Rare Disease Day

Today it’s Rare Disease Day and the focus this year is on research. As some of you will know, rare diseases aren’t actually that rare. One in every 17 people will be affected by a rare disease at some point in their life. Every treatment that has ever been made available for any disease is as a result of medical research. Yet for those living with rare diseases (sometimes known as orphan diseases) treatments just aren’t as easily found as research is more costly when it can’t be offset against a large patient base. On the other hand, research into rare diseases is a real trailblazer and can bring about new options for other conditions too.

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Some rare diseases are wildly different to Pudding’s diagnosis of Mucopolysaccharidosis (Type II – Hunter Syndrome) and some are much closer. Today I want to tell you about Batten Disease – one very similar to MPS. You’re probably wondering why. After all, this is a blog about Hunter Syndrome and how we’re living with it on a day to day basis.

Well, there was a family on This Morning the other week, and they are living our future right now. Watch it, and you will see so many similarities with our situation: like MPS, Batten Disease is a genetic condition caused by a missing enzyme; children seem healthy at first and are often not diagnosed till around the age of 3; they slowly lose skills such as the ability to talk, walk or swallow; and parents face the agonising fate of watching their children die too early. Way too early.

Like us, this family managed to get their children onto a clinical trial and have seen the drug stabilise their loved ones and even allow a little progress. Unlike others now and in the past who have not received this treatment, these children have a chance at life. Yet NICE have now decided not to make this treatment available in the UK. And there is no way that any individual could afford a drug like this.

This could be us in a few months time.

I know people will, and do, say things like ‘The NHS doesn’t have unlimited funds’, and I understand that. I really do. (Maybe I’ll address those sort of arguments in a future blog.)

But this is the reality of Ultra-Rare Disease. Research is needed so badly, but it is a double-edged sword.

Just imagine it, if you can. Your lovely son or daughter is diagnosed with a life-limiting disorder. You deal with this devastating news however you can. Then you are given some hope – a research trial results in a treatment that is keeping children alive. Yet, because of the country you live in, your child will not continue to receive it. There is a treatment available. But not for your child.

How would you feel?

You can help them by signing a petition asking for this drug to be made available. Please do. You can also follow their journey on Facebook at ‘Ollie’s Army Battling Against Battens’.

Audiology (sort of)

Those of you who follow us on Facebook will know that we ended up in A&E on Monday night – nothing serious – just being checked out when Pudding started vomiting following a head bump. Both the doctor and I thought it was unrelated but we had to be sure because of course he couldn’t tell us how he was feeling. It got me thinking about what Pudding’s learning disability actually means for him and his future.

Many studies have shown that people with a learning difficulty often have worse health than those in the general population. Sometimes that is due to an underlying health condition that also causes their learning difficulty (for instance, Pudding’s diagnosis of MPS). But this is not always the case. When premature deaths are analysed, apparently 38% of people with a learning disability died from an avoidable cause, compared to 9% of those without a learning disability.

I’ll just give you a moment to read that again. 38% of premature deaths in those with a learning disability could have been avoided. 

The reasons of course are varied and complicated, but can often be put down to a series of misunderstandings or miscommunications or plain indifference. Take for example, the case of Richard Handley (related here in a slightly sweary way) from a bowel problem. Or that of Connor Sparrowhawk  an autistic man with epilepsy who drowned in a bath unsupervised.

All (well, almost all) our interactions with health professionals so far have been exemplary. Take audiology a few weeks ago. Pudding isn’t always very cooperative at appointments but they took their time and didn’t rush us. One lady did a marvellous job of distracting him with toys but at the same time allowing him to listen and react to the sounds.

First she tried getting him to jump the little wooden men into the boat each time he heard a noise but that didn’t work. Pudding just wanted to jump them all in straight away – why bother waiting?! So next, they used the test for much younger children where some puppets light up and start dancing whenever the sound plays. He soon learns that when he hears a sound he can look at the puppet and it will start.

Pudding watching TV in the hospital playroomThe lovely audiologist in the other room had the difficult task of trying to work out whether his reactions were genuine or whether he was anticipating the stimulus. The results agreed with the last hearing test he had, showing moderate hearing loss. But she wasn’t prepared to just accept that. She wants to be sure it’s a genuine result rather than just the difficulty of testing someone who doesn’t understand why we’re getting him to do this. So we’re going to try again another time, and also have someone observing him in school to see what he is like in a functional situation.

The pediatric specialists we have seen work hard to engage with Pudding and listen to my parental expertise. And I wonder whether part of that is that they are used to dealing with a wide range of ages and abilities. Therefore children with a learning disability don’t really phase them.

