The FDA is failing rare disease patients. I’m one of them.

In this powerful conversation, G [Josie] Van Londen, MD, shares her journey with primary mitochondrial disease and the life-changing impact of the investigational drug elamipretide. She describes the invisible toll of her condition, the relief of a long-awaited diagnosis, and the real-world improvements she’s experienced on treatment. As she urges the FDA to reconsider its recent denial, Josie highlights what’s at stake—not just for herself, but for the entire rare disease community.

This link contains more resources (podcasts and news articles) as well as action items (to contact legislators and FDA). 

And here is a link to the podcast transcript with links to explain the terminology/definitions. 

General Links:

• Disclaimers: https://cancersurvivormd.org/disclaimers/
• Brad Buchanan: https://linktr.ee/bradthechimera
• G [Josie] van Londen: https://linktr.ee/cancersurvivormd
• CancerBridges: https://cancerbridges.org/

Transcript

Can you tell us about your diagnosis?

What do you think is important for people to know or understand about your condition? What’s the biggest misconception? How has your condition impacted your family?

I have a form of primary mitochondrial disease called primary mitochondrial myopathy. This affects the mitochondria—our cells’ energy producers—and leads to progressive, multisystem symptoms: muscle weakness, autonomic dysfunction, breathing problems, fatiguability, and more, double vision.

I use a power wheelchair and a ventilator, but much of my disability is invisible. People don’t see e.g. the decreased stamina, swallowing problems, bowel and bladder dysfunction, or the sheer effort it takes to stay upright.

One of the biggest misconceptions is that mitochondrial disease is just about being tired—or that it only affects children. In reality, it can strike at any age and it touches every part of life.

My family has been deeply impacted. My college-aged son grew up with a mom whose body couldn’t always keep up, and my husband now also serves as my caregiver. But we’ve built a life anchored in connection, creativity, and resilience—shaped around what I can still do.

What has been your journey with elamipretide?

How long have you been on it? How did you find out about it and start treatment?

Shortly after my diagnosis, my doctor recommended enrollment in the third, expanded access arm of an elamipretide trial. Ethically, my doctor told me that I was too ill to risk being randomized to placebo. I started daily subcutaneous injections at home and have now been on the drug for over three years.

It took a few months to notice changes, but they were real and meaningful. 

What was your health like before starting elamipretide?

How do I begin. The story is obviously more protracted than this. But in short: I was steadily declining over 10+ years. 

I pushed myself to keep working, eventually with accommodations, but everything else—relationships, basic functioning, even my health—fell apart. For years, I didn’t know why. I chalked it up to stress or deconditioning or my other conditions.

I needed more and more help with daily tasks. My stamina was declining constantly. Very slowly in the beginning, but in the end rapidly, when I even had trouble turning around in bed. Losing my voice forced me to stop working abruptly. As a last-ditch effort, I saw a rare disease specialist, who diagnosed me with primary mitochondrial disease. It was a huge relief—not because I wanted to be sick, but because I finally had an explanation. I wasn’t crazy. I could be believed. And I could access disability and treatment.

Can you describe the physical experience of being on elamipretide?

The improvements are subtle—but hugely meaningful. My body simply started failing or crashing less often. I could sit upright longer. Breathe more easily. I could regain some independence. 

These changes built gradually. And the effect is short-lasting. When I had to stop treatment for just a week, the decline was immediate. Restarting helped—but it took time to recover.

What will happen if you don’t have access to elamipretide?

I don’t have Barth syndrome which is also a mitochondrial disease—but if the FDA doesn’t grant full approval for Barth syndrome with broad labeling, access to elamipretide will end for everyone. That includes me. Even though clinical trials for primary mitochondrial myopathy and other diseases are underway, it will be too late to save the company that produces it.

If I lose access, I expect a rapid decline—across nearly all bodily systems. My caregiving needs will increase drastically. I’ll lose my ability to advocate, to participate in family life, and to care for myself.

This isn’t just about not feeling well. It’s about losing the gains I’ve made and falling back into a fragile state that endangers my quality of life, safety, dignity and most of all survival.

In your opinion, why has the FDA not yet approved elamipretide?

I believe the FDA is trying to apply traditional drug review standards to a disease that doesn’t fit traditional models. Mitochondrial disease is complex, variable, and ultra-rare. Large placebo-controlled trials are often unethical or impossible.

While my KevinMD article simplified things, the whole story is more complex. 

