to a genetic variant that resulted in a frameshift. For example, Val251Phefs refers to a frameshift mutation at amino acid position 251 that resulted in a change from valine to phenylalanine.

In some embodiments of any of the methods or uses described herein, the subject has a clinical record indicating that the subject has a dysregulation of an MPS -associated gene, an MPS-associated protein, or expression or activity or level of any of the same (e.g., having one or more mutations in an MPS-associated gene and/or MPS-associated protein, as described herein). In some embodiments, the clinical record indicates that the subject should be treated with a the trehalose formulations described herein. In some embodiments, the subject with a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same is a subject having one or more point mutations in an MPS-associated gene and/or an MPS-associated protein. In some embodiments, the subject with a dysregulation of an MPS-associated gene, an MPS- associated protein, or expression or activity or level of any of the same is determined using a regulatory agency-approved, e.g., FDA-approved, assay or kit. In some embodiments, the sample with a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same is determined using a regulatory agency- approved, e.g., FDA-approved, assay or kit.

Also provided are methods of treating a subject that include administering a the trehalose formulations described herein to a subject having a clinical record that indicates that the subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same. Also provided is the use of a the trehalose formulations described herein for the manufacture of a medicament for treating an MPS in a subject having a clinical record that indicates that the subject has a dysregulation of an MPS-associated gene, an MPS -associated protein, or expression or activity or level of any of the same. Some embodiments of these methods and uses can further include: a step of performing an assay (e.g., an in vitro assay) on a sample obtained from the subj ect to determine whether the subj ect has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, and recording the information in a subject’s clinical file (e.g., a computer readable medium) that the subject has been identified to have a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same. In some embodiments, the assay is an in vitro assay. For example, an assay that utilizes genetic techniques, such as next generation sequencing, or measures GAG levels in a sample, or measures the activity of one or more enzymes in a sample. In some embodiments, the assay is a regulatory agency-approved, e.g., FDA-approved, kit.

Also provided herein is a method of treating a subject. In some embodiments, the method includes performing an assay on a sample obtained from the subject to determine whether the subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or level of any of the same. In some such embodiments, the method also includes administering to a subject determined to have a dysregulation of an MPS- associated gene, an MPS-associated protein, or activity or level of any of the same. In some embodiments, the method includes determining that a subject has a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or level of any of the same via an assay performed on a sample obtained from the subject. In such embodiments, the method also includes administering to a subject a the trehalose formulations described herein. In some embodiments, the dysregulation in an MPS-associated gene, an MPS- associated protein, or expression or activity or level of any of the same is one or more point mutation in the MPS-associated gene (e.g., any of the one or more of the point mutations described herein, such as in Table 1). The one or more point mutations in an MPS- associated gene can result, e.g., in the translation of an MPS-associated protein having one or more of the amino acid substitutions described in Table 1. Some embodiments of these methods further include administering to the subject another therapy to the subject, such as an enzyme replacement therapy or substrate reduction therapy, as described herein. In some embodiments, the methods described herein provide trehalose formulations that exhibit brain and/or central nervous system (CNS) penetrance. Thus, the methods described herein provide trehalose that is capable of crossing the blood brain barrier and providing a therapeutically effective amount of trehalose in the brain and/or other CNS structures. For example, treatment of a subject with an MPS having effects on the brain and/or CNS such as cognitive effects.

In some embodiments, the methods described herein provide trehalose formulations that exhibit penetrance into muscle tissue (including skeletal and smooth muscle). Thus, the methods described herein provide trehalose that is capable of penetrating into muscle tissue, thus providing a therapeutically effective amount of trehalose in the muscle fibers. For example, treatment of a subject with an MPS having effects on the muscles, such as kinesthetic or movement effects.

Also provided are methods (e.g., in vitro methods) of selecting a treatment for a subject identified or diagnosed as having an MPS. Some embodiments can further include administering the selected treatment to the subject identified or diagnosed as having an MPS. For example, the selected treatment can include administration of a the trehalose formulations described herein. Some embodiments can further include a step of performing an assay on a sample obtained from the subject to determine whether the subject has a dysregulation of an MPS-associated gene, an MPS -associated protein, or expression or activity or level of any of the same, and identifying and diagnosing a subject determined to have a dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, as having an MPS. In some embodiments, the subject has been identified or diagnosed as having an MPS through the use of a regulatory agency-approved, e.g., FDA-approved, kit for identifying dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or level of any of the same, in a subject or a sample from the subject. In some embodiments, the assay is an in vitro assay. For example, an assay that utilizes genetic techniques, such as next generation sequencing, or measures GAG levels in a sample, or measures the activity of one or more enzymes in a sample. In some embodiments, the assay is a regulatory agency- approved, e.g., FDA-approved, kit.. In some embodiments of any of the methods or uses described herein, an assay used to determine whether the subject has a dysregulation of an MPS-associated gene, an MPS- associated protein, or expression or activity or level of any of the same, using a sample from a subject can include, for example, next generation sequencing, immunohistochemistry, fluorescence microscopy, Southern blotting, Western blotting, FACS analysis, Northern blotting, PCR-based amplification (e.g., RT-PCR and quantitative real-time RT-PCR), enzymatic activity assays, and assays to measure GAG levels in a sample. Assays can utilize other detection methods known in the art for detecting dysregulation of an MPS-associated gene, an MPS-associated protein, or expression or activity or levels of any of the same.

In some embodiments, the MPS-associated gene is selected from IDUA, IDS, SGSH, NAGLU, HGSNAT, GNS, GALNS, GLB1, ARSB, GUSB, and HYALl. In some embodiments, the MPS-associated gene is IDUA. In other embodiments, the MPS- associated gene is IDS. In still other embodiments, the MPS-associated gene is SGSH. In some embodiments, the MPS-associated gene is NAGLU. In other embodiments, the MPS-associated gene is HGSNAT. In still other embodiments, the MPS-associated gene is GNS. In some embodiments, the MPS-associated gene is GALNS. In other embodiments, the MPS-associated gene is GLB1. In still other embodiments, the MPS- associated gene is ARSB. In some embodiments, the MPS-associated gene is GUSB. In other embodiments, the MPS-associated gene is HYALL

In some embodiments, the MPS-associated protein is selected from a-L- iduronidase, iduronate sulfatase, heparan sulfamidase, N-acetylglucosaminidase, heparan- a-glucosaminide N-acetyl transferase, N-acetyl glucosamine 6-sulfatase, galactose-e- sulfate sulfatase, b-galactosidase, N-acetylgalactosamine-4-sulfatase, b-glucuronidase, and hyaluronidase. In some embodiments, the MPS-associated protein is a-L-iduronidase. In other embodiments, the MPS-associated protein is iduronate sulfatase. In still other embodiments, the MPS-associated protein is N-acetylglucosaminidase. In some embodiments, the MPS-associated protein is heparan-a-glucosaminide N- acetyltransferase. In other embodiments, the MPS-associated protein is N- acetylglucosamine 6-sulfatase. In still other embodiments, the MPS-associated protein is galactose-6-sulfate sulfatase. In some embodiments, the MPS-associated protein is b- galactosidase. In other embodiments, the MPS-associated protein is N- acetylgalactosamine-4-sulfatase. In still other embodiments, the MPS-associated protein is b-glucuronidase. In some embodiments, the MPS-associated protein is hyaluronidase. In some embodiments, the mucopolysaccharidosis (or “MPS”) is selected from the group consisting of: Hurler syndrome (MPS IH), Hurler-Scheie syndrome (MPS IH/S), Scheie syndrome (MPS IS or MPS V), Hunter syndrome (MPS II), Sanfillippo syndrome A (MPS IPA), Sanfillippo syndrome B (MPS MB), Sanfillippo syndrome C (MPS IIIC), Sanfillippo syndrome D (MPS HID), Morquio syndrome A (MPS IV A), Morquio syndrome B (MPS IVB), Maroteaux-Lamy syndrome (MPS VI), Sly syndrome (MPS VII), and Natowicz syndrome (MPS IX).

