2019 (from the January-February 2019 Issue
Winter Is Coming: Rallying the Undead (Mechanisms)
There have been multiple sightings of resurrected mechanisms, long thought dead and gone, now alive, or more provisionally, undead. Whether they will be shown to be truly viable, or just products of overexercised fantasy, remains to be seen:
This glutamatergic receptor subtype was long heralded as a route to cognitive enhancement by CortexP harmaceuticals, Lilly, Servier, and Organon (amongst many), revisited by Takeda, and quietly, by Pfizer. While Takeda ran into tox concerns with TAK-653, Pfizer showed enough with PF-04958242 to catch Biogen‘s eye, not an easy catch, given that schizophrenia is the putative focus. Biogen acquired the compound, overcoming what had become an industry antipathy for AMPA in particular, and their own reticence about Psychiatry in general. Will the PhIIb bring AMPA fully back to life, for CIAS? This MOA now has its best shot ever.
Pheromones have not elicited a lot of attention in the industry, though one tiny firm did focus upon them–Pherin Pharmaceuticals. Pherin has been walking a narrow tightrope between corporate life and death for the past two plus decades, as they sought to develop intranasal drugs based on pheromones. Janssen, Organon, and Taisho had all taken turns partnering this work 15-25 years ago, all eventually departed. Columbia U. psychiatrist and Pherin consultant Michael Liebowitz has single-handedly kept PH94B (an intranasal spray intended for use by females in socially stressful situations) alive, overseeing three underfunded pilot studies from which significant impact on anxious distress in a Social Anxiety population was reported–the study cited as preparation for Phase III enrolled just 23 women. VistaGen has now partnered PH94B, they plan to go into PhIII.
3) PARP inhibitors were once seen as a viable intervention for neurodegeneration, but Guilford Pharmaceuticals failed with their program, others moved into oncology, where PARP has been a useful target, and toxicity less of a concern. A Johns Hopkins group has now shown that low-doses of approved (for cancer) PARP inhibitors (Rubraca, Lynparza), as well as veliparib, show in vivo and in vitro signs of efficacy in an alpha-synuclein model, reducing neuron loss and alpha-synuclein pathology, which points to a role for PARP in PD pathophysiology. Now we will see if AbbVie, AstraZeneca, or Clovis Oncology will choose to explore this–it is only a good fit for AbbVie.
4) NeuroHealing‘s subQ apomorphine for coma-awakening is finally going back into a clinical trial–in Belgium.
5) Feinstein Institute researchers just published that ‘rewiring’ can be imaged in patients who had received AAV2-GAD gene therapy in a 2008-10 Neurologix trial for Parkinson’s. Neurologix declared bankruptcy in 2012.
(from the Sept/Oct Alzheimer’s Review)
Passive Vaccines: the AB mAbs
The passive vaccine approach uses monoclonal antibodies to bind/deactivate beta-amyloid, and this has become the most popular route taken by late-stage programs, with ambiguous, mixed results at best. The hypotheses for why so many have failed include the stage of disease being too advanced, the brain penetrance for the antibodies too limited, or the beta-amyloid species targeted the wrong one.
Bapineuzumab: In Phase II, Elan/Wyeth‘s (eventually, Pfizer/JNJ‘s) bapineuzumab missed its endpoints for cognition, but they had already initiated a massive Phase III program, based on a posthoc analysis that showed a bifurcation based on the ApoE4 genotype: The 65% who were carriers showed no significant benefit from bapineuzumab, although their completers had a slightly (2.6 ADAS-cog points) better outcome than the placebo group. The non-carriers showed a difference of 5 ADAS-cog points, which did reach significance. This became an example par excellence of the problems presented by differing background rates of decline: The placebo group’s rate of decline was essentially the same as the drug group until they reached the final six months of the trial, when a nosedive took them towards the extreme end of the range in terms of the slope of cognitive decline. Vasogenic edema was a complicating factor, and the drug failed in Phase III.
Solanezumab: Lilly’s solanezumab/LY2062430 preferentially targeted soluble amyloid monomers rather than plaques and fibrils. In theory, this reduces vasogenic edema risk, since it spares plaque attached to the endothelial walls of the brain vasculature. But it also requires that the antibody neutralize an enormous ‘pool’ of amyloid. After a 52pt Phase II, covering only a twelve-week period, Lilly deemed solanezumab ready for two Phase III trials, that enrolled 1000 patients each, with solanezumab administered twenty times over eighty weeks. Those trials both failed on their primary endpoints. However, Lilly seized upon a posthoc analysis of data pooled from both trials that they believed pointed to cognitive benefit in patients with mild AD. The finding that benefit was restricted to mild patients could be interpreted as meaning that, by the time Alzheimer’s has reached moderate stage, it is too late to intervene in the amyloid pathway, and Lilly chose to interpret it that way. They also noted that 26% of the patients enrolled on the basis of cognitive impairment had negative results on florbetapir scans, concluding that the lack of plaque meant that these individuals did not have Alzheimer’s, or at the very least, did not have sufficient amyloid involvement to make solanezumab responsivity likely. This overlooks the confound that florbetapir only identifies plaque, while solanezumab targets soluble beta-amyloid, not plaque.
Lilly’s final Phase III trial (EXPEDITION3), enrolled 2100 patients who met the criteria for mild AD, infusions given monthly for eighty weeks, and amyloid pathology had to be shown via imaging or CSF assay. In theory, this enhanced the homogeneity of the population, but constitutes a pathophysiological tightrope: Scanned patients had to be advanced enough to have significant plaque deposits that show on PET, but not so advanced that they had anything more than mild cognitive impairment. All of this was for naught: The Sola group showed a consistent pattern of slowed decline on the six measures, ranging from 7% on the FAQ (p=.14) to 15% on the ADCS-ADL (p=.009) and on the CDR-SB (p=.004). On the primary endpoint, the ADAS-cog14, the drug group declined 11% less than the placebo group (p=.095). Lilly acknowledged that the magnitude of observed therapeutic benefit, generally in the 11-15% range, was not clinically meaningful, and thus did not warrant continued development–a refreshing example of ethical clarity–some might have considered filing based on the overall preponderance of evidence, from all solanezumab trials, that the drug has a statistically ‘visible’ effect on disease-progression, even if the clinical impact was so small as to be invisible. This conundrum will be encountered again in the AD area, not everyone will make the ethical choice.
Solanezumab was also selected for two major prospective studies of intervention in nonsymptomatic individuals:
1) The A4 Alzheimer’s study of nonsymptomatic elderly individuals with evidence of amyloid pathology based on florbetapir scans. 1150 individuals are to be enrolled in this five-year treatment duration study, largely funded by the NIH, results coming in 2022.
2) Solanezumab is one of three treatments (along with gantenerumab and a BACEi) used in the DIAN trial, enrolling genetically vulnerable individuals, compared with placebo, plus family members without the genetic mutation. That study, assessing whether any of the three drugs impacts the progression of genetically vulnerable individuals to AD, should have its solanezumab/gantenerumab outcome data in 2019, the arm with JNJ’s BACEi will complete its biomarker (amyloid-PET) phase in 2023, but the drug’s impact on cognitive decline will be tracked longterm.
Aducanumab: Licensed by Biogen from Neurimmune in 2007, this mAB targets an undisclosed beta-amyloid epitope, identified as relevant in elderly individuals who had not shown any cognitive deterioration, the premise being that this reflects AD-‘resistance.’ It is not intuitively apparent why a ‘resistance’-linked target would still be pertinent in an active AD population that was non-‘resistant’. Aducanumab binds to plaque and fibrils, not monomers, which differentiates it from solanezumab.
Biogen ran a 166pt study (30-32 patients per dose-group) PhIIb. There were four dose levels, 1mg/kg, 3mg/kg, 6mg/kg, and 10mg/kg, all infused on a monthly basis. The 6mg/kg dose was added after the study was underway, due to vasogenic edema concerns and a high discontinuation rate with the 10mg dose. The 6mg dose did not separate from placebo at 26 weeks on the CDR-SB or MMSE, unlike the other doses, thus the dose-response relationship was not what was hoped for. The other major cognitive assessment tools used, the NTB and FCSRT, showed no effect from the drug at any dose.
The most positive interpretation of the data is that the drug, at best, produced an approximately six-month’s worth of impact on the pace of degeneration. However, the rate of vasogenic edema in the 6mg group was almost the same as seen with the highest dose (10mg) group. Biogen stated that the cases of vasogenic edema emerged early and eventually resolved, but that was within the context of a clinical trial setting wherein neuroimaging was routine. While 78% of ARIA cases were described as ‘mild to moderate’, 22% were more severe, some requiring hospitalization. Top-line results from the ongoing long-term extension study were just released, going out 36-48 months. The numbers of patients in each treatment group is dwindling, but the trendlines of amyloid reduction and (limited) impact on decline rates apparently remain the same, and the incidence of ARIA (vasogenic edema) is 25%, as detected by neuroimaging. Given what appears to be a limited magnitude of therapeutic impact, the cost-benefit analysis of whether the gain achieved is commensurate with the safety monitoring needed remains very much in doubt.
Because of the association of vasogenic edema risk with the ApoE4 genotype and dosing, the Phase III trials, each enrolling 1350 mild AD patients, are slowly titrating dosing. Originally limited to 6mg doses in the ApoE4+ groups, the EMA eventually gave Biogen permission to go as high as 10mg, the same as for ApoE4- patients. The treatment duration is eighteen months, and unlike the previous trial, these trials will allow concurrent ChEi use. One would hope that an interim futility analysis is planned, but otherwise these trials will not finish until 2020. Even if the hint of a signal proves out in the larger trials, they face the distinct risk that achieving even a borderline level of clinical impact will court the risk of vasogenic edema. It should be noted that there is a minority school of thought that holds that some vasogenic edema may be necessary in order to disrupt the blood-brain-barrier and thereby facilitate brain access for the mAb, but the aducanumab record thus far suggests that the degree of vasogenic edema ‘achieved’ too often goes beyond anything that could be construed as beneficial.
Gantenerumab: The results for aducanumab led Roche to reconsider its plan to shelve R1450/gantenerumab, a mAb (licensed from Morphosys) that attacks both plaque and fibrillar forms of AB. There have been reports of vasogenic edema, not surprising given its plaque-targeting and stimulation of microglial activity, even though less than 1% of the mAb reaches the brain. Originally, the drug entered Phase II, focused on prodromal AD, this was then expanded into a pivotal Phase II/III trial, more than doubling the planned enrollment, to 770, given monthly for two years, Roche conducted an interim analysis that they interpreted as providing a ‘go’ signal, the trial continuing into its Phase III stage, but it was eventually terminated in the wake of an interim futility analysis. The gantenerumab group did show significantly reduced CSF p-tau and total tau over a one year period, and PET-scan data indicating better brain amyloid clearance compared to placebo. Additionally, the interim analysis of the first 312 completers did not include 190 patients who had dropped out, and Roche subsequently concluded that the removal of patients who were rapidly progressing while on placebo prevented the identification of a signal, and that a nascent, dose-related post hoc signal of effect on progression rate could be discerned, and that higher dosing was needed. Interestingly, in the small group of completers who had florbetapir imaging, reductions in amyloid plaque load appeared associated with a reduction in phosphorylated tau in CSF, suggesting that impacting either of the major AD targets can impact the other.