But of course, once that child gets bigger and less cute and moves up to adult services, parents sometimes have less involvement in daily support and health issues. The parents’ expertise in their child can be sidelined. Little health problems can be missed and worsen. Not everyone will care enough to worry about every little symptom that appears and look into potential causes.

I will always want to look out for Pudding and keep him safe and happy, but I won’t be able to for ever.

Sometimes I would love for time to simply…..stop.

The Good, The Bad, and The Ugly

Finally getting round to explaining what set off my last rant about MPS. Of course, I always hate MPS (who wouldn’t when your child has been diagnosed with a life-limiting illness?), but I found last week’s hospital trip particularly hard.

So here it is – the good, the bad, and the ugly. Though as I always prefer to end on a positive note if I can, it’s actually the ugly, the bad and the good!

The Ugly

As you may have read before, the clinical trial Pudding is on had disappointing first year results. Before the boys received their doses this time, our consultant (who also runs this phase of the trial in the UK) gathered us parents together to explain what he has heard, and answer any of our questions. He wasn’t able to give us too much information as the full results are embargoed until February when they will be announced at a conference. But what he could tell us was that he was more heartened by the results than he had expected.

The reason I’m still calling it the Ugly is that analysing data for such a small group is …well… complicated. Without going into a whole essay about the mechanics of designing clinical trials (I find it fascinating, but you probably wouldn’t!) one year of data is just not enough to show clear benefits. So their next step is possibly to include data from other studies done previously which show the normal course of decline in MPSII. Not a straightforward process, but there is potential.

Of course, there will still be the issue of getting agreement from NICE and NHS England to fund it if the drug is approved. But I’m trying to hold onto something our doctor also said about the many battles he has had to fight in his clinical career. ‘I’ve realised that the only way I can get through, is by dealing with them one step at a time.’

The Bad

This is the one that knocked me for six. After a bad night’s sleep on the ward (Pudding was still climbing out of bed and switching the lights on and off until nearly 11pm) and the morning’s discussion on trial issues, I had another talk with the consultant. He told me that Pudding has developed antibodies to the enzyme infusion that he receives every week.

Pudding on a see-saw in a bright red ladybird-design coat.

Again without going into all the details (lesson on cell biology, anyone?), the basics are that all sorts of different antibodies circulate in the blood. The ones that we really don’t want to see are neutralising antibodies which stop the enzyme being taken up into the cells to do their job. And yes, those are the ones that Pudding has.

These results are actually a year old, so there is a possibility that more recent results will show that the antibodies have gone down again. It’s unlikely though, as there have been a few other reasons to think that the enzyme is just not working as well as it should be for him. Of course, without the enzyme clearing away as many of the waste sugars, they will be building up again, and potentially causing new damage to his organs, joints and so on. So…next stage will be to think about ways to get round it. This will probably mean some form of immune suppression drugs.

The news wasn’t entirely unexpected. Some boys with this condition have a small ‘spelling mistake’ on the DNA, meaning that their body produces a faulty version of the enzyme or just not enough of it. Pudding, however, has a full gene deletion. So the synthetic enzyme he gets is completely foreign to his body, and hence…antibodies.

In the grand scheme of things it’s not the worst news in the world. But it certainly wasn’t what I wanted to hear.

The Good

Yes, that’s it from the depressing side! Yay!

Even in the depths of this horrible MPS world, the silver lining is always the other people that support us along the way. Our lovely doctor, who cares so much for each and every one of his patients and hates giving us bad news. The nurses and play specialist who look after Pudding so I can off by myself for a cry. And of course, my fabulous, wonderful MPS family. This hospital visit was the first time in ages that all four boys on this phase were treated on the same day, so I could have a chat with the other parents.

When I got our bad news, one of them gave me a massive hug with a tear in his eye. Hugs that come from someone who truly understands what you’re going through are the absolute best. They can never make things completely better, but it’s a bloody good substitute!

 

PS. We do have another bit of good news that I’ve heard this week, but I won’t write about it until we’ve got the official letter!

Cliff-edge

I wrote recently about feeling lucky, and that’s still the case. But of course, life is more complicated than that. The truth is that right now we’re walking on a fairly even path. The sun is shining, we’re having a fun outing as a family and we’re enjoying the view. But somewhere up ahead of us is a cliff-edge.

We don’t know when we’re going to get to it, though we know it’s close. We can’t change direction to avoid it. We have no choice but to keep on walking forward and just hope that we don’t fall headlong down into the chasm below.

Sorry, that analogy went on longer than I expected. Yes, I’m talking about Pudding’s clinical trial.