In some embodiments, the mucopolysaccharidosis (or “MPS”) is Hurler syndrome (MPS IH). In other embodiments, the MPS is Hurler-Scheie syndrome (MPS IH/S). In still other embodiments, the MPS is Scheie syndrome (MPS IS or MPS V). In some embodiments, the MPS is Hunter syndrome (MPS II). In some embodiments, the MPS is selected from the group consisting of: Sanfillippo syndrome A (MPS IIIA), Sanfillippo syndrome B (MPS IIIB), Sanfillippo syndrome C (MPS IIIC), and Sanfillippo syndrome D (MPS HID). In some embodiments, the MPS is Sanfillippo syndrome A (MPS IIIA). In other embodiments, the MPS is Sanfillippo syndrome B (MPS MB). In still other embodiments, the MPS is Sanfillippo syndrome C (MPS IIIC). In some embodiments, the MPS is and Sanfillippo syndrome D (MPS HID). In some embodiments, the MPS is Morquio syndrome A (MPS IV A). In other embodiments, the MPS is Morquio syndrome B (MPS IVB). In still other embodiments, the MPS is Maroteaux-Lamy syndrome (MPS VI). In some embodiments, the MPS is Sly syndrome (MPS VII). In other embodiments, the MPS is and Natowicz syndrome (MPS IX).

Some embodiments described herein include determining that a subject has a lysosomal enzyme deficiency, treating a subject that has been determined to have a lysosomal enzyme deficiency, or alleviating one or more symptoms in a subject that has been determined to have a lysosomal enzyme deficiency. The determination that a subject has a lysosomal deficiency can include various tests, for example, a genetic test, a blood test, a urine test, an in vitro enzymatic assay (e.g., testing a sample of cells and/or tissue(s) and/or bodily fluid(s) for enzymatic activity), or a combination of any of the foregoing. In some embodiments, determining that a subject has a lysosomal enzyme deficiency comprises a genetic test. In other embodiments, determining that a subject has a lysosomal enzyme deficiency comprises a blood test. In still other embodiments, determining that a subject has a lysosomal enzyme deficiency comprises a urine test. In some embodiments, determining that a subject has a lysosomal enzyme deficiency comprises an in vitro enzymatic assay. In some embodiments, determining that a subject has a lysosomal enzyme deficiency comprises amniocentesis, chorionic villus sampling, or a combination thereof.

In some embodiments, the alleviation of one or more symptoms in a subject that has been determined to have a lysosomal enzyme deficiency can include, but is not limited to, reducing the frequency of respiratory infections, sleep apnea, hearing loss, ear infections, corneal clouding, diarrhea, skin growths, irregularities in bone shape and/or size, irregularities in heart valve structure and/or function, hoarse voice, joint stiffness, aggressive behavior, distended abdomen, spinal stenosis, and developmental delays.

In some embodiments, the enzyme deficiency is a deficiency in an enzyme selected from the group consisting of: a-L-iduronidase, iduronate sulfatase, heparan sulfamidase, N-acetylglucosaminidase, heparan-a-glucosaminide N-acetyltransferase, N- acetylglucosamine 6-sulfatase, galactose-6-sulfate sulfatase, b-galactosidase, N- acetylgalactosamine-4-sulfatase, b-glucuronidase, and hyaluronidase. In some embodiments, the enzyme deficiency is a deficiency in a-L-iduronidase. In other embodiments, the enzyme deficiency is a deficiency in iduronate sulfatase. In still other embodiments, the enzyme deficiency is a deficiency in N-acetylglucosaminidase. In some embodiments, the enzyme deficiency is a deficiency in heparan-a-glucosaminide N- acetyltransferase. In other embodiments, the enzyme deficiency is a deficiency in N- acetylglucosamine 6-sulfatase. In still other embodiments, the enzyme deficiency is a deficiency in galactose-6-sulfate sulfatase. In some embodiments, the enzyme deficiency is a deficiency in b-galactosidase. In other embodiments, the enzyme deficiency is a deficiency in N-acetylgalactosamine-4-sulfatase. In still other embodiments, the enzyme deficiency is a deficiency in b-glucuronidase. In some embodiments, the enzyme deficiency is a deficiency in hyaluronidase.

In some embodiments, the methods described herein provide a reduction in one or more of the aggregation products of the MPS in a subject (e.g., one or more of heparan sulfate, dermatan sulfate, keratan sulfate, chondroitin sulfate, and/or hyaluronic acid). For example, a reduction (e.g., about 20% to about 99% reduction, about 20% to about 95% reduction, about 20% to about a 90% reduction, about 20% to about a 85% reduction, about 20% to about a 80% reduction, about 20% to about a 75% reduction, about 20% reduction to about 70% reduction, about 20% reduction to about 65% reduction, about 20% reduction to about 60% reduction, about 20% reduction to about 55% reduction, about 20% reduction to about 50% reduction, about 20% reduction to about 45% reduction, about 20% reduction to about 40% reduction, about 20% reduction to about 35% reduction, about 1% reduction to about 30% reduction, about 20% reduction to about 25% reduction, about 20% to about 99% reduction, about 25% to about 99% reduction, about 30% to about 99% reduction, about 35% to about 99% reduction, about 40% to about 99% reduction, about 45% to about 99% reduction, about 50% to about 99% reduction, about 55% to about 99% reduction, about 60% to about 99% reduction, about 65% to about 99% reduction, about 70% to about 99% reduction, about 75% to about 95% reduction, about 80% to about 99% reduction, about 90% reduction to about 99% reduction, about 95% to about 99% reduction, about 20% to about 40% reduction, about 25% to about 50% reduction, about 35% to about 55% reduction, about 40% to about 60% reduction, about 50% reduction to about 75% reduction, about 60% reduction to about 80% reduction, or about 65% to about 85% reduction) in levels of one or more of heparan sulfate, dermatan sulfate, keratan sulfate, chondroitin sulfate, and/or hyaluronic acid in a subject.

EXAMPLES

The following examples illustrate the invention.

Example 1 : STUDY TO ASSESS SAFETY AND EFFICACY OF IV TREHALOSE INJECTION IN PATIENTS WITH SANFILIPPO SYNDROME TYPE A OR TYPE B Methodology: A three-part study of IV Trehalose Injection 90 mg/mL for the treatment of Sanfilippo syndrome type A and type B is conducted. Patients with genetically confirmed Sanfilippo syndrome type A or B who have elevated excretion of GAGs in the urine and/or elevated levels of HS in plasma and/or urine are eligible for enrollment. The study will be conducted in three parts as described below.

Part 1: Part 1 has a 4-week screening period followed by an initial 30-week dose escalation period (7-week open-label dose escalation period, followed by 23 weeks of treatment) (Table 1). This period of the study will be used to assess the safety and tolerability of escalating dose levels of IV trehalose, to identify patients who will continue as the enriched cohort in Part 2 of the study using MDRI at Week 30, and to assess the association over time between neurocognitive and behavioral symptoms and biomarkers.

During the screening period, urinary GAG, and urinary and plasma HS biomarkers will be collected 3 times, 7 days apart, to establish the baseline excretion and plasma concentration. Patients will have the following baseline assessments: physical exam, safety labs, electrocardiogram (ECG), CT scan of the liver and spleen for volumetric determination, and ABR. Neurocognitive and behavioral assessments will be performed using the VABS-3, either the BSID-III or the KABC-II, and the SBRS. Quality of life will be assessed using the PedsQL™.

