From NP Winter Issue 2023
Lecanemab’s Risk-Benefit Conundrum:
Anti-amyloid mAbs have been the repository of more wishful thinking than any other category of neurotherapeutics. Which accounts for this quote from the CMO for Alzheimer’s UK, who said in reference to lecanemab: “It’s just a first step, but this new Alzheimer’s drug could be a huge breakthrough.” Which to our eyes seems semi-detached from reality, given that there is ample debate as to whether lecanemab’s treatment effect, barely visible to the empirical naked eye, will be perceptible to patients and families beyond hopeful expectancy. Less aspirational and more to the practical point were two critical quotes to be found in a November 27 piece in Science titled ‘Second Death Linked to Potential Antibody Treatment for Alzheimer’s Disease‘, quotes that bring into stark profile the dilemma that prescribers and families are going to face when it comes to lecanemab and, most likely, donanemab as well:
“Even if that (antibody treatment) only means 6 or 12 more months of knowing who their kids are…it’s meaningful to dementia patients and their families.” (University ofKentucky neuroscientist Donna Wilcox)
s“As soon as they put it (tPA) in her, it was like her body was on fire, She was screaming, and it took like eight people to hold herdown.” (the husband of a patient who died)
The conundrum? There may be no more heart-wrenching an anecdotal image of the toll taken by AD than a parent who not longer recognizes their own children; evoking that nightmare scenario is a potent gambit for those advocating the use of an anti-amyloid mAb. But the calculation of acceptable risk is transformed when contemplating the even-more-awful image of an elderly parent ‘screaming…like her body was on fire.’ Many families (and physicians) who might otherwise consider worthwhile any chance of extending autonomy and awareness will recalculate the risk-benefit analysis if the risk includes even a small possibility of such horrific suffering.
The context of the death was this: A woman who had received lecanemab (believed to have been initiated in the open-label extension) developed stroke symptoms and was administered tPA. The thrombolytic triggered extensive cerebral bleeding which led to her death a few days later. The autopsy found signs of cerebral amyloid angiopathy (CAA), which perhaps had weakened the blood vessels, a weakening exacerbated by the impact of the mAb on vascular amyloid, so that tPA then precipitated a massive rupture nd hemorrhage. CAA is another manifestation of amyloid pathology, and is believed to be present in up to half of AD patients, though it is difficult to diagnose other than post-mortem. There was another report of a lecanemab-linked death where a patient had also received an anticoagulant, for atrial fibrillation, and a third death, details unavailable. A subsequent (1/4/23) case report in NEJM suggested that the stroke reflected a causal role of lecanemab in the onset of stroke.
This reminds us that, when discussing the emergence of ARIA-E (edema) or ARIA-H (microhemorrhages), sponsors tend to emphasize that 98-99% of ARIA patients ‘fully resolve’ after the mAb is stopped and treatment is provided. We have always wondered about the other 1-2%, those that do not ‘fully resolve.’ 1-2% sounds rare, but when talking about a disease affecting 6.5 million patients in the US alone, that represents a potentially substantial subgroup. In the case of the lecanemab CLARITY trial, 2.8% of lecanemab patients developed symptomatic ARIA-E, 81% of whom were described as fully resolved at four months, which begs the question of what happened with the other 19%, who comprised 0.53% of the active treatment group; 21 patients whose longterm AE sequelae were not disclosed. This blind spot is from a rigorously executed and monitored study, where the level of clinical oversight surely exceeded what can generally be expected in clinical practice.
It has been suggested that the risk of potentially dangerous CAA would be reduced if amyloid mAB therapy was restricted to patients with mild AD, but according to the Science report, this woman had only retired from a professional position a year before, so this was relatively early, and her CAA was not flagged by Eisai’s screening. APOE4+ patients appear to carry more risk of ARIA-E, but with that genetic loading found in up to 70% of the AD population, that is not a viable exclusionary criterion. Thus it may not be possible to parse out the at-risk population, leaving families and prescribers to contend with the fear that a well-intentioned intervention might have deadly results.
With all due respect to the claims that lecanemab is a potentially “huge breakthrough“, a .45 point impact on the CDR-SB falls well short of the one point difference commonly cited as the Minimum Clinically Important Difference for that measure. Even ICER seemed befuddled: “In aggregate, the net health benefits of lecanemab in patients with early AD may be small or even substantial, but there remains a possibility of net harm from ARIA.” Which covers the full gamut of possible outcomes.
Unlike Biogen with Aduhelm, Eisai did leave the microphones in the CTAD auditorium, though the questions lobbed from the floor were softballs that sounded like pre-specified plants. Eisai pushed back on the safety issue raised by the patient deaths, though they acknowledged that these risk factors would have to be weighed in a treatment decision.
We have expected that a significant subset of Alzheimer’s patients would be willing to try a therapy that could be even modestly useful in extending functional independence, but this presumes that the downside is not overly daunting. The phrase ‘like her body was on fire‘ will reverberate in the Alzheimer’s community, reducing the portion that believes the limited upside gains are worth such uncommon but devastating risks, and deterring physicians leery of taking them on. Even Eisai cited a target market penetrance of just 100,000 patients by year three of the launch, which, given the size of the AD population, is strikingly tiny. Perhaps that explains their pricing Leqembi at $26,500 per year, portraying this as an $11,100 discount to the ‘real”value of the drug, well beyond the $8500-20,600 range estimated by ICER. Eisai seems to expect very limited adoption; if they truly believe in its value, they might have considered pricing it lower and expanding its range.
2022 was a year where the psychedelic therapies movement featured an odd mélange of the credible and the absurd, reflecting the still-early developmental stage of this area. A few examples of each:
Credible: The New England Journal of Medicine, which epitomizes traditional medical practice as much as does any publication, published Compass Pathways‘ detailed findings from their ground-breaking PhII trial of psilocybin in TRD. The detailed findings support our initial comment that ‘COMP360’ is a “tool, not a panacea.” 29% of the high-dose group were in remission after three weeks, not an unimpressive accomplishment in a refractory population, but a panacea would not leave 71% of the treatment population behind. Compass is about to launch a PhIII study that will enroll ‘almost 1000’ TRD patients, adding a second dosing three weeks after the first. Given the complexity of the undertaking, it was reassuring that Compass hired an Otsuka drug executive, Kabir Nath, to become their CEO, an essential addition of industry expertise to a Company that had lacked the organizational coherency required for this developmental stage. The question remains open as to whether Compass’ IP strategy is viable, or whether they are blazing a path that eases the way for numerous competitors as well.
Incredible: The National Park Service issued a Public Service Announcement reminding readers that they should eschew licking the Sonoran desert toad which is a source of the psychedelic molecule 5-MeO-DMT, along with other, potentially less appetizing alkaloids. We suspect that the numbers of toad-lickers is relatively small, but it is a reminder that, unlike any other area of drug development, even as the biopharm industry attempts to systematize and medicalize the testing and eventual deployment of these substances, there is an extensive parallel movement that is geared towards the sacramental, spiritual, and relatively unregulated use of psychedelics. This is a movement that reflects thousands of years of ethnobotanical tradition that intermittently percolates into broader public awareness. NIR is sympathetic to that tradition and its aspirations, but that is not the focus of our coverage, aimed at exploring the possible expansion of the quasi-spiritual into a broader utilization in the treatment of psychiatric distress and illness. We occasionally trigger an ‘OK Boomer’ reflex response from those who believe that the lessons of the sixties and seventies are not relevant to this psychedelic renaissance, and/or that attempts to medicalize psychedelics are greed-driven and antithetical to their consciousness-raising potential. While we disagree, there may be no nearterm route to bridging that divide. But surely we can at least agree on this: Sonoran toads should only be licked if they have provided informed consent and chosen a ‘safe word.’
The Role of Psychotherapeutic Support/Integration:
The degree to which psychedelic therapies rely upon psychotherapeutic support for maximum treatment impact is a critical component of the clinical development process, with adherents on both sides of the argument. Much of the anecdotal literature regarding psychedelics/empathogens from the 1950s and 1960s came from psychotherapists who utilized psychedelics as adjuncts to ongoing therapy, not as stand-alone interventions. This tradition was recapitulated by the first two pioneers to make it into highly controlled clinical testing: MAPS‘ work with MDMA in PTSD, Compass‘ psilocybin trial in TRD. Both of these trials emphasize preparatory and integration work as integral to the therapeutic experience, but this comes at considerable cost: The MAPS MDMA protocol utilized more than forty(!) therapist hours, the Compass PhII trial required at least fifteen hours, which will increase with their PhIII, since that utilizes two dosing sessions. Such therapeutic packages require extensive training to ensure that the therapists follow the protocol, with varying allowances for skilled improvisation. Such protocols, if commercialized, would carry a hefty pricetag, well into five figures. Companies like Small Pharma and Beckley Psytech have also adopted psychotherapeutic support as core elements of their clinical trial structure.
In contrast, MindMed is running its pilot study of LSD in Generalized Anxiety Disorder without any psychotherapeutic prep or integration: A ‘monitor’ sits with the patient during the twelve hour dosing for the sake of safety, but that is it. Somewhat to our surprise, MindMed’s CMO is an eloquent advocate of psychodynamic psychotherapy, but he explains the MindMed approach as zeroing in on the purely pharmacological impact of the LSD session, without conflation with psychotherapy. It is reassuring that this decision was not based on a devaluation of psychotherapy per se, but it is ironic that, despite the embrace of the concept that medication and psychotherapy are best delivered in concert, the program would eschew it in testing this legacy psychedelic. One can make the logical case that this protocol could set the stage for a relatively more affordable psychedelic treatment program, though we question the practicality of such a long-duration agent. Somewhat tongue-in- cheek, we would note that the use of LSD without psychotherapy as anxiolysis does not enjoy extensive anecdotal support, there were no reports of a ‘Great Tranquillity’ during the years 1966-69. Our bias is that, given the generally acknowledged salience of ‘set and setting’, that this sacrifices the potential value promoted by incorporating psychological preparation into that ‘set’ from the outset. Synergy is a terrible thing to waste.
Even as some companies in the US experiment with reducing the psychotherapeutic component, Health Canada has now mandated two therapists be ‘in-the-room’, while setting standards for preparation and integration work. This was partially due to the MAPS PhII scandal where two therapists were grossly inappropriate with a patient, though that episode showed the risks even with a therapist pair. Based on these guidelines, MindMed’s LSD trial would be not be permitted in Canada.
The Most Critical Question in Psychedelics:
Are hallucinations a bug or a feature? Do the erstwhile benefits of compounds aggregated under the umbrella of ‘psychedelics’ reflect an impact upon neuroplasticity, and if so, does such psychoplastogenicity require a psychedelic, hallucinatory experience? While the initial consensus leaned towards the widely held belief that an efficacious therapeutic journey requires a ‘trip’, companies like Delix, Cognesy, Onsero, Psilera, and BetterLife are among those holding that a hallucinatory experience is a nonessential side effect. From a traditional pharma viewpoint, relevant to partnering potential, eliminating the ‘trip’ and turning these molecules into at-home, self-administered pills would be far more familiar, and appealing framework, than figuring out how to commercialize a therapeutic package that must be administered in a clinic setting.