First of all, let me tell you about the Orphan Drug Act which was designed for complex and rare situations exactly like this. And elamipretide received the orphan drug designation for Barth syndrome in 2018. This act not only provides financial and regulatory support to companies working in rare diseases. It also allows the FDA to use a more flexible framework—to consider not just strict trial endpoints, but also extension studies, natural history data comparison, real world expanded access results, case reports as well as case series, patient testimonials, and real-world outcomes. 

Now back to elamipretide’s timeline. The FDA refused to file elamipretide’s first New Drug Application (NDA) submission in 2021 due to lack of effectiveness. A second NDA that included much more of the multiple orphan drug act endpoints that I just described was submitted in January 2024 under the traditional approval pathway. The FDA’s own advisory committee voted to recommend approval in October 2024. However, in May 2025, the FDA issued a Complete Response Letter (CRL) denying elamipretide’s second NDA. Instead, the agency suggested submitting a third NDA and this time through the accelerated approval pathway. The drug company has submitted a request for reconsideration, which the FDA is expected to decide on in early Aug 2025.

This denial decision was especially unexpected given that relevant parties such as drug sponsors and the FDA typically meet regularly throughout the drug development process to align on study design, endpoints, and regulatory expectations—steps intended to increase the likelihood of a successful NDA submission when the time comes. Furthermore, in the vast majority of cases, the FDA approves a drug following a positive FDA advisory committee meeting.

This raises so many questions a few of which are: Why does the FDA recommend a third NDA? And why was an accelerated pathway not pursued for the second NDA submission?

And despite being awarded the drug priority review status, why did the FDA withheld the benefits associated with that designation, resulting in large delays and loss of continuity over time. 

No matter whether the FDA will reconsider their denial of elamipretide, this is a history-defining moment. If the FDA reconsiders and grants full approval, elamipretide will become the first approved drug for mitochondrial disease. If they don’t reconsider their denial of full approval and continue recommending a third NDA under the accelerated pathway, the consequences will be devastating for the rare disease community as a whole.

First of all, without insurance payments tied to full FDA approval, the company will not survive – they have already let go a third of their personnel. Access to elamipretide will end for those currently on it and future access will be delayed by years if not decennia, because accelerated is a misnomer since its a highly scrutinized process. Even if another larger company would be willing to take over the development of elamipretide, they would have to start over with a 3rd new drug application for elamipretide: recruit globally from an ultra-small pool of patients and navigate immense logistical and regulatory barriers. 

Secondly, this isn’t just about one drug. This decision sends a chilling message to the entire rare disease community. If the FDA keeps moving the goalposts, who in their right mind will ever take on the financial and scientific risk of developing another drug for an ultra-rare disease?

The data are convincing, the FDA advisory committee recommended approval, and the Orphan Drug Act exists for exactly rare and complex diseases like Barth syndrome. The FDA may be worried about setting precedent or broader off-label use, but the risk of doing nothing—for this patient community and for rare disease innovation—is far greater. Fully approving elamipretide with broad labeling wouldn’t just help me—it would signal that the system can work for patients like us.

What would you say to a newly diagnosed adult with mitochondrial disease?

You’re not alone. A diagnosis like this can feel isolating, especially when people don’t understand it. But there’s a community of patients, caregivers, and clinicians who walk this path.

And believe it or not, many of us felt relief when we were diagnosed. Not because we wanted to be sick—but because we finally knew we weren’t imagining it. We weren’t lazy. There was a name. And a path forward.

Give yourself time to grieve and adjust. Then build your support system—medical, emotional, and practical. You deserve care in all areas of life.

And most of all, know this: it’s okay to live slowly. To live differently. Your value isn’t in your productivity. It’s in how you show up, how you stay present, and how you continue—on your terms. Be kind to yourself. 

What gives you hope today?

The community gives me hope—who are raising their voices with courage and clarity.

The science gives me hope. We’ve come so far in understanding diseases that were once complete mysteries.

And advocacy gives me hope. When people speak out—especially together—systems do begin to shift.

And honestly, the fact that I’ve experienced real benefit from elamipretide gives me hope. That benefit is not hypothetical. It’s lived. And if it’s true for me, it could be true for others too.

How can listeners help support your advocacy or get involved?

Please share the message. Write to your lawmakers. Ask the FDA to reconsider. Use the hashtag #ApproveElamipretide. Every voice helps build momentum.

You can read and share this post and/or my story on KevinMD, and follow me at CancerSurvivorMD.org and @CancerSurvivorMD.

And if you work in healthcare, research, or policy—please don’t overlook the ultra-rare. Our numbers may be small, but our lives are not. And what we learn from rare disease can improve medicine for everyone.