The drug continues in another Phase III trial that began in 2014, aimed at enrolling 1000 mild AD patients, but it was cut back to 389 patients, data expected next year. In an attempt to focus higher dosing on a slightly earlier-stage population, Roche has recently initiated two 760pt, two-year duration Phase III studies in MCI/prodromal AD patients, which will report in 2022. Along with solanezumab and a BACEi, gantenerumab is offered in the DIAN trial (previously described) as a preventative/slowing option; enrollment is complete, data for the two mAbs is expected in 2019.
Crenezumab: This AB antibody program came from AC Immune, who outlicensed it to Genentech in 2006. It is based on an Ig backbone thought to be less pro-inflammatory than its peers in terms of stimulating microglial activity, it does show activity against both soluble and insoluble forms of beta-amyloid. It is likely to have a lower risk of vasogenic edema, and was chosen as the disease-modifier of choice for the API trial, as is described below.
Crenezumab failed in a 431pt Phase II trial that enrolled both mild and moderate AD patients, using both subQ and IV delivery. The IV was deemed equivalent to a ‘high’ dose, and in the mild subgroup of patients, a statistically significant impact (3.44 point mean difference) was seen on the ADAS-cog, reflecting a 52% reduction in the rate of decline on that endpoint, along with a 41.5% reduction in the rate of decline on the CDR-SB. Post hoc analyses of the high-dose (n=247) population by MMSE score at entry showed a relatively consistent trend towards cognitive preservation, on the ADAS-cog and some domains of the CDR-SB, in more mildly impaired patients, with an inverse correlation between baseline severity and improvement. Such posthoc population parsing is fraught with risk, but it was sufficient to convince Genentech to run another trial. A 750pt Phase III, using a two year treatment period and restricting enrollment to patients with mild AD (MMSE>22) is projected to finish in 2021.
Crenezumab also continues in the API study, a prospective trial wherein the mAb is used as prophylaxis in members of an extended Colombian family (approximately 5000 members) with a presenilin gene variant associated with very early onset AD. A variety of biomarkers are being tracked, and the trial will run until 2020, though interim results are expected before then. Such prospective studies should begin to answer the question of whether amyloid antibodies work when employed early enough, if one assumes that the API trial, this particular presenilin mutation, and the accelerated dementia that it produces, are sufficiently similar to sporadic AD to be predictive for the nonfamilial type. Which will cast a significant shadow of doubt across any trends that may emerge.
Roche has thus doubled down on the amyloid mAb concept; they control two Phase III mAB candidates that have each offered just enough posthoc promise–from their own data and from a competitor’s–to offer a rationale for continuation. Both crenezumab and gantenerumab are also in prophylaxis studies that are partly funded by other entities, and will not report data for years. NIR had previously commented that it was hard to imagine Roche funding two amyloid mAb programs in parallel, not when there are other targets worthy of exploration and investment–but they are indeed doing so, at a cost that is reported to be over $4 billion. We continue to doubt that they will end up getting ‘their money’s worth.’
BAN2401: BioArctic (subsequently partnered with Eisai) developed an antibody that attacks AB protofibrils. BAN2401 was subsequently repartnered by Eisai with Biogen, and was the subject of the most recent round of hyperbolic Alzheimer’s headlines. BAN2401’s Phase II data from a substantially scaled dose-finding trial (854 patients treated, four dose levels ranging from 2.5mg/kg bimonthly to 10mg/kg bimonthly) were billed as showing both a significant impact upon amyloid levels and a dose-related impact upon progression rates. The highest dose was reported to show a 30% slowing of decline on the ADCOM (a composite endpoint developed by Eisai) at eighteen months; a 46% slowing of decline on the ADAS-cog, and a 26% slowing of decline on the CDR-SB, all compared with the placebo group. Which would most likely have exceeded even Biogen/Eisai’s expectations, had only it been genuine. Once again, a major pharma company(s) had tripped itself up with an unrealistically parsed presentation of data from a high-profile Alzheimer’s amyloid-antibody trial. They neglected to mention a confounding factor that invalidated all of the comparisons between the highest-dose cohort and the placebo group: ApoE4 genotype. While the study was underway, regulators became concerned (due to aducanumab) that the risk of vasogenic edema (VE) was excessive when combining the highest dose with ApoE4+ genotypes, and stopped the enrollment of ApoE4+ patients in the high-dose group, while withdrawing ApoE4+ patients from the study who had not been in for at least six months. What this produced was a highly apparent discrepancy between the 71% of patients in the placebo group with an ApoE4+ genotype, versus the 30% in the high-dose group.
This matters, because the best evidence available indicates that ApoE4+ alleles are associated with more rapid clinical decline in Alzheimer’s. Following a spate of studies with conflicting findings, Holtzman et al reported in Nature last year data from the state-of-the-art ADNI study: Over a ten year period, patients homozygous for ApoE4 declined at a 23% more rapid rate than ApoE4 negatives, heterozygous patients declined 14% faster than ApoE4 negative patients. Which strongly suggests that the slower decline in the BAN2401 highest-dose group was partially due to their having a less-pathological ApoE4 genotype. Biogen/Eisai could have, but did not, report on what percentage of BAN2401-study patients were homozygous as opposed to heterozygous, but a simple eyeball assessment suggests, indeed compels, the conclusion that the reported rates of slowed decline on the aforementioned outcome measures were tainted by this confound, and should have been reported with an bold-type asterisk, if reported at all. Our unsophisticated assessment of the outcome curves suggests that when the ApoE4 imbalance is taken into account, that BAN2401’s impact on progression is in a range where clinical significance is dubious.
The second issue is safety, vis-a-vis ARIA/vasogenic edema. One out of every seven (14.6%) of ApoE4+ patients who did receive the highest dose-regimen of BAN2401 developed ARIA, though only three out of the 48 cases were considered ‘severe.’ While this appears to indicate a less problematic prevalence of ARIA than seen with aducanumab, if BAN2401 were deployed in the Alzheimer’s population as a clinical option, that might still be considered an unacceptable risk given the sheer numbers of patients involved.
As was the case for aducanumab, one can argue that there are hints of success to be found here; this antibody was at its essence designed to reduce amyloid levels, and the PET scan data shows that it does so, in a dose-related manner. But whether such beta-amyloid reductions lead to clinically meaningful impact on disease progression is still not proven. Both of the 10mg hint-of-a-signal groups also display a not insubstantial rate of ARIA/VE for both E4+ and E4- groups. In other words, efficacy and risk continue to be inextricably intertwined for the beta-amyloid mAbs, and whether there is enough of the former to justify the latter continues to be unclear.
A German group (Technical University Munich) reported that some amyloid mAbs appear to increase cortical neuron hyperexcitability in the presence of AB, which could have a negative effect on cognitive function. This has yet to be shown in humans. One hypothesis is that this might occur as a result of breaking down plaque into oligomers that directly trigger hyperexcitation. Thus, beyond the questions of brain access and target suitability traditionally raised, there is a possibility that amyloid mAbs could trigger deleterious consequences that offset some or all of the benefit that might have been expected from AB dissolution/clearance.
from the November-December 2017 Issue
Parkinson’s Review: The Gut-Brain Connection
This is a hot topic in the neurodegeneration field, nowhere more than in Parkinson’s. An Emory University group has reported that inflammatory cytokines (e.g. IL-8, IL-6) are elevated in colonic tissue and stool samples from PD patients. There is a highly speculative theory that categorizes PD as an age-related immunodeficiency syndrome, chronic infection and inflammation setting the stage for an increased vulnerability to PD: In this model, chronic inflammation does not cause PD, but it creates a permissive environment wherein it is more likely to manifest. Various researchers have produced contradictory profiles for the gut bacteria that they consider emblematic of prodromal PD, thus this is a narrative that is still early in development. It has also been speculated that the early development of hyposmia (impaired sense of smell) could be the manifestation of infection/inflammation via another vulnerable somatic interface, the nasal passages.
This is congruent with work published by Axial Biotherapeutics, a newco established around gut-brain pathology work done at Caltech. A PD model (published in Cell) showed that short-chain fatty acids produced by gut bacteria promoted CNS inflammation and motor symptoms. The group transplanted microbes from the gut of PD patients into germ-free, alpha-synuclein transgenic mice; compared with mice who received transplants from non-PD human sources, the PD-microbes were associated with greater motor dysfunction.
Suggesting something more than a ‘permissive’ environment is data from a Danish retrospective study (Annals of Neurology) of individuals who had their vagus nerves severed as a treatment for ulcers–some 15,000 patients were in the database. The data indicated that the risk of developing Parkinson’s was cut by half, but partial transections did not have this effect. The researchers hypothesized that PD begins in the GI tract, and travels to the brain via the vagus nerve.
This gut-brain connection is a conceptual parallel to a theory advanced by a UCSF researcher that suggests gut-based bacteria infiltrate the brain in the course of neurodegenerative disease, yielding an unorthodox neuroprotectant approach underlying Cortexyme, looking to commercialize that work. Their premise postulates the entry of an unspecified bacterial protease into the brain, interacting with misfolded proteins, leading to neurodegeneration. Cortexyme has an antibiotic that targets that protease, being readied for the clinic, with Alzheimer’s their primary indication.
This is semi-reminiscent of work previously done by Rudy Tanzi’s group on amyloid as an anti-infection agent, with misfolding/aggregation impairing that function. There is speculation that alpha-synuclein may have a similar role, thus Parkinson’s is a potential second target.
As was noted earlier, Takeda has partnered with Prana Biotechnology on PBT434, which Prana had left relatively neglected as it focused on Alzheimer’s and Huntington’s. Prana has some animal data indicating motor function restoration, but Takeda is specifically interested in the compound’s impact upon GI dysfunction, including the assessment of its impact in an alpha-synuclein mouse model. They hope to be in Phase I this year.
This is far more thought-provoking than validated at this point, but reflects the increasingly prevalent view that the CNS is best conceptualized and evaluated as part of an organismic whole, including the ‘inflammasome’ and immunomodulatory systems.
Pride Goeth Before the Fall: Axovant and Hubris
It is possible that intepirdine’s trial in Lewy Body Dementia may yet yield positive results. There is a significant cholinergic deficit in LBD, and with intepirdine being given as a monotherapy, it may have a better shot than as an adjunct to another cholinergic drug, as was the case in its AD Phase III. There may be a limit to how much one can drive a dying cholinergic system. As was the case in AD, there is little chance of anything robust, but even a mediocre treatment effect is something that has commercial potential.
But not like in Alzheimer’s, a market fifty times larger than is LBD. Axovant has not suffered a fatal blow by any means, but intepirdine’s prospects must be dialed down considerably. Which may have a salutory effect on Axovant’s primary defining characteristic to this point, hubris. Give the founding CEO Vivek Ramaswamy credit, he charmed some pretty astute investors (and some who are not so astute) into giving him over a half billion dollars, including an enormous IPO, at $315 million. All this primarily on the basis of Ramaswamy convincing them that Axovant was the proverbial ‘smartest kid in the room’, able to perceive and exploit the potential of a drug GSK had written off, and was willing to outlicense for just $5 million upfront. But NIR was never enamored of the RVT-101/intepirdine thesis in Alzheimer’s. As we said in NeuroPerspective’s Alzheimer’s review in September:
“…the premise is that an earlier, mediocre differentiation from the control group can be buttressed and enhanced via a higher-powered trial. Our view is that the higher-powered trial may provide intepirdine’s results with statistical significance, though the idalopirdine outcome is a cautionary note that trial size does not guarantee a better statistical profile. But even if it does accomplish this for intepirdine, GSK’s data points to a clinically mediocre, arguably meaningless effect.”