For NIR’s part, we find intuitive resonance in the idea that some cognitive-behavioral patterns are so structurally embedded that they must be disassembled in order to promulgate fresh neural iterations. Our suspicion is that some behaviorally entrenched disorders, particularly addictions that have ‘hijacked’ the neural reward system, may require full-blown ‘demo and renovation’ for lasting change. Indeed, the very promising Johns Hopkins work on smoking cessation and NYU‘s alcohol abuse trials use exceptionally high doses of psilocybin, ranging up to more than 60% above Compass‘ high dose. On the other hand, the dramatic but transient disarray of hallucinatory experience may not be as crucial in anxiety disorders, for example. But this is purely speculation, the proof will be in the data yet to come.
But while we await solidly grounded, empirical evidence, it is hard to shake the feeling that this class of psychoactive drugs is somehow different. Even Onsero‘s founder, the eminent and highly rational neuropharmacologist Bryan Roth, said this at ACNP: “There may be something magical about psychedelics per se.”
From NP Summer Issue 2022
Excerpt from Psychedelics Review: Bad Ideas
Deprofessionalization in the Name of Democratization: The safe therapeutic utilization of psychedelics requires screening patients for those who might benefit while providing adequate preparation, support, and integration, but also requires screening out those who should not be treated with psychedelics. Anxiety about the spectre of psychedelics being restricted to the well-to-do is understandable, but dumbing down the screening and treatment processes for the sake of broadening access is risky. Screening out those patients who might be vulnerable to psychotic decompensation requires a degree of professional training well beyond Oregon’s proposed 120 hours, it is even beyond physicians who have been trained in anesthesiology rather than psychiatry. The Compass results show that, even for those not at risk of psychosis, the majority of patients may end up disappointed by the results: Professional preparation, support, and integration did not prevent suicidal acts in this monitored, supervised treatment group, one can only imagine what the risks would be without these safeguards.
LSD for anything: This may seem overly dogmatic, but twelve hour drug sessions exceed the bounds of what can be reasonably expected in most treatment contexts, with intrinsic unnecessary and hard-to-manage excess. If pressed to consider possible exceptions, Addiction and Cancer Pain are perhaps contexts where such duration is either desirable or tolerable. But proposals to add a chemical adjunct (e.g. a 5HT-2a antagonist) that terminates the LSD effect at some pre-selected timepoint is a clumsy adaptation that will go nowhere, given the availability of alternatives that are inherently shorter-acting. With all due respect to the recent Liechtl clinic paper (see p.11), there is ample anecdotal weight to the argument that LSD carries some added risk of anxiogenesis. When it comes to psychedelic treatments that are not strictly boutique-level in their accessibility, these factors make LSD a non-starter. This is particularly true for a couple of proposed treatment contexts:
ADHD and LSD: There is literature supporting the concept that ADHD reflects a network failure to suppress default mode activity when there is a task at hand requiring attentional focus. Psychostimulants appear to inhibit default circuit activation, thereby permitting focus without mental ‘wandering.’ But there is a difference between an ADHD scenario where one is seeking to suppress default mode functioning in the service of making planning and problem-solving more figural, in contrast to the most popular psychedelic premise (best articulated by Carhart-Harris) that suppressing default mode functioning via psychedelics allows a broad emergence of new networks and novel ideational activity. In other words, there is a difference between psychedelic-induced neural equipotentiality and psychostimulant-enhanced engagement with a singular cognitive focus, the former more associated with novel, creative thinking, and latter with pragmatic task-orientation. Yet there are those who believe that psychedelic micro-dosing is a viable alternative to psychostimulants in the treatment of ADHD. This has arisen partly via anecdotal reports from the LSD micro-dosing subculture that emerged in Silicon Valley. NIR believes that this is a reverse-engineered fallacy, the enhancement of creative thinking in individuals who formerly utilized Adderall and other stimulants as performance enhancers does not mean that they were treating actual ADHD, and does not mean low-dose LSD is a valid option for treating Adult ADHD. But MindMed has gone ahead with an EU trial of LSD in ADHD. From a safety and regulatory viewpoint, and the fact that the non-psychedelic impact of micro-dosing can be easily thwarted by combining doses, this is a non-starter.
Neurodegeneration and LSD: There are credible researchers who view psychedelics as increasing neuroplasticity and the building of new neural connectivity, ‘psychoplastogens’ potentially remediating neurodegeneration. Classic psychedelics are known to possess anti-inflammatory effects, a 2020 publication identified a specific chemical component of 5HT-2A agonists, 2C-H (2,5-dimethoxyphenethylamine), as the anti-inflammatory factor, active in animal models of asthma, but we do not have much optimism for procognitive or anti-inflammatory effects from psychedelics that might significantly impact Alzheimer’s. A Johns Hopkins study is assessing the impact of psilocybin on anxiety, depression, and cognition in early Alzheimer’s, but while an impact on anxiety and depression seems achievable, we doubt that a procognitive benefit can be anticipated. Eleusis reported that low-dose LSD was well-tolerated by healthy older adults in a PhI, and the CEO said (in Forbes) that “this (classic psychedelics) could be a therapy to modify the course of Alzheimer’s“. While the theme of neuroinflammation as a contributor to many disorders has resonated loudly over the past decade, thinking of this as widening the potential market for classic psychedelics or their progeny seems both misguided and highly inefficient: There will be better routes to address neuroinflammation and/or fostering neurotrophic effects. Psychedelics could help with the emotional accompaniments of dementia, depression and anxiety (e.g. Biomind is in PhII with oral 5-MeO-DMT for Alzheimer’s depression and anxiety), but they are not next-gen candidates for arresting the neurodegenerative disease process.
Micro-dosing: Commonly attributed to Silicon Valley experimentation in performance enhancement, there has also been the trendy emergence of ‘micro-dosing’, using a ‘subperceptual’ dose level that does not precipitate hallucinations. Adherents claim that this promotes creativity and productivity. Micro-dosing was discussed in the preceding section on ADHD, but in the long run, it likely to be the province of recreational rather than therapeutic use, particularly when it comes to long-acting agents like LSD and mescaline.
There’s No Place Like Home (for Ketamine?): There are a few companies that have seized upon the pandemic-induced boom in telemedicine as an excuse for at-home ketamine ‘therapy’, neglecting the attention to set and setting that is intrinsic to psychedelic therapies. Mindbloom has generated considerable media coverage–some quite critical–of their at-home sublingual ketamine program. Sessions are conducted without an in-person guide: “we’ll be there in spirit, and in video.” While sublingual ketamine is less bioavailable than IV, this promise is not reassuring. Home-delivering a highly psychoactive drug without any, even amateurish, in-person accompaniment/supervision–what could go wrong? Innerwell just raised $3 million to fund its at-home ketamine protocol, which claims to emphasize a psychotherapy component.
Nue Life Health raised $23 million in a Series A with which to fund their at-home ketamine therapy program, which include a trendy digital therapy-by-app component. It also relies on sublingual ketamine that is delivered to the patient’s home, the patient expected to provide their own ‘sitter’ (no training or experience required). They have now partnered with Field Trip Health, using FT’s ketamine protocol, which might fortunately include upgrading the monitoring/support element.
Pasithea Therapeutics proposes ketamine treatments in patients’ homes, administered by anesthesiologists. At least this model includes a professional component, albeit generally lacking psychiatric training, but such anesthesiology ‘house calls’ would be a costly gimmick.
Each of these companies feature psychiatrists as founders, though their actual level of involvement is ambiguous. In each case, they should know better.
From NP Spring Issue 2022
Excerpt from Stroke Review: Quelling Excitotoxicity
During the 1990’s, stemming the excitotoxic tide was considered the wave of the future for stroke treatment, based on the hope that the impact of glutamate overrelease could be ameliorated. This search ventured into a molecular minefield: Merck’s MK-801 was a competitive NMDA blocker which remains the imperfect gold standard against which candidates are preclinically tested. Unfortunately, in addition to its ability to reduce infarct size, MK801 caused vacuoles in the brain. The parade of failures continued, killing programs from Bristol-Myers Squibb, Elan,Paion, Merck, Cambridge NeuroScience, Janssen, Astra, Pfizer, Hoechst, Novartis, and NPS. AMPA, glycine and polyamine site blockers were considered as other options for reducing glutamatergic activation, but compounds from NeuroSearch, CoCensys and GSK all eventually failed.
Magnesium infusion (which has effects at the NMDA receptor) had been associated with decreased mortality in a pilot stroke study, and NINDS finally ran a 1700 pt PhIII trial, with paramedics administering magnesium sulfate in the field to maximize the time advantage, followed by an inpatient magnesium infusion. Ironically titled FAST-MAG, it was exceptionally slow to enroll, and when it finished eight years later, it came up completely empty.
NoNO: One of the very few neuroprotective, clinical-stage drug NCE candidates left standing for ischemic stroke after the long marathon of attrition is NoNO’s nerinetide. Nerinetide is an IV-administered peptide that blocks PSD-95, co-localized with NMDA receptors, from activating downstream neurotoxic pathways (e.g. nitric oxide) otherwise triggered by NMDA receptor hyperactivation. A Phase II was done in patients undergoing repair of subarachnoid brain aneurysms, with an IV infusion given at the end of the procedure. The trial was completed in mid-2011, having enrolled 185 patients: No effect was seen on the volume of lesions, or on either the Rankin or NIHSS, but an impact on the number of lesions was reported. NoNO was able to find additional funding, and after one false start, initiated a Phase III trial aimed at enrolling 1120 AIS patients, with nerinetide administered via infusion. That trial showed nerinetide missed its primary endpoint, but patients who did not first receive tPA showed a 40% reduction in mortality. Further work indicated that tPA and nerinetide have a negative chemical interaction, tPA deactivating nerinetide. NoNO then initiated a 1020pt Phase III where nerinetide would be given first, by EMTs, well before tPA can be cleared for use by CT scan. Results are cited as being expected during 3Q:22. While this process still requires the neuroprotectant to achieve access to infarcted tissue, and decades of disappointment have left stroke researchers rather hope-deficient, there is some quiet excitement about this nerinetide trial, and the possibility that neuroprotection may finally be within reach.
NoNO has announced that they have developed protease-resistant next-generation PSD-95 antagonists that can ‘coexist’ with tPA/alteplase, opening up the full gamut of stroke patients to treatment and improving access to the penumbra.
Avilex Pharma is a University of Copenhagen spinout also targeting PSD-95, in the service of reducing excitotoxicity and oxidative stress. AVLX-144 is a peptide that is reportedly 1000X more potent than nerinetide, more effective at reducing infarct sizes in mouse models, and with better BBB penetrance. Last December, Simcere partnered AVLX-144 for China, making an undisclosed upfront payment which, along with undisclosed milestones, could total up to US$175 million. This funding should allow Avilex to finally start PhII testing for AVLX-144.
Selective NR2B subtype inhibitors developed at Emory were licensed to the startup NeurOp, animal data showing that infusing the prototype compound prior to arterial occlusion reduced infarct volume. NeurOp developed NR2B antagonists designed to be active only in the acidified environment found post-stroke. NP10679 will first be directed towards subarachnoid hemorrhage, and following the completion of PhI testing, NeurOp expects to enter PhII in 2023.
