Mila Makovec has high pigtails in her dark hair and a cloth doll tucked under her arm as she wakes up in a hospital bed, where she’s just been injected with a one-of-a-kind drug intended to save her life.
The drug works for only one person in the world — this 9-year-old girl from Boulder.
In a spectacular example of what the future might hold for precision medicine, the drug was made only for her in a quest to save Mila from a neurological disease that is destroying her brain. Her DNA is in the formula. The 22-letter genome sequence in the drug’s recipe matches the one in Mila’s cells that is broken.
It is the first time the FDA has approved a drug for a single person.
The drug — appropriately called milasen — might not have come soon enough to save Mila, as it can only slow the process of degeneration, not replace the brain cells that have already died.
But this story is no longer just about Mila; it never actually was.
“This is not just for my daughter anymore,” said Julia Vitarello, who took to social media to fundraise and find a researcher and drug manufacturer who would help her. “This is for something much bigger.”
Mila’s case catapulted specialized drug development at least a decade into the future, her doctors say, opening a new path for other children with rare genetic diseases that have no cure.
Children’s Hospital Colorado, where Mila was diagnosed three years ago and now receives her treatment, and Boston Children’s, where her drug was designed, are leading the way in creating a model in which academic researchers could help perhaps a handful of children each year by crafting one-of-a-kind medicines. Next year, Children’s Colorado will begin whole-genome sequencing with a new machine called a Novaseq, a major step in the process of finding mutations in DNA.
The whole concept raises ethical questions for sure: How safe is it to initiate a clinical trial for a single child? Who makes sure the children who could benefit most — not just those whose families have money or the ability to raise money — get the specialized treatment?
Vitarello, who created Mila’s Miracle Foundation and raised $3 million while trying to save her daughter, wants to establish funding for children who need drugs tailored to their own cellular biology. She suggests an admissions process where the researchers deciding whether to help a child do not know that child’s name, face or ability to pay.
“There are going to be parents who are going to do anything for their kid,” Vitarello said. “They are going to come with money. That’s totally fine, no judgment. I would do the same thing. But in an ideal world, there would be patients coming through a funnel with no names or faces or money attached. Whoever is at the table makes the best decision.”
The path forward is likely in the academic, nonprofit space, Vitraello said. She is initiating talks with the National Institutes of Health, the largest public funder of biomedical research, as well as research institutions, the FDA and the pharmaceutical industry. An estimated 1.3 million people with rare genetic diseases could potentially benefit from a treatment like Mila’s, she said.
“There are 1.3 million kids that are dying that have no other treatment, no pharma company is going to help them, there is nothing that we can do, and now suddenly, we’ve opened up a pathway for that,” she said Tuesday at the hospital in Aurora, as Mila rested following her injection. “The only way to get it is to have more academic institutions treat more kids — one, two, five, 10. Open it up.”
The goal is that kids with flaws in their DNA could receive precision medicine sooner, halting neurological diseases before they steal the ability to walk, talk, eat or see.
Mila was a perfectly healthy child the first three years of her life. She was learning to ski, went hiking with her parents and had a vocabulary advanced beyond her years.
Her mom noticed the subtle changes before anyone — the way she pulled books close to her face because she couldn’t see, how her feet turned inward, that she began bumping into things and fell for no reason, how she stuttered sometimes but it wasn’t like typical stuttering.
Vitarello brought her to 100 doctors and therapists from the East Coast to the West and in Canada, many of whom told her to calm down and that her daughter seemed fine. “I had doctors tell me I was pretty much crazy. Very top level doctors told me to chill out,” she said. “Well, I wasn’t going to chill out. I just kept going.”
By age 7, Mila was having trouble walking and eating and was going blind. Her body was wracked with multiple seizures each day.
“I spent three years trying to figure out what was wrong with her,” Vitarello said. “I basically gave up and brought her to the ER” at Children’s Colorado.
Mila was admitted and her case assigned to Dr. Austin Larson, a geneticist whose main job at the hospital is to figure out what’s wrong with patients who have an undiagnosed disease. An MRI found that the part of Mila’s brain that is responsible for balance, the cerebellum, was smaller than expected. But it was a genetic test that for the first time gave Vitarello a name for Mila’s illness: Batten disease, and a specific type of Batten that is so rare, just 25 people in the world are known to have it.
The disease occurs when both of a child’s two CNL7 genes are mutated — one mutation from each parent.
Larson was able to identify the defective gene from Mila’s father, but could not find one from her mother. At the time, Children’s Colorado — along with most places — didn’t have the technology to search that deeply into Mila’s DNA through whole-genome sequencing, and Larson warned Mila’s family that it was likely impossible to find a clinical lab that could. She would need a researcher.
Vitarello turned to Facebook, begging for help for Mila but also so she could find out if her son, who was 2 at the time and completely healthy, had the same devastating disease that was taking away her daughter.
“I was going to get nowhere with Mila unless I just opened up my story fully, to everyone,” her mom said.
Dr. Larson had given her enough information and the right words to make a plea. A Boston physician saw her message and connected her with Dr. Timothy Yu, a neurogeneticist at Boston Children’s.
At the same time, the FDA had just approved a new drug called Spinraza, the first drug to treat a separate genetic condition called spinal muscular atrophy. The drug, injected into the fluid around the spinal cord, helped babies in clinical trials improve head control, sitting and standing.