I think it’s getting pretty clear to anyone who knows Pudding that he is still gaining skills, whereas boys with Hunter Syndrome really shouldn’t be at this age. Yesterday I watched a video from school of him taking part in a relay race. I just couldn’t believe that it was my little boy running to a classmate, handing over the beanbag and then waiting patiently for his next turn. Yes, of course he still needed support, but the understanding and concentration he was demonstrating were… Well, we were all amazed and T begged to see it again and again. So, from our point of view, the trial that is putting enzyme into Pudding’s brain has to be making a difference.

But what is the cliff-edge?

Around this time in 2016, the final boys were recruited onto the clinical trial which officially runs for one year. (Pudding is currently on the extension study where he still gets the enzyme, but we don’t have quite as much testing.) The pharmaceutical company will therefore have all the data they need to look at the numbers and see whether it is a treatment option that is worth pursuing.

At that point they could just decide to cut and run. That is the first stumbling block but I don’t actually think it’s likely. Some boys have been on this intrathecal enzyme for years now, and are continuing to gain skills. Some trials (including for MPSIII drugs) get pulled part-way through the clinical period due to interim results. But that has not happened with this one which makes me think that the figures so far are promising enough.

The next step is for the drugs company to apply to the FDA and EMA (the bodies overseeing medicines in USA and Europe) for approval. This is a complicated process, could take months and even if the drugs company think they have good evidence, could still result in a ‘no’.

And then, and then…. the NHS would have to decide whether to fund the treatment. That’s the one I’m most scared about.

As ever, it’s the not-knowing that I find hardest to deal with. Not knowing how long we have to wait until we find out. Not knowing what the answers will be. The analysing and second-guessing can drive you crazy.

I don’t think I can deal with thinking about it much. So I’m doing what I can to stay relatively sane. Until we reach that cliff-edge and are teetering on the brink I’m going to keep on walking, ignore the inevitable and enjoy the day while we can.

And I will continue to remind myself that we are indeed still lucky. Other families are much nearer that cliff-edge than us. While decisions are being made, Pudding’s treatments will probably continue to be offered by the pharmaceutical company. Boys who didn’t make it onto the trial still have nothing.

A letter to our doctor

We usually meet in a clinic situation of course. Whilst I and the nurses don’t treat you with the proper respect and joke about all the time you spend away from the hospital playing golf (which you don’t) there is always a professional boundary. A line which I don’t feel I can step over.

At the MPS conference though I took the chance to give you a hug and tell you how much I thought of you. You laughed it off with a comment about being emotionally unavailable. You may also have thought I was a little bit tipsy. (I suppose I was, but I’d only had one glass – just enough to loosen my tongue.)

I’ve written about the wonderful nurses before and how they kept me going. But at a time when some pediatric doctors’ expertise and integrity has been called into question by sections of the media, I think it’s important you know what you yourself mean to our family, and I’m sure many others.

Just over two years ago, on Wednesday the 1st July 2015, we were told that our youngest son has MPS II, a progressive, life-limiting condition. These are the words that no parent wants to hear. Ever. We had been called in to see our local pediatrician who confirmed the diagnosis we had been expecting. And he told us that an appointment had been arranged for us to see the experts in Manchester the following Monday.

You’re probably used to shell-shocked parents arriving in your office, but to us of course it was all new. And yet… Having heard the worst already (at least I thought we had) it was reassuring to be there amongst people who knew all about this terrible diagnosis.

Infusion pump in sharp focus with Pudding on hospital bed behind.I’d already read everything the internet had to offer on Hunter Syndrome, or so it seemed. But you were so patient explaining it all again to Hubby and taking us through the next steps, telling us about the enzyme replacement treatment Pudding could start the next week. I’ve no idea how long we were in that office – over an hour I think – but I never felt that you were rushing us.

Over the next few weeks you often popped in when Pudding was having his ERT to see how we were doing and answer my questions. I had a lot, and you never shied from giving me the difficult answers. It was often hard to hear, but I needed and appreciated your honesty.

You joke about the nurses calling you emotionally unavailable but I think we all know that is far from the truth. When you had to tell me that Pudding’s DNA results showed a complete gene deletion (meaning inevitable progression of Hunter Syndrome) I could see how deeply you cared about us all.  Later when we talked about the fight that MPS IV patients had (and will face again) for a treatment to be made available, your anger at the situation was clear.

I have entrusted my son’s life to many people already – anesthetists, surgeons, pharmacists, even down to those who safely access either of his ports – but you are the expert at the heart of all these services. A kind, caring, down-to-earth, approachable expert that I am very grateful to rely on.