From NP Winter Issue 2022.
This image brought to mind NP’s first assessment of the full PhIIb dataset for aducanumab, published in NP Sept/Oct 2015. Or to put it another way, seven years and almost $12 billion ago. It offers a reminder of the selective blindness that led Biogen to pursue the biggest strategic blunder ever made in pharma drug development. All of this was avoidable.
<<Aducanumab: As was disclosed at AAIC, 26 patients in total completed all cognitive test sequences in the long-awaited 6mg/12 month group. That is not a cohort size about which much is generally said when it comes to Alzheimer’s. Anomalies in the readout could reflect some outlier patient(s) whose impact would be greatly magnified by the small n. But when Biogen presented the results, they claimed that they fell in line with the preliminary data from last March, which is not completely true. The rate of decline on the CDR-SB did indeed place the 6mg group between the 3mg and 10mg groups, but it was much closer to the 3mg group. The neat dose-response relationship that had initially surfaced in March vaporized: The MMSE score decline for the 6mg group was almost identical to the very limited effect seen from 1mg, while the 3mg and 10mg groups clustered together in an oasis of statistical significance. The impact on amyloid plaque was linear, but since that did not consistently line up with functional effect, this raises more questions than it answers. Finally, the incidence of vasogenic edema in the 6mg group (37%) was nearly the same as in the 10mg group (41%), far above that seen with 3mg (6%). So the hope that the 6mg dose might ‘walk the tightrope’ and somehow provide 10mg dosing efficacy along with 3mg dose adverse effects was not fulfilled, or at least, not in this trial. While Biogen tried to reassure observers that the vasogenic edema findings were not particularly problematic (“typically resolved within 4-12 weeks”), the fact is that while 78% were “mild to moderate”, this means 22% were more severe. In a trial that enrolls 166 patients and makes brain scans easily available, that is manageable. In a general Alzheimer’s population, perhaps not. For example, if 100,000 patients were to receive aducanumab at the 6mg dose, and if the incidence rate in this trial is predictive, 37,000 could develop vasogenic edema, with 7500 of those cases being severe.
That becomes a clinical monitoring and management challenge that could outweigh what looks like a modest-at-best treatment effect: Even the most seemingly efficacious dose (10mg) achieved just a 2.25 point difference on the MMSE decline rate at 12 months, on a test where three points is the minimum considered to be clinically meaningful. On the CDR-SB, where mild Alzheimer’s patients decline 1.4 points annually, the 10mg dose approached that level with a 1.24 point effect, the 6mg dose had just a .76 point impact, close to the ‘six-month’s worth’ noted for the MMSE. Again, these are tiny dose cohorts, and may not mean anything, but the additional data only beclouded the issue for aducanumab.
Even though the consensus of AD experts NIR consulted with was that aducanumab has made a more convincing case for a signal than has solanezumab; because of the added concern about vasogenic edema, the aducanumab headline reads like this: Aducanumab May Do Something, But Not Much–It Might be Better Than Nothing, But Possibly Not.>>
And that’s where the story continues to stand almost seven years later. Such a waste.
(from the Winter Issue CNS Sector Review)
1) Schizophrenia: The pharmacotherapy of schizophrenia has been essentially static for at least two decades, with all due respect to the minor changes around the tolerability edges provided by more recently introduced drugs. Core deficits involving cognitive sharpness and motivation, the oft-cited cognitive and negative symptoms, have never been consistently and safely (in reference to clozapine) impacted. That appears to be changing: Sunovion will have PhIII results in 2022 from ulotaront/SEP-363856, a 5HT-1a/TAAR1 activator; Karuna anticipates PhIII results for its muscarinic agonist KarXT in 2022. There are other drugs in earlier stages of development in schizophrenia (Cerevel, Boehringer Ingelheim, Merck, Neurocrine Biosciences, Biogen) that are worth tracking, but the two frontrunners will offer important new options for the treatment of a wider spectrum of schizophreniform symptoms, translating into tangible gains in real-world functioning for these patients.
2) A Direction for Compass: As we noted in our 11/9 Neurogram+, and in this issue’s Psychedelics Update section (p.31), Compass’ landmark, 233pt PhIIb trial of psilocybin in Treatment Resistant Depression (TRD) was a success, albeit grossly underappreciated. The therapeutic dose was established (25mg), which produced rapid (2 day) and durable (12 week) improvement on the MADRS. Expectations had been fueled for a panacea, an expectation fueled by euphoric anecdotes in the popular press, so there was disappointment that depressive symptoms remitted in just one out of every four patients in the high-dose group. In this chronically depressed population, where depression has become embedded in a patient’s engrained concept of personal identity, this is impressive enough. It shows that psychedelics have a role to play in the treatment of some psychiatric disorders, but will not offer radical transformation to all comers. Had the trial failed, it might have turned off the waterfall of cash infusions that have populated a wide swathe of relatively newco’s; this is a dose of combined hope and reality that may temper and focus that investment more pragmatically. The longterm viability of psilocybin therapy was further enhanced by Compass’ later report that combining psilocybin with ongoing SSRI therapy did not appear to diminish its therapeutic impact or tolerability. With Compass’ share price down over 50% during 2021, one can only imagine what would have happened if they’d had bad news.
3) Fiscal Flow: 2021 was never going to match the record set in 2020 for institutional investment and partnerships with small and midsize CNS companies, but it ended up a respectable historical third, behind 2020 and 2018. Disease-modifiers for neurodegeneration came in first, Psychiatry was a strong second, consistent with its renaissance as an investment focus.
2021 saw a decreased flow of IPOs, with Acumen‘s $160 million, Eliem‘s $92 million, and Cognition Therapeutics’ $52.5 million the stand-outs, followed by a bevy of micro-IPOs, as was noted above. But the funding flow was steady, particularly for the new wave of portfolio companies looking to emulate the Bridge Bio model (before Bridge itself melted down after a clinical failure). Neumora and Atai were first and fourth, and had Neurvati disclosed its Blackstone funding total, it would have been near the top as well.
There is more information about institutional investment and funding activity on p.7-8 and 13.
3) Biogen exercised its option on TMS-007, a novel thrombolytic that in PhII, demonstrated a window of 12 hours post-stroke for utilization, compared with 3-4 hours for tPA. The latter is generally insufficient to permit imaging to rule out hemorrhagic stroke, only 3-5% of stroke patients receive tPA. Add in the forthcoming results from NoNo‘s second PhIII trial of their stroke neuroprotectant, nerinetide, and one can well imagine a long-awaited transformation of the neuropharm standard of care for ischemic stroke–of which there almost 800,000 per year in the US alone.
4) MDMA in PTSD: The countercultural non-profit group MAPS pulled off a PhIII with results that would be the envy of any Big Pharma running a trial in Psychiatry: A treatment effect of .91 is a magnitude generally only encountered in some psychostimulant trials in ADHD. The second PhIII was originally projected to finish this year, now the timeframe has shifted to the end of 2022.
5) Emalex Biosciences: The time between trial completion and readout had us concerned, but the results were quite positive: A 153pt PhIIb trial of ecopipam (D1 antagonist) in pediatric Tourette’s–a low-profile but very undertreated therapeutic area–was very successful.
6) Patience pays off: In January 2015, Neuropore partnered its preclinical alpha-synuclein anti-aggregation compound NPT200-11 with UCB Pharma. A few months later, they went into PhI, which finished in early 2016. UCB then took NPT200-11/UCB5099 inhouse for extensive vetting, not starting PhII in Parkinson’s until almost five years later, in late 2020. A year later, Novartis has now partnered with UCB on UCB0599 (and an earlier-stage alpha-synuclein mAb), paying $150 million upfront to UCB. More than once, NIR wondered if the lengthy delay in clinical progression augured ill for UCB0599, it turns out that it did not.
(from the November/December Review of Parkinson’s)
Gene therapy per se has not been particularly relevant to PD as a whole, given the lack of a highly contributory single gene target. It is, in theory, applicable to select subtypes, for example the GBA gene mutation subgroups discussed earlier, and perhaps could be turned to boosting the overall level of GCase in idiopathic PD, as is the case for Prevail Therapeutics, though such programs begin with genetic-subtypes like PD-GBA, as is discussed in that section (see p.25).
Gene therapy has been tested in a relatively general category of sporadic PD, often in the service of either delivering neurotrophic factors, or boosting dopamine levels:
Upregulating neurotrophic factor expression was the goal of Ceregene’s program. CERE-120 involved the delivery of neurturin-expressing genes via AAV. A 58pt Phase IIb’s results were negative on the primary endpoint (off-time), but were positive on several other endpoints. Histological assessments indicated that, damaged striatal projections did not adequately transport neurturin from the putamen injection areas to the substantia nigra. Ceregene then did another Phase IIb, adding 1-2 injection sites in each substantia nigra, in order to address striatal tracts from both cell bodies and terminals. The data did not show any significant separation from placebo, both the CERE-120 and sham surgery groups showed improvement on the UPDRS ‘off’ time scale. Ceregene was acquired for almost nothing by Sangamo Biosciences, which had no interest in their clinical programs.
Bayer‘s subsidiary AskBio is in PhIb using an AAV to deliver the gene for GDNF to the putamen. Ten patients had been enrolled as of this past June.
Brain Neurotherapy Bio is sponsoring a 12 pt study of AAV2 delivered GDNF gene therapy, a study that began in mid-2020, and will have topline results in 2023.
The other subtheme for gene therapy in sporadic Parkinson’s was the facilitation of dopamine-expression: Voyager Therapeutics developed VY-AADC, an AAV2-delivered product for the gene encoding AADC, which facilitates the conversion of levodopa into dopamine. Voyager believed they could achieve 5+ years of payload delivery with this technology, and that stabilizing dopamine availability could be disease-modifying, a theory yet to be proven. After three years of PhIb testing, Voyager and their partner-at-the-time Neurocrine Biosciences (Sanofi had previously exited), announced that 14 of the 15 patients treated had shown an overall improvement, average OFF time reduced by 1.91 hours, average ON time increased by 2.23 hours daily. However, the trial, already disrupted by Covid-19, was then halted in its tracks by the FDA: They placed a clinical hold on the program due to MRI abnormalities in some patients. Soon after, Neurocrine exited from the Parkinson’s portion of the partnership, and Voyager announced a couple months later that they would not advance the program on their own, in the face of FDA requirements that were going to be difficult and expensive to meet. Voyager stated that they expected “to turn the future development and commercialization of VY-AADC over to a partner once the potential path forward for the program is determined.” The prospect of finding a partner eager to take on a gene therapy program that is fundamentally symptom-reducing at its core, with a safety signal that could be difficult to resolve, is somewhere between zero and dismal. Voyager has removed VY-AADC from its published pipeline and has moved on to developing a new generation of capsids, partnered with Pfizer. VY-AADC was an expensive experiment that did not pan out.
