Repurposing Gaucher disease therapy for Saposin C deficiency: Proof-of-concept with eliglustat.

Saposin C (Sap C) deficiency (GDSAPC, OMIM #610539, ORPHA:309252) is an ultra-rare autosomal recessive disorder caused by mutations in the PSAP gene. Sap C functions as an essential activating cofactor of glucosylceramidase (GCase) and facilitates the degradation of glucosylceramide in the lysosome. In the absence of its activator, GCase is structurally intact but its function is impaired, leading to pathological accumulation of glucosylceramide in the lysosome. Sap C deficiency resembles another rare autosomal recessive disorder, Gaucher disease (GD), in which pathogenic variants in the GBA1 gene result in GCase deficiency and accumulation of glucosylceramide within the lysosomal compartment of the mononuclear phagocyte system. Despite the overlapping clinical features of Sap C and GD, the therapeutic implication is utterly different. To date, no specific therapy is approved for Sap C deficiency. Enzyme replacement therapy (ERT), highly effective in GD is biologically implausible in Sap C deficiency, where the GCase structure is normal but lacks its essential activator for its functions. In GD, substrate reduction therapy (SRT) is an alternative to ERT by limiting the synthesis of glucosylceramide through inhibition of glucosylceramide synthase. Given that substrate accumulation is the common pathological consequence in both GD and Sap C deficiency, we hypothesized that SRT with Eliglustat, a potent glucosylceramide synthase inhibitor, could also benefit patients with Sap C deficiency. We describe the first documented therapeutic attempt using eliglustat in Sap C deficiency. A 47-year-old patient with PSAP mutations causing Sap C deficiency who presented with features similar to those seen in GD, has received Eliglustat over the course of 9 years, demonstrating an improvement in her hepatosplenomegaly, haematological parameters, biomarkers and bone density, providing proof-of-concept that Eliglustat can be of benefit when the GCase cofactor is deficient. However, no improvement was observed in the patient's seizure activity where future brain penetrant molecules may be of benefit.