Baseline assessment of mobility will include the TUG test. Baseline functional and motor capabilities will be assessed, and the patient will be videotaped during the assessments. The assessments include the 9-hole peg test (9-HPT), TUG test, 10-meter Walk test, and pre-specified items of the Gross Motor Function Measure (GMFM). Subsequently, an independent physical therapist or other qualified clinician will review video of the patient completing the assessments and score the degree of the patient’ s change in ability to perform assessments using the CGIC scale.

Caregivers will be administered the CaGIS through an interview by a physical therapist or other qualified clinician. Baseline assessment of swallowing will include the 80 mL cold water drinking test and the Sydney Swallowing questionnaire. Baseline assessment of hearing will be performed by the ABR test. Dose Escalation: The dose escalation will begin on treatment Week 1 with a starting dose of 0.25 g/kg of trehalose administered IV over 60 minutes once weekly. At Week 3 (after the first 2 weekly doses of 0.25 g/kg), patients will have safety labs, selected biomarkers (urinary GAGs, urinary and plasma HS), and PK levels assessed. A Safety Review Committee (SRC) consisting of the sponsor’s chief medical officer or designee with a medical degree, the lead principal investigator (PI), an external physician with clinical trial safety data review experience, and a PK expert will be convened. The SRC will review each patient’s safety, PK, and biomarker data within 1 week of the Week 3 dose. If there are no safety, PK or biomarker concerns identified, the dose will be increased to 0.50 g/kg at Week 4. Although the committee will make a recommendation, the ultimate decision to escalate the dose, continue the same dose or stop treatment is the responsibility of the local PI at all decision points. At Week 6 (after 2 weekly doses of 0.50 g/kg), patients will have safety labs, biomarkers, and PK levels assessed. The SRC will review each patient’s safety, PK, and biomarker data within 1 week of the Week 6 dose. If there are no safety, PK or biomarker issues identified by the SRC, the dose will be increased to 0.75 g/kg at Week 7. At Week 9 (after 2 weekly doses of 0.75 g/kg), patients will have safety labs, biomarkers, and PK levels assessed. The SRC will review each patient’s safety, PK, and biomarker data within 1 week of the Week 9 dose. If there are no safety, PK or biomarker issues identified by the SRC, the dose will remain at 0.75 g/kg. Patients will reach their maximum tolerated dose (MTD) by Week 7 and will continue treatment at their MTD to the end of the 30-week treatment period. At Week 30, all safety and efficacy measures will be performed including: adverse events, physical exam, safety labs, biomarkers, ECG, PK, CT of liver and spleen, ABR, neurocognitive and behavioral testing, swallowing, mobility, and video assessments, as well as quality of life assessment.

Treatment Assignment for Part 2: Once each patient has completed the safety and efficacy assessments at Week 30, an independent DMC will be convened to review patient data. The DMC will be composed of clinical experts and an independent statistician. Using a priori defined criteria (MDRI), the DMC will assign the patient to either receive placebo (enriched cohort) or continue receiving IV trehalose (active treatment cohort) in Part 2 of the study.

The criteria for inclusion in the study are, for example, subjects having (i) at least a pre-specified minimum reduction in any of the following biomarkers (urinary GAGs or HS, plasma HS) at Week 30; or (ii) evidence of slowed or stabilized disease progression or improvement in neurocognitive or behavioral assessments at Week 30. These subjects will receive placebo in Part 2 of the study. This group of patients will constitute the enriched cohort for Part 2 of the study. Patients who do not meet the predefined criteria will continue IV trehalose treatment as part of active treatment cohort in Part 2 of the study.

Part 2: Part 2 is an 18-week assessment period composed of a 2-week transition followed by a 16-week crossover to placebo for the enriched cohort and continuation of IV trehalose for the active treatment cohort (Table 2). This phase of the study will be used to assess the loss of effect (deterioration) in the enriched cohort following a one-way crossover to placebo, assess the continued safety and tolerability and effect of continued IV trehalose in the active treatment cohort, as well as determine the efficacy of IV trehalose as assessed by effects on GAGs and HS and neurocognitive and behavioral symptoms in patients with Sanfilippo syndrome type A and type B.

All patients will receive IV trehalose during the 2-week transition period. Once treatments for Part 2 are assigned, patients will receive placebo or continued IV trehalose during the 16 week treatment period.

The 16-week treatment period occurs from Weeks 33 through 48 with patients assigned to one of two treatment cohorts: (i) The active treatment cohort, receiving weekly IV trehalose 90 mg/mL at individual MTD; and (ii) the enriched cohort, receiving weekly IV placebo (sodium chloride injection, 0.9%, USP).

At each study site, the blinded treatment assignment will be provided to the unblinded pharmacist or designee who will prepare the active drug or placebo for administration.

Safety lab, ECG, and efficacy assessments will take place at Weeks 40 and 48 (safety lab assessment also at Week 34), while biomarker assessments will take place every 2 weeks during the treatment crossover period. All results will be monitored by the DMC chair. The one-way crossover to placebo for patients in the enriched cohort is intended to last for 16 weeks. To control for bias during Part 2, only the pharmacist or designee, the pharmacy monitor, and the statistician will be aware of the assignment of study drug because assignment to the active treatment or enriched cohort will not be revealed. The treatment assignment in Part 2 of the study will be blinded to prevent bias in the determination of the MDRI for the assessment of efficacy after 48 weeks on study.

Part 3 : During the concluding 24-week open-label extension period, all patients will receive weekly dosing with IV trehalose 90 mg/mL at the individual MTD (Table 3). Safety lab assessments occur at Weeks 50 and 56 and then every 8 weeks for the duration of the open-label extension period. Biomarker assessments occur every 2 weeks for the first 8 weeks, then every 4 weeks for the duration of the open-label extension period. An ECG and all efficacy assessments are performed at Week 72 (final visit).

Patients who complete the 76-week study may continue treatment under a separate treatment extension protocol in lieu of marketing approval. Exemplary criteria for diagnosis and main criteria for inclusion & exclusion are listed below.

Inclusion:

1. Provided written informed consent signed by parent(s) or legal guardian(s)

2. Genetically confirmed Sanfilippo syndrome type A or type B, a. Genomic DNA analysis demonstrating a homozygous or compound heterozygous pathogenic variants in the SGSH (type A) or NAGLU (type B) genes

3. Elevated excretion of urinary GAGs and/or urinary or plasma HS at screening (mean of 3 assessments > upper limit of normal [ULN])

4. Male or female; 6 to 21 years of age, inclusive 5. Negative urine or beta-human chorionic gonadotropin (B-hCG) pregnancy result at screening for female patients with child-bearing potential

6. Willingness to comply with sexual abstinence or contraception guidelines as instructed Exclusion:

1. Prior administration of stem cell or gene therapy, or enzyme replacement therapy (ERT) for Sanfilippo syndrome type A or type B 2. Previously diagnosed with diabetes or a hemoglobin Ale (HgbAlc) result > 6.0% at screening

3. Poorly controlled seizures, defined as one or more seizure per week for the last 4-6 weeks 4. Visual or hearing impairment sufficient to preclude cooperation with neurodevelopmental testing

5. Any other medical condition that, in the opinion of the investigator, would confound interpretation of safety or efficacy data or would place a patient at undue risk