‘Discovering’ a second-in-line 5HT-6 antagonist as a potential second-in-line competitor for pimavanserin, and ‘discovering’ Lewy Body Dementia, are markers of a highly derivative and incremental road map, not a dramatic leap forward for CNS drug development. Ramaswamy once told NIR that “I want to cure Alzheimer’s;” it was in retrospect, perhaps unfortunate that we did not immediately respond with: “Well, you’re going about it in a really weird way.” Ramaswamy was quoted in an interview (with Forbes‘ Matthew Herper and Nathan Vardi) following intepirdine’s Phase III failure as saying that ‘“This is the single greatest failure of my career…I feel much more accountable and it hurts me to have disappointed others who took a bet on something I believed in…It’s a humbling day.” Good. Given his undeniable salesmanship skills, this could be a positive turning point, because it would be terrific if Roivant/Axovant now turns some of its talent and resources to projects that might make a real difference in clinical care.
from the September-October 2017 Issue
Alzheimer’s: The Plasma Fountain of Youth
Alkahest is working on a therapeutic program that is a next-generation elaboration upon something of a throwback neuroregenerative option; taking blood plasma from the young and infusing it into older adults in the hope of spurring neuroregeneration. Regeneration through the absorption of ‘young’ blood is a theme that has percolated through primitive rituals, vampire tales, and some ill-fated experiments of early medicine; but this program, spun out as Alkahest, incubated in a JNJ Jlabs facility, comes from work done at Stanford, which sets it distinctly apart from these predecessors. Animal experiments there showed that infusing plasma from young mice into old mice stimulated the generation of new brain cells, and improved cognitive functioning/learning, while injecting plasma from old mice into the young had an opposite and deleterious effect. Work published in Nature Medicine showed that plasma improved synaptic plasticity, operating via CREB, critical to learning/memory. In 2015, Grifols acquired 45% of Alkahest for $37.5 million, and made an additional $12.5 million payment, in return for worldwide rights.
While seeking to isolate which particular factors were upregulated via young plasma, the simplest tactic for establishing preliminary HOC was to infuse plasma itself. An 18 patient, double-blinded Phase II trial was initiated, using weekly plasma infusions from individuals under age thirty, in patients with mild to moderate (MMSE 12-24) Alzheimer’s, with a trial duration of nine weeks. Most standard cognitive tests were utilized as efficacy measures, nine weeks into the trial. The trial was finished earlier this year, preliminary results will be presented at CTAD. It is highly unlikely that any marked contrasts will be seen, since this is a tiny, short-duration trial, and it is not known whether (as is the case in other AD trials) these patients may be too advanced in their disease to benefit from the trophic effects of plasma, while it is also not known whether the donors themselves are too old to provide maximally ‘potent’ plasma in terms of the inherent level of regenerative factors. If there is a therapeutic product to be had here, this would raise all sorts of practical and ethical issues around plasma supply, and IP regarding the application of the technology. As NIR has commented tongue-in-cheek in the past, one can only imagine the dinner table conversations between middle-aged parents and their teenage offspring: “Yes, you can borrow the car, but there’s something you have to do for us in return…” This even made it onto HBO’s satirical comedy, Silicon Valley, where a narcissistic CEO was depicted lounging at home with his plasma donor.
From a longterm pragmatic perspective, identifying critical regenerative factors would be far more useful, and those Stanford researchers reported (in Nature) that they had identified a key protein in cord plasma that they believe accounts for the regenerative effects of umbilical cord plasma in mice: TIMP2. TIMP2 levels are reduced in the hippocampi of older adults, and infusing mice with the protein induced the same procognitive changes as did cord plasma. NIH Director Francis Collins rhapsodized about the finding in his blog: “...might the elusive elixir of youth that people have long pined for been inside us all along?” As we have noted previously, that is more than a tad hyperbolic, but the TIMP2 finding suggests both a mechanism and a commercial path forward for Alkahest, if TIMP2 can be developed as a therapeutic agent. Alkahest believes human testing is at least two years away (it does not fall under their Grifols agreement, which is limited to plasma products). The premise is not universally embraced: Science quoted a researcher from across the Bay (UC Berkeley‘s Conboy) questioning whether the magnitude of benefit was truly noteworthy compared to more mundane interventions, like exercise, while postulating that the contrast between cord and aged plasma is actually due to the presence of degeneration-associated proteins in aged plasma.
from the July-August 2017 Issue
Spinal Cord Injury: Inhibiting the Inhibitors
As was noted above, barriers to regeneration/rewiring are both physical and biochemical, and finding a way to interrupt growth-inhibiting signals has been perhaps the most heavily pursued strategy in SCI pharmacotherapy R&D. Many of these factors are components of myelin, easily found in the myelin ‘debris’ around the spinal injury site. Three of the inhibitory factors found in myelin are MAG (myelin-associated glycoprotein), OMGP (oligodendrocyte myelin glycoprotein), and the best known such factor, Nogo-A/Reticulon-4, These all bind to different areas of the Nogo receptor, which itself is part of a complex involving that receptor plus either p75 or the protein TROY (both related to the TNF family, and hence relevant to inflammatory processes), and/or the protein Lingo-1. When this receptor complex is activated via any or all of these binding sites, the next step along the pathway is Rho, which is discussed in more detail below. When Rho is activated, the growth cones that guide axonal extension collapse, and growth stops. Additionally, inhibiting the inhibitors at this stage can also mean inhibiting apoptosis, since p75 is involved in apoptosis. Classifying this pathway as purely regenerative is something of a misnomer used for the sake of brevity: Choosing the right target will not only allow regeneration to proceed, but will also protect surviving tracts from subsequent apoptotic cell death.
From a historical perspective, this crucial understanding of endogenous ‘anti-growth’ processes dates back to when Martin Schwab first identified Nogo, in 1988. Nogo has been recharacterized over time as a regulator of axonal sprouting, and multiple programs aimed at suppressing Nogo have been conceived–and demised. The first tactic licensed by Schwab to Regeneron involved the use of monoclonal antibodies (NI-35, NI-250), but those antibodies eventually proved nonviable. Novartis (with whom Schwab subsequently worked) eventually produced another antibody, IN-1. In a primate model, where 90% of tracts were destroyed, full function was eventually restored. IN-1 blocked the Nogo protein itself, and was the basis for ATI-355, a product that went through a Phase I trial (the FDA did not allow US sites due to safety concerns) that utilized intrathecal infusion, beginning within 4-14 days of the injury. The program eventually disappeared from Novartis’ pipeline; Schwab was reportedly going to run another trial in Switzerland, at his own University of Zurich laboratory, but there is no evidence that this ever started.
Biogen took a slightly different tack to Nogo, working with NEPI-40, a Nogo antagonist peptide, but that program was dropped. Sanofi had a program pursuing the Nogo target, but sidelined it. GSK ran a trial in ALS with their Nogo mAb, ozanezumab/1223249, rather than pursuing SCI, and after that trial showed no therapeutic benefit, they dropped the program. The initial allure of Nogo as a target has pretty much vaporized. While it plays a role in the pathological cascade, it does not appear to constitute a viable target.
AbbVie did some discovery work in this area, in regard to the use of a selective antibody against Nogo Receptor 1/Nogo-66, reporting in 2013 that mAb 50 did enhance functional motor recovery in a rat model of SCI. But they have shifted their SCI target to Repulsive Guidance Molecules (RGMs). ABT-555/elezanumab is an antibody to RGMa, whose presence on the cell surface inhibits axonal regrowth and remyelination. In 2015 they initiated a PET-study of ABT-555 in the UK, aimed at RRMS; that trial was suspended last October, and terminated this past February. But this was not due to a safety issue, AbbVie has begun enrolling a 30pt Phase II trial in RRMS, with a six-month treatment duration. They cite early 2019 as the expected completion timeframe, but they are also planning to initiate a Phase II trial in SCI, perhaps this year.
There are other candidates for the role of inhibitory mediator, through which growth-inhibiting signals from various sources must pass, that offers an attractive target for blocking these inhibitory processes, and in our view, Rho has been the leading possibility. As was noted above, activation of the two major Nogo complexes (combined with either p75 or TROY) eventually leads to Rho activation. Rho can also be activated by proteoglycans found in the scar tissue, the aforementioned neurochemical obstacle arising from the extracellular matrix components of scarring. Rho antagonism thus blocks not only the impact of Nogo, but also impacts pathways triggered by other growth-retarding factors, including proteoglycans and axonal repulsion factors. Rho proteins modulate signal transduction within the growth cone itself, controlling axon growth and cell proliferation. Blocking Rho promotes neuroprotection and axon growth, working upstream of nogo, and both in vitro and in vivo studies have shown axonal growth after Rho antagonism. One concern with the Rho target is the fact that Rho proteins are ubiquitous throughout the body, but no safety/tolerability issues have arisen in the clinical testing done thus far.
There were originally two companies pursuing the Rho target, BioAxone and Migragen. Both took a known Rho-antagonist with very poor absorption, the enzyme c3-transferase, and modified it. Migragen combined CT-3 with a component taken from botulinum toxin, which increased membrane permeability. But Migragen ran out of money and sold their IP to Schering, who did not have interest in it for therapeutic development.
In contrast, BioAxone has persevered (albeit in two corporate iterations) for more than fifteen years with the development of Cethrin, a recombinant version of c3-transferase that antagonizes Rho. It is neuroprotective (reducing apoptotic cell death 50% in one model), and reduces TNF-alpha, thus reducing inflammation and scar formation. It is effective in promoting growth, and no significant treatment related adverse events have been seen.
In a 48pt (mean time to treatment was 52 hrs post-injury) open-label PhI/II program using five doses of Cethrin, 43% of the patients showed functional gains of two ASIA grades or more, from a starting point at ASIA-A (complete loss of function below the level of injury). Some improved up to Level D, where at least half of the muscles innervated from below the injury regained significant functionality. In the 12 patients with cervical injuries (thoracic injury patients tend to show little benefit from interventions, and were included primarily to assess safety), the mean improvement over twelve months was 27.3 points for the 3mg group, 21.3 points for the 1mg group. Historical control data suggests only about 10% of ASIA A patients show this level of ASIA-category improvement, and it usually occurs fairly early in the post-injury period. Motor function and sensory improvement were noted, and no adverse event or tolerability problems were reported.
Historical control comparisons must be viewed with considerable skepticism, though these results are striking. The the lack of a control group in that dataset considerably complicated the process of finding partners, and the task of assembling and completing a placebo-controlled Phase II/III trial turned into a marathon, one not yet fully run. BioAxone originally partnered Cethrin with Alseres in 2006, but Alseres failed to carry out the promised PhIIb trial, and BioAxone eventually (and with no small amount of effort expended) regained those rights and reconstituted itself. In 2014, BioAxone found a highly credible partner in Vertex Pharmaceuticals, which paid $10 million upfront, the deal included an option to acquire BioAxone. A placebo-controlled Phase IIb for VX-210 began in February 2016, aimed at enrolling 150 patients with acute cervical SCI, using two dose-levels, surgery done within 72 hours of the injury. Improvement over six months in upper extremity strength is the primary endpoint, and that trial is projected to finish next June, a highly significant dataset for the SCI world.
LRP1(Low-Density Lipoprotein Receptor Protein-1) has been identified by Novoron Bioscience as a target for intervention, based on LRP1’s role as a convergence point for multiple inhibitory factors, with the downstream effect of hyperactivating Rho-A. Novoron is working with a biologic (a recombinant derivative of RAP–Receptor-Associated Protein–a chaperone protein) that prevents that hyperactivation. Working with grant funding thus far, Novoron is first pursuing remyelination in MS, but SCI would be the next indication-of-interest.
