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Tawil R, Wagner KR, Hamel JI, Leung DG, Statland JM, Wang LH, Genge A, Sacconi S, Lochmüller H, Reyes-Leiva D, Diaz-Manera J, Alonso-Perez J, Muelas N, Vilchez JJ, Pestronk A, Gibson S, Goyal NA, Hayward LJ, Johnson N, LoRusso S, Freimer M, Shieh PB, Subramony SH, van Engelen B, Kools J, Leinhard OD, Widholm P, Morabito C, Moxham CM, Cadavid D, Mellion ML, Odueyungbo A, Tracewell WG, Accorsi A, Ronco L, Gould RJ, Shoskes J, Rojas LA, Jiang JG. Safety and efficacy of losmapimod in facioscapulohumeral muscular dystrophy (ReDUX4): a randomised, double-blind, placebo-controlled phase 2b trial. Lancet Neurol 2024; 23:477-486. [PMID: 38631764 DOI: 10.1016/s1474-4422(24)00073-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Facioscapulohumeral muscular dystrophy is a hereditary progressive myopathy caused by aberrant expression of the transcription factor DUX4 in skeletal muscle. No approved disease-modifying treatments are available for this disorder. We aimed to assess the safety and efficacy of losmapimod (a small molecule that inhibits p38α MAPK, a regulator of DUX4 expression, and p38β MAPK) for the treatment of facioscapulohumeral muscular dystrophy. METHODS We did a randomised, double-blind, placebo-controlled phase 2b trial at 17 neurology centres in Canada, France, Spain, and the USA. We included adults aged 18-65 years with type 1 facioscapulohumeral muscular dystrophy (ie, with loss of repression of DUX4 expression, as ascertained by genotyping), a Ricci clinical severity score of 2-4, and at least one skeletal muscle judged using MRI to be suitable for biopsy. Participants were randomly allocated (1:1) to either oral losmapimod (15 mg twice a day) or matching placebo for 48 weeks, via an interactive response technology system. The investigator, study staff, participants, sponsor, primary outcome assessors, and study monitor were masked to the treatment allocation until study closure. The primary endpoint was change from baseline to either week 16 or 36 in DUX4-driven gene expression in skeletal muscle biopsy samples, as measured by quantitative RT-PCR. The primary efficacy analysis was done in all participants who were randomly assigned and who had available data for assessment, according to the modified intention-to-treat principle. Safety and tolerability were assessed as secondary endpoints. This study is registered at ClinicalTrials.gov, number NCT04003974. The phase 2b trial is complete; an open-label extension is ongoing. FINDINGS Between Aug 27, 2019, and Feb 27, 2020, 80 people were enrolled. 40 were randomly allocated to losmapimod and 40 to placebo. 54 (68%) participants were male and 26 (33%) were female, 70 (88%) were White, and mean age was 45·7 (SD 12·5) years. Least squares mean changes from baseline in DUX4-driven gene expression did not differ significantly between the losmapimod (0·83 [SE 0·61]) and placebo (0·40 [0·65]) groups (difference 0·43 [SE 0·56; 95% CI -1·04 to 1·89]; p=0·56). Losmapimod was well tolerated. 29 treatment-emergent adverse events (nine drug-related) were reported in the losmapimod group compared with 23 (two drug-related) in the placebo group. Two participants in the losmapimod group had serious adverse events that were deemed unrelated to losmapimod by the investigators (alcohol poisoning and suicide attempt; postoperative wound infection) compared with none in the placebo group. No treatment discontinuations due to adverse events occurred and no participants died during the study. INTERPRETATION Although losmapimod did not significantly change DUX4-driven gene expression, it was associated with potential improvements in prespecified structural outcomes (muscle fat infiltration), functional outcomes (reachable workspace, a measure of shoulder girdle function), and patient-reported global impression of change compared with placebo. These findings have informed the design and choice of efficacy endpoints for a phase 3 study of losmapimod in adults with facioscapulohumeral muscular dystrophy. FUNDING Fulcrum Therapeutics.
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Affiliation(s)
- Rabi Tawil
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kathryn R Wagner
- Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Johanna I Hamel
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Doris G Leung
- Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Leo H Wang
- University of Washington, Seattle, WA, USA
| | - Angela Genge
- Montreal Neurological Institute and Hospital, Montreal, QC, Canada
| | - Sabrina Sacconi
- Peripheral Nervous System and Muscle Department, Nice University Hospital and University of Côte d'Azur, Nice, France
| | - Hanns Lochmüller
- Children's Hospital of Eastern Ontario Research Institute, Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Reyes-Leiva
- Institut de Recerca IIB Sant Pau, Hospital Universitari Santa Creu i Sant Pau, Barcelona, Spain
| | - Jordi Diaz-Manera
- Institut de Recerca IIB Sant Pau, Hospital Universitari Santa Creu i Sant Pau, Barcelona, Spain; John Walton Muscular Dystrophy Research Center, Newcastle University, Newcastle, UK
| | - Jorge Alonso-Perez
- Neuromuscular Diseases Unit, Neurology Department, Hospital Universitario Nuestra Señora de Candelaria, Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Santa Cruz de Tenerife, Tenerife, Spain; Neuromuscular Diseases Unit, Neurology Department, Institut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nuria Muelas
- Neuromuscular Diseases Unit, Neurology Department, Hospital Universitari i Politecnic La Fe and Neuromuscular Reference Centre, Valencia, Spain; Neuromuscular and Ataxias Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras, Barcelona, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Juan J Vilchez
- Neuromuscular and Ataxias Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Alan Pestronk
- Washington University in St Louis, St Louis, MO, USA
| | | | | | | | | | | | - Miriam Freimer
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Perry B Shieh
- University of California at Los Angeles, Los Angeles, CA, USA
| | - S H Subramony
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Baziel van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joost Kools
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Olof Dahlqvist Leinhard
- AMRA Medical, Linköping, Sweden; Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| | - Per Widholm
- AMRA Medical, Linköping, Sweden; Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Radiology, Linköping University, Linköping, Sweden
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