6. Inability to cooperate with protocol-required assessments or procedures 7. Prior treatment with IV trehalose

8. Known hypersensitivity to trehalose

9. Use of genistein-rich soy isoflavone within 30 days before signing of consent

10. Use of oral trehalose within 7 days before signing of consent

11. Evidence of hepatitis B or hepatitis C infection upon serological testing at screening 12. Currently receiving anti-coagulant treatment (e.g., warfarin, enoxaparin), other than anti-platelet treatments, which are not a reason for exclusion

13. Currently participating in another clinical trial or has completed an interventional trial less than 90 days prior to planned first dosing

Investigational product, dosage and mode of administration: Trehalose 90 mg/mL solution will be administered IV in Part 1 over 60 ± 5 minutes once weekly in a dose escalation manner as described above starting with a dose of 0.25 g/kg and up to a maximum dose of 0.75 g/kg. Patients will be administered trehalose IV or placebo over 60 ± 5 minutes once weekly in Part 2 (active treatment cohort and enriched cohort, respectively) and IV trehalose for all patients in Part 3. Indwelling catheters are not permitted. Reference therapy, dosage and mode of administration: Placebo (sodium chloride injection, 0.9%, USP administered IV)

Restricted Medications: There are no known drug-drug interactions with IV trehalose 90 mg/mL. If the patient starts the study on miglustat, the dose must remain the same throughout the study. Patients are not permitted to initiate treatment with miglustat while on study. Cannabidiol (CBD) oil is permitted but the dose must remain the same throughout the study. Behavioral medications (stimulants, non-stimulants, psychotropic medications) are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible. Oral trehalose and genistein-rich soy isoflavones are not permitted during the study. Patients should not change concomitant medications during the study unless they experience an exacerbation of epilepsy or an acute illness. Patients may receive concomitant medications that are medically necessary as standard care only to treat symptoms, AEs, inter-current illnesses, and to prevent illness, e.g. vaccines. Over-the-counter (OTC) medications such as vitamins or herbal supplements are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible.

Statistical methods: Patients enrolled into this clinical investigation are expected to represent a heterogeneous population relative to their symptoms and clinical presentation. To account for these differences, the evaluation of a patient will use a multi-domain responder index (MDRI). The criterion for establishing response will be documented in the DMC charter, given it will be under the purview of the DMC to sanction patients for participation in the cross-over portion of Part 2 of the study and assess the loss of effect. The DMC will be blinded to treatment assignment in Part 2 of the study to prevent bias in the determination of the MDRI on an intra-patient basis.

Descriptive summaries of continuous safety and efficacy data including number of evaluable subjects, mean, median, standard deviation (SD), maximum and minimum will be provided by treatment and scheduled visit. Summaries for categorical variables will include number evaluable, frequencies, and percentages. Additionally, the same descriptive statistics will be provided for changes from baseline and percent changes from baseline at each post-baseline visit, when appropriate.

The following analysis populations are defined for the study:

• Safety Population: all patients who have received at least 1 dose of study drug, including partial infusions.

• Full Analysis Set (FAS): all patients who have received at least 1 dose of study drug during the Part 1 and who have at least 1 post-baseline efficacy assessment for determination of the MDRI during Part 1 of the study. It is from this pool of patients that response will be examined to determine response during Part 1 and entry into Enriched population.

• Enriched population: Patients who enter the cross-over portion of Part 2 of the study for evaluation of the MDRI. The Enriched population will be the primary population for establishing efficacy.

• PK population: all patients who have received at least 1 dose of study drug and have at least one evaluable blood sample for PK analysis collected.

The focus of the safety analyses will be predicated on the Safety population composed of all consented patients who are enrolled into the study and receive at least 1 dose of the study drug. The safety analysis will be based on AEs, physical examination, ECG, vital signs, and clinical laboratory assessment recorded over the course of the study. Tolerability will be defined with respect to time using two defined treatment patterns: Safety population receiving study drug during the study and the Enriched population that will receive placebo during Part 2. Descriptive statistics will be prepared for all parameters and stratified by disease type, including 2-sided 95% confidence limits.

Example 2: STUDY TO ASSESS SAFETY AND EFFICACY OF IV TREHALOSE INJECTION TREATMENT ON FUNCTIONAL OUTCOME IN PATIENTS WITH SANFILIPPO SYNDROME TYPE A OR TYPE B

Methodology: An 82-week, randomized, double-blind, placebo-controlled trial to assess the safety and efficacy of IV Trehalose Injection 90 mg/mL for the treatment of Sanfilippo syndrome type A and type B is conducted. Patients 3 to 12 years of age with genetically confirmed Sanfilippo syndrome type A or B who are considered to have rapidly progressive disease based on specific mutations or early diagnosis (less than 6 years of age), an AEqs greater than or equal to 24 months on the Vineland-3, and who have elevated excretion of GAGs in the urine and/or elevated levels of HS in plasma and/or urine are eligible for enrollment. Patients will be randomized 1:1 to receive weekly infusions of IV trehalose or placebo. Randomization will be stratified by disease type (A or B). The study includes a 4-week screening period. During the screening period, urinary GAG, and urinary and plasma HS biomarkers will be collected 3 times, 7 days apart, to establish the baseline excretion and plasma concentration. Patients will have the following baseline assessments: physical exam, safety labs, CSF HS level, and electrocardiogram (ECG). Neurocognitive and behavioral assessments will be performed using the Vineland-3, either the BSID-III or the KABC-II (based on the AEqs on the Vineland-3), and the SBRS. Quality of life will be assessed using the PedsQL™.

Baseline gross and fine motor function will be assessed by a physical therapist and videoed for scoring. The assessments include the 9-hole peg test (9-HPT), timed up and go (TUG) test, 10-meter walk test, and pre-specified items of the Gross Motor Function Measure (GMFM). An independent physical therapist or other qualified clinician will review video of the patient completing the assessments and score the degree of the patient’ s change in ability to perform assessments using the CGIC scale.

Dosing and Dose Titration: Following screening, eligible patients will be randomized to receive weekly infusions of either IV trehalose or placebo for the duration of their participation. All patients participating in the study will have their safety data monitored approximately every 3 weeks by the Safety Review Committee (SRC) during the 9-week dose titration period.

During the 9-week dose titration period, patients randomized to IV trehalose will be titrated to 0.75 g/kg of IV trehalose or the MTD. Patients randomized to placebo (normal saline) will receive a weight-based equal volume of placebo. The blinded dose titration will begin on treatment Week 1 with an assigned starting dose of 0.25 g/kg of trehalose or matching placebo administered IV over 60 minutes once weekly. At Week 3 (after the first 2 weekly doses of 0.25 g/kg), patients will have safety labs assessed. The SRC consisting of the sponsor’s chief medical officer or designee, the lead principal investigator (PI) (or their designated physician sub -investigator), and an external physician with clinical trial safety data review experience, and a PK expert (unblinded) will be convened. The SRC will review each patient’s safety and PK data (as available) within 1 week of the Week 3 dose. If there are no safety concerns identified, the dose will be increased to 0.50 g/kg at Week 4. Although the SRC will make a recommendation, the ultimate decision to escalate the dose, continue the same dose or stop treatment is the responsibility of the local PI at all decision points. At Week 6 (after 2 weekly doses of 0.50 g/kg), patients will have safety labs assessed. The SRC will review each patient’s safety data within 1 week of the Week 6 dose. If there are no safety issues identified by the SRC, the dose will be increased to 0.75 g/kg at Week 7. At Week 9 (after 2 weekly doses of 0.75 g/kg for patients assigned to IV trehalose), patients will have safety labs assessed. The SRC will review each patient’s safety data within 1 week of the Week 9 dose. If there are no safety issues identified by the SRC, the dose will remain at 0.75 g/kg.