In the same dopamine-augmentation vein, Oxford Biomedica developed ‘ProSavin’, a lentiviral vector delivering three genes encoding enzymes for dopamine synthesis. In a monkey model, the monkeys showed durable reversal of their motor deficits, going out 27 months without loss of efficacy. In Phase I/II, using four dose levels, the 24 month data showed low-dose patients with a mean UPDRS improvement of 20%, the highest being 30%. In the highest dose group, Oxford reported a mean improvement of 30% on the UPDRS, with one patient showing a 41% improvement. Oxford decided to instead focus on OXB-102, which in preclinical testing, appeared to be five times more potent than ProSavin. Axovant Gene Therapies (later renamed Sio Gene Therapies) partnered OXB-102 for $30 million upfront, and began a multi-dose cohort sequence of PhI/II testing. In 2019, Axovant announced that first cohort showed a UPDRS average’ improvement of 17 points, a mean improvement of 29%. At the end of 2020, the second dose cohort yielded ‘two evaluable patients’ for whom the ‘mean improvement was 21 points, or 40%, though high variability in individual patient responses has already been a hallmark of this program. Dosing apparently stopped due to a manufacturing delay at Oxford Biomedica, they predict resumption of the trial in 2022.
More than a decade ago, Neurologix developed an AAV2 delivered PD therapy that provided the GAD gene expressing the precursor to GABA. Delivered to the subthalamic nucleus, it was intended to modulate hyperactivation in that region. Clinical results were ambiguous, and the company went bankrupt. A Feinstein Institute group went back and assessed neural activation patterns in the 15 GAD patients compared with the 21 who received sham surgery. They reported that AAV2-GAD patients showed evidence of an alternate network being activated, one that linked the subthalamic nucleus to motor regions, which was in turn associated with improvement on the UPDRS. Those changes, and the motor function improvement, were not seen in the sham surgery group. This work has been picked up by MeiraGTx Holdings, which cites their program as being in PhII, clearly referring to the old Neurologix study. For their part, MeiraGTx projected filing a new IND for AAV-GA in 3Q:21, which did not happen; they are focusing most of their corporate energy on a retinitis pigmentosa program.
Biogen and Sangamo are partnered on ST-502, a preclinical ZFP designed to suppress the SNCA gene.
Matthew Disney’s group at Scripps Florida developed a small molecule that targets the mRNA for SNCA, reducing alpha-synuclein production. In an in vitro model, the molecule also was protective against SNCA fibrils, thus its impact was not just on production.
Atalanta has partnered its U.Mass-sourced siRNA technology, which links multiple modified siRNA molecules, with Roche/Genentech for Parkinson’s (and Alzheimer’s). They believe that these ‘branched siRNAs’ promote long-lasting gene downregulation in deeper portions of the brain parenchyma.
Alnylam has used its RNAi technology in PD models, and reported that they were able to lower alpha-synuclein levels in a mouse model of PD, using the RNAi product Mayo852m. But PD is not cited on their pipeline.
A University of Pittsburgh group used an AAV-delivered RNAi against alpha-synuclein mRNA in a rodent model. At 12 months post-innoculation, alpha-synuclein mRNA was reduced in the substantia nigra by 90%. The knockdown did not produce any evidence of neurodegeneration or functional deficits, suggesting that alpha-synuclein knockdown does not interfere with necessary biological functions.
Micro-RNAs have been postulated to be an access point for disease-modification, but other than ApicBio‘s SOD1 program, in PhI/II, this is early-stage.
(from the March/April Review of Psychedelic Therapeutics)
Other Considerations (p.30-32)
1) REMS and Cost: There is good reason to expect that clinical efficacy will be demonstrated by some of these psychedelic therapy programs, since MAPS obtained an impressive treatment effect with MDMA in its first PTSD PhIII. That does not guarantee success for Compass Pathways’ PhIIb for psilocybin in depression, but there are reasons for optimism. If there is success for that trial as well, and both of these pioneer programs makes it successfully through PhIII and on to NDA filing, there are issues that will loom large at that intersection of the regulatory and the commercial.
MDMA and psilocybin both have histories as drugs of abuse. The safety record for psilocybin is near-pristine, more so than for MDMA, and the latter’s association with euphoria and ‘raves’ are sure to be of concern to the FDA and DEA in the US, and the corollary regulatory bodies in the EU and Japan. But given that the FDA has deemed both a ‘breakthrough therapy’, for disorders that are undertreated (PTSD) or are treatment-refractory (TRD), the momentum would seem to be on the side of approval. As a precedent, marijuana has had greatly broadened acceptance as both a therapeutic and recreational agent in the US. Oregon is the first state to give governmental cover to the therapeutic use of psilocybin, as has Canada.
It is not as if Pharma has uniformly shied away from developing pharmaceutical products that are at risk of abuse–opioid analgesics and psychostimulants have been highly controlled but commercially successful. However, the opioid epidemic is a cautionary note for what can go wrong with abuse-vulnerable products. The reality is that psychedelics are far different from those classes, they are not prone to physical or psychological dependence. But their overblown reputation precedes them, and will provoke some anxiety in the pharma industry and for regulators.
When approval comes, there will be concerns regarding drug diversion and misuse, so we expect extraordinarily stringent REMS requirements to be in place. This not just requiring a centralized pharmaceutical dispensary, but in terms of the treatment packaging that has been such a salient part of the clinical development process for both. We would expect that the REMS requirements will include hewing to the protocols with which the drugs were validated, and that is a potential problem: How does one turn MDMA or psilocybin into a viable product when the protocols are so costly? For example, the MAPS PhIII protocol involves three drug administration sessions, each (thus far) requiring an overnight stay, plus preparatory and integrative therapy sessions that produce a total of 42 hours of therapist time for each patient, not including psychiatrist/medical or assistant hours, or the cost of the space and the drug itself. Even though MAPS is working on eliminating the overnight stay requirements, one can easily imagine a treatment course cost of well over $20,000 for each PTSD patient. Military-PTSD cases might be covered by Department of Defense or VA funding, but otherwise, outside of addiction treatment, we expect strenuous pushback by commercial insurors on psychedelic therapy packages. Some micro-companies naively predict that insurors will eagerly embrace psychedelic therapies because of their superior, cost-effective impact, they have obviously never dealt with insuror gatekeepers.
Compass Pathways has designed a comparatively less onerous treatment protocol, there is just one dosing session, and even with preparatory and integrative therapy hours, the total therapist time is around 15 hours, plus assistant and psychiatric/medical/space costs. But even if the cost is under half of the MAPS PTSD protocol, that is going to be resisted by payors concerned about the size of the potential treatment population. Unlike MAPS, Compass has an investor base that will expect healthy revenue growth.
2) Democratization: The question is whether psychedelic therapies are destined to be solely a platinum priced premium treatment tier for the well-off. The development of ‘psychedelic spas’ by companies like Field Trip, with upscale furnishings and aesthetics, will have appeal for a narrow slice of the PTSD and depression patient populations, but this leaves out the majority. There is already some discussion about how to democratize psychedelic therapy access so that it does not become yet another context for growing inequality. For example, ATAI Life Sciences has its Introspect digital therapy subsidiary developing apps that would provide adjunctive therapy support, and is considering the use of Virtual Reality to maximize the subjective aesthetics of the treatment environment, creating Virtual psychedelic spas, as it were. This would not eliminate treatment inequality, there will still be a difference between a highly trained therapist and an app, but it could provide a pragmatic complement.
3) Parsing Patients: There has been a strong self-selection bias in the patient populations that have enrolled in these trials. Many of them had a positive attribution assigned to ‘psychedelic therapy’, some have already had experience with psychedelics via underground sources. It will be interesting to see whether observed efficacy diminishes as the net is cast in a larger pool of prospective patients who may not have such an engrained expectancy. But beyond predispositions to belief, and besides the economic factors that will inevitably be relevant to treatment choice, it may be that potential treatment-responders could be identified as such prior to making a choice that may be expensive and time-consuming. For example, there is more than one isoform of the 5HT-2A receptor, it may be wondered whether those isoforms may have differential responsivity to different drugs. Entheon acquired HaluGen for its self-administered swab test, which claim to identify the “20% of people” with a specific 5HT-2A variant they believe to be overly reactive to serotonergic psychedelics, and the presence of a CYP2B6 genetic variant that slows ketamine metabolism, hence increasing its bioavailability. Entheon says that the test, whose degree of human validation is unclear, is being prepared for commercial launch.
4) Clinical Complexities: The treatment protocols utilized by MAPS, Compass, and Usona are the most complicated psychiatric trial protocols NIR has seen. But there are other clinical trial challenges not as immediately apparent. First of all, it is near-impossible to devise a classic placebo control, this is one of the rare instances where patients know within an hour or two whether or not they received the active drug. There are occasional exceptions, there are patients who have had a subperceptual experience on a full dose of a drug, believed they had received a placebo, and yet eventually reported having had a positive experience–this is experientially complicated and not predictable. Sponsors have generally turned to a low-dose version of the compound being tested as the control measure, the alternative is to use an alternative, nonpsychedelic but ‘palpable’ control, such as niacin or, as was done in some ketamine trials, midazolam, a benzodiazepine. Secondly, since patients generally know if they received placebo, there is the challenge of ensuring that they comply with followup visits weeks or months later, when they may indeed feel shortchanged by the trial process. That is one of the situations where the skill of the therapist in establishing an alliance makes the difference between a full and incomplete data record.
5) Safety: With the exception of ibogaine, the broad category of psychedelics is, physiologically, a relatively safe one. As was noted earlier, the classic psychedelics can induce hypertensive episodes, and how they interact with other serotonergic drugs is an issue very pertinent to drug ‘washout’ before trials and in eventual clinical use. MDMA is known to have cardiac safety issues. But dependency and concerns regarding potentially fatal overdoses are relatively low-profile. Certainly there can be acute panic and confusional states, and the classic psychedelics are generally thought risky for anyone with prodromal schizophrenia, based on concerns that a psychotic decompensation can be hastened. There are a few researchers who think that MDMA could be useful in schizophrenia, but most do not consider this worth the risk.
The field will have to hew to high training standards and careful patient screening, psychedelic therapy and training conferences are popping up at a dizzying pace, which means that quality control is going to become more challenging. It only takes one highly publicized tragedy to skew the societal conversation: Fifty years ago, American TV personality Art Linkletter claimed that his daughter’s suicide was caused by her ingestion of LSD, and while this tragic event did not create the backlash that led to the outlawing of all psychedelic research in the US, it helped catalyze it. NIR has detected a certain degree of idealistic naiveté re-emerging during this cycle of psychedelics research, which belies the potency of reactionary political dynamics manifested in ways that we have all witnessed.
(from the January/February CNS Sector Overview)
1) Biogen: Aducanumab must be parsed into a category of its own (see p. 10-11), and the fact that Biogen accounted for 76% of all partnership upfronts in CNS during 2020 is a bit unnerving. But paying $1.53 billion upfront to partner Sage‘s zuranolone program in depression is mind-boggling for several reasons. First, it concretizes Biogen’s willingness to invest in Psychiatry, which we had wondered about given the low profile of their only existing Psych program, the Ampakine trial in CIAS. It also demonstrates (again) that Biogen’s dedication to neurotherapeutics and its enormous resources allow it to make very substantial investments in licensing (as it also showed in the Denali deal). Third, they undoubtedly did painstaking due diligence about the Sage program, regarding which NIR had doubts, and signing on to this scale affirms that there is value to be unlocked with the zuranolone/interval dosing paradigm. Finally, it is a reminder that even if aducanumab does not end up approved and commercialized, Biogen has numerous other programs of potential high value. One way or the other, there will be life after aducanumab.