Yale‘s Martin Strittmatter developed a fusion protein which served as a decoy receptor, binding three anti-regenerative, myelin-based factors in combination: Nogo, MAG, and OMG. Strittmatter’s animal work indicated that inhibiting all three nogo receptor ligands provided additive benefit, exceeding what could be achieved via a single factor. The belief has been that working with chronic SCI might be easier, given that six months out, natural recovery has run its course, thus removing an element of placebo response, and permitting the use of smaller patient samples without the pressure of trying to enroll and treat within a few days of the injury. This program was a core component of Axerion Therapeutics, which has been reorganized as ReNetX, and at present they are not disclosing the status of any of their inhouse programs.
Much of the work in this area as it pertains to SCI has been continued by academic groups. A Harvard Medical School-affiliated group has worked on the OMGP pathway to Nogo modulation, while a Johns Hopkins group has reported animal work wherein recombinant neuraminidase blocked MAG and enhanced motor function.
A Genentech group identified leukocyte immunoglobin B2 (LILRB2, also known as PirB–generally thought to have a role in controlling inflammation, since it is a receptor for MHC antigens) as being bound by several inhibitory factors, including Nogo-A, OMG, and MAG. In mice, a PirB antibody significantly improves neurite growth, suggesting that LILRB2 antagonism in humans might be another broad-spectrum approach to restricting axonal growth inhibitors. However, Genentech‘s work on LILRB2 focused primarily on its potential role in Alzheimer’s, not SCI, and that program appear to have been culled.
Articulating the Lingo
Biogen has pursued utilizing the Lingo-1 component of the growth inhibitor complex as a target: After a promising trial in acute optic neuritis, wherein the mAb against Lingo-1(BIIB033) improved the speed of signal transmission, they had disappointing results in RRMS, which they attributed to anomalies in the dose-response profile (they intend to resume testing in RRMS). They have not articulated any plan to go into SCI, but if they do succeed in eventually spurring remyelination in RRMS, SCI would be a logical avenue for label-extension.
Whereas the growth-inhibitory factors described above, and the physical barriers posed by proteoglycans discussed later, constitute obstacles outside of the neuron that slow or prevent regrowth post-injury, there are also components within the neuron that pose an obstacle to regrowth. The highest-profile intrinsic factor is PTEN (phosphatase and tensin homolog), a protein that regulates cell growth. Due to its role in tumor suppression, it was long pursued by a number of companies in oncology, who have sought to upregulate its action. However, PTEN’s restrictive effect on cell growth also led to a flurry of research by a number of academic groups, particularly at Harvard and UC Irvine, looking at its inhibition in SCI, in the service of fostering axonal regeneration. This came to a head in 2014, when the UC Irvine group published work showing dramatic results when rats, injected with an AAV vector delivering PTEN inhibition (via RNAi), showed impressive functional recovery (up to 95%), but only when the PTEN RNA-silencing vector was accompanied by salmon fibrin, believed to provide a scaffold for the regenerating axons. In this model, the PTEN-silencing and fibrin injection were done before the induced injury, and while the lead investigator said that recovery is also seen with treatment concurrent with the injury, it has been unclear if this intervention, administered post-injury, would have the same effect. It is also not clear whether PTEN knockdown can be accomplished without the risk of tumor development: PTEN has been a target-of-interest in the treatment of glioblastoma, and given the relative youth of the SCI population, safety over the very long run would have to be established. BioAxone and the Harvard/Boston Children’s Hospital group did receive some NIH/NINDS funding for their work on developing RNAi to knock-down PTEN expression, BioAxone’s BA-434 is their PTEN RNAi payload, a ‘self-delivering’ RNAi factor that has good cell permeability even without utilizing a vector (like AAV). In rodents BA-434 knocks down PTEN with an extending duration of effect, and in rat retina, promotes neurite growth and axonal regeneration.
Bob Yant, who founded the SCI-supply company CureMedical, and who himself has quadriplegia following an SCI, has licensed some of Harvard‘s IP around PTEN, and is collaborating with venBio‘s Corey Goodman in forming a newco that will focus on PTEN in SCI; no details have been made available.
from the May-June 2017 Issue
Insomnia: Paradigm Shift-Orexin Antagonism
The orexin system, also targeted by the alertness drug Provigil, became the context for the next real paradigm shift in insomnia treatment, orexin receptor antagonism. The key concept here was that, in contrast to other insomnia drugs in clinical use, which upregulate sleep (and sedation) associated pathways, orexin antagonism downregulates excitatory/arousal pathways, or as it was put in the popular press, ‘turning down the wake switch instead of turning on the sleep switch.’ This, at least in theory, might provide a different risk-benefit profile.
Merck became the trail-blazer in this area, as a GSK/Actelion entrant faltered (see below) and they successfully developed the dual orexin subtype (OX1R and OX2R) antagonist MK-4305/suvorexant. In two 1000+ Phase III trials that followed patients for three months, suvorexant’s high dose (40mg, 30mg for elderly) hit all of its co-primary endpoints, reducing TSO (sleep onset delay) by 8.4 minutes and 12.2 minutes, and WASO by 22.9 and 19.4 minutes. In a 737pt 12-month study, suvorexant improved sleep latency, and was reported to have no impact on next-day driving, whereas zopiclone did negatively impact driving. Where the suvorexant story became particularly surprising was at the FDA. The FDA’s Advisory Committee voted 13-3 to support starting doses of 15 and 20mg (in elderly and non-elderly respectively), but 8-7 against the higher doses (30/40mg) that had produced Merck’s most clearly positive results. There was some discussion of whether the high dose was sufficiently tolerable in terms of residual effects, and whether Merck should be required to run an even lower-dose trial (10mg). But after receiving manufacturing data for the 5 and 10mg dose tablets, the FDA eventually approved the NDA for suvorexant at 10mg, a dose that even Merck did not see as efficacious (depending on endpoint, optimal dosing varied from 20 to 40mg), and Belsomra was commercialized. At time that this occurred, NIR commented that, while we were glad to see Merck’s work rewarded and Belsomra approved, that this was a potentially confusing outcome in terms of guidance for those who might follow Merck. It can also be argued that, while there was obviously some benefit to Merck in not having to run another Phase III, approval at a subtherapeutic dose is not without its own cost: Patients and prescribers can grow disenchanted by an initial lack of impact, and while some might then escalate dosing, some will not, and this is not the kind of ‘word of mouth’ experience that gives a new drug momentum. Merck has still not broken out the sales for Belsomra, which suggests that the numbers are weak: Would they have been better off had they further pursued a starting dose that matched their own efficacy data? We will never know, but this was a downside to the FDA’s flexibility wherein they prioritized the avoidance of side effects, even those encountered with any hypnotic, over efficacy.
In any event, Belsomra’s clinical case vis-a-vis existing drugs was not definitively made by its pivotal testing, and some payors are treating it as a higher-tier option to be utilized in cases where generic hypnotics have not been satisfactory. Kaiser Permanente, for example, requires failure on four generic drugs before they will cover Belsomra. The more euphoric analyst predictions for Belsomra’s sales growth have been ratcheted down quite a bit.
The efficacy questions did not end with the FDA: The Australian Department of Health initially rejected Merck’s application to sell Belsomra there due to what they viewed as moderate therapeutic benefit accompanied by the same kind of next-day drowsiness as plagues current drugs, along with ‘abnormal sleep behaviors and suicidal ideation’ (albeit without any particular evidence of the latter; rare instances of sleep paralysis, and about a 10.6% rate of somnolence at the 20mg dose). They eventually did approve the 15 and 20mg starting doses. Unlike the FDA, they did not approve the 10mg dose, nor did they approve Belsomra for longterm use (the low-dose trials only went out three months).
Merck did have a follow-on molecule, filorexant/MK-6096, also a dual receptor antagonist, but they dropped development after Phase II testing was done in 2014.
There is some debate in the field as to whether blocking both orexin receptor subtypes inevitably means that the pro-sleep effects of OX2R antagonism will be offset by sedation/dulling associated with OX1 antagonism. Rodent studies indicate that OX2R antagonism is more critical for improved sleep, but dual-receptor antagonists appear to induce sleep somewhat faster. Regardless of the specificity issue, the fact that suvorexant’s half-life is in the 9-13.5 hour range likely accounts for the next-day drowsiness risk.
Minerva/JNJ‘s MIN-202 could provide the first opportunity to test the specificity thesis. MIN-202 is an OX2R antagonist that was developed by Janssen/JNJ (as JNJ-42847922) then licensed by Minerva Neurosciences for co-development in 2014, when insomnia was deprioritized at Janssen. A 28pt Phase IIa showed MIN-202 did improve sleep parameters over a five day period, somnolence and abnormal dreams were reported. Minerva has also done testing parsing MIN-202’s impact on sleep from its benefit upon depression in pilot studies, but has not yet initiated a Phase IIb study in insomnia, perhaps hoping for either a partner or funding from licensing another of their assets.
Eisai has developed their own dual orexin-receptor antagonist, lemborexant/E2006. In a 291pt Phase II, five dose-levels all showed efficacy over a fifteen day period, only the highest dose appeared associated with next-day drowsiness (the half-life has not been disclosed). It should be noted that drowsiness was measured via self-report, not via any objective cognitive or functional testing. Purdue Pharma partnered with Eisai, in an agreement that includes cost-sharing plus co-promotion in the US. Purdue has the advantage of having brought in the Merck scientist who drove Belsomra’s development there, saving them from having to ‘reinvent the wheel’ on many points. A 950pt Phase III in individuals over 55 will finish 3Q:17, comparing lemborexant to zolpidem-CR. Another Phase III, enrolling 900 patients and following daily use for twelve months, is expected to finish late 2018. There is also a Phase II trial in Alzheimer’s patients with sleep disturbance.
There was a time that GlaxoSmithKline and Actelion were at the head of the orexin field with the dual receptor antagonist almorexant. Actelion stated that they achieved PhII benefit in both induction and sleep maintenance, without impacting sleep architecture, and claimed that no cognitive sequelae were seen, though we have heard that questioned by interested observers who had seen the data; almorexant’s 40hr half-life would seem to guarantee residual adverse effects. Phase III used zolpidem as the active comparator, and Actelion announced completion at the end of 2009, successful save for some “safety observations.” Those must have been significant, because eventually the partners dropped almorexant, shifted to a backup orexin antagonist, and then GSK exited completely.
Actelion has carried on: The backup ACT-541468 is in a 300pt Phase II trial expected to complete later this year, using zolpidem as an active comparator. A 50pt Phase II in elderly patients should finish around the same time. All of this will now be done under the auspices of the R&D newco (run by Actelion management) spun out of JNJ/Actelion (along with a $1 billion in funding) when JNJ acquired Actelion earlier this year. GSK itself had an inhouse orexin dual receptor antagonist, SB-649868, but they dropped this early on, due to an undisclosed toxicity issue. Novartis disclosed OX2R selective compounds back in 2013, which were 30X more selective for OX2 than OX1. It does not appear that Novartis did anything with these assets.
Heptares Therapeutics has done early-stage work on selective OX1R antagonists, applicable to compulsive behavior disorders and addiction, but has not discussed any interest in OX2R and insomnia.
The major unknown/undisclosed variable for MIN-202, lemborexant, and ACT-541468 is half-life, since extended bioavailability would seem likely to lead to the risk of next-day residual effects. But then again, zolpidem is not without the risk of residual effects, and its half-life is cited as being in the two-three hour range, so this is not such a clearcut criterion for viability.
from the January-February 2017 Issue
The Year of Living Dangerously–the Sequel, Coming to Everyone’s Neighborhood….