It is expected that patients will reach their MTD by Week 7 and will continue treatment at their MTD to the end of the 78-week treatment period.

Safety and Efficacy: The primary assessment of safety is incidence of serious and non- serious TEAEs.

Efficacy assessments will be performed at Weeks 13, 26, 39, 52, 65, and 78. The primary assessment of efficacy is neurocognitive function evaluated at Week 78. The primary endpoint is a comparison of the mean change from baseline in AEqs on the Vineland 3 (3 domains; Socialization, Daily Living Skills, and Motor Function) between patients treated with IV trehalose vs. placebo at Week 78.

An independent Data Monitoring Committee (DMC) will review safety and PK data at time points to be defined in the DMC Charter. In addition, a futility analysis will be performed when 16 patients have reached Week 52 or have discontinued the trial.

Patients who complete the current trial may be eligible for enrollment in an extension study.

Exemplary criteria for diagnosis and main criteria for inclusion & exclusion are listed below.

Inclusion:

1. Provided written informed consent signed by parent(s) or legal guardian(s)

2. Genetically confirmed Sanfilippo syndrome type A or type B, а. Genomic DNA analysis demonstrating a homozygous or compound heterozygous pathogenic variants in the SGSH (type A) or NAGLU (type B) genes

3. Elevated excretion of urinary GAGs and/or urinary or plasma HS at screening (mean of 3 assessments > upper limit of normal [ULN]) 4. Male or female; 3 to 12 years of age, inclusive

5. Age-equivalent score (AEq) greater than or equal to 24 months on the Vineland-3 at screening. This will be determined based on the sum of the scores from 4 domains: Communication, Daily Living Skills, Socialization, and Motor Skills. б. Patients with rapidly progressive Sanfilippo syndrome type A or B as defined by genotype or diagnosis before age 6

7. Negative urine or serum beta-human chorionic gonadotropin (B-hCG) pregnancy result at screening for female patients with child-bearing potential

8. Willingness to comply with sexual abstinence or contraception guidelines as instructed

Exclusion: 1. Prior administration of stem cell or gene therapy, or enzyme replacement therapy

(ERT) for Sanfilippo syndrome type A or type B а. Patients who are at least one-year post ERT therapy at time of consent may be enrolled with documented evidence of a > 3 month decline in AEqs according to Vineland, BSID, or KABC assessment within the last 12 months 2. Previously diagnosed with diabetes or a hemoglobin Ale (HgbAlc) result > 6.0% at screening

3. Poorly controlled seizures, defined as one or more seizure per week for the last 4 6 weeks

4. Visual or hearing impairment sufficient to preclude cooperation with neurodevelopmental testing

5. Any other medical condition that, in the opinion of the investigator, would confound interpretation of safety or efficacy data or would place a patient at undue risk б. Inability to cooperate with protocol-required assessments or procedures

7. Prior treatment with IV trehalose 8. Known hypersensitivity to trehalose 9. Use of genistein-rich soy isoflavone within 30 days before signing of consent

10. Use of oral trehalose within 7 days before signing of consent

11. Evidence of hepatitis B or hepatitis C infection upon serological testing at screening

12. Currently receiving anti-coagulant treatment (e.g., warfarin, enoxaparin), other than anti-platelet treatments, which are not a reason for exclusion

13. Currently participating in another clinical trial or has completed an interventional trial less than 90 days prior to planned first dosing

Investigational product, dosage and mode of administration: Trehalose 90 mg/mL solution will be administered IV over 60 ± 5 minutes once weekly. Trehalose will be administered in a dose titration manner as described above (Week 1 through Week 9) starting with a dose of 0.25 g/kg and up to a maximum dose of 0.75 g/kg. Indwelling catheters are not permitted.

Reference therapy, dosage and mode of administration: Placebo (sodium chloride injection, 0.9%, USP) will be administered IV over 60 ± 5 minutes once weekly. Placebo will be administered in a dose titration manner as described above (Week 1 through Week 9) starting with a weight-based volume equivalent to 0.25 g/kg and up to a maximum weight- based volume equivalent to 0.75 g/kg. Indwelling catheters are not permitted.

Restricted Medications: There are no known drug-drug interactions with IV trehalose 90 mg/mL. If the patient starts the study on miglustat, the dose must remain the same throughout the study. Patients are not permitted to initiate treatment with miglustat while on study. Cannabidiol (CBD) oil is permitted but the dose must remain the same throughout the study. Behavioral medications (stimulants, non-stimulants, psychotropic medications) are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible. Oral trehalose and genistein- rich soy isoflavones are not permitted during the study. Patients should not change concomitant medications during the study unless they experience an exacerbation of epilepsy or an acute illness. Patients may receive concomitant medications that are medically necessary as standard care to treat symptoms such as AEs, inter-current illnesses, anxiety and to prevent illness, e.g. vaccines. Over-the-counter (OTC) medications such as vitamins or herbal supplements are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible.

Statistical methods:

Analysis Populations: The following analysis populations will be used for all statistical analyses and presentations:

• The full analysis set (FAS) includes all randomized patients who receive any study medication.

• The per protocol set (PPS) includes all patients in the FAS, except those who are excluded because of major protocol violations, where a major protocol violation is one that may affect the interpretation of the study results (violating an inclusion criteria, receiving less than a specified amount of study medication during the course of the study, unavailability of the primary assessment).

• The safety set (SAF) includes all patients who receive any study medication.

• The PK analysis set (PKS) includes all patients in the SAF for whom a sufficient number of plasma trehalose concentrations are available to allow for PK analysis. Patients who are excluded from the PK analysis will be listed in the PK report along with the reason for exclusion.

The FAS will be used for all hypothesis tests of efficacy. The PPS will be used for supportive or sensitivity efficacy analyses. The SAF will be used for all safety analyses.

Sample size considerations:

The sample size is primarily based on feasibility; however, it is estimated that 16 patients (8 per treatment group) will have 80% power to detect a difference between treatment groups of at least 4.4 months in the AEqs, using a 2-sided, alpha of 0.05, and assuming a standard deviation of the change from baseline in the AEqs of 2.9 months. Statistical methods: A detailed description of the planned data analysis for the study will be documented in the Statistical Analysis Plan (SAP). All statistical tests will be 2-sided and use an overall study-wise alpha of 0.05, unless otherwise stated in the SAP. Analysis of efficacy data will be analyzed and the results presented by randomized treatment assignment. Safety data will be summarized by actual treatment received.

The primary efficacy analysis will use a main-effects, mixed-model for repeated measures (MMRM) for the primary endpoint of change from baseline in the AEqs at Week 78. The model will include treatment, disease type, visit (categorical), treatment -by-vi sit interaction as fixed effects, baseline AEqs as covariate and patient as a random effect. Supportive modelling will include a MMRM main-effects model with treatment, disease type, time and patient. Model assumptions will be evaluated and if parametric assumptions are inappropriate, analysis based on ranks will be conducted. Supportive sensitivity analyses will include a multiple imputations approach for missing values in a main-effects analysis of covariance (ANCOVA) with baseline AEqs as the covariate on the change from baseline AEqs at Week 78. The same statistical methodology will be applied to analysis of the secondary continuous endpoints. The secondary analysis based on time to progression of 3 months in the AEqs will be a presentation of Kaplan-Meyer curves and inferential treatment comparison by the log rank test. The secondary analysis of the proportion of patients progressing by Week 78 will be by Fisher’s exact test and the Cochran-Mantel- Haenszel test.