The way Spinraza was designed was a game-changer for medicine and key in helping Mila. Yu and his team in Boston wondered if they could make a similar drug for the Colorado girl.
The Boston team spent days staring at screens of Mila’s DNA sequences until they discovered the other piece of the genetic puzzle — in addition to the gene mutation from her father, Mila had inherited extra genetic material from her mother. The combination meant that, in the most basic terms, Mila had a sequence of broken DNA in her cells.
The drug created only for Mila contains little pieces of synthetic genetic material that search for a specific 22-letter sequence and cover it up so that her cells cannot read it. “We are taking a Band-Aid and sticking it onto that part,” said Dr. Scott Demarest, a pediatric neurologist at Children’s Colorado and a specialist in rare genetic epilepsies. “That is literally what is happening. It is sticking to that spot so that the cell skips over that and goes to the next part that is correct.”
The only difference between Spinraza and milasen is the genetic sequence inside — the drugs send “Band-Aids” to different addresses.
After discovering the genetic flaw, Yu in Boston and Larson in Colorado called Mila’s mom together to give her the news. Her son did not have either of the recessive genes, and her daughter had both.
“It was a huge mix of extreme happiness and, within the same second, just extreme falling-to-the-floor sadness for Mila,” Vitarello recalled. “My daughter had gotten both of the bad mutations and my son had gotten both of the good ones.”
Next, Vitarello had to persuade a drugmaker to make a drug for one, and the FDA to allow doctors to inject it in her daughter’s spinal fluid.
“The stars aligned,” she says, still in disbelief.
Mila’s team made it happen by emphasizing that although this drug had the potential to work only on one person, the process could become a blueprint for other patients. Only the DNA sequence in the medicine would change.
They persuaded a drug manufacturer in California, TriLink Biotechnologies, to make Mila’s drug. And the FDA agreed to speed up the clinical trial process by allowing Yu to test the drug on rats at the same time Mila was receiving her first dose. The doctor had first tested it on Mila’s skin cells.
Milasen is technically now in clinical trial — a trial of one patient involving two children’s hospitals.
The night before Mila’s first injection in January 2018, as Vitarello went for a run in subzero Boston, she told herself she was OK with whatever happened. Mila was out of time. Vitarello had seen the descriptions online and knew where Mila was headed.
“My daughter’s trajectory of not treating her was so black and white,” Vitarello said. “Everyone always wonders what is going to happen to your life. When you have a rare disease, you can see exactly what is going to happen to your child ahead of time and it’s not a good thing.
“I figured the worst-case scenario was not her dying, it was her being in pain,” Vitarello said, recalling that she asked Yu to tell the FDA that she thought the drugs potential benefits outweighed the risk. “I said, ‘If my daughter dies on the spot, I’m OK with that.’”
Instead, the injections that first year seemed to stop the disease’s progression. Mila quit eating through a g-tube and started eating her mom’s pureed food again. She could hold up her head and her upper body, and her walking improved. Her seizures decreased from 30 a day to two or three.
“Quality of life, those are huge,” Vitarello said.
Now in the second year of treatment, some of Mila’s symptoms have declined, but not as steeply as other children with her disease. Mila’s team has upped her doses and started injecting them every two months instead of every three, but they have no precedent to follow.
They could find out years from now that they were giving Mila 1,000 times too little, her mother said.
“I honestly don’t know if it was in time for Mila,” Vitarello said. “She was really progressed when she received her treatment. There is still hope.”
The key to saving more children from rare genetic diseases is diagnosing them earlier — ideally at birth.
“What if we found this three years sooner?” Larson asked. “I think about that a lot. What would it have taken to have found this the first time that (Vitarello) took Mila to a physician and said, ‘I am concerned about the subtle difference in the way she walks?’
“The answer is it takes having a very broad test and being very good at interpreting that very broad swath of information.”
Science is a ways off from being able to detect diseases as rare as Mila’s in newborns. But breakthroughs are coming for other genetic diseases.
Starting in January, spinal muscular atrophy will become one of 38 genetic diseases newborn babies are screened for via blood tests, said Raphe Schwartz, chief strategy officer for Children’s.
Children’s intends to take what it has learned through Mila’s case, partner with other institutions and use it to help more children, Schwartz said. “What we learn reveals the roadmap for the future,” he said. “The future ones we do are more effective … and less expensive over time.”
There is a sense of urgency, but also caution.
“We want to make sure we are doing it right, we are doing it safely, we are doing it for kids who are going to benefit the most,” Demarest said. “There are ethical challenges around it. We need to be very thoughtful and careful that we are doing this the right way, but we’re also doing it in a way that allows this to be a reality for kids as soon as possible and for as many as possible.”
For now, Vitarello is grateful that Mila can receive her treatments in Colorado. Until September, they were traveling to Boston every other month for 10 days, but now they can leave home after breakfast on treatment days and return by dinner.
On Tuesday, Vitarello recited “Goldilocks and the Three Bears” and sang camp songs while Mila, bundled in blankets, received the 10-minute injection in her lower back, which Vitarello said doesn’t seem to hurt Mila. They celebrated Mila’s 9th birthday last week, and her little brother, now 5, picked out a squishy toy and a sequined mermaid for her birthday presents.
“I’m faced with a huge amount of sadness around this, but at the same time, it’s making such a huge difference that it gives a lot of purpose to her life and it gives a lot of purpose to my life,” Vitarello said. “We are still fighting hard for Mila. But I can see this making a much bigger impact.”