2016 passes into the history books with hardly a ripple, the progress of humankind towards a brighter tomorrow smoothly advancing without so much as a hiccup. 2017 promises to be modestly more dramatic, with pundits predicting outcomes ranging from Apocalypse to Armageddon. The stock market has been booming. Somewhere, we can hear Nero fiddling as the Empire binges on ayahuasca.
When it comes to the biopharma world in general, there was a sense of déja vu. Another year, another amyloid antibody yielded its bounty of disappointment. Some pharma observers believe that the sudden 180 degree turn in Presidential mindsets means that the heat on the industry will be off, the pressure on pricing diminished by an industry-friendly administration. It does not look that way to everybody. NIR quoted Allergan‘s Brent Saunders in November, now we cite this excerpt from a piece he wrote for the December 1 issue of Forbes:
“…our industry has a social contract. Patients understand that making new medicines requires significant investment. Companies doing the hard, long and risky work of bringing new medicines to market have generally understood that they have to price medicines in a way that makes them accessible to patients while providing sufficient profit to encourage future investment. Everybody wins when it works the way it should. But some have violated this social contract, and the whole industry is under attack. The election results don’t change that debate. The election may give the industry time to demonstrate that it can self-govern. Time to demonstrate that the social contract is alive and well. If not, our elected leaders may act without us–at the peril of innovations that could help millions of patients.”
Citing Tufts estimates for the cost of developing drugs, and whining about the costs of Innovation, have been burned out as arguments with the public audience. They simply do not believe us, and an administration with a limited tolerance for scientific truth, a minimal attention span, a low bar for ‘facts’, and a penchant for populism cannot be relied upon as a shield when we offer such a convenient target: It’s not as if we make something useful, like air conditioners. The bill is coming due for Pharma’s public relations, which have been a chronically abysmal failure. We have allowed callow sociopaths like Martin Shkreli to seize the limelight and frame all of us as bathed in a miasma of unmitigated greed. This is not accurate, and is not fair, but we have failed to make our case or live up to our part of the social contract. If we do not show some collective spine in developing self-discipline, it will be done for and to us.
from the January-February 2017 Issue
Everything You Always Wanted To Know About the Amyloid Hypothesis (But Were Afraid To Ask Because the Shareholders Might Not Like What They Hear)
“Maybe we’re all just stumbling from the right questions to the wrong answers, or maybe from the right answers to the wrong questions.” –Malek, R. Mr. Robot 2016
“This (the sola study) is confirmation of the amyloid hypothesis, our strongest confirmation to date.” –Aisen, P. 12/8/16 CTAD
Which just shows how low the amyloid bar is, confirmation-wise. But in this instance, the conversation ricocheted from the wrong question to the wrong answer.
The wrong question: ‘What do these results say about the amyloid hypothesis?’
This infers that there is a single, archetypal amyloid hypothesis (AH), but in fact there are several, because there are multiple iterations of the Amyloid Hypothesis which have evolved over time as the earlier versions began to show their flaws.
AH 1.0: The original hypothesis says that Alzheimer’s is caused by the accumulation of amyloid plaque within the brain. If AH 1.0 were correct, aducanumab’s ability to reduce plaque deposition by 25-30% should translate into tangible cognitive/functional benefit. But while the 10mg dose showed a tentative signal on the CDR-SB, the 6mg dose, in spite of its similar PET-scan credentials, was a flop at 110 weeks. That could be due to the variance born of small cohorts, only a larger trial will tell. It is worth noting that solanezumab, in spite of not binding to plaque at all, produced a consistent albeit clinically meaningless effect on cognition.
Any question about AH 1.0 is the wrong question. It’s like asking about the ‘link’ between vaccinations and autism.
AH 2.0 postulates that amyloid in some non-plaque form (e.g. fibril, oligomer, monomer) is the causal key to Alzheimer’s. One counter-argument to AH 2.0 is offered by solanezumab, which produced a dramatic effect upon plasma amyloid, increasing it 500-800 fold, but the weakness of the therapeutic effect in the face of that biomarker does not portend a robust relationship. Sola’s first two Phase III trials showed an increase in total CSF AB40 as well, again without any connection to a clearcut treatment effect. The sola results neither prove nor disprove AH 2.0: We do not know if the weak response promoted by solanezumab means that the antibody binds to a suboptimal form of AB; not enough antibody reached the brain to bind enough AB; the patients were too advanced to benefit from a post hoc reduction of AB; or the answer includes a combination of some or all of these. It is worth noting that a recent in vitro study published in PNAS (Sun et al) did not support the traditional contention that longer, more aggregation-prone variants of beta-amyloid (e.g. AB42) would be associated with more severe, earlier-onset forms of Alzheimer’s–no correlation was found. While this does not disprove the amyloid hypothesis, it adds to the evidence stacked against AH1.0 or AH2.0.
AH 3.0 proposes that amyloid is a secondary rather than primary pathophysiological feature; it is not the foremost pathological actor, but plays some facilitative or ancillary role. This is consistent with the recent hypothesis that amyloid sets the stage for tau to disperse and cause the bulk of the direct damage. AH 3.0 seems to be best current model for understanding the data up to this point, one that leaves open the possibility that targeting amyloid could have a clinically meaningful role in AD treatment–-but by no means guarantees it, and makes it unlikely to be the optimal target for a monotherapy.
But wait, there’s more. These are lower profile, partly because of the potential for terminal embarrassment for the leading lights of neuropharm if it turns out that either one is true.
AH 4.0 says that amyloid is benign. It could be a warning flag for ‘system errors’, cellular misprocessing of APP which exerts a toxic effect separate from amyloid-as-byproduct. It could reflect problems in APOE processing, which have been linked to effects on neuroinflammation and mitochondrial function that do not trace their roots back to amyloid.
AH 5.0 claims that amyloid has been framed, not only wrongly convicted, but in reality playing an erstwhile (albeit eventually futile) part in defending the brain. Rudy Tanzi has proposed that beta-amyloid plays a role as a defense against infection, encapsulating microbes in amyloid protofibrils. A University of Madrid group hypothesized that beta-amyloid is a defense against fungal infection, while Cortexyme is based on UCSF work indicting a bacterial protease as critical to Alzheimer’s in an infection motif, though in that scenario, beta-amyloid is an ancillary but damaging byproduct, more in line with AH 3.0.
None of these have been proven. AH 1.0 has been largely disproven, but the rest are all conceptual models, hypotheses to be tested.
Returning to CTAD, and the question posed to the sola panel: It was ‘wrong’ because it referred to ‘the amyloid hypothesis’, as opposed to ‘an amyloid hypothesis,’ without specifying which one. And with all due respect to Paul Aisen, who knows far more about Alzheimer’s than NIR ever will, he provided the ‘wrong answer’, regardless of which AH species he may have been referring to: Nothing was ‘confirmed’ by the sola results.
So much has been invested by so many in the amyloid hypotheses that any results that do not contradict it/them is seized upon like a drowning man grabbing hold of a flotation ring. There are outstanding scientists who have devoted their professional lives to the explication of one or more Amyloid Hypotheses, and it is human nature to seek corroboration, particularly when there is no viable reverse gear by which they can switch belief systems.
Having commented upon the confluence of ‘wrong questions’ and ‘wrong answers’ as pertains to the Amyloid Hypotheses, we have our own list of questions and answers about the state of the mAb art and what this means, some of which are guaranteed to be just as ‘wrong’ as those discussed above. Being wrong is an inevitable side effect of scientific inquiry, where it becomes problematic is when a belief system takes on a life of its own, despite evidence to the contrary.
At the CTAD presentation of the detailed results from the most recent sola trial, Lilly‘s Eric Siemers several times responded to questions with the honest and accurate “I really don’t know.” For most of the questions oft-asked, no one knows the answer, yet. But based on the hodgepodge of information gleaned from the several AB mAb trials that have reported results, this is how it looks.
1) Solanezumab reached statistical significance in its impact on four out of six outcome variables. What future does it have, if any?
The drug group showed a consistent pattern of slowed decline on the six measures, ranging from 7% on the FAQ (p=.14) to 15% on the ADCS-ADL (p=.009) and on the CDR-SB (p=.004). On the primary endpoint, the ADAS-cog14, the drug group declined 11% less than the placebo group (p=.095). Based on the selection of the ADAS-cog14 as primary, the trial failed, this would at best be considered a trend. Recalling that Lilly had originally cited co-primary endpoints, including a functional endpoint combining the ADCS-iADL and FAQ, eyeballing the p values for those two tests suggests that combining them would not have reached statistical significance, and would not have changed the verdict on the trial. It should also be kept in mind that the p values reported were not corrected for their multiplicity, they would have been higher had they been corrected.
But that really does not matter–Lilly acknowledged that the magnitude of observed therapeutic benefit, generally in the 11-15% range, is not clinically meaningful, and thus does not warrant continued development for sola. The fact that the primary endpoint missed hitting p=.05 saved Lilly from having to decide whether to file for a drug that they knew achieved statistical but not clinical significance in its effect, a debate that would have been roiled by commercial needs as much as clinical and ethical considerations. The same question might have been begged by the p=.004 value reported for the CDR-SB, a functional endpoint being utilized as the primary by Biogen in its aducanumab Phase III program. At the time that the EXPEDITION3 trial was being designed, the CDR-SB was not viewed as a primary endpoint candidate, but even if it had been, a 15% slowing of decline is not clinically meaningful. Lilly should be commended for its current clarity on this point. There are companies that would have considered filing based on the overall preponderance of evidence, from all solanezumab trials, that the drug does have a statistically ‘visible’ effect on disease-progression. But Lilly had expected, with the requirement of amyloid-positive biomarkers for inclusion, that this ‘purer’ patient population would reveal a treatment effect of around 30%, close to what they reported from the amyloid-positive dataset pooled from the first two trials. Falling so far short of that begs questions of what might have happened had a higher dose been used (the drug is very well tolerated), or if they had somehow identified an earlier-stage population (hard to do when requiring amyloid biomarkers for inclusion) for intervention, but also suggests that tweaking dose and population is unlikely to achieve clinically meaningful results. Lilly did hedge on whether they would consider going ahead with sola based on such tweaks. Lilly’s announcement the day after CTAD that they were partnering with AstraZeneca on another AB1-42 antibody program may be tangible proof that they have moved on from sola–although that particular choice seems like switching from Coke to Pepsi for health reasons, unlikely to make any difference at all.
2) What does the sola outcome say about Biogen and aducanumab?
Not much, though it may reassure Biogen that CDR-SB is a more sensitive endpoint and perhaps better for their Phase III program. The Phase IIb data for aducanumab did suggest a possible signal, but the small size of the study makes this tentative, as does the very shaky dose-response relationship. The 6mg dose group performed more poorly than the 3 or 10mg groups on the CDR-SB, and matched placebo on the MMSE. It is not reassuring that switching the placebo group to active treatment with the 3mg or 6mg dose at 12 months did not seem to impact the slope of deterioration at all, while the slope of the 10mg group was inconsistent. The aducanumab data also does not support AH 1.0: The two highest dose levels reduced plaque deposition rates by 25-30%, but while the 10mg dose showed the strongest association with cognitive benefit, the 6mg dose performed poorly, in spite of its PET scan results. Reducing plaque is meaningless save as a marker of specific target-engagement. Aducanumab shows a trend suggesting the highest dose has an effect on cognitive decline, but the dose-response relationship is nonlinear, and the inconsistency means that the small size of the dataset precludes taking anything as having been demonstrated efficacy-wise.