Multiplicity of the secondary efficacy endpoints will employ a conditional sequence approach to control alpha. The primary analysis of the primary endpoint will be tested first, and conditional on statistical significance will proceed to the secondary endpoints. Details for the control of type I error in analysis of the secondary endpoints will be described in the SAP.

Observed values and changes from baseline for continuous endpoints will be summarized descriptively by treatment group and visit using mean, median, quartiles, and standard deviation. Binary endpoints will be summarized using frequencies and percentages by treatment group and visit. Independent Data Monitoring Committee and Interim Analysis: An external, independent Data Monitoring Committee (DMC) will review safety and PK data at time points defined in the DMC Charter. In addition, the DMC will review the results of an Interim Analysis (IA) of efficacy data.

An unblinded IA for efficacy futility will be conducted when 16 patients have completed their Week 52 visit or have discontinued from the trial. The IA will consist of an analysis of (1) the mean change from baseline in the AEqs and (2) the time-to- progression of 3 months in the AEqs. The results of the analysis will be presented to the DMC, who will make a recommendation on whether the study should continue as planned or stop for efficacy futility. There is no plan to stop the study for efficacy success nor to provide early unblinded results to the sponsor or others involved in conducting the study. Further details of the statistical methodology for the IA, including suggested stopping boundaries, will be included in the DMC Charter and Interim Analysis Plan (LAP).

Example 3: STUDY TO ASSESS SAFETY AND EFFICACY OF INTRAVENOUS TREHALOSE INJECTION TREATMENT ON FUNCTIONAL OUTCOME IN PATIENTS WITH SANFILIPPO SYNDROME

Methodology: A 78-week, open-label, single-arm study to assess the safety and efficacy of IV Trehalose Injection 90 mg/mL for the treatment of Sanfilippo syndrome is conducted. Patients 3 to 25 years of age with genetically confirmed Sanfilippo syndrome (any type) who have an AEqs >12 months on the Vineland 3 are eligible for enrollment. Any patient 3 to 12 years of age, inclusive, with a confirmed diagnosis of Sanfilippo type A or B who has an AEqs of >24 months on the Vineland-3 must be considered for enrollment in the study described in above Examples first. If such a patient is a screen failure for the study described in above Examples, they may be considered for enrollment in this study. In addition, patients who have completed the study described in above Examples are eligible for enrollment in the current study irrespective of AEqs at completion of the study described in above Examples. The study includes up to a 6-week screening period for de novo patients. During the screening period, urinary GAG, and urinary and plasma HS biomarkers will be collected 3 times, 7 days apart, to establish the baseline excretion and plasma concentration. Patients will have the following baseline assessments: physical exam, safety labs, and electrocardiogram (ECG). Neurocognitive and behavioral assessments will be performed using the Vineland 3 and the SBRS. Quality of life will be assessed using the PedsQL™, CaGIS and CaGIC. Baseline gross motor function will be assessed using the 10-meter walk test. Patients who screen fail may be rescreened once.

Patients who participated in the study described in above Examples will continue to be administered the BSID-II or KABC II in this study. Their last assessment (e.g., laboratory analyses, screening labs, Vineland-3, BSID-III and/or KABC-II scores, 10- meter walk test, CaGIS and CaGIC) will serve as their baseline data for the current study; therefore, there is no screening period for these patients in the current study. Patients who participated in the study described in above Examples must be enrolled in the current study within 3 weeks of completion of the study described in above Examples.

Dosing and Dose Titration: Following screening, eligible patients will receive weekly infusions of IV trehalose for the duration of their participation. All patients participating in the study will have their safety data monitored approximately every 3 weeks by the Safety Review Committee (SRC) during the 12-week dose titration period.

During the 12-week dose titration period, all patients will be titrated to 0.75 g/kg of IV trehalose or the MTD, including patients who completed the study described in above Examples (to maintain study blinding). Dose titration will begin on treatment Week 1 with a starting dose of 0.25 g/kg of trehalose administered IV over 60 minutes. At Week 4 (after the first 3 weekly doses of 0.25 g/kg), patients will have PK samples drawn with that infusion and safety labs assessed. The SRC consisting of the sponsor’s chief medical officer or designee, the site principal investigator (PI) (or their designated physician sub investigator), and an external physician with clinical study safety data review experience, and a PK expert will be convened. The SRC will review each patient’s safety and PK data within 1 week of the Week 4 dose. If there are no safety concerns identified, the dose will be increased to 0.50 g/kg at Week 5. Although the SRC will make a recommendation, the ultimate decision to escalate the dose, continue the same dose or stop treatment is the responsibility of the local PI at all decision points. At Week 8 (after 3 weekly doses of 0.50 g/kg), patients will have PK samples drawn and safety labs assessed. The SRC will review each patient’s safety data within 1 week of the Week 8 dose. If there are no safety issues identified by the SRC, the dose will be increased to 0.75 g/kg at Week 9. At Week 12 (after 3 weekly doses of 0.75 g/kg for patients assigned to IV trehalose), patients will have PK samples drawn and safety labs assessed. The SRC will review each patient’s safety data within 1 week of the Week 12 dose. If there are no safety issues identified by the SRC, the dose will remain at 0.75 g/kg.

It is expected that patients will reach their MTD by Week 12 and will continue treatment at their MTD to the end of the 72-week treatment period.

Safety and Efficacy: The primary safety endpoint is incidence of serious and non-serious TEAEs.

Efficacy assessments will be performed at Weeks 12, 24, 48, and 72. The primary efficacy endpoint is the change from baseline in the ABC score at Week 72 on the Vineland 3. The ABC is calculated from the standard scores of the Communication, Daily Living Skills, and Socialization domains.

Exemplary criteria for diagnosis and main criteria for inclusion & exclusion are listed below.

Inclusion:

1. Provided written informed consent signed by parent(s) or legal guardian(s).

2. Genetically confirmed Sanfilippo syndrome type A, B, C, or D. a. Genomic DNA analysis demonstrating a homozygous or compound heterozygous pathogenic variants.

3. Patients with a score >24 months on the Vineland-3 must have either completed the study described in the above Examples or failed to meet other screening criteria for the study described in the above Examples. 4. Male or female; 3 to 25 years of age, inclusive.

5. Have an AEqs that meets either: a. >12 months on the Vineland-3 AEqs at screening. This will be determined based on the mean of the AEqs from the 3 sub-domains: Communication, Daily Living Skills, and Socialization b. Any AEqs provided the patient has completed the study described in the above Examples.

6. Negative urine or serum beta-human chorionic gonadotropin (B-hCG) pregnancy result at screening for female patients with child-bearing potential. 7. Parent or legally authorized representative oversees and provides either assurance of sexual abstinence or acceptance of contraception guidelines as instructed.

Exclusion:

1. Prior administration of stem cell or gene therapy, or enzyme replacement therapy (ERT) for Sanfilippo syndrome type A, B, C, or D. a. Patients who are at least one-year post ERT therapy at time of consent may be enrolled provided there is no evidence of clinical benefit.

2. Previously diagnosed with diabetes or a hemoglobin Ale (HgbAlc) result > 6.0% at screening.

3. Poorly controlled seizures, defined as one or more seizure per week for the last 4 6 weeks.

4. Visual or hearing impairment sufficient to preclude cooperation with neurodevelopmental testing.

5. Any other medical condition that, in the opinion of the investigator, would confound interpretation of safety or efficacy data or would place a patient at undue risk. 6. Inability to cooperate with protocol-required assessments or procedures.

7. Prior treatment with IV trehalose except for patients previously enrolled in the study described in the above Examples, where treatment assignment in the study described in the above Examples will not be revealed at the time of enrollment in the current study.

