Effects of asfotase alfa on fracture healing of adult patient with hypophosphatasia and literature review.

Abstract

Objective: Hypophosphatasia (HPP) is a rare inherited disorder caused by ALPL gene mutations, with fracture nonunion being a serious complication. This study investigated the effects of teriparatide and asfotase alfa (AA) on femoral fracture healing of an adult patient with HPP, accompanied with a literature review.

Methods: A 37-year-old woman wheelchair-bound was diagnosed with HPP due to an extremely low serum alkaline phosphatase (ALP) level (4-10 U/L), who suffered from bilateral femur pain and non-union of femoral shaft fractures on both sides. Compound heterozygous missense mutations (c.382G > A and c.461C > T) were identified in exon5 of ALPL gene. The patient received teriparatide sequential AA therapy. Serum levels of ALP, β-isomerized carboxy-telopeptide of type I collagen (β-CTX) and procollagen type 1 amino-terminal peptide (P1NP), bone mineral density (BMD) and skeletal X-ray were measured during the treatment. Literature was searched by keywords of "Hypophosphatasia", "HPP", "ALPL", "TNSALP", "ALP" combined with "Asfotase alfa", "AA", "enzyme replacement therapy", and "ERT".

Results: After unsuccessful 6-month teriparatide treatment for femoral fracture, AA treatment was initiated, at a dose of 2 mg/kg, 3 times a week. After the first month of AA treatment, serum ALP level increased from 4 to 9206 U/L, and serum calcium and phosphate levels decreased, with increase in PTH, β-CTX, and P1NP levels. After 4 months of AA treatment, her bone pain significantly alleviated, accompanied by significant shortening of the fracture line. After 10 months of AA therapy, the fracture demonstrated complete healing and the patient could walk independently. BMD at lumbar spine and hips was significantly increased. Among 295 adult patients with HPP reported in the literature, 213 (72.2%) exhibited skeletal-related symptoms and 91 (30.8%) presented with bone fractures. In addition to skeletal manifestations, the patients presented with early tooth loss, muscle weakness and ectopic calcification. AA treatment, spanning 9 weeks to 3 years, has been shown to increase ALP levels, promote fracture healing, improve mobility, and alleviate bone pain.

Conclusion: Adult HPP patients mainly present with recurrent or poorly healing fractures, bone pain, and early loss of teeth. AA replacement therapy can effectively promote fracture healing, relieve bone pain, and enhance mobility.