Aducanumab Sings an ARIA-again: These less-than-exemplary efficacy results came at the price of a substantial incidence of vasogenic edema/ARIA, a safety issue not encountered by solanezumab. At CTAD, Biogen reported results from a 23pt titration trial of aducanumab, wherein APOE4 patients, who are most at risk of ARIA, showed a reduction of ARIA frequency when the dose of aducanumab was slowly titrated up to 10mg: Titration reduced the incidence of ARIA by 36%, from the 55% seen in the fixed dose 10mg group, down to 35%. But all of those ARIA cases developed on the 3 or 6mg dose-levels; thus avoiding the 10mg dose in Phase III, where 6mg is the highest dose being given APOE4 patients, is unlikely to avoid ARIA. Biogen accentuated the fact that in the extended treatment phase of the regular PhIIb trial, no patients developed ARIA during their second year of drug treatment. But 25% of the group who switched from placebo to 3 or 6mg did develop ARIA. Thus while it is mildly reassuring that those who do not develop ARIA relatively early, during their first year of treatment, are unlikely to develop it later, this does not offset the significant incidence of ARIA, even with titration, even at lower doses.
In the original Phase IIb, 22% of ARIA cases were severe, some requiring hospitalization, which would justify a back-of the-envelope projection that about 6% of the APOE4 population (which is roughly two-thirds of the AD population overall) would develop severe ARIA. This is not an inconsequential safety problem. APOE4 genotyping can be easily done, but administering MRI scans on a routine and repeated basis to hundreds of thousands, even millions, of AD patients would constitute a major logistical and financial headache, but this scale of incidence cannot be ignored. Biogen does have experience with a safety issue with Tysabri, where PML is of much lower frequency, albeit much higher lethality, and identifying a predictor of PML vulnerability became a high priority. Biogen knows better than anyone that they have two tasks: Not only showing that there is a consistent benefit afforded by aducanumab that is clinically meaningful, but also to find some biomarker identifying at-risk patients who would need early and repeated imaging.
3) What do the sola/adu results say about the amyloid hypotheses?
Nothing definitive. AB mAbs are not a homogenous group, they target different epitopes on beta-amyloid and hence bind very different beta-amyloid species. Solanezumab only binds AB monomers; aducanumab does not bind monomers, but instead binds to aggregates (plaque, fibrils, oligomers). There are those who think that the monomer binding approach is too inefficient, sopping up large pools of AB monomers using an antibody that has very limited (0.1%) brain penetrance is unwieldy at best.
The consistent but therapeutically impotent response produced by solanezumab raises as many questions as answers. If the antibody binds to a suboptimal form of AB, what is optimal? Setting aside plaque as a failed candidate, one could consider targeting oligomers only (as Acumen does with their antibody) to see if that is a more focused and efficient target. If not enough antibody reached the brain to bind enough AB, that does not infer that Lilly should run a high-dose sola trial, the magnitude of benefit strikes us as simply to small to be correctable via dosing. But with just .1% of the antibody achieving brain penetrance, one could seek technologies that enhance brain availability, a theme Roche and Genentech have been enthusiastically pursuing. If the patients were too advanced to benefit from a post hoc reduction of AB, one would have to find a valid and reliable marker of pre-Alzheimer’s (and pre-plaque) MCI to zero in on during the testing. Since using PET and CSF levels did not produce the kind of differentiation hoped for, this throws into question the criteria via which many sponsors now seek to achieve a more homogenous patient population.
4) Next steps?
With all the resources allocated to bapineuzumab, solanezumab, gantenerumab, crenezumab, and aducanumab, we still do not know if the amyloid theory that spawned them offers any hint of a blueprint for clinical therapeutics–or not. Lilly’s effort to now be rational about sola’s prospects stands out for its rarity. Hopefully, the rationality with which Lilly stopped sola’s development will not become diluted and diverted into some exploratory study using higher doses in MCI patients.
Whether other antibody programs might thread the therapeutic efficacy needle more effectively than the first three remains to be seen. There are several still on deck in various stages of development: Roche/Genentech have gantenerumab and crenezumab; Lilly has the new collaboration with Astra Zeneca; Acumen has its oligomer-specific antibody; Biogen/BioArctic, Sanofi have others. It is worth noting that Roche/Genentech are running their trial of crenezumab dosing at 60mg/kg–at the very least, this represents an imposing manufacturing challenge, since a dose might average 4.2 grams of antibody. We propose that the Millennials now spawning craft breweries by the bushel be recruited to manufacture artisanal antibodies in small scale.
The eyes of the amyloid world will now turn to Merck‘s BACEi Phase III program; verubecestat will report its first results next year. BACEi in theory offers the prospect of turning off the source of beta-amyloid rather than retrospectively cleaning it up, and there are several other BACEi programs also out there (e.g. Biogen/Eisai, JNJ, Lilly/AZ, Novartis). Whether BACE is the optimal vehicle for doing so has not been proven, and Probiodrug, Lilly, and American Life Sciences Pharma have programs targeting alternative beta-amyloid pathways. Then there are off-the-beaten track strategies that tap into amyloid pathology in divergent ways; Proclara has its cross-motif inhibitor in the clinic, Cortexyme has a lead compound chosen for development, to name but two.
We are not going to review the various alternative mechanistic frameworks available to AD therapeutic programs–we utilized 60 pages to do so in the September/October 2016 issue, and will doubtlessly reach the same volumetric marker of verbosity in next fall’s edition. The field largely, albeit not unanimously, wedded amyloid more than twenty years ago, based on in vitro findings showing beta-amyloid’s effect on cultured neurons. The use of in vitro and animal models to predict the course of the human disease has been an unmitigated disaster, so we are not going to repeat that error with tau. Tau is very much on the ascendancy as an Alzheimer’s target, and there has been work that postulates a tau-centric model for AD that better approximates the human disease than do amyloid-centric models, but it still has to earn its stripes in clinical testing. The same can be said for the pursuit of neuroinflammation as a key pathophysiological factor.
5) The Bottom-Line
For a target that was the consensus choice from 1995-2010, and had tens of billions of dollars devoted to it, amyloid has thus far offered far more disappointment than utility, regardless of how much researchers say that they have learned from the process. The four mAbs with significant clinical data thus far in hand; Bapineuzumab, solanezumab, aducanumab, and gantenerumab, must have totalled over $5 billion in development costs. It seems fair to say that no one has gotten their money’s worth.
from the Sept-Oct 2016 Alzheimer’s/MCI issue
Beyond protection is repair. The competition was once intense in the small molecule neurotrophin stimulant/mimetic area, but that has proven a veritable minefield for the well-intentioned and unwary. At present, the major regenerative activity in CNS is vis-a-vis remyelination, and AD and the other neurodegenerative disorders will be a likely area for extension for anything that passes the initial test in MS.
Neural cell implants
Just as Parkinson’s was for a long time erroneously defined as a disease of the striatum, some have embraced the convenient shorthand that Alzheimer’s is a strictly a disease of the hippocampus. While the hippocampus is an early locus of degeneration, the damage spreads widely, and Alzheimer’s is not an intuitively obvious target for cell therapy. This has not prevented some interesting research from being undertaken: ReNeuron has interest in Alzheimer’s, but chose stroke for its first clinical target. Saneron received a $2.6 million NIH grant to fund their work using human umbilical cord blood cells in animal models of AD. They believe that these cells will provide a beneficial anti-inflammatory effect, without triggering immunoreactivity. StemCells established a collaboration with UC Irvine for the use of their human neural stem cells in Alzheimer’s models, and reported that their hNSCs restored memory in an animal model of AD, but that program, along with all of their cell therapy portfolio, has demised, the Company absorbed by an Israeli medical robotics firm in a reverse merger.
Stemedica International reported that its allogenic mesenchymal stem cells reduced beta-amyloid plaque by 30% in a transgenic animal model. The relevance of plaque load as an endpoint for stem cell therapy is obscure at best. But they received funding for a 40pt Phase II trial, to be run at UC Irvine and Emory, testing one IV administration of these cells in mild-moderate AD–that trial began enrolling patients this past July.
A Korean group (Samsung Medical Center) published a report regarding their stereotactic implantation of mesenchymal stem cells into nine Alzheimer’s patients. The two year followup did not show evidence of any serious side effects, though the authors noted that the rate of decline on the MMSE was more accelerated than is generally expected in an AD population; this may have been due to these patients being relatively more advanced in their disease. The lack of a control group precluded any substantive analysis of the cognitive data obtained.
Another issue that will becloud the use of cells in Alzheimer’s until proven or disproven is whether the disease process may also attack the implanted cells, rendering them as nonfunctional as the patient’s original cells, which has been the fate of some fetal cell implants in Parkinson’s.
Intuitively, the concept of offsetting neurodegeneration by enhancing endogenous stem cell proliferation has appeal. The one neurogenesis-focused company prioritizing Alzheimer’s is Neuronascent, whose founder played a major role in the development of NeuralStem’s depression compounds. Neuronascent has molecules that enhance neuronal differentiation from progenitors, enhance hippocampal neurogenesis and migration of those new neurons, and bring cognition in aged mice back to “young” levels. Alzheimer’s has been first on their menu of indications, but their resources are very limited, National Institute of Aging grants have been slowly funding the work required for IND submission. They raised $1.2 million last year with which to complete NNI-362’s IND-preparation, but they need more funding to actually run a clinical trial.They have refined their explication of the MOA for NNI-362, now describing it as modulating a kinase leading to activation in progenitor cells, deactivation in cells that have differentiated, Otherwise, the status of neurogenesis programs for AD has been bleak, and deteriorating. BrainCells went bankrupt; NeuralStem has turned its small molecule program to depression; NeuroNova was acquired by Newron, its programs upregulating neurogenesis for ALS and PD eventually shut own by Newron due to problems with the ICV catheter system being utilized.
Effective neurogenic interventions could involve mediating the signaling pathway mediated by synaptojanin-1 that controls the proportion of new cells that are glial, rather than neuronal. In a disorder like Alzheimer’s, the likely priority will be to generate more neurons than glial cells, and downregulating the synaptojanin-1 pathway might be a way of steering neurogenesis in the desired direction. An optimal intervention might include both the neurogenic ‘accelerant’ and a guidance factor to steer production towards some ostensibly optimal proportion of neuronal/glial cells.
The Plasma Fountain of Youth
Alkahest is developing an eerily straightforward, yet something of a throwback, neuroregenerative option: Taking blood plasma from the young and infusing it into older adults in the hope of spurring neurogenesis. Regeneration through the absorption of ‘young’ blood is a theme that has percolated through primitive rituals, vampire tales, and some ill-fated experiments of early medicine; but this program comes from work done at Stanford, which sets it distinctly apart from these predecessors. Animal experiments there showed that infusing plasma from young mice into old mice stimulated the generation of new brain cells, and improved cognitive functioning/learning, while injecting plasma from old mice into the young had an opposite and deleterious effect. Work published in Nature Medicine showed that plasma improved synaptic plasticity, operating via CREB, critical to learning/memory. While the Stanford group did try to isolate which particular factors were upregulated via young plasma, and identified a couple of them (GDF11 and B2M), the simplest tactic for turning this thesis into a treatment is simply to infuse plasma itself, utilizing what may be a complex multitude of downstream effects as a whole, rather than trying to parse out and develop critical core components.
This work was spun out as Alkahest, incubated in a JNJ Jlabs facility. An 18 patient, double-blinded Phase II trial was initiated, using four, weekly plasma infusions from individuals under age thirty, in patients with mild to moderate (MMSE 12-24) Alzheimer’s. Last year, Grifols acquired 45% of Alkahest for $37.5 million, and made an additional $12.5 million payment to Alkahest, in return for worldwide commercial rights. The trial is expected to finish some time this year, with most standard cognitive tests utilized as efficacy measures, eighteen weeks into the trial. Expectations must be constrained: It is highly unlikely that marked contrasts will be seen, since this is a tiny, relatively short-duration trial, and it is not known whether (as is the case in other AD trials) these patients may be too advanced in their disease to benefit from the trophic effects of plasma, while it is also not known whether the donors themselves are too old to provide maximally ‘potent’ plasma in terms of the inherent level of regenerative factors. Having stated the caveats, it should be a fascinating dataset to see; if there is a therapeutic product to be had here, this will raise all sorts of practical and ethical issues around plasma supply, and IP regarding the application of the technology. As NIR has commented in the past, one can only imagine the dinner table conversations between middle-aged parents and their teenage offspring: “Yes, you can borrow the car, but there’s something you have to do for us in return…”
Prophylaxis via Lifestyle
Mental activity does appear to confer some protection against Alzheimer’s, which could infer the impact of activity-driven neurogenesis, although it could reflect the confounding effect of a stronger ‘cognitive reserve’, wherein there is farther to decline before reaching clinical dementia. But a paper out of Rush Alzheimer’s Center reported that, even when such factors as SES, social or physical activity, and premorbid cognitive capacity were controlled for, that elderly individuals who were at the 10th percentile of cognitive activity were 2.6 times more likely to develop Alzheimer’s than those at the 90th percentile. But after appraising the impact of diet, drugs, supplements, exercise, and cognitive activity in all of their various permutations, the NIH Consensus Panel report on ‘Preventing Alzheimer’s’ concluded that none have been proven to work. Provisional support was given to cognitive ‘engagement’, walking, and a ‘Mediterranean diet.’ Yet, as was noted earlier, a recent epidemiological study found that the incidence of Alzheimer’s onset is decreasing and emerging later in life, and while causality has not been defined, the usual hypotheses regarding activity level, overall health maintenance, and dietary moderation seem as reasonable an explanation and path forwards as we have at this point. ‘Use it or lose it’ continues to be a benign avenue to slowing deterioration. At the very least, it is a proactive and rewarding way to forestall boredom.
from the May-June 2016 Stroke/TBI issue
The image du jour for TBI has changed once again, even though the song remains the same in terms of the lack of viable treatment options. Twenty years ago, the paradigm revolved around a twenty-something male taking the search for speed and thrill too far. Ten years ago, the new image of TBI came from wartime, the ravages of IEDs upon troops in Iraq and Afghanistan–The Hurt Locker. Now, there is Concussion, a Hollywood film with Will Smith, focused upon the quiet epidemic of sports-related TBI, epitomized by the toll taken by American football upon those who play it. We are not going to pay false homage to the latter by referring to them as another iteration of ‘warriors;’ they are not, but the game they play can have devastating consequences.
Even though the back stories differ drastically, TBI has always been an epidemic hidden in plain sight. NIR reviewed TBI for the first time back in June 1996, and began with this:”In every urban center in the United States, and indeed in most developed countries, there are coma units housing patients who are in persistent vegetative states. These are quiet places, save for the pervasive murmur of the electromechanical devices which preserve the life functions of their residents. They are contemporary cathedrals of a sort, bearing mute witness to our infatuation with steel and speed. Most of the residents of these facilities will never leave; they are for the most part young men who have been in motor vehicle accidents, whose lives have entered limbo, a kind of extraordinarily costly suspended animation……the illusion of immortality that seems to accompany the testosterone storms of male adolescence lingers into early adulthood; by the time they discover that ‘it can happen to them,’ it is too late.”
Much of this remains true, young males still put themselves in harm’s way via thrill-seeking of various sorts. But the public face of TBI has gone through a number of gradual transformations over the years. Instead of the crash of automotive metal and glass, the image switched to the pulverizing shock waves from the explosive devices used to such deadly effect in Iraq and Afghanistan, and more recently to the repetitive concussive blows incurred by athletes in sports that feature levels of physical violence that would be illegal if they happened on a city street, epitomized by football, hockey, and boxing.
There are some significant differences between these phenomena, centered upon the common distinction between acute and chronic. Car accidents and explosive blasts do immediate and obvious damage to brain structures, and a resultant loss of function is immediately apparent, though the longterm profile of functional decrement can take months to fully emerge. Sports-related trauma/CTE, and ‘mild’ instances of blast and accident injuries, have a far more insidious course, with the cumulative effects of chronic CTE only emerging years later. In some ways, the two categories–which are anything but mutually exclusive, an acute injury (or several) can have more subtle but worsening longterm consequences–constitute acute trauma vs. longterm neurodegeneration, akin to the difference between a stroke and Alzheimer’s, where an individual may be robbed of their capabilities in an instant….or over many years. As is discussed in this review, the pathophysiologies of acute and chronic TBI appear to have some significant differences, but while the external manifestations may differ, and the internal pathophysiologies diverge, the impact of both can be devastating.
Acute TBI: The Legacy of War
Head injuries were dubbed the ‘signature wound ‘of the Iraq and Afghanistan wars: As the use of explosive devices grew more common, the incidence of TBI in the US military escalated, and for several years, accounted for 30-35,000 new cases a year. That might seem micro-scaled compared with the estimated 1.7 million TBI cases each year in the US, but it stands out because these men and women were injured in the line of duty, and they knew all too well that ‘it could happen to them.’ The technological advances in battlefield medicine that have saved the lives of so many have also yielded an unintended and grim bounty; a dramatically escalated proportion of wounded veterans with lasting brain injury. 56% of blast survivors were assessed as suffering moderate to severe TBI, while many cases of mild closed head injury (mTBI) never ended up in military hospitals, and likely went unreported, and unrecorded. The soldiers who carried their more severely wounded comrades to safety counted themselves lucky by comparison, but many blast survivors had lingering post-concussive injuries that compromised their cognitive abilities, altered their mood states and personalities, and prevented them from functioning to their full potential. The IED harvest that will never be fully quantified is characterized by occupational dead ends, depressive episodes, rage outbursts, alcohol abuse, and fragmented families. The Department of Defense’s own figures put the total number of US military TBI cases from 2000 to 2015 at 320,000, the vast majority being closed-head injuries, rather than penetrating wounds. There is a high correlation between TBI and PTSD in these military populations; 43.9% of soldiers who experienced TBI with a loss of consciousness also experienced PTSD symptoms. The relationship between TBI and PTSD is still being explored, including work now underway sponsored by Cohen Veterans Biosciences. That nonprofit research organization (which originally began as Orion Bionetworks) is being funded by the hedge fund manager Steven Cohen, who has pledged $275 million to the treatment of mental health issues in veterans.
Private and governmental funding of TBI research has taken on a high profile due to the failure of the pharma industry to display even minimal leadership in this large but challenging therapeutic area. Following a series of program failures in the 1990s, Big Pharma completely wrote off TBI as a drug development target. As with stroke, the major pharmaceutical firms came to see TBI as too difficult and risky to warrant a significant expenditure of resources. War bred an alternative, albeit inadequate, source of funding, and the phenomenon of blast-induced TBI did catalyze governmental support of TBI research. The toll of the battlefield led to a massive expenditure of federal funds from a variety of Department of Defense agencies, totalling $800 million in 2010 alone, probably 80 times or more what the industry as a whole spent on TBI in that same year. The single highest-profile government investment in addressing these military casualties came in the form of a five year, $107.5 million grant by the DoD/VA, funding consortia regarding the identification of biomarkers, the delineation of the clinical course of mild TBI (and PTSD), and the prevention and treatment of these disorders.
Another major collaborative initiative emerged under the aegis of the One Mind for Research program, geared to boosting precompetitive research and collaboration, receiving an initial funding ‘bolus’ of $2 million from JNJ/Janssen. The first initiative pursued by One Mind was to develop a data-integration center for information relevant to TBI research.
Research interest in TBI temporarily burgeoned in response to these high-profile patient populations and the availability of federal research funding. In 2007, NIR covered seventeen programs in our TBI review, in 2012 the number was forty-seven. But in the wake of still more clinical failures, the number has regressed, to thirty-eight programs, and only twenty-one of those are currently active, clinically or preclinically. Only two of these constitute NCEs whose active, primary application is in TBI, a third has yet to have its primary focus defined. The others are either repurposings, secondary interests, or in funding limbo. This should be a source of embarrassment to the pharma industry–but they appear to feel no shame around it.
Chronic TBI: For the Love of the Game Money
It is more than a little embarrassing that, in keeping with the American penchant for celebrity and spectacle, the public profile of TBI in the United States has been raised less by the epidemic of war-related brain injuries than by press coverage of the cumulative neurological toll taken by football. There has been an escalating drumbeat of media coverage of American football players found to be suffering from traumatic encephalopathy leading to early-onset dementia. In a number of cases, an ex-player has suicided in response to their cognitive decline, unable to tolerate the prospect of disability and helplessness, or else overwhelmed by the clinical depression that frequently characterizes CTE. This is neurodegeneration in slow motion, as opposed to the sudden and dramatic ablation of tissue and function seen in major blast injuries. CTE represents the cumulative effect of hundreds, even thousands of mini-traumas, and the brutal reality was best summarized by Lehman et al in their 2012 Neurology review: “The neurodegenerative mortality of this cohort is 3 times higher than that of the general US population; that for 2 of the major neurodegenerative subcategories, AD and ALS, is 4 times higher. These results are consistent with recent studies that suggest an increased risk of neurodegenerative disease among football players.” It is to the discredit of the football industry–which it is–that its executives long resisted attempts to define the risks and toll taken, and indeed withdrew funding from one CTE study because it was to be run by a researcher believed to be critical of how professional football polices itself vis-a-vis TBI. It was only this past March 14, in a Congressional hearing, that an NFL executive finally, publicly acknowledged the link between playing football and CTE. A few weeks later, data presented at the AAN meeting by a Florida researcher (Conidi) showed that 43% of retired NFL players show evidence of traumatic brain injury on diffusion tensor MRI imaging. The functional toll was suggested by neuropsychological testing data ta=hat showed a high prevalence of deficits in specific functional domains, such as executive functioning (50%), attention/concentration(42%), and learning/memory (44.7%).
For those who believe that this is an issue only for the minuscule slice of athletes who play professional football, there is chilling data indicating that the more than one million high school football players in the United States may also be placing themselves at similar longterm risk. A Mayo Clinic review of post-mortem brain studies showed that one-third of men who had played high school contact sports showed histopathological signs of CTE, signs seen in none of those who had not played such sports.American football is not unique in this regard: While there has been a long-acknowledged (and unsurprising) connection with boxing, exemplified by Muhammad Ali’s descent into Parkinsonian immobility (dementia pugilistica), hockey and soccer have been implicated as well. Expanding the potential range of concern is that there is no established baseline for minimum exposure risk, thus there are open questions regarding the millions of youthful participants in these sports at an amateur level, and the undefined but genuine risk they take.
The Societal Scope
Changes in the diagnostic criteria and epidemiological methodology have rendered TBI a moving target when it comes to both incidence and prevalence. Early this year, a Mayo Clinic study concluded that the incidence of TBI is far greater than had been previously estimated: While the CDC had been using an incidence estimate of 341 per 100,000 people, the Mayo estimate, using a broader definition of TBI, was 62% higher; 558 cases per 100,000. Two-thirds of this additional population had TBI symptoms, while the other third was not overtly symptomatic–but 74% of the ‘missing’ cases had actually presented to a hospital/ER. If this is an accurate appraisal, the 1.7 million annual US TBI cases estimated in 2013 might translate into an annual incidence of 2.5-3 million cases per year. This enlarged population cohort involves relatively mild to moderate TBI, the same degree of error would not apply to TBI requiring hospitalization or deaths, estimated to be 283,000 and 52,800 per year in the United States alone.In terms of prevalence, an Australian epidemiological study concluded that, over their lifetime, 5.6-6% of the population suffers a TBI that causes at least 15 minutes loss of consciousness, a more serious level of brain disruption than is generally associated with the milder end of the spectrum.
The traditional breakdown of moderate to severe TBI is that 10% die immediately; while 10% of the remainder are severely injured, less than half surviving; and those who survive are severely disabled. Another 10% are moderately injured, most suffering significant residual disability. Acute care following severe head injury can cost tens of thousands of dollars per day, and for those who survive such injuries but remain in a coma or persistent vegetative state–and there are thousands of these patients in the US–the maintenance care that they require in this twilight state of existential limbo can cost hundreds of thousand dollars per year.
While the great majority of TBI cases are ‘mildly’ injured, ‘mild’ injury is relative,and should not be confused with ‘innocuous’. The longterm cost for head injury patients relates to the jobs they will not be able to obtain or keep, and the safety net of medical and psychosocial services that they will require. The more severely injured can appear demented, and indeed there are pathophysiological similarities (increases in beta-amyloid and tau) which are seen in both TBI and Alzheimer’s. One study estimated that 43.6% of Americans hospitalized for TBI had residual disability a year later. This is a toll for which modern medicine is still very limited in what it can do, and even the most conservative TBI market estimates would provide an effective TBI drug with billion-dollar+ annual revenue potential.
While some sports-related injuries involve acute, catastrophic TBI, the new paradigm involves chronic exposure to repeated neural trauma. A 2011 estimate of sports-related TBIs in the US, utilizing South Carolina hospital and ER data from 1998-2011, concluded that the incidence was increasing, from 19.7 cases per 100,000 people in 1998, to 45.6 per 100,000 in 2011. Our suspicion is that the increase may at least partly reflect a broadening of TBI diagnostic criteria over time. At that 45.6/100,000 rate, one might extrapolate to about 150,000 sports-related cases per year. However, with the evidence suggesting that CTE cases exist and progress in symptomatic ‘silence’ for years and even decades, no one can claim to know with certainty what the true prevalence of TBI is at this point, particularly given that the potential toll of repetitive concussions (CTE) can be cumulative, not linked to a single, signal event, and such cases are particularly liable to slip by screening.
The Clinical Picture
Traumatic Brain Injury is highly heterogeneous, and the nature of an individual’s enduring deficits will vary with the type of injury and its specific impact on brain structures, and their clinical outcome can also depend on the toll taken by other, non-CNS injuries. In terms of closed head injury, patients with moderate-severe damage tend to show some common characteristics. Many of these patients encounter lifelong problems with attentional focus, social skills, and the ability to manage their emotions and/or to organize their lives. They display profound problems with judgment, insight, social appropriateness, attention, memory, and planning.
Post-TBI, an individual’s personality can be altered, even though they may not be aware of this. Particularly if the injury reached moderate severity, these patients may seem like strangers to family and friends, resulting in social isolation and enormous stress upon their familial relationships. Depending on the locus of damage, they may come across as apathetic and dulled emotionally, or they may seem constantly irritable and impulsive, with a ‘hair trigger’ temper. Because the connections between frontal and limbic areas of the brain are often damaged, these patients often have difficulty managing their own emotions. Frontal damage also reduces a patient’s capacity to focus and sustain attention; they become impulsive and easily distracted, unable to manage complex information. Even damage that seems less severe on standard neurological and neuropsychological evaluations can impair an individual’s ability to work up to their premorbid capacity: One epidemiological study noted that only 29% of TBI patients studied were working full time when assessed later, up to twenty years post-injury. Even though the concept of native neural plasticity has broadened in recent years, many significantly injured TBI patients appear to reach a ceiling beyond which further recovery does not occur, often after one to two years, falling short of the previous level of social/vocational functioning for probably two-thirds of these patients.
As was noted earlier, there is a large cohort of mild concussions that are either often ignored altogether, due to a lack of overt symptoms, or else are cursorily assessed and dismissed. It used to be believed that these the effects of such injuries would disappear over time, but that increasingly seems to be untrue, particularly when there is a pattern of repeated head trauma. In the long run, even when the patient may indeed look as though he/she is fully recovered, a careful neuropsychological evaluation, or interviews with wives or co-workers, will often reveal something less benign. Given that many falls, accidents, and sports injuries never end up incorporated into the epidemiological calculations, conservative estimates of TBI incidence almost surely undershoot the mark, as do estimates of prevalence and longterm functional impairment. As data regarding Chronic Traumatic Encephalopathy are now being gathered more systematically, there is an underacknowledged substrate of post-concussion cases wherein an underlying degenerative process may have ben set into motion, manifesting itself overtly only many years later. In the wake of whatever acute symptomatology may (or may not) have been displayed, patients with CTE eventually begin to show a disease course that begins with irritable depression and impulsivity, epitomized by the suicides by former professional football players that galvanized public attention. As CTE progresses, it begins to follow one of several neurodegenerative routes, emulating either Alzheimer’s, Parkinson’s, or ALS, depending on the particular form of the disease. It is not clear what determines the course that emerges for any individual patient.
from the March-April 2016 Depression/Autism issue
Focus on Suicide
There are efforts underway (e.g. NIH‘s RDoCs) to parse out specific behavioral manifestations of psychiatric disorders as more measurable and treatable neurobehavioral domains than are their ‘parent’ disorders. Suicidality is one of these domains, and while it can it can manifest in a variety of conditions, from unipolar depression to bipolar illness to schizophrenia (and others), it is with depression (both unipolar and bipolar variants) that it is most commonly associated. Suicidal ideation became a favored endpoint in a number of ketamine and ketamine-like drug trials, which makes some intuitive sense: As an NMDA antagonist, ketamine might be thought of as a means of disrupting patterns of cognition, and even though it is argued by some that depression in general reflects thinking gone astray, suicidal ideation is a specific and potentially lethal manifestation of cognition ‘in error.’ Just as ECT–amongst its several effects–disrupts learning and memory, perhaps the acute effects of ketamine and its ilk include a similar clearing of the cognitive ‘slate’. One study that looked at neuropsychological functioning assessed just after IV-ketamine administration found that the patients who were treatment responders 24 hours later had performed worse on cognitive testing–perhaps supporting the hypothesis that one must disrupt cognition in order to alter depressive mood in general, suicidal ideation in particular.
AstraZeneca pursued suicidality with IV AZD6423, the successor to the failed (in Phase IIb, albeit with a high placebo response rate) NMDA antagonist AZD6765, but after a 175pt Phase I was completed, that compound was itself replaced with orally-bioavailable AZD8108, for which a 258pt Phase I trial was completed last year. There has been no public announcement, but apparently no gross safety issues have arisen, since it is still cited as in development.
The Mayo Clinic is running a 30pt trial of ketamine in depressed patients with suicidal ideation, that trial wrapping up this year: The MADRS is the primary endpoint, but suicidal ideation is the secondary endpoint. MGH is going to run a ketamine study in suicidal patients, with a suicidality scale as the primary endpoint. A VA study will enroll 40 patients when it is initiated this year. NY State Psychiatric Institute has launched a 70pt study of ketamine’s effect on suicidality, and has fully enrolled a 20pt trial in bipolar depression/suicidality. A Mt. Sinai study that found 53% of previously suicidal patients similar had a complete remission of explicit suicidal ideation 24 hours after a ketamine infusion, compared to 24% of those receiving midazolam. University of Alabama is conducting a 240pt study assessing the potential of plasma microRNA biomarkers for suicidality and ketamine responsivity.
Trials using ketamine to treat suicidal ideation are being done at a number of other US centers and by Canadian, French, and Israeli groups.
JNJ/Janssen is running a 70pt Phase II trial of esketamine in patients believed to be at imminent risk of suicide, both to assess drug effect (4 hours post-administration) and to assess the utility of their measurement strategy for acute suicidality. That trial should be wrapping up in the next few months.
Cerecor ran its Phase II trial of CERC-301 in depressed patients with suicidality, combining two trials into one. That trial was unsuccessful, but they now intend to run another Phase II with a higher dose, emphasizing impact upon depression rather than suicidality.
NeuroRx is developing a combination therapy aimed at suicidality in bipolar depression: A ketamine IV infusion, followed by an oral, fixed-dose combination of lurasidone and d-cycloserine (‘Cyclurad’). It represents something akin to a glutamatergic bolus, followed by glutamatergic maintenance, counterbalanced with an antipsychotic. The data behind the combination consists of a eight patient, open-label, eight-week trial, for which they report a 50% reduction in depressive symptoms, a 75% reduction in suicidal ideation. As is discussed in the Company Spotlight on p.52, there is an unsettling degree of hyperbole and hypercertainty that has characterized the company’s self-promotion.
from the Jan-Feb 2016 Overview issue, Highlights/Lowlights section:
1) Aducanumab: Some time had passed since the most recent Alzheimer’s vaccine hyperbole-fest, so it was almost inevitable that aducanumab would provide Biogen and the Alzheimer’s field in general another opportunity for overreach in the face of ambiguity. It is not that the trial proved failure, it did not, but the questions left unanswered are huge, and little has been definitively established:
a) It does appear clear that target-engagement is achieved, though it requires enough disruption of the BBB that vasogenic edema is frequent and problematic.
b) It seems clear that this mAb does reduce plaque significantly, and there was nothing in these results that pointed towards a negative impact from doing so.
c) Clinical benefit is where the audience bifurcates, with many accepting Biogen’s explanation and enthusiasm for the disclosed data, many others remaining skeptical. There is data that has not been generally released to the public, in terms of results from some of the other neuropsychological tests administered, and the belated 6mg/kg results suggest a very narrow tightrope walk between plaque clearance and vasogenic edema. There was a considerable incidence of VE at higher doses, and while 78% were described as ‘mild to moderate’, this means that 22% were more severe, some requiring hospitalization. It will require a far better understanding of aducanumab’s efficacy at various dose levels, differentiated by APOE genotype, to sort out the risk-benefit profile for aducanumab, and the size of the window for achieving therapeutic benefit with acceptable tolerability.
The trends reported neither prove nor disprove the case for the amyloid hypothesis or for aducanumab. The results provide a highly provisional hint of an efficacy signal, one whose clinical meaningfulness is unclear at best.
2) LRRK2 Safety Alarm: We still think that Genentech going public with their tox findings demonstrated corporate maturity, as was the ensuing collaboration of Genentech, Merck, and Pfizer with MJFF to independently assess other LRRK-inhibitor candidates for pulmonary safety risk. This was a very positive sign of the industry adaptively expanding what is deemed pre-competitive space. The bonus is that the tox finding is not a class-wide phenomenon: Merck (at least) is going to move ahead with its LRRK-inhibiting program.
3) Axovant. After years of drought, the biotech El Nino dropped a foot of fiscal rain across much of the neuro sector, and while this provided sustenance, it also led to some eyeball-rolling from observers who wished that Roivant/Axovant would at least pretend to care about how self-serving their behaviors look.