8. Known hypersensitivity to trehalose. 9. Use of genistein-rich soy isoflavone within 30 days before signing of consent. 10. Use of oral trehalose within 7 days before signing of consent.

11. Evidence of hepatitis B or hepatitis C infection upon serological testing at screening.

12. Currently participating in another clinical trial or has completed an interventional trial less than 90 days prior to planned first dose in the current study excepting patients who completed the study described in the above Examples and enrolled in the current study within 3 weeks of completion of the study described in the above Examples.

Investigational product, dosage, and mode of administration: Trehalose 90 mg/mL solution will be administered IV over 60 ± 5 minutes once weekly. Trehalose will be administered in a dose titration manner as described above (Week 1 through Week 12) starting with a dose of 0.25 g/kg and up to a maximum dose of 0.75 g/kg. Indwelling catheters are not permitted.

Restricted Medications: There are no known drug-drug interactions with IV trehalose 90 mg/mL. If the patient starts the study on miglustat, the dose must remain the same throughout the study. Patients are not permitted to initiate treatment with miglustat while on study. Cannabidiol (CBD) oil is permitted but the dose must remain the same throughout the study. Behavioral medications (stimulants, non-stimulants, psychotropic medications) are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible. Oral trehalose and genistein- rich soy isoflavones are not permitted during the study. Patients should not change concomitant medications during the study unless they experience an exacerbation of epilepsy or an acute illness. Patients may receive concomitant medications that are medically necessary as standard care to treat symptoms such as adverse events (AEs), inter current illnesses, anxiety and to prevent illness, e.g. vaccines. Over-the-counter (OTC) medications such as vitamins or herbal supplements are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible.

Statistical Methods: Analysis populations: The following analysis populations will be used for all analyses and presentations:

• The full analysis set (FAS) and the safety set (SAF) are the same and include all patients who receive any study medication during the study.

• The PK analysis set (PKS) includes all patients in the FAS/SAF for whom a sufficient number of plasma trehalose concentrations are available to allow for PK analysis. Patients who are excluded from the PK analysis will be listed in the PK report along with the reason for exclusion.

Sample size considerations: The sample size for this open-label, single-arm study is based on feasibility. All patients who completed the study described in the above Examples will be allowed to enroll as well as direct de novo enrollees, for a maximum of 24 total patients.

Statistical methods: A detailed description of the planned data analysis for the study will be documented in the Statistical Analysis Plan (SAP).

Observed values and changes from baseline for continuous efficacy and pharmacodynamic endpoints will be summarized descriptively by study visit using mean, median, quartiles, minimum, maximum, standard deviation, standard error, and 95% confidence intervals. Binary endpoints will be summarized using frequencies and percentages by visit. Descriptive statistics will be presented for the following subgroups defined by their entry category:

• Patients who completed the study described in the above Examples, who received double-blind trehalose during that study

• Patients who completed the study described in the above Examples, who received double-blind placebo during that study

• De novo patients who had not previously enrolled in the study described in the above Examples.

Safety data will be summarized by study visit for the entire population, as well as by the above subgroups. Example 4: SAFETY AND EFFICACY STUDY OF INTRAVENOUS TREHALOSE INJECTION ON FUNCTIONAL OUT COME AND BIOMARKERS IN PATIENTS WITH SANFILIPPO SYNDROME TYPE A OR TYPE B Methodology: A 57-week, open label trial to assess the safety and efficacy of IV

Trehalose Injection 90 mg/mL for the treatment of Sanfilippo syndrome type A and type B is conducted.

Patients 3 to 16 years of age with genetically confirmed Sanfilippo syndrome type A or B who are considered to have rapidly progressive disease based on specific mutations or early diagnosis (less than 6 years of age), and who have elevated excretion of GAGs in the urine and/or elevated levels of HS in plasma and/or urine are eligible for enrollment. Patients will receive weekly infusions of IV trehalose.

The safety population will consist of all patients who receive at least one infusion or partial infusion of trehalose. The primary efficacy population will consist of the subgroup of patients in the safety population who are age 3 through 7 at time of consent (Cohort 1).

The study includes a 4-week screening period. During the screening period, urinary GAG, and urinary and plasma HS biomarkers will be collected 3 times, 7 days apart, to establish the baseline excretion and plasma concentration. Patients will have the following baseline assessments: physical exam, safety labs, and electrocardiogram (ECG).

Neurocognitive and behavioral assessments will be performed using the Vineland- 3, the BSID-III and the SBRS. Sleep will be assessed using the Promis® Parent Proxy Sleep Disturbance Short Form 8A. A Rater Training Plan will outline the educational and experience requirements for site raters, as well as the process for training and certification.

Dosing and Dose Titration: Following screening, eligible patients will receive weekly infusions of IV trehalose for 52 weeks. An end of study assessment will be performed at week 53, 1 week after the final infusion.

The first 9 weeks are a dose titration period. The dose of trehalose will be titrated up from 0.25 g/kg to 0.75 g/kg or the maximum tolerated dose (MTD). The dose titration will begin on treatment Week 1 with the starting dose of 0.25 g/kg administered IV over 60 minutes once weekly. At Week 3 (after the first 2 weekly doses of 0.25 g/kg), patients will have safety labs assessed. The Safety Review Committee (SRC) consisting of the sponsor’s chief medical officer or designee, the principal investigator (PI) (or their designated physician subinvestigator), and an external physician with clinical trial safety data review experience, and a PK expert will be convened. The SRC will review each patient’s safety and PK data (as available) within 1 week of the Week 3 dose. If there are no safety concerns identified, the dose will be increased to 0.50 g/kg at Week 4. Although the SRC will make a recommendation, the ultimate decision to escalate the dose, continue the same dose or stop treatment is the responsibility of the local PI at all decision points. At Week 6 (after 2 weekly doses of 0.50 g/kg), patients will have safety labs assessed. The SRC will review each patient’s safety data within 1 week of the Week 6 dose. If there are no safety issues identified by the SRC, the dose will be increased to 0.75 g/kg at Week 7. At Week 9 (after 2 weekly doses of 0.75 g/kg for patients assigned to IV trehalose), patients will have safety labs assessed. The SRC will review each patient’s safety data within 1 week of the Week 9 dose. If there are no safety issues identified by the SRC, the dose will remain at 0.75 g/kg. It is expected that patients will reach their MTD by Week 7 and will continue treatment at their MTD to the end of the 52-week treatment period. End of study assessments will be performed 1 week after the final infusion (Week 53).

Safety and Efficacy: The primary assessment of safety is incidence of serious and non- serious TEAEs, physical examination findings, vital signs, and clinical laboratory tests. The study will enroll patients from 3 to 16 years of age divided into 2 cohorts, 3 to 7 years of age (Cohort 1) and 8 to 16 years of age (Cohort 2) inclusive. Efficacy will be assessed using the Vineland-3, BSID-III and SBRS. Efficacy assessments will be performed at Weeks 13, 26, 39, and 52 in all patients. However due to the rapidly progressive nature of this disease, the primary assessment of efficacy will be restricted to the 3 to 7 year age cohort. Based on the two natural history studies in Sanfilippo Type A and Type B patients, (Shapiro et. al 2016 and Whitely et. al 2018) 69% of patients between the ages of 3 to 7 are expected to decline >3 months on the Vineland-3 in a 12-month period. Therefore, the primary assessment of efficacy is neurocognitive function evaluated on the Vineland-3 (3 domains; Socialization, Daily Living Skills, and Motor Function). The primary endpoint is a comparison of the percent of patients with >3 month decline on the Vineland-3 over a period of 52 weeks compared to the natural history data. Additional secondary efficacy endpoints include the change from baseline in the AEqs of the Vineland-3 at various time points and change in biomarkers. Exploratory endpoints include assessment of the change from baseline in the BSID-III and the SBRS. In addition, efficacy will be explored in the 8 to 16-year-old cohort using descriptive statistics for change from baseline in each of the scales.