2) Fiscal Flow: 2020 was the best year on record for institutional investment in small and midsize CNS companies. Which reflects a remarkable degree of focus given the chaos so rampant elsewhere. There was also refreshing diversity in the treatment areas gathering attention: While neurodegeneration came in first, Psychiatry was a strong second. Companies with their own products entering the market were the biggest beneficiaries; SK Biopharma, Intra-Cellular, Biohaven, and Zogenix accounted for six of the ten largest rounds. Partnering upfronts also reached a new record level, $3.95 billion, eclipsing 2018’s $2.7 billion by a remarkable margin, thanks to Biogen‘s willingness to spend on the grand scale (almost $3 billion in upfronts).There is more information about both institutional investment and funding activity on p.17.
The first half of 2020 saw a dearth of IPOs, with Passage Bio the exception (we do not attribute much importance to the $12 million Annovis ‘IPO.’) But 2H, particularly July and August, saw a constant stream of IPO activity, with Annexon, Praxis Precision Medicine, Athira Pharma, Taysha Gene Therapies, and Compass Pathways going public via IPO. Cerevel took the SPAC route to the same destination, Yumanity utilized a reverse merger.
3) Acadia Pharmaceuticals and Neurocrine Biosciences have both broadened their portfolios in a tangible embrace of a wider role in neuroscience, fueled by, but not limited to, the success of their self-marketed lead assets, Nuplazid and Ingrezza. We have often questioned the wisdom of small companies aspiring to be fully vertical, developing commercial capabilities rather than partnering with companies already established in that domain. But Acadia and Neurocrine are case studies of small companies that have done so successfully, with the fruits of such labor reinvested in pipeline expansion. It is where Intra-Cellular hopes to be in a couple of years, once Caplyta establishes itself.
4) Psychedelics: After five decades of underground semi-dormancy, the re-emergence of psychedelic substances as potential therapeutics in Psychiatry and Pain blasted off this past year, with investors looking for a way into an area that had been completely off-radar for fifty years. Compass Pathways was the first such company to go public in the US, raising a total of $246.6 million in 2020. Atai Life Sciences, which owns 29% of Compass, raised $125 million in its own Series C. Canada’s Mind Medicine went public in Toronto, raising a total of US$44 million this year. MAPS (the Multidisciplinary Association for Psychedelic Studies) raised over $100 million thus far to run a Phase III for MDMA in PTSD, though the lack of detail in the trial report left most questions still to be answered. There is also a flock of micro-companies looking to participate in the hottest new subsection of the neuro-world; some are competent, others are dubiously conceptualized and constituted. The rapid infiltration of this formerly discredited work into mainstream thinking is epitomized by the fact that the Johns Hopkins study results reported on p.2 were published in the stalwart of mainstream medicine, the Journal of the American Medical Association. An upcoming issue of NeuroPerspective will cover the area of Psychedelic Therapies in detail.
5) Sage Therapeutics took a gamble on an innovative interval dosing paradigm in depression which became all-the-higher-profile after Covid-19 demolished their nascent Zulresso franchise in Post-Partum Depression. And despite all the naysaying, including ours; their extension data, and Biogen‘s partnership, confirm that the gamble was well-placed, their ROI is already off-the-charts.
6) Denali published details of their proprietary approach to using the transferrin receptor to gain CNS entry for large molecule payloads. They had been very close-mouthed up to this point, and had publicly emphasized their small-molecule programs. But there is now a timeline for the clinical validation of their technology for delivering antibodies, enzymes, and ASOs.
7) Lilly acquired Prevail Therapeutics and Disarm Therapeutics, while partnering with Evox, in a 2020 reconfiguration that, in aggregate, advances Lilly’s CNS portfolio a decade, from a somewhat antiquated set of 2015-era priorities to programs that have a shot at being cutting-edge in 2023.
8) Cortexyme: It was just an interim analysis, designed to establish whether there was either a nearly 100% chance of success, or of abject failure, based on the first 300 patients. But the fact Cortexyme’s atuzaginstat will continue to its planned end, without a recommendation to increase the sample size beyond 643 patients, is a positive for this dark horse Alzheimer’s candidate, pursing a distinctly minority-view mechanistic hypothesis. It was not at all realistic to hope for ‘overwhelming efficacy’ after just 300 enrollees, and the absence of clear futility (underperforming placebo) does not guarantee anything. But the December unblinding of the full dataset is near the top of ‘must-see’ data events for 2021.
1)Biogen Becomes Too Big to Fail: This is the flip side of the dominant role Biogen has assumed in the neuro sector: Providing 76% of the partnership upfront payments for a year is unhealthy, no single company should be in such a key position in a critical pharmaceutical industry domain. This is not a criticism of Biogen by any means, they have ‘walked the walk’ by making such large-scale investments, but it does render the sector uncomfortably vulnerable to disruptions in Biogen-world, perturbations that have already begun (threats to Tecfidera, Spinraza) and will resonate, if not detonate, should aducanumab fall as short in its regulatory review as it did in its clinical testing.
2) Neurocrine/Takeda Alliance: As was mentioned on p.4, this deal marks a bold move by Neurocrine to widen and deepen its developmental reach in Psychiatry, which is indubitably a good thing. But it is also ‘mixed’, because it reflects Takeda’s withdrawal from the small-molecule CNS space, which is a loss. Takeda had been looking to off-load these programs for at least a year, and while still maintaining some degree of involvement, (like with the Ovid alliance), they have shifted their emphasis elsewhere.
3) Six CGRP antagonists: In under three years, the CGRP antagonist platform has gone from zero to sixapproved therapies that constitute the first major post-triptan wave in migraine. There are now four approved (Teva, Lilly, Novartis/Amgen, Lundbeck/Alder) CGRP-antagonist injectibles for prevention, and two oral CGRP antagonists (AbbVie and Biohaven) approved for acute migraine treatment. AbbVie’s atogepant and Biohaven’s rimegepant (label-expansion) are both on their way to approval as orally-bioavailable prophylaxis, bringing the total to seven different drugs. Given the patient preference for oral options in almost every circumstance, AbbVie and Biohaven’s prophylactic options will pose imposing threats to the injectibles that narrowly preceded them. As we have noted over time, none of these are panaceas, but all have demonstrated efficacy. The great news is that these are valuable additions to the clinical armamentarium, the bad news is that they all arrived in such a compressed timeframe, competing for the substantial migraine market not satisfied with the triptan standards. We cannot recall a neurotherapeutic area that ever saw so many quality programs come to fruition in such a short period of time. The longterm value of some, if not most, of these franchises will be a disappointment to the companies who got them there.
4) NoNO: Their PSD95 inhibitor nerinetide failed in PhIII, the drug missed its primary endpoint. However, in the 446 patients (40% of 1105 patients in total) in the study who did not first receive tPA, the difference in the percentage of patients achieving full independence was 59.4%, compared with 49.8%, and mean infarct size was 22% smaller. More impressively, mortality was reduced by 40%, which reached statistical significance. It appears tPA and nerinetide interact deleteriously, and NoNo is preparing a Phase III where nerinetide is given first, by EMTs, since tPA cannot be used until hemorrhagic stroke has been ruled out by CT scan. That trial is expected to read out this year, a promising candidate in a therapeutic area long bereft of pharmacological hope.
1) Worst aducanumab faux pas. It’s hard to choose from such a lengthy roster of candidates; Aducanumab’s marathon journey is discussed elsewhere (see p.10-11). But here are two quotes from the ADCOM materials of 11/6/20 that should never have been said, and should never be said again:
a) “Combined FDA and Biogen Briefing Information for the November 6, 2020 Meeting of the Peripheral and Central Nervous System Drugs Advisory Committee”
b) “Does Study 302, viewed independently and without regard for Study 301, provide strong evidence that supports the effectiveness of aducanumab for the treatment of Alzheimer’s disease?”
Since when do sponsors co-write presentation summaries with the Agency reviewing the subject of those summaries? Why the FDA bedded down so publicly with Biogen is a mystery all its own, but whatever the answer, it isn’t good enough to justify such a blatant conflict of interest. And only such conflicted judgment could have yielded Point B, the first question presented to the ADCOM, which instructed them to review data out of context, without regard to contradictory input, despite the necessity of considering ‘the totality’ of the data.
2) Covid-19 and Zulresso: When it comes to undeserved corporate collateral damage, it is hard to top the toll taken by the coronavirus on Sage Therapeutics‘ erstwhile launch of Zulresso in Post-Partum Depression. They had already found the preparation of inpatient sites to meet the REMS requirements attached to this 60 hour infusion regimen to be very slow-going, but once the pandemic hit, few if any new mothers were going to be brought into a viral war zone in order to treat their PPD, no matter how severe. As a result, Sage’s launch process was cut off at the knees, leading to the layoff of 340 employees in order to maximize the runway for their cash resources. Zulresso was likely to be an interim option for severe PPD, a bridge to the eventual advent of oral zuranolone for PPD, but the dismantling of the Zulresso marketing group reflects the finality with which Covid-19 shut that window of commercial opportunity. Zuranolone is likely to be of value in Post-Partum Depression once approved, even without the lead-in from Zulresso. There was no error on Sage’s part, they were tripped up by circumstances that could not have been predicted, or better managed.
2) Reading the Tau Leaves: So far, not so good. Progressive Supranuclear Palsy had been hoped to be the fast route to POC, but AbbVie and Biogen both saw their initial forays in PSP fail. Axon-Neuroscience had announced success for their active vaccine in a PhII trial, without detail. They finally reported that there was no overall difference on cognitive testing, but in a pre-specified analysis of just 43 enrollees under age 67, the Company reported that decline rates were reduced by 26-42%, and plasma neurofilament (NfL) levels and atrophy increased at a slower rate in the vaccine group. Axon-Neuroscience claims this represents a disease-modifying effect, and plans to run a Phase III trial covering 24-30 months of treatment. It is unclear what this post hoc data parsing means in light of the other failures.
Finally, the Genentech/AC Immune PhII trial for semorinemab in Alzheimer’s was a failure, which casts considerable doubt on the hope that, lacking access to intracellular tau, mAbs could modify disease-course by intercepting tau en route as it propagates from neuron to neuron. There are other tau mAb programs which differ in epitope binding, but the task of finding relevance in anti-tau therapeutics may eventually rest on access to intracellular tau, aspired to by Biogen/Ionis ‘ anti-tau ASO, and the Lilly/AC Immune tau ‘morphomer’ program.
3) NIR often makes the point that statistical significance without clinical significance is useless. Arguably, the converse is true as well. BrainStorm had hoped that their mesenchymal stem cells, injected intrathecally, would generate sufficient neurotrophic impact to slow the progression of ALS–NIR has consistently questioned the utility of this nonspecific payload and targeting. The primary and secondary endpoints were definitively failed, the Company claimed a ‘clinically meaningful’ impact on a pre-specified subgroup of early-stage patients: But p-values of .288 and .198 on the two main endpoints come nowhere near any contemporary criterion for statistical validation.
4) Proof-Reading 101: After their Alzheimer’s PhII/III, Axsome reported that the reduction on the CMAI was -15.4 points, compared with -11.5 points for placebo, a mean reduction from baseline of 25.6%, a mean reduction for placebo of 19.1%. But Axsome also claimed that AXS-05 reduced CMAI scores by a mean of 48%, compared with 38% for placebo, roughly double the change that their own figures for the CMAI indicated. They had also stated that a change of 30% or more on the CMAI was the threshold for clinical significance (notably, the 25.6% change in their CMAI scores would fall short of this), and that 73.2% of AXS-05 patients met that criterion, compared with 57.1% of the placebo group. This made no sense; if the actual mean change was 25.6%, it is highly unlikely that almost three quarters of the AXS-05 group had improvements of over 30%. At best, this qualifies as sloppy. We inquired about the discrepancies, but received no reply.
(from the November/December 2020 Issue on Autism)
Autism: Enhancing Social Relatedness
The Oxytocin-Vasopressin Axis
Targeting the oxytocin-vasopressin ‘axis’ has been arguably the therapeutic strategy that comes closest to directly addressing a core behavioral component of ASD. A case can certainly be made that the disruption in interpersonal ‘drive’, skills, and tolerance is the most phenotypically distinct element of ASD; it may be the most painful for the families of these patients.
While the oxytocin system has been most closely linked to, and targeted, in autism, vasopressin and oxytocin circuits are interwoven and complementary. Oxytocin agonism and vasopressin inhibition were anticipated to have similar downstream effects (with a possible exception, noted below). Unlike most of the treatment schemata that are operative in other domains of autistic symptomatology, there have been targets available for intervention which appear intrinsically related to this core component. Unfortunately, to this point, they have not proven fruitful, oxytocin has not been the general booster of social cognition and drive it had been hoped to be, though the very limited brain access for intranasal oxytocin, and its ephemeral half-life, means that the oxytocin hypothesis has not had a definitive test. Vasopressin-1a antagonism has been a clinical disappointment as well, and may have been more thoroughly disproven as a therapeutic option, though there it can be argued that the balovaptan patient population should have been more specifically defined, and there have been questions as to whether the Vineland (a nonspecific scale tapping a range of behaviors) may have been a suboptimal choice.
Oxytocin, as an upregulator of affiliative drive and/or a downregulator of amygdala-based anxiety/fear responses, received a lot of popular press coverage for several years (the ‘Cuddle Hormone’), certainly there is intuitive appeal to the concept of a pharmacological intervention that might increase affiliative behaviors, spurring what might be hoped to be a self-perpetuating virtuous cycle, affording the opportunity to experience social contact as rewarding, thereby increasing the likelihood of continued social engagement. There were pilot studies indicating that oxytocin might be of benefit in autism, improving eye gaze, social awareness/emotional recognition, and interpersonal responsivity. One imaging study indicated an increase in activity in the fusiform gyrus, wherein the recognition of human faces appears to be generated, perhaps increasing the valence of human vs. nonhuman object responsivity. Whether this means that there is a deficiency in endogenous oxytocin levels (as is indicated by a Stanford group’s work), or the provision of oxytocin serves to work around some other structural or neurochemical anomaly, has yet to be defined, or operationalized.
The plasma half-life of oxytocin is only three minutes, but it has been believed that the duration of CNS activation considerably exceeds that, perhaps tenfold. It is possible that one only needs an initial, facilitative effect that would allow someone to enter into interaction, after which both behavioral therapy and the (hopefully and increasingly)intrinsic reward of human interaction would hopefully sustain that behavioral change. However, oxytocin, used as Pitocin in obstetric settings, has safety issues with chronic use, its effect on the vasopressin-1b receptor can lead to hyponatremia. There are also animal findings suggesting that longterm exogenous oxytocin may downregulate the production of endogenous oxytocin.
An Australian study assessed the impact of intranasal oxytocin in 31 young (ages 3-8) children over a five week period. This double-blinded study showed a significant impact upon caregiver-rated social responsiveness. Stanford hosted a 32pt pediatric autism trial, administering intranasal oxytocin once daily for four weeks. The impact of drug vs. placebo approached but fell shy of statistical significance, but when endogenous oxytocin levels were included as a co-factor, the oxytocin-treated children showed significant improvement in social functioning (but not repetitive behaviors), especially those with the lowest endogenous levels.
MGHhas been running a 100pt study of intranasal oxytocin and cognitive-behavioral/social skills therapy, it was supposed to be completed at the end of 2017, but was still recruiting subjects last summer.
A Duke group completed a 290pt pediatric autism trial of intranasal oxytocin, no results have been announced. A Hamamatsu University group is running a 144pt trial of intranasal oxytocin.
A Toronto group ran a 70pt trial in adults, that trial appears to have wrapped up late last year, no results have been disclosed.
Small molecule oxytocin-receptor agonists at one time received some attention, Wyeth developed WAY267464, a first-generation prototype, but that program demised.
Carbetocin is an oxytocin analog with a longer half-life, but Kyalin Biosciences has not been able to find funding to develop it for autism.
Besides targeting oxytocin receptors, alternative tactics could involve increasing the release of endogenous oxytocin. The melanocortin-4 system, which has been heavily studied in the area of feeding/obesity, has been shown (by work at Emory University) to be a route by which oxytocin release can be increased downstream. Given its linkage to key metabolic processes, melanocortin-4 would have its own safety/tolerability issues as a target.
As was noted earlier, an indirect route to increasing oxytocinergic circuit activation in animal models where Nlrg3 has been knocked out is to inhibit MNK kinases, and there is a tool compound (ETC-168) that does that, enhancing neuronal and behavioral activity.
Two vasopressin receptor subtypes (1a and 1b) are found in circuits connecting to the limbic system, V-1a is the predominant subtype in the CNS. Vasopressin-1a receptor activation is believed to impact the valence of negative affective stimuli; vasopressin levels are elevated in animal models of depression and anxiety, and in relevant areas of the cortex and limbic region. Vasopressin-1a antagonists had originally been considered avenues to anxiolysis, but as was noted above, inhibiting the vasopressin system may have effects similar to those achieved via oxytocin activation.
In a 223pt adult PhII that provided treatment for 12 weeks (at three dose levels), Roche‘s vasopressin-1a antagonist balovaptan/ RG7314, no improvement was seen on a social responsivity scale, but improvements in the two higher dose groups were reported on socialization and communication. Roche then went into a 350pt Phase III, but that trial was stopped last April following a dismal futility analysis, two pediatric studies were terminated as well.
Azevan Pharmaceuticals developed two orally-bioavailable vasopressin-1a antagonists, SRX246 and its backup, SRX251. SRX246 was cited as meeting its primary and secondary endpoints in a Phase II for Intermittent Explosive Disorder. Phase II trials in Huntington’s irritability and PTSD have been completed, with no disclosure of results, which almost certainly means failure.
Blackthorn Therapeutics had licensed a selective vasopressin-1a antagonist (BTRX-323511), to be aimed at autism. Blackthorn had expected to go into PhI earlier this year, but after Roche‘s balovaptan implosion, it seems improbable that they are going to proceed until they devise a more productive route to assessing efficacy.
Conversely, there have been reports of improvement from increasing vasopressin levels. In a 28 pt pediatric study of intranasal vasopressin, which was placebo-controlled, the vasopressin group increased their score on a social responsiveness scale by an average of 13 points, significantly better than the placebo group. The level of improvement was greater in children with lower baseline levels of vasopressin, or higher availability of vasopressin receptors. These constitute possible biomarkers predicting treatment response, and the researchers suggested that this might be a vasopressin-deficient subgroup of the ASD population, similar to the greater response of oxytocin-deficient children to treatment with that hormone. A Stanford group reported positive results for intranasal vasopressin in a 50pt trial, a 100pt trial will be completed in 2022. Vasopressin augmentation may now get a closer look for a segment of the ASD population.
A prominent ASD researcher suggested to NIR that glutamatergic procognitive drugs could be another route to boosting the activity of brain circuits relevant to social responsivity, which means that procognitive drug trials will have to monitor social engagement as well.
With ketamine having been tried in such a broad plethora of disorders, it was not surprising that it was tried in autism, with social withdrawal the primary focus. Roivant Sciences, the progenitor of Axovant, provided support for the trial, done at U. Cincinnati. 21 individuals ages 14-29 were treated with two doses of intranasal ketamine or placebo. No benefit was observed. There is a trial ongoing that combines ketamine with dexmedetomidine, the latter under development for Alzheimer’s agitation; this is unlikely to go any better.
N-acetyl cysteine, a dietary supplement with antioxidant properties, is one of those substances whose frequent deployment in academic trials seems more a function of its availability than its actual utility. But there was a recent paper that reported N-acetyl cysteine attenuated hyperactivity and social withdrawal in mice with an autism-related gene deletion (16p 11.2 DEL), presented as evidencing its role as an ‘excitation/inhibition modulator.’ The same paper reported that the anti-migraine drug eletriptan had a similar impact on those phenotypic features, which was equally unconvincing.
The Miscellaneous and Dubious
Stem cell ‘therapy’ has been a profitable refuge for any number of programs which constitute quackery under the guise of medical practice. We are not going to go into these enterprises in any detail, they tend to rely on vaguely articulated premises of anti-inflammatory effects. One such program utilizes autologous mesenchymal cells, those cells injected into the subarachnoid space, ostensibly migrating to the “injured area,” as if autism constitutes some type of traumatic injury. Given the evidence that autism is instead a disorder of dysfunctional neural networks, this seemed to be, at best, ill-considered. There is less vagueness around the motivation, one such Panama-based clinic includes autism as one of the therapeutic areas for which their mesenchymal stem cells are suited: Their fees start at “$15,825 for children and $23,150 for adults.” But to their credit, they do throw in a “Hilton hotel room with breakfast, WIFI....”
BrainStorm Therapeutics reported that in a mouse model trial, a single administration of their NurOwn (autologous mesenchymal) cells led to behavioral and cognitive improvement in those mice. But cell replacement therapy is not generally seen as an avenue to treating ASD at present, and the presence of pseudo-clinical hucksters at the fringes does not lend credence to the concept.
(from the May/June 2020 Issue)
Depression: Rebooting the System-Psychedelics
Back in 2018, we said this: “Academic groups at Johns Hopkins and the University of Helsinki are running Phase II trials exploring the use of psilocybin in major depression. The Johns Hopkins study is enrolling 24 patients, and should produce top-line data this year. Is this a high-probability candidate for use in highly refractory depression? Given the times, it is hard to say anything but no to that, but then again, there were times that the neurotherapeutic use of ketamine, and the broad utilization of medical marijuana, would have seemed equally implausible.” No domain within neurotherapeutics has been more radically transformed over the past two years than this one. Research into the therapeutic benefits offered by nontraditional psychoactive drugs, thwarted for decades, is moving forward, at a dramatic clip. There have been small studies indicating longterm antidepressant effects, lasting months, provided by one or two psilocybin sessions. Some observations have provided more questions than answers: A Louisiana State group did a trial comparing the effects of LSD, psilocybin, and ketamine in a rodent model of depression, and reported (2020) that the two psychedelic drugs provided a more durable antidepressant effect than did ketamine. But our attention was seized by their statement “our results…suggest that a subjective existential experience may not be necessary for therapeutic effects“, begging the question of what might constitute a ‘subjective existential experience’ for a rat, and how one would measure it.
Michael Pollan’s How to Change Your Mind, detailing his extensive exploration of psychedelic research, both above ground and underground, has afforded the area a bonanza of public exposure, not an unmitigated boon, since there is always the risk that this resurgence could be undermined by countervailing forces alarmed by the prospect–as happened fifty years ago. But buttressed by FDA support (and designation of psilocybin as a potential ‘breakthrough’ therapy for TRD), companies like Compass Pathways and ATAI Life Sciences have brought rigor and expertise to exploring the therapeutic potential of the unorthodox. Compass Pathways presented data from their 89pt PhI trial of COMP360/psilocybin, which demonstrated the feasibility and tolerability of systematized psilocybin sessions. A 216pt, double-blinded, dose-ranging (three dose levels) PhII trial, utilizing highly regarded academic centers in the US and EU, has been enrolling patients for the past year, assessing MADRS impact for up to three months after a single administration. It had been expected to be finished in early 2021, that timeframe has been disrupted by the Covid-19 pandemic. One additional challenge: while the lowest dose used in the Compass trial is considered to be a relative ‘placebo’, with very attenuated effects, there is no viable way to provide a truly blinded placebo experience.
Psilocybin, as do most psychedelic therapies (the exceptions including MDMA), works primarily through 5HT-2a receptor agonism, though psilocybin has been reported to also have 5HT-1a agonist binding, and LSD has some dopamine receptor binding. This class of drugs appear to produce a profound, albeit time-limited, reconfiguration of cognitive biases/beliefs regarding an individual’s sense of self and relationships with others. Accordingly, controlled trials of psilocybin involve some preparatory sessions, a drug session that involves accompaniment by a specialty-trained psychologist or therapist, and is followed by at least one ‘debriefing’ session which is aimed not only at outcome assessment, but aiding and abetting the ‘digestion’ of the experience. This class of drugs is also being studied in a range of other disorders (e.g. PTSD, substance abuse, headaches), but the complexity of the administration regimen, particularly the 6-8 hours required for the core drug-administration (and the as-yet undefined possible benefit from eventual readministration) likely would put this out of reach for the majority of the TRD population–this would be the premium-class intervention for the well-heeled.
To address this market accessibility issue, there is a search for drugs that might provide some of the same cognitive ‘reset’ that appears to be afforded by psilocybin, but in a more time-efficient framework. Atai Life Sciences, which has a major stake in Compass Pathways, (and acquired majority ownership of Perception Neuroscience, for R-ketamine) is sponsoring a search for other, lesser known psychedelic molecules, some of which have been produced by underground chemists far out of the mainstream of drug research. Atai has spun out a subsidiary, Entheogenix, specifically tasked with that compound hunt, with one major focus being on compounds that might have a shorter duration of effect. They do exist: Peruvian shamans (and their California underground counterparts) have developed a cottage industry of guided ayahuasca experiences, ayahuasca being the botanic source of the psychedelic compound dimethyltriptamine/DMT. While shorter, because of the use of a concurrent MAO-inhibiting botanical to extend the duration, ayahuasca experiences can last up to six hours, which (shamanic supervision aside) would still preclude any broad applicability.
(from the March/April 2020 Issue)
Epilepsy: Dravet Syndrome
This is an epileptic encephalopathy–also known as Severe Myoclonic Epilepsy of Infancy–with a US population size of up to 15,000 cases. It leads to pronounced developmental delays affecting cognition, motor function, and autonomic function, and is treatment-refractory. There appears to be a substantial genetic component, with 80% of Dravet patients having a loss of function in their Nav 1.1 sodium channel due to SCN1A mutations.
Some GABAergic drugs worsen Dravet seizures, as do sodium channel blockers. Clobazam has had significant utilization in the US, while in Europe, Biocodex’s stiripentol has long been used, this drug believed to be acting via either the GABA-A alpha-3 or beta-3 subunit. US approval was finally received in 2018 for the use of Diacomit/stiripentol as an adjunct to clobazam in the treatment of Dravet.
Back in 2013, a case of Dravet Syndrome was highlighted by a CNN report on the medical use of a strain of marijuana that had high levels of cannabidiol, which galvanized attention regarding the use of cannabinoids in childhood epilepsies. Even though cannabidiol shows only weak anti-seizure activity in animal models, given a dramatic reduction in seizure activity for that child, such anecdotal human data jump-started cannabinoid utilization in Dravet and other pediatric epilepsies, with some parents moving to states where they could legally obtain CBD-preferential strains of cannabis. Seven years later, medical marijuana is legal in thirty-three states in the US, recreational marijuana is legal in eleven states, and in the pharmaceutical world, it has been GW Pharmaceuticals that has made the most of the opportunity. GW Pharma was ideally positioned to exploit its expertise with purified cannabis extracts in order to develop Epidiolex, a plant-derived liquid cannabidiol extract. GW Pharmaceuticals ran a 120pt PhIII trial of Epidiolex (20mg/kg) in Dravet Syndrome (the average age was ten, with a history of having failed four other AEDs), assessing the reduction of seizure activity from baseline over fourteen weeks. The results showed that Epidiolex to be useful, albeit far from a panacea: The Epidiolex group showed a mean seizure frequency reduction of 39%, compared with 13% for placebo. Epidiolex (which uses a sesame oil suspension) is also not side effect-free, with somnolence, diarrhea, fatigue, and vomiting all seen in 10% or more of those patients; 13% of the Epidiolex group withdrew from treatment due to side effects. Following a second successful trial, GW Pharma obtained FDA approval, and 2019 sales of Epidiolex totalled $296 million, approaching a $400 million annualized rate during 4Q. They have also received approval for the treatment of Lennox-Gastaut Syndrome and have filed for use in Tuberous Sclerosis.
The diarrhea often associated with Epidiolex’s sesame oil suspension is problematic, though GW Pharma hopes to remedy this via the development of a capsule formulation. Serina Therapeutics has developed a polymer-linked formulation of cannabidiol that they state would avoid the chronic GI side effects associated with Epidiolex’s current oil formulation; SER-228 is in early preclinical development.
Insys Therapeutics was developing a synthetic form of cannabidiol, to be aimed first at Dravet and LGS. However, their former CEO and other managers were convicted on federal racketeering charges related to kickbacks paid physicians to prescribe Insys’ fentanyl product, and Insys filed for bankruptcy last year.
Anecdotal reports of Dravet symptoms being impacted by fenfluramine (which acts via the release and inhibited reuptake of serotonin), the drug that first came to attention as part of the ‘fen-phen’ anti-obesity combination of the 1990s, turned into an open-label prospective study done in Belgium wherein 7 of 9 patients receiving low-dose fenfluramine showed a greater than 50% reduction in seizure rate, the other two patients showed a reduction as well. Side effects included sleepiness and appetite reduction, no valvulopathy was observed, though this was a minuscule sample. The therapeutic principle was supported by zebrafish work showing that fenfluramine had antiepileptic effects in SCN1A-mutation zebrafish.
Zogenix took on (via the acquisition of Brabant Pharma) the development of ZX008/fenfluramine in pediatric epilepsies, first pursuing Dravet Syndrome. Since higher-dose fenfluramine use had been associated with pulmonary hypertension when used for obesity (‘fen-phen’), the FDA was stringent in their demands for echocardiogram monitoring, which led to a delay in the inception of pivotal trials. But once underway, in a prospectively-defined merged analysis of two Phase III studies of 119 child/adolescent patients, the higher dose of ZX008 produced a 63.9% placebo-adjusted mean reduction in baseline seizure frequency, and a median reduction of 72.4% in seizure frequency, compared with 17.4% median reduction for placebo. These results were numerically superior to the decrease provided by Epidiolex in Dravet, albeit not tested head-to-head. Prominent side effects were somnolence, lethargy, and fatigue, but while appetite suppression was frequently seen (unsurprising given its legacy as an anti-obesity drug), the GI side effects so frequently reported with Epidiolex were not present with ZX008. Zogenix initially received a CRL from the FDA for Fintepla/ZX008, but the NDA has been resubmitted. While the PDUFA date has just been extended to June 25, we do expect Fintepla to be approved, and it will provide robust competition to Epidiolex in Dravet Syndrome, based on both its efficacy and tolerability advantages.
Ovid Therapeutics made news when they partnered with Takeda on the latter’s TAK-935, a drug that addresses a novel target, inhibiting cholesterol 24-hydroxylase. The premise is that 24-hydroxylase functions as an inhibitor of 24-hydroxycholesterol, which itself functions as an endogenous positive allosteric modulator of NMDA receptors–hence it is an overly circuitous route to glutamatergic activity suppression. It had been taken through four Phase I trials, but it was not high on Takeda’s priority list, so they collaborated with Ovid, who is emphasizing rare epilepsies with the program. An 18pt Phase I/II trial in adults with rare epilepsies (Dravet, LGS, CDKL5) showed a dose-dependent reduction in 24HC levels, very tentatively (due to the tiny cohort size) correlated with a reduction in seizure frequency: the seven patients who reached target reductions in plasma 24HC had a mean decrease in seizure frequency (at 85 days, in the open-label extension phase) of 69%, compared with a decrease of just 3% in those who did not reach that biomarker criterion. Three patients who were also receiving perampanel showed an increase in seizure activity, indicating an iatrogenic synergy between these two drugs that both target glutamatergic systems.
OV935 is now in a 126pt pediatric rare epilepsy study (Dravet and LGS) that uses a revised titration and duration protocol, following patients for a total of five months, and excludes patients receiving perampanel. That trial is projected to complete in mid-2021. The wisdom of combining DS and LGS patients in the same study is questionable, given that LGS is far less diagnostically defined than is Dravet; they feature different seizure types (drop and convulsive seizures, respectively); and the Zogenix results with Fintepla in the two disorders suggests that treatment responsivity can vary between the two disorders. Ovid is also combining patients with two different rare disorders, 15q duplication and CDKL5 deficiency, in another 30pt open-label pilot study, finishing later this year, introducing heterogeneity into patient samples is a debatable tactic.
Verapamil is a L-type calcium channel blocker utilized in the United States for hypertension, cardiac arrhythmias, and headaches for over thirty years. The premise for its adjunctive use in Dravet Syndrome is that it improves defects in autonomic control by downregulating sympathetic nervous system activity, though it has also been hypothesized that verapamil may slow the transport of anti-epileptic drugs out of cells, thereby improving their pk profile. There are reports of children with Dravet Syndrome who responded to the use of verapamil as an adjunct, the effect persisting for several months. Mayo Clinic ran a Phase II trial whose results were apparently ambiguous, and it is not clear who would bankroll further testing given the drug’s generic availability and the increasingly competitive environment in Dravet treatment.
Supernus is developing Biscayne‘s Huperzine A, in XR form, for Dravet; that program (SPN-817) is currently in PhI.
Stoke Therapeutics has developed an oligonucleotide (STK-001) that targets the mRNA for mutant Nav1.1/SCN1A protein, decreasing its production, while bringing Nav1.1/SCN1A production to near normal levels. In mouse studies, 76% of DS-model mice were seizure free (from postnatal days 22-46) after receiving STK-001, compared with 48% of mice receiving placebo infusions. The frequency of seizures in treated mice was reduced by 80%, and the survival rate (to day 90) was 97% of treated mice, 23% for the placebo group. Nonhuman primate studies showed that STK-001 increased Nav1.1 expression throughout the cortex. Stoke was able to raise $163 million in their 2019 IPO (and $130 million previously) on the basis of this promising work, and hopes to initiate a PhI/II trial in 1H:20. This program represents a nightmare scenario for Dravet drug developers, since if it works as hoped, it could do for the 90% of Dravet patients with the mutation what the gene-editing therapies have done for SMA, which could make symptomatic treatments irrelevant. But this has yet to be established in human testing.
Right behind Stoke is Encoded Therapeutics, which has raised $158 million thus far, from high quality VCs, to develop its AAV gene therapy programs. The lead program (ETX101) is in Dravet, where they are using AAV to deliver transcription factors that are intended to upregulate the expression of SCN1A/Nav1.1 channels in inhibitory neurons. They apparently have preclinical data that tells them they can provide both payload and location specificity, they hope to be in human testing next year.
CURNA, a company spun out of Emory University, developed CUR-1740, another antisense oligonucleotide targeting mutated SCN1A, which reportedly increased functional SCN1A mRNA eightfold in a human fibroblast model. Opko Health acquired CURNA, naming the asset OPK8801. Back in 2017, Opko claimed the IND would be filed before the end of the year, and two years later, that has not yet occurred–which likely means that the ASO did not pan out, and has been shelved.
LifeSplice Pharma developed a splicing oligonucleotide that reduces the expression of SCN8A receptors, found primarily on excitatory neurons. In a mouse model of Dravet, LSP-SCN8 reduces mortality ‘dramatically.’ They received a $700K NIH grant back in 2014 for this program, followed five years later by a $670K grant aimed at furthering preclinical development. Thus this program is moving at a snail’s pace.
(from the January/February 2020 Issue)
Negative Space: Missing Pieces in the Aducanumab Story
It was the most eagerly awaited event of the Alzheimer’s holiday season: Biogen had promised to provide additional data buttressing its decision to remove aducanumab from the futility dustbin, and after a fresh coat of paint, submit it to the FDA for approval in the treatment of Alzheimer’s. CTAD’s annual meeting provided a suitable setting, and it was a packed house on December 5. Biogen’s Samantha Haeberlein provided an extensive review of aducanumab data and the rationale for claiming that disease-slowing had been demonstrated in the truncated Phase III trials. But it was not so much what was shown and said, but rather more what was missing, that was most striking. Among the omissions:
Dissent. The panel of discussants at the Biogen presentation were primarily investigators for the PhIII trial in question, plus Paul Aisen from USC, an amyloid-theory stalwart. They spoke movingly of their wish to have something to offer patients otherwise bereft of hope, and the importance of extending a patient’s capacity for autonomous functioning. Our background is clinical, we get it, but in this scientific setting, it came across as cheerleading based on a pre-specified wishlist, not clear-eyed science. There was no shortage of skeptics in the room, surely someone qualified could have been invited to participate as a spokesperson for the loyal opposition. Instead, the panel seemed to be parroting the party line.
Microphones. At CTAD, as at most large conferences, microphones are placed at various locations around the room so that questions can be asked of the presenter after the presentation has finished. For Biogen’s aducanumab talk, and for no other session, those microphones had been removed. In their place, attendees were invited to text questions to a moderator who selected a few softball queries, dutifully responded to by panel members. Oddly, when asked about regional differences, Biogen’s curt response was “we are not commenting on that” (why not?). This was a curated and controlled media moment, not the opportunity for scientific interchange for which CTAD would in theory have been an ideal locale.
The extended version of ARIA’s song. Biogen acknowledged the high rate of ARIA-E and H in the 10mg/kg, APOE4+ group, 50-54%, but was dismissive around the details, stating that only 20-29% of these cases were symptomatic, and “the majority” were able to eventually resume aducanumab. What happened to the plurality who were not able to resume treatment? In the PhII PRIME study, 22% of ARIA cases were severe (Biogen disclosed only that ‘78% were mild to moderate’, one had to do the math to figure out the rest). What percentage were severe in Phase III? And what happened to those patients? One of the panel members stated that he is comfortable ‘managing ARIA’, which may well be the case, backed up as he is by Brown University Medical School’s resources and imaging capabilities. That may not be so easily duplicated by general practice neurologists in the field. This is a safety issue not to be so cavalierly dismissed–the FDA will not ignore it.
Having seen one media report of an “electric atmosphere” following the Biogen presentation,we can report that NIR spoke to at least a dozen attendees about that presentation, and without exception, the reaction was one of disbelief and annoyance at having been subjected to an infomercial for aducanumab and the amyloid hypothesis. Or to put it another way, the atmosphere was more shocked than electric.
The Bottom Line:
Statistical purists may suggest that the announcement of the futility analysis results, and subsequent trial termination, irrevocably altered the framework for everything that followed, including the inclusion of later subjects and the post hoc revisiting of the ENGAGE trial. If so, it would then follow that neither study can be properly described as successfully documenting efficacy, and at most, the EMERGE trial puts forth a hypothesis to be tested. But if the FDA were hewing to this strict standard, and saw neither trial as constituting a valid pivotal study, we suspect that this would have been conveyed to Biogen during subsequent discussions. So for those keeping score at home, we will chalk up EMERGE as appearing to support aducanumab’s case. But on the other hand, all the post hoc genie-lamp rubbing cannot turn ENGAGE into anything other than a failed trial, indeed some numerical trends showed a worsening of the aducanumab group compared to placebo. So one trial was positive, one negative. Which was the outlier? Post hoc data mining cannot definitively answer that question.
What will happen now? There are a few possible scenarios:
A Tiebreaker is Required: If the FDA follows its own procedures and precedents, a third Phase III will be mandated. ENGAGE was not confirmatory, and those hoping that the Phase II results from the PRIME trial might substitute forget that the whole dose-response pattern in that trial was turned on its head. A tiebreaker should and will be the outcome, unless the following occurs:
Aducanumab Turns Into A Political Football: Given Alzheimer’s massive toll, well-meaning people may well decide that ‘something is better than
nothing.’ We can also imagine a political environment, with a Presidential election looming, and an impeachment trial that will not end with a conviction, where this would be seen as a potential crowd-pleasing ‘win’. Regulators will be under great pressure to be ‘flexible’, and there are examples of doing so in the past, single trial approvals in Duchenne Muscular Dystrophy and Parkinsonian psychosis come to mind. But this is different, in both the stakes and scale. The sheer size of the Alzheimer’s market dwarfs either of those, and there are safety issues with aducanumab not seen in those other contexts. To open the floodgates of demand for an Alzheimer’s treatment would mean millions of people could be exposed to a drug of unclear utility, wherein the impact of even a low-incidence adverse event will be greatly magnified by the size of the population using it. And in terms of reverberating effects: At best, aducanumab would be a mediocre treatment making the enrollment of trials for other, potentially superior therapies, nearly impossible, save for treatment failures unlikely to respond to any disease-modifier, or those with ‘unmanageable’ ARIA.
These concerns will not matter one iota to those who see this as potentially adding to the case for a Presidential re-election. In their view, a win is a win is a win, and the ability to claim that this administration ‘cured’ Alzheimer’s would be intoxicating. The most cynical scenario we can conjure up combines ‘‘It’s a nice little Agency you have here, it would be a shame if something happened to it’ and ‘I need a favor, though.’
The window of timing opportunity would be narrow, given that Biogen will file the NDA in early 2020, just months before the election. We can imagine immense pressure to act ASAP. However, there is also a new FDA Commissioner now in place, for whom the calculations could be both medico-ethical and political. We would like to think the former would rule the day, but if the latter is a factor, and if Stephen Hahn wants to be Commissioner longer than one year, he would have to consider the likelihood that if he is perceived as having ‘caved’ to Administration pressure, and the Democratic candidate then wins in November, his tenure will be short. This calculation would be inverted in the scenario of a Trump re-election.
Any eventual approval for aducanumab would have significant conditions attached. Given the ARIA issue, we expect a REMS requirement for quarterly MRI scans for the first eighteen months of a prescription, good news for the owners of imaging centers.
It seems almost bizarre to suggest that a decision that could affect millions of lives, cost billions of dollars in health care expenditures, and could constitute a major obstacle to the validation of other therapies in development, could be impacted by election-year maneuvering. But bizarre has become the new normal.
One Other Alzheimer’s Note
We do not question the sincerity of aducanumab’s supporters within the Alzheimer’s community. We do question the objectivity of their judgment. Aducanumab, as has been the case with previous high-profile projects, has become the poster child for cognitive dissonance theory, people seeing what they want to see in order to maintain consistency with long and deeply held beliefs. Paul Aisen proclaimed at CTAD that aducanumab is a “truly major advance”. We recall a previous CTAD where Aisen concluded that the solanezumab Phase III data set ‘proved’ the amyloid hypothesis. Neither statement was accurate, though we are sure that Aisen believes both to be true. The degree to which well-intentioned experts can twist their thinking in the service of cognitive congruency was exemplified by a later CTAD panel on BACE inhibitors, a class where the story has turned to the assessment and reversal of drug-induced cognitive worsening. Most presenters seemed to acknowledge that the therapeutic window for BACE inhibition, other than perhaps for rare autosomal dominant AD, is essentially nil. A couple of them suggested that, while BACE inhibitors impair memory, they seem to improve language fluency, a pyrrhic victory at best. Banner Health’s Eric Reiman took a contrarian view, proposing (as did Aisen the next day) that BACE inhibition should continue to be explored as a therapeutic option, particularly in APOE4+ patients without amyloid deposits, arguing that brain volume loss comes early and is neither ‘progressive’ nor clearly correlated with cognitive deterioration, which he stated might be both ‘tolerable’ and reversible. The notion that patients whose disease involves cognitive decline might be able to ‘tolerate’ treatment-induced impairment seems incongruous at best. While Reiman may have been intentionally provocative in his suggestions, they did illustrate the pretzeled logic that so often permeates the Alzheimer’s field.
Moments after their CTAD presentation, Biogen held a conference call for major investors/analysts. Where they fielded a number of questions in real-time; they were more open to investors than to their scientific peers. In that call, they provided more detail about their rationale for seeing ENGAGE as a net positive for aducanunab, but they still responded to a number of queries with ‘we’re not going to talk about that.‘ There continues to be a dearth of ARIA outcome information, other than bland assurances that it is ‘manageable.’ They insist they have no intention of running another pre-NDA trial. What do they know that we do not? Plenty, that’s a low bar. But Biogen’s parsing and filtering of information still strikes a sour, defensive note to our ears.