His Rare Disease's Cure Was Sitting on the Pharmacy Shelf
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His Rare Disease's Cure Was Sitting on the Pharmacy Shelf

; David Fajgenbaum, MD, MBA, MSc

Disclosures

October 31, 2023

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This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol with the Medscape podcast Medicine and the Machine. I'm delighted today to have Dr David Fajgenbaum join me from the University of Pennsylvania, Penn Med. He has a remarkable story that will be familiar to some of you in the medical community, but there are a lot more chapters going forward. Welcome, David.

David Fajgenbaum, MD: Eric, thanks so much for having me.

Topol: I recently had a chance to read your amazing book, Chasing My Cure. It is quite a story. Let's go back to 2010 when you picked up that something wasn't right about your health, after having been the picture of health: bench-pressing 375 pounds — friends called you The Beast. But then something went off the track. Maybe we could start at that point.

Fajgenbaum: I was a healthy, third-year medical student, never had any health problems in my whole life. And then out of nowhere, I started feeling more tired than ever before. You remember during training — we were sort of always tired, right? In that context, what is feeling more tired than ever before? But it felt different. Then I noticed some lumps and bumps in my neck, which turned out to be enlarged lymph nodes. I noticed fluid pooling around my ankles, which seemed unusual, and this horrible abdominal pain. It got worse and worse over the course of a couple of weeks. I was on an ob/gyn rotation. I went from taking my medical school exam for ob/gyn to walking down the hall to the emergency department.

They ran blood work, and I'll never forget: My doctor walked into the room and said, "David, your liver, your kidneys, your bone marrow, your heart, and your lungs are shutting down. We have to hospitalize you right away." Within days, I was in the intensive care unit and had my last rites, because my doctors didn't think I would survive. I was on dialysis, and it got even worse from there.

Topol: I know you courted death at least five times.

Fajgenbaum: That's right.

Topol: You were diagnosed with a form of Castleman disease. As I understand it, there are two forms. You had the most serious, multicentric form. Maybe you could explain since you are now the world authority on Castleman disease. What is the difference between the more benign and the more serious form?

Fajgenbaum: The thing that's in common between both forms of Castleman's is that if you cut out a lymph node, they look the same under the microscope. But the form I have — what's called idiopathic multicentric Castleman disease — is a deadly form where the immune system attacks and shuts down the vital organs for an unknown reason. Until recently, the only thing you could treat it with was chemotherapy.

The more benign form behaves completely differently. Patients typically are cured with surgery. This shows the importance of molecular medicine. Something may look the same under the microscope, but molecularly, it behaves very differently and, therefore, patients have completely different outcomes.

Topol: Your presentation told us right from the get-go that you didn't have the form that is easily cured. We're going to get into cures because this is a theme of yours. You went from "chasing my cure" to chasing cures for all.

One of the most memorable quotes about you was in the New York Times profile a few years back, where an Emory University professor said, "I almost wish that every disease had a David to be part of the charge." That says a lot right there.

You discovered something that helped you, having tried many different interventions. But you finally came upon something that made a difference. You've been in remission for about 8 years now. Is that right?

Fajgenbaum: Over 9 years on a drug that you know well and that many have been talking about a lot. Sirolimus, also called rapamycin, is a drug that was never intended for Castleman's and had never been used before for Castleman's. Sirolimus is a potent inhibitor of mTOR. Based on work I did in the lab, and based on the data in front of me that my mTOR signaling pathway was turned into overdrive, I became the first patient with my disease to be treated with this drug. It's been more than 9 years, and we've got patients all over the world who are now on it.

Topol: How did you come to give rapamycin a shot?

Fajgenbaum: After my fourth relapse, I'd gone back to Penn Medical School, got another year of med school under my belt, and relapsed again. That relapse was so difficult because I was on an experimental drug that blocks interleukin-6 (IL-6), and it didn't work. That's when I realized that if I wanted any chance of survival, I would need to get involved in research. I knew it was unlikely that I would find anything that would help me, but it was the only shot I had.

So I started collecting blood samples on myself, storing them in the freezer every couple of weeks. Any chance I got, while I was finishing up medical school, I went into the lab to work on these samples. I relapsed and nearly died for a fifth time while I was collecting these samples.

Thankfully, I was given a combination of seven different chemotherapies. They saved my life. But when I got out of the hospital after those seven chemos, I went into the lab and began performing a series of experiments. First, I assessed serum proteomics where I measured over 1000 different molecules in my blood from multiple time points. I did flow cytometry to look at the status of the various immune cells in my body, and how activated and not activated they were.

From these multiple datasets, there was what's called an mTOR signature. Basically, the proteins that were elevated in my blood were the proteins that are elevated when the communication line called mTOR is turned on. It wasn't proof, but it was a signature. Then I went to a lymph node that had been resected during my last relapse and I did a simple stain. It cost about $17 to run this experiment, which showed, in black and white, that this particular communication line, mTOR, was turned on to overdrive.

I drove down to Washington, DC, and I took the results to a doctor of mine at National Institutes of Health and showed them to him. I said, "What do you think? I've got this deadly disease. I keep relapsing. There's no way I'm going to make it to my wedding day unless we try something new. I'm out of options." And he said, "Sure, let's give rapamycin a try."

Topol: It's remarkable because rapamycin has a multiplicity of effects.

Fajgenbaum: That's right.

Topol: One effect is, of course, that it can help with mitochondrial dysfunction. But also, it can suppress the immune system; it is a standard drug for transplant to prevent rejection. So you came upon this and then you had to find the right dose that wouldn't necessarily knock out your immune response capability. Did you have to explore doses to find a dose that worked? And how would you know? Did you keep doing all of these tests on yourself to figure that out?

Fajgenbaum: It's such an important question because, just as you said, rapamycin is one of those drugs where the dose really, really matters. I know Peter Attia has shared that at a low dose, rapamycin may actually boost the immune system in some ways, as opposed to suppressing it. So you must get the dose right.

In my case, with Castleman's, literally, the immune system attacks the vital organs, almost as though they're foreign organs. My immune system attacks my kidneys and my lungs and liver almost as though they should be rejected like transplanted organs. So, we thought, let's start with an organ transplant rejection dose. Let's start with the dose we give to patients after kidney transplants, and that dose was too high. My immune system was completely wiped out.

So we started dialing it back until we got to a level where my symptoms were controlled. It's now been 9 years without a relapse, and I'm going to knock on some wood on my desk. My symptoms were controlled but my white blood cell count shouldn't be just zero. We wanted to find that middle ground. So it was a bit more trial and error to get that right dose and a bit less quantitative proteomics, but I think we found the right dose.

Topol: Then you took all the lessons you learned to form a Castleman's global network. Tell us about how you went from an N of 1 to an N of thousands.

Fajgenbaum: My book is called Chasing My Cure, but I think that was the wrong title. It should have been Chasing Our Cure because it really wasn't me working on my own. Yes, I was the one doing the experiments in the lab, but I also had this amazing network of people around me from all over the world, just as you mentioned — a scientific advisory board representing nearly every continent in the world, physicians, researchers, patients, all working together with this common mission: We've got this disease that is deadly and relentless. Can we build a team that's also relentless to try to find solutions for it?

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