Biomarker levels measured in plasma and urine will be monitored at Weeks 3, 6, 9, 13, 26, 39, and 52.

Since patients with Sanfilippo experience significant sleep disturbances, the Promis® Parent Proxy Sleep Disturbance Short Form 8A will be used to determine the effect of treatment on sleep patterns at Week 13, 26, 39, and 52.

In addition to the SRC, an independent Data Monitoring Committee (DMC) will review safety data at time points to be defined in the DMC Charters (at least at weeks 13, 26, and 39). Patients who complete the current trial may be eligible for enrollment in an extension study.

Sample Size Justification: Up to 20 patients with Sanfilippo Type A or Type B will be enrolled. The sample size is not based on statistical considerations due to the orphan nature of the disease. However at least 10 patients between the ages of 3 years and 7 years need to be enrolled for the primary assessment of efficacy.

Exemplary criteria for diagnosis and main criteria for inclusion & exclusion are listed below.

Inclusion:

1. Provided written informed consent signed by parent(s) or legal guardian(s)

2. Genetically confirmed Sanfilippo syndrome type A or type B а. Genomic DNA analysis demonstrating a homozygous or compound heterozygous pathogenic variants in the SGSH (type A) or NAGLU (type B) genes

3. Elevated excretion of urinary GAGs and/or urinary or plasma HS at screening (mean of 3 assessments > upper limit of normal [ULN]) 4. Male or female; 3 to 16 years of age, inclusive

5. Patients with rapidly progressive Sanfilippo syndrome type A or B as defined by genotype or diagnosis before age 6 б. Negative urine or serum beta-human chorionic gonadotropin (B-hCG) pregnancy result at screening for female patients with child-bearing potential 7. Willingness to comply with sexual abstinence or contraception guidelines outlined in the protocol

Exclusion:

1. Prior administration of stem cell or gene therapy, or enzyme replacement therapy (ERT) for Sanfilippo syndrome type A or type B a. Patients who are at least one-year post ERT therapy at time of consent may be enrolled with no demonstrable effect of treatment.

2. Previously diagnosed with diabetes or a hemoglobin Ale (HgbAlc) result > 6.0% at screening

3. Poorly controlled seizures, defined as one or more seizure per week for the last 4-6 weeks

4. Visual or hearing impairment sufficient to preclude cooperation with neurodevelopmental testing

5. Any other medical condition that, in the opinion of the investigator, would confound interpretation of safety or efficacy data or would place a patient at undue risk 6. Inability to cooperate with protocol-required assessments or procedures

7. Prior treatment with IV trehalose

8. Known hypersensitivity to trehalose

9. Use of genistein-rich soy isoflavone within 30 days before signing of consent

10. Use of oral trehalose within 7 days before signing of consent 11. Evidence of hepatitis B or hepatitis C infection upon serological testing at screening 12. Currently receiving anti-coagulant treatment (e.g., warfarin, enoxaparin), other than anti-platelet treatments, which are not a reason for exclusion

13. Currently participating in another clinical trial or has completed an interventional trial less than 90 days prior to planned first dosing

Investigational product, dosage and mode of administration: Trehalose 90 mg/mL solution will be administered IV over 60 ± 5 minutes once weekly.

Trehalose will be administered in a dose titration manner as described above (Week 1 through Week 9) starting with a dose of 0.25 g/kg and up to a maximum dose of 0.75 g/kg. Indwelling catheters are not permitted.

Duration of treatment: The study includes a 4-week screening period and 52-week treatment period which includes the 9 week dose titration period.

Restricted Medications: There are no known drug-drug interactions with IV trehalose 90 mg/mL. If the patient starts the study on miglustat, the dose must remain the same throughout the study. Patients are not permitted to initiate treatment with miglustat while on study. Cannabidiol (CBD) oil is permitted but the dose must remain the same throughout the study. Behavioral medications (stimulants, non-stimulants, psychotropic medications) are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible. Oral trehalose and genistein- rich soy isoflavones are not permitted during the study. Patients should not change concomitant medications during the study unless they experience an exacerbation of epilepsy or an acute illness. Patients may receive concomitant medications that are medically necessary as standard care to treat symptoms such as AEs, inter-current illnesses, anxiety and to prevent illness, e.g. vaccines. Over-the-counter (OTC) medications such as vitamins or herbal supplements are permitted if the patient is taking them at the time of consent. The dose and frequency should remain the same throughout the study if at all possible. Statistical methods: The safety population will consist of all patients who receive at least one infusion or partial infusion of trehalose. The primary efficacy population will consist of the subgroup of patients in the safety population who are age 3 through 7 at signing of consent (Cohort 1).

Safety analyses will include descriptive summaries of the incidence and severity of treatment-emergent adverse events, incidence of serious adverse events, physical examination findings, vital signs, and clinical laboratory tests. AEs and SAEs will be tabulated by system organ class, preferred term, severity and relationship to drug.

The primary efficacy endpoint is the proportion of patients (aged 3-7 at signing of consent) with at least a 3 month decline in the Vineland-3 Age Equivalent Score (AEqs) at Week 52. This will be compared to an historical control group, (16 patients) which will be obtained from longitudinal natural history studies (noted above) during which patients were treated with standard of care. The primary analysis will be a comparison between groups using the Cochran-Mantel-Haenszel, Chi-square test with disease type (A or B) as a stratification variable. The Fisher’s exact test will be used if there is an inadequate number of patients in any treatment/stratum cell.

The planned sample size is primarily based on feasibility; however, it is estimated that 10 patients in the treated group and 16 patients in the historical control group will have approximately 80% power to detect as significant (2-sided, a=0.05) true rates of decline (at least 3 points in the AEqs at Week 52) of 0.09 and 0.69, respectively. With an increase in sample size to 16 in the treated group, the proportion estimated to provide 80% power increases to 0.16. This assumes that the treated and historical control groups are effectively sampled from equivalent patient populations with comparable, if untreated, rates of decline in the Vineland-3 AEqs. The least significant decline rate in the treated group, under the above assumptions, is estimated to be 0.21 and 0.28 for sample sizes of 10 and 16, respectively.

A secondary analysis will be conducted for the difference between the treated group and the historical control group for mean change from baseline in the AEqs. This will use a mixed-effects model for repeated measures (MMRM) including treatment, disease type (A or B), visit (categorical), and treatment-by-visit interaction as fixed effects, baseline AEqs as covariate, and patient as a random effect. An additional supportive model will assess the treatment effect on the slope of the AEqs change using an MMRM with treatment, disease type, time (continuous), and baseline AEqs.

Analysis of the secondary and exploratory endpoints will be presented descriptively and analyzed with the same statistical models described above.

Given the small sample size of the study, the occurrence of dropouts and missing values may potentially have a large impact on the efficacy inferences and estimates. It will, therefore, be important to obtain the Week 52 Vineland-3 assessment for all treated patients. Every effort will be made to bring patients who have discontinued back to the clinic for their Week 52 safety and efficacy assessments. These assessments will be used in the primary efficacy analysis. For patients who have discontinued and for whom the Week 52 Vineland-3 assessment remains missing, the AEqs will be imputed as having declined by 3 months for the primary analysis. Additional sensitivity analyses will be conducted of the impact of missing data on the conclusions from the primary and secondary analysis of change in Vineland-3 AEqs. The methods for these will be described in the SAP.