All our love,

From your biggest fans

Surgery

Surgery this evening.

After finding out in March that the port that delivers Pudding’s trial medication to his brain is no longer working properly, he is having it replaced today.

This morning I chased him and let him climb on my back  and tickled him until we were both in helpless giggles, as I knew we wouldn’t be able to do that for a while.  I watched him eat a very early lunch knowing that in a few hours he would be looking at me with those accusing eyes and repeatedly asking for ‘bibit’ (biscuit). He kept running away with the bag I was trying to pack and for once I didn’t get cross or frustrated because I knew that he’s going to feel reluctant to move at all for the next week or so.

Pudding was very excited when we got back to the trial ward in  Manchester. We’ve not been for three months now so he was obviously keen to make up for lost time, running up and down the corridor and shouting ‘Found you!’ at all the nurses. Very cute, but it was difficult to share his enthusiasm knowing that in a few hours I had to sign a consent form for surgery listing ‘permanent nerve damage’ as a potential side effect.

The anesthetists here are fantastic, and experienced with the short neck and difficult airways that Hunter Syndrome produces. I trust them with my son’s life but I wish I didn’t have to.

At 6pm we walked down to surgery with him complaining all the way. It was nearly his bedtime. He was tired and hungry and had had enough. I watched his eyes roll back into his head as the anesthetic took effect. Now we wait for three hours until we can see him in recovery and listen to those pitiful cries as he tries to tell us that he feels rotten and he hurts and he doesn’t know why. And I’ll feel helpless because I can’t explain to him why he needs to go through this.

We’ll stand ready with the sick bowl and obsessively watch the SATS monitor over the next few hours. The TV will stay on for a week and we’ll check his dressings for any leakage of spinal fluid.

It’s his sixth general anaesthetic since diagnosis almost 2 years ago, and we’ve got used to the routine but it never gets any easier.

An end to hope?

I like being right. Most of us do, don’t we?

Yet there have been a few too many times in the last few years where I have hoped, desperately hoped, that I was wrong.

When our paediatrician first mentioned mucopolysaccharidosis to us, I of course googled it. I saw pictures of other children with this progressive disease and I read the symptoms and I knew this was the answer as to why my Pudding was not reaching his development targets. I hoped I was wrong, but I was right.

He started on weekly enzyme replacement therapy to halt the build up of waste products in his body and we gradually got used to our new normal.

They checked his DNA to see whether he was likely to have the severe form. I had done my reading and I knew that those on the milder end of the condition rarely had development delay. I watched my son having reactions to this new enzyme in his body, I tracked every struggle and his difficulties gaining new skills. Deep down I knew that he had the severe form that meant a gradual loss of skills – the ability to walk, talk, even to swallow. And death in his teenage years. I hoped I was wrong, but I was right.

Pudding got on a clinical trial for a new form of the enzyme to help his brain. It has already halted the disease progression in a number of boys and we knew it would give our son a chance at life again. The drug is delivered by a special portacath that lies just under his skin and connects to the space around his spinal cord. For a while now I’ve been worried that this wasn’t functioning properly and a CT scan confirmed it this week. The dose hasn’t been getting to where it is supposed to. I hoped I was wrong, but I was right.

Yesterday I thought we were facing another surgery to fix this and I was devastated but today my fears are much worse. Today I heard that from the 1st April, at incredibly short notice, a cost-effectiveness threshold is being brought in by NICE and NHS England for orphan drugs (the name given to drugs that are developed for ultra-rare diseases like MPS). So even after Pudding’s port is fixed, even if the trial has all the data it needs to show success, even if it receives approval by the European Medicines Agency, someone in a suit will decide – based on limited patient numbers and data – whether my son will receive a life-saving medicine or whether we will watch him gradually be taken from us, skill by slowly-disappearing skill.

I have got through the last year by refusing to believe my son will die, and now even that is being taken from me. Writing this has been so difficult as the computer screen keeps disappearing behind my pesky tears that won’t stop coming.

This is not just our story but the story of any family who has been devastated by rare disease. A life-limiting illness is hard enough to deal with. Yet knowing your loved one has a life-limiting illness for which there IS a treatment available which you may not access is harder still.

I hope that if enough people write to their MP in the next few days we can get this decision paused until the impact on families like ours can be properly assessed and considered. Please, please, please prove me right this time.

Update: I have spoken to the office of my MP this morning (Julian Sturdy, York Outer) and he will be making representations to NICE, NHS England and the Department of Health on our behalf. Thank you so much to everyone that has already shown their support. The more MPs that do this, the better.

Further information:

MPS Society press release

Information from the